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.

- 2-

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

Case: 2:08-cv-00475-ALM-MRA Doc #: 2 Filed: 05/16/08 Page: 4 of 10 PAGEID #: 5

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

-4 -

Case: 2:08-cv-00475-ALM-MRA Doc #: 2 Filed: 05/16/08 Page: 5 of 10 PAGEID #: 6

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.

-5-

Case: 2:08-cv-00475-ALM-MRA Doc #: 2 Filed: 05/16/08 Page: 6 of 10 PAGEID #: 7

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

-6-

Case: 2:08-cv-00475-ALM-MRA Doc #: 2 Filed: 05/16/08 Page: 7 of 10 PAGEID #: 8

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).

- 7-

Case: 2:08-cv-00475-ALM-MRA Doc #: 2 Filed: 05/16/08 Page: 8 of 10 PAGEID #: 9

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

-8-

Case: 2:08-cv-00475-ALM-MRA Doc #: 2 Filed: 05/16/08 Page: 9 of 10 PAGEID #: 10

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.

- 9-

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

GREGORY G. LOCKHART

United States Attorney

southern District of Ohio

303 Marconi Boulevard

Suite 200

Columbus, OH 43215

(614) 469-5715

.

;

~~~

/;}

:I

/ / ·~~ /J

I

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

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

- 10 -

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

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

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

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

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

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

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

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

I.

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

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

Operated Juvenile Correctional Facilities;

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

DYS Compliance Coordinator in S.H.;

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

performance data gathered by the Monitor in . and

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

prepared by the Monitor in S.H.

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

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

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

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

River VaHey Juvenile Correctional Facility, and the Freedom Center.

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

-4DATE:

June 5, 2008

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

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

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

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

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

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

S.H., and all other similarly situated,

)

et ai.,

)

)

Plaintiffs,

)

)

v.

) CIVIL ACTION NO:

) 2:04-cv-1206

TOM STICKRATH,

) ) JUDGE ALGENON L. MARBLEY

Defendant.

)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

6.

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

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

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

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

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

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

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

expert.

4

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

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

VII. Implementation. Enforcement. and Termination

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

VIII. Miscellaneous

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

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

IT IS SO STIPULATED AND AGREED.

FOR THE UNITED STATES:

Date: November 23, 2009

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

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

5

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

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

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

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

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

6

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

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

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

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

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 2 of 27 PAGEID #: 61

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

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 3 of 27 PAGEID #: 62

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·

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 4 of 27 PAGEID #: 63

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

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 5 of 27 PAGEID #: 64

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

·'

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 6 of 27 PAGEID #: 65
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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 7 of 27 PAGEID #: 66

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

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 8 of 27 PAGEID #: 67
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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 9 of 27 PAGEID #: 68

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:

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 10 of 27 PAGEID #: 69

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,

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 11 of 27 PAGEID #: 70

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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 12 of 27 PAGEID #: 71
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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 13 of 27 PAGEID #: 72
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 14 of 27 PAGEID #: 73

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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 15 of 27 PAGEID #: 74

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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 16 of 27 PAGEID #: 75

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

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 22 of 27 PAGEID #: 81

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).

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 23 of 27 PAGEID #: 82

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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 24 of 27 PAGEID #: 83
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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 25 of 27 PAGEID #: 84

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

-'"'

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 26 of 27 PAGEID #: 85

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
-2-

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?
-5-

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.]
12

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
13

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.
14

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.
15

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.
16

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
17

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.
18

Case: 2:08-cv-00475-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 21 of 26 PAGEID #: 1811
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.
19

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).
20

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.
21

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.
22

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

23

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.

24

 
 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."
2

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

Case: 2:08-cv-00475-ALM-MRA Doc #: 81 Filed: 06/06/11 Page: 4 of 6 PAGEID #: 1777
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.
-2-

Case: 2:08-cv-00475-ALM -MRA Doc #: 42 Filed: 06/04/10 Page: 3 of 7 PAGEID #: 382
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.
-3-

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
-4-

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.)
-5-

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
-7-

Case: 2:08-cv-00475-ALM -MRA Doc #: 42-1 Filed: 06/04/10 Page: 1 of 1 PAGEID #: 387

Case: 2:08-cv-00475-ALM -MRA Doc #: 42-2 Filed: 06/04/10 Page: 1 of 1 PAGEID #: 388

Case: 2:08-cv-00475-ALM -MRA Doc #: 42-3 Filed: 06/04/10 Page: 1 of 1 PAGEID #: 389

Case: 2:08-cv-00475-ALM -MRA Doc #: 42-4 Filed: 06/04/10 Page: 1 of 1 PAGEID #: 390

Case: 2:08-cv-00475-ALM -MRA Doc #: 42-5 Filed: 06/04/10 Page: 1 of 1 PAGEID #: 391

 
 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

-2-

 
 Case: 2:08-cv-00475-ALM-MRA Doc #: 61 Filed: 09/20/10 Page: 1 of 2 PAGEID #: 758

Case: 2:08-cv-00475-ALM-MRA Doc #: 61 Filed: 09/20/10 Page: 2 of 2 PAGEID #: 759

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 1 of 31 PAGEID #: 760

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 2 of 31 PAGEID #: 761

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 3 of 31 PAGEID #: 762

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 4 of 31 PAGEID #: 763

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 5 of 31 PAGEID #: 764

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 6 of 31 PAGEID #: 765

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 7 of 31 PAGEID #: 766

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 8 of 31 PAGEID #: 767

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 9 of 31 PAGEID #: 768

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 10 of 31 PAGEID #: 769

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 11 of 31 PAGEID #: 770

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 12 of 31 PAGEID #: 771

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 13 of 31 PAGEID #: 772

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 14 of 31 PAGEID #: 773

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 15 of 31 PAGEID #: 774

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 16 of 31 PAGEID #: 775

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 17 of 31 PAGEID #: 776

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 18 of 31 PAGEID #: 777

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 19 of 31 PAGEID #: 778

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 20 of 31 PAGEID #: 779

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 21 of 31 PAGEID #: 780

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 22 of 31 PAGEID #: 781

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 23 of 31 PAGEID #: 782

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 24 of 31 PAGEID #: 783

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 25 of 31 PAGEID #: 784

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 26 of 31 PAGEID #: 785

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 27 of 31 PAGEID #: 786

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 28 of 31 PAGEID #: 787

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 29 of 31 PAGEID #: 788

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 30 of 31 PAGEID #: 789

Case: 2:08-cv-00475-ALM-MRA Doc #: 61-1 Filed: 09/20/10 Page: 31 of 31 PAGEID #: 790

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 1 of 41 PAGEID #: 791

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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 3 of 41 PAGEID #: 793
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.

USDOJ v The State of Ohio

Protection From Harm Compliance Report 3.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 4 of 41 PAGEID #: 794

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 4.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 5 of 41 PAGEID #: 795

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.

USDOJ v The State of Ohio

Protection From Harm Compliance Report 5.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 6 of 41 PAGEID #: 796

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.

USDOJ v The State of Ohio

Protection From Harm Compliance Report 6.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 7 of 41 PAGEID #: 797

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 7.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 8 of 41 PAGEID #: 798

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 8.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 9 of 41 PAGEID #: 799

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.

USDOJ v The State of Ohio

Protection From Harm Compliance Report 9.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 10 of 41 PAGEID #: 800

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‐

USDOJ v The State of Ohio

Protection From Harm Compliance Report 10.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 11 of 41 PAGEID #: 801
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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 11.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 12 of 41 PAGEID #: 802

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 12.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 13 of 41 PAGEID #: 803

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 13.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 14 of 41 PAGEID #: 804
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.

USDOJ v The State of Ohio

Protection From Harm Compliance Report 14.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 15 of 41 PAGEID #: 805

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 15.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 16 of 41 PAGEID #: 806

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 16.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 17 of 41 PAGEID #: 807

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 17.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 18 of 41 PAGEID #: 808

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 18.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 19 of 41 PAGEID #: 809

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.

USDOJ v The State of Ohio

Protection From Harm Compliance Report 19.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 20 of 41 PAGEID #: 810

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 20.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 21 of 41 PAGEID #: 811

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);

USDOJ v The State of Ohio

Protection From Harm Compliance Report 21.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 22 of 41 PAGEID #: 812

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 22.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 23 of 41 PAGEID #: 813

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 23.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 24 of 41 PAGEID #: 814

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 24.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 25 of 41 PAGEID #: 815

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)

USDOJ v The State of Ohio

Protection From Harm Compliance Report 25.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 26 of 41 PAGEID #: 816

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 26.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 27 of 41 PAGEID #: 817

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 27.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 28 of 41 PAGEID #: 818

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 28.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 29 of 41 PAGEID #: 819

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 29.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 30 of 41 PAGEID #: 820

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 30.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 31 of 41 PAGEID #: 821

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 31.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 32 of 41 PAGEID #: 822

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 32.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 33 of 41 PAGEID #: 823

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 33.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 34 of 41 PAGEID #: 824
“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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 34.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 35 of 41 PAGEID #: 825

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.

USDOJ v The State of Ohio

Protection From Harm Compliance Report 35.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 36 of 41 PAGEID #: 826

 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,

USDOJ v The State of Ohio

Protection From Harm Compliance Report 36.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 37 of 41 PAGEID #: 827

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 37.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 38 of 41 PAGEID #: 828

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 38.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 39 of 41 PAGEID #: 829

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 39.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 40 of 41 PAGEID #: 830

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 40.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 41 of 41 PAGEID #: 831
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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 41.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62-1 Filed: 09/21/10 Page: 1 of 18 PAGEID #: 832
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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62-1 Filed: 09/21/10 Page: 2 of 18 PAGEID #: 833
Scioto Special Education Page 2 of 18
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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62-1 Filed: 09/21/10 Page: 3 of 18 PAGEID #: 834
Scioto Special Education Page 3 of 18

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

Case: 2:08-cv-00475-ALM-MRA Doc #: 62-1 Filed: 09/21/10 Page: 4 of 18 PAGEID #: 835
Scioto Special Education Page 4 of 18
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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62-1 Filed: 09/21/10 Page: 5 of 18 PAGEID #: 836
Scioto Special Education Page 5 of 18

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/

Case: 2:08-cv-00475-ALM-MRA Doc #: 62-1 Filed: 09/21/10 Page: 6 of 18 PAGEID #: 837
Scioto Special Education Page 6 of 18
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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62-1 Filed: 09/21/10 Page: 7 of 18 PAGEID #: 838
Scioto Special Education Page 7 of 18
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 62-1 Filed: 09/21/10 Page: 8 of 18 PAGEID #: 839
Scioto Special Education Page 8 of 18
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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62-1 Filed: 09/21/10 Page: 9 of 18 PAGEID #: 840
Scioto Special Education Page 9 of 18
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,

Case: 2:08-cv-00475-ALM-MRA Doc #: 62-1 Filed: 09/21/10 Page: 10 of 18 PAGEID #: 841
Scioto Special Education Page 10 of 18
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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62-1 Filed: 09/21/10 Page: 11 of 18 PAGEID #: 842
Scioto Special Education Page 11 of 18

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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62-1 Filed: 09/21/10 Page: 12 of 18 PAGEID #: 843
Scioto Special Education Page 12 of 18
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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62-1 Filed: 09/21/10 Page: 13 of 18 PAGEID #: 844
Scioto Special Education Page 13 of 18
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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62-1 Filed: 09/21/10 Page: 14 of 18 PAGEID #: 845
Scioto Special Education Page 14 of 18
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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62-1 Filed: 09/21/10 Page: 15 of 18 PAGEID #: 846
Scioto Special Education Page 15 of 18
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 62-1 Filed: 09/21/10 Page: 16 of 18 PAGEID #: 847
Scioto Special Education Page 16 of 18

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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62-1 Filed: 09/21/10 Page: 17 of 18 PAGEID #: 848
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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62-1 Filed: 09/21/10 Page: 18 of 18 PAGEID #: 849
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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 2 of 57 PAGEID #: 880
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 3 of 57 PAGEID #: 881
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 4 of 57 PAGEID #: 882
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 5 of 57 PAGEID #: 883
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 6 of 57 PAGEID #: 884
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 7 of 57 PAGEID #: 885
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 8 of 57 PAGEID #: 886
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 9 of 57 PAGEID #: 887
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 10 of 57 PAGEID #: 888
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 11 of 57 PAGEID #: 889
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 12 of 57 PAGEID #: 890
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 13 of 57 PAGEID #: 891
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 14 of 57 PAGEID #: 892
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 15 of 57 PAGEID #: 893
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
15

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 16 of 57 PAGEID #: 894
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.
16

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 17 of 57 PAGEID #: 895
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
17

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 18 of 57 PAGEID #: 896
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
18

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 19 of 57 PAGEID #: 897
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
19

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 20 of 57 PAGEID #: 898
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
20

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 21 of 57 PAGEID #: 899
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
21

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 22 of 57 PAGEID #: 900
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.
22

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 23 of 57 PAGEID #: 901
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 24 of 57 PAGEID #: 902
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.”
24

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 25 of 57 PAGEID #: 903
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.
25

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 26 of 57 PAGEID #: 904
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.
26

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 27 of 57 PAGEID #: 905
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.
27

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 28 of 57 PAGEID #: 906
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.
28

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 29 of 57 PAGEID #: 907
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.
29

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 30 of 57 PAGEID #: 908
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.
30

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 31 of 57 PAGEID #: 909
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.”
31

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 32 of 57 PAGEID #: 910
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
32

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 33 of 57 PAGEID #: 911
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.
33

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 34 of 57 PAGEID #: 912
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
34

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 35 of 57 PAGEID #: 913
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.”
35

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 36 of 57 PAGEID #: 914
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.
36

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 37 of 57 PAGEID #: 915
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
37

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 38 of 57 PAGEID #: 916
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
38

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 39 of 57 PAGEID #: 917
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
39

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 40 of 57 PAGEID #: 918
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:
40

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 41 of 57 PAGEID #: 919
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
41

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 42 of 57 PAGEID #: 920
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
42

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 43 of 57 PAGEID #: 921
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
43

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 44 of 57 PAGEID #: 922
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 45 of 57 PAGEID #: 923
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.
45

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 46 of 57 PAGEID #: 924
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
46

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 47 of 57 PAGEID #: 925
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)
47

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 48 of 57 PAGEID #: 926
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,
48

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 49 of 57 PAGEID #: 927
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.
49

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 50 of 57 PAGEID #: 928
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.
50

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 51 of 57 PAGEID #: 929
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
51

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 52 of 57 PAGEID #: 930
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).
52

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 53 of 57 PAGEID #: 931
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
53

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 54 of 57 PAGEID #: 932
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
54

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 55 of 57 PAGEID #: 933
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
55

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 56 of 57 PAGEID #: 934
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).
56

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 57 of 57 PAGEID #: 935

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

57

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 1 of 39 PAGEID #: 936

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 2 of 39 PAGEID #: 937

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 3 of 39 PAGEID #: 938

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 4 of 39 PAGEID #: 939

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 5 of 39 PAGEID #: 940

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 6 of 39 PAGEID #: 941

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 7 of 39 PAGEID #: 942

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 8 of 39 PAGEID #: 943

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 9 of 39 PAGEID #: 944

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 10 of 39 PAGEID #: 945

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 11 of 39 PAGEID #: 946

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 12 of 39 PAGEID #: 947

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 13 of 39 PAGEID #: 948

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 14 of 39 PAGEID #: 949

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 15 of 39 PAGEID #: 950

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 16 of 39 PAGEID #: 951

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 17 of 39 PAGEID #: 952

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 18 of 39 PAGEID #: 953

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 19 of 39 PAGEID #: 954

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 20 of 39 PAGEID #: 955

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 21 of 39 PAGEID #: 956

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 22 of 39 PAGEID #: 957

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 23 of 39 PAGEID #: 958

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 24 of 39 PAGEID #: 959

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 25 of 39 PAGEID #: 960

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 26 of 39 PAGEID #: 961

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 27 of 39 PAGEID #: 962

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 28 of 39 PAGEID #: 963

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 29 of 39 PAGEID #: 964

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 30 of 39 PAGEID #: 965

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 31 of 39 PAGEID #: 966

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 32 of 39 PAGEID #: 967

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 33 of 39 PAGEID #: 968

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 34 of 39 PAGEID #: 969

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 35 of 39 PAGEID #: 970

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 36 of 39 PAGEID #: 971

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 37 of 39 PAGEID #: 972

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 38 of 39 PAGEID #: 973

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-2 Filed: 02/08/11 Page: 39 of 39 PAGEID #: 974

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 1 of 25 PAGEID #: 975

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 2 of 25 PAGEID #: 976

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 3 of 25 PAGEID #: 977

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 4 of 25 PAGEID #: 978

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 5 of 25 PAGEID #: 979

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 6 of 25 PAGEID #: 980

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 7 of 25 PAGEID #: 981

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 8 of 25 PAGEID #: 982

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 9 of 25 PAGEID #: 983

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 10 of 25 PAGEID #: 984

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 11 of 25 PAGEID #: 985

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 12 of 25 PAGEID #: 986

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 13 of 25 PAGEID #: 987

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 14 of 25 PAGEID #: 988

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 15 of 25 PAGEID #: 989

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 16 of 25 PAGEID #: 990

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 17 of 25 PAGEID #: 991

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 18 of 25 PAGEID #: 992

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 19 of 25 PAGEID #: 993

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 20 of 25 PAGEID #: 994

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 21 of 25 PAGEID #: 995

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 22 of 25 PAGEID #: 996

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 23 of 25 PAGEID #: 997

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 24 of 25 PAGEID #: 998

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-3 Filed: 02/08/11 Page: 25 of 25 PAGEID #: 999

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-4 Filed: 02/08/11 Page: 1 of 15 PAGEID #: 1000

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-4 Filed: 02/08/11 Page: 2 of 15 PAGEID #: 1001

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-4 Filed: 02/08/11 Page: 3 of 15 PAGEID #: 1002

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-4 Filed: 02/08/11 Page: 4 of 15 PAGEID #: 1003

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-4 Filed: 02/08/11 Page: 5 of 15 PAGEID #: 1004

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-4 Filed: 02/08/11 Page: 6 of 15 PAGEID #: 1005

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-4 Filed: 02/08/11 Page: 7 of 15 PAGEID #: 1006

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-4 Filed: 02/08/11 Page: 8 of 15 PAGEID #: 1007

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-4 Filed: 02/08/11 Page: 9 of 15 PAGEID #: 1008

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-4 Filed: 02/08/11 Page: 10 of 15 PAGEID #: 1009

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-4 Filed: 02/08/11 Page: 11 of 15 PAGEID #: 1010

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-4 Filed: 02/08/11 Page: 12 of 15 PAGEID #: 1011

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-4 Filed: 02/08/11 Page: 13 of 15 PAGEID #: 1012

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-4 Filed: 02/08/11 Page: 14 of 15 PAGEID #: 1013

Case: 2:08-cv-00475-ALM-MRA Doc #: 72-4 Filed: 02/08/11 Page: 15 of 15 PAGEID #: 1014

 
 Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 1 of 37 PAGEID #: 1021

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

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 2 of 37 PAGEID #: 1022
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.
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 3 of 37 PAGEID #: 1023
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 4 of 37 PAGEID #: 1024
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.
4

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 5 of 37 PAGEID #: 1025
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.
5

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 6 of 37 PAGEID #: 1026
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.
6

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 7 of 37 PAGEID #: 1027
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
7

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 8 of 37 PAGEID #: 1028
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.
8

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 9 of 37 PAGEID #: 1029
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
9

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 10 of 37 PAGEID #: 1030
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
10

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 11 of 37 PAGEID #: 1031
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).
11

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 12 of 37 PAGEID #: 1032
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.
12

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 13 of 37 PAGEID #: 1033
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
13

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 14 of 37 PAGEID #: 1034
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.
14

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 15 of 37 PAGEID #: 1035
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
15

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 16 of 37 PAGEID #: 1036
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.
16

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 17 of 37 PAGEID #: 1037
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.”
17

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 18 of 37 PAGEID #: 1038
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
18

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 19 of 37 PAGEID #: 1039
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.
19

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 20 of 37 PAGEID #: 1040
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
20

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 21 of 37 PAGEID #: 1041
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.
21

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 22 of 37 PAGEID #: 1042
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
22

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 23 of 37 PAGEID #: 1043
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
23

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 24 of 37 PAGEID #: 1044
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.”
24

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 25 of 37 PAGEID #: 1045
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
25

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 26 of 37 PAGEID #: 1046
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,
26

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 27 of 37 PAGEID #: 1047
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.
27

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 28 of 37 PAGEID #: 1048
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
28

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 29 of 37 PAGEID #: 1049
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
29

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 30 of 37 PAGEID #: 1050
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
30

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 31 of 37 PAGEID #: 1051
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
31

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 32 of 37 PAGEID #: 1052
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.
32

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 33 of 37 PAGEID #: 1053
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.
33

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 34 of 37 PAGEID #: 1054
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
34

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 35 of 37 PAGEID #: 1055
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.
35

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 36 of 37 PAGEID #: 1056
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.
36

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-1 Filed: 02/16/11 Page: 37 of 37 PAGEID #: 1057
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
37

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 1 of 39 PAGEID #: 1058
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
1

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.
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 4 of 39 PAGEID #: 1061

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)
3

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 5 of 39 PAGEID #: 1062

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.

4

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 6 of 39 PAGEID #: 1063

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

5

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 7 of 39 PAGEID #: 1064

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
6

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 8 of 39 PAGEID #: 1065

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)

7

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 9 of 39 PAGEID #: 1066

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.”

8

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 10 of 39 PAGEID #: 1067

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

9

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 11 of 39 PAGEID #: 1068

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
10

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 12 of 39 PAGEID #: 1069
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
11

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 13 of 39 PAGEID #: 1070

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

12

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 14 of 39 PAGEID #: 1071

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)

13

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 15 of 39 PAGEID #: 1072

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
14

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 16 of 39 PAGEID #: 1073
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
15

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 17 of 39 PAGEID #: 1074 progress and the updating of goals and objectives.

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).

16

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 18 of 39 PAGEID #: 1075

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
17

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 19 of 39 PAGEID #: 1076

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

18

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 20 of 39 PAGEID #: 1077

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
19

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 21 of 39 PAGEID #: 1078

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

20

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 22 of 39 PAGEID #: 1079

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
21

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 23 of 39 PAGEID #: 1080

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

22

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 24 of 39 PAGEID #: 1081

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
23

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 25 of 39 PAGEID #: 1082

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

24

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 26 of 39 PAGEID #: 1083

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
25

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 27 of 39 PAGEID #: 1084

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

26

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 28 of 39 PAGEID #: 1085

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
27

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 29 of 39 PAGEID #: 1086
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
28

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 30 of 39 PAGEID #: 1087

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

29

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 31 of 39 PAGEID #: 1088

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
30

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 32 of 39 PAGEID #: 1089

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

31

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 33 of 39 PAGEID #: 1090

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
32

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 34 of 39 PAGEID #: 1091

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

33

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 35 of 39 PAGEID #: 1092

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

34

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 36 of 39 PAGEID #: 1093

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
35

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 37 of 39 PAGEID #: 1094

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

36

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 38 of 39 PAGEID #: 1095

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
37

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 39 of 39 PAGEID #: 1096

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

38

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 1 of 22 PAGEID #: 1097

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 2 of 22 PAGEID #: 1098

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 3 of 22 PAGEID #: 1099

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 4 of 22 PAGEID #: 1100

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 5 of 22 PAGEID #: 1101

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 6 of 22 PAGEID #: 1102

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 7 of 22 PAGEID #: 1103

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 8 of 22 PAGEID #: 1104

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 9 of 22 PAGEID #: 1105

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 10 of 22 PAGEID #: 1106

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 11 of 22 PAGEID #: 1107

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 12 of 22 PAGEID #: 1108

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 13 of 22 PAGEID #: 1109

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 14 of 22 PAGEID #: 1110

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 15 of 22 PAGEID #: 1111

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 16 of 22 PAGEID #: 1112

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 17 of 22 PAGEID #: 1113

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 18 of 22 PAGEID #: 1114

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 19 of 22 PAGEID #: 1115

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 20 of 22 PAGEID #: 1116

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 21 of 22 PAGEID #: 1117

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-3 Filed: 02/16/11 Page: 22 of 22 PAGEID #: 1118

 
 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.
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 3 of 88 PAGEID #: 1569

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)

3

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 4 of 88 PAGEID #: 1570
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
4

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 5 of 88 PAGEID #: 1571
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.
5

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 6 of 88 PAGEID #: 1572
• 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
6

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 7 of 88 PAGEID #: 1573
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
7

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 8 of 88 PAGEID #: 1574
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)
8

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 9 of 88 PAGEID #: 1575
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
9

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 10 of 88 PAGEID #: 1576
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
10

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 11 of 88 PAGEID #: 1577
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
11

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 12 of 88 PAGEID #: 1578
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
12

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 13 of 88 PAGEID #: 1579
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.
13

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 14 of 88 PAGEID #: 1580
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.
14

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 15 of 88 PAGEID #: 1581
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
15

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 16 of 88 PAGEID #: 1582
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.”)).
16

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 17 of 88 PAGEID #: 1583
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
17

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 18 of 88 PAGEID #: 1584
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,
18

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 19 of 88 PAGEID #: 1585
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,
19

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 20 of 88 PAGEID #: 1586
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).
20

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 21 of 88 PAGEID #: 1587
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.
21

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 22 of 88 PAGEID #: 1588
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
22

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 23 of 88 PAGEID #: 1589
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
23

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 24 of 88 PAGEID #: 1590
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
24

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 25 of 88 PAGEID #: 1591
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.
25

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 26 of 88 PAGEID #: 1592
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:
26

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 27 of 88 PAGEID #: 1593
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
27

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 28 of 88 PAGEID #: 1594
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
28

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 29 of 88 PAGEID #: 1595
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
29

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 30 of 88 PAGEID #: 1596
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
30

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 31 of 88 PAGEID #: 1597
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
31

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 32 of 88 PAGEID #: 1598
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.
32

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 33 of 88 PAGEID #: 1599
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
33

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 34 of 88 PAGEID #: 1600
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”).
34

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 35 of 88 PAGEID #: 1601
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
35

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 36 of 88 PAGEID #: 1602
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
36

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 37 of 88 PAGEID #: 1603
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 38 of 88 PAGEID #: 1604
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
38

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 39 of 88 PAGEID #: 1605
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:
39

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 40 of 88 PAGEID #: 1606
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
40

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 41 of 88 PAGEID #: 1607
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
41

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 42 of 88 PAGEID #: 1608
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.
42

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 43 of 88 PAGEID #: 1609
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.
43

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 44 of 88 PAGEID #: 1610
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,
44

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 45 of 88 PAGEID #: 1611
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).
45

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 46 of 88 PAGEID #: 1612
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
46

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 47 of 88 PAGEID #: 1613
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
47

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 48 of 88 PAGEID #: 1614
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.
48

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 49 of 88 PAGEID #: 1615
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.
49

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 50 of 88 PAGEID #: 1616
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).
50

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 51 of 88 PAGEID #: 1617
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.
51

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 52 of 88 PAGEID #: 1618
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.
52

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 53 of 88 PAGEID #: 1619
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
53

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 54 of 88 PAGEID #: 1620
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
54

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 55 of 88 PAGEID #: 1621
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
55

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 56 of 88 PAGEID #: 1622
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.
56

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 57 of 88 PAGEID #: 1623
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
57

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 58 of 88 PAGEID #: 1624
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.
58

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 59 of 88 PAGEID #: 1625
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
59

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 60 of 88 PAGEID #: 1626
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
60

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 61 of 88 PAGEID #: 1627
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
61

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 62 of 88 PAGEID #: 1628
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
62

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 63 of 88 PAGEID #: 1629
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.
63

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 64 of 88 PAGEID #: 1630
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.
64

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 65 of 88 PAGEID #: 1631
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
65

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 66 of 88 PAGEID #: 1632
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)
66

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 67 of 88 PAGEID #: 1633
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.
67

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 68 of 88 PAGEID #: 1634
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.
68

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 69 of 88 PAGEID #: 1635
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
69

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 70 of 88 PAGEID #: 1636
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
70

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 71 of 88 PAGEID #: 1637
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
71

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 72 of 88 PAGEID #: 1638
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.
72

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 73 of 88 PAGEID #: 1639
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
73

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 74 of 88 PAGEID #: 1640
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.
Compliance Rating: Substantial Compliance 74

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 75 of 88 PAGEID #: 1641
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.
75

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 76 of 88 PAGEID #: 1642
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
76

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 77 of 88 PAGEID #: 1643
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
77

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 78 of 88 PAGEID #: 1644
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.
78

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 79 of 88 PAGEID #: 1645
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
79

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 80 of 88 PAGEID #: 1646
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
80

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 81 of 88 PAGEID #: 1647
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
81

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 82 of 88 PAGEID #: 1648
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))
82

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 83 of 88 PAGEID #: 1649
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
83

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 84 of 88 PAGEID #: 1650
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.
84

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 85 of 88 PAGEID #: 1651
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
85

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 86 of 88 PAGEID #: 1652
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
86

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 87 of 88 PAGEID #: 1653
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.
87

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 88 of 88 PAGEID #: 1654

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

88

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 1 of 24 PAGEID #: 1655
Attachment A

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 2 of 24 PAGEID #: 1656

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 1.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 3 of 24 PAGEID #: 1657

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.

USDOJ v The State of Ohio

Protection From Harm Compliance Report 2.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 4 of 24 PAGEID #: 1658
 “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.

USDOJ v The State of Ohio

Protection From Harm Compliance Report 3.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 5 of 24 PAGEID #: 1659

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 4.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 6 of 24 PAGEID #: 1660

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 5.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 7 of 24 PAGEID #: 1661

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,

USDOJ v The State of Ohio

Protection From Harm Compliance Report 6.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 8 of 24 PAGEID #: 1662

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 7.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 9 of 24 PAGEID #: 1663

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 8.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 10 of 24 PAGEID #: 1664

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 9.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 11 of 24 PAGEID #: 1665

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 10.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 12 of 24 PAGEID #: 1666

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 11.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 13 of 24 PAGEID #: 1667

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 12.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 14 of 24 PAGEID #: 1668

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 13.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 15 of 24 PAGEID #: 1669

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 14.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 16 of 24 PAGEID #: 1670

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 15.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 17 of 24 PAGEID #: 1671

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 16.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 18 of 24 PAGEID #: 1672

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.

USDOJ v The State of Ohio

Protection From Harm Compliance Report 17.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 19 of 24 PAGEID #: 1673

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 18.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 20 of 24 PAGEID #: 1674

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‐

USDOJ v The State of Ohio

Protection From Harm Compliance Report 19.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 21 of 24 PAGEID #: 1675

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 20.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 22 of 24 PAGEID #: 1676

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

USDOJ v The State of Ohio

Protection From Harm Compliance Report 21.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 23 of 24 PAGEID #: 1677

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

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-3 Filed: 05/09/11 Page: 2 of 16 PAGEID #: 1680
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
1.

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.
2.

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.
3.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-3 Filed: 05/09/11 Page: 5 of 16 PAGEID #: 1683

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.

4.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-3 Filed: 05/09/11 Page: 6 of 16 PAGEID #: 1684

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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-3 Filed: 05/09/11 Page: 7 of 16 PAGEID #: 1685

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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-3 Filed: 05/09/11 Page: 8 of 16 PAGEID #: 1686

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.

7.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-3 Filed: 05/09/11 Page: 9 of 16 PAGEID #: 1687

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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-3 Filed: 05/09/11 Page: 10 of 16 PAGEID #: 1688

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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-3 Filed: 05/09/11 Page: 11 of 16 PAGEID #: 1689

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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-3 Filed: 05/09/11 Page: 12 of 16 PAGEID #: 1690

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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-3 Filed: 05/09/11 Page: 13 of 16 PAGEID #: 1691

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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-3 Filed: 05/09/11 Page: 14 of 16 PAGEID #: 1692

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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-3 Filed: 05/09/11 Page: 15 of 16 PAGEID #: 1693

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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-3 Filed: 05/09/11 Page: 16 of 16 PAGEID #: 1694

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.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 1 of 49 PAGEID #: 1695
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 4 of 49 PAGEID #: 1698

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

2

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 5 of 49 PAGEID #: 1699

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
3

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 6 of 49 PAGEID #: 1700

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

4

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 7 of 49 PAGEID #: 1701

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.
5

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 8 of 49 PAGEID #: 1702

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

6

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 9 of 49 PAGEID #: 1703

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
7

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 10 of 49 PAGEID #: 1704

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

8

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 11 of 49 PAGEID #: 1705

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
9

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 12 of 49 PAGEID #: 1706
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
10

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 13 of 49 PAGEID #: 1707

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

11

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 14 of 49 PAGEID #: 1708

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)

12

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 15 of 49 PAGEID #: 1709

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.

13

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 16 of 49 PAGEID #: 1710

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
14

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 17 of 49 PAGEID #: 1711
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
15

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 18 of 49 PAGEID #: 1712
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”
16

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 19 of 49 PAGEID #: 1713

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

17

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 20 of 49 PAGEID #: 1714

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

18

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 21 of 49 PAGEID #: 1715

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,
19

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 22 of 49 PAGEID #: 1716

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

20

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 23 of 49 PAGEID #: 1717

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,
21

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 24 of 49 PAGEID #: 1718

“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

22

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 25 of 49 PAGEID #: 1719

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
23

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 26 of 49 PAGEID #: 1720

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

24

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 27 of 49 PAGEID #: 1721

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
25

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 28 of 49 PAGEID #: 1722

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

26

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 29 of 49 PAGEID #: 1723

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
27

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 30 of 49 PAGEID #: 1724

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

28

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 31 of 49 PAGEID #: 1725

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
29

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 32 of 49 PAGEID #: 1726
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
30

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 33 of 49 PAGEID #: 1727
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
31

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 34 of 49 PAGEID #: 1728
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
32

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 35 of 49 PAGEID #: 1729

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

33

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 36 of 49 PAGEID #: 1730

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
34

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 37 of 49 PAGEID #: 1731
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

35

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 38 of 49 PAGEID #: 1732

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
36

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 39 of 49 PAGEID #: 1733

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.

37

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 40 of 49 PAGEID #: 1734

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
38

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 41 of 49 PAGEID #: 1735

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

39

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 42 of 49 PAGEID #: 1736

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

40

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 43 of 49 PAGEID #: 1737

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
41

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 44 of 49 PAGEID #: 1738
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.
42

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 45 of 49 PAGEID #: 1739

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

43

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 46 of 49 PAGEID #: 1740

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
44

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 47 of 49 PAGEID #: 1741

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
45

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 48 of 49 PAGEID #: 1742
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
46

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 49 of 49 PAGEID #: 1743

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.

47

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-5 Filed: 05/09/11 Page: 1 of 11 PAGEID #: 1744
Attachment D

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-5 Filed: 05/09/11 Page: 2 of 11 PAGEID #: 1745
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-5 Filed: 05/09/11 Page: 3 of 11 PAGEID #: 1746
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.
1

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-5 Filed: 05/09/11 Page: 4 of 11 PAGEID #: 1747
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
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-5 Filed: 05/09/11 Page: 5 of 11 PAGEID #: 1748
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
3

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-5 Filed: 05/09/11 Page: 6 of 11 PAGEID #: 1749
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
4

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-5 Filed: 05/09/11 Page: 7 of 11 PAGEID #: 1750
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
5

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-5 Filed: 05/09/11 Page: 8 of 11 PAGEID #: 1751
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.
6

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-5 Filed: 05/09/11 Page: 9 of 11 PAGEID #: 1752
C.6 MEDICATION MANAGEMENT
The Facilities shall not discontinue a chronically ill youth’s usual medication for non-medical reasons, including that the medication is not on the Facilities’ formulary.
Medications were continued for youth with chronic medical conditions. Medication administration records were documented thoroughly that youth were receiving their medications. Progress notes documented treatment refusals made by youth. Chronically ill youth that arrive with medications at the facility are continued as ordered upon timely review by the facility physician. Prescriber’s orders for medications and medication administration records are complete and in all the youth health records. Medications are being administered and documented by nurses as ordered. Consents for psychotropic medications are present in the youth record where applicable. Hot weather precautions were included for youth on certain medications predisposing them to heat sensitivity. Abnormal Involuntary Movement Scale (AIMS) were also documented for youth on psychotropic medication.
Status: Maintained
C.7 DENTAL CARE
The Facilities shall ensure that: Dental restorative needs are listed on a dental treatment plan for the youth, tracked by the dental program, and treated on a timely basis consistent with generally accepted professional standards of care; b. Prosthetic dental services are provided based on need, as determined by the treating dentist, with appropriate consideration for the replacement or repair of missing front teeth, according to generally accepted professional standards of care; c. Youth experiencing dental pain are not denied adequate pain medication; d. Health records contain adequate documentation of all outside dental consults, including the clinical examination, treatment plan, procedures performed, orders for management after the procedures, and any follow-up appointment or plan; and e. Dental staffing is adequate to meet the restorative dental needs of the Facilities’ populations.
Statistical data for dental services was provided for review. The dental hygienist works up to 16 hours/week and averaged 1-2 dental prophylaxis/hour. The dentist and dental assistant work up to 30 hours/week and completed an average of 97 examinations and 34 restorations per month. Dental staffing appears to be adequate; however, there was a downward trend in the number of youth examined between September and December 2010 compared to the previous months of the year. Each youth examined received 3-4 dental x-rays each. Appropriately, far more restorations were completed than extractions. There was documentation in the health record that youth were receiving sealants, appropriate dental referrals were being made and dental prostheses (night guards) were being provided. Youth experiencing dental pain were seen by the nurse and given pain medication until seen by the dentist, usually the
7

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-5 Filed: 05/09/11 Page: 10 of 11 PAGEID #: 1753
following day. One youth, NH, had more than one sick call request complaining of dental pain. The nurse documented in the progress note that the youth had admitted that she had seen the dentist, but refused to get fillings because she was afraid of needles.
Status: Improved
C.8 MANAGEMENT OF CHRONIC ILLNESSES
The Facilities shall ensure that: a. Chronic disease policies, protocols, and practices are appropriate for chronically ill adolescents; b. Youth with chronic asthma are continued on their established medicines on admission unless the youth’s condition warrants a change in treatment; and c. Youth who frequently use rescue inhalers are appropriately monitored and treated by physicians to minimize preventable asthma hospitalization resulting from acute respiratory crisis that follows an inadequately treated exacerbation of chronic asthma.
Cases of youth were identified and treated appropriately for hypertension, seizure disorder, hypothyroidism, renal disease, asthma, hepatitis C, latent tuberculosis, and a cardiac condition. Health records were also reviewed for the care and treatment of two pregnant females. One pregnant girl’s care was particularly a challenge due to additional diagnoses of hypertension, renal disease and asthma. Prenatal care was provided using the community standard of care (ACOG). The youth with hepatitis C received extensive education on her disease, liver ultrasound studies, appropriate laboratory tests and immunizations. There were four youth whose records indicated a history of Asthma. Three of the cases were mild and only required use of an inhaler as needed. However, one of these youth did experience an exercise induced asthma attack and required use of the inhaler imminently. KS’s medication order was changed to allow use of the inhaler prior to exercise. The other youth had severe persistent asthma with numerous past hospitalizations requiring multiple medications. This youth was well managed by the health care staff including continuing outside allergist consultation visits for Xolair medication injections. Excellent continuity of care occurred for youth with chronic diseases. Medical records from community providers were included in the health record as well as care plans documented for when youth were to be released back into the community.
Status: Maintained
C.9 ACCESS TO SPECIALTY CARE
Absent clinically justified rationale, the Facilities shall not withhold access to specialist services recommended by a treating physician and shall ensure that: prior approval of specialty medical consultations is made by a physician trained and qualified in pediatrics and adolescent medicine; and assessment
8

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-5 Filed: 05/09/11 Page: 11 of 11 PAGEID #: 1754
criteria for the necessity of specialty consultations are based on pediatric and adolescent medicine. Upon review of the heath record, youth continued to have access to specialty care. Referrals are being made appropriately by the facility pediatrician and family practice physician. Optometry care was provided and glasses purchased routinely when youth failed the vision screening. Youth received appropriate outside consultations with Nephrology, Cardiology, Neurology and Obstetrics specialists in the health records reviewed. Other diagnostic studies such as x-rays, ultrasounds, EKGs, and other studies were provided as appropriate. Status: Maintained
C.10 IMMUNIZATIONS The State shall make reasonable efforts to obtain immunization records for all youth who are detained at the facilities for more than one (1) month. The State shall ensure that medical staff update immunizations for such youth in accordance with nationally recognized guidelines and state school admission requirements. The physicians who determine that the vaccination of a youth is medically inappropriate shall properly record such determination in the youth’s medical record.
As in the previous health record review, youth in general were receiving appropriate immunizations including HPV and influenza vaccine. Immunization records were included in all 12 health records except one, where the youth had only recently been admitted to the facility. Only one youth, SM, was not brought current on her immunizations although her previous immunization records were in the health record. Immunization policies have not been updated. Status: Maintained in 11 of 12 health records
9

 
 Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 1 of 104 PAGEID #: 1864

	   	   	   	   	   	   	  

U.S.	  Department	  of	  Justice	  v.	  The	  State	  of	  Ohio	  

Civil	  Action	  No:	  2:08-­‐cv-­‐475	  

Monitor’s	  First	  Report	  on	  the	  Amended	  Stipulation	  dated	  June	  28,	  2011	  

	  

	  

	  

	  

	  

	  

	  

	  

	  

	  

	  

Kelly	  Dedel,	  Ph.D.,	  Lead	  Monitor	  

Daphne	  Glindmeyer,	  M.D.,	  Subject	  Matter	  Expert	  

Michelle	  Staples-­‐Horne,	  M.D.,	  Subject	  Matter	  Expert	  

	  

One	  in	  37	  Research,	  Inc.	  

1608	  NW	  Riverscape	  Street	  

Portland,	  OR	  	  97209	  

(503)799-­‐0915	  

kdedel@comcast.net	  

	  

	  

	  

Draft	  Submitted	  December	  2,	  2011	  

Final	  Submitted	  January	  23,	  2012	  

	  

	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 2 of 104 PAGEID #: 1865

TABLE	  OF	  CONTENTS	  
	   Introduction	.  ......................................................................................................................	3   	   Executive	  Summary	.  ...........................................................................................................	4   	  
Protection	  from	  Harm	  ..............................................................................................................	  9	   General	  Protection	  From	  Harm	 .  ...........................................................................................	  9	   Seclusion	.  ............................................................................................................................	 1  4	   Investigation	  of	  Serious	  Incidents	  ......................................................................................	 1  9	   Grievances	 .  .........................................................................................................................	 2  3	   Grievances	  Explained	  to	  Youth	.  ..........................................................................................	 2  5	   Structured	  Programming	.   ...................................................................................................	 2  6	   Orientation	 .  ........................................................................................................................	 3  0	  
	   Mental	  Health	  Services	.  .........................................................................................................	 3  3	  
Mental	  Health	  Screening	  ...................................................................................................	 3  3	   Immediate	  Referral	  to	  QMHP	 .  ...........................................................................................	 3  5	   Identification	  of	  Previously	  Unidentified	  Youth	.  ................................................................	 3  7	   Mental	  Health	  Assessment	 .  ...............................................................................................	 3  9	   Adequate	  Care	  and	  Treatment	 .  .........................................................................................	 4  3	   Treatment	  Planning	  ...........................................................................................................	 4  9	   Treatment	  Teams	.  ..............................................................................................................	 5  0	   Integrated	  Treatment	  Plans	.   ..............................................................................................	 5  4	   Access	  to	  QMHP	.  ................................................................................................................	 5  7	   Mental	  Health	  Involvement	  in	  Housing	  and	  Placement	 .  ...................................................	 5  9	   Staffing	.  ..............................................................................................................................	 6  2	   Medication	  Notice	  .............................................................................................................	 6  5	   Mental	  Health	  Medications	 .  ..............................................................................................	 6  7	   MH/DD	  Training	  for	  Direct	  Care	  Staff	 .  ...............................................................................	 7  2	   Staff	  Mental	  Health	  Training	.  .............................................................................................	 7  4	   Suicide	  Prevention	 .  ............................................................................................................	 7  7	   Transition	  Planning	 .  ...........................................................................................................	 8  1	   Oversight	  of	  Mental	  Health	  ...............................................................................................	 8  6	   Documentation	 .  .....................................................................................................................	 8  9	   Progress	  Notes	.   ..................................................................................................................	 8  9	   Accessibility	  of	  Information	 .  ..............................................................................................	 9  0	   	   Medical	  Services	  ....................................................................................................................	 9  1	   General	  Medical	  Care	  ........................................................................................................	 9  1	   Health	  Records	.  ..................................................................................................................	 9  4	   Access	  to	  Health	  Systems	  ..................................................................................................	 9  7	   	   Special	  Education	  Services	.  ....................................................................................................	 9  9	   Provision	  of	  Special	  Education	.   ..........................................................................................	 9  9	   Individual	  Education	  Plans	.   ..............................................................................................	 1  02	   Vocational	  Education	.   ......................................................................................................	 1  04	  

	  

2	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 3 of 104 PAGEID #: 1866

	  
INTRODUCTION	   	  

On	  June	  4,	  2008,	  The	  United	  States	  Department	  of	  Justice	  (DOJ)	  and	  the	  State	  of	  Ohio	  (the	  

State)	  signed	  a	  stipulation	  for	  injunctive	  relief	  (the	  Stipulation)	  concerning	  conditions	  at	  the	  

Scioto	  Juvenile	  Correctional	  Facility	  (Scioto)	  and	  the	  Marion	  Juvenile	  Correctional	  Facility	  

(Marion;	  which	  was	  closed	  shortly	  after	  the	  Stipulation	  was	  signed).	  Fred	  Cohen,	  the	  Lead	  

Monitor	  of	  the	  concurrent	  conditions	  of	  confinement	  lawsuit,	  S.H.	  v	  Stickrath	  et	  al.,	  served	  

as	  the	  monitor	  for	  the	  Stipulation	  until	  late	  2009.	  At	  that	  point,	  Mr.	  Cohen	  resigned	  and	  the	  

DOJ	  assumed	  the	  role	  of	  Monitor,	  with	  Dr.	  Kelly	  Dedel,	  Dr.	  Daphne	  Glindmeyer,	  and	  Dr.	  

Michelle	  Staples-­‐Horne	  serving	  as	  subject	  matter	  experts.	  	  

	  

As	  the	  original	  stipulation	  expired,	  the	  Parties	  recognized	  that	  the	  State	  had	  not	  yet	  reached	  

substantial	  compliance	  with	  several	  key	  portions	  of	  the	  Stipulation.	  Thus,	  the	  Stipulation	  

was	  renegotiated	  to	  include	  a	  subset	  of	  the	  original	  provisions.	  The	  Amended	  Stipulation	  

terminates	  when	  the	  State	  has	  achieved	  substantial	  compliance	  with	  each	  provision	  and	  has	  

maintained	  substantial	  compliance	  for	  two	  reporting	  periods	  (i.e.,	  12	  months).	  The	  Parties	  

also	  agreed	  that	  the	  Amended	  Stipulation	  is	  subject	  to	  the	  termination	  provisions	  of	  the	  

Prison	  Litigation	  Reform	  Act.	  	  

	  

The	  Monitor	  for	  the	  Amended	  Stipulation	  is	  Dr.	  Kelly	  Dedel,	  who	  evaluates	  the	  State’s	  

progress	  in	  the	  areas	  of	  Protection	  From	  Harm,	  Grievances,	  Programming	  and	  Special	  

Education.	  She	  is	  assisted	  by	  two	  Subject	  Matter	  Experts,	  Dr.	  Daphne	  Glindmeyer,	  who	  

evaluates	  the	  State’s	  progress	  on	  provisions	  related	  to	  Mental	  Health	  Services,	  and	  Dr.	  

Michelle	  Staples-­‐Horne,	  who	  evaluates	  the	  State’s	  progress	  on	  provisions	  related	  to	  Medical	  

Care.	  	  

	  

As	  the	  Monitor,	  Dr.	  Dedel	  is	  the	  primary	  liaison	  between	  the	  Monitoring	  Team	  and	  the	  

Parties	  and	  she	  compiles	  the	  Monitor’s	  Report.	  To	  do	  so,	  she	  combines	  Drs.	  Glindmeyer’s	  

and	  Staples-­‐Horne’s	  reports	  with	  her	  own	  to	  form	  a	  coherent	  whole,	  but	  does	  not	  change	  

the	  substance	  of	  the	  reports	  by	  either	  of	  the	  Subject	  Matter	  Experts,	  who	  are	  responsible	  

for	  forming	  their	  own	  opinions	  about	  the	  level	  of	  compliance	  for	  each	  provision	  in	  their	  

areas	  of	  expertise.	  	  

	  

This	  is	  the	  Monitor’s	  first	  report	  on	  the	  State’s	  progress	  toward	  the	  reforms	  required	  by	  the	  

Amended	  Stipulation.	  The	  monitoring	  period	  is	  June	  4,	  2011	  through	  October	  31,	  2011.	  

Progress	  reports	  will	  be	  issued	  approximately	  every	  six	  months	  hereafter.	  	  

	  

	  

	  

	  

3	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 4 of 104 PAGEID #: 1867

EXECUTIVE	  SUMMARY	  
	   The	  Amended	  Stipulation	  includes	  33	  provisions	  related	  to	  Protection	  From	  Harm	  (n=3);	   Grievances	  (n=2);	  Programming	  (n=2);	  Mental	  Health	  Care	  (n=18)	  and	  Documentation	  (n=2);	   Medical	  Care	  (n=3);	  and	  Special	  Education	  (n=3).	  Each	  provision	  is	  listed	  in	  the	  table	  below,	   along	  with	  the	  Monitor’s	  or	  Subject	  Matter	  Expert’s	  compliance	  rating.	  	   	   The	  following	  compliance	  ratings	  are	  used	  throughout	  this	  report:	   	  
• Substantial	  Compliance	  means	  that	  the	  facility	  has	  drafted	  relevant	  policies	  and	   procedures;	  has	  trained	  the	  staff	  responsible	  for	  implementation;	  has	  sufficient	  staff	   to	  implement	  the	  required	  reform;	  has	  demonstrated	  the	  ability	  to	  properly	   implement	  the	  procedures	  during	  the	  majority	  of	  the	  monitoring	  period;	  and	  has	   ascertained	  that	  the	  procedures	  accomplish	  the	  outcome	  envisioned	  by	  the	   provision.	  Non-­‐compliance	  with	  mere	  technicalities	  or	  a	  temporary	  failure	  to	  comply	   (due	  to	  staff	  vacancy	  or	  illness,	  facility	  disruptions,	  or	  other	  short-­‐term	  events)	   during	  an	  otherwise	  sustained	  period	  of	  compliance	  do	  not	  constitute	  a	  failure	  to	   achieve	  or	  maintain	  substantial	  compliance.	  Conversely,	  temporary	  compliance	   during	  a	  period	  of	  sustained	  non-­‐compliance	  does	  not	  constitute	  substantial	   compliance.	   	  
• Non-­‐Compliance	  means	  that	  the	  facility	  has	  not	  drafted	  relevant	  policies	  and	   procedures;	  and/or	  has	  not	  trained	  the	  staff	  responsible	  for	  implementation;	  and/or	   does	  not	  have	  sufficient	  staff	  to	  implement	  the	  required	  reform;	  and/or	  has	  not	   implemented	  the	  procedures	  over	  a	  significant	  period	  of	  time;	  and/or	  has	  not	  yet	   ascertained	  whether	  the	  procedures	  accomplish	  the	  outcome	  envisioned	  by	  the	   provision.	  
	   	   	   	  
Table	  1.	  Compliance	  Ratings	  for	  Each	  Provision	  

No	  

Provision	  

Rating	  

Protection	  From	  Harm	  

III.A.	  1	   General	  Protection	  From	  Harm	  

NC	  

III.A.3	  

Seclusion	  

NC	  

III.A.5	  

Investigation	  of	  Serious	  Incidents	  

SC	  

III.D.1	  

Grievances	  

NC	  

III.D.2	  

Grievances	  Explained	  to	  Youth	  

NC	  

III.F.1	  

Structured	  Programming	  

NC	  

III.F.2	  

Orientation	  

NC	  

	  

4	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 5 of 104 PAGEID #: 1868

Mental	  Health	  Services	  

III.B.1	  

Mental	  Health	  Screening	  

NC	  

III.B.2	  

Immediate	  Referral	  to	  QMHP	  

NC	  

III.B.3	  

Identification	  of	  Previously	  Unidentified	  Youth	  	  

NC	  

III.B.4	  

Mental	  Health	  Assessment	  

NC	  

III.B.5	  

Adequate	  Care	  and	  Treatment	  

NC	  

III.B.6	  

Treatment	  Planning	  

NC	  

III.B.7	  

Treatment	  Teams	  

NC	  

III.B.8	  

Integrated	  Treatment	  Plans	  

NC	  

III.B.9	  

Access	  to	  QMHP	  

NC	  

III.B.10	   Mental	  Health	  Involvement	  in	  Housing	  and	  Plcmt	  

NC	  

III.B.11	   Staffing	  

NC	  

III.B.12	   Medication	  Notice	  

NC	  

III.B.13	   Mental	  Health	  Medications	  

NC	  

III.B.14	   MH/DD	  Training	  for	  Direct	  Care	  Staff	  

NC	  

III.B.15	   Staff	  Mental	  Health	  Training	  

NC	  

III.B.16	   Suicide	  Prevention	  

NC	  

III.B.17	   Transition	  Planning	  

NC	  

III.B.18	   Oversight	  of	  Mental	  Health	  

NC	  

III.G.1	  

Progress	  Notes	  

NC	  

III.G.2	  

Accessibility	  of	  Information	  

NC	  

Medical	  Services	  

III.C.1	  

General	  Medical	  Care	  

SC	  

III.C.2	  

Health	  Records	  

SC	  

III.C.5	  

Access	  to	  Health	  Services	  

SC	  

Special	  Education	  Services	  

III.E.1	  

Provision	  of	  Special	  Education	  

NC	  

III.E.7	  

Individual	  Education	  Plans	  

NC	  

III.E.8	  

Vocational	  Education	  

NC	  

	   	   Overall,	  the	  State	  is	  in	  substantial	  compliance	  with	  4	  of	  the	  33	  provisions	  (15%).	  Compliance	   ratings	  for	  each	  section	  and	  key	  issues	  to	  be	  addressed	  are	  highlighted	  below.	  	  

	  

5	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 6 of 104 PAGEID #: 1869
	   Protection	  from	  Harm	  (includes	  Grievances	  and	  Programming)	   	   The	  facility	  is	  in	  substantial	  compliance	  with	  1	  of	  the	  7	  provisions	  (14%)	  related	  to	  protecting	   youth	  from	  harm.	  Two	  provisions,	  those	  related	  to	  the	  Grievance	  process,	  require	  only	  very	   minor	  actions	  to	  reach	  substantial	  compliance.	  More	  significant	  concerns	  plague	  the	  other	   provisions	  and	  the	  following	  actions	  should	  be	  prioritized:	   	  
• Determine	  the	  underlying	  causes	  of	  youth	  violence	  and	  enact	  targeted	  violence	   prevention	  strategies	  to	  reduce	  youth-­‐on-­‐youth	  and	  youth-­‐on-­‐staff	  assaults.	  	  
• Address	  the	  pattern	  of	  perceptions	  by	  female	  residents	  that	  some	  staff	  speak	  or	   behave	  in	  sexually	  inappropriate	  ways.	  Expand	  the	  dialog	  among	  administrators,	   girls	  and	  staff	  about	  this	  issue	  to	  ensure	  that	  the	  facility	  is	  aware	  of	  and	  addresses	  all	   such	  perceptions.	  	  
• Decrease	  the	  reliance	  on	  regular	  seclusion	  to	  respond	  to	  mid-­‐level,	  non-­‐violent	   misconduct.	  	  
• Address	  staff	  shortages	  to	  ensure	  sufficient	  personnel	  are	  available	  to	  provide	  youth	   with	  safe	  access	  to	  a	  full	  range	  of	  programming.	  	  
• Improve	  the	  quality	  of	  internal	  investigations.	  	   • Expand	  the	  PROGRESS	  Unit’s	  program	  design	  to	  ensure	  treatment	  plans	  and	  
treatment	  team	  meetings	  are	  focused	  around	  realistic,	  measurable	  goals	  and	  that	   data	  are	  routinely	  captured	  to	  assess	  youth	  progress	  and	  readiness	  to	  transition	  to	   the	  general	  population.	  	   • Ensure	  that	  youth	  admitted	  to	  the	  PROGRESS	  Unit	  receive	  a	  timely,	  comprehensive	   Orientation.	  	   • Ensure	  youth	  have	  access	  to	  a	  full	  range	  of	  structured	  programming	  so	  that	  idle	  time	   is	  kept	  to	  a	  minimum,	  particularly	  among	  youth	  who	  have	  graduated	  from	  high	   school	  or	  obtained	  a	  GED.	  	   	   	   Mental	  Health	  Services	   	   The	  facility	  is	  not	  in	  substantial	  compliance	  with	  any	  (0%)	  of	  the	  18	  provisions	  related	  to	   mental	  health	  services.	  The	  following	  actions	  are	  required:	   • Review	  and	  revise	  policies	  and	  procedures,	  as	  needed,	  to	  ensure	  they	  are	   compatible	  with	  the	  facility’s	  new	  mission	  as	  a	  long-­‐term	  placement.	   • Adequately	  staff	  the	  facility	  with	  qualified	  social	  workers,	  clinicians,	  psychiatrists	   and	  psychiatric	  nurses	  so	  that	  mental	  health	  treatment	  can	  be	  implemented	  to	  meet	   the	  needs	  of	  all	  youth.	  Increase	  psychiatry	  clinical	  resources.	  	   • Develop	  an	  organized	  training	  schedule	  for	  mental	  health	  staff.	  	   • Train	  direct	  care	  staff	  and	  mental	  health	  staff	  to	  understand	  the	  behavior	  and	  needs	   of	  youth	  with	  mental	  illnesses	  and	  developmental	  disabilities	  and	  recognize	  and	   respond	  to	  signs	  and	  symptoms	  of	  serious	  mental	  illness.	  	  

	  

6	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 7 of 104 PAGEID #: 1870

• Train	  mental	  health	  staff	  to	  develop	  high-­‐quality	  case	  conceptualizations	  that	   integrate	  the	  information	  generated	  by	  the	  multiple	  assessments	  administered	  to	   youth	  upon	  admission.	  	  
• Train,	  coach	  and	  adequately	  supervise	  direct	  care	  staff	  and	  mental	  health	  staff	  to	   implement	  the	  Phoenix	  New	  Freedom	  curriculum,	  particularly	  in	  skills	  for	  leading	   group	  therapy	  sessions	  to	  ensure	  the	  interactions	  and	  documentation	  reflect	   generally	  accepted	  practices	  for	  mental	  health	  care.	  	  
• Ensure	  all	  screenings	  are	  completed	  within	  24	  hours	  of	  the	  youth’s	  admission.	   • Provide	  a	  written	  rationale	  for	  all	  placement	  decisions	  by	  the	  Behavior	  Review	  
Panel.	  	   • Develop	  procedures	  to	  ensure,	  and	  to	  document,	  that	  youth	  are	  assessed	  by	  a	  
qualified	  mental	  health	  professional	  within	  12	  hours	  when	  a	  serious	  risk	  to	  the	   youth’s	  safety	  is	  identified.	  	   • Ensure	  mental	  health	  staff	  assesses	  youth	  on	  suicide	  precautions,	  those	  in	  seclusion,	   and	  those	  on	  the	  Progress	  Units	  every	  24	  hours.	  	   • Ensure	  youth	  with	  acute	  mental	  illnesses	  requiring	  extensive	  mental	  health	   treatment	  have	  access	  to	  more	  appropriate	  placements.	   • Ensure	  treatment	  plans	  are	  individualized	  including	  measurable	  goals	  and	  targeted	   interventions	  to	  address	  the	  goals.	  Update	  treatment	  plans	  regularly	  and	  monitor	   youth’s	  progress	  toward	  achieving	  treatment	  goals.	  Adapt	  treatment	  plans	  for	  youth	   who	  are	  not	  progressing.	   • Ensure	  Interdisciplinary	  Treatment	  Team	  meetings	  include	  representatives	  from	  the	   major	  sectors	  of	  the	  facility	  including	  social	  workers,	  direct	  care	  staff	  and	   psychiatrists	  and	  that	  Treatment	  Teams	  are	  focused	  on	  treatment	  issues	  and	  the	   youth’s	  progress	  toward	  treatment	  goals.	   • Ensure	  youth	  on	  the	  Progress	  Units	  are	  appropriate	  for	  the	  secure	  setting	  and	   receive	  appropriate	  treatment.	  Conduct	  thorough	  assessments	  of	  all	  youth	  currently	   housed	  on	  the	  Progress	  Units	  and	  those	  proposed	  for	  placement	  in	  the	  future.	  	   • Ensure	  youth	  receive	  proper	  laboratory	  examinations	  and	  side-­‐effect	  monitoring	   commensurate	  with	  the	  psychotropic	  medications	  prescribed	  and	  reflecting	   generally	  accepted	  practices.	  	   • Beginning	  at	  admission,	  hold	  structured	  discussions	  in	  Treatment	  Team	  meetings	   about	  discharge	  needs	  and	  appropriate	  community	  services.	  Ensure	  aftercare	   appointments	  and	  linkages	  are	  set	  up	  prior	  to	  youths’	  release	  from	  Scioto.	  	   • Develop	  a	  coherent,	  coordinated	  quality	  assurance	  process	  that	  provides	  a	  cogent	   review	  of	  social	  work,	  psychological	  and	  psychiatric	  services	  at	  the	  facility.	  	   	   	   Medical	  Services	   	   The	  facility	  is	  in	  substantial	  compliance	  with	  all	  3	  (100%)	  of	  the	  provisions	  related	  to	  medical	   services.	  The	  following	  suggestions	  are	  offered	  in	  the	  spirit	  of	  continually	  improving	  those	   services,	  and	  are	  discussed	  in	  greater	  detail	  under	  the	  relevant	  provision:	   • Expand	  the	  immunization	  program	  to	  Include	  Hepatitis	  A	  and	  HPV	  vaccinations	  of	   youth.	  	  

	  

7	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 8 of 104 PAGEID #: 1871

• Develop	  protocols	  for	  decontamination	  and	  medical	  assessment	  of	  youth	  after	   exposure	  to	  OC	  spray.	  	  
• Provide	  AEDs	  (Automated	  External	  Defibrillators)	  on	  site,	  train	  staff	  in	  its	  use	  and	   include	  them	  in	  the	  Emergency	  Medical	  Response	  and	  Services	  Policy.	  
• Improve	  completeness	  of	  youth	  Problem	  List	  in	  health	  record	  to	  include	  all	  chronic	   diagnoses,	  including	  mental	  health,	  substance	  abuse	  and	  acute	  diagnoses	  such	  as	   headache,	  shoulder	  pain,	  etc.	  
• Improve	  Quality	  Assurance	  (QA)	  activities	  by	  considering	  a	  review	  at	  least	  annually	   by	  a	  source	  external	  to	  ODYS	  Health	  Services.	  ODYS	  should	  also	  consider	  expansion	   of	  the	  QA	  process	  to	  include	  some	  additional	  quality	  indicators.	  
• Continue	  to	  improve	  process	  for	  sharing	  of	  health	  information	  between	  medical	  and	   mental	  health	  to	  include	  psychologists.	  Consider	  implementation	  of	  electronic	   health	  record	  or	  if	  not	  possible	  now,	  allow	  medical	  staff	  to	  access	  to	  the	  Mental	   Health	  database.	  
• Continue	  to	  review	  and	  update	  policies	  and	  procedures	  annually.	  Reduce	  length	  of	   policies	  and	  procedures	  and	  attempt	  to	  consolidate	  some.	  	  	  
• Encourage	  youth	  to	  complete	  Health	  Call	  forms	  in	  non-­‐emergency	  situations	  in	   order	  to	  fully	  document	  medical	  responses	  to	  youth	  requests.	  	  
	   	   Special	  Education	   	   The	  facility	  is	  not	  in	  substantial	  compliance	  with	  any	  of	  the	  3	  education-­‐related	  provisions	   (0%).	  The	  following	  actions	  should	  be	  prioritized:	  
• Improve	  the	  documentation	  of	  Unit	  Instruction	  and	  ascertain	  whether	  youth	  receive	   the	  required	  education	  services	  while	  serving	  time	  in	  disciplinary	  seclusion.	  	  
• Increase	  attendance	  rates	  among	  youth	  on	  the	  PROGRESS	  units.	  	   • Improve	  the	  quality	  of	  IEP	  progress	  reporting	  to	  ensure	  reports	  are	  grounded	  in	  data	  
that	  are	  responsive	  to	  a	  set	  of	  realistic,	  measurable	  IEP	  goals.	   • Develop	  sufficient	  vocational	  opportunities	  to	  meet	  the	  needs	  of	  the	  population	  of	  
Scioto	  students	  and	  graduates.	  	   	   	   	   The	  facility	  has	  undergone	  a	  massive	  transformation	  since	  the	  Stipulation	  was	  amended.	   Originally,	  Scioto	  was	  the	  central	  reception	  facility	  for	  all	  DYS	  facilities.	  In	  the	  summer	  of	   2011,	  DYS	  began	  to	  de-­‐centralize	  its	  reception	  process	  to	  convert	  Scioto	  to	  a	  long-­‐term	   facility	  that	  houses	  medium	  and	  close	  custody	  boys.	  Scioto	  remains	  the	  reception	  center	  for	   girls	  and	  also	  operates	  a	  long-­‐term	  girls’	  program	  and	  a	  mental	  health	  unit	  for	  girls.	  The	   facility	  has	  struggled	  mightily	  with	  these	  changes	  which	  is	  disheartening	  given	  the	  significant	   progress	  toward	  compliance	  with	  the	  Stipulation	  Scioto	  had	  made	  as	  a	  reception	  center.	   With	  the	  change	  in	  target	  population	  came	  a	  set	  of	  new	  problems,	  with	  different	  dynamics,	   and	  different	  solutions	  than	  the	  challenges	  that	  had	  been	  conquered	  in	  the	  past.	  Facility	   administrators	  and	  staff	  are	  commended	  for	  their	  adaptability	  and	  encouraged	  to	  apply	  the	   same	  level	  of	  problem	  solving	  and	  commitment	  to	  the	  new	  challenges	  they	  face.	  	  

	  

8	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 9 of 104 PAGEID #: 1872

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

Compliance	  Rating	   Non-­‐Compliance	  

Self	  Assessment	  

The	  State	  provided	  an	  array	  of	  data	  to	  illustrate	  the	  trends	  in	  youth	   violence,	  restraints,	  seclusion,	  and	  allegations	  of	  employee	   misconduct,	  along	  with	  an	  interpretation	  of	  the	  trends	  and	  the	   underlying	  causes	  of	  recent	  increases.	  While	  the	  interpretation	  of	   these	  data	  leads	  to	  significant	  concern	  for	  the	  safety	  of	  youth	  and	   staff	  at	  Scioto,	  the	  fact	  that	  the	  facility	  continues	  to	  be	  able	  to	  collect	   and	  analyze	  an	  array	  of	  data	  related	  to	  key	  indicators	  of	  youth	  safety	   is	  very	  positive.	  Without	  this	  capacity,	  the	  facility	  would	  be	  unable	  to	   craft	  new	  violence	  prevention	  initiatives	  to	  address	  the	  underlying	   causes	  of	  the	  youths’	  behavior.	  When	  the	  facility’s	  target	  population	   changed,	  so	  did	  the	  factors	  that	  contribute	  to	  youth	  violence.	  In	  the	   past,	  the	  facility	  clearly	  demonstrated	  its	  ability	  to	  analyze	  and	   respond	  to	  youth	  violence	  in	  its	  reception	  population.	  It	  must	  employ	   these	  same	  skills	  to	  its	  new	  population	  of	  long-­‐term	  residents.	  	  	   	   Trends	  in	  youth	  violence,	  restraints,	  and	  allegations	  of	  over-­‐ familiarization	  are	  discussed	  here,	  while	  detailed	  discussions	  about	   the	  use	  of	  seclusion	  and	  staff	  misconduct	  can	  be	  found	  in	  III.A.3	  and	   III.A.5	  respectively.	  	   	   Youth	  Violence	   Early	  in	  the	  monitoring	  period,	  youth	  violence	  was	  concentrated	  in	   two	  units:	  Jefferson	  (younger	  boys’	  reception)	  and	  Buckeye	  (boys’	   intensive	  mental	  health	  program).	  	  The	  State	  enacted	  a	  variety	  of	   violence	  prevention	  strategies	  and	  achieved	  significant	  reductions	  in	   the	  rates	  of	  youth	  violence	  by	  July	  2011.	  	   	   As	  noted	  in	  the	  Introduction,	  in	  late	  Summer	  2011,	  Scioto	  converted	   from	  a	  reception	  center	  and	  boys’	  mental	  health	  unit	  to	  a	  long-­‐term	   program.	  Scioto’s	  boys’	  program	  now	  includes	  general	  population	   housing	  for	  medium	  and	  close	  custody	  boys	  and	  a	  maximum-­‐security	   segregation	  unit.	  Scioto’s	  girls’	  program	  continues	  to	  include	   reception,	  general	  population	  and	  an	  intensive	  mental	  health	   program.	  With	  this	  conversion	  came	  rather	  immediate	  and	  significant	   increases	  in	  the	  rates	  of	  youth	  violence.	  In	  contrast	  to	  the	  previous	   eight	  months	  where	  the	  average	  rate	  of	  youth	  violence	  was	  .34,	  the	  

	  

9	  

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	  

	  

10	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 11 of 104 PAGEID #: 1874

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	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 12 of 104 PAGEID #: 1875

	   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	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 13 of 104 PAGEID #: 1876

Information	  
	   	   	  

interpretation	  for	  III.A.1,	  prepared	  at	  my	  request	   • Incident	  reports	  and	  youth	  interviews	  regarding	  Operation	  
Safety	  First,	  conducted	  in	  early	  October	  2011	   • Interviews	  with	  n=29	  youth	  housed	  on	  the	  PROGRESS	  units,	  
conducted	  by	  the	  Monitor	  and	  the	  DOJ	  attorney	  during	  two	   site	  visits	  in	  October	  2011	  
	  

	  

13	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 14 of 104 PAGEID #: 1877

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

Compliance	  Rating	   Non-­‐Compliance	  

Self	  Assessment	  

The	  State	  presented	  data	  on	  the	  use	  of	  seclusion	  across	  the	  previous	   nine	  months.	  	   	   Regular	  Seclusion	   Data	  on	  the	  use	  of	  regular	  seclusion	  (a	  period	  of	  isolation	  imposed	  by	   direct	  care	  staff	  in	  response	  to	  mid-­‐level,	  non-­‐violent	  misconduct)	   showed	  significant	  increases	  in	  both	  its	  use	  and	  duration	  beginning	  in	   August	  2011.	  The	  average	  number	  of	  seclusions	  from	  January	  to	  July	   was	  71.	  In	  August,	  the	  number	  of	  seclusions	  tripled	  to	  205,	  and	  then	   doubled	  again	  to	  430	  in	  September	  2011.	  These	  data	  reflect	  the	  high	   level	  of	  non-­‐violent	  (yet	  still	  concerning)	  behavior	  that	  accompanied	   the	  influx	  of	  long-­‐term,	  medium	  and	  close	  custody	  boys.	  Further,	  the	   duration	  of	  seclusion	  increased	  significantly.	  In	  the	  first	  seven	  months	   of	  2011,	  approximately	  85%	  of	  seclusions	  were	  4	  hours	  or	  less.	  In	   August	  and	  September,	  only	  about	  half	  were	  4	  hours	  or	  less,	  with	  the	   remainder	  anywhere	  between	  4	  and	  72	  hours.	  	   	   Pre-­‐Hearing	  Seclusion	   Data	  on	  the	  use	  of	  pre-­‐hearing	  seclusion	  (PHS;	  a	  period	  of	  isolation	   imposed	  following	  an	  act	  of	  violence,	  pending	  a	  disciplinary	  hearing)	   showed	  significant	  increases	  in	  the	  use	  of	  PHS	  in	  September	  2011,	   concurrent	  with	  the	  increase	  in	  youth-­‐on-­‐staff	  assaults	  discussed	  in	   III.A.1.	  Whereas	  the	  average	  number	  of	  PHSs	  in	  the	  preceding	  eight	   months	  was	  55,	  there	  were	  91	  PHSs	  in	  September	  2011.	  Over	  one-­‐ third	  of	  these	  lasted	  56	  hours	  or	  more	  (which	  makes	  sense	  given	  the	   high	  proportion	  of	  staff	  assaults	  after	  which,	  according	  to	  the	  IRAV	   policy,	  youth	  are	  not	  eligible	  for	  release	  from	  PHS	  pending	  the	   disciplinary	  hearing).	  In	  prior	  months,	  only	  about	  15%	  of	  youth	  who	   committed	  an	  act	  of	  violence	  were	  in	  PHS	  longer	  than	  56	  hours.	  	   	   Intervention	  Seclusion	   Intervention	  hearings	  are	  held	  to	  determine	  whether	  youth	  are	   culpable	  for	  serious	  misconduct	  and	  whether	  additional	  time	  in	   seclusion	  is	  warranted.	  Sometimes,	  youth	  are	  suspected	  of	  taking	  part	   in	  an	  act	  of	  group	  violence,	  but	  the	  subsequent	  investigation	  shows	   they	  were	  not	  involved.	  The	  hearing	  officer	  may	  also	  decide	  that	  a	   treatment-­‐related	  sanction,	  combined	  with	  the	  time	  already	  spent	  in	   PHS,	  is	  sufficient	  to	  address	  the	  youth’s	  behavior.	  In	  these	  cases,	   intervention	  seclusion	  is	  not	  used.	  The	  self-­‐assessment	  showed	  that	  

	  

14	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 15 of 104 PAGEID #: 1878

the	  proportion	  of	  youth	  receiving	  intervention	  seclusion	  is	  lower	  than	   that	  witnessed	  in	  previous	  months.	  In	  August	  and	  September,	  an	   average	  of	  35%	  of	  youth	  in	  PHS	  received	  intervention	  seclusion,	   compared	  to	  an	  average	  of	  57%	  in	  the	  previous	  seven	  months.	  This	   decrease	  reflects	  the	  dynamics	  of	  the	  disciplinary	  process,	  particularly	   for	  a	  group	  of	  youth	  who	  are	  relatively	  unfamiliar	  to	  staff.	  	   	   Overall,	  the	  total	  number	  of	  hours	  of	  seclusion	  utilized	  in	  the	  day-­‐to-­‐ day	  operation	  of	  the	  facility	  has	  increased	  significantly	  in	  recent	   months.	  In	  contrast	  to	  June	  and	  July	  2011,	  when	  the	  facility	  had	   begun	  to	  get	  a	  handle	  on	  the	  violent	  behavior	  of	  youth	  in	  the	   reception	  units,	  the	  total	  number	  of	  seclusion	  hours	  nearly	  doubled	  in	   August	  and	  September	  2011	  (5,428	  total	  hours	  in	  June	  and	  July	  versus	   10,074	  total	  hours	  in	  August	  and	  September).	  	  

Steps	  Taken	  to	   Assess	  Compliance	  

The	  data	  presented	  for	  the	  self-­‐assessment	  suggest	  that	  the	  use	  of	   seclusion	  has	  become	  a	  more	  central	  feature	  in	  the	  facility’s	  response	   to	  youth	  misconduct.	  The	  use	  of	  regular,	  pre-­‐hearing	  and	  intervention	   seclusion	  all	  increased	  significantly	  at	  the	  end	  of	  the	  monitoring	   period.	  In	  large	  part,	  these	  increases	  reflect	  the	  increase	  in	  youth	   violence	  at	  the	  facility	  and	  may	  have	  been	  an	  appropriate	  response	  in	   a	  crisis	  situation.	  Moving	  forward,	  as	  the	  staff	  become	  more	  familiar	   with	  the	  youth	  involved	  and	  the	  dynamics	  among	  groups	  of	  youth,	   staff	  should	  become	  able	  to	  respond	  to	  misconduct	  in	  a	  more	   productive,	  less	  punitive	  manner.	  	   	   In	  the	  past,	  a	  major	  concern	  related	  to	  the	  use	  of	  seclusion	  was	  the	   extent	  to	  which	  staff	  followed	  required	  procedures	  to	  mitigate	  the	   risk	  of	  self-­‐harm	  posed	  by	  youth	  confined	  to	  their	  rooms	  for	   disciplinary	  reasons.	  For	  several	  years,	  the	  administrative	  team	  has	   conducted	  random	  reviews	  of	  videotape	  footage	  to	  ensure	  that	  staff	   conduct	  the	  required	  safety	  and	  welfare	  checks.	  Over	  the	  past	  seven	   months,	  45	  reviews	  were	  conducted	  (about	  6	  per	  month).	  In	  about	   20%	  of	  these	  reviews,	  staff	  were	  cited	  for	  their	  failure	  to	  follow	  some	   aspect	  of	  the	  policy.	  In	  contrast	  to	  previous	  reviews,	  the	  severity	  of	   these	  policy	  violations	  has	  decreased	  with	  staff	  missing	  a	  very	  small	   number	  of	  checks	  during	  a	  shift,	  rather	  than	  failing	  to	  conduct	  safety	   checks	  during	  an	  entire	  shift.	  The	  facility’s	  continued	  vigilance	  and	   quality	  assurance	  efforts	  in	  this	  area	  offer	  a	  solid	  mechanism	  for	   protecting	  youth	  from	  self-­‐harm.	  	   	   However,	  compared	  to	  previous	  visits	  to	  Scioto,	  two	  recent	  situations	   have	  caused	  youth	  to	  spend	  more	  time	  in	  isolation	  behind	  their	   locked	  doors.	  First,	  Scioto	  has	  experienced	  significant	  staff	  shortages	   in	  the	  past	  few	  months.	  Of	  the	  170	  Youth	  Specialists,	  27	  staff	  (16%)	   were	  on	  extended	  leave	  due	  to	  work-­‐related	  injury	  or	  FMLA	  and	  8	  

	  

15	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 16 of 104 PAGEID #: 1879

positions	  are	  vacant	  (5%).	  Staff	  and	  youth	  reported	  and	  unit	  logbooks	   confirmed	  that	  over	  the	  past	  couple	  months,	  several	  units	  were	   locked	  down,	  mostly	  during	  1st	  shift,	  because	  sufficient	  staff	  were	  not	   available	  to	  operate	  the	  program	  safely.	  When	  confined	  to	  their	  cells,	   youth	  are	  denied	  access	  to	  the	  normal	  range	  of	  programming	  and	   their	  risk	  of	  becoming	  frustrated,	  anxious	  and	  self-­‐injurious	  increases	   accordingly.	  	   	   Second,	  some	  of	  the	  youth	  confined	  in	  the	  maximum-­‐security	   segregation	  units	  	  (i.e.,	  Cedar	  and	  Sycamore;	  the	  PROGRESS	  Units)	   appear	  to	  be	  spending	  excessive	  amounts	  of	  time	  locked	  in	  their	   rooms.	  The	  program	  design	  includes	  two	  phases	  (Phase	  I	  and	  II)	  with	   different	  levels	  of	  restrictiveness.	  Phase	  I	  youth	  are	  permitted	  out	  of	   their	  cells	  for	  school,	  one	  hour	  of	  large	  muscle	  activity,	  treatment,	   and	  showers.	  Meals	  and	  leisure	  time	  are	  spent	  in-­‐cell.	  Once	  promoted	   to	  Phase	  II,	  youth	  may	  also	  spend	  their	  leisure	  time	  out-­‐of-­‐cell.	  While	   youth	  in	  both	  Phases	  should	  be	  out	  of	  their	  rooms	  during	  the	  school	   day,	  during	  Intersession,	  PROGRESS	  youth	  were	  in	  their	  rooms	   throughout	  most	  of	  the	  day	  because	  Intersession	  activities	  had	  not	   been	  planned	  for	  them.	  Even	  once	  school	  was	  back	  in	  session	  in	  mid-­‐ October	  2011,	  attendance	  records	  revealed	  high	  levels	  of	  chronic	   absenteeism.	  If	  not	  attending	  school,	  or	  if	  they	  have	  graduated,	  youth	   on	  the	  PROGRESS	  units	  spend	  most	  of	  their	  day	  locked	  in	  their	  cells.	   The	  facility’s	  ability	  to	  identify	  and	  address	  this	  problem	  is	  hampered	   by	  the	  lack	  of	  valid	  data.	  The	  PROGRESS	  Unit’s	  logbooks	  have	  a	  form	   for	  recording	  the	  location	  of	  each	  youth,	  each	  hour	  of	  the	  day.	  If	  filled	   in	  properly,	  the	  facility	  would	  have	  a	  record	  of	  precisely	  how	  much	   time	  each	  PROGRESS	  youth	  spends	  in	  his	  cell.	  However,	  staff	  do	  not	   exercise	  adequate	  care	  in	  completing	  this	  form.	  Most	  often,	  they	   simply	  place	  an	  “X”	  in	  each	  box,	  indicating	  that	  the	  youth	  is	  on	  the	   unit,	  but	  without	  distinguishing	  whether	  the	  youth	  is	  in	  his	  room,	  the	   dayroom,	  the	  group	  room,	  etc.	  These	  records	  should	  be	  maintained	   more	  conscientiously.	  	   	   Further,	  the	  PROGRESS	  units	  have	  only	  been	  operating	  for	  a	  couple	   months,	  and	  the	  program	  design	  has	  not	  been	  fully	  developed.	  In	   particular,	  the	  requirements	  around	  treatment	  planning,	  articulating	   treatment	  goals,	  and	  conducting	  treatment	  teams	  have	  not	  been	  fully	   explicated.	  A	  review	  of	  treatment	  team	  notes	  for	  nine	  PROGRESS	   youth	  indicated	  pervasive	  problems	  conceptualizing	  specific,	   measurable	  goals	  for	  the	  youth	  on	  these	  units.	  Even	  when	  youth	  have	   goals	  that	  could	  be	  measured,	  updates	  on	  the	  youth’s	  progress	  at	   weekly	  interdisciplinary	  team	  meetings	  (IDT	  meetings)	  do	  not	  include	   data	  that	  reflect	  youth	  progress	  on	  their	  goals.	  Most	  often	  the	   “Outcomes”	  section	  of	  the	  IDT	  report	  is	  completely	  blank.	  As	  a	  result,	  

	  

16	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 17 of 104 PAGEID #: 1880

youth	  are	  not	  moving	  through	  Phase	  I,	  to	  Phase	  II,	  to	  Transition	  as	   quickly	  as	  they	  would	  if	  the	  program	  were	  better	  orchestrated.	  As	  a	   result,	  youth	  are	  held	  in	  highly	  restrictive	  settings	  without	  a	  clear	   pathway	  for	  a	  return	  to	  the	  general	  population.	  	   	   In	  addition,	  facility	  staff	  were	  confused	  about	  the	  process	  for	  phase	   promotion	  and	  demotion	  on	  the	  PROGRESS	  Units.	  As	  noted	  above,	  by	   design,	  the	  PROGRESS	  Unit	  behavior	  management	  program	  has	  two	   phases.	  Once	  youth	  complete	  goals	  for	  Phase	  I,	  they	  should	  be	   promoted	  to	  Phase	  II.	  If	  a	  Phase	  II	  youth	  engages	  in	  an	  act	  of	  violence,	   he	  should	  be	  demoted	  to	  Phase	  I.	  However,	  in	  practice,	  this	  process	   became	  blurred	  with	  the	  SBBMS,	  where	  youth	  were	  not	  demoted	  but	   their	  Phase	  was	  “frozen”	  for	  a	  period	  of	  time.	  	  While	  the	  end	  result	   may	  have	  been	  the	  same	  (youth	  lose	  status	  and	  thus	  spend	  more	   time	  in	  their	  room	  than	  a	  Phase	  II	  youth),	  the	  reason	  for	  demotion	   and	  the	  consequent	  seclusion	  must	  be	  accurately	  described	  and	   implemented	  so	  that	  the	  youth	  understand	  the	  workings	  of	  the	   system.	  	   	   In	  summary,	  the	  increased	  levels	  of	  misconduct	  and	  violence	  among	   youth	  who	  were	  not	  well	  known	  to	  staff,	  staffing	  shortages,	  and	  early	   implementation	  issues	  on	  the	  PROGRESS	  units	  have	  resulted	  in	  the	   increased	  use	  and	  duration	  of	  seclusion	  at	  Scioto.	  Not	  only	  is	   seclusion	  one	  of	  the	  least	  effective	  tools	  for	  managing	  youth	   behavior,	  it	  also	  decreases	  youth’s	  access	  to	  needed	  treatment	   programs	  and	  increases	  their	  risk	  of	  self-­‐harm.	  As	  a	  result,	  its	  use	   should	  be	  minimized.	  	  

Recommendations	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Continue	  to	  track	  data	  on	  the	  use	  of	  seclusion	  to	  ensure	  that	   it	  is	  used	  only	  in	  response	  to	  the	  most	  serious	  misconduct	  and	   is	  only	  of	  the	  duration	  necessary	  to	  ensure	  the	  safety	  of	  the	   facility.	  Continue	  to	  review	  videotaped	  footage	  to	  ensure	  that	   staff	  conduct	  required	  safety	  checks	  when	  youth	  are	  confined	   to	  their	  rooms.	  	  
2. Address	  the	  underlying	  causes	  of	  mid-­‐level	  misconduct	   resulting	  in	  regular	  seclusion	  and	  expand	  the	  use	  of	   alternative	  sanctions	  (i.e.,	  non-­‐seclusion)	  for	  these	  behaviors.	  	  
3. Address	  staff	  shortages	  to	  ensure	  that	  sufficient	  staff	  are	   available	  to	  operate	  the	  program	  without	  confining	  youth	  to	   their	  rooms	  during	  non-­‐sleeping	  hours.	  [The	  remedy	  to	  this	   problem	  involves	  systemic	  reforms	  that	  are	  currently	  being	   undertaken	  by	  the	  S.H.	  Monitoring	  Team.]	  
4. Improve	  the	  quality	  of	  record	  keeping	  on	  the	  PROGRESS	  units	   so	  that	  the	  precise	  number	  of	  hours	  youth	  spend	  locked	  inside	  

	  

17	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 18 of 104 PAGEID #: 1881

Sources	  of	   Information	  
	   	  

their	  rooms	  can	  be	  ascertained.	  	   5. Expand	  the	  development	  of	  the	  PROGRESS	  Unit	  program	  
design	  to	  address	  the	  issues	  of	  treatment	  planning,	   articulating	  treatment	  goals	  and	  conducting	  treatment	  teams	   to	  facilitate	  the	  youth’s	  transition	  to	  the	  general	  population	  as	   quickly	  as	  possible.	  Ensure	  that	  PROGRESS	  Unit	  youth	  are	  not	   confined	  to	  their	  rooms,	  except	  as	  articulated	  in	  the	  original	   program	  design	  (e.g.,	  all	  youth	  are	  out	  of	  their	  rooms	  for	   school,	  recreation,	  treatment	  and	  showers;	  Phase	  II	  youth	  are	   also	  out	  of	  their	  rooms	  for	  leisure	  time).	  	  
• Self-­‐assessment	  data	  and	  oral	  presentation	  of	  its	   interpretation	  for	  III.A.3,	  prepared	  at	  my	  request	  
• Interviews	  with	  29	  youth	  on	  the	  PROGRESS	  Units	  conducted	   by	  the	  Monitor	  and	  DOJ	  attorney	  in	  October	  2011,	  plus	   information	  from	  interviews	  with	  20	  general	  population	  youth	   conducted	  by	  the	  DOJ	  attorney	  in	  late	  October	  2011	  
• SOP	  303.01.07	  “PROGRESS	  Unit”,	  draft	  dated	  10/20/11	   • Draft	  “PROGRESS	  Unit	  Handbook”	  and	  “Transition	  Unit	  
Manual”,	  received	  October	  26,	  2011	   • “Unit	  PROGRESS	  and	  Transition	  Training,”	  PowerPoint	  
presentation	  slides,	  received	  October	  26,	  2011	   • Treatment	  plans	  and	  IDT	  minutes	  for	  n=9	  youth	  from	  the	  
Cedar	  and	  Sycamore	  units	   • Attendance	  records	  for	  the	  Cedar	  and	  Sycamore	  units,	  
October	  18-­‐31,	  2011	   • Unit	  logbooks	  for	  the	  Cedar	  and	  Sycamore	  units,	  October	  
2011	  
	  

	  

18	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 19 of 104 PAGEID #: 1882

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

Compliance	  Rating	   Substantial	  Compliance	  

Self	  Assessment	  

The	  State	  submitted	  a	  log	  of	  all	  investigations	  related	  to	  excessive	   uses	  of	  force,	  allegations	  of	  abuse,	  allegations	  of	  verbal	  abuse,	  and	   inappropriate	  relationships.	  More	  serious	  allegations	  (n=22)	  were	   investigated	  by	  the	  Chief	  Inspector’s	  Office	  (CIO),	  while	  less	  serious	   allegations	  (n=29)	  were	  investigated	  by	  facility-­‐based	  investigators.	   Training	  for	  facility-­‐based	  investigators	  by	  the	  CIO	  is	  planned	  for	   November	  2011.	  	   	   Between	  January	  and	  August	  2011,	  the	  facility	  completed	  51	   investigations	  related	  to	  the	  topics	  covered	  by	  this	  provision.	  [The	   facility	  also	  conducted	  approximately	  60	  investigations	  of	  time	  and	   attendance	  issues	  during	  this	  same	  time	  period.]	  Across	  the	  51	   investigations,	  20	  were	  substantiated	  (39%),	  the	  vast	  majority	  for	   violating	  the	  use	  of	  force	  policy.	  	   	   The	  CIO	  conducts	  quarterly	  audits	  of	  the	  investigations	  to	  ensure	  they	   are	  high	  quality	  and	  completed	  within	  required	  timelines.	  A	  number	   of	  deficits	  in	  investigative	  technique	  were	  noted	  in	  the	  Q1	  audit,	  and	   most	  of	  these	  had	  been	  rectified	  by	  the	  Q2	  audit.	  The	  facility’s	   Administrative	  Reviews	  of	  all	  investigations	  likely	  contributed	  to	  these	   improvements.	  	  

Steps	  Taken	  to	   Assess	  Compliance	  

Rate	  of	  Substantiated	  Allegations	   Of	  the	  51	  investigations	  completed,	  20	  allegations	  were	  substantiated	   (39%).	  Approximately	  12	  of	  these	  were	  for	  improper	  uses	  of	  force.	   More	  specifically:	  
• failing	  to	  submit	  an	  incident	  report	  or	  witness	  statement	  (5	  of	   20);	  
• using	  an	  unauthorized	  restraint	  technique	  (e.g.,	  headlock,	  arm	   lock,	  grabbing	  a	  youth’s	  collar;	  4	  of	  20);	  
• pushing	  a	  youth	  (3	  of	  20);	   • excessive	  force	  (e.g.,	  lifting	  a	  youth	  off	  the	  ground	  and	  
slamming	  him	  to	  the	  ground;	  throwing	  a	  punch	  at	  a	  youth;	   pinning	  a	  youth’s	  arms	  to	  his	  side	  and	  taking	  him	  to	  the	  floor;	   3	  of	  20);	   • restraining	  a	  youth	  who	  did	  not	  pose	  an	  immediate	  threat	  (2	   of	  20);	  	  

	  

19	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 20 of 104 PAGEID #: 1883

• inappropriate	  relationships	  with	  youth	  via	  FaceBook	  (2	  of	  20);	   and	  	  
• verbal	  abuse	  (1	  of	  20).	  	   	   For	  the	  most	  part,	  these	  data	  mirror	  the	  youth’s	  perceptions	  of	  their	   treatment	  by	  staff.	  The	  12	  substantiated	  allegations	  were	  among	   approximately	  1,150	  physical	  restraints	  during	  that	  time	  period	  (or,	   approximately	  1%).	  By	  and	  large,	  youth	  reported	  that	  staff	  do	  not	   physically	  abuse	  them	  or	  treat	  them	  heavy-­‐handedly	  during	   restraints.	   	   As	  discussed	  in	  Provision	  I.A.1,	  above,	  the	  DOJ	  has	  consistently	   received	  a	  larger	  number	  of	  allegations	  of	  inappropriate	  comments,	   touching	  and	  sexual/inappropriate	  relationships	  when	  interviewing	   youth	  than	  is	  reflected	  in	  the	  facility’s	  investigation	  log.	  The	  reasons	   for	  this	  disparity	  are	  unknown,	  but	  the	  State	  is	  encouraged	  to	   broaden	  its	  inquiry	  about	  these	  types	  of	  concerns	  among	  the	  girls	  to	   determine	  whether	  the	  difference	  in	  frequency	  can	  be	  attributed	  the	   DOJ’s	  proactive	  inquiry	  (see	  I.A.1	  for	  a	  more	  detailed	  discussion	  of	   this	  issue).	  	   	   Quality	  of	  Investigations	   A	  random	  sample	  of	  15	  investigations	  of	  alleged	  physical	  abuse	  or	   excessive	  uses	  of	  force	  were	  selected	  for	  in-­‐depth	  review.	  These	   investigations	  were	  completed	  by	  the	  CIO	  and	  were	  particularly	  well	   done.	  They	  featured	  comprehensive	  interviews	  with	  all	  key	  witnesses,	   and	  pursued	  tangential	  issues	  that	  emerged	  during	  the	  course	  of	  the	   initial	  inquiry.	  Across	  the	  sample,	  the	  findings	  appeared	  to	  be	   reasonable	  and	  the	  basis	  for	  the	  conclusion	  was	  clearly	  identified	   among	  the	  evidence.	  	   	   In	  order	  to	  examine	  the	  State’s	  response	  to	  allegations	  of	  verbal	   mistreatment,	  all	  14	  investigations	  of	  this	  type	  were	  selected	  for	   review.	  [Only	  11	  of	  the	  14	  investigations	  could	  be	  reviewed	  because	   three	  of	  the	  electronic	  files	  were	  mismarked.]	  Scioto	  supervisory	  staff	   conduct	  investigations	  of	  alleged	  verbal	  abuse.	  While	  most	  of	  the	   internal	  investigations	  were	  at	  least	  adequate,	  a	  small	  number	  (36%;	   4	  of	  the	  11)	  were	  poorly	  done:	  	  
• 5501110021	  failed	  to	  substantiate	  the	  alleged	  inappropriate	   conduct,	  even	  though	  the	  subject	  of	  the	  investigation	   admitted	  that	  she	  made	  the	  statement	  alleged	  by	  the	  youth.	   The	  reason	  that	  the	  comment	  was	  judged	  by	  the	  investigator	   to	  be	  appropriate	  was	  not	  explained;	  	  	  
• 550110025	  is	  very	  convoluted	  in	  its	  presentation	  of	  the	  facts.	   It	  is	  not	  clear	  how	  the	  facility	  became	  aware	  of	  the	  incident	  or	  

	  

20	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 21 of 104 PAGEID #: 1884

why	  it	  took	  over	  one	  month	  to	  assign	  the	  investigation.	   Further,	  the	  investigator	  did	  not	  interview	  the	  alleged	  victim	   until	  two	  months	  after	  the	  incident	  occurred.	  Finally,	  a	  youth	   witness	  corroborated	  the	  youth’s	  allegation,	  and	  the	  reason	   for	  discounting	  this	  evidence	  was	  not	  explained;	   • 5500110070	  noted	  that	  4	  youth	  witnesses	  corroborated	  the	   youth’s	  allegation	  but	  did	  not	  explain	  why	  this	  evidence	  was	   discounted.	  	   • 5500110085	  does	  not	  pursue	  a	  full	  investigation,	  apparently	   because	  the	  youth	  indicated	  that	  he	  did	  not	  want	  to	  pursue	   the	  allegation.	  The	  summary	  of	  the	  interview	  with	  the	   accused	  staff	  said	  only	  that	  the	  staff	  “denied”	  making	  the	   comments	  and	  “said	  there	  were	  no	  witnesses.”	  The	   investigator	  never	  describes	  the	  situation	  in	  which	  the	   comments	  were	  alleged	  to	  have	  occurred	  and	  the	  paucity	  of	   this	  contextual	  information	  makes	  it	  appear	  that	  the	  inquiry	   was	  dropped	  simply	  because	  the	  youth	  did	  not	  want	  to	   pursue	  it.	  	  	   	   Unfortunately,	  these	  shoddy	  investigations	  cluster	  around	  an	  issue	  of	   significant	  concern—inappropriate	  comments	  or	  antagonizing	   language	  by	  staff.	  While	  not	  the	  overwhelming	  sentiment	  across	   youth,	  a	  significant	  minority	  of	  youth	  reported	  that	  some	  staff	  treat	   them	  disrespectfully	  and	  the	  youth	  believe	  that	  these	  staff	  are	  not	   held	  accountable	  for	  their	  behavior.	  As	  discussed	  in	  Provision	  III.D.1,	   the	  State	  has	  not	  yet	  developed	  procedures	  to	  inform	  youth	  of	  the	   outcome	  of	  grievances	  that	  are	  referred	  for	  investigation.	  The	  shoddy	   quality	  of	  some	  of	  these	  investigations	  may	  contribute	  to	  the	   perception	  that	  staff	  are	  not	  held	  accountable	  for	  their	  verbal	   mistreatment	  of	  youth.	   	   Timeliness	  of	  Investigations	   Across	  the	  51	  investigations	  submitted	  for	  review,	  a	  significant	   proportion	  (42%)	  were	  not	  completed	  before	  their	  due	  dates.	  Often,	   the	  assigned	  investigator	  experienced	  a	  delay	  of	  between	  4	  and	  7	   days	  while	  awaiting	  approval	  from	  the	  Ohio	  State	  Patrol	  (the	  law	   enforcement	  agency	  with	  jurisdiction	  to	  bring	  criminal	  charges)	  to	   pursue	  the	  internal	  investigation.	  Compared	  to	  other	  jurisdictions,	  the	   investigation	  timelines	  in	  Ohio	  are	  relatively	  short	  (particularly	  the	  14	   days	  allocated	  for	  use	  of	  force	  investigations).	  The	  DYS	  may	  want	  to	   reconsider	  the	  timelines	  required	  by	  policy	  so	  that	  they	  remain	  both	   speedy	  and	  reasonable,	  but	  so	  that	  the	  vast	  majority	  of	  investigations	   could	  be	  completed	  on	  time.	  This	  would	  highlight	  those	  investigations	   experiencing	  unusual	  delays.	  	  	  
Recommendations	   The	  State	  is	  in	  substantial	  compliance	  with	  this	  provision.	  However,	  in	  

	  

21	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 22 of 104 PAGEID #: 1885

Sources	  of	   Information	  
	   	  

order	  to	  maintain	  substantial	  compliance,	  the	  State	  must	  improve	  the	   quality	  of	  its	  internal	  investigations	  to	  ensure	  they	  are	  promptly	   assigned,	  thoroughly	  and	  properly	  investigated.	  	  
• Self-­‐assessment	  data	  and	  oral	  presentation	  of	  its	   interpretation	  for	  III.A.5,	  prepared	  at	  my	  request	  	  
• Log,	  “Investigations	  of	  Serious	  Incidents,	  January-­‐August,	   2011”	  
• Random	  sample	  of	  n=15	  CIO	  investigations	  completed	  since	   February	  2011	  
• Review	  of	  n=11	  internal	  investigations	  of	  alleged	  verbal	  abuse	   completed	  since	  February	  2011	  
• Communication	  with	  DOJ	  attorney	  regarding	  the	  allegations	   of	  verbal	  mistreatment	  made	  by	  youth	  on	  the	  girls’	  units,	   October	  2011	  
	  

	  

22	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 23 of 104 PAGEID #: 1886

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

Compliance	  Rating	   Non-­‐Compliance	  

Self	  Assessment	  

The	  Grievance	  Officer	  reported	  that	  the	  process	  is	  unchanged	  from	   previous	  visits	  and	  continues	  to	  meet	  the	  requirements	  of	  this	   provision:	  no	  preconditions;	  review	  by	  Chief	  Inspector;	  timely	   initiation	  and	  resolution;	  appropriate	  corrective	  action;	  and	  written	   notification	  to	  youth	  of	  the	  final	  resolution	  of	  the	  grievance.	  	   	   Between	  February	  and	  September	  2011,	  Scioto	  youth	  filed	  over	  300	   grievances.	  The	  Chief	  Inspector’s	  Office’s	  Q1	  and	  Q2	  audits	  found	  that	   all	  grievances	  were	  resolved	  in	  a	  timely	  manner.	  Scioto	  also	  had	  a	   lower	  rate	  of	  grievances	  per	  youth	  than	  the	  other	  DYS	  facilities.	  	   	   Each	  month,	  the	  Grievance	  Officer	  drafts	  a	  monthly	  report	  showing	   the	  number	  and	  type	  of	  grievances	  coming	  from	  each	  housing	  unit.	   The	  report	  also	  describes	  the	  major	  dynamics	  in	  the	  facility.	  Reading	   the	  past	  nine	  months’	  summaries	  in	  succession	  illuminates	  the	   challenges	  that	  have	  faced	  the	  facility	  during	  its	  conversion	  to	  a	  long-­‐ term	  program.	  	   	   Staff	  training	  in	  this	  area	  admonishes	  staff	  not	  to	  impede	  the	   grievance	  process	  in	  any	  way,	  e.g.,	  by	  refusing	  access	  to	  necessary	   supplies	  or	  by	  threatening	  or	  intimidating	  youth	  who	  choose	  to	  file	  a	   grievance.	  	  

Steps	  Taken	  to	   Assess	  Compliance	  

Between	  February	  and	  September	  2011,	  a	  total	  of	  321	  grievances	   were	  submitted.	  The	  most	  frequent	  types	  of	  concerns	  were	   complaints	  about	  unfair	  treatment	  by	  staff	  (32%);	  living	  conditions	   (9%);	  medical	  care	  (7%)	  and	  verbal	  abuse	  by	  staff	  (4%).	  Together,	   these	  four	  categories	  accounted	  for	  over	  half	  (52%)	  of	  all	  grievances.	   Of	  the	  321	  grievances	  received,	  24	  (7%)	  were	  closed	  and	  forwarded	   for	  investigation.	  [Although	  the	  data	  were	  not	  presented	  this	  way,	  the	   Monitor	  suspects	  these	  24	  referrals	  included	  the	  complaints	  about	   verbal	  abuse	  (n=13)	  and	  physical	  abuse/excessive	  force	  (n=10).]	  	   	   As	  the	  facility	  converted	  from	  a	  reception	  to	  a	  long-­‐term	  program,	  the	   number	  and	  content	  of	  grievances	  changed	  noticeably.	  During	  the	   first	  half	  of	  2011,	  the	  facility	  averaged	  about	  35	  grievances	  per	   month.	  In	  September,	  once	  the	  facility	  had	  completely	  switched	  over	   to	  a	  long-­‐term	  program,	  70	  grievances	  were	  submitted.	  Many	  of	  

	  

23	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 24 of 104 PAGEID #: 1887

these	  reflected	  youth’s	  attempts	  to	  become	  familiar	  with	  a	  new	   facility	  with	  slightly	  different	  rules	  and	  to	  ensure	  that	  possessions	  and	   privileges	  from	  their	  previous	  facility	  were	  transferred	  to	  Scioto.	   Some	  of	  the	  grievances	  also	  highlighted	  staff’s	  lack	  of	  familiarity	  with	   procedures	  for	  the	  long-­‐term	  program	  (e.g.,	  certain	  features	  of	  the	   SBBMS;	  Phase	  Freeze;	  commissary).	  	   	   The	  Grievance	  Officer	  has	  exhibited	  tremendous	  compassion	  towards	   both	  youth	  and	  staff	  as	  they	  attempt	  to	  adapt	  to	  the	  transition.	  Youth	   at	  Scioto	  continue	  to	  have	  dependable	  access	  to	  a	  grievance	  process	   that	  is	  timely,	  thorough	  and	  responsive	  to	  their	  concerns.	  When	   interviewed,	  youth	  continue	  to	  have	  positive	  reviews	  of	  the	  Grievance	   Officer	  and	  the	  process	  for	  handling	  most	  of	  their	  concerns.	  	  	   	   However,	  as	  discussed	  in	  previous	  reports,	  the	  Grievance	  Process	  has	   not	  yet	  been	  adapted	  to	  provide	  sufficient	  feedback	  to	  youth	   regarding	  their	  allegations	  of	  staff	  misconduct	  that	  are	  forwarded	  for	   investigation.	  Youth	  are	  told	  that	  their	  complaint	  was	  referred	  for	   investigation	  and	  the	  grievance	  response	  includes	  the	  assigned	   investigation	  number;	  however,	  youth	  are	  not	  informed	  when	  the	   investigation	  has	  been	  concluded	  and	  whether	  the	  allegation	  was	   substantiated.	  For	  this	  reason,	  youth	  tend	  to	  believe	  that	  the	  issue	   was	  dropped	  and	  that	  staff	  are	  never	  held	  accountable.	  The	   Grievance	  Officer	  reported	  that	  policy	  revisions	  toward	  this	  end	  are	   underway.	  The	  Monitor	  would	  like	  to	  review	  the	  policy	  revisions	  prior	   to	  the	  policy	  being	  finalized.	  	  When	  the	  process	  is	  fully	  implemented	   and	  youth	  are	  informed	  of	  the	  outcomes	  of	  investigations	  of	  their	   allegations,	  the	  facility	  will	  be	  in	  substantial	  compliance	  with	  this	   provision.	  	  

Recommendations	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Develop	  procedures	  and	  practices	  to	  inform	  youth	  that	   investigations	  of	  staff	  misconduct	  have	  been	  completed	  and	   whether	  the	  allegation	  was	  substantiated	  or	  not.	  	  

Sources	  of	   Information	  
	  

• Self-­‐assessment	  data	  and	  oral	  presentation	  of	  its	   interpretation	  for	  III.D.1,	  prepared	  at	  my	  request	  
• Grievance	  Monthly	  Reports,	  February	  through	  September	   2011	  
• Q1	  and	  Q2	  Grievance	  Audits	  by	  the	  Chief	  Inspector’s	  Office	   • Youth	  Grievances	  from	  March,	  June,	  August	  and	  September	  
2011	   • Interviews	  with	  n=20	  youth	  in	  the	  general	  population,	  
conducted	  by	  the	  DOJ	  attorney	  in	  late	  October	  2011	  

	  

24	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 25 of 104 PAGEID #: 1888

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

Compliance	  Rating	   Non-­‐Compliance	  

Self	  Assessment	  

The	  Grievance	  Officer	  held	  “Grievance	  Clinics”	  during	  the	  most	  recent	   Intersession.	  These	  clinics	  discussed	  the	  mechanics	  of	  the	  grievance	   process	  and	  what	  youth	  should	  expect.	  A	  learning	  activity	  asked	   youth	  to	  critique	  sample	  grievances	  as	  to	  whether	  1)	  the	  issue	  was	   grieveable	  and	  2)	  all	  necessary	  information	  had	  been	  included.	  	  Youth	   reported	  an	  improved	  understanding	  of	  the	  process	  after	  attending	   the	  clinics.	  Given	  that	  many	  of	  the	  youth	  involved	  have	  been	  released	   from	  the	  facility,	  the	  Clinics	  will	  be	  offered	  again	  in	  December	  2011.	  	   	   The	  facility	  continues	  to	  audit	  a	  random	  10%	  sample	  of	  admissions	   files	  every	  month	  to	  ensure	  compliance	  with	  policy	  and	  procedure.	   Each	  month,	  February	  through	  September	  2011,	  100%	  of	  the	  youth	   sampled	  received	  a	  complete	  orientation	  to	  the	  facility,	  which	   included	  information	  on	  how	  to	  access	  the	  grievance	  system.	  	  

Steps	  Taken	  to	   Assess	  Compliance	  

I	  did	  not	  need	  to	  conduct	  any	  additional	  inquiry	  to	  assess	  compliance.	   As	  noted	  in	  III.D.1,	  the	  orientation	  process	  has	  not	  yet	  been	  adapted	   to	  inform	  youth	  that	  they	  will	  be	  advised	  when	  grievances	  that	  are	   referred	  for	  investigation	  are	  concluded	  and	  whether	  the	  allegation	   was	  substantiated.	  Policy	  revisions	  are	  reportedly	  underway.	  The	   Monitor	  would	  like	  to	  review	  the	  revisions	  prior	  to	  the	  policy	  being	   finalized.	  When	  this	  process	  is	  explained	  to	  youth	  during	  Orientation,	   the	  facility	  will	  be	  in	  substantial	  compliance	  with	  this	  provision.	  	  

Recommendations	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Adapt	  the	  orientation	  process	  to	  explain	  how	  grievances	   alleging	  staff	  misconduct	  will	  be	  handled	  and	  that	  youth	  will	   be	  informed	  that	  the	  investigation	  is	  concluded	  and	  whether	   the	  allegation	  was	  substantiated.	  	  

Sources	  of	   Information	  
	   	   	  

• Self-­‐assessment	  data	  and	  oral	  presentation	  of	  its	   interpretation	  for	  III.D.2,	  prepared	  at	  my	  request	  
• Intake	  Audit	  Report,	  February	  through	  September,	  2011	  
	  

	  

25	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 26 of 104 PAGEID #: 1889

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

Compliance	  Rating	   Non-­‐compliance	  

Self	  Assessment	  

Structured	  Programming	   The	  facility’s	  Youth	  Activity	  Tracking	  System	  (YATS)	  is	  now	  operational	   and	  is	  used	  to	  track	  youth	  participation	  in	  the	  variety	  of	  programs	   available	  to	  them.	  These	  include	  recreation,	  religious	  programming,	   programs	  delivered	  by	  volunteers	  and	  those	  facilitated	  by	  direct	  care	   staff.	  	   	   Data	  from	  the	  YATS’s	  first	  month	  of	  implementation	  (September	   2011)	  were	  not	  particularly	  promising.	  A	  one-­‐weekday	  snapshot	   showed	  that	  youth	  were	  involved	  in	  an	  average	  of	  only	  1.2	  hours	  of	   structured	  programming	  that	  day.	  A	  one-­‐weekend-­‐day	  snapshot	   showed	  that	  youth	  were	  involved	  in	  an	  average	  of	  only	  1.5	  hours	  of	   structured	  programming	  that	  day.	  Further	  investigation	  into	  these	   trends	  revealed	  problems	  with	  data	  collection	  (Unit	  Managers	  were	   not	  completing	  youth	  sign-­‐in	  sheets,	  collecting	  them	  or	  delivering	   them	  for	  data	  entry).	  Two	  interventions	  were	  designed	  to	  target	  this	   problem:	  1)	  using	  a	  student	  clerk	  to	  prepare	  attendance	  sheets	  for	   each	  day’s	  activities	  and	  to	  ensure	  they	  are	  collected	  and	  submitted;	   and	  2)	  requiring	  youth	  to	  sign	  the	  attendance	  sheets	  before	  the	   activity	  begins,	  rather	  than	  after.	  These	  measures	  should	  improve	  the	   quality	  of	  the	  data	  so	  that	  in	  subsequent	  months,	  the	  extent	  to	  which	   staff	  are	  actually	  providing	  access	  and	  delivering	  programs	  as	   required	  can	  be	  discerned.	  	   	   SBBMS	   With	  Scioto’s	  conversion	  to	  a	  long-­‐term	  program,	  staff	  are	  now	   required	  to	  deliver	  the	  fully-­‐loaded	  SBBMS	  rather	  than	  the	  SBBMS-­‐lite	   program	  that	  operated	  in	  the	  reception	  units.	  Since	  the	  long-­‐term	  

	  

26	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 27 of 104 PAGEID #: 1890

population	  arrived	  at	  Scioto,	  the	  Grievance	  Officer	  has	  received	  a	   significant	  number	  of	  informal	  complaints	  and	  formal	  grievances	   indicating	  that	  some	  staff	  have	  not	  properly	  implemented	  the	  fully-­‐ loaded	  SBBMS.	  Youth	  complained	  that	  staff	  did	  not	  provide	  access	  to	   earned	  incentives,	  reported	  that	  commissary	  orders	  were	  not	   delivered,	  and	  were	  confused	  about	  Phase	  Freeze.	  Staff	  errors	  may	  be	   training-­‐related—approximately	  65	  direct	  care	  staff	  have	  not	  yet	   completed	  training	  on	  the	  fully-­‐loaded	  SBBMS	  used	  in	  the	  long-­‐term	   program.	  	  Facility	  administrators	  continue	  to	  oversee	  the	  program’s	   implementation	  carefully,	  through	  the	  monthly	  meetings	  in	  which	   staff	  practices	  around	  the	  use	  of	  Character	  Coupons	  and	  other	   features	  of	  the	  system	  are	  tracked.	  The	  SBBMS	  has	  a	  solid	  program	   design;	  in	  the	  past,	  when	  properly	  implemented,	  the	  SBBMS	  was	   compelling	  to	  youth	  and	  contributed	  to	  the	  effective	  management	  of	   aggressive	  behavior.	  	  

Steps	  Taken	  to	   Assess	  Compliance	  

The	  YATS	  data	  reported	  in	  the	  State’s	  self-­‐assessment	  mirror	  the	   youth’s	  comments	  about	  the	  programming	  available	  to	  them.	  Youth	   reported	  excessive	  idle	  time	  in	  the	  afternoons	  and	  particularly	  on	  the	   weekends.	  Many	  youth	  at	  Scioto	  have	  graduated	  from	  high	  school	  or	   have	  obtained	  their	  GED.	  These	  students	  complained	  that	  there	  were	   too	  few	  work	  assignments	  and	  post-­‐secondary	  options	  available	  to	   them	  and	  that	  they	  spent	  the	  majority	  of	  the	  weekdays	  on	  the	  units	   with	  nothing	  to	  occupy	  their	  time.	  Education	  staff	  reported	  that	  the	   Career-­‐Based	  Intervention	  program	  has	  identified	  approximately	  60	   jobs	  on	  campus,	  but	  has	  yet	  to	  be	  implemented.	  Once	  implemented,	   the	  State	  will	  need	  to	  devise	  additional	  self-­‐assessment	  mechanisms	   to	  capture	  these	  data.	  Technical	  assistance	  toward	  this	  end	  is	   available	  upon	  request.	  	   	   At	  one	  time,	  the	  facility	  had	  achieved	  notable	  success	  in	  requiring	   direct	  care	  staff	  to	  provide	  structured	  programming	  during	  non-­‐ school	  hours,	  but	  it	  appears	  staff	  compliance	  with	  the	  unit	  schedules	   has	  waned.	  These	  programs	  served	  an	  essential	  role	  in	  reducing	  youth	   idle	  time,	  developing	  rapport	  between	  staff	  and	  youth,	  and	  building	   the	  skills	  necessary	  for	  effective	  youth	  rehabilitation.	  	   	   The	  lack	  of	  programming	  is	  caused	  by	  staff	  shortages	  of	  two	  types.	   The	  shortages	  of	  direct	  care	  staff	  noted	  in	  III.A.3,	  above,	  have	  caused	   multiple	  institution-­‐wide	  lockdowns	  over	  the	  past	  several	  months.	   Not	  only	  do	  these	  shortages	  result	  in	  an	  increased	  reliance	  on	   isolation	  to	  ensure	  the	  safety	  of	  the	  youth,	  but	  they	  also	  deny	  these	   same	  youth	  access	  to	  the	  education,	  treatment	  and	  recreational	   programming	  to	  which	  they	  are	  legally	  entitled.	  In	  addition,	  9	  of	  the	   facility’s	  18	  social	  worker	  positions	  are	  unfilled	  (7	  are	  vacant,	  2	  are	  on	   FMLA)	  which	  compromises	  the	  ability	  to	  run	  CBT	  groups	  and	  other	  

	  

27	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 28 of 104 PAGEID #: 1891

treatment	  programs.	  	   	   The	  language	  of	  this	  provision	  also	  addresses	  programming	  for	  youth	   in	  closed-­‐cell	  environments	  to	  ensure	  they	  are	  not	  confined	  to	  their	   cells	  unnecessarily	  and	  that	  they	  have	  access	  to	  rehabilitative	  services	   that	  meet	  their	  needs.	  The	  facility	  now	  operates	  the	  PROGRESS	  unit,	   which	  is	  a	  closed-­‐cell	  program.	  Concerns	  about	  the	  amount	  of	  time	   these	  youth	  spend	  in	  their	  rooms	  due	  to	  staff	  shortages	  and	  “Phase	   Freeze”	  were	  discussed	  in	  III.A.3,	  Seclusion.	  The	  PROGRESS	  unit	  is	   newly	  implemented	  and	  additional	  program	  planning	  is	  needed	  to	   address	  the	  following	  problems:	  	  
• Orientation	  is	  relatively	  unstructured	  and	  often	  does	  not	   occur	  until	  several	  days	  after	  the	  youth	  has	  been	  assigned	  to	   the	  unit;	  
• Treatment	  plans	  lack	  specific	  goals	  with	  discrete	  behavioral	   objectives	  and	  a	  specific	  timeline	  for	  movement	  to	  the	  next	   phase;	  
• Treatment	  Teams	  do	  not	  appear	  to	  assess	  youth’s	  progress	   toward	  these	  goals	  systematically	  nor	  facilitate	  youth	   movement	  to	  a	  less	  restrictive	  environment	  in	  a	  consistent	   manner;	  
• Contact	  standards	  for	  individual	  sessions	  with	  social	  workers	   and	  mental	  health	  staff	  have	  not	  been	  clearly	  articulated;	  and	  
• Performance	  measures	  to	  determine	  program	  effectiveness	   have	  not	  been	  established.	  	  
Fully	  developing	  and	  implementing	  the	  PROGRESS	  program	  design	  is	   required	  to	  meet	  the	  requirements	  of	  this	  provision.	  	  

Recommendations	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Provide	  structured	  programming	  to	  general	  population	  youth	   during	  non-­‐school	  hours	  and	  on	  weekends	  to	  minimize	  the	   amount	  of	  idle	  time.	  	  
2. Ensure	  all	  direct	  care	  staff	  are	  trained	  and	  properly	  implement	   the	  SBBMS.	  Continue	  to	  utilize	  the	  grievance	  system	  and	   monthly	  administrative	  meetings	  to	  identify	  emerging	   problems	  with	  the	  SBBMS.	  	  
3. Develop	  structured	  activities	  for	  youth	  who	  have	  graduated	   from	  high	  school	  or	  obtained	  their	  GED	  so	  that	  they	  are	   engaged	  in	  meaningful	  activities	  throughout	  the	  day.	  	  
4. Address	  direct	  care	  staff	  and	  social	  worker	  shortages	  to	   ensure	  that	  all	  youth	  have	  access	  to	  structured	  activities	  and	   rehabilitative	  programming	  throughout	  the	  day.	  	  
5. Fully	  develop	  the	  PROGRESS	  unit’s	  program	  features	  (e.g.,	   treatment	  plans,	  treatment	  teams,	  individual	  sessions,	  etc.)	  to	   ensure	  youth	  have	  maximal	  access	  to	  structured	  

	  

28	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 29 of 104 PAGEID #: 1892

Sources	  of	   Information	  
	   	  

programming,	  given	  their	  legitimate	  safety	  concerns.	  	   	  
• Self-­‐assessment	  data	  and	  oral	  presentation	  of	  its	   interpretation	  for	  III.F.1,	  prepared	  at	  my	  request	  
• Interviews	  with	  n=20	  general	  population	  youth	  conducted	  by	   the	  DOJ	  attorney	  in	  late	  October	  2011;	  interviews	  with	  n=29	   youth	  on	  PROGRESS	  units	  conducted	  by	  the	  Monitor	  and	  DOJ	   attorney	  in	  October	  2011	  
• SOP	  303.01.07	  “PROGRESS	  Unit”,	  draft	  dated	  10/20/11	   • Draft	  “PROGRESS	  Unit	  Handbook”	  and	  “Transition	  Unit	  
Manual”,	  received	  October	  26,	  2011	   • “Unit	  PROGRESS	  and	  Transition	  Training,”	  PowerPoint	  
presentation	  slides,	  received	  October	  26,	  2011	  
	  

	  

29	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 30 of 104 PAGEID #: 1893

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

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

During	  the	  current	  monitoring	  period,	  the	  DYS	  changed	  from	  a	   centralized	  reception	  process	  at	  Scioto	  to	  a	  decentralized	  intake	   process	  at	  each	  facility.	  The	  intake	  process	  at	  Scioto	  is	  now	  only	  4-­‐ days	  long.	  The	  facility	  continues	  to	  audit	  a	  random	  10%	  sample	  of	   admissions	  files	  every	  month	  to	  ensure	  compliance	  with	  policy	  and	   procedure.	  Each	  month,	  February	  through	  September,	  100%	  of	  the	   youth	  sampled	  received	  a	  complete	  orientation	  to	  the	  facility	  which	   included,	  among	  other	  things:	  
• Youth	  Handbook	   • Orientation	  Video	   • Facility	  rules	  and	  consequences	  (IRAV)	   • Strength	  Based	  Behavior	  Management	  System	  (SBBMS)	   • Obtaining	  legal	  assistance	   • Accessing	  medical	  and	  mental	  health	  care	   • Sexual	  abuse	  and	  sexual	  assault	  information	   • Grievance	  system	  

Steps	  Taken	  to	   Assess	  Compliance	  

Religious	  Accommodations	   Given	  the	  audit	  results	  above,	  the	  Orientation	  program	  for	  youth	  in	   the	  general	  population	  at	  Scioto	  nearly	  meets	  the	  requirements	  of	   this	  provision.	  However,	  this	  provision	  also	  requires	  the	  State	  to	   provide	  youth	  with	  “information	  pertinent	  to	  the	  youth’s	   participation	  in	  facility	  programs,”	  which	  includes	  participation	  in	   religious	  programming.	  As	  discussed	  in	  DOJ’s	  compliance	  letter	  issued	  

	  

30	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 31 of 104 PAGEID #: 1894

at	  the	  end	  of	  the	  term	  for	  the	  original	  Stipulation,	  the	  facility’s	  Youth	   Handbook	  still	  needs	  to	  be	  adapted	  to	  describe	  the	  youth’s	  rights	   related	  to	  practicing	  their	  religion	  of	  choice,	  in	  particular,	  how	  they	   may	  seek	  accommodations	  for	  religious	  beliefs,	  practices	  or	   observance	  as	  described	  in	  SOP	  #507.02.06.	  	  A	  draft	  of	  the	  revised	   Handbook	  was	  reviewed	  while	  on	  site	  in	  October	  2011	  and	   suggestions	  for	  stating	  the	  youth’s	  rights	  more	  clearly	  were	  offered	  at	   the	  time.	  Just	  prior	  to	  the	  final	  report	  being	  issued,	  the	  State	  reported	   that	  the	  Youth	  Handbook	  had	  been	  revised	  to	  include	  better	   information	  on	  the	  youth’s	  right	  to	  practice	  their	  religion	  of	  choice.	   The	  Handbook	  now	  informs	  youth	  that	  they	  have	  a	  right	  to	  the	   resources	  to	  practice	  their	  religion	  of	  choice	  providing	  it	  does	  not	   interfered	  with	  the	  safety	  and	  security	  of	  the	  institution.	  The	  revised	   Handbook	  was	  put	  into	  use	  on	  January	  12,	  2012.	  Although	  this	   revision	  was	  not	  put	  into	  practice	  during	  the	  Monitoring	  period,	  as	   long	  as	  youth’s	  religious	  beliefs	  are	  adequately	  accommodated,	  the	   State	  will	  remain	  in	  substantial	  compliance.	  Note	  that	  the	  State	  must	   seek	  alternative	  ways	  for	  the	  youth	  to	  practice	  his/her	  religion,	  even	   when	  a	  legitimate	  safety	  concerns	  exists.	  	   	   PROGRESS	  Unit	  Orientation	   While	  most	  of	  the	  youth	  at	  Scioto	  undergo	  an	  Orientation	  to	  the	   general	  Scioto	  population,	  youth	  can	  also	  be	  admitted	  directly	  to	  the	   PROGRESS	  Unit,	  and	  thus	  the	  Orientation	  for	  that	  program	  is	  relevant	   to	  this	  provision.	  Draft	  SOP	  303.01.07	  “Progress	  Unit”	  requires	  the	   Unit	  Manager	  to	  ensure	  that	  the	  PROGRESS	  Youth	  Handbook	  is	   available	  to	  all	  youth	  and	  that	  a	  staff	  member	  provides	  a	  thorough	   orientation	  to	  youth	  upon	  their	  admission	  to	  the	  Unit.	  Youth	  must	   sign	  the	  Handbook’s	  signature	  page	  to	  acknowledge	  receipt	  of	  the	   information.	  The	  most	  recent	  version	  of	  the	  Handbook	  is	  dated	   January	  10,	  2012	  and	  remains	  in	  draft	  form.	  It	  includes	  information	  on	   the	  Unit’s	  rules	  and	  expectations;	  phases,	  treatment	  planning	  and	   treatment	  team	  meetings;	  programs	  (education,	  mental	  health,	   recreation,	  religion);	  telephone	  use,	  mail	  and	  visitation;	  grievance	   procedures;	  and	  access	  to	  legal	  services.	  	  	   	   The	  signature	  pages	  for	  the	  youth	  admitted	  to	  the	  Progress	  Unit	  were	   requested	  for	  review.	  A	  total	  of	  51	  youth	  were	  admitted	  between	   September	  1,	  2011	  and	  January	  7,	  2010.	  Of	  these,	  no	  documentation	   was	  provided	  for	  13	  youth	  (25%).	  Among	  the	  remaining	  youth,	  nearly	   all	  received	  the	  Orientation	  between	  1	  and	  4	  months	  AFTER	  their	   admission	  to	  the	  Unit.	  A	  timely	  orientation	  to	  the	  unit	  is	  essential	  to	   ensure	  that	  youth	  are	  aware	  of	  the	  Unit’s	  rules	  and	  the	  consequences	   for	  breaking	  them,	  understand	  how	  to	  progress	  to	  the	  transition	   phase	  and	  back	  to	  the	  general	  population,	  and	  how	  to	  access	  services	  

	  

31	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 32 of 104 PAGEID #: 1895

while	  on	  the	  Unit.	  The	  lack	  of	  a	  timely,	  structured	  orientation	  to	  the	   Unit	  likely	  contributed	  to	  the	  frustration	  that	  many	  youth	  expressed	   about	  their	  placement	  and	  their	  lack	  of	  progress	  moving	  through	  the	   Unit’s	  phases.	  	  

Recommendations	  

In	  order	  to	  achieve	  substantial	  compliance	  with	  this	  provision,	  the	   State	  must:	  
1. Finalize	  SOP	  303.01.07	  and	  the	  PROGRESS	  Unit	  Student	   Handbook.	  	  
2. Provide	  a	  comprehensive	  and	  timely	  Orientation	  to	  all	  youth	   admitted	  to	  the	  Progress	  Unit	  to	  ensure	  that	  youth	   understand	  the	  rules,	  expectations	  and	  how	  to	  access	   services.	  	  

Sources	  of	   Information	  
	   	   	  

• Self-­‐assessment	  data	  and	  oral	  presentation	  of	  its	   interpretation	  for	  III.F.2,	  prepared	  at	  my	  request	  
• Intake	  Audit	  Report,	  February	  through	  September,	  2011	   • Scioto	  Youth	  Handbook,	  dated	  January	  10,	  2012	   • Draft	  SOP	  303.01.07	  “Progress	  Unit,”	  dated	  October	  20,	  2010	   • Draft	  PROGRESS	  Unit	  Youth	  Handbook,	  dated	  January	  10,	  
2012	   • Orientation	  records	  for	  youth	  admitted	  to	  the	  PROGRESS	  Unit	  
between	  September	  1,	  2010	  and	  January	  7,	  2012.	  	  
	  

	  

32	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 33 of 104 PAGEID #: 1896

MENTAL	  HEALTH	  SERVICES	  
	  
III.B.	  1	  	  Mental	  Health	  Screening.	  	  The	  State	  shall	  implement	  policies,	  procedures	  and	   practices	  to	  ensure	  that	  all	  youth	  admitted	  to	  the	  facilities	  are	  comprehensively	  screened	   for	  mental	  disorders,	  including	  substance	  abuse,	  depression,	  and	  serious	  mental	  illness,	   within	  twenty-­‐four	  hours	  of	  admission.	  This	  screening	  shall	  be	  performed	  by	  qualified	   personnel,	  as	  part	  of	  the	  intake	  process,	  consistent	  with	  generally	  accepted	  professional	   standards	  of	  care.	  	  

Compliance	  Rating	   Non	  Compliance	  	  

Self	  Assessment	   N/A,	  the	  facility	  did	  not	  assign	  a	  compliance	  rating	  

Steps	  Taken	  to	   Assess	  Compliance	  

Per	  the	  SJCF	  self-­‐assessment,	  the	  facility	  continued	  to	  function	  as	  the	   intake	  facility	  for	  all	  youth	  admitted	  to	  ODYS.	  According	  to	  the	  self-­‐ assessment,	  “the	  recently	  developed	  policy	  and	  procedure	   ‘Behavioral	  Health	  Assessment,	  Screening,	  Appraisal	  and	  Evaluation’	   has	  been	  implemented	  and	  quality	  assurance	  monitoring	  and	  clinical	   supervision	  is	  being	  documented	  in	  the	  format	  provided	  in	  policy.”	  
	  
Per	  the	  documents	  reviewed,	  it	  was	  evident	  that	  there	  was	  a	  process	   in	  place	  to	  screen	  youth	  admitted	  to	  the	  facility	  for	  mental	  health	   and	  substance	  abuse	  disorders.	  Ten	  recent	  intake	  packets	  were	   reviewed;	  six	  of	  these	  youth	  were	  identified	  as	  needing	  mental	   health	  follow-­‐up.	  In	  reviewing	  policy	  404.01:	  “Behavioral	  Health	   Services,”	  it	  stated	  “all	  youth	  committed	  to	  ODYS	  shall	  receive	  a	   Behavioral	  Health	  screening	  within	  one	  hour	  of	  admission	  into	   reception,	  in	  accordance	  with	  ODYS	  Policy	  403.10…The	  screening	   shall	  identify	  risk/need	  areas	  and	  assist	  in	  the	  classification	  and	   future	  case	  planning	  processes,	  in	  accordance	  with	  ODYS	  Policy	   404.01.01…”	  In	  reviewing	  the	  admission	  date	  and	  administration	  of	   the	  Reception	  Assessment	  Summary,	  which	  includes	  the	  initial	   mental	  health	  screening,	  nine	  of	  the	  ten	  youth	  appear	  to	  have	  been	   screened	  within	  24	  hours	  of	  arrival	  at	  the	  facility.	  	  
	  
With	  regard	  to	  the	  nursing	  intake	  screening/assessment,	  all	  youth	   records	  provided	  for	  review	  revealed	  that	  this	  assessment	  was	   performed	  on	  the	  date	  of	  admission.	  	  It	  was	  not	  possible	  to	   determine	  if	  this	  was	  performed	  within	  one	  hour	  of	  admission,	  as	   although	  the	  time	  the	  instrument	  was	  administered	  was	   documented	  on	  the	  form,	  data	  regarding	  the	  time	  the	  youth	  entered	   the	  facility	  was	  not	  included	  in	  the	  documentation.	  
	  
Most	  of	  the	  assessment	  packets	  provided	  included	  the	  ODYS	   Behavioral	  Health	  Appraisal.	  The	  timing	  of	  the	  administration	  of	  this	  

	  

33	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 34 of 104 PAGEID #: 1897

tool	  varied	  from	  one	  day	  after	  admission	  to	  two	  weeks	  after	   admission.	  This	  tool	  provided	  a	  detailed	  exploration	  of	  symptoms	   that	  youth	  could	  be	  experiencing.	  It	  was	  reported	  during	  the	   previous	  monitoring	  tour	  that	  this	  document	  would	  provide	   information	  required	  for	  improved	  case	  conceptualization	  and	   diagnostic	  clarifications	  with	  recommendations	  for	  treatment.	   However,	  it	  was	  unclear	  at	  this	  time	  how	  this	  tool	  is	  utilized	  to	   formulate	  diagnoses	  and	  case	  conceptualizations.	  Again,	  the	  clinical	   summaries	  were	  minimal	  and	  did	  not	  identify	  specific	  diagnostic	   criteria.	  Additionally,	  the	  use	  of	  this	  document	  as	  a	  means	  to	   identifying	  recommendations	  appears	  basic.	  The	  identification	  of	   mental	  health	  symptoms	  and	  case	  conceptualizations	  are	  further	   discussed	  in	  provision	  4	  below.	  

Recommendations	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Full	  implementation	  of	  policy	  and	  procedure	  “Behavioral	   Health	  Assessment,	  Screening,	  Appraisal	  and	  Evaluation.”	  	   Given	  the	  change	  in	  facility	  mission,	  review	  and	  revise	  this	   policy	  as	  necessary.	  
2. Begin	  quality	  assurance	  monitoring	  or	  clinical	  supervision	   regarding	  the	  reception	  assessment	  summary	  documents.	  
3. Begin	  quality	  assurance	  monitoring	  to	  ensure	  that	  timelines	   required	  by	  policy	  and	  procedure	  are	  adhered	  to.	  

Sources	  of	   Information	  
	   	  

• Review	  of	  provided	  documents	  	   • Staff	  interview	  
	  

	  

34	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 35 of 104 PAGEID #: 1898

	  
III.B.2	  	  Immediate	  Referral.	  If	  the	  mental	  health	  screen	  identifies	  an	  issue	  that	  places	  the	   youth’s	  safety	  at	  immediate	  risk,	  the	  youth	  shall	  be	  immediately	  referred	  to	  a	  qualified	   mental	  health	  professional	  for	  assessment,	  treatment	  and	  any	  other	  appropriate	  action,	   such	  as	  transfer	  to	  another,	  more	  appropriate	  setting.	  The	  State	  shall	  ensure	  that,	  absent	   extraordinary	  circumstances,	  qualified	  mental	  health	  professionals	  are	  available	  for	   consultation	  within	  12	  hours	  of	  such	  referrals.	  	  

Compliance	  Rating	   Non	  Compliance	  

Self	  Assessment	   N/A,	  the	  facility	  did	  not	  assign	  a	  compliance	  rating	  

Steps	  Taken	  to	   Assess	  Compliance	  

Per	  the	  facility	  self-­‐assessment,	  several	  changes	  were	  implemented	   in	  order	  “to	  ensure	  that	  qualified	  staff	  are	  available	  for	  consultation	   within	  24	  hours	  of	  an	  emergent	  need.”	  This	  included	  extended	  work	   hours	  for	  social	  work	  and	  psychology	  staff,	  placement	  of	  psychology	   offices	  on	  the	  living	  units,	  and	  installation	  of	  secure	  boxes	  on	  each	   unit.	  Per	  the	  self-­‐assessment,	  mental	  health	  staff	  were	  scheduled	  to	   be	  at	  the	  facility	  until	  8pm	  on	  weeknights	  and	  from	  8am	  to	  4:30pm	   on	  weekends.	  This	  was	  echoed	  by	  the	  review	  of	  staff	  schedules	   provided	  via	  the	  document	  request.	  	  
	  
The	  self-­‐assessment	  admitted	  that	  historically,	  the	  documentation	  of	   response	  times	  to	  requests	  for	  services	  was	  not	  a	  priority.	  “In	   addition	  to	  the	  new	  formal	  process	  for	  requesting	  services	   represented	  by	  the	  secure	  boxes	  on	  units,	  we	  have	  begun	  to	  include	   not	  only	  the	  time	  of	  the	  visits	  in	  case	  notes,	  but	  also	  the	  time	  a	   verbal	  request	  was	  made.”	  Please	  see	  the	  discussion	  documented	   regarding	  provision	  9	  below	  for	  further	  information	  regarding	  this	   topic.	  	  
	  
Given	  that	  facility	  administrative	  and	  behavioral	  health	  staff	  as	  well	   as	  DYS	  administrative	  staff	  verbalized	  the	  need	  to	  revise	  behavioral	   health	  policy	  and	  procedure,	  this	  process	  must	  be	  formalized	  in	   policy	  and	  procedure.	  	  Following	  the	  development	  and	   implementation	  of	  policy	  and	  procedure	  to	  guide	  this	  process,	  data	   regarding	  the	  time	  interval	  between	  identification	  of	  an	  issue	  that	   places	  the	  youth’s	  safety	  at	  risk	  and	  when	  he	  or	  she	  is	  actually	   assessed	  by	  a	  mental	  health	  professional	  must	  be	  collated	  and	   reviewed	  via	  a	  quality	  assurance	  process.	  
	  
This	  provision	  includes	  a	  requirement	  for	  staff	  ability	  to	  access	   transfer	  of	  a	  youth	  to	  “another,	  more	  appropriate	  setting.”	  	  During	   the	  last	  two	  monitoring	  tours,	  youth	  with	  exacerbated	  mental	  illness	   requiring	  intensive	  mental	  health	  treatment	  were	  discovered	  at	  SJCF.	  	   As	  discussed	  in	  provision	  16	  below,	  it	  was	  concerning	  that	  during	  

	  

35	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 36 of 104 PAGEID #: 1899

both	  of	  these	  tours,	  facility	  mental	  health	  staff	  were	  unable	  to	  access	   more	  appropriate	  placements.	  	  During	  upcoming	  monitoring	  tours,	   this	  will	  be	  a	  focus	  of	  attention.	  	  	  

Recommendations	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Revise	  policy	  and	  procedure	  to	  address	  the	  newly	  instituted	   process	  regarding	  immediate	  referral	  to	  a	  qualified	  mental	   health	  professional.	  
2. Collect	  data	  regarding	  the	  time	  lapse	  between	  referral	  and	   actual	  evaluation	  or	  assessment	  for	  quality	  assurance	   monitoring.	  
3. Ensure	  that	  staff	  are	  aware	  of	  the	  process	  by	  which	  a	  youth	   may	  access	  other	  appropriate	  mental	  health	  services	  (e.g.	  a	   facility	  based	  mental	  health	  unit	  or	  an	  inpatient	  psychiatric	   facility).	  	  This	  may	  be	  accomplished	  via	  policy	  and	  procedure	   development,	  staff	  training,	  and	  staff	  supervision.	  

Sources	  of	   Information	  
	   	  

• Review	  of	  provided	  documents	  	   • Observation	   • Staff	  interview	  
	  

	  

36	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 37 of 104 PAGEID #: 1900

	  
III.B.3	  	  	  Identification	  of	  Previously	  Unidentified	  Youth.	  The	  facilities	  shall	  implement	   policies,	  procedures	  and	  practices	  consistent	  with	  generally	  accepted	  professional	  standards	   of	  care	  to	  identify	  and	  address	  potential	  manifestations	  of	  mental	  or	  behavioral	  disorder	  in	   youth	  who	  have	  not	  been	  previously	  identified	  as	  presenting	  mental	  health	  or	  behavioral	   needs	  requiring	  treatment.	  	  

Compliance	  Rating	   Non	  Compliance	  

Self	  Assessment	   N/A,	  the	  facility	  did	  not	  assign	  a	  compliance	  rating	  

Steps	  Taken	  to	   Assess	  Compliance	  

Per	  the	  facility	  self-­‐assessment,	  “under	  our	  current	  mission,	  we	  are	   anticipating	  that	  this	  will	  be	  a	  more	  common	  occurrence.”	  	  The	  self-­‐ assessment	  identified	  numerous	  steps	  that	  the	  facility	  had	  identified	   in	  order	  to	  ensure	  that	  youth	  with	  mental	  health	  disorders	  were	   identified.	  	  These	  included:	  “the	  new	  Behavioral	  Health	   Appraisal…includes	  an	  enhanced…MSE	  [mental	  status	   exam]…psychology	  staff	  meet	  on	  a	  weekly	  basis…standard	   component	  of…meetings	  a….discussion	  of	  ‘red-­‐flag’	  youth.”	  
	  
Per	  the	  facility	  assessment	  and	  staff	  interviews,	  given	  the	  change	  in	   facility	  mission,	  with	  more	  male	  youth	  residing	  at	  the	  facility	  as	  their	   primary	  site,	  this	  was	  opined	  to	  become	  more	  of	  an	  issue.	  	  In	  the	   past,	  the	  facility	  housed	  greater	  numbers	  of	  female	  youth,	  the	   majority	  of	  who	  were	  added	  to	  the	  mental	  health	  caseload	  upon	   admission.	  	  Currently	  with	  an	  increased	  census	  of	  long	  term	  male	   youth,	  many	  of	  whom	  were	  not	  initially	  identified	  as	  requiring	   mental	  health	  services,	  this	  was	  likely	  to	  become	  a	  significant	  issue.	  
	  
Per	  the	  most	  recent	  monitoring	  tour,	  there	  were	  concerns	  that	   facility	  mental	  health	  staff	  were	  experiencing	  difficulty	  with	   recognizing	  and	  responding	  to	  signs	  and	  symptoms	  of	  serious	  mental	   illness.	  Deficiencies	  of	  this	  type	  were	  discussed	  in	  the	  previous	   monitoring	  report	  regarding	  Youth	  060.	  	  	  
	  
Youth	  060	  was	  experiencing	  the	  signs	  and	  symptoms	  of	  a	  serious	   mental	  illness	  including	  but	  not	  limited	  to,	  experiencing	  auditory	   hallucinations,	  engaging	  in	  bizarre	  behavior,	  refusing	  to	  leave	  his	  cell,	   and	  refusing	  to	  engage	  in	  mental	  health	  treatment.	  	  While	  staff	  had	   identified	  him	  as	  mentally	  ill,	  they	  were	  having	  difficulty	  with	  the	   development	  of	  a	  treatment	  plan,	  and	  with	  making	  the	   determination	  regarding	  his	  appropriateness	  for	  placement	  at	  SJCF.	  	   Ultimately,	  following	  prompting	  from	  the	  monitor,	  this	  youth	  was	   transferred	  from	  SJCF	  into	  a	  treatment	  facility.	  
	  
A	  similar	  issue	  occurred	  during	  the	  most	  recent	  monitoring	  tour.	  

	  

37	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 38 of 104 PAGEID #: 1901

Youth	  040	  was	  reportedly	  declining	  to	  engage	  in	  mental	  health	   treatment	  and	  programming.	  	  Upon	  the	  request	  of	  the	  monitor,	  this	   youth	  was	  interviewed	  by	  the	  facility	  psychiatrist	  and	  was	  noted	  to	   exhibit	  signs	  and	  symptoms	  of	  psychosis	  requiring	  his	  transfer	  to	   another	  facility	  so	  that	  he	  could	  receive	  mental	  health	  treatment.	  	  It	   was	  concerning	  that	  while	  behavioral	  health	  staff	  had	  questioned	  the	   existence	  of	  psychiatric	  illness;	  they	  had	  not	  taken	  steps	  to	  ensure	   that	  he	  received	  a	  further	  assessment	  or	  necessary	  treatment.	  	  	  
	  
Observation	  of	  and	  interaction	  with	  several	  of	  the	  male	  youth	   currently	  housed	  on	  the	  Progress	  Unit	  at	  SJCF	  raised	  concerns	   regarding	  their	  mental	  health	  needs.	  The	  need	  for	  comprehensive	   assessments	  of	  these	  youth	  is	  discussed	  in	  the	  ensuing	  provisions	   (see	  the	  discussion	  regarding	  provision	  10	  below).	  
	  
The	  goal	  of	  this	  provision	  was	  to	  ensure	  that	  youth	  who	  may	  not	   present	  with	  a	  history	  of	  mental	  illness	  and	  who	  are	  not	  identified	  at	   the	  time	  of	  initial	  assessment	  as	  being	  at	  risk	  for	  mental	  illness	  or	   behavioral	  challenges,	  are	  monitored	  over	  the	  course	  of	  their	   incarceration	  for	  exacerbations	  of	  symptoms	  and	  referred	  for	  mental	   health	  treatment.	  Administrative	  staff	  were	  aware	  of	  the	  need	  for	   ongoing	  and	  improved	  quality	  assurance	  to	  review	  documentation	   and	  the	  decision-­‐making	  process	  regarding	  youth	  mental	  health	   needs.	  	  As	  discussed	  in	  provision	  4	  below,	  multiple	  assessment	   documents	  were	  being	  generated,	  however,	  there	  were	  no	   acceptable	  case	  formulations	  reviewed	  in	  the	  documents	  that	  tied	  all	   the	  information	  obtained	  together	  in	  a	  coherent	  package	  for	  the	   reader.	  	  This	  was	  an	  area	  that	  would	  be	  amenable	  to	  quality	   assurance,	  peer	  review	  process	  and	  clinical	  supervision.	  	  	  

Recommendations	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Develop	  quality	  assurance	  monitoring	  regarding	  re-­‐ evaluation	  of	  youth	  who	  experience	  an	  exacerbation	  of	   mental	  health	  symptoms	  or	  behavioral	  challenges.	  
2. Ensure	  the	  creation	  of	  a	  case	  conceptualization	  for	  each	   youth.	  
3. Ensure	  that	  direct	  care	  staff	  and	  behavioral	  health	  staff	  are	   trained	  to	  recognize	  and	  respond	  to	  signs	  and	  symptoms	  of	   serious	  mental	  illness.	  

Sources	  of	   Information	  
	  

• Review	  of	  provided	  documents	  (e.g.	  Policy	  and	  Procedure,	   draft	  Policy	  and	  Procedure,	  youth	  records).	  
• Staff	  interview	  
	  

	  

38	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 39 of 104 PAGEID #: 1902

	  
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	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 40 of 104 PAGEID #: 1903

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	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 41 of 104 PAGEID #: 1904

Interview,	  and	  PREA	  Flier.	  As	  stated	  above	  there	  was	  a	  lack	  of	   utilization	  of	  these	  tools	  in	  the	  development	  of	  comprehensive	  case	   conceptualizations.	  	  	  
	  
It	  was	  reported	  during	  the	  monitoring	  tour	  that	  staff	  have	  begun	  to	   develop	  case	  conceptualizations.	  Provided	  as	  part	  of	  the	  document	   request	  were	  ten	  case	  conceptualization	  examples,	  which	  served	  to	   further	  demonstrate	  the	  need	  to	  evaluate	  and	  train	  staff	  on	  case	   conceptualizations.	  	  For	  example:	  
	  
Youth	  090	  was	  admitted	  8.26.11	  and	  his	  case	  conceptualization	  was	   completed	  9.7.11.	  There	  were	  no	  diagnostic	  criteria	  or	  clear	   symptom	  picture	  documented.	  His	  diagnoses	  at	  the	  time	  of	  the	   report	  were:	  History	  of	  Bipolar	  Disorder,	  history	  of	  ADHD,	  history	  of	   Learning	  Disorder.	  	  
	  
Youth	  210	  had	  been	  at	  the	  facility	  since	  at	  least	  October	  2010	  (an	   exact	  date	  was	  unclear	  from	  the	  assessment)	  and	  the	  case	   conceptualization	  was	  completed	  on	  the	  psychological	  services	   summary	  form	  on	  7.5.11.	  The	  writer	  expanded	  on	  this	  youth’s	  history	   and	  summary	  of	  services,	  as	  well	  as	  explaining	  testing	  results.	   However,	  the	  diagnostic	  picture	  was	  unclear,	  despite	  a	  long	   incarceration.	  Diagnoses	  at	  the	  time	  of	  the	  report	  were:	  Mood	   Disorder,	  NOS;	  Schizoaffective	  Disorder;	  R/O	  Bipolar	  Disorder;	   Conduct	  Disorder;	  and	  Polysubstance	  Abuse,	  by	  history.	  
	  
Per	  a	  review	  of	  the	  10	  reception/assessment	  summaries	  provided	   per	  the	  document	  request,	  six	  youth	  were	  identified	  at	  intake	  as	   requiring	  mental	  health	  follow-­‐up.	  	  Four	  of	  these	  were	  diagnosed	   with	  Mood	  Disorder,	  NOS.	  The	  fifth	  was	  diagnosed	  with	  Depressive	   Disorder,	  NOS.	  The	  sixth	  youth	  reported	  auditory	  and	  visual	   hallucinations	  and	  was	  also	  placed	  on	  the	  mental	  health	  caseload;	   however,	  no	  mental	  health	  diagnosis	  was	  given	  during	  the	  intake	   process.	  Three	  of	  the	  youth	  were	  also	  diagnosed	  a	  disorder	  in	  the	   spectrum	  of	  attention	  deficit	  hyperactivity	  disorder.	  	  In	  no	  case	  were	   diagnostic	  criteria	  expounded	  upon,	  making	  it	  difficult	  to	  ascertain	   the	  reason	  behind	  the	  clinical	  impressions.	  It	  is	  necessary	  to	  identify	   the	  specific	  symptoms	  a	  youth	  identifies,	  in	  addition	  to	  utilizing	   collateral	  information	  from	  parents	  or	  guardians	  and	  treatment	   providers,	  in	  order	  to	  develop	  a	  comprehensive	  mental	  health	   assessment.	  	  
	  
As	  indicated	  in	  the	  previous	  monitoring	  report,	  despite	  the	  generation	   of	  multiple	  assessment	  forms,	  there	  was	  no	  document	  to	  tie	  all	  the	  

	  

41	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 42 of 104 PAGEID #: 1905

information	  obtained	  together	  in	  a	  coherent	  package	  for	  the	  reader,	   treatment	  team,	  or	  future	  treatment	  provider	  inclusive	  of	  a	  diagnostic	   formulation	  or	  case	  conceptualization.	  	  This	  is	  an	  area	  that	  would	  be	   amenable	  to	  quality	  assurance,	  peer	  review	  process	  and	  clinical	   supervision.	  	  	  

Recommendations	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Continue	  and	  expand	  quality	  assurance	  measures	  including	  a	   peer	  review	  process	  and	  clinical	  supervision	  to	  ensure	  the	   development	  of	  a	  case	  conceptualization	  that	  ties	  together	   information	  gleaned	  in	  the	  assessment	  process.	  	  In	  order	  for	   quality	  assurance	  to	  be	  meaningful,	  a	  subset	  of	  case	  records	   must	  be	  reviewed,	  one	  case	  review	  does	  not	  suffice	  as	  quality	   assurance.	  
2. Consider	  individual	  clinical	  supervision	  regarding	  the	   assessment	  process	  and	  development	  of	  the	  case	   formulation.	  
3. Ensure	  that	  behavioral	  health	  staff	  are	  aware	  of	  the	   necessary	  components	  of	  a	  quality	  case	  formulation.	  
4. Review	  and	  revise	  policy	  and	  procedure	  to	  reflect	  the	   requirements	  of	  this	  provision	  and	  the	  new	  facility	  mission.	  

Sources	  of	   Information	  
	   	  

• Review	  of	  policy	  and	  procedure	   • Review	  of	  youth	  records	   • Review	  of	  other	  provided	  documents	   • Staff	  interview	  
	  

	  

42	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 43 of 104 PAGEID #: 1906

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

Compliance	  Rating	   Non	  Compliance	  

Self	  Assessment	   N/A,	  the	  facility	  did	  not	  assign	  a	  compliance	  rating	  

Steps	  Taken	  to	   Assess	  Compliance	  

Per	  the	  facility	  self-­‐assessment,	  the	  Freedom	  New	  Phoenix	  Cognitive	   Behavioral	  Health	  Program	  (NFP)	  was	  implemented	  on	  all	  units.	  	  This	   program	  was	  reportedly	  a	  component	  of	  the	  “Ohio	  Model…a	   comprehensive	  program	  that	  includes	  evidence-­‐based	  concepts	  of	   cognitive-­‐behavioral	  therapy	  (CBT),	  motivational	  enhancement	   (MET),	  motivational	  interviewing	  (MI),	  and	  social	  learning.”	  	  
	  
	  Per	  the	  facility	  self-­‐assessment,	  NFP	  was	  implemented	  “after	   training	  all	  staff	  including	  Youth	  Specialists	  on	  how	  to	  conduct	  the	   Managing	  Anger	  and	  Violence	  groups.	  	  Social	  Workers	  were	  trained	   on	  Core	  A	  which	  is	  the	  Social	  Worker	  component	  and	  Social	  Workers	   and	  Psychology	  staff	  were	  trained	  on	  the	  overlay	  components	  of	  the	   program.”	  	  Following	  the	  training,	  the	  self-­‐assessment	  described	   coaching	  by	  administrative	  staff	  as	  well	  as	  the	  formation	  of	  a	   Cognitive	  Behavior	  Therapy	  Oversight	  Committee	  (CBTOC).	  The	   reported	  purpose	  of	  coaching	  was	  to	  assist	  staff	  with	  “understanding	   the	  curriculum,	  how	  to	  run	  groups,	  how	  to	  complete	  documentation,	   etc.”	  
	  
Following	  the	  change	  of	  mission	  and	  focus	  of	  the	  SJCF,	  personnel	   changes	  necessitated	  by	  the	  “pick-­‐a-­‐post”	  resulted	  in	  staff	  unfamiliar	   with	  the	  CBT	  processes	  in	  place	  at	  SJCF.	  “Pick-­‐a-­‐post”	  allows	  direct	   care	  staff	  to	  choose,	  according	  to	  seniority,	  where	  they	  will	  work.	   With	  this	  process	  in	  place,	  staff	  who	  have	  not	  been	  properly	  trained	   in	  a	  specific	  modality	  (e.g.,	  CBT),	  can	  request	  work	  on	  a	  particular	   unit	  in	  the	  absence	  of	  training.	  Per	  the	  self-­‐	  assessment,	  “we	  then	   began	  a	  QA/QI	  process	  to	  implement	  a	  new	  coaching	  project	  for	   each	  of	  the	  teams	  so	  that	  we	  could	  provide	  technical	  support	  and	   assistance	  to	  the	  teams	  as	  they	  began	  their	  new	  missions.	  	  This	   process	  is	  in	  the	  beginning	  stage.”	  
	  
In	  reviewing	  the	  Freedom	  New	  Phoenix	  Cognitive	  Behavioral	  Health	   program	  curriculum,	  the	  inclusion	  of	  direct	  care	  staff	  is	  vital	  to	  the	   success	  of	  the	  program.	  Per	  the	  documents	  provided	  and	  the	  self-­‐ assessment,	  it	  was	  reported	  that	  youth	  specialists	  are	  being	  

	  

43	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 44 of 104 PAGEID #: 1907

integrated	  into	  treatment	  team	  meetings	  to	  further	  involve	  them	  in	   group	  process	  and	  gather	  information	  regarding	  their	  observations	  of	   youth.	  	  
	  
Youth	  specialists	  facilitate	  CBT	  groups	  on	  the	  units.	  It	  appeared	  from	   the	  two	  youth	  specialist	  run	  groups	  observed	  during	  the	  monitoring	   tour	  that	  additional	  training,	  coaching,	  modeling	  was	  required.	  	  Basic	   tenets	  of	  effective	  group	  facilitation	  were	  not	  utilized,	  these	  included	   environment,	  review	  of	  group	  rules,	  direction	  of	  group	  topic,	  and	   engagement	  of	  the	  youth.	  	  	  
	  
In	  one	  group	  observed,	  youth	  were	  spread	  about	  a	  large	  room,	   seated	  in	  groups	  at	  tables.	  	  Youth	  were	  not	  engaged	  in	  the	  group	   process,	  rather	  talking	  amongst	  themselves	  or	  playing	  cards.	  	  The	   facilitator	  did	  not	  attempt	  to	  engage	  the	  youth,	  but	  continued	  to	   read	  directly	  from	  a	  prepared	  document	  regarding	  the	  scheduled	   group	  topic	  for	  that	  day.	  	  When	  youth	  continued	  to	  avoid	   engagement	  in	  the	  group	  process,	  another	  youth	  specialist,	  not	  the	   group	  facilitator,	  began	  to	  shout	  at	  the	  youth,	  threatening,	  “if	  you	   aren’t	  going	  to	  participate,	  you	  can	  go	  to	  your	  rooms.”	  	  As	  the	  group	   progressed,	  the	  youth	  facilitator	  became	  understandably	  frustrated.	  	   It	  was	  noted	  by	  the	  monitor	  that	  the	  facilitator	  was	  attempting	  to	   lead	  the	  group,	  but	  was	  ill	  equipped	  for	  the	  task.	  	  This	  was	  an	   untenable	  situation	  for	  both	  the	  youth	  specialist	  and	  the	  youth	   participants.	  	  	  
	  
It	  was	  pertinent	  to	  note	  that	  concurrently,	  mental	  health	  staff	   assigned	  to	  this	  unit	  was	  conducting	  a	  group.	  	  There	  were	  two	  youth	   in	  the	  mental	  health	  group	  and	  approximately	  twenty	  youth	  in	  the	   group	  facilitated	  by	  the	  youth	  specialist.	  	  This	  was	  another	  factor	   contributing	  to	  the	  youth	  specialist’s	  inability	  to	  engage	  the	  youth.	  	   Effective	  groups	  should	  have	  no	  more	  than	  eight	  to	  ten	  youth	   participants.	  
	  
A	  second	  group	  facilitated	  by	  a	  youth	  specialist	  was	  observed.	  	  	  This	   group	  was	  comprised	  of	  seven	  female	  youth.	  	  These	  youth	  were	   initially	  engaged	  in	  the	  group	  process.	  	  There	  were	  periods	  of	  good	   interaction	  between	  the	  youth	  and	  the	  facilitator,	  however,	  the	   topics	  discussed	  ran	  the	  gamut,	  and	  the	  monitor	  was	  unclear	  with	   regard	  to	  the	  CBT	  topic	  being	  addressed.	  	  Maintaining	  order	  was	  a	   challenge,	  as	  in	  middle	  of	  group,	  three	  youth	  stood	  and	  walked	  away	   from	  the	  discussion,	  while	  another	  began	  to	  talk	  loudly	  with	  no	   redirection	  from	  the	  group	  facilitator.	  	  Again,	  it	  was	  opined	  that	  the	   youth	  specialist	  was	  attempting	  to	  lead	  the	  group,	  but	  was	  ill	  

	  

44	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 45 of 104 PAGEID #: 1908

equipped	  for	  the	  task.	  
	  
Both	  of	  these	  examples	  indicate	  that	  additional	  modeling	  and	   coaching	  are	  necessary.	  	  Also,	  administration	  needs	  to	  review	  group	   structure	  in	  order	  to	  ensure	  that	  appropriate	  numbers	  of	  youth	  are	   assigned	  to	  a	  specific	  group	  interaction.	  	  	  
	  
With	  regard	  to	  treatment	  provided	  by	  mental	  health	  staff,	  two	  group	   interactions	  were	  observed.	  	  One	  of	  these	  groups	  held	  on	  the	  girls	   mental	  health	  unit	  was	  well	  run.	  	  The	  group	  leader	  engaged	  the	  six	   youth	  participants.	  	  Appropriate	  topics	  were	  introduced	  and	   supported	  with	  toys	  and	  other	  visual	  aides	  to	  ensure	  that	  youth	  “got	   the	  message.”	  	  This	  was	  a	  trauma	  -­‐focused	  group,	  and	  toward	  the	   end,	  one	  youth	  became	  visibly	  distressed.	  	  The	  mental	  health	  staff	   appropriately	  addressed	  this	  youth’s	  issues,	  but	  other	  youth	  became	   distressed	  as	  a	  result.	  	  The	  unit	  social	  worker,	  unit	  manger	  and	  youth	   specialists	  did	  a	  good	  job	  of	  ensuring	  the	  safety	  of	  all	  youth	   participating	  in	  group	  and	  of	  addressing	  the	  distress	  of	  all	  youth	   participants.	  
	  
A	  second	  trauma	  focused	  mental	  health	  facilitated	  group	  was	   observed	  on	  Cedar	  unit.	  	  This	  group	  was	  attended	  by	  six	  youth.	  	   Unlike	  the	  group	  observed	  with	  the	  female	  youth	  where	  the	  unit	   social	  worker	  was	  in	  attendance,	  this	  group	  had	  no	  other	  mental	   health	  staff	  in	  attendance.	  	  The	  mental	  health	  facilitator	  had	   prepared	  documents	  for	  the	  youth	  to	  read	  and	  review.	  	  The	   facilitator	  attempted	  to	  engage	  the	  youth;	  however,	  these	  attempts	   became	  futile	  following	  her	  disclosure	  of	  confidential	  information	   that	  three	  separate	  youth	  had	  disclosed	  to	  her	  during	  individual	   sessions	  (e.g.,	  statements	  from	  the	  mental	  health	  professional	  such	   as	  “you	  know	  about	  that	  [insert	  youth	  name]…you	  told	  me	  about	   that	  in	  therapy.”)	  	  Following	  this,	  youth	  became	  frustrated	  and	  the	   facilitator	  lost	  credibility.	  	  Youth	  were	  noted	  to	  mumble	  under	  their	   breath,	  looking	  at	  peers	  across	  the	  room,	  stating	  audibly,	  “I	  didn’t	  say	   that	  …she	  don’t	  know	  what	  she	  is	  saying.”	  	  Concerns	  regarding	  this	   inappropriate	  disclosure	  of	  confidential	  information	  were	  discussed	   with	  administrative	  mental	  health	  staff	  during	  the	  monitoring	  tour.	  	   Subsequent	  documentation	  received	  from	  the	  facility	  indicated	  that	   it	  was	  being	  addressed	  via	  supervision.	  
	  
Per	  the	  requested	  documents,	  sign-­‐in	  sheets	  for	  groups	  completed	   during	  the	  90	  days	  prior	  to	  the	  monitoring	  visit	  were	  provided.	   According	  to	  these	  sign-­‐in	  sheets,	  attendance	  and	  participation	  in	   each	  group	  varied.	  Documentation	  indicated	  anywhere	  from	  one	  to	  

	  

45	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 46 of 104 PAGEID #: 1909

18	  youth	  in	  attendance	  at	  group	  sessions.	  As	  stated	  above,	  the	   facility	  must	  address	  the	  issue	  of	  too	  many	  youth	  assigned	  to	  one	   group	  therapy	  interaction.	  	  Additionally,	  one	  youth	  in	  attendance	   does	  not	  qualify	  as	  a	  group	  therapeutic	  interaction.	  
	  
Additionally,	  per	  the	  documentation	  provided,	  there	  were	  groups	   cancelled	  due	  to	  mental	  health	  staff	  being	  unavailable.	  	  This	  issue	   was	  further	  discussed	  with	  regard	  to	  staffing	  patterns	  in	  the	   discussion	  of	  provision	  11.	  When	  fully	  staffed,	  there	  must	  be	   provisions	  to	  provide	  services	  in	  the	  absence	  of	  primary	  staff.	  	  
	  
Review	  of	  progress	  notes	  regarding	  individual	  therapy	  sessions	   revealed	  marked	  variability	  in	  the	  quality	  of	  the	  documentation,	  the	   duration	  of	  the	  therapeutic	  interactions	  and	  the	  frequency	  of	  the	   therapeutic	  interactions.	  	  Some	  mental	  health	  providers	  were	  noted	   to	  meet	  frequently	  with	  youth	  for	  brief	  periods	  of	  time	  (15	  minutes	   to	  30	  minutes),	  where	  others	  met	  less	  frequently	  for	  longer	  periods	   (45	  minutes).	  	  A	  review	  of	  treatment	  planning	  documents	  did	  not	   reveal	  documentation	  regarding	  the	  level	  of	  care	  or	  frequency	  of	   interaction	  prescribed	  for	  each	  individual	  youth.	  	  Therefore,	  it	  was	   not	  possible	  to	  determine	  if	  the	  frequency	  noted	  via	  record	  review	   was	  appropriate	  for	  a	  particular	  youth.	  	  On	  a	  positive	  note,	   documentation	  and	  observed	  interaction	  between	  occupational	   therapy	  staff	  and	  youth	  was	  superior.	  
	  
Given	  the	  above,	  it	  was	  apparent	  that	  while	  some	  treatment	  was	   occurring,	  improvements	  to	  the	  overall	  treatment	  program	  and	   documentation	  of	  treatment	  planned	  and	  provided	  will	  be	  necessary	   for	  the	  facility	  to	  meet	  the	  requirements	  of	  this	  provision.	  	  In	  the	   upcoming	  monitoring	  tour,	  additional	  information	  regarding	  the	   facilities	  mental	  health	  treatment	  program	  will	  be	  requested	  and	   reviewed.	  
	  
Specific	  concerns	  were	  noted	  regarding	  the	  treatment	  program	  for	   youth	  housed	  in	  the	  Progress	  unit.	  	  It	  was	  concerning	  that	  this	   particular	  unit	  relied	  on	  room	  confinement	  with	  a	  paucity	  of	  mental	   health	  treatment	  for	  youth,	  some	  whom,	  were	  identified	  as	  having	   serious	  mental	  health	  issues.	  	  As	  discussed	  with	  the	  facility	   administration,	  facility	  mental	  health	  staff	  and	  DYS	  administration,	   the	  programming	  on	  this	  unit	  must	  be	  a	  priority	  and	  will	  be	  the	  focus	   of	  future	  monitoring	  visits.	  	  In	  the	  meantime,	  it	  is	  strongly	   recommended	  and	  discussed	  via	  this	  monitoring	  report	  that	  the	   facility	  begin	  to	  reevaluate	  all	  the	  youth	  housed	  in	  this	  program	  with	   respect	  to	  their	  mental	  health	  and	  intellectual	  functioning	  in	  order	  to	  

	  

46	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 47 of 104 PAGEID #: 1910

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	  

	  

47	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 48 of 104 PAGEID #: 1911

• Staff	  interview	  

	  

	  

	  

	  

48	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 49 of 104 PAGEID #: 1912

	  
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)	  
	  

	  

49	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 50 of 104 PAGEID #: 1913

	  
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	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 51 of 104 PAGEID #: 1914

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	  

	  

51	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 52 of 104 PAGEID #: 1915

previous	  monitoring	  period.	  	  Per	  the	  facility	  self-­‐assessment,	  “coaches	   have	  been	  assigned	  to	  every	  IDT…a	  kick	  off	  meeting	  is	  scheduled	  for	   11/15/11	  to	  clarify	  the	  role	  of	  each	  coach…[to]	  increase	  participation	   in	  the	  meeting	  from	  all	  members;	  work	  with	  the	  team	  in	  developing	   and	  monitoring	  measurable	  goals	  and	  objectives	  related	  for	  each	   youth;	  conduct	  on	  the	  spot	  feedback	  to	  allow	  for	  a	  more	  improved	   process	  and	  clarification	  of	  goals	  for	  each	  youth;	  [and]	  coaches	  are	  to	   attend	  all	  meetings	  whenever	  possible.”	  	   	   Full	  implementation	  of	  the	  coaching	  plan	  may	  improve	   communication	  and	  treatment	  planning	  within	  the	  IDT.	  	   Unfortunately,	  the	  facility	  had	  not	  begun	  the	  QA	  process	  for	  IDT	   meetings.	  	  A	  review	  of	  two	  quality	  assurance	  reports	  dated	  9.13.11	   (covering	  months	  January,	  February,	  and	  March	  2011)	  and	   9.14.11(covering	  months	  April,	  May,	  and	  June	  2011)	  revealed	  no	  QA	   data	  for	  IDT	  meetings.	  	   	   Per	  the	  documentation	  9.13.11,	  “Supervisor	  attended	  treatment	   team	  on	  the	  boys	  mental	  health	  unit,	  but	  did	  not	  document	  the	   reviews	  for	  1st	  quarter…Supervisor	  needs	  to	  be	  given	  more	  time	  to	   conduct	  IDT	  reviews	  and	  to	  make	  sure	  that	  he	  documents	  the	  ones	   that	  he	  is	  able	  to	  review…Psychology	  supervisor	  does	  not	  have	  time	   to	  attend	  IDT	  meetings	  due	  to	  his	  host	  of	  other	  duties.”	  	  	   	   Per	  the	  documentation	  9.14.11,	  “Supervisor	  did	  not	  conduct	  IDT	   reviews	  this	  quarter.	  	  The	  Supervisor	  should	  be	  given	  time	  to	  sit	  in	  on	   these	  meetings	  once	  per	  month.	  Current	  workload	  does	  not	  permit	   this…Supervisors	  time	  is	  so	  consumed	  that	  he	  does	  not	  have	  the	   opportunity	  to	  sit	  in	  on	  the	  IDT	  meetings.”	  

Recommendations	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Ensure	  psychiatric	  resources	  are	  available	  to	  allow	   participation	  in	  Interdisciplinary	  Treatment	  Team	  meetings.	  
2. Ensure	  that	  direct	  care	  staff	  are	  included	  in	  and	  valued	   members	  of	  the	  IDT.	  
3. Begin	  Quality	  Assurance	  monitoring	  of	  treatment	  planning	   efforts	  and	  IDT	  meetings.	  
4. Increase	  staff	  training/education	  regarding	  the	  timely	   formulation	  of	  a	  treatment	  plan	  and	  interventions	   developed	  as	  a	  result	  of,	  among	  other	  things,	  the	  discussion	   in	  IDT.	  	  These	  plans	  must	  then	  be	  implemented,	  first	  via	   training	  direct	  care	  staff.	  
5. Review	  the	  psychology	  supervisor	  duties	  and	  schedule	  to	   determine	  the	  need	  for	  additional	  resources	  such	  that	  this	  

	  

52	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 53 of 104 PAGEID #: 1916

Sources	  of	   Information	  
	   	  

staff	  member	  can	  complete	  the	  current	  assigned	  tasks.	  
• Staff	  Interview	   • Observation	  of	  Interdisciplinary	  Treatment	  Team	  meeting	   • Review	  of	  provided	  documents	  	   • Youth	  interview	  
	  

	  

53	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 54 of 104 PAGEID #: 1917

	  
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	  

	  

54	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 55 of 104 PAGEID #: 1918

the	  facility	  self-­‐assessment	  and	  review	  of	  the	  provided	  documents,	   information	  included	  in	  the	  previous	  monitoring	  report	  will	  be	   italicized	  below	  for	  review:	  
	  
“Per	  the	  recently	  implemented	  policy	  entitled	  “Behavioral	  Health	   Services”	  the	  Integrated	  Treatment	  Plan	  is	  “a	  formal	  strategy	   developed	  to	  address	  the	  habilitation,	  education,	  rehabilitation,	   social,	  mental	  health	  and	  psychiatric	  needs	  of	  a	  specific	  youth.	  	  The	   plan	  is	  developed	  by	  an	  assigned	  Clinician	  or	  Provider	  in	  collaboration	   with	  the	  youth	  and	  the	  Interdisciplinary	  Team	  (IDT),	  and	  is	   implemented	  by	  both	  the	  youth	  and	  all	  Behavioral	  Health	  Services	   staff	  who	  work	  with	  the	  youth...Acceptable	  Integrated	  Treatment	   Plans	  must	  include	  measurable	  goals	  and	  objectives,	  with	  available	   targeted	  interventions	  to	  address	  each	  goal.	  	  Progress	  notes	  authored	   regarding	  the	  youth’s	  treatment	  should	  refer	  to	  the	  youth’s	  treatment	   goals	  and	  document	  the	  response	  (or	  lack	  thereof)	  to	  the	  prescribed	   interventions…Integrated	  Treatment	  Plans	  should	  be	  reviewed	  at	  each	   Interdisciplinary	  Treatment	  Team	  meeting	  scheduled	  for	  the	  youth,	   and	  must	  be	  authored	  and	  reviewed	  with	  the	  participation	  of	  the	   youth	  and	  their	  parent	  or	  guardian	  (if	  appropriate).”	  	  

Recommendations	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Finalize	  and	  implement	  policy	  and	  procedure	  regarding	   Integrated	  Treatment	  Plans.	  
2. Train	  Behavioral	  Health	  Staff	  regarding	  development	  of	   Integrated	  Treatment	  Plans.	  
3. Ensure	  that	  Integrated	  Treatment	  Teams	  utilize	  the	   Integrated	  Treatment	  Plans	  as	  a	  road	  map	  for	  youth	   treatment	  and	  progress,	  and	  that	  the	  Integrated	  Treatment	   Plans	  are	  updated	  regularly	  as	  per	  policy	  and	  procedure	   pending	  implementation.	  
4. Develop	  quality	  assurance	  monitoring	  tools	  that	  are	  both	   process	  (e.g.	  were	  the	  targeted	  interventions	  appropriate	  for	   a	  particular	  youth;	  were	  measurable	  goals	  and	  objectives	   identified;	  per	  a	  review	  of	  the	  youth’s	  progress	  notes,	  did	   treatment	  provided	  to	  the	  youth	  follow	  the	  outline	  of	  the	   Integrated	  Treatment	  Plan)	  and	  outcome	  oriented	  (e.g.	  did	   the	  youth	  improve	  over	  the	  course	  of	  treatment	  per	  the	   Integrated	  Treatment	  Plan).	  

Sources	  of	   Information	  

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

	  

55	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 56 of 104 PAGEID #: 1919

	  

	  

	  

	  

56	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 57 of 104 PAGEID #: 1920

III.B.9	  	  Access	  to	  a	  QMHP.	  	  The	  State	  shall	  develop	  and	  implement	  policies,	  procedures	  and	   practices	  to	  ensure	  that	  youth	  who	  seek	  access	  to	  a	  qualified	  mental	  health	  professional	  are	   provided	  appropriate	  access	  in	  a	  timely	  manner.	  	  

Compliance	  Rating	   Non	  Compliance	  

Self	  Assessment	   N/A,	  the	  facility	  did	  not	  assign	  a	  compliance	  rating	  

Steps	  Taken	  to	   Assess	  Compliance	  

Per	  the	  review	  of	  policy	  and	  procedure	  entitled	  “Mental	  Health	   Referral,	  Evaluation	  and	  Disposition,”	  and	  the	  associated	  policy	   entitled	  “Referrals	  to	  Mental	  Health	  Services”	  performed	  for	  the	   previous	  monitoring	  report,	  these	  documents	  outline	  the	  process	  for	   any	  facility	  staff	  to	  refer	  a	  youth	  for	  an	  assessment	  to	  determine	  the	   need	  for	  mental	  health	  services.	  	  There	  are	  designated	  time	  limits	  for	   response	  to	  requests.	  	  Psychology	  must	  respond	  within	  five	  working	   days,	  psychiatry	  within	  ten	  working	  days	  and	  if	  the	  request	  is	  for	   additional	  evaluation,	  there	  is	  a	  fourteen	  working	  day	  response	   window.	  	  	  
	  
Per	  the	  documents	  provided	  and	  observations	  made	  during	  the	  most	   recent	  monitoring	  visit,	  psychology	  staff	  offices	  were	  located	  on	  the	   housing	  units,	  providing	  access	  to	  mental	  health	  professionals.	  Per	   the	  documents	  received	  regarding	  this	  provision,	  it	  was	  noted,	   “…youth	  typically	  ask	  to	  be	  seen	  directly	  and	  face	  to	  face,	  and	  when	   their	  psychology	  staff	  is	  not	  available,	  they	  typically	  wait	  until	  he	  or	   she	  is	  available.”	  It	  was	  further	  noted	  that	  “when	  a	  youth…needs	  to	   see	  psychology	  staff	  urgently,	  unit	  staff	  will	  call…all	  urgent	  requests	   are	  seen	  within	  24	  hours…notification	  of	  these	  needs	  typically	  is	   done	  by	  phone	  without	  the	  intermediate	  step	  of	  form	   completion…completion	  of	  forms…would	  be	  more	  likely	  to	  slow	   down	  the	  process	  of	  accessing	  psychology	  services.”	  
	  
A	  review	  of	  sample	  documentation	  regarding	  psychology	  response	   time	  to	  urgent	  mental	  health	  requests	  revealed	  six	  examples.	  	  Of	   these,	  two	  youth	  were	  seen	  immediately	  following	  their	  request,	  one	   was	  seen	  1.5	  hours	  following	  their	  request,	  and	  one	  was	  seen	  ten	   minutes	  following	  their	  request.	  	  Request	  times	  were	  not	   documented	  on	  the	  other	  two	  examples	  provided.	  	  	  
	  
Per	  the	  self-­‐assessment,	  secure	  mailboxes	  have	  been	  provided	  on	   the	  units	  for	  youth	  to	  request	  services	  without	  reliance	  upon	  direct	   care	  staff	  to	  communicate	  their	  request.	  Psychology	  or	  social	  work	   staff	  check	  these	  boxes	  daily.	  Youth	  interviewed	  during	  this	   monitoring	  tour	  were	  able	  to	  show	  the	  monitor	  the	  box	  within	  which	   to	  place	  their	  requests	  for	  services	  on	  their	  individual	  units.	  	  It	  is	   imperative	  that	  youth	  are	  able	  to	  independently	  access	  mentalhealth	  

	  

57	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 58 of 104 PAGEID #: 1921

care;	  as	  unfortunately,	  there	  may	  be	  situations	  where	  direct	  care	   staff	  could	  unintentionally	  or	  purposefully	  impede	  the	  youth’s	  access	   to	  necessary	  mental	  health	  treatment	  with	  resultant	  negative	   outcomes.	  
	  
One	  concern	  noted	  and	  communicated	  during	  the	  monitoring	  tour	   was	  access	  to	  mental	  health	  services	  for	  youth	  housed	  on	  the	   Progress	  unit.	  	  These	  youth	  were	  assigned	  to	  single	  cells	  where	  they	   remained	  the	  majority	  of	  the	  day.	  	  Youth	  on	  phase	  one	  of	  the	   program	  are	  in	  ambulatory	  restraints	  (“gators”)	  when	  they	  are	   outside	  of	  their	  cells.	  	  Youth	  and	  psychology	  staff	  interviewed	   revealed	  that	  these	  youth	  were	  not	  assessed	  by	  mental	  health	  staff	   on	  a	  daily	  basis,	  they	  were	  reportedly	  being	  checked	  three	  times	   weekly.	  	  These	  youth	  are	  at	  high	  risk	  for	  self-­‐injury	  and	  for	  the	   exacerbation	  of	  mental	  health	  symptoms.	  	  As	  such,	  they	  must	  be	   assessed	  on	  a	  daily	  basis	  by	  mental	  health	  staff.	  	  Following	   recommendations	  made	  by	  the	  monitor	  during	  the	  monitoring	  tour	   the	  facility	  self-­‐assessment	  revealed	  that	  now	  “Behavioral	  Health	   staff	  assigned	  to	  Progress	  programs	  will	  make	  rounds	  daily	  as	  a	  check	   in	  with	  all	  youth.	  They	  are	  required	  to	  speak	  with	  all	  youth	  and	   follow	  up	  where	  needed.”	  	  
	  
Per	  a	  review	  of	  mental	  health	  staff	  schedules	  provided,	  mental	   health	  staff	  scheduling	  included	  both	  evening	  (until	  8:00	  p.m.)	  and	   weekend	  hours,	  allowing	  for	  better	  daily	  coverage	  of	  youth	  mental	   health	  needs.	  However,	  of	  the	  mental	  health	  staff,	  only	  the	   psychology	  supervisor	  was	  on-­‐call	  24	  hours	  per	  day.	  	  

Recommendations	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Revise	  policy	  and	  procedure	  to	  reflect	  requirements	  for	  daily	   mental	  health	  assessments	  for	  those	  youth	  housed	  on	  the	   Progress	  unit.	  
2. Develop	  quality	  assurance	  monitoring	  to	  audit	  requests	  for	   mental	  health	  services	  inclusive	  of	  staff	  response	  time	  as	  well	   as	  timelines	  for	  completion	  of	  other	  mental	  health	  services	  as	   outlined	  by	  facility	  policy	  and	  procedure.	  
3. Ensure	  the	  youth’s	  open	  access	  to	  mental	  health	  services	  

Sources	  of	   Information	  
	   	  

• Facility	  self-­‐assessment	   • Review	  of	  provided	  documents	   • Youth	  interviews	   • Staff	  interviews	  

	  

58	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 59 of 104 PAGEID #: 1922

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

Compliance	  Rating	   Non	  compliance	  

Self	  Assessment	   N/A,	  the	  facility	  did	  not	  assign	  a	  compliance	  rating	  

Steps	  Taken	  to	   Assess	  Compliance	  

Per	  the	  policy	  and	  procedure	  entitled	  “Mental	  Health	  Referral,	   Evaluation,	  and	  Disposition”	  reviewed	  for	  the	  prior	  monitoring	   report,	  this	  policy	  “identifies	  the	  process	  for	  consideration	  and	   referral	  for	  mental	  health	  treatment,	  including	  placement	  on	  a	   mental	  health	  unit	  when	  determined	  to	  be	  necessary.	  Youth	   demonstrating	  serious	  mental	  health	  issues	  and/or	  who	  are	   determined	  to	  be	  unable	  to	  adequately	  manage	  the	  demands	  of	   living	  in	  the	  general	  population	  are	  referred	  for	  placement	  on	  an	   alternative	  living	  unit.”	  
	  
Policy	  and	  procedure	  implemented	  January	  1,	  2011	  entitled	   “Behavioral	  Health-­‐Special	  Services	  Living	  Units”	  included	  “guidelines	   for	  the	  referral	  of	  youth	  identified	  through	  clinical	  assessment	  as	   needing	  specialized	  housing	  and	  programming	  for	  the	  stabilization	  of	   the	  symptoms	  of	  an	  identified	  mental	  illness	  and	  program	   modifications	  due	  to	  cognitive	  and/or	  developmental	  limitations.”	  	   This	  policy	  guided	  the	  creation	  of	  the	  “Behavioral	  Health	  Review	   Panel”	  whose	  responsibility	  it	  was	  to	  “review	  information	  obtained	  in	   the	  reception	  process	  and	  determine	  the	  best	  options	  for	  each	  youth	   in	  regard	  to	  housing,	  programming…”	  	  
	  
In	  the	  intervening	  period	  since	  the	  last	  monitoring	  visit,	  the	  facility	   has	  undergone	  a	  change	  in	  mission.	  	  Per	  a	  memorandum	  dated	  8.4.11	   authored	  by	  legal	  counsel	  from	  DYS,	  “SJCF	  will	  serve	  all	  security	   classifications	  as	  a	  permanent	  facility	  for	  both	  male	  and	  female	  youth.	  	   It	  will	  include	  initial	  intake	  for	  youth	  from	  all	  88	  counties	  with	  referral	   and	  transfer	  to	  other	  sites	  within	  4	  days.	  	  SJCF	  will	  continue	  to	  have	   Central	  Medical	  Facility	  and	  will	  now	  house	  behaviorally	  challenged	   boys	  on	  a	  specialized	  unit	  named	  PROGRESS	  (Programming	  for	  Real	   Opportunity	  through	  Growth,	  Respect,	  Education,	  Safety,	  and	   Success)	  that	  will	  include	  a	  transition	  program.	  	  The	  male	  mental	   health	  unit	  has	  been	  transferred	  to	  Indian	  River	  Juvenile	  Correctional	   Facility	  (IRJCF)…Reception	  is	  Condensed	  to	  a	  Four	  Day	  Process	  at	  SJCF	   and	  Continues	  at	  the	  Youth’s	  Parent	  Facility…Day	  Twenty-­‐five:	   Behavioral	  Health	  Review	  Panel	  meets,	  Reception	  Assessment	   Summary	  completed…”	  Per	  interviews	  with	  facility	  and	  statewide	  

	  

59	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 60 of 104 PAGEID #: 1923

mental	  health	  administration,	  policy	  and	  procedure	  revisions	  required	   by	  the	  aforementioned	  change	  in	  mission	  remained	  pending	  at	  the	   time	  of	  the	  most	  recent	  monitoring	  visit.	  	  This	  is	  concerning	  as	  there	   has	  been	  a	  significant	  lapse	  in	  time	  between	  the	  change	  in	  mission	   and	  adjustment	  of	  facility	  policy	  and	  procedure	  to	  govern	  processes.	   	  
Per	  a	  review	  of	  provided	  documents,	  the	  behavioral	  review	  panel	  at	   SJCF	  had	  met	  on	  a	  weekly	  basis.	  	  The	  review	  of	  the	  panel’s	  meeting	   agenda	  and	  recommendations	  was	  limited	  by	  the	  documents	   provided.	  	  Minutes	  of	  the	  meeting	  consisted	  of	  a	  listing	  of	  youth	   reviewed	  that	  day.	  	  Additional	  documentation	  was	  not	  provided	  for	   review.	  
	  
A	  review	  of	  other	  provided	  documentation	  revealed	  concerns	  with	   the	  outcome	  of	  the	  intake	  assessment	  and	  housing	  unit	  assignments.	  	   For	  example,	  there	  were	  six	  female	  youth	  identified	  per	  the	   document	  request	  who	  were	  initially	  approved	  for	  placement	  in	  the	   general	  population.	  	  These	  youth,	  however,	  ultimately	  required	   enhanced	  services	  and	  required	  referral	  to	  the	  mental	  health	  unit.	  	  It	   should	  be	  noted	  that	  all	  six	  of	  these	  youth	  were	  appropriately	   assigned	  to	  the	  mental	  health	  caseload	  upon	  admission.	  	  It	  may	  be	   useful	  to	  complete	  retrospective	  record	  reviews	  for	  these	  youth	  to	   determine	  if	  there	  were	  any	  patterns	  or	  warning	  signs	  that	  may	  aid	   in	  formulating	  recommendations	  for	  youth	  in	  the	  future.	  	  	  
	  
Additional	  concerns	  regarding	  this	  particular	  provision	  include	  youth	   identified	  as	  appropriate	  for	  assignment	  to	  the	  Progress	  Unit.	  	  A	   review	  of	  the	  youth	  reviewed	  by	  the	  Behavioral	  Health	  Review	  Panel	   did	  not	  reveal	  reviews	  of	  these	  youth	  for	  appropriateness	  of	   placement.	  During	  the	  monitor’s	  most	  recent	  monitoring	  tour,	  there	   were	  concerns	  brought	  to	  the	  attention	  of	  both	  facility	  and	  statewide	   mental	  health	  staff	  regarding	  the	  appropriateness	  of	  youth	  currently	   assigned	  to	  the	  Progress	  unit.	  	  One	  youth	  was	  determined	  to	  be	   experiencing	  psychotic	  symptoms	  (e.g.,	  mumbling,	  unable	  to	  engage	   in	  conversation,	  staring	  without	  blinking	  for	  periods	  as	  long	  as	  90	   seconds,	  appearing	  to	  respond	  to	  internal	  stimuli)	  requiring	   treatment	  in	  another	  more	  appropriate	  setting.	  	  Other	  youth	  were	   identified	  as	  having	  mental	  health	  disorders.	  	  	  
	  
Given	  the	  restrictive	  nature	  of	  this	  unit	  and	  the	  unique	  behavioral	   and	  mental	  health	  challenges	  of	  youth	  assigned	  to	  this	  unit,	  a	   thorough	  evaluation	  of	  each	  youth	  currently	  residing	  on	  this	  unit	  and	   of	  youth	  proposed	  for	  placement	  on	  this	  unit	  must	  be	  performed.	  	   This	  process	  must	  be	  completed	  for	  all	  youth	  considered	  for	  

	  

60	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 61 of 104 PAGEID #: 1924

placement	  on	  the	  Progress	  unit.	  	  For	  those	  youth	  who	  are	  deemed	   appropriate	  for	  participation	  in	  the	  Progress	  unit	  program,	  but	  are	   not	  successfully	  navigating	  the	  program,	  a	  review	  of	  their	   individualized	  treatment	  plan	  must	  ensue	  in	  order	  to	  determine	   alternative	  interventions	  they	  may	  require	  in	  order	  for	  them	  to	   succeed.	  

Recommendations	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Review	  and	  revise	  policy	  and	  procedure	  to	  reflect	  the	  change	   in	  facility	  mission.	  
2. Improve	  documentation	  promulgated	  by	  the	  Behavioral	   Review	  Panel	  to	  include	  rationale	  for	  specific	  placement	   recommendations.	  
3. For	  those	  youth	  who	  require	  enhanced	  treatment	  following	   the	  initial	  placement	  determination,	  consider	  performing	   retrospective	  record	  review	  (e.g.	  QA)	  in	  order	  to	  improve	  the	   function	  of	  the	  panel.	  
4. Perform	  a	  thorough	  evaluation	  of	  all	  youth	  currently	  housed	   or	  proposed	  for	  placement	  in	  the	  Progress	  unit	  to	  determine	   the	  appropriateness	  of	  their	  participation	  in	  this	  type	  of	   restrictive	  program.	  	  	  This	  evaluation	  must	  include	  specific	   recommendations	  for	  other	  more	  appropriate	  settings	  per	   the	  youth’s	  individual	  needs.	  
5. For	  youth	  housed	  on	  the	  Progress	  unit	  who	  are	  not	   progressing	  through	  the	  program,	  a	  review	  of	  their	  current	   status	  and	  treatment	  plan	  must	  ensue	  in	  order	  to	  determine	   specific	  individualized	  treatment	  or	  interventions	  that	  may	   assist	  them	  with	  their	  progress.	  

Sources	  of	   Information	  
	   	  

• Staff	  interview	   • Review	  of	  provided	  documents	  	   • Review	  of	  youth	  records	   • Youth	  interview	  and	  observation	  
	  

	  

61	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 62 of 104 PAGEID #: 1925

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

Compliance	  Rating	   Non	  Compliance	  

Self	  Assessment	   N/A,	  the	  facility	  did	  not	  assign	  a	  compliance	  rating	  

Steps	  Taken	  to	   Assess	  Compliance	  

Per	  staff	  interviews,	  the	  facility	  self-­‐assessment,	  and	  a	  review	  of	   provided	  documents,	  it	  was	  clear	  that	  there	  continued	  to	  be	  staff	   shortages	  at	  the	  Scioto	  facility.	  Currently,	  the	  psychiatrist	  contract	  is	   for	  20	  hours	  per	  week.	  Please	  see	  the	  discussion	  in	  provision	  13	  for	   further	  information	  regarding	  psychiatric	  staffing	  issues.	  
	  
The	  self-­‐assessment	  reported	  that	  all	  psychology	  positions	  were	   filled.	  Based	  on	  the	  spreadsheet	  of	  mental	  health	  positions	  provided,	   psychology	  staff	  was	  comprised	  of	  six	  psychology	  assistants,	  three	   psychologists,	  one	  psychiatric	  nurse,	  and	  one	  psychology	  supervisor.	   Both	  staff	  interviews	  and	  the	  self-­‐report	  indicated	  that	  the	  workload	   for	  psychology	  staff	  had	  increased	  due	  to	  vacancies	  in	  social	  work	   staff	  positions.	  Once	  social	  work	  positions	  are	  filled,	  it	  will	  be	   necessary	  to	  examine	  the	  current	  psychology	  staffing	  pattern	  to	   determine	  the	  need	  for	  additional	  staff.	  	  In	  order	  to	  accomplish	  this,	   the	  facility	  administration	  and	  mental	  health	  leadership	  should	   consider	  the	  development	  of	  workload	  indicators	  to	  objectively	   determine	  the	  need	  for	  additional	  staff.	  	  These	  indicators	  must	  be	   based	  on	  the	  mental	  health	  treatment	  program	  planned	  for	  this	   facility.	  	  Unfortunately,	  to	  assess	  this	  at	  the	  present	  time	  would	  be	  a	   wasted	  effort,	  as	  this	  facility	  was	  in	  a	  state	  of	  flux,	  with	  little	   direction	  or	  course	  with	  regard	  to	  the	  mental	  health	  programming.	  	   The	  only	  exception	  to	  this	  criticism	  was	  programming	  currently	   provided	  on	  the	  female	  mental	  health	  unit.	  
	  
As	  stated	  above,	  deficiencies	  in	  social	  work	  staffing	  continued	  in	  the	   intervening	  period	  since	  the	  last	  monitoring	  report.	  In	  fact,	  the	  self-­‐ assessment	  and	  spreadsheet	  of	  mental	  health	  positions	  reported	   seven	  current	  vacancies.	  These	  positions	  have	  been	  vacant	  since:	   5.9.10,	  9.25.10,	  10.25.10,	  4.15.11,	  7.30.11,	  and	  7.31.11	  (two).	  Three	   positions	  have	  been	  vacant	  for	  over	  a	  year.	  It	  was	  reported	  that	   more	  recently,	  six	  licensed	  social	  workers	  have	  been	  hired;	  however,	  

	  

62	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 63 of 104 PAGEID #: 1926

they	  had	  not	  begun	  work	  at	  the	  facility	  at	  the	  time	  of	  this	  monitoring	   tour,	  as	  all	  were	  required	  to	  attend	  pre-­‐service	  training.	  
	  
Per	  staff	  interviews	  and	  documentation	  provided	  regarding	  support	   staff	  for	  psychiatry,	  the	  psychiatric	  nurse	  was	  carrying	  a	  large	   workload.	  According	  to	  the	  documents	  reviewed,	  the	  nurse	  provided	   the	  following	  support	  services	  to	  psychiatry:	  scheduling	  new	  and	   follow-­‐up	  appointments;	  preparing	  medical	  records	  for	  review;	   providing	  dictated	  reports	  for	  review;	  updating	  the	  mental	  health	   database;	  attending	  team	  meetings	  and	  providing	  updates	  to	  the	   psychiatrist	  when	  he	  was	  unavailable	  to	  attend;	  responding	  to	  staff	   concerns	  and	  preparing	  assessment	  information	  for	  psychiatry;	   assisting	  with	  the	  notification	  of	  parents/guardians	  of	  any	  changes	  in	   the	  youth’s	  mental	  health	  status	  or	  treatment;	  providing	  updates,	   changes,	  and	  concerns	  regarding	  youth	  to	  psychiatry;	  assisting	  in	   education	  of	  youth	  regarding	  mental	  health	  issues;	  monitoring,	   counseling,	  and	  reporting	  regarding	  medication	  compliance;	  and	   communicating	  day	  to	  day	  issues	  regarding	  psychiatric	  care	  to	  the	   health	  services	  administrator.	  	  	  
	  
This	  list	  of	  tasks	  was	  daunting,	  and	  physically	  impossible	  for	  one	   individual	  to	  complete,	  although	  the	  individual	  currently	  in	  this	   position	  was	  doing	  her	  best	  to	  manage	  the	  workload	  and	  did	  not	   complain.	  During	  the	  previous	  monitoring	  tour,	  there	  were	  two	   mental	  health	  nurse	  positions	  at	  the	  facility.	  It	  was	  explained	  to	  the	   monitor	  that	  due	  to	  budgetary	  issues,	  and	  the	  transition	  of	  the	  male	   mental	  health	  unit	  to	  another	  DYS	  facility,	  that	  this	  position	  was	   eliminated.	  	  It	  was	  evident,	  however,	  that	  the	  nursing	  duties	  had	  not	   only	  expanded,	  but	  the	  number	  of	  youth	  requiring	  mental	  health	   treatment	  and	  treated	  with	  psychotropic	  medication	  at	  the	  facility	   had	  doubled	  in	  the	  intervening	  period	  since	  the	  last	  monitoring	  tour.	  	   As	  such,	  the	  need	  for	  additional	  staff	  coverage	  in	  this	  area	  was	   obvious.	  
	  
There	  were	  several	  examples	  in	  the	  provided	  documentation	  of	  the	   compromise	  of	  clinical	  services	  as	  a	  result	  of	  inadequate	  mental	   health	  staff.	  	  There	  were	  multiple	  documents	  indicating	  that	  CBT	   group	  was	  cancelled	  when	  the	  social	  worker	  responsible	  was	  on	   leave	  or	  otherwise	  detained.	  Additionally,	  in	  the	  quality	  assurance	   documents	  provided,	  other	  staffing	  deficiencies	  were	  identified.	  A	   staff	  member	  was	  placed	  on	  a	  performance	  improvement	  plan	  due	   to	  failure	  to	  document	  individual	  counseling	  sessions.	  	  Per	  the	  quality	   assurance	  chart	  review,	  “the	  clinician	  explained	  to	  the	  supervisor	   that	  she	  was	  spending	  too	  much	  time	  out	  of	  the	  facility	  doing	  CBT	  

	  

63	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 64 of 104 PAGEID #: 1927

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	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 65 of 104 PAGEID #: 1928

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	  

	  

65	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 66 of 104 PAGEID #: 1929

information	  sheets)	  should	  be	  provided	  to	  the	  youth	  and	  their	   parents	  for	  their	  review	  such	  that	  full	  disclosure	  of	  potential	   medication	  side	  effects	  is	  provided.	  
	  
Interviews	  with	  youth	  at	  the	  facility	  revealed	  that	  in	  general,	  youth	   were	  able	  to	  name	  their	  prescribed	  medication.	  	  Youth	  also	  had	   some	  knowledge	  regarding	  the	  potential	  side	  effects	  associated	  with	   their	  prescribed	  medication.	  	  This	  indicated	  that	  informed	  consent	   practices	  were	  occurring	  with	  respect	  to	  treatment	  with	   psychotropic	  medications.	  	  
	  
Per	  the	  document	  request,	  there	  were	  no	  court	  petitions	  for	   involuntary	  administration	  of	  psychotropic	  medications	  in	  the	  90	   days	  prior	  to	  this	  monitoring	  visit.	  

Recommendations	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Continue	  documentation	  regarding	  informed	  consent	  that	  is	   consistent	  with	  generally	  accepted	  practices	  and	  facility	   policy	  and	  procedure.	  
2. Finalize	  policy	  and	  procedure	  regarding	  informed	  consent.	   3. Consider	  a	  peer	  review	  or	  quality	  assurance	  process	  for	  
informed	  consent	  and	  other	  psychiatric	  documentation.	   4. Consider	  the	  development	  of	  or	  use	  of	  commercially	  
available	  information	  regarding	  side	  effects	  of	  psychotropic	   medication	  that	  is	  written	  such	  that	  an	  individual	  unfamiliar	   with	  medical	  jargon	  would	  understand	  the	  information.	  	  This	   information	  should	  be	  provided	  to	  the	  youth	  and	  sent	  via	   mail	  to	  their	  parent	  or	  guardian.	  

Sources	  of	   Information	  
	   	   	  

• Youth	  record	  review	   • Review	  of	  provided	  documents	  	   • Youth	  interview	   • Staff	  interview	  
	  

	  

66	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 67 of 104 PAGEID #: 1930

	  
III.B.13	  	  	  Mental	  Health	  Medications.	  	  The	  State	  shall	  develop	  and	  implement	  policies,	   procedures	  and	  practices	  to	  ensure	  that	  psychoactive	  medications	  are	  prescribed,	   distributed	  and	  monitored	  properly	  and	  safely,	  and	  consistent	  with	  generally	  accepted	   practices.	  The	  State	  shall	  provide	  regular	  training	  to	  all	  health	  and	  mental	  health	  staff	  on	   current	  issues	  in	  psychopharmacological	  treatment,	  including	  information	  necessary	  to	   monitor	  for	  side	  effects	  and	  efficacy.	  The	  State	  shall	  issue	  and	  implement	  policies	  and	   procedures	  for	  the	  administration	  of	  appropriate	  tests	  (including,	  for	  example,	  blood	  tests,	   EKGs,	  and	  Abnormal	  Involuntary	  Movement	  Scale	  tests)	  to	  monitor	  the	  efficacy	  and	  any	  side	   effects	  of	  psychoactive	  medications	  in	  accordance	  with	  generally	  accepted	  professional	   standards.	  The	  State	  shall	  also:	  a)	  share	  medication	  compliance	  data	  with	  the	  psychiatrist	   and	  document	  the	  sharing	  of	  this	  information;	  b)	  not	  withhold	  the	  provision	  of	   psychostimulants	  to	  youth	  when	  such	  treatment	  is	  clinically	  warranted.	  	  

Compliance	  Rating	   Non	  Compliance	  

Self	  Assessment	   N/A,	  the	  facility	  did	  not	  assign	  a	  compliance	  rating	  

Steps	  Taken	  to	   Assess	  Compliance	  

Currently,	  Policy	  403.18.03,	  entitled	  “Psychotropic	  Medication,	  Use	   and	  Management	  Of,”	  dated	  as	  being	  in	  effect	  7/1/02;	  remains	  in	  the	   pending	  policy/draft	  section.	  	  Per	  staff	  interviews	  performed	  during	   the	  most	  recent	  monitoring	  tour,	  there	  were	  plans	  to	  review	  and	   revise	  the	  facility	  behavioral	  health	  policies.	  	  This	  should	  include	  a	   review	  and	  finalization	  of	  the	  policy	  and	  procedure	  regarding	   psychiatric	  treatment.	  
	  
From	  the	  records	  provided,	  it	  was	  determined	  via	  a	  review	  of	  the	   “Youth	  on	  MH	  Caseload	  with	  Recent	  Meds	  and	  Chronic	  Conditions”	   that	  74	  youth	  were	  prescribed	  medication	  by	  the	  psychiatrist.	  This	   was	  an	  increase	  over	  the	  previous	  monitoring	  period	  where	  33	  youth	   were	  prescribed	  psychotropic	  medication.	  	  	  As	  such,	  despite	  greater	   than	  100%	  increase	  in	  the	  number	  of	  youth	  requiring	  psychiatric	   services	  at	  the	  facility,	  there	  has,	  of	  yet,	  been	  no	  increase	  in	   psychiatric	  clinical	  resources.	  
	  
It	  was	  recognized,	  however,	  that	  there	  might	  be	  inaccuracies	  in	  the	   “Youth	  on	  the	  MH	  Caseload	  with	  Recent	  Meds	  and	  Chronic	   Conditions”	  provided	  via	  the	  document	  request.	  This	  made	  it	  difficult	   to	  ascertain	  the	  exact	  make	  up	  of	  the	  psychiatric	  caseload	  at	  this	   time.	  For	  example,	  63	  youth	  entries	  included	  in	  this	  document	  had	   no	  information	  of	  why	  they	  were	  included.	  	  The	  pages	  below	  their	   names	  were	  essentially	  blank	  forms.	  Additionally,	  there	  were	   multiple	  youth	  included	  in	  that	  list	  who	  were	  discharged	  (these	   youth	  were	  not	  included	  in	  the	  calculations	  above).	  Medication	   orders	  do	  not	  appear	  to	  be	  updated	  consistently	  in	  the	  system	   tracking,	  as	  many	  prescriptions	  appeared	  outdated.	  The	  written	  

	  

67	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 68 of 104 PAGEID #: 1931

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	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 69 of 104 PAGEID #: 1932

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.	  

	  

69	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 70 of 104 PAGEID #: 1933

	  
It	  should	  be	  noted	  that	  the	  above	  medical	  record	  reviews	  were	   performed	  off	  site,	  with	  documentation	  provided	  by	  the	  facility.	  	  It	   was	  recognized	  that	  the	  required	  laboratory	  or	  monitoring	  items	   may	  be	  in	  the	  youth’s	  total	  medical	  record,	  however,	  they	  were	  not	   provided	  for	  off	  site	  review.	  	  This	  is	  important	  to	  note,	  as	  there	  were	   examples	  of	  medical	  records	  that	  did	  evidence	  appropriate	   laboratory	  monitoring	  (four	  out	  of	  13	  records	  reviewed).	  
	  
Observations	  of	  the	  facility	  psychiatrist	  with	  youth	  in	  clinic	  revealed	   that	  he	  was	  knowledgeable,	  caring,	  and	  invested	  in	  the	  mental	   health	  treatment	  of	  the	  youth.	  	  Documentation	  regarding	  the	  youth’s	   history	  of	  mental	  health	  issues,	  diagnoses,	  and	  psychiatric	  treatment	   plans	  varied	  with	  regard	  to	  detail.	  	  It	  was	  apparent	  that	  there	  were	   not	  enough	  clinical	  resources	  allocated	  for	  the	  physician	  to	  perform	   his	  duties	  adequately.	  

Recommendations	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Update	  policy	  and	  procedure	  regarding	  behavioral	  health	  to	   include	  timelines	  for	  psychiatric	  services.	  
2. Investigate	  other	  avenues	  to	  increase	  psychiatry	  clinical	   resources	  at	  the	  facility	  (e.g.	  telemedicine,	  association	  with	   academic	  institutions,	  use	  of	  residents	  or	  fellows	  with	   appropriate	  supervision).	  
3. In	  order	  to	  determine	  the	  appropriate	  number	  of	  full	  time	   equivalent	  psychiatric	  clinicians	  required	  by	  the	  facility,	   consider	  workload	  indicators	  inclusive	  of	  all	  clinical	   responsibilities	  required	  of	  the	  physician	  (e.g.	  clinic,	   documentation,	  treatment	  team	  meetings,	  crisis	  response).	  
4. Ensure	  clinical	  coverage	  for	  the	  current	  psychiatric	  treatment	   provider.	  
5. Update	  and	  maintain	  the	  document	  regarding	  the	  current	   mental	  health	  caseload.	  
6. Ensure	  that	  youth	  are	  receiving	  proper	  laboratory	   examinations	  and	  side	  effect	  monitoring	  commensurate	  with	   the	  psychotropic	  medication	  they	  are	  prescribed.	  

Sources	  of	   Information	  

• Staff	  interview	   • Clinic	  observation	   • Treatment	  Team	  observation	   • Youth	  record	  review	  

	  

70	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 71 of 104 PAGEID #: 1934

• Review	  of	  provided	  documents	  	   • Youth	  interview	  

	  

	  

	  

	  

71	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 72 of 104 PAGEID #: 1935

	  
III.B.14	  	  Mental	  Health	  and	  Developmental	  Disability	  Training	  for	  Direct	  Care	  Staff.	  	  The	   State	  shall	  develop	  and	  implement	  strategies	  for	  providing	  direct	  care	  and	  other	   appropriate	  staff	  with	  training	  on	  mental	  health	  and	  developmental	  disabilities	  sufficient	  for	   staff	  to	  understand	  the	  behaviors	  and	  needs	  of	  youth	  residents	  in	  order	  to	  supervise	  them	   appropriately.	  	  

Compliance	  Rating	   Non	  compliance	  

Self	  Assessment	   N/A,	  the	  facility	  did	  not	  assign	  a	  compliance	  rating	  

Steps	  Taken	  to	   Assess	  Compliance	  

Per	  the	  facility	  self-­‐assessment,	  staff	  interviews	  performed	  during	   the	  most	  recent	  monitoring	  tour,	  and	  the	  review	  of	  provided	   documents	  (outlined	  in	  the	  discussion	  regarding	  provision	  15	  below),	   specific	  training	  regarding	  mental	  health	  and	  developmental	   disabilities	  as	  required	  by	  this	  provision	  has	  not	  begun.	  	  Facility	  staff	   reported,	  “we	  have	  not	  done	  this	  yet…we	  have	  had	  so	  many	  other	   trainings…do	  a	  lot	  of	  training.”	  Per	  the	  facility	  self-­‐assessment,	  “due	   to	  the	  many	  training	  demands	  over	  the	  past	  six	  months,	  additional	   mental	  health	  training	  have	  not	  been	  developed	  or	  offered	  to	  direct	   care	  staff.”	  	  	  
	  
As	  stated	  in	  the	  previous	  report,	  the	  goal	  of	  this	  provision	  paragraph	   is	  to	  provide	  training	  to	  facility	  staff	  such	  that	  they	  have	  a	  working	   knowledge	  of	  the	  youth’s	  challenges	  (both	  from	  a	  mental	  health	  and	   developmental	  perspective)	  and	  to	  provide	  them	  with	  strategies	  to	   assist	  in	  their	  daily	  supervisory	  tasks	  with	  the	  youth.	  	  	  Training	  for	   direct	  care	  staff	  is	  important	  as	  in	  the	  correctional	  setting;	  they	   function	  as	  the	  de	  facto	  parents	  of	  the	  youth	  in	  their	  care.	  As	  direct	   care	  staff	  are	  an	  integral	  part	  of	  the	  youth’s	  treatment	  team,	  they	   should	  be	  aware	  that	  due	  to	  specific	  mental	  health	  diagnoses,	  youth	   may	  have	  special	  needs	  (i.e.	  a	  youth	  diagnosed	  with	  ADHD	  may	  not	   respond	  to	  you	  the	  first	  or	  even	  second	  time	  that	  you	  call	  his	  name	   because	  he	  is	  distracted	  by	  extraneous	  stimuli).	  They	  should	  also	  be	   aware	  of	  which	  youth	  are	  being	  treated	  with	  psychotropic	  medication	   and	  have	  a	  basic	  knowledge	  of	  the	  potential	  side	  effects	  of	  the	   medication	  so	  that	  they	  can	  monitor	  the	  youth	  in	  their	  care.	  	   	  
As	  discussed	  in	  detail	  in	  provision	  15	  below,	  there	  is	  a	  need	  for	  an	   organized	  response	  to	  facility	  training	  needs.	  

Recommendations	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	   1. Develop	  an	  organized	  training	  schedule	  and	  training	  curriculum	  
for	  facility	  staff	  that	  addresses	  the	  requirements	  of	  this	  provision	   and	  addresses	  the	  facility	  mental	  health	  programming	  initiatives.	  	  	  

	  

72	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 73 of 104 PAGEID #: 1936

Sources	  of	   Information	  
	   	  

2. This	  training	  must	  be	  based	  on	  facility	  policy	  and	  procedure	  that	   given	  the	  facility	  mission	  change	  must	  be	  revised.	  
3. Continue	  to	  track	  staff	  compliance	  with	  training	  requirements.	  
• Review	  of	  provided	  documents	  	   • Staff	  interview	  
	  

	  

73	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 74 of 104 PAGEID #: 1937

	  
III.B.15	  	  Staff	  Mental	  Health	  Training.	  The	  facilities	  shall	  train:	  a)	  all	  staff	  who	  directly	   interact	  with	  youth	  (e.g.,	  JCOs	  ,	  social	  workers,	  teachers,	  etc.)	  on:	  (i)	  basic	  mental	  health	   information	  (e.g.,	  diagnosis,	  specific	  problematic	  behaviors,	  psychiatric	  medication,	   additional	  areas	  of	  concern)	  and	  recognition	  of	  signs	  and	  symptoms	  evidencing	  a	  response	   to	  trauma;	  and	  (ii)	  teenage	  development,	  strength-­‐based	  treatment	  strategies,	  suicide,	  and	   for	  staff	  who	  work	  with	  female	  youth,	  female	  development;	  b)	  clinical	  staff	  on	  the	   prevalence,	  signs	  and	  symptoms	  of	  Post	  Traumatic	  Stress	  Disorder	  and	  other	  disorders	   associated	  with	  trauma.	  	  

Compliance	  Rating	   Non	  compliance	  

Self	  Assessment	   N/A,	  the	  facility	  did	  not	  assign	  a	  compliance	  rating	  

Steps	  Taken	  to	   Assess	  Compliance	  

Per	  the	  SJCF	  Self-­‐Assessment	  dated	  11/7/11,	  there	  are	  further	  steps	   that	  need	  to	  be	  taken	  to	  ensure	  appropriate	  training	  is	  being	   provided	  to	  all	  staff	  providing	  direct	  care.	  The	  self-­‐assessment	   indicated,	  “due	  to	  the	  many	  training	  demands	  over	  the	  past	  six	   months	  additional	  mental	  health	  trainings	  have	  not	  been	   developed.”	  It	  also	  reported	  a	  plan	  for	  the	  Central	  Office	  of	   Behavioral	  Health	  to	  develop	  an	  “organized,	  mandatory	  training	   schedule.”	  	  
	  
The	  development	  of	  an	  organized,	  mandatory	  training	  schedule	  was	   a	  recommendation	  from	  the	  previous	  monitoring	  visit.	  Given	  the	   issues	  noted	  during	  this	  monitoring	  tour,	  it	  is	  absolutely	  necessary	  to	   develop	  and	  implement	  a	  training	  schedule	  for	  all	  staff	  providing	   care	  for	  youth	  with	  regard	  to	  mental	  health	  issues.	  This	  training	  must	   also	  address	  staff	  recognition	  of	  and	  response	  to	  the	  signs	  and	   symptoms	  of	  a	  serious	  mental	  illness	  in	  evolution.	  	  Staff	  challenges	   with	  this	  particular	  task	  were	  noted	  in	  both	  the	  most	  recent	  and	   prior	  monitoring	  visit.	  
	  
The	  training	  schedule	  must	  be	  reasonable	  and	  address	  specific	  topics	   to	  ensure	  that	  staff	  are	  able	  to	  implement	  the	  facility	  mental	  health	   program.	  	  It	  was	  concerning	  that	  in	  the	  intervening	  period	  since	  the	   last	  monitoring	  visit,	  while	  multiple	  training	  sessions	  were	   conducted,	  staff	  were	  reportedly	  required	  to	  attend	  so	  many	   trainings	  that	  they	  were	  unable	  to	  perform	  their	  basic	  job	  duties.	  	   While	  training	  is	  important,	  the	  facility	  must	  be	  able	  to	  maintain	   sufficient	  staff	  onsite	  to	  ensure	  that	  treatment	  and	  security	  services	   are	  available.	  
	  
Another	  recommendation	  from	  the	  previous	  monitoring	  visit	  was	  to	   create	  a	  spreadsheet	  that	  delineates	  staff	  attendance	  and	   completion	  of	  required	  training	  modules.	  This	  spreadsheet	  was	  

	  

74	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 75 of 104 PAGEID #: 1938

submitted	  with	  the	  documents	  requested.	  There	  were	  297	  staff	   identified	  from	  various	  disciplines.	  The	  trainings	  identified	  for	  2011	   were:	  1.	  Meal	  Refusal	  Policy	  (1	  hour);	  2.	  MYR	  1st	  Quarter	  (4	  hours);	  3.	   PSB	  Review	  (1	  hour);	  4.	  MIS	  Test	  Out	  (.5	  hour);	  5.	  Safety	  and	  Security	   Policy	  Test	  Out	  (.5	  hour);	  6.	  MYR	  2nd	  Quarter	  (4	  hours);	  7.	  Child	  Abuse	   and	  Neglect	  (.5	  hour);	  8.	  Youth	  Grievance	  (.5	  hour);	  9.	  Emergency	   Response	  (1	  hour);	  10.	  Blood	  Borne	  Pathogens	  (.5	  hour);	  11.	  Ethics	   (.5	  hour);	  12.	  PREA	  (.5	  hour);	  13.	  General	  Work	  Rules	  (.5	  hour);	  14.	   Equal	  Employment	  Opportunity	  (.5	  hour).	  It	  was	  unclear	  which,	  if	   any,	  of	  these	  trainings	  were	  considered	  to	  be	  mental	  health	  related,	   as	  curriculum	  for	  the	  individual	  training	  programs	  was	  not	  included	   in	  the	  documents	  received,	  however,	  per	  the	  facesheet	  attached	  to	   this	  document	  request,	  these	  were	  “mandated	  trainings”	  for	  active	   staff.	  	  Per	  the	  provided	  spreadsheet,	  attendance	  at	  the	  required	   trainings	  varied	  from	  88.77%	  to	  89.98%	  of	  required	  attendees.	  This	   demonstrates	  that	  further	  work	  needs	  to	  be	  done	  in	  order	  to	  ensure	   all	  staff	  are	  being	  trained	  appropriately,	  while	  ensuring	  available	  staff	   for	  job	  duties	  as	  noted	  above.	  	  
	  
Additionally,	  the	  2010	  training	  spreadsheet	  was	  provided	  in	  the	   document	  review.	  The	  trainings	  for	  2010	  were:	  1.	  Medical	  Risks	  with	   Restraint	  Use	  (1	  hour);	  2.	  Strengths	  Based	  Behavior	  Management	   System	  (2	  or	  24	  hours);	  3.	  Emergency	  Response	  Training	  (2.5	  hours);	   4.	  Verbal	  Strategies	  (2	  hours);	  5.	  Mental	  Health	  Training	  (2	  hours);	   and	  6.	  Behavioral	  Health	  Policies	  (2	  or	  8	  hours).	  For	  5	  of	  the	  6	   trainings,	  the	  completion	  rate	  was	  between	  89.51%	  and	  97.9%.	   However,	  Behavioral	  Health	  Policies	  had	  a	  63.64%	  completion	  rate.	   This	  may	  explain	  some	  of	  the	  facility	  challenges	  with	  respect	  to	   implementation	  of	  behavioral	  health	  interventions.	  As	  there	  was	  no	   curriculum	  provided,	  it	  was	  not	  possible	  to	  explore	  the	   appropriateness	  of	  these	  trainings	  based	  on	  their	  content.	   Additionally,	  it	  was	  unclear	  whether	  these	  trainings	  were	  completed	   one	  time	  or	  whether	  these	  were	  annual	  trainings	  focused	  on	  the	   review	  and	  improvement	  of	  skills	  related	  to	  behavioral	  health	   interventions.	  
	  
Per	  the	  documents	  provided,	  “since	  February	  2011	  SJCF	  Staff	  have	   participated	  in	  three	  (3)	  different	  trainings,	  preparing	  them	  to	   implement	  and	  oversee	  the	  New	  Freedom	  Phoenix	  Program.”	  It	  was	   reported	  during	  the	  monitoring	  visit	  and	  in	  the	  documentation	   provided	  for	  review	  that	  174	  staff	  members	  attended	  a	  three-­‐day	   training	  that	  included	  an	  overview	  of	  the	  New	  Freedom	  Phoenix	   Program.	  One	  of	  the	  stated	  goals	  of	  this	  training,	  “to	  provide	  Youth	   Specialists	  and	  Social	  Workers	  with	  facilitation	  skill	  training.”	   However,	  the	  groups	  observed	  during	  the	  monitoring	  visit	  indicated	  

	  

75	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 76 of 104 PAGEID #: 1939

Recommendations	  

that	  further	  training	  and	  supervision	  was	  needed.	  	   	   According	  to	  the	  self-­‐assessment,	  additional	  mental	  health	  training	   was	  provided	  including:	  	  CBT	  training;	  sex	  offender	  training;	  Gang	   curriculum,	  training	  the	  trainer;	  SBBMS	  training,	  IDT	  training;	   Progress/transition	  training;	  site	  specific	  training	  regarding	  youth	   transferred	  into	  the	  facility	  from	  ORV	  and	  Circleville;	  Behavior	   Management	  training	  for	  Progress	  and	  Transition	  teams;	  and	   Behavioral	  Analysis	  training.	  	  Information	  regarding	  training	   attendance	  or	  curriculum	  for	  these	  trainings	  was	  not	  included	  in	  the	   documents	  available	  for	  review.	   	   As	  can	  be	  seen	  from	  the	  information	  documented	  above,	  multiple	   trainings	  regarding	  a	  myriad	  of	  topics	  have	  been	  offered	  to	  facility	   staff	  in	  the	  intervening	  period	  since	  the	  previous	  monitoring	  report.	  	   Unfortunately,	  given	  the	  multiple	  trainings	  and	  the	  shift	  in	  facility	   focus	  and	  mission	  over	  the	  six	  months	  prior	  to	  this	  monitoring	  tour,	  it	   appeared	  that	  trainings	  and	  program	  initiatives	  were	  occurring	   haphazardly,	  with	  little	  organization	  or	  planning.	  	  The	  review	  of	   trainings	  was	  very	  confusing	  for	  the	  monitor,	  so	  the	  monitor	  can	  only	   imagine	  how	  difficult	  this	  must	  be	  for	  staff	  attempting	  to	  provide	   behavioral	  health	  services	  or	  security	  services	  at	  the	  facility.	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Develop	  an	  organized	  training	  schedule	  and	  training	   curriculum	  for	  facility	  staff	  that	  addresses	  the	  requirements	  of	   this	  provision	  and	  addresses	  the	  facility	  mental	  health	   programming	  initiatives.	  	  	  
2. Over	  time,	  the	  facility	  may	  identify	  the	  need	  for	  enhanced	   training	  on	  a	  particular	  topic	  (i.e.,	  more	  time	  devoted	  to	  a	   particular	  topic)	  or	  additional	  specialty	  topics	  via	  quality	   assurance	  or	  staff	  recommendation	  that	  may	  be	  useful	  (e.g.,	   abuse	  reporting).	  	  
3. Consider	  offering	  multiple	  trainings	  for	  each	  topic	  so	  that	  staff	   can	  schedule	  trainings	  while	  ensuring	  that	  their	  regular	  job	   duties	  are	  addressed.	  
4. Continue	  to	  track	  staff	  attendance	  and	  compliance	  with	   training	  requirements.	  

Sources	  of	   Information	  
	  

• Review	  of	  provided	  documents.	   • Staff	  interviews.	  

	  

76	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 77 of 104 PAGEID #: 1940

III.B.16	  	  Suicide	  Prevention.	  	  The	  State	  shall	  review	  and,	  as	  appropriate,	  revise	  current	   suicide	  prevention	  practices	  to	  ensure	  that	  suicide	  preventions	  and	  interventions	  are	   implemented	  consistently	  and	  appropriately,	  consistent	  with	  generally	  accepted	   professional	  standards	  of	  care.	  	  

Compliance	  Rating	   Non	  Compliance	  

Self	  Assessment	   N/A,	  the	  facility	  did	  not	  assign	  a	  compliance	  rating.	  

Steps	  Taken	  to	   Assess	  Compliance	  

According	  to	  the	  facility	  self-­‐assessment,	  “the	  revised	  Suicide	   Prevention	  and	  Response	  policy	  became	  effective	  11/1/2011.”	  This	   policy	  was	  not	  included	  in	  the	  provided	  documents,	  where	  policy	  and	   procedure	  (both	  currently	  implemented	  and	  draft	  documents)	  were	   requested.	  The	  self-­‐assessment	  further	  stated	  that	  quality	  assurance	   for	  suicide	  precautions	  “is	  an	  ongoing	  process	  by	  way	  of	  direct	   supervision	  and	  discussion	  of	  all	  recommendations	  for	  precautionary	   status	  made	  by	  unlicensed	  psychology	  staff,	  daily	  updating	  of	  a	   shared	  Precautionary	  Status	  table	  that	  documents	  each	  incident	  of	   placement	  on	  or	  change	  in	  Precautionary	  Status,	  and	  continual	   review	  of	  incidents	  and	  patterns	  of	  behavior	  during	  the	  group	  and	   individual	  supervision	  meetings.”	  	  
	  
Per	  the	  document	  request,	  a	  written	  description	  of	  the	  process	  by	   which	  psychiatry	  is	  informed	  of	  youth’s	  placement	  on	  suicide	  watch	   was	  provided.	  This	  document	  indicated	  “psychology	  staff	  will	  send	  an	   email	  to	  [psychiatrist]	  when	  they	  place	  a	  youth	  on	  suicide	  watch	  or	   when	  they	  learn	  a	  youth	  has	  been	  placed	  on	  watch	  when	  psychology	   staff	  are	  not	  available	  on	  campus.”	  	  Staff	  were	  required	  to	  copy	  this	   email	  to	  the	  psychology	  supervisor,	  health	  services	  administrator	  and	   mental	  health	  nurse.	  Several	  emails	  were	  provided	  as	  evidence	  of	   this	  process.	  	  
	  
Per	  the	  email	  documentation,	  a	  review	  of	  the	  listing	  of	  youth	   requiring	  precautionary	  status	  over	  the	  previous	  three	  months,	  and	  a	   review	  of	  available	  youth	  medical	  and	  mental	  health	  records,	  youth	   444	  was	  placed	  on	  precautionary	  status	  on	  9.8.11.	  	  A	  review	  of	  this	   youth’s	  medical	  record	  revealed	  that	  the	  youth	  was	  not	  evaluated	  by	   psychiatry	  in	  a	  timely	  manner	  following	  placement	  on	  watch	  status.	  	   This	  youth	  was	  ultimately	  evaluated	  by	  psychiatry	  one	  month	  later	   on	  10.7.11.	  	  A	  review	  of	  the	  mental	  health	  record	  revealed	  that	  this	   youth	  was	  seen	  by	  psychology	  staff	  8.23.11,	  approximately	  two	   weeks	  prior	  to	  placement	  on	  precautionary	  status.	  	  Following	   placement	  on	  precautionary	  status,	  he	  was	  seen	  by	  psychology	  staff	   9.9.11,	  9.12.11,	  9.13.11,	  and	  9.17.11.	  	  It	  should	  be	  noted	  that	  this	   youth	  resides	  on	  the	  Progress	  Unit,	  where	  he	  spends	  a	  great	  deal	  of	   time	  in	  his	  cell.	  	  The	  absence	  of	  documented	  daily	  mental	  health	  

	  

77	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 78 of 104 PAGEID #: 1941

contacts	  for	  this	  youth,	  or	  any	  youth	  in	  similar	  circumstances	  was	   unacceptable.	  
	  
Youth	  777	  required	  suicide	  precautions	  8.19.11.	  	  The	  psychiatrist	   ultimately	  saw	  this	  youth	  over	  two	  months	  later	  on	  10.25.11.	  	  A	   review	  of	  this	  youth’s	  psychology	  file	  revealed	  no	  documents	  other	   than	  those	  generated	  at	  intake.	  	  There	  was	  no	  documentation	  of	   mental	  health	  contact	  visits	  included.	  
	  
Youth	  888	  required	  suicide	  precautions	  9.11.11.	  	  Per	  a	  review	  of	  this	   youth’s	  medical	  record,	  there	  were	  no	  psychiatric	  clinical	  encounters	   as	  of	  the	  date	  of	  the	  monitoring	  tour	  10.24.11.	  	  A	  review	  of	  this	   youth’s	  psychology	  file	  revealed	  no	  documents	  other	  than	  those	   generated	  at	  intake.	  	  There	  was	  no	  documentation	  of	  mental	  health	   contact	  visits	  included.	  
	  
On	  a	  positive	  note,	  Youth	  555	  was	  admitted	  to	  the	  facility	  on	   precautionary	  status.	  	  This	  youth	  had	  reportedly	  attempted	  suicide	   prior	  to	  admission,	  and	  was	  therefore	  placed	  on	  precautionary	  status	   immediately.	  	  This	  youth	  was	  admitted	  9.14.11	  and	  was	  evaluated	  by	   the	  psychiatrist	  9.15.11.	  	  A	  review	  of	  this	  youth’s	  psychology	  file	   revealed	  consistent	  contact	  with	  a	  mental	  health	  treatment	  provider.	  
	  
The	  above	  review	  was	  performed	  regarding	  youth	  who	  reportedly	   required	  precautionary	  status	  during	  their	  stay	  at	  SJCF.	  	  It	  is	   recognized	  that	  although	  additional	  documentation	  may	  exist,	  this	   documentation	  was	  not	  provided	  for	  review	  off	  site.	  
	  
Per	  the	  document	  request	  submitted	  for	  this	  monitoring	  tour,	  a	  copy	   of	  any	  reviews	  or	  quality	  assurance	  data	  regarding	  suicide	   precautions	  was	  requested.	  	  Per	  the	  document	  request	  response,	  the	   “Suicide	  Precaution	  Performance	  Indicators	  are	  audited	  during	  the	   annual	  Ohio	  Standards	  audit.	  	  The	  audit	  for	  Scioto…is	  scheduled	  for	   later	  this	  year;	  therefore,	  we	  do	  not	  have	  any	  new	  audit	  data	  since	   February	  2011.”	  
	  
It	  is	  generally	  accepted	  that	  youth	  in	  seclusion	  are	  at	  higher	  risk	  of	   self-­‐injury	  and	  suicide.	  	  In	  reviewing	  the	  Seclusion	  Tracking	  data	   provided	  as	  part	  of	  the	  quality	  assurance	  materials,	  there	  were	  noted	   concerns.	  Specifically,	  when	  youth	  were	  in	  seclusion,	  documentation	   available	  for	  off	  site	  review	  revealed	  that	  mental	  health	  staff	  did	  not	   assess	  some	  for	  over	  24	  hours.	  For	  example	  during	  the	  week	  of	   6.30.2011-­‐7.6.2011:	  	  

	  

78	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 79 of 104 PAGEID #: 1942

	  
• Youth	  999	  was	  assessed	  at	  9:55am	  and	  then	  was	  not	   reassessed	  until	  4pm	  the	  following	  day.	  	  
• Youth	  010	  had	  an	  undocumented	  time	  for	  one	  assessment.	  	   Therefore,	  it	  was	  impossible	  to	  determine	  if	  the	  assessment	   was	  performed	  within	  an	  appropriate	  margin	  of	  time.	  	  
• Youth	  020	  was	  assessed	  at	  11:45am	  and	  not	  until	  9:30pm	  the	   following	  day.	  This	  is	  over	  33	  hours	  without	  review	  of	  mental	  
health	  staff.	  	  
During	  the	  week	  of	  9.1.11-­‐9.7.11:	   	  
• Youth	  030	  was	  on	  seclusion	  status	  from	  9.4.11-­‐9.7.11;	   however,	  there	  were	  no	  documented	  visits	  on	  9.5.11	  or	   9.6.11.	  	  
	   The	  above	  are	  selected	  examples,	  further	  review	  of	  the	  data	   revealed	  multiple	  similar	  situations.	  	  When	  youth	  are	  placed	  in	   seclusion,	  they	  must	  be	  seen	  a	  minimum	  of	  every	  twenty-­‐four	  hours.	  	   Similar	  deficiencies	  were	  observed	  in	  the	  Progress	  Unit,	  where	  youth	   were	  decompensated	  with	  regard	  to	  their	  mental	  health	  status,	   however,	  as	  they	  were	  not	  evaluated	  daily,	  their	  condition	  could	  go	   unchecked	  for	  a	  period	  of	  time,	  leading	  to	  further	  decompensation.	  	   During	  this	  monitoring	  tour,	  mental	  health	  staff	  indicated	  that	  they	   were	  assessing	  youth	  on	  the	  Progress	  Unit	  approximately	  three	  times	   per	  week.	  	  Per	  discussions	  with	  mental	  health	  staff,	  some	  youth	  had	   extended	  periods	  where	  they	  did	  not	  engage	  with	  a	  mental	  health	   treatment	  provider	  because	  they	  were	  “asleep”	  or	  refused	  to	  talk	  to	   the	  provider.	  	  One	  such	  youth,	  Youth	  040,	  was	  described	  by	  the	   mental	  health	  staff	  as	  “always	  asleep…he	  doesn’t	  want	  to	  talk.”	  	  The	   psychiatrist	  evaluated	  Youth	  040	  during	  the	  monitoring	  tour	  at	  the	   monitor’s	  insistence.	  	  This	  youth	  was	  observed	  by	  the	  monitor	  to	  be	   psychotic.	  	  Given	  the	  youth’s	  presentation,	  the	  facility	  psychiatrist	   arranged	  for	  transfer	  to	  a	  mental	  health	  unit	  at	  another	  DYS	  facility.	  	  	   	   This	  event	  raised	  multiple	  concerns,	  including	  but	  not	  limited	  to	  the	   appropriateness	  of	  all	  youth	  currently	  housed	  on	  the	  Progress	  Unit,	   the	  need	  for	  daily	  mental	  health	  contact	  with	  youth	  housed	  on	  the	   Progress	  Unit,	  mental	  health	  staff’s	  ability	  to	  recognize	  and	  respond	   to	  signs	  and	  symptoms	  of	  serious	  mental	  illness,	  and	  the	  facilities	   ability	  to	  advocate	  for	  and	  transfer	  those	  youth	  with	  serious	  mental	   illness	  to	  a	  more	  appropriate	  setting.	   	  

	  

79	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 80 of 104 PAGEID #: 1943

Recommendations	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Review	  and	  revise	  policy	  and	  procedure	  to	  reflect	  time	  limits	  for	   psychiatric	  evaluation	  following	  a	  youth’s	  placement	  on	  suicide	   precautions.	  
2. Review	  and	  revise	  policy	  and	  procedure	  to	  reflect	  the	  minimum	   frequency	  of	  clinical	  contact	  with	  mental	  health	  treatment	   providers	  following	  a	  youth’s	  placement	  on	  suicide	  precautions.	  
3. Review	  and	  revise	  policy	  and	  procedure	  to	  reflect	  the	  frequency	   of	  clinical	  contact	  with	  youth	  on	  the	  Progress	  Unit.	  	  Youth	  must	   be	  evaluated	  on	  a	  daily	  basis.	  
4. Review	  and	  revise	  if	  necessary	  policy	  and	  procedure	  to	  reflect	   the	  frequency	  of	  clinical	  contact	  with	  youth	  in	  seclusion.	  	  Youth	   must	  be	  evaluated	  on	  a	  daily	  basis.	  
5. Define	  the	  requirements	  for	  and	  documentation	  necessary	  for	   youth	  assessed	  while	  in	  seclusion	  or	  housed	  in	  the	  Progress	   Unit.	  
6. Ensure	  that	  all	  mental	  health	  staff	  are	  appropriately	  trained	  to	   recognize	  and	  respond	  to	  signs	  and	  symptoms	  of	  serious	  mental	   illness.	  	  	  
7. Consider	  a	  mental	  health	  re-­‐evaluation	  of	  all	  youth	  currently	   housed	  on	  the	  Progress	  Unit	  in	  an	  effort	  to	  determine	  the	   appropriateness	  of	  their	  placement	  in	  this	  program.	  

Sources	  of	   Information	  

• Review	  of	  provided	  documents.	   • Staff	  interview.	   • Youth	  interview.	  

	  

	  

	  

	  

80	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 81 of 104 PAGEID #: 1944

	  
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,	  

	  

81	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 82 of 104 PAGEID #: 1945

“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	  

	  

82	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 83 of 104 PAGEID #: 1946

antipsychotic	  medication,	  Haldol	  D,	  via	  a	  monthly	  injection.	  The	   psychological	  summary	  of	  services	  form	  noted	  “at	  this	  time,	  youth’s	   symptoms	  appear	  to	  have	  stabilized	  but	  he	  will	  continue	  to	  require	  a	   high	  level	  of	  wrap	  around	  services	  in	  the	  community.”	  The	   medication	  management	  and	  consistency	  that	  an	  intramuscular	   medication	  provides	  would	  assist	  in	  stabilization.	  However,	  this	   youth’s	  history	  indicates	  a	  need	  for	  continuity	  of	  care	  in	  order	  to	   avoid	  a	  relapse	  of	  symptoms	  once	  released.	  This	  youth	  has	  a	   documented	  history	  of	  psychosis	  including	  command	  auditory	   hallucinations	  that	  tell	  him	  to	  kill	  himself.	  He	  has	  a	  documented	   history	  of	  suicidal	  ideation,	  gestures,	  and	  attempts.	  Although	  a	   community	  treatment	  provider	  was	  identified,	  no	  follow-­‐up	   appointment	  was	  scheduled.	  As	  he	  was	  prescribed	  an	  intramuscular	   medication,	  he	  will	  need	  services	  based	  on	  the	  last	  date	  his	  injection	   was	  given.	  As	  noted	  in	  the	  medical	  release	  summary,	  he	  was	   released	  1/11/11	  with	  his	  next	  injection	  due	  2/9/11.	  	  A	  contact	  name	   and	  telephone	  number	  was	  provided	  via	  the	  medical	  release	   summary;	  however,	  an	  appointment	  was	  not	  scheduled.	  	  Any	  delay	   in	  services	  and	  medication	  administration	  may	  lead	  to	   decompensation	  of	  his	  mental	  status.	  Further,	  it	  is	  unclear	  whether	   the	  identified	  treatment	  provider	  matches	  the	  level	  of	  care	  this	   youth	  will	  need	  upon	  release.	  It	  is	  necessary	  to	  identify	  the	  services	   youth	  are	  being	  referred	  to	  and	  make	  a	  determination	  as	  to	  whether	   these	  are	  the	  appropriate	  services.	  	  
	  
Youth	  333	  had	  diagnoses	  including	  Pervasive	  Development	  Disorder,	   NOS;	  Conduct	  Disorder;	  Bipolar	  I	  Disorder,	  most	  recent	  episode	   depressed;	  Alcohol	  Abuse;	  and	  Cannabis	  Abuse.	  This	  youth’s	   psychological	  services	  summary	  was	  completed	  2.7.11	  and	  she	  was	   not	  released	  until	  9.6.11.	  The	  recommendations	  include	  “With	  PDD	   and	  [youth’s]	  other	  mental	  health	  symptoms	  in	  mind	  it	  is	  very	   important	  for	  [youth]	  to	  maintain	  on	  going	  mental	  health	   treatment…”	  The	  writer	  of	  the	  psychological	  services	  summary	  form	   identified	  that	  this	  youth	  would	  likely	  need	  respite	  services	  and/or	   residential	  treatment	  in	  the	  future.	  In	  providing	  appropriate	   transition	  planning	  and	  continuity	  of	  care,	  it	  was	  necessary	  for	  this	   youth’s	  treatment	  provider	  discuss	  future	  treatment	  needs	  and	  assist	   the	  family	  in	  understanding	  how	  to	  link	  with	  services	  that	  may	  be	   needed	  in	  the	  future.	  Despite	  the	  advanced	  recommendations	  in	  the	   psychological	  services	  summary,	  there	  was	  not	  a	  follow-­‐up	  mental	   health	  appointment	  scheduled	  for	  this	  youth	  at	  the	  time	  of	  her	   release.	  In	  reviewing	  transition	  documents,	  it	  was	  clear	  that	  this	   youth	  would	  need	  intensive	  mental	  health	  and	  rehabilitation	   services,	  family	  counseling,	  substance	  abuse	  treatment,	  and	  further	   evaluation.	  However,	  none	  of	  these	  services	  were	  arranged	  prior	  to	  

	  

83	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 84 of 104 PAGEID #: 1947

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.	  

	  

84	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 85 of 104 PAGEID #: 1948

Sources	  of	   Information	  
	   	  

3. Provide	  clinical	  supervision	  to	  treatment	  teams	   inexperienced	  in	  transition	  planning.	  
• Review	  of	  provided	  documents.	  	   • Staff	  interview	  
	  

	  

85	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 86 of 104 PAGEID #: 1949

	  
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	  

	  

86	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 87 of 104 PAGEID #: 1950

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	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 88 of 104 PAGEID #: 1951

Sources	  of	   Information	  
	  

• Staff	  Interview.	   • Review	  of	  the	  provided	  documents.	  
	  

	  

88	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 89 of 104 PAGEID #: 1952

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	  	  

	  

89	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 90 of 104 PAGEID #: 1953

	  
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	  	  

	  

90	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 91 of 104 PAGEID #: 1954

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	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 92 of 104 PAGEID #: 1955

optometry	  consults	  and	  eyeglasses	  provided.	  One	  youth	  even	   received	  a	  second	  pair	  after	  losing	  the	  first.	  	   	   Health	  Requests	  were	  reviewed	  and	  in	  each	  case	  traced	  back	  to	  a	   corresponding	  progress	  note	  to	  determine	  if	  the	  complaint	  had	  been	   addressed.	  In	  all	  cases,	  the	  requests	  had	  been	  adequately	  assessed	   and	  treated	  by	  registered	  nursing	  staff	  and	  in	  some	  cases	  by	  the	   physician.	  Progress	  notes	  also	  included	  assessments	  that	  did	  not	  have	   a	  corresponding	  Health	  Request	  slip	  in	  the	  health	  record.	  When	   nurses	  made	  isolation	  checks,	  they	  were	  documented	  in	  the	  progress	   notes.	  I	  cannot	  determine	  if	  all	  youth	  housed	  in	  segregation/isolation	   were	  assessed	  daily	  by	  the	  nursing	  staff	  based	  on	  the	  information	   provided	  to	  me	  for	  review.	  	  One	  youth	  in	  particular	  had	  several	   seclusion	  checks	  documented	  while	  there	  were	  others	  that	  did	  not	   have	  any.	  Daily	  checks	  of	  youth	  in	  seclusion/segregation	  by	  medical	   staff	  are	  a	  requirement	  of	  the	  National	  Commission	  on	  Correctional	   Health	  Care	  Standards	  for	  Juvenile	  Detention	  and	  Confinement	   Facilities.	  Documentation	  on	  the	  Youth	  injury	  and	  Assessment	   Reports	  for	  youth	  sprayed	  with	  OC	  did	  not	  always	  include	  vital	  signs,	   flushing	  of	  all	  exposed	  areas	  with	  water,	  showering	  or	  documentation	   of	  clothing	  decontamination.	  	   	   Medication	  administration	  records	  and	  physician	  orders	  were	  also	   reviewed	  for	  accuracy	  and	  medication	  compliance.	  Immunization	   records	  were	  reviewed	  for	  completeness.	  With	  the	  exception	  of	   Hepatitis	  A	  and	  HPV,	  youth	  immunizations	  were	  current.	  Internal	   Quality	  Assurance	  documents	  were	  reviewed	  that	  were	  provided	  by	   ODYS.	  The	  overwhelming	  majority	  of	  the	  items	  monitored	  were	  found	   to	  be	  in	  100%	  compliance.	  	   	   Three	  female	  youth	  health	  records	  were	  reviewed	  as	  a	  result	  of	   allegations	  of	  unresponsive	  health	  requests.	  One	  female	  complained	   of	  a	  “bump”	  in	  the	  genital	  area.	  Two	  health	  requests	  were	  in	  her	   health	  record.	  She	  was	  seen	  by	  the	  nurse	  for	  both	  requests.	  She	  was	   referred	  to	  the	  physician	  and	  the	  bump	  was	  examined	  by	  the	  MD	  and	   diagnosed	  as	  a	  carbuncle.	  	  The	  other	  two	  females	  complained	  of	   menstrual	  irregularities,	  but	  both	  were	  on	  DepoProvera	  injections	  for	   birth	  control,	  which	  is	  a	  common	  side	  effect	  of	  this	  medication.	  	  Both	   female’s	  health	  requests	  were	  addressed	  appropriately	  in	  the	  health	   record.	  One	  female	  with	  abdominal	  pain	  complaints	  received	  a	  CT	   scan	  and	  pelvic	  ultrasound,	  with	  negative	  results.	  Youth	  with	   complaints	  of	  menstrual	  cramps	  were	  prescribed	  anti-­‐inflammatory	   medications	  for	  pain	  as	  needed.	  One	  female	  expressed	  concern	  over	   having	  a	  male	  gynecologist	  to	  examine	  her.	  Chaperones	  of	  the	  same	   sex	  as	  the	  patient	  are	  always	  required	  whenever	  a	  medical	  

	  

92	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 93 of 104 PAGEID #: 1956

professional	  examines	  the	  female	  patient’s	  breasts	  or	  genitalia.	  

Recommendations	  

The	  State	  is	  in	  substantial	  compliance	  with	  this	  provision.	  In	  the	  spirit	   of	  continually	  improving	  services,	  the	  following	  are	  recommended:	  
1. Expand	  the	  immunization	  program	  to	  Include	  Hepatitis	  A	  and	   HPV	  vaccinations	  of	  youth.	  	  
2. Develop	  protocols	  for	  decontamination	  and	  medical	   assessment	  of	  youth	  after	  exposure	  to	  OC	  spray.	   Documentation	  on	  the	  Youth	  injury	  and	  Assessment	  Reports	   for	  youth	  sprayed	  with	  OC	  did	  not	  always	  include	  vital	  signs,	   flushing	  of	  all	  exposed	  areas	  with	  water,	  showering	  or	   documentation	  of	  clothing	  decontamination.	  
3. Provide	  AEDs	  (Automated	  External	  Defibrillators)	  on	  site,	  train	   staff	  in	  its	  use	  and	  include	  them	  in	  the	  Emergency	  Medical	   Response	  and	  Services	  Policy.	  
4. Improve	  completeness	  of	  youth	  Problem	  List	  in	  health	  record	   to	  include	  all	  chronic	  diagnoses,	  including	  mental	  health,	   substance	  abuse	  and	  acute	  diagnoses	  such	  as	  headache,	   shoulder	  pain,	  etc.	  
5. Improve	  Quality	  Assurance	  (QA)	  activities	  by	  considering	  a	   review	  at	  least	  annually	  by	  a	  source	  external	  to	  ODYS	  Health	   Services.	  ODYS	  should	  also	  consider	  expansion	  of	  the	  QA	   process	  to	  include	  some	  additional	  quality	  indicators.	  	  

Sources	  of	   Information	  
	   	   	  

• Review	  of	  ten	  youth	  health	  records:	  ID	  #	  216224,	  215725,	   211428,	  215728,	  214897,	  217657,	  217487,	  215980,	  217724,	   and	  216734.	  Youth	  Injury	  and	  Assessment	  Forms:	   5505111337,	  2105111709,	  2105111710,	  5505111288,	   2105111712,	  2105111716,	  2105111715,	  and	  2105111711.	   Health	  records	  of	  three	  female	  youth	  at	  Scioto:	  ID#217709,	   217497,	  and	  217002	  	  
	  

	  

93	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 94 of 104 PAGEID #: 1957

III.C.2	  	  Health	  Records.	  The	  State	  shall	  develop	  and	  implement	  policies,	  procedures	  and	   practices	  to	  ensure	  that,	  consistent	  with	  State	  and	  federal	  law,	  at	  a	  minimum,	  the	  juvenile	   courts	  in	  the	  State,	  all	  juvenile	  detention	  facilities	  and	  all	  placement	  settings	  from	  which	   youth	  are	  committed	  shall	  timely	  forward	  to	  Scioto,	  or	  to	  the	  facility	  of	  placement	  (if	  the	   records	  arrive	  after	  the	  youth	  has	  been	  placed),	  all	  pertinent	  youth	  records	  regarding	   medical	  and	  mental	  health	  care.	  The	  facilities	  shall	  develop	  and	  implement	  policies,	   procedures	  and	  practices	  to	  ensure	  that	  health	  care	  staff,	  including	  mental	  health	  care	  staff,	   have	  access	  to	  documents	  that	  are	  relevant	  to	  the	  care	  and	  treatment	  of	  the	  youth.	  	  

Compliance	  Rating	   Substantial	  Compliance	  

Self	  Assessment	  

The	  relevant	  policies,	  procedures,	  and	  practices	  are	  at	  or	  above	  the	   level	  that	  was	  observed	  for	  the	  Third	  Compliance	  Report,	  wherein	  it	   was	  observed	  that	  the	  State	  “demonstrate[s]	  a	  commitment	  to	   continuity	  of	  care	  for	  Scioto’s	  youth.”	  [See	  Doc.	  79-­‐1,	  at	  56].	  SJCF	  is	  no	   longer	  a	  reception	  facility.	  Therefore,	  the	  provision	  about	  forwarding	   to	  the	  facility	  of	  placement	  is	  moot.	  In	  the	  Third	  Compliance	  Report,	   the	  Department	  of	  Justice	  (DOJ)	  stated	  that	  substantial	  compliance	   with	  this	  provision	  would	  be	  achieved	  by	  “combin[ing]	  medical	  and	   psychology	  records.”	  See	  id.	  Due	  to	  the	  physical	  layout	  of	  SJCF,	   combining	  medical	  and	  psychology	  records	  into	  one	  record	  would	   prove	  extremely	  difficult,	  if	  not	  impossible.	  There	  is	  a	  great	  distance	   between	  the	  Clinic	  and	  the	  nine	  housing	  units.	  Removal	  of	  a	  medical	   record	  from	  the	  clinic	  could	  lead	  to	  the	  lack	  of	  access	  to	  critical	   medical	  information	  in	  an	  emergency	  situation.	   	   SJCF	  has	  a	  Mental	  Health	  Database	  that	  psychologists	  may	  access.	   Although	  not	  all	  inclusive,	  this	  database	  includes	  diagnosis,	   medication	  information	  and	  medication	  compliance.	  Psychology	  staff	   directly	  involved	  with	  the	  care	  and	  treatment	  of	  the	  Youth	  at	  SJCF	   have	  access	  to	  the	  psychiatry	  notes	  via	  the	  Mental	  Health	  Nurse.	  And	   treatment	  teams	  are	  verbally	  informed	  of	  medication	  compliance	  by	   the	  psychology	  staff	  when	  necessary	  and	  relevant	  on	  a	  weekly	  basis	   to	  allow	  any	  issues	  to	  be	  addressed.	  Because	  all	  relevant	  staff	  have	   access	  to	  the	  relevant	  health	  records	  (and	  because	  the	  policies,	   procedures,	  and	  practices	  continue	  to	  be	  in	  place	  as	  stated	  above),	   SJCF	  is	  in	  substantial	  compliance	  with	  this	  provision.	  

Steps	  Taken	  to	   Assess	  Compliance	  

Review	  of	  ten	  youth	  health	  records.	  Review	  of	  Policies	  and	   Procedures	  and	  Standard	  Operating	  Procedures	  (SOP)	  effective	   7/1/11	  provided	  by	  ODYS.	  A	  few	  health	  records	  contained	  some	   transfer	  health	  information	  from	  the	  county	  probation	  offices	  or	   other	  facilities.	  Since	  Scioto	  is	  no	  longer	  a	  reception	  center,	  transfer	   information	  is	  no	  longer	  required.	  As	  stated	  in	  the	  first	  section,	  there	   was	  little	  mental	  health	  information	  housed	  within	  the	  health	  record	   of	  youth	  in	  the	  majority	  of	  cases.	  Since	  this	  assessment	  was	   completed	  based	  on	  the	  information	  submitted,	  I	  cannot	  determine	  

	  

94	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 95 of 104 PAGEID #: 1958

how	  successful	  the	  process	  for	  sharing	  health	  information	  occurs	   between	  medical	  and	  mental	  health.	  A	  better	  determination	  would	   be	  made	  based	  on	  a	  facility	  site	  visit.	  

Recommendations	  

The	  State	  is	  in	  substantial	  compliance	  with	  this	  provision.	  In	  the	  spirit	   of	  continually	  improving	  services,	  the	  following	  are	  recommended:	  
1. Continue	  to	  improve	  process	  for	  sharing	  of	  health	  information	   between	  medical	  and	  mental	  health	  to	  include	  psychologists,	   possibly	  through	  the	  use	  of	  a	  summary	  sheets	  provided	  to	   medical	  for	  inclusion	  in	  the	  health	  record	  and	  pertinent	   medical	  information	  provided	  for	  the	  mental	  health	  record.	  	  	  
2. Consider	  implementation	  of	  electronic	  health	  record	  or	  if	  not	   possible	  now,	  allow	  medical	  staff	  to	  access	  to	  the	  Mental	   Health	  database.	  
3. Continue	  to	  review	  and	  update	  policies	  and	  procedures	   annually.	  There	  was	  a	  five	  and	  a	  half	  year	  period	  lapsed	   between	  the	  current	  ODYS	  Policies	  and	  Procedures	   implemented	  7/2011	  and	  the	  previous	  set	  of	  ODYS	  Policies	   and	  Procedures	  implemented	  1/2006.	  	  
4. Reduce	  length	  of	  policies	  and	  procedures	  and	  attempt	  to	   consolidate	  some.	  	  Try	  to	  eliminate	  references	  back	  to	  other	   policy	  numbers	  within	  the	  text.	  Some	  policies	  and	  Standard	   Operating	  Procedures	  (SOP)	  should	  be	  shortened	  and	  some	   details	  removed	  and	  placed	  into	  protocols	  (for	  example,	  the	   details	  of	  the	  World	  Health	  Organization’s	  Pandemic	  Phases	   included	  in	  the	  18-­‐page	  Pandemic	  Response	  Plan	  for	  Medical	   and	  Mental	  Health	  Services	  SOP).	  When	  policies	  become	  too	   lengthy	  and	  cumbersome,	  it	  is	  more	  difficult	  for	  staff	  to	   understand	  them	  and	  maintain	  compliance.	  

Sources	  of	   Information	  

• Review	  of	  ten	  youth	  health	  records:	  ID	  #	  216224,	  215725,	   211428,	  215728,	  214897,	  217657,	  217487,	  215980,	  217724,	   and	  216734.	  
• Review	  of	  Policies	  and	  Procedures	  supplied	  to	  me	  by	  ODYS	   effective	  July	  1,	  2011	  to	  include:	  Pharmaceutical	   Management;	  Health	  Education	  and	  Prevention;	  Emergency	   Medical	  Response	  and	  Services;	  Communicable	  Disease	   Management;	  Health	  Services	  Internal	  Review,	  Quality	   Assurance	  Monitoring	  and	  Reporting.	  Review	  of	  Standard	   Operating	  Procedures	  (SOP)	  effective	  July	  1,	  2011:	   Pharmaceutical	  Prescribing,	  Procurement	  and	  Documentation	   Procedures;	  Pharmaceutical	  Receipt,	  Storage,	  Inventory,	  and	   Disposal	  Management;	  Medication	  Administration	  and	   Documentation;	  Pharmaceutical	  Transfer	  within	  the	   Department;	  Aftercare	  Pharmaceuticals;	  First	  Aid	  and	   Emergency	  Care;	  HIV	  Screening,	  Testing	  and	  Management;	  

	  

95	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 96 of 104 PAGEID #: 1959

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	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 97 of 104 PAGEID #: 1960

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.	  

	  

97	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 98 of 104 PAGEID #: 1961

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.	  

	  

98	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 99 of 104 PAGEID #: 1962

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.	  	  

	  

99	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 100 of 104 PAGEID #: 1963

Steps	  Taken	  to	   Assess	  Compliance	  

When	  interviewed,	  youth	  reported	  short	  stays	  in	  the	  ABC	  room	  and	   the	  opportunity	  to	  talk	  through	  their	  issues	  with	  staff.	  Many	  of	  those	   who	  had	  spent	  time	  in	  disciplinary	  seclusion	  reported	  that	  they	  did	   not	  receive	  instruction	  from	  teachers	  or	  work	  packets	  during	  the	  time	   in	  their	  room.	  An	  attempt	  was	  made	  to	  verify	  these	  claims	  using	  the	   Unit	  Instruction	  binder	  maintained	  by	  the	  school,	  but	  as	  reported	  by	   the	  Assistant	  Principal,	  many	  of	  the	  records	  were	  missing	  or	   incomplete.	  Although	  these	  data	  are	  therefore	  not	  sufficient	  to	   demonstrate	  compliance	  with	  this	  provision,	  the	  Unit	  Instruction	   paperwork	  and	  process	  appear	  to	  be	  sufficient	  to	  the	  task	  once	  fully	   implemented	  (i.e.,	  data	  is	  captured	  for	  all	  youth	  in	  seclusion,	  every	   school	  day).	  	   	   Since	  my	  last	  visit,	  the	  facility	  began	  to	  operate	  a	  maximum-­‐security	   segregation	  unit,	  the	  PROGRESS	  Unit.	  This	  unit	  consists	  of	  two	  18-­‐bed	   housing	  units.	  Students	  on	  the	  PROGRESS	  unit	  attend	  school	   separately	  from	  the	  general	  population,	  in	  two	  mobile	  units	   specifically	  dedicated	  for	  this	  purpose.	  The	  classrooms	  are	  well	   appointed	  and	  sufficiently	  spacious	  to	  serve	  students	  from	  both	  units.	  	   	   To	  assess	  the	  extent	  to	  which	  youth	  on	  the	  PROGRESS	  units	  have	   access	  to	  the	  education	  program,	  attendance	  records	  for	  the	  two	   weeks	  following	  the	  October	  Intersession	  were	  reviewed.	  These	   records	  revealed	  very	  sporadic	  attendance.	  On	  both	  units,	  school	  was	   held	  on	  the	  unit	  for	  3	  of	  the	  10	  days.	  It	  is	  unknown	  whether	  youth	   received	  services	  in	  their	  rooms,	  or	  whether	  instruction	  complied	   with	  the	  Unit	  Instruction	  format	  recently	  developed	  with	  the	  S.H.	   monitors.	  	   	   Attendance	  for	  the	  remaining	  7	  days	  was	  coded	  using	  the	  following	   schema:	  a	  youth	  was	  considered	  to	  have	  been	  “present”	  for	  the	  day	  if	   he	  attended	  at	  least	  3	  of	  the	  4	  academic	  classes.	  A	  youth	  was	   considered	  to	  have	  been	  “excused”	  for	  the	  day	  if	  he	  was	  excused	   from	  2	  or	  more	  academic	  periods.	  A	  youth	  was	  considered	  to	  be	   “unexcused”	  for	  the	  day	  if	  he	  refused	  or	  was	  removed	  from	  2	  or	  more	   academic	  periods.	  	   	   Of	  the	  12	  youth	  on	  the	  Sycamore	  unit,	  only	  one	  youth	  was	  considered	   “present”	  for	  all	  7	  days.	  Another	  youth	  was	  present	  for	  4	  of	  the	  7	   days.	  The	  remaining	  10	  youth	  (83%	  of	  Sycamore	  youth)	  were	  present	   on	  2	  or	  fewer	  days.	  Equal	  proportions	  had	  “excused”	  and	   “unexcused”	  absences.	  	   	   Of	  the	  11	  youth	  on	  the	  Cedar	  unit,	  four	  youth	  were	  considered	   “present”	  for	  6	  or	  7	  of	  the	  days.	  The	  remaining	  7	  youth	  (64%	  of	  Cedar	  

	  

100	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 101 of 104 PAGEID #: 1964

youth)	  were	  present	  on	  2	  or	  fewer	  days,	  with	  2	  of	  those	  never	   attending	  school	  at	  all.	  Equal	  proportions	  had	  “excused”	  and	   “unexcused”	  absences.	  	   	   Clearly,	  additional	  work	  is	  needed	  to	  increase	  the	  level	  of	  attendance	   at	  school	  among	  PROGRESS	  youth.	  First,	  the	  reasons	  underlying	  the	   high	  rates	  of	  excused	  absences	  should	  be	  reviewed	  to	  determine	  if	   these	  activities	  could	  be	  scheduled	  in	  a	  way	  that	  does	  not	  conflict	   with	  the	  school	  day.	  Second,	  the	  incentives	  for	  school	  attendance	  and	   the	  consequences	  for	  refusing	  should	  be	  reviewed	  to	  determine	  how	   to	  make	  school	  attendance	  more	  compelling	  to	  youth	  on	  the	   PROGRESS	  units.	  	  

Recommendations	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Document	  the	  provision	  of	  Unit	  Instruction	  to	  all	  youth	  held	  in	   disciplinary	  isolation.	  This	  instruction	  should	  include	  four	  daily	   visits	  of	  at	  least	  30	  minutes	  each	  by	  certified	  teachers.	  Audit	   these	  data	  on	  a	  monthly	  basis	  to	  ensure	  sustained	  compliance	   with	  the	  requirements	  of	  this	  provision	  and	  the	  S.H.	   Agreement.	  	  
2. Increase	  the	  level	  of	  attendance	  at	  school	  among	  youth	  on	   the	  PROGRESS	  units.	  	  
3. Reach	  substantial	  compliance	  with	  the	  other	  two	  education-­‐ related	  provisions	  in	  the	  Amended	  Stipulation.	  	  

Sources	  of	   Information	  
	   	  

• Oral	  presentation	  and	  underlying	  documentation	  for	  provision	   III.E.1,	  prepared	  at	  my	  request	  
• Interviews	  with	  n=20	  general	  population	  youth	  conducted	  by	   the	  DOJ	  attorney	  in	  late	  October	  2011,	  along	  with	  interviews	   with	  n=29	  youth	  on	  the	  PROGRESS	  units	  conducted	  by	  the	   Monitor	  and	  DOJ	  attorney	  in	  October	  2011	  
• Unit	  Instruction	  binder	  maintained	  by	  Scioto	  school	   administrators	  
• Attendance	  records	  for	  Cedar	  and	  Sycamore	  units,	  October	  18	   through	  31,	  2011	  	  
	  

	  

101	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 102 of 104 PAGEID #: 1965

	  
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	  

	  

102	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 103 of 104 PAGEID #: 1966

Steps	  Taken	  to	   Assess	  Compliance	  
Recommendations	   Sources	  of	   Information	   	   	  

indicated	  that	  63%	  lacked	  specific	  data	  related	  to	  the	  goals	  listed	  on	   the	  IEP.	  Non-­‐specific	  indicators	  of	  student	  progress	  (e.g.,	  “Completes	   work”	  “Adequate	  progress”)	  offer	  little	  to	  the	  assessment	  of	  whether	   the	  student	  is	  acquiring	  the	  skills	  needed	  to	  progress	  through	  the	   curriculum.	  	  
A	  random	  sample	  of	  four	  IEPs	  (18%	  of	  the	  22	  IEPs	  revised	  in	  the	   previous	  90	  days)	  was	  reviewed	  to	  verify	  the	  findings	  of	  the	  self-­‐ assessment.	  In	  all	  cases,	  portions	  of	  the	  IEPs	  were	  extremely	  well	   written.	  The	  description	  of	  the	  student’s	  present	  levels	  of	   performance	  was	  connected	  to	  goals	  in	  each	  area	  and	  led	  to	  a	  clear	   roadmap	  for	  supporting	  students	  in	  the	  regular	  or	  special	  education	   classrooms.	  	   	   A	  set	  of	  progress	  reports	  from	  the	  most	  recent	  grading	  period	  (ending	   September	  2011)	  was	  reviewed	  for	  four	  special	  education	  students.	   Their	  quality	  was	  inconsistent—some	  student’s	  progress	  reports	  were	   well-­‐written	  and	  featured	  specific	  data	  to	  describe	  the	  youth’s	   progress,	  but	  others	  were	  not	  updated	  or	  were	  vague	  and	  lacked	   specific	  indicators	  of	  progress	  that	  reflected	  each	  goal.	  These	  findings	   mirror	  those	  of	  the	  State’s	  self-­‐assessment.	  	   	   So,	  while	  the	  teachers	  have	  shown	  great	  improvement	  in	  complying	   with	  progress	  reporting	  requirements,	  the	  content	  of	  those	  progress	   reports	  needs	  to	  be	  grounded	  in	  data	  that	  are	  responsive	  to	  the	  way	   in	  which	  the	  goals	  were	  articulated.	  If	  the	  incoming	  IEP	  did	  not	   articulate	  measurable	  goals,	  the	  IEP	  must	  be	  revised	  upon	  admission.	   Particularly	  now	  that	  youth	  are	  committed	  to	  Scioto	  are	  likely	  to	   spend	  significant	  periods	  of	  time	  there,	  the	  facility	  must	  improve	  its	   practices	  around	  measuring	  student	  progress	  in	  order	  to	  maximize	   the	  ability	  of	  the	  special	  education	  program	  to	  meet	  students’	  needs.	  	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Ensure	  that	  the	  content	  of	  IEP	  progress	  reports	  is	  grounded	  in	   data	  that	  are	  responsive	  to	  a	  set	  of	  realistic,	  measurable	  IEP	   goals.	  If	  needed,	  update	  incoming	  IEPs	  to	  ensure	  that	   students’	  goals	  are	  properly	  articulated.	  	  
• Oral	  presentation	  and	  underlying	  documentation	  for	  provision	   III.E.7,	  prepared	  at	  my	  request	  
• Review	  of	  n=4	  IEPs	  of	  current	  Scioto	  students’	  IEPs	  and	   progress	  reports	  from	  the	  most	  recent	  grading	  period	  
	  

	  

103	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 104 of 104 PAGEID #: 1967

	  
III.E.8	  Vocational	  Education.	  The	  State	  shall	  provide	  appropriate	  vocational	  services	  that	  are	   required	  transition	  services	  for	  disabled	  youth	  under	  the	  IDEA.	  	  

Compliance	  Rating	   Non-­‐Compliance	  

Self	  Assessment	  

The	  State	  submitted	  data	  on	  student	  enrollment	  in	  the	  three	   currently	  available	  vocational	  classes.	  Of	  the	  168	  youth	  at	  Scioto:	  
• 22	  students	  (18	  boys,	  4	  girls;	  13%	  of	  the	  population)	  are	   enrolled	  in	  Administrative	  Office	  Technology;	  
• 10	  students	  (5	  boys,	  5	  girls;	  6%	  of	  the	  population)	  are	  enrolled	   in	  Career-­‐Based	  Intervention	  (a	  work	  program	  that	  includes	   Math	  and	  English	  courses);	  and	  	  
• 23	  students	  (18	  boys,	  5	  girls;	  13%	  of	  the	  population)	  are	   enrolled	  in	  Transition	  Skills.	  
	   The	  State	  also	  provided	  information	  on	  a	  recently	  established	   community	  partnership.	  This	  partnership	  will	  allow	  both	  students	  and	   graduates	  to	  obtain	  industry-­‐standard	  certificates	  in	  restaurant	   hospitality,	  customer	  service,	  and	  OSHA	  regulations.	  Other	  courses	   may	  be	  added	  depending	  on	  student	  needs	  and	  interests.	  	  

Steps	  Taken	  to	   Assess	  Compliance	  

Opportunities	  for	  students	  to	  develop	  job	  skills	  are	  very	  limited,	  with	   less	  than	  half	  of	  Scioto	  students	  participating	  in	  any	  meaningful	   vocational	  coursework	  or	  employment	  experience.	  The	  community	   partnership	  is	  very	  promising	  and,	  if	  implemented	  as	  designed,	  should	   provide	  sufficient	  program	  slots	  to	  meet	  demand	  and	  should	  offer	   valuable	  job	  skill	  development	  and	  work	  experience.	  Once	  this	   program	  is	  implemented,	  the	  State	  will	  need	  to	  develop	  additional	   self-­‐assessment	  measures	  to	  capture	  the	  relevant	  data.	  Technical	   assistance	  toward	  this	  end	  is	  available	  upon	  request.	  	  

Recommendations	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Develop	  sufficient	  vocational	  opportunities	  to	  engage	  all	   students	  in	  meaningful	  job	  skill	  development	  and/or	  work	   experience.	  	  

Sources	  of	   Information	  
	  

• Oral	  presentation	  and	  underlying	  documentation	  for	  provision	   III.E.8,	  prepared	  at	  my	  request	  

	  

104	  

 
 Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 1 of 109 PAGEID #: 2072
U.S. Department of Justice v. The State of Ohio
Civil Action No: 2:08-cv-475 Monitor’s Second Report on the Amended Stipulation dated June 28, 2011
Kelly Dedel, Ph.D., Lead Monitor Daphne Glindmeyer, M.D., Subject Matter Expert Michelle Staples-Horne, M.D., Subject Matter Expert One in 37 Research, Inc. 16 Rock Street Cody, WY 82414 (503)799-0915 kelly.dedel@gmail.com
Draft Submitted May 25, 2012 Final Submitted June 22, 2012

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 2 of 109 PAGEID #: 2073

TABLE OF CONTENTS
Introduction ....................................................................................................... 3 Executive Summary.............................................................................................. 4
Protection from Harm..................................................................................................................................... 12 General Protection From Harm .................................................................................................................. 12 Seclusion.................................................................................................................................................... 18 Investigation of Serious Incidents.............................................................................................................. 25 Grievances ................................................................................................................................................. 29 Grievances Explained to Youth .................................................................................................................. 32 Structured Programming ........................................................................................................................... 34 Orientation ................................................................................................................................................. 38
Mental Health Services .......................................................................................................................... 41 Mental Health Screening ........................................................................................................................... 41 Immediate Referral to QMHP .................................................................................................................... 43 Identification of Previously Unidentified Youth.......................................................................................... 45 Mental Health Assessment........................................................................................................................ 47 Adequate Care and Treatment.................................................................................................................. 50 Treatment Planning................................................................................................................................... 54 Treatment Teams ...................................................................................................................................... 55 Integrated Treatment Plans ...................................................................................................................... 58 Access to QMHP........................................................................................................................................ 60 Mental Health Involvement in Housing and Placement............................................................................. 63 Staffing...................................................................................................................................................... 66 Medication Notice ..................................................................................................................................... 70 Mental Health Medications........................................................................................................................ 72 MH/DD Training for Direct Care Staff ........................................................................................................ 76 Staff Mental Health Training...................................................................................................................... 77 Suicide Prevention .................................................................................................................................... 80 Transition Planning ................................................................................................................................... 83 Oversight of Mental Health ....................................................................................................................... 86
Documentation .......................................................................................................................................... 89 Progress Notes ......................................................................................................................................... 89 Accessibility of Information ....................................................................................................................... 90
Medical Services ...................................................................................................................................... 91 General Medical Care ................................................................................................................................ 91 Health Records ......................................................................................................................................... 95 Access to Health Systems ......................................................................................................................... 97
Special Education Services .................................................................................................................. 99 Provision of Special Education.................................................................................................................. 99 Individual Education Plans ...................................................................................................................... 103 Vocational Education .............................................................................................................................. 108

	  

2.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 3 of 109 PAGEID #: 2074
INTRODUCTION
On June 4, 2008, The United States Department of Justice (DOJ) and the State of Ohio (the State) signed a stipulation for injunctive relief (the Stipulation) concerning conditions at the Scioto Juvenile Correctional Facility (Scioto) and the Marion Juvenile Correctional Facility (Marion; which was closed shortly after the Stipulation was signed). Fred Cohen, the Lead Monitor of the concurrent conditions of confinement lawsuit, S.H. v Reed et al., served as the monitor for the Stipulation until late 2009. At that point, Mr. Cohen resigned and the DOJ assumed the role of Monitor, with Dr. Kelly Dedel, Dr. Daphne Glindmeyer, and Dr. Michelle Staples-Horne serving as subject matter experts.
As the original stipulation expired, the Parties recognized that the State had not yet reached substantial compliance with several key portions of the Stipulation. Thus, the Stipulation was renegotiated to include a subset of the original provisions. The Amended Stipulation terminates when the State has achieved substantial compliance with each provision and has maintained substantial compliance for two reporting periods (i.e., 12 months). The Parties also agreed that the Amended Stipulation is subject to the termination provisions of the Prison Litigation Reform Act.
The Monitor for the Amended Stipulation is Dr. Kelly Dedel, who evaluates the State’s progress in the areas of Protection From Harm, Grievances, Programming and Special Education. She is assisted by two Subject Matter Experts, Dr. Daphne Glindmeyer, who evaluates the State’s progress on provisions related to Mental Health Services, and Dr. Michelle Staples-Horne, who evaluates the State’s progress on provisions related to Medical Care.
As the Monitor, Dr. Dedel is the primary liaison between the Monitoring Team and the Parties and she compiles the Monitor’s Report. To do so, she combines Drs. Glindmeyer’s and Staples-Horne’s reports with her own to form a coherent whole, but does not change the substance of the reports by either of the Subject Matter Experts, who are responsible for forming their own opinions about the level of compliance for each provision in their areas of expertise.
This is the Monitor’s second report on the State’s progress toward the reforms required by the Amended Stipulation. The monitoring period is October 1, 2011 through March 31, 2012. Progress reports will be issued approximately every six months hereafter.

	  

3.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 4 of 109 PAGEID #: 2075

EXECUTIVE SUMMARY
The Amended Stipulation includes 33 provisions related to Protection From Harm (n=3); Grievances (n=2); Programming (n=2); Mental Health Care (n=18) and Documentation (n=2); Medical Care (n=3); and Special Education (n=3). Each provision is listed in the table below, along with the Monitor’s or Subject Matter Expert’s compliance rating.
The Monitor’s first report used only two compliance levels: substantial compliance and non-compliance. This report uses a three-tiered system (substantial compliance, partial compliance and non-compliance), defined as follows:
· Substantial Compliance means that the facility has drafted relevant policies and procedures; has trained the staff responsible for implementation; has sufficient staff to implement the required reform; has demonstrated the ability to properly implement the procedures during the majority of the monitoring period; and has ascertained that the procedures accomplish the outcome envisioned by the provision. Non-compliance with mere technicalities or a temporary failure to comply (due to staff vacancy or illness, facility disruptions, or other short-term events) during an otherwise sustained period of compliance do not constitute a failure to achieve or maintain substantial compliance. Conversely, temporary compliance during a period of sustained non-compliance does not constitute substantial compliance.
· Partial Compliance means that the facility has drafted policies and procedures, has trained staff responsible for implementation, and has sufficient staff to implement the required reform. While progress has been made toward implementing the procedures described by policy, performance has been inconsistent throughout the monitoring period and additional modifications are needed to ensure that procedures are sufficiently comprehensive to translate policy into practice.
· Non-Compliance means that the facility has made only very preliminary efforts to implement the required reform, but significant work remains. Policy may need to be overhauled, the majority of staff may need to be trained, procedures may not have been developed, and no one has begun to ascertain whether the procedures accomplish the outcome envisioned by the provision.

The Monitor does not intend to change the meaning, spirit or requirements of the Stipulation in any way. Rather, the rating scheme was expanded in an effort to better recognize the State’s progress (which is essential for staff morale during long-term reform efforts), to provide an easy mechanism for determining which provisions will require the greatest amount of time and effort to reach substantial compliance, and to promote greater compatibility with the S.H. v. Reed, et al. Monitor’s report on Scioto, which also uses a three-tiered system. In order to highlight the areas in which progress has been made or slippage has been noted, the Monitor and subject matter experts revised the compliance levels from the first report, using the new three-tiered system. Both ratings are presented in the chart below. Ratings that were upgraded since the previous Monitor’s Report are presented in green; ratings that were downgraded are presented in red.
The DOJ disagrees with this change, particularly the revisions to the compliance levels for the Monitor’s First Report (used as the basis for comparison to the current compliance ratings in the table below). While the Monitor recognizes that the Parties did not have an opportunity to comment on the revised compliance

	  

4.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 5 of 109 PAGEID #: 2076
levels, the Monitor believes that using a revised rating provides a more accurate sense of whether the State has made progress since the prior reporting period. Otherwise, many provisions would show a NonCompliance rating for the first monitoring period (although the provision would have been rated in Partial Compliance had the three-tiered system been in use), and then would appear to have been promoted to Partial Compliance when, in reality, the level of compliance remains the same. The Monitor apologizes for the disruption caused by this mid-course correction, but truly believes it is the best course of action to support the State’s progress in complying with the Stipulation.

	  

5.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 6 of 109 PAGEID #: 2077

Table 1. Compliance Ratings for Each Provision

No.

Provision

Protection From Harm

III.A. 1

General Protection From Harm

III.A.3

Seclusion

III.A.5

Investigation of Serious Incidents

III.D.1

Grievances

III.D.2

Grievances Explained to Youth

III.F.1

Structured Programming

III.F.2

Orientation

Mental Health Services

III.B.1

Mental Health Screening

III.B.2

Immediate Referral to QMHP

III.B.3

Identification of Previously Unidentified Youth

III.B.4

Mental Health Assessment

III.B.5

Adequate Care and Treatment

III.B.6

Treatment Planning

III.B.7

Treatment Teams

III.B.8

Integrated Treatment Plans

III.B.9

Access to QMHP

III.B.10

Mental Health Involvement in Housing and Plcmt

III.B.11

Staffing

III.B.12

Medication Notice

III.B.13

Mental Health Medications

III.B.14

MH/DD Training for Direct Care Staff

III.B.15

Staff Mental Health Training

III.B.16

Suicide Prevention

III.B.17

Transition Planning

III.B.18

Oversight of Mental Health

III.G.1

Progress Notes

III.G.2

Accessibility of Information

	  

1st Report (revised)
NC NC SC PC PC NC PC
PC PC NC NC NC NC PC NC NC NC NC PC PC NC PC PC PC NC PC NC

2nd Report
PC PC PC PC SC NC PC
PC PC PC PC PC PC PC PC PC PC PC PC PC NC PC PC PC NC PC NC 	  

	  

6.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 7 of 109 PAGEID #: 2078

Medical Services

III.C.1

General Medical Care

III.C.2

Health Records

III.C.5

Access to Health Services

Special Education Services

III.E.1

Provision of Special Education

III.E.7

Individual Education Plans

III.E.8

Vocational Education

SC

PC

SC

PC

SC

SC

PC

PC

PC

PC

NC

NC

Overall, the State is in substantial compliance with 2 of the 33 provisions (6%), in partial compliance with 26 provisions (79%) and in non-compliance with 5 provisions (15%). As noted earlier, the Monitor and subject matter experts revised the ratings from the previous monitoring period using the three-tiered system, so that comparisons could be made. Across the 33 provisions, the compliance rating was upgraded for 11 provisions (33%) and downgraded for 3 provisions (9%). Compliance ratings for each section and key issues to be addressed are highlighted below.
Protection from Harm (includes Grievances and Programming)
The facility is in substantial compliance with 1 of the 7 provisions (14%) related to protecting youth from harm. It is in non-compliance with the provision related to Structured Programming. The following actions should be prioritized:
• Continue to utilize aggregate data on youth violence to identify trends that threaten youth and staff safety. Identify the underlying causes of youth violence and develop targeted violence prevention strategies to address the factors that contribute to assaultive behavior among youth.
• Ensure that adequate numbers of well-trained staff are present on each unit so that youth do not endure unnecessary seclusion and have access to the full range of academic, rehabilitative and other structured programming.
• Launch the planned initiative to expand the conversation surrounding the allegations by some of the female residents that a few staff engage in sexually inappropriate talk and behavior. Reinforce the prohibition against this type of behavior with staff and ensure staff know how to recognize and respond to such behavior.
• Revisit the duration of pre-hearing seclusion prescribed by the IRAV to ensure that youth remain in pre-hearing seclusion no longer than necessary to de-escalate their behavior and ensure they do not pose a threat to the safety of other youth or staff.
• Limit the use of disciplinary seclusion, relying instead on sanctions that provide an opportunity for skill-development and treatment in order to create behavior change.
• Operate the PROGRESS Unit as it was designed, adhering to the prescribed limits on a youth’s time in cell (i.e., address staff shortages, design a strategy to address the interference of Phase 1 youth movement on Phase 2 youth’s time out of cell; facilitate youth’s advancement through the phases and to the Transition Unit with quality treatment plans and progress reporting). Ensure

	  

7.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 8 of 109 PAGEID #: 2079

that PROGRESS youth have access to intensive programming and support that addresses their violent behavior. Finalize the PROGRESS Unit’s policy and Youth Handbook. • Address the serious deficits in the quality of investigations that are conducted by facility staff. • Ensure grievances are resolved in a timely manner and are supported by appropriate documentation, attached to the grievance. • Fully implement the process for notifying youth of the outcome of any investigation referred by the grievance process. • Develop an appropriately focused rehabilitative program for youth who have graduated from High School or obtained their GED. Include both post-secondary educational opportunities and job skills and vocational training.
Mental Health Services
The facility is not in substantial compliance with any (0%) of the 20 provisions related to mental health services and documentation. It is in partial compliance with 17 (85%) of the provisions and in noncompliance with 3 of the provisions (15%). The following actions are required:
• ODYS has recently completed a collaborative policy and procedure review and revision process. These policies are currently in the process of review by the Monitors in both this case and S.H. v. Reed. The policies must be completed and implemented.
• The facility must be staffed with sufficient psychiatric (both psychiatric physicians and psychiatric nurses) resources to provide psychiatric evaluation, medication monitoring, and treatment team interaction.
• Develop an organized training schedule for mental health staff. • Train direct care staff and mental health staff to understand the behavior and needs of youth with
mental illnesses and developmental disabilities and recognize and respond to signs and symptoms of serious mental illness. • Train mental health staff to develop high-quality case conceptualizations that integrate the information generated by the multiple assessments administered to youth upon admission. • Train, coach and adequately supervise direct care staff and mental health staff to implement the Phoenix New Freedom curriculum, particularly in skills for leading group therapy sessions to ensure the interactions and documentation reflect generally accepted practices for mental health care. This should include treatment integrity checks (e.g. observation of group interaction with subsequent education and training as necessary). • Develop procedures to ensure, and to document, that youth are assessed by a qualified mental health professional within 12 hours when a serious risk to the youth’s safety is identified. • Ensure mental health staff assesses youth on suicide precautions, those in seclusion, and those on the Progress Units every 24 hours. • Ensure youth with acute mental illnesses requiring extensive mental health treatment have access to more appropriate placements. • Ensure treatment plans are individualized including measurable goals and targeted interventions to address the goals. Update treatment plans regularly and monitor youth’s progress toward achieving treatment goals. Adapt treatment plans for youth who are not progressing.

	  

8.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 9 of 109 PAGEID #: 2080

• Ensure Interdisciplinary Treatment Team meetings include representatives from the major sectors of the facility including social workers, direct care staff and psychiatrists and that Treatment Teams are focused on treatment issues and the youth’s progress toward treatment goals.
• Ensure youth on the Progress Units are appropriate for the secure setting and receive appropriate treatment. Conduct thorough assessments of all youth proposed for placement in the future.
• Continue the current practice of assigning all youth housed in the Progress Units to the mental health caseload.
• Ensure youth receive proper laboratory examinations and side-effect monitoring commensurate with the psychotropic medications prescribed and reflecting generally accepted practices.
• Develop a coherent, coordinated quality assurance process that provides a cogent review of social work, psychological and psychiatric services at the facility. This should include peer review. It should also include both process and outcome measures.
• Address limitations to treatment resulting from the fragmented recordkeeping process via the creation of a unified record.

Medical Services
The facility is in substantial compliance with one of the provisions (33%) related to medical services and in partial compliance with the other 2 provisions (66%). The provisions related to General Medical Care and Health Records were downgraded to partial compliance.
During this assessment period, the Scioto facility for the most part ensured that youth received routine, preventive, medical and care consistent with current, generally accepted professional standards. Concerns identified during this period were a result of being on site at the facility as opposed to only an off-site medical record review and the charts reviewed on this audit. The Subject Matter Expert’s concern is whether youth were being adequately assessed while in seclusion for very long periods of time and after fight-related injuries occurred. Many times youth are refusing to be seen by the nurse after a fight or use of restraints or the nurse completes an assessment with the youth still inside the cell. Youth assessments should be done at a time that youth is cooperative enough to conduct an adequate face-to-face examination including vital signs. It is unacceptable to conduct clinical assessments on youth while they are still inside their cell. Policy time frames may need to be adjusted to allow a later assessment in these cases. This is also why the Subject Matter Expert recommended the addition of a satellite clinic and medication room for the Buckeye units. It is often difficult to get these youth down to the main medical clinic for an adequate medical evaluation.
The Subject Matter Expert had no concerns about individuals with health problems being identified at intake, assessed, diagnosed, and treated consistent with current, generally accepted professional standards of care. There were no concerns regarding dental care. With the exception of one unit that failed to have the health request slips out next to the drop box, the facility was ensuring that youth could request to be seen by medical staff confidentially and independent from JCOs and custodial staff. The health call slips are kept in a separate binder rather than the medical record. A self-assessment is needed to be sure all health requests from the slips are addressed within each youth’s medical record progress notes.
The health record is still fragmented due to the psychological and counseling notes being housed separately on the housing units. However, after the site visit and observation of the facility layout, it would

	  

9.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 10 of 109 PAGEID #: 2081

be impractical to have a combined physical health record. It is imperative that an electronic health record is established for the sharing of the mental health and medical information by expansion of the existing mental health database to include pertinent health data, and if not, purchase of a new electronic medical record computer program.
Policies, procedures and forms reviewed for the March 2012 effective date were very good. There were cases were the effective date had not been revised to show as current. All policies should be reviewed on an annual basis. All Quality Assurance activities are not fully operational as outlined in the National Commission on Correctional Health Care Juvenile Health Standards. Based on those QA audit tools provided for review, there were the same compliance issues identified as found by the Subject Matter Expert, such as not charting vital signs for all assessments and failure to adequately complete the Problem List.
Resolution of these identified issues will allow the facility to obtain substantial compliance in all areas.
Special Education
The facility is not in substantial compliance with any of the 3 education-related provisions (0%). The following actions should be prioritized:
• Ensure that sufficient direct care staff and education staff are available to provide students with dependable access to education services.
• Address students’ chronic absenteeism with individualized plans to improve attendance and by delivering services to youth in alternative settings as needed.
• Provide dependable staffing and space to ensure that the ABC room is available to teachers and students each school day.
• Improve the consistency with which Unit Instruction data are recorded and entered so that compliance with this policy can be demonstrated. Toward this end, cross-referencing with the list of youth on Disciplinary Seclusion will be necessary to demonstrate that all eligible youth receive services.
• Improve the specificity of 1) Student Profiles and 2) Present Levels of Academic and Functional Performance sections of IEP documents to ensure that the skills students need to acquire in order to progress through the curriculum are clearly articulated in IEP goals. Develop objectives that address these skill deficits.
• Ensure that IEP Progress Reports are skill-specific and provide a clear description of what the student has mastered and what still needs to be addressed in order for the student to meet the goal.
• Develop sufficient vocational opportunities to engage all students in meaningful job skill development and/or work experience. The choice among the vocational options should be tailored to the risks and needs of youth at Scioto.

The facility has undergone a massive transformation since the Stipulation was amended. Originally, Scioto was the central reception facility for all DYS facilities. In the summer of 2011, DYS began to de-centralize its reception process to convert Scioto to a long-term facility that houses medium and close custody boys. Scioto remains the reception center for girls and also operates a long-term girls’ program and a mental health unit for girls. This change in mission required staff to adjust to a new type of youth (generally higher-risk) and to new responsibilities for their long-term care and treatment. In addition, the facility

	  

10.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 11 of 109 PAGEID #: 2082
received an entirely new Administrative Team in February 2012. This new team has an impressive array of skills, experience and enthusiasm and the Monitor is encouraged by their approach to the facility’s reform.
One of the common themes affecting compliance in nearly all areas of the Stipulation is staffing. Ensuring that a facility is adequately staffed to implement the reform consistently is a complicated endeavor. First, the facility must have an adequate number of funded positions to ensure that youth are supervised at the proper ratios. Facilities must also ensure that the number of vacancies is not excessive and must address any systemic barriers to filling open positions. In addition, facilities must ensure that staff who are filling the positions actually report to work. Once these conditions are met, the facility must address the usual and customary staff resignations efficiently to ensure that security is maintained and youth’s access to programming is not disrupted.
At various points throughout this report, the Monitor comments on the impact of staffing on the State’s ability to comply with the Stipulation. In the area of Protection From Harm, the facility appears to have an adequate number of funded positions. While there are several vacant direct care staff positions, the main barrier to adequate staffing is the number of staff who are currently filling a position but who do not report to work. Remedies, currently underway, are discussed in III.A.1, below. In Education, the facility appears to have an adequate number of funded teachers’ positions but struggled to fill key vacancies throughout the past two grading periods. At the time this report was drafted, these vacancies had reportedly been filled for the upcoming grading period. The Monitor has endeavored to explain the nuances of the staffing issues in each area and to identify the systemic barriers to the facility’s having a sufficient number of trained staff actually reporting to work so that youth and staff safety and programming are not compromised.

	  

11.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 12 of 109 PAGEID #: 2083

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

	  

12.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 13 of 109 PAGEID #: 2084

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.

	  

13.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 14 of 109 PAGEID #: 2085

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

	  

14.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 15 of 109 PAGEID #: 2086

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

	  

15.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 16 of 109 PAGEID #: 2087

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

	  

16.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 17 of 109 PAGEID #: 2088

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

	  

17.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 18 of 109 PAGEID #: 2089

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%

	  

18.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 19 of 109 PAGEID #: 2090

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.

	  

19.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 20 of 109 PAGEID #: 2091

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

	  

20.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 21 of 109 PAGEID #: 2092

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,

	  

21.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 22 of 109 PAGEID #: 2093

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

	  

22.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 23 of 109 PAGEID #: 2094

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

	  

23.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 24 of 109 PAGEID #: 2095
• 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

	  

24.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 25 of 109 PAGEID #: 2096

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

	  

25.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 26 of 109 PAGEID #: 2097

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

	  

26.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 27 of 109 PAGEID #: 2098

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

	  

27.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 28 of 109 PAGEID #: 2099
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)

	  

28.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 29 of 109 PAGEID #: 2100

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

	  

29.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 30 of 109 PAGEID #: 2101

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

	  

30.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 31 of 109 PAGEID #: 2102

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

	  

31.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 32 of 109 PAGEID #: 2103

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.

	  

32.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 33 of 109 PAGEID #: 2104

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

	  

33.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 34 of 109 PAGEID #: 2105

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.

	  

34.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 35 of 109 PAGEID #: 2106

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.

	  

35.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 36 of 109 PAGEID #: 2107

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

	  

36.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 37 of 109 PAGEID #: 2108
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

	  

37.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 38 of 109 PAGEID #: 2109

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

	  

38.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 39 of 109 PAGEID #: 2110

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.

	  

39.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 40 of 109 PAGEID #: 2111

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

	  

40.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 41 of 109 PAGEID #: 2112

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

	  

41.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 42 of 109 PAGEID #: 2113

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

	  

42.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 43 of 109 PAGEID #: 2114

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,

	  

43.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 44 of 109 PAGEID #: 2115

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

	  

44.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 45 of 109 PAGEID #: 2116

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.

	  

45.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 46 of 109 PAGEID #: 2117

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

	  

46.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 47 of 109 PAGEID #: 2118

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

	  

47.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 48 of 109 PAGEID #: 2119

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.

	  

48.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 49 of 109 PAGEID #: 2120

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

	  

49.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 50 of 109 PAGEID #: 2121

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).

	  

50.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 51 of 109 PAGEID #: 2122

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

	  

51.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 52 of 109 PAGEID #: 2123

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,

	  

52.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 53 of 109 PAGEID #: 2124

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

	  

53.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 54 of 109 PAGEID #: 2125

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)

	  

54.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 55 of 109 PAGEID #: 2126

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

	  

55.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 56 of 109 PAGEID #: 2127

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

	  

56.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 57 of 109 PAGEID #: 2128

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

	  

57.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 58 of 109 PAGEID #: 2129

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.

	  

58.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 59 of 109 PAGEID #: 2130

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

	  

59.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 60 of 109 PAGEID #: 2131

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,

	  

60.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 61 of 109 PAGEID #: 2132

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

	  

61.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 62 of 109 PAGEID #: 2133
• Youth interviews • Staff interviews

	  

62.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 63 of 109 PAGEID #: 2134

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

	  

63.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 64 of 109 PAGEID #: 2135

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

	  

64.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 65 of 109 PAGEID #: 2136
• Review of youth records • Youth interview and observation

	  

65.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 66 of 109 PAGEID #: 2137

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,

	  

66.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 67 of 109 PAGEID #: 2138

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

	  

67.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 68 of 109 PAGEID #: 2139

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

	  

68.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 69 of 109 PAGEID #: 2140

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

	  

69.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 70 of 109 PAGEID #: 2141

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

	  

70.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 71 of 109 PAGEID #: 2142

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

	  

71.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 72 of 109 PAGEID #: 2143

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.

	  

72.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 73 of 109 PAGEID #: 2144

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

	  

73.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 74 of 109 PAGEID #: 2145

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,

	  

74.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 75 of 109 PAGEID #: 2146

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

	  

75.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 76 of 109 PAGEID #: 2147

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

	  

76.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 77 of 109 PAGEID #: 2148

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

	  

77.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 78 of 109 PAGEID #: 2149

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

	  

78.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 79 of 109 PAGEID #: 2150

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.

	  

79.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 80 of 109 PAGEID #: 2151

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

	  

80.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 81 of 109 PAGEID #: 2152

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

	  

81.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 82 of 109 PAGEID #: 2153

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.

	  

82.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 83 of 109 PAGEID #: 2154

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

	  

83.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 84 of 109 PAGEID #: 2155

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

	  

84.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 85 of 109 PAGEID #: 2156

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

	  

85.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 86 of 109 PAGEID #: 2157

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

	  

86.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 87 of 109 PAGEID #: 2158

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

	  

87.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 88 of 109 PAGEID #: 2159

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.

	  

88.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 89 of 109 PAGEID #: 2160

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

	  

89.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 90 of 109 PAGEID #: 2161

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

	  

90.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 91 of 109 PAGEID #: 2162

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;

	  

91.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 92 of 109 PAGEID #: 2163

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

	  

92.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 93 of 109 PAGEID #: 2164

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

	  

93.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 94 of 109 PAGEID #: 2165

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.

	  

94.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 95 of 109 PAGEID #: 2166

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.

	  

95.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 96 of 109 PAGEID #: 2167
• 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.

	  

96.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 97 of 109 PAGEID #: 2168

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;

	  

97.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 98 of 109 PAGEID #: 2169
218026; 217809; 217931; 217246; 217655; 217246; 217951; 217732 and 217926.

	  

98.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 99 of 109 PAGEID #: 2170

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

	  

99.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 100 of 109 PAGEID #: 2171

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

	  

100.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 101 of 109 PAGEID #: 2172

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

	  

101.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 102 of 109 PAGEID #: 2173

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

	  

102.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 103 of 109 PAGEID #: 2174

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

	  

103.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 104 of 109 PAGEID #: 2175

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

	  

104.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 105 of 109 PAGEID #: 2176

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

	  

105.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 106 of 109 PAGEID #: 2177

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.

	  

106.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 107 of 109 PAGEID #: 2178

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)

	  

107.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 108 of 109 PAGEID #: 2179

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

	  

108.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 109 of 109 PAGEID #: 2180

	  

109.

 
 Case: 2:08-cv-00475-ALM-MRA Doc #: 109 Filed: 01/18/13 Page: 1 of 17 PAGEID #: 2337
Case: 2:08-cv-00475-ALM-MRA Doc#: 107-1 Filed: 12/19/12 Page: 1 of 17 PAGEID #: 2189

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

Case: 2:08-cv-00475-ALM-MRA Doc #: 109 Filed: 01/18/13 Page: 2 of 17 PAGEID #: 2338 Case: 2:08-cv-00475-ALM-MRA Doc#: 107-1 Filed: 12/19/12 Page: 2 of 17 PAGEID #: 2190
and days C'Structured Programming"). The State shall develop and implement Structured Programming at each facility from the end ofthe school day until youth &o to bed, and on weekends. For youth housed in closed~cell environments, Structured Programming shall be designed to ensure that youth are not confined in locked cells except: (1) from after Structured. Programming to wake-up; (b) as necessary where the youth poses an immediate risk of harm to self or others; or (c) following an adequate disciplinary hearing, pursuant to an appropriate disciplinary sanction. The Structured Programming shall be designed to modify behaviors. provide rehabilitation to the types of youth committed to each facility, address general health and mental health needs, and be coordinated with youth's individual behavioral and treatment plans. The State shall use teachers, school adininistrators, correctional officers, caseworkers, school counselors, cottage staff, and any other qualifi.ed assistance to develop and implement the Structured Programmins. The State shall provide youth with access to programming activities that are required for parole eligibility.
4. By letter dated September 26,2012, the United States notified the State of its determination
that che State is not in substantial compliance with Sections III.A.3 and III.F.l of the
Amended Stipulation and that, therefore, pursuant to Section VII.D and E of the Amended
Stipulation, the United States was initiating the dispute resolution process set forth in
paragraph 256 of the Stipulation.for Injunctive ReJief inS. H. v. Reed (No. 2:04-cv-1206) (the
"S.H. Stipulation"). S~cificallyt the Plaintiffs contend that the State continues to subject
youth housed on Scioto's special management unit, currently referred to as the f'PROORESS
Unit,. and currently consisting of three "phases" (Phase I, Phase II, and Transition), to
excessive seclusion, and fails to provide these youth with adequate structured programming.
5. On October 15 -19, 2012, the monitor team conducted a site visit at Scioto, to assess the
State's implementation of the Amended Stipulation and prepare the semi-annual compliance
report required under Section V.H. of the Amended Stipulation. Based on the Monitor,s
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 109 Filed: 01/18/13 Page: 3 of 17 PAGEID #: 2339 Case: 2:08-cv-00475-ALM-MRA Doc#: 107-1 Filed: 12/19/12 Page: 3 of 17 PAGEID #: 2191
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.
3

Case: 2:08-cv-00475-ALM-MRA Doc #: 109 Filed: 01/18/13 Page: 4 of 17 PAGEID #: 2340 Case: 2:08-cv-00475-ALM-MRA Doc#: 107-1 Filed: 12/19/12 Page: 4 of 17 PAGEID #: 2192
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.
4

Case: 2:08-cv-00475-ALM-MRA Doc #: 109 Filed: 01/18/13 Page: 5 of 17 PAGEID #: 2341 Case: 2:08-cv-00475-ALM-MRA Doc#: 107-1 Filed: 12/19/12 Page: 5 of 17 PAGEID #: 2193
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 109 Filed: 01/18/13 Page: 6 of 17 PAGEID #: 2342 Case: 2:08-cv-00475-ALM-MRA Doc#: 107-1 Filed: 12/19/12 Page: 6 of 17 PAGEID #: 2194
•
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 109 Filed: 01/18/13 Page: 7 of 17 PAGEID #: 2343 Case: 2:08-cv-00475-ALM-MRA Doc#: 107-1 Filed: 12/19/12 Page: 7 of 17 PAGEID #: 2195
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 109 Filed: 01/18/13 Page: 8 of 17 PAGEID #: 2344

i

Case: 2:08-cv-00475-ALM-MRA Doc#: 107-1 Filed: 12/19/12 Page: 8 of 17 PAGEID #: 2196

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

Case: 2:08-cv-00475-ALM-MRA Doc #: 109 Filed: 01/18/13 Page: 9 of 17 PAGEID #: 2345 Case: 2:08-cv-00475-ALM-MRA Doc#: 107-1 Filed: 12/19/12 Page: 9 of 17 PAGEID #: 2197
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 109 Filed: 01/18/13 Page: 10 of 17 PAGEID #: 2346 Case: 2:08-cv-00475-ALM-MRA Doc#: 107-1 Filed: 12/19/12 Page: 10 of 17 PAGEID #: 2198
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 109 Filed: 01/18/13 Page: 11 of 17 PAGEID #: 2347 Case: 2:08-cv-00475-ALM-MRA Doc#: 107-1 Filed: 12/19/12 Page: 11 of 17 PAGEID #: 2199
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 109 Filed: 01/18/13 Page: 12 of 17 PAGEID #: 2348 Case: 2:08-cv-00475-ALM-MRA Doc#: 107-1 Filed: 12/19/12 Page: 12 of 17 PAGEID #: 2200
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 109 Filed: 01/18/13 Page: 13 of 17 PAGEID #: 2349 Case: 2:08-cv-00475-ALM-MRA Doc#: 107-1 Filed: 12/19/12 Page: 13 of 17 PAGEID #: 2201
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 109 Filed: 01/18/13 Page: 14 of 17 PAGEID #: 2350 Case: 2:08-cv-00475-ALM-MRA Doc#: 107-1 Filed: 12/19/12 Page: 14 of 17 PAGEID #: 2202
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

Case: 2:08-cv-00475-ALM-MRA Doc #: 109 Filed: 01/18/13 Page: 15 of 17 PAGEID #: 2351 Case: 2:08-cv-00475-ALM-MRA Doc#: 107-1 Filed: 12/19/12 Page: 15 of 17 PAGEID #: 2203

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

;;j, I DATE: Cj /t 2.
THOMAS E. PEREZ Assistant Attorney General Civil Rights Division
JONATHAN M. SMITH Section Chief Special Litigation Section
BENJAMIN 0. TAYLOE, JR. Deputy Chief Special Litigation Section
~~ j(JUCliilecuncannan Trial Attorney Special Litigation Section U.S. Department of Justice Civil Rights Division 950 Pennsylvania Avenue, NW Washington, D.C. 20530 Telephone: (202) 616-2556 Fax: (202) 514-4883 JacqueJine.Cuncannan@usdoj .gov

15

Case: 2:08-cv-00475-ALM-MRA Doc #: 109 Filed: 01/18/13 Page: 16 of 17 PAGEID #: 2352 Case: 2:08-cv-00475-ALM-MRA Doc#: 107-1 Filed: 12/19/12 Page: 16 of 17 PAGEID #: 2204

IT IS SO STIPULATED AND AGREED. FOR THE STATE:

I I\ ~ q DATE: J

z._

v- -;-ru-v~. 1/tJ o-J..
Mindy WorlyfT Principal Assistant Attorney General
Ohio Attorney General's Office Criminal Justice Section 150 East Gay Street, 16th Floor Columbus, OH 43215

16

Case: 2:08-cv-00475-ALM-MRA Doc #: 109 Filed: 01/18/13 Page: 17 of 17 PAGEID #: 2353 Case: 2:08-cv-00475-ALM-MRA Doc#: 107-1 Filed: 12/19/12 Page: 17 of 17 PAGEID #: 2205
- WHEREFORE, for good cause shown,
it is SO ORDERED this ffday of J~'-'tto/20!J.
17

 
 Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 1 of 129 PAGEID #: 2354

	   	   	   	   	   	   	  

U.S.	  Department	  of	  Justice	  v.	  The	  State	  of	  Ohio	  

Civil	  Action	  No:	  2:08-­‐cv-­‐475	  

Monitor’s	  Third	  Report	  on	  the	  Amended	  Stipulation	  signed	  June	  28,	  2011	  

	  

	  

	  

	  

	  

	  

	  

	  

	  

	  

	  

Kelly	  Dedel,	  Ph.D.,	  Lead	  Monitor	  

Daphne	  Glindmeyer,	  M.D.,	  Subject	  Matter	  Expert	  

Michelle	  Staples-­‐Horne,	  M.D.,	  Subject	  Matter	  Expert	  

	  

One	  in	  37	  Research,	  Inc.	  

16	  Rock	  Street	  	  Cody,	  WY	  	  82414	  

(503)799-­‐0915	  

kelly.dedel@gmail.com	  

	  

	  

	  

Draft	  Submitted	  November	  30,	  2012	  

Final	  Submitted	  January	  23,	  2013	  

	  

	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 2 of 129 PAGEID #: 2355

TABLE	  OF	  CONTENTS	  
	   Introduction	  ............................................................................................................................	  3	   Executive	  Summary	  .................................................................................................................	  4	  
Protection	  from	  Harm	.   ..................................................................................................................	  10	   General	  Protection	  From	  Harm	.  ................................................................................................	  10	   Seclusion	 .  ..................................................................................................................................	  21	   Investigation	  of	  Serious	  Incidents	 .  ............................................................................................	  30	   Grievances	.  ................................................................................................................................	  35	   Grievances	  Explained	  to	  Youth	  .................................................................................................	  39	   Structured	  Programming	  ..........................................................................................................	  41	   Orientation	.  ...............................................................................................................................	  49	  
	   Mental	  Health	  Services	  ................................................................................................................	  52	  
Mental	  Health	  Screening	.   .........................................................................................................	  52	   Immediate	  Referral	  to	  QMHP	  ..................................................................................................	  54	   Identification	  of	  Previously	  Unidentified	  Youth	 .  ......................................................................	  56	   Mental	  Health	  Assessment	  ......................................................................................................	  58	   Adequate	  Care	  and	  Treatment	.   ................................................................................................	  60	   Treatment	  Planning	.   .................................................................................................................	  64	   Treatment	  Teams	 .  ....................................................................................................................	  65	   Integrated	  Treatment	  Plans	  .....................................................................................................	  69	   Access	  to	  QMHP	 .  ......................................................................................................................	  72	   Mental	  Health	  Involvement	  in	  Housing	  and	  Placement	.  ..........................................................	  75	   Staffing	  .....................................................................................................................................	  80	   Medication	  Notice	.   ...................................................................................................................	  84	   Mental	  Health	  Medications	.  .....................................................................................................	  87	   MH/DD	  Training	  for	  Direct	  Care	  Staff	.  ......................................................................................	  92	   Staff	  Mental	  Health	  Training	 .  ...................................................................................................	  95	   Suicide	  Prevention	.  ...................................................................................................................	  98	   Transition	  Planning	.  ................................................................................................................	  101	   Oversight	  of	  Mental	  Health	.   ...................................................................................................	  104	   Documentation	.   ..........................................................................................................................	  107	   Progress	  Notes	  .......................................................................................................................	  107	   Accessibility	  of	  Information	.  ...................................................................................................	  109	   	   Medical	  Services	 .  ........................................................................................................................	  110	   General	  Medical	  Care	.   ............................................................................................................	  110	   Health	  Records	 .  ......................................................................................................................	  114	   Access	  to	  Health	  Systems	.   ......................................................................................................	  116	   	   Special	  Education	  Services	  .........................................................................................................	  117	   Provision	  of	  Special	  Education	  ...............................................................................................	  117	   Individual	  Education	  Plans	  .....................................................................................................	  123	   Vocational	  Education	  .............................................................................................................	  127	   	   	  

	  

2.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 3 of 129 PAGEID #: 2356

INTRODUCTION	  
	  

On	  June	  4,	  2008,	  The	  United	  States	  Department	  of	  Justice	  (DOJ)	  and	  the	  State	  of	  Ohio	  (the	  State)	  

signed	  a	  stipulation	  for	  injunctive	  relief	  (the	  Stipulation)	  concerning	  conditions	  at	  the	  Scioto	  

Juvenile	  Correctional	  Facility	  (Scioto)	  and	  the	  Marion	  Juvenile	  Correctional	  Facility	  (Marion;	  

which	  was	  closed	  shortly	  after	  the	  Stipulation	  was	  signed).	  Fred	  Cohen,	  the	  Lead	  Monitor	  of	  the	  

concurrent	  conditions	  of	  confinement	  lawsuit,	  S.H.	  v	  Reed	  et	  al.,	  served	  as	  the	  monitor	  for	  the	  

Stipulation	  until	  late	  2009.	  At	  that	  point,	  Mr.	  Cohen	  resigned	  and	  the	  DOJ	  assumed	  the	  role	  of	  

Monitor,	  with	  Dr.	  Kelly	  Dedel,	  Dr.	  Daphne	  Glindmeyer,	  and	  Dr.	  Michelle	  Staples-­‐Horne	  serving	  as	  

subject	  matter	  experts.	  	  

	  

In	  June	  2011,	  as	  the	  original	  stipulation	  expired,	  the	  Parties	  recognized	  that	  the	  State	  had	  not	  

yet	  reached	  substantial	  compliance	  with	  several	  key	  portions	  of	  the	  Stipulation.	  Thus,	  the	  

Stipulation	  was	  renegotiated	  to	  include	  a	  subset	  of	  the	  original	  provisions.	  The	  Amended	  

Stipulation	  terminates	  when	  the	  State	  has	  achieved	  substantial	  compliance	  with	  each	  provision	  

and	  has	  maintained	  substantial	  compliance	  for	  two	  reporting	  periods	  (i.e.,	  12	  months).	  The	  

Parties	  also	  agreed	  that	  the	  Amended	  Stipulation	  is	  subject	  to	  the	  termination	  provisions	  of	  the	  

Prison	  Litigation	  Reform	  Act.	  	  

	  

The	  Monitor	  for	  the	  Amended	  Stipulation	  is	  Dr.	  Kelly	  Dedel,	  who	  evaluates	  the	  State’s	  progress	  

in	  the	  areas	  of	  Protection	  From	  Harm,	  Grievances,	  Programming	  and	  Special	  Education.	  She	  is	  

assisted	  by	  two	  Subject	  Matter	  Experts,	  Dr.	  Daphne	  Glindmeyer,	  who	  evaluates	  the	  State’s	  

progress	  on	  provisions	  related	  to	  Mental	  Health	  Services,	  and	  Dr.	  Michelle	  Staples-­‐Horne,	  who	  

evaluates	  the	  State’s	  progress	  on	  provisions	  related	  to	  Medical	  Care.	  	  

	  

As	  the	  Monitor,	  Dr.	  Dedel	  is	  the	  primary	  liaison	  between	  the	  Monitoring	  Team	  and	  the	  Parties	  

and	  she	  compiles	  the	  Monitor’s	  Report.	  To	  do	  so,	  she	  combines	  Drs.	  Glindmeyer’s	  and	  Staples-­‐

Horne’s	  reports	  with	  her	  own	  to	  form	  a	  coherent	  whole,	  but	  does	  not	  change	  the	  substance	  of	  

the	  reports	  by	  either	  of	  the	  Subject	  Matter	  Experts,	  who	  are	  responsible	  for	  forming	  their	  own	  

opinions	  about	  the	  level	  of	  compliance	  for	  each	  provision	  in	  their	  areas	  of	  expertise.	  	  

	  

This	  is	  the	  Monitor’s	  third	  report	  on	  the	  State’s	  progress	  toward	  the	  reforms	  required	  by	  the	  

Amended	  Stipulation.	  The	  monitoring	  period	  is	  April	  1	  through	  September	  30,	  2012.	  Progress	  

reports	  are	  issued	  approximately	  every	  six	  months.	  	  

	  

	  

	  

	  

3.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 4 of 129 PAGEID #: 2357

EXECUTIVE	  SUMMARY	  

	  

The	  Amended	  Stipulation	  includes	  33	  provisions	  related	  to	  Protection	  From	  Harm	  (n=3);	  

Grievances	  (n=2);	  Programming	  (n=2);	  Mental	  Health	  Care	  (n=18)	  and	  Documentation	  (n=2);	  

Medical	  Care	  (n=3);	  and	  Special	  Education	  (n=3).	  Each	  provision	  is	  listed	  in	  the	  table	  below,	  

along	  with	  the	  Monitor’s	  or	  Subject	  Matter	  Expert’s	  compliance	  rating.	  	  

	  

The	  Monitor’s	  first	  report	  used	  only	  two	  compliance	  levels:	  substantial	  compliance	  and	  non-­‐

compliance.	  The	  subsequent	  reports	  use	  a	  three-­‐tiered	  system	  (substantial	  compliance,	  partial	  

compliance	  and	  non-­‐compliance),	  defined	  as	  follows:	  

	  

·∙	  	  	  	  	  Substantial	  Compliance	  means	  that	  the	  facility	  has	  drafted	  relevant	  policies	  and	  procedures;	  

has	  trained	  the	  staff	  responsible	  for	  implementation;	  has	  sufficient	  staff	  to	  implement	  the	  

required	  reform;	  has	  demonstrated	  the	  ability	  to	  properly	  implement	  the	  procedures	  during	  

the	  majority	  of	  the	  monitoring	  period;	  and	  has	  ascertained	  that	  the	  procedures	  accomplish	  

the	  outcome	  envisioned	  by	  the	  provision.	  Non-­‐compliance	  with	  mere	  technicalities	  or	  a	  

temporary	  failure	  to	  comply	  (due	  to	  staff	  vacancy	  or	  illness,	  facility	  disruptions,	  or	  other	  

short-­‐term	  events)	  during	  an	  otherwise	  sustained	  period	  of	  compliance	  do	  not	  constitute	  a	  

failure	  to	  achieve	  or	  maintain	  substantial	  compliance.	  Conversely,	  temporary	  compliance	  

during	  a	  period	  of	  sustained	  non-­‐compliance	  or	  partial	  compliance	  does	  not	  constitute	  

substantial	  compliance.	  

	  	  

·∙	  	  	  	  	  	  Partial	  Compliance	  means	  that	  the	  facility	  has	  drafted	  policies	  and	  procedures,	  has	  trained	  

staff	  responsible	  for	  implementation,	  and	  has	  sufficient	  staff	  to	  implement	  the	  required	  

reform.	  While	  progress	  has	  been	  made	  toward	  implementing	  the	  procedures	  described	  by	  

policy,	  performance	  has	  been	  inconsistent	  throughout	  the	  monitoring	  period	  and	  additional	  

modifications	  are	  needed	  to	  ensure	  that	  procedures	  are	  sufficiently	  comprehensive	  to	  

translate	  policy	  into	  practice.	  	  

	  	  

·∙	  	  	  	  	  Non-­‐Compliance	  means	  that	  the	  facility	  has	  made	  only	  very	  preliminary	  efforts	  to	  implement	  

the	  required	  reform,	  but	  significant	  work	  remains.	  Policy	  may	  need	  to	  be	  overhauled,	  the	  

majority	  of	  staff	  may	  need	  to	  be	  trained,	  procedures	  may	  not	  have	  been	  developed,	  and	  no	  

one	  has	  begun	  to	  ascertain	  whether	  the	  procedures	  accomplish	  the	  outcome	  envisioned	  by	  

the	  provision.	  	  

	  

	  

The	  Monitor	  wants	  to	  emphasize	  that	  the	  substantial	  compliance	  rating	  is	  given	  only	  when	  the	  

required	  reforms	  address	  all	  of	  the	  issues	  discussed	  in	  the	  Provision	  and	  when	  solid	  

implementation	  of	  the	  reforms	  has	  been	  consistently	  demonstrated,	  through	  reliable	  data,	  

observations	  and	  reports	  from	  staff	  and	  youth,	  for	  a	  majority	  of	  the	  monitoring	  period.	  Partial	  

compliance	  indicates	  that	  some	  of	  the	  issues	  addressed	  in	  the	  Provision	  have	  been	  resolved,	  but	  

that	  problems,	  some	  of	  them	  serious,	  still	  remain.	  The	  application	  of	  the	  partial	  compliance	  

rating	  is	  only	  a	  brief	  indicator—the	  entire	  discussion	  should	  be	  read	  to	  fully	  understand	  the	  type	  

and	  magnitude	  of	  remaining	  problems.	  	  

	  

	  

	  

	  

	  

4.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 5 of 129 PAGEID #: 2358

Table	  1.	  Compliance	  Ratings	  for	  Each	  Provision	  

No.	  

Provision	  

Protection	  From	  Harm	  

III.A.	  1	  

General	  Protection	  From	  Harm	  

III.A.3	  

Seclusion	  

III.A.5	  

Investigation	  of	  Serious	  Incidents	  

III.D.1	  

Grievances	  

III.D.2	  

Grievances	  Explained	  to	  Youth	  

III.F.1	  

Structured	  Programming	  

III.F.2	  

Orientation	  

Mental	  Health	  Services	  

III.B.1	  

Mental	  Health	  Screening	  

III.B.2	  

Immediate	  Referral	  to	  QMHP	  

III.B.3	  

Identification	  of	  Previously	  UnID	  Youth	  	  

III.B.4	  

Mental	  Health	  Assessment	  

III.B.5	  

Adequate	  Care	  and	  Treatment	  

III.B.6	  

Treatment	  Planning	  

III.B.7	  

Treatment	  Teams	  

III.B.8	  

Integrated	  Treatment	  Plans	  

III.B.9	  

Access	  to	  QMHP	  

III.B.10	  

MH	  Involvement	  in	  Housing	  and	  Plcmt	  

III.B.11	  

Staffing	  

III.B.12	  

Medication	  Notice	  

III.B.13	  

Mental	  Health	  Medications	  

III.B.14	  

MH/DD	  Training	  for	  Direct	  Care	  Staff	  

III.B.15	  

Staff	  Mental	  Health	  Training	  

III.B.16	  

Suicide	  Prevention	  

III.B.17	  

Transition	  Planning	  

III.B.18	  

Oversight	  of	  Mental	  Health	  

III.G.1	  

Progress	  Notes	  

III.G.2	  

Accessibility	  of	  Information	   	  

1st	  Report	  	   2nd	  Report	   3rd	  Report	  

NC	  

PC	  

PC	  

NC	  

PC	  

PC	  

SC	  

PC	  

PC	  

PC	  

PC	  

PC	  

PC	  

SC	  

SC	  

NC	  

NC	  

PC	  

PC	  

PC	  

PC	  

PC	  

PC	  

SC	  

PC	  

PC	  

SC	  

NC	  

PC	  

PC	  

NC	  

PC	  

PC	  

NC	  

PC	  

PC	  

NC	  

PC	  

PC	  

PC	  

PC	  

PC	  

NC	  

PC	  

PC	  

NC	  

PC	  

SC	  

NC	  

PC	  

PC	  

NC	  

PC	  

PC	  

PC	  

PC	  

PC	  

PC	  

PC	  

PC	  

NC	  

NC	  

NC	  

PC	  

PC	  

PC	  

PC	  

PC	  

PC	  

PC	  

PC	  

PC	  

NC	  

NC	  

NC	  

PC	  

PC	  

PC	  

NC	  

NC	  

NC	  

	  

	  

5.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 6 of 129 PAGEID #: 2359

Medical	  Services	  

III.C.1	  

General	  Medical	  Care	  

SC	  

PC	  

PC	  

III.C.2	  

Health	  Records	  

SC	  

PC	  

PC	  

III.C.5	  

Access	  to	  Health	  Services	  

SC	  

SC	  

SC	  

Special	  Education	  Services	  

III.E.1	  

Provision	  of	  Special	  Education	  

PC	  

PC	  

PC	  

III.E.7	  

Individual	  Education	  Plans	  

PC	  

PC	  

SC	  

III.E.8	  

Vocational	  Education	  

NC	  

NC	  

SC	  

	   	   	   Overall,	  the	  State	  is	  in	  substantial	  compliance	  with	  7	  of	  the	  33	  provisions	  (21%,	  compared	  to	  6%	   during	  the	  previous	  monitoring	  period),	  in	  partial	  compliance	  with	  23	  provisions	  (70%;	   compared	  to	  79%	  during	  the	  previous	  monitoring	  period)	  and	  in	  non-­‐compliance	  with	  3	   provisions	  (9%,	  compared	  to	  15%	  during	  the	  previous	  monitoring	  period).	  Across	  the	  33	   provisions,	  the	  compliance	  rating	  was	  upgraded	  for	  6	  provisions	  (18%).	  The	  compliance	  rating	   was	  not	  downgraded	  for	  any	  provision.	  Compliance	  ratings	  for	  each	  section	  and	  key	  issues	  to	  be	   addressed	  are	  highlighted	  below.	  	   	   	   Protection	  from	  Harm	  (includes	  Grievances	  and	  Programming)	   	   The	  facility	  is	  in	  substantial	  compliance	  with	  1	  of	  the	  7	  provisions	  (14%)	  related	  to	  protecting	   youth	  from	  harm	  and	  in	  partial	  compliance	  with	  the	  remaining	  6	  provisions	  (86%).	  The	  following	   actions	  should	  be	  prioritized:	   	  
• Conduct	  a	  problem-­‐solving	  analysis	  to	  determine	  the	  nature	  of	  youth-­‐on-­‐staff	  assaults	   and	  implement	  interventions	  that	  target	  the	  underlying	  causes	  and	  patterns.	  
• Improve	  the	  quality	  of	  FIA	  reviews	  of	  the	  use	  of	  physical	  restraint	  to	  ensure	  that	  staff	   have	  exhausted	  all	  other	  means	  for	  resolving	  problems	  with	  youth.	  Ensure	  that	  staff	  are	   provided	  with	  coaching	  to	  help	  develop	  their	  skills	  in	  this	  area	  and	  to	  ensure	  their	   compliance	  with	  all	  related	  policies.	  	  
• Ensure	  that	  sufficient	  direct	  care	  staff	  are	  recruited,	  hired	  and	  retained	  in	  order	  to	   reduce	  the	  reliance	  on	  mandated	  overtime	  to	  meet	  minimum	  staffing	  requirements.	  	  
• Reinforce	  the	  prohibition	  against	  provoking,	  taunting,	  belittling	  and	  otherwise	   disrespecting	  youth.	  Investigate	  complaints	  vigorously	  and	  enforce	  the	  conduct	   standards	  when	  they	  are	  violated.	  	  
• Modify	  the	  IRAV	  to	  ensure	  that	  youth	  remain	  in	  pre-­‐hearing	  seclusion	  no	  longer	  than	   necessary	  to	  de-­‐escalate	  their	  behavior	  and	  ensure	  they	  do	  not	  pose	  a	  threat	  to	  the	   safety	  of	  other	  youth	  and	  staff.	  Ensure	  that	  Intervention	  Hearings	  are	  held	  in	  a	  timely	   manner.	  	  
• Limit	  the	  use	  of	  intervention	  seclusion,	  relying	  instead	  of	  sanctions	  that	  provide	  an	   opportunity	  for	  skill	  development	  and	  treatment	  in	  order	  to	  create	  behavior	  change,	   and	  collect	  data	  to	  demonstrate	  the	  extent	  to	  which	  this	  has	  occurred.	  Develop	  quality	  

	  

6.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 7 of 129 PAGEID #: 2360

assurance	  mechanisms	  around	  the	  use	  of	  seclusion	  in	  Intervention	  Hearings	  and	  to	   determine	  whether	  the	  IDT	  sanctioning	  process	  is	  a	  viable	  strategy	  for	  reducing	  the	   reliance	  on	  seclusion	  and	  increasing	  safety.	  	   • Ensure	  that	  youth	  on	  the	  PROGRESS	  Unit	  are	  not	  scheduled	  to	  be	  in	  their	  rooms	  in	  any	   greater	  measure	  than	  youth	  in	  the	  general	  population.	   • Ensure	  that	  youth	  on	  the	  PROGRESS	  Unit	  are	  out	  of	  their	  rooms,	  attending	  treatment	   education	  or	  other	  structured	  programming	  throughout	  the	  day.	  This	  programming	   must	  be	  delivered	  with	  integrity	  so	  that	  the	  youth	  are	  able	  to	  meet	  their	  treatment	   goals	  and	  return	  to	  the	  general	  population	  within	  a	  reasonable	  period	  of	  time.	  	   • Finalize	  the	  PROGRESS	  Unit	  policies,	  SOP	  and	  Youth	  Handbook	  so	  that	  they	  provide	  an	   accurate	  description	  of	  the	  current	  operation	  of	  the	  Unit.	  Revise	  these	  documents	  as	   the	  program	  evolves.	  	   • Reduce	  the	  number	  of	  individuals	  authorized	  to	  conduct	  facility-­‐based	  investigations	   and	  ensure	  that	  these	  individuals	  have	  the	  requisite	  skills	  for	  the	  task.	  Ensure	  that	   producing	  timely,	  high-­‐quality	  investigations	  is	  a	  specific	  job	  responsibility	  and	  that	   employees	  are	  held	  accountable	  for	  their	  failure	  to	  produce	  reports	  that	  meet	   professional	  standards.	  	   • Promptly	  notify	  youth	  of	  the	  outcome	  of	  any	  grievance	  referred	  for	  investigation.	   Construct	  a	  plan	  to	  respond	  to	  the	  problems	  discovered	  by	  the	  CIO’s	  2011	  grievance	   survey.	  	   • Ensure	  that	  individual	  and	  group	  treatment	  is	  delivered	  at	  the	  required	  frequency	  and	   duration	  on	  all	  units.	  	   	   	   Mental	  Health	  Services	   	   The	  facility	  is	  in	  substantial	  compliance	  with	  3	  (15%)	  of	  the	  20	  provisions	  related	  to	  mental	   health	  services	  and	  documentation.	  It	  is	  in	  partial	  compliance	  with	  14	  (70%)	  of	  the	  provisions	   and	  in	  non-­‐compliance	  with	  3	  of	  the	  provisions	  (15%).	  	  The	  following	  actions	  are	  required:	   	   • Finalize	  and	  implement	  policies.	  ODYS	  has	  recently	  completed	  a	  collaborative	  policy	  and	   procedure	  review	  and	  revision	  process.	  	  The	  Monitors	  in	  both	  this	  case	  and	  S.H.	  v.	  Reed	   have	  reviewed	  these	  policies.	  	  	   • Staff	  the	  facility	  with	  sufficient	  psychiatric	  (both	  psychiatric	  physicians	  and	  psychiatric	   nurses)	  resources	  to	  provide	  psychiatric	  evaluation,	  medication	  monitoring,	  and	   treatment	  team	  interaction.	   • Develop	  an	  organized	  training	  schedule	  for	  mental	  health	  staff.	  	   • Train	  direct	  care	  staff	  and	  mental	  health	  staff	  to	  understand	  the	  behavior	  and	  needs	  of	   youth	  with	  mental	  illnesses	  and	  developmental	  disabilities	  and	  recognize	  and	  respond	   to	  signs	  and	  symptoms	  of	  serious	  mental	  illness.	  	   • Train	  mental	  health	  staff	  to	  develop	  high-­‐quality	  case	  conceptualizations	  that	  integrate	   the	  information	  generated	  by	  the	  multiple	  assessments	  administered	  to	  youth	  upon	   admission.	  	   • Train,	  coach	  and	  adequately	  supervise	  direct	  care	  staff	  and	  mental	  health	  staff	  to	   implement	  the	  Phoenix	  New	  Freedom	  curriculum,	  particularly	  in	  skills	  for	  leading	  group	   therapy	  sessions	  to	  ensure	  the	  interactions	  and	  documentation	  reflect	  generally	   accepted	  practices	  for	  mental	  health	  care.	  	  This	  should	  include	  treatment	  integrity	  

	  

7.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 8 of 129 PAGEID #: 2361

checks	  (e.g.	  observation	  of	  group	  interaction	  with	  subsequent	  education	  and	  training	  as	   necessary).	   • Develop	  procedures	  to	  ensure,	  and	  to	  document,	  that	  youth	  are	  assessed	  by	  a	  qualified	   mental	  health	  professional	  within	  12	  hours	  when	  a	  serious	  risk	  to	  the	  youth’s	  safety	  is	   identified.	  	   • Ensure	  mental	  health	  staff	  assesses	  youth	  on	  suicide	  precautions,	  those	  in	  seclusion,	   and	  those	  on	  the	  PROGRESS	  Units	  every	  24	  hours.	  	   • Ensure	  youth	  with	  acute	  mental	  illnesses	  requiring	  extensive	  mental	  health	  treatment	   have	  access	  to	  more	  appropriate	  placements.	   • Ensure	  treatment	  plans	  are	  individualized	  including	  measurable	  goals	  and	  targeted	   interventions	  to	  address	  the	  goals.	  Update	  treatment	  plans	  regularly	  and	  monitor	   youth’s	  progress	  toward	  achieving	  treatment	  goals.	  Adapt	  treatment	  plans	  for	  youth	   who	  are	  not	  progressing.	   • Ensure	  Interdisciplinary	  Treatment	  Team	  meetings	  include	  representatives	  from	  the	   major	  sectors	  of	  the	  facility	  including	  social	  workers,	  direct	  care	  staff,	  educators,	  and	   psychiatrists	  and	  that	  Treatment	  Teams	  are	  focused	  on	  treatment	  issues	  and	  the	  youth’s	   progress	  toward	  treatment	  goals.	   • Ensure	  youth	  on	  the	  PROGRESS	  Units	  are	  appropriate	  for	  the	  secure	  setting	  and	  receive	   appropriate	  treatment.	  Conduct	  thorough	  assessments	  of	  all	  youth	  proposed	  for	   placement	  in	  the	  future.	  	   • Continue	  the	  current	  practice	  of	  assigning	  all	  youth	  housed	  in	  the	  PROGRESS	  Units	  to	   the	  mental	  health	  caseload.	   • Ensure	  youth	  receive	  proper	  laboratory	  examinations	  and	  side-­‐effect	  monitoring	   commensurate	  with	  the	  psychotropic	  medications	  prescribed	  and	  reflecting	  generally	   accepted	  practices.	  	   • Develop	  a	  coherent,	  coordinated	  quality	  assurance	  process	  that	  provides	  a	  cogent	   review	  of	  social	  work,	  psychological	  and	  psychiatric	  services	  at	  the	  facility.	  This	  should	   include	  peer	  review.	  	  It	  should	  also	  include	  both	  process	  and	  outcome	  measures	  with	   corrective	  action	  inclusive	  of	  individual	  supervision,	  staff	  training,	  or	  adjustment	  of	   systems	  as	  necessary.	   • Address	  limitations	  to	  treatment	  resulting	  from	  the	  fragmented	  recordkeeping	  process	   via	  the	  creation	  of	  a	  unified	  record.	   	   	   Medical	  Services	   	   The	  facility	  is	  in	  substantial	  compliance	  with	  one	  of	  the	  provisions	  (33%)	  related	  to	  medical	   services	  and	  in	  partial	  compliance	  with	  the	  other	  2	  provisions	  (66%).	  The	  following	  actions	   should	  be	  prioritized:	   	   • Complete	  satellite	  clinic	  and	  medication	  room	  on	  Buckeye	  Units	  for	  adequate	  injury	   assessments	  of	  youth	  and	  medication	  administration	  on	  the	  unit.	  	   • Limit	  time	  of	  youth	  in	  seclusion	  and	  improve	  documentation	  of	  health	  status	  during	   segregation.	   • Continue	  to	  improve	  Quality	  Assurance	  (QA)	  activities	  by	  considering	  a	  review	  at	  least	   annually	  by	  a	  source	  external	  to	  ODYS	  Health	  Services.	  ODYS	  should	  also	  consider	   expansion	  of	  the	  QA	  process	  to	  include	  some	  additional	  quality	  indicators.	  Conduct	  

	  

8.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 9 of 129 PAGEID #: 2362

Quality	  Assurance	  Program	  as	  outlined	  in	  the	  National	  Commission	  on	  Correctional	  

Health	  Care	  Juvenile	  Health	  Standards.	  This	  would	  satisfy	  the	  need	  for	  a	  self-­‐

assessment.	  

• Continue	  to	  improve	  the	  process	  for	  sharing	  of	  health	  information	  between	  medical	  and	  

mental	  health	  to	  include	  psychologists	  through	  implementation	  of	  eClinical	  Works	  EHR.	  

ODYS	  medical	  management	  staff	  should	  be	  intimately	  involved	  in	  the	  process	  of	  

customization	  of	  the	  EMR	  to	  be	  relevant	  to	  youth	  medical	  services.	  

	  

	  

Special	  Education	  

	  

The	  facility	  is	  in	  substantial	  compliance	  with	  2	  of	  the	  3	  education-­‐related	  provisions	  (66%)	  and	  is	  

in	  partial	  compliance	  with	  one	  provision	  (33%).	  The	  following	  actions	  should	  be	  prioritized:	  

• Address	  the	  preventable	  causes	  of	  absenteeism,	  address	  data	  entry	  and	  data	  

management	  issues,	  and	  ensure	  average	  attendance	  rates	  of	  85%	  or	  better	  are	  achieved	  

for	  each	  housing	  unit.	  	  

• Continue	  to	  provide	  access	  to	  alternative	  education	  services	  for	  youth	  in	  seclusion	  

through	  the	  use	  of	  Unit	  Instruction.	  Ensure	  that	  the	  type,	  quality	  and	  duration	  of	  

instruction	  comply	  with	  the	  S.H.	  Parties’	  agreement.	  Come	  to	  an	  agreement	  with	  the	  SH	  

Parties	  as	  to	  whether	  youth	  will	  be	  served	  behind	  their	  doors	  or	  may	  be	  brought	  out	  

into	  the	  dayroom,	  when	  that	  can	  be	  accomplished	  safely.	  	  

	  

	  

	  

	  

The	  facility	  has	  undergone	  several	  transformations	  since	  the	  original	  Stipulation	  was	  signed.	  

Originally,	  Scioto	  was	  the	  central	  reception	  facility	  for	  all	  DYS	  facilities.	  In	  the	  summer	  of	  2011,	  

DYS	  began	  to	  de-­‐centralize	  its	  reception	  process	  to	  convert	  Scioto	  to	  a	  long-­‐term	  facility	  that	  

houses	  medium	  and	  close	  custody	  boys.	  Scioto	  remains	  the	  reception	  center	  for	  girls	  and	  also	  

operates	  a	  long-­‐term	  girls’	  program	  and	  a	  mental	  health	  unit	  for	  girls.	  The	  facility	  also	  houses	  a	  

special	  management	  unit	  (the	  PROGRESS	  Unit),	  which	  has	  been	  the	  topic	  of	  much	  controversy	  

during	  the	  current	  monitoring	  period.	  	  

	  

The	  change	  in	  the	  facility’s	  mission	  required	  staff	  to	  adjust	  to	  a	  new	  type	  of	  youth	  (generally	  

higher-­‐risk)	  and	  to	  new	  responsibilities	  for	  their	  long-­‐term	  care	  and	  treatment.	  In	  addition,	  the	  

facility	  received	  an	  entirely	  new	  Administrative	  Team	  in	  February	  2012,	  and	  then	  received	  a	  new	  

Superintendent	  in	  September	  2012.	  The	  multitude	  of	  changes	  have	  made	  steady	  progress	  

toward	  substantial	  compliance	  difficult	  to	  achieve.	  	  

	  

The	  remainder	  of	  this	  report	  is	  organized	  as	  follows:	  1)	  each	  Provision	  is	  presented,	  verbatim;	  2)	  

the	  compliance	  rating	  is	  noted;	  3)	  information	  the	  State	  presented	  to	  demonstrate	  compliance	  

with	  the	  Provision	  is	  summarized;	  4)	  additional	  activities	  undertaken	  by	  the	  Monitor	  or	  subject	  

matter	  expert	  to	  determine	  the	  level	  of	  compliance	  are	  discussed;	  5)	  the	  steps	  required	  to	  

achieve	  substantial	  compliance	  with	  the	  Provision	  are	  listed;	  6)	  the	  sources	  of	  information	  the	  

Monitor	  or	  subject	  matter	  expert	  used	  to	  form	  her	  opinion	  are	  listed.	  	  

	  

	  

	  

9.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 10 of 129 PAGEID #: 2363

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

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

The	  State	  provided	  an	  array	  of	  data	  to	  illustrate	  the	  trends	  in	  youth	   violence,	  restraints,	  seclusion,	  and	  allegations	  of	  employee	  misconduct,	   along	  with	  an	  interpretation	  of	  the	  trends	  and	  the	  underlying	  causes	  of	   any	  changes.	  The	  structure	  of	  the	  Monitor’s	  most	  recent	  visit	  did	  not	   provide	  as	  much	  time	  to	  discuss	  the	  interpretation	  of	  the	  data	  as	  in	   previous	  monitoring	  periods.	  As	  a	  result,	  much	  of	  the	  following	  discussion	   is	  based	  on	  the	  Monitor’s	  own	  analysis	  but	  is	  contained	  in	  the	  self-­‐ assessment	  section	  for	  the	  sake	  of	  clarity.	  	   	   While	  on	  site,	  the	  Monitor	  learned	  of	  several	  quality	  assurance	   mechanisms	  that,	  if	  data	  are	  interpreted	  properly	  and	  used	  as	  a	  basis	  for	   action,	  will	  improve	  the	  State’s	  ability	  to	  protect	  youth	  from	  harm.	  Trends	   in	  youth	  violence,	  restraints,	  and	  allegations	  of	  over-­‐familiarization	  are	   discussed	  here,	  while	  detailed	  discussions	  about	  the	  use	  of	  seclusion	  and	   staff	  misconduct	  can	  be	  found	  in	  III.A.3	  and	  III.A.5	  respectively.	  	   	   Youth	  Violence	   	   The	  table	  below	  presents	  the	  rate	  of	  youth-­‐on-­‐youth	  and	  youth-­‐on-­‐staff	   violence	  for	  the	  past	  18	  months.	  These	  data	  reveal	  a	  steady	  reduction	  in	   youth-­‐on-­‐youth	  violence.	  The	  average	  rate	  for	  the	  past	  three	  six-­‐month	   monitoring	  periods	  was	  .24,	  .13	  and	  .08.	  Changes	  in	  the	  rates	  of	  violence	   are	  customarily	  related	  to	  a	  complex	  constellation	  of	  factors	  including	   staffing,	  programming,	  treatment,	  the	  type	  of	  youth	  housed,	  amount	  of	   idle	  time,	  and	  the	  staff’s	  skill	  at	  de-­‐escalating	  the	  tension	  that	  arise.	  Most	   recently,	  the	  facility	  attributed	  its	  lower	  rates	  of	  youth-­‐on-­‐youth	  violence	   to	  changes	  in	  staffing.	  Specifically,	  permanent	  assignments	  were	  made	   for	  both	  the	  Operations	  Administrator	  and	  Unit	  Management	   Administrator,	  who	  worked	  and	  collaborated	  on	  daily	  issues	  and	  used	   proactive	  approaches	  to	  ensure	  that	  youth	  were	  protected	  from	  harm.	  In	   addition,	  since	  March	  2012,	  all	  units	  have	  had	  a	  Unit	  Manager.	  Finally,	  the	   facility	  did	  not	  operate	  below	  minimum	  staffing	  levels	  at	  any	  time	  during	   the	  current	  monitoring	  time.	  [Recall	  that	  short	  staffing	  was	  identified	  as	  a	   major	  contributor	  to	  a	  variety	  of	  operational	  problems	  in	  the	  2nd	   Monitor’s	  Report.]	   	   In	  addition,	  the	  PROGRESS	  Unit	  (PU)	  school	  was	  identified	  as	  a	  hot	  spot	   for	  youth-­‐on-­‐youth	  violence.	  The	  level	  of	  surveillance	  in	  the	  school	  was	  

	  

10.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 11 of 129 PAGEID #: 2364

drastically	  increased	  to	  include	  five	  Youth	  Specialists	  to	  assist	  with	  school	   movement	  and	  support	  during	  school	  hours.	  Support	  for	  this	  change	  was	   offered	  by	  nearly	  everyone	  with	  whom	  the	  Monitor	  spoke	  while	  on	  site,	   and	  it	  is	  strongly	  recommended	  that	  the	  State	  take	  steps	  to	  ensure	  that	   this	  level	  of	  staff	  support	  is	  permanently	  available.	  [Currently,	  the	  five	  YSs	   voluntarily	  leave	  their	  assigned	  posts	  to	  provide	  this	  assistance.]	  In	   addition,	  the	  school	  environment	  was	  “hardened”	  by	  bolting	  down	   furniture	  and	  computers	  and	  replacing	  keyboards	  that	  youth	  had	  been	   using	  as	  weapons.	  	   	   Youth	  violence	  also	  tended	  to	  occur	  among	  the	  close	  custody	  youth	   during	  2nd	  shift.	  As	  discussed	  in	  the	  review	  of	  structured	  programming	  in	   Provision	  III.F.1,	  the	  Gang	  Intervention	  Specialist	  began	  running	  groups	   with	  this	  population	  in	  the	  afternoons	  and	  has	  been	  more	  present	  on	  the	   units	  during	  the	  evenings	  and	  weekends.	  Finally,	  recreation	  staff	  and	   Youth	  Specialists	  have	  collaborated	  to	  provide	  additional	  programming	   opportunities	  to	  youth	  on	  the	  weekends	  to	  reduce	  the	  amount	  of	  idle	   time.	  All	  of	  these	  efforts	  appear	  to	  have	  accomplished	  the	  intended	   objective	  of	  reducing	  the	  rate	  of	  youth-­‐on-­‐youth	  violence.	  	   	  
Youth	  Violence,	  April	  2011	  through	  September	  2012	  

Month	  

Youth-­‐Youth	  

#	  

ADP	   Rate	  

Youth-­‐Staff	  

#	  

ADP	  

Rate	  

Apr	  11	  

30	  

128	  

.23	  

13	  

128	  

.10	  

May	  11	  

40	  

114	  

.35	  

14	  

114	  

.12	  

June	  11	  

25	  

110	  

.23	  

13	  

110	  

.12	  

July	  11	  

19	  

101	  

.19	  

9	  

101	  

.09	  

Aug	  11	  

24	  

108	  

.22	  

15	  

108	  

.14	  

Sept	  11	  

29	  

138	  

.21	  

45	  

138	  

.33	  

Oct	  11	  

31	  

164	  

.19	  

29	  

164	  

.18	  

Nov	  11	  

29	  

161	  

.18	  

29	  

161	  

.18	  

Dec	  11	  

18	  

159	  

.11	  

11	  

159	  

.07	  

Jan	  12	  

21	  

158	  

.13	  

30	  

158	  

.19	  

Feb	  12	  

10	  

137	  

.07	  

19	  

137	  

.14	  

Mar	  12	  

9	  

125	  

.07	  

21	  

125	  

.17	  

Apr	  12	  

9	  

118	  

.08	  

31	  

118	  

.26	  

May	  12	  

11	  

101	  

.11	  

16	  

101	  

.16	  

June	  12	  

4	  

91	  

.04	  

14	  

91	  

.15	  

July	  12	  

10	  

83	  

.12	  

18	  

83	  

.22	  

Aug	  12	  

11	  

88	  

.12	  

22	  

88	  

.25	  

Sept	  12	  

1	  

86	  

.01	  

14	  

86	  

.16	  

	  

	  

11.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 12 of 129 PAGEID #: 2365

Unfortunately,	  the	  rate	  of	  youth-­‐on-­‐staff	  violence	  has	  been	  more	   resistant	  to	  change.	  The	  average	  rate	  of	  youth-­‐on-­‐staff	  violence	  has	   actually	  increased	  about	  30%	  over	  the	  past	  three	  monitoring	  periods	  (1st	   monitoring	  period	  =	  .15;	  2nd	  monitoring	  period	  =	  .16;	  and	  3rd	  monitoring	   period	  =	  .20).	  	   	   Previous	  discussions	  with	  facility	  administrators	  centered	  around	  the	   belief	  that	  the	  largest	  contributor	  to	  the	  rate	  of	  youth-­‐on-­‐staff	  assaults	   was	  the	  throwing	  of	  bodily	  fluids	  and	  other	  liquids	  on	  staff	  in	  the	  PU.	  The	   use	  of	  container-­‐less	  meals	  (where	  youth	  receive	  the	  same	  food,	  but	  it	  is	   served	  without	  cups	  or	  cartons,	  trays	  with	  hard	  dividers	  or	  other	   structures	  that	  youth	  could	  use	  to	  store	  liquid	  to	  be	  used	  as	  a	  projectile)	   was	  said	  to	  significantly	  decrease	  the	  frequency	  of	  this	  behavior.	  While	   the	  number	  of	  these	  types	  of	  assaults	  has	  indeed	  declined,	  the	  rate	  of	   youth-­‐on-­‐staff	  assaults	  remains	  high,	  indicating	  that	  other	  types	  of	  youth	   violence	  against	  staff	  need	  to	  be	  addressed.	   	   The	  recent	  efforts	  to	  increase	  staffing	  levels	  and	  shore	  up	  the	  security	  of	   the	  classroom	  environments	  on	  the	  PU	  should	  be	  assessed	  for	  their	   impact	  on	  youth	  on	  staff	  violence.	  If	  the	  desired	  results	  are	  not	  being	   obtained,	  the	  facility	  should	  undertake	  a	  facility-­‐wide	  problem-­‐solving	   analysis	  to	  specify	  the	  types	  of	  assaults	  (e.g.,	  unprovoked	  physical	  assault	   versus	  assault	  that	  occurs	  while	  resisting	  a	  physical	  restraint),	  the	  severity	   of	  these	  assaults,	  the	  places	  and	  times	  where	  they	  occur,	  and	  the	   characteristics	  of	  the	  youth	  involved	  (e.g.,	  are	  they	  gang-­‐related	  assaults;	   are	  the	  youth	  on	  the	  mental	  health	  caseload;	  what	  skills	  do	  the	  youth	  and	   staff	  lack	  for	  managing	  their	  behavior	  appropriately?),	  and	  the	  general	   demeanor	  of	  staff	  involved	  (did	  they	  somehow	  provoke	  the	  youth	  or	   otherwise	  escalate	  the	  incident?).	  Once	  more	  is	  known	  about	  the	  nature	   of	  the	  problem,	  the	  facility	  should	  launch	  targeted	  interventions	  designed	   to	  address	  these	  specific	  causes	  and	  features	  of	  the	  problem.	  	   	   For	  example,	  throughout	  the	  Monitors’	  interviews,	  youth	  reported	   frustration	  with	  certain	  staff	  who	  were	  described	  as	  antagonizing,	   provoking,	  and	  otherwise	  speaking	  and	  behaving	  in	  ways	  that	  could	   increase	  youth’s	  propensity	  for	  violence	  toward	  them.	  This	  solution	  to	   this	  problem	  has	  many	  facets,	  including	  skill	  development	  among	  youth	   to	  tolerate	  frustration,	  make	  requests	  appropriately,	  control	  impulses,	   etc.	  along	  with	  reiterating	  and	  enforcing	  requirements	  around	   appropriate	  behavior	  and	  demeanor	  among	  staff,	  teaching	  them	  skills	  for	   tolerating	  their	  frustrations	  with	  youth,	  and	  holding	  them	  accountable	  for	   failing	  to	  meet	  these	  standards.	   	   Use	  of	  Restraints	   	   The	  previous	  Monitor’s	  Report	  registered	  concern	  about	  the	  use	  of	   physical	  restraints.	  Restraint	  use	  was	  very	  high	  at	  the	  beginning	  of	  the	  

	  

12.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 13 of 129 PAGEID #: 2366

previous	  monitoring	  period,	  but	  had	  begun	  to	  decrease	  during	  the	  last	   half	  of	  the	  previous	  monitoring	  period.	   	   The	  use	  of	  physical	  restraints	  decreased	  slightly	  during	  the	  current	   monitoring	  period.	  The	  average	  rate	  of	  restraint	  for	  the	  total	  population	   during	  the	  previous	  monitoring	  period	  was	  .72,	  compared	  to	  .62	  for	  the	   current	  monitoring	  period.	  However,	  looking	  only	  at	  the	  total	  population	   masks	  the	  significant	  gender	  difference	  and	  thus	  obscures	  an	  area	  that	  is	   ripe	  for	  a	  problem-­‐solving	  effort.	  	   	   Nearly	  all	  of	  the	  decrease	  in	  the	  use	  of	  physical	  restraint	  can	  be	  attributed	   to	  the	  decreases	  witnessed	  among	  the	  female	  population	  at	  Scioto.	   Although	  the	  girls	  had	  a	  higher	  average	  rate	  across	  the	  current	  6-­‐month	   period	  (.73	  versus	  .58),	  the	  patterns	  across	  the	  months	  tell	  a	  different	   story.	  The	  boy’s	  rate	  of	  restraint	  remained	  relatively	  constant,	  at	  .45	  or	   higher.	  However,	  the	  girls’	  rate	  of	  restraint	  decreased	  significantly	   throughout	  the	  monitoring	  period,	  from	  a	  high	  of	  2.08	  at	  the	  beginning	  of	   the	  period	  down	  to	  .08	  at	  the	  end	  of	  the	  period.	  Most	  likely,	  this	  can	  be	   attributed	  to	  the	  reduction	  in	  the	  size	  of	  the	  girls’	  mental	  health	   population.	  While	  the	  use	  of	  a	  rate	  controls	  for	  changes	  in	  the	  size	  of	  the	   population,	  it	  does	  not	  account	  for	  the	  differing	  management	  issues	  that	   come	  with	  serving	  a	  population	  with	  serious	  mental	  health	  issues.	  	   	   	  

Physical	  Restraints,	  January	  through	  September	  2012	  

Month	  

Total	  

Males	  

Females	  

#	   ADP	   rate	   #	   ADP	   rate	   #	   ADP	   rate	  

Oct	  11	   150	   164	   .91	   103	   128	   .81	   47	   36	   1.31	  

Nov	  11	   177	   161	   1.10	   111	   128	   .87	   66	   33	   2.00	  

Dec	  11	   99	   159	   .62	   49	   124	   .40	   50	   35	   1.43	  

Jan	  12	   93	   158	   .59	   61	   125	   .48	   32	   33	   .97	  

Feb	  12	   88	   137	   .64	   50	   106	   .47	   38	   31	   1.23	  

Mar	  12	   59	   125	   .47	   34	   97	   .35	   25	   28	   .89	  

Apr	  12	   94	   118	   .80	   40	   92	   .43	   54	   26	   2.08	  

May	  12	   55	   101	   .54	   35	   77	   .45	   20	   24	   .83	  

Jun	  12	   52	   91	   .57	   36	   68	   .53	   16	   23	   .70	  

July	  12	   70	   83	   .84	   60	   64	   .94	   10	   20	   .50	  

Aug	  12	   51	   88	   .58	   48	   72	   .67	   3	   16	   .19	  

Sep	  12	   35	   86	   .41	   34	   75	   .45	   1	   12	   .08	  

	   	   The	  facility	  should	  be	  applauded	  for	  its	  efforts	  to	  move	  girls	  with	  serious	   mental	  health	  issues	  to	  a	  more	  appropriate	  setting,	  but	  the	  Monitor	  

	  

13.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 14 of 129 PAGEID #: 2367

Steps	  Taken	  to	   Assess	  Compliance	  

remains	  concerned	  that	  the	  use	  of	  physical	  restraint	  among	  the	  boys’	   population	  at	  Scioto	  has	  not	  shown	  much	  improvement	  over	  the	  past	  12	   months.	  This	  is	  not	  to	  say	  that	  staff	  should	  not	  restrain	  youth	  who	  pose	  a	   legitimate	  threat	  to	  the	  safety	  of	  other	  youth,	  staff	  or	  themselves,	  but	   rather	  that	  the	  facility	  as	  a	  whole	  needs	  to	  better	  address	  the	  underlying	   causes	  of	  their	  misconduct	  and	  distress	  that	  leads	  to	  the	  restraint.	  	   	   A	  comprehensive	  internal	  and	  external	  quality	  assurance	  process	  has	   been	  in	  place	  for	  several	  years,	  and	  should	  be	  engaged	  to	  determine	   whether	  opportunities	  exist	  to	  reduce	  the	  need	  for	  restraints	  (i.e.,	   whether	  incidents	  could	  be	  better	  handled	  before	  escalating	  to	  the	  point	   of	  needing	  a	  restraint	  to	  ensure	  staff	  or	  youth	  safety).	  The	  Facility	   Intervention	  Administrator	  (FIA)	  is	  responsible	  for	  reviewing	  every	   incident	  involving	  restraints	  and	  determining	  whether	  staff’s	  actions	   complied	  with	  policy.	  The	  FIA	  has	  the	  option	  to	  approve	  the	  use	  of	  force	   as	  appropriate,	  to	  identify	  a	  “teachable	  moment”	  and	  provide	  specific	   coaching	  to	  the	  staff	  involved,	  or	  to	  refer	  the	  incident	  for	  investigation.	   Each	  month,	  the	  FIA’s	  assessment	  and	  decision-­‐making	  is	  reviewed	  by	  a	   Facility	  Resource	  Administrator	  (FRA)	  from	  DYS	  Central	  Office.	  Over	  the	   past	  few	  months,	  the	  FRA	  has	  identified	  a	  number	  of	  problems	  that	   suggest	  the	  FIA	  review	  process	  is	  not	  as	  robust	  as	  it	  should	  be.	  	   	   First,	  the	  FRA	  has	  consistently	  found	  that	  the	  FIA	  has	  missed	  several	   “teachable	  moments”	  in	  his	  reviews.	  These	  include	  things	  like	  the	  way	  a	   particular	  MYR	  technique	  was	  executed,	  the	  use	  of	  the	  hand-­‐held	   camera,	  or	  the	  presence	  and	  actions	  of	  the	  Supervisors	  on	  the	  scene.	  The	   FRA’s	  monthly	  reports	  encourage	  the	  FIA	  to	  be	  more	  vigilant	  about	  such	   things	  and	  to	  ensure	  that	  he	  documents	  the	  coaching	  and	  training	   delivered	  to	  staff	  (which	  is	  the	  whole	  point	  of	  the	  review—to	  help	  staff	   develop	  skills	  to	  manage	  the	  next	  incident	  better).	  The	  number	  of	   “teachable	  moments”	  identified	  by	  the	  FIA	  increased	  sharply	  toward	  the	   end	  of	  the	  monitoring	  period,	  perhaps	  in	  response	  to	  this	  feedback	  from	   the	  FRA.	  While	  the	  fact	  that	  the	  FRA	  was	  detecting	  so	  many	  unidentified	   problems	  indicated	  that	  the	  FIA	  review	  process	  was	  not	  functioning	  as	   designed,	  the	  multi-­‐layered	  audit	  process—all	  focused	  around	  whether	   staff	  are	  being	  provided	  with	  the	  feedback	  they	  need	  to	  increase	  their	   skills—is	  a	  tremendous	  asset.	  The	  State’s	  ability	  to	  identify	  and	  resolve	  to	   its	  own	  problems,	  absent	  DOJ	  oversight,	  is	  a	  very	  important	  part	  of	  their	   ability	  to	  achieve	  substantial	  compliance	  with	  the	  Stipulation.	  	  
Staffing	   	   The	  previous	  monitoring	  period	  identified	  staffing	  as	  one	  of	  the	  major	   contributors	  to	  the	  facility’s	  difficulty	  in	  reaching	  substantial	  compliance	   with	  the	  Stipulation.	  Youth	  in	  the	  general	  population	  were	  denied	  access	   to	  programming,	  youth	  on	  the	  Progress	  Unit	  were	  spending	  exorbitant	   amount	  of	  time	  in	  their	  rooms,	  and	  the	  prevalence	  of	  youth	  violence	  was	   attributed,	  in	  part,	  to	  not	  having	  sufficient	  numbers	  of	  staff	  available	  to	  

	  

14.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 15 of 129 PAGEID #: 2368

supervise	  the	  youth.	  	   	   When	  the	  facility	  began	  to	  hold	  Involuntary	  Disability	  Separation	  (IDS)	   hearings	  in	  January	  2012,	  the	  staffing	  situation	  began	  to	  improve	   noticeably	  because	  positions	  historically	  filled	  by	  staff	  who	  had	  exhausted	   their	  leave	  benefits	  became	  vacant	  and	  could	  be	  filled	  by	  someone	  who	   was	  able	  to	  report	  to	  work.	  	   	   In	  2011,	  the	  facility	  averaged	  approximately	  8	  vacant	  YS	  positions,	  but	   had	  approximately	  40	  staff	  who	  were	  not	  reporting	  to	  work	  because	  of	   OIL,	  FMLA,	  etc.	  Throughout	  2012,	  IDS	  hearings	  lead	  to	  an	  increase	  to	   approximately	  20	  vacant	  positions	  (which	  could	  then	  be	  filled)	  and	  a	   reduction	  to	  approximately	  20	  staff	  who	  were	  not	  reporting	  to	  work.	   Obviously,	  the	  IDS	  hearings	  broke	  the	  logjam	  and	  have	  improved	  the	   facility’s	  capacity	  to	  rectify	  its	  staffing	  problem.	  	   	   In	  addition,	  the	  facility	  utilized	  data	  on	  its	  YS	  turnover	  rate	  to	  justify	  the	   need	  to	  overhire,	  which	  resulted	  in	  a	  net	  increase	  in	  the	  number	  of	  staff.	   Knowing	  that	  the	  turnover	  rate	  among	  YS	  staff	  was	  approximately	  50%,	   between	  March	  and	  September	  2012,	  the	  facility	  hired	  41	  staff.	  When	   balanced	  against	  the	  21	  positions	  that	  became	  vacant	  via	  resignation	  or	   termination,	  the	  facility	  had	  20	  new	  staff	  remaining,	  which	  mitigated	  the	   overall	  number	  of	  vacancies.	  Still,	  facility	  and	  DYS	  administrators	  report	   that	  the	  turnover	  rate	  at	  Scioto	  is	  the	  highest	  across	  the	  system	  and	   continued	  efforts	  are	  necessary	  to	  ensure	  that	  sufficient	  numbers	  of	  staff	   are	  available.	  On	  any	  given	  day,	  approximately	  25%	  of	  the	  YS	  positions	   are	  either	  vacant	  or	  occupied	  by	  someone	  who	  is	  not	  reporting	  to	  work.	   While	  this	  shortage	  if	  offset	  to	  some	  extent	  by	  interim	  staff,	  even	  with	   those	  additional	  staff,	  the	  facility’s	  staffing	  levels	  still	  come	  up	  short.	  	   	   On	  several	  days	  during	  the	  previous	  monitoring	  period,	  insufficient	   numbers	  of	  YS	  reported	  to	  work	  causing	  several	  units	  to	  be	  locked	  down.	   During	  the	  current	  monitoring	  period,	  while	  the	  facility	  continued	  to	   require	  staff	  to	  work	  overtime	  in	  order	  to	  meet	  required	  staffing	  levels,	   the	  levels	  of	  staff	  were	  sufficient	  to	  avoid	  lockdowns	  and	  to	  provide	   youth	  with	  access	  to	  education	  and	  other	  required	  programming.	   However,	  excessive	  reliance	  on	  overtime	  is	  neither	  a	  practically	  nor	   fiscally	  sustainable	  strategy	  for	  managing	  the	  facility.	  Each	  month,	  the	   Superintendent’s	  Report	  identifies	  the	  number	  of	  times	  a	  Youth	  Specialist	   was	  required	  to	  work	  overtime	  in	  order	  to	  meet	  required	  minimum	   staffing	  levels.	  As	  a	  crude	  measure	  of	  frequency,	  note	  that	  there	  are	   approximately	  90	  shifts	  in	  a	  month	  (30	  days	  x	  3	  shifts	  =	  90).	  The	  number	   of	  times	  staff	  were	  held	  over	  varied	  significantly	  across	  the	  monitoring	   period	  (March	  77;	  April	  51;	  May	  48;	  June	  19;	  July	  22;	  August	  48;	  and	   September	  80),	  with	  an	  average	  of	  49	  times	  per	  month	  (or,	  on	  a	  little	  over	   half	  of	  the	  shifts).	  Clearly,	  at	  some	  points	  during	  the	  monitoring	  period,	   the	  use	  of	  overtime	  was	  relatively	  low,	  while	  at	  other	  times,	  overtime	  was	  

	  

15.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 16 of 129 PAGEID #: 2369

needed	  far	  more	  frequently.	  High	  overtime	  months	  were	  associated	  with	   serious	  staff	  assaults	  and	  the	  resulting	  resignations	  of	  staff,	  along	  with	   the	  beginning	  of	  football	  season,	  when	  staff	  were	  more	  likely	  to	  call	  out	   on	  the	  weekends.	  	   	   Continued	  efforts	  to	  ensure	  that	  vacancies	  are	  kept	  to	  a	  minimum	  and	   that	  staff	  report	  to	  work	  as	  expected	  are	  absolutely	  essential	  to	  the	   State’s	  ability	  to	  comply	  with	  the	  Stipulation.	  Without	  sufficient	  numbers	   of	  well-­‐trained,	  well-­‐rested	  staff,	  the	  facility	  will	  be	  unable	  to	  reduce	   violence,	  limit	  the	  use	  of	  seclusion,	  and	  provide	  adequate	  programming,	   as	  required.	  Moving	  forward,	  the	  facility	  intends	  to	  continue	  with	  its	  IDS	   hearings	  and	  increase	  the	  number	  of	  interim	  staff	  to	  reduce	  the	  number	   of	  days	  the	  facility	  is	  running	  short.	  Further,	  recent	  improvements	  to	  On-­‐ The-­‐Job	  training	  were	  designed	  to	  improve	  job	  satisfaction	  and	  increase	   retention	  levels.	  Finally,	  in	  January	  2012,	  the	  facility	  intends	  to	  combine	   two	  of	  the	  boys’	  general	  population	  units	  (accomplished	  in	  large	  part	  by	   transferring	  approximately	  15	  to	  18	  boys	  to	  other	  facilities)	  which	  will	   reduce	  the	  overall	  number	  of	  staff	  required	  on	  any	  given	  day	  by	   approximately	  12	  staff.	  	   	   Investigations	  Related	  to	  Use	  of	  Force,	  Seclusion	  and	  Abusive	  Practices	   	   Over	  the	  past	  six	  months,	  28	  allegations	  of	  excessive	  or	  inappropriate	   uses	  of	  force	  were	  investigated,	  6	  by	  the	  Chief	  Inspector’s	  Office	  (CIO)	   and	  22	  by	  a	  facility-­‐based	  investigator.	  Eleven	  of	  the	  facility-­‐based	   investigations	  were	  pending,	  nearly	  all	  of	  which	  had	  far	  exceeded	  the	  14	   days	  permitted	  for	  their	  completion.	  	   	   Of	  the	  17	  investigations	  that	  had	  been	  completed,	  two	  (11%;	  one	  CIO,	   one	  facility-­‐based)	  were	  substantiated	  for	  unnecessary	  or	  excessive	  force.	   Although	  these	  28	  referrals	  flowed	  from	  nearly	  350	  restraints	  during	  this	   time	  period	  (rate	  of	  allegations	  is	  7%),	  the	  poor	  quality	  of	  the	   investigations	  completed	  by	  facility-­‐based	  staff	  creates	  concern	  about	  the	   extent	  to	  which	  staff	  who	  use	  force	  improperly	  can	  be	  accurately	   identified	  via	  the	  investigation	  process.	  These	  concerns	  are	  discussed	  in	   detail	  in	  III.A.5,	  below,	  but	  are	  relevant	  to	  this	  provision	  insofar	  as	  a	   poorly	  constructed	  investigation	  does	  not	  adequately	  protect	  youth	  from	   harm	  at	  the	  hands	  of	  staff,	  as	  required	  by	  this	  provision.	   	   In	  addition	  to	  the	  use	  of	  force	  investigations,	  the	  CIO	  also	  investigated	   and	  sustained	  3	  allegations	  of	  abusive	  practices:	  
• After	  an	  initial	  refusal	  to	  come	  out	  of	  the	  shower	  when	  directed	   to	  do	  so	  by	  staff,	  a	  youth	  was	  left	  in	  a	  locked	  bathroom	  overnight;	  	  
• Several	  youth	  were	  denied	  dinner	  and	  were	  left	  in	  soft	  restraints	   overnight;	  and	  
• A	  staff	  member	  turned	  off	  two	  youth’s	  air	  vents	  and	  water	  supply	   over	  night	  because	  they	  refused	  to	  close	  their	  cuff	  ports.	  	  

	  

16.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 17 of 129 PAGEID #: 2370

All	  of	  these	  incidents	  occurred	  on	  the	  PROGRESS	  Unit.	  While	  it	  is	  positive	   that	  the	  incidents	  were	  reported,	  investigated	  thoroughly,	  substantiated	   based	  on	  the	  facts,	  and	  staff	  were	  held	  accountable,	  the	  fact	  that	  staff	   continue	  to	  engage	  in	  these	  types	  of	  behaviors,	  particularly	  during	  a	  time	   when	  the	  PROGRESS	  Unit	  has	  been	  under	  such	  scrutiny,	  is	  disturbing.	  	   	   	   Allegations	  of	  Verbal	  Mistreatment	  or	  Inappropriate	  Sexual	  Relationships	   	   Each	  of	  the	  previous	  Monitor’s	  reports	  has	  discussed	  the	  problem	  of	   allegations	  of	  verbal	  abuse	  by	  staff	  and	  inappropriate	  relationships	   between	  Scioto	  staff	  and	  youth.	  The	  usual	  tools	  to	  combat	  this	  type	  of	   problem	  (e.g.,	  staff	  training,	  a	  robust	  grievance	  process,	  and	  procedures	   for	  investigating	  allegations)	  have	  not	  been	  sufficient,	  as	  youth	  continue	   to	  report	  inappropriate	  comments	  and	  behaviors	  by	  staff	  to	  both	  the	   Monitors,	  DOJ	  attorneys	  and	  facility	  staff.	  Although	  the	  frequency	  of	   allegations	  of	  a	  sexual	  nature	  has	  decreased	  somewhat,	  more	  prevalent	   are	  reports	  from	  youth	  that	  staff	  provoke,	  antagonize,	  belittle	  or	   otherwise	  interact	  in	  unprofessional,	  counterproductive	  and	  hurtful	  ways	   with	  youth.	  	   	   Indeed,	  there	  were	  approximately	  12	  new	  allegations	  of	  such	  behaviors	   referred	  for	  investigation	  during	  the	  current	  monitoring	  period	  (6	  related	   to	  inappropriate	  sexual	  relationships	  between	  staff	  and	  youth	  and	  6	   related	  to	  verbal	  threatening,	  name-­‐calling,	  or	  unprofessional	  conduct	  by	   staff	  in	  their	  interactions	  with	  youth).	  Five	  allegations	  of	  a	  sexual	  nature	   were	  unsubstantiated	  by	  the	  CIO,	  although	  one	  is	  still	  pending.	  As	  noted	   in	  previous	  reports	  and	  in	  Provision	  III.A.5,	  below,	  the	  investigations	  by	   the	  CIO	  are	  high-­‐quality,	  thorough,	  and	  certainly	  capable	  of	  sustaining	  a	   true	  allegation	  if	  the	  evidence	  were	  available.	  On	  the	  other	  hand,	  facility-­‐ based	  investigations	  were	  undertaken	  for	  the	  other	  six	  allegations,	  none	   of	  which	  were	  substantiated.	  As	  noted	  in	  the	  discussion	  of	  Provision	   III.A.5,	  the	  poor	  quality	  of	  the	  investigations	  results	  in	  the	  likely	  inability	   to	  sustain	  a	  true	  allegation,	  even	  if	  the	  evidence	  were	  available.	  	   	   Also	  troubling	  is	  youth’s	  continued	  belief	  that	  neither	  the	  grievance	   process	  nor	  the	  investigation	  process	  can	  protect	  them	  because	  neither	   will	  result	  in	  staff	  being	  held	  accountable	  for	  their	  behavior.	  During	  the	   site	  visit	  week,	  the	  vast	  majority	  of	  the	  youth	  currently	  housed	  at	  Scioto	   were	  interviewed	  either	  by	  Monitors	  of	  the	  DOJ	  case,	  the	  Lead	  Monitor	  of	   the	  SH	  case,	  or	  the	  DOJ	  attorney.	  Nearly	  all	  of	  the	  youth	  reported	   concerns	  about	  a	  number	  of	  staff	  who	  appear	  to	  act	  with	  impunity,	  who	   treat	  the	  youth	  poorly	  and	  then	  taunt	  the	  youth	  to	  write	  a	  grievance	   because	  “nothing	  will	  happen.”	  When	  youth	  gave	  examples	  of	  poor	   treatment	  by	  staff,	  the	  interviewers	  asked	  if	  they	  had	  reported	  the	   incident	  to	  anyone	  at	  the	  facility.	  In	  some	  cases	  they	  had,	  in	  other	  cases	   they	  hadn’t,	  but	  in	  all	  cases	  their	  experience	  suggested	  to	  them	  that	  it	  

	  

17.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 18 of 129 PAGEID #: 2371

would	  not	  change	  the	  environment	  for	  the	  better.	  While	  the	  Monitor	   recognizes	  that	  youth	  are	  not	  always	  truthful	  when	  interviewed,	  the	   similarities	  in	  their	  descriptions	  of	  staff’s	  bravado	  suggest	  that	  the	  facility	   needs	  to	  address	  the	  manner	  in	  which	  some	  staff	  relate	  to	  the	  youth	  in	   their	  care.	  	   	   During	  the	  previous	  monitoring	  period,	  the	  facility’s	  administrative	  team	   committed	  to	  implement	  two	  new	  initiatives	  designed	  to	  address	   allegations	  of	  inappropriate	  sexual	  relationships	  in	  particular,	  but	  which	   could	  also	  be	  useful	  in	  addressing	  the	  more	  general	  complaints	  about	   staff	  verbal	  mistreatment.	  The	  State	  was	  asked	  to	  provide	  an	  update	  on	   the	  status	  of	  these	  initiatives:	  
• Although	  the	  previous	  facility	  Superintendent	  indicated	  that	  the	   topic	  of	  inappropriate	  conduct	  by	  staff,	  boundary	  issues,	  etc.	   would	  be	  added	  to	  the	  girls’	  Trauma	  Group	  curriculum	  in	  April	   2012,	  it	  was	  not	  implemented	  until	  August	  2012.	  The	  6-­‐week	   “Healthy	  Boundaries	  and	  Relationships”	  group	  was	  led	  by	  a	  social	   worker	  who	  works	  for	  a	  contracted	  treatment	  provider	  and	  was	   co-­‐facilitated	  by	  Scioto	  social	  workers	  on	  the	  Davey	  and	  Allman	   units.	  	   	   Progress	  notes	  from	  6	  girls	  who	  participated	  in	  the	  program	  were	   reviewed.	  The	  curriculum	  included	  an	  appropriate	  range	  of	  topics	   (e.g.,	  characteristics	  of	  healthy/unhealthy	  relationships,	   boundaries,	  inappropriate	  relationships	  due	  to	  age	  or	  roles,	   grooming	  behaviors	  to	  encourage	  girls	  to	  acquiesce,	  etc.).	  Various	   homework	  assignments	  were	  given	  including	  discussing	  people	   with	  whom	  they’ve	  had	  boundary	  issues	  and	  the	  different	  choices	   they	  could	  have	  made,	  or	  writing	  a	  letter	  to	  a	  sibling	  to	  describe	   what	  was	  learned	  in	  the	  group.	  None	  of	  the	  girls	  in	  either	  of	  the	   groups	  raised	  issues	  related	  to	  inappropriate	  relationships	  or	   conduct	  by	  Scioto	  staff.	  	   	   The	  group	  was	  reportedly	  well	  received,	  with	  several	  girls	  asking	   to	  continue	  the	  discussion	  and	  to	  incorporate	  role	  play	  so	  that	   they	  could	  practice	  the	  skills	  they	  were	  learning.	  The	  facility	  also	   plans	  to	  incorporate	  materials	  available	  through	  the	  NIC/PREA	   curriculum.	  A	  timeline	  for	  restarting	  the	  group	  was	  not	  provided	   to	  the	  Monitor.	  	   	  
• In	  the	  last	  Monitor’s	  report,	  the	  Monitor	  also	  advised	  the	  facility	   to	  incorporate	  the	  topics	  of	  over-­‐familiarization	  and	  boundary	   issues	  between	  staff	  and	  youth	  into	  the	  weekly	  Interdisciplinary	   Treatment	  (IDT)	  meetings.	  The	  topic	  was	  added	  to	  the	  IDT	   agendas	  beginning	  in	  August	  2012	  and	  was	  broadly	  defined	  to	   include	  youth	  who	  may	  be	  touching	  each	  other	  inappropriately	   and	  youth	  who	  seem	  to	  be	  developing	  crushes	  on	  staff	  an	  

	  

18.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 19 of 129 PAGEID #: 2372

Recommendations	  

behaving	  in	  inappropriate	  ways.	  This	  addition	  to	  the	  agenda	   reportedly	  helped	  staff	  to	  be	  able	  to	  address	  issues	  with	  a	   number	  of	  youth	  and	  helped	  staff	  to	  discusses	  what	  may	  have	   otherwise	  been	  sensitive	  topics.	  New	  staff	  were	  reminded	  not	  to	   be	  alone	  with	  girls	  in	  areas	  where	  there	  were	  no	  cameras	  and	   were	  instructed	  to	  take	  another	  youth	  or	  staff	  with	  them	  to	   ensure	  there	  was	  a	  witness	  to	  all	  of	  their	  interactions.	   	   Unfortunately,	  record	  keeping	  in	  this	  area	  was	  substandard	  and	   does	  not	  provide	  for	  a	  review	  of	  the	  actual	  interactions	  that	  took	   place	  during	  the	  IDT	  meetings.	  The	  facility	  has	  identified	   improvements	  in	  the	  quality	  and	  detail	  of	  the	  IDT	  minutes	  as	  an	   area	  in	  need	  of	  development.	  	   	   The	  “Healthy	  Relationships	  and	  Boundaries”	  groups	  have	  clearly	  provided	   new	  opportunities	  for	  youth	  to	  think	  about	  and	  discuss	  any	  inappropriate	   relationships	  they	  may	  have	  had.	  The	  Monitor	  fully	  supports	  the	   continuation	  of	  this	  group,	  along	  with	  any	  other	  efforts	  to	  fortify	  the	   screening	  and	  vetting	  of	  staff	  for	  their	  appropriateness	  to	  work	  with	  girls.	  	   	   However,	  from	  the	  discussions	  with	  youth,	  it	  appears	  that	  the	  problem	   does	  not	  entirely	  reside	  in	  their	  not	  having	  any	  forum	  to	  voice	  their	   concerns,	  but	  rather	  in	  their	  belief	  that	  the	  facility	  will	  not	  act	  on	  their	   complaints.	  This	  was	  an	  issue	  for	  both	  the	  boys	  and	  girls	  housed	  at	  Scioto.	   The	  facility	  has	  indicated	  its	  intention	  to	  work	  with	  the	  YS	  union	  in	  order	   to	  be	  able	  to	  reassign	  staff	  who	  garner	  a	  number	  of	  complaints	  from	   youth.	  More	  broadly,	  emphasizing	  appropriate	  communication	  skills	  for	   staff	  and	  clear	  prohibitions	  against	  the	  use	  of	  any	  language	  that	  could	  be	   construed	  as	  taunting,	  provoking	  or	  belittling	  should	  become	  a	   centerpiece	  of	  shift-­‐briefings,	  staff	  meetings,	  training,	  and	  any	  other	   forum	  available	  to	  reinforce	  this	  central	  value.	  Finally,	  improving	  the	   quality	  of	  the	  facility-­‐based	  investigation	  process	  may	  provide	  the	  facility	   with	  additional	  opportunities	  to	  hold	  staff	  accountable	  in	  a	  way	  that	  may	   be	  persuasive	  to	  staff	  who	  persist	  in	  acting	  with	  impunity.	  	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Reach	  substantial	  compliance	  with	  provisions	  related	  to	   seclusion,	  investigations	  of	  abuse	  and	  neglect,	  grievances	  and	   programming.	  	  
2. Conduct	  a	  problem-­‐solving	  analysis	  to	  determine	  the	  nature	  of	   youth	  on	  staff	  assaults	  and	  implement	  interventions	  that	  target	   the	  underlying	  causes	  and	  patterns.	  	  
3. Improve	  the	  quality	  of	  FIA	  reviews	  of	  the	  use	  of	  physical	  restraint	   to	  ensure	  that	  staff	  have	  exhausted	  all	  other	  means	  for	  resolving	   problems	  with	  youth.	  Ensure	  that	  staff	  are	  provided	  with	   coaching	  to	  help	  develop	  their	  skills	  in	  this	  area	  and	  to	  ensure	   their	  compliance	  with	  all	  related	  policies.	  	  

	  

19.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 20 of 129 PAGEID #: 2373

Sources	  of	   Information	  
	   	   	  

4. Maximize	  the	  number	  of	  permanent,	  full-­‐time	  staff	  who	  are	   recruited,	  hired	  and	  retained	  so	  that	  staff	  turnover	  and	  mandated	   overtime	  can	  be	  minimized.	  	  
5. Continue	  to	  provide	  forums	  for	  female	  youth	  to	  discuss	  their	   problematic	  relationships	  with	  staff,	  whether	  sexually	   inappropriate,	  verbally	  abusive	  or	  otherwise	  unprofessional.	   Consider	  developing	  a	  similar	  forum	  for	  male	  youth.	  Investigate	   and	  enforce	  the	  prohibition	  against	  inappropriate	  sexual	   behavior,	  verbal	  mistreatment	  and	  policies	  prohibiting	  male	  staff	   from	  being	  alone	  with	  female	  youth.	  Ensure	  staff	  know	  how	  to	   recognize,	  respond	  to,	  and	  report	  such	  behavior.	  
6. Reinforce	  the	  prohibition	  against	  provoking,	  taunting,	  belittling	   and	  otherwise	  disrespecting	  youth.	  Investigate	  complaints	   vigorously	  and	  enforce	  the	  conduct	  standards	  when	  they	  are	   violated.	  	  
• Self-­‐assessment	  data	  and	  its	  interpretation	  for	  III.A.1,	  prepared	  at	   my	  request	  
• Interviews	  with	  facility	  Superintendent	  and	  Deputies,	  along	  with	   staff	  from	  DYS	  Central	  Office	  
• Monthly	  Superintendent’s	  Reports,	  April	  through	  September	   2012	  
• Monitor’s	  Monthly	  Data,	  Scioto	  Male	  and	  Female	  Population,	   2011	  and	  2012,	  to	  date	  
• CIO	  and	  facility	  based	  investigation	  log,	  April	  through	  September	   2012	  
• CIO	  and	  facility-­‐based	  investigations	  completed	  between	  April	   and	  September	  2012	  
• Description	  and	  Group	  Notes	  from	  “Healthy	  Relationships	  and	   Boundaries”	  groups,	  August	  through	  October	  2012	  
• Description	  of	  Overfamiliarization	  Initiative,	  prepared	  at	  my	   request	  
• Interviews	  with	  n=16	  youth	  housed	  at	  Scioto	  on	  October	  19,	   2012,	  and	  consultation	  with	  other	  Monitors	  and	  the	  DOJ	  attorney	   who	  interviewed	  approximately	  30	  other	  youth	  housed	  at	  the	   facility	  in	  October	  2012	  
	  

	  

20.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 21 of 129 PAGEID #: 2374

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

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

The	  State	  presented	  data	  on	  the	  use	  of	  seclusion	  during	  the	  previous	  six	   months.	  The	  Monitor	  structured	  the	  site	  visit	  such	  that	  the	  opportunities	   for	  interpreting	  the	  trends	  was	  more	  limited	  than	  it	  had	  been	  in	  the	  past.	   In	  addition,	  the	  Facility	  Superintendent	  had	  only	  been	  in	  place	  for	   approximately	  two	  weeks	  and	  thus	  was	  not	  in	  a	  position	  to	  explain	  the	   practices	  of	  the	  prior	  Superintendent	  nor	  had	  he	  had	  an	  opportunity	  to	   demonstrate	  the	  direction	  in	  which	  he	  hoped	  to	  take	  the	  facility	  with	   regard	  to	  the	  issue	  of	  seclusion.	  Thus,	  the	  Monitor	  interpreted	  the	  trends	   in	  regular,	  pre-­‐hearing	  and	  intervention	  seclusion	  data	  without	   significant	  input	  from	  the	  State.	  	  	  	   	   The	  Monitor	  became	  aware	  of	  several	  quality	  assurance	  tools	  that	  instill	   confidence	  in	  the	  State’s	  capacity	  to	  make	  data-­‐driven	  decisions	  and	  to	   measure	  the	  effect	  of	  reforms.	  The	  State	  has	  offered	  verbal	   commitments	  to	  reform	  its	  use	  of	  seclusion,	  the	  particulars	  of	  which	  are	   discussed	  below.	  	  	   	   Finally,	  over	  the	  past	  few	  months,	  the	  Monitor	  has	  engaged	  in	  lengthy	   conversations	  with	  the	  State,	  Plaintiff’s	  counsel,	  and	  monitoring	  teams	   for	  both	  this	  and	  the	  S.H.	  case	  about	  the	  implementation	  of	  the	   PROGRESS	  Unit	  (PU).	  These	  conversations	  are	  well-­‐documented	   elsewhere	  and	  will	  not	  be	  repeated	  here.	  For	  its	  part,	  the	  State	   acknowledged	  that	  the	  amount	  of	  in-­‐room	  time	  (a.k.a.,	  seclusion)	   endured	  by	  the	  average	  PU	  youth	  was	  higher	  than	  desired	  during	  the	   current	  monitoring	  period	  and	  that	  a	  complex	  constellation	  of	  staffing,	   treatment,	  philosophical	  and	  environmental	  issues	  needed	  to	  be	   addressed.	  	  

Steps	  Taken	  to	   Assess	  Compliance	  

Regular	  Seclusion	   Regular	  seclusion	  is	  a	  time-­‐out,	  or	  short	  period	  of	  isolation	  imposed	  by	   direct	  care	  staff	  in	  response	  to	  mid-­‐level,	  non-­‐violent	  misconduct	  such	  as	   throwing	  things,	  property	  damage,	  storming	  around	  the	  unit,	  etc.	  Staff	   must	  obtain	  approval	  from	  a	  supervisor	  before	  placing	  a	  youth	  in	  regular	   seclusion	  and	  again	  at	  the	  one-­‐hour	  mark.	  If	  the	  youth	  remains	  in	   seclusion	  at	  the	  three-­‐hour	  mark,	  the	  supervisor	  must	  document	  in	   writing	  the	  reason	  that	  seclusion	  remains	  necessary.	   	   As	  discussed	  in	  the	  1st	  Monitors’	  Report,	  the	  facility	  witnessed	  a	  huge	   spike	  in	  the	  use	  of	  regular	  seclusion	  just	  after	  the	  facility	  converted	  to	  a	   long-­‐term	  facility.	  Historically,	  the	  facility	  averaged	  about	  70	  regular	   seclusions	  per	  month.	  In	  August	  and	  September	  2011,	  however,	  the	   number	  skyrocketed	  to	  approximately	  400	  and	  well	  over	  50%	  of	  the	  

	  

21.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 22 of 129 PAGEID #: 2375

seclusions	  lasted	  longer	  than	  4	  hours.	  The	  Second	  Monitor’s	  Report	   noted	  that	  the	  use	  of	  regular	  seclusion	  had	  returned	  to	  historical	  levels,	   with	  an	  average	  of	  65	  seclusions	  per	  month	  (average	  rate	  per	  youth	  =	   .43).	  Across	  the	  previous	  monitoring	  period,	  88%	  of	  the	  seclusions	  lasted	   less	  than	  4	  hours	  and	  12%	  lasted	  more	  than	  4	  hours.	  	   	   As	  shown	  in	  the	  table	  below,	  during	  the	  current	  monitoring	  period,	  the	   number	  of	  regular	  seclusions	  decreased	  again	  to	  an	  average	  of	  50	  per	   month;	  however,	  because	  of	  the	  declining	  population,	  the	  rate	  of	  regular	   seclusion	  actually	  increased	  to	  an	  average	  of	  .53	  (an	  increase	  of	   approximately	  23%).	  An	  increase	  in	  the	  use	  of	  regular	  seclusion	  is	  not	   necessarily	  a	  bad	  thing,	  if	  the	  time	  in	  seclusion	  allows	  the	  youth	  to	  regain	   control	  of	  his	  behavior	  and	  prevents	  a	  subsequent	  act	  of	  violence.	   However,	  the	  length	  of	  stay	  in	  seclusion	  should	  be	  carefully	  monitored	  to	   ensure	  that	  staff	  do	  not	  resort	  to	  seclusion	  as	  a	  way	  to	  avoid	  working	   with	  the	  youth	  to	  resolve	  the	  problem.	  	   	   Compared	  to	  the	  previous	  monitoring	  period,	  the	  proportion	  of	  seclusion	   episodes	  lasting	  more	  than	  4	  hours	  increased.	  Currently,	  19%	  of	  regular	   seclusions	  last	  more	  than	  4	  hours.	  The	  average	  length	  of	  stay	  varied	   considerably,	  between	  3	  and	  13	  hours	  across	  the	  six-­‐month	  period,	  with	   an	  overall	  average	  of	  7	  hours.	  [The	  facility	  attributed	  these	  increases	  to	   the	  influx	  of	  close	  custody	  youth	  from	  IRJCF	  and	  CJCF.]	  The	  shift	  away	   from	  previous	  trends—where	  approximately	  90%	  of	  the	  youth	  in	  regular	   seclusion	  were	  released	  in	  less	  than	  4	  hours—coupled	  with	  an	  increasing	   average	  length	  of	  stay—which	  means	  that	  the	  youth	  who	  stay	  in	  regular	   seclusion	  are	  there	  for	  a	  significant	  period	  of	  time—is	  concerning.	  In	  July	   and	  August	  2012,	  approximately	  15-­‐20%	  of	  the	  population	  had	  a	  stay	  in	   regular	  seclusion	  that	  lasted	  well	  beyond	  what	  is	  customarily	  considered	   to	  be	  a	  “cool-­‐off.”	  	   	  

Regular	  Seclusion,	  April	  through	  September	  2012	  

Month	  

#	  

Rate	   (#/ADP)	  

%	  4hrs	  or	   less	  

ALOS	   (hrs)	  

April	  2012	  

59	  

.50	  

83%	  

8	  

May	  2012	  

55	  

.55	  

97%	  

3	  

June	  2012	  

41	  

.45	  

91%	  

5	  

July	  2012	  

45	  

.54	  

71%	  

8	  

Aug	  2012	  

45	  

.51	  

60%	  

13	  

Sept	  2012	  

56	  

.65	  

88%	  

5	  

Source:	  Data	  prepared	  by	  DYS	  to	  respond	  to	  the	  Monitor’s	  request	  for	  information	  on	   the	  use	  of	  seclusion.	  	  
	   Quality	  assurance	  audits	  of	  the	  use	  of	  regular	  seclusion	  need	  to	  be	   conducted	  to	  ensure	  that	  supervisors	  are	  assessing	  youth	  for	  their	  

	  

22.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 23 of 129 PAGEID #: 2376

readiness	  for	  release	  at	  the	  required	  intervals	  and	  that	  continued	  time	  in	   seclusion	  is	  warranted	  and	  properly	  documented.	  These	  data	  should	  be	   submitted	  to	  the	  Monitor	  for	  review	  over	  the	  next	  monitoring	  period.	  	   	   Pre-­‐Hearing	  Seclusion	   Pre-­‐Hearing	  Seclusion	  (PHS)	  is	  a	  period	  of	  isolation	  imposed	  following	  an	   act	  of	  violence	  (AOV),	  pending	  a	  disciplinary	  hearing.	  Youth	  on	  PHS	   remain	  in	  their	  rooms	  except	  for	  showers.	  Youth	  are	  supposed	  to	  receive	   recreation	  and	  Unit	  Instruction	  (i.e.,	  education)	  outside	  of	  their	  rooms,	   but	  as	  discussed	  in	  the	  Special	  Education	  section	  of	  this	  report,	  this	  has	   not	  yet	  been	  accomplished.	  The	  length	  of	  time	  a	  youth	  remains	  on	  PHS	  is	   primarily	  determined	  by	  his	  or	  her	  IRAV	  score,	  which	  is	  based	  on	  the	   severity	  of	  the	  current	  rule	  violation	  and	  the	  youth’s	  history	  of	  non-­‐ compliant	  behavior.	  	   	   The	  rate	  of	  PHS	  generally	  tracks	  increases	  and	  decreases	  in	  the	  rate	  of	   AOV	  and	  does	  not	  give	  much	  insight	  into	  the	  facility’s	  seclusion	  practices.	   Rather,	  it	  is	  changes	  in	  the	  youth’s	  lengths	  of	  stay	  that	  reflect	  whether	   practices	  around	  the	  use	  of	  PHS	  are	  being	  reformed	  as	  required	  by	  this	   Provision.	  During	  the	  previous	  monitoring	  period,	  the	  time	  spent	  in	  PHS	   was	  relatively	  stable	  across	  the	  months,	  with	  67%	  remaining	  in	  PHS	  for	   more	  than	  24	  hours.	  	   	   Throughout	  the	  current	  monitoring	  period,	  an	  increasing	  proportion	  of	   youth	  spent	  at	  least	  24	  hours	  on	  PHS.	  During	  the	  last	  4	  months	  of	  the	   monitoring	  period,	  nearly	  all	  youth	  spent	  over	  24	  hours	  in	  PHS.	  The	   average	  length	  of	  stay	  (ALOS)	  in	  PHS	  also	  increased	  throughout	  the	   monitoring	  period.	  Across	  the	  6-­‐month	  period,	  the	  average	  youth	  spent	   over	  two	  days	  in	  PHS	  (53	  hours).	  These	  patterns	  remain	  when	  the	  length	   of	  stay	  is	  viewed	  within	  the	  IRAV	  risk	  groups.	  In	  other	  words,	  both	  high	   risk	  (A	  level)	  and	  moderate	  risk	  (B	  level)	  youth’s	  ALOS	  increased	   throughout	  the	  monitoring	  period.	  [There	  were	  too	  few	  low	  risk	  (C-­‐level)	   youth	  for	  meaningful	  analysis.]	   	  
Pre-­‐Hearing	  Seclusion,	  April	  through	  September	  2012	  

Month	  

#	  

Rate	  

%	  24+	  hours	  

ALOS	  

(#/ADP)	  

(hrs)	  

April	  2012	  

48	  

.41	  

73%	  

54	  

May	  2012	  

32	  

.32	  

75%	  

37	  

June	  2012	  

27	  

.30	  

89%	  

45	  

July	  2012	  

49	  

.59	  

90%	  

54	  

Aug	  2012	  

46	  

.52	  

88%	  

61	  

Sept	  2012	  

26	  

.30	  

96%	  

67	  

Source:	  Data	  prepared	  by	  DYS	  to	  respond	  to	  the	  Monitor’s	  request	  for	  information	  on	   the	  use	  of	  seclusion.	  	  

	  

23.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 24 of 129 PAGEID #: 2377

In	  addition	  to	  the	  trend	  data	  discussed	  above,	  the	  State	  also	  provided	   disaggregated	  data	  that	  better	  illustrate	  the	  problems	  in	  this	  area.	   Spreadsheets	  tracking	  each	  individual	  act	  of	  violence	  (AOV)	  reveal	  that	  in	   July	  2012,	  most	  youth	  spent	  well	  over	  two	  days	  in	  PHS,	  although	  the	   individual	  lengths	  of	  stay	  varied	  and	  thus	  appeared	  to	  be	  individually	   derived.	  However,	  in	  August	  and	  September	  2012,	  nearly	  all	  of	  the	  PHS	   episodes	  lasted	  the	  maximum	  of	  72	  hours.	  The	  purpose	  of	  PHS	  is	  to	   ensure	  allow	  the	  youth	  sufficient	  time	  to	  regain	  control	  of	  his	  behavior	   and	  for	  staff	  to	  talk	  to	  the	  youth	  to	  understand	  what	  occurred	  and	   whether	  a	  risk	  of	  subsequent	  violence	  (i.e.,	  retaliation)	  exists.	  PHS	  should	   not	  be	  used	  as	  a	  punishment—however,	  given	  the	  uniformity	  in	  duration	   across	  youth	  and	  the	  fact	  that	  nearly	  all	  youth	  are	  held	  to	  the	  maximum	   allowable	  time,	  it	  appears	  that	  the	  facility	  has	  been	  using	  PHS	  punitively.	  	   	   The	  trends	  witnessed	  in	  the	  previous	  monitoring	  period—of	  a	  decreasing	   length	  of	  stay	  on	  PHS	  for	  youth	  at	  all	  IRAV	  levels—have	  apparently	   reversed.	  Although	  the	  Monitor	  supports	  the	  use	  of	  structured	  decision-­‐ making	  tools	  in	  general,	  it	  appears	  that	  IRAV	  has	  gone	  too	  far	  in	   removing	  staff	  discretion	  in	  determining	  a	  youth’s	  readiness	  for	  release.	   Rather	  than	  making	  a	  considered	  assessment	  of	  the	  youth’s	  current	   behavior	  and	  readiness	  to	  safely	  return	  to	  the	  general	  population,	  IRAV	   seems	  to	  have	  resulted	  in	  staff’s	  leaning	  toward	  the	  top	  end	  of	  the	   ranges	  prescribed	  by	  IRAV.	  Revisions	  to	  the	  IRAV	  lengths	  of	  stay	  ranges	   were	  pilot	  tested	  at	  CJCF	  during	  the	  current	  monitoring	  period.	   Discussions	  with	  the	  S.H.	  subject	  matter	  expert	  overseeing	  these	  reforms	   indicated	  that	  the	  significant	  reductions	  in	  the	  lengths	  of	  stay	  for	  each	   IRAV	  category	  were	  accomplished	  without	  an	  escalation	  of	  violence	  at	   the	  facility.	  These	  data	  are	  compelling	  and	  suggest	  that	  the	  IRAV	  is	  ripe	   for	  further	  modification.	  	   	   While	  on	  site,	  the	  Monitor	  discussed	  ideas	  for	  reforming	  IRAV	  with	  DYS	   administrators.	  A	  tempered	  approach	  to	  this	  reform	  is	  absolutely	   necessary	  in	  order	  to	  create	  buy-­‐in	  among	  staff	  (who	  could	  be	  persuaded	   by	  showing	  that	  incremental	  reductions	  in	  the	  duration	  of	  PHS	  do	  not	   result	  in	  more	  youth	  violence,	  as	  shown	  by	  the	  Circleville	  IRAV	  pilot)	  and	   to	  constrain	  the	  extent	  to	  which	  youth	  attempt	  to	  “test	  the	  limits”	  of	  the	   new	  procedures.	  The	  Monitor	  recommends	  that,	  as	  an	  initial	  first	  step,	   the	  DYS	  maintain	  the	  minimum	  thresholds	  being	  proposed	  by	  the	  SH	   monitor	  for	  each	  risk	  level,	  but	  that,	  thereafter,	  a	  youth’s	  readiness	  for	   release	  is	  evaluated	  at	  3-­‐hour	  intervals.	  This	  assessment	  must	  include	  a	   broad	  range	  of	  indicators	  (e.g.,	  youth’s	  willingness	  to	  discuss	  the	  issue	   with	  staff,	  mediate	  the	  issue	  with	  the	  youth/staff	  involved,	  undertake	   some	  sort	  of	  restorative	  activity,	  etc.),	  but	  should	  NOT	  be	  based	  on	  the	   staff’s	  disapproval	  of	  the	  youth’s	  original	  rule	  violation.	  PHS	  is	  not	  about	   punishment—it	  is	  about	  protecting	  other	  youth	  and	  staff	  from	   subsequent	  violence	  from	  the	  youth	  involved.	  Retribution	  should	  not	  be	   a	  part	  of	  the	  length	  of	  stay	  calculation.	  At	  each	  three-­‐hour	  interval,	  if	  the	  

	  

24.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 25 of 129 PAGEID #: 2378

Supervisor	  determines	  that	  the	  youth	  cannot	  be	  returned	  safely	  to	  the	   general	  population,	  the	  specific	  reasons	  for	  this	  decision	  must	  be	   articulated	  in	  writing.	  Conversations	  with	  DYS	  and	  the	  S.H.	  subject	   matter	  expert	  during	  the	  review	  phase	  of	  this	  report	  resulted	  in	  a	  broad	   consensus	  about	  the	  next	  phase	  of	  revisions	  to	  the	  IRAV.	  The	  Monitor	   approved	  the	  policy	  revision	  on	  December	  24,	  2012.	  Changes	  in	  the	   length	  of	  stay	  in	  PHS	  will	  be	  tracked	  throughout	  the	  next	  monitoring	   period.	  Hopefully,	  the	  policy	  revision	  will	  produce	  the	  intended	   reductions	  and	  outcome	  data	  will	  lay	  the	  foundation	  for	  additional	   reductions	  in	  the	  minimum	  length	  of	  stay	  for	  A-­‐level	  youth.	  	   	   At	  Scioto,	  the	  duration	  of	  PHS	  does	  not	  appear	  to	  be	  at	  all	  related	  to	  the	   length	  of	  time	  required	  to	  prepare	  for	  the	  Intervention	  Hearing	  (IH),	   which	  is	  how	  many	  jurisdictions	  anchor	  the	  “top	  end”	  of	  PHS	  (i.e.,	  the	   youth	  is	  held	  in	  PHS	  until	  the	  hearing,	  which	  must	  occur	  within	  a	   designated	  period	  of	  time).	  While	  facility	  administrators	  reported	  that	   the	  IH	  “should”	  occur	  within	  72	  hours,	  the	  disaggregated	  AOV	  data	   indicate	  that	  it	  rarely	  does.	  The	  IH	  was	  usually	  held	  7-­‐10	  after	  the	   incident	  occurred.	  The	  delay	  between	  the	  incident	  and	  the	  procedure	   employed	  to	  hold	  youth	  accountable	  severely	  compromises	  the	   effectiveness	  of	  the	  sanctions	  imposed.	  [Sanctions	  are	  more	  effective	   when	  they	  are	  imposed	  soon	  after	  the	  behavior	  of	  concern].	  	   	   The	  IH	  officer	  needs	  some	  time	  to	  ensure	  that	  the	  incident	  is	  investigated	   thoroughly	  and	  the	  youth	  must	  be	  provided	  notice	  of	  the	  proceedings	   and	  have	  an	  opportunity	  to	  prepare	  his	  or	  her	  defense.	  However,	   requiring	  staff	  to	  hold	  these	  proceedings	  sooner	  rather	  than	  later	  is	   certainly	  in	  the	  interest	  of	  justice	  (because	  it	  would	  remove	  the	  claim	   that	  the	  youth	  is	  serving	  the	  punishment	  in	  the	  form	  of	  PHS,	  before	  the	   hearing	  is	  held),	  would	  afford	  greater	  protection	  from	  the	  risk	  of	  self-­‐ harm	  (a	  significant	  proportion	  of	  successful	  suicides	  in	  juvenile	   correctional	  facilities	  occur	  among	  youth	  who	  are	  in	  some	  form	  of	   disciplinary	  seclusion),	  and	  would	  speed	  the	  process	  for	  actually	   addressing	  the	  underlying	  causes	  of	  the	  	  youth’s	  behavior	  through	  the	   consequences	  that	  are	  selected	  by	  the	  hearing	  officer	  or	  IDT.	  During	  the	   review	  period	  for	  this	  report,	  DYS	  shared	  plans	  for	  an	  upcoming	  policy	   revision	  (Policy	  #	  303.01.03	  “Youth	  Intervention	  Hearings”).	  When	  the	   new	  policy	  takes	  effect	  (projected	  for	  February	  2013),	  the	  timeline	  for	  IH	   hearings	  will	  be	  7	  days.	  While	  this	  is	  an	  improvement,	  the	  Monitor	   encourages	  DYS	  to	  continue	  efforts	  to	  hold	  hearings	  in	  closer	  proximity	   to	  the	  incident	  for	  which	  the	  youth	  is	  being	  sanctioned.	   	   Intervention	  Seclusion	   Intervention	  hearings	  are	  held	  to	  determine	  whether	  youth	  are	  culpable	   for	  serious	  misconduct	  and	  whether	  additional	  time	  in	  seclusion	  is	   warranted.	  While	  on	  Intervention	  Seclusion,	  youth	  remain	  in	  their	  rooms	   except	  for	  showers.	  Youth	  should	  receive	  recreation	  and	  Unit	  Instruction	  

	  

25.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 26 of 129 PAGEID #: 2379

(i.e.,	  education)	  out	  of	  their	  rooms,	  but	  anecdotal	  reports	  from	  youth	   suggest	  that	  they	  do	  not.	  By	  policy,	  youth	  can	  receive	  a	  maximum	  of	  5	   days	  of	  Intervention	  Seclusion,	  but	  the	  policy	  also	  allows	  for	  the	  use	  of	   alternative	  sanctions	  to	  respond	  to	  primary	  rule	  violation.	  Recently,	  a	   some	  of	  the	  major	  rule	  violations	  are	  being	  handled	  by	  the	  IDT,	  which	  is	   a	  promising	  practice	  given	  that	  treatment	  teams	  tend	  to	  design	  sanctions	   that	  are	  more	  responsive	  to	  the	  underlying	  causes	  of	  the	  youth’s	   behavior.	  In	  contrast,	  seclusion	  serves	  only	  to	  suppress	  a	  youth’s	   negative	  behavior	  during	  the	  time	  that	  he	  or	  she	  is	  behind	  a	  locked	  door	   and	  also	  denies	  youth	  access	  to	  the	  very	  treatment	  programs	  they	  need	   in	  order	  to	  change	  their	  behavior.	  	   	   The	  previous	  Monitor’s	  report	  discussed	  the	  significant	  decreases	  in	  the	   use	  of	  Intervention	  Seclusion,	  due	  in	  part	  to	  an	  overall	  reduction	  in	  AOVs	   and	  also	  to	  the	  former	  Superintendent’s	  commitment	  to	  use	  alternative	   sanctions	  more	  frequently.	  Evidence	  of	  the	  more	  limited	  use	  of	  seclusion	   as	  a	  sanction	  continued	  into	  the	  beginning	  of	  the	  monitoring	  period,	  but	   then	  the	  use	  of	  intervention	  seclusion	  increased	  sharply.	  The	  total	  IS	   hours	  imposed	  increased,	  as	  did	  the	  number	  of	  hours	  per	  youth	  (which	  is	   calculated	  only	  to	  neutralize	  changes	  in	  the	  number	  of	  youth	  involved	  in	   AOV.	  Since	  some	  youth	  do	  not	  receive	  any	  seclusion	  time,	  the	  actual	   number	  of	  hours	  in	  seclusion	  for	  those	  who	  received	  it	  is	  longer	  than	  the	   average	  number	  would	  indicate.)	   	   	  
Intervention	  Seclusion	  Hours,	  April	  through	  September	  2012	  

Month	  

#	  Y	  involved	  	   in	  AOV	  

Total	  IS	   hours	  

Hours	  per	   Youth	  

April	  2012	  

46	  

76	  

1.65	  

May	  2012	  

40	  

159	  

3.98	  

June	  2012	  

29	  

24	  

0.83	  

July	  2012	  

34	  

186	  

5.47	  

Aug	  2012	  

30	  

163	  

5.43	  

Sept	  2012	  

29	  

899	  

31.00	  

Source:	  Monthly	  Superintendent’s	  Report,	  which	  counts	  the	  number	   of	  youth	  involved	  in	  AOV	  (not	  AOV	  incidents)	  and	  the	  total	  number	   of	  IS	  hours	  
	   Other	  data	  submitted	  by	  the	  State	  (AOV	  spreadsheets)	  revealed	  that	  the	   proportion	  of	  Intervention	  Hearings	  that	  utilized	  seclusion	  as	  a	  sanction	   also	  increased	  throughout	  the	  monitoring	  period.	  In	  July	  2012,	  only	  3%	   of	  the	  IH	  resulted	  in	  seclusion,	  compared	  to	  August	  and	  September	  2012	   when	  40%	  and	  79%	  of	  IHs	  resulted	  in	  the	  use	  of	  seclusion	  as	  a	  sanction.	  	   	   These	  increases	  are	  concerning	  and	  their	  underlying	  causes	  are	  

	  

26.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 27 of 129 PAGEID #: 2380

undoubtedly	  complex,	  including	  but	  by	  no	  means	  limited	  to	  a	   combination	  of	  the	  facility’s	  leadership’s	  philosophy,	  the	  severity	  of	  the	   AOV,	  and	  the	  alternative	  sanctions	  available.	  	  As	  discussed	  in	  previous	   reports,	  not	  only	  is	  seclusion	  one	  of	  the	  least	  effective	  tools	  for	  managing	   youth	  behavior,	  it	  also	  decreases	  youth’s	  access	  to	  needed	  treatment	   programs	  and	  increases	  frustration	  and	  anger	  and	  thus	  elevates	  their	  risk	   of	  self-­‐harm.	  	   	   The	  recent	  assignment	  of	  the	  IDT	  to	  handle	  certain	  rule	  violations	  is	   certainly	  positive.	  IDTs	  can	  pull	  on	  the	  resources	  of	  their	  multi-­‐ disciplinary	  members	  to	  construct	  sanctions	  that	  are	  balanced	  between	   treatment	  and	  supervision,	  and	  provide	  an	  ideal	  opportunity	  for	  direct	   care	  staff	  to	  engage	  in	  the	  important	  work	  of	  supporting	  the	  skill	   development	  that	  takes	  place	  in	  treatment.	  However,	  IDTs	  should	  be	   cautioned	  not	  to	  order	  sanctions	  of	  questionable	  value	  (e.g.,	  rote	  writing	   assignments,	  “sitting	  on	  the	  door”	  for	  days	  on	  end	  without	  adjunct	   treatment	  work,	  community	  service	  work	  or	  other	  restorative	  activity).	   While	  the	  Monitor	  did	  not	  have	  aggregate	  data	  regarding	  the	  types	  of	   sanctions	  the	  IDTs	  imposed,	  anecdotes	  from	  youth	  suggested	  that	  at	   times,	  the	  sanctions	  imposed	  were	  of	  questionable	  value.	  The	  AOV	   spreadsheets	  identify	  the	  proportion	  of	  AOVs	  that	  were	  handled	  by	  the	   IDT	  rather	  than	  the	  IH	  process.	  The	  IDTs	  handled	  fewer	  cases	  toward	  the	   end	  of	  the	  monitoring	  period—in	  July	  30%	  of	  AOVs	  were	  handled	  by	  the	   IDT,	  compared	  to	  only	  22%	  in	  August	  and	  12%	  in	  September	  2012.	  The	   reasons	  for	  this	  decline	  are	  unknown.	  	   	   The	  State	  did	  not	  offer	  any	  quality	  assurance	  data	  related	  to	  this	  function	   of	  the	  IDT	  meetings	  and,	  if	  it	  has	  not	  already	  done	  so,	  should	  develop	   performance	  measures	  that	  are	  regularly	  assessed	  to	  determine	  whether	   this	  process	  has	  been	  implemented	  as	  intended	  (e.g.,	  types	  of	  sanctions	   that	  are	  imposed)	  and	  whether	  the	  intended	  outcomes	  are	  being	   achieved	  (e.g.,	  youth’s	  subsequent	  involvement	  in	  violent	  misconduct).	  A	   new	  sanctions	  grid	  will	  be	  rolled	  out	  in	  February	  2013	  and	  DYS	  should	  be	   conscientious	  about	  collecting	  data	  to	  assess	  the	  impact	  of	  the	  changes.	   The	  new	  grid	  reduces	  the	  amount	  of	  intervention	  seclusion	  time	  and	   intervention	  time	  that	  may	  be	  added	  to	  youth’s	  sentences.	  These	   changes	  are	  very	  positive,	  but	  good	  data	  are	  needed	  to	  demonstrate	  to	   the	  various	  constituents	  that	  sanctions	  conform	  to	  the	  new	  prescriptions	   and	  that	  they	  were	  accomplished	  without	  compromising	  the	  safety	  and	   security	  of	  the	  facility.	  	   	   Seclusion	  among	  Youth	  on	  the	  Progress	  Units	  (PU)	   	   The	  Monitor	  has	  voiced	  serious	  concerns	  about	  the	  operation	  of	  the	  PU	   since	  its	  inception	  at	  Scioto	  in	  September	  2011.	  The	  Parties	  and	   Monitoring	  Team	  members	  have	  had	  multiple	  conversations	  about	  the	   term	  “seclusion”	  and	  whether	  it	  applied	  to	  the	  in-­‐room	  time	  on	  the	  PU.	  

	  

27.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 28 of 129 PAGEID #: 2381

Until	  the	  new	  schedule	  was	  implemented	  on	  October	  15,	  2012	   (discussed	  below),	  youth	  on	  the	  PU	  spent	  nearly	  all	  of	  their	  waking	  hours	   in	  their	  rooms.	  This	  in-­‐room	  time	  was	  not	  a	  sanction	  for	  a	  proximate	   disciplinary	  offense	  (like	  the	  seclusion	  discussed	  above),	  but	  was	   imposed	  only	  by	  virtue	  of	  their	  being	  housed	  on	  the	  PU	  as	  a	  result	  of	   their	  history	  of	  misconduct	  and	  the	  State’s	  failure	  to	  schedule	   programming	  throughout	  the	  day	  for	  these	  youth.	  	   	   The	  Monitor	  inadvertently	  implied	  that	  this	  in-­‐room	  time	  was	  part	  of	  the	   PU	  treatment	  program	  by	  calling	  it	  “Programmatic	  Seclusion”	  in	  previous	   Monitor’s	  Reports.	  This	  label	  was	  selected	  only	  to	  differentiate	  these	  in-­‐ room	  hours	  from	  those	  endured	  by	  youth	  as	  an	  immediate	  consequence	   for	  an	  AOV	  and	  was	  not	  intended	  to	  imply	  that	  in-­‐room	  time	  was	  an	   acceptable	  component	  of	  the	  PU	  program	  design.	  In	  fact,	  a	  label	  was	   applied	  in	  order	  to	  stress	  the	  importance	  of	  eradicating	  the	  practice.	   Protracted	  arguments	  about	  the	  label	  that	  should	  be	  applied	  appeared	   to	  steer	  conversation	  away	  from	  the	  fact	  that	  a	  program	  intended	  to	   treat	  and	  manage	  the	  system’s	  most	  violent	  youth	  cannot	  rely	  on	  the	  use	   of	  in-­‐room	  time	  to	  the	  extent	  that	  the	  PU	  has	  since	  its	  inception.	  Youth	   on	  these	  units	  should	  be	  engaged	  in	  meaningful	  treatment,	  education	   and	  programming	  throughout	  their	  waking	  hours	  (as	  required	  by	   Provision	  III.F.1,	  below).	  Extensive	  time	  in	  their	  rooms	  will	  only	  lead	  to	   frustration	  and	  anger,	  which	  most	  of	  these	  youth	  will	  express	  in	  the	  form	   of	  violence—the	  very	  behavior	  that	  the	  PU	  purports	  to	  want	  to	  minimize.	   The	  extent	  to	  which	  PU	  youth	  were	  actually	  engaged	  in	  programming	   during	  the	  current	  monitoring	  period	  is	  discussed	  in	  III.F.1,	  below.	  	   	   Only	  recently	  (just	  after	  the	  current	  monitoring	  period	  ended)	  were	   tangible	  changes	  made	  to	  the	  program	  design	  to	  try	  to	  reduce	  the	   extreme	  over-­‐reliance	  on	  in-­‐room	  time	  to	  manage	  youth’s	  behavior.	  In	   addition	  to	  increasing	  the	  staffing	  of	  all	  types	  (education,	  direct	  care,	   mental	  health,	  recreation	  and	  Supervisors)	  on	  the	  unit,	  a	  24-­‐hour	   schedule	  in	  which	  all	  PU	  youth	  are	  out	  of	  their	  rooms	  during	  waking	   hours	  in	  the	  same	  measure	  as	  youth	  from	  the	  general	  population	  was	   implemented	  on	  October	  15,	  2012.	  The	  key	  performance	  measures	  must	   be	  tracked	  on	  an	  individual	  level	  over	  a	  sustained	  period	  of	  time	  (e.g.,	  in-­‐ room	  time	  for	  each	  youth,	  over	  a	  90-­‐day	  period)	  in	  order	  to	  develop	   even	  a	  preliminary	  finding	  that	  the	  schedule	  has	  been	  properly	   implemented.	  At	  this	  point,	  the	  schedule	  is	  far	  too	  new	  to	  make	  any	   conclusions	  about	  whether	  it	  has	  resolved	  the	  extreme	  overreliance	  on	   seclusion	  that	  has	  characterized	  the	  PU	  since	  its	  inception.	  	  	   	   Other	  planned	  modifications	  to	  the	  PU	  program	  design	  should	  be	   implemented	  to	  further	  reduce	  the	  amount	  of	  time	  that	  PU	  youth	  spend	   on	  intervention	  seclusion	  (in	  addition	  to	  the	  system-­‐wide	  reforms	  to	   IRAV	  discussed	  above).	  These	  include	  improvements	  in	  treatment	   planning,	  measuring	  youth’s	  progress	  toward	  tangible	  goals	  and	  

	  

28.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 29 of 129 PAGEID #: 2382

Recommendations	  
Sources	  of	   Information	   	   	  

procedures	  for	  re-­‐examining	  the	  treatment	  approach	  with	  youth	  who	  are	   not	  progressing	  as	  planned.	  The	  details	  for	  these	  modifications	  have	  not	   yet	  been	  finalized,	  nor	  has	  a	  quality	  assurance	  process	  to	  ensure	  that	  key	   outcomes	  (e.g.,	  decreased	  involvement	  in	  violent	  misconduct,	  shortened	   length	  of	  stay	  on	  each	  Phase,	  shortened	  overall	  stay	  on	  PU)	  are	  being	   achieved.	  	  	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Identify	  and	  address	  the	  underlying	  causes	  of	  recent	  increases	  in	   the	  length	  of	  stay	  in	  regular	  seclusion.	  	  
2. Modify	  the	  IRAV	  to	  ensure	  that	  youth	  remain	  in	  pre-­‐hearing	   seclusion	  no	  longer	  than	  necessary	  to	  de-­‐escalate	  their	  behavior	   and	  ensure	  they	  do	  not	  pose	  a	  threat	  to	  the	  safety	  of	  other	   youth	  or	  staff.	  Consider	  adjusting	  the	  requirements	  surrounding	   the	  timing	  of	  Intervention	  Hearings	  to	  improve	  the	  effectiveness	   of	  the	  sanctioning	  process.	  
3. Limit	  the	  use	  of	  intervention	  seclusion,	  relying	  instead	  on	   sanctions	  that	  provide	  an	  opportunity	  for	  skill	  development	  and	   treatment	  in	  order	  to	  create	  behavior	  change,	  and	  collect	  data	  to	   demonstrate	  the	  extent	  to	  which	  this	  change	  has	  occurred.	   Develop	  quality	  assurance	  mechanisms	  around	  the	  use	  of	   seclusion	  in	  Intervention	  Hearings	  and	  to	  determine	  whether	  the	   recently	  implemented	  IDT	  sanctioning	  process	  is	  a	  viable	  strategy	   for	  reducing	  the	  reliance	  on	  intervention	  seclusion.	  	  
4. Ensure	  that	  youth	  on	  the	  PROGRESS	  Unit	  are	  not	  scheduled	  to	  be	   in	  their	  rooms	  in	  any	  greater	  measure	  than	  youth	  in	  the	  general	   population.	  Ensure	  their	  daily	  access	  to	  a	  full	  range	  of	  education,	   treatment,	  recreation	  and	  structured	  programming.	  	  
5. Ensure	  that	  the	  PROGRESS	  Unit’s	  program	  design	  (e.g.,	  staffing,	   treatment,	  programming,	  etc.)	  is	  sufficient	  to	  reduce	  youth’s	   involvement	  in	  violent	  misconduct	  so	  that	  the	  use	  of	  pre-­‐hearing	   and	  intervention	  seclusion	  is	  limited.	  	  
• Self-­‐assessment	  data	  for	  III.A.3,	  prepared	  at	  my	  request	   • Monthly	  Superintendent’s	  Reports,	  April	  through	  September	  
2012	   • Consultation	  with	  Steve	  Martin,	  subject	  matter	  expert	  for	  S.H.	  v.	  
The	  State	  of	  Ohio,	  regarding	  modifications	  to	  IRAV	   • On-­‐going	  discussions	  with	  the	  Parties	  regarding	  the	  design	  and	  
operation	  of	  the	  PROGRESS	  Unit	  
	  

	  

29.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 30 of 129 PAGEID #: 2383

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

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

The	  State	  submitted	  a	  log	  of	  all	  investigations	  related	  to	  excessive	  uses	  of	   force,	  allegations	  of	  abuse,	  allegations	  of	  verbal	  abuse,	  and	  inappropriate	   relationships	  completed	  during	  the	  current	  monitoring	  period.	  The	  Chief	   Inspector’s	  Office	  (CIO)	  investigated	  the	  more	  serious	  allegations,	  while	   facility-­‐based	  investigators	  addressed	  the	  less	  serious	  allegations.	  	   	   Between	  April	  2012	  and	  September	  2012,	  a	  total	  of	  32	  investigations	   were	  completed	  related	  to	  the	  topics	  covered	  by	  this	  provision	  (17	  of	   these	  were	  completed	  by	  facility-­‐based	  investigators	  and	  15	  were	   completed	  by	  the	  CIO).	  Only	  1	  of	  the	  17	  facility-­‐based	  investigations	  (6%)	   was	  substantiated	  (unnecessary	  use	  of	  force).	  This	  represents	  a	  generally	   declining	  trend	  in	  the	  proportion	  of	  investigations	  that	  are	  substantiated	   (1st	  Monitors’	  Report	  reported	  39%;	  2nd	  Monitors’	  Report	  reported	  10%).	   As	  noted	  in	  the	  previous	  Monitors’	  report,	  the	  low	  proportion	  of	   substantiated	  allegations	  is	  likely	  due	  to	  the	  poor	  quality	  of	  the	  facility-­‐ based	  investigatory	  process.	  	   	   Five	  the	  15	  CIO	  investigations	  (33%)	  resulted	  in	  a	  substantiated	  finding.	   Staff	  were	  cited	  for:	  
• Inappropriate	  contact	  with	  a	  youth	  after	  she	  was	  released;	   • Unnecessary	  use	  of	  force;	   • Leaving	  a	  youth	  locked	  in	  a	  shower/bathroom	  overnight;	   • Denying	  several	  youth	  dinner	  and	  leaving	  them	  in	  soft-­‐restraints	  
overnight;	  and	   • Turning	  off	  the	  air	  vents	  and	  water	  flow	  to	  two	  youth’s	  rooms.	  	   As	  discussed	  in	  the	  next	  section,	  in	  contrast	  to	  the	  facility-­‐based	   investigations,	  the	  CIO	  investigations	  are	  generally	  of	  high	  quality.	  	   	   Historically,	  the	  CIO	  has	  conducted	  quarterly	  audits	  of	  the	  facility’s	   investigations	  and	  provided	  detailed	  technical	  assistance	  in	  its	  written	   reports.	  The	  most	  recent	  CIO	  report	  covered	  Q1	  2012	  (prior	  to	  the	   beginning	  of	  the	  current	  monitoring	  period)	  although	  the	  report	  was	   issued	  in	  July	  2012.	  The	  Q1	  report	  focused	  exclusively	  on	  the	  AMS	   incident	  reporting	  procedures	  and	  not	  on	  the	  process	  or	  quality	  of	  the	   facility-­‐based	  investigations.	  However,	  recent	  technical	  assistance	  and	   training	  has	  been	  provided	  to	  the	  Labor	  Relations	  Officer	  (who	  is	  tasked	   with	  assigning	  and	  tracking	  the	  investigations)	  and	  the	  Deputy	   Superintendents	  who	  are	  responsible	  for	  reviewing	  and	  approving	  the	  

	  

30.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 31 of 129 PAGEID #: 2384

Steps	  Taken	  to	   Assess	  Compliance	  

quality	  of	  the	  investigations.	  Given	  the	  findings	  detailed	  below,	   additional	  training	  for	  investigators	  is	  sorely	  needed.	  	   	   Moving	  forward,	  the	  CIO	  plans	  to	  shift	  its	  monitoring	  strategy	  so	  that	   each	  DYS	  facility	  will	  be	  monitored	  every	  4	  months.	  This	  shift	  will	  permit	   a	  more	  rigorous	  review	  and	  more	  timely	  reports,	  since	  the	  facilities	  will	   now	  be	  audited	  one	  at	  a	  time.	  	  
Investigations	  Conducted	  by	  the	  Chief	  Inspectors	  Office	  (CIO)	   	   Timeliness.	  Of	  the	  15	  investigations	  reviewed,	  10	  (66%)	  were	  completed	   within	  the	  timelines	  prescribed	  by	  policy	  (i.e.,	  14	  business	  days	  for	  use	  of	   force	  investigations;	  30	  calendar	  days	  for	  all	  others)	  or	  were	  granted	  an	   extension	  for	  cause	  (e.g.,	  key	  witness	  was	  unavailable;	  delay	  in	  obtaining	   permission	  to	  proceed	  from	  the	  OSHP).	  The	  remaining	  5	  investigations	   (36%)	  were	  submitted	  beyond	  the	  timelines	  permitted	  by	  policy	  but	  had	   not	  been	  granted	  an	  extension	  (average	  number	  of	  days	  late	  =	  6).	  While	   the	  goal	  of	  producing	  a	  high-­‐quality	  investigation	  is	  paramount,	   investigators	  must	  either	  complete	  investigations	  within	  the	  prescribed	   timelines	  or	  should	  obtain	  an	  extension,	  even	  when	  only	  a	  few	  extra	  days	   are	  needed.	  Occasional	  timeline	  violations	  are	  unavoidable,	  but	  the	   current	  rate	  of	  timeliness	  (66%)	  is	  simply	  not	  sufficient.	  	  	  	   	   At	  the	  time	  of	  the	  Monitor’s	  site	  visit,	  the	  CIO	  also	  had	  8	  pending	   investigations,	  3	  of	  which	  had	  not	  yet	  reached	  their	  due	  dates	  and	  the	   other	  5	  had	  legitimate	  reasons	  for	  an	  extension	  (e.g.,	  suspect	  was	  in	  jail;	   awaiting	  DNA	  evidence;	  key	  witness	  had	  been	  in	  car	  accident).	   	   Quality.	  Each	  of	  the	  15	  CIO	  investigations	  completed	  during	  the	   Monitoring	  period	  was	  reviewed.	  As	  in	  the	  past,	  the	  investigations	  were	   very	  well	  done.	  They	  featured	  comprehensive	  interviews	  with	  all	  key	   witnesses,	  utilized	  videotaped	  footage	  effectively,	  and	  pursued	   tangential	  issues	  that	  emerged	  during	  the	  course	  of	  the	  initial	  inquiry.	   Across	  the	  sample,	  the	  findings	  appeared	  to	  be	  reasonable	  and	  the	  basis	   for	  the	  conclusions	  was	  clearly	  identified	  among	  the	  evidence.	  	   	   Investigations	  Conducted	  by	  Scioto	  Staff	   	   Timeliness.	  Of	  the	  17	  investigations	  conducted	  by	  Scioto	  staff	  during	  the	   current	  monitoring	  period,	  only	  4	  (23%)	  were	  completed	  within	  the	   timelines	  prescribed	  by	  policy.	  The	  remaining	  13	  (77%)	  were	  late	  (an	   average	  of	  18	  business	  days),	  which	  is	  a	  significant	  increase	  from	  the	   previous	  monitoring	  period	  where	  42%	  were	  late.	  	   	   In	  addition,	  at	  the	  time	  of	  the	  Monitor’s	  site	  visit,	  11	  facility-­‐based	   investigations	  were	  pending	  and	  overdue	  (average	  days	  overdue	  was	  57).	   Two	  other	  pending	  cases	  had	  not	  yet	  reach	  their	  due	  dates.	  The	  State	   reported	  that	  it	  was	  aware	  of	  these	  problems	  and	  had	  recently	  made	  

	  

31.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 32 of 129 PAGEID #: 2385

changes	  to	  the	  assignment,	  oversight	  and	  review	  process	  in	  an	  effort	  to	   correct	  these	  deficiencies.	  	   	   Timely	  investigations	  are	  essential	  for	  a	  robust	  process	  to	  address	   allegations	  of	  employee	  misconduct.	  Should	  the	  allegation	  be	   substantiated,	  staff	  training	  or	  discipline	  needs	  to	  occur	  as	  soon	  as	   possible	  so	  the	  individual	  can	  either	  return	  to	  duty,	  be	  retrained,	  or	  be	   terminated,	  as	  appropriate.	  If	  the	  allegation	  is	  not	  substantiated,	  the	   employee	  needs	  to	  be	  cleared	  so	  that	  he	  or	  she	  may	  return	  to	  full	  duty	   and	  be	  relieved	  of	  the	  stress	  and	  stigma	  of	  being	  “under	  investigation.”	  	   	   Quality.	  The	  previous	  Monitor’s	  report	  downgraded	  the	  compliance	   rating	  for	  this	  provision	  to	  Partial	  Compliance	  upon	  finding	  that	  the	   quality	  of	  the	  investigations	  conducted	  by	  Scioto	  staff	  had	  sunk	  far	  below	   professional	  standards.	  Unfortunately,	  the	  quality	  of	  the	  investigations	   has	  not	  improved	  at	  all.	  	  	  	   	   As	  in	  the	  previous	  monitoring	  period,	  the	  Monitor	  provided	  detailed	   feedback	  on	  each	  of	  the	  17	  cases	  to	  develop	  consensus	  around	  the	   essential	  elements	  of	  a	  quality	  investigation	  and	  to	  highlight	  the	  many	   features	  that	  were	  lacking	  from	  the	  most	  recent	  set	  of	  investigations.	  To	   summarize:	  
• Allegation	  statements	  need	  to	  be	  specific	  (who	  is	  alleged	  to	  have	   done	  what	  to	  whom,	  and	  when?)	  in	  order	  to	  set	  the	  context	  for	   the	  subsequent	  information.	  Too	  often,	  key	  facts	  were	  missing	   and	  it	  was	  not	  until	  several	  pages	  into	  the	  investigation	  that	  the	   nature	  of	  the	  allegation	  could	  be	  understood.	  	  	  
• Any	  delays	  in	  assigning	  or	  initiating	  the	  investigation	  need	  to	  be	   explained.	  Long	  delays	  in	  initiating	  investigations	  were	  noted,	   and	  were	  unexplained.	  In	  part,	  the	  situation	  could	  be	  clarified	  if	   the	  investigator	  explained	  how	  and	  when	  the	  facility	  became	   aware	  of	  the	  allegation	  (which	  would	  account	  for	  those	   situations	  when	  the	  youth	  did	  not	  report	  the	  concern	   immediately	  after	  it	  happened).	  	  
• Everyone	  who	  can	  contribute	  to	  the	  understanding	  of	  what	   occurred	  should	  be	  interviewed.	  In	  several	  cases,	  the	   investigator	  identified	  a	  very	  limited	  set	  of	  witnesses	  (e.g.,	  the	   accused	  staff,	  the	  victim	  and	  possibly	  one	  other	  staff	  witness)	   even	  though	  other	  people	  were	  in	  the	  vicinity	  when	  the	  incident	   allegedly	  occurred.	  None	  of	  the	  investigations	  reviewed	  included	   a	  single	  youth	  witness	  interview.	  	  
• Witnesses	  should	  be	  asked	  to	  describe	  what	  happened	  in	  their	   own	  words,	  and	  the	  investigator	  should	  seek	  clarification	  or	   additional	  detail	  through	  appropriate	  follow-­‐up	  questions.	  Many	   times,	  it	  appeared	  that	  the	  witness	  was	  simply	  asked	  to	  respond	   to	  a	  set	  of	  yes/no	  questions.	  Without	  providing	  an	  actual	   transcript,	  the	  full	  exchange	  between	  the	  investigator	  and	  the	  

	  

32.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 33 of 129 PAGEID #: 2386

Recommendations	  

witness	  needs	  to	  be	  captured	  in	  the	  interview	  summary.	  	   • The	  sequence	  of	  the	  interviews	  is	  important.	  The	  alleged	  victim	  
should	  be	  interviewed	  first	  in	  order	  to	  obtain	  a	  complete	   accounting	  of	  the	  youth’s	  concerns	  and	  to	  obtain	  details	  that	   can	  be	  used	  to	  construct	  questions	  with	  the	  witnesses	  and	  the	   accused	  staff.	  The	  accused	  staff	  should	  be	  interviewed	  last,	  so	   that	  he	  or	  she	  can	  be	  asked	  to	  respond	  to	  the	  specific	  allegations	   discovered	  during	  the	  previous	  interviews.	  In	  several	  cases,	  the	   accused	  staff	  was	  interviewed	  first,	  and	  thus	  the	  interview	  did	   not	  reflect	  the	  variety	  of	  issues	  raised	  in	  subsequent	  interviews.	  	   • The	  basis	  for	  the	  conclusions	  must	  be	  clearly	  articulated	  and	   must	  rest	  upon	  facts	  that	  were	  gathered	  during	  the	   investigation.	  Many	  of	  the	  investigators	  do	  not	  write	  coherent	   narratives	  and	  do	  not	  summarize	  the	  facts	  that	  supported	  the	   conclusion,	  and	  did	  not	  explain	  why	  they	  discounted	  facts	  that	   didn’t	  fit.	  	   	   It	  is	  worth	  noting	  that	  this	  is	  the	  exact	  same	  list	  of	  problems	  articulated	   in	  the	  previous	  Monitors’	  Report.	  It	  appears	  that	  the	  State	  has	  made	  no	   progress	  whatsoever	  in	  improving	  the	  quality	  of	  this	  essential	  function.	   The	  primary	  contributor	  to	  this	  problem	  appears	  to	  be	  the	  continued	   practice	  of	  distributing	  the	  investigations	  across	  a	  large	  number	  of	  staff	   (16	  different	  people	  completed	  the	  17	  investigations	  reviewed).	   Dispersing	  the	  responsibility	  so	  broadly	  will	  inevitably	  lead	  to	   inconsistency,	  and	  because	  each	  staff	  person	  may	  only	  do	  one	  or	  two	   investigations	  per	  year,	  their	  opportunities	  to	  develop	  the	  appropriate	   skill	  set	  are	  very	  limited.	  	   	   In	  order	  to	  accelerate	  the	  State’s	  progress	  toward	  compliance	  with	  this	   provision,	  the	  Monitor	  strongly	  recommends	  that	  the	  State	  significantly	   reduce	  the	  number	  of	  people	  who	  are	  authorized	  to	  conduct	  an	  internal	   investigation	  and	  that	  this	  responsibility	  is	  assigned	  only	  to	  individuals	   who	  have	  demonstrated	  that	  they	  have	  the	  requisite	  skill	  set.	  Of	  great	   concern	  is	  the	  fact	  that	  several	  investigations	  were	  assigned	  to	  staff	  who	   have	  not	  attended	  the	  investigators’	  training.	  The	  poor	  quality	  of	  these	   reports	  cannot	  continue.	  Although	  the	  allegations	  investigated	  at	  the	   facility-­‐level	  are	  generally	  less	  serious,	  the	  nature	  of	  the	  allegations	  are	   at	  the	  heart	  of	  the	  facility’s	  staff	  culture	  that	  has	  been	  labeled	  as	   problematic	  by	  past	  administrations	  and	  that	  was	  the	  chief	  complaint	   among	  the	  youth	  interviewed	  during	  the	  current	  monitoring	  period.	   Youth	  often	  described	  staff	  behaving	  with	  impunity,	  boasting	  that	   “nothing	  will	  happen”	  if	  the	  youth	  filed	  a	  compliant.	  The	  lack	  of	   accountability	  brought	  to	  bear	  by	  the	  shoddy	  internal	  investigation	   process	  is	  a	  major	  contributing	  factor	  to	  this	  problem.	  	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Reduce	  the	  number	  of	  individuals	  authorized	  to	  conduct	  facility-­‐

	  

33.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 34 of 129 PAGEID #: 2387

Sources	  of	   Information	  
	   	  

based	  investigations	  and	  ensure	  that	  these	  individuals	  have	  the	   requisite	  skills	  for	  the	  task.	  Ensure	  that	  producing	  timely,	  high-­‐ quality	  investigations	  is	  a	  specific	  job	  responsibility	  and	  that	   employees	  are	  held	  accountable	  for	  their	  failure	  to	  produce	   reports	  that	  meet	  professional	  standards.	  	  	   2. Produce	  high-­‐quality	  investigations	  of	  all	  allegations	  of	   inappropriate	  conduct	  by	  staff.	  Whether	  completed	  by	  the	  CIO	   or	  by	  a	  facility-­‐based	  investigator,	  the	  investigations	  must	   reflect	  timely,	  comprehensive	  interviews	  with	  all	  key	  witnesses	   and	  must	  arrive	  at	  reasonable	  conclusions	  based	  on	  the	  facts	  in	   evidence.	  Enact	  accountability	  measures	  to	  address	  poor	   performance	  by	  staff	  tasked	  with	  the	  responsibility	  to	   investigated	  allegations	  of	  all	  types.	  	  	  	  
• Self-­‐assessment	  data	  and	  oral	  presentation	  of	  its	  interpretation	   for	  III.A.5,	  prepared	  at	  my	  request	  	  
• CIO’s	  2012	  Q1	  “AMS	  Incident	  Report	  &	  Investigation	  Coaching	   Review,”	  July	  2012	  
• Log,	  “Investigation	  Tracking	  Log,	  April	  through	  September	  2012”	   • Log,	  “Investigation	  Tracking	  Log—PENDING,	  April	  through	  
September	  2012”	   • Email	  communication	  with	  J.	  Fears,	  CIO,	  related	  to	  CIO	  cases	  
pending	  as	  of	  October	  31,	  2012	   • “List	  of	  staff	  currently	  authorized	  and	  trained	  to	  conduct	  facility-­‐
based	  investigations,”	  prepared	  at	  my	  request	   • Review	  of	  15	  CIO	  investigations	  completed	  since	  April	  2012	  
(100%	  of	  total)	   • Review	  of	  17	  investigations	  conducted	  by	  Scioto	  staff	  since	  April	  
2012	  (100%	  of	  total)	  
	  

	  

34.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 35 of 129 PAGEID #: 2388

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

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

At	  the	  time	  of	  the	  previous	  Monitor’s	  Report,	  the	  grievance	  process	  at	   Scioto	  was	  experiencing	  difficulties	  due	  to	  staffing	  instability	  and	  staff	   performance	  issues.	  In	  May	  2012,	  a	  new	  Grievance	  Coordinator	  was	   hired,	  followed	  by	  a	  back-­‐up	  Coordinator	  in	  July	  2012,	  and	  these	   problems	  have	  largely	  been	  resolved.	  	   	   The	  CIO	  conducts	  quarterly	  audits	  of	  the	  grievance	  process	  at	  Scioto.	  The	   2012	  Q1	  report	  was	  published	  in	  May	  2012	  and	  details	  the	  variety	  of	   problems	  with	  the	  grievance	  process	  discussed	  in	  the	  previous	  Monitor’s	   report.	  The	  2012	  Q2	  and	  Q3	  reports	  were	  published	  in	  July	  and	  October	   2012,	  respectively.	  These	  reports	  showed	  that	  the	  number	  of	  grievances	   submitted	  has	  been	  unstable	  (Q1	  =	  105;	  Q2	  =	  201;	  Q3	  =	  74)	  and	   accurately	  notes	  that	  there	  is	  no	  “correct”	  number	  of	  grievances.	  Rather,	   the	  underlying	  causes	  of	  trends	  should	  be	  examined	  to	  determine	   whether	  youth	  simply	  have	  more/fewer	  complaints	  or	  whether	  they	   access	  to	  or	  belief	  in	  the	  system	  has	  been	  somehow	  compromised.	  	   	   Fortunately,	  the	  various	  performance	  measures	  improved	  significantly	   from	  those	  reported	  in	  the	  previous	  Monitor’s	  report.	  With	  regard	  to	   timeliness,	  compared	  to	  Q1	  when	  61%	  were	  resolved	  past	  the	  14-­‐day	   timeline	  permitted	  by	  policy,	  only	  23%	  of	  grievances	  were	  overdue	  in	  Q2	   and	  only	  3%	  were	  overdue	  in	  Q3.	  With	  regard	  to	  the	  quality	  of	   resolution,	  the	  proportion	  of	  grievances	  requiring	  follow-­‐up	   documentation	  has	  decreased	  steadily	  from	  62%	  (Q1)	  to	  49%	  (Q2)	  to	   39%	  (Q3).	  The	  improvements	  were	  attributed	  to	  the	  significant	  support	   received	  from	  the	  DYS	  Central	  Office	  at	  the	  beginning	  of	  the	  monitoring	   period	  and	  the	  arrival	  of	  the	  new	  Grievance	  Coordinator	  at	  the	  end	  of	   May	  2012.	  	   	   The	  youth’s	  chief	  concerns	  discussed	  in	  the	  2012	  Q2	  report	  included	   complaints	  about	  staff’s	  decisions	  (25%	  of	  the	  201	  grievances	  submitted),	   medical	  care	  (11%),	  verbal	  abuse	  by	  staff	  (8%)	  and	  the	  behavior	   management	  system	  (7%).	  In	  Q3,	  the	  top	  complaints	  were	  about	  staff	   decisions	  (18%),	  medical	  care	  (11%),	  food	  (10%),	  living	  conditions	  (10%)	   and	  education	  (10%).	  	  These	  have	  remained	  relatively	  stable	  over	  time.	  	  	   	   The	  CIO’s	  quarterly	  review	  process	  continues	  to	  satisfy	  the	  Monitor’s	   requirement	  for	  the	  State	  to	  demonstrate	  an	  internal	  ability	  to	  identify	   and	  address	  its	  problems	  related	  to	  grievances.	  The	  CIO	  has	  recently	   shifted	  its	  monitoring	  schedule	  to	  ensure	  that	  reports	  are	  issued	  more	  

	  

35.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 36 of 129 PAGEID #: 2389

Steps	  Taken	  to	   Assess	  Compliance	  

quickly.	  Scioto	  will	  be	  monitored	  on	  a	  rotating	  schedule	  every	  4	  months	   so	  that	  the	  CIO	  auditors	  are	  completing	  only	  one	  audit	  at	  a	  time,	  rather	   than	  trying	  to	  complete	  quarterly	  audits	  for	  all	  four	  DYS	  facilities	  every	   quarter.	  This	  shift	  in	  the	  monitoring	  schedule	  appears	  to	  be	  prudent	  so	   that	  facility	  staff	  can	  become	  aware	  of	  and	  address	  any	  deficiencies	  more	   quickly.	  	  	  
In	  addition	  to	  an	  obvious	  commitment	  to	  addressing	  youth’s	  grievances	   by	  mobilizing	  the	  resources	  available	  at	  the	  facility,	  the	  Grievance	   Coordinator	  also	  has	  a	  refreshing	  commitment	  to	  teach	  youth	  how	  to	   resolve	  their	  own	  problems	  (e.g.,	  how	  to	  access	  the	  sick	  call	  mechanism)	   and	  to	  reinforce	  the	  skills	  they	  learn	  in	  group	  therapy	  related	  to	  asking	   for	  assistance	  and	  making	  requests	  in	  an	  appropriate	  manner.	  	   	   Quality	  of	  Resolution	   As	  discussed	  in	  the	  previous	  section,	  the	  quality	  of	  the	  resolution	  has	   steadily	  improved.	  It	  is	  important	  to	  understand	  that	  the	  “Follow	  Up	   Needed”	  status	  in	  AMS	  is	  dynamic.	  When	  the	  problems	  is	  cured,	  the	  AMS	   status	  is	  changed	  to	  “Completed,”	  which	  means	  that	  it	  is	  difficult	  to	   obtain	  a	  running	  total	  of	  the	  proportion	  that	  required	  additional	   information	  in	  a	  given	  time	  period.	  However,	  point-­‐in-­‐time	  snapshots	  are	   useful	  toward	  this	  end.	  	   	   At	  the	  Monitor’s	  request,	  the	  State	  produced	  a	  list	  of	  the	  cases	  needing	   follow	  up	  action	  as	  of	  October	  11,	  2012.	  In	  contrast	  to	  the	  Q2	  CIO	  report	   where	  98	  cases	  required	  follow	  up,	  only	  16	  cases	  needed	  additional	   information	  in	  order	  to	  be	  considered	  “Complete”	  by	  the	  CIO.	  Of	  these,	   50%	  (8	  cases)	  were	  grievances	  submitted	  prior	  to	  the	  current	  Grievance	   Coordinator’s	  tenure	  at	  the	  facility.	  During	  an	  interview	  with	  the	   Monitor,	  he	  discussed	  his	  on-­‐going	  efforts	  to	  clear	  the	  backlog	  of	   problems	  that	  he	  inherited	  when	  he	  assumed	  the	  position.	  That	  he	  has	   reduced	  the	  number	  still	  in	  need	  of	  attention	  to	  only	  8	  is	  commendable.	  	   	   As	  for	  the	  other	  8,	  all	  of	  them	  were	  submitted	  in	  September	  2012.	  The	   absence	  of	  any	  cases	  submitted	  in	  June,	  July	  or	  August	  testifies	  to	  the	   Grievance	  Coordinator’s	  commitment	  to	  address	  and	  rectify	  problems	   that	  are	  identified	  by	  the	  CIO.	  This	  is	  precisely	  the	  purpose	  and	   anticipated	  outcome	  of	  the	  CIO	  review	  process.	  Feedback	  on	  the	  8	  cases	   from	  September	  included	  reminders	  to	  scan	  documentation	  into	  AMS,	   suggestions	  to	  strengthen	  the	  quality	  of	  the	  response,	  and	  notification	   about	  applicable	  policy	  (e.g.,	  if	  a	  youth	  indicates	  a	  safety	  concern,	  he	   should	  have	  a	  Safety	  Plan).	  The	  input	  appears	  to	  be	  the	  type	  of	  on-­‐going	   coaching	  required	  by	  all	  new	  staff.	  	  Two	  other	  grievances	  were	  classified	   as	  “Corrective	  Action	  Needed,”	  referring	  to	  the	  Grievance	  Coordinator’s	   need	  for	  additional	  instruction	  around	  referring	  incidents	  for	   investigation.	  The	  Grievance	  Coordinator	  does	  not	  appear	  to	  need	  an	   excessive	  amount	  of	  coaching	  and	  the	  types	  of	  things	  for	  which	  he	   receives	  guidance	  are	  reasonable.	  	  

	  

36.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 37 of 129 PAGEID #: 2390

	   Thus,	  the	  new	  grievance	  coordinator	  appears	  to	  have	  resolved	  all	  of	  the	   issues	  with	  timeliness	  and	  quality	  of	  response	  that	  were	  of	  concern	  in	   the	  previous	  Monitor’s	  Report.	  	   	   Youth	  Survey	   	   As	  discussed	  in	  the	  previous	  Monitor’s	  Report,	  the	  CIO’s	  2011	  Youth	   Survey	  found	  significant	  numbers	  of	  youth	  who	  reported	  that	  staff	  told	   them	  that	  they	  could	  not	  use	  the	  grievance	  process	  to	  report	  staff	   misconduct	  (17%),	  that	  staff	  treated	  them	  badly	  after	  filing	  a	  grievance	   (20%),	  or	  that	  staff	  told	  them	  nothing	  would	  happen	  if	  they	  filed	  a	   grievance	  (53%).	  The	  CIO	  required	  each	  facility	  Superintendent	  to	   construct	  a	  plan	  to	  address	  these	  concerns.	  The	  Scioto	  plan	  has	  not	  yet	   been	  developed.	  The	  new	  Superintendent	  has	  been	  tasked	  with	  doing	  so	   before	  the	  end	  of	  the	  year.	  The	  CIO	  plans	  to	  conduct	  a	  follow-­‐up	  Youth	   Survey	  at	  the	  end	  of	  2012.	  If	  the	  Scioto	  plan	  is	  not	  implemented	  soon,	  it	   is	  unlikely	  that	  the	  facility	  will	  see	  any	  improvement	  in	  this	  area.	  	   	   Notification	  to	  Youth	  about	  the	  Outcome	  of	  Investigations	   	   Grievances	  involving	  verbal	  or	  physical	  abuse	  or	  serious	  policy	  violations	   are	  usually	  referred	  for	  investigation	  by	  the	  facility	  or	  by	  the	  CIO.	   However,	  if	  a	  youth	  makes	  an	  allegation	  of	  verbal	  abuse	  and	  the	  initial	   contact	  by	  the	  Grievance	  Coordinator	  indicates	  that	  no	  witnesses	  were	   present,	  the	  grievance	  may	  be	  closed	  without	  referral.	  While	  it	  is	  true	   that	  an	  investigation	  of	  a	  verbal	  exchange	  with	  no	  witnesses	  is	  unlikely	  to	   be	  productive,	  the	  Monitor	  recommends	  that	  the	  employee’s	  supervisor	   be	  notified	  of	  the	  allegation,	  in	  case	  a	  pattern	  should	  emerge	  (e.g.,	   problems	  between	  the	  same	  individuals,	  or	  allegations	  containing	  the	   same	  unique	  language,	  gestures,	  etc.)	   	   In	  March	  2012,	  the	  Grievance	  Policy	  (#	  304.03)	  was	  revised	  to	  include	   written	  notification	  to	  the	  youth	  of	  the	  outcome	  of	  investigations	  that	   were	  triggered	  by	  a	  youth’s	  grievance.	  A	  letter	  to	  the	  youth	  from	  the	   facility’s	  Labor	  Relations	  Officer	  (LRO)	  refers	  to	  the	  investigation	  number	   and	  indicates	  whether	  the	  allegation	  was	  substantiated	  or	   unsubstantiated.	  The	  Investigation	  Policy	  (#101.15)	  and	  the	  Youth	   Handbook	  were	  also	  updated	  to	  reflect	  this	  change	  in	  procedure.	   	   During	  the	  current	  monitoring	  period,	  a	  total	  of	  11	  grievances	  were	   referred	  for	  investigation.	  Youth’s	  allegations	  included	  not	  being	   permitted	  to	  use	  the	  toilet,	  staff’s	  use	  of	  threatening	  language,	  staff’s	   teasing	  the	  youth,	  being	  denied	  food,	  and	  excessive	  time	  in	  restraints.	   Across	  the	  11	  cases,	  two	  investigations	  are	  still	  pending	  and	  the	  location	   of	  two	  youth	  who	  were	  released	  is	  still	  trying	  to	  be	  discerned.	  Letters	  to	   youth	  notifying	  them	  of	  the	  outcome	  of	  the	  investigation	  were	  presented	  

	  

37.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 38 of 129 PAGEID #: 2391

Recommendations	   Sources	  of	   Information	  
	   	  

to	  the	  remaining	  7	  youth	  (100%).	  Youth	  signed	  the	  letters	  to	   acknowledge	  their	  receipt	  of	  the	  information.	  Although	  letters	  were	  sent	   out	  in	  every	  case,	  many	  of	  the	  cases	  had	  a	  significant	  delay	  between	  the	   date	  the	  investigation	  was	  completed	  and	  the	  day	  the	  letter	  was	  drafted.	   The	  number	  of	  business	  days	  from	  investigation	  completion	  to	  letter	   drafting	  ranged	  from	  2	  to	  29,	  with	  an	  average	  of	  15	  business	  days.	   Perhaps	  coincidentally,	  letters	  were	  drafted	  in	  3	  of	  the	  7	  cases	  on	  the	  day	   the	  Monitor	  requested	  the	  documents.	  These	  cases	  had	  delays	  of	  6,	  17	   and	  21	  business	  days.	  Thus,	  youth	  are	  being	  notified	  of	  the	  outcome	  of	   the	  investigations,	  but	  the	  notification	  needs	  to	  be	  far	  more	  timely	  in	   order	  to	  meet	  the	  spirit	  of	  the	  requirement	  and	  to	  address	  youth’s	   persistent	  belief	  that	  staff	  are	  not	  held	  accountable	  for	  their	  behavior	  in	   any	  meaningful	  way.	  	  Prompt	  notification	  could	  help	  to	  counteract	  this	   belief.	  	  	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Promptly	  notify	  youth	  of	  the	  outcome	  of	  any	  investigation	   referred	  via	  the	  grievance	  process.	  	  	  
• Self-­‐assessment	  data	  and	  oral	  presentation	  of	  its	  interpretation	   for	  III.D.1,	  prepared	  at	  my	  request	  
• 2012	  Q2	  and	  Q3	  Grievance	  Audits	  completed	  by	  the	  Chief	   Inspector’s	  Office	  
• 2012	  Q3	  Grievance	  data,	  prepared	  at	  the	  request	  of	  the	  Monitor	   • Grievance	  Monthly	  Reports,	  April	  through	  September	  2012	   • AMS	  Grievance	  Summary	  for	  grievances	  submitted	  April	  through	  
September	  2012	   • List	  of	  grievances	  referred	  for	  investigation,	  April	  through	  
September	  2012	   • Copies	  of	  Youth	  notification	  letters	  for	  grievances	  referred	  for	  
investigation,	  April	  through	  September	  2012	  
	  

	  

38.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 39 of 129 PAGEID #: 2392

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

Compliance	  Rating	   Substantial	  Compliance	  

Self	  Assessment	  

The	  Orientation	  process	  includes	  two	  videos—one	  is	  a	  general	   Orientation	  video	  covering	  several	  topics	  including	  Youth	  Rights	  and	  the	   purpose	  of	  the	  grievance	  system.	  A	  second	  video	  focuses	  on	  the	   grievance	  process	  and	  includes	  information	  about	  what	  to	  do	  if	  the	  youth	   has	  a	  problem	  with	  living	  conditions,	  medical	  care,	  staff	  treatment,	   education	  services,	  etc.	  The	  video	  describes	  the	  differing	  roles	  of	  the	   Grievance	  Coordinator,	  the	  Chief	  Inspector’s	  Office,	  and	  the	  Legal	   Assistance	  Program	  attorneys.	  Finally,	  youth	  are	  provided	  step-­‐by-­‐step	   instructions	  for	  navigating	  the	  grievance	  system.	  The	  information	  in	  the	   video	  is	  reinforced	  by	  a	  written	  Youth	  Grievance	  Handbook,	  which	  an	   intake	  staff	  member	  discusses	  with	  the	  youth.	  Youth	  are	  also	  provided	   in-­‐depth	  information	  about	  sexual	  abuse	  and	  sexual	  assault	  in	  the	   correctional	  setting,	  and	  how	  to	  handle	  situations	  in	  which	  they	  may	  feel	   threatened	  or	  that	  the	  staff	  is	  being	  inappropriate.	  	   	   The	  CIO	  is	  also	  developing	  a	  formal	  Lesson	  Plan	  for	  each	  DYS	  facility’s	   orientation	  in	  order	  to	  ensure	  that	  consistent,	  accurate	  information	  is	   delivered	  to	  all	  DYS	  youth.	  The	  Lesson	  Plans	  are	  scheduled	  to	  be	  rolled	   out	  in	  Q4	  2012.	  	   	   All	  youth	  are	  required	  to	  sign	  several	  forms	  indicating	  that	  they	  received	   and	  understand	  information	  about	  the	  grievance	  process.	  The	  facility	   audits	  a	  random	  sample	  of	  admissions	  files	  every	  month	  to	  ensure	   compliance	  with	  policy	  and	  procedure.	  Each	  month,	  April	  through	   September	  2012,	  100%	  of	  the	  youth	  sampled	  (30	  total	  youth;	  10%	  of	  all	   admissions)	  received	  a	  complete	  orientation	  to	  the	  facility,	  which	   included	  information	  on	  how	  to	  access	  the	  grievance	  system.	  Signed	   Orientation	  Acknowledgement	  Forms	  were	  submitted	  for	  the	  Monitor’s	   verification.	  	  

Steps	  Taken	  to	   Assess	  Compliance	  

At	  the	  end	  of	  the	  previous	  monitoring	  period,	  the	  facility’s	  veteran	   Grievance	  Coordinator	  retired	  and	  a	  new	  Coordinator	  had	  been	  hired.	   This	  staff	  eventually	  moved	  on	  and	  the	  facility	  had	  to	  rely	  on	  support	   from	  Central	  Office	  to	  keep	  the	  grievance	  process	  limping	  along.	  At	  the	   end	  of	  May	  2012,	  a	  new	  Grievance	  Coordinator	  was	  hired.	  Upon	  arriving	   at	  Scioto,	  the	  Grievance	  Coordinator	  began	  attending	  UM	  meetings	  and	   unit	  community	  meetings	  to	  explain	  the	  grievance	  process,	  his	   expectations	  for	  both	  youth	  and	  staff,	  and	  to	  answer	  questions.	  The	   Coordinator	  makes	  himself	  available	  to	  all	  youth	  and	  staff	  to	  mediate	   disputes	  or	  respond	  to	  crises.	  	   	   The	  Monitor	  interviewed	  15	  youth	  while	  on-­‐site.	  Although	  all	  of	  them	  

	  

39.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 40 of 129 PAGEID #: 2393

Recommendations	   Sources	  of	   Information	  
	   	   	  

understood	  the	  grievance	  process	  and	  how	  to	  use	  it,	  over	  half	  of	  them	   appeared	  to	  lack	  confidence	  in	  the	  system,	  believing	  it	  was	  “fixed”	  or	   otherwise	  not	  capable	  of	  addressing	  their	  needs.	  Oddly,	  approximately	   half	  of	  these	  same	  youth	  had	  accessed	  the	  grievance	  system	  and	   reported	  that	  the	  issue	  was	  resolved	  to	  their	  satisfaction.	  As	  noted	  in	  the	   previous	  provision,	  the	  facility	  is	  required	  by	  the	  CIO	  to	  plan	  an	  initiative	   to	  bolster	  the	  standing	  of	  the	  grievance	  process,	  which	  may	  improve	  its	   reputation	  among	  the	  youth.	  
The	  State	  is	  in	  substantial	  compliance	  with	  this	  provision.	  	  	  
• Self-­‐assessment	  data	  and	  oral	  presentation	  of	  its	  interpretation	   for	  III.D.2,	  prepared	  at	  my	  request	  
• Interview	  with	  the	  Grievance	  Coordinator	   • Interviews	  with	  15	  youth	  housed	  at	  Scioto	  on	  October	  19,	  2012	  
	  

	  

40.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 41 of 129 PAGEID #: 2394

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

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

Structured	  Programming	   The	  facility	  offers	  multiple	  types	  of	  programs	  that	  can	  be	  tracked	  using	   multiple	  databases:	  
• All	  youth	  who	  have	  not	  graduated	  from	  High	  School	  or	  obtained	   a	  GED	  are	  required	  to	  attend	  330	  minutes	  of	  instruction	  per	  day.	   Their	  attendance	  is	  tracked	  using	  the	  Chancery	  database.	  
• All	  youth	  should	  receive	  one-­‐hour	  of	  large	  muscle	  activity	   (recreation)	  per	  day.	  The	  Unit	  Managers	  are	  responsible	  for	   ensuring	  that	  recreation	  is	  delivered	  each	  day	  by	  the	  General	   Activity	  Therapists	  (GAT).	  Disruptions	  to	  the	  recreation	  schedule	   should	  be	  logged	  in	  the	  Unit	  Log.	  	  
• All	  youth	  attend	  some	  combination	  of	  group	  and	  individual	   therapy,	  depending	  upon	  their	  needs.	  The	  Social	  Workers	  and	   Psychologists,	  using	  the	  CaseNotes	  database,	  track	  youth’s	   participation	  in	  these	  groups.	  	  
• Youth	  also	  have	  the	  opportunity	  to	  attend	  religious	  services,	   programs	  delivered	  by	  volunteers	  and	  activities	  earned	  through	   the	  SBBMS.	  IRJCF	  is	  currently	  piloting	  a	  database	  to	  track	  youth’s	   participation	  in	  these	  activities	  and	  Scioto	  is	  planning	  to	  adopt	   this	  database	  in	  the	  near	  future.	  	   	  
Strength-­‐Based	  Behavior	  Management	  System	  (SBBMS)	   The	  facility	  provided	  an	  update	  on	  the	  on-­‐going	  efforts	  to	  ensure	  that	  the	   SBBMS	  is	  properly	  implemented.	  Reportedly,	  youth	  continue	  to	  receive	   privileges	  that	  they	  have	  not	  earned,	  which	  dampens	  their	  motivation	  to	   conduct	  themselves	  in	  a	  manner	  that	  would	  allow	  them	  to	  promote	   phases.	  UMs	  continue	  to	  coach	  the	  YSs	  assigned	  to	  their	  units,	  many	  of	   whom	  are	  new,	  on	  how	  to	  use	  the	  SBBMS	  effectively.	  In	  addition,	  

	  

41.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 42 of 129 PAGEID #: 2395

videogames	  were	  moved	  off	  the	  unit	  into	  a	  game	  room	  to	  ensure	  that	   youth	  who	  have	  not	  earned	  the	  privilege	  cannot	  play	  them	  without	   permission.	  Further,	  the	  OM	  often	  makes	  rounds	  at	  bedtime	  to	  ensure	   that	  YSs	  are	  not	  allowing	  youth	  to	  stay	  up	  past	  their	  prescribed	  bedtimes.	   These	  modifications	  indicate	  that	  the	  facility	  administration	  remains	   vigilant	  to	  the	  various	  ways	  in	  which	  the	  SBBMS	  can	  be	  circumvented	   and	  then	  develops	  solutions	  to	  ensure	  that	  the	  program	  is	  implemented	   with	  fidelity.	  	   	   Programming	  for	  Graduates	   During	  the	  current	  monitoring	  period,	  the	  facility	  made	  significant	   progress	  in	  developing	  programming	  for	  youth	  who	  have	  graduated	  from	   high	  school	  or	  obtained	  their	  GED.	  Graduates	  are	  now	  occupied	   throughout	  the	  day	  in	  a	  combination	  of	  post-­‐secondary	  education	  and	   employment.	  	  
• The	  primary	  academic	  program	  is	  delivered	  by	  Ashland	  College,	   which	  provides	  coursework	  for	  students	  in	  English	  101,	  Basic	   Financial	  Literacy,	  Entrepreneurship	  (Fall)	  and	  Problem	  Solving	   and	  Life	  Skills	  (Summer).	  Classes	  are	  held	  twice	  per	  week	  for	  4.5	   hours.	  (Classes	  were	  held	  three	  times	  per	  week	  during	  the	  May-­‐ August	  grading	  period).	  On	  the	  “off	  days,”	  study	  hall	  is	  held.	  	  
• An	  additional	  academic	  program	  is	  delivered	  by	  Henkles	  &	   McCoy.	  TechBridges/Employability	  Skills	  is	  an	  intensive	  one-­‐ week	  class,	  held	  from	  8a	  to	  4:30p	  each	  day	  and	  offered	  once	  per	   grading	  period.	  Youth	  learn	  how	  to	  disassemble	  and	  rebuild	   computers,	  and	  also	  learn	  essential	  employability	  skills	  to	   prepare	  them	  for	  release.	  Upon	  release,	  students	  are	  connected	   to	  Henkels	  &	  McCoy’s	  community	  facility	  where	  they	  may	   continue	  the	  academic	  instruction	  and	  also	  receive	  assistance	   with	  job	  preparation	  and	  interview	  skills.	  	  
• The	  Youth	  Work	  Program	  was	  designed	  to	  provide	  jobs	  for	   graduates.	  [Note:	  non-­‐graduates	  may	  still	  obtain	  employment	   through	  Career	  Based	  Intervention.]	  Graduates	  must	  under	  go	  an	   application	  and	  interview	  process	  and	  once	  hired,	  are	  paid	  $0.50	   per	  hour.	  The	  work	  supervisor	  communicates	  regularly	  with	  the	   youth’s	  treatment	  team	  to	  ensure	  that	  youth	  are	  maintaining	  a	   high	  standard	  of	  behavior	  and	  performance	  on	  the	  job.	  	   	   Available	  jobs	  include:	  cafeteria,	  storeroom,	  maintenance,	   porters	  for	  the	  living	  units,	  religious	  services,	  program	  services,	   school,	  recreation	  and	  cosmetology	  aides.	  An	  academic	  tutor,	  to	   be	  paid	  $0.90	  per	  hour,	  will	  be	  added	  in	  the	  near	  future.	  Hours	   vary	  according	  to	  the	  Department’s	  need	  and	  the	  youth’s	   availability.	  Graduates	  may	  work	  up	  to	  35	  hours	  per	  week	  but	   must	  also	  ensure	  that	  they	  attend	  all	  required	  treatment	   programs.	  There	  are	  enough	  jobs	  available	  to	  support	  all	  youth	   who	  desire	  to	  have	  one.	  	  

	  

42.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 43 of 129 PAGEID #: 2396

Steps	  Taken	  to	   Assess	  Compliance	  

Structured	  Programming	   The	  previous	  Monitors’	  Report	  discussed	  the	  staffing	  problems	  that	   frequently	  disrupted	  the	  delivery	  of	  education	  and	  other	  programming.	   Fortunately,	  the	  staffing	  problems	  have	  been	  largely	  resolved.	  While	  the	   facility	  often	  uses	  mandated	  overtime	  to	  meet	  minimum	  staffing	  levels,	   they	  have	  been	  able	  to	  ensure	  sufficient	  staff	  are	  available	  to	  deliver	  all	   youth	  programs	  during	  the	  current	  monitoring	  period.	  Interviews	  with	   youth	  indicated	  that	  recreation	  and	  volunteer	  programs	  are	  delivered	  as	   scheduled,	  even	  though	  youth	  often	  wished	  for	  a	  different	  composition	   to	  the	  recreation	  program	  (e.g.,	  wanting	  to	  be	  outside;	  wanting	  to	  be	  in	   the	  gym;	  more	  basketball;	  less	  basketball).	  If	  it	  does	  not	  already	  do	  so,	   the	  facility	  should	  implement	  a	  structured	  way	  to	  verify	  that	  recreation	  is	   delivered	  each	  day	  (e.g.,	  this	  could	  be	  part	  of	  the	  UM’s	  weekly	  report	   and/or	  the	  Superintendent’s	  Monthly	  Report).	  These	  data	  should	  be	   presented	  to	  the	  Monitor	  for	  inclusion	  in	  the	  next	  Monitors’	  Report.	  	  	   	   A	  review	  of	  monthly	  activity	  schedules	  revealed	  a	  broad	  range	  of	   volunteer	  programs	  available	  to	  the	  general	  population	  youth	  at	  Scioto.	   These	  include	  religious	  services	  (Protestant	  and	  Catholic	  services;	  bible	   study;	  and	  other	  programs	  offering	  guidance	  to	  youth	  from	  faith-­‐based	   organizations),	  gender-­‐specific	  services	  for	  girls,	  academic	  tutoring,	   sports	  programs	  and	  a	  variety	  of	  creative/art	  programs.	  The	  activity	   schedules	  revealed	  that	  the	  programs	  are	  slated	  for	  delivery	  to	  all	  of	  the	   general	  population	  units	  on	  a	  rotating	  basis.	  Moving	  forward,	  the	  State	   needs	  to	  adopt	  the	  database	  being	  piloted	  at	  IRJCF	  so	  that	  it	  can	   demonstrate,	  to	  both	  the	  Monitor	  and	  the	  Release	  Authority,	  that	  the	   youth	  was	  engaged	  in	  a	  range	  of	  structured	  activities	  throughout	  their	   stay	  at	  Scioto.	  	   	   A	  sample	  of	  10	  youth’s	  files	  from	  the	  CaseNotes	  database	  was	  requested	   to	  ascertain	  attendance	  rates	  for	  group	  and	  individual	  counseling	  during	   the	  month	  of	  September.	  While	  more	  detail	  will	  be	  provided	  in	  the	   Mental	  Health	  section	  of	  this	  report,	  the	  review	  of	  treatment	   participation	  was	  not	  encouraging:	  
• Gang	  Intervention.	  This	  was	  the	  most	  reliably	  delivered	  group.	   Three	  of	  the	  youth	  participated	  in	  the	  9	  sessions	  that	  were	  held	   in	  September.	  Groups	  were	  held	  between	  2	  and	  4	  times	  per	   week.	  	  
• Core	  A.	  Even	  though	  all	  youth	  are	  supposed	  to	  receive	  this	   group,	  only	  4	  of	  the	  10	  youth’s	  participation	  was	  documented.	   Core	  A	  groups	  are	  held	  much	  more	  dependably	  on	  the	  girls’	  units	   (15	  sessions	  in	  September)	  than	  the	  boys’	  units	  (2-­‐4	  sessions	  in	   September).	  	  
• Core	  B.	  None	  of	  the	  8	  boys	  received	  this	  group.	  The	  two	  girls	   participated	  in	  the	  group	  2	  and	  4	  times,	  respectively,	  during	   September.	  	  
• Core	  C.	  Two	  of	  the	  boys	  had	  entries	  for	  this	  group	  showing	  

	  

43.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 44 of 129 PAGEID #: 2397

participation	  in	  1	  and	  2	  sessions,	  respectively,	  in	  September.	  	   • Healthy	  Relationships.	  As	  discussed	  in	  III.A.1,	  this	  9-­‐session	  group	  
was	  delivered	  to	  the	  girls	  between	  August	  and	  October.	  There	   were	  2	  sessions	  in	  September.	  	   • Extended	  Stay.	  Three	  of	  the	  youth	  had	  entries	  for	  this	  group	   showing	  participation	  in	  1,	  2	  and	  4	  sessions,	  respectively,	  in	   September.	   • Substance	  Abuse.	  Only	  one	  youth	  participated	  in	  this	  group,	  and	   only	  for	  one	  session.	  Another	  youth’s	  notes	  indicated	  that	  he	   needed	  these	  services	  for	  parole,	  but	  was	  not	  yet	  enrolled.	  	   • Individual	  treatment.	  All	  10	  youth	  had	  entries,	  but	  the	  frequency	   and	  duration	  of	  the	  sessions	  varied.	  Nearly	  all	  of	  the	  youth	  had	   only	  one	  or	  two	  sessions	  in	  September,	  although	  one	  youth	  had	   4	  sessions.	  Most	  of	  the	  sessions	  were	  30	  minutes	  in	  length,	  or	   shorter.	  	   While	  the	  treatment	  contact	  standards	  and	  the	  extent	  to	  which	  they	  are	   being	  met	  will	  be	  discussed	  in	  detail	  in	  the	  Mental	  Health	  section	  of	  the	   report,	  it	  appears	  that	  this	  component	  of	  the	  facility’s	  Programming	   initiative	  needs	  additional	  oversight	  to	  ensure	  that	  youth	  are	  engaged	  in	   the	  various	  groups	  at	  the	  expected	  frequency.	  	  	   	   Programming	  for	  Graduates	   Work	  records	  were	  reviewed	  for	  each	  of	  the	  12	  graduates	  currently	   housed	  at	  the	  facility	  (18%	  of	  the	  total	  population).	  One	  of	  the	  youth	  was	   pending	  transfer	  to	  CJCF	  and	  did	  not	  have	  a	  job.	  Across	  the	  other	  11	   youth,	  5	  were	  working	  the	  café,	  3	  were	  working	  as	  porters,	  1	  was	   working	  in	  the	  storeroom,	  1	  was	  working	  in	  maintenance,	  and	  1	  was	   assisting	  the	  Chaplain.	  Work	  schedules	  and	  timesheets	  verified	  that	  the	   youth	  had	  been	  consistently	  employed,	  often	  for	  several	  months.	  	   	   A	  list	  of	  vacant	  job	  positions	  included	  additional	  porter	  positions,	  school	   office	  aide,	  several	  maintenance	  positions	  and	  an	  academic	  tutor.	  The	   facility	  clearly	  has	  the	  capacity	  to	  accommodate	  more	  graduates	  with	   jobs,	  if	  needed.	  	   	   Attendance	  records	  indicated	  that	  all	  but	  two	  youth	  were	  enrolled	  in	  at	   least	  one	  of	  the	  college	  courses	  (most	  were	  enrolled	  in	  two	  or	  three).	   The	  two	  youth	  who	  were	  not	  enrolled	  were	  new	  to	  the	  facility	  and,	   because	  the	  courses	  are	  co-­‐ed,	  needed	  to	  undergo	  a	  period	  of	   observation	  to	  ensure	  that	  no	  security	  risk	  would	  be	  presented	  by	  their	   attendance.	  Courses	  had	  been	  ongoing	  for	  both	  the	  2012	  Summer	  and	   Fall	  semesters	  and	  had	  sufficient	  capacity	  to	  serve	  more	  students,	  if	   needed.	  	   	   The	  facility	  has	  sufficient	  funding	  for	  at	  least	  one	  more	  semester	  of	  these	   programs	  and	  is	  currently	  seeking	  continuation	  funding	  so	  that	  the	   programs	  can	  continue	  and	  expand.	  Interviews	  with	  three	  students	  in	  

	  

44.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 45 of 129 PAGEID #: 2398

the	  graduate	  program	  suggested	  tremendous	  satisfaction	  with	  the	   opportunities	  now	  available	  to	  them.	  Students	  who	  had	  been	  at	  Scioto	   for	  a	  long	  period	  of	  time	  kept	  reminding	  the	  new	  student,	  “You	  have	  no	   idea	  how	  much	  better	  things	  are	  now!!”	  The	  facility’s	  progress	  in	   meeting	  the	  needs	  of	  Scioto	  graduates	  is	  reflected	  in	  the	  upgrade	  to	   Partial	  Compliance.	  	   	   PROGRESS	  Unit	  (PU)	   	   The	  upgrade	  to	  partial	  compliance	  is	  credited	  entirely	  to	  the	   improvements	  related	  to	  graduate	  programming;	  unfortunately,	  no	   improvements	  were	  evident	  in	  increasing	  the	  quantity	  of	  programming	   available	  to	  youth	  on	  the	  Progress	  Unit	  (PU).	  As	  discussed	  elsewhere	  in	   this	  report,	  the	  facility	  only	  attempted	  to	  meet	  the	  minimum	   requirements	  of	  this	  provision—for	  youth	  in	  closed-­‐cell	  environments	  to	   be	  engaged	  in	  programming	  during	  all	  waking	  hours,	  except	  when	  in	   intervention	  seclusion—on	  October	  15,	  2012	  when	  the	  24-­‐hour	  schedule	   was	  first	  implemented.	  Sufficient	  time	  has	  not	  yet	  passed	  to	  determine	   whether	  the	  schedule	  has	  been	  implemented	  with	  fidelity	  to	  its	  design	   and	  whether	  youth	  are	  accessing	  the	  range	  of	  programs	  designed	  to	   address	  their	  violent	  and	  aggressive	  behavior.	  	  	   	   Unfortunately,	  throughout	  the	  current	  monitoring	  period,	  the	  PU	  did	  not	   provide	  youth	  with	  dependable	  access	  to	  programming	  and	  services.	   Late	  in	  the	  monitoring	  period	  (June	  2012),	  the	  facility	  began	  to	   emphasize	  with	  PU	  staff	  the	  need	  to	  bring	  the	  youth	  out	  of	  their	  rooms	   for	  school,	  recreation	  and	  treatment	  groups.	  However,	  a	  review	  of	  Unit	   Logs	  from	  the	  end	  of	  the	  monitoring	  period	  indicated	  that	  this	  effort	  was	   not	  particularly	  successful.	  While	  the	  PU	  was	  no	  longer	  operating	  as	  a	  23-­‐ hour	  lockdown	  (as	  it	  had	  during	  its	  previous	  incarnation	  at	  another	   facility	  and	  during	  the	  early	  stages	  of	  its	  implementation	  at	  Scioto),	  PU	   youth	  still	  did	  not	  have	  dependable	  access	  to	  essential	  activities	  and	   remained	  locked	  in	  their	  cells	  far	  beyond	  the	  hours	  permitted	  by	  this	   Provision.	  	   	   The	  Sycamore	  Unit	  Log	  was	  reviewed	  for	  a	  9-­‐day	  period	  at	  the	  end	  of	   September	  2012.	  A	  random	  sample	  of	  4	  youth	  (44%	  of	  the	  Sycamore	   population)	  was	  selected	  and	  the	  number	  of	  times	  each	  youth	  was	   engaged	  in	  various	  activities	  was	  tallied.	  The	  findings	  were	  discouraging:	  
• Across	  the	  9-­‐day	  period,	  youth	  were	  engaged	  in	  recreation/unit	   leisure	  time	  an	  average	  of	  4	  times	  (range	  3	  to	  5).	  Most	  youth	  did	   not	  receive	  recreation	  on	  the	  weekdays.	  All	  youth	  should	  have	   large	  muscle	  activity	  at	  least	  once	  per	  day.	  	  
• Across	  the	  9-­‐day	  period,	  youth	  were	  engaged	  in	  a	  treatment	   activity	  (e.g.,	  group	  or	  individual	  session)	  an	  average	  of	  5	  times	   (range	  4	  to	  7).	  This	  is	  less	  than	  once	  per	  day	  and	  obviously	   counter	  to	  the	  idea	  of	  intensive	  programming,	  which	  should	  be	  

	  

45.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 46 of 129 PAGEID #: 2399

at	  the	  core	  of	  a	  special	  management	  unit	  if	  behavior	  change	  is	   truly	  the	  goal.	  	   • Across	  the	  9-­‐day	  period,	  youth	  were	  offered	  showers	  an	  average	   of	  7.25	  times	  (range	  5	  to	  8).	  While	  this	  may	  be	  a	  documentation	   problem,	  it	  highlights	  the	  difficulty	  the	  facility	  has	  had	  in	  offering	   and/or	  recording	  even	  the	  most	  straightforward	  activities	  on	  the	   PU.	  	   • Youth	  appeared	  to	  be	  attending	  school	  consistently	  on	  school	   days,	  although	  sometimes	  it	  appeared	  that	  afternoon	  sessions	   were	  cut	  short.	  	   • Meals	  were	  documented	  consistently,	  three	  times	  per	  day.	  	   Considered	  another	  way,	  most	  of	  the	  youth	  on	  this	  unit	  attended	  in	   school	  on	  the	  weekdays	  and	  were	  involved	  in	  a	  single	  therapeutic	  activity	   after	  school	  about	  half	  the	  time,	  but	  remained	  locked	  in	  their	  rooms	  until	   the	  next	  morning	  the	  other	  half.	  On	  weekends,	  most	  youth	  were	  out	  of	   their	  rooms	  for	  only	  one	  or	  two	  hours	  each	  day.	  	   	   A	  similar	  review	  was	  conducted	  using	  the	  Cedar	  Unit	  Logs	  during	  a	  10-­‐ day	  period	  in	  late	  September	  2012.	  A	  random	  sample	  of	  5	  youth	   (approximately	  36%	  of	  the	  population,	  which	  fluctuated	  during	  the	   period	  reviewed)	  was	  selected	  and	  their	  engagement	  in	  various	  activities	   was	  tallied.	  The	  findings	  were	  somewhat	  better,	  but	  still	  far	  from	   sufficient	  to	  meet	  the	  requirements	  of	  this	  provision:	  	   • Across	  the	  10-­‐day	  period,	  youth	  were	  engaged	  in	  recreation/unit	   leisure	  an	  average	  of	  5	  times	  (range	  0	  to	  8).	  Most	  youth	  did	  not	   receive	  recreation	  on	  the	  weekdays.	  	   • Youth	  were	  engaged	  in	  a	  treatment	  activity	  an	  average	  of	  9.4	   times	  (range	  7	  to	  11),	  or	  about	  once	  per	  day.	  	   • Youth	  were	  offered	  the	  opportunity	  to	  shower	  an	  average	  of	  3	   times	  (range	  2	  to	  4).	  Again,	  this	  may	  be	  a	  documentation	   problem,	  but	  highlights	  the	  difficulty	  the	  facility	  has	  had	  in	   offering	  and/or	  recording	  even	  the	  most	  straightforward	   activities	  on	  the	  PU.	  	   • Youth	  attended	  school	  for	  a	  full	  day	  each	  weekday.	  The	  one	   exception	  was	  a	  youth	  who	  was	  a	  graduate,	  who	  remained	  in	  his	   room	  throughout	  the	  school	  hours.	  	   	   Note	  that	  the	  time	  period	  reviewed	  was	  well	  after	  DYS	  enhanced	  the	  PU	   staffing	  and	  began	  to	  emphasize	  the	  need	  for	  out-­‐of-­‐cell	  time.	  One	  can	   assume	  that	  services	  to	  PU	  youth	  were	  similarly	  limited	  during	  the	  early	   part	  of	  the	  monitoring	  period,	  before	  the	  DYS	  had	  even	  begun	  to	  rethink	   its	  program	  implementation	  strategy.	  Thus,	  during	  the	  current	   monitoring	  period,	  on	  the	  typical	  weekday,	  PU	  youth	  spent	   approximately	  16	  hours	  in	  their	  rooms.	  While	  11	  of	  these	  hours	  were	   sleeping	  hours,	  the	  other	  5	  were	  hours	  during	  which	  the	  State	  should	   have	  been	  providing	  access	  to	  treatment,	  recreation	  and	  other	   structured	  programming	  designed	  to	  rehabilitate	  youth	  and	  facilitate	  

	  

46.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 47 of 129 PAGEID #: 2400

Recommendations	  

their	  return	  to	  the	  general	  population.	  On	  the	  weekend,	  most	  youth	   spent	  about	  22	  hours	  in	  their	  rooms,	  remaining	  idle	  and	  secluded	  during	   the	  approximately	  11	  hours	  that	  should	  have	  been	  used	  to	  deliver	   programming.	  	   	   Further,	  the	  PU	  has	  a	  dearth	  of	  programming	  for	  youth	  who	  have	   graduated	  from	  high	  school	  or	  obtained	  a	  GED.	  For	  security	  reasons,	   none	  of	  the	  programs	  that	  have	  been	  developed	  for	  the	  general	   population	  are	  available	  to	  youth	  housed	  on	  the	  PU.	  As	  a	  result,	  while	   their	  counterparts	  are	  in	  school,	  graduates	  spend	  most	  of	  the	  weekdays	   in	  their	  rooms.	  In	  the	  past,	  youth	  have	  reported	  the	  dearth	  of	   programming	  to	  be	  a	  disincentive	  to	  their	  completing	  their	  degree	   requirements,	  which	  is	  obviously	  counter	  to	  the	  overall	  intent	  of	  the	   Stipulation	  and	  DYS’	  own	  mission.	  This	  situation	  must	  be	  rectified	   immediately.	  	   	   In	  the	  original	  concept,	  the	  programming	  on	  the	  PU	  was	  supposed	  to	  be	   intensive.	  However,	  the	  vast	  amount	  of	  time	  that	  youth	  on	  the	  PU	  spend	   in	  their	  rooms	  has	  interfered	  with	  the	  delivery	  of	  services	  and	  the	  PU	  has	   not	  been	  capable	  of	  creating	  the	  kind	  of	  behavior	  change	  needed	  for	  the	   youth	  housed	  there	  to	  be	  integrated	  into	  the	  general	  population.	  The	  sad	   irony	  is	  that	  these	  youth	  are	  the	  most	  in	  need	  of	  services,	  but	  yet	  are	   receiving	  the	  least	  amount	  of	  service	  of	  any	  youth	  at	  Scioto.	  This	   situation	  must	  be	  rectified—youth	  must	  be	  out	  of	  their	  rooms,	  attending	   treatment,	  education	  or	  other	  structured	  programming	  throughout	  the	   day.	  The	  programming	  must	  be	  delivered	  with	  integrity	  so	  that	  youth	   learn	  to	  control	  their	  aggressive	  behavior	  without	  the	  imposition	  of	  the	   security	  features	  of	  the	  PU	  and	  are	  able	  to	  return	  to	  the	  general	   population	  within	  a	  reasonable	  period	  of	  time.	  	   	   Given	  the	  long-­‐history	  of	  non-­‐compliance	  with	  this	  provision,	  a	   significant	  period	  of	  time	  in	  which	  youth	  are	  actively	  engaged	  in	   structured	  programing	  throughout	  their	  waking	  hours	  will	  be	  needed	  to	   demonstrate	  that	  the	  changes	  are	  durable	  and	  that	  the	  State	  is	  capable	   of	  delivering	  the	  24-­‐hour	  schedule	  even	  as	  the	  youth	  characteristics	  and	   size	  of	  the	  population	  changes.	  	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Develop	  the	  capacity	  to	  track	  youth’s	  involvement	  in	  volunteer	   and	  religious	  programming	  and	  to	  ensure	  that	  recreation	   programming	  is	  delivered	  at	  the	  required	  frequency.	  	  	  
2. Ensure	  that	  individual	  and	  group	  treatment	  is	  delivered	  at	  the	   required	  frequency	  and	  duration	  on	  all	  units.	  	  
3. Ensure	  that	  youth	  on	  the	  PROGRESS	  Unit	  are	  out	  of	  their	  rooms,	   attending	  treatment,	  education	  or	  other	  structured	   programming	  throughout	  the	  day.	  Develop	  quality	  weekday	   program	  for	  youth	  who	  have	  graduated	  from	  high	  school	  or	  

	  

47.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 48 of 129 PAGEID #: 2401

Sources	  of	   Information	  
	   	  

obtained	  a	  GED.	  This	  programming	  must	  be	  delivered	  with	   integrity	  so	  that	  the	  youth	  are	  able	  to	  meet	  their	  treatment	  goals	   and	  return	  to	  the	  general	  population	  within	  a	  reasonable	  period	   of	  time.	  	  	  
• Self-­‐assessment	  data	  and	  oral	  presentation	  of	  its	  interpretation	   for	  III.F.1,	  prepared	  at	  my	  request	  
• CaseNote	  records	  for	  10	  randomly	  selected	  youth	  housed	  at	   Scioto	  on	  October	  18,	  2012	  
• Work	  schedules,	  timesheets	  and	  job	  descriptions	  for	  all	  12	   graduates	  housed	  at	  Scioto	  as	  of	  October	  15,	  2012	  
• Course	  descriptions	  and	  attendance	  records	  for	  all	  post-­‐ secondary	  courses	  for	  the	  Summer	  and	  Fall	  semesters	  2012	  
• Interviews	  with	  15	  youth	  housed	  at	  Scioto	  on	  October	  19,	  2012	   • Draft	  schedule	  for	  the	  PROGRESS	  Unit,	  as	  of	  October	  15,	  2012	  
	  

	  

48.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 49 of 129 PAGEID #: 2402

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

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

The	  facility	  continues	  to	  audit	  a	  random	  10%	  sample	  of	  admissions	  files	   every	  month	  to	  ensure	  compliance	  with	  policy	  and	  procedure.	  Between	   April	  2012	  and	  September	  2012,	  approximately	  300	  youth	  were	  admitted	   to	  the	  facility;	  10%,	  or	  30	  youth,	  were	  included	  in	  the	  audit.	  Each	  month,	   100%	  of	  the	  youth	  sampled	  received	  a	  complete	  orientation	  to	  the	   facility	  which	  included,	  among	  other	  things:	  
• Youth	  Handbook	   • Orientation	  Video	   • Facility	  rules	  and	  consequences	  (IRAV)	   • Strength	  Based	  Behavior	  Management	  System	  (SBBMS)	   • Obtaining	  legal	  assistance	   • Accessing	  medical	  and	  mental	  health	  care	   • Sexual	  abuse	  and	  sexual	  assault	  information	   • Grievance	  system	  

Steps	  Taken	  to	   Assess	  Compliance	  

Religious	  Accommodations	   	   The	  previous	  Monitor’s	  report	  required	  the	  State	  to	  provide	  youth	  with	   information	  that	  clearly	  described	  the	  youth’s	  rights	  related	  to	  practicing	   their	  religion	  of	  choice,	  in	  particular,	  how	  they	  make	  seek	   accommodations	  for	  religious	  beliefs,	  practices	  or	  observance.	  The	  State	   revised	  the	  handbook	  by	  inserting	  the	  following	  language:	   	   Every	  youth	  has	  the	  right	  to	  practice	  their	  religion.	  You	  are	  permitted	  to	   have	  the	  resources	  of	  your	  faith	  as	  long	  as	  it	  does	  not	  affect	  the	  safety	  of	   the	  facility.	  	   	   The	  revised	  Handbook	  was	  put	  into	  use	  on	  January	  12,	  2012.	  Department	  

	  

49.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 50 of 129 PAGEID #: 2403

heads	  and	  supervisors	  provided	  information	  to	  their	  staff	  on	  the	   requirement	  to	  accommodate	  youth’s	  religious	  beliefs.	  As	  of	  March	  15,	   2012,	  87%	  of	  all	  staff	  had	  been	  trained	  and	  completed	  a	  post-­‐test	  about	   the	  facility’s	  religious	  accommodations	  policy.	   	   During	  the	  current	  monitoring	  period,	  three	  grievances	  were	  submitted	   by	  youth	  who	  wanted	  the	  freedom	  to	  practice	  their	  religion	  of	  choice.	  	  
• A	  youth	  requested	  a	  copy	  of	  the	  Holy	  Quran,	  and	  was	  dissatisfied	   that	  he’d	  received	  the	  Glorious	  Quran	  (the	  two	  versions	  have	  the	   same	  content,	  but	  different	  covers,	  per	  an	  area	  Islamic	   bookstore).	  The	  youth	  was	  provided	  with	  this	  information,	   accepted	  the	  Glorious	  Quran	  and	  was	  also	  permitted	  to	  receive	  a	   copy	  of	  the	  Holy	  Quran	  from	  his	  parents	  if	  he	  preferred.	  
• A	  youth	  requested	  permission	  to	  grow	  his	  hair	  into	  dreadlocks	  in	   order	  to	  practice	  his	  faith,	  Rastafarianism.	  An	  application	  for	   religious	  hair	  accommodation	  was	  submitted	  on	  his	  behalf	  and	   an	  appointment	  with	  the	  cosmetologist	  was	  scheduled	  so	  that	  he	   could	  learn	  the	  proper	  techniques	  to	  care	  for	  his	  hairstyle.	  	  
• A	  youth	  indicated	  that	  he	  is	  Muslim	  and	  therefore	  should	  be	   exempt	  from	  facility	  policies	  that	  require	  him	  to	  shave.	  The	   Chaplain	  consulted	  with	  the	  youth,	  who	  retracted	  his	  request,	   indicating	  that	  “Islam	  is	  too	  confusing	  to	  follow.”	  	  
	  	   The	  revised	  Youth	  Handbook	  clearly	  articulates	  that	  youth	  are	  free	  to	   practice	  their	  religion	  of	  choice	  and	  the	  facility	  has	  demonstrated	  its	   willingness	  to	  make	  religious	  accommodations	  when	  the	  issue	  has	  arisen.	  	   	   PROGRESS	  Unit	  Orientation	   While	  most	  of	  the	  youth	  at	  Scioto	  undergo	  an	  orientation	  to	  the	  general	   population,	  youth	  can	  also	  be	  admitted	  directly	  to	  the	  PROGRESS	  Unit	   (PU),	  and	  thus	  the	  orientation	  for	  that	  program	  is	  relevant	  to	  this	   provision.	  Draft	  SOP	  303.01.07	  “Progress	  Unit”	  requires	  the	  Unit	   Manager	  to	  ensure	  that	  the	  PU	  Youth	  Handbook	  is	  available	  to	  all	  youth	   and	  that	  a	  staff	  member	  provides	  a	  thorough	  orientation	  to	  youth	  upon	   their	  admission	  to	  the	  Unit.	  Youth	  must	  sign	  the	  Handbook’s	  signature	   page	  to	  acknowledge	  receipt	  of	  the	  information.	  	   	   The	  PU	  Handbook	  remains	  in	  draft	  form,	  along	  with	  the	  SOP.	  Given	  the	   recent	  modifications	  to	  the	  PU	  program	  (discussed	  in	  III.A.3	  and	  III.F.1,	   above),	  the	  draft	  Handbook	  will	  need	  to	  be	  revised	  from	  its	  current	   incarnation,	  and	  finalized	  along	  with	  the	  SOP,	  in	  order	  for	  the	  State	  to	   reach	  substantial	  compliance	  with	  this	  provision.	  [The	  PU	  has	  never	  been	   governed	  by	  a	  formal	  policy—it	  has	  only	  ever	  existed	  in	  draft	  form.	  Once	   initially	  signed	  into	  effect,	  subsequent	  modifications	  to	  the	  SOP	  or	  the	   Handbook	  to	  keep	  pace	  with	  the	  program’s	  evolution	  will	  not	  cause	  the	   State	  to	  fall	  out	  of	  substantial	  compliance.]	   	  

	  

50.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 51 of 129 PAGEID #: 2404

Recommendations	  
Sources	  of	   Information	  
	   	   	  

To	  assess	  the	  extent	  to	  which	  youth	  admitted	  to	  the	  PU	  received	  an	   orientation	  (even	  if	  it	  is	  not	  yet	  required	  by	  policy),	  Orientation	   Acknowledgement	  Forms	  were	  requested	  and	  reviewed	  for	  the	  17	  youth	   admitted	  during	  the	  monitoring	  period,	  April	  through	  September	  2012.	   Signed	  orientation	  sheets	  were	  available	  for	  all	  of	  17	  youth.	  At	  times,	  the	   dates	  on	  the	  sheets	  curiously	  pre-­‐dated	  the	  youth’s	  transfer	  to	  the	  unit.	   Additional	  investigation	  revealed	  that	  the	  youth’s	  transition	  dates	  were	   not	  entered	  immediately	  upon	  their	  placement.	  While	  this	  problem	  does	   not	  affect	  compliance	  with	  this	  provision,	  it	  should	  be	  rectified	  given	  that	   the	  length	  of	  stay	  on	  the	  PU	  is	  a	  topic	  of	  much	  concern	  and	  it	  is	   important	  for	  admission	  dates	  to	  be	  correct.	  	  	  	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Finalize	  the	  PU	  Youth	  Handbook	  and	  SOP	  so	  that	  they	  provide	  an	   accurate	  description	  of	  the	  current	  operation	  of	  the	  PROGRESS	   unit.	  	  
• Self-­‐assessment	  data	  and	  oral	  presentation	  of	  its	  interpretation	   for	  III.F.2,	  prepared	  at	  my	  request	  
• Intake	  Audit	  Report,	  April	  2012	  through	  September	  2012	   • Scioto	  Youth	  Handbook,	  last	  modified	  March	  16,	  2012	   • Grievances	  related	  to	  religious	  accommodation	  (n=3),	  submitted	  
between	  April	  and	  September	  2012	   • Admission	  dates	  and	  orientation	  records	  for	  youth	  admitted	  to	  
the	  PROGRESS	  Unit	  since	  April	  1,	  2012	  	  
	  

	  

51.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 52 of 129 PAGEID #: 2405

MENTAL	  HEALTH	  SERVICES	  
	   	  
III.B.	  1	  Mental	  Health	  Screening.	  	  The	  State	  shall	  implement	  policies,	  procedures	  and	  practices	  to	   ensure	  that	  all	  youth	  admitted	  to	  the	  facilities	  are	  comprehensively	  screened	  for	  mental	   disorders,	  including	  substance	  abuse,	  depression,	  and	  serious	  mental	  illness,	  within	  twenty-­‐four	   hours	  of	  admission.	  This	  screening	  shall	  be	  performed	  by	  qualified	  personnel,	  as	  part	  of	  the	   intake	  process,	  consistent	  with	  generally	  accepted	  professional	  standards	  of	  care.	  	  

Compliance	  Rating	   Substantial	  Compliance	  

Self	  Assessment	  

Per	  the	  SJCF	  oral	  self-­‐assessment,	  policy	  and	  procedure	  regarding	  this	   process	  remains	  pending.	  

Steps	  Taken	  to	   Assess	  Compliance	  

Per	  a	  review	  of	  ten	  intake	  packets	  provided	  for	  off	  site	  review	  revealed	   that	  all	  youth	  admitted	  had	  Reception	  Screening	  for	  Assaultive	   Behavior,	  Sexually	  Aggressive	  Behavior,	  and	  Risk	  for	  Sexual	  Victimization	   on	  the	  day	  of	  admission.	  	  Substance	  Abuse	  Screening	  was	  included	  via	   documents,	  such	  as	  the	  Juvenile	  Automated	  Substance	  Evaluation.	  It	   was	  notable	  that	  every	  assessment	  example	  provided	  recommended	   further	  assessment	  by	  psychology	  staff	  to	  complete	  a	  Behavioral	  Health	   Appraisal.	  	  The	  intake	  packets	  initially	  provided	  for	  review	  did	  not	   include	  documentation	  of	  the	  immediate	  screening	  by	  nursing	  staff,	  nor	   did	  they	  include	  MAYSI-­‐2	  results.	  	  Following	  submission	  of	  the	  draft	   report,	  nursing	  screening	  and	  MAYSI	  results	  were	  provided	  for	  review.	  	   These	  were	  completed	  appropriately	  with	  the	  exception	  of	  the	  date	  on	   the	  MAYSI	  screen.	  	  Each	  document	  had	  a	  sticker	  with	  the	  youth’s	  name	   and	  date	  of	  admission;	  however,	  the	  space	  on	  the	  MAYSI	  form	  where	   the	  date	  was	  to	  be	  entered	  was	  blank	  in	  five	  out	  of	  ten	  examples.	  	  	  Per	   discussions,	  it	  was	  determined	  that	  the	  MAYSI	  is	  performed	  on	  the	  date	   of	  admission;	  however,	  as	  discussed	  with	  ODYS	  administrative	  staff,	  it	  is	   necessary	  for	  the	  date	  blank	  to	  be	  completed	  by	  the	  individual	   administering	  the	  MAYSI	  and	  any	  other	  assessment	  documents.	  	  This	  is	   an	  issue	  that	  should	  be	  followed	  via	  ongoing	  QA.	   	   Per	  interviews	  performed	  during	  the	  previous	  monitoring	  visit,	  it	  was	   apparent	  that	  current	  policy	  and	  procedure	  regarding	  this	  process	  was	   confusing,	  mostly	  related	  to	  the	  multiple	  assessment	  documents	  and	   terminology	  utilized.	  	  In	  an	  effort	  to	  address	  this	  issue,	  and	  to	  simplify	  all	   Behavioral	  Health	  policies,	  ODYS	  promoted	  a	  review	  and	  revision	  of	  all	   policies	  with	  the	  involvement	  of	  central	  office	  leadership,	  facility	   administration,	  and	  facility	  behavioral	  health	  staff.	  	  Individuals	  were	   assigned	  to	  work	  groups	  with	  responsibility	  to	  review	  and	  revise	  policy	   as	  part	  of	  an	  integrated	  behavioral	  health	  system	  of	  care.	  	  The	  final	   policy	  was	  pending;	  however,	  per	  discussions	  with	  behavioral	  health	   administrative	  staff,	  policies	  and	  procedures	  have	  been	  completed,	  and	   are	  in	  the	  final	  stages	  of	  review	  with	  full	  implementation	  planned	  for	   the	  first	  quarter	  of	  2013.	  	  	  

	  

52.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 53 of 129 PAGEID #: 2406

Recommendations	  
Sources	  of	   Information	   	   	   	  

	   Please	   note	   that	   throughout	   the	   mental	   health	   report,	   there	   are	   multiple	  references	  regarding	  the	  need	  to	  finalize	  policy	  and	  procedure.	  	   While	   policy	   and	   procedure	   is	   in	   existence	   and	   has	   been	   implemented	   to	  address	  processes	  associated	  with	  the	  delivery	  of	  mental	  health	  care,	   ODYS	   is	   currently	   in	   the	   final	   process	   of	   a	   review	   and	   simplification	   of	   said	   policy.	   	   As	   such,	   the	   recommendation	   for	   finalizing	   policy	   is	   in	   reference	   to	   the	   revision	   and	   simplification	   process.	   	   There	   are	   existing	   policies	   in	   place	   that	   are	   fully	   implemented	   and	   as	   such	   the	   individual	   provisions	  below	  would	  meet	  the	  criteria	  for	  a	  partial	  compliance	  rating.	  	   The	   plan	   to	   simplify	   policy	   and	   via	   this	   process	   integrate	   the	   various	   mental	   health	   disciplines	   into	   a	   behavioral	   health	   team	   is	   positive	   and	   may	  result	  in	  more	  cohesive	  mental	  health	  treatment	  for	  the	  youth.	   	   While	  it	  is	  apparent	  that	  multiple	  assessment	  instruments	  are	  utilized	   for	  youth	  admitted	  to	  ODYS,	  this	  remains	  a	  complicated	  process,	   highlighting	  the	  need	  for	  policy	  and	  procedure	  revision	  and	  quality	   assurance	  monitoring.	  	  
In	  order	  to	  maintain	  substantial	  compliance	  with	  this	  provision,	  the	   State	  must:	   1. Fully	  implement	  policy	  and	  procedure	  “Behavioral	  Health	  
Assessment,	  Screening,	  Appraisal	  and	  Evaluation.”	  	  Given	  the	   change	  in	  facility	  mission,	  review	  and	  revise	  this	  policy	  as	  necessary.	   2. Begin	  quality	  assurance	  monitoring	  or	  clinical	  supervision	  regarding	   the	  reception	  assessment	  summary	  documents.	   3. Begin	  quality	  assurance	  monitoring	  to	  ensure	  that	  timelines	   required	  by	  policy	  and	  procedure	  are	  adhered	  to.	  
• Review	  of	  provided	  documents	  	   • Staff	  interview	  
	  

	  

53.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 54 of 129 PAGEID #: 2407

III.B.2	  	  Immediate	  Referral.	  If	  the	  mental	  health	  screen	  identifies	  an	  issue	  that	  places	  the	  youth’s	   safety	  at	  immediate	  risk,	  the	  youth	  shall	  be	  immediately	  referred	  to	  a	  qualified	  mental	  health	   professional	  for	  assessment,	  treatment	  and	  any	  other	  appropriate	  action,	  such	  as	  transfer	  to	   another,	  more	  appropriate	  setting.	  The	  State	  shall	  ensure	  that,	  absent	  extraordinary	   circumstances,	  qualified	  mental	  health	  professionals	  are	  available	  for	  consultation	  within	  12	   hours	  of	  such	  referrals.	  	  

Compliance	  Rating	   Substantial	  Compliance	  

Self	  Assessment	  

Per	  the	  oral	  facility	  self-­‐assessment,	  facility	  mental	  health	  staff	  were	   using	  central	  office	  as	  a	  “safety	  net”	  in	  order	  to	  effect	  transfers	  to	  other	   programs	  if	  necessary.	  	  There	  were	  examples	  provided	  of	  youth	   transferred	  to	  other	  facilities	  to	  access	  programs.	  

Steps	  Taken	  to	   Assess	  Compliance	  

This	  was	  an	  area	  of	  ongoing	  improvement	  in	  the	  intervening	  period	   since	  the	  previous	  monitoring	  review.	  	  Discussions	  with	  behavioral	   health	  staff	  revealed	  that	  they	  felt	  empowered	  to	  advocate	  for	  the	   youth	  in	  the	  facility	  without	  fear	  of	  reprisal.	  	  There	  were	  examples	  of	   active	  advocacy	  noted.	  	  For	  example,	  previously,	  if	  a	  youth	  were	   suspected	  of	  acute	  mental	  health	  needs	  requiring	  transfer	  to	  the	  mental	   health	  unit,	  there	  was	  a	  cumbersome	  process	  to	  arrange	  this	  transfer.	  	   With	  recent	  shifts	  in	  process	  and	  administration,	  this	  is	  now	  reportedly	  a	   relatively	  painless	  process.	  	  	   	   For	  example,	  in	  April	  2012,	  Youth	  #404	  was	  assessed	  on	  intake	  at	  SJCF	   and	  noted	  to	  be	  experiencing	  symptoms	  of	  psychosis.	  	  He	  was	   immediately	  referred	  for	  transfer	  to	  the	  mental	  health	  unit.	  	  	  In	  May	   2012,	  Youth	  #505	  was	  assessed	  on	  intake	  at	  SJCF	  and	  noted	  to	  have	  a	   developmental	  disability.	  	  He	  was	  immediately	  referred	  for	  transfer	  to	   the	  life	  skills	  unit.	  	  In	  September,	  two	  additional	  youth	  were	  identified	  at	   intake	  at	  SJCF	  as	  having	  developmental	  disabilities	  and	  referred	  to	  the	   life	  skills	  unit.	  	  In	  September	  2012,	  Youth	  #606	  experienced	  an	   exacerbation	  of	  mental	  health	  symptoms	  and	  was	  transferred	  to	  a	   behavioral	  health	  facility	  for	  acute	  care.	  	   	   Given	  the	  review	  of	  the	  current	  behavioral	  health	  staff	  schedule,	  staff	   are	  working	  a	  flex	  schedule	  with	  one	  required	  evening	  per	  week	  and	   one	  required	  weekend	  per	  month.	  	  This	  allows	  for	  broad	  behavioral	   health	  coverage.	  	  One	  weakness	  of	  the	  schedule	  was	  the	  lack	  of	   behavioral	  health	  staff	  scheduled	  on	  holidays.	  	  There	  was	  an	  on-­‐call	   schedule,	  and	  the	  Psychology	  Supervisor	  was	  responsible	  for	  this,	   specifically	  after	  hours	  telephone	  contact.	  	  The	  Psychology	  supervisor	   was	  also	  reportedly	  available	  to	  come	  to	  the	  facility	  for	  face-­‐to-­‐face	   assessments	  if	  the	  need	  arose.	   	   Given	  the	  review	  of	  documents	  performed	  for	  this	  and	  other	   paragraphs,	  it	  was	  apparent	  that	  there	  was	  an	  improvement	  in	  referral	   to	  a	  mental	  health	  provider,	  response	  from	  mental	  health	  providers,	   and	  access	  to	  other	  mental	  health	  treatment	  programs	  as	  needed.	  	  As	  

	  

54.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 55 of 129 PAGEID #: 2408

Recommendations	  
Sources	  of	   Information	   	   	   	  

such,	  this	  provision	  will	  be	  placed	  in	  Substantial	  Compliance.	  	  In	  order	  to	   maintain	  this	  level,	  ongoing	  efforts	  must	  be	  made	  to	  ensure	  that	  youth	   obtain	  the	  level	  of	  care	  that	  is	  necessary.	  	  In	  addition,	  quality	  assurance	   monitoring	  will	  be	  necessary	  with	  regard	  to	  timely	  response	  to	  referral	   and	  access	  to	  other	  behavioral	  health	  care	  options.	  
In	  order	  to	  maintain	  substantial	  compliance	  with	  this	  provision,	  the	   State	  must:	   1. Collect	  data	  regarding	  the	  time	  lapse	  between	  referral	  and	  actual	  
evaluation	  or	  assessment	  for	  quality	  assurance	  monitoring.	   2. Ensure	  that	  staff	  are	  aware	  of	  the	  process	  by	  which	  a	  youth	  may	  
access	  other	  appropriate	  mental	  health	  services	  (e.g.	  a	  facility	  based	   mental	  health	  unit	  or	  an	  inpatient	  psychiatric	  facility).	  
• Review	  of	  provided	  documents	  	   • Observation	   • Staff	  interview	  
	  

	  

55.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 56 of 129 PAGEID #: 2409

III.B.3	  	  	  Identification	  of	  Previously	  Unidentified	  Youth.	  The	  facilities	  shall	  implement	  policies,	   procedures	  and	  practices	  consistent	  with	  generally	  accepted	  professional	  standards	  of	  care	  to	   identify	  and	  address	  potential	  manifestations	  of	  mental	  or	  behavioral	  disorder	  in	  youth	  who	   have	  not	  been	  previously	  identified	  as	  presenting	  mental	  health	  or	  behavioral	  needs	  requiring	   treatment.	  	  

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

Per	  the	  facility	  oral	  self-­‐assessment,	  the	  majority	  of	  youth	  assigned	  to	   the	  Progress	  Unit	  (18	  out	  of	  20)	  were	  on	  the	  mental	  health	  caseload.	  	   There	  were	  a	  total	  of	  ten	  female	  youth,	  with	  all	  of	  them	  on	  the	  mental	   health	  caseload.	  	  The	  total	  facility	  population	  at	  the	  time	  of	  the	   monitoring	  visit	  was	  72.	  	  The	  mental	  health	  roster	  indicated	  that	  there	   were	  a	  total	  of	  50	  youth	  (70%)	  assigned	  to	  the	  mental	  health	  caseload.	  	  

Steps	  Taken	  to	   Assess	  Compliance	  

With	  regard	  to	  the	  identification	  of	  youth	  previously	  unidentified	  as	   having	  mental	  health	  challenges,	  the	  facility	  has	  made	  changes	  to	  the	   facility	  environment	  in	  an	  effort	  to	  ensure	  that	  all	  youth	  requiring	   services	  are	  identified	  as	  such.	  	  For	  example,	  there	  are	  behavioral	  health	   staff	  (both	  psychology	  and	  social	  workers)	  housed	  on	  the	  units.	  	  There	   was	  also	  enhanced	  mental	  health	  presence	  on	  the	  Progress	  Units.	  	  	   	   A	  full	  time	  mental	  health	  nurse	  began	  providing	  services	  at	  the	  facility	   approximately	  one	  month	  prior	  to	  the	  end	  of	  the	  monitoring	  period.	  	  He	   has	  been	  assigned	  to	  the	  Progress	  Unit	  and	  performs	  rounds	  every	   weekday.	  	  Also,	  a	  psychiatrist	  has	  been	  assigned	  to	  the	  Progress	  Unit,	   beginning	  work	  there	  approximately	  two	  weeks	  prior	  to	  the	  end	  of	  this	   monitoring	  period.	   	   In	  addition,	  facility	  staff	  were	  performing	  daily	  mini	  mental	  status	   reviews	  for	  youth	  housed	  on	  Phase	  One	  of	  the	  Progress	  Units.	  	  These	   reviews	  serve	  several	  purposes,	  to	  monitor	  youth	  housed	  in	  this	  area	  for	   decompensation,	  to	  identify	  youth	  requiring	  mental	  health	  intervention,	   and	  to	  ensure	  access	  to	  health	  care	  for	  those	  youth	  housed	  on	  that	  unit.	  	   It	  should	  be	  noted	  that	  late	  in	  the	  monitoring	  period,	  youth	  were	   allowed	  out	  of	  their	  cells	  on	  a	  daily	  basis	  for	  increasing	  amounts	  of	  time,	   which	  is	  positive.	  	  As	  this	  progresses,	  and	  youth	  are	  out	  of	  their	  cells	  for	   the	  majority	  of	  their	  waking	  hours,	  the	  need	  for	  daily	  mini	  mental	  status	   reviews	  will	  be	  reduced.	  	  	   	   Administrative	  behavioral	  health	  staff	  instituted	  a	  comprehensive	   screening	  process	  for	  those	  youth	  proposed	  for	  placement	  on	  the	   Progress	  Unit.	  	  This	  process	  began	  during	  the	  summer	  of	  2012;	  however,	   became	  more	  extensive	  during	  the	  late	  fall.	  	  It	  is	  noted	  that	  this	  process	   has	  improved	  overall	  since	  October	  2012;	  however,	  needs	  additional	   time	  for	  assessment	  prior	  to	  achieving	  Substantial	  Compliance.	   	   A	  review	  of	  the	  total	  number	  of	  youth	  currently	  on	  the	  mental	  health	   caseload	  revealed	  that	  10/10	  female	  youth	  (100%)	  were	  identified.	  	  

	  

56.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 57 of 129 PAGEID #: 2410

Recommendations	  
Sources	  of	   Information	   	   	  

With	  regard	  to	  male	  youth	  40/61	  (65%)	  were	  identified.	  	  Additionally,	   via	  a	  review	  of	  the	  caseloads	  of	  psychology	  staff	  assigned	  to	  the	   Progress	  Units,	  it	  was	  apparent	  that	  90%	  of	  the	  youth	  currently	  housed	   on	  those	  units	  were	  identified	  and	  currently	  receiving	  mental	  health	   services.	  Additional	  information	  received	  via	  the	  document	  request	   revealed	  that	  in	  the	  intervening	  period	  since	  the	  previous	  monitoring	   review,	  “there	  have	  been	  no	  youth	  initially	  assigned	  to	  the	  general	   population	  who	  were	  then	  identified	  as	  requiring	  mental	  health	   services.”	   	   As	  discussed	  in	  the	  ensuing	  provisions	  there	  are	  several	  examples	  of	   assessment	  and	  diagnostic	  issues	  which	  are	  concerning.	  	  More	  prevalent	   was	  potential	  minimization	  of	  mental	  health	  issues	  and	  their	   contribution	  to	  challenging	  behavior.	   	   The	  goal	  of	  this	  provision	  was	  to	  ensure	  that	  youth	  who	  may	  not	   present	  with	  a	  history	  of	  mental	  illness	  and	  who	  are	  not	  identified	  at	  the	   time	  of	  initial	  assessment	  as	  being	  at	  risk	  for	  mental	  illness	  or	  behavioral	   challenges,	  are	  monitored	  over	  the	  course	  of	  their	  incarceration	  for	   exacerbations	  of	  symptoms	  and	  referred	  for	  mental	  health	  treatment.	   Administrative	  staff	  were	  aware	  of	  the	  need	  for	  ongoing	  and	  improved	   quality	  assurance	  to	  review	  documentation	  and	  the	  decision	  making	   process	  regarding	  youth	  mental	  health	  needs.	  	  As	  discussed	  in	  provision	   4	  below,	  multiple	  assessment	  documents	  were	  being	  generated,	   however,	  there	  was	  wide	  variability	  with	  regard	  to	  case	  formulations	   reviewed	  in	  the	  documents	  that	  tied	  all	  the	  information	  obtained	   together	  in	  a	  coherent	  package	  for	  the	  reader.	  	  This	  was	  an	  area	  that	   would	  be	  amenable	  to	  quality	  assurance,	  peer	  review	  process	  and	   clinical	  supervision.	  	  	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	   1. Quality	  assurance	  monitoring	  regarding	  re-­‐evaluation	  of	  youth	  who	  
experience	  an	  exacerbation	  of	  mental	  health	  symptoms	  or	   behavioral	  challenges.	   2. Ensure	  the	  creation	  of	  a	  case	  conceptualization	  for	  each	  youth.	   3. Ensure	  that	  direct	  care	  staff	  and	  behavioral	  health	  staff	  are	  trained	   to	  recognize	  and	  respond	  to	  signs	  and	  symptoms	  of	  serious	  mental	   illness.	   4. Maintain	  the	  practice	  of	  the	  comprehensive	  screening	  of	  all	  youth	   proposed	  for	  placement	  on	  the	  Progress	  Units.	  
• Review	  of	  provided	  documents	  (e.g.	  Policy	  and	  Procedure,	  
draft	  Policy	  and	  Procedure,	  youth	  records).	  
• Staff	  interview	  
	  

	  

57.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 58 of 129 PAGEID #: 2411

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

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

Per	  the	  oral	  facility	  self	  assessment,	  staff	  participated	  in	  a	  training	   regarding	  case	  formulation.	  	  ODYS	  central	  office	  staff	  has	  engaged	  in	   review	  of	  some	  of	  these	  documents.	  

Steps	  Taken	  to	   Assess	  Compliance	  

Per	  the	  previous	  monitoring	  report,	  policy	  and	  procedure	  entitled	   “Behavioral	  Health	  Assessment,	  Screening,	  Appraisal	  and	  Evaluation”	   was	  in	  the	  process	  of	  review	  and	  revision.	  This	  was	  necessary	  not	  only	   due	  to	  omissions	  in	  the	  previously	  authored	  documents,	  but	  due	  to	  the	   change	  in	  mission	  incurred	  at	  SJCF.	  	  This	  policy,	  along	  with	  others	   regarding	  Behavioral	  Health	  services	  have	  been	  reviewed	  and	  revised	  in	   a	  collaborative	  manner	  between	  ODYS	  administration	  and	  facility	   behavioral	  health	  staff.	  	  The	  policies	  were	  submitted	  to	  the	  monitors	  for	   review	  and	  comment.	  	  The	  final	  drafts	  of	  these	  documents	  was	  pending	   at	  the	  time	  of	  this	  monitoring	  review.	   	   A	  necessary	  part	  of	  any	  mental	  health	  assessment	  is	  the	  case	   conceptualization	  or	  diagnostic	  formulation.	  	  This	  information	  is	   intended	  to	  review	  specific	  symptoms	  experienced	  by	  the	  youth	  in	  order	   to	  justify	  a	  specific	  diagnosis.	  	  In	  addition,	  the	  diagnostic	  formulation	  or	   case	  conceptualization	  must	  integrate	  relevant	  factors	  impacting	  a	   youth’s	  development/behavior/mental	  status,	  including	  biological,	   psychological,	  social,	  and	  cultural	  perspectives	  that	  can	  be	  utilized	  by	   the	  clinician	  to	  identify	  specific	  risk	  factors	  or	  targets	  for	  ongoing	   behavioral	  and	  mental	  health	  therapies.	  	  From	  this	  information,	  an	   individualized	  and	  integrated	  treatment	  plan	  could	  be	  derived.	  	   	   Nine	  examples	  of	  case	  formulations	  were	  provided.	  The	  quality	  of	  these	   documents	  as	  well	  as	  the	  psychological	  services	  summary	  was	  variable	   and	  would	  benefit	  from	  quality	  assurance	  monitoring.	  For	  example,	  the	   case	  formulation	  regarding	  Youth	  #303	  dated	  9.23.12	  was	  reviewed.	  	   This	  formulation	  provided	  a	  great	  deal	  of	  information	  with	  regard	  to	  this	   youth’s	  legal	  history	  and	  family	  history.	  	  There	  was	  also	  information	   regarding	  his	  progress	  during	  his	  stay	  at	  the	  facility.	  	  The	  document	   indicated	  this	  youth	  spent	  nine	  months	  on	  the	  Progress	  Units,	  and	  that	   he	  had	  received	  multiple	  intervention	  hearings	  accruing	  295	  additional	   days.	  	  There	  was	  mention	  of	  a	  cannabis	  abuse	  diagnosis	  at	  the	  time	  of	   admission	  on	  6.23.11;	  however,	  as	  of	  the	  date	  of	  this	  case	  formulation,	   he	  was	  not	  scheduled	  into	  this	  treatment	  modality,	  and	  it	  was	  planned	  

	  

58.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 59 of 129 PAGEID #: 2412

Recommendations	  
Sources	  of	   Information	   	  

for	  this	  to	  occur	  following	  his	  release	  from	  the	  facility.	  	  As	  substance	   abuse	  is	  a	  serious	  risk	  factor	  for	  recidivism,	  it	  was	  not	  acceptable	  that	   this	  youth’s	  need	  in	  this	  risk	  area	  was	  not	  addressed	  during	  his	  lengthy	   stay	  at	  the	  facility.	   	   This	  youth	  was	  additionally	  diagnosed	  with	  mood	  disorder,	  not	   otherwise	  specified	  and	  conduct	  disorder.	  	  The	  case	  formulation	  did	  not	   review	  specific	  symptoms	  that	  this	  youth	  was	  experiencing.	  	  There	  was	   notation	  that	  this	  youth	  was	  prescribed	  mood	  stabilizing	  medication,	   leading	  the	  reader	  to	  question	  if	  this	  youth	  would	  meet	  criteria	  for	  a	   diagnosis	  in	  the	  bipolar	  spectrum.	  	  This,	  along	  with	  his	  history	  of	   behavioral	  challenges	  raises	  concerns	  that	  a	  misdiagnoses	  and	  possible	   under	  treatment	  of	  his	  mental	  health	  disorder	  served	  to	  exacerbate	   unrecognized	  mental	  health	  symptoms	  prolonging	  his	  incarceration.	  	  	   This	  case	  formulation	  was	  variable	  with	  regard	  to	  quality;	  it	  evidenced	   good	  information,	  but	  did	  not	  tie	  this	  information	  together	  such	  that	  it	   could	  be	  utilized	  for	  treatment	  planning.	   	   As	  indicated	  in	  the	  previous	  monitoring	  report,	  despite	  the	  generation	   of	  multiple	  assessment	  forms,	  there	  was	  the	  need	  for	  a	  document	  to	  tie	   all	  the	  information	  obtained	  together	  in	  a	  coherent	  package	  for	  the	   reader,	  treatment	  team,	  or	  future	  treatment	  provider	  inclusive	  of	  a	   diagnostic	  formulation	  or	  case	  conceptualization.	  	  The	  current	   documentation	  was	  an	  attempt	  to	  improve	  upon	  that	  process,	  but	  there	   is	  work	  to	  be	  done	  from	  a	  quality	  perspective.	  	  It	  is	  hoped	  that	  ongoing	   training	  inclusive	  of	  peer	  review	  and	  quality	  assurance	  monitoring	   regarding	  this	  process	  will	  be	  beneficial	  for	  staff.	  	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	   1. Continue	  and	  expand	  quality	  assurance	  measures	  including	  a	  peer	  
review	  process	  and	  clinical	  supervision	  to	  ensure	  the	  development	   of	  a	  case	  conceptualization	  that	  ties	  together	  information	  gleaned	  in	   the	  assessment	  process.	   2. Consider	  individual	  clinical	  supervision	  and	  training	  regarding	  the	   assessment	  process	  and	  development	  of	  the	  case	  formulation.	   3. Ensure	  that	  behavioral	  health	  staff	  are	  aware	  of	  the	  necessary	   components	  of	  a	  quality	  case	  formulation.	   4. Begin	  quality	  assurance	  monitoring	  of	  case	  formulations	  and	   resultant	  ITP	  documents.	   5. Review	  and	  revise	  policy	  and	  procedure	  to	  reflect	  the	  requirements	   of	  this	  provision	  and	  the	  new	  facility	  mission.	  
• Review	  of	  policy	  and	  procedure	   • Review	  of	  youth	  records	   • Review	  of	  other	  provided	  documents	   • Staff	  interview	  
	  

	  

59.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 60 of 129 PAGEID #: 2413

	  
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.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 61 of 129 PAGEID #: 2414

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.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 62 of 129 PAGEID #: 2415

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	  

	  

62.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 63 of 129 PAGEID #: 2416

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.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 64 of 129 PAGEID #: 2417

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

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

Per	  the	  oral	  facility	  self	  assessment,	  the	  facility	  has	  engaged	  in	  training	   for	  staff	  with	  regard	  to	  treatment	  planning.	  	  Policy	  and	  procedure	   revisions	  are	  pending,	  as	  is	  formal	  quality	  assurance	  monitoring.	  	  There	   has	  been	  review	  of	  treatment	  planning	  documentation	  via	  central	  office.	  

Steps	  Taken	  to	   Assess	  Compliance	  

As	  part	  of	  the	  ODYS	  Behavioral	  Health	  administrative	  review,	  there	  are	   plans	  for	  continuing	  monitoring	  with	  regard	  to	  the	  authorship	  of	  ITP	   documents.	  	  As	  discussed	  in	  paragraph	  18	  below,	  the	  facility	  must	   develop	  a	  quality	  assurance	  process	  to	  review	  both	  compliance	  with	   process	  and	  to	  determine	  outcomes	  associated	  with	  behavioral	  health	   treatment.	  	  For	  additional	  discussion	  regarding	  Treatment	  Planning	  and	   IDT	  meetings,	  please	  see	  the	  discussion	  regarding	  the	  provisions	  below	   (7	  and	  8).	  

Recommendations	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	   1. Review,	  revise,	  and	  implement	  policy	  and	  procedure	  regarding	  
treatment	  planning	  and	  the	  IDT	  process.	   2. Develop	  quality	  assurance	  monitoring	  regarding	  ITP	  development,	  
implementation,	  and	  progress.	   3. Address	  recommendations	  provided	  regarding	  provisions	  7	  and	  8	  
below.	  

Sources	  of	   Information	  
	   	   	  

• Staff	  interview	   • Review	  of	  provided	  documents	  	  
	  

	  

64.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 65 of 129 PAGEID #: 2418

III.B.7	  	  Treatment	  Teams.	  	  	  At	  a	  minimum,	  the	  interdisciplinary	  treatment	  team	  for	  each	  youth	  in	   need	  of	  mental/behavioral	  health	  and/or	  substance	  abuse	  treatment	  should:	  a)	  be	  guided	  by	  a	   trained	  treatment	  professional	  who	  shall	  provide	  clinical	  oversight	  and	  ensure	  the	  proper	   functioning	  of	  treatment	  team	  meetings;	  b)	  consist	  of	  a	  stable	  core	  of	  members,	  including	  at	   least	  the	  youth,	  the	  social	  worker,	  a	  JCO,	  one	  of	  the	  youth’s	  teachers,	  the	  Unit	  Manager,	  and	  as	   warranted	  by	  the	  needs	  of	  the	  youth,	  the	  treating	  psychiatrist,	  the	  treating	  psychologist,	   registered	  nurse,	  and,	  as	  appropriate,	  other	  staff;	  c)	  ensure	  that	  needed	  psychiatric	  evaluations	   are	  conducted	  on	  a	  youth	  before	  administering	  psychotropic	  medications	  to	  the	  youth;	  d)	   monitor	  as	  appropriate	  but	  at	  least	  monthly,	  the	  efficacy	  and	  the	  side	  effects	  of	  psychotropic	   medications,	  including	  consultation	  with	  family	  medical,	  counseling	  and	  other	  staff	  who	  are	   familiar	  with	  the	  youth;	  e)	  for	  youth	  under	  a	  psychiatrist’s	  care:	  ensure	  the	  provision	  of	   individual	  counseling	  and	  psychotherapy	  when	  needed,	  in	  coordination	  with	  facility	   psychologists;	  ensure	  that	  all	  youth	  referred	  as	  possibly	  in	  need	  of	  psychiatric	  services	  are	   evaluated	  and	  treated	  in	  a	  timely	  manner;	  and	  provide	  adequate	  documentation	  of	  treatment	  in	   the	  facility	  medical	  records;	  f)	  include	  to	  the	  fullest	  extent	  practicable,	  proactive	  efforts	  to	   obtain	  the	  participation	  of	  parents	  or	  guardians,	  unless	  their	  participation	  would	  be	   inappropriate	  for	  some	  reason	  (e.g.,	  the	  child	  has	  been	  removed	  from	  the	  parent’s	  custody),	  in	   order	  to	  obtain	  relevant	  information,	  understand	  family	  goals	  and	  concerns,	  and	  foster	  ongoing	   engagement;	  g)	  meet	  to	  assess	  the	  treatment	  plan’s	  efficacy	  at	  least	  every	  30	  days	  and	  more	   often	  as	  necessary;	  and	  h)	  document	  treatment	  team	  meetings	  and	  planning	  in	  the	  youth’s	   mental	  health	  records.	  	  

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

The	  facility	  self-­‐assessment	  was	  delivered	  orally	  during	  the	  monitoring	   visit.	  	  Per	  staff	  interviewed,	  the	  psychiatrist	  has	  been	  participating	  in	   treatment	  team	  (IDT)	  on	  the	  Progress	  Units	  for	  the	  past	  week.	  	  There	  has	   not	  been	  psychiatric	  participation	  for	  treatment	  team	  regarding	  youth	   housed	  in	  general	  population.	  	  In	  the	  absence	  of	  the	  psychiatrist,	  mental	   health	  nurses	  have	  been	  attending	  IDT	  when	  they	  are	  able	  and	  providing	   information	  to	  the	  treating	  psychiatrists.	  	  Staff	  indicated	  that	  family	   members	  attended	  IDT	  regarding	  one	  youth	  on	  the	  Progress	  Units.	  	  They	   indicated	  that	  effort	  had	  been	  made	  to	  include	  family	  members	  in	  IDT	   meeting	  on	  the	  female	  unit,	  but	  this	  had	  been	  unsuccessful	  due	  to	   technological	  issues.	  

Steps	  Taken	  to	   Assess	  Compliance	  

One	  treatment	  team	  meeting	  was	  observed	  during	  this	  monitoring	  visit.	   There	  were	  no	  representatives	  from	  the	  school	  participating.	  	  The	   youth’s	  parents	  were	  not	  in	  attendance.	  	  Other	  necessary	  staff,	  including	   the	  newly	  hired	  psychiatrist	  were	  present.	  	  	   	   The	  IDT	  reviewed	  the	  youth’s	  recent	  behavioral	  challenges.	  	  There	  was	   limited	  discussion	  with	  regard	  to	  the	  reason	  or	  contributing	  factors	  to	   the	  youth’s	  behavior.	  	  Staff	  were	  knowledgeable	  regarding	  the	  youth’s	   behavior,	  but	  did	  not	  appear	  to	  have	  a	  deeper	  understanding	  of	  the	   youth’s	  issues	  and	  underlying	  motivations.	  	  For	  example,	  Youth	  #888	  was	   reportedly	  not	  adhering	  to	  the	  prescribed	  medication	  regimen.	  	  It	  was	   discussed	  that	  he	  was	  declining	  to	  take	  his	  morning	  medication	  because,	   “he	  just	  doesn’t	  feel	  like	  coming	  to	  the	  door.”	  	  It	  was	  noted	  that	  after	  

	  

65.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 66 of 129 PAGEID #: 2419

two	  missed	  dosages,	  “he	  struggled	  in	  class	  and	  was	  asked	  to	  leave	  due	  to	   being	  irritable.”	  	  Staff	  did	  a	  cursory	  review	  of	  this	  issue	  and	  moved	  on	  to	   the	  next	  youth	  up	  for	  discussion.	  	  There	  was	  no	  indication	  that	  anyone	   had	  a	  meaningful	  discussion	  with	  this	  youth	  in	  order	  to	  determine	  the	   reason	  he	  had	  begun	  to	  refuse	  his	  morning	  medication	  (e.g.	  side	  effects,	   bedtime	  medication	  causing	  morning	  sedation,	  treatment	  resistance,	   etc.)	  	  	   	   It	  was	  noted	  that	  several	  youth	  were	  experiencing	  difficulties	  that	  staff	   attributed	  to	  psychotropic	  medication.	  ITP	  goals	  do	  not	  regularly	  include	   treatment	  with	  psychotropic	  medication,	  which	  should	  be	  added	  to	  the	   ITP	  for	  those	  youth	  with	  prescribed	  psychotropic	  medications.	  	  As	  the	   psychiatrist	  becomes	  an	  integral	  part	  of	  the	  IDT,	  it	  is	  hoped	  that	  these	   issues	  can	  be	  addressed	  in	  concert	  with	  him.	   	   A	  review	  of	  the	  IDT	  minutes	  for	  the	  three	  months	  prior	  to	  the	  monitoring	   visit	  revealed	  scant	  detail	  of	  the	  meeting.	  	  For	  example,	  the	  IDT	  minutes	   from	  Allman	  unit	  dated	  9.5.12	  include	  details	  regarding	  “announcements	   and	  accomplishments”	  for	  the	  unit.	  	  Information	  regarding	  the	  three	   youth	  reviewed	  stated,	  “went	  over	  youth’s	  goals	  and	  objectives”	  for	  two	   youth,	  and	  for	  the	  third,	  “youth	  was	  brought	  in	  to	  discuss	  her	  job	   suspension	  for	  three	  weeks.”	  	  This	  documentation	  was	  not	  reflective	  of	  a	   rich	  IDT	  meeting.	   	   IDT	  minutes	  generated	  on	  Cedar	  Unit	  9.18.12	  revealed	  ongoing	  attention	   to	  “announcements	  and	  accomplishments”	  but	  also	  included	  information	   regarding	  each	  youth’s	  goals.	  	  There	  was	  also	  documentation	  regarding	   the	  youth’s	  progress	  toward	  goals.	  	  For	  example	  Youth	  #101	  “is	  having	   issues	  in	  all	  areas	  and	  making	  little	  or	  no	  progress.”	  	  There	  was	  also	   documentation	  that	  this	  youth	  was	  “not	  accepting	  responsibility	  for	  his	   actions…needs	  to	  work	  on	  peer	  pressure	  issues	  and	  criminal	  thinking…”	   The	  minutes	  did	  not	  include	  information	  regarding	  the	  IDT’s	  plan	  to	   address	  these	  issues	  with	  the	  youth,	  or	  what	  interventions	  would	  be	   added	  or	  changed	  to	  allow	  this	  youth	  to	  acquire	  the	  skills	  necessary	  to	   progress.	  	  There	  was	  an	  obvious	  need	  for	  better	  integration	  of	  services	   and	  the	  formulation	  of	  a	  collaborative	  case	  conceptualization	  so	  that	  all	   team	  members	  could	  “be	  on	  the	  same	  page”	  with	  regard	  to	  the	   management	  of	  this	  youth.	  	  	   	   In	  previous	  monitoring	  reports,	  a	  shortcoming	  addressed	  was	  that	  in	   general:	   IDT	  minutes	  reflected	  significant	  time	  spent	  in	  the	  discussion	  of	  	   “housekeeping”	  issues	  such	  as	  the	  unit	  schedule	  and	  youth	  rules.	  With	   the	  exception	  of	  the	  girls	  mental	  health	  unit	  (where	  documentation	  of	  IDT	   addressed	  youth	  mental	  health	  issues)	  documented	  discussions,	   particularly	  regarding	  mental	  health	  treatment	  issues	  appeared	  to	  be	   minimal.	  This	  had	  improved	  over	  prior	  visits.	  	  Per	  discussions	  with	  ODYS	  

	  

66.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 67 of 129 PAGEID #: 2420

Recommendations	  

Behavioral	  Health	  administrative	  staff,	  there	  were	  plans	  to	  move	  the	   discussion	  of	  unit	  issues	  to	  the	  end	  of	  the	  IDT	  meeting	  in	  order	  to	   minimize	  the	  “housekeeping”	  discussion	  and	  highlight	  the	  importance	  of	   the	  youth’s	  treatment.	   	   One	  of	  the	  recommendations	  from	  the	  March	  2011	  report	  was	  to	   integrate	  youth	  specialists	  into	  weekly	  IDT	  meetings.	  The	  self-­‐assessment	   reported	  “a	  QI	  process	  was	  implemented	  regarding	  the	  integration	  of	   direct	  care	  staff…there	  has	  been	  an	  increase	  in	  Youth	  Specialist	  presence	   and	  involvement	  in	  all	  Interdisciplinary	  Teams.”	  	  Unfortunately,	  results	  of	   this	  QI	  process	  or	  other	  quality	  assurance	  monitoring	  regarding	  IDT	   meetings	  were	  not	  presented	  for	  review.	  During	  the	  observed	  IDT	   meeting,	  youth	  specialists	  were	  present	  and	  were	  noted	  to	  participate	  in	   the	  discussion.	  	  This	  was	  indicative	  of	  some	  effort	  to	  include	  all	   disciplines	  in	  review	  and	  planning	  of	  youth	  treatment.	  	   	   Reportedly	  due	  to	  an	  ongoing	  paucity	  of	  psychiatric	  resources,	  the	   psychiatrist	  was	  not	  a	  participant	  in	  IDT	  meetings.	  	  Psychiatric	  nurses	   were	  attending	  IDT	  in	  lieu	  of	  the	  psychiatrist.	  	  This	  had	  been	  remedied	  on	   the	  Progress	  Units.	  Approximately	  one	  week	  prior	  to	  the	  monitoring	  visit,	   additional	  psychiatric	  resources	  had	  been	  obtained,	  with	  plans	  for	  this	   new	  staff	  member	  to	  focus	  his	  attention	  on	  the	  Progress	  Units	  inclusive	   of	  attendance	  at	  the	  IDT	  meetings.	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Ensure	  psychiatric	  resources	  are	  available	  to	  allow	   participation	  in	  Interdisciplinary	  Treatment	  Team	  meetings	  for	   all	  youth	  assigned	  to	  the	  mental	  health	  caseload.	  
2. In	  an	  effort	  to	  maximize	  the	  use	  of	  staff	  resources,	  separate	   administrative	  or	  “housekeeping”	  discussions	  from	  IDT	   meetings.	  	  	  
3. Increase	  efforts	  to	  include	  the	  youth’s	  parent	  or	  guardian	  in	   the	  treatment	  planning	  process.	  
4. Ensure	  that	  direct	  care	  staff	  are	  included	  in	  and	  valued	   members	  of	  the	  IDT.	  
5. Ensure	  that	  all	  necessary	  staff	  disciplines	  participate	  in	  IDT,	   inclusive	  of	  educational	  staff.	  
6. Begin	  Quality	  Assurance	  monitoring	  of	  treatment	  planning	   efforts	  and	  IDT	  meetings.	  	  This	  would	  include	  the	  development	   of	  both	  process	  and	  outcome	  measures	  inclusive	  of	  trending	   data	  and	  corrective	  action	  where	  necessary.	  
7. Increase	  staff	  training/education	  regarding	  the	  timely	   formulation	  of	  a	  treatment	  plan	  and	  interventions	  developed	   as	  a	  result	  of,	  among	  other	  things,	  the	  discussion	  in	  IDT.	  	  These	   plans	  must	  then	  be	  implemented,	  first	  via	  training	  direct	  care	   staff.	  

	  

67.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 68 of 129 PAGEID #: 2421

Sources	  of	   Information	  
	   	   	  

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

	  

68.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 69 of 129 PAGEID #: 2422

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

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

Per	  the	  oral	  facility	  self-­‐assessment,	  staff	  have	  received	  training	  on	  the	   integrated	  treatment	  plan	  (ITP)	  process	  inclusive	  of	  case	   conceptualization.	  	  It	  was	  reported	  that	  policy	  and	  procedure	  regarding	   ITP’s	  remained	  pending	  at	  the	  time	  of	  the	  visit.	  

Steps	  Taken	  to	   Assess	  Compliance	  

Document	  review	  revealed	  some	  improvement	  in	  ITP	  documentation.	  	   Specifically,	  youth	  strengths	  and	  measurable	  goals	  were	  identified	  on	   some	  documents.	  	  There	  was	  room	  for	  improvements	  with	  regard	  to	   ensuring	  goals	  were	  measurable.	  In	  some	  of	  the	  examples,	  interventions	   were	  identified;	  however,	  they	  did	  not	  routinely	  address	  skills	  the	  youth	   needed	  to	  acquire	  in	  order	  to	  achieve	  the	  goal.	  	  Rather,	  they	  included	   workbook	  assignments	  or	  other	  tasks	  the	  youth	  was	  to	  complete.	  	  In	   addition,	  mental	  health	  and	  medication	  management	  goals	  were	  not	   routinely	  addressed.	  	  For	  an	  example	  of	  this,	  please	  see	  the	  discussion	  in	   provision	  G1	  regarding	  Youth	  #111.	   	   In	  a	  second	  example,	  the	  ITP	  regarding	  youth	  #888	  did	  not	  include	   information	  regarding	  this	  youth’s	  mental	  health	  diagnoses,	  or	   treatment	  with	  psychotropic	  medications.	  	  He	  has	  diagnoses	  including	   mood	  disorder,	  not	  otherwise	  specified	  and	  posttraumatic	  stress	   disorder.	  	  He	  is	  prescribed	  atypical	  antipsychotic	  medication.	  	   	  	   One	  of	  Youth	  #888’s	  goals	  was	  to	  “demonstrate	  healthy	  sexual	   boundaries	  with	  females	  within	  ODYS.”	  	  The	  objective	  stated,	  “I	  will	  not	   expose	  my	  penis	  to	  any	  female	  for	  the	  next	  14	  days…monitoring	  by	  not	   receiving	  an	  YBIR’s	  for	  sexual	  conduct	  or	  sexual	  assault	  within	  that	  14	   days….If	  I	  feel	  the	  urge	  to	  expose	  myself	  or	  masturbate	  in	  front	  of	  a	   female	  while	  on	  progress,	  I	  will	  complete	  a	  decisional	  balance	   worksheet	  and	  process	  the	  information	  with	  my	  social	  worker	  during	   weekly	  individual	  sessions.	  	  I	  will	  talk	  to	  my	  behavioral	  health	  [sic]	  at	   least	  one	  time	  per	  week	  during	  my	  sexual	  misconduct	  urges.”	  This	   treatment	  intervention	  does	  not	  address	  specific	  skills	  that	  the	  youth	   needs	  to	  learn	  and	  implement	  with	  regard	  to	  “healthy	  sexual	   boundaries.”	  	  It	  also	  does	  not	  indicate	  the	  function	  that	  this	  behavior	   serves	  for	  this	  particular	  youth	  (e.g.	  attention	  seeking,	  control,	  etc),	  or	   how	  this	  was	  being	  addressed.	   	   The	  ITP	  regarding	  youth	  #999	  included	  descriptions	  of	  interventions	  

	  

69.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 70 of 129 PAGEID #: 2423

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.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 71 of 129 PAGEID #: 2424

Sources	  of	   Information	  
	   	  

treatment	  per	  the	  Integrated	  Treatment	  Plan).	   • Staff	  interview	   • Review	  of	  provided	  documents	  	   • Review	  of	  youth	  records	  
	  

	  

71.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 72 of 129 PAGEID #: 2425

III.B.9	  	  Access	  to	  a	  QMHP.	  	  The	  State	  shall	  develop	  and	  implement	  policies,	  procedures	  and	   practices	  to	  ensure	  that	  youth	  who	  seek	  access	  to	  a	  qualified	  mental	  health	  professional	  are	   provided	  appropriate	  access	  in	  a	  timely	  manner.	  	  

Compliance	  Rating	   Substantial	  Compliance	  

Self	  Assessment	  

The	  facility	  self-­‐assessment	  was	  provided	  orally.	  	  Increased	  mental	   health	  staffing	  was	  reported	  on	  the	  Progress	  Units	  in	  an	  effort	  to	   enhance	  youth	  access	  to	  mental	  health	  services.	  	  It	  was	  reported	  that	   daily	  “door	  checks”	  were	  occurring	  on	  Phase	  I.	  	  Youth	  on	  Phase	  II	   received	  a	  “door	  check”	  twice	  weekly.	  	  Policy	  and	  procedure	  regarding	   this	  requirement	  was	  pending.	  	  	  	  

Steps	  Taken	  to	   Assess	  Compliance	  

In	  response	  to	  a	  request	  for	  data	  regarding	  access	  to	  mental	  health	   services,	  the	  facility	  stated,	  “the	  presence	  of	  psychology	  offices	  on	  the	   units	  makes	  access	  to	  psychology	  staff	  simple	  and	  immediate.	  	  The	  use	   of	  forms	  and	  tracking	  systems	  to	  measure	  the	  response	  time	  would	  slow	   the	  process	  and	  increase	  the	  length	  of	  time	  between	  request	  and	   actually	  being	  seen.	  	  While	  forms	  are	  available	  to	  youth	  to	  make	  formal	   requests	  to	  be	  seen,	  and	  secure	  boxes	  are	  available	  on	  the	  units	  for	   these	  requests,	  the	  vase	  majority	  of	  contacts	  are	  by	  the	  schedule	  or	  by	   direct,	  face	  to	  face	  requests.”	   	   In	  an	  effort	  show	  compliance	  with	  the	  above	  provision,	  seven	  examples	   of	  youth	  contact	  with	  psychology	  staff	  were	  provided	  (five	  of	  these	  were	   for	  female	  youth,	  two	  were	  for	  male	  youth).	  	  Five	  examples	  indicated	   that	  the	  youth	  requested	  to	  be	  seen	  and	  was	  seen	  immediately.	  	  Two	  of	   the	  examples	  were	  for	  individual	  sessions,	  both	  of	  which	  the	  youth	   declined	  to	  participate	  in	  the	  session	  beyond	  a	  few	  minutes.	  	   Supervisory	  staff	  indicated	  that	  currently,	  the	  practice	  is	  for	  psychology	   staff	  to	  indicate	  the	  time	  of	  the	  youth’s	  request	  and	  the	  time	  that	  the	   assessment	  began.	  	  	  	   	   Per	  the	  document	  request	  and	  observation,	  secure	  mailboxes	  have	  been	   provided	  on	  the	  units	  for	  youth	  to	  request	  services	  without	  reliance	   upon	  direct	  care	  staff	  to	  communicate	  their	  request.	  Psychology	  or	   social	  work	  staff	  check	  these	  boxes	  daily.	  Youth	  interviewed	  during	  this	   monitoring	  tour	  were	  able	  to	  show	  the	  monitor	  the	  box	  within	  which	  to	   place	  their	  requests	  for	  services	  on	  their	  individual	  units.	  	  It	  is	   imperative	  that	  youth	  are	  able	  to	  independently	  access	  mental	  health	   care;	  as	  unfortunately,	  there	  may	  be	  situations	  where	  direct	  care	  staff	   could	  unintentionally	  or	  purposefully	  impede	  the	  youth’s	  access	  to	   necessary	  mental	  health	  treatment	  with	  resultant	  negative	  outcomes.	  	   Given	  the	  Behavioral	  Health	  presence	  on	  the	  units,	  this	  is	  less	  of	  a	   concern,	  however,	  there	  are	  times	  (nights	  and	  weekends)	  where	   Behavioral	  Health	  staff	  are	  not	  immediately	  available,	  and	  youth	  must	   be	  able	  to	  make	  independent	  requests	  for	  services.	   	   One	  concern	  noted	  and	  communicated	  during	  the	  previous	  and	  current	  

	  

72.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 73 of 129 PAGEID #: 2426

Recommendations	  

monitoring	  tours	  was	  access	  to	  mental	  health	  services	  for	  youth	  housed	   on	  the	  Progress	  unit.	  	  These	  youth	  were	  assigned	  to	  single	  cells	  where	   they	  remained	  the	  majority	  of	  the	  day.	  	  Youth	  on	  phase	  one	  of	  the	   program	  are	  in	  ambulatory	  restraints	  (“gators”)	  when	  they	  are	  outside	   of	  their	  cells.	  	  There	  have	  been	  changes	  to	  the	  procedure	  for	  monitoring	   on	  the	  Progress	  Units,	  specifically,	  psychology	  and	  social	  work	  staff	  are	   required	  to	  make	  daily	  contact	  with	  youth	  on	  phase	  one	  which	  includes	   a	  mini	  mental	  status	  examination	  and	  encouraging	  youth	  to	  meet	  with	   and	  talk	  to	  the	  Behavioral	  Health	  staff.	  	  Per	  record	  review	  performed	   during	  the	  monitoring	  visit,	  documentation	  of	  these	  encounters	  was	   located.	  	  	   	   These	  reviews	  serve	  several	  purposes,	  to	  monitor	  youth	  housed	  in	  this	   area	  for	  decompensation,	  to	  identify	  youth	  requiring	  mental	  health	   intervention,	  and	  to	  ensure	  access	  to	  health	  care	  for	  those	  youth	   housed	  on	  that	  unit.	  	  It	  should	  be	  noted	  that	  late	  in	  the	  monitoring	   period,	  youth	  were	  allowed	  out	  of	  their	  cells	  on	  a	  daily	  basis	  for	   increasing	  amounts	  of	  time,	  which	  is	  positive.	  	  As	  this	  progresses,	  and	   youth	  are	  out	  of	  their	  cells	  for	  the	  majority	  of	  their	  waking	  hours,	  the	   need	  for	  daily	  mini	  mental	  status	  reviews	  will	  be	  reduced.	  	  	   	   Review	  of	  the	  documentation	  of	  these	  encounters	  revealed	  that	  in	   general	  they	  were	  brief	  (one	  to	  three	  minutes).	  	  Written	  documentation	   of	  these	  encounters	  included	  a	  mental	  status	  examination,	  which	  would	   be	  impossible	  to	  complete	  in	  this	  amount	  of	  time.	  	  This	  process	  must	  be	   codified	  in	  policy	  and	  procedure	  and	  reviewed	  via	  quality	  assurance.	   	   It	  should	  be	  noted	  that	  in	  general,	  youth	  interviewed	  in	  general	   population	  and	  on	  the	  girls	  mental	  health	  units	  believed	  that	  they	  had	   good	  access	  to	  their	  counselor	  and	  that	  mental	  health	  needs	  were	   addressed	  in	  a	  timely	  manner.	  	  Youth	  housed	  in	  the	  Progress	  Units	  were	   less	  satisfied	  with	  their	  mental	  health	  treatment	  and	  contact.	  	  Several	   youth	  interviewed	  indicated	  that	  they	  were	  not	  receiving	  regular	   individual	  therapy	  sessions.	  	  One	  youth	  filed	  a	  grievance	  to	  this	  effect.	  	   Please	  see	  the	  discussion	  in	  III.B.18	  for	  additional	  information	  regarding	   this	  issue.	   	   Per	  a	  review	  of	  mental	  health	  staff	  schedules	  provided,	  mental	  health	   staff	  scheduling	  included	  both	  evening	  (until	  8:00	  p.m.)	  and	  weekend	   hours,	  allowing	  for	  better	  daily	  coverage	  of	  youth	  mental	  health	  needs.	   However,	  of	  the	  mental	  health	  staff,	  only	  the	  psychology	  supervisor	  was	   on-­‐call	  24	  hours	  per	  day.	  	  
In	  order	  to	  maintain	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	   1. Revise	  policy	  and	  procedure	  to	  reflect	  requirements	  for	  daily	  mental	  
health	  assessments	  for	  those	  youth	  housed	  on	  Phase	  I	  of	  the	   Progress	  unit.	  

	  

73.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 74 of 129 PAGEID #: 2427

Sources	  of	   Information	  
	   	  

2. Revise	  policy	  and	  procedure	  to	  reflect	  requirements	  for	  twice	   weekly	  mental	  health	  assessments	  for	  those	  youth	  housed	  on	  Phase	   II	  of	  the	  Progress	  unit.	  
3. Develop	  quality	  assurance	  monitoring	  to	  ensure	  timeliness	  and	   adequacy	  of	  clinical	  contact	  with	  those	  youth	  housed	  on	  the	   Progress	  Unit.	  
4. Develop	  quality	  assurance	  monitoring	  to	  audit	  requests	  for	  mental	   health	  services	  inclusive	  of	  staff	  response	  time	  as	  well	  as	  timelines	   for	  completion	  of	  other	  mental	  health	  services	  as	  outlined	  by	  facility	   policy	  and	  procedure.	  
5. Ensure	  the	  youth’s	  open	  access	  to	  mental	  health	  services	  
• Review	  of	  provided	  documents	   • Youth	  interviews	   • Staff	  interviews	  
	  

	  

74.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 75 of 129 PAGEID #: 2428

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	  

	  

75.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 76 of 129 PAGEID #: 2429

monitoring	  visit,	  it	  was	  recommended	  that	  this	  youth	  be	  considered	  for	   a	  psychiatric	  evaluation	  and	  consideration	  for	  transfer	  to	  the	  mental	   health	  unit.	  	  Information	  received	  following	  the	  visit	  indicated	  that	  the	   youth	  was	  considered	  for	  transfer;	  however,	  this	  ultimately	  was	  not	   performed.	  	  The	  rationale	  was	  as	  follows:	   	  	   “Current	  Functioning:	  …recommended	  for	  promotion	  to	  Transition	  and	   continues	  to	  maintain	  stability	  and	  solid	  behavior	  on	  the	  Progress	  Unit.	   He	  is	  sitting	  for	  the	  official	  GED	  test	  all	  day	  today	  and	  so	  far	  is	  doing	  very	   well.	  Based	  on	  his	  improvements	  and	  stability,	  …earned	  a	  release	  date	  of	   11/28/2012	  contingent	  on	  successful	  completion	  of	  the	  Progress	  Unit	   program.	  	   	  	   While	  he	  continues	  to	  be	  a	  challenge	  with	  regards	  to	  medication	  and	   medication	  compliance,	  he	  is	  engaged	  in	  the	  process	  and	  has	   demonstrated	  an	  openness	  to	  continue	  a	  discussion	  of	  the	  issues.	   Conversely,	  his	  response	  to	  and	  engagement	  in	  psychotherapy	  with	  his	   clinical	  staff	  has	  become	  consistent,	  something	  to	  which	  he	  looks	   forward,	  and	  appears	  to	  have	  become	  a	  significant	  source	  of	  support	   and	  a	  catalyst	  for	  change	  and	  progress.	  	   	  	   With	  an	  approved	  release	  date	  so	  close,	  it	  is	  not	  at	  all	  clear	  that	  the	   (possible,	  but	  not	  certain)	  benefits	  of	  transfer	  to	  the	  MH	  unit	  would	   surpass	  the	  potential	  loss	  and	  harm	  that	  may	  result	  from	  a	  complete	   change	  not	  only	  in	  setting	  but	  also	  in	  the	  entire	  team	  and	  clinicians	   working	  with	  him.	  While	  the	  original	  notion	  of	  potential	  referral,	  and	   ultimate	  formal	  referral,	  were	  based	  on	  the	  emergence	  and	  recognition	   of	  his	  mental	  health	  issues,	  the	  nearness	  of	  his	  release	  date	  was	  not	   included	  in	  the	  deliberation	  and	  decision.	  Because	  he	  has	  not	  only	  been	   very	  stable	  for	  an	  extended	  period,	  but	  is	  in	  fact	  presenting	  as	   increasingly	  stable,	  the	  release	  date	  clearly	  becomes	  a	  matter	  of	  central	   importance.	   	  	   Likely	  Gains	  from	  Treatment:	  	  Following	  from	  the	  above,	  my	  discussions	   over	  the	  last	  24	  hours	  have	  led	  to	  a	  question	  of	  likely	  gain	  from	  transfer	   as	  compared	  to	  what	  might	  be	  gained	  from	  remaining	  at	  SJCF	  with	   promotion	  to	  the	  Transition	  Unit	  and	  continued	  intensive	  treatment	   within	  the	  already	  established	  relationships	  with	  his	  clinicians	  here.	   While	  the	  MH	  unit	  at	  IRJCF	  will	  provide	  a	  solid	  clinical	  team	  and	  all	  the	   benefits	  of	  the	  specialized	  unit,	  there	  is	  always	  a	  period	  of	  adjustment,	   transition	  and	  accommodation	  involved	  in	  the	  development	  of	  truly	   therapeutic	  relationships.	  I	  did	  not	  consider	  this	  factor	  adequately	  in	  the	   context	  of	  the	  November	  release	  date	  when	  I	  initially	  made	  the	  referral.	   It	  became	  more	  clear	  in	  and	  through	  the	  discussion…may	  be	  the	  most	   important	  issue	  to	  consider.	  	   	  	   Re-­‐entry	  Planning:	  	  Finally,	  the	  matter	  of	  re-­‐entry	  planning	  is	  a	  critical	  

	  

76.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 77 of 129 PAGEID #: 2430

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	  

	  

77.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 78 of 129 PAGEID #: 2431

Recommendations	  

recommended,	  “evaluate	  for	  mental	  health	  caseload.”	  	  Additional	   information	  included	  revealed	  that	  the	  OYAS	  performed	  1.10.12	   indicated	  the	  youth	  was	  moderate	  risk	  in	  the	  areas	  of	   “Substance/Mental	  Health.”	  	   	   Per	  the	  ODYS	  unified	  case	  plan	  dated	  2.2.12,	  this	  youth	  had	  mental	   health	  diagnoses	  including	  “Bipolar	  Disorder,	  not	  otherwise	  specified;	   Conduct	  Disorder;	  Cannabis	  Dependence;	  Alcohol	  Abuse;	  ADHD	  by	   history;	  Tourettes	  Syndrome;	  and	  Borderline	  Intellectual	  Functioning.”	  A	   review	  of	  the	  treatment	  goals	  proposed	  by	  the	  case	  plan	  revealed	  that	   there	  were	  “no	  goals	  being	  addressed	  for	  this	  domain	  at	  this	  time”	  in	   the	  areas	  of	  substance	  abuse	  and	  mental	  health..	   	   Per	  a	  psychological	  evaluations	  dated	  3.29.10	  performed	  at	  SJCF,	  this	   youth	  presented	  with	  behavioral	  observations	  including	  “rapid	  and	   pressured	  speech…difficult	  to	  understand…thoughts…concrete,	  were	   logical	  and	  coherent…minor	  attention	  problems…easily	  distracted…”	   	   Given	  the	  above,	  it	  was	  apparent	  that	  mental	  health	  issues	  were	   significant	  and	  not	  appropriately	  addressed	  prior	  to	  transfer	  to	  the	   Progress	  Unit	  and	  during	  the	  majority	  of	  his	  stay	  there.	   	  	   Nine	  examples	  of	  intake	  assessment	  and	  subsequent	  Behavioral	  Health	   Appraisal	  documents	  were	  reviewed.	  	  In	  the	  sample	  provided,	  all	  youth	   were	  referred	  for	  a	  Behavioral	  Health	  Appraisal	  at	  intake.	  	  Included	  in	   the	  Behavioral	  Health	  Appraisal	  was	  a	  recommendation	  for	  placement.	  	   All	  of	  the	  examples	  received	  were	  recommended	  for	  placement	  in	  the	   general	  population.	   While	  overall	  there	  were	  improvements	  noted	  in	  the	  quality	  of	   documentation,	  variability	  remained.	  	  This	  is	  an	  area	  that	  should	  be	   monitored	  via	  quality	  improvement.	  	  Some	  documents	  were	  completed;	   others	  were	  not.	  	  What	  was	  lacking	  in	  all	  documentation	  was	  a	  case	   conceptualization	  outlining	  the	  justification	  for	  specific	  diagnosis.	  	  At	   this	  stage,	  it	  is	  acknowledged	  that	  the	  case	  conceptualization	  would	  be	   brief,	  with	  further	  detail	  and	  refinement	  performed	  by	  the	  youth’s	   mental	  health	  treatment	  provided	  upon	  assignment	  to	  a	  specific	   treatment	  provider.	  	  	  	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	   1. Complete	  policy	  and	  procedure	  review.	   2. Review	  the	  referral	  process	  for	  youth	  considered	  for	  placement	  on	  
the	  Progress	  Units.	  	  Ensure	  that	  appropriate	  services	  have	  been	   considered	  and	  provided	  prior	  to	  referral.	  	  Determine	  specific	   mental	  health	  diagnoses	  that	  would	  be	  inappropriate	  for	   consideration	  (e.g.	  thought	  disorders;	  acute	  mental	  health	   exacerbations;	  developmental	  disabilities;	  etc.)	   3. For	  those	  youth	  who	  require	  enhanced	  treatment	  following	  the	  

	  

78.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 79 of 129 PAGEID #: 2432

Sources	  of	   Information	  
	   	   	  

initial	  placement	  determination,	  consider	  performing	  retrospective	   record	  review	  (e.g.	  QA)	  in	  order	  to	  improve	  assessment	  and	   placement	  process.	   4. Begin	  quality	  assurance	  monitoring	  regarding	  intake	  and	  placement	   documentation	  and	  processes.	   5. Indicate	  the	  method	  by	  which	  youth	  who	  are	  not	  referred	  for	  a	   Behavioral	  Health	  Appraisal	  are	  assessed	  for	  appropriate	  placement	   within	  the	  facility.	   6. Improve	  documentation	  promulgated	  by	  the	  Behavioral	  Health	   Appraisal.	   	  
• Staff	  interview	   • Review	  of	  provided	  documents	  	   • Review	  of	  youth	  records	   • Youth	  interview	  and	  observation	  
	  

	  

79.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 80 of 129 PAGEID #: 2433

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

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

The	  facility	  self-­‐assessment	  was	  provided	  orally,	  and	  indicated	  increased	   psychiatric	  resources.	  	  For	  additional	  information,	  please	  see	  the	   discussion	  in	  provision	  III.B.13	  below.	  

Steps	  Taken	  to	   Assess	  Compliance	  

A	  review	  of	  the	  provided	  documents	  revealed	  a	  spreadsheet	  of	  all	   mental	  health	  positions.	  	  There	  were	  a	  total	  of	  14	  filled	  social	  work	   positions	  (including	  two	  supervisory	  positions).	  	  Of	  these,	  11	  were	   licensed.	  	  This	  represented	  increased	  vacancies	  since	  the	  previous	   report	  where	  there	  18	  filled	  social	  work	  positions.	  	  There	  were	  six	   vacant	  social	  worker	  positions.	  	  One	  of	  these	  positions	  was	  noted	  as	   vacant	  as	  of	  3.11.12,	  others	  were	  noted	  as	  vacant	  as	  of	  later	  in	  the	  year	   2012,	  with	  one	  vacancy	  noted	  as	  a	  “new	  position.”	   	   There	  were	  a	  total	  of	  eight	  filled	  psychology	  positions	  (including	  one	   supervisor).	  	  Of	  these	  four	  were	  psychology	  assistants	  (unlicensed).	  	   Four	  were	  licensed	  psychology	  staff	  (inclusive	  of	  the	  psychology	   supervisor).	  	  There	  were	  two	  vacant	  psychology	  positions,	  one	  assistant	   and	  one	  psychologist.	  	  	  	  These	  positions	  were	  noted	  as	  vacant	  as	  of	   3.11.12	  and	  9.9.12	  respectively.	  	  There	  were	  two	  licensed	  psychiatric	   nurses.	  	  	  Other	  mental	  health	  staff	  positions	  included	  two	  occupational	   therapists,	  a	  transcription	  service,	  and	  the	  two	  facility	  psychiatrists.	   	   Schedules	  for	  psychology	  staff	  were	  provided	  for	  review.	  	  Per	  this	   document,	  psychology	  staff	  work	  a	  flex	  80	  hour	  schedule	  every	  two	   weeks.	  	  Regular	  hours	  are	  8:00	  am	  to	  4:30	  pm,	  and	  they	  are	  required	  to	   work	  one	  late	  night	  per	  week	  and	  one	  weekend	  per	  month	  in	  an	  effort	   to	  provide	  greater	  clinical	  coverage	  at	  the	  facility.	  	  The	  exception	  to	  this	   coverage	  is	  holidays,	  where	  per	  the	  schedule	  examples	  provided,	  no	   psychology	  staff	  is	  on	  duty.	  	  Per	  staff	  report,	  the	  psychology	  supervisor	   is	  on	  call	  after	  hours	  and	  holidays	  and	  will	  present	  to	  the	  facility	  as	   needed.	   	   In	  an	  effort	  to	  address	  clinical	  need	  on	  the	  Progress	  Units,	  mental	  health	   staff	  resources	  have	  been	  shifted.	  	  There	  are	  now	  three	  psychology	  staff	   assigned	  to	  these	  units,	  with	  plans	  for	  the	  youth	  to	  keep	  the	  same	   psychology	  staff	  as	  they	  progress	  through	  each	  phase,	  including	   transition.	  	  Additionally,	  there	  have	  been	  efforts	  to	  assign	  both	  a	   psychologist	  and	  social	  worker	  to	  each	  housing	  unit.	  	  These	  shifts	  were	   the	  initial	  phase	  of	  a	  larger	  plan	  verbalized	  by	  ODYS	  to	  create	  a	  

	  

80.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 81 of 129 PAGEID #: 2434

behavioral	  health	  team	  in	  contrast	  to	  the	  previous	  silos	  inherent	  in	   having	  artificial	  divisions	  between	  the	  departments	  of	  social	  work	  and	   psychology.	  	  The	  revision	  process	  for	  policy	  and	  procedure	  was	  also	  a	   step	  toward	  this	  integration	  as	  per	  staff	  interview;	  staff	  from	  various	   disciplines	  were	  assigned	  to	  work	  groups	  in	  order	  to	  provide	  input	  into	   the	  policy	  and	  procedure	  documents.	   	   Per	  the	  previous	  monitoring	  report,	  the	  workload	  for	  psychology	  staff	   had	  increased	  due	  to	  vacancies	  in	  social	  work	  staff	  positions.	  It	  was	   opined	  by	  the	  monitor	  that	  once	  social	  work	  positions	  were	  filled,	  it	   would	  be	  advantageous	  to	  examine	  the	  current	  psychology	  staffing	   pattern	  and	  required	  psychology	  workload	  in	  order	  to	  objectively	   determine	  the	  need	  for	  additional	  staff.	  	  With	  the	  planned	  integration	  of	   departments	  and	  creation	  of	  a	  behavioral	  health	  team	  focus,	  this	  may	   be	  premature.	  	  The	  deficiencies	  in	  social	  work	  staffing	  have	  reemerged,	   as	  there	  are	  currently	  six	  vacancies	  as	  opposed	  to	  two	  vacancies	  at	  the	   time	  of	  the	  previous	  monitoring	  report.	   	   Per	  staff	  interviews	  and	  documentation	  provided	  during	  the	  previous	   monitoring	  period	  regarding	  support	  staff	  for	  psychiatry,	  the	  psychiatric	   nurse	  was	  carrying	  a	  large	  workload.	  According	  to	  the	  documents	   reviewed,	  the	  nurse	  provided	  the	  following	  support	  services	  to	   psychiatry:	  scheduling	  new	  and	  follow-­‐up	  appointments;	  preparing	   medical	  records	  for	  review;	  providing	  dictated	  reports	  for	  review;	   updating	  the	  mental	  health	  database;	  attending	  team	  meetings	  and	   providing	  updates	  to	  the	  psychiatrist	  when	  he	  was	  unavailable	  to	   attend;	  responding	  to	  staff	  concerns	  and	  preparing	  assessment	   information	  for	  psychiatry;	  assisting	  with	  the	  notification	  of	   parents/guardians	  of	  any	  changes	  in	  the	  youth’s	  mental	  health	  status	  or	   treatment;	  providing	  updates,	  changes,	  and	  concerns	  regarding	  youth	  to	   psychiatry;	  assisting	  in	  education	  of	  youth	  regarding	  mental	  health	   issues;	  monitoring,	  counseling,	  and	  reporting	  regarding	  medication	   compliance;	  and	  communicating	  day	  to	  day	  issues	  regarding	  psychiatric	   care	  to	  the	  health	  services	  administrator.	  	  	   	   This	  list	  of	  tasks	  was	  daunting,	  and	  physically	  impossible	  for	  one	   individual	  to	  complete,	  although	  the	  individual	  in	  this	  position	  was	  doing	   her	  best	  to	  manage	  the	  workload	  and	  did	  not	  complain.	  	  Approximately	   one	  month	  prior	  to	  this	  monitoring	  visit,	  a	  second	  psychiatric	  nurse	  had	   been	  hired.	  	  The	  two	  nurses	  worked	  collaboratively	  and	  were	  excited	   regarding	  their	  potential	  efforts	  with	  two	  staff.	  	  Currently,	  one	  nurse	   was	  assigned	  to	  the	  progress	  units	  and	  one	  nurse	  was	  assigned	  to	  all	   other	  housing	  units.	  	  Each	  nurse	  was	  assigned	  to	  a	  specific	  psychiatrist.	   	   There	  were	  examples	  in	  the	  provided	  documentation	  of	  the	  ongoing	   therapeutic	  activities	  in	  the	  intervening	  period	  since	  the	  last	  monitoring	   visit.	  	  For	  example,	  per	  the	  document	  review	  regarding	  youth	  mental	  

	  

81.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 82 of 129 PAGEID #: 2435

health	  contacts:	  	  	   • Between	  7.1.12	  and	  9.29.12	  there	  were	  1020	  total	  mental	   health	  contacts	  with	  female	  youth.	  	  This	  included	  group,	   individual,	  and	  crisis	  intervention.	   • Between	  7.1.12	  and	  9.30.12	  there	  were	  a	  total	  of	  2978	  mental	   health	  contacts	  with	  male	  youth.	  	  This	  included	  group,	   individual,	  crisis	  intervention,	  and	  daily	  door	  checks	  on	  Progress	   Units.	  
	   While	  these	  mental	  health	  units	  are	  an	  improvement	  from	  prior	  contact	   reports,	  there	  remain	  issues.	  	  For	  example,	  the	  number	  of	  youth	   attending	  a	  group	  session	  was	  noted	  to	  be	  excessive.	  	  This	  was	  noted	   more	  frequently	  with	  group	  activities	  led	  by	  social	  worker	  staff.	  	  For	   example,	  Core	  Modules	  provided	  7.1.12	  by	  social	  work	  staff	  included	  16	   male	  youth.	  	  “Anger,	  Aggression	  and	  Violence”	  group	  provided	  9.1.12	   included	  11	  male	  youth.	  	  	  This	  number	  of	  youth	  in	  a	  group	  interaction	  is	   not	  conducive	  to	  either	  learning	  or	  process.	  	  Behavioral	  health	  staff	   should	  determine	  the	  maximum	  amount	  of	  youth	  who	  may	  attend	  any	   one	  group	  therapy.	  	  	   	   Given	  the	  above	  information,	  there	  were	  a	  total	  of	  3998	  mental	  health	   contacts	  over	  a	  three	  month	  period.	  	  Unfortunately,	  the	  average	  daily	   census	  over	  this	  time	  period	  is	  not	  known,	  therefore	  it	  was	  not	  possible	   to	  calculate	  the	  number	  of	  mental	  health	  contacts	  per	  youth.	  	  	  	  In	   addition,	  the	  total	  number	  would	  have	  to	  be	  adjusted	  with	  the	  removal	   of	  the	  daily	  door	  checks	  provided	  on	  the	  Progress	  Unit,	  which	  artificially	   inflate	  this	  number	  (daily	  door	  checks	  are	  brief	  interactions	  designed	  to	   ensure	  that	  youth	  are	  not	  decompensating,	  and	  would	  not	  qualify	  as	   individual	  therapy).	   	   Interviews	  with	  staff	  revealed	  that	  ODYS	  had	  done	  a	  review	  of	  the	   number	  of	  mental	  health	  contacts	  youth	  on	  the	  Progress	  units	  received.	  	   In	  the	  month	  of	  January	  2012,	  41	  youth	  received	  an	  average	  of	  7.8	   hours	  of	  mental	  health	  services.	  	  The	  average	  over	  the	  four	  months	   prior	  to	  the	  monitoring	  visit	  was	  reported	  as	  16.56	  hours	  of	  mental	   health	  services	  per	  month.	  	  This	  is	  a	  substantial	  increase.	  	  This	   information	  was	  provided	  via	  verbal	  report,	  actual	  data	  were	  not	   provided	  for	  review.	   	   During	  the	  monitoring	  visit,	  discussions	  with	  administrative	  staff	   revealed	  a	  focus	  on	  increasing	  group	  encounters,	  and	  holding	  staff	   accountable	  for	  group.	  	  With	  the	  current	  behavioral	  health	  staff,	  each	   clinician	  should	  be	  expected	  to	  engage	  in	  a	  minimum	  number	  of	  group	   therapy	  activities	  per	  week.	  	  Quality	  assurance	  monitoring	  to	  ensure	   that	  appropriate	  services	  with	  regard	  to	  both	  quantity	  (number	  of	   contact	  hours)	  and	  quality	  (with	  regard	  to	  fidelity	  to	  the	  model)	  are	   necessary.	  

	  

82.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 83 of 129 PAGEID #: 2436

Recommendations	  
Sources	  of	   Information	   	   	  

	   Given	  the	  serious	  staff	  shortages	  in	  social	  work	  and	  the	  need	  to	  ensure	   that	  current	  staff	  are	  able	  to	  provide	  the	  appropriate	  number	  of	  group	   and	  individual	  therapies	  to	  youth	  via	  a	  quality	  assurance	  process,	  this	   paragraph	  is	  in	  partial	  compliance.	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	   1. Recruit	  and	  fill	  current	  vacancies	   2. Determine	  the	  need	  for	  additional	  staff	  via	  workload	  indicators	   3. Improve	  coordination	  between	  staff	  disciplines	  via	  the	  development	  
of	  the	  behavioral	  health	  department.	   4. Ensure	  coverage	  for	  staff	  during	  required	  trainings	  and	  other	  
absences.	   5. Ensure	  the	  creation	  of	  a	  unified	  behavioral	  health	  team.	   6. Begin	  quality	  assurance	  to	  review	  both	  the	  quantity	  and	  quality	  of	  
individual	  and	  group	  therapeutic	  interactions	  provided	  to	  youth.	  
• Staff	  interview	   • Review	  of	  provided	  documents	  
	  

	  

83.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 84 of 129 PAGEID #: 2437

III.B.12	  	  Medication	  Notice.	  	  	  Before	  renewing	  a	  psychoactive	  medication	  prescription	  from	  a	   community	  provider	  or	  commencing	  the	  administration	  of	  a	  psychoactive	  medication	  to	  a	   youth,	  the	  State	  shall	  ensure	  that	  the	  youth	  and	  to	  the	  fullest	  extent	  practicable	  and	   appropriate,	  his	  or	  her	  parent	  or	  caregiver,	  are	  provided	  with	  information	  regarding	  the	  goals,	   risks,	  benefits	  and	  the	  potential	  side	  effects	  of	  the	  medication	  and	  given	  an	  explanation	  of	  the	   potential	  consequences	  of	  not	  treating	  with	  the	  medication,	  and	  that	  the	  youth	  has	  an	   opportunity	  to	  consent	  to	  such	  medication.	  	  A)	  Involuntary	  administration	  of	  psychotropic	   medications	  to	  juveniles	  shall	  comply	  with	  applicable	  federal	  and	  state	  laws	  and	  regulations.	  The	   DYS	  clinical	  director,	  in	  consultation	  with	  the	  DYS	  medical	  director,	  shall	  review	  and	  request	  with	   DYS	  Legal	  Services	  prior	  to	  the	  approval	  for	  involuntary	  administration.	  	  

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

The	  facility’s	  oral	  self-­‐assessment	  indicated	  that	  policy	  and	  procedure	   development	  remained	  pending.	  	  They	  also	  indicated	  a	  peer	   review/quality	  assurance	  process	  for	  informed	  consent;	  however,	   documentation	  of	  completed	  reviews	  was	  not	  received	  for	  review.	  

Steps	  Taken	  to	   Assess	  Compliance	  

Per	  the	  draft	  policy	  and	  procedure	  reviewed	  for	  this	  monitoring	  report	   entitled	  “Psychotropic	  Medication,	  Use	  and	  Management”	  education	   including	  “addressing	  the	  goals,	  risks,	  benefits,	  and	  potential	  side	  effects	   associated	  with	  any	  given	  medication	  is	  given	  to	  each	  youth	  and	  his	  or	   her	  parent	  or	  guardian…	  the	  prescribing	  physician	  provides	  an	   explanation	  of	  the	  potential	  consequences	  of	  not	  taking	  the	  medication	   and	  explains	  that	  the	  youth	  has	  an	  opportunity	  a	  consent	  or	  withhold	   consent	  to	  be	  treated…provides	  guidelines	  within	  which	  medical	   professionals	  may	  petition	  the	  court	  to	  authorize	  involuntary	   administration	  of	  psychotropic	  medication.”	  	  A	  revised	  policy	  and	   procedure	  was	  provided	  for	  review	  and	  comments	  were	  given	  during	   the	  monitoring	  visit.	   	   Eleven	  examples	  of	  informed	  consent	  documentation	  were	  provided	  via	   the	  document	  request.	  	  These	  examples	  included	  a	  form	  entitled	   “Information	  about	  and	  consent	  for	  medications	  for	  youth	  with	  mental	   health	  diagnoses.”	  	  These	  forms,	  competed	  by	  the	  youth,	  outlined	  what	   information	  the	  youth	  retained	  following	  their	  discussion	  with	  the	   psychiatrist	  regarding	  the	  prescribed	  medication.	  	  The	  form	  also	  allows	   for	  documentation	  by	  the	  psychiatrist	  of	  attempts	  to	  or	  successful	   contact	  with	  the	  youth’s	  parent	  or	  guardian	  in	  order	  to	  review	  potential	   psychotropic	  medications	  and	  obtain	  parental	  consent.	  	  Additional	   information	  (i.e.	  medication	  information	  sheets)	  are	  reportedly	   provided	  to	  the	  youth	  and	  their	  parents	  via	  the	  psychiatric	  nurses	  for	   their	  review	  such	  that	  full	  disclosure	  of	  potential	  medication	  side	  effects	   is	  provided.	   	   Of	  the	  examples	  provided,	  all	  were	  signed	  by	  the	  psychiatrist.	  	  All	   examples	  were	  signed	  by	  the	  youth	  and	  included	  brief	  descriptions	  of	   side	  effect	  information	  retained	  by	  the	  youth	  following	  discussion	  with	   the	  psychiatrist.	  	  Of	  the	  examples	  where	  parental	  consent	  was	  required	  

	  

84.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 85 of 129 PAGEID #: 2438

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	  	  

	  

85.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 86 of 129 PAGEID #: 2439

• Youth	  interview	  

• Staff	  interview	  

	  

	  

	  

	  

86.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 87 of 129 PAGEID #: 2440

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	  

	  

87.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 88 of 129 PAGEID #: 2441

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.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 89 of 129 PAGEID #: 2442

mental	  health	  caseload	  document	  and	  the	  medication	  sheet	  for	  each	  of	   the	  youth	  that	  at	  the	  time	  of	  this	  monitoring	  visit,	  63	  youth	  were	   prescribed	  medication	  by	  the	  psychiatrist.	  This	  was	  a	  similar	  result	  to	   the	  previous	  monitoring	  period	  where	  71	  youth	  were	  prescribed	   psychotropic	  medication.	  	  	   	   In	  the	  previous	  monitoring	  reports,	  inaccuracies	  in	  the	  tracking	  data	  for	   youth	  on	  the	  mental	  health	  caseload	  were	  discussed.	  	  Per	  the	  review	  of	   the	  data	  for	  this	  period,	  there	  were	  improvements.	  	  The	  dates	  of	   treatment	  plans,	  caseload	  assignments,	  medication	  start	  dates,	   medication	  dosage,	  compliance	  with	  psychotropic	  medications,	  and	   current	  diagnoses	  appeared	  to	  be	  updated.	  	  From	  a	  system	  perspective,	   it	  was	  difficult	  to	  look	  at	  trends	  of	  data	  (e.g.	  trends	  of	  prescribing,	   trends	  with	  regard	  to	  medication	  compliance,	  timeliness	  of	  psychiatric	   evaluation,	  regularity	  of	  medication	  management)	  as	  the	  data	  were	   supplied	  for	  each	  individual	  youth	  with	  no	  compilation	  provided.	  It	   would	  be	  useful	  to	  determine	  if	  the	  data	  management	  system	  can	  be	   adjusted	  to	  provide	  reporting	  of	  data	  points	  for	  groups	  of	  youth	  over	  a	   period	  of	  time.	  	  This	  could	  also	  allow	  some	  quality	  assurance	  monitoring	   and	  the	  identification	  of	  possible	  issues	  for	  further	  quality	  assurance	   studies.	   	   Given	  the	  manner	  of	  the	  data	  presentation,	  it	  was	  difficult	  to	  determine	   the	  timeliness	  of	  psychiatric	  treatment.	  	  Per	  a	  review	  of	  the	  psychiatric	   clinic	  schedule,	  it	  was	  apparent	  that	  clinic	  occurred	  once	  or	  twice	   weekly	  in	  the	  previous	  90	  days.	  	  It	  was	  not	  possible	  to	  determine	  the	   time	  period	  between	  the	  youth’s	  admission	  to	  the	  facility	  and	  their	   referral	  for	  a	  psychiatric	  evaluation.	  	  Timelines	  must	  be	  addressed	  via	   policy	  and	  procedure,	  and	  they	  should	  be	  monitored	  via	  quality	   assurance.	  	  	   	   Another	  challenge	  with	  the	  data	  presentation	  was	  determining	   timeliness	  of	  psychiatry	  clinic	  follow	  up.	  	  In	  an	  effort	  to	  determine	  this,	   the	  clinic	  schedule	  was	  reviewed,	  in	  general,	  there	  was	  documentation	   that	  youth	  were	  seen	  monthly.	  	  There	  were	  two	  notable	  exceptions:	   Youth	  #444	  was	  last	  seen	  in	  January	  2012	  and	  is	  currently	  prescribed	   stimulant	  medication;	  and	  Youth	  #555	  was	  last	  seen	  in	  March	  2012	  and	   is	  currently	  prescribed	  stimulant	  medication	  and	  antidepressant	   medication.	  	  Generally	  accepted	  practices	  as	  well	  as	  draft	  facility	  policy	   and	  procedure	  require	  that	  youth	  treated	  with	  psychotropic	   medications	  are	  assessed	  by	  the	  psychiatrist	  at	  least	  monthly.	  This	  was	   another	  area	  where	  quality	  assurance	  monitoring	  may	  be	  beneficial.	   	   Once	  the	  new	  psychiatric	  provider	  begins	  to	  establish	  clinic,	  the	  facility	   will	  need	  to	  determine	  if	  the	  current	  clinical	  resources	  are	  adequate	  for	   the	  psychiatrists	  to	  provide	  clinical	  services,	  participate	  in	  treatment	   team	  meetings,	  for	  response	  to	  crisis	  situations,	  for	  provision	  of	  on-­‐

	  

89.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 90 of 129 PAGEID #: 2443

Recommendations	  

call/after	  hours	  consultations;	  and	  for	  the	  psychiatrist	  to	  function	  as	  an	   integral	  member	  of	  the	  treatment	  team.	  	  If	  necessary,	  the	  facility	  must	   investigate	  other	  avenues	  in	  order	  to	  address	  the	  paucity	  of	  psychiatric	   clinical	  services.	  	  These	  could	  include	  telemedicine;	  developing	  an	   association	  with	  a	  residency	  training	  program	  where	  residents	  or	  fellows	   (with	  appropriate	  clinical	  supervision)	  could	  provide	  services.	  	  	  	   	   With	  regard	  to	  other	  issues	  required	  per	  this	  provision,	  the	   Administrative	  Psychiatrist	  indicated	  during	  the	  previous	  monitoring	   visit	  that	  he	  was	  in	  the	  process	  of	  developing	  training	  for	  staff	  with	   regard	  to	  current	  issues	  in	  psychopharmacological	  treatment,	  including	   information	  necessary	  to	  monitor	  for	  side	  effects	  and	  efficacy.	  	  The	   development	  of	  this	  training	  was	  pending.	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	   1. Update	  policy	  and	  procedure	  regarding	  behavioral	  health	  to	  include	  
timelines	  for	  psychiatric	  services.	   2. Finalize	  policy	  and	  procedure	  regarding	  psychotropic	  medication	  
management.	   3. Ensure	  that	  youth	  receive	  timely	  evaluation	  and	  appropriate	  
medication	  management	  follow	  up.	  	  This	  is	  an	  area	  that	  would	  be	   amenable	  to	  quality	  improvement	  monitoring	  and	  review.	   4. In	  order	  to	  determine	  the	  appropriate	  number	  of	  full	  time	   equivalent	  psychiatric	  clinicians	  required	  by	  the	  facility,	  consider	   workload	  indicators	  inclusive	  of	  all	  clinical	  responsibilities	  required	   of	  the	  physician	  (e.g.	  clinic,	  documentation,	  treatment	  team	   meetings,	  crisis	  response).	   5. If	  necessary,	  investigate	  other	  avenues	  to	  increase	  psychiatry	  clinical	   resources	  at	  the	  facility	  (e.g.	  telemedicine,	  association	  with	   academic	  institutions,	  use	  of	  residents	  or	  fellows	  with	  appropriate	   supervision).	   6. Ensure	  clinical	  coverage	  for	  the	  current	  psychiatric	  treatment	   provider.	   7. Maintain	  the	  document	  regarding	  the	  current	  mental	  health	   caseload.	  	  Edits	  to	  this	  document	  may	  assist	  in	  quality	  assurance.	   8. Begin	  the	  peer	  review/quality	  assurance	  monitoring	  for	  psychiatric	   treatment	  and	  documentation.	  	  This	  would	  include	  a	  review	   evaluation	  and	  diagnostics,	  of	  treatment	  planning	  for	  psychotropic	   medication,	  of	  target	  symptom	  identification	  for	  treatment	  with	   psychotropic	  medication,	  assessment	  for	  side	  effects	  with	   psychotropic	  medications,	  and	  the	  assessment	  of	  benefit	  from	   psychotropic	  medication.	   9. Ensure	  that	  youth	  are	  receiving	  proper	  laboratory	  examinations	  and	   side	  effect	  monitoring	  commensurate	  with	  the	  psychotropic	   medication	  they	  are	  prescribed.	  	  This	  would	  require	  updating	  of	  the	   laboratory	  matrix	  and	  quality	  assurance	  monitoring.	   10. Develop	  and	  implement	  training	  for	  staff	  with	  regard	  to	  current	  

	  

90.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 91 of 129 PAGEID #: 2444

Sources	  of	   Information	  
	   	  

issues	  in	  psychopharmacological	  treatment,	  including	  information	   necessary	  to	  monitor	  for	  side	  effects	  and	  efficacy.	  	  Present	  this	   training	  curriculum	  to	  the	  monitor	  for	  review.	  
• Staff	  interview	   • Treatment	  Team	  observation	   • Youth	  record	  review	   • Review	  of	  provided	  documents	  	  
• Youth	  interview	  
	  

	  

91.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 92 of 129 PAGEID #: 2445

III.B.14	  	  Mental	  Health	  and	  Developmental	  Disability	  Training	  for	  Direct	  Care	  Staff.	  	  The	  State	   shall	  develop	  and	  implement	  strategies	  for	  providing	  direct	  care	  and	  other	  appropriate	  staff	   with	  training	  on	  mental	  health	  and	  developmental	  disabilities	  sufficient	  for	  staff	  to	  understand	   the	  behaviors	  and	  needs	  of	  youth	  residents	  in	  order	  to	  supervise	  them	  appropriately.	  	  

Compliance	  Rating	   Non-­‐	  Compliance	  

Self	  Assessment	  

The	  facility	  self-­‐assessment	  was	  provided	  orally.	  	  Staff	  indicated	  that	   every	  year,	  all	  staff	  receive	  40	  hours	  of	  inservice	  training,	  with	  an	   additional	  eight	  hours	  of	  “booster”	  sessions	  that	  are	  staff	  specific	  and	   tailored	  to	  meet	  the	  needs	  of	  the	  facility.	  	  Staff	  reported	  that	  in	  the	   upcoming	  year,	  it	  was	  planned	  that	  staff	  would	  receive	  a	  total	  of	  16	   hours	  of	  “booster”	  sessions	  with	  eight	  hours	  devoted	  to	  mental	  health	   topics.	  

Steps	  Taken	  to	   Assess	  Compliance	  

As	  stated	  in	  the	  previous	  report,	  the	  goal	  of	  this	  provision	  paragraph	  is	  to	   provide	  training	  to	  facility	  staff	  such	  that	  they	  have	  a	  working	  knowledge	   of	  the	  youth’s	  challenges	  (both	  from	  a	  mental	  health	  and	  developmental	   perspective)	  and	  to	  provide	  them	  with	  strategies	  to	  assist	  in	  their	  daily	   supervisory	  tasks	  with	  the	  youth.	  	  	  Training	  for	  direct	  care	  staff	  is	   important	  as	  in	  the	  correctional	  setting;	  they	  function	  as	  the	  de	  facto	   parents	  of	  the	  youth	  in	  their	  care.	  As	  direct	  care	  staff	  are	  an	  integral	  part	   of	  the	  youth’s	  treatment	  team,	  they	  should	  be	  aware	  that	  due	  to	  specific	   mental	  health	  diagnoses,	  youth	  may	  have	  special	  needs	  (i.e.	  a	  youth	   diagnosed	  with	  ADHD	  may	  not	  respond	  to	  you	  the	  first	  or	  even	  second	   time	  that	  you	  call	  his	  name	  because	  he	  is	  distracted	  by	  extraneous	   stimuli).	  They	  should	  also	  be	  aware	  of	  which	  youth	  are	  being	  treated	   with	  psychotropic	  medication	  and	  have	  a	  basic	  knowledge	  of	  the	   potential	  side	  effects	  of	  the	  medication	  so	  that	  they	  can	  monitor	  the	   youth	  in	  their	  care.	  	   	   Per	  the	  facility	  self-­‐assessment	  provided	  for	  the	  previous	  monitoring	   report,	  the	  administrative	  psychiatrist	  was	  collaborating	  with	  the	   psychology	  supervisor	  to	  develop	  training	  for	  all	  staff	  to	  educate	  them	  on	   psychiatric	  medications,	  side	  effects,	  benefits	  and	  long	  term	  concerns.	  	   This	  training	  curriculum	  has	  yet	  to	  be	  provided	  to	  the	  monitor	  for	  review.	   	   There	  was	  documentation	  of	  mental	  health	  specific	  training	  provided	  to	   direct	  care	  staff	  as	  outlined	  below.	  	  Unfortunately,	  corresponding	   curriculum	  was	  not	  provided	  to	  the	  monitor	  for	  review.	  	  Additionally,	  per	   a	  review	  of	  the	  topics	  presented,	  it	  appears	  that	  this	  training	  would	  be	   an	  excellent	  resource	  for	  direct	  care	  staff,	  and	  it	  was	  unfortunate	  that	   only	  eight	  direct	  care	  staff	  were	  able	  to	  attend	  (eight	  attended	  each	  day).	   	  
“Juvenile	  Offenders	  with	  Mental	  Health	  Disorders”	  was	  presented	  by	   Lisa	  Boesky,	  Ph.D.,	  September	  25	  and	  25,	  2012.	  	  Reportedly,	  a	  third	   training	  session	  is	  planned	  in	  May	  2013.	  	  Topics	  included:	  	  

• Which	  Juvenile	  Offenders	  REALLY	  Have	  a	  Mental	  Health	  

	  

92.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 93 of 129 PAGEID #: 2446

Disorder?	   • Your	  Role	  with	  Mentally	  Ill	  Juveniles	   • Where	  Are	  You	  on	  the	  MHAT	  Continuum?	   • Juveniles	  with	  Attention-­‐Deficit/Hyperactivity	  Disorder	  (ADHD)	   • Juveniles	  with	  Conduct	  Disorder	  or	  Antisocial	  Personality	  
Disorder	   • Juveniles	  with	  Depression	  or	  Dysthymic	  Disorder	   • Juveniles	  with	  Bipolar	  Disorder	   • Psychotropic	  Medication	   • Suicide:	  Which	  Juveniles	  Are	  At	  Risk	  of	  Dying	   • Anxiety	  and	  Juvenile	  Offenders	   • Juveniles	  with	  Posttraumatic	  Stress	  Disorder	  (PTSD)	   • More	  Than	  Just	  A	  Bump	  on	  the	  Head	   • Juveniles	  Who	  Act	  Bizarrely	  or	  Hear	  Voices	   • Communication	  and	  Collaboration	  (juvenile	  justice,	  mental	  
health,	  medical,	  school)	   • Juveniles	  Who	  Cut	  or	  Carve	  Themselves	  to	  Feel	  Better	   • Key	  Role	  YOU	  Play	  with	  Juveniles	  Who	  Have	  Mental	  Health	  
Disorders	  
Reportedly,	  eight	  youth	  specialists	  (the	  majority	  of	  these	  working	  on	   Progress	  Units),	  three	  operations	  managers,	  and	  two	  unit	  managers	   attended	  this	  two	  day	  training.	  	  Evaluations	  completed	  by	  the	   participants	  revealed	  that	  72.22%	  of	  the	  ratings	  were	  “excellent.”	  	  Per	   staff	  interviews,	  there	  were	  plans	  to	  repeat	  this	  training	  in	  the	  spring	  of	   2013.	  	  ODYS	  is	  commended	  for	  this	  training	  opportunity	  for	  staff.	  	  It	  was	   unfortunate	  that	  additional	  staff	  members	  were	  not	  able	  to	  participate.	  	   As	  there	  is	  an	  opportunity	  in	  spring	  of	  2013,	  it	  is	  hoped	  that	  all	  staff	  will	   be	  able	  to	  attend.	  	  Given	  the	  large	  number	  of	  staff	  requiring	  specialized	   training	  regarding	  specific	  mental	  health	  and	  developmental	  disabilities,	   this	  provision	  will	  remain	  in	  noncompliance.
Pre-­‐service	  for	  new	  employees	  receive	  training	  in	  the	  following	  areas:	   • Adolescent	  Development	  (2hrs)	   • Mental	  Health	  (1.5hrs)	   • SBBMS	  (2hrs)	   • Cognitive	  Behavior	  Therapy	  (1.5hrs)	   • Sex	  Offender(1.5hrs)	   • Emergency	  Response-­‐	  Suicide	  Prevention	  (7hrs)	  
	   Current	  8hr.	  in-­‐service	  (booster)	  training	  covers	  the	  following	  areas:	  
• Strengths	  Based	  Behavior	  Management	  System	   • Interdisciplinary	  Team	   • Group	  Process	   • CBT	  Skill	  Cards	   	   For	  additional	  information	  regarding	  training,	  please	  see	  the	  discussion	  

	  

93.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 94 of 129 PAGEID #: 2447

Recommendations	  
Sources	  of	   Information	   	   	  

regarding	  paragraph	  15	  below.	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	   1. Develop	  an	  organized	  training	  schedule	  and	  training	  curriculum	  for	  
facility	  staff	  that	  addresses	  the	  requirements	  of	  this	  provision	  and	   addresses	  the	  facility	  mental	  health	  programming	  initiatives.	  	  	   2. Provide	  curriculum	  of	  newly	  developed	  training	  to	  the	  monitor	  for	   review.	   3. Track	  staff	  compliance	  with	  training	  requirements	  and	  provide	   documentation	  to	  the	  monitor.	  
• Review	  of	  provided	  documents	  	   • Staff	  interview	  
	  

	  

94.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 95 of 129 PAGEID #: 2448

III.B.15	  	  Staff	  Mental	  Health	  Training.	  The	  facilities	  shall	  train:	  a)	  all	  staff	  who	  directly	  interact	   with	  youth	  (e.g.,	  JCOs	  ,	  social	  workers,	  teachers,	  etc.)	  on:	  (i)	  basic	  mental	  health	  information	   (e.g.,	  diagnosis,	  specific	  problematic	  behaviors,	  psychiatric	  medication,	  additional	  areas	  of	   concern)	  and	  recognition	  of	  signs	  and	  symptoms	  evidencing	  a	  response	  to	  trauma;	  and	  (ii)	   teenage	  development,	  strength-­‐based	  treatment	  strategies,	  suicide,	  and	  for	  staff	  who	  work	  with	   female	  youth,	  female	  development;	  b)	  clinical	  staff	  on	  the	  prevalence,	  signs	  and	  symptoms	  of	   Post	  Traumatic	  Stress	  Disorder	  and	  other	  disorders	  associated	  with	  trauma.	  	  

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

The	  facility	  self-­‐assessment	  was	  provided	  orally,	  and	  reviewed	  recent	   trainings	  conducted	  including	  the	  ITP	  process,	  case	  conceptualization,	   and	  “Juvenile	  Offenders	  with	  Mental	  Health	  Disorders.”	  

Steps	  Taken	  to	   Assess	  Compliance	  

Per	  the	  document	  request,	  copies	  of	  any	  newly	  developed	  mental	   health	  training	  curriculum	  were	  requested	  and	  none	  were	  received.	  	   Documentation	  of	  training	  provided	  in	  the	  six	  months	  prior	  to	  the	   monitoring	  visit	  was	  requested.	  	  This	  documentation	  noted:	   	  
1.	  	  “Juvenile	  Offenders	  with	  Mental	  Health	  Disorders”	  was	  presented	   by	  Lisa	  Boesky,	  Ph.D.,	  September	  25	  and	  25,	  2012.	  	  Reportedly,	  a	   third	  training	  session	  is	  planned	  in	  May	  2013.	  	  Topics	  included:	  	  

• Which	  Juvenile	  Offenders	  REALLY	  Have	  a	  Mental	  Health	   Disorder?	  
• Your	  Role	  with	  Mentally	  Ill	  Juveniles	   • Where	  Are	  You	  on	  the	  MHAT	  Continuum?	   • Juveniles	  with	  Attention-­‐Deficit/Hyperactivity	  Disorder	  (ADHD)	   • Juveniles	  with	  Conduct	  Disorder	  or	  Antisocial	  Personality	  
Disorder	   • Juveniles	  with	  Depression	  or	  Dysthymic	  Disorder	   • Juveniles	  with	  Bipolar	  Disorder	   • Psychotropic	  Medication	   • Suicide:	  Which	  Juveniles	  Are	  At	  Risk	  of	  Dying	   • Anxiety	  and	  Juvenile	  Offenders	   • Juveniles	  with	  Posttraumatic	  Stress	  Disorder	  (PTSD)	   • More	  Than	  Just	  A	  Bump	  on	  the	  Head	   • Juveniles	  Who	  Act	  Bizarrely	  or	  Hear	  Voices	   • Communication	  and	  Collaboration	  (juvenile	  justice,	  mental	  
health,	  medical,	  school)	   • Juveniles	  Who	  Cut	  or	  Carve	  Themselves	  to	  Feel	  Better	   • Key	  Role	  YOU	  Play	  with	  Juveniles	  Who	  Have	  Mental	  Health	  
Disorders	  

Reportedly,	  eight	  youth	  specialists	  (the	  majority	  of	  these	  working	  on	   Progress	  Units),	  three	  operations	  managers,	  and	  two	  unit	  managers	   attended	  this	  two	  day	  training.	  	  Evaluations	  completed	  by	  the	   participants	  revealed	  that	  72.22%	  of	  the	  ratings	  were	  “excellent.”	  

	  

95.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 96 of 129 PAGEID #: 2449

2. Psychology	  training	  documentation	  revealed	  that	  nine	  staff	   attended	  an	  eight	  hour	  training	  on	  “family	  engagement.”	  
3. Other	  training	  attended	  by	  psychology	  staff	  included,	   “CPR/FA/AED”,	  “MIS	  CBTO”,	  “Youth	  Supervision	  Rules	  of	   Conduct”,	  “Safety	  and	  Security”,	  “Child	  Abuse	  and	  Neglect”,	   “Youth	  Grievance”,	  “Emergency	  Response”,	  “Blood	  borne	   Pathogens”,	  “Ethics”,	  “PREA”,	  “General	  Work	  Rules”,	  “Equal	   Employment	  Opportunity”,	  “MYR	  1st	  quarter”,	  “Wellness”,	  “MYR	   2nd	  quarter”,	  “Emergency	  Response	  Belt	  Review”,	  and	  “Shield	   Review”.	  
4. ITP	  training	  was	  provided	  to	  behavioral	  health	  staff	  by	  ODYS	   central	  office	  staff.	  
5. ITP	  training	  and	  case	  formulation	  training	  was	  provided	  to	   behavioral	  health	  staff	  by	  Andrea	  Weisman,	  Ph.D.	  
Unfortunately,	  training	  curriculum	  was	  not	  provided	  for	  review	  for	  any	  of	   the	  above	  noted	  trainings.	  	  Attendance	  was	  only	  available	  for	  those	   trainings	  where	  it	  was	  noted	  above.	  	  Given	  the	  confirmed	  attendance,	   there	  were	  staff	  of	  all	  disciplines	  who	  have	  not	  received	  training.	  	  Per	  a	   review	  of	  the	  presented	  topics,	  it	  appeared	  that	  the	  two	  day	  training	  via	   Dr.	  Boesky	  would	  be	  an	  excellent	  resource	  for	  youth	  specialists,	  and	  as	   such,	  it	  was	  unfortunate	  that	  only	  eight	  direct	  care	  staff	  had	  the	  ability	  to	   attend.	  	  	  
Per	  the	  review	  of	  the	  training	  topics	  above,	  they	  did	  not	  include	  those	   topics	  required	  by	  the	  agreement.	  	  However,	  the	  State	  invested	   considerable	  time	  and	  resources	  in	  training	  that	  is	  needed	  to	  fully	   comply	  with	  the	  Stipulation.	  Previous	  monitoring	  reports	  have	   indicated,	  “the	  facility	  self-­‐assessment	  included,	  ‘all	  staffs	  [sic]	  have	   been	  trained	  on	  BHS	  [Behavioral	  Health	  Services]	  policies	  and	   procedures.	  	  Staff	  receive	  a	  minimum	  of	  40	  hours	  of	  in-­‐service	  yearly.	  	  In	   addition,	  ODYS	  brings	  in	  outside	  experts	  to	  train	  frontline	  staff	  as	  well.’	  	   The	  self-­‐assessment	  then	  discussed	  draining	  performed	  by	  Dr.	  Lisa	   Boesky	  in	  August	  2011,	  with	  plans	  for	  an	  additional	  two-­‐day	  training	   provided	  by	  Dr.	  Boesky	  in	  May	  2012.	  	  The	  self-­‐assessment	  also	  indicated,	   ‘staff	  have	  been	  trained	  extensively	  in	  CBT,	  motivational	  interviewing	   and	  strength	  based	  approaches.’	  	  No	  new	  documentation	  of	  completed	   training	  with	  regard	  to	  these	  topics	  was	  provided	  for	  the	  current	   monitoring	  period.	  	  Additionally,	  ODYS	  is	  currently	  in	  the	  process	  of	  a	   significant	  review	  and	  revision	  of	  behavioral	  health	  policy	  and	   procedure,	  which	  would	  require	  review/refresher	  training	  for	  staff.”	   	   The	  development	  of	  an	  organized,	  mandatory	  training	  schedule	  was	  a	   recommendation	  from	  the	  previous	  monitoring	  visits.	  It	  is	  absolutely	   necessary	  to	  develop	  and	  implement	  a	  training	  schedule	  for	  all	  staff	   providing	  care	  for	  youth	  with	  regard	  to	  mental	  health	  issues.	  This	   training	  must	  also	  address	  staff	  recognition	  of	  and	  response	  to	  the	  signs	   and	  symptoms	  of	  a	  serious	  mental	  illness	  in	  evolution	  as	  well	  as	  the	  

	  

96.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 97 of 129 PAGEID #: 2450

Recommendations	  
Sources	  of	   Information	   	   	   	  

specific	  training	  topics	  required	  by	  the	  agreement.	   	   The	  training	  schedule	  must	  be	  reasonable	  and	  address	  specific	  topics	  to	   ensure	  that	  staff	  are	  able	  to	  implement	  the	  facility	  mental	  health	   program.	  	  While	  training	  is	  important,	  the	  facility	  must	  be	  able	  to	   maintain	  sufficient	  staff	  onsite	  to	  ensure	  that	  treatment	  and	  security	   services	  are	  available.	   	   The	  oral	  self-­‐assessment	  indicated	  a	  more	  proactive	  approach	  to	   providing	  training	  was	  occurring,	  and	  this	  is	  positive,	  however,	  both	   curriculum	  and	  spreadsheets	  indicating	  completion	  must	  be	  provided	  to	   the	  monitor.	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	   1. Develop	  an	  organized	  training	  schedule	  and	  training	  curriculum	  for	  
facility	  staff	  that	  addresses	  the	  requirements	  of	  this	  provision	  and	   addresses	  the	  facility	  mental	  health	  programming	  initiatives.	  	   Provide	  the	  curriculum	  for	  behavioral	  health	  training	  topics	  and	   spreadsheets	  regarding	  attendance	  to	  the	  monitor	  for	  review.	   2. Consider	  offering	  multiple	  trainings	  for	  each	  topic	  so	  that	  staff	  can	   schedule	  trainings	  while	  ensuring	  that	  their	  regular	  job	  duties	  are	   addressed.	   3. Track	  staff	  attendance	  and	  compliance	  with	  training	  requirements.	  
• Review	  of	  provided	  documents.	   • Staff	  interviews.	  
	  

	  

97.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 98 of 129 PAGEID #: 2451

III.B.16	  	  Suicide	  Prevention.	  	  The	  State	  shall	  review	  and,	  as	  appropriate,	  revise	  current	  suicide	   prevention	  practices	  to	  ensure	  that	  suicide	  preventions	  and	  interventions	  are	  implemented	   consistently	  and	  appropriately,	  consistent	  with	  generally	  accepted	  professional	  standards	  of	   care.	  	  

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

The	  facility	  self	  assessment	  was	  provided	  orally	  and	  indicated	  that	  the	   draft	  policy	  and	  procedure	  was	  reviewed	  by	  Lindsay	  Hayes,	  and	   comments	  were	  integrated	  into	  the	  draft	  policy	  and	  procedure.	  	  The	   completed	  document	  remained	  pending	  at	  the	  time	  of	  this	  monitoring	   visit.	  

Steps	  Taken	  to	   Assess	  Compliance	  

As	  noted	  above,	  staff	  reported	  that	  existing	  policy	  and	  procedure	  was	   submitted	  to	  Lindsay	  Hayes	  for	  review,	  and	  his	  comments	  had	  been	   incorporated	  into	  the	  draft	  document.	  	  The	  current	  draft	  was	  not	   submitted	  for	  review	  this	  monitoring	  period.	  	  The	  following	  information	   was	  provided	  for	  the	  previous	  monitoring	  review,	  and	  will	  be	  included	   here	  for	  comparison	  when	  the	  revised	  policy	  is	  completed.	   	   “The	  policy	  and	  procedure	  entitled	  “Suicide	  Prevention	  and	  Response”	   revised	  October	  3,	  2011	  was	  provided	  for	  review.	  	  Specific	  issues	   identified	  with	  this	  policy	  include:	  
1. Procedures	   a. Screening	  and	  Assessment	   i. 	  Reception	  -­‐	  There	  is	  no	  designated	  time	  within	   which	  the	  Risk	  Assessment	  Interview	  must	  be	   completed	  (as	  attachments	  were	  not	  provided	   with	  the	  policy	  received,	  it	  was	  not	  possible	  to	   review	  the	  Risk	  Assessment	  Interview	   document).	   ii. Transfer	  –	  There	  was	  no	  mention	  of	  the	   assessment	  or	  watch	  precautions	  to	  be	  provided	   to	  youth	  on	  watch	  status	  during	  or	  following	  a	   facility	  transfer.	  	  There	  is	  a	  requirement	  for	  the	   “immediate”	  completion	  of	  a	  Risk	  Assessment	   Interview	  following	  positive	  responses	  to	   questions	  concerning	  suicide	  ideation	  and	  self-­‐ injurious	  behavior	  during	  the	  transfer	  process.	  	   The	  time	  limit	  for	  the	  completion	  of	  this	   assessment	  was	  not	  indicated.	   b. Communication	   i. “Psychology	  staff	  are	  required	  to	  review	   psychology	  file	  information	  within	  five	  days	  of	  a	   youth’s	  admission	  to	  a	  facility	  in	  order	  to	   identify	  possible	  areas	  of	  concern	  regarding	   mental	  status,	  suicide	  or	  self	  injury	  and	  the	  need	   for	  any	  follow	  up	  services.”	  	  The	  policy	  does	  not	   designate	  where	  this	  review	  is	  to	  be	  

	  

98.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 99 of 129 PAGEID #: 2452

documented,	  nor	  does	  it	  indicate	  if	  this	  review	  is	   for	  all	  youth	  admitted	  or	  only	  for	  those	  youth	   who	  have	  positive	  responses	  to	  the	  intake	   health	  screen.	  	  	   c. Precautionary	  Status	   i. This	  section	  of	  the	  policy	  indicates	  that	  youth	   placed	  on	  precautionary	  status	  must	  have	  a	  Risk	   Assessment	  Interview	  within	  four	  hours.	  	  This	  is	   the	  first	  mention	  of	  a	  time	  frame	  within	  which	   this	  assessment	  must	  be	  completed.	   ii. Youth	  placed	  on	  “watch”	  and	  who	  are	  “assessed	   as	  being	  at	  the	  highest	  risk	  for	  suicide…engaged	   in	  critical	  suicide	  attempts”	  are	  required	  to	  have	   “constant	  visual	  monitoring	  within	  close	   proximity	  (i.e	  closer	  than	  15	  feet)…line	  of	  sight	   shall	  be	  unencumbered.”	  	  With	  these	   requirements,	  the	  staff	  to	  youth	  ratio	  is	  required	   to	  be	  “not	  greater	  than	  one	  staff	  to	  three	  youth.	   Where	  an	  adjustment	  pod	  exists	  the	  rations	   shall	  be	  not	  greater	  than	  one	  staff	  to	  six	  youth.”	  	  	   These	  ratios	  do	  not	  allow	  for	  close	  monitoring	  of	   youth.	  	  For	  youth	  who	  are	  actively	  suicidal,	  one	   to	  one	  monitoring	  is	  required.	  The	  policy	  does	   not	  allow	  for	  this	  level	  of	  monitoring	  except	  in	   the	  case	  of	  “youth	  designated	  as	  making	  a	   critical	  suicide	  attempt.”	  	  The	  level	  of	   monitoring	  should	  be	  determined	  clinically,	   given	  the	  results	  of	  behavioral	  health	   assessments.	  	  Regardless	  of	  a	  critical	  suicide	   attempt,	  if	  youth	  are	  at	  serious	  risk,	  there	  must	   be	  the	  ability	  to	  access	  one	  to	  one	  supervision.	   iii. With	  regard	  to	  “observation”	  status,	  there	  is	  no	   staff	  to	  youth	  ratio	  designated.	   iv. With	  regard	  to	  “behavioral”	  status,	  there	  is	  no	   staff	  to	  youth	  ratio	  designated.	   d. Additional	  comments:	  	  The	  policy	  does	  not	  designate	  the	   process	  by	  which	  psychiatrist	  is	  notified	  of	  a	  youth	   requiring	  watch	  status.	  	  Currently,	  per	  the	  document	   request,	  this	  is	  performed	  informally	  via	  email;	  however,	   it	  must	  be	  codified	  in	  policy.”	   	   The	  agreement	  requires	  that	  ODYS	  demonstrate	  that	  interventions	  are	   implemented	  consistently	  and	  appropriately.	  	  In	  order	  for	  ODYS	  to	   ensure	  this,	  quality	  assurance	  data	  based	  on	  policy	  and	  procedure	   would	  be	  required.	  	  Per	  review	  of	  current	  policy,	  there	  is	  a	  requirement	   for	  monitoring	  “ongoing	  reviews	  shall	  be	  conducted	  by	  the	  designated	   Interdisciplinary	  team	  on	  a	  quarterly	  basis	  as	  part	  of	  the	  Departments	  

	  

99.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 100 of 129 PAGEID #: 2453

Recommendations	  
Sources	  of	   Information	   	   	  

Continuous	  Quality	  Improvement	  Process.”	  	  Per	  the	  document	  request	   for	  this	  monitoring	  period,	  “any	  reviews	  or	  quality	  assurance	  data	   regarding	  suicide	  precautions”	  were	  requested.	  	  The	  response	  received	   indicated,	  “there	  is	  QA	  built	  into	  the	  monitoring	  log	  form…any	   discrepancies	  are	  to	  be	  noted	  and	  reported.	  	  Administration	  is	  also	   required	  to	  review	  monitoring	  logs	  when	  making	  round…to	  units…the	   OA	  and	  UMA	  will	  review	  random	  monitoring	  logs	  as	  a	  policy…but	  there	   is	  not	  a	  form	  or	  formal	  requirement	  attached	  to	  this	  process.”	  	  	   	   In	  the	  previous	  three	  months,	  there	  were	  a	  total	  of	  five	  youth	  placed	  on	   suicide	  watch,	  and	  as	  such,	  there	  were	  youth	  records	  that	  could	  have	   been	  reviewed	  to	  assess	  compliance	  with	  policy.	  	  This	  would	  include	   process	  reviews,	  outcome	  reviews,	  and	  a	  review	  of	  data	  trends	  and	   analysis	  in	  order	  to	  determine	  compliance	  with	  policy,	  the	  need	  for	   individual	  corrective	  action,	  and	  the	  identification	  of	  systems	  issues	   affecting	  policy	  implementation.	  	  Based	  on	  the	  existing	  policy	  and	   procedure,	  partial	  compliance	  will	  be	  assigned.	  	  	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	   1. Review	  and	  revise	  current	  policy	  to	  address	  timelines	  and	  ensure	  
appropriate	  ratios	  for	  youth	  supervision.	   2. Perform	  quality	  assurance	  monitoring	  to	  ensure	  compliance	  with	  
policy	  and	  procedure	  as	  well	  as	  the	  need	  for	  corrective	  action	  (see	   III.B.18	  for	  details).	  
• Review	  of	  provided	  documents.	   • Staff	  interview.	   • Youth	  interview.	  
	  

	  

100.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 101 of 129 PAGEID #: 2454

III.B.17	  	  Transition	  Planning.	  	  The	  State	  shall	  ensure	  that	  staff	  create	  transition	  plans	  for	  youth	   leaving	  the	  facilities,	  consistent	  with	  generally	  accepted	  professional	  standards	  of	  care.	  	  

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

The	  facility	  self-­‐assessment	  was	  provided	  orally,	  and	  did	  not	  include	   information	  regarding	  this	  provision.	  	  

Steps	  Taken	  to	   Assess	  Compliance	  

In	  response	  to	  a	  document	  request	  for	  transition	  plans	  for	  ten	  youth	   (five	  of	  whom	  were	  prescribed	  psychotropic	  medication)	  discharged	   from	  the	  facility,	  the	  monitor	  was	  provided	  with	  the	  “Regional	   Accountability	  and	  Community	  Engagement	  Report”	  completed	  by	  the	   youth’s	  parole	  officer,	  not	  the	  youth’s	  treatment	  provider	  at	  the	  facility.	  	   Transition	  planning	  must	  start	  at	  the	  time	  of	  admission,	  and	  plans	  must	   be	  created	  by	  the	  current	  treatment	  provider	  in	  order	  to	  inform	  the	   community	  parole	  officer	  and	  other	  community	  providers	  of	  the	  youth’s	   needs.	   	   Nine	  examples	  of	  the	  facility	  generated	  “medical	  release	  summary”	   were	  reviewed.	  This	  document	  listed	  the	  youth’s	  diagnoses,	  medication	   and	  dosages.	  	  It	  also	  included	  the	  need	  for	  follow	  up	  psychiatric	   treatment.	  	  Specific	  referrals	  (e.g.	  clinic	  name,	  phone	  number)	  were	  not	   included	  on	  this	  document.	  	  There	  was	  one	  complete	  set	  of	  documents	   (i.e.	  a	  “Regional	  Accountability	  and	  Community	  Engagement	  Report”	   and	  “Medical	  Release	  Summary”	  for	  the	  same	  youth).	  	  Per	  these	   documents,	  Youth	  #333	  had	  a	  history	  of	  mental	  health	  diagnoses,	  and	   was	  prescribed	  psychotropic	  medication.	  	  Specific	  referral	  information	   was	  included	  on	  the	  summary	  with	  regard	  to	  gastroenterology	  clinic,,	   but	  not	  for	  psychiatry	  clinic.	  	  The	  “Regional	  Accountability	  and	   Community	  Engagement	  Report”	  indicated	  that	  this	  youth	  had	  a	  three	   day	  supply	  of	  medication	  provided	  to	  her	  at	  discharge,	  with	  a	  thirty	  day	   supply	  of	  medication	  mailed	  to	  her.	  	  There	  was	  also	  documentation	  of	   an	  initial	  appointment	  with	  a	  mental	  health	  treatment	  provider.	  	  	   	   Furthermore,	  the	  “Medical	  Release	  Summary”	  indicated	  that	  this	  youth	   gave	  birth	  approximately	  one	  month	  prior	  to	  her	  admission	  to	  the	   facility.	  	  There	  was	  no	  note	  of	  the	  infant	  included	  in	  the	  “Regional	   Accountability	  and	  Community	  Engagement	  Report.”	  Unfortunately,	  the	   transitional	  planning	  documentation	  was	  not	  included	  with	  these	   examples;	  therefore,	  other	  information	  regarding	  the	  infant,	  the	  youth’s	   need	  for	  parenting	  skills,	  or	  other	  services	  was	  not	  available.	   	   In	  previous	  reviews,	  psychological	  services	  summary	  documents	  were	   provided	  for	  review	  that	  included	  a	  review	  of	  the	  youth’s	  presenting	   problem;	  history	  of	  suicidal	  ideation,	  suicide	  attempts,	  and	  self	  injurious	   behavior;	  diagnostic	  impressions	  at	  intake;	  diagnosis	  history;	  five	  axis	   diagnosis;	  overall	  progress	  in	  treatment;	  goals;	  services	  provided;	   current	  medications;	  clients	  response	  to	  treatment;	  continuity	  of	   care/referral	  information;	  and	  aftercare	  options.	  	  Per	  the	  prior	  

	  

101.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 102 of 129 PAGEID #: 2455

monitoring	  report,	  “the	  completeness	  of	  documentation	  was	  variable	   between	  documents,	  and	  would	  be	  amenable	  to	  quality	  assurance	   monitoring	  and	  corrective	  action.	  	  The	  documents	  were	  inconsistent	  in	   terms	  of	  specific	  discharge	  plans	  and	  lacked	  definitive	  plans	  with	  regard	   to	  referrals,	  support	  services,	  and	  parent	  education.	  	  Most	   recommendations	  were	  stated	  as	  “most	  likely”	  or	  “will	  probably.”	  	  The	   transition	  plan	  recommendations	  should	  include	  concrete	  discharge	   plans	  for	  the	  youth	  and	  as	  such,	  should	  define	  a	  plan	  of	  action	  that	  the	   youth	  and	  their	  parent/guardian	  can	  follow.	  	  Again,	  there	  was	  marked	   variability	  in	  these	  documents…For	  youth	  prescribed	  psychotropic	   medication;	  follow	  up	  recommendations	  did	  not	  include	  the	   identification	  of	  clinical	  resources	  for	  follow	  up.	  	  There	  was	  no	  mention	   of	  a	  designated	  medical	  provider	  to	  perform	  continued	  monitoring	  of	  the	   prescribed	  medications	  on	  an	  outpatient	  basis.	  	  These	  summary	   documents	  may	  not	  be	  reflective	  of	  the	  discharge	  and	  transition	   planning	  activities	  performed	  by	  the	  behavioral	  health	  staff…In	   reviewing	  existing	  policies	  related	  to	  transition	  planning,	  there	  was	   ambiguity	  regarding	  who	  the	  responsible	  party	  is	  for	  creating	  and	   implementing	  transition	  plans	  prior	  to	  release,	  particularly	  with	  regard	   to	  mental	  health	  follow-­‐up.	  For	  example,	  in	  the	  policy	  entitled	   “Transition	  Planning	  for	  Age	  21	  Youth,”	  the	  policy	  clearly	  states	  that	  the	   juvenile	  parole	  officer	  “shall	  provide	  each	  youth	  with	  a	  comprehensive	   list	  of	  community	  based	  resources	  specific	  to	  the	  youth’s	  needs.”	  	  This	  is	   to	  include	  “treatment	  links/mental	  health	  services.”	  	  With	  regard	  to	   youth	  under	  age	  21,	  there	  was	  no	  specific	  policy	  included	  in	  the	   documents	  for	  review	  regarding	  transition	  planning;	  rather	  this	  is	   incorporated	  into	  the	  policy	  entitled,	  “Behavioral	  Health	  Services.”	  	  Per	   this	  policy,	  “youth	  in	  need	  of	  continued	  mental	  health	  services	  shall	   receive,	  as	  part	  of	  their	  re-­‐entry	  plans,	  referrals	  for	  continued	  treatment.	  	   Efforts	  shall	  be	  made	  to	  connect	  the	  youth	  and	  family	  directly	  with	  the	   community	  provider.”	  The	  policy	  does	  not	  denote	  which	  staff	  are	   responsible	  for	  this	  task.	  	  It	  will	  be	  necessary	  to	  determine	  what	  tasks	   need	  to	  be	  completed	  as	  part	  of	  transition	  planning	  and	  who	  the	   responsible	  part	  will	  be	  in	  order	  to	  ensure	  youth	  leave	  the	  facility	  with	   appropriate	  scheduled	  follow-­‐up	  services.	  	  As	  stated	  in	  the	  discussion	  for	   many	  of	  the	  paragraphs	  in	  this	  report,	  ODYS	  was	  in	  the	  process	  of	  a	   review	  of	  policy	  and	  procedure	  that	  should	  address	  these	  challenges.”	   	   Per	  ODYS	  staff,	  policy	  and	  procedure	  revision	  continued,	  and	   completion/implementation	  of	  policy	  and	  procedure	  was	  pending.	  	   Transition	  planning	  for	  all	  youth	  should	  include	  referral	  to	  appropriate	   community	  resources.	  For	  mentally	  ill	  youth	  this	  is	  especially	  important,	   and	  must	  include	  linkages	  to	  community	  mental	  health	  clinics	  and	  a	   scheduled	  appointment	  such	  that	  youth	  can	  access	  follow	  up	  care	   without	  an	  interruption	  in	  medication	  treatment.	  	  The	  documentation	   provided	  for	  review	  did	  not	  include	  designated	  follow-­‐up	  appointments	   for	  care	  following	  transition	  into	  the	  community.	  	  Due	  to	  the	  state	  of	  

	  

102.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 103 of 129 PAGEID #: 2456

Recommendations	  
Sources	  of	   Information	   	   	  

outpatient	  mental	  health	  services,	  appointments	  may	  take	  more	  than	   30	  days	  advanced	  notice	  to	  schedule.	  As	  youth	  are	  released	  with	  30	   days	  of	  medications,	  it	  is	  vital	  that	  they	  have	  appointments	  scheduled	  in	   advance	  to	  ensure	  continuity	  of	  care.	  	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	   1. Revise	  Behavioral	  Health	  Policy	  and	  Procedure	  to	  reflect	  the	  
requirements	  of	  this	  provision.	  	  This	  should	  include	  delineating	  the	   responsible	  party	  for	  transition	  planning	  to	  include	  mental	  health	   aftercare	  appointments.	   2. Begin	  transition	  planning	  at	  the	  time	  of	  admission	  to	  ensure	  that	   youth	  receive	  appropriate	  services	  at	  the	  time	  of	  discharge.	  	  This	   must	  include	  involvement	  of	  the	  youth’s	  parent	  or	  guardian.	   3. Document	  transition	  activities	  in	  the	  transition/discharge	   documents.	   4. Begin	  quality	  assurance	  monitoring	  of	  transition	  planning.	  
• Review	  of	  provided	  documents.	  	   • Staff	  interview	  
	  

	  

103.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 104 of 129 PAGEID #: 2457

III.B.18	  	  Oversight	  of	  Mental	  Health	  Services.	  	  The	  facilities	  shall	  ensure	  that	  youth	  receive	  the	   care	  they	  need	  by	  developing	  and	  implementing	  an	  adequate	  mental	  health	  Quality	   Assurance/Improvement	  Program;	  annually	  assessing	  the	  overall	  efficacy	  of	  the	  staffing,	   treatments	  and	  interventions	  used	  at	  the	  facilities;	  and	  as	  appropriate	  revising	  such	  staffing,	   treatments	  and	  interventions.	  	  

Compliance	  Rating	   Non-­‐Compliance	  

Self	  Assessment	  

The	  facility	  self-­‐assessment	  was	  provided	  orally,	  and	  did	  not	  include	   information	  regarding	  this	  provision.	  	  

Steps	  Taken	  to	   Assess	  Compliance	  

As	  noted	  in	  the	  previous	  monitoring	  report,	  the	  facility	  had	   developed	  policy	  and	  procedure	  regarding	  Quality	   Assurance/Improvement.	  	  This	  policy,	  with	  an	  effective	  date	  of	   January	  1,	  2011	  entitled	  “Behavioral	  Health	  Quality	   Assurance/Quality	  Improvement”	  outlined	  the	  process	  for	  clinical	   supervision	  and	  audits	  of	  clinical	  documentation.	   	   As	  noted	  above	  in	  this	  monitoring	  report,	  there	  was	  a	  recent	  effort	   undertaken	  by	  ODYS	  administration	  to	  perform	  a	  global	  review	  and	   rewrite	  of	  policy	  and	  procedure	  regarding	  behavioral	  health	   services.	  	  The	  goal	  of	  this	  process	  was	  to	  streamline	  policy	  and	  to	   promote	  the	  integration	  of	  mental	  health	  services	  (psychiatry,	   psychology,	  and	  social	  work)	  into	  one	  behavioral	  health	  program.	  	  In	   order	  to	  achieve	  this	  goal,	  ODYS	  designated	  work	  groups	  to	  review	   and	  edit	  policy	  and	  procedure.	  	  The	  revised	  policies,	  including	  policy	   and	  procedure	  regarding	  quality	  assurance	  remain	  pending.	  	  Quality	   assurance	  audits	  with	  respect	  to	  process	  should	  be	  developed	  to	   address	  specific	  policy	  and	  procedure	  requirements.	   	   Quality	  assurance	  audits	  were	  provided	  for	  review.	  	  These	  were	   performed	  via	  the	  clinical	  supervision	  sessions.	  	  The	  forms	  included	   sections	  headed	  “caseload	  review”,	  “quality	  review”,	  and	   “professional	  review.”	  	  The	  majority	  of	  the	  forms	  contained	  blank	   spaces,	  and	  did	  not	  reflect	  a	  systematic	  review	  of	  clinical	  quality	  or	   documentation.	  	  	  As	  data	  were	  not	  presented	  in	  a	  collated	  format,	  it	   was	  not	  possible	  to	  determine	  trends,	  or	  the	  need	  for	  corrective	   action	  with	  regard	  to	  one	  particular	  clinician,	  one	  particular	  housing	   unit,	  or	  if	  there	  were	  issues	  requiring	  attention	  from	  a	  systems	   perspective.	  	  	  	   	   It	  was	  noted	  on	  each	  individual	  audit	  that	  there	  were	  either	   compliments	  for	  the	  clinician’s	  work	  or	  specific	  issues	  reviewed	  with	   the	  clinician	  under	  review;	  however	  documentation	  provided	   revealed	  that	  no	  formal	  corrective	  action	  had	  been	  instituted	  from	   quality	  assurance	  monitoring	  in	  the	  90	  days	  prior	  to	  the	  monitoring	   visit.	  	  	   	   Issues	  with	  this	  type	  of	  quality	  assurance	  monitoring	  can	  be	  

	  

104.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 105 of 129 PAGEID #: 2458

illustrated	  by	  the	  case	  of	  Youth	  #222.	  	  This	  youth	  filed	  a	  grievance	   indicating	  that	  he	  had	  not	  been	  receiving	  individual	  mental	  health	   counseling	  sessions.	  	  The	  grievance	  was	  dismissed	  as	  having	  “no	   merit”	  as	  the	  youth	  was	  receiving	  daily	  door	  checks	  via	  psychology.	  	   Daily	  door	  checks	  are	  not	  a	  substitute	  for	  individual	  therapy.	  A	   review	  of	  this	  youth’s	  mental	  health	  documentation	  revealed	  no	   individual	  therapy	  sessions	  between	  7.1.12	  and	  7.23.12.	  	  Regular	   quality	  assurance	  could	  monitor	  for	  lapses	  in	  treatment	  in	  addition	   to	  the	  clinical	  quality	  of	  documentation.	   	   One	  behavioral	  health	  peer	  review	  narrative	  was	  provided	  for	   review.	  	  Unfortunately,	  this	  documentation	  did	  not	  include	  the	   comments	  of	  the	  peers.	  	  Additional	  information	  provided	  with	  this	   example	  indicated,	  “the	  new	  peer	  review	  process	  outlined	  in	  current	   policy	  has	  not	  yet	  been	  implemented	  system	  wide.”	   	   As	  noted	  above,	  the	  review	  of	  available	  documentation	  regarding	   quality	  assurance	  revealed	  a	  disjointed	  process	  that	  did	  not	  lend	   itself	  to	  a	  cogent	  review	  of	  the	  system	  or	  services	  provided.	  	   Additionally,	  at	  the	  time	  of	  this	  monitoring	  tour,	  there	  was	  no	   formal	  quality	  assurance	  monitoring	  occurring	  with	  respect	  to	  the	   psychiatric	  physician.	  	  	   	   It	  will	  be	  necessary	  that	  ODYS	  quality	  assurance	  monitoring	  review	   four	  specific	  areas,	  include	  a	  review/analysis	  of	  the	  resulting	  data,	   and	  corrective	  action	  as	  needed.	  	  Additionally,	  a	  predetermined	   percentage	  of	  all	  available	  records	  should	  be	  reviewed	  (e.g.	  10%).	  	  	  
1. Process	  measures-­‐	  this	  type	  of	  quality	  assurance	  would	   determine	  if	  behavioral	  health	  services	  are	  provided	  in	   keeping	  with	  implemented	  policy	  and	  procedure	  (e.g.	  were	   evaluations	  performed	  within	  a	  specific	  timeline;	  were	   laboratory	  examinations	  required	  via	  laboratory	  parameters	   ordered,	  reviewed	  and	  addressed;	  did	  youth	  receive	  the	   mental	  health	  services	  as	  directed	  by	  their	  treatment	  plan;	   were	  requests	  for	  mental	  health	  services	  performed	  in	  a	   timely	  manner;	  were	  psychiatric	  evaluations	  performed	  in	  a	   timely	  manner,	  etc.).	  	  For	  process	  measures	  regarding	   psychiatric	  evaluation	  and	  treatment,	  monitoring	  should	  be	   done	  via	  a	  medical	  model	  in	  concert	  with	  quality	  assurance	   monitoring	  performed	  for	  medical	  services.	  
2. Outcome	  measures-­‐	  this	  type	  of	  quality	  assurance	  would	   determine	  if	  behavioral	  health	  services	  provided	  were	  of	   benefit	  to	  the	  youth.	  	  Specifically,	  did	  they	  result	  in	  a	   reduction	  of	  youth	  symptoms	  and	  improvement	  in	  youth	   functioning?	  	  This	  could	  be	  determined	  via	  review	  of	  youth	   on	  youth	  violence	  statistics,	  youth	  aggression	  statistics,	  and	   the	  use	  of	  segregation.	  	  Additionally,	  pre	  and	  post	  testing	  

	  

105.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 106 of 129 PAGEID #: 2459

Recommendations	  
Sources	  of	   Information	   	   	  

measures	  could	  be	  utilized	  (e.g.	  reduction	  in	  the	  scores	  on	   depression	  scales).	  	  It	  is	  recognized	  that	  improvements	  in	   the	  indices	  discussed	  above	  would	  be	  multifactorial	  and	  not	   solely	  the	  result	  of	  behavioral	  health	  services.	  	  Other	   outcome	  measures	  could	  include	  youth	  satisfaction	  surveys.	   3. Peer	  review/Treatment	  integrity-­‐	  this	  type	  of	  quality	   assurance	  would	  include	  a	  critical	  review	  of	  behavioral	   health	  services	  provided	  via	  a	  peer-­‐review	  process	  (e.g.	   psychiatrists	  would	  periodically	  review	  each	  other’s	  work	   and	  provide	  feedback).	  	  Additionally,	  group	  therapeutic	   process	  could	  be	  observed	  with	  feedback	  provided	  to	  the	   clinician	  or	  youth	  specialist	  leading	  group	  in	  order	  to	  ensure	   adherence	  to	  the	  model	  and	  provide	  opportunities	  for	   coaching	  and	  improvement	  of	  the	  provided	  services.	   4. Selected	  studies	  –	  If	  a	  specific	  issue	  is	  suspected,	  or	  specific	   difficulties	  are	  observed	  with	  one	  particular	  unit,	  specific	   quality	  assurance	  studies	  could	  be	  performed	  with	  a	  critical	   analysis	  of	  the	  data	  in	  order	  to	  determine	  the	  need	  to	   adjust	  processes	  or	  treatments	  in	  order	  to	  improve	  efficacy.	   5. Corrective	  action	  –	  Any	  comprehensive	  quality	  assurance	   process	  must	  include	  both	  the	  synthesis	  and	  review	  of	   collected	  data	  on	  a	  regular	  basis.	  	  Data	  must	  be	  collected	  on	   a	  continuous	  basis	  and	  reviewed	  so	  that	  issues	  can	  be	   addressed	  in	  a	  timely	  manner.	  	  These	  issues	  may	  include	   challenges	  with	  the	  practice	  and	  documentation	  attributed	   to	  a	  specific	  staff	  member	  or	  they	  may	  identify	  systems	   issues.	  	  Issues	  that	  are	  identified	  must	  be	  addressed	  via	  a	   corrective	  action	  plan	  (e.g.	  staff	  training,	  staff	  supervision,	   policy/procedure	  review).	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	   1. Complete	  the	  revision	  of	  behavioral	  health	  policy	  and	  
procedure.	   2. Develop	  quality	  assurance	  monitoring	  based	  on	  policy	  and	  
procedure.	  This	  would	  include	  process	  measures,	  outcome	   measures,	  peer	  review/treatment	  integrity,	  and	  data	   analysis/corrective	  action.	  
• Staff	  Interview.	   • Review	  of	  the	  provided	  documents.	  
	  

	  

106.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 107 of 129 PAGEID #: 2460

G.1	  Progress	  Notes.	  The	  Facilities	  shall	  promulgate	  and	  implement	  a	  policy	  requiring	  that	  all	   health	  professionals	  be	  required	  to	  create	  and	  use	  progress	  notes	  to	  document,	  on	  a	  regular	   basis,	  interactions	  and	  each	  assessment	  of	  youth	  with	  mental/behavioral	  health	  or	  substance	   abuse	  needs.	  In	  particular,	  progress	  notes	  shall:	  	   a.)	  In	  the	  assessment,	  address	  the	  efficacy	  of	  interventions,	  currently	  presenting	  problems,	  and	   the	  available	  options	  to	  address	  those	  problems;	  and	  	   b.)	  Provide	  thorough	  documentation	  of	  all	  crisis	  interventions	  or,	  if	  not	  thoroughly	   documented	  in	  the	  progress	  notes,	  provide	  a	  reference	  to	  alert	  staff	  to	  another	  document	  in	   the	  youth’s	  file	  containing	  the	  details	  of	  the	  crisis	  intervention.	  	  

Compliance	  Rating	  	   Partial	  Compliance	  

Self	  Assessment	  	  

The	  facility	  self-­‐assessment	  was	  provided	  orally,	  and	  did	  not	  include	   information	  regarding	  this	  provision.	  	  

Steps	  Taken	  to	   Assess	  Compliance	  	  

Per	  interviews	  with	  mental	  health	  staff	  from	  both	  the	  facility	  and	  ODYS	   administration,	  a	  review	  and	  revision	  of	  mental	  health	  policy	  and	   procedure	  is	  in	  progress.	  Mental	  health	  documentation	  reviewed	  for	   the	  preparation	  of	  this	  monitoring	  report,	  while	  improved	  over	   previous	  reviews,	  continued	  to	  reveal	  deficiencies	  in	  clinical	   documentation.	  	   	   Mental	  health	  staff	  were	  authoring	  case	  conceptualizations;	  however,	   these	  were	  not	  located	  in	  all	  records	  reviewed	  on	  site.	  	  Documents	   reviewed	  revealed	  that	  overall,	  the	  case	  conceptualizations	  were	  in	   need	  of	  improvement.	  	  For	  example,	  the	  case	  conceptualization	   regarding	  Youth	  #111	  adequately	  described	  this	  youth’s	  home	  life	  and	   gang	  involvement.	  	  Treatment	  goals	  were	  identified	  to	  address	   challenges	  in	  these	  areas.	  	  Goals	  were	  not	  measurable,	  for	  example,	  “I	   will	  make	  a	  plan	  to	  develop	  new	  friends	  in	  the	  community	  and	  practice	   my	  positive	  social	  skills	  in	  ODYS.”	  	  Treatment	  objectives	  included	  a	  time	   limit	  within	  which	  the	  objective	  was	  to	  be	  completed,	  “I	  will	  figure	  out	   what	  makes	  a	  good	  friend	  as	  evidenced	  by	  completing	  workbook…and	   process	  it	  with	  my	  social	  worker	  by	  9.30.12.”	  	  	  The	  youth’s	  progress	   toward	  the	  identified	  objective	  was	  documented.	  	  The	  treatment	  plan	   would	  have	  been	  strengthened	  by	  the	  addition	  of	  measurable	  goals	   and	  objectives	  with	  regard	  to	  teaching	  positive	  social	  skills.	   	   In	  addition,	  this	  youth	  also	  had	  substance	  abuse	  and	  mental	  health	   diagnoses	  and	  was	  prescribed	  psychotropic	  medication.	  	  The	  case	   conceptualization	  did	  not	  review	  the	  youth’s	  mental	  health	  history,	  nor	   did	  it	  review	  the	  symptoms	  the	  youth	  was	  experiencing	  in	  order	  to	   justify	  the	  diagnoses.	  	  A	  review	  of	  the	  youth’s	  treatment	  plan	  revealed	   no	  treatment	  goals	  targeting	  substance	  abuse,	  the	  mental	  health	   diagnosis,	  or	  psychotropic	  medication.	   	   Specifically,	  mental	  health	  assessments	  did	  not	  routinely	  evidence	   adequate	  case	  conceptualization	  information	  required	  to	  develop	  a	   treatment	  plan	  addressing	  the	  youth’s	  needs.	  	  The	  documentation	  was	  

	  

107.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 108 of 129 PAGEID #: 2461

Recommendations	  	  
Sources	  of	   Information	  	   	   	  

especially	  weak	  with	  regard	  to	  mental	  health	  and	  substance	  abuse	   diagnoses.	  	  There	  was	  wide	  variability	  in	  the	  quality	  of	  progress	  notes	   documenting	  treatment.	  There	  were	  noted	  improvements	  in	  isolated	   instances,	  as	  discussed	  in	  the	  paragraphs	  regarding	  mental	  health	   services	  above.	  	  As	  discussed	  during	  the	  monitoring	  visit,	  this	  was	  an	   area	  that	  may	  be	  amenable	  to	  quality	  assurance	  monitoring.	  	   	   Examples	  of	  documentation	  regarding	  crisis	  intervention	  were	  limited;	   however,	  those	  reviewed	  revealed	  improvements	  with	  regard	  to	   timeliness	  of	  assessment.	  	  Record	  review	  revealed	  that	  in	  general,	   documentation	  was	  completed	  within	  24	  hours.	  	  In	  addition,	  when	   follow	  up	  visits	  were	  recommended,	  documentation	  was	  located.	  	  In	   future	  monitoring	  visits,	  additional	  examples	  of	  crisis	  intervention	   documentation	  will	  be	  requested.	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  	  
1. Ensure	  that	  case	  formulations	  are	  complete,	  outlining	  criteria	   for	  specific	  diagnoses	  and	  indicating	  specific	  youth	  risk	  factors	   for	  ongoing	  challenges.	  	  	  
2. Ensure	  that	  treatment	  plans	  include	  measurable	   goals/objectives	  with	  targeted	  interventions	  included	  to	   address	  each	  treatment	  goal	  and	  that	  progress	  notes	  reflect	   interventions	  aimed	  at	  addressing	  specific	  treatment	  goals.	  	  
3. Complete	  the	  planned	  review	  and	  revision	  of	  policy	  and	   procedure.	  
• Mental	  health	  records	  	   • Interviews	  with	  ODYS	  administrative	  staff	   • Interviews	  with	  facility	  mental	  health	  staff	  	  
	  

	  

108.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 109 of 129 PAGEID #: 2462

G.2	  Accessibility	  of	  Relevant	  Information.	  The	  Facilities	  shall	  ensure	  that	  youth	  records	  are	   organized	  in	  a	  manner	  providing	  treatment	  teams	  prompt	  access	  to	  relevant,	  complete,	  and	   accurate	  documentation	  regarding	  the	  youth’s	  status.	  	  

Compliance	  Rating	  	   Non-­‐Compliance	  

Self	  Assessment	  	  

The	  facility	  self-­‐assessment	  was	  provided	  orally,	  and	  did	  not	  include	   information	  regarding	  this	  provision.	  	  

Steps	  Taken	  to	   Assess	  Compliance	  	  

Currently,	  the	  record-­‐keeping	  program	  at	  the	  facility	  is	  cumbersome.	   There	  are	  multiple	  databases	  where	  information	  is	  stored,	  making	   access	  to	  information	  challenging.	  	  For	  example,	  the	  integrated	  progress	   notes	  reviewed	  contained	  information	  that	  was	  generated	  by	  psychiatry	   and	  psychology,	  there	  was	  no	  social	  work	  information	  included.	  	  The	   medical	  record	  included	  psychiatric	  documentation	  (evaluations	  and	   medication	  management	  progress	  notes),	  but	  did	  not	  include	  other	   mental	  health	  documentation.	  	  Given	  the	  multiple	  locations	  where	   information	  is	  stored,	  the	  information	  gathering	  process	  is	  laborious,	   therefore	  increasing	  the	  possibility	  of	  error.	  	  	  	   	   Per	  interviews	  with	  ODYS	  administration,	  there	  are	  plans	  to	  implement	   an	  integrated	  electronic	  health	  record,	  but	  at	  the	  time	  of	  this	   monitoring	  visit,	  this	  project	  remained	  in	  the	  planning	  stages.	  	  Pending	   this	  improvement,	  mental	  health	  staff	  of	  all	  disciplines	  are	  hampered	  by	   the	  current	  documentation	  system.	  	   	   Regardless,	  as	  stated	  in	  G1	  above,	  per	  the	  review	  of	  youth	  records	  and	   mental	  health	  documentation	  available	  for	  off	  site	  review,	  there	  was	   considerable	  variability	  in	  the	  quality	  of	  documentation	  regarding	   mental	  health	  treatment.	  	  This	  is	  an	  area	  that	  would	  be	  amenable	  to	   quality	  assurance	  (with	  associated	  corrective	  action)	  and	  peer	  review.	  	  	  

Recommendations	  	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  	  
1. Ensure	  that	  all	  mental	  health	  staff,	  including	  psychiatrists,	  have	   access	  to	  relevant,	  complete	  and	  accurate	  documentation	   regarding	  the	  youth’s	  mental	  health	  status	  and	  treatment.	  	  
2. Continue	  and	  expand	  quality	  assurance	  monitoring	  of	  mental	   health	  documentation.	  	  This	  would	  include	  a	  review	  of	  a	   percentage	  of	  mental	  health	  records	  along	  with	  corrective	   action	  plans	  as	  needed.	  

Sources	  of	   Information	  	  
	   	   	  
	  

• Mental	  health	  records	  	   • Interviews	  with	  ODYS	  and	  facility	  mental	  health	  staff	  	   • Medical	  records	  
	  

	  

109.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 110 of 129 PAGEID #: 2463

MEDICAL	  SERVICES	  
	  
III.C.1	  	  General.	  The	  facilities	  shall	  ensure	  that	  the	  individuals	  they	  serve	  receive	  routine,	   preventive,	  and	  emergency	  medical	  and	  dental	  care	  consistent	  with	  current,	  generally	  accepted	   professional	  standards.	  The	  facilities	  shall	  ensure	  that	  individuals	  with	  health	  problems	  are	   identified,	  assessed,	  diagnosed,	  and	  treated	  consistent	  with	  current,	  generally	  accepted	   professional	  standards	  of	  care.	  	  

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

The	  Ohio	  Department	  of	  Youth	  Services	  (ODYS)	  did	  not	  conduct	  a	  self-­‐ assessment	  for	  the	  level	  of	  medical	  and	  dental	  care	  provided	  at	  SJCF	   during	  this	  assessment	  period.	  However,	  there	  has	  been	  significant	   improvement	  in	  their	  quality	  assurance	  processes,	  which	  in	  essence	   completes	  the	  task	  of	  self-­‐assessment	  for	  the	  purpose	  of	  this	  report.	  	  

Steps	  Taken	  to	   Assess	  Compliance	  

An	  onsite	  visit	  was	  conducted	  at	  the	  Scioto	  Juvenile	  Correctional	  Facility	   on	  October	  16-­‐18,	  2012.	  It	  was	  this	  monitor’s	  second	  visit	  to	  the	  facility.	   All	  previous	  reviews	  of	  health	  information	  and	  other	  related	  documents	   had	  been	  conducted	  off	  site	  from	  records	  provided	  by	  ODYS.	  Some	  of	  the	   living	  units	  were	  undergoing	  repairs	  secondary	  to	  storm	  damage.	   Available	  living	  units	  were	  visited	  and	  procedural	  operations	  and	  access	   related	  to	  health	  care	  observed.	  Youth	  were	  interviewed	  on	  the	  units	  as	   to	  how	  to	  access	  sick	  call	  and	  if	  they	  had	  any	  complaints	  regarding	  their	   medical	  care.	  The	  food	  service	  area	  was	  toured	  and	  the	  medication	  room	   located	  there	  observed.	  The	  satellite	  clinics	  for	  Buckeye	  had	  not	  been	   completed.	  The	  rooms	  had	  been	  identified	  and	  converted	  from	  existing	   cells.	  The	  toilet/sink	  combinations	  were	  still	  remained	  in	  the	  room	  with	   an	  exam	  table.	  There	  was	  not	  an	  appropriate	  sink	  or	  adequate	  medical	   equipment	  to	  make	  it	  suitable	  as	  an	  exam	  room	  or	  to	  use	  to	  dispense	   medications.	  	  The	  main	  clinic	  was	  still	  found	  to	  be	  adequate,	  with	   appropriate	  space,	  medical	  supplies	  and	  equipment	  for	  medical	  and	   dental	  care	  of	  the	  youth.	   	   Documentation	  from	  January	  12,	  2012	  was	  provided	  by	  Dr.	  John	  Bradley,	   ODYS	  Medical	  Director	  stating	  completion	  of	  the	  annual	  review	  and	   revision	  of	  each	  policy,	  procedure	  and	  program	  in	  the	  health	  care	   delivery	  system	  with	  an	  attached	  list	  of	  said	  policies	  and	  standard	   operating	  procedures.	  	  	  	   	  	   A	  review	  of	  eight	  youth	  health	  records	  housed	  at	  the	  Scioto	  Facility	  was	   conducted.	  This	  included	  any	  Youth	  Injury	  and	  Assessment	  Forms	  present	   in	  the	  chart.	  The	  health	  record	  review	  included	  assessing	  completeness	   of	  the	  Problem	  List,	  the	  presence	  and	  timeliness	  of	  the	  Nursing	  Intake	   Screening,	  Mental	  Health	  Screening,	  Physical	  Exam,	  Dental	  Exam,	  Dental	   Treatment,	  Oral	  Hygiene	  Instruction	  and	  Growth	  Chart.	  	  Admission	  labs	   were	  checked	  for	  completion	  and	  results	  within	  20	  days;	  STD	  screening	   for	  Gonorrhea	  and	  Chlamydia;	  Chronic	  Care	  and	  Specialty	  Care	  Consult	  

	  

110.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 111 of 129 PAGEID #: 2464

documentation;	  Transfer	  of	  Health	  Records;	  Immunizations	  and	   Tuberculosis	  Screening;	  Medication	  Administration	  Records;	  Mental	   Health	  Documentation;	  Progress	  Notes	  and	  Physician	  Orders	  were	   checked	  in	  each	  health	  record.	  Since	  the	  last	  visit,	  the	  health	  records	  now	   contain	  the	  original	  health	  request	  completed	  by	  the	  youth,	  which	  are	   addressed	  by	  medical	  staff	  in	  the	  progress	  notes.	  	   	   All	  records	  documented	  timely	  completion	  of	  intake	  assessments	  such	  as	   nurse	  screenings	  health	  appraisals	  and	  physical	  examinations	  all	  on	  the	   same	  day	  of	  admission.	  Growth	  Charts	  were	  present	  for	  all	  youth.	  There	   was	  documentation	  of	  admission	  labs	  being	  drawn	  with	  results	  available	   all	  within	  a	  week.	  STD	  screening	  results	  were	  documented	  in	  all	  records.	   Immunization	  records	  were	  up	  to	  date	  on	  all	  records	  reviewed.	  HPV	   vaccine	  is	  now	  being	  administered	  to	  all	  youth,	  male	  and	  females,	  as	   available.	  There	  is	  a	  back	  order	  on	  the	  HPV	  vaccine	  through	  the	  Federal	   Vaccines	  for	  Children	  Program.	  I	  reviewed	  the	  facility’s	  vaccine	   accountability	  order	  documentation.	  Youth	  had	  already	  been	   administered	  influenza	  vaccine	  for	  the	  current	  flu	  season.	  All	  youth	   received	  tuberculosis	  screening	  with	  documented	  results.	  	  Dental	   examinations	  were	  completed	  within	  a	  week	  of	  admission	  with	   instruction	  given	  on	  oral	  hygiene.	  Dental	  treatment	  was	  provided	  as	  a	   result	  of	  the	  dental	  examination	  or	  as	  a	  result	  of	  a	  Health	  Request.	  Youth	   are	  being	  recalled	  every	  6	  months	  for	  dental	  care.	  	  All	  youth	  allergies	   were	  noted	  in	  their	  health	  record.	  	   	   Medication	  administration	  records	  and	  physician	  orders	  were	  also	   reviewed	  for	  accuracy	  and	  medication	  compliance.	  There	  was	   documentation	  of	  three	  optometry	  consults	  for	  youth	  to	  receive	  glasses.	   Youth	  complaining	  of	  headaches	  received	  a	  neurology	  consult	  and	  CT	   scan.	  Diabetic	  youth	  appropriately	  received	  ophthalmology,	  endocrine	   and	  podiatry	  consults.	  Two	  of	  the	  eight	  youth	  records	  reviewed	  had	  with	   chronic	  medical	  conditions	  (diabetes).	  Both	  received	  appropriate	   assessments	  and	  treatment	  plans.	  There	  were	  only	  five	  youth	  at	  the	   facility	  with	  chronic	  medical	  diagnoses,	  including	  the	  two	  reviewed.	  Six	  of	   the	  eight	  youth	  records	  reviewed	  had	  at	  least	  one	  mental	  health	   diagnosis.	  All	  mental	  health	  diagnoses	  as	  well	  as	  medical	  diagnoses	  were	   listed	  on	  the	  problem	  list.	  This	  is	  a	  significant	  improvement	  since	  the	  last	   review.	  	   	   Medical	  services	  for	  the	  10	  females	  at	  the	  facility	  were	  discussed	  with	   their	  provider,	  Dr.	  Stein.	  He	  stated	  most	  of	  the	  girls	  have	  already	  had	  PAP	   smears	  and	  refuse	  the	  pelvic	  exam.	  The	  American	  College	  of	  Obstetrics	   and	  Gynecology	  (ACOG)	  no	  longer	  recommends	  PAP	  smears	  in	  females	   less	  than	  21	  years	  of	  age.	  All	  females	  are	  screened	  for	  Gonorrhea	  and	   Chlamydia	  using	  a	  urine	  test.	  There	  were	  no	  pregnant	  girls	  at	  the	  facility,	   but	  services	  are	  either	  provided	  through	  their	  designated	  Hospital	   (Grady)	  or	  girls	  are	  transported	  back	  to	  their	  community	  Obstetrician	  for	  

	  

111.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 112 of 129 PAGEID #: 2465

continued	  care.	  	  	  

	  

When	  nurses	  made	  seclusion	  checks,	  they	  were	  documented	  in	  the	  

progress	  notes.	  Logs	  were	  posted	  on	  the	  unit	  doors.	  Some	  youth	  

identified	  through	  review	  of	  the	  medical	  records	  spent	  several	  days	  in	  

seclusion.	  Progress	  notes	  simply	  state	  “seclusion	  check”	  without	  details	  

of	  the	  youth’s	  health	  status.	  A	  full	  progress	  note	  is	  needed	  in	  SOAP	  

format.	  Youth	  are	  spending	  a	  significant	  amount	  of	  time	  in	  seclusion	  on	  

the	  Progress	  Unit,	  therefore	  making	  it	  even	  more	  important	  to	  document	  

the	  details	  of	  their	  health	  status.	  There	  was	  one	  youth	  with	  3	  days	  

documented	  since	  his	  arrival	  on	  6/14/12.	  One	  youth	  had	  24	  days	  of	  

seclusion	  checks	  documented	  between	  February	  and	  October	  2012.	  

Another	  had	  51days	  in	  seclusion	  between	  January	  and	  the	  time	  of	  the	  

visit.	  A	  fourth	  youth	  had	  69	  days	  of	  documented	  seclusion	  checks	  within	  

a	  year.	  Many	  of	  the	  days	  in	  seclusion	  ran	  in	  continuous	  blocks.	  	  At	  least	  

half	  of	  the	  medical	  records	  reviewed	  had	  documentation	  of	  youth	  having	  

been	  secluded.	  	  

	  

	  

Documentation	  on	  the	  Youth	  injury	  and	  Assessment	  Reports	  were	  

reviewed	  for	  those	  included	  in	  the	  eight	  health	  records.	  There	  has	  been	  

overall	  improvement	  in	  the	  documentation	  provided	  by	  nursing	  staff	  for	  

youth	  assessed	  for	  injuries.	  There	  are	  still	  some	  individual	  nurses	  that	  are	  

not	  adequately	  documenting	  these	  assessments.	  This	  was	  discussed	  with	  

the	  Nurse	  Manager,	  Ms.	  Vickie	  Donohue,	  who	  was	  already	  aware	  

through	  the	  continuous	  quality	  improvement	  (CQI)	  review	  process.	  These	  

individuals	  have	  been	  placed	  on	  a	  performance	  improvement	  plans.	  	  

	  

Internal	  (CQI)	  Quality	  Assurance	  documents	  were	  reviewed	  that	  were	  

provided	  by	  ODYS	  which	  included	  several	  audit	  instruments.	  The	  QA	  

instruments	  and	  processes	  have	  been	  revised	  since	  the	  last	  visit.	  The	  

Nurse	  Manager	  is	  now	  involving	  more	  staff	  nurses	  in	  the	  process	  and	  the	  

documents	  have	  been	  formatted	  differently	  for	  easier	  use.	  This	  is	  a	  good	  

idea	  and	  helps	  staff	  to	  understand	  and	  complete	  the	  process	  better.	  

Chronic	  Care	  audits	  are	  now	  conducted	  quarterly	  due	  to	  the	  small	  

number	  of	  youth	  with	  chronic	  medical	  conditions.	  Medication	  

Administration	  Record	  Continuous	  Quality	  Improvement	  (CQI)	  

documents	  for	  April	  10,	  2012	  and	  August	  3,	  2012	  was	  reviewed.	  Between	  

April	  and	  August	  there	  was	  improvement	  from	  60%	  to	  100%	  on	  the	  

compliance	  indicator	  of	  medication	  frequency,	  doses,	  route,	  start	  and	  

stop	  date	  documented.	  Improvements	  from	  60%	  to	  100%	  were	  also	  

shown	  in	  3	  other	  areas	  of	  medication	  compliance	  indicators.	  The	  CQI	  

Problem	  List	  review	  showed	  significant	  compliance	  with	  documentation	  

of	  all	  chronic	  medical	  conditions,	  including	  mental	  health	  diagnoses.	  This	  

is	  consistent	  with	  the	  improvement	  I	  noted	  on	  this	  visit	  compared	  to	  the	  

previous	  one.	  There	  still	  needs	  to	  be	  improvement	  on	  documenting	  acute	  

medical	  conditions	  on	  the	  problem	  list,	  as	  noted	  in	  the	  CQI	  report.	  Vital	  

signs	  at	  the	  time	  of	  encounter	  were	  reviewed	  on	  June	  5,	  2012	  and	  August	  

	  

112.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 113 of 129 PAGEID #: 2466

Recommendations	  
Sources	  of	   Information	   	  

7,	  2012.	  The	  documentation	  of	  vital	  signs	  CQI	  audit	  showed	  improvement	   from	  85%	  to	  95%.	  The	  CQI	  Processing	  of	  Specialty	  Consults	  was	  reviewed	   from	  June	  2012,	  September	  6,	  2012	  and	  October	  9,	  2012.	  The	  initial	  June	   review	  identified	  the	  need	  for	  improvement	  In	  all	  areas,	  except	  physician	   orders	  being	  written	  for	  consultation	  and	  youth	  being	  seen	  by	  the	   physician	  at	  the	  next	  clinic	  visit.	  The	  September	  audit	  showed	   improvement	  to	  90%	  in	  all	  areas	  but	  one.	  The	  October	  CQI	  review	   showed	  100%	  compliance	  in	  80%	  of	  the	  compliance	  indicators.	  CQI	   documents	  for	  completion	  of	  the	  Youth	  Injury	  Assessment	  Form	  (YIAF)	   were	  reviewed	  from	  June	  5,	  2012,	  July	  9,	  2012	  and	  October	  5,	  2012	  and	   showed	  improvement	  of	  youth	  on	  the	  Progress	  Unit	  being	  brought	  to	  the	   exam	  room	  for	  evaluation.	  The	  Nurse	  Manager,	  also	  through	  the	  CQI	   process	  was	  able	  to	  identify	  certain	  staff	  not	  properly	  conducting	   assessments,	  as	  previously	  noted.	  What	  is	  most	  important	  is	  the	  process	   and	  that	  medical	  staff	  are	  conducting	  self	  assessments	  and	  developing	   corrective	  action	  plans	  based	  on	  their	  findings	  in	  order	  to	  continuously	   improve	  the	  quality	  of	  health	  care.	  During	  this	  site	  visit,	  I	  met	  with	  Dr.	   John	  Brady,	  Medical	  Director	  and	  Pamela	  Robbins,	  Director	  of	  Nursing	   along	  with	  Scioto	  Nurse	  Manager,	  Vickie	  Donohue	  to	  discuss	  all	  medical	   findings.	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  	  	  
1. Complete	  satellite	  clinic	  and	  medication	  room	  on	  Buckeye	  Units	   for	  adequate	  injury	  assessments	  of	  youth	  and	  medication	   administration	  on	  the	  unit.	  	  
2. Limit	  time	  of	  youth	  in	  seclusion	  and	  improve	  documentation	  of	   health	  status	  during	  segregation.	  
3. Continue	  to	  improve	  Quality	  Assurance	  (QA)	  activities	  by	   considering	  a	  review	  at	  least	  annually	  by	  a	  source	  external	  to	   ODYS	  Health	  Services.	  ODYS	  should	  also	  consider	  expansion	  of	   the	  QA	  process	  to	  include	  some	  additional	  quality	  indicators.	   Conduct	  Quality	  Assurance	  Program	  as	  outlined	  in	  the	  National	   Commission	  on	  Correctional	  Health	  Care	  Juvenile	  Health	   Standards.	  This	  would	  satisfy	  the	  need	  for	  a	  self	  assessment.	  
• Site	  visit	  tour;	  Review	  of	  eight	  youth	  health	  records:	  ID	  #	  217938,	   217241,	  217365,	  217718,	  215927,	  218016,	  218076,	  and	  218098;	   CQI	  Documentation	  as	  outlined	  above.	  	  
	  

	  

113.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 114 of 129 PAGEID #: 2467

III.C.2	  	  Health	  Records.	  The	  State	  shall	  develop	  and	  implement	  policies,	  procedures	  and	   practices	  to	  ensure	  that,	  consistent	  with	  State	  and	  federal	  law,	  at	  a	  minimum,	  the	  juvenile	   courts	  in	  the	  State,	  all	  juvenile	  detention	  facilities	  and	  all	  placement	  settings	  from	  which	   youth	  are	  committed	  shall	  timely	  forward	  to	  Scioto,	  or	  to	  the	  facility	  of	  placement	  (if	  the	   records	  arrive	  after	  the	  youth	  has	  been	  placed),	  all	  pertinent	  youth	  records	  regarding	   medical	  and	  mental	  health	  care.	  The	  facilities	  shall	  develop	  and	  implement	  policies,	   procedures	  and	  practices	  to	  ensure	  that	  health	  care	  staff,	  including	  mental	  health	  care	   staff,	  have	  access	  to	  documents	  that	  are	  relevant	  to	  the	  care	  and	  treatment	  of	  the	  youth.	  	  

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

The	  Ohio	  Department	  of	  Youth	  Services	  (ODYS)	  did	  not	  conduct	  a	   self-­‐assessment	  for	  the	  level	  of	  medical	  and	  dental	  care	  provided	  at	   SJCF	  during	  this	  assessment	  period.	  However	  the	  health	  records	  are	   being	  reviewed	  as	  a	  part	  of	  the	  CQI	  process.	  	  	  

Steps	  Taken	  to	   Assess	  Compliance	  

Review	  of	  eight	  youth	  health	  records.	  There	  were	  no	  new	  Health	   Policies	  and	  Procedures	  or	  Standard	  Operating	  Procedures	  (SOP)	   completed	  by	  ODYS	  since	  the	  last	  visit.	  All	  health	  records	  reviewed	   contained	  some	  health	  information	  transferred	  from	  the	  county	   probation	  offices	  or	  other	  facilities.	  I	  still	  have	  a	  concern	  that	  the	   offense	  data	  contained	  within	  the	  Disposition	  Investigative	  Report	   is	  included	  in	  some	  of	  the	  health	  records	  along	  with	  the	  medical	   information	  on	  the	  youth.	  The	  offense	  information	  is	  irrelevant	  to	   the	  provision	  of	  the	  youth’s	  health	  care	  and	  should	  not	  be	  included	   in	  the	  health	  record.	  The	  health	  record	  is	  still	  fragmented	  due	  to	   the	  psychological	  and	  counseling	  notes	  being	  housed	  separately	  on	   the	  housing	  units.	  However,	  two	  weeks	  prior	  to	  this	  visit,	  an	  RFP	   was	  awarded	  to	  eClinical	  Works	  through	  the	  Ohio	  Department	  of	   Administrative	  Services	  and	  the	  Office	  of	  Information	  Technology	   (OIT)	  for	  implementation	  of	  an	  electronic	  health	  record	  (EHR).	  I	   reviewed	  the	  Adult	  Department	  of	  Rehabilitation	  and	  Correction	   (DRC)	  Electronic	  Health	  Record	  (EHR)	  workflow	  and	  documentation	   requirements	  included	  in	  the	  RFP,	  which	  was	  very	  comprehensive.	   The	  system	  seems	  to	  be	  able	  to	  provide	  adequate	  health	   information	  in	  an	  electronic	  format	  at	  the	  facilities.	  The	  plan	  is	  for	   the	  EHR	  to	  also	  connect	  the	  state	  and	  community	  providers,	   initially	  to	  begin	  with	  the	  (DRC),	  followed	  by	  ODYS,	  KALOS	   Pharmacy,	  Central	  Medical	  Lab,	  Franklin	  Medical	  Center	  and	  OSU	   Hospital	  records.	  	  The	  program	  will	  be	  customized	  for	  each	  of	  its	   users	  to	  include	  links	  that	  may	  be	  specific	  to	  DYS,	  such	  as	  the	  state	   immunization	  records.	  The	  EHR	  is	  to	  be	  piloted	  at	  one	  female	  adult	   correctional	  facility	  in	  April	  2013.	  The	  electronic	  health	  record	   being	  established	  will	  facilitate	  the	  sharing	  of	  the	  mental	  health	   and	  medical	  information.	  SJCF	  currently	  has	  a	  Mental	  Health	   Database	  that	  I	  observed	  during	  the	  April	  2012	  visit.	  Although	  not	   all-­‐inclusive,	  this	  database	  includes	  diagnosis,	  medication	   information	  and	  medication	  compliance.	  Psychology	  staff	  that	  are	   directly	  involved	  with	  the	  care	  and	  treatment	  of	  the	  Youth	  at	  SJCF	  

	  

114.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 115 of 129 PAGEID #: 2468

have	  access	  to	  the	  psychiatry	  notes.	  This	  system	  can	  continue	  to	  be	   used	  until	  the	  full	  development	  and	  implementation	  of	  eClinical	   Works.	  	  

Recommendations	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	   State	  must:	  
1. Continue	  to	  improve	  the	  process	  for	  sharing	  of	  health	   information	  between	  medical	  and	  mental	  health	  to	  include	   psychologists	  through	  implementation	  of	  eClinical	  Works	   EHR.	  ODYS	  medical	  management	  staff	  should	  be	  intimately	   involved	  in	  the	  process	  of	  customization	  of	  the	  EMR	  to	  be	   relevant	  to	  youth	  medical	  services.	  
2. Redact	  offense-­‐related	  information	  from	  the	  Disposition	   Investigation	  Report	  contained	  in	  the	  health	  record.	  	  

Sources	  of	   Information	  
	   	   	   	  

• Site	  visit	  tour;	  Review	  of	  eight	  youth	  health	  records:	  ID	  #	   Site	  visit	  tour;	  Review	  of	  ten	  youth	  health	  records:	  217938,	   217241,	  217635,	  217718,	  215927,	  218016,	  218076,	  and	   218098.	  	  
• Discussion	  with	  and	  documentation	  provided	  by	  Dr.	  John	   Bradley,	  Medical	  Director,	  regarding	  EHR	  RFP	  
	  

	  

115.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 116 of 129 PAGEID #: 2469

III.C.5	  	  Access	  to	  Health	  Services.	  The	  facilities	  shall	  ensure	  that	  youth	  can	  request	  to	  be	  seen	  by	   medical	  staff	  confidentially	  and	  independent	  from	  JCOs	  and	  custodial	  staff.	  	  

Compliance	  Rating	   Substantial	  Compliance	  

Self	  Assessment	  

The	  Ohio	  Department	  of	  Youth	  Services	  (ODYS)	  did	  not	  conduct	  a	  self-­‐ assessment	  for	  the	  level	  of	  medical	  and	  dental	  care	  provided	  at	  SJCF	   during	  this	  assessment	  period.	  	  	  

Steps	  Taken	  to	   Assess	  Compliance	  

Health	  Request	  call	  drop	  boxes	  were	  missing	  on	  some	  of	  the	  living	  units,	   which	  appeared	  to	  be	  freshly	  painted.	  It	  appeared	  to	  be	  an	  oversight	  in	   replacing	  the	  boxes	  on	  the	  units.	  Health	  Request	  boxes	  were	  present	  in	   the	  Cafeteria	  and	  in	  the	  School.	  Youth	  interviewed	  with	  the	  exception	  of	   one,	  all	  knew	  where	  the	  boxes	  were	  located	  and	  all	  could	  verbalize	  how	   to	  gain	  access	  to	  health	  services.	  Progress	  Notes	  and	  Nurse	  Health	   Requests	  were	  reviewed	  in	  8	  health	  records.	  The	  original	  Health	   Requests	  are	  now	  included	  in	  the	  health	  record	  and	  not	  in	  a	  separate	   binder	  as	  on	  the	  previous	  visit.	  Health	  requests	  included	  in	  these	  health	   records	  were	  responded	  to	  adequately	  and	  documented	  by	  medical	  staff	   100%	  of	  the	  time.	  Health	  Requests	  were	  reviewed	  and	  in	  each	  case	   traced	  back	  to	  a	  corresponding	  progress	  note	  to	  determine	  if	  the	   complaint	  had	  been	  addressed.	  In	  all	  cases,	  the	  requests	  had	  been	   adequately	  assessed	  and	  treated	  by	  registered	  nursing	  staff	  and	  in	  some	   cases	  by	  the	  physician.	  Most	  requests	  were	  relatively	  minor	  such	  as	  sore	   throat,	  runny	  nose	  and	  skin	  complaints.	  There	  were	  several	  related	  to	   dental	  complaints.	  All	  were	  addressed	  in	  a	  timely	  manner	  by	  health	  care	   staff.	  	  	  

Recommendations	  

In	  order	  to	  maintain	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Ensure	  Health	  Request	  slips	  and	  boxes	  are	  readily	  available	  to	   youth	  on	  all	  housing	  units.	  Youth	  should	  not	  have	  to	  rely	  on	   custody	  staff	  to	  request	  forms.	  	  	  

Sources	  of	   Information	  
	   	   	   	  

• Site	  visit	  tour;	  Review	  of	  ten	  youth	  health	  records:	  217938,	   217241,	  217365,	  217718,	  215927,	  218016,	  218076,	  and	  218098.	  
	  

	  

116.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 117 of 129 PAGEID #: 2470

SPECIAL	  EDUCATION	  
	  
III.E.1	  Provision	  of	  Special	  Education.	  The	  State	  shall,	  at	  all	  times,	  provide	  all	  youth	  confined	  at	   the	  facilities	  with	  adequate	  special	  education	  in	  compliance	  with	  the	  Individuals	  with	  Disabilities	   Education	  Act	  (IDEA),	  20	  U.S.C.	  §	  1400-­‐1482,	  and	  regulations	  promulgated	  thereunder,	  and	  this	   Stipulation.	  	  

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

Prior	  to	  the	  Monitor’s	  visit	  in	  October	  2012,	  the	  State	  was	  asked	  to	   produce	  data	  and	  explanations	  for	  a	  limited	  range	  of	  issues	  related	  to	  the	   three	  education-­‐related	  provisions	  that	  are	  included	  in	  the	  Amended	   Stipulation.	  The	  first	  provision	  pertains	  to	  the	  delivery	  of	  special	   education	  services	  in	  general.	  In	  the	  past,	  the	  key	  compliance	  issues	  were	   related	  to	  providing	  education	  services	  to	  youth	  who	  were	  removed	  from	   school	  during	  the	  day	  or	  who	  were	  held	  on	  the	  unit	  for	  disciplinary	   reasons.	  	   	   School	  Safety	   	   Schools	  cannot	  facilitate	  learning	  if	  the	  environment	  is	  not	  safe.	  Shortly	   after	  the	  facility	  converted	  to	  a	  long-­‐term	  placement	  for	  medium	  and	   close	  custody	  youth,	  the	  rates	  of	  youth	  violence	  increased	  significantly.	   During	  the	  previous	  monitoring	  period,	  school	  schedules	  were	  shifted	  so	   that	  medium	  custody	  and	  close	  custody	  boys	  attended	  school	  in	  different	   buildings,	  and	  the	  girls	  attend	  school	  separately	  as	  well.	  This	  appears	  to	   have	  created	  a	  safer	  environment	  that	  is	  much	  more	  conducive	  to	   learning.	  	   	   With	  many	  of	  the	  staffing	  problems	  now	  resolved,	  as	  discussed	  below,	   the	  safety	  of	  the	  school	  environment	  has	  continued	  to	  improve.	  In	  the	   PROGRESS	  Unit	  (PU)	  school,	  additional	  YS	  staff	  have	  been	  deployed	  to	   provide	  extra	  security	  during	  school	  hours	  and	  the	  classroom	   environments	  have	  been	  “hardened”	  (e.g.,	  furniture	  bolted	  down,	  flex	   keyboards	  put	  into	  use,	  etc.)	  resulting	  in	  greater	  safety	  for	  both	  youth	   and	  staff.	  In	  January	  2012,	  48	  YBIRs	  were	  issued	  in	  the	  PU	  school,	   compared	  to	  only	  9	  in	  September	  2012.	  Other	  elements	  related	  to	  the	   ability	  to	  of	  students	  to	  access	  and	  teachers	  to	  deliver	  the	  special	   education	  program	  are	  discussed	  in	  more	  detail	  below.	  	   	   Staffing	  Issues	   	   At	  the	  conclusion	  of	  the	  previous	  monitoring	  period,	  the	  school	  was	   short	  two	  special	  education	  teachers,	  one	  math	  teacher	  and	  one	  science	   teacher.	  	  Several	  more	  teachers	  were	  out	  on	  disability	  leave	  and	  the	   facility	  did	  not	  have	  sufficient	  numbers	  of	  substitute	  teachers	  to	  cover	  all	   the	  classes.	  These	  education	  staffing	  problems	  were	  compounded	  by	   direct	  care	  staffing	  shortages	  that	  prevented	  youth	  from	  being	  

	  

117.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 118 of 129 PAGEID #: 2471

transported	  to	  the	  school	  buildings.	  Throughout	  most	  of	  the	  previous	   monitoring	  period,	  students	  did	  not	  have	  dependable	  access	  to	  the	  daily	   330	  minutes	  of	  instruction	  required	  by	  State	  law.	  	   	   During	  the	  current	  monitoring	  period,	  these	  staffing	  issues	  were	  largely	   resolved.	  Many,	  but	  not	  all,	  of	  the	  vacant	  teacher	  positions	  were	  filled	   and	  nearly	  all	  of	  the	  teachers	  on	  disability	  returned	  to	  work.	  	   	   However,	  the	  Science	  teacher	  position	  was	  vacant	  for	  the	  entire	   monitoring	  period.	  The	  attendance	  secretary	  position	  was	  vacant	  for	  the	   last	  three	  months	  (but	  was	  filled	  just	  prior	  to	  the	  Monitor’s	  visit	  in	   October	  2012).	  A	  Math	  teacher	  position	  became	  vacant	  during	  the	  last	   month	  of	  the	  monitoring	  period.	  On	  the	  positive	  side,	  all	  of	  the	  special	   education	  teaching	  positions	  were	  filled	  throughout	  the	  entire	   monitoring	  period,	  along	  with	  three	  substitute	  teacher	  positions.	  These	   improvements	  in	  staffing	  meant	  that	  no	  classes	  were	  cancelled	  due	  to	   teacher	  shortages	  throughout	  the	  entire	  six-­‐month	  monitoring	  period.	   On	  the	  Youth	  Specialist	  (YS)	  side,	  only	  two	  instructional	  days	  were	   modified	  due	  to	  short	  staffing	  during	  the	  current	  monitoring	  period	  (one	   in	  April,	  one	  in	  May,	  both	  in	  the	  PU	  school).	  Improvements	  are	   particularly	  pronounced	  in	  the	  PU	  school,	  where	  classes	  have	  been	  held	   daily,	  with	  very	  few	  exceptions,	  throughout	  the	  entire	  monitoring	  period.	   [It	  is	  worth	  noting	  that	  some	  PU	  students’	  behavior	  issues	  result	  in	   frequent	  periods	  of	  seclusion	  and	  removal	  from	  the	  school	  program.	   Treatment	  planning	  and	  behavior	  modification	  efforts	  for	  these	  youth	   are	  the	  subject	  of	  a	  current	  Dispute	  Resolution	  between	  the	  Parties.]	  	   	   While	  vacancies	  have	  and	  will	  continue	  to	  occur,	  the	  facility’s	  staffing	   pattern	  has	  returned	  to	  appropriate	  levels	  and	  no	  longer	  represents	  a	   barrier	  to	  the	  youth’s	  ability	  to	  access	  the	  special	  education	  program.	  	   	   ABC	  Room	   In	  the	  past,	  youth	  who	  exhibited	  non-­‐compliant	  behavior	  in	  the	   classroom	  could	  be	  suspended	  from	  school	  and	  returned	  to	  their	  living	   units	  where	  they	  did	  not	  receive	  education	  services	  of	  any	  kind.	  The	   State	  ceased	  suspending	  students	  in	  June	  2011,	  relying	  more	  heavily	  on	   its	  in-­‐school	  suspension	  room	  (the	  Academic	  Behavior	  Center	  (ABC))	  and	   its	  procedure	  for	  Unit	  Instruction.	  	   	   The	  ABC	  room	  provides	  youth	  an	  opportunity	  to	  regain	  control	  of	  their	   behavior	  and	  to	  return	  to	  the	  classroom	  setting	  without	  going	  back	  to	   their	  living	  units.	  Youth	  are	  referred	  to	  the	  ABC	  room	  for	  rule	  violations	   pertaining	  to	  offensive	  or	  threatening	  conduct,	  being	  disruptive,	   distracting	  other	  students	  or	  being	  outside	  an	  authorized	  area.	  During	   the	  previous	  monitoring	  period,	  staff	  shortages	  left	  this	  resource	   unavailable	  to	  teachers,	  which	  frequently	  resulted	  in	  youth	  being	  sent	   back	  to	  their	  units	  during	  the	  school	  day	  and	  the	  loss	  of	  integrity	  of	  the	  

	  

118.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 119 of 129 PAGEID #: 2472

entire	  ABC	  intervention.	  During	  the	  current	  monitoring	  period,	  the	  boys’	   and	  girls’	  ABC	  rooms	  were	  staffed	  daily,	  except	  for	  just	  one	  day	  in	  the	   boys’	  school.	  	   	   The	  number	  of	  youth	  sent	  to	  the	  ABC	  room	  during	  the	  current	   monitoring	  period	  varied	  significantly.	  Nearly	  three	  times	  the	  number	  of	   youth	  were	  sent	  in	  April	  (100	  youth),	  May	  (148),	  June	  (94)	  than	  in	  July	  (32	   youth),	  August	  (31)	  and	  September	  (21).	  The	  source	  of	  these	  variations	  is	   likely	  the	  significantly	  lower	  number	  of	  instructional	  days	  during	  the	  last	   half	  of	  the	  monitoring	  period	  and	  the	  stable	  teacher	  assignments,	  which	   ensured	  that	  the	  ABC	  rules	  were	  enforced	  more	  carefully.	  	   	   The	  length	  of	  stay	  in	  the	  ABC	  room	  remained	  relatively	  constant—most	   youth	  stayed	  between	  1.5	  to	  2	  hours.	  Youth	  may	  earn	  10	  minutes	  off	   their	  ABC	  time	  for	  every	  30	  minutes	  they	  spend	  focused	  and	  engaged	  in	   their	  schoolwork.	  	   	   Unit	  Instruction	   	   Previously,	  the	  Parties	  to	  the	  S.H.	  lawsuit	  negotiated	  an	  agreement	   regarding	  the	  delivery	  of	  education	  services	  to	  youth	  who	  are	  confined	  to	   the	  living	  units	  for	  disciplinary	  reasons.	  Within	  48	  hours	  of	  their	   placement	  in	  seclusion,	  students	  must	  receive	  instruction	  from	  a	  certified	   teacher	  four	  times	  per	  day,	  for	  at	  least	  30	  minutes	  per	  visit	  (i.e.,	  Unit	   Instruction).	  	  The	  State	  submitted	  documentation	  for	  Unit	  Instruction	   provided	  during	  the	  July-­‐September	  2012	  grading	  period	  and	  described	   the	  process	  for	  providing	  services.	   	   Each	  morning,	  the	  Assistant	  Principal	  calls	  each	  unit	  for	  the	  AOV	  and	  Unit	   Restriction	  list.	  A	  Unit	  Instruction	  list	  is	  compiled	  and	  delivered	  to	  all	   teachers,	  along	  with	  the	  Unit	  Instructor	  schedule.	  Teachers	  who	  serve	   students	  on	  the	  list	  prepare	  course	  work,	  along	  with	  a	  copy	  of	  the	  IEP	  at-­‐ a-­‐glance	  for	  special	  education	  students.	  The	  Unit	  Instructor	  delivers	  the	   work	  to	  each	  student,	  and	  also	  provides	  30-­‐minutes	  of	  instruction,	  four	   times	  per	  day.	  	   	   Teachers	  currently	  provide	  the	  coursework	  and	  instruction	  through	  the	   youth’s	  door.	  This	  strategy	  has	  obvious	  shortcomings	  in	  terms	  of	  the	   quality	  of	  instruction.	  For	  their	  part,	  teachers	  would	  prefer	  to	  provide	   face-­‐to-­‐face	  instruction,	  but	  believe	  that	  the	  YS	  on	  the	  unit	  (rather	  than	   the	  teacher)	  could	  likely	  make	  a	  more	  accurate	  assessment	  of	  whether	   individual	  youth	  could	  be	  safely	  brought	  to	  the	  dayroom.	  Procedures	  to	   make	  individualized	  decisions	  regarding	  whether	  students	  can	  be	  safely	   instructed	  in	  the	  day	  room	  need	  to	  be	  established	  and	  implemented	   consistently,	  in	  accordance	  with	  the	  Court	  Order	  governing	  this	  issue	  in	   the	  S.H.	  case.	  	   	  

	  

119.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 120 of 129 PAGEID #: 2473

Steps	  Taken	  to	   Assess	  Compliance	  

The	  State	  compiled	  monthly	  compliance	  data	  regarding	  the	  number	  of	   youth	  on	  seclusion	  and	  number	  of	  periods	  that	  Unit	  Instruction	  was	   required.	  Compliance	  rates	  were	  reportedly	  96%	  in	  July,	  91%	  in	  August,	   and	  96%	  in	  September	  2012.	  However,	  the	  State	  cautioned	  that	  the	   reliability	  of	  these	  data	  might	  not	  be	  solid	  because	  three	  different	   individuals	  were	  managing	  the	  data	  before	  the	  new	  attendance	  clerk	  was	   hired	  in	  late	  September	  2012.	  Additional	  analysis	  was	  undertaken	  by	  the	   Monitor	  and	  is	  discussed	  below.	  	  	  	   	   The	  school	  administrators	  expend	  significant	  energy	  to	  review	  and	   monitor	  Unit	  Instruction	  records	  to	  ensure	  compliance.	  Each	  morning,	   the	  Assistant	  Principal	  reviews	  records	  from	  the	  prior	  day	  to	  ensure	  that	   all	  students	  were	  served.	  In	  addition,	  the	  DYS	  Special	  Education	   Coordinator	  reviews	  these	  records	  on	  a	  monthly	  basis.	  The	  Coordinator’s	   October	  2012	  report	  noted	  significant	  improvements	  in	  record	  keeping	   attributed	  to	  the	  arrival	  of	  the	  full-­‐time	  Attendance	  Clerk.	  	   	   The	  point	  of	  internal	  efforts	  to	  monitor	  performance	  are	  not	  to	   determine	  whether	  procedures	  were	  implemented	  perfectly,	  but	  rather	   to	  develop	  systems	  that	  are	  capable	  of	  identifying	  and	  addressing	  the	   problems	  that	  will	  inevitably	  arise	  with	  the	  complex	  web	  of	  service	   delivery	  that	  characterizes	  correctional	  facilities.	  In	  this	  case,	  the	  internal	   monitoring	  efforts	  are	  rigorous,	  accurately	  identify	  problems,	  and	  most	   importantly,	  lead	  to	  corrective	  action	  to	  address	  the	  deficits.	  	  The	  quality	   assurance	  efforts	  are	  a	  tremendous	  asset	  to	  the	  State’s	  pursuit	  of	   substantial	  compliance.	  	  
Attendance	   	   Overall	  school	  attendance	  rates	  are	  reported	  every	  month	  on	  the	   Superintendent’s	  report.	  Attendance	  rates	  during	  the	  current	  monitoring	   period	  ranged	  between	  73%	  and	  84%,	  with	  a	  six-­‐month	  average	  of	  79%.	   Unit-­‐level	  attendance	  rates	  were	  calculated	  based	  on	  data	  submitted	  by	   the	  State.	  Three-­‐month	  averages	  revealed	  that	  the	  boys’	  general	   population	  units	  had	  the	  lowest	  attendance	  rates	  (Jefferson	  66%;	  Carver	   77%;	  Boone	  79%),	  the	  Progress	  Units	  had	  higher	  rates	  (Cedar	  82%;	   Buckeye	  82%;	  Sycamore	  85%),	  and	  the	  girls’	  units	  had	  the	  highest	  rates	   (Davey	  88%;	  Allman	  94%).	  While	  they	  have	  still	  not	  attained	  the	  85%	   threshold	  [agreed	  upon	  by	  the	  S.H.	  subject	  matter	  expert	  and	  DYS	  and	   commonly	  used	  by	  the	  Monitor	  in	  this	  case]	  consistently,	  the	  attendance	   rates	  are	  much	  improved	  over	  the	  attendance	  rates	  witnessed	  in	  the	   previous	  monitoring	  period.	  	   	   According	  to	  school	  administrators,	  the	  attendance	  data	  still	  have	   “noise”	  from	  inconsistent	  data	  entry	  and	  other	  data	  management	   problems	  (e.g.,	  students	  who	  have	  left	  the	  facility	  remaining	  on	  the	   population	  roster	  and	  thus	  being	  counted	  as	  absent).	  Until	  these	  data	   issues	  are	  resolved,	  the	  true	  rates	  of	  attendance	  cannot	  be	  known,	  but	  it	  

	  

120.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 121 of 129 PAGEID #: 2474

appears	  that	  recent	  efforts	  to	  improve	  the	  accuracy	  with	  which	  data	  are	   entered	  have	  provided	  a	  clearer	  and	  more	  positive	  picture	  of	  students’	   access	  to	  education	  services.	  	  	   	   Indirectly	  related	  to	  the	  attendance	  issue	  is	  a	  recent	  School	  Task	  Force	   report	  that	  broadly	  studied	  youth’s	  and	  teacher’s	  classroom	  behaviors	  to	   identify	  strategies	  to	  improve	  school	  engagement.	  The	  facility	  should	  be	   commended	  for	  undertaking	  the	  project,	  the	  rigor	  of	  the	  inquiry	  (it	   utilized	  standardized	  Functional	  Behavior	  Assessment	  tools)	  and	  for	   developing	  a	  comprehensive	  set	  of	  recommendations	  to	  improve	   classroom	  management	  and	  to	  shift	  the	  facility	  culture	  to	  better	  support	   the	  education	  program.	  In	  combination,	  these	  strategies	  should	  reduce	   the	  absences	  caused	  by	  disruptive	  student	  behaviors	  and	  exacerbated	  by	   the	  staff’s	  and	  teachers’	  response	  to	  those	  behaviors.	  	   	   Unit	  Instruction	   	   As	  discussed	  in	  the	  previous	  Monitors’	  Report,	  without	  a	  system	  to	  cross	   reference	  Unit	  Instruction	  data	  with	  the	  AMS	  database’s	  seclusion	   records,	  it	  would	  be	  impossible	  to	  certify	  that	  all	  youth	  on	  seclusion	  and	   eligible	  for	  Unit	  Instruction	  were	  served.	  [In	  the	  court	  order,	  youth	  on	   seclusion	  must	  be	  served	  within	  48	  hours	  of	  their	  seclusion;	  in	  reality,	   youth	  are	  served	  within	  the	  first	  24	  hours.]	  To	  assess	  the	  integrity	  of	  the	   Unit	  Instruction	  procedures,	  the	  Unit	  Instruction	  records	  maintained	  by	   the	  school	  were	  cross-­‐referenced	  with	  a	  list	  of	  youth	  who	  had	  been	  on	   seclusion	  between	  July	  1	  and	  September	  30,	  2012	  generated	  by	  AMS.	  	   	   First,	  a	  random	  sample	  of	  14	  youth	  with	  seclusion	  stays	  well	  in	  excess	  of	   48	  hours	  was	  selected	  from	  the	  AMS	  list.	  Instructional	  days	  were	   identified	  using	  the	  School	  Calendar	  (there	  were	  quite	  a	  few	  non-­‐ instructional	  days	  during	  the	  period	  of	  inquiry,	  e.g.,	  intersession	  in	  July,	   every	  Friday	  in	  August,	  etc.).	  Six	  of	  the	  14	  youth	  (43%)	  did	  not	  serve	  time	   on	  an	  instructional	  day	  (sometimes,	  the	  Intervention	  Hearing	  officer	  will	   schedule	  intervention	  seclusion	  to	  be	  served	  on	  the	  weekends	  so	  that	  it	   does	  not	  interfere	  with	  the	  youth’s	  education).	  Seven	  of	  the	  8	  youth	   (88%)	  received	  seven	  periods	  worth	  of	  course	  work	  on	  the	  instructional	   days	  during	  which	  they	  were	  in	  seclusion.	  The	  one	  exception	  did	  not	   receive	  Unit	  Instruction	  on	  the	  last	  day	  of	  his	  5-­‐day	  seclusion.	  	   	   Second,	  for	  each	  of	  the	  38	  youth	  on	  the	  Unit	  Instruction	  list,	  the	  dates	  of	   service	  were	  cross-­‐referenced	  with	  the	  AMS	  roster	  to	  ensure	  that	  youth	   were	  served	  on	  all	  of	  the	  instructional	  days	  during	  which	  they	  were	   secluded.	  Service	  dates	  were	  verified	  for	  all	  but	  3	  of	  the	  youth	  (92%	   compliance).	  It	  is	  worth	  noting	  that	  about	  10%	  of	  the	  Scioto	  student	  body	   received	  education	  services	  via	  Unit	  Instruction	  for	  a	  significant	   proportion	  of	  instructional	  days	  (between	  17%	  and	  30%).	  While	   treatment	  and	  behavior	  modification	  efforts	  should	  focus	  on	  the	  

	  

121.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 122 of 129 PAGEID #: 2475

Recommendations	  
Sources	  of	   Information	  
	   	  

underlying	  causes	  of	  the	  youth’s	  behavior	  in	  order	  to	  minimize	  the	   amount	  of	  time	  youth	  spend	  in	  seclusion,	  until	  that	  occurs,	  Unit	   Instruction	  is	  essential	  to	  the	  effort	  to	  maintain	  the	  youth’s	  engagement	   in	  school.	  	   	   Once	  cross-­‐referenced	  with	  AMS,	  the	  Unit	  Instruction	  data	  clearly	   demonstrated	  that	  the	  facility	  is	  in	  compliance	  with	  its	  obligations	   around	  providing	  education	  services	  to	  youth	  who	  are	  in	  seclusion.	   Continued	  quality	  assurance	  efforts	  are	  needed	  to	  ensure	  that	  the	   preference	  for	  youth	  to	  receive	  face-­‐to-­‐face	  instruction	  is	  maximized,	   and	  that	  students	  receive	  the	  full	  30	  minutes	  of	  contact	  on	  each	  of	  the	  4	   visits.	  	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Address	  the	  preventable	  causes	  of	  absenteeism	  and	  address	  data	   entry	  and	  data	  management	  issues	  to	  ensure	  that	  average	   attendance	  rates	  of	  85%	  or	  better	  are	  achieved	  for	  each	  housing	   unit.	  	  
The	  State	  is	  also	  encouraged	  to:	   2. Continue	  to	  maintain	  Youth	  Specialist	  and	  teacher	  staffing	  levels	   that	  are	  sufficient	  to	  ensure	  dependable	  access	  to	  school	  for	   youth	  in	  all	  units.	  Continue	  to	  ensure	  that	  the	  ABC	  rooms	  are	   consistently	  staffed	  to	  limit	  the	  need	  for	  youth	  to	  return	  to	  the	   unit	  during	  the	  school	  day.	  	   3. Continue	  to	  provide	  access	  to	  alternative	  education	  services	  for	   youth	  in	  seclusion	  through	  the	  use	  of	  Unit	  Instruction.	  Ensure	   that	  the	  type,	  quality	  and	  duration	  of	  instruction	  comply	  with	  the	   S.H.	  Parties’	  agreement.	  Develop	  procedures	  to	  serve	  youth	  in	   the	  dayroom,	  rather	  than	  behind	  their	  doors,	  when	  instruction	  in	   the	  dayroom	  can	  be	  accomplished	  safely.	  	  
• Oral	  presentation	  and	  underlying	  documentation	  for	  provision	   III.E.1,	  prepared	  at	  my	  request	  
• Interviews	  with	  n=15	  general	  population	  youth	  housed	  at	  Scioto	   on	  October	  19,	  2012	  
• Education	  staffing	  roster,	  January	  through	  September	  2012	   • Unit	  Instruction	  data,	  July	  through	  September	  2012,	  and	  follow-­‐
up	  discussions	  with	  Scioto	  and	  DYS	  school	  administrators	  via	   email.	  	   • AMS	  Seclusion	  Records,	  July	  through	  September	  2012	   • Attendance	  records,	  by	  unit	  and	  by	  individual	  youth,	  July	  through	   September	  2012	   • Scioto	  School	  Task	  Force	  Report,	  undated	  
	  

	  

122.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 123 of 129 PAGEID #: 2476

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

Compliance	  Rating	   Substantial	  Compliance	  

Self	  Assessment	  

The	  State	  provided	  data	  on	  the	  35	  special	  education	  students	  in	  custody	   as	  of	  October	  1,	  2012	  (approximately	  40%	  of	  the	  total	  population).	  Of	   these	  youth,	  two	  student’s	  IEPs	  were	  expired,	  but	  they	  were	  newly	   admitted	  to	  the	  facility	  and	  staff	  had	  already	  taken	  steps	  to	  collect	  the	   necessary	  information	  and	  schedule	  IEP	  meetings.	  The	  other	  33	  youth	   (94%)	  had	  current	  IEPs.	  	   	   Historically,	  the	  State	  has	  struggled	  ensure	  that	  IEPs	  include	  measurable	   goals	  and	  objectives.	  Training	  and	  technical	  assistance	  has	  been	  on	   going,	  with	  both	  the	  facility’s	  Special	  Education	  Administrator	  and	   Intervention	  Specialist	  reviewing	  draft	  IEP	  documents	  prior	  to	  the	  IEP	   meetings’	  being	  held.	  Teachers	  must	  now	  complete	  a	  Planning	   Worksheet	  for	  each	  IEP	  goal	  that	  describes	  how	  and	  when	  the	  goal	  will	   be	  measured,	  and	  by	  whom.	  These	  sheets	  are	  attached	  to	  every	  IEP.	  	   	   Only	  when	  the	  IEP	  goals	  and	  objectives	  are	  clearly	  stated	  can	  meaningful	   progress	  reporting	  be	  accomplished.	  Facilitating	  students’	  progress	   through	  the	  curriculum	  is	  the	  entire	  point	  of	  special	  education,	  and	   without	  assessing	  progress,	  the	  program	  cannot	  identify	  whether	  it	  is	   meeting	  students’	  special	  education	  needs.	  	   	   The	  State	  submitted	  IEP	  progress	  reports	  for	  each	  of	  the	  40	  special	   education	  students	  (100%)	  who	  were	  at	  Scioto	  at	  the	  end	  of	  the	  April-­‐ June	  2012	  grading	  period,	  and	  for	  the	  35	  special	  education	  youth	  (100%)	   who	  were	  in	  custody	  at	  the	  end	  of	  the	  July-­‐September	  2012	  grading	   period.	  That	  progress	  reports	  were	  sent	  out	  for	  each	  and	  every	  special	   education	  student	  is	  a	  significant	  improvement	  from	  the	  state	  of	  affairs	   when	  the	  Monitor	  became	  involved	  with	  this	  case.	  The	  content	  of	  the	   progress	  reports	  is	  discussed	  below.	  	   	  

	  

123.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 124 of 129 PAGEID #: 2477

Steps	  Taken	  to	   Assess	  Compliance	  

DYS	  recently	  developed	  and	  implemented	  a	  three-­‐tiered	  Quality	   Assurance	  program	  for	  special	  education.	  In	  Tier	  One,	  the	  Special	   Education	  Administrator	  selects	  a	  sample	  of	  students	  each	  month	  (e.g.,	   six	  of	  the	  35	  current	  students	  were	  selected	  in	  September	  2012)	  and	   conducts	  a	  comprehensive	  file	  audit.	  IEPs	  are	  evaluated	  based	  on	  a	  set	  of	   criteria	  that	  reflect	  the	  many	  requirements	  of	  IDEA.	  Written	  feedback	  is	   provided	  to	  the	  teachers	  in	  order	  to	  improve	  teacher	  skills.	  In	  Tier	  Two,	   each	  quarter,	  the	  DYS	  Special	  Education	  Director	  reviews	  the	  same	  files	   to	  ensure	  that	  all	  deficits	  were	  identified	  in	  the	  local	  audit	  and	  that	   teachers	  completed	  any	  required	  corrections.	  In	  Tier	  Three,	  each	  of	  the	   DYS	  schools	  is	  audited	  annually	  by	  DYS	  and	  also	  tri-­‐annually	  by	  the	  Ohio	   Department	  of	  Education.	  Results	  of	  the	  audits	  will	  be	  reviewed	  in	  future	   monitoring	  periods.	  	  
Special	  Education	  Population	  and	  IEP	  Development	   	   Across	  the	  current	  special	  education	  population,	  26	  of	  the	  35	  students	   (74%)	  qualified	  under	  the	  Emotional	  Disability	  category,	  8	  had	  Specific	   Learning	  Disabilities	  (23%),	  and	  one	  student	  was	  Cognitively	  Disabled	   (3%).	  With	  6	  special	  education	  teachers	  currently	  on	  staff,	  the	  caseload	   sizes	  are	  well	  below	  the	  state	  limits	  (generally,	  12	  for	  ED;	  24	  for	  SLD).	   	   A	  sample	  of	  15	  IEPs	  were	  reviewed.	  The	  sample	  consisted	  of	  the	  last	  15	   IEPs	  written	  by	  Scioto	  prior	  to	  the	  Monitor’s	  October	  2012	  site	  visit	   which	  was	  43%	  of	  the	  current	  special	  education	  population.	  In	  terms	  of	   the	  prescribed	  level	  of	  service,	  2	  of	  the	  15	  students	  in	  the	  IEP	  sample	   (13%)	  were	  served	  in	  the	  self-­‐contained	  classrooms	  on	  the	  girls’	  mental	   health	  unit;	  10	  students	  (66%)	  were	  served	  in	  the	  resource	  room	  for	   between	  one	  and	  four	  class	  periods	  per	  day	  (average	  2.3	  periods)	  and	  3	   students	  (20%)	  were	  served	  entirely	  in	  the	  general	  education	  classrooms.	   In	  addition,	  60%	  of	  the	  IEPs	  prescribed	  bi-­‐weekly	  consultation	  between	   the	  Intervention	  Specialist	  and	  student	  to	  discuss	  behavior	  and	  40%	  of	   the	  IEPs	  prescribed	  consultation	  between	  the	  Intervention	  Specialist	  and	   general	  education	  teachers.	  In	  terms	  of	  related	  services,	  13%	  of	  the	   students	  received	  services	  from	  the	  Speech-­‐Language	  Pathologist	  and	   27%	  received	  services	  from	  the	  Occupational	  Therapist.	  Occasionally,	  the	   Description	  of	  Specially	  Designed	  Instruction	  section	  and	  the	  services	   listed	  in	  the	  Least	  Restrictive	  Environment	  section	  were	  in	  conflict,	  but	   overall,	  the	  level	  of	  service	  prescribed	  appeared	  to	  be	  individualized	  and	   appropriate	  given	  the	  description	  of	  the	  youth’s	  academic	  and	  functional	   performance	  contained	  in	  the	  IEPs.	  	   	   IEP	  Goal	  Development	   	   The	  question	  of	  whether	  progress	  can	  be	  accurately	  measured	  rests	  on	   the	  quality	  of	  articulation	  of	  the	  IEP	  goals	  and	  objectives,	  which	  depends,	   in	  turn,	  on	  clear	  descriptions	  of	  the	  students’	  skill	  deficits.	  For	  the	  most	   part,	  the	  IEPs’	  Student	  Profiles	  contained	  excellent	  descriptions	  of	  the	  

	  

124.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 125 of 129 PAGEID #: 2478

youth’s	  strengths	  and	  weaknesses,	  including	  a	  mix	  of	  standardized	  test	   scores	  and	  teachers’	  observations	  about	  the	  students’	  capabilities	  and	   skill	  deficits,	  and	  descriptions	  of	  the	  youth’s	  behavior	  and	  school	   attendance.	  The	  Profiles	  were	  much	  improved	  compared	  to	  the	   Monitor’s	  previous	  review.	  	   	   Similarly,	  the	  Present	  Level	  of	  Performance	  section	  used	  to	  set	  up	  each	   IEP	  goal	  now	  includes	  relevant	  test	  scores	  and	  descriptions	  of	  the	   students’	  strengths	  and	  weaknesses	  in	  the	  subject	  matter	  at	  hand.	  While	   at	  times	  the	  Present	  Level	  of	  Performance	  sections	  and	  Student	  Profile	   sections	  were	  redundant,	  the	  information	  provided	  necessary	  context	  for	   the	  goals	  and	  the	  underlying	  objectives.	  Nearly	  all	  of	  the	  goals	  reviewed	   across	  the	  15	  IEPs	  were	  individualized,	  measurable	  and	  appeared	  to	   achievable	  within	  a	  1-­‐year	  period,	  and	  the	  objectives	  identified	  the	  skills	   necessary	  for	  the	  student	  to	  acquire	  in	  order	  to	  meet	  the	  goal.	  Behavior	   goals	  are	  now	  individualized	  and	  anchored	  in	  a	  description	  of	  problem	   behaviors	  and	  the	  situations	  in	  which	  they	  are	  likely	  to	  occur.	  Methods	  to	   assess	  progress	  on	  behavior	  goals	  generally	  include	  a	  combination	  of	   citizenship	  scores,	  YBIRs,	  ABC	  referrals,	  attendance	  rates	  and	  “working	   behaviors.”	  All	  students	  had	  transition	  goals	  that	  appeared	  to	  be	  relevant	   to	  the	  student’s	  current	  grade	  level	  and	  the	  number	  of	  credits	  they’d	   earned.	  Goals	  were	  also	  varied	  according	  to	  students’	  interests.	  In	   summary,	  IEP	  goals	  and	  objectives	  were	  much	  improved	  compared	  to	   the	  Monitor’s	  previous	  review.	   	   Progress	  Reporting	   	   As	  noted	  above,	  IEP	  Progress	  Reports	  are	  now	  created	  reliably	  at	  the	   conclusion	  of	  each	  grading	  period.	  Measuring	  student	  progress	  toward	   IEP	  goals	  is	  the	  sole	  mechanism	  by	  which	  the	  Parties	  can	  discern	  whether	   the	  special	  education	  program	  is	  meeting	  students’	  needs.	  Finally,	  after	   several	  years	  of	  hard	  work,	  the	  Progress	  Reports	  generated	  for	  Scioto	   students	  do	  just	  that—provide	  a	  tangible,	  meaningful	  assessment	  of	  the	   extent	  to	  which	  students	  have	  acquired	  the	  skills	  needed	  to	  progress	   through	  the	  curriculum.	  	  	   	   A	  sample	  of	  10	  Progress	  Reports	  was	  selected	  from	  among	  the	  40	   prepared	  at	  the	  conclusion	  of	  the	  April-­‐June	  2012	  grading	  period	  (25%	  of	   all	  reports).	  Across	  these	  10	  reports,	  most	  of	  them	  offered	  detailed,	   comprehensive	  descriptions	  of	  student	  progress,	  particularly	  for	  the	   academic	  goals.	  Although	  a	  couple	  of	  the	  reports	  had	  to	  work	  around	   poorly	  articulated	  goals	  that	  were	  difficult	  to	  measure,	  the	  vast	  majority	   had	  a	  logical	  flow	  between	  the	  goal,	  how	  it	  was	  supposed	  to	  be	  assessed,	   the	  information	  presented,	  and	  the	  conclusion	  about	  whether	  the	   student	  was	  making	  adequate	  progress.	  The	  only	  glaring	  problem	  was	   that	  Progress	  Reports	  for	  4	  of	  the	  10	  students	  (40%)	  did	  not	  have	  any	   entry	  for	  or	  discussion	  about	  the	  students’	  transition	  goals.	  	  

	  

125.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 126 of 129 PAGEID #: 2479

Recommendations	   Sources	  of	   Information	  
	   	  

	   In	  order	  to	  focus	  on	  that	  particular	  issue,	  the	  transition	  goals	  were	   reviewed	  for	  each	  of	  the	  35	  Progress	  Reports	  generated	  at	  the	   conclusion	  of	  the	  July-­‐September	  2012	  grading	  period.	  The	  fruits	  of	  the	   considerable	  technical	  assistance	  delivered	  to	  teachers	  by	  the	  Special	   Education	  Administrator	  were	  easily	  visible.	  The	  vast	  majority	  (29	  of	  the	   35	  reports;	  83%)	  had	  detailed	  entries	  for	  the	  students’	  transition	  goals,	   either	  discussing	  the	  things	  the	  student’s	  had	  accomplished	  or	  discussing	   why	  progress	  had	  not	  yet	  been	  witnessed	  (most	  often,	  because	  the	   student	  was	  not	  close	  enough	  to	  his	  or	  her	  release	  date	  to	  undertake	   some	  of	  the	  late-­‐stage	  transition	  activities).	  The	  remaining	  6	  cases	  simply	   needed	  more	  information	  about	  why	  the	  objective	  had	  not	  yet	  been	   undertaken	  or	  needed	  to	  provide	  information	  that	  was	  relevant	  to	  the	   specific	  goal	  and	  objective.	  Together,	  the	  Progress	  Reports	  from	  the	   Summer	  and	  Fall	  quarters	  demonstrate	  that	  the	  facility	  is	  now	  fully	   capable	  of	  demonstrating	  their	  efforts	  to	  deliver	  services	  that	  are	   responsive	  to	  students’	  special	  education	  needs	  and	  identifying	  whether	   those	  services	  are	  helping	  the	  student	  progress	  through	  the	  curriculum.	  	  
The	  State	  has	  achieved	  substantial	  compliance	  with	  this	  provision.	  	  	  
• Oral	  presentation	  and	  underlying	  documentation	  for	  provision	   III.E.7,	  prepared	  at	  my	  request	  
• DYS	  Education	  Quality	  Assurance	  materials,	  April	  through	   September	  2012	  
• Review	  of	  the	  n=15	  IEPs	  development	  most	  recently	  at	  Scioto	   (43%	  of	  the	  current	  special	  education	  population)	  
• Review	  of	  n=10	  Progress	  Reports	  from	  the	  April-­‐June	  2012	   grading	  period	  (25%	  sample)	  and	  the	  Transition	  Goals	  from	  n=35	   Progress	  Reports	  from	  July-­‐September	  2012	  grading	  period	   (100%	  sample)	  	  
	  

	  

126.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 127 of 129 PAGEID #: 2480

	  
III.E.8	  Vocational	  Education.	  The	  State	  shall	  provide	  appropriate	  vocational	  services	  that	  are	   required	  transition	  services	  for	  disabled	  youth	  under	  the	  IDEA.	  	  

Compliance	  Rating	   Substantial	  Compliance	  

Self	  Assessment	  

Scioto	  students	  who	  are	  either	  Juniors	  or	  Seniors	  (by	  credit)	  are	  eligible	   for	  vocational	  programming.	  Students	  with	  low	  reading	  or	  math	  levels	   are	  not	  excluded	  from	  vocational	  programs.	  	   	   In	  its	  self-­‐assessment,	  the	  State	  discussed	  data	  on	  student	  enrollment	  in	   the	  three	  currently	  available	  vocational	  classes.	  On	  the	  first	  day	  of	  the	   2012	  school	  year	  (July	  23,	  2012),	  of	  the	  63	  students	  enrolled	  at	  school:	  
• 14	  students	  (22%)	  were	  enrolled	  in	  Administrative	  Office	   Technology	  (a	  course	  that	  teaches	  students	  how	  to	  use	  various	   computer	  applications	  to	  prepare	  them	  for	  clerical,	  data	  entry,	   graphics,	  or	  other	  office-­‐based	  jobs);	  
• 4	  students	  (6%)	  were	  enrolled	  in	  Career-­‐Based	  Intervention	  (i.e.,	   work-­‐based	  learning,	  student	  earns	  credit);	  and	  	  
• 27	  students	  (43%)	  were	  enrolled	  in	  Transition	  Skills	  (students	   must	  take	  this	  course	  prior	  to	  release;	  includes	  job	  skills,	  resume	   building,	  interview	  skills).	  
Overall,	  43	  students	  were	  enrolled	  in	  vocational	  programming	  (two	   students	  were	  taking	  two	  classes),	  which	  is	  68%	  of	  the	  student	   population.	  By	  the	  end	  of	  the	  grading	  period	  (October	  5,	  2012),	   enrollment	  had	  shrunk	  a	  bit	  to	  58%	  of	  the	  student	  population.	  This	  is	  a	   significant	  improvement	  over	  the	  previous	  monitoring	  period	  where	  less	   than	  half	  the	  students	  were	  involved	  in	  vocational	  programming.	  School	   administrators	  indicated	  that	  they	  have	  not	  expanded	  the	  capacity	  of	  any	   of	  the	  programs,	  but	  have	  simply	  emphasized	  these	  programs,	   encouraging	  teachers	  to	  identify	  students	  who	  need	  vocational	   programming.	  Each	  of	  the	  three	  courses	  have	  sufficient	  capacity	  to	  serve	   significantly	  more	  students	  if	  they	  were	  eligible	  and	  needed	  vocational	   programming.	  	  	   	   The	  Ohio	  DYS	  vocational	  programs	  were	  audited	  twice	  during	  the	  current	   monitoring	  period.	  First,	  the	  ODE	  Office	  for	  Exceptional	  Children	  audited	   DYS’s	  special	  education	  program.	  IDEA	  requires	  the	  IEPs	  for	  students	  age	   14	  and	  older	  to	  include	  a	  Transition	  Plan	  to	  ensure	  that	  the	  school	   delivers	  services	  in	  preparation	  for	  life	  after	  graduation	  (and,	  in	  this	  case,	   after	  they	  return	  to	  the	  community).	  The	  audit	  found	  Scioto	  to	  be	  in	   compliance	  with	  the	  standard	  related	  to	  Transition	  Planning	  (SPP	   Indicator	  20	  for	  Secondary	  Transition	  Plans).	  Specifically,	  ODE	  found	  that	   Scioto’s	  plans	  “prescribed	  reasonable	  services	  to	  meet	  post-­‐secondary	   goals.”	  In	  other	  words,	  Scioto	  youth	  have	  access	  to	  courses	  that	  address	   their	  pursuits	  after	  high	  school.	  	   	   In	  addition,	  ODE’s	  Office	  of	  Career-­‐Technical	  Education	  conducted	  a	  

	  

127.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 128 of 129 PAGEID #: 2481

Steps	  Taken	  to	   Assess	  Compliance	  

comprehensive	  review	  of	  all	  career-­‐technical	  education	  programs	   offered	  at	  Scioto.	  Through	  teacher	  surveys,	  document	  review	  and	  on-­‐site	   program	  observations,	  the	  audit	  noted	  significant	  improvement	  in	  the	   participation	  rates	  in	  Scioto’s	  vocational	  programs	  (mirroring	  the	   Monitor’s	  findings	  discussed	  below).	  In	  addition,	  the	  audit	  noted	  that	   vocational	  textbooks	  were	  current	  and	  that	  supplies	  and	  facilities	  were	   adequate.	  	   	   The	  report’s	  Opportunities	  for	  Improvement	  included	  a	  variety	  of	   suggestions	  to	  improve	  the	  administration	  of	  the	  programs	  (e.g.,	   involving	  Central	  Office	  in	  vocational	  teacher	  hiring;	  improving	   communication)	  or	  to	  enrich	  the	  curriculum	  delivery	  (e.g.,	  developing	  a	   method	  for	  internet	  access	  with	  appropriate	  firewalls;	  emphasizing	   employability	  skills	  in	  all	  courses).	  The	  audit	  also	  recommended	  that	  the	   DYS	  formalize	  student’s	  course	  completion	  via	  industry-­‐based	   credentialing	  tests	  and	  formal	  graduation	  ceremonies.	  Notably,	  the	  ODE	   did	  not	  require	  or	  advise	  any	  modifications	  to	  the	  course	  offerings,	   apparently	  finding	  they	  were	  adequate	  to	  meet	  the	  needs	  of	  students.	  	  
While	  the	  facility	  has	  not	  enhanced	  the	  array	  of	  vocational	  options	  since	   the	  Monitor’s	  previous	  review,	  it	  has	  significantly	  increased	  the	   proportion	  of	  youth	  who	  are	  engaged	  in	  vocational	  programming.	  Some	   of	  Scioto’s	  students	  simply	  are	  not	  eligible	  (because	  they	  are	  too	  young	   or	  have	  not	  earned	  enough	  credits).	  All	  eligible	  general	  population	   students	  have	  the	  opportunity	  to	  participate	  in	  vocational	  programs;	   however,	  some	  students	  choose	  to	  focus	  on	  college	  prep	  materials	  and	   may	  not	  choose	  to	  take	  vocational	  courses	  as	  a	  result.	  Youth	  on	  the	  PU	   may	  not	  enroll	  in	  vocational	  courses	  during	  their	  stay	  on	  the	  PU.	  The	  CBI	   and	  AOT	  courses	  require	  the	  freedom	  to	  travel	  throughout	  the	  campus	   (which	  PU	  youth	  do	  not	  have)	  and	  also	  require	  the	  student	  to	  have	   completed	  all	  16	  credits	  of	  the	  core	  courses,	  which	  most	  PU	  students	   have	  not	  yet	  achieved.	  All	  youth	  take	  the	  Transition	  Course	  at	  some	  point	   3	  to	  6	  months	  before	  their	  scheduled	  release	  date.	  	  	   	   While	  the	  Monitor	  would	  prefer	  to	  see	  additional	  options	  for	  hands-­‐on	   learning	  and	  opportunities	  for	  youth	  to	  earn	  vocational	  certificates	  that	   could	  assist	  in	  their	  future	  job	  searches,	  Scioto’s	  program	  options	  are	   adequate.	  In	  particular,	  these	  services	  can	  fully	  address	  the	  transition	   needs	  and	  services	  prescribed	  in	  Scioto’s	  IEPs	  which	  include	  completing	   career	  interest	  inventories,	  conducting	  job	  opportunity	  searches,	   developing	  employability	  skills,	  and	  compiling	  transition	  portfolios.	  	  The	   improvements	  noted	  in	  the	  facility’s	  IEP	  goal	  articulation	  and	  progress	   reporting	  makes	  it	  easier	  for	  the	  Monitor	  to	  certify	  the	  compatibility	   between	  student	  needs	  and	  the	  transition	  program	  resources	  available	   to	  special	  education	  students.	  	   	   Finally,	  particularly	  now	  that	  the	  facility	  has	  a	  well-­‐developed	  program	   for	  graduates,	  the	  opportunities	  for	  students	  to	  develop	  job	  and	  

	  

128.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 129 of 129 PAGEID #: 2482

Recommendations	   Sources	  of	   Information	  
	  

employability	  skills	  are	  far	  greater	  than	  they	  were	  at	  the	  time	  Stipulation	   was	  signed.	  	  
The	  State	  has	  reached	  substantial	  compliance	  with	  this	  provision.	  	  
• Oral	  presentation	  and	  underlying	  documentation	  for	  provision	   III.E.8,	  prepared	  at	  my	  request	  
• Student	  rosters	  for	  each	  of	  the	  three	  vocational	  courses,	  April-­‐ June	  and	  July-­‐September	  2012	  grading	  periods.	  	  
• ODE	  Office	  of	  Exceptional	  Children	  audit	  report,	  November,	  2012	   • ODE	  Office	  of	  Career-­‐Technical	  Education	  audit	  report,	  
November	  2012	  

	  

129.	  

 
 Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 1 of 67 PAGEID #: 2495

	   	   	   	   	   	   	  

U.S.	  Department	  of	  Justice	  v.	  The	  State	  of	  Ohio	  

Civil	  Action	  No:	  2:08-­‐cv-­‐475	  

Monitor’s	  Fourth	  Report	  	  

	  

	  

	  

	  

	  

	  

	  

	  

	  

	  

	  

Kelly	  Dedel,	  Ph.D.,	  Lead	  Monitor	  

Daphne	  Glindmeyer,	  M.D.,	  Subject	  Matter	  Expert	  

Michelle	  Staples-­‐Horne,	  M.D.,	  Subject	  Matter	  Expert	  

	  

One	  in	  37	  Research,	  Inc.	  

16	  Rock	  Street	  	  Cody,	  WY	  	  82414	  

(503)799-­‐0915	  

kelly.dedel@gmail.com	  

	  

	  

	  

Draft	  Submitted	  May	  31,	  2013	  

Final	  Submitted	  June	  18,	  2013	  

	  

	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 2 of 67 PAGEID #: 2496

TABLE	  OF	  CONTENTS	  
	   Introduction	  ............................................................................................................................	  3	   Executive	  Summary	  .................................................................................................................	  4	  
Protection	  from	  Harm	.   ....................................................................................................................	  9	   General	  Protection	  From	  Harm	.  ..................................................................................................	  9	   Seclusion	 .  ..................................................................................................................................	  20	   Investigation	  of	  Serious	  Incidents	 .  ............................................................................................	  27	   Grievances	.  ................................................................................................................................	  33	   Grievances	  Explained	  to	  Youth	  .................................................................................................	  38	   Structured	  Programming	  ..........................................................................................................	  39	   Orientation	.  ...............................................................................................................................	  45	  
	   Mental	  Health	  Services	  ....................................................................................................................	  	  
Mental	  Health	  Screening	.   .............................................................................................................	  	   Immediate	  Referral	  to	  QMHP	  ......................................................................................................	  	   Identification	  of	  Previously	  Unidentified	  Youth	 .  ..........................................................................	  	   Mental	  Health	  Assessment	  ..........................................................................................................	  	   Adequate	  Care	  and	  Treatment	.   ....................................................................................................	  	   Treatment	  Planning	.   .....................................................................................................................	  	   Treatment	  Teams	 .  ........................................................................................................................	  	   Integrated	  Treatment	  Plans	  .........................................................................................................	  	   Access	  to	  QMHP	 .  ..........................................................................................................................	  	   Mental	  Health	  Involvement	  in	  Housing	  and	  Placement	.  ..............................................................	  	   Staffing	  .........................................................................................................................................	  	   Medication	  Notice	.   .......................................................................................................................	  	   Mental	  Health	  Medications	.  .........................................................................................................	  	   MH/DD	  Training	  for	  Direct	  Care	  Staff	.  ..........................................................................................	  	   Staff	  Mental	  Health	  Training	 .  .......................................................................................................	  	   Suicide	  Prevention	.  .......................................................................................................................	  	   Transition	  Planning	.  ......................................................................................................................	  	   Oversight	  of	  Mental	  Health	.   .........................................................................................................	  	   Documentation	.   ................................................................................................................................	  	   Progress	  Notes	  .............................................................................................................................	  	   Accessibility	  of	  Information	.  .........................................................................................................	  	   	   Medical	  Services	 .  ..........................................................................................................................	  47	   General	  Medical	  Care	.   ..............................................................................................................	  47	   Health	  Records	 .  ........................................................................................................................	  52	   Access	  to	  Health	  Systems	.   ........................................................................................................	  54	   	   Special	  Education	  Services	  ...........................................................................................................	  55	   Provision	  of	  Special	  Education	  .................................................................................................	  55	   Individual	  Education	  Plans	  .......................................................................................................	  60	   Vocational	  Education	  ...............................................................................................................	  64	   	   	  

	  

2.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 3 of 67 PAGEID #: 2497

INTRODUCTION	  
	  

On	  June	  4,	  2008,	  The	  United	  States	  Department	  of	  Justice	  (DOJ)	  and	  the	  State	  of	  Ohio	  (the	  State)	  

signed	  a	  stipulation	  for	  injunctive	  relief	  (the	  Stipulation)	  concerning	  conditions	  at	  the	  Scioto	  

Juvenile	  Correctional	  Facility	  (Scioto)	  and	  the	  Marion	  Juvenile	  Correctional	  Facility	  (Marion;	  

which	  was	  closed	  shortly	  after	  the	  Stipulation	  was	  signed).	  Fred	  Cohen,	  the	  Lead	  Monitor	  of	  the	  

concurrent	  conditions	  of	  confinement	  lawsuit,	  S.H.	  v	  Reed	  et	  al.,	  served	  as	  the	  monitor	  for	  the	  

Stipulation	  until	  late	  2009.	  At	  that	  point,	  Mr.	  Cohen	  resigned	  and	  the	  DOJ	  assumed	  the	  role	  of	  

Monitor,	  with	  Dr.	  Kelly	  Dedel,	  Dr.	  Daphne	  Glindmeyer,	  and	  Dr.	  Michelle	  Staples-­‐Horne	  serving	  as	  

subject	  matter	  experts.	  	  

	  

In	  June	  2011,	  as	  the	  original	  stipulation	  expired,	  the	  Parties	  recognized	  that	  the	  State	  had	  not	  

yet	  reached	  substantial	  compliance	  with	  several	  key	  portions	  of	  the	  Stipulation.	  Thus,	  the	  

Stipulation	  was	  renegotiated	  to	  include	  a	  subset	  of	  the	  original	  provisions.	  The	  Amended	  

Stipulation,	  signed	  June	  28,	  2011,	  terminates	  when	  the	  State	  has	  achieved	  substantial	  

compliance	  with	  each	  provision	  and	  has	  maintained	  substantial	  compliance	  for	  two	  reporting	  

periods	  (i.e.,	  12	  months).	  The	  Parties	  also	  agreed	  that	  the	  Amended	  Stipulation	  is	  subject	  to	  the	  

termination	  provisions	  of	  the	  Prison	  Litigation	  Reform	  Act.	  	  

	  

The	  Monitor	  for	  the	  Amended	  Stipulation	  is	  Dr.	  Kelly	  Dedel,	  who	  evaluates	  the	  State’s	  progress	  

in	  the	  areas	  of	  Protection	  From	  Harm,	  Grievances,	  Programming	  and	  Special	  Education.	  She	  is	  

assisted	  by	  two	  Subject	  Matter	  Experts,	  Dr.	  Daphne	  Glindmeyer,	  who	  evaluates	  the	  State’s	  

progress	  on	  provisions	  related	  to	  Mental	  Health	  Services,	  and	  Dr.	  Michelle	  Staples-­‐Horne,	  who	  

evaluates	  the	  State’s	  progress	  on	  provisions	  related	  to	  Medical	  Care.	  	  

	  

As	  the	  Monitor,	  Dr.	  Dedel	  is	  the	  primary	  liaison	  between	  the	  Monitoring	  Team	  and	  the	  Parties	  

and	  she	  compiles	  the	  Monitor’s	  Report.	  To	  do	  so,	  she	  combines	  Drs.	  Glindmeyer’s	  and	  Staples-­‐

Horne’s	  reports	  with	  her	  own	  to	  form	  a	  coherent	  whole,	  but	  does	  not	  change	  the	  substance	  of	  

the	  reports	  by	  either	  of	  the	  Subject	  Matter	  Experts,	  who	  are	  responsible	  for	  forming	  their	  own	  

opinions	  about	  the	  level	  of	  compliance	  for	  each	  provision	  in	  their	  areas	  of	  expertise.	  	  

	  

This	  is	  the	  Monitor’s	  fourth	  report	  on	  the	  State’s	  progress	  toward	  the	  reforms	  required	  by	  the	  

Amended	  Stipulation.	  The	  monitoring	  period	  is	  October	  1,	  2012	  through	  March	  31,	  2013.	  

Progress	  reports	  are	  issued	  approximately	  every	  six	  months.	  This	  report	  includes	  only	  Protection	  

from	  Harm,	  Medical	  Services	  and	  Special	  Education.	  DYS	  was	  unavailable	  to	  present	  the	  

required	  self-­‐assessment	  of	  Mental	  Health	  Services	  until	  just	  before	  the	  report’s	  due	  date,	  

leaving	  Dr.	  Glindmeyer	  with	  insufficient	  time	  to	  integrate	  the	  State’s	  assessment	  with	  her	  own.	  

The	  draft	  Mental	  Health	  report	  was	  submitted	  to	  the	  Parties	  for	  review	  and	  comment	  on	  June	  

17,	  2013.	  The	  absence	  of	  information	  regarding	  Mental	  Health	  Services	  in	  this	  report	  should	  not	  

be	  construed	  to	  mean	  that	  the	  State	  is	  in	  substantial	  compliance	  with	  those	  provisions.	  	  

	  

	  

	  

	  

3.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 4 of 67 PAGEID #: 2498

EXECUTIVE	  SUMMARY	  

	  

The	  Amended	  Stipulation	  includes	  33	  provisions	  related	  to	  Protection	  From	  Harm	  (n=3);	  

Grievances	  (n=2);	  Programming	  (n=2);	  Mental	  Health	  Care	  (n=18)	  and	  Documentation	  (n=2);	  

Medical	  Care	  (n=3);	  and	  Special	  Education	  (n=3).	  Each	  provision	  is	  listed	  in	  the	  table	  below,	  

along	  with	  the	  Monitor’s	  or	  Subject	  Matter	  Expert’s	  compliance	  rating.	  	  

	  

The	  Monitor	  and	  subject	  matter	  experts	  use	  a	  three-­‐tiered	  system	  (substantial	  compliance,	  

partial	  compliance	  and	  non-­‐compliance),	  defined	  as	  follows:	  

	  

·∙	  	  	  	  	  Substantial	  Compliance	  means	  that	  the	  facility	  has	  drafted	  relevant	  policies	  and	  procedures;	  

has	  trained	  the	  staff	  responsible	  for	  implementation;	  has	  sufficient	  staff	  to	  implement	  the	  

required	  reform;	  has	  demonstrated	  the	  ability	  to	  properly	  implement	  the	  procedures	  during	  

the	  majority	  of	  the	  monitoring	  period;	  and	  has	  ascertained	  that	  the	  procedures	  accomplish	  

the	  outcome	  envisioned	  by	  the	  provision.	  Non-­‐compliance	  with	  mere	  technicalities	  or	  a	  

temporary	  failure	  to	  comply	  (due	  to	  staff	  vacancy	  or	  illness,	  facility	  disruptions,	  or	  other	  

short-­‐term	  events)	  during	  an	  otherwise	  sustained	  period	  of	  compliance	  do	  not	  constitute	  a	  

failure	  to	  achieve	  or	  maintain	  substantial	  compliance.	  Conversely,	  temporary	  compliance	  

during	  a	  period	  of	  sustained	  non-­‐compliance	  or	  partial	  compliance	  does	  not	  constitute	  

substantial	  compliance.	  

	  	  

·∙	  	  	  	  	  	  Partial	  Compliance	  means	  that	  the	  facility	  has	  drafted	  policies	  and	  procedures,	  has	  trained	  

staff	  responsible	  for	  implementation,	  and	  has	  sufficient	  staff	  to	  implement	  the	  required	  

reform.	  While	  progress	  has	  been	  made	  toward	  implementing	  the	  procedures	  described	  by	  

policy,	  performance	  has	  been	  inconsistent	  throughout	  the	  monitoring	  period	  and	  additional	  

modifications	  are	  needed	  to	  ensure	  that	  procedures	  are	  sufficiently	  comprehensive	  to	  

translate	  policy	  into	  practice.	  	  

	  	  

·∙	  	  	  	  	  Non-­‐Compliance	  means	  that	  the	  facility	  has	  made	  only	  very	  preliminary	  efforts	  to	  implement	  

the	  required	  reform,	  but	  significant	  work	  remains.	  Policy	  may	  need	  to	  be	  overhauled,	  the	  

majority	  of	  staff	  may	  need	  to	  be	  trained,	  procedures	  may	  not	  have	  been	  developed,	  and	  no	  

one	  has	  begun	  to	  ascertain	  whether	  the	  procedures	  accomplish	  the	  outcome	  envisioned	  by	  

the	  provision.	  	  

	  

	  

The	  Monitor	  wants	  to	  emphasize	  that	  the	  substantial	  compliance	  rating	  is	  given	  only	  when	  the	  

required	  reforms	  address	  all	  of	  the	  issues	  discussed	  in	  the	  Provision	  and	  when	  solid	  

implementation	  of	  the	  reforms	  has	  been	  consistently	  demonstrated,	  through	  reliable	  data,	  

observations	  and	  reports	  from	  staff	  and	  youth,	  for	  a	  majority	  of	  the	  monitoring	  period.	  Partial	  

compliance	  indicates	  that	  some	  of	  the	  issues	  addressed	  in	  the	  Provision	  have	  been	  resolved,	  but	  

that	  problems,	  some	  of	  them	  serious,	  still	  remain.	  The	  application	  of	  the	  partial	  compliance	  

rating	  is	  only	  a	  brief	  indicator—the	  entire	  discussion	  should	  be	  read	  to	  fully	  understand	  the	  type	  

and	  magnitude	  of	  remaining	  problems.	  	  

	  

	  

	  

	  

	  

4.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 5 of 67 PAGEID #: 2499

Table	  1.	  Compliance	  Ratings	  for	  Each	  Provision	  

No.	  

Provision	  

1st	  Report	  	   2nd	  Report	   3rd	  Report	   4th	  Report	  

Protection	  From	  Harm	  

III.A.	  1	   General	  Protection	  From	  Harm	  

NC	  

PC	  

PC	  

PC	  

III.A.3	   Seclusion	  

NC	  

PC	  

PC	  

PC	  

III.A.5	   Investigation	  of	  Serious	  Incidents	  

SC	  

PC	  

PC	  

PC	  

III.D.1	   Grievances	  

PC	  

PC	  

PC	  

PC	  

III.D.2	   Grievances	  Explained	  to	  Youth	  

PC	  

SC	  

SC	  

SC	  

III.F.1	   Structured	  Programming	  

NC	  

NC	  

PC	  

PC	  

III.F.2	   Orientation	  

PC	  

PC	  

PC	  

SC	  

Mental	  Health	  Services	  

III.B.1	   Mental	  Health	  Screening	  

PC	  

PC	  

SC	  

	  

III.B.2	   Immediate	  Referral	  to	  QMHP	  

PC	  

PC	  

SC	  

	  

III.B.3	   Identification	  of	  Unidentified	  Youth	  	   NC	  

PC	  

PC	  

	  

III.B.4	   Mental	  Health	  Assessment	  

NC	  

PC	  

PC	  

	  

III.B.5	   Adequate	  Care	  and	  Treatment	  

NC	  

PC	  

PC	  

	  

III.B.6	   Treatment	  Planning	  

NC	  

PC	  

PC	  

	  

III.B.7	   Treatment	  Teams	  

PC	  

PC	  

PC	  

	  

III.B.8	   Integrated	  Treatment	  Plans	  

NC	  

PC	  

PC	  

	  

III.B.9	   Access	  to	  QMHP	  

NC	  

PC	  

SC	  

	  

III.B.10	   Involvement	  in	  Housing	  and	  Plcmt	  

NC	  

PC	  

PC	  

	  

III.B.11	   Staffing	  

NC	  

PC	  

PC	  

	  

III.B.12	   Medication	  Notice	  

PC	  

PC	  

PC	  

	  

III.B.13	   Mental	  Health	  Medications	  

PC	  

PC	  

PC	  

	  

III.B.14	   MH/DD	  Training	  for	  Line	  Staff	  

NC	  

NC	  

NC	  

	  

III.B.15	   Staff	  Mental	  Health	  Training	  

PC	  

PC	  

PC	  

	  

III.B.16	   Suicide	  Prevention	  

PC	  

PC	  

PC	  

	  

III.B.17	   Transition	  Planning	  

PC	  

PC	  

PC	  

	  

III.B.18	   Oversight	  of	  Mental	  Health	  

NC	  

NC	  

NC	  

	  

III.G.1	   Progress	  Notes	  

PC	  

PC	  

PC	  

	  

III.G.2	   Accessibility	  of	  Information	  

NC	  

NC	  

NC	  

	  

	  

	  

	  

5.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 6 of 67 PAGEID #: 2500

Medical	  Services	   No.	  

Provision	  

1st	  Report	  	   2nd	  Report	   3rd	  Report	   4th	  Report	  

III.C.1	   General	  Medical	  Care	  

SC	  

PC	  

PC	  

PC	  

III.C.2	   Health	  Records	  

SC	  

PC	  

PC	  

PC	  

III.C.5	   Access	  to	  Health	  Services	  

SC	  

SC	  

SC	  

SC	  

Special	  Education	  Services	  

III.E.1	   Provision	  of	  Special	  Education	  

PC	  

PC	  

PC	  

SC	  

III.E.7	   Individual	  Education	  Plans	  

PC	  

PC	  

SC	  

SC	  

III.E.8	   Vocational	  Education	  

NC	  

NC	  

SC	  

SC	  

	   	   Overall	  compliance	  rates	  could	  not	  be	  calculated	  because	  the	  Mental	  Health	  section	  is	  not	   included	  with	  this	  report.	  Individual	  sections	  of	  the	  Stipulation	  are	  discussed	  below.	  	   	   Protection	  from	  Harm	  (includes	  Grievances	  and	  Programming)	   	   The	  facility	  is	  in	  substantial	  compliance	  with	  2	  of	  the	  7	  provisions	  (29%)	  related	  to	  protecting	   youth	  from	  harm	  and	  is	  in	  partial	  compliance	  with	  the	  remaining	  5	  provisions	  (71%).	  The	   following	  actions	  should	  be	  prioritized:	   	  
• Assess	  the	  effectiveness	  of	  the	  various	  strategies	  that	  have	  been	  recently	  implemented	   to	  address	  the	  problem	  of	  youth-­‐on-­‐staff	  violence.	  Make	  modifications	  as	  necessary	  to	   effect	  substantial	  reductions	  in	  the	  rate	  of	  youth-­‐on-­‐staff	  assaults.	  	  
• Reinforce	  the	  prohibition	  against	  provoking,	  taunting,	  belittling	  and	  otherwise	   disrespecting	  youth.	  Investigate	  complaints	  vigorously	  and	  enforce	  the	  conduct	   standards	  when	  they	  are	  violated.	  	  
• Improve	  staff	  accountability	  measures	  to	  ensure	  that	  all	  staff	  are	  held	  responsible	  not	   just	  for	  maintaining	  the	  code	  of	  conduct,	  but	  for	  reporting	  concerns	  about	  staff	  who	  fail	   to	  do	  so.	  	  
• Develop	  a	  robust	  Quality	  Assurance/Quality	  Improvement	  process	  to	  determine	   whether	  the	  IRAV	  and	  sanctions	  grid	  revisions	  are	  properly	  implemented	  and	  whether	   they	  have	  significantly	  reduced	  the	  reliance	  on	  isolation	  to	  control	  and	  respond	  to	  youth	   behavior.	  The	  QA/QI	  process	  should	  include	  standards	  that	  clearly	  articulate	  a	   preference	  for	  non-­‐seclusion	  based	  sanctions	  when	  appropriate,	  a	  methodology	  for	   auditing	  facility	  practices,	  analysis	  and	  interpretation	  of	  data,	  and	  a	  Quality	   Improvement	  Plan	  for	  any	  area	  in	  which	  performance	  deficits	  are	  revealed.	  	  
• Reduce	  the	  number	  of	  individuals	  authorized	  to	  conduct	  local	  investigations	  and	  ensure	   that	  these	  individuals	  have	  the	  requisite	  skills	  for	  the	  task.	  Ensure	  that	  producing	  timely,	   high-­‐quality	  investigations	  is	  a	  specific	  job	  responsibility	  and	  that	  employees	  are	  held	   accountable	  for	  their	  failure	  to	  produce	  reports	  that	  meet	  professional	  standards.	  	   o The	  lack	  of	  progress	  in	  the	  area	  of	  Local	  Investigations	  suggests	  that	  additional	   oversight	  may	  be	  necessary.	  The	  Monitor	  encourages	  DYS	  to	  create	  a	  Quality	   Improvement	  Plan	  that	  determines	  the	  underlying	  causes	  of	  the	  delay	  and	  poor	  

	  

6.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 7 of 67 PAGEID #: 2501

quality	  products.	  Once	  known,	  specific	  strategies	  should	  be	  developed	  to	  target	   each	  underlying	  factor	  so	  that	  the	  quality	  of	  the	  product	  is	  significantly	   improved.	  The	  effectiveness	  of	  these	  strategies	  should	  be	  assessed	  frequently	   (e.g.,	  monthly	  or	  bi-­‐monthly).	  The	  Monitor	  will	  request	  copies	  of	  completed	  local	   investigations	  on	  a	  monthly	  basis	  in	  order	  to	  provide	  more	  frequent	  progress	   reports	  to	  the	  Parties	  and	  to	  the	  Court.	  	   • Promptly	  notify	  youth	  of	  the	  outcome	  of	  any	  grievance	  referred	  for	  investigation.	  [If	  DYS	   completes	  this	  straightforward	  task	  very	  soon,	  the	  provision	  may	  be	  rated	  in	  Substantial	   Compliance	  for	  the	  April-­‐October	  2013	  monitoring	  period.]	   • Create	  and	  implement	  a	  Quality	  Improvement	  Plan	  to	  improve	  compliance	  with	  Quality	   Assurance	  standards	  related	  to	  all	  three	  components	  of	  Structured	  Programming	  (i.e.,	   MAV,	  Victim	  Awareness	  and	  Phoenix	  groups;	  recreation	  and	  community	  service;	   religious	  and	  volunteer-­‐led	  programs).	  	   	   Mental	  Health	  Services	   	   DYS	  was	  unavailable	  to	  present	  the	  required	  self-­‐assessment	  of	  Mental	  Health	  Services	  until	  just	   before	  the	  due	  date,	  leaving	  Dr.	  Glindmeyer	  with	  insufficient	  time	  to	  integrate	  the	  State’s	   assessment	  with	  her	  own.	  The	  draft	  Mental	  Health	  report	  was	  submitted	  to	  the	  Parties	  for	   review	  and	  comment	  on	  June	  17,	  2013.	  The	  absence	  of	  information	  regarding	  Mental	  Health	   Services	  in	  this	  report	  should	  not	  be	  construed	  to	  mean	  that	  the	  State	  is	  in	  substantial	   compliance	  with	  those	  provisions.	  	   	   Medical	  Services	   	   The	  facility	  is	  in	  substantial	  compliance	  with	  one	  of	  the	  provisions	  (33%)	  related	  to	  medical	   services	  and	  in	  partial	  compliance	  with	  the	  other	  2	  provisions	  (66%).	  The	  following	  actions	   should	  be	  prioritized:	   	   • Complete	  satellite	  clinic	  and	  medication	  room	  on	  Buckeye	  Units	  for	  adequate	  injury	   assessments	  of	  youth	  and	  medication	  administration	  on	  the	  unit.	  	   • Continue	  to	  limit	  time	  of	  youth	  in	  seclusion	  and	  adequately	  document	  health	  status	  in	   during	  segregation.	   • Continue	  to	  improve	  Quality	  Assurance	  (QA)	  activities	  by	  continuing	  an	  external	  review	   through	  accreditation	  by	  the	  American	  Correctional	  Association.	  ODYS	  should	  also	   consider	  expansion	  of	  the	  QA	  process	  to	  include	  some	  additional	  quality	  outcome	   indicators.	  	   • Continue	  to	  improve	  the	  process	  for	  sharing	  of	  health	  information	  between	  medical	  and	   mental	  health	  to	  include	  psychologists	  through	  implementation	  of	  eClinical	  Works	  EHR.	   ODYS	  medical	  management	  staff	  should	  be	  intimately	  involved	  in	  the	  process	  of	   customization	  of	  the	  EMR	  to	  be	  relevant	  to	  youth	  medical	  services.	   • Ensure	  Health	  Request	  slips	  and	  boxes	  are	  readily	  available	  to	  youth	  on	  all	  housing	  units.	   Youth	  should	  not	  have	  to	  rely	  on	  custody	  staff	  to	  request	  forms.	  	  	   	   Special	  Education	   	   The	  facility	  is	  in	  substantial	  compliance	  with	  all	  3	  of	  the	  education-­‐related	  provisions	  (100%)!	  

	  

7.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 8 of 67 PAGEID #: 2502

	  

	  

During	  the	  current	  monitoring	  period,	  the	  Parties	  negotiated	  a	  Consent	  Order	  regarding	  the	  

operation	  of	  the	  PROGRESS	  Unit	  (PU).	  Signed	  by	  Judge	  Marbley	  on	  January	  18,	  2013,	  the	  Order	  

requires	  specific	  modifications	  to	  the	  PU	  that	  are	  monitored	  separately	  from	  the	  Amended	  

Stipulation.	  The	  most	  recent	  Status	  Report	  for	  the	  PU	  is	  attached	  to	  this	  report.	  Once	  the	  State	  

comes	  into	  substantial	  compliance	  with	  all	  of	  the	  provisions	  and	  maintains	  that	  level	  of	  

performance	  for	  six	  months,	  monitoring	  of	  the	  PU	  shifts	  back	  to	  the	  Amended	  Stipulation	  and	  

will	  be	  reported	  here	  in	  the	  sections	  for	  the	  relevant	  provisions.	  The	  operation	  of	  the	  PU	  is	  

therefore	  not	  discussed	  in	  this	  report.	  	  

	  

The	  remainder	  of	  this	  report	  is	  organized	  as	  follows:	  1)	  each	  Provision	  is	  presented,	  verbatim;	  2)	  

the	  compliance	  rating	  is	  noted;	  3)	  information	  the	  State	  presented	  to	  demonstrate	  compliance	  

with	  the	  Provision	  is	  summarized;	  4)	  additional	  activities	  undertaken	  by	  the	  Monitor	  or	  subject	  

matter	  expert	  to	  determine	  the	  level	  of	  compliance	  are	  discussed;	  5)	  the	  steps	  required	  to	  

achieve	  substantial	  compliance	  with	  the	  Provision	  are	  listed;	  6)	  the	  sources	  of	  information	  the	  

Monitor	  or	  subject	  matter	  expert	  used	  to	  form	  her	  opinion	  are	  listed.	  	  

	  

	  

	  

8.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 9 of 67 PAGEID #: 2503

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

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

Trends	  in	  youth	  violence,	  restraints,	  and	  allegations	  of	  over-­‐ familiarization	  are	  discussed	  here,	  while	  detailed	  discussions	  about	  the	   use	  of	  seclusion	  and	  investigating	  staff	  misconduct	  can	  be	  found	  in	  III.A.3	   and	  III.A.5	  respectively.	  	   	   Via	  its	  work	  on	  the	  S.H.	  case,	  several	  new	  Quality	  Assurance	  (QA)	   programs	  have	  been	  established	  to	  provide	  the	  internal	  capacity	  to	   identify	  and	  respond	  to	  problems	  in	  the	  core	  areas	  of	  youth	  violence,	   investigations,	  and	  seclusion.	  These	  join	  pre-­‐existing	  efforts	  to	  track	   facility	  performance	  (youth	  violence)	  and	  offer	  technical	  assistance	   (restraints).	  However,	  the	  QA	  programs	  in	  each	  area	  are	  in	  different	   phases	  of	  development.	  Some	  have	  articulated	  standards,	  some	  have	  an	   articulated	  audit	  methodology	  and	  performance	  measures,	  some	  have	   pilot	  tested	  the	  methodology.	  To	  date,	  a	  “QA	  Report”	  on	  the	  success	  with	   which	  the	  facility	  has	  met	  the	  standards	  and	  performance	  measures	  in	   each	  area	  has	  not	  been	  produced.	  Further,	  structured	  Quality	   Improvement	  Plans	  have	  not	  yet	  been	  developed	  to	  remediate	  identified	   deficits.	  DYS’	  progress	  in	  sculpting	  a	  formal	  QA	  process	  is	  an	  important	   accomplishment,	  although	  significant	  work	  still	  remains.	  	  	  	   	   Quality	  Assurance	  Efforts	  Related	  to	  Youth	  Violence	   DYS	  has	  leveraged	  its	  participation	  in	  the	  Performance	  Based	  Standards	   (PbS)	  project	  to	  provide	  a	  framework	  for	  its	  QA	  process	  in	  this	  area.	  Data	   on	  the	  rate	  of	  youth-­‐on-­‐youth	  and	  youth-­‐on-­‐staff	  violence	  is	  collected	   monthly	  and	  progress	  is	  measured	  using	  the	  6-­‐month	  PbS	  cycle	  (every	   April	  and	  October).	  Each	  facility	  is	  expected	  to	  reduce	  its	  rates	  of	  youth	   violence	  by	  at	  least	  10%	  each	  reporting	  period.	  	   	   While	  the	  facility	  has	  participated	  in	  PbS	  for	  several	  years,	  the	  full	  QA	   framework	  for	  identifying	  the	  underlying	  causes	  of	  increases	  or	  decreases	   in	  youth	  violence	  was	  established	  only	  recently.	  Each	  month,	  the	  Bureau	   Director	  of	  Facility	  Programs	  meets	  with	  each	  Facility	  Superintendent	  to	   discuss	  the	  various	  influences	  on	  youth	  violence	  and	  to	  create	  strategies	   for	  addressing	  them.	  During	  the	  first	  two	  months	  that	  the	  QA	  program	   was	  operational	  (January	  and	  February,	  2013),	  conversations	  with	  the	   Scioto	  Superintendent	  focused	  on	  the	  two	  youth	  who	  were	  responsible	   for	  nearly	  half	  of	  the	  youth-­‐on-­‐staff	  assaults.	  These	  two	  youth	  had	  been	   referred	  to	  the	  PROGRESS	  Unit.	  In	  addition,	  the	  agency-­‐wide	  “Back	  to	  

	  

9.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 10 of 67 PAGEID #: 2504

Steps	  Taken	  to	   Assess	  Compliance	  

Basics”	  strategy	  was	  identified	  as	  a	  tool	  to	  fortify	  the	  supervision	  and	   teamwork	  skills	  of	  direct	  care	  staff.	  	   	   Quality	  Assurance	  Efforts	  Related	  to	  Restraints	   As	  discussed	  in	  the	  previous	  Monitor’s	  Report,	  the	  DYS	  has	  a	  system	  for	   both	  internal	  and	  external	  QA.	  Scioto’s	  Facility	  Intervention	  Administrator	   (FIA)	  is	  responsible	  for	  reviewing	  every	  incident	  involving	  restraints	  and	   determining	  whether	  staff’s	  actions	  complied	  with	  policy.	  The	  FIA	  has	  the	   option	  to	  approve	  the	  use	  of	  force	  as	  appropriate,	  to	  identify	  a	   “teachable	  moment”	  and	  provide	  specific	  coaching	  to	  the	  staff	  involved,	   or	  to	  refer	  the	  incident	  for	  investigation.	  Each	  month,	  the	  Facility	   Resource	  Administrator	  (FRA)	  from	  DYS	  Central	  Office	  reviews	  the	  FIA’s	   assessment	  and	  decision-­‐making	  for	  a	  sample	  of	  incidents	  occurring	  in	   that	  month.	  	   	   Since	  the	  previous	  monitoring	  period,	  the	  FRA’s	  reviews	  suggest	  that	  the	   detection	  of	  “teachable	  moments”	  has	  improved.	  The	  FIA	  now	  keeps	  a	   log	  of	  these	  opportunities,	  which	  both	  documents	  the	  substance	  of	  the	   issue	  and	  verifies	  that	  the	  staff	  involved	  received	  feedback.	  Both	  of	  these	   mechanisms	  are	  essential	  for	  the	  ongoing	  training	  of	  new	  staff	  and	   refining	  the	  skill	  sets	  of	  veteran	  staff.	  	   	   The	  weak	  link	  in	  this	  system,	  however,	  is	  the	  poor	  quality	  of	  the	  local	   investigations,	  which	  are	  discussed	  in	  depth	  in	  III.A.5,	  below.	  When	  a	   more	  serious	  concern	  about	  the	  use	  of	  restraints	  is	  detected	  by	  the	  FIA,	   the	  incident	  is	  referred	  for	  investigation.	  That	  referral	  is	  a	  sound	  practice,	   however,	  the	  poor	  technique	  of	  many	  of	  the	  facility-­‐based	  investigators	   seriously	  undermines	  the	  integrity	  of	  this	  process	  and	  offers	  youth	  little	   protection	  from	  undue	  restraints.	  	  	  
Youth	  Violence	   The	  table	  below	  presents	  the	  rate	  of	  youth-­‐on-­‐youth	  and	  youth-­‐on-­‐staff	   violence	  for	  the	  past	  24	  months.	  These	  data	  reveal	  a	  steady	  reduction	  in	   youth-­‐on-­‐youth	  violence.	  The	  average	  rate	  for	  the	  past	  three	  six-­‐month	   monitoring	  periods	  was	  .24,	  .13	  and	  .08.	  The	  average	  rate	  for	  the	  current	   period	  was	  .09,	  even	  with	  the	  spike	  in	  violence	  in	  November	  2012.	   Overall,	  rates	  of	  youth-­‐on-­‐youth	  violence	  have	  been	  low	  for	  a	  little	  over	   one	  year.	  	   	   Unfortunately,	  the	  rate	  of	  youth-­‐on-­‐staff	  violence	  has	  been	  more	   resistant	  to	  change.	  The	  average	  rate	  of	  youth-­‐on-­‐staff	  violence	  increased	   over	  the	  past	  three	  six-­‐month	  monitoring	  periods,	  and	  recently	  leveled	   off	  (i.e.,	  .15,	  .16,	  .20,	  and	  most	  recently,	  .17).	  Youth-­‐on-­‐staff	  assaults	   occurred	  almost	  two	  times	  as	  often	  as	  youth-­‐on-­‐youth	  assaults.	  Several	  of	   the	  youth-­‐on-­‐staff	  assaults	  were	  very	  serious,	  with	  staff	  admitted	  to	  the	   hospital.	  	   	   Conversations	  with	  facility	  administrators	  revealed	  some	  solid	  problem-­‐

	  

10.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 11 of 67 PAGEID #: 2505

solving	  efforts	  around	  this	  issue.	  Profiles	  of	  staff	  victims	  tend	  to	  fall	  into	   three	  categories:	  1)	  vulnerable	  staff	  who	  are	  new,	  frightened,	  and	   inexperienced;	  2)	  staff	  who	  fail	  to	  identify	  the	  youth’s	  immediate	   behavioral	  cues	  that	  indicate	  a	  heightened	  risk	  of	  violence;	  and	  3)	   accountability-­‐focused	  staff	  who	  are	  targeted	  by	  youth	  in	  an	  effort	  to	  get	   the	  staff	  removed	  from	  the	  unit.	  Efforts	  to	  better	  protect	  these	  victims	   are	  underway.	  For	  example,	  encouraging	  the	  unit	  staff	  to	  function	  as	   team	  so	  that	  all	  staff	  are	  better	  supported,	  so	  that	  operational	  practices	   are	  consistently	  implemented,	  and	  so	  the	  team	  is	  less	  susceptible	  to	   youth’s	  efforts	  to	  split	  staff	  and	  exploit	  their	  vulnerabilities.	   	   Other,	  less	  serious	  forms	  of	  youth-­‐on-­‐staff	  violence	  have	  been	  addressed	   via	  environmental	  strategies	  such	  as	  container-­‐less	  meals	  (to	  prevent	   youth	  from	  being	  able	  to	  collect	  and	  throw	  liquids	  at	  staff)	  and	  spit	  masks	   (to	  prevent	  youth	  from	  being	  able	  to	  spit	  on	  staff).	  	   	   These	  two	  approaches—efforts	  to	  better	  protect	  victims	  and	   environmental	  strategies	  that	  make	  the	  offenses	  more	  difficult	  to	   accomplish—are	  essential	  supplements	  to	  efforts	  that	  address	  the	   youth’s	  behavior,	  decision-­‐making,	  empathy	  or	  sanctions.	  While	  the	   facility	  still	  has	  much	  to	  do	  to	  create	  a	  safer	  environment	  for	  staff	  (and	  to	   shield	  youth	  from	  the	  consequences	  they	  will	  and	  should	  face	  when	  they	   engage	  in	  that	  type	  of	  violence),	  its	  recent	  efforts	  to	  focus	  on	  the	   underlying	  causes	  of	  youth-­‐on-­‐staff	  violence	  are	  very	  promising.	  	   	   That	  said,	  the	  Monitor	  and	  DOJ	  Attorney	  continued	  to	  hear	  complaints	   from	  youth	  about	  their	  frustrations	  with	  certain	  staff	  who	  were	  described	   as	  antagonizing,	  provoking,	  and	  otherwise	  speaking	  and	  behaving	  in	  ways	   that	  could	  increase	  youth’s	  propensity	  for	  violence	  toward	  them.	  The	   solution	  to	  this	  problem	  has	  many	  facets,	  such	  as	  reiterating	  and	   enforcing	  requirements	  around	  appropriate	  behavior	  and	  demeanor	   among	  staff,	  teaching	  staff	  skills	  for	  tolerating	  their	  frustrations	  with	   youth,	  and	  holding	  them	  accountable	  for	  failing	  to	  meet	  these	  standards.	   On	  the	  other	  hand,	  helping	  youth	  to	  develop	  skills	  for	  tolerating	   frustration,	  making	  requests	  appropriately,	  controlling	  impulses,	  etc.	   should	  also	  contribute	  to	  a	  reduction	  in	  the	  rate	  of	  youth-­‐on-­‐staff	   violence.	  	   	   	  

Youth	  Violence,	  April	  2011	  through	  March	  2013	  

Month	  

Youth-­‐Youth	  

#	  

ADP	   Rate	  

Youth-­‐Staff	  

#	  

ADP	  

Rate	  

Apr	  11	  

30	  

128	  

.23	  

13	  

128	  

.10	  

May	  11	  

40	  

114	  

.35	  

14	  

114	  

.12	  

June	  11	  

25	  

110	  

.23	  

13	  

110	  

.12	  

	  

11.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 12 of 67 PAGEID #: 2506

July	  11	  

19	  

101	  

.19	  

Aug	  11	  

24	  

108	  

.22	  

Sept	  11	  

29	  

138	  

.21	  

9	  

101	  

.09	  

15	  

108	  

.14	  

45	  

138	  

.33	  

Oct	  11	  

31	  

164	  

.19	  

Nov	  11	  

29	  

161	  

.18	  

Dec	  11	  

18	  

159	  

.11	  

Jan	  12	  

21	  

158	  

.13	  

Feb	  12	  

10	  

137	  

.07	  

Mar	  12	  

9	  

125	  

.07	  

29	  

164	  

.18	  

29	  

161	  

.18	  

11	  

159	  

.07	  

30	  

158	  

.19	  

19	  

137	  

.14	  

21	  

125	  

.17	  

Apr	  12	  

9	  

118	  

.08	  

May	  12	  

11	  

101	  

.11	  

June	  12	  

4	  

91	  

.04	  

July	  12	  

10	  

83	  

.12	  

Aug	  12	  

11	  

88	  

.12	  

Sept	  12	  

1	  

86	  

.01	  

31	  

118	  

.26	  

16	  

101	  

.16	  

14	  

91	  

.15	  

18	  

83	  

.22	  

22	  

88	  

.25	  

14	  

86	  

.16	  

Oct	  12	  

4	  

76	  

.05	  

15	  

76	  

.20	  

Nov	  12	  

17	  

82	  

.21	  

15	  

82	  

.18	  

Dec	  12	  

9	  

72	  

.12	  

11	  

72	  

.15	  

Jan	  13	  

3	  

62	  

.05	  

11	  

62	  

.18	  

Feb	  13	  

4	  

59	  

.07	  

12	  

59	  

.21	  

Mar	  13	  

2	  

60	  

.03	  

7	  

60	  

.12	  

	   	   Use	  of	  Restraints	   The	  previous	  Monitor’s	  Report	  discussed	  the	  decline	  in	  the	  use	  of	   restraints	  witnessed	  during	  that	  monitoring	  period	  and	  how	  it	  could	  be	   attributed	  primarily	  to	  decreases	  in	  the	  use	  of	  restraints	  among	  the	   female	  population	  at	  Scioto.	  During	  the	  current	  monitoring	  period,	  the	   average	  rate	  of	  physical	  restraint	  use	  declined	  across	  the	  board,	  despite	  a	   spike	  in	  the	  use	  of	  restraints	  in	  November	  2012	  that	  mirrored	  the	  spike	  in	   youth-­‐on-­‐youth	  violence.	  Over	  the	  past	  three	  monitoring	  periods,	  the	   average	  rate	  of	  physical	  restraint	  use	  for	  the	  total	  population	  was	  .72,	  .62	   and,	  most	  recently,	  .47.	  This	  represents	  a	  24%	  decrease	  from	  the	   previous	  monitoring	  period.	  Note	  that	  the	  rate	  of	  restraints	  decreased	   more	  sharply	  than	  the	  more	  modest	  decreases	  in	  youth	  violence	  would	   suggest.	  	   	   Separated	  by	  gender,	  the	  average	  rate	  of	  physical	  restraint	  use	  for	  males	   and	  females	  has	  equalized.	  Previously,	  the	  males’	  6-­‐month	  average	  rates	   were	  .56	  (Oct	  11-­‐Mar	  12),	  .58	  (April	  12-­‐Sept	  12).	  The	  average	  rate	  for	  the	   current	  monitoring	  period	  (Oct	  12-­‐Mar	  13)	  was	  .47,	  which	  represents	  a	  

	  

12.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 13 of 67 PAGEID #: 2507

19%	  reduction	  from	  the	  previous	  period.	  The	  females’	  6-­‐month	  average	   rates	  were	  1.31	  (Oct	  11-­‐Mar	  12),	  .73	  (April	  12-­‐Sept	  12),	  and	  .47	  for	  the	   current	  monitoring	  period	  (Oct	  12-­‐Mar	  13),	  which	  represents	  a	  36%	   reduction	  from	  the	  previous	  period.	  	   	   These	  statistics	  suggest	  positive	  changes	  are	  occurring	  at	  the	  facility.	  For	   one,	  the	  population	  continues	  to	  decrease,	  which	  may	  provide	  staff	  with	   additional	  time	  and	  patience	  to	  utilize	  their	  verbal	  strategies	  to	  de-­‐ escalate	  youth	  who	  lose	  control.	  In	  addition,	  the	  facility’s	  population	  of	   girls	  with	  serious	  mental	  health	  issues	  continues	  to	  decline	  as	  they	  are	   placed	  in	  alternative	  settings.	  Historically,	  this	  group	  of	  girls	  was	   restrained	  more	  often	  than	  youth	  in	  the	  general	  population.	  	   	   	  

Physical	  Restraints,	  October	  2011	  through	  March	  2013	  

Month	  

Total	  

Males	  

Females	  

#	   ADP	   rate	   #	   ADP	   rate	   #	   ADP	   rate	  

Oct	  11	   150	   164	   .91	   103	   128	   .81	   47	   36	   1.31	  

Nov	  11	   177	   161	   1.10	   111	   128	   .87	   66	   33	   2.00	  

Dec	  11	   99	   159	   .62	   49	   124	   .40	   50	   35	   1.43	  

Jan	  12	   93	   158	   .59	   61	   125	   .48	   32	   33	   .97	  

Feb	  12	   88	   137	   .64	   50	   106	   .47	   38	   31	   1.23	  

Mar	  12	   59	   125	   .47	   34	   97	   .35	   25	   28	   .89	  

Apr	  12	   94	   118	   .80	   40	   May	  12	   55	   101	   .54	   35	   Jun	  12	   52	   91	   .57	   36	   July	  12	   70	   83	   .84	   60	   Aug	  12	   51	   88	   .58	   48	   Sep	  12	   35	   86	   .41	   34	  

92	   .43	   54	   77	   .45	   20	   68	   .53	   16	   64	   .94	   10	   72	   .67	   3	   75	   .45	   1	  

26	   2.08	   24	   .83	   23	   .70	   20	   .50	   16	   .19	   12	   .08	  

Oct	  12	   27	   76	   .36	   23	   64	   .36	   4	   12	   .33	  
Nov	  12	   63	   82	   .77	   56	   68	   .82	   7	   14	   .50	  
Dec	  12	   37	   72	   .51	   28	   58	   .48	   9	   15	   .60	  
Jan	  13	   36	   62	   .58	   28	   47	   .60	   8	   16	   .50	  
Feb	  13	   22	   59	   .37	   18	   42	   .43	   4	   16	   .25	  
Mar	  13	   16	   60	   .27	   6	   43	   .14	   10	   18	   .56	   	   	   As	  noted	  in	  the	  Introduction	  to	  this	  report,	  the	  functioning	  and	   operational	  practices	  on	  the	  PROGRESS	  Unit	  are	  discussed	  in	  a	  separate	   document,	  which	  is	  attached	  to	  this	  report.	  The	  use	  of	  mechanical	   restraints	  with	  Phase	  I	  youth	  continues	  to	  be	  a	  concern	  for	  both	  the	  

	  

13.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 14 of 67 PAGEID #: 2508

Monitors	  and	  the	  Plaintiffs,	  and	  discussions	  about	  how	  to	  mitigate	  any	   harmful	  effects	  of	  their	  use	  are	  on-­‐going.	  	   	   Staffing	   Adequately	  staffing	  the	  facility	  to	  ensure	  youth	  and	  staff	  safety	  and	  youth	   access	  to	  programming	  has	  been	  an	  ongoing	  challenge	  for	  Scioto.	   However,	  recently,	  the	  various	  strategies	  enacted	  to	  ensure	  adequate	   numbers	  of	  direct	  care	  staff	  report	  to	  work	  have	  begun	  to	  reap	  dividends.	  	   	   As	  noted	  in	  previous	  Monitor’s	  Reports,	  the	  facility	  began	  to	  hold	   Involuntary	  Disability	  Separation	  (IDS)	  hearings	  in	  January	  2012.	  These	   hearings	  vacated	  positions	  historically	  filled	  by	  staff	  who	  had	  exhausted	   their	  leave	  benefits,	  positions	  which	  could	  then	  be	  filled	  by	  someone	  who	   was	  willing	  and	  able	  to	  report	  to	  work.	  The	  commitment	  to	  ensure	  that	   direct	  care	  staff	  positions	  are	  functionally	  occupied	  has	  continued.	  During	   the	  current	  monitoring	  period,	  DYS	  held	  18	  IDS	  hearings	  (and	  won	  16	  of	   those).	  	   	   In	  addition,	  DYS	  closed	  one	  girls’	  (Hunter)	  and	  one	  boys’	  (Carver)	  general	   population	  unit.	  While	  there	  were	  several	  factors	  underlying	  this	  decision,	   one	  of	  them	  was	  to	  alleviate	  the	  chronic	  staff	  shortages	  that	  had	  plagued	   the	  facility	  for	  years.	  Hunter	  Unit	  was	  closed	  at	  the	  end	  of	  June	  2012,	  and	   more	  recently,	  Carver	  Unit	  was	  closed	  in	  December	  2012.	  Hunter	  staff	  bid	   on	  and	  were	  placed	  on	  other	  posts;	  Carver	  staff	  were	  placed	  in	  the	  relief	   pool	  to	  assist	  with	  staff	  coverage	  in	  other	  areas	  of	  the	  facility.	  	  	   	   Both	  Hunter	  and	  Carver	  staff	  positions	  are	  still	  considered	  in	  the	  facility’s	   staffing	  allocation,	  which	  makes	  the	  facility’s	  data	  on	  staff	  vacancies	  and	   overtime	  difficult	  to	  interpret.	  Furthermore,	  the	  facility’s	  population	  is	   very	  low,	  but	  the	  number	  of	  mandated	  positions	  allocated	  to	  each	  unit	   via	  the	  Pick-­‐A-­‐Post	  collective	  bargaining	  agreement	  has	  not	  yet	  been	   adjusted.	  As	  a	  result,	  the	  facility	  is	  required	  to	  call	  staff	  in	  and	  pay	  them	   overtime	  to	  cover	  a	  shortage,	  even	  though	  the	  staff-­‐to-­‐youth	  ratio	  would	   fall	  within	  the	  generally	  accepted	  practice.	  	   	   For	  all	  of	  these	  reasons,	  on	  paper,	  the	  Scioto	  staffing	  situation	  appears	  to	   be	  worse	  than	  it	  is.	  Except	  for	  one	  situation	  in	  November	  where	  youth	   were	  confined	  to	  their	  rooms	  for	  43	  minutes	  during	  the	  normal	  wake	  up	   and	  hygiene	  routine,	  staff	  shortages	  have	  not	  resulted	  in	  a	  lack	  of	  access	   to	  youth	  programming	  or	  services.	  As	  discussed	  in	  the	  previous	  section,	   youth-­‐on-­‐youth	  violence	  remains	  low.	  Perhaps	  most	  telling	  are	  the	   statistics	  related	  to	  the	  number	  of	  staff	  off	  work—during	  the	  previous	   monitoring	  period,	  a	  whopping	  47	  staff	  on	  the	  roster	  were	  not	  reporting	   to	  work.	  More	  recently,	  that	  number	  hovers	  around	  6	  staff.	  	   	   The	  facility	  continues	  to	  address	  the	  factors	  that	  result	  in	  the	  abuse	  of	  the	   time/attendance	  policies.	  Furthermore,	  given	  that	  most	  of	  the	  turnover	  

	  

14.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 15 of 67 PAGEID #: 2509

occurs	  among	  interim	  staff	  (who	  work	  full	  time,	  but	  who	  do	  not	  receive	   benefits),	  stabilizing	  this	  segment	  of	  the	  workforce	  continues	  to	  be	  a	   priority.	  New	  initiatives	  to	  recognize	  high-­‐performing	  staff	  and	  to	  fortify	   the	  mentoring	  relationships	  created	  via	  On-­‐The-­‐Job	  training	  are	  also	   underway.	  	   	   Investigations	  Related	  to	  Use	  of	  Force,	  Seclusion	  or	  Abusive	  Practices	   Over	  the	  past	  six	  months,	  50	  allegations	  of	  excessive	  or	  inappropriate	   uses	  of	  force,	  verbal	  or	  other	  misconduct	  were	  investigated,	  13	  by	  the	   Chief	  Inspector’s	  Office	  (CIO)	  and	  37	  by	  a	  facility-­‐based	  investigator.	  This	   is	  a	  significant	  increase	  over	  the	  previous	  six-­‐month	  period,	  when	  28	   investigations	  were	  completed.	  [During	  the	  previous	  monitoring	  period,	  a	   large	  number	  of	  investigations	  were	  “pending”	  which	  may	  account	  for	  the	   difference	  in	  the	  number	  of	  investigations	  completed	  and	  available	  for	   review.]	   	   Across	  the	  50	  investigations,	  18	  were	  substantiated	  (19%	  of	  the	  local	   investigations	  and	  85%	  of	  the	  CIO	  investigations,	  36%	  combined).	  Among	   them:	  
• 9	  (50%)	  involved	  an	  unsanctioned	  restraint	  technique	  (e.g.,	  elbow	   in	  the	  youth’s	  face;	  hooking	  an	  arm	  around	  the	  youth’s	  neck;	   unsafe	  take	  down;	  laying	  on	  a	  youth	  who	  was	  prone;	  dragging	  a	   youth	  by	  his	  shirt);	  
• 3	  (17%)	  involved	  an	  inappropriate	  comment	  or	  behavior	  (e.g.,	  a	   comment	  about	  a	  youth’s	  mother;	  using	  gang-­‐related	  hand	   signals;	  backing	  into	  a	  youth’s	  room	  in	  a	  suggestive	  manner);	  
• 2	  (11%)	  involved	  physical	  abuse	  or	  an	  abusive	  practice	  (e.g.,	   exchanging	  punches	  with	  a	  youth;	  cutting	  off	  a	  youth’s	  water	  and	   vent);	  and	  
• 4	  (22%)	  involved	  improper	  procedures	  (e.g.,	  failing	  to	  use	  the	   handheld	  camera	  and	  notifying	  Operations	  about	  a	  youth’s	   refusal	  to	  remove	  restraints;	  failure	  to	  report	  a	  fight	  or	  use	  of	   force;	  leaving	  post	  without	  relief;	  bringing	  a	  personal	  cell	  phone	   into	  the	  facility;	  inappropriate	  contact	  with	  youth	  via	  FaceBook).	  	   	  
As	  noted	  in	  prior	  reports,	  the	  poor	  quality	  of	  the	  local	  investigations	   creates	  concern	  about	  the	  extent	  to	  which	  staff	  who	  use	  force	  improperly	   or	  otherwise	  mistreat	  youth	  can	  be	  accurately	  identified	  via	  the	   investigation	  process.	  These	  concerns	  are	  discussed	  in	  detail	  in	  III.A.5,	   below,	  but	  are	  relevant	  to	  this	  provision	  insofar	  as	  a	  poorly	  constructed	   investigation	  does	  not	  adequately	  protect	  youth	  from	  harm	  at	  the	  hands	   of	  staff,	  as	  required	  by	  this	  provision.	   	   Allegations	  of	  Inappropriate	  Relationships	   Each	  of	  the	  previous	  Monitor’s	  reports	  discussed	  the	  problem	  of	   allegations	  of	  sexualized	  comments	  by	  staff	  and	  inappropriate	   relationships	  between	  Scioto	  staff	  and	  youth.	  Historically,	  the	  usual	  tools	  

	  

15.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 16 of 67 PAGEID #: 2510

to	  combat	  this	  type	  of	  problem	  (e.g.,	  staff	  training,	  a	  robust	  grievance	   process,	  and	  procedures	  for	  investigating	  allegations)	  have	  not	  been	   sufficient,	  as	  youth	  continued	  to	  report	  inappropriate	  comments	  and	   behaviors	  by	  staff	  to	  the	  Monitors,	  DOJ	  attorneys	  and	  facility	  staff.	  	   	   For	  the	  first	  time	  since	  the	  Monitor	  became	  involved	  in	  the	  case,	  none	  of	   the	  girls	  interviewed	  reported	  an	  inappropriate	  relationship	  or	  sexually	   inappropriate	  comments	  or	  conduct	  to	  either	  the	  Monitors	  or	  the	  DOJ	   Attorney	  (all	  but	  two	  of	  the	  girls	  in	  custody	  were	  interviewed	  by	  one	  or	   the	  other).	  There	  were	  a	  few	  grievances	  about	  sexualized	  comments	  by	   female	  staff	  to	  male	  residents	  (none	  of	  which	  were	  found	  to	  have	  merit	   by	  the	  facility’s	  Grievance	  Coordinator)	  and	  one	  grievance	  about	   sexualized	  behavior	  by	  female	  staff	  toward	  a	  male	  resident	  (which	  was	   sustained;	  involved	  a	  female	  staff	  backing	  into	  a	  youth’s	  room	  in	  a	   suggestive	  manner).	  Otherwise,	  neither	  the	  Monitor	  nor	  the	  facility	  has	   been	  made	  aware	  of	  continued	  problems	  in	  this	  area.	   	   However,	  a	  recent	  report	  by	  the	  Bureau	  of	  Justice	  Statistics	  (Beck,	  A.,	  D.	   Cantor,	  J.	  Hartge	  and	  T.	  Smith	  (2013)	  Sexual	  Victimization	  in	  Juvenile	   Facilities	  Reported	  by	  Youth,	  2012.)	  ranked	  Ohio,	  and	  Scioto	  in	  particular,	   among	  the	  highest	  in	  the	  nation	  for	  sexual	  assault	  committed	  against	   incarcerated	  youth,	  suggesting	  that	  serious	  problems	  remain.	  At	  the	  time	   this	  report	  was	  issued,	  the	  Governor	  Kasich	  had	  convened	  an	  interagency	   Task	  Force	  to	  develop	  immediate,	  short	  and	  long-­‐term	  remedies	  to	   address	  the	  problem.	  Progress	  implementing	  those	  remedies	  will	  be	   reviewed	  in	  subsequent	  Monitor’s	  Reports.	  	   	   Verbal	  Mistreatment	   Although	  no	  new	  allegations	  of	  inappropriate	  relationships	  or	  sexualized	   language	  or	  behaviors	  were	  reported	  to	  the	  facility,	  the	  Monitor	  or	  the	   DOJ	  Attorney,	  youth	  continue	  to	  report	  that	  staff	  provoke,	  antagonize,	   belittle	  or	  otherwise	  interact	  in	  unprofessional,	  counterproductive	  and	   hurtful	  ways	  with	  youth.	  	   	   Also	  troubling	  is	  youth’s	  continued	  belief	  that	  neither	  the	  grievance	   process	  nor	  the	  investigation	  process	  can	  protect	  them	  because	  neither	   will	  result	  in	  staff	  being	  held	  accountable	  for	  their	  behavior.	  Many	  of	  the	   youth	  interviewed	  by	  the	  DOJ	  attorney	  reported	  concerns	  about	  a	   number	  of	  staff	  who	  appear	  to	  act	  with	  impunity,	  who	  treat	  the	  youth	   poorly	  and	  then	  taunt	  the	  youth	  to	  write	  a	  grievance	  because	  “nothing	   will	  happen.”	  When	  youth	  gave	  examples	  of	  poor	  treatment	  by	  staff,	  the	   interviewers	  asked	  if	  they	  had	  reported	  the	  incident	  to	  anyone	  at	  the	   facility.	  In	  some	  cases	  they	  had,	  in	  other	  cases	  they	  hadn’t,	  but	  in	  all	  cases	   their	  experience	  suggested	  to	  them	  that	  it	  would	  not	  change	  the	   environment	  for	  the	  better.	  While	  the	  Monitor	  recognizes	  that	  youth	  are	   not	  always	  truthful	  when	  interviewed,	  the	  similarities	  in	  their	  descriptions	   of	  staff’s	  bravado	  suggest	  that	  the	  facility	  needs	  to	  address	  the	  manner	  in	  

	  

16.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 17 of 67 PAGEID #: 2511

which	  some	  staff	  relate	  to	  the	  youth	  in	  their	  care.	  	   	   However,	  from	  the	  discussions	  with	  youth,	  it	  appears	  that	  the	  problem	  is	   not	  the	  lack	  of	  a	  forum	  to	  voice	  their	  concerns	  (all	  of	  the	  youth	  gave	  the	   Grievance	  process	  high	  marks),	  but	  rather	  in	  their	  belief	  that	  the	  facility	   will	  not	  act	  on	  their	  complaints.	  The	  delays	  in	  assigning	  and	  completing	   local	  investigations	  of	  their	  complaints	  and	  the	  poor	  quality	  of	  the	   investigations	  (which	  rarely	  lead	  to	  a	  sustained	  finding)	  likely	  contribute	   to	  this	  perception.	  Improving	  the	  quality	  of	  the	  local	  investigation	  process	   may	  create	  additional	  opportunities	  to	  hold	  staff	  accountable	  in	  a	  way	   that	  may	  be	  persuasive	  to	  staff	  who	  persist	  in	  acting	  with	  impunity,	  and	   may	  help	  youth	  to	  gain	  confidence	  in	  the	  system.	  	  	  	   	   Tools	  to	  Ensure	  Staff	  Accountability	   The	  DOJ	  launched	  its	  investigation	  at	  a	  time	  when	  over	  10%	  of	  the	   facility’s	  staff	  were	  under	  indictment	  for	  physical	  or	  sexual	  abuse	  of	   Scioto	  youth.	  Since	  then,	  the	  DYS	  has	  enacted	  a	  number	  of	  measures	   intended	  to	  prevent	  the	  reoccurrence	  of	  such	  a	  tragedy.	  Some	  of	  these	   measures	  have	  been	  well	  implemented	  and	  definitely	  improve	  the	  State’s	   ability	  to	  protect	  youth	  from	  harm	  at	  the	  hands	  of	  staff.	  Among	  them:	  
• Additional	  stationary	  and	  hand-­‐held	  video	  cameras;	   • A	  robust	  grievance	  process;	   • Revised	  policies	  and	  procedures;	  and	   • Investigations	  by	  the	  Chief	  Inspector’s	  Office.	   Other	  measures	  are	  less	  well-­‐developed,	  but	  if	  fully	  implemented,	  could	   add	  additional	  protection:	   • Compliance	  with	  PREA	  standards;	  
o In	  particular,	  the	  facility	  should	  develop	  guidelines	  to	   prohibit	  staff	  from	  being	  alone	  with	  youth	  in	  places	  that	   do	  not	  have	  either	  camera	  surveillance	  or	  natural	   surveillance	  opportunities.	  The	  DYS	  has	  already	  made	   substantive	  efforts	  to	  move	  toward	  compliance	  with	  PREA	   standards	  (e.g.,	  policy	  review	  and	  revision;	  staff	  training;	   youth	  education).	  Scioto	  is	  scheduled	  for	  a	  “Vulnerability	   Assessment”	  before	  the	  end	  of	  2013,	  which	  should	   indicate	  the	  extent	  to	  which	  PREA	  standards	  are	  being	   met.	  	  
• “Healthy	  Boundaries,	  Healthy	  Relationships”	  group;	  	   o During	  the	  first	  half	  of	  the	  monitoring	  period,	  the	  facility	   delivered	  the	  second	  cycle	  of	  its	  6-­‐week	  “Healthy	   Boundaries	  and	  Relationships”	  group,	  co-­‐facilitated	  by	  a	   contracted	  provider	  and	  the	  girls’	  social	  worker.	  Progress	   notes	  for	  the	  August-­‐October	  2012	  group	  revealed	  an	   appropriate	  range	  of	  topics	  (e.g.,	  characteristics	  of	   healthy/unhealthy	  relationships,	  boundaries,	   inappropriate	  relationships	  due	  to	  age	  or	  roles,	  grooming	   behaviors	  to	  encourage	  girls	  to	  acquiesce,	  etc.).	  It	  appears	  

	  

17.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 18 of 67 PAGEID #: 2512

this	  group	  is	  held	  only	  twice	  per	  year	  (once	  in	  the	  previous	   monitoring	  period,	  once	  in	  the	  current	  monitoring	  period).	   Positive	  reviews	  from	  the	  girls	  who	  have	  attended	  the	   program,	  and	  the	  unique	  forum	  for	  identifying	  potentially	   inappropriate	  relationships	  among	  youth	  and	  staff,	   suggest	  that	  the	  group	  should	  be	  delivered	  continuously.	   • Forum	  during	  Interdisciplinary	  Team	  (IDT)	  meetings;	   o The	  topics	  of	  over-­‐familiarization	  and	  boundary	  issues	   between	  staff	  and	  youth	  were	  incorporated	  into	  the	  staff	   portion	  of	  the	  weekly	  Interdisciplinary	  Team	  (IDT)	   meetings.	  The	  facility	  provided	  IDT	  minutes	  from	  six	   meetings	  that	  occurred	  during	  the	  current	  monitoring	   period	  to	  demonstrate	  the	  extent	  to	  which	  this	  strategy	   had	  been	  implemented.	  The	  topic	  was	  broadly	  defined	  to	   include	  youth	  who	  may	  be	  touching	  each	  other	   inappropriately	  and	  youth	  who	  seem	  to	  be	  developing	   crushes	  on	  staff	  and	  behaving	  inappropriately.	  For	  the	   most	  part,	  the	  conversations	  revolved	  around	  youth	   having	  inappropriate	  relationships	  with	  each	  other	  and	   little	  evidence	  was	  available	  to	  establish	  that	  staff-­‐youth	   boundaries	  were	  discussed	  with	  staff,	  even	  when	  there	   were	  clear	  indicators	  of	  such	  dynamics	  (e.g.,	  two	  female	   youth	  were	  arguing	  because	  they	  both	  had	  a	  crush	  on	  the	   same	  YS).	  While	  the	  forum	  for	  these	  discussions	  has	   clearly	  been	  established	  (it	  is	  a	  standing	  agenda	  item	  on	   the	  IDT	  minutes),	  the	  discussions	  appear	  to	  lack	  substance	   or	  pointed	  conversations	  about	  staff’s	  involvement	  in	   these	  situations.	  Two	  recent	  investigations	  of	   inappropriate	  relationships	  between	  youth	  and	  staff	   suggested	  that	  several	  staff	  had	  concerns	  about	  the	  YSs’	   poor	  boundaries	  and	  inappropriate	  relationships	  with	  the	   alleged	  victims,	  yet	  none	  of	  them	  addressed	  the	  matter	  in	   the	  Unit’s	  IDT	  meetings	  or	  otherwise	  reported	  their	   concerns.	  	   While	  these	  measures	  are	  surely	  a	  step	  in	  the	  right	  direction,	  they	   nonetheless	  fall	  short	  of	  substantial	  compliance	  with	  the	  portion	  of	  this	   provision	  related	  to	  protecting	  youth	  from	  harm	  at	  the	  hands	  of	  staff.	   During	  a	  recent	  conference	  call	  between	  the	  State,	  DOJ	  and	  the	  Monitor,	   the	  DYS	  agreed	  to	  pursue	  the	  following	  strategies	  in	  order	  to	  more	  fully	   develop	  its	  process	  for	  staff	  accountability:	   • Reconfiguring	  the	  local	  investigations	  process	  by,	  for	  starters,	   seeking	  to	  create	  a	  position	  for	  a	  dedicated	  facility-­‐based	   investigator;	  	   o As	  noted	  throughout	  this	  report,	  the	  poor	  quality	  of	  the	   local	  investigations	  is	  the	  weak	  link	  in	  the	  system.	   Without	  a	  solid	  mechanism	  to	  determine	  the	  veracity	  of	   youth’s	  allegations	  and	  to	  hold	  staff	  accountable	  for	  

	  

18.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 19 of 67 PAGEID #: 2513

Recommendations	  
Sources	  of	   Information	  

violating	  policy,	  the	  culture	  change	  that	  the	  DYS	  seeks	  to	   catalyze	  will	  be	  impossible	  to	  achieve.	  	   • Fortifying	  the	  policy	  language	  and	  enforcement	  of	  mandates	  for	   staff	  to	  uphold	  the	  standards	  of	  conduct	  and	  to	  report	  instances	   when	  they	  observe	  other	  staff	  not	  upholding	  those	  standards.	   o Once	  established	  in	  policy,	  compliance	  with	  these	   standards	  needs	  to	  be	  addressed	  through	  the	   investigations	  into	  these	  peripheral	  issues	  that	  emerge	   while	  investigating	  an	  allegation	  of	  staff	  mistreatment.	  	   	   Until	  the	  DYS	  has	  established	  a	  dependable	  mechanism	  to	  investigate	  and	   hold	  staff	  accountable	  for	  their	  failure	  to	  protect	  youth	  from	  harm,	  and	   for	  the	  instances	  in	  which	  they,	  themselves,	  are	  the	  source	  of	  harm,	  the	   DYS	  will	  not	  be	  able	  to	  achieve	  substantial	  compliance	  with	  this	  provision.	  	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Reach	  substantial	  compliance	  with	  provisions	  related	  to	   seclusion,	  investigations	  of	  abuse	  and	  neglect,	  grievances	  and	   programming.	  	  
2. Implement	  and	  assess	  the	  effectiveness	  of	  interventions	  that	   target	  the	  underlying	  causes	  and	  patterns	  of	  youth-­‐on-­‐staff	   violence.	  Make	  modifications	  as	  necessary	  to	  effect	  substantial	   reductions	  in	  the	  rate	  of	  youth-­‐on-­‐staff	  assaults.	  	  
3. Address	  the	  poor	  quality	  of	  local	  investigations	  to	  improve	  the	   ability	  to	  protect	  youth	  from	  harm	  related	  to	  inappropriate	  uses	   of	  force	  and	  verbal	  abuse	  (e.g.,	  provoking,	  taunting,	  belittling	  and	   otherwise	  disrespecting	  youth).	  	  
4. Improve	  staff	  accountability	  measures	  to	  ensure	  that	  all	  staff	  are	   held	  responsible	  not	  just	  for	  maintaining	  the	  code	  of	  conduct,	  but	   for	  reporting	  their	  concerns	  about	  staff	  who	  fail	  to	  do	  so.	  	  
• Self-­‐assessment	  data	  and	  its	  interpretation	  for	  III.A.1,	  prepared	  at	   my	  request	  
• Interviews	  with	  Facility	  Superintendent	  and	  Deputies,	  along	  with	   staff	  from	  DYS	  Central	  Office	  
• Monthly	  Superintendent’s	  Reports,	  October	  2012	  through	  March	   2013	  
• Monitor’s	  Monthly	  Data,	  Scioto	  Male	  and	  Female	  Population,	   2012	  and	  2013,	  to	  date	  
• CIO	  and	  local	  investigation	  log,	  October	  2012	  through	  March	   2013	  
• CIO	  and	  local	  investigations	  completed	  between	  October	  2012	   and	  March	  2013	  
• Description	  and	  Group	  Notes	  from	  “Healthy	  Relationships	  and	   Boundaries”	  groups,	  August	  through	  October	  2012	  
• IDT	  Minutes	  from	  October	  2012	  through	  March	  2013	  that	   document	  conversations	  surrounding	  boundary	  issues	  between	  

	  

19.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 20 of 67 PAGEID #: 2514

youth	  and	  staff	   • Interviews	  with	  youth	  housed	  at	  Scioto	  between	  March	  24-­‐26,	  
2013,	  in	  consultation	  with	  other	  Monitors	  and	  the	  DOJ	  attorney	   who	  interviewed	  approximately	  20	  youth	  housed	  at	  the	  facility	  	   • Review	  of	  13	  CIO	  investigations	  completed	  since	  October	  2012	   (100%	  of	  total)	   • Review	  of	  37	  investigations	  conducted	  by	  Scioto	  staff	  since	   October	  2012	  (100%	  of	  total)	  

	  

	  

	  

	  

	  

20.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 21 of 67 PAGEID #: 2515

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

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

Although	  the	  facility	  provided	  a	  large	  volume	  of	  data	  on	  the	  use	  of	   seclusion	  at	  the	  Monitor’s	  request,	  its	  interpretation	  was	  challenging	  for	   a	  number	  of	  reasons.	  First,	  the	  facility	  had	  yet	  another	  change	  in	   Superintendent	  and	  thus	  the	  sense	  of	  “starting	  over”	  with	  regard	  to	  the	   role	  that	  seclusion	  would	  play	  in	  the	  facility’s	  disciplinary	  process	  was	   predominant.	  Second,	  the	  IRAV	  policy	  and	  Sanctions	  grid	  underwent	  a	   major	  transformation	  at	  the	  end	  of	  the	  current	  monitoring	  period.	   Although	  its	  formal	  implementation	  did	  not	  occur	  until	  April	  2013,	  just	   after	  the	  monitoring	  period	  ended,	  conversations	  with	  DYS	   Administrators	  suggested	  that	  in	  some	  places,	  the	  reforms	  began	  to	  seep	   into	  the	  facility’s	  practices	  even	  in	  advance	  of	  the	  policy’s	  formal	   implementation.	  Both	  of	  these	  changes	  are	  very	  positive	  and	  the	   Monitor	  anticipates	  significant	  changes	  to	  the	  use	  of	  seclusion	  in	  the	   upcoming	  monitoring	  period	  (April	  through	  September	  2013).	  	   	   In	  terms	  of	  Quality	  Assurance,	  the	  facility	  has	  multiple	  tools	  at	  its	   disposal.	  First,	  each	  month,	  the	  Facility	  Superintendent	  is	  required	  to	   report	  seclusion	  hours	  in	  the	  Superintendent’s	  Monthly	  Report	  and	  must	   explain	  any	  increases	  or	  decreases	  in	  the	  various	  categories	  of	  seclusion.	   These	  explanations	  generally	  connect	  the	  consumption	  of	  seclusion	   hours	  to	  the	  number	  of	  AOV	  and	  the	  number	  of	  youth	  involved,	  but	  do	   not	  look	  at	  whether	  the	  seclusion	  procedures,	  themselves,	  were	  properly	   implemented.	  	   	   Second,	  the	  Central	  Office’s	  Facility	  Resource	  Administrator	  (FRA)	   reviews	  the	  use	  of	  seclusion	  on	  a	  monthly	  basis	  and	  discusses	  any	   procedural	  problems	  (e.g.,	  exceeding	  the	  maximum	  length	  of	  stay;	  failing	   to	  make	  safety	  and	  welfare	  checks	  at	  the	  required	  intervals).	  For	  the	  first	   three	  months	  of	  the	  monitoring	  period,	  the	  FRA	  noted	  a	  variety	  of	   deficiencies	  in	  the	  documentation	  (e.g.,	  lack	  of	  supervisory	  approval	  for	   continuation	  or	  release,	  lack	  of	  information	  regarding	  the	  reason	  for	   seclusion,	  exact	  15-­‐minute	  increments	  on	  the	  monitoring	  logs).	  In	   addition,	  the	  FRA	  noted	  that	  large	  proportions	  of	  youth	  were	  being	  held	   in	  pre-­‐hearing	  seclusion	  for	  the	  maximum	  allowable	  time,	  even	  when	  an	   Intervention	  Hearing	  was	  not	  utilized.	  The	  FRA	  encouraged	  the	  facility	  to	   hold	  the	  hearings	  more	  quickly	  so	  that	  the	  length	  of	  stay	  in	  pre-­‐hearing	   confinement	  could	  be	  reduced.	  By	  February	  2013,	  these	  deficiencies	  had	   been	  corrected,	  which	  suggests	  that	  the	  FRA	  review	  and	  communication	   with	  the	  Direct	  Deputy,	  and	  others,	  is	  an	  effective	  avenue	  for	  program	   improvements.	   	  

	  

21.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 22 of 67 PAGEID #: 2516

Steps	  Taken	  to	   Assess	  Compliance	  

Finally,	  via	  the	  S.H.	  stipulation,	  the	  facility	  designed	  a	  QA	  process	  to	   monitor	  the	  implementation	  of	  the	  IRAV	  and	  sanctions	  grid	  revisions.	   Unfortunately,	  the	  rollout	  of	  the	  policies	  did	  not	  coincide	  with	  the	   monitoring	  period	  for	  this	  report,	  and	  thus	  complete	  results	  are	  not	   available.	  However,	  the	  first	  month	  of	  the	  revised	  IRAV’s	  implementation	   (April	  2013)	  produced	  some	  encouraging	  reductions.	  To	  maximize	  its	   effectiveness,	  the	  QA	  process	  should	  be	  anchored	  to	  a	  set	  of	  standards	   that	  clearly	  articulate	  DYS’	  objectives	  regarding	  reducing	  the	  use	  of	   seclusion.	  	  

Regular	  Seclusion	   Regular	  seclusion	  is	  a	  time-­‐out,	  or	  short	  period	  of	  isolation	  imposed	  by	   direct	  care	  staff	  in	  response	  to	  mid-­‐level,	  non-­‐violent	  misconduct	  such	  as	   throwing	  things,	  property	  damage,	  storming	  around	  the	  unit,	  etc.	  Staff	   must	  obtain	  approval	  from	  a	  supervisor	  before	  placing	  a	  youth	  in	  regular	   seclusion	  and	  again	  at	  the	  one-­‐hour	  mark.	  If	  the	  youth	  remains	  in	   seclusion	  at	  the	  three-­‐hour	  mark,	  the	  supervisor	  must	  document	  in	   writing	  the	  reason	  that	  seclusion	  remains	  necessary.	   	   During	  the	  2nd	  monitoring	  period	  (October	  2011-­‐March	  2012),	  regular	   seclusion	  was	  used	  at	  a	  rate	  of	  .43	  (rate	  =	  #	  seclusion	  episodes/ADP).	   This	  rate	  increased	  23%	  during	  the	  3rd	  monitoring	  period	  to	  .53.	  The	  3rd	   Monitor’s	  Report	  also	  noted	  an	  increase	  in	  the	  length	  of	  stay	  in	  regular	   seclusion.	  Between	  15%	  and	  20%	  of	  youth	  who	  were	  placed	  in	  regular	   seclusion	  remained	  there	  for	  longer	  than	  what	  would	  normally	  be	   considered	  a	  “cool-­‐off.”	  [The	  average	  length	  of	  stay	  was	  7	  hours.]	   	   During	  the	  current	  monitoring	  period,	  these	  problems	  were	  resolved.	   The	  rate	  of	  regular	  seclusion	  returned	  to	  its	  previous	  level,	  .43.	  More	   significantly,	  95%	  of	  regular	  seclusions	  lasted	  4	  hours	  or	  less,	  with	  the	   average	  length	  of	  stay	  decreasing	  considerably,	  to	  1.6	  hours.	  These	   length	  of	  stay	  statistics	  reflect	  a	  practice	  that	  is	  far	  more	  in	  line	  with	   generally	  accepted	  practices	  regarding	  a	  “cool-­‐off.”	  	  Quality	  assurance	   efforts,	  particularly	  those	  by	  the	  FRA,	  should	  continue	  to	  reinforce	  and	   encourage	  this	  trend.	  	   	  
Regular	  Seclusion,	  October	  2012	  through	  March	  2013	  

Month	  

#	  

Rate	   (#/ADP)	  

%	  4hrs	  or	   less	  

ALOS	   (hrs)	  

October	  2012	  

42	  

.55	  

100%	  

1.4	  

November	  2012	  

25	  

.30	  

88%	  

1.6	  

December	  2012	  

28	  

.39	  

93%	  

1.7	  

January	  2013	  

21	  

.34	  

100%	  

1.4	  

February	  2013	  

28	  

.48	  

89%	  

1.9	  

March	  2013	  

31	  

.51	  

94%	  

1.7	  

Source:	  Data	  prepared	  by	  DYS	  to	  respond	  to	  the	  Monitor’s	  request	  for	  information	  on	  

	  

22.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 23 of 67 PAGEID #: 2517

the	  use	  of	  seclusion.	  	  
	   Pre-­‐Hearing	  Seclusion	   Pre-­‐Hearing	  Seclusion	  (PHS)	  is	  a	  period	  of	  isolation	  imposed	  following	  an	   act	  of	  violence	  (AOV),	  pending	  a	  disciplinary	  hearing.	  Youth	  on	  PHS	   remain	  in	  their	  rooms	  except	  for	  showers.	  Youth	  must	  receive	  recreation	   and	  Unit	  Instruction	  (i.e.,	  education),	  although	  the	  instruction	  is	   delivered	  through	  the	  youth’s	  door.	  The	  length	  of	  time	  a	  youth	  remains	   on	  PHS	  is	  primarily	  determined	  by	  his	  or	  her	  IRAV	  score,	  which	  is	  based	   on	  the	  severity	  of	  the	  current	  rule	  violation	  and	  the	  youth’s	  history	  of	   non-­‐compliant	  behavior.	  	   	   The	  rate	  of	  PHS	  generally	  tracks	  increases	  and	  decreases	  in	  the	  rate	  of	   AOV	  and	  does	  not	  give	  much	  insight	  into	  the	  facility’s	  seclusion	  practices.	   Rather,	  it	  is	  changes	  to	  the	  youth’s	  lengths	  of	  stay	  that	  reflect	  whether	   practices	  around	  the	  use	  of	  PHS	  are	  being	  reformed	  as	  required	  by	  this	   Provision.	  During	  the	  previous	  monitoring	  period,	  nearly	  all	  PHS	  episodes	   exceeded	  24	  hours	  and	  the	  average	  length	  of	  stay	  was	  53	  hours.	  	   	   As	  noted	  above,	  DYS	  revised	  the	  IRAV	  policy	  during	  the	  current	   monitoring	  period,	  incorporating	  most	  of	  the	  suggestions	  discussed	  in	   the	  previous	  Monitor’s	  Report.	  The	  policy	  was	  scheduled	  to	  be	  rolled	  out	   in	  April	  2013;	  however,	  with	  changes	  on	  the	  horizon,	  the	  length	  of	  stay	  in	   PHS	  began	  to	  decrease	  even	  before	  the	  policy	  was	  issued.	  In	  the	  first	  half	   of	  the	  monitoring	  period,	  no	  major	  changes	  were	  evident.	  An	  average	  of	   90%	  of	  pre-­‐hearing	  seclusions	  lasted	  more	  than	  24	  hours	  and	  the	  ALOS	   was	  54	  hours.	  In	  the	  second	  half,	  however,	  the	  proportion	  lasting	  more	   than	  24	  hours	  decreased	  to	  66%	  and	  the	  average	  length	  of	  stay	   decreased	  to	  37	  hours	  (a	  30%	  decrease).	  Across	  the	  IRAV	  levels,	  far	  more	   youth	  were	  released	  prior	  to	  the	  maximum	  allowable	  time	  for	  each	  level	   and	  ALOS	  also	  decreased	  within	  each	  level.	  Once	  the	  new	  IRAV	  policy	  is	   implemented,	  it	  is	  likely	  that	  these	  decreases	  will	  become	  even	  more	   pronounced.	  	   	   Notably,	  the	  new	  IRAV	  policy	  brings	  additional	  and	  more	  frequent	   opportunities	  for	  youth	  to	  be	  released	  from	  PHS	  once	  they	  demonstrate	   a	  willingness	  and	  ability	  to	  return	  to	  the	  general	  population	  safely.	   Individualizing	  the	  length	  of	  stay	  in	  PHS	  this	  way	  is	  far	  more	  compatible	   with	  the	  generally	  accepted	  practice	  than	  the	  historical	  reliance	  on	  pre-­‐ determined	  lengths	  of	  stay.	  	  	   	  
Pre-­‐Hearing	  Seclusion,	  October	  2012	  through	  March	  2013	  

Month	  

#	  

Rate	   (#/ADP)	  

%	  24+	  hours	  

ALOS	   (hrs)	  

October	  2012	  

23	  

.30	  

96%	  

61	  

November	  2012	  

63	  

.77	  

86%	  

52	  

	  

23.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 24 of 67 PAGEID #: 2518

December	  2012	  

28	  

.39	  

89%	  

50	  

January	  2013	  

24	  

.39	  

58%	  

36	  

February	  2013	  

20	  

.34	  

65%	  

38	  

March	  2013	  

12	  

.20	  

75%	  

36	  

Source:	  Data	  prepared	  by	  DYS	  to	  respond	  to	  the	  Monitor’s	  request	  for	  information	  on	   the	  use	  of	  seclusion.	  	  
	   	   Intervention	  Seclusion	   Intervention	  hearings	  are	  held	  to	  determine	  whether	  youth	  are	  culpable	   for	  serious	  misconduct	  and	  whether	  additional	  time	  in	  seclusion	  is	   warranted.	  While	  on	  Intervention	  Seclusion,	  youth	  remain	  in	  their	  rooms	   except	  for	  showers.	  Youth	  must	  receive	  recreation	  and	  Unit	  Instruction	   (i.e.,	  education)	  outside	  of	  their	  rooms.	  By	  policy,	  youth	  can	  receive	   Intervention	  Seclusion	  for	  a	  primary	  rule	  violation,	  some	  of	  which	  are	   non-­‐violent	  (e.g.,	  exposure).	  The	  Hearing	  Officer	  can	  impose	  a	  maximum	   of	  5	  days	  of	  Intervention	  Seclusion,	  but	  policy	  also	  allows	  for	  the	  use	  of	   alternative	  sanctions	  to	  respond	  to	  primary	  rule	  violations.	  	   	   During	  the	  current	  monitoring	  period,	  the	  DYS	  revised	  policies	  regarding	   the	  Intervention	  Hearings	  (requiring	  them	  to	  be	  held	  more	  quickly)	  and	   Sanctioning	  process	  (instituting	  a	  new	  sanctions	  grid	  that	  limits	   discretion	  and	  significantly	  reduces	  the	  amount	  of	  seclusion	  that	  can	  be	   imposed).	  These	  policies	  are	  scheduled	  to	  be	  rolled	  out	  in	  May	  2013	  and	   are	  expected	  to	  reduce	  the	  State’s	  reliance	  on	  seclusion	  as	  a	  sanction.	  	   	   While	  these	  changes	  are	  very	  positive	  and	  certainly	  headed	  in	  the	  right	   direction,	  it	  is	  worth	  noting	  that	  the	  use	  of	  isolation	  as	  a	  disciplinary	   sanction	  is	  increasingly	  being	  prohibited	  by	  juvenile	  justice	  systems	   throughout	  the	  country.	  Research	  on	  the	  deleterious	  effects	  of	  isolation	   on	  youth’s	  mental	  health	  suggests	  that	  skill-­‐based,	  restorative	  and	   treatment-­‐focused	  responses	  and	  sanctions	  available	  through	  the	   behavior	  management/incentive	  system	  are	  less	  harmful	  and	  more	   effective	  than	  isolation	  in	  changing	  youth’s	  behavior.	  The	  Monitor	   strongly	  encourages	  DYS	  to	  reconsider	  its	  use	  of	  disciplinary	  isolation.	  	   	   The	  new	  IH	  policy	  and	  sanctions	  grid	  will	  ensure	  that	  an	  increasing	   proportion	  of	  rule	  violations	  are	  handled	  by	  the	  IDT,	  which	  is	  a	  promising	   practice	  given	  that	  treatment	  teams	  tend	  to	  design	  sanctions	  that	  are	   more	  responsive	  to	  the	  underlying	  causes	  of	  the	  youth’s	  behavior.	  In	   contrast,	  seclusion	  serves	  only	  to	  suppress	  a	  youth’s	  negative	  behavior	   during	  the	  time	  that	  he	  or	  she	  is	  behind	  a	  locked	  door	  and	  also	  denies	   youth	  access	  to	  the	  very	  treatment	  programs	  they	  need	  in	  order	  to	   change	  their	  behavior.	  	   	   As	  shown	  in	  the	  table	  below,	  the	  use	  of	  intervention	  seclusion	  varied	  

	  

24.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 25 of 67 PAGEID #: 2519

across	  the	  monitoring	  period,	  with	  rates	  ranging	  from	  a	  low	  of	  .18	  to	  a	   high	  of	  .47,	  with	  no	  obvious	  patterns.	  [Using	  a	  rate,	  rather	  than	  the	   number	  of	  youth,	  neutralizes	  the	  impact	  of	  changes	  in	  the	  size	  of	  the	   population.]	  Given	  that	  a	  small	  number	  of	  youth	  are	  involved	  in	  a	   disproportionate	  number	  of	  seclusion	  events,	  a	  rate	  of	  use	  across	  the	   population	  simultaneously	  overestimates	  (by	  making	  the	  practice	  seem	   more	  widespread	  than	  it	  is)	  and	  underestimates	  (by	  ignoring	  the	  effect	  of	   repeated	  seclusion	  experiences	  on	  a	  single	  youth)	  the	  impact	  of	  the	   practice.	  For	  these	  reasons,	  it	  is	  not	  a	  particularly	  useful	  statistic.	  	   	   Monthly	  AOV	  spreadsheets	  track	  the	  disposition	  of	  each	  AOV.	  These	  data	   indicated	  that,	  on	  average,	  seclusion	  was	  used	  to	  sanction	  72%	  of	  the	   youth	  who	  committed	  AOVs	  (monthly	  percentages	  ranged	  from	  60%	  to	   88%	  across	  the	  monitoring	  period).	  Once	  the	  new	  grid	  is	  imposed,	  DYS	   should	  monitor	  its	  implementation	  and	  encourage	  the	  use	  of	  seclusion	   only	  as	  a	  last	  resort.	  Quality	  Assurance	  efforts	  should	  also	  examine	   individual	  cases	  to	  determine	  whether	  the	  full	  range	  of	  non-­‐seclusion	   sanctions	  have	  been	  exhausted	  prior	  to	  imposing	  seclusion.	  	   	   The	  total	  number	  of	  Intervention	  Seclusion	  hours	  varied	  widely	  across	   the	  monitoring	  period,	  driven	  by	  the	  number	  of	  youth	  who	  received	  it	  as	   a	  sanction	  (e.g.,	  the	  spike	  in	  youth	  violence	  that	  occurred	  in	  November	   2012	  doubled	  the	  number	  of	  youth	  who	  were	  placed	  in	  seclusion,	  and	   led	  to	  longer	  lengths	  of	  stay,	  which	  drastically	  increased	  the	  total	   number	  of	  hours).	  Similarly,	  the	  ALOS	  varied	  throughout	  the	  monitoring	   period,	  with	  no	  obvious	  patterns.	  Except	  for	  those	  who	  received	  IS	  in	   November	  2012,	  the	  average	  youth	  spent	  approximately	  two	  days	  in	   Intervention	  Seclusion	  (which	  followed	  a	  period	  of	  Pre-­‐Hearing	   Seclusion).	  	   	  
Intervention	  Seclusion	  Hours,	  October	  2012	  through	  March	  2013	  

Month	  

#	  Y	  who	   received	  IS	  

Rate	  	   (#	  Y/ADP)	  

Total	  IS	   hours	  

ALOS	  

Oct	  2012	  

14	  

.18	  

595	  

42.5	  

Nov	  2012	  

39	  

.47	  

3,312	  

84.9	  

Dec	  2012	  

17	  

.23	  

657	  

38.6	  

Jan	  2013	  

20	  

.32	  

1,001	  

50.5	  

Feb	  2013	  

20	  

.34	  

881	  

44.0	  

March	  2013	  

15	  

.24	  

733	  

48.9	  

Source:	  Data	  prepared	  by	  DYS	  to	  respond	  to	  the	  Monitor’s	  request	  for	  information	  on	   the	  use	  of	  seclusion.	  
	   	   Although	  aggregate	  data	  is	  useful	  for	  identifying	  trends	  and	  overall	  

	  

25.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 26 of 67 PAGEID #: 2520

Recommendations	  

increases	  and	  decreases	  in	  the	  use	  of	  seclusion,	  it	  can	  mask	  the	  impact	  of	   the	  facility’s	  disciplinary	  strategy	  on	  individual	  youth.	  A	  review	  of	  AMS	   Seclusion	  records	  for	  the	  Special	  Education	  provisions	  of	  the	  Stipulation	   casts	  this	  problem	  in	  sharp	  relief.	  One	  youth,	  CC,	  spent	  16	  consecutive	   days	  in	  seclusion,	  with	  only	  one	  24-­‐hour	  period	  in	  the	  general	   population.	  Another	  youth,	  TB,	  spent	  8	  consecutive	  days	  in	  seclusion.	   While	  these	  youth	  committed	  serious	  acts	  of	  violence,	  their	  long	  stays	  in	   seclusion	  likely	  exacerbated	  their	  anger	  and	  frustration	  and	  did	  nothing	   to	  help	  them	  develop	  the	  anger	  management	  skills,	  impulse	  control,	   empathy,	  etc.	  they	  so	  desperately	  needed.	  In	  this	  way,	  the	  use	  of	   seclusion	  may	  very	  well	  exacerbate	  the	  exact	  problems	  that	  the	  facility	  is	   trying	  to	  solve.	  The	  Monitor	  strongly	  encourages	  the	  State	  to	  seek	  other	   ways	  to	  manage	  and	  respond	  to	  youth’s	  behavior.	  	   	   Quality	  Assurance	   Pilot	  testing	  of	  the	  Quality	  Assurance	  process	  developed	  via	  the	  S.H.	  case	   was	  limited	  due	  to	  the	  mismatch	  between	  the	  Order’s	  termination	  date	   and	  the	  date	  on	  which	  the	  policy	  revisions	  were	  implemented.	  While	   early	  returns	  on	  the	  IRAV	  policy	  suggest	  that	  revisions	  will	  produce	  some	   decreases	  in	  the	  length	  of	  stay	  in	  PHS,	  DYS	  is	  encouraged	  to	  revisit	  the	   task	  of	  developing	  a	  QA	  procedure	  for	  the	  use	  of	  seclusion	  to	  ensure	  it	  is	   anchored	  to	  specific	  standards	  (i.e.,	  What	  are	  the	  agency’s	  expectations	   regarding	  the	  length	  of	  stay	  in	  PHS?	  What	  are	  the	  agency’s	  expectations	   surrounding	  the	  use	  of	  seclusion	  as	  a	  sanction	  versus	  the	  use	  of	   alternatives	  to	  seclusion?).	  Once	  anchored	  to	  clear	  standards,	  the	  mass	   of	  QA	  data	  regarding	  PHS	  and	  Intervention	  Seclusion	  can	  be	  more	  easily	   interpreted.	  Setting	  specific	  targets	  will	  permit	  the	  agency	  to	  evaluate	  its	   facilities’	  performance	  in	  context	  and	  will	  permit	  the	  agency	  to	   substantiate,	  with	  objective	  data,	  whether	  it	  has	  complied	  with	  the	   requirements	  of	  this	  provision.	  Historically,	  the	  Monitor	  has	  interpreted	   data	  related	  to	  seclusion—moving	  forward,	  the	  DYS	  should	  assume	  this	   responsibility.	  The	  Monitor	  is	  available	  to	  provide	  technical	  assistance	  on	   setting	  standards,	  collecting,	  analyzing,	  and	  interpreting	  data,	  if	  desired.	  	   	   Seclusion	  among	  Youth	  on	  the	  Progress	  Units	  (PU)	   As	  noted	  in	  the	  Introduction,	  the	  conditions	  of	  confinement	  on	  the	  PU	   are	  discussed	  in	  a	  Status	  Report	  that	  is	  attached	  to	  this	  report.	  Once	  the	   State	  reaches	  substantial	  compliance	  with	  all	  of	  the	  provisions	  of	  the	   Court	  Order	  governing	  the	  PU,	  the	  use	  of	  seclusion	  on	  the	  PU	  will	  again	   be	  discussed	  in	  this	  section	  of	  the	  report.	  	  	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Develop	  robust	  Quality	  Assurance/Quality	  Improvement	   processes	  to	  determine	  whether	  the	  IRAV	  and	  Sanction	  Grid	   revisions	  are	  properly	  implemented	  and	  whether	  they	  have	   significantly	  reduced	  the	  reliance	  on	  isolation	  to	  control	  and	   respond	  to	  youth’s	  behavior.	  These	  processes	  should	  include:	  

	  

26.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 27 of 67 PAGEID #: 2521

Sources	  of	   Information	  
	   	  

a. 	  Standards	  that	  indicate	  the	  benchmarks	  against	  which	   performance	  will	  be	  measured,	  which	  should	  clearly	   indicate	  a	  preference	  for	  non-­‐seclusion	  based	  sanctions	   and	  methods	  for	  de-­‐escalating	  youth’s	  behavior.	  	  
b. Audit	  methodologies;	   c. Analysis	  and	  interpretation	  of	  data;	   d. Development	  of	  a	  Quality	  Improvement	  Plan	  for	  each	  
area	  in	  which	  performance	  deficits	  are	  identified.	  	   2. Once	  the	  Consent	  Order	  for	  the	  PROGRESS	  Unit	  has	  been	  
satisfied,	  maintain	  the	  current	  procedures	  for	  out-­‐of-­‐room	  time	   on	  the	  PROGRESS	  Unit.	  	  
• Self-­‐assessment	  data	  for	  III.A.3,	  prepared	  at	  my	  request	   • Monthly	  Superintendent’s	  Reports,	  October	  2012	  through	  March	  
2013	   • Consultation	  with	  Steve	  Martin,	  subject	  matter	  expert	  for	  S.H.	  v.	  
Reed	  et	  al.,	  and	  various	  DYS	  personnel	  regarding	  modifications	  to	   IRAV	  and	  Sanctions	  Grid	   • AMS	  Seclusion	  Log,	  February	  and	  March	  2013	  
	  

	  

27.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 28 of 67 PAGEID #: 2522

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

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

The	  State	  submitted	  a	  log	  of	  all	  investigations	  related	  to	  excessive	  uses	  of	   force,	  allegations	  of	  abuse,	  allegations	  of	  verbal	  abuse,	  and	  inappropriate	   relationships	  completed	  during	  the	  current	  monitoring	  period.	  The	  Chief	   Inspector’s	  Office	  (CIO)	  investigated	  the	  more	  serious	  allegations,	  while	   facility-­‐based	  investigators	  addressed	  the	  less	  serious	  allegations.	  	   	   Between	  October	  2012	  and	  March	  2013,	  a	  total	  of	  50	  investigations	  were	   completed	  related	  to	  the	  topics	  covered	  by	  this	  provision	  (37	  of	  these	   were	  completed	  by	  facility-­‐based	  investigators	  and	  13	  were	  completed	   by	  the	  CIO).	  Of	  these,	  7	  of	  the	  local	  investigations	  (19%)	  were	   substantiated	  and	  11	  of	  the	  CIO	  investigations	  were	  substantiated	  (85%),	   or	  36%	  overall.	  As	  noted	  in	  previous	  Monitors’	  Reports,	  the	  low	   proportion	  of	  substantiated	  allegations	  is	  likely	  due	  to	  the	  poor	  quality	  of	   the	  local	  investigations.	  	   	   Among	  the	  substantiated	  investigations:	  
• 9	  (50%)	  involved	  an	  unsanctioned	  restraint	  technique	  (e.g.,	   elbow	  in	  the	  youth’s	  face;	  hooking	  an	  arm	  around	  the	  youth’s	   neck;	  unsafe	  take	  down;	  laying	  on	  a	  youth	  who	  was	  prone;	   dragging	  a	  youth	  by	  his	  shirt);	  
• 3	  (17%)	  involved	  an	  inappropriate	  comment	  or	  behavior	  (e.g.,	  a	   comment	  about	  a	  youth’s	  mother;	  using	  gang-­‐related	  hand	   signals;	  backing	  into	  a	  youth’s	  room	  in	  a	  suggestive	  manner);	  
• 2	  (11%)	  involved	  physical	  abuse	  or	  an	  abusive	  practice	  (e.g.,	   exchanging	  punches	  with	  a	  youth;	  cutting	  off	  a	  youth’s	  water	  and	   vent);	  and	  
• 4	  (22%)	  involved	  improper	  procedures	  (e.g.,	  failing	  to	  use	  the	   handheld	  camera	  and	  notifying	  about	  a	  youth’s	  refusal	  to	   remove	  restraints;	  failure	  to	  report	  a	  fight	  or	  use	  of	  force;	  leaving	   post	  without	  relief;	  bringing	  in	  a	  personal	  cell	  phone;	   inappropriate	  contact	  with	  youth	  via	  FaceBook).	  	  
	   Quality	  Assurance	   The	  CIO	  conducts	  an	  audit	  of	  the	  facility’s	  investigations	  every	  four	   months.	  The	  audit	  process	  was	  recently	  enhanced	  to	  include	  a	  variety	  of	   performance	  indicators.	  The	  most	  recent	  CIO	  report,	  covering	  September	   through	  December	  2012,	  uses	  these	  performance	  indicators	  to	  assess	   the	  quality	  of	  a	  random	  sample	  of	  12	  local	  investigations.	  Several	  

	  

28.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 29 of 67 PAGEID #: 2523

Steps	  Taken	  to	   Assess	  Compliance	  

performance	  indicators	  were	  met:	   • 90%	  appropriately	  documented	  the	  allegation	   • 80%	  included	  a	  narrative	  summary	  of	  each	  interview	   • 90%	  used	  correct	  terminology	  in	  the	  conclusion	   • 100%	  included	  all	  attachments	   • All	  of	  the	  investigators	  had	  been	  trained	   • 83%	  of	  the	  investigations	  were	  properly	  scanned	  into	  AMS	   • 100%	  issued	  Notification	  Letters	  to	  youth	  whose	  allegations	  were	   reported	  via	  the	  Grievance	  System.	  	   	  
However,	  the	  CIO	  report	  identified	  that	  a	  large	  number	  of	  performance	   indicators,	  arguably	  the	  more	  substantive	  of	  the	  lot	  and	  those	  that	   reflect	  the	  quality	  of	  the	  investigation,	  were	  not	  met:	  
• Only	  40%	  included	  a	  review	  of	  all	  relevant	  documents	  and	  video;	   • Only	  10%	  were	  started	  in	  a	  timely	  manner;	   • Only	  40%	  interviewed	  all	  relevant	  staff	  and	  youth;	   • Only	  60%	  notified	  staff	  of	  their	  status	  (as	  a	  witness	  or	  the	  
subject)	  during	  the	  interview;	   • Only	  50%	  noted	  the	  time	  and	  date	  of	  the	  interview;	   • Only	  30%	  asked	  all	  of	  the	  necessary	  questions	  required	  to	  
respond	  to	  the	  allegation;	   • Only	  60%	  came	  to	  a	  conclusion	  that	  was	  supported	  by	  the	  
evidence;	  	   • Only	  17%	  met	  all	  required	  timelines.	  	   	   These	  results	  mirror	  the	  Monitor’s	  and,	  obviously,	  create	  serious	  concern	   about	  the	  ability	  of	  the	  investigation	  process	  undertaken	  at	  the	  facility	   level	  to	  adequately	  protect	  youth	  from	  harm	  at	  the	  hands	  of	  staff.	  On	  a	   positive	  note,	  however,	  the	  revised	  audit	  methodology	  and	  performance	   indicators	  add	  a	  great	  deal	  of	  integrity	  to	  the	  investigation	  process.	   Hopefully,	  the	  CIO’s	  new	  process	  will	  catalyze	  much	  needed	   improvements	  to	  the	  local	  investigation	  protocol	  and	  product.	  	  	  
Chief	  Inspectors	  Office	  (CIO)	  Investigations	   Timeliness.	  Of	  the	  13	  investigations	  reviewed,	  12	  (92%)	  were	  completed	   within	  the	  timelines	  prescribed	  by	  policy	  (i.e.,	  14	  business	  days	  for	  use	  of	   force	  investigations;	  30	  calendar	  days	  for	  all	  others)	  or	  were	  granted	  an	   extension	  for	  cause	  (e.g.,	  key	  witness	  was	  unavailable;	  delay	  in	  obtaining	   permission	  to	  proceed	  from	  the	  OSHP).	  At	  the	  time	  of	  the	  Monitor’s	  site	   visit,	  the	  CIO	  also	  had	  2	  pending	  investigations,	  neither	  of	  which	  had	  yet	   reached	  their	  due	  dates.	  The	  timeliness	  of	  CIO	  investigations	  has	   improved	  significantly	  since	  the	  previous	  Monitor’s	  report.	  	   	   Quality.	  Each	  of	  the	  13	  CIO	  investigations	  completed	  during	  the	   Monitoring	  period	  was	  reviewed.	  As	  in	  the	  past,	  the	  investigations	  were	   very	  well	  done.	  They	  featured	  comprehensive	  interviews	  with	  all	  key	   witnesses,	  utilized	  videotaped	  footage	  effectively,	  and	  pursued	  

	  

29.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 30 of 67 PAGEID #: 2524

peripheral	  issues	  that	  emerged	  during	  the	  course	  of	  the	  initial	  inquiry.	   Across	  the	  sample,	  the	  findings	  appeared	  to	  be	  reasonable	  and	  the	  basis	   for	  the	  conclusions	  was	  clearly	  identified	  among	  the	  evidence.	  	   	   Local	  Investigations	   Timeliness.	  Of	  the	  37	  investigations	  completed	  by	  Scioto	  staff	  during	  the	   current	  monitoring	  period,	  only	  18	  (49%)	  were	  completed	  within	  the	   timelines	  prescribed	  by	  policy.	  While	  this	  is	  an	  improvement	  over	  the	  last	   monitoring	  period,	  where	  only	  23%	  were	  on-­‐time,	  the	  timeliness	  of	   investigations	  conducted	  at	  the	  facility	  level	  is	  a	  major	  concern.	  The	   remaining	  19	  investigations	  (51%)	  were	  late	  (an	  average	  of	  61	  calendar	   days!).	  In	  addition,	  at	  the	  time	  of	  the	  Monitor’s	  site	  visit,	  2	  local	   investigations	  were	  pending	  and	  both	  were	  significantly	  overdue.	   	   As	  discussed	  in	  each	  of	  the	  previous	  Monitor’s	  Reports,	  the	  investigation	   process	  is	  a	  critical	  feature	  of	  the	  State’s	  ability	  to	  protect	  youth	  from	   harm.	  The	  continued	  and	  widespread	  delays	  in	  completing	  investigations	   have	  deleterious	  consequences	  across	  the	  board:	  	  
• Delays	  greatly	  compromise	  the	  ability	  to	  accurately	  assess	  the	   veracity	  of	  the	  allegation;	  
• Delays	  prevent	  guilty	  staff	  from	  receiving	  necessary	  re-­‐training,	   discipline	  or	  termination,	  which	  perpetuates	  the	  risk	  to	  youth;	  
• Delays	  unfairly	  stress	  innocent	  staff	  who	  may	  be	  placed	  on	   modified	  duty	  awaiting	  the	  outcome	  of	  the	  investigation;	  and	  
• Delays	  exacerbate	  the	  already	  prevalent	  sense	  among	  youth	  that	   the	  facility	  does	  not	  take	  their	  complaints	  seriously	  or	  that	   “nothing	  will	  be	  done”	  about	  the	  concerns	  they	  have	  regarding	   their	  treatment.	  	  	  
	   This	  problem	  has	  been	  at	  the	  forefront	  of	  the	  Monitor’s	  concerns	  since	   the	  inception	  of	  this	  case.	   	   Quality.	  Even	  after	  the	  Monitor	  downgraded	  the	  compliance	  level	  for	  this	   provision	  in	  the	  2nd	  Monitor’s	  Report	  and	  commented	  extensively	  on	  the	   various	  inadequacies	  identified	  among	  the	  reports	  for	  the	  past	  two	   monitoring	  periods,	  the	  quality	  of	  the	  investigations	  has	  not	  improved	   and	  remains	  far	  below	  professional	  standards.	  	   	   As	  in	  the	  previous	  monitoring	  period,	  the	  Monitor	  provided	  detailed	   feedback	  on	  each	  of	  the	  37	  cases	  to	  develop	  consensus	  around	  the	   essential	  elements	  of	  a	  quality	  investigation	  and	  to	  highlight	  the	  many	   features	  that	  were	  lacking	  from	  the	  most	  recent	  set	  of	  investigations.	   Among	  the	  most	  serious	  problems:	  
• Everyone	  who	  can	  contribute	  to	  the	  understanding	  of	  what	   occurred	  should	  be	  interviewed.	  In	  several	  cases,	  the	   investigator	  identified	  a	  very	  limited	  set	  of	  witnesses	  (e.g.,	  the	   accused	  staff,	  the	  victim	  and	  possibly	  one	  other	  staff	  witness)	  

	  

30.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 31 of 67 PAGEID #: 2525

even	  though	  other	  people	  were	  in	  the	  vicinity	  when	  the	  incident	   allegedly	  occurred.	  	   • Witnesses	  should	  be	  asked	  to	  describe	  what	  happened	  in	  their	   own	  words,	  and	  the	  investigator	  should	  seek	  clarification	  or	   additional	  detail	  through	  appropriate	  follow-­‐up	  questions.	  Many	   times,	  it	  appeared	  that	  the	  witness	  was	  simply	  asked	  to	  respond	   to	  a	  set	  of	  yes/no	  questions.	  The	  absence	  of	  follow-­‐up	  questions	   from	  many	  of	  the	  investigators	  suggested	  that	  the	  investigators	   were	  simply	  going	  through	  the	  motions	  without	  a	  particular	   drive	  to	  determine	  what	  actually	  occurred.	  	  	   • The	  sequence	  of	  the	  interviews	  is	  important.	  The	  alleged	  victim	   should	  be	  interviewed	  first	  in	  order	  to	  obtain	  a	  complete	   accounting	  of	  the	  youth’s	  concerns	  and	  to	  obtain	  details	  that	   can	  be	  used	  to	  construct	  questions	  with	  the	  witnesses	  and	  the	   accused	  staff.	  The	  accused	  staff	  should	  be	  interviewed	  last,	  so	   that	  he	  or	  she	  can	  be	  asked	  to	  respond	  to	  the	  specific	  allegations	   discovered	  during	  the	  previous	  interviews.	  In	  several	  cases,	   sequence	  was	  off,	  which	  meant	  that	  the	  investigator	  could	  not	   conduct	  the	  subsequent	  interviews	  effectively.	   • The	  investigator	  should	  follow-­‐up	  on	  peripheral	  issues	  that	   emerge,	  such	  as	  staff	  witnesses’	  failure	  to	  report	  misconduct	   that	  they	  observe	  or	  failing	  to	  write	  an	  accurate	  incident	  report.	  	   • The	  basis	  for	  the	  conclusions	  must	  be	  clearly	  articulated	  and	   must	  rest	  upon	  facts	  that	  were	  gathered	  during	  the	   investigation.	  Many	  of	  the	  investigators	  did	  not	  write	  coherent	   narratives	  and	  did	  not	  summarize	  the	  facts	  that	  supported	  the	   conclusion,	  and	  did	  not	  explain	  why	  they	  discounted	  facts	  that	   didn’t	  fit.	  In	  one	  case	  (#5501120122),	  the	  Monitor	  had	  the	   opportunity	  to	  review	  videotaped	  footage	  of	  the	  incident	  in	   question.	  The	  investigator	  left	  out	  many	  relevant	  details,	  did	  not	   confront	  witnesses	  with	  various	  omissions	  and	  contradictions	  in	   their	  written	  statements,	  and	  ultimately	  came	  to	  a	  conclusion	   that	  the	  allegation	  was	  not	  substantiated,	  despite,	  in	  the	   Monitor’s	  opinion,	  rather	  clear	  evidence	  that	  the	  subject	  of	  the	   investigation	  used	  excessive/improper	  force.	  The	  Monitor	   strongly	  recommends	  that	  the	  CIO	  re-­‐open	  this	  case	  and	  re-­‐ examine	  the	  evidence.	  One	  wonders	  how	  often	  this	  occurs— that	  the	  investigation	  is	  so	  shoddily	  done	  that	  true	  allegations	   do	  not	  get	  substantiated.	  	   	   It	  is	  worth	  noting	  that	  these	  same	  problems	  were	  articulated	  in	  the	   previous	  two	  Monitors’	  Reports,	  and	  more	  recently,	  by	  the	  CIO’s	  Quality	   Assurance	  process.	  The	  shoddy	  investigation	  protocol	  is	  insufficient	  to	   produce	  accurate	  findings	  of	  an	  allegation’s	  veracity	  and,	  as	  a	  result,	   places	  youth	  at	  significant	  risk	  of	  harm.	  When	  an	  investigation	  fails	  to	   substantiate	  a	  true	  allegation:	  	   • Youth	  lose	  faith	  in	  the	  processes	  designed	  to	  protect	  them	  (i.e.,	  

	  

31.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 32 of 67 PAGEID #: 2526

“the	  grievance	  process	  doesn’t	  work”)	  and	  may	  be	  even	  less	   likely	  to	  report	  mistreatment	  in	  the	  future;	   • Staff	  are	  not	  held	  accountable	  and	  thus	  are	  not	  subjected	  to	  the	   retraining	  or	  discipline	  designed	  to	  modify	  their	  behavior,	  which	   increases	  the	  likelihood	  they	  will	  repeat	  the	  behavior	  in	  the	   future;	  	   • A	  culture	  in	  which	  staff	  behave	  with	  impunity	  and	  believe	  that	   “nothing	  will	  happen”	  if	  a	  youth	  reports	  mistreatment	  is	  allowed	   to	  perpetuate,	  which	  creates	  a	  risk	  that	  staff	  will	  continue	  to	   violate	  the	  boundaries	  of	  acceptable	  behavior	  because	  they	  do	   not	  fear	  the	  consequences.	  	   	   The	  State	  has	  made	  no	  progress	  in	  improving	  the	  quality	  of	  this	  essential	   function.	  The	  primary	  contributor	  to	  this	  problem	  appears	  to	  be	  the	   continued	  practice	  of	  distributing	  the	  investigations	  across	  a	  large	   number	  of	  staff.	  Dispersing	  the	  responsibility	  so	  broadly	  will	  inevitably	   lead	  to	  inconsistency,	  and	  because	  each	  staff	  person	  may	  only	  do	  one	  or	   two	  investigations	  per	  year,	  their	  opportunities	  to	  develop	  the	   appropriate	  skill	  set	  are	  very	  limited.	  	   	   In	  order	  to	  accelerate	  the	  State’s	  progress	  toward	  compliance	  with	  this	   provision,	  the	  Monitor	  strongly	  recommends	  that	  the	  State	  significantly	   reduce	  the	  number	  of	  people	  who	  are	  authorized	  to	  conduct	  a	  local	   investigation	  and	  that	  this	  responsibility	  is	  assigned	  only	  to	  individuals	   who	  have	  demonstrated	  that	  they	  have	  the	  requisite	  skill	  set.	  In	  a	   conference	  call	  between	  DYS,	  the	  DOJ,	  and	  the	  Monitor	  just	  prior	  to	  this	   report	  being	  issued,	  DYS	  agreed	  to	  pursue	  this	  strategy,	  if	  funding	   permits.	  	   	   The	  poor	  quality	  of	  these	  reports	  cannot	  continue.	  Although	  the	   allegations	  investigated	  at	  the	  facility-­‐level	  are	  generally	  less	  serious,	  the	   nature	  of	  the	  allegations	  are	  at	  the	  heart	  of	  the	  facility’s	  staff	  culture	  that	   has	  been	  labeled	  as	  problematic	  by	  past	  administrations	  and	  that	  was	   the	  chief	  complaint	  among	  the	  youth	  interviewed	  during	  the	  current	   monitoring	  period.	  Youth	  often	  described	  staff	  behaving	  with	  impunity,	   boasting	  that	  “nothing	  will	  happen”	  if	  the	  youth	  filed	  a	  compliant.	  The	   lack	  of	  accountability	  brought	  to	  bear	  by	  the	  shoddy	  local	  investigation	   process	  is	  a	  major	  contributing	  factor	  to	  this	  problem.	  	   	   The	  lack	  of	  progress	  in	  this	  area	  suggests	  that	  additional	  oversight	  may	   be	  necessary.	  The	  Monitor	  recommends	  that	  the	  DYS	  create	  a	  specific	   Corrective	  Action	  Plan/Quality	  Improvement	  Plan	  (perhaps	  via	  the	  Quality	   Assurance	  process	  that	  the	  CIO	  has	  recently	  implemented)	  to	  determine	   the	  underlying	  causes	  of	  the	  delays	  and	  poor	  quality	  products,	  and	  to	   enact	  specific	  strategies	  to	  target	  each	  of	  the	  underlying	  factors	  in	  order	   to	  significantly	  improve	  performance	  in	  this	  area.	  The	  Monitor	  will	  also	   request	  copies	  of	  all	  completed	  local	  investigations	  on	  a	  monthly	  basis	  so	  

	  

32.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 33 of 67 PAGEID #: 2527

Recommendations	  
Sources	  of	   Information	  
	   	  

that	  more	  frequent	  status	  reports	  can	  be	  made	  to	  the	  Parties	  and	  the	   Court.	  	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Reduce	  the	  number	  of	  individuals	  authorized	  to	  conduct	  local	   investigations	  and	  ensure	  that	  these	  individuals	  have	  the	   requisite	  skills	  for	  the	  task.	  Ensure	  that	  producing	  timely,	  high-­‐ quality	  investigations	  is	  a	  specific	  job	  responsibility	  and	  that	   employees	  are	  held	  accountable	  for	  their	  failure	  to	  produce	   reports	  that	  meet	  professional	  standards.	  	  	  
2. Produce	  high-­‐quality	  investigations	  of	  all	  allegations	  of	   misconduct	  by	  staff.	  The	  investigations	  must	  reflect	  timely,	   comprehensive	  interviews	  with	  all	  key	  witnesses,	  must	  address	   peripheral	  issues	  (e.g.,	  witnesses’	  failure	  to	  report)	  and	  must	   arrive	  at	  reasonable	  conclusions	  based	  on	  the	  facts	  in	  evidence.	   Enact	  accountability	  measures	  to	  address	  poor	  performance	  by	   staff	  tasked	  with	  the	  responsibility	  to	  investigate	  allegations	  of	   all	  types.	  	  	  	  
• Self-­‐assessment	  data	  and	  oral	  presentation	  of	  its	  interpretation	   for	  III.A.5,	  prepared	  at	  my	  request	  	  
• “Scioto	  Juvenile	  Correctional	  Facility	  Coaching	  and	  Monitoring	   Report,”	  by	  the	  Chief	  Inspector’s	  Office,	  January	  2013	  
• Log,	  “Investigation	  Tracking	  Log,	  October	  2012	  through	  March	   2013”	  
• Email	  communication	  with	  J.	  Fears,	  CIO,	  and	  C.	  Price,	  Scioto	   Correctional	  Facility,	  to	  verify	  dates	  of	  submission	  of	  various	   reports	  
• Review	  of	  13	  CIO	  investigations	  completed	  since	  October	  2012	   (100%	  of	  total)	  
• Review	  of	  37	  investigations	  conducted	  by	  Scioto	  staff	  since	   October	  2012	  (100%	  of	  total)	  
• Conference	  call	  with	  Ohio	  Attorney	  General’s	  office,	  DYS	  Chiefs	   of	  Staff,	  Department	  of	  Justice	  and	  the	  Monitor,	  May	  29,	  2013.	  
	  

	  

33.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 34 of 67 PAGEID #: 2528

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

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

The	  previous	  Monitor’s	  Report	  noted	  that	  the	  Scioto	  Grievance	   Coordinator	  hired	  in	  May	  2012	  had	  largely	  resolved	  the	  systemic	   deficiencies	  with	  the	  process.	  	   	   Quality	  Assurance	   As	  before,	  the	  CIO	  reviews	  all	  grievances	  on	  an	  on-­‐going	  basis.	  If	  the	   grievance	  response	  includes	  all	  the	  necessary	  actions	  and	   documentation,	  it	  is	  “closed”	  by	  the	  CIO.	  If	  additional	  documentation	  or	   information	  is	  needed,	  “follow-­‐up	  action”	  is	  requested.	  Once	  the	   grievance	  coordinator	  provides	  the	  necessary	  information,	  the	  grievance	   is	  then	  closed.	  [For	  statistical	  purposes,	  “follow-­‐up	  action”	  is	  a	  fluid	  status	   and	  it	  can	  only	  provide	  a	  snapshot	  of	  the	  grievance	  process	  on	  any	  given	   day.]	  If	  the	  CIO	  finds	  that	  the	  resolution	  of	  the	  grievance	  is	  at	  odds	  with	   facility	  procedure,	  “corrective	  action”	  is	  required	  and	  the	  grievance	   coordinator	  must	  revisit	  the	  issue	  with	  the	  youth	  and	  explain	  how	  the	   grievance	  was	  resolved	  in	  error.	  Only	  4	  of	  142	  grievances	  (3%)	  required	   corrective	  action	  during	  the	  current	  monitoring	  period:	  
• A	  grievance	  was	  marked	  “closed	  by	  investigation,”	  but	  the	  CIO	   investigated	  a	  different	  part	  of	  the	  issue	  (fight)	  and	  not	  what	  was	   the	  substance	  of	  the	  grievance	  (commissary).	  The	  Grievance	   Coordinator	  corrected	  the	  notification	  letter	  and	  also	  refunded	   the	  youth’s	  commissary	  funds.	  	  
• A	  youth	  complained	  that	  the	  clean	  clothing	  still	  smelled.	  The	   Grievance	  Coordinator	  didn’t	  actually	  smell	  the	  clothing	  and	  the	   UM	  had	  indicated	  there	  had	  been	  problems	  with	  the	  unit’s	  dryer.	   The	  grievance	  coordinator	  was	  encouraged	  to	  conduct	  a	  broader	   inquiry	  should	  a	  similar	  complaint	  occur	  in	  the	  future.	  	  
• A	  youth	  alleged	  that	  a	  staff	  called	  her	  a	  “dumb	  ass.”	  The	  staff	  was	   never	  asked	  to	  make	  a	  statement.	  Upon	  re-­‐opening	  the	  issue	  at	   the	  request	  of	  the	  CIO,	  the	  staff	  refused	  to	  make	  a	  statement,	  so	   the	  matter	  was	  referred	  for	  investigation.	  	  
• A	  youth	  alleged	  physical	  mistreatment	  during	  a	  restraint.	  The	   matter	  should	  have	  been	  immediately	  referred	  for	  investigation,	   but	  instead	  the	  grievance	  coordinator	  took	  additional	  steps	  to	   investigate	  the	  matter	  on	  his	  own.	  The	  CIO	  admonished	  him	  from	   doing	  so	  in	  the	  future.	  	  
	   The	  Grievance	  Coordinator	  also	  prepares	  a	  monthly	  report	  for	  review	  by	   the	  CIO,	  and	  grievance	  data	  (number	  and	  type)	  are	  part	  of	  the	  weekly	   Management	  by	  Measurement	  (MBM)	  data	  that	  the	  facility	  

	  

34.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 35 of 67 PAGEID #: 2529

Superintendent	  receives.	   	   In	  addition	  to	  this	  on-­‐going	  Quality	  Assurance,	  the	  CIO	  also	  audits	  the	   grievance	  process	  every	  four	  months.	  This	  process	  includes	  observations	   of	  the	  interaction	  between	  the	  grievance	  coordinator	  and	  youth;	  visual	   verification	  that	  the	  grievance	  boxes	  and	  necessary	  supplies	  are	  available	   to	  youth;	  and	  checks	  to	  ensure	  that	  the	  general	  procedures	  are	  in	  place.	   Scioto’s	  most	  recent	  QA	  audit	  covered	  October	  2012	  through	  January	   2013.	  The	  auditor	  reported	  that	  the	  grievance	  coordinator	  knew	  the	   youth	  and	  the	  youth	  knew	  him;	  comprehensive	  monthly	  reports	  were	   being	  produced;	  and	  all	  supplies	  were	  accessible.	  In	  addition,	  a	  random	   sample	  of	  10	  grievances	  was	  reviewed	  to	  determine	  their	  compliance	   with	  policy.	  In	  all	  cases,	  the	  grievance	  coordinator	  met	  with	  the	  youth	   face-­‐to-­‐face,	  medical	  issues	  and	  abuse	  allegations	  were	  handled	  per	   policy,	  follow-­‐up	  occurred	  as	  needed,	  and	  all	  	  youth	  were	  given	  a	  copy	  of	   the	  grievance	  and	  its	  resolution.	  The	  only	  point	  of	  development	  was	  to	   ensure	  that	  the	  new	  lesson	  plan	  for	  Orientation,	  created	  by	  the	  CIO	  to	   standardize	  the	  information	  presented	  across	  the	  facilities,	  was	  used.	  	   	   Clearly,	  the	  grievance	  process	  benefits	  from	  a	  great	  deal	  of	  oversight	  to	   ensure	  that	  grievances	  are	  resolved	  timely	  and	  that	  youth	  are	  provided	   with	  a	  solid	  mechanism	  to	  voice	  their	  concerns	  and	  to	  ensure	  they	  are	   treated	  fairly.	  	   	   Other	  performance	  indicators	  continued	  to	  improve	  throughout	  the	   current	  monitoring	  period,	  as	  compared	  to	  the	  systemic	  problems	  noted	   in	  previous	  reports.	  In	  Q4	  2012	  (October-­‐December),	  100%	  of	  the	   grievances	  were	  resolved	  within	  required	  timelines,	  and	  in	  Q1	  2013	   (January-­‐March),	  98%	  of	  grievances	  were	  resolved	  timely.	  In	  terms	  of	   substance,	  in	  Q4	  2012,	  32	  of	  80	  (40%)	  grievances	  required	  follow-­‐up	   action,	  generally,	  questions	  about	  how	  the	  incident	  was	  coded	  or	  to	   clarify	  how	  the	  issue	  was	  framed.	  As	  noted	  above,	  “follow-­‐up	  required”	  is	   a	  status	  that	  can	  be	  quickly	  remediated	  with	  additional	  information	  or	   documentation.	  The	  CIO	  did	  not	  report	  this	  statistic	  for	  Q1	  2013.	  	   	   A	  total	  of	  80	  grievances	  were	  submitted	  in	  Q4	  2012	  and	  62	  were	   submitted	  in	  Q1	  2013.	  The	  rate	  of	  grievances	  per	  youth	  has	  remained	   stable	  for	  quite	  some	  time,	  save	  for	  a	  spike	  in	  Q2	  2012.	  The	  youth’s	  chief	   concerns	  included	  complaints	  about	  staff’s	  decisions	  (18%	  of	  the	  142	   grievances	  submitted),	  program	  concerns	  (10%),	  physical	  abuse	  (9%),	   verbal	  abuse	  (8%),	  and	  medical	  concerns	  (8%).	  More	  specifically,	   examples	  include:	  
• Alleged	  Verbal	  Abuse:	  “staff	  threatened	  to	  extend	  my	  stay,”	   “staff	  called	  me	  ‘a	  joke’,”	  “social	  worker	  has	  an	  attitude,”	  “staff	   said	  ‘Wake	  your	  fat	  ass	  up!’,”	  “staff	  threatened	  to	  write	  me	  up,”	   “staff	  called	  me	  a	  ‘fag’	  and	  said	  he’d	  get	  my	  sister	  pregnant,”	  “	   social	  worker	  made	  sexual	  comments	  to	  me,”	  and	  “YS	  is	  bragging	  

	  

35.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 36 of 67 PAGEID #: 2530

Steps	  Taken	  to	   Assess	  Compliance	  

that	  he’s	  going	  to	  fight	  me.”	  [These	  last	  two	  were	  referred	  for	   investigation.]	   • Alleged	  Physical	  Abuse:	  “staff	  put	  her	  hand	  on	  my	  back,”	  “staff	   smacked	  my	  hand	  when	  I	  grabbed	  a	  tray,”	  “	  staff	  pushed	  me	   when	  I	  hit	  him	  with	  a	  basketball,”	  “staff	  squeezed	  my	  wrist	  to	  get	   a	  bag	  of	  chips,”	  “staff	  pulled	  hard	  on	  my	  gators,”	  “staff	  choked	   me	  and	  banged	  my	  head	  on	  the	  wall,”	  “staff	  hit	  me	  on	  the	  neck,	   lays	  hands	  on	  us	  a	  lot.”	  [The	  last	  four	  were	  referred	  for	   investigation.]	   	   In	  terms	  of	  the	  grievances’	  resolution,	  69%	  had	  no	  merit,	  20%	  had	  merit,	   7%	  were	  referred	  for	  investigation,	  and	  4%	  were	  pending	  at	  the	  time	  of	   the	  CIO’s	  report.	  	  	   	   Not	  only	  does	  the	  DYS	  have	  a	  robust	  system	  for	  monitoring	  the	  grievance	   process,	  but	  the	  results	  of	  those	  audits	  reveal	  fidelity	  to	  the	  design	  and	  a	   clear	  commitment	  to	  ensure	  that	  youth	  have	  ready	  access	  to	  a	   confidential	  grievance	  process.	  	  
The	  DYS	  has	  done	  such	  an	  exceptional	  job	  of	  auditing	  its	  grievance	   process	  that	  the	  Monitor	  had	  little	  to	  add.	  	   	   Youth	  Survey	   The	  CIO	  re-­‐administered	  its	  Youth	  Survey	  in	  Q4	  2012.	  The	  results	  largely	   paralleled	  the	  previous	  survey—30%	  reported	  they’d	  been	  told	  they	   could	  not	  use	  the	  grievance	  process	  to	  report	  staff	  misconduct,	  39%	   reported	  they	  were	  treated	  “differently”	  after	  filing	  a	  grievance,	  and	  62%	   said	  that	  staff	  told	  them	  nothing	  would	  happen	  if	  they	  filed	  a	  grievance.	   On	  the	  surface	  these	  results	  would	  appear	  to	  conflict	  with	  what	  the	  	   Monitor	  and	  the	  DOJ	  Attorney	  heard	  in	  their	  interviews	  with	  youth,	  who	   listed	  the	  grievance	  process	  among	  the	  facility’s	  strengths,	  and	  reported	   that	  they	  knew	  and	  appreciated	  the	  Grievance	  Coordinator’s	  accessibility	   and	  approach	  to	  dealing	  with	  their	  issues.	  However,	  the	  responses	  to	  the	   CIO’s	  survey	  suggest	  that	  the	  youth’s	  concerns	  about	  the	  process	  lie	  not	   with	  the	  Grievance	  Coordinator	  but	  with	  the	  direct	  care	  staff’s	  attempts	   to	  undermine	  the	  process.	  	   	   In	  response	  to	  this	  survey,	  the	  Facility	  Superintendent	  has	  attended	  Roll	   Call	  for	  each	  shift	  and	  reinforced	  the	  importance	  of	  supporting,	  and	   warned	  against	  undermining,	  the	  grievance	  process.	  	  	   	   Notification	  to	  Youth	  about	  the	  Outcome	  of	  Investigations	   In	  March	  2012,	  the	  Grievance	  Policy	  (#	  304.03)	  was	  revised	  to	  include	   written	  notification	  to	  the	  youth	  of	  the	  outcome	  of	  investigations	  that	   were	  triggered	  by	  a	  youth’s	  grievance.	  A	  letter	  to	  the	  youth	  from	  the	   facility’s	  Labor	  Relations	  Officer	  (LRO)	  refers	  to	  the	  investigation	  number	   and	  indicates	  whether	  the	  allegation	  was	  substantiated	  or	   unsubstantiated.	  The	  Investigation	  Policy	  (#101.15)	  and	  the	  Youth	  

	  

36.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 37 of 67 PAGEID #: 2531

Handbook	  were	  also	  updated	  to	  reflect	  this	  change	  in	  procedure.	   	   During	  the	  current	  monitoring	  period,	  a	  total	  of	  8	  investigations	  were	   closed	  that	  were	  initiated	  via	  a	  youth	  grievance.	  Letters	  to	  youth	   notifying	  them	  of	  the	  outcome	  of	  the	  investigation	  were	  presented	  to	  all	   youth	  (100%).	  However,	  as	  noted	  in	  the	  previous	  Monitor’s	  Report,	   although	  letters	  were	  sent	  out	  in	  every	  case,	  some	  of	  the	  cases	  had	  a	   significant	  delay	  between	  the	  date	  the	  investigation	  was	  completed	  and	   the	  day	  the	  letter	  was	  drafted.	  The	  table	  below	  summarizes	  the	  key	  dates	   for	  each	  case:	   	  
Timeliness	  of	  Youth	  Notification	  Letters	  

Investigation	  #	  

Date	  Case	  Closed	  

Date	  of	  Letter	   (business	  days	  from	  
completion)	  

Date	  Signed	  by	   Youth	  (business	   days	  from	  letter	  
being	  sent)	  

5501120080	  

10/15/12	  

11/21/12	  (22	  days)	   11/26/12	  (3	  days)	  

5501120098	  

10/11/12	  

11/6/12	  (17	  days)	   11/7/12	  (1	  day)	  

1001120087	   (youth	  1)	  

10/13/12	  

11/6/12	  (17	  days)	   11/6/12	  (~)	  

1001120087	   (youth	  2)	  

10/13/12	  

11/6/12	  (17	  days)	   11/6/12	  (~)	  

5501120105	  

10/29/12**	  

11/6/12	  (6	  days)	  

11/6/12	  (~)	  

5501120110	  

11/6/12**	  

11/15/12	  (7	  days)	   11/15/12	  (~)	  

5501120117	  

11/30/12**	  

12/6/12	  (4	  days)	  

12/7/12	  (1	  day)	  

5501120132	  

1/4/12	  

1/23/12	  (13	  days)	   2/8/12	  (12	  days)	  

**These	  investigations	  did	  not	  have	  a	  closure	  date	  on	  the	  log	  submitted	  to	  the	  Monitor,	  so	  the	   date	  the	  investigation	  was	  completed	  was	  used.	  Given	  that	  the	  closure	  occurs	  after	  the	  report	  is	   submitted,	  the	  closure	  date	  would	  not	  change	  the	  outcome	  of	  this	  analysis.	  	  
	   Current	  DYS	  policy	  does	  not	  set	  a	  specific	  timeline	  for	  sending	  out	   notification	  letters,	  although	  an	  upcoming	  revision	  will	  require	  the	  letters	   to	  be	  sent	  within	  5	  or	  10	  business	  days.	  Using	  10	  business	  days	  from	  the	   date	  of	  case	  closure	  as	  an	  outside	  limit,	  the	  table	  above	  illustrates	  that	   letters	  are	  generally	  not	  sent	  out	  timely.	  Across	  the	  8	  investigations,	  only	   3	  were	  sent	  out	  timely	  (38%;	  range	  4	  to	  22	  business	  days;	  average	  13	   business	  days).	  It	  is	  also	  worth	  noting	  that	  the	  Notification	  Letter	  for	  one	   of	  these	  investigations	  (1101120087)	  erroneously	  indicated	  that	  the	   allegation	  was	  unsubstantiated,	  when	  in	  fact,	  it	  was	  found	  to	  be	  true.	   Youth	  generally	  sign	  the	  Notification	  Letters	  in	  a	  timely	  manner.	  Although	   the	  situation	  did	  not	  occur	  during	  the	  current	  monitoring	  period,	  in	  the	   past,	  DYS	  has	  delivered	  the	  Notification	  Letters	  to	  youth	  who	  were	   released	  prior	  to	  the	  investigation’s	  completion.	   	   Thus,	  youth	  are	  being	  notified	  of	  the	  outcome	  of	  the	  investigations,	  but	   the	  notification	  needs	  to	  be	  timely	  in	  order	  to	  meet	  the	  spirit	  of	  the	  

	  

37.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 38 of 67 PAGEID #: 2532

Recommendations	   Sources	  of	   Information	  
	   	  

requirement	  and	  to	  address	  youth’s	  persistent	  belief	  that	  staff	  are	  not	   held	  accountable	  for	  their	  behavior	  in	  any	  meaningful	  way.	  	  Prompt	   notification	  could	  help	  to	  counteract	  this	  belief.	  	  The	  CIO	  plans	  to	   monitor	  the	  timeliness	  of	  the	  Notification	  Letters	  in	  the	  future,	  which	   should	  accelerate	  progress	  toward	  compliance.	  	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Promptly	  notify	  youth	  of	  the	  outcome	  of	  any	  investigation	   referred	  via	  the	  grievance	  process.	  	  	  
• Self-­‐assessment	  data	  and	  oral	  presentation	  of	  its	  interpretation	   for	  III.D.1,	  prepared	  at	  my	  request	  
• Q4	  2012	  and	  Q1	  2013	  Grievance	  Audits	  completed	  by	  the	  Chief	   Inspector’s	  Office	  
• Grievance	  Monthly	  Reports,	  October	  2012	  through	  March	  2013	   • AMS	  Grievance	  Summary	  for	  grievances	  submitted	  October	  2012	  
through	  March	  2012	   • List	  of	  Grievances	  requiring	  “follow-­‐up	  action”	  and	  the	  substance	  
of	  that	  action,	  Q1	  2013	   • List	  of	  Grievances	  requiring	  “corrective	  action”	  and	  the	  substance	  
of	  that	  action,	  Q4	  2012	  and	  Q1	  2013	   • List	  of	  completed	  investigations	  that	  were	  triggered	  by	  a	  
grievance,	  October	  2012	  through	  March	  2013	   • Copies	  of	  Youth	  notification	  letters	  for	  grievances	  referred	  for	  
investigation,	  October	  2012	  though	  March	  2013	  
	  

	  

38.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 39 of 67 PAGEID #: 2533

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

Compliance	  Rating	   Substantial	  Compliance	  

Self	  Assessment	  

The	  Orientation	  process	  includes	  two	  videos—one	  is	  a	  general	   Orientation	  video	  covering	  several	  topics	  including	  Youth	  Rights	  and	  the	   purpose	  of	  the	  grievance	  system.	  The	  second	  video	  focuses	  on	  the	   grievance	  process	  and	  includes	  information	  about	  what	  to	  do	  if	  the	  youth	   has	  a	  problem	  with	  living	  conditions,	  medical	  care,	  staff	  treatment,	   education	  services,	  etc.	  The	  video	  describes	  the	  differing	  roles	  of	  the	   Grievance	  Coordinator,	  the	  Chief	  Inspector’s	  Office,	  and	  the	  Legal	   Assistance	  Program	  attorneys.	  Finally,	  youth	  are	  provided	  step-­‐by-­‐step	   instructions	  for	  navigating	  the	  grievance	  system.	  The	  information	  in	  the	   video	  is	  reinforced	  by	  a	  written	  Youth	  Grievance	  Handbook,	  which	  an	   intake	  staff	  member	  discusses	  with	  the	  youth.	  Youth	  are	  also	  provided	   in-­‐depth	  information	  about	  sexual	  abuse	  and	  sexual	  assault	  in	  the	   correctional	  setting,	  and	  how	  to	  handle	  situations	  in	  which	  they	  may	  feel	   threatened	  or	  that	  the	  staff	  is	  being	  inappropriate.	  	   	   The	  CIO	  has	  developed	  a	  formal	  Lesson	  Plan	  for	  each	  DYS	  facility’s	   orientation	  in	  order	  to	  ensure	  that	  consistent,	  accurate	  information	  is	   delivered	  to	  all	  DYS	  youth.	  The	  most	  recent	  QA	  report,	  issued	  February	   2013,	  found	  that	  Scioto	  had	  yet	  to	  implement	  the	  new	  lesson	  plan,	  and	   were	  still	  using	  they	  one	  they	  had	  developed	  internally.	  	   	   All	  youth	  are	  required	  to	  sign	  several	  forms	  indicating	  that	  they	  received	   and	  understand	  information	  about	  the	  grievance	  process.	  The	  facility	   audits	  a	  random	  sample	  of	  admissions	  files	  every	  month	  to	  ensure	   compliance	  with	  policy	  and	  procedure.	  Each	  month,	  October	  2012	   through	  March	  2013,	  100%	  of	  the	  youth	  sampled	  (30	  total	  youth;	  10%	  of	   all	  admissions)	  received	  a	  complete	  orientation	  to	  the	  facility,	  which	   included	  information	  on	  how	  to	  access	  the	  grievance	  system.	  Signed	   Orientation	  Acknowledgement	  Forms	  were	  submitted	  for	  the	  Monitor’s	   verification.	  	  

Steps	  Taken	  to	   Assess	  Compliance	  

The	  State	  continues	  to	  conduct	  rigorous	  audits	  of	  facility	  records	  to	   ensure	  that	  the	  Orientation	  to	  the	  grievance	  process	  is	  delivered	  upon	   admission.	  All	  of	  the	  underlying	  documentation	  submitted	  to	  the	   Monitor	  verified	  the	  reported	  results—that	  100%	  of	  the	  sample	  received	   a	  proper	  introduction	  to	  the	  grievance	  process.	  	  

Recommendations	   The	  State	  remains	  in	  substantial	  compliance	  with	  this	  provision.	  	  	  

Sources	  of	   Information	  
	  

• Self-­‐assessment	  data	  and	  oral	  presentation	  of	  its	  interpretation	   for	  III.D.2,	  prepared	  at	  my	  request	  
	  

	  

39.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 40 of 67 PAGEID #: 2534

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

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

Structured	  Programming	   Via	  the	  S.H.	  litigation,	  the	  DYS	  developed	  and	  implemented	  a	  Quality	   Assurance	  Protocol	  for	  structured	  programming	  during	  the	  current	   monitoring	  period.	  Over	  the	  years,	  DYS	  has	  struggled	  to	  assemble	  and	   interpret	  the	  large	  volume	  of	  data	  regarding	  program	  participation.	  The	   QA	  protocol	  is	  a	  tremendous	  breakthrough.	  	   	   DYS	  developed	  a	  full	  set	  of	  standards	  from	  which	  performance	  can	  be	   measured.	  Given	  how	  many	  different	  activities	  comprise	  Structured	   Programming,	  the	  area	  was	  broken	  into	  component	  parts.	  Programming	   includes	  the	  Managing	  Anger	  and	  Violence	  (MAV)	  groups,	  Victim	   Awareness	  groups	  and	  the	  Phoenix	  Program.	  Standards	  for	  this	   component	  include:	  
• All	  youth	  admitted	  to	  DYS	  shall	  participate	  in	  all	  50	  Core	  B	  (MAV)	   sessions,	  until	  completed	  or	  released.	  A	  minimum	  of	  12	  MAV	   groups	  shall	  be	  facilitated	  monthly	  by	  staff	  on	  each	  unit.	  Unless	   attending	  a	  priority	  treatment	  program,	  youth	  shall	  attend	  no	   less	  than	  10	  MAV	  sessions	  per	  month	  until	  completion.	  	  
• Youth	  identified	  at	  Intake	  as	  needing	  victim	  awareness	  shall	   attend	  and	  complete	  the	  Victim	  Awareness	  Education	  Program	   prior	  to	  release	  from	  the	  facility.	  A	  minimum	  of	  4	  Victim	   Awareness	  sessions	  shall	  be	  facilitated	  monthly	  by	  qualified	  staff.	   Until	  completion,	  identified	  youth	  shall	  attend	  no	  less	  than	  4	   Victim	  Awareness	  sessions	  per	  month.	  Due	  to	  the	  Victim	   Awareness	  Education	  Program	  being	  a	  closed	  group,	  a	  waiting	   list	  shall	  be	  developed	  and	  available.	  	  
• If	  appropriate,	  youth	  identified	  as	  active	  Security	  Threat	  Group	   (STG)	  members	  upon	  admission,	  or	  at	  any	  point	  during	  their	  

	  

40.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 41 of 67 PAGEID #: 2535

incarceration,	  shall	  participate	  in	  the	  Phoenix	  Program.	  A	   minimum	  of	  4	  Phoenix	  Program	  sessions	  shall	  be	  facilitated	   monthly	  by	  qualified	  staff.	  Until	  completion,	  identified	  youth	   shall	  attend	  no	  less	  than	  4	  Phoenix	  sessions	  per	  month.	  Due	  to	   the	  Phoenix	  Program	  being	  a	  closed	  group,	  a	  waiting	  list	  shall	  be	   developed	  and	  available.	  	   With	  regard	  to	  Recreation	  and	  Community	  Service,	  the	  following	   standard	  was	  developed:	   • Youth	  shall	  receive	  at	  least	  one	  hour	  of	  large	  muscle	  activity	  per	   day.	  The	  program	  involves	  a	  wide	  variety	  of	  physical	  activities	   and	  intends	  to	  produce	  physical	  skill	  building	  and	  personal	   fitness.	  At	  least	  70%	  of	  youth	  are	  expected	  to	  participate	  in	  the	   Presidential	  Fitness	  Test	  each	  quarter.	  Recreation	  staff	  provide	   input	  into	  youth’s	  treatment	  reviews	  by	  attending	  the	  IDT	   meetings	  each	  week.	  Total	  community	  service	  hours	  should	   equal	  twice	  the	  ADP.	  	   With	  regard	  to	  Religious	  and	  Volunteer	  Programming,	  the	  following	   standard	  was	  developed:	   • In	  order	  to	  reduce	  idleness	  and	  advance	  the	  goal	  of	   rehabilitation,	  the	  facility	  maintains	  an	  array	  of	  religious	  and	   volunteer-­‐led	  programing	  for	  youth.	  Each	  facility	  will	  provide	  a	   minimum	  of	  350	  hours	  of	  volunteer-­‐led	  programming	  each	   month.	  The	  Chaplain	  at	  each	  facility	  will	  offer,	  at	  a	  minimum,	  one	   congregate	  worship	  service	  each	  week	  for	  eligible	  youth.	  	   	   Together,	  these	  five	  Standards	  cover	  the	  full	  range	  of	  structured	   programming	  for	  youth	  and	  provide	  clear,	  measurable	  goals	  for	  youth’s	   participation.	  	   	   Using	  these	  standards	  and	  a	  rigorous	  methodology,	  DYS	  conducted	  an	   audit	  of	  the	  facility’s	  performance	  in	  March	  2013.	  The	  findings	  were	   discouraging:	   • Programming	  results	  were	  mixed.	  With	  regard	  to	  MAV,	  the	  girls’	   units	  met	  the	  standard	  related	  to	  the	  groups,	  but	  did	  not	  meet	   the	  threshold	  for	  individual	  participation	  rates.	  None	  of	  the	  boys’	   units	  met	  the	  standards	  for	  groups,	  and	  only	  one	  youth	  attended	   the	  minimum	  number	  of	  MAV	  sessions.	  The	  facility	  met	  the	   standard	  related	  to	  the	  Phoenix	  Program,	  but	  did	  not	  meet	  the	   standard	  related	  to	  Victim	  Awareness	  programming.	  	   • With	  regard	  to	  Recreation	  and	  Community	  Service,	  all	  of	  the	   units	  held	  the	  required	  number	  of	  recreation	  sessions,	  and	  all	   but	  1	  had	  sufficient	  attendance	  rates.	  Participation	  rates	  were	   high	  in	  6	  of	  the	  7	  units	  (and	  the	  other	  unit	  only	  missed	  the	   benchmark	  by	  2	  percentage	  points).	  The	  President’s	  Physical	   Fitness	  Challenge	  is	  not	  scheduled	  until	  June	  2013,	  so	   participation	  could	  not	  be	  audited.	  Only	  12%	  of	  youth	  in	   seclusion	  participated	  in	  recreation.	  A	  lack	  of	  detail	  in	  unit	  

	  

41.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 42 of 67 PAGEID #: 2536

records	  prevented	  the	  auditor	  from	  assessing	  GAT	   presence/input	  at	  IDT	  meetings.	  The	  facility	  did	  meet	  the	   standard	  related	  to	  Community	  Service,	  with	  each	  youth	  given	  at	   least	  two	  opportunities	  to	  participate	  per	  month.	  	   • With	  regard	  to	  Religious	  and	  Volunteer-­‐Led	  programming,	  the	   facility	  exceeded	  the	  requirements	  with	  460	  hours	  of	  Volunteer	   Programming,	  although	  the	  auditors	  did	  not	  collect	  the	  required	   information	  on	  youth	  participation	  levels.	  The	  facility	  also	  far	   exceeded	  the	  requirements	  around	  Congregate	  Services,	  with	  24	   services	  offered.	  	   	   While	  the	  audit	  results	  are	  concerning,	  the	  fact	  that	  DYS	  is	  now	  capable	   of	  auditing	  and	  reporting	  on	  the	  quality	  of	  youth	  programming	  in	  an	   integrated	  and	  coherent	  fashion	  is	  a	  tremendous	  accomplishment.	   Hopefully,	  the	  innovations	  surrounding	  the	  auditing	  process	  will	  lead	  to	   substantive	  Quality	  Improvement	  Plans	  that	  will	  accelerate	  the	  facility’s	   movement	  toward	  substantial	  compliance.	  	  	   	   Recently,	  the	  facility	  changed	  the	  location	  where	  groups	  (MAV,	  Victim	   Awareness,	  Phoenix,	  etc.)	  are	  held	  to	  ensure	  that	  groups	  occur	  as	   scheduled.	  Due	  to	  the	  facility’s	  low	  population,	  the	  Annex	  of	  the	  school	   building	  has	  sufficient	  capacity	  to	  house	  groups	  for	  the	  general	   population	  in	  the	  afternoons	  and	  on	  weekends.	  More	  consistent	   oversight	  by	  the	  Unit	  Managers,	  improved	  supervision	  by	  the	  Youth	   Specialists	  and	  focused	  attention	  from	  the	  Deputy	  who	  oversees	   programming	  should	  ameliorate	  the	  problems	  related	  to	  scheduling	   revealed	  by	  the	  QA	  audit.	  Problems	  related	  to	  documentation	  and	  data	   entry	  were	  also	  identified	  during	  the	  audit.	  	   	   Programming	  for	  Graduates	   During	  the	  previous	  monitoring	  period,	  the	  facility	  made	  significant	   progress	  in	  developing	  programming	  for	  youth	  who	  have	  graduated	  from	   high	  school	  or	  obtained	  their	  GED.	  These	  programs	  have	  all	  been	   sustained.	  Graduates	  are	  engaged	  throughout	  the	  day	  in	  a	  combination	   of	  post-­‐secondary	  education	  and	  employment.	  	   • The	  primary	  academic	  program	  is	  delivered	  by	  Ashland	  College,	   which	  provides	  coursework	  for	  students	  in	  English	  101,	  Basic	   Finance,	  Entrepreneurship,	  and	  Accounting.	  Courses	  are	  offered	   on	  a	  rotating	  basis	  and	  classes	  are	  held	  twice	  per	  week	  for	  4.5	   hours.	  On	  the	  “off	  days,”	  study	  hall	  is	  held.	  	   • An	  additional	  academic	  program	  is	  delivered	  by	  Henkles	  &	   McCoy.	  TechBridges/Employability	  Skills	  is	  an	  intensive	  one-­‐ week	  class,	  held	  from	  8a	  to	  4:30p	  each	  day	  and	  offered	  once	  per	   grading	  period.	  Youth	  learn	  how	  to	  disassemble	  and	  rebuild	   computers,	  and	  also	  learn	  essential	  employability	  skills	  to	   prepare	  them	  for	  release.	  Upon	  release,	  students	  are	  connected	   to	  Henkels	  &	  McCoy’s	  community	  facility	  where	  they	  may	  

	  

42.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 43 of 67 PAGEID #: 2537

Steps	  Taken	  to	   Assess	  Compliance	  

continue	  the	  academic	  instruction	  and	  also	  receive	  assistance	   with	  job	  preparation	  and	  interview	  skills.	  	   • The	  Youth	  Work	  Program	  was	  designed	  to	  provide	  jobs	  for	   graduates.	  [Note:	  non-­‐graduates	  may	  still	  obtain	  employment	   through	  Career	  Based	  Intervention.]	  Graduates	  must	  under	  go	  an	   application	  and	  interview	  process	  and	  once	  hired,	  are	  paid	  $0.50	   per	  hour.	  The	  work	  supervisor	  communicates	  regularly	  with	  the	   youth’s	  treatment	  team	  to	  ensure	  that	  youth	  are	  maintaining	  a	   high	  standard	  of	  behavior	  and	  performance	  on	  the	  job.	  Available	   jobs	  include:	  cafeteria,	  storeroom,	  maintenance,	  porters	  for	  the	   living	  units,	  religious	  services,	  program	  services,	  school,	   recreation	  and	  cosmetology	  aides.	  An	  academic	  tutor	  is	  paid	   $0.90	  per	  hour.	  Hours	  vary	  according	  to	  the	  Department’s	  need	   and	  the	  youth’s	  availability.	  Graduates	  may	  work	  up	  to	  35	  hours	   per	  week	  but	  must	  also	  ensure	  that	  they	  attend	  all	  required	   treatment	  programs.	  There	  are	  enough	  jobs	  available	  to	  support	   all	  youth	  who	  desire	  to	  have	  one.	  	  
Structured	  Programming	   The	  DYS’	  new	  Quality	  Assurance	  protocol	  provides	  all	  of	  the	  data	   necessary	  to	  determine	  whether	  the	  State	  is	  in	  substantial	  compliance	   with	  this	  part	  of	  the	  provision—the	  Monitor	  did	  not	  need	  to	  conduct	  any	   subsequent	  audits.	  As	  noted	  above,	  the	  March	  2013	  audit	  revealed	  some	   serious	  performance	  deficits	  that	  must	  be	  rectified	  in	  order	  to	  reach	   substantial	  compliance	  with	  this	  provision.	  Once	  the	  scheduling	  and	   documentation/data	  entry	  issues	  are	  addressed,	  another	  audit	  should	  be	   conducted	  to	  determine	  whether	  problems	  remain.	  The	  Monitor	  will	   then	  validate/confirm	  the	  QA	  audit’s	  findings	  with	  her	  subsequent	   audits.	  	   	   Although	  additional	  data	  collection	  and	  analysis	  was	  not	  required	  to	   assess	  compliance,	  interviews	  with	  staff	  and	  the	  Deputy	  responsible	  for	   programming	  suggested	  that	  the	  facility	  continues	  to	  evolve,	  pushing	   forward	  to	  ensure	  that	  youth’s	  idle	  time	  is	  limited.	  A	  Game	  Room	  and	  a	   Small	  Muscle	  Activity	  area	  equipped	  with	  board	  games,	  video	  games,	   foosball,	  Ping-­‐Pong,	  etc.	  were	  created.	  Some	  of	  the	  units	  have	  time	   scheduled	  into	  these	  rooms,	  while	  other	  youth	  are	  permitted	  to	   purchase	  admission	  using	  SBBMS	  points.	  In	  addition,	  the	  facility	  is	   looking	  to	  bolster	  the	  volunteer	  programming	  available	  to	  males	  in	  the	   general	  population.	  [During	  the	  time	  that	  Scioto	  was	  a	  male	  reception	   center,	  the	  volunteer	  programs	  catered	  to	  the	  female	  population	   because	  of	  their	  longer	  length	  of	  stays.]	   	   Programming	  for	  Graduates	   At	  the	  time	  of	  the	  Monitor’s	  site	  visit,	  10	  youth	  housed	  at	  Scioto	  had	   graduated	  from	  High	  School	  or	  obtained	  a	  GED.	  Of	  these,	  90%	  of	  those	   eligible	  had	  jobs	  (one	  youth	  is	  on	  the	  PU	  and	  is	  not	  eligible	  to	  have	  a	   job—the	  UM	  is	  responsible	  for	  developing	  a	  daily	  schedule	  for	  all	  

	  

43.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 44 of 67 PAGEID #: 2538

Recommendations	  

graduate	  youth;	  the	  other	  youth	  did	  not	  want	  to	  work).	  Seven	  of	  the	  10	   youth	  were	  enrolled	  in	  the	  Accounting	  course	  (those	  not	  attending	  either	   arrived	  at	  Scioto	  after	  the	  class	  began,	  or	  were	  not	  accepted	  to	  the	   program).	  A	  female	  youth	  with	  very	  high	  ACT	  scores	  was	  also	  taking	  on-­‐ line	  classes	  at	  Columbus	  State.	  Finally,	  a	  new	  Job	  Readiness	  course	  is	   available	  to	  graduate	  boys	  in	  the	  general	  population	  (all	  were	  attending).	   In	  the	  near	  future,	  an	  11-­‐week	  Barbering	  class	  that	  offers	  certification	   will	  be	  available	  as	  well.	  	   	   Attendance	  records	  for	  the	  graduate	  academic	  program	  revealed	  that	  a	   total	  of	  14	  youth	  participated	  in	  at	  least	  one	  of	  the	  four	  courses	  offered	   during	  the	  current	  monitoring	  period.	  Youth	  attendance	  was	  extremely	   high,	  with	  few	  class	  periods	  missed	  by	  any	  youth.	  Occasionally,	  youth	   were	  removed	  from	  the	  classes	  due	  to	  on-­‐going,	  serious	  behavior	  issues	   that	  disrupted	  the	  learning	  environment.	  	   	   The	  facility	  keeps	  monthly	  data	  showing	  the	  proportion	  of	  graduates	   who	  are	  employed.	  Throughout	  the	  monitoring	  period,	  the	  rate	  of	   employment	  for	  male	  graduates	  averaged	  86%	  (range	  64%	  to	  100%)	  and	   the	  rate	  of	  employment	  for	  female	  graduates	  averaged	  94%	  (range	  66%	   to	  100%).	  Each	  month,	  the	  facility	  had	  a	  surplus	  of	  available	  jobs	  and	   clearly	  has	  the	  capacity	  to	  accommodate	  more	  graduates	  with	  jobs,	  if	   needed.	  	  	  	   	   When	  interviewed,	  graduate	  youth	  reported	  there	  was	  “more	  to	  do	  at	   the	  facility	  than	  there	  used	  to	  be,”	  although	  also	  noted	  that	  they	  had	   more	  free	  time	  than	  the	  non-­‐graduate	  youth	  when	  their	  jobs	  ended	  for	   the	  day.	  Overall,	  the	  facility	  continues	  to	  operate	  a	  solid	  program	  for	   graduates	  that	  constructively	  occupies	  the	  portion	  of	  the	  day	  that	  non-­‐ graduate	  youth	  spend	  in	  school.	  	   	   PROGRESS	  Unit	  (PU)	   Improvements	  to	  the	  programming	  schedule	  for	  youth	  housed	  on	  the	  PU	   are	  discussed	  in	  the	  attached	  Status	  Report.	  Once	  DYS	  achieves	   substantial	  compliance	  with	  the	  Consent	  Order,	  information	  on	   programming	  for	  youth	  on	  the	  PU	  will	  again	  be	  reported	  here.	  	  	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Create	  a	  Quality	  Improvement	  Plan	  to	  improve	  compliance	  with	   QA	  standards	  related	  to	  all	  three	  components	  of	  Structured	   Programming.	  Implement	  strategies	  directed	  at	  each	  of	  the	   underlying	  causes	  of	  the	  failure	  to	  meet	  performance	  standards.	   Track	  the	  effectiveness	  of	  these	  strategies	  on	  a	  monthly	  basis	   until	  the	  problems	  are	  rectified.	  	  
2. Once	  the	  Consent	  Order	  related	  to	  the	  PROGRESS	  Unit	  has	  been	   satisfied,	  continue	  to	  implement	  structured	  programming	   opportunities	  for	  youth	  housed	  on	  the	  PROGRESS	  Unit,	  as	  

	  

44.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 45 of 67 PAGEID #: 2539

Sources	  of	   Information	  
	   	  

required	  by	  this	  provision.	  
• Self-­‐assessment	  data	  and	  oral	  presentation	  of	  its	  interpretation	   for	  III.F.1,	  prepared	  at	  my	  request	  
• Interview	  with	  Deputy	  Superintendent	  for	  Programming	   • Quality	  Assurance	  audit	  for	  Structured	  Programming,	  March	  
2013	   • Work	  schedules	  for	  graduates	  housed	  at	  Scioto	  as	  of	  October	  1,	  
2012	   • Course	  attendance	  records	  for	  all	  post-­‐secondary	  courses	  held	  
since	  October	  1,	  2012	  
	  

	  

45.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 46 of 67 PAGEID #: 2540

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

Compliance	  Rating	   Substantial	  Compliance	  

Self	  Assessment	  

The	  facility	  continues	  to	  audit	  a	  random	  10%	  sample	  of	  admissions	  files	   every	  month	  to	  ensure	  compliance	  with	  policy	  and	  procedure.	  Between	   October	  2012	  and	  March	  2013,	  approximately	  300	  youth	  were	  admitted	   to	  the	  facility;	  10%,	  or	  30	  youth,	  were	  included	  in	  the	  audit.	  Each	  month,	   the	  audits	  found	  that	  100%	  of	  the	  youth	  sampled	  received	  a	  complete	   orientation	  to	  the	  facility	  which	  included,	  among	  other	  things:	  
• Youth	  Handbook	   • Orientation	  Video	   • Facility	  rules	  and	  consequences	  (IRAV)	   • Strength	  Based	  Behavior	  Management	  System	  (SBBMS)	   • Obtaining	  legal	  assistance	   • Accessing	  medical	  and	  mental	  health	  care	   • Sexual	  abuse	  and	  sexual	  assault	  information	   • Grievance	  system	  

Steps	  Taken	  to	   Assess	  Compliance	  

Religious	  Accommodations	   With	  the	  update	  of	  the	  Youth	  Handbook	  and	  appropriate	  response	  to	   grievances	  pertaining	  to	  religious	  freedom,	  the	  DYS	  satisfied	  the	   requirements	  of	  this	  provision	  during	  the	  previous	  monitoring	  period.	   During	  the	  current	  monitoring	  period,	  three	  youth	  submitted	  grievances	   pertaining	  to	  religious	  freedom.	  Two	  of	  these	  were	  found	  to	  have	  no	   merit:	  
• A	  youth	  requested	  information	  about	  Wicca.	  He	  had	  already	   received	  all	  of	  the	  information,	  and	  had	  met	  with	  both	  the	   librarian	  and	  the	  Chaplain.	  	  
• A	  youth	  complained	  that	  he’d	  received	  a	  YBIR	  for	  wearing	  a	  kufi.	   The	  YBIR	  was	  issued	  because	  the	  kufi	  did	  not	  belong	  to	  the	   youth.	  	  

	  

46.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 47 of 67 PAGEID #: 2541

Recommendations	   Sources	  of	   Information	  
	   	  
	  

One	  of	  the	  grievances	  was	  found	  to	  have	  merit:	   • A	  youth	  did	  not	  want	  to	  shave	  because	  it	  violated	  his	  religious	   beliefs.	  [The	  youth	  is	  Muslim.]	  His	  request	  was	  granted.	  	  
	   The	  Youth	  Handbook	  clearly	  articulates	  that	  youth	  are	  free	  to	  practice	   their	  religion	  of	  choice	  and	  the	  facility	  continues	  to	  demonstrate	  its	   willingness	  to	  make	  religious	  accommodations	  when	  the	  issue	  has	  arisen.	  	   	   PROGRESS	  Unit	  Orientation	   While	  most	  of	  the	  youth	  at	  Scioto	  undergo	  an	  orientation	  to	  the	  general	   population,	  youth	  can	  also	  be	  admitted	  directly	  to	  the	  PROGRESS	  Unit	   (PU),	  and	  thus	  the	  orientation	  for	  that	  program	  is	  relevant	  to	  this	   provision.	  SOP	  303.01.07	  “Unit	  PROGRESS”	  requires	  the	  Unit	  Manager	  to	   ensure	  that	  the	  PU	  Youth	  Handbook	  is	  available	  to	  all	  youth	  and	  that	  a	   staff	  member	  provides	  a	  thorough	  orientation	  to	  youth	  upon	  their	   admission	  to	  the	  Unit.	  Youth	  must	  sign	  the	  Handbook’s	  signature	  page	  to	   acknowledge	  receipt	  of	  the	  information.	  Both	  the	  policy	  and	  handbook	   (now	  final	  and	  signed	  into	  effect!)	  are	  the	  subject	  of	  the	  Consent	  Order	   covering	  the	  Unit’s	  operation	  and	  thus	  are	  not	  discussed	  here.	  However,	   given	  that	  some	  youth	  enter	  the	  facility	  via	  the	  PU,	  their	  timely	   orientation	  is	  discussed	  in	  this	  report.	  	   	   During	  the	  current	  monitoring	  period,	  14	  youth	  were	  admitted	  to	  the	  PU	   (some	  youth	  had	  multiple	  admissions,	  but	  are	  counted	  separately	  given	   that	  they	  must	  receive	  an	  orientation	  on	  each	  admission).	  Signed	   “Handbook	  Signature	  Sheets”	  were	  submitted	  for	  all	  youth	  and	  verified	   that	  all	  youth	  received	  a	  timely	  Orientation	  (usually	  on	  the	  same	  day	  of	   transfer,	  occasionally	  on	  the	  next	  day).	  	  	  	  
The	  State	  is	  in	  substantial	  compliance	  with	  this	  provision.	  	  	  
• Self-­‐assessment	  data	  and	  oral	  presentation	  of	  its	  interpretation	   for	  III.F.2,	  prepared	  at	  my	  request	  
• Intake	  Audit	  Report,	  October	  2012	  through	  March	  2013	   • Scioto	  Youth	  Handbook,	  last	  modified	  March	  16,	  2012	   • Grievances	  related	  to	  religious	  accommodation	  (n=3),	  submitted	  
between	  October	  2012	  and	  March	  2013	   • Admission	  dates	  and	  orientation	  records	  for	  youth	  admitted	  to	  
the	  PROGRESS	  Unit	  since	  October	  1,	  2012	  	  
	  

	  

47.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 48 of 67 PAGEID #: 2542

MEDICAL	  SERVICES	   	  
	  
III.C.1	  	  General.	  The	  facilities	  shall	  ensure	  that	  the	  individuals	  they	  serve	  receive	  routine,	   preventive,	  and	  emergency	  medical	  and	  dental	  care	  consistent	  with	  current,	  generally	  accepted	   professional	  standards.	  The	  facilities	  shall	  ensure	  that	  individuals	  with	  health	  problems	  are	   identified,	  assessed,	  diagnosed,	  and	  treated	  consistent	  with	  current,	  generally	  accepted	   professional	  standards	  of	  care.	  	  

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

The	  Ohio	  Department	  of	  Youth	  Services	  (ODYS)	  does	  not	  conduct	  a	  self-­‐ assessment	  for	  the	  level	  of	  medical	  and	  dental	  care	  provided	  at	  SJCF.	   However,	  there	  continues	  to	  be	  improvement	  in	  their	  quality	  assurance	   processes,	  which	  in	  essence	  completes	  the	  task	  of	  self-­‐assessment	  for	  the	   purpose	  of	  this	  report.	  Also,	  the	  facility	  was	  accredited	  through	  the	   American	  Correctional	  Association	  (ACA)	  in	  September	  2012	  to	  include	   health	  care	  standards.	  	  	  

Steps	  Taken	  to	   Assess	  Compliance	  

An	  onsite	  visit	  was	  conducted	  at	  the	  Scioto	  Juvenile	  Correctional	  Facility	   on	  April	  23-­‐25,	  2013.	  It	  was	  this	  monitor’s	  third	  visit	  to	  the	  facility.	  All	   previous	  reviews	  of	  health	  information	  and	  other	  related	  documents	  had	   been	  conducted	  off	  site	  from	  records	  provided	  by	  ODYS.	  	  All	  living	  units	   where	  youth	  were	  being	  housed	  were	  visited.	  The	  Hunter	  and	  Carver	   Units	  had	  been	  closed.	  There	  has	  been	  a	  continuing	  decrease	  in	  the	   facility’s	  population	  over	  the	  last	  several	  visits,	  down	  to	  37	  males	  and	  17	   females	  on	  this	  site	  visit.	  The	  location	  of	  the	  sick	  call	  health	  request	  boxes	   and	  availability	  of	  the	  health	  request	  slips	  were	  observed	  on	  each	  living	   unit.	  Slips	  were	  not	  in	  place	  outside	  the	  box	  on	  two	  units.	  Youth	  were	   interviewed	  on	  the	  units	  as	  to	  how	  to	  access	  health	  services	  and	  if	  they	   had	  any	  complaints	  regarding	  their	  medical	  care.	  All	  the	  youth	  I	   interviewed	  knew	  the	  correct	  process	  to	  obtain	  health	  services	  and	  had	   no	  complaints	  about	  the	  health	  services.	  There	  was	  one	  complaint	  made	   to	  a	  member	  of	  the	  team	  by	  one	  of	  the	  females	  that	  she	  had	  been	   ignored	  by	  the	  medical	  staff	  while	  in	  labor.	  	   	   The	  food	  service	  area	  was	  toured	  and	  the	  medication	  room	  located	  there	   observed.	  The	  satellite	  clinics	  for	  Buckeye	  have	  not	  been	  completed.	  The	   population	  housed	  on	  those	  Progress	  units	  has	  been	  significantly	   reduced.	  The	  main	  clinic	  was	  still	  found	  to	  be	  adequate,	  with	  appropriate	   space,	  medical	  supplies	  and	  equipment	  for	  medical	  and	  dental	  care	  of	   the	  youth.	   	  	   A	  review	  of	  seven	  youth	  health	  records	  housed	  at	  the	  Scioto	  Facility	  was	   conducted.	  This	  included	  three	  females	  and	  four	  males.	  The	  health	   record	  review	  included	  assessing	  completeness	  of	  the	  Problem	  List,	  the	   presence	  and	  timeliness	  of	  the	  Nursing	  Intake	  Screening,	  Mental	  Health	   Screening,	  Physical	  Exam,	  Dental	  Exam,	  Dental	  Treatment,	  Oral	  Hygiene	  

	  

48.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 49 of 67 PAGEID #: 2543

Instruction	  and	  Growth	  Chart.	  	  Admission	  labs	  were	  checked	  for	   completion	  and	  results	  within	  20	  days;	  STD	  screening	  for	  Gonorrhea	  and	   Chlamydia;	  Chronic	  Care	  and	  Specialty	  Care	  Consult	  documentation;	   Transfer	  of	  Health	  Records;	  Immunizations	  and	  Tuberculosis	  Screening;	   Medication	  Administration	  Records;	  Mental	  Health	  Documentation;	   Youth	  Injury	  and	  Assessment	  Forms;	  Youth	  Health	  Requests	  and	  medical	   staff	  responses;	  Progress	  Notes	  including	  seclusion	  checks	  and	  Physician	   Orders	  were	  identified	  in	  each	  health	  record.	  	   	   All	  health	  records	  documented	  timely	  completion	  of	  intake	  assessments.	  	   Nurse	  screening	  health	  appraisals	  were	  completed	  on	  the	  same	  day	  of	   admission.	  Physical	  examinations,	  including	  gynecological	  exams	  for	   females	  were	  completed	  the	  following	  day.	  Problem	  lists	  were	  inclusive	   of	  medical,	  mental	  health	  and	  dental	  conditions.	  Growth	  charts	  were	   present	  in	  the	  health	  records	  of	  all	  youth.	  All	  youth	  allergies	  were	  noted	   on	  their	  health	  record.	  	  	   	   There	  was	  documentation	  of	  admission	  labs	  being	  drawn	  with	  results	   available	  all	  within	  a	  week.	  Specialized	  laboratory	  testing	  was	   documented	  such	  as	  Strep	  testing,	  Hemoglobin	  A1C	  for	  diabetes,	  and	   Beta	  HCG	  for	  pregnancy	  confirmation.	  STD	  (Gonorrhea	  and	  Chlamydia)	   urine	  screening	  test	  results	  were	  documented	  in	  all	  records.	  One	  youth	   identified	  in	  the	  screening	  process	  to	  be	  positive	  for	  a	  Chlamydia	  STD	   received	  treatment.	  Immunization	  records	  were	  present	  in	  all	  records	   reviewed.	  HPV	  vaccine	  is	  now	  being	  administered	  to	  youth,	  male	  and	   female	  (43	  in	  the	  last	  quarter).	  The	  previous	  back	  order	  on	  the	   HPV	  vaccine	  through	  the	  Federal	  Vaccines	  for	  Children	  Program	  has	  been	   resolved	  with	  only	  one	  youth	  of	  seven	  reviewed	  not	  receiving	  that	   vaccine.	  All	  youth	  reviewed	  received	  tuberculosis	  screening	  with	   documented	  results.	  One	  youth	  with	  a	  previous	  history	  of	  a	  positive	  TB	   skin	  test	  appropriately	  received	  a	  chest	  x-­‐ray	  upon	  admission,	  rather	  than	   another	  skin	  test	  being	  administered.	  	   	   Dental	  examinations	  were	  completed	  within	  three	  days	  of	  admission	  with	   instruction	  given	  on	  oral	  hygiene	  and	  prophylaxis	  completed.	  Dental	   treatment	  was	  provided	  as	  a	  result	  of	  the	  dental	  examination	  or	  as	  a	   result	  of	  a	  health	  request	  in	  a	  timely	  manner.	  Two	  long	  term	  youth	  were	   recalled	  for	  routine	  dental	  care	  annually.	  The	  latest	  recommendation	   from	  the	  American	  Dental	  Association	  is	  for	  dental	  prophylaxis	  to	  be	   completed	  every	  6	  months.	  	  	  	   	   Medication	  administration	  records	  (MAR)	  and	  physician	  orders	  were	  also	   reviewed	  for	  accuracy	  and	  medication	  compliance.	  Nurses	  are	   documenting	  medication	  administration	  as	  well	  as	  when	  youth	  refuse	   medications.	  In	  two	  cases,	  the	  MAR	  was	  also	  utilized	  to	  document	  blood	   pressure	  checks.	  Special	  diets	  were	  ordered	  appropriately.	   	  

	  

49.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 50 of 67 PAGEID #: 2544

Few	  youth	  with	  chronic	  medical	  conditions	  were	  housed	  at	  Scioto.	  Of	  the	   records	  reviewed,	  there	  was	  one	  diabetic	  and	  two	  hypertensive	  youth	   housed	  at	  Scioto.	  All	  received	  appropriate	  assessments	  and	  treatment	   plans.	  The	  diabetic	  youth	  that	  also	  had	  a	  history	  of	  asthma,	  received	  a	   special	  diet,	  proper	  medication	  management,	  blood	  glucose	  monitoring,	   appropriate	  laboratory	  testing,	  and	  ophthalmology	  and	  endocrine	   specialty	  consults.	  One	  youth	  was	  pregnant	  when	  admitted	  on	  11/2/12	   to	  the	  facility	  and	  delivered	  during	  her	  stay.	  Her	  obstetrical	  care	  provided	   during	  her	  stay	  was	  reviewed	  based	  on	  her	  statement	  to	  a	  member	  of	   the	  monitoring	  team	  that	  her	  complaint	  of	  labor	  pain	  was	  ignored	  by	   medical	  staff.	  She	  had	  been	  seen	  by	  Dr.	  Stein	  at	  the	  facility	  and	  received	   9	  regular	  visits	  to	  Dr.	  Koffler,	  Obstetrician	  for	  Central	  Ohio	  OBGYN,	  the	   last	  of	  which	  was	  the	  day	  before	  she	  delivered	  on	  4/17/13.	  At	  that	  time	   there	  was	  no	  indication	  of	  her	  being	  in	  active	  labor	  at	  39	  weeks	  pregnant.	   On	  4/18/13,	  youth	  began	  complaining	  of	  back	  and	  stomach	  pain	  at	  7:15	   AM.	  She	  was	  seen	  by	  medical	  staff	  at	  that	  time	  and	  again	  at	  10:05	  AM	   complaining	  of	  pain	  and	  wanting	  a	  tranquilizer.	  Medical	  explained	  the	   labor	  process	  and	  encouraged	  walking	  and	  fluid	  intake.	  Contractions	   were	  irregular	  at	  that	  time.	  Youth	  was	  brought	  from	  school	  on	  the	  golf	   cart	  to	  medical	  and	  seen	  at	  12:47	  PM	  with	  continuing	  irregular	   contractions,	  having	  vomited	  a	  small	  amount	  after	  eating	  lunch.	  Her	   baby’s	  heart	  rate	  was	  documented	  on	  the	  exam.	  Youth	  was	  instructed	  to	   return	  to	  the	  unit	  and	  rest	  with	  increased	  fluids.	  The	  facility	  nurse	   contacted	  Dr.	  Koffler’s	  office	  and	  informed	  their	  nurse	  practitioner	  of	  the	   situation	  and	  asked	  for	  any	  further	  instructions.	  At	  3:15	  PM,	  medical	  was	   called	  and	  unit	  staff	  reported	  passage	  of	  the	  mucous	  plug.	  Youth	  was	   assessed	  in	  medical	  with	  regular	  contractions	  2-­‐3	  minutes	  apart	  and	  fetal	   heart	  tones	  present.	  Youth	  was	  then	  transported	  to	  Grady	  Memorial	   Hospital	  and	  delivered	  without	  complications	  at	  5:15	  PM,	  progressing	   faster	  than	  usual	  for	  a	  first	  delivery.	   	   Three	  of	  the	  seven	  youth	  records	  reviewed	  had	  at	  least	  one	  mental	   health	  diagnosis.	  	  Mental	  health	  diagnoses	  have	  continued	  to	  be	   consistently	  listed	  on	  the	  problem	  list	  along	  with	  the	  medical	  diagnoses.	   None	  of	  the	  psychological	  documentation	  for	  the	  youth	  in	  included	  in	  the	   health	  record.	   	   When	  nurses	  made	  seclusion	  checks,	  they	  were	  documented	  in	  the	   progress	  notes.	  Logs	  were	  posted	  on	  the	  unit	  doors.	  There	  appears	  to	  be	   some	  reduction	  in	  the	  use	  of	  room	  seclusion	  based	  on	  documentation	  in	   the	  health	  record.	  One	  youth	  housed	  on	  the	  Progress	  Unit	  averaged	   about	  four	  episodes	  of	  room	  seclusion	  a	  month	  between	  November	  13th	   and	  February	  1st.	  	  For	  the	  remainder	  of	  February	  and	  March	  there	  were	   still	  about	  the	  same	  number	  of	  room	  seclusions,	  but	  the	  number	  of	  days	   in	  each	  episode	  grew	  shorter.	  	  The	  medical	  progress	  notes	  state	   “seclusion	  check”	  and	  now	  include	  details	  of	  the	  youth’s	  health	  status	  in	   SOAP	  format.	  This	  is	  an	  improvement	  over	  the	  last	  site	  visit.	  	  

	  

50.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 51 of 67 PAGEID #: 2545

	  

	  

Documentation	  on	  the	  Youth	  injury	  and	  Assessment	  Reports	  were	  

reviewed	  for	  those	  included	  in	  the	  seven	  health	  records.	  The	  

documentation	  provided	  by	  nursing	  staff	  for	  youth	  assessed	  for	  injuries	  

has	  significantly	  improved.	  The	  Nurse	  Manager,	  Ms.	  Vickie	  Donohue	  has	  

continued	  to	  monitor	  these	  assessments	  through	  the	  continuous	  quality	  

improvement	  (CQI)	  review	  process.	  There	  was	  one	  Youth	  Injury	  and	  

Assessment	  form	  reviewed	  secondary	  to	  an	  allegation	  of	  staff	  abuse.	  

Medical	  was	  called	  on	  3/23/13	  to	  the	  Cedar	  Unit	  to	  assess	  youth	  after	  he	  

had	  assaulted	  a	  staff	  member.	  At	  5:55	  PM,	  a	  visual	  check	  was	  made	  by	  

the	  nurse	  and	  no	  injuries	  noted.	  The	  youth	  had	  no	  complaints	  and	  was	  

told	  he	  would	  be	  further	  assessed	  in	  the	  exam	  room	  when	  he	  calmed	  

down.	  At	  approximately	  6:15	  PM,	  youth	  was	  escorted	  by	  unit	  staff	  cuffed	  

from	  behind	  to	  the	  exam	  room.	  No	  visible	  injuries	  to	  the	  face	  or	  hands	  

were	  noted.	  Youth	  denied	  having	  any	  injuries	  twice	  to	  medical	  staff.	  

Youth	  was	  taken	  to	  Sycamore	  Unit	  by	  staff.	  Youth	  requested	  to	  see	  nurse	  

and	  was	  taken	  to	  exam	  room	  on	  unit	  at	  approximately	  6:40	  PM.	  	  Youth	  

then	  made	  an	  allegation	  to	  the	  nurse	  that	  staff	  beat	  him	  up.	  The	  medical	  

exam	  at	  that	  time	  documented	  that	  the	  left	  side	  of	  his	  face	  was	  swollen	  

and	  tender,	  his	  left	  forearm	  and	  wrist	  were	  swollen	  with	  deformity	  and	  

his	  left	  ankle	  swollen.	  He	  complained	  of	  pain	  upon	  touching	  his	  face,	  arm	  

and	  wrist.	  He	  had	  visual	  complaints	  that	  had	  resolved	  by	  the	  time	  of	  the	  

exam.	  	  

	  

Internal	  Continuous	  Quality	  Improvement	  (CQI)	  documents	  were	  

reviewed	  that	  were	  provided	  by	  the	  Scioto	  nurse	  manager.	  The	  nurse	  

manager	  and	  staff	  nurses	  continue	  to	  participate	  in	  the	  CQI	  process.	  The	  

Medication	  Administration	  Record	  CQI	  document	  for	  January	  2013	  

averaged	  87%	  based	  on	  the	  10	  compliance	  indicators	  reviewed.	  The	  CQI	  

Intra-­‐system	  Transfer	  tool	  of	  January	  2013	  showed	  100%	  compliance	  for	  

nine	  of	  ten	  quality	  indicators	  with	  75%	  for	  one	  indicators	  regarding	  

documentation	  in	  the	  progress	  notes.	  Four	  charts	  in	  January	  and	  five	  

charts	  in	  April	  were	  selected	  for	  a	  CQI	  audit	  of	  the	  processing	  of	  specialty	  

consults.	  There	  was	  90	  -­‐100%	  compliance	  for	  six	  of	  nine	  quality	  

indicators.	  Low	  compliance	  percentages	  occurred	  for	  documentation	  that	  

a	  parent	  or	  guardian	  had	  been	  notified	  and	  with	  scheduling	  follow	  up	  

physician	  appointments.	  The	  nurse	  health	  call	  CQI	  audit	  of	  March	  2013	  

showed	  100%	  compliance	  on	  8	  of	  10	  compliance	  indicators.	  

Improvement	  was	  needed	  on	  documenting	  vital	  signs	  on	  each	  encounter.	  

The	  Nurse	  Charting	  Review	  CQI	  audit	  of	  March	  3013	  showed	  9	  of	  10	  

quality	  indicators	  at	  100%	  and	  one	  at	  90%.	  Vital	  signs	  at	  the	  time	  of	  each	  

encounter	  were	  reviewed	  on	  March	  5,	  2013.	  The	  documentation	  of	  vital	  

signs	  CQI	  audit	  showed	  100%	  compliance	  with	  the	  4	  quality	  indicators.	  

The	  CQI	  audit	  tool	  for	  Laboratory	  and	  Diagnostic	  Tests	  was	  reviewed	  for	  

January	  and	  March	  2013.	  The	  two	  lowest	  compliance	  indicators	  at	  60%	  

were	  for	  lack	  of	  documentation	  that	  youth	  were	  informed	  of	  normal	  or	  

abnormal	  test	  results.	  Since	  the	  last	  visit,	  the	  CQI	  audits	  for	  completion	  of	  

	  

51.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 52 of 67 PAGEID #: 2546

Recommendations	  
Sources	  of	   Information	   	  

the	  Youth	  Injury	  Assessment	  Form	  (YIAF)	  have	  been	  reviewed	  monthly	   since	  January	  2013	  due	  to	  deficiencies	  identified	  from	  the	  previous	   report.	  	  Over	  those	  months	  the	  documentation	  and	  compliance	   indicators	  continued	  to	  improve.	  Lack	  of	  documentation	  of	  youth	   education	  was	  noted	  as	  a	  particular	  area	  of	  weakness.	  The	  last	  audit	  of	   3/29/13	  had	  100%	  compliance	  in	  9	  of	  10	  quality	  indicators	  with	  90%	  in	   that	  one	  indicator.	  This	  outcome	  demonstrates	  the	  true	  benefit	  of	  a	  self-­‐	   auditing	  process.	  Medical	  staff	  also	  identified	  through	  this	  process	  the	   need	  to	  modify	  the	  CQI	  instrument	  to	  monitor	  discharge	  planning.	  	   Medical	  findings	  were	  discussed	  with	  Dr.	  John	  Brady,	  Medical	  Director	   and	  Scioto	  Nurse	  Manager,	  Vickie	  Donohue.	  
In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  	  	  
1. Complete	  satellite	  clinic	  and	  medication	  room	  on	  Buckeye	  Units	   for	  adequate	  injury	  assessments	  of	  youth	  and	  medication	   administration	  on	  the	  unit.	  	  
2. Continue	  to	  limit	  time	  of	  youth	  in	  seclusion	  with	  documentation	   of	  health	  status	  during	  segregation.	  
3. Continue	  to	  improve	  Quality	  Assurance	  (QA)	  activities	  to	  include	   some	  additional	  quality	  outcome	  indicators.	  	  
4. Continue	  accreditation	  through	  the	  American	  Correctional	   Association	  as	  an	  external	  auditing	  process.	  
• Site	  visit	  tour;	  Review	  of	  seven	  youth	  health	  records:	  ID	  #	   218418,	  217757,	  218277,	  218393,	  217113,	  218312,	  216642;	  CQI	   Documentation	  as	  outlined	  above.	  	  
	  

	  

52.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 53 of 67 PAGEID #: 2547

III.C.2	  	  Health	  Records.	  The	  State	  shall	  develop	  and	  implement	  policies,	  procedures	  and	   practices	  to	  ensure	  that,	  consistent	  with	  State	  and	  federal	  law,	  at	  a	  minimum,	  the	  juvenile	   courts	  in	  the	  State,	  all	  juvenile	  detention	  facilities	  and	  all	  placement	  settings	  from	  which	   youth	  are	  committed	  shall	  timely	  forward	  to	  Scioto,	  or	  to	  the	  facility	  of	  placement	  (if	  the	   records	  arrive	  after	  the	  youth	  has	  been	  placed),	  all	  pertinent	  youth	  records	  regarding	   medical	  and	  mental	  health	  care.	  The	  facilities	  shall	  develop	  and	  implement	  policies,	   procedures	  and	  practices	  to	  ensure	  that	  health	  care	  staff,	  including	  mental	  health	  care	   staff,	  have	  access	  to	  documents	  that	  are	  relevant	  to	  the	  care	  and	  treatment	  of	  the	  youth.	  	  

Compliance	  Rating	   Partial	  Compliance	  

Self	  Assessment	  

The	  Ohio	  Department	  of	  Youth	  Services	  (ODYS)	  does	  not	  conduct	  a	   self-­‐assessment	  for	  the	  level	  of	  medical	  and	  dental	  care	  provided	  at	   SJCF.	  However	  the	  health	  records	  are	  being	  reviewed	  as	  a	  part	  of	   the	  CQI	  process.	  	  	  

Steps	  Taken	  to	   Assess	  Compliance	  

Review	  of	  seven	  youth	  health	  records.	  There	  were	  no	  new	  Health	   Policies	  and	  Procedures	  or	  Standard	  Operating	  Procedures	  (SOP)	   completed	  by	  ODYS	  since	  the	  last	  visit.	  Three	  of	  seven	  youth	  had	   been	  transferred	  from	  other	  facilities.	  These	  youth	  health	  records	   contained	  health	  information	  from	  the	  transferring	  facility.	  The	   offense	  information	  was	  not	  present	  in	  the	  health	  records	  reviewed	   at	  this	  visit.	  The	  health	  record	  is	  still	  incomplete,	  due	  to	  the	   psychological	  and	  counseling	  notes	  being	  housed	  separately	  on	  the	   housing	  units.	  The	  RFP	  awarded	  to	  eClinical	  Works	  for	  an	  electronic	   health	  record	  (EHR)	  through	  the	  Ohio	  Department	  of	   Administrative	  Services	  and	  the	  Office	  of	  Information	  Technology	   (OIT)	  was	  in	  the	  implementation	  phase	  during	  this	  visit.	  	  The	   eClinical	  Works	  EHR	  correctional	  module	  has	  been	  used	   successfully	  in	  other	  correctional	  settings.	  	  I	  attended	  the	   presentation	  to	  demonstrate	  how	  the	  adult	  Department	  of	   Rehabilitation	  and	  Correction	  (DRC)	  had	  structured	  the	  use	  of	  the	   EHR	  in	  their	  system.	  In	  attendance	  were	  Dr.	  John	  Bradley	  (Medical	   Director),	  Jacqueline	  Carter	  (Nursing	  Director)	  and	  other	  DYS	   central	  office	  health	  staff	  in	  order	  to	  review	  the	  system	  and	   determine	  how	  best	  to	  utilize	  it	  to	  meet	  the	  needs	  of	  DYS.	  Certified	   trainers	  are	  being	  used	  to	  train	  certified	  users	  for	  current	  field	   testing	  in	  DRC.	  The	  same	  process	  will	  be	  required	  in	  order	  to	   adequately	  train	  DYS	  medical	  staff	  in	  the	  use	  of	  the	  system.	  The	   plan	  is	  for	  the	  EHR	  to	  also	  connect	  the	  state	  and	  community	   providers,	  initially	  to	  begin	  with	  the	  (DRC),	  followed	  by	  ODYS,	   KALOS	  Pharmacy,	  Central	  Medical	  Lab,	  Immunization	  database,	   Franklin	  Medical	  Center	  and	  OSU	  Hospital	  records.	  	  Of	  great	   significance,	  the	  youth	  mental	  health	  records	  will	  interface	  with	  the	   new	  EHR.	  The	  eClinical	  Works	  electronic	  health	  record	  being	   established	  will	  facilitate	  the	  sharing	  of	  the	  mental	  health	  and	   medical	  information	  into	  one	  combined	  health	  record.	  The	  system	   is	  web	  based	  will	  be	  able	  to	  interface	  with	  community	  providers	   and	  pharmacies	  and	  improve	  continuity	  of	  health	  care	  for	  youth	  

	  

53.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 54 of 67 PAGEID #: 2548

upon	  release.	  	  	  

Recommendations	  

In	  order	  to	  reach	  substantial	  compliance	  with	  this	  provision,	  the	   State	  must:	  
1. Continue	  to	  improve	  the	  process	  for	  sharing	  of	  health	   information	  between	  medical	  and	  mental	  health	  to	  include	   psychologists	  and	  counselors	  through	  implementation	  of	   eClinical	  Works	  EHR.	  	  
2. ODYS	  medical	  management	  staff	  should	  continue	  to	  be	   intimately	  involved	  in	  the	  process	  of	  customization	  of	  the	   EHR	  to	  be	  relevant	  to	  youth	  medical	  services.	  

Sources	  of	   Information	  
	   	   	   	  

• Site	  visit	  tour;	  Review	  of	  seven	  youth	  health	  records:	  ID	  #	   218418,	  217757,	  218277,	  218393,	  217113,	  218312,	  and	   216642.	  	  
• Presentation	  on	  eClinical	  Works	  electronic	  health	  record	  
	  

	  

54.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 55 of 67 PAGEID #: 2549

III.C.5	  	  Access	  to	  Health	  Services.	  The	  facilities	  shall	  ensure	  that	  youth	  can	  request	  to	  be	  seen	  by	   medical	  staff	  confidentially	  and	  independent	  from	  JCOs	  and	  custodial	  staff.	  	  

Compliance	  Rating	   Substantial	  Compliance	  

Self	  Assessment	  

The	  Ohio	  Department	  of	  Youth	  Services	  (ODYS)	  does	  not	  conduct	  a	  self-­‐ assessment	  for	  the	  level	  of	  medical	  and	  dental	  care	  provided	  at	  SJCF.	  	  	  

Steps	  Taken	  to	   Assess	  Compliance	  

Health	  Request	  drop	  boxes	  were	  present	  on	  all	  the	  units	  where	  youth	   were	  housed.	  	  Health	  Request	  boxes	  were	  present	  in	  the	  cafeteria	  and	  in	   the	  school.	  Of	  the	  7	  housing	  units	  toured,	  slips	  were	  outside	  the	  boxes	   and	  readily	  available	  to	  youth	  on	  all	  but	  2	  units.	  On	  one	  unit,	  the	  staff	   immediately	  located	  the	  slips	  and	  refilled	  the	  box	  ;	  on	  the	  other,	  staff	   could	  not	  locate	  the	  blank	  health	  request	  slips.	  One	  youth	  when	   questioned	  on	  that	  same	  unit	  stated	  that	  the	  slips	  were	  not	  always	   available.	  This	  is	  an	  acceptable	  rate	  of	  error.	  	   	   Youth	  were	  interviewed	  on	  the	  units	  as	  to	  how	  to	  access	  confidential	   health	  services.	  Youth	  interviewed	  knew	  where	  the	  boxes	  were	  located	   and	  all	  could	  verbalize	  how	  to	  gain	  access	  to	  health	  services.	  Nurse	   Health	  Requests	  submitted	  by	  the	  youth	  were	  reviewed	  in	  7	  health	   records.	  Most	  health	  requests	  were	  related	  to	  skin	  complaints	  such	  as	   acne	  and	  rashes,	  musculoskeletal	  pains	  and	  dental	  complaints.	  Each	   Health	  Request	  was	  reviewed	  and	  traced	  back	  to	  a	  corresponding	   progress	  note	  to	  determine	  if	  the	  complaint	  had	  been	  addressed.	  Health	   requests	  included	  in	  these	  health	  records	  were	  responded	  to	  adequately	   and	  documented	  by	  medical	  staff	  100%	  of	  the	  time.	  In	  all	  cases,	  the	   requests	  had	  been	  adequately	  assessed	  and	  treated	  in	  a	  timely	  manner	   by	  registered	  nursing	  staff,	  physician	  or	  dentist.	  	  	  

Recommendations	  

In	  order	  to	  maintain	  substantial	  compliance	  with	  this	  provision,	  the	  State	   must:	  
1. Ensure	  Health	  Request	  slips	  and	  boxes	  are	  readily	  available	  to	   youth	  on	  all	  housing	  units.	  Youth	  should	  not	  have	  to	  rely	  on	   custody	  staff	  to	  request	  forms.	  	  	  

Sources	  of	   Information	  
	   	   	  
	  

• Site	  visit	  tour;	  Review	  of	  seven	  youth	  health	  records:	  ID	  #218418,	   217757,	  218277,	  218393,	  217113,	  218312,	  and	  216642.	  
	  

	  

55.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 56 of 67 PAGEID #: 2550

SPECIAL	  EDUCATION	  
	  
III.E.1	  Provision	  of	  Special	  Education.	  The	  State	  shall,	  at	  all	  times,	  provide	  all	  youth	  confined	  at	   the	  facilities	  with	  adequate	  special	  education	  in	  compliance	  with	  the	  Individuals	  with	  Disabilities	   Education	  Act	  (IDEA),	  20	  U.S.C.	  §	  1400-­‐1482,	  and	  regulations	  promulgated	  thereunder,	  and	  this	   Stipulation.	  	  

Compliance	  Rating	   Substantial	  Compliance	  

Self	  Assessment	  

This	  provision	  pertains	  to	  the	  facility’s	  ability	  to	  deliver	  the	  special	   education	  program.	  Certain	  foundations	  need	  to	  be	  in	  place—adequate	   safety,	  sufficient	  numbers	  of	  qualified	  teachers,	  and	  dependable	  access	   to	  the	  education	  program	  that	  is	  not	  interrupted	  by	  disciplinary	   procedures	  that	  remove	  students	  from	  school	  for	  long	  periods	  of	  time.	   The	  State	  was	  asked	  to	  comment	  on	  each	  of	  these	  issues	  (summarized	   here)	  and	  to	  provide	  quantitative	  data	  to	  demonstrate	  their	  level	  of	   compliance	  (analyzed	  below).	  	   	   School	  Safety	   Although	  at	  times	  in	  the	  past	  the	  school	  was	  a	  hotspot	  for	  youth	   violence,	  changes	  were	  made	  to	  the	  way	  students	  cycled	  through	  the	   school	  facility,	  the	  number	  of	  staff	  posted	  in	  the	  school	  buildings,	  and	  to	   the	  physical	  features	  of	  the	  classrooms.	  These	  modifications,	  coupled	   with	  the	  stabilizing	  influence	  of	  a	  highly	  competent	  set	  of	  school	   administrators,	  have	  transformed	  the	  school	  into	  a	  relatively	  safe	   environment	  where	  learning	  can	  occur.	  	   	   Education	  has	  also	  become	  better	  integrated	  with	  the	  rest	  of	  the	   facility’s	  programming.	  The	  Superintendent,	  Direct	  Deputy	  and	   Programming	  Deputy	  all	  attend	  the	  school’s	  morning	  meeting,	  allowing	   for	  the	  free	  exchange	  of	  information	  across	  disciplines.	  Even	  though	  the	   youth	  violence	  problem	  in	  school	  has	  improved,	  school	  administrators	   continue	  to	  develop	  new	  strategies	  to	  improve	  the	  school	  environment	   and	  increase	  student’s	  engagement.	   	   A	  school	  incentive	  program	  was	  introduced	  to	  supplement	  the	  SBBMS.	   When	  students	  meet	  a	  set	  of	  education-­‐related	  behavioral	  expectations	   (e.g.,	  perfect	  attendance,	  no	  YBIRs,	  no	  ABC	  referrals,	  good	  hallway	   movement)	  and	  performance	  measures	  (e.g.,	  effort	  in	  class,	  complete	   assignments),	  they	  earn	  tokens	  (i.e.,	  “apples”)	  that	  can	  be	  used	  to	   purchase	  admission	  to	  a	  Friday	  assembly	  along	  with	  a	  variety	  of	  snacks	   and	  drinks.	  This	  program	  has	  reportedly	  improved	  student	  behavior	  and	   performance	  in	  the	  classroom.	  	   	   Staffing	  Issues	   Although	  the	  teaching	  roster	  still	  has	  a	  few	  vacancies	  (science,	  math,	   special	  education	  and	  substitutes),	  the	  facility’s	  low	  population	  means	   that	  the	  current	  complement	  of	  staff	  is	  sufficient	  to	  provide	  all	  core	  

	  

56.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 57 of 67 PAGEID #: 2551

subjects,	  vocational	  courses,	  and	  electives	  without	  interruption.	  Students	   in	  all	  of	  Scioto’s	  programs	  now	  have	  dependable	  access	  to	  the	  330	   minutes	  of	  education	  required	  by	  State	  law.	  	   	   ABC	  Room	   In	  the	  past,	  youth	  who	  exhibited	  non-­‐compliant	  behavior	  in	  the	   classroom	  could	  be	  suspended	  from	  school	  and	  returned	  to	  their	  living	   units	  where	  they	  did	  not	  receive	  education	  services	  of	  any	  kind.	  While	   youth	  may	  be	  sent	  back	  to	  the	  unit	  in	  emergency	  situations	  (i.e.,	  out	  of	   control	  behavior,	  fights,	  etc.),	  the	  State	  ceased	  suspending	  students	  in	   June	  2011,	  relying	  instead	  on	  its	  in-­‐school	  suspension	  room	  (the	   Academic	  Behavior	  Center	  (ABC))	  and	  its	  procedure	  for	  Unit	  Instruction.	  	   	   The	  ABC	  room	  provides	  youth	  an	  opportunity	  to	  regain	  control	  of	  their	   behavior	  and	  to	  return	  to	  the	  classroom	  setting	  without	  going	  back	  to	   their	  living	  units.	  Youth	  are	  referred	  to	  the	  ABC	  room	  for	  rule	  violations	   pertaining	  to	  offensive	  or	  threatening	  conduct,	  being	  disruptive,	   distracting	  other	  students	  or	  being	  outside	  an	  authorized	  area.	  Most	   youth	  stay	  between	  1.5	  to	  2	  hours—they	  may	  earn	  10	  minutes	  off	  their	   ABC	  time	  for	  every	  30	  minutes	  they	  spend	  focused	  and	  engaged	  in	  their	   classwork.	  In	  the	  past,	  staffing	  shortages	  left	  this	  resource	  unavailable	  to	   teachers,	  which	  frequently	  resulted	  in	  youth	  being	  sent	  back	  to	  their	   units	  during	  the	  school	  day	  and	  the	  loss	  of	  integrity	  of	  the	  entire	  ABC	   intervention.	  The	  staffing	  problems	  have	  been	  resolved,	  and	  the	  ABC	   room	  has	  been	  available	  on	  a	  daily	  basis	  for	  over	  a	  year.	  	   	   The	  number	  of	  youth	  sent	  to	  the	  ABC	  room	  during	  the	  current	   monitoring	  period	  fluctuated.	  During	  the	  2nd	  grading	  period,	  26	  youth	   were	  referred	  to	  the	  ABC	  room,	  as	  compared	  to	  76	  referrals	  during	  the	   3rd	  grading	  period.	  However,	  across	  this	  same	  time	  period,	  there	  were	   193	  and	  106	  emergency	  removals	  (i.e.,	  youth	  returned	  directly	  to	  the	   housing	  units,	  bypassing	  the	  ABC	  room).	  These	  data	  suggest	  that	  youth’s	   classroom	  behavior	  is	  being	  managed	  more	  effectively—teachers	  are	   intervening	  earlier	  and	  sending	  youth	  to	  the	  ABC	  room	  rather	  than	   sending	  them	  directly	  to	  the	  unit.	  This	  effort	  to	  maintain	  the	  youth	  in	  the	   classroom	  is	  fully	  aligned	  with	  the	  intent	  of	  this	  provision.	  	   	   Unit	  Instruction	   Previously,	  the	  Parties	  to	  the	  S.H.	  lawsuit	  negotiated	  an	  agreement	   regarding	  the	  delivery	  of	  education	  services	  to	  youth	  who	  are	  confined	  to	   the	  living	  units	  for	  disciplinary	  reasons.	  Within	  48	  hours	  of	  their	   placement	  in	  seclusion,	  students	  must	  receive	  instruction	  from	  a	  certified	   teacher	  four	  times	  per	  day,	  for	  at	  least	  30	  minutes	  per	  visit	  (i.e.,	  Unit	   Instruction).	  	  	   	   Each	  morning,	  the	  attendance	  clerk	  calls	  each	  unit	  for	  the	  AOV	  and	  Unit	   Restriction	  list.	  A	  Unit	  Instruction	  list	  is	  compiled	  and	  delivered	  to	  all	  

	  

57.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 58 of 67 PAGEID #: 2552

teachers,	  along	  with	  the	  Unit	  Instructor	  schedule.	  Teachers	  who	  serve	   students	  on	  the	  list	  prepare	  course	  work,	  along	  with	  a	  copy	  of	  the	  IEP	  at-­‐ a-­‐glance	  for	  special	  education	  students.	  The	  Unit	  Instructor	  (which	   rotates	  throughout	  the	  day)	  delivers	  the	  work	  to	  each	  student,	  and	  also	   provides	  30-­‐minutes	  of	  instruction,	  four	  times	  per	  day.	  	   	   Classwork	  for	  youth	  on	  Pre-­‐Hearing	  Seclusion	  (PHS)	  for	  an	  act	  of	  violence	   is	  delivered	  underneath	  the	  youth’s	  door.	  For	  most	  youth,	  PHS	  lasts	  less	   than	  2	  days	  (see	  the	  discussion	  for	  III.A.3,	  above).	  If	  a	  youth	  receives	   additional	  seclusion	  time	  as	  a	  sanction,	  they	  are	  brought	  out	  to	  the	  table	   in	  the	  dayroom,	  unless	  their	  behavior	  suggests	  a	  risk	  of	  violence.	  The	   Operations	  staff	  makes	  these	  determinations,	  and	  the	  assumption	  is	  that	   youth	  on	  Intervention	  Seclusion	  will	  be	  served	  in	  the	  dayroom,	  unless	   otherwise	  indicated.	  	   	   The	  school’s	  clerical	  staff	  and	  administrators	  expend	  significant	  time	  and	   energy	  reviewing	  and	  monitoring	  Unit	  Instruction	  records	  to	  ensure	   compliance.	  A	  teacher	  reviews	  each	  youth’s	  folder	  every	  afternoon,	   makes	  sure	  the	  documents	  are	  filled	  out	  correctly	  and	  enters	  the	   information	  in	  to	  the	  database.	  The	  attendance	  officer	  double	  checks	  the	   paperwork	  and	  the	  entry	  into	  the	  database	  and	  files	  the	  student’s	   paperwork.	  On	  a	  monthly	  basis,	  the	  Unit	  Instruction	  log	  is	  compared	  to	   the	  AMS	  seclusion	  list	  by	  at	  least	  two	  school	  administrators.	  Finally,	   Central	  Office	  reviews	  the	  information	  every	  couple	  of	  months	  and	  sends	   written	  feedback	  to	  the	  facility.	  Reviews	  during	  the	  current	  monitoring	   period	  found	  high	  rates	  of	  compliance.	  	   	   Progress	  Unit	  School	   As	  noted	  in	  the	  previous	  Monitor’s	  Reports,	  the	  PROGRESS	  Unit	  (PU)	   school	  was	  the	  site	  of	  numerous	  staff	  and	  youth	  assaults.	  Enhancements	   to	  the	  direct	  care	  staffing	  levels	  and	  the	  physical	  “hardening”	  of	  the	   environment	  (different	  furniture,	  bolting	  down	  monitors,	  flex	  keyboards,	   etc.)	  reported	  in	  the	  previous	  Monitor’s	  Reports	  have	  largely	  solved	  this	   problem.	  While	  misconduct	  still	  occurs	  among	  these	  high-­‐security	  youth,	   the	  environment	  has	  settled,	  teachers	  are	  becoming	  more	  creative	  and	   youth	  are	  becoming	  more	  engaged	  in	  the	  program.	  PU	  students	  have	   made	  important	  academic	  achievements	  (one	  earned	  a	  GED,	  one	  earned	   a	  diploma,	  several	  made	  the	  Honor	  Roll	  and	  Merit	  Roll,	  and	  one	  of	  the	   students	  had	  the	  highest	  GPA	  on	  campus).	  New	  course	  offerings	  (PE	  for	   Phase	  2	  youth	  and	  Health	  for	  Phase	  1	  youth)	  will	  help	  to	  ensure	  that	  PU	   students	  continue	  to	  earn	  needed	  credits	  during	  their	  stay	  on	  the	  PU.	  	   	   Overall,	  the	  school	  administrators	  are	  vigilant	  about	  the	  school	   environment	  and	  the	  various	  barriers	  that	  could	  impede	  access	  to	  the	   education	  program.	  The	  system	  of	  internal	  review	  and	  monitoring	  is	  fully	   capable	  of	  identifying	  and	  responding	  to	  any	  problems	  that	  may	  arise	   over	  time.	  	  	  

	  

58.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 59 of 67 PAGEID #: 2553

Steps	  Taken	  to	   Assess	  Compliance	  

Attendance	   Overall	  school	  attendance	  rates	  are	  reported	  every	  month	  on	  the	   Superintendent’s	  report,	  and	  the	  DYS	  also	  provided	  these	  data	   disaggregated	  by	  housing	  unit.	  Across	  the	  six-­‐month	  monitoring	  period	   (October	  2012	  through	  March	  2013)	  average	  unit	  attendance	  rates	   ranged	  between	  83%	  (Sycamore)	  and	  95%	  (Allman)	  with	  an	  overall	   average	  of	  89%.	  Importantly,	  only	  one	  of	  the	  units	  (Sycamore)	  was	  below	   the	  85%	  benchmark,	  and	  only	  by	  two	  percentage	  points.	  The	  attendance	   rates	  consistently	  met	  or	  exceeded	  the	  85%	  threshold	  across	  the	  rest	  of	   the	  housing	  units.	  	   	   Unit	  Instruction	   To	  assess	  the	  integrity	  of	  the	  Unit	  Instruction	  procedures,	  the	  Unit	   Instruction	  records	  maintained	  by	  the	  school	  were	  cross-­‐referenced	  with	   a	  list	  of	  youth	  who	  had	  been	  on	  seclusion	  between	  February	  1	  and	  March	   31,	  2013	  generated	  by	  AMS.	  	   	   First,	  a	  random	  sample	  of	  23	  youth	  with	  seclusion	  stays	  in	  excess	  of	  48	   hours	  was	  selected	  from	  the	  AMS	  list.	  A	  surprising	  number	  of	  youth	  had	   to	  be	  excluded	  from	  the	  analysis	  because	  they	  were	  in	  seclusion	  only	   over	  the	  weekend	  or	  on	  a	  non-­‐instructional	  day.	  [This	  is	  positive	  given	   that,	  in	  these	  cases,	  seclusion	  does	  not	  obstruct	  student’s	  access	  to	   school.	  However,	  separating	  in	  time	  the	  sanction	  from	  the	  behavior	  one	   is	  trying	  to	  address	  is	  not	  a	  particularly	  effective	  behavior	  modification	   strategy.]	  Once	  the	  non-­‐instructional	  days	  were	  filtered	  out,	  a	  sample	  of	   9	  youth	  remained.	  In	  each	  case,	  students	  were	  provided	  with	  education	   services	  in	  accordance	  with	  DYS	  Policy	  #303.01.05	  “School	   Interventions.”	  In	  most	  cases,	  youth	  received	  education	  services	  on	  the	   next	  school	  day	  following	  their	  seclusion,	  though	  in	  a	  couple	  cases,	  they	   received	  work	  toward	  the	  end	  of	  the	  48-­‐hour	  timeline.	  The	  Unit	   Instruction	  log	  recorded	  whether	  the	  work	  was	  received	  or	  declined	   (most	  youth	  accepted	  the	  work)	  and	  whether	  the	  instruction	  was	   provided	  in	  or	  out	  of	  the	  room	  (youth	  on	  intervention	  seclusion	  were	   served	  out	  of	  their	  rooms;	  youth	  on	  pre-­‐hearing	  seclusion	  were	  served	  in	   their	  rooms).	  	   	   Second,	  for	  each	  of	  the	  14	  youth	  on	  the	  Unit	  Instruction	  list,	  the	  dates	  of	   service	  were	  cross-­‐referenced	  with	  the	  AMS	  roster	  to	  ensure	  that	  youth	   were	  served	  on	  all	  of	  the	  instructional	  days	  during	  which	  they	  were	   secluded.	  Service	  dates	  were	  verified	  for	  all	  but	  2	  of	  the	  youth	  (86%	   compliance),	  each	  of	  whom	  appeared	  to	  be	  in	  seclusion	  on	  a	  given	  day	   but	  did	  not	  have	  service	  recorded	  in	  the	  Unit	  Instruction	  Log.	  This	  is	  an	   acceptable	  rate	  of	  error,	  particularly	  given	  the	  complexity	  of	  the	  AMS	   seclusion	  logs.	  	   	   In	  summary,	  once	  cross-­‐referenced	  with	  AMS,	  the	  Unit	  Instruction	  data	   demonstrated	  that	  the	  facility	  is	  in	  compliance	  with	  its	  obligations	  

	  

59.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 60 of 67 PAGEID #: 2554

Recommendations	   Sources	  of	   Information	  
	   	  

around	  providing	  education	  services	  to	  youth	  who	  are	  in	  seclusion.	   However,	  it	  is	  worth	  noting	  that	  several	  youth	  spent	  an	  extraordinary	   amount	  of	  time	  in	  seclusion	  (a	  commentary	  on	  the	  facility’s	  disciplinary	   practices,	  not	  on	  the	  education	  program).	  For	  example,	  youth	  CC	  spent	   16	  days	  in	  a	  row	  in	  seclusion	  with	  only	  one	  day	  out	  in	  the	  general	   population.	  Another	  youth,	  TB,	  spent	  8	  days	  in	  a	  row	  in	  seclusion.	  The	   facility’s	  reliance	  on	  seclusion	  to	  address	  violent	  misconduct	  is	  discussed	   in	  provision	  III.A.3,	  above.	  Revisions	  to	  the	  sanctioning	  grid,	  to	  be	   implemented	  in	  the	  very	  near	  future,	  should	  decrease	  the	  amount	  of	   time	  youth	  spend	  in	  seclusion,	  and	  by	  extension,	  the	  need	  for	  Unit	   Instruction.	  Unit	  Instruction	  is	  an	  essential	  tool	  to	  ensure	  that	  education	   services	  are	  not	  disrupted	  by	  the	  disciplinary	  system	  chosen	  by	  the	   facility.	  	  
The	  facility	  is	  in	  substantial	  compliance	  with	  this	  provision.	  	  	  
• Oral	  presentation	  and	  underlying	  documentation	  for	  provision	   III.E.1,	  prepared	  at	  my	  request	  
• Education	  staffing	  roster,	  October	  2012	  through	  March	  2013	   • Unit	  Instruction	  data,	  February	  and	  March	  2013,	  and	  follow-­‐up	  
discussions	  with	  Scioto	  and	  DYS	  school	  administrators	  via	  email.	  	   • AMS	  Seclusion	  Records,	  February	  and	  March	  2013	   • Attendance	  records,	  by	  unit,	  October	  2012	  through	  March	  2013	  
	  

	  

60.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 61 of 67 PAGEID #: 2555

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

Compliance	  Rating	   Substantial	  Compliance	  

Self	  Assessment	  

The	  State	  provided	  data	  on	  the	  19	  special	  education	  students	  in	  custody	   as	  of	  April	  19,	  2013	  (approximately	  41%	  of	  the	  total	  population;	  59%	  of	   the	  females	  and	  31%	  of	  the	  males).	  Of	  these	  youth,	  three	  student’s	  IEPs	   were	  expired,	  but	  staff	  had	  taken	  steps	  to	  collect	  the	  necessary	   information	  and	  schedule	  IEP	  meetings	  during	  the	  month	  of	  April	  2013.	   The	  other	  16	  youth	  had	  current	  IEPs	  and	  current	  eligibility.	  	   	   The	  State	  has	  implemented	  a	  solid,	  multi-­‐level	  process	  to	  ensure	  the	   quality	  of	  the	  IEPs	  written	  at	  Scioto.	  For	  teachers,	  a	  variety	  of	  tools	  have	   been	  created:	  
• IEP	  Documentation	  Guidelines	  Checklist:	  discusses	  the	   procedures	  for	  submitting	  draft	  IEPs	  for	  review,	  what	  needs	  to	   be	  completed	  during	  the	  IEP	  meeting,	  and	  what	  documents	  need	   to	  be	  submitted	  once	  the	  IEP	  meeting	  has	  been	  held.	  	  
• IEP	  Goal	  Planning	  Worksheet:	  requires	  teachers	  to	  articulate	  the	   various	  components	  of	  a	  well-­‐written	  IEP	  goal	  and	  to	  devise	  a	   plan	  for	  how	  progress	  will	  be	  measured.	  	  
• Goal	  Tracking	  Sheet:	  for	  each	  IEP	  goal,	  asks	  whether	  the	  goal	  was	   met	  or	  not	  met,	  and	  whether	  a	  problem	  with	  how	  the	  goal	  was	   articulated	  made	  it	  difficult	  to	  measure.	  [Recommendation:	  it	   might	  also	  be	  useful	  to	  ask	  the	  teacher	  to	  indicate	  the	  basis	  for	   determining	  whether	  the	  goal	  was	  met	  or	  not,	  although	  the	   review	  of	  Progress	  Reports	  may	  address	  quality	  assurance	  needs	   in	  this	  area.]	  
The	  Special	  Education	  Administrator	  at	  the	  facility	  also	  reviews	  IEPs	  each	   month.	  The	  following	  documents	  are	  used	  to	  guide	  this	  review:	  
• Continuous	  IEP	  Compliance	  Monitoring	  Checklist:	  assesses,	  in	   detail,	  whether	  the	  required	  content	  is	  present	  within	  each	  of	   the	  14	  sections	  of	  the	  IEP	  document.	  Written	  feedback	  is	   provided	  to	  the	  teachers	  in	  order	  to	  improve	  their	  skills.	  

	  

61.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 62 of 67 PAGEID #: 2556

Steps	  Taken	  to	   Assess	  Compliance	  

• On-­‐Site	  Monthly	  Monitoring	  Form:	  used	  to	  rate	  a	  sample	  of	  10	   IEPs	  on	  12	  performance	  measures	  (e.g.,	  whether	  the	  IEP	  is	   current,	  whether	  the	  ETR	  is	  current,	  whether	  the	  goals	  and	   objectives	  are	  appropriate,	  whether	  progress	  notes	  have	  been	   updated,	  whether	  school	  refusals	  are	  being	  addressed,	  if	  parents	   have	  been	  properly	  notified,	  etc.).	  	  
• Monthly	  Local	  Special	  Education	  Accountability	  and	  Compliance	   Review:	  provides	  summary	  statistics	  for	  each	  of	  the	  various	   indicators	  measured	  using	  the	  Monthly	  Monitoring	  Form.	  	  
These	  monthly	  reviews	  are	  “Tier	  One”	  of	  the	  QA	  program.	  In	  Tier	  Two,	   each	  quarter,	  the	  DYS	  Special	  Education	  Director	  reviews	  the	  same	  files	   to	  ensure	  that	  all	  deficits	  were	  identified	  in	  the	  local	  audit	  and	  that	   teachers	  completed	  any	  required	  corrections.	  Sadly,	  the	  extremely	   talented	  DYS	  Special	  Education	  Director	  retired	  during	  the	  current	   monitoring	  period.	  She	  has	  not	  yet	  been	  replaced	  and	  thus	  Tier	  Two	  was	   not	  completed	  during	  the	  current	  monitoring	  period.	  However,	  the	   excellent	  results	  obtained	  via	  the	  Tier	  One	  process	  (at	  least	  90%	   compliance	  in	  January,	  February,	  and	  March)	  make	  this	  hiatus	  less	  of	  a	   concern.	  Tier	  Two	  should	  be	  reinstated	  as	  soon	  as	  possible	  to	  maintain	   the	  integrity	  of	  the	  QA	  system.	  	   	   In	  Tier	  Three,	  each	  of	  the	  DYS	  schools	  is	  audited	  annually	  by	  DYS	  and	  also	   tri-­‐annually	  by	  the	  Ohio	  Department	  of	  Education.	  Neither	  of	  these	   audits	  was	  scheduled	  during	  the	  current	  monitoring	  period.	  	  	  
Special	  Education	  Population	  and	  IEP	  Development	   Across	  the	  current	  special	  education	  population,	  16	  of	  the	  19	  students	   (84%)	  qualified	  under	  the	  Emotional	  Disability	  category,	  one	  student	  had	   a	  Specific	  Learning	  Disabilities	  (5%),	  one	  student	  was	  Cognitively	  Disabled	   (5%),	  and	  one	  student	  was	  Other	  Health	  Impaired	  (5%).	  With	  4	  special	   education	  teachers	  currently	  on	  staff,	  the	  caseload	  sizes	  are	  well	  below	   the	  state	  limits	  (generally,	  12	  for	  ED;	  24	  for	  SLD).	   	   The	  Monitor	  reviewed	  a	  sample	  of	  the	  last	  10	  IEPs	  written	  by	  Scioto	  staff	   prior	  to	  the	  Monitor’s	  April	  2013	  site	  visit	  (53%	  of	  the	  current	  special	   education	  population).	  As	  expected	  after	  reviewing	  the	  QA	  results,	  all	  of	   the	  procedural	  requirements	  were	  met	  and	  the	  content	  of	  each	  section	   of	  the	  IEP	  conformed	  to	  the	  IDEA’s	  requirements.	  What	  was	  particularly	   impressive	  was	  the	  level	  of	  consideration	  given	  to	  the	  constellation	  of	   services	  that	  was	  prescribed	  for	  each	  student.	  The	  student’s	  response	  to	   the	  previous	  level	  of	  service	  was	  discussed	  and	  reconsidered	  to	   determine	  whether	  a	  different	  arrangement	  might	  better	  fit	  the	   student’s	  needs.	  In	  some	  cases,	  the	  service	  was	  delivery	  was	  modified	   with	  the	  hope	  that	  the	  student	  would	  become	  more	  engaged	  in	  the	   program.	  For	  example,	  one	  student	  had	  previously	  received	  Occupational	   Therapy	  (OT)	  services	  in	  the	  general	  education	  classroom,	  but	  the	   therapist	  noted	  that	  the	  youth	  did	  better	  when	  she	  worked	  with	  him	  1:1.	   The	  team	  modified	  the	  service	  delivery	  accordingly.	  	  

	  

62.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 63 of 67 PAGEID #: 2557

	   IEP	  Goal	  Development	   The	  quality	  of	  articulation	  of	  the	  IEP	  goals	  and	  objectives	  is	  paramount	  to	   ensure	  that	  students	  progress	  through	  the	  curriculum.	  This	  task	  is	  much	   easier	  when	  the	  teacher/team	  can	  relay	  on	  clear	  descriptions	  of	  the	   students’	  skill	  deficits.	  For	  the	  most	  part,	  the	  IEPs’	  Student	  Profiles	   contained	  excellent	  descriptions	  of	  the	  youth’s	  strengths	  and	   weaknesses,	  including	  a	  mix	  of	  standardized	  test	  scores	  and	  teachers’	   observations	  about	  the	  students’	  capabilities	  and	  skill	  deficits,	  and	   descriptions	  of	  the	  student’s	  behavior	  and	  school	  attendance.	  	   	   Similarly,	  the	  Present	  Level	  of	  Performance	  section	  used	  to	  set	  up	  each	   IEP	  goal	  includes	  relevant	  test	  scores	  and	  descriptions	  of	  the	  students’	   strengths	  and	  weaknesses	  in	  the	  subject	  matter	  at	  hand.	  This	   information	  provided	  necessary	  context	  for	  the	  goals	  and	  the	  underlying	   objectives.	  Nearly	  all	  of	  the	  goals	  reviewed	  across	  the	  10	  IEPs	  were	   individualized,	  measurable	  and	  appeared	  to	  be	  achievable	  within	  a	  1-­‐ year	  period,	  and	  the	  objectives	  identified	  the	  skills	  necessary	  to	  meet	  the	   goal.	  Behavior	  goals	  were	  individualized	  and	  anchored	  in	  a	  description	  of	   problem	  behaviors	  and	  the	  situations	  in	  which	  they	  are	  likely	  to	  occur.	   Methods	  to	  assess	  progress	  on	  behavior	  goals	  generally	  include	  a	   combination	  of	  citizenship	  scores,	  YBIRs,	  ABC	  referrals,	  attendance	  rates	   and	  “working	  behaviors.”	  All	  students	  had	  transition	  goals	  that	  appeared	   to	  be	  relevant	  to	  the	  student’s	  current	  grade	  level	  and	  the	  number	  of	   credits	  they’d	  earned.	  These	  goals	  and	  objectives	  provide	  a	  solid	   platform	  from	  which	  student	  progress	  can	  be	  measured.	  	   	   Progress	  Reporting	   Meaningful	  progress	  reporting	  is	  essential	  to	  ensuring	  compliance	  with	   IDEA.	  Facilitating	  students’	  progress	  through	  the	  curriculum	  is	  the	  entire	   point	  of	  special	  education,	  and	  without	  assessing	  progress,	  the	  program	   cannot	  identify	  whether	  it	  is	  meeting	  students’	  special	  education	  needs.	  	   	   The	  State	  submitted	  IEP	  progress	  reports	  for	  the	  15	  special	  education	   students	  (100%)	  who	  were	  at	  Scioto	  at	  the	  end	  of	  the	  Jan-­‐March	  2013	   grading	  period	  (the	  other	  four	  were	  admitted	  just	  before	  the	  grading	   period	  ended,	  or	  their	  IEPs	  had	  just	  been	  developed).	  As	  noted	  in	  the	   previous	  Monitor’s	  Report,	  DYS	  has	  a	  dependable	  procedure	  for	  ensuring	   that	  progress	  reports	  are	  issued	  each	  grading	  period.	  Further,	  the	   content	  of	  the	  progress	  reports	  continues	  to	  provide	  tangible,	   meaningful	  assessments	  of	  the	  extent	  to	  which	  students	  have	  acquired	   the	  skills	  needed	  to	  progress	  through	  the	  curriculum.	  	  	   	   Most	  of	  the	  15	  progress	  reports	  offered	  detailed,	  comprehensive	   descriptions	  of	  students’	  progress	  on	  behavior,	  academic	  and	  transition	   goals.	  Most	  flowed	  logically	  from	  the	  goal,	  to	  the	  assessment	   information,	  to	  a	  conclusion	  about	  the	  extent	  to	  which	  the	  student	  was	  

	  

63.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 64 of 67 PAGEID #: 2558

Recommendations	   Sources	  of	   Information	  
	   	  

progressing.	  The	  best	  of	  the	  reports	  offered	  both	  specific	  assessments	   (e.g.,	  “In	  a	  108	  word	  essay,	  there	  were	  10	  capitalization	  errors	  and	  half	  a	   dozen	  punctuation	  errors…”)	  and	  general	  conclusions	  about	  the	   student’s	  progress	  (e.g.,	  “While	  he	  can	  express	  his	  thoughts	  fairly	  clearly	   in	  writing,	  it	  is	  full	  of	  errors	  and	  lacks	  proper	  structure.”).	   	   Occasionally,	  specific	  objectives	  were	  listed	  (e.g.,	  remain	  in	  the	   designated	  area,	  complete	  assignments,	  respect	  personal	  space),	  but	   only	  a	  general	  indicator	  of	  progress	  was	  given	  (e.g.,	  “the	  youth	  received	  8	   YBIRs.”).	  While	  this	  may	  be	  a	  good	  starting	  place,	  the	  assessment	  of	   progress	  would	  be	  more	  precise	  if	  the	  teacher	  discussed	  the	  nature	  of	   those	  8	  YBIRs	  and	  their	  relationship	  to	  the	  objectives.	  Similarly,	  a	  couple	   of	  reports	  contained	  reasonable	  goals	  (e.g.,	  “Explore	  job	  opportunities”)	   but	  contained	  assessments	  that	  were	  non-­‐responsive	  (e.g.,	  “student	  is	   passing	  all	  classes…studying	  for	  the	  GED…had	  8	  unexcused	  absences”).	   These	  examples	  refer	  to	  a	  very	  small	  minority	  of	  IEP	  Progress	  Reports— most	  of	  those	  reviewed	  gave	  sufficient	  information	  about	  the	  youth’s	   classroom	  performance.	  	   	   Together,	  the	  IEPs,	  goals	  and	  objectives	  and	  progress	  reports	  document	   the	  planning	  and	  delivery	  of	  special	  education	  services	  that	  are	   responsive	  to	  individual	  student’s	  needs.	  Most	  importantly,	  the	  progress	   reports	  reveal	  that	  most	  of	  Scioto’s	  students	  are	  making	  progress	  toward	   their	  behavior,	  academic	  and	  transition	  goals	  via	  the	  services	  they	   receive	  in	  the	  special	  education	  program.	  	  	  
The	  State	  remains	  in	  substantial	  compliance	  with	  this	  provision.	  	  	  
• Oral	  presentation	  and	  underlying	  documentation	  for	  provision	   III.E.7,	  prepared	  at	  my	  request	  
• DYS	  Education	  Quality	  Assurance	  materials,	  January	  through	   March	  2013	  
• Review	  of	  the	  n=10	  IEPs	  development	  most	  recently	  at	  Scioto	   (53%	  of	  the	  current	  special	  education	  population)	  
• Review	  15	  Progress	  Reports	  from	  the	  January-­‐March	  2013	   grading	  period	  	  
	  

	  

64.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 65 of 67 PAGEID #: 2559

	  
III.E.8	  Vocational	  Education.	  The	  State	  shall	  provide	  appropriate	  vocational	  services	  that	  are	   required	  transition	  services	  for	  disabled	  youth	  under	  the	  IDEA.	  	  

Compliance	  Rating	   Substantial	  Compliance	  

Self	  Assessment	  

Although	  vocational	  eligibility	  criteria	  normally	  require	  students	  to	  be	   either	  Juniors	  or	  Seniors	  (by	  credit),	  Scioto	  obtained	  a	  waiver	  from	  the	   ODE	  to	  serve	  a	  larger	  segment	  of	  its	  student	  population.	  Many	  of	  Scioto’s	   9th	  and	  10th	  graders	  are	  between	  17	  and	  19	  years	  old,	  are	  behind	  in	   credits	  and	  may	  not	  graduate.	  They	  would	  benefit	  greatly	  from	   opportunities	  to	  develop	  vocational	  skills	  and	  thus	  the	  ODE	  granted	  the	   facility	  the	  flexibility	  to	  allow	  such	  youth	  to	  participate	  in	  the	   programming.	  	   	   In	  its	  self-­‐assessment,	  the	  State	  discussed	  data	  on	  student	  enrollment	  in	   the	  three	  currently	  available	  vocational	  classes.	  As	  of	  April	  22,	  2013,	   there	  were	  47	  youth	  on	  the	  school	  roster.	  Ten	  of	  these	  were	  graduates,	   and	  ten	  were	  housed	  on	  the	  PROGRESS	  Unit,	  leaving	  27	  students	  in	  the	   general	  population.	  Of	  these:	  
• 7	  students	  (26%)	  were	  enrolled	  in	  Administrative	  Office	   Technology	  (a	  course	  that	  teaches	  students	  how	  to	  use	  various	   computer	  applications	  to	  prepare	  them	  for	  clerical,	  data	  entry,	   graphics,	  or	  other	  office-­‐based	  jobs);	  
• 5	  students	  (19%)	  were	  enrolled	  in	  Career-­‐Based	  Intervention	   (i.e.,	  work-­‐based	  learning,	  student	  earns	  credit);	  and	  	  
• 7	  students	  (26%)	  were	  enrolled	  in	  Transition	  Skills	  (students	  must	   take	  this	  course	  prior	  to	  release;	  includes	  job	  skills,	  resume	   building,	  interview	  skills).	  
Overall,	  71%	  of	  the	  students	  in	  the	  general	  population	  were	  involved	  in	   vocational	  courses,	  along	  with	  one	  or	  two	  graduates	  who	  were	  simply	   interested	  in	  the	  course	  offerings.	  Even	  with	  the	  expansion	  of	  the	   “eligibility	  criteria,”	  each	  of	  the	  three	  courses	  has	  sufficient	  capacity	  to	   serve	  significantly	  more	  students	  if	  needed.	  	   	   The	  Ohio	  DYS	  vocational	  programs	  were	  audited	  twice	  during	  the	   previous	  monitoring	  period.	  First,	  the	  ODE	  Office	  for	  Exceptional	  Children	   audited	  DYS’s	  special	  education	  program.	  IDEA	  requires	  the	  IEPs	  for	   students	  age	  14	  and	  older	  to	  include	  a	  Transition	  Plan	  to	  ensure	  that	  the	   school	  delivers	  services	  in	  preparation	  for	  life	  after	  graduation	  (and,	  in	   this	  case,	  after	  they	  return	  to	  the	  community).	  The	  audit	  found	  Scioto	  to	   be	  in	  compliance	  with	  the	  standard	  related	  to	  Transition	  Planning	  (SPP	   Indicator	  20	  for	  Secondary	  Transition	  Plans).	  Specifically,	  ODE	  found	  that	   Scioto’s	  plans	  “prescribed	  reasonable	  services	  to	  meet	  post-­‐secondary	   goals.”	  In	  other	  words,	  Scioto	  youth	  have	  access	  to	  courses	  that	  address	   their	  pursuits	  after	  high	  school.	  	   	   In	  addition,	  ODE’s	  Office	  of	  Career-­‐Technical	  Education	  conducted	  a	  

	  

65.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 66 of 67 PAGEID #: 2560

Steps	  Taken	  to	   Assess	  Compliance	  

comprehensive	  review	  of	  all	  career-­‐technical	  education	  programs	  offered	   at	  Scioto.	  Through	  teacher	  surveys,	  document	  review	  and	  on-­‐site	   program	  observations,	  the	  audit	  noted	  significant	  improvement	  in	  the	   participation	  rates	  in	  Scioto’s	  vocational	  programs	  (mirroring	  the	   Monitor’s	  findings	  discussed	  below).	  In	  addition,	  the	  audit	  noted	  that	   vocational	  textbooks	  were	  current	  and	  that	  supplies	  and	  facilities	  were	   adequate.	  	   	   The	  report’s	  Opportunities	  for	  Improvement	  included	  a	  variety	  of	   suggestions	  to	  improve	  the	  administration	  of	  the	  programs	  (e.g.,	   involving	  Central	  Office	  in	  vocational	  teacher	  hiring;	  improving	   communication)	  or	  to	  enrich	  the	  curriculum	  delivery	  (e.g.,	  developing	  a	   method	  for	  internet	  access	  with	  appropriate	  firewalls;	  emphasizing	   employability	  skills	  in	  all	  courses).	  The	  audit	  also	  recommended	  that	  the	   DYS	  formalize	  student’s	  course	  completion	  via	  industry-­‐based	   credentialing	  tests	  and	  formal	  graduation	  ceremonies.	  Notably,	  the	  ODE	   did	  not	  require	  or	  advise	  any	  modifications	  to	  the	  course	  offerings,	   apparently	  finding	  they	  were	  adequate	  to	  meet	  the	  needs	  of	  students.	  	  
The	  State	  has	  continued	  its	  efforts	  to	  increase	  the	  proportion	  of	  youth	   who	  are	  engaged	  in	  vocational	  programming.	  All	  students	  in	  the	  general	   population	  have	  the	  opportunity	  to	  participate	  in	  vocational	  programs;	   however,	  some	  students	  choose	  to	  focus	  on	  college	  prep	  materials	  and	   may	  not	  choose	  to	  take	  vocational	  courses	  as	  a	  result.	  Some	  of	  Scioto’s	   students	  simply	  are	  not	  eligible	  (because	  they	  are	  too	  young	  and	  are	  on	   track	  to	  graduate).	  Further,	  a	  significant	  portion	  of	  Scioto’s	  students	  is	   housed	  on	  the	  PROGRESS	  Unit	  (i.e.,	  21%	  of	  the	  students	  included	  in	  this	   review).	  These	  students	  do	  not	  have	  access	  to	  the	  AOT	  classroom	  and	  are	   not	  permitted	  to	  have	  jobs	  (CBI).	  However,	  once	  they	  are	  transferred	  to	   the	  Transition	  Unit,	  where	  they	  attend	  school	  with	  the	  general	   population,	  they	  are	  enrolled	  in	  the	  courses	  they	  need.	  The	  State	   provided	  documentation	  showing	  such	  enrollments	  for	  two	  youth	  who	   recently	  transferred	  from	  the	  PU.	  All	  youth	  take	  the	  Transition	  Course	  at	   some	  point	  3	  to	  6	  months	  before	  their	  scheduled	  release	  date.	  	  	   	   The	  Monitor	  has	  expressed	  a	  preference	  for	  hands-­‐on	  learning	   opportunities	  and	  the	  facility	  has	  been	  vigilant	  about	  identifying	  new	   opportunities.	  As	  noted	  in	  the	  Programming	  provision	  (III.F.1),	  an	  11-­‐ week	  Barbering	  class	  offering	  certification	  will	  soon	  be	  available.	  In	   addition,	  a	  few	  of	  the	  facility’s	  volunteers	  are	  employed	  in	  various	  trades	   (e.g.,	  construction,	  landscaping)	  and	  have	  agreed	  to	  provide	  hands-­‐on	   programming	  to	  students.	  Currently,	  8	  students	  are	  formulating	  ideas	  for	   a	  cabinet-­‐making	  project.	  	   	   In	  summary,	  the	  opportunities	  for	  students	  to	  develop	  job	  and	   employability	  skills	  are	  far	  greater	  than	  they	  were	  at	  the	  time	  Stipulation	   was	  signed.	  Scioto’s	  available	  services	  can	  fully	  address	  the	  transition	   needs	  and	  services	  prescribed	  in	  Scioto’s	  IEPs	  which	  include	  completing	  

	  

66.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 67 of 67 PAGEID #: 2561

Recommendations	   Sources	  of	   Information	  
	  

career	  interest	  inventories,	  conducting	  job	  opportunity	  searches,	   developing	  employability	  skills,	  and	  compiling	  transition	  portfolios.	  
The	  State	  remains	  in	  substantial	  compliance	  with	  this	  provision.	  	  
• Oral	  presentation	  and	  underlying	  documentation	  for	  provision	   III.E.8,	  prepared	  at	  my	  request	  
• Student	  rosters	  for	  each	  of	  the	  three	  vocational	  courses,	  January-­‐ March	  2013	  grading	  period	  
• Documentation	  of	  vocational	  enrollment	  for	  two	  former	  PU	   students	  
• ODE	  Office	  of	  Exceptional	  Children	  audit	  report,	  November,	  2012	   • ODE	  Office	  of	  Career-­‐Technical	  Education	  audit	  report,	  
November	  2012	  

	  

67.	  

 
 Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 1 of 34 PAGEID #: 2562

	   	   	   	   	   	   	   	  
PROGRESS	  Unit	  at	  the	  Scioto	  Juvenile	  Correctional	  Facility	  
1st	  Status	  Report	   Civil	  Actions	  2:08-­‐cv-­‐00475	  and	  2:04-­‐cv-­‐01206	  
	   	   	   	   	   Submitted	  by:	   	   Kelly	  Dedel,	  Ph.D.	   One	  in	  37	  Research,	  Inc.	   16	  Rock	  Street	  	  Cody,	  WY	  	  82414	   (503)799-­‐0915	  	  kelly.dedel@gmail.com	   	   Daphne	  Glindmeyer,	  M.D.	   229	  Bellemeade	  Boulevard	  Suite	  420	   Gretna,	  Louisiana	  70056	   (504)666-­‐1600	  	  	  dglindmeyer@gmail.com	  	   	   	   Reviewed	  by:	   	   Will	  Harrell,	  J.D.,	  LL.M	   1221	  Kerlerec	   New	  Orleans,	  LA	  	  70117	   (512)695-­‐7519	  	  shmonitor.harrell@gmail.com	  	   	   Terry	  Schuster,	  J.D.	   1037	  Neil	  Ave.,	  Apt.	  C	   Columbus,	  Oh	  43201	   (512)468-­‐4486	  	  shmonitor.schuster@gmail.com	  	   	   	   	   Draft	  submitted	  March	  15,	  2013	   Final	  submitted	  March	  27,	  2013	   	  

	  

1.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 2 of 34 PAGEID #: 2563

TABLE	  OF	  CONTENTS	   	   	  
Introduction	  .................................................................................................................................................	 3  	  	  

Purpose	  and	  Structure	  of	  the	  Report	.   ..........................................................................................................	 3  	  

	  
II.14	  Policies,	  Procedures	  and	  Handbooks	  ...................................................................................................	 7  	  

	  
II.9	  Admissions	  Screening	.  ............................................................................................................................	 8  	  

	  
II.10	  Daily	  Schedule	 .  ...................................................................................................................................	 1  1	  

Out	  of	  Room	  Time	.   ........................................................................................................................	 1  1	  

Daily	  Activities	.   ..............................................................................................................................	 1  2	  

Graduate	  Programming	.  ................................................................................................................	 1  3	  

	  
II.11	  Staffing	 .  ..............................................................................................................................................	 1  5	  

Staff	  Numbers	  and	  Training	  ..........................................................................................................	 1  5	  

Impact	  on	  Safety	  ...........................................................................................................................	 1  7	  

	  
II.12	  Treatment	  Planning	.  ...........................................................................................................................	 1  9	  

Clinical	  Staffing	.   .............................................................................................................................	 1  9	  

Treatment	  Planning	.  ......................................................................................................................	 1  9	  

Progress	  Reporting	  and	  Promotion	.   ..............................................................................................	 2  2	  

InterDisciplinary	  Team	  (IDT)	.  .........................................................................................................	 2  3	  

IDT	  Substance	.  ...............................................................................................................................	 2  4	  

Length	  of	  Stay	  ...............................................................................................................................	 2  5	  

Central	  Office	  Review	  Board	  (CORB)	  Composition	  and	  Timelines	  ................................................	 2  7	  

CORB	  Substance	 .  ...........................................................................................................................	 2  8	  

	  
II.13	  Phase	  Demotions	  ...............................................................................................................................	 3  0	  

	  
III.C.3	  Quality	  Assurance	  ............................................................................................................................	 3  2	  

	  

	  

	  

2.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 3 of 34 PAGEID #: 2564

INTRODUCTION	  
	   In	  October	  and	  November	  2012,	  pursuant	  to	  the	  United	  States	  v.	  Ohio	  and	  S.H.	  v.	  Reed	   Stipulations,	  the	  U.S.	  Department	  of	  Justice	  (DOJ)	  and	  the	  S.H.	  plaintiff	  class	  each	  initiated	  a	   process	  for	  dispute	  resolution	  to	  address	  concerns	  regarding	  the	  purpose,	  structure,	  and	   operation	  of	  the	  PROGRESS	  and	  Transition	  Units	  at	  the	  Scioto	  Juvenile	  Correctional	  Facility	  (the	   PU).	  	  The	  Monitors	  and	  Plaintiffs	  in	  both	  cases	  have	  expressed	  on-­‐going	  concerns	  about	  DYS’	   operation	  of	  special	  management	  units	  since	  at	  least	  2007.	  The	  Ohio	  Department	  of	  Youth	   Services	  (DYS)	  and	  DOJ	  negotiated	  and	  agreed	  upon	  a	  proposed	  Consent	  Order,	  filed	  with	  the	   Court	  on	  December	  19,	  2012.	  	  The	  Court	  did	  not	  sign	  the	  Order	  until	  January	  18,	  2013	  when	  it	   was	  also	  incorporated	  into	  a	  broader	  settlement	  between	  DYS	  and	  the	  S.H.	  plaintiff	  class.	  	  The	   Consent	  Order	  sets	  standards	  related	  to	  PU	  policies,	  admissions	  screening,	  programming,	  out-­‐ of-­‐room	  time,	  staffing,	  treatment	  planning,	  length	  of	  stay,	  and	  promotion	  and	  demotion	   between	  phases.	  	  The	  S.H.	  settlement	  supplements	  the	  Consent	  Order	  with	  additional	  standards	   related	  to	  PU	  behavioral	  health	  staffing	  and	  quality	  assurance.	  	  	   	  
PURPOSE	  AND	  STRUCTURE	  OF	  THE	  REPORT	  
	   Although	  the	  DOJ	  monitoring	  team	  issues	  reports	  every	  six	  months,	  Drs.	  Dedel	  and	  Glindmeyer	   feel	  strongly	  that	  progress	  can	  be	  facilitated	  by	  more	  frequent	  feedback	  to	  the	  Parties.	  The	  PU	   program	  is	  changing	  quickly,	  and	  more	  frequent	  feedback	  will	  both	  recognize	  the	  State’s	   progress	  and	  also	  provide	  sufficient	  guidance	  to	  keep	  the	  program	  development	  on	  track	  with	   what	  is	  required	  in	  the	  Order.	  The	  Parties	  and	  Monitors	  agreed	  that	  Drs.	  Dedel	  and	  Glindmeyer	   would	  write	  this	  first	  status	  report,	  covering	  the	  period	  January	  18,	  2013	  (the	  date	  the	  order	  was	   signed)	  through	  February	  28,	  2013.	  While	  January	  18,	  2013	  is	  the	  official	  “start	  date,”	  it	  is	   important	  to	  recognize	  that	  the	  PU	  reform	  effort	  predates	  the	  Order.	  The	  State,	  DOJ	  and	   Monitors	  began	  sketching	  out	  a	  new	  vision	  for	  the	  PU	  in	  early	  November	  2012,	  and	  the	  State	   began	  submitting	  data	  documenting	  these	  changes	  in	  late	  November	  2012.	  Status	  Reports	  will	   be	  issued	  every	  three	  months	  hereafter.	  The	  next	  one	  will	  cover	  the	  period	  March	  1	  through	   May	  31,	  2013	  and	  will	  be	  issued	  sometime	  in	  June	  2013.	  	   	   In	  order	  to	  facilitate	  progress,	  this	  report	  is	  formatted	  as	  a	  Quality	  Assurance	  (QA)	  report.	  When	   the	  Order	  was	  incorporated	  into	  the	  S.H.	  settlement,	  a	  requirement	  for	  a	  QA	  plan	  to	  be	   developed	  and	  implemented	  was	  imposed.	  While	  there	  are	  many	  ways	  to	  accomplish	  this	  task,	   Drs.	  Dedel	  and	  Glindmeyer	  believe	  that	  structuring	  feedback	  using	  a	  QA	  model	  will	  provide	  a	   clearer	  sense	  of	  our	  expectations	  of	  the	  State	  toward	  this	  end,	  and	  will	  advance	  the	  State’s	   understanding	  of	  Quality	  Assurance	  and	  Quality	  Improvement	  (QA/QI)	  by	  using	  concrete,	  real-­‐ time	  examples.	  We	  hope	  that	  this	  format	  is	  helpful	  to	  the	  Plaintiffs	  in	  their	  effort	  to	  assess	  the	   current	  conditions	  of	  the	  PU	  and	  to	  the	  State	  in	  their	  efforts	  to	  adopt	  a	  QA/QI	  system	  that	   creates	  the	  internal	  capacity	  to	  identify	  and	  solve	  problems.	  	  	   	   Technical	  assistance	  notes	  are	  offered	  throughout	  the	  report.	  These	  are	  designed	  to	  improve	   the	  DYS’	  ability	  to	  monitor	  program	  performance	  (and,	  concurrently,	  assist	  the	  Monitors	  in	   providing	  a	  comprehensive	  review	  of	  the	  program).	  Generally,	  these	  issues	  cluster	  around	  data	   collection	  issues	  and	  documentation	  needed	  to	  substantiate	  program	  performance.	  	   	  

	  

3.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 4 of 34 PAGEID #: 2565

For	  each	  of	  the	  seven	  substantive	  areas	  in	  the	  Order	  [identified	  by	  the	  Consent	  Order’s	   paragraph	  number	  in	  brackets],	  the	  report	  includes	  the	  following:	   	  
• Standard:	  A	  statement	  of	  what	  the	  State	  is	  trying	  to	  achieve	  in	  the	  particular	  substantive	   area.	  Multiple	  standards	  may	  apply	  to	  a	  single	  substantive	  area.	  The	  standards	  are	   based	  on	  the	  requirements	  of	  the	  Court	  Order.	  However,	  they	  are	  a	  statement	  of	  what	   “should	  be,”	  not	  necessarily	  a	  description	  of	  what	  currently	  exists	  at	  this	  point	  in	  time.	  	   	  
• Status:	  For	  the	  purpose	  of	  the	  status	  report,	  the	  Monitors	  use	  a	  two-­‐level	  system	  for	   each	  substantive	  area:	  the	  area	  is	  either	  in	  substantial	  compliance	  or	  it	  is	  not.	  [Once	  the	   DYS	  adopts	  a	  comprehensive	  QA	  program,	  it	  is	  encouraged	  to	  adopt	  non-­‐legal	  language	   for	  these	  categories.	  For	  example,	  “Exemplary	  Performance,”	  “Adequate	  Performance”	   and	  “Performance	  Needs	  Remediation.”	  Further,	  under	  the	  QA	  program,	  each	  standard	   within	  the	  substantive	  area	  should	  be	  rated	  individually	  to	  provide	  a	  more	  precise	   measure	  of	  the	  PU’s	  performance.]	  	  
	   • Methodology:	  The	  data	  that	  should	  be	  used	  to	  assess	  performance	  toward	  the	  standard.	   In	  some	  cases,	  this	  goes	  beyond	  the	  data	  that	  have	  been	  sent	  to	  the	  Monitors.	  
	  	   • Analysis	  and	  Interpretation:	  A	  presentation	  of	  the	  data	  collected	  for	  the	  timeframe,	   January	  18-­‐February	  28,	  2013,	  and	  an	  interpretation	  of	  what	  it	  says	  about	  the	  extent	  to	   which	  the	  standard	  is	  being	  achieved.	  [At	  times,	  this	  report	  relies	  on	  older	  data	  to	   provide	  a	  better	  context	  for	  the	  discussion	  or	  to	  better	  illustrate	  patterns	  that	  have	   emerged.]	  
	   • Recommendations:	  Statements	  regarding	  what	  must	  occur	  in	  order	  for	  the	  standard	  to	   be	  achieved.	  The	  Monitors	  also	  provide	  technical	  assistance	  throughout	  this	  document,	   intended	  to	  solidify	  quality	  assurance	  procedures	  or	  ensure	  the	  integrity	  of	  the	  program	   design.	  	   	  
The	  recommendations	  refer	  to	  a	  Quality	  Improvement	  Plan	  (QIP).	  This	  structure	  is	  utilized	  to	   shift	  responsibility	  for	  the	  ongoing	  monitoring	  of	  the	  PU	  to	  the	  DYS,	  in	  order	  to	  make	  external	   monitoring	  unnecessary.	  A	  QIP	  is	  recommended	  for	  each	  area	  in	  which	  the	  Monitors	  have	   identified	  areas	  of	  concern.	  A	  multidisciplinary	  team	  should	  be	  involved	  in	  analyzing	  the	   problems	  to	  understand	  the	  reasons	  they	  occur,	  and	  then	  drafting	  a	  QIP	  to	  address	  the	   underlying	  causes	  of	  the	  problem.	  	   	   Subsequent	  status	  reports	  will	  ask	  for	  the	  State’s	  analysis	  and	  interpretation	  of	  current	  data,	   which	  will	  be	  validated	  by	  the	  Monitors.	  From	  there,	  the	  Monitors	  will	  review	  the	  progress	   made	  on	  QIPs	  developed	  in	  response	  to	  this	  report.	  As	  substantial	  compliance	  is	  reached	  with	  all	   of	  the	  standards,	  the	  State	  should	  begin	  to	  produce	  both	  the	  QA	  and	  QI	  portions	  of	  the	  report.	  	   	   Although	  DYS	  is	  not	  yet	  in	  substantial	  compliance	  with	  any	  of	  the	  standards,	  it	  is	  essential	  to	   recognize	  that	  less	  than	  two	  months	  have	  elapsed	  since	  the	  Order	  was	  signed.	  In	  several	  cases,	   DYS	  has	  addressed	  most	  of	  the	  requirements	  of	  the	  subsection	  and	  must	  refine	  only	  a	  small	  part	   of	  the	  required	  procedures.	  	   	  

	  

4.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 5 of 34 PAGEID #: 2566

The	  Order	  is	  very	  specific.	  Dissecting	  the	  PU	  at	  this	  level	  risks	  “missing	  the	  forest	  for	  the	  trees.”	   The	  PU	  is	  a	  radically	  different	  program	  than	  it	  was	  a	  year	  ago,	  when	  the	  Plaintiffs	  for	  both	   lawsuits	  raised	  serious	  concerns	  about	  the	  amount	  of	  isolation	  and	  lack	  of	  treatment	  that	   characterized	  the	  youths’	  experience.	  Today,	  all	  youth	  on	  the	  PU	  are	  out	  of	  their	  rooms	  during	   waking	  hours	  and	  are	  engaged	  in	  a	  full	  range	  of	  education	  and	  rehabilitative	  programming.	  This	   change	  represents	  a	  massive	  cultural	  shift	  for	  DYS	  and	  the	  PU	  staff.	  From	  here,	  DYS	  must	  tie	  up	   some	  procedural	  loose	  ends	  and	  must	  advance	  the	  substance	  and	  quality	  of	  the	  treatment	   offered	  to	  youth	  on	  the	  PU	  so	  that	  they	  can	  return	  to	  the	  general	  population	  more	  quickly.	  Even	   in	  the	  short	  time	  since	  the	  PU	  reform	  effort	  began,	  the	  DYS	  has	  made	  significant	  positive	   changes	  to	  the	  quality	  of	  the	  youth’s	  living	  conditions.	   	   Furthermore,	  DYS	  has	  been	  dutiful	  in	  its	  submission	  of	  required	  data	  and	  information	  and	  has	   supported	  the	  monitoring	  team’s	  efforts	  to	  obtain	  current,	  accurate	  descriptions	  of	  the	  PU’s	   functioning.	  In	  late	  February	  2013,	  the	  S.H.	  Lead	  Monitor	  and	  his	  Assistant	  made	  an	   unannounced	  visit	  to	  the	  PU.	  DYS	  cooperated	  fully	  and	  the	  Monitors’	  observations	  largely	   validated	  the	  data	  that	  DYS	  had	  been	  submitting.	  Not	  only	  were	  all	  youth	  out	  of	  their	  rooms	   during	  waking	  hours,	  but	  they	  also	  remained	  out	  of	  their	  rooms	  even	  after	  a	  youth	  engaged	  in	  a	   serious	  incident.	  Such	  observations	  are	  very	  encouraging.	  	   	   While	  there	  has	  been	  significant	  progress,	  much	  work	  remains.	  One	  of	  the	  key	  findings	  of	  this	   status	  report	  is	  the	  frequency	  with	  which	  youth	  are	  recycled	  back	  through	  the	  phases,	  resulting	   in	  prolonged	  lengths	  of	  stay	  on	  the	  PU	  for	  most	  youth.	  While	  most	  of	  the	  procedures	  designed	   to	  ensure	  prompt	  promotion	  have	  been	  properly	  implemented,	  many	  youth	  continue	  to	  engage	   in	  problematic	  behaviors	  even	  after	  they	  are	  promoted	  toward	  the	  general	  population.	  While	   some	  of	  these	  youth	  may	  persist	  in	  problem	  behaviors	  no	  matter	  what	  treatment	  interventions	   and	  behavior	  management	  strategies	  are	  attempted,	  the	  deficits	  in	  treatment	  planning	  suggest	   that	  improvements	  in	  this	  area	  may	  produce	  better	  outcomes,	  and	  shorter	  lengths	  of	  stay,	  for	   many	  of	  the	  PU	  youth.	  DYS	  is	  strongly	  encouraged	  to	  focus	  on	  the	  reasons	  that	  youth	  are	  not	   moving	  through	  the	  program	  back	  to	  the	  general	  population	  within	  the	  basic	  prescribed	   timelines	  (i.e.,	  not	  the	  behavior,	  but	  rather	  the	  skill	  deficits).	  	  Questions	  about	  whether	  youth	   are	  receiving	  the	  type	  and	  intensity	  of	  treatment	  prescribed	  by	  their	  treatment	  plans	  are	  also	   still	  pending,	  given	  the	  difficulties	  experienced	  in	  matching	  current	  ITPs	  to	  the	  CaseNotes	  data.	  	   	   The	  monitoring	  team	  sincerely	  hopes	  that	  this	  report	  brings	  greater	  clarity	  to	  the	  work	  that	  lies	   ahead	  and	  provides	  a	  useful	  template	  for	  the	  DYS	  Quality	  Assurance/Quality	  Improvement	   program.	  	   	   	  
Technical	  Assistance	  Note:	  Data	  Analysis	  and	  Interpretation	  
The	  Court	  Order	  requires	  DYS	  to	  provide	  a	  broad	  range	  of	  data	  to	  substantiate	  compliance	  with	  the	   various	  requirements.	  Simply	  providing	  the	  data	  is	  only	  the	  first	  step—these	  data	  must	  demonstrate	  that	   the	  PU	  is	  functioning	  in	  a	  manner	  that	  cures	  concerns	  about	  the	  program’s	  design,	  the	  treatment	  and	   services	  provided	  to	  youth,	  whether	  youth	  develop	  the	  skills	  necessary	  to	  meet	  behavioral	  expectations	   and	  treatment	  goals,	  and	  the	  youth’s	  length	  of	  stay	  on	  the	  unit.	  In	  order	  to	  do	  so,	  the	  data	  must	  be	  specific	   and	  must	  be	  structured	  to	  reveal	  the	  dynamics	  of	  the	  care	  provided	  to	  youth.	   	   Toward	  that	  end,	  the	  Monitors	  provided	  feedback	  to	  DYS	  designed	  to	  improve	  the	  quality	  of	  the	  data.	  DYS	   began	  submitting	  data	  to	  the	  Monitors	  well	  before	  the	  Order	  was	  signed.	  Since	  early	  December	  2012,	  the	  

	  

5.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 6 of 34 PAGEID #: 2567

Monitors	  provided	  feedback	  to	  address	  the	  following	  issues:	   • Categorization	  and	  completeness	  of	  data	  contained	  in	  the	  CaseNotes	  database	  to	  accurately	   depict	  the	  amount	  of	  CBT	  group	  therapy,	  other	  treatment,	  and	  various	  contacts	  with	  youth.	   • Accuracy	  of	  the	  data	  contained	  in	  the	  Youth	  Activity	  Tracking	  data	  to	  ensure	  that	  it	  can	  be	  used	   to	  troubleshoot	  issues	  that	  became	  evident	  with	  leisure	  time,	  delivery	  of	  MAV	  groups	  by	  the	   Youth	  Specialists,	  meals	  being	  eaten	  in	  rooms,	  and	  opportunities	  for	  recreation.	  	   • Methods	  for	  validating	  the	  activities	  categorized	  as	  “Structured	  Programming.”	   • Functioning	  of	  the	  Central	  Office	  Review	  Board.	   • Tracking	  youth’s	  progress	  toward	  behavioral	  expectations	  and	  treatment	  goals	  and	  how	  these	   could	  be	  captured	  in	  the	  IDT	  minutes	  rather	  than	  continuing	  to	  utilize	  the	  Behavioral	  Tracking	   Sheets	  that	  were	  originally	  designed	  for	  this	  purpose.	  	   • Capturing	  the	  youth’s	  length	  of	  stay	  on	  each	  phase,	  and	  cycling	  back	  through	  the	  phases	  when	  it	   occurred.	  	   • Analyzing	  and	  interpreting	  the	  data	  in-­‐house	  so	  that	  program	  modifications	  can	  be	  made	  more	   quickly	  and	  without	  needing	  the	  Monitors	  to	  direct	  these	  improvements.	  	  
	   In	  mid-­‐February,	  DYS	  requested	  a	  hiatus	  in	  providing	  data	  so	  that	  the	  bugs	  in	  the	  various	  databases	  could	   be	  addressed	  and	  an	  internal	  effort	  to	  review	  and	  interpret	  data	  could	  be	  launched.	  As	  of	  the	  writing	  of	   this	  report,	  fixes	  to	  the	  databases	  are	  underway	  but	  the	  facility	  has	  yet	  to	  undertake	  the	  task	  of	  analyzing	   and	  interpreting	  the	  large	  volume	  of	  data	  submitted.	  The	  Monitors	  requested	  that	  the	  data	  submission	   resume	  in	  order	  to	  ensure	  that	  current	  data	  are	  immediately	  available	  and	  to	  ensure	  that	  progress	  toward	   meeting	  the	  performance	  objectives	  envisioned	  in	  the	  Order	  does	  not	  stall.	  All	  historical	  data,	  albeit	   unanalyzed	  was	  submitted	  prior	  to	  the	  drafting	  of	  this	  report.	  Hopefully,	  the	  format	  of	  this	  report	  will	  help	   DYS	  to	  conceptualize	  the	  type	  of	  internal	  review	  that	  is	  still	  needed	  to	  demonstrate	  that	  this	  type	  of	   intensive,	  external	  oversight	  is	  no	  longer	  necessary.	  	  

	  

	  

	  

	  

	  

	  

6.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 7 of 34 PAGEID #: 2568

[II.14]	  	  Policies,	  Procedures	  and	  Handbooks	  [monitored	  by	  Dr.	  Dedel]	  

Status:	  Not	  in	  Substantial	  Compliance	  

	  

(1)	  Standard:	  Policies	  and	  Procedures	  

Policies	  and	  procedural	  manuals	  are	  current,	  accurately	  describe	  the	  operation	  of	  the	  PU,	  and	  

provide	  guidance	  to	  staff	  in	  implementing	  the	  standards	  for	  the	  Unit.	  The	  Youth	  Handbook	  

accurately	  describes	  the	  operation	  of	  the	  PU	  so	  youth	  know	  what	  to	  expect	  from	  the	  program	  

and	  what	  is	  expected	  of	  them.	  	  

	  

Methodology.	  	  

The	  following	  information	  is	  used	  to	  determine	  compliance	  with	  the	  standard:	  

• PU	  Policy	  	  

• PU	  Procedural	  Manuals	  

• PU	  Youth	  Handbook	  

	  

Analysis	  and	  Interpretation.	  	  

The	  Court	  Order	  grants	  DYS	  60	  days	  from	  the	  day	  of	  signing	  to	  submit	  policies,	  procedures	  and	  

Handbooks	  that	  accurately	  describe	  the	  operation	  of	  the	  PU.	  DYS	  submitted	  these	  materials	  to	  

the	  Monitor	  within	  the	  required	  timelines.	  Because	  the	  timeline	  fell	  outside	  of	  the	  review	  period	  

and	  because	  both	  documents	  will	  require	  some	  revision	  to	  ensure	  they	  capture	  all	  of	  the	  

information	  required	  by	  the	  Court	  Order,	  the	  adequacy	  of	  the	  documents	  will	  be	  discussed	  in	  

the	  next	  Status	  Report.	  	  

	  

Recommendations.	  	  

In	  order	  to	  meet	  the	  standard	  associated	  with	  Policies	  and	  Procedures,	  the	  DYS	  should	  develop	  a	  

Quality	  Improvement	  Plan	  to	  address	  the	  following	  issues:	  

1. Creating	  written	  policies,	  procedures	  and	  a	  Youth	  Handbook	  that	  accurately	  describe	  

the	  operation	  of	  the	  PU.	  Reviewing	  and	  revising	  the	  documents	  as	  needed	  to	  keep	  pace	  

with	  the	  evolution	  of	  the	  program.	  	  

	  	  

	  

	  

	  

	  

	  

7.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 8 of 34 PAGEID #: 2569

II.9	  	  Admission	  Screening	  [monitored	  by	  Dr.	  Glindmeyer]	   Status:	  Not	  in	  Substantial	  Compliance	  
	   (1)	  Standard:	  Admissions	  Screening.	  	   The	  PU	  accepts	  only	  those	  youth	  who	  can	  be	  reasonably	  expected	  to	  respond	  positively	  to	  the	   type	  of	  program	  and	  treatment	  services	  on	  the	  Unit.	  As	  such,	  their	  behavior	  and	  mental	  health	   history	  is	  reviewed	  to	  ensure	  that	  the	  behaviors	  are	  not	  the	  symptoms	  of	  mental	  illness	   (including	  undiagnosed	  or	  untreated	  mental	  illness).	  	  Youth	  with	  the	  following	  DSM-­‐IV	  diagnoses	   or	  conditions	  are	  excluded	  from	  placement	  on	  the	  PU:	  
• Thought	  Disorders	   • Mood	  Disorders	   • Developmental	  Disorders	   • Recurring	  self-­‐injurious	  behavior	  or	  suicidal	  ideation.	   	   Methodology:	  The	  following	  information	  is	  used	  to	  determine	  compliance	  with	  the	  standard:	   • “Requests	  for	  PROGRESS	  Placement”	  table	   	   	  
Technical	  Assistance	  Note:	  Admissions	  Screening	  
The	  methodology	  for	  auditing	  the	  PU	  admissions	  process	  needs	  to	  be	  fortified	  in	  order	  to	  gain	  a	  more	   complete	  picture	  of	  the	  characteristics	  of	  youth	  who	  are	  admitted	  to	  the	  PU	  and	  the	  screening	  process	   itself	  (e.g.,	  whether	  the	  admissions	  protocol	  was	  followed,	  whether	  youth	  with	  disqualifying	  diagnoses	   were	  denied	  admission).	  This	  information	  would	  also	  be	  useful	  to	  determine	  whether	  certain	  diagnoses	   may	  be	  harbingers	  for	  poor	  adjustment	  to	  the	  PU.	  Future	  submissions	  to	  the	  Monitor	  should	  include:	  
• Notes	  from	  the	  Administrative	  Psychiatrists’	  documenting	  the	  pre-­‐admission	  review	   • Mental	  health	  files	  of	  youth	  who	  are	  admitted	  to	  the	  PU.	  [Note:	  During	  a	  conference	  call	  in	  
February	  2013,	  Dr.	  Glindmeyer	  requested	  mental	  health	  files	  for	  all	  youth	  admitted	  to	  the	  PU,	  but	   was	  directed	  to	  request	  them	  individually.	  Only	  three	  youth	  had	  been	  admitted	  at	  that	  point	  and	   so	  it	  was	  unclear	  why	  this	  request	  could	  not	  be	  fulfilled.]	   The	  DYS	  QA	  team	  should	  review	  these	  same	  documents,	  once	  comprehensive	  internal	  audits	  of	  the	  PU	  are	   established.	  	  
	   	   Analysis	  and	  Interpretation.	  	   The	  “Requests	  for	  PROGRESS	  Placement”	  grid	  included	  the	  following	  information:	  youth’s	  name;	   identification	  number;	  facility;	  date	  the	  PU	  packet	  was	  received;	  adjudicated	  offense;	  mental	   health	  caseload	  status;	  educational	  program	  (e.g.	  regular	  or	  special	  education);	  DSM	  diagnoses;	   reason	  for	  request	  for	  PU	  placement;	  outcome	  of	  request	  (e.g.	  either	  approved	  or	  denied);	  the	   rationale	  for	  the	  approval/denial	  of	  placement;	  and	  the	  date	  of	  transfer	  to	  the	  unit.	   	   Per	  a	  review	  of	  the	  grids	  for	  December	  2012	  and	  January	  2013,	  there	  were	  a	  total	  of	  five	  youth	   referred	  for	  PU	  placement.	  Of	  those	  five	  youth,	  two	  were	  declined	  for	  PU	  placement.	  The	  first,	   JH,	  was	  declined,	  as	  “youth	  had	  not	  been	  placed	  on	  any	  special	  management	  plans	  to	  address	   his	  behavior.”	  TH,	  the	  second	  youth,	  was	  declined	  as	  “the	  youth’s	  ITP	  had	  not	  been	  updated	  to	   reflect	  the	  youth’s	  current	  behaviors	  so	  that	  they	  could	  be	  addressed…the	  youth	  had	  not	  been	   placed	  on	  a	  behavior	  contract.”	  Both	  of	  these	  cases	  revealed	  the	  recognition	  of	  the	  need	  for	  the	  

	  

8.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 9 of 34 PAGEID #: 2570

implementation	  of	  intermediate	  steps	  to	  address	  the	  youth’s	  behavioral	  challenges	  prior	  to	   resorting	  to	  PU	  placement.	   	   Of	  the	  remaining	  three	  youth	  approved	  for	  PU	  placement,	  all	  had	  DSM-­‐IV-­‐TR	  diagnoses	  listed;	   however,	  only	  two	  youth	  were	  assigned	  to	  the	  mental	  health	  caseload.	  	  The	  third	  youth,	  KD,	  had	   diagnoses	  including	  ADHD	  and	  Borderline	  Intellectual	  Functioning.	  	  There	  was	  a	  notation	  of	   previous	  diagnoses	  including	  Conduct	  Disorder;	  Bipolar	  Mood	  Disorder,	  not	  otherwise	  specified;	   Alcohol	  Abuse;	  Cannabis	  Abuse;	  and	  Antisocial	  Personality	  Disorder.	  	  Given	  these	  significant	   mental	  health	  diagnoses,	  it	  would	  be	  expected	  that	  this	  youth	  would	  be	  assigned	  to	  the	  mental	   health	  caseload.	  	  It	  is	  also	  concerning	  that	  this	  youth	  had	  a	  previous	  diagnosis	  of	  a	  mood	   disorder,	  which	  would	  be	  an	  automatic	  exclusion	  to	  PU	  acceptance.	  	  It	  is	  recognized	  that	  this	   diagnosis	  may	  have	  been	  revised	  prior	  to	  his	  PU	  referral;	  however,	  a	  review	  of	  medical	  records	   would	  be	  necessary	  to	  determine	  this.	   	   There	  was	  a	  notation	  in	  the	  “Central	  Office	  Progress/Transition	  Unit	  Review	  Board”	   documentation	  dated	  1.30.13	  that	  youth	  KD	  “requested	  to	  see	  the	  psychiatrist	  and	  restart	  his	   medication.”	  It	  was	  noted	  that	  Depakote	  ER	  (a	  mood	  stabilizing	  medication)	  was	  prescribed,	   with	  the	  dosage	  increased	  on	  January	  23,	  2013	  to	  a	  total	  of	  1000	  mg	  daily.	  	  This	  document	   indicated	  that	  KD’s	  diagnosis	  included	  “rule	  out	  Bipolar	  Disorder,	  not	  otherwise	  specified;”	   however,	  the	  utilization	  of	  this	  medication	  was	  suspicious	  for	  an	  actual	  diagnosis	  of	  Bipolar	   Mood	  Disorder.	  There	  was	  also	  documentation	  of	  this	  youth	  engaging	  in	  assaultive	  behaviors	   and	  sexually	  inappropriate	  behaviors.	  Moreover,	  the	  document	  provided	  recommendations	  to	   the	  Interdisciplinary	  Team	  (IDT)	  which	  included,	  “the	  youth’s	  psychological	  services	  summary	   does	  not	  include	  a	  case	  formulation,	  treatment	  progress,	  or	  the	  youth’s	  response	  to	  treatment”	   indicating	  the	  likelihood	  that	  the	  youth’s	  diagnoses	  had	  not	  been	  formulated	  in	  a	  collaborative	   manner	  prior	  to	  his	  referral	  to	  the	  PU	  or	  for	  the	  period	  between	  his	  acceptance	  to	  the	  PU	  on	   12.31.12	  and	  the	  review	  board	  documentation	  dated	  1.30.13	  and	  signed	  2.5.13.	  	  Regardless,	  this	   youth’s	  record,	  inclusive	  of	  the	  documentation	  of	  the	  Administrative	  Psychiatrist’s	  review,	   should	  be	  reviewed	  closely	  given	  his	  admission	  to	  the	  PU	  with	  a	  potential	  mood	  disorder,	  which	   should	  have	  been	  ruled	  out	  prior	  to	  admission.	   	   Of	  the	  three	  youth	  accepted	  for	  the	  PU,	  two	  were	  receiving	  special	  education	  services.	  	  One	   youth,	  TB,	  was	  noted	  as	  receiving	  special	  education	  services	  due	  to	  “ED”	  indicating	  “emotional	   disturbance.”	  	  This	  youth	  also	  had	  mental	  health	  diagnoses	  including	  Cannabis	  Dependence;	   Oppositional	  Defiant	  Disorder;	  Conduct	  Disorder;	  and	  rule	  out	  Psychotic	  Disorder,	  not	  otherwise	   specified.	  	  This	  youth	  was	  accepted	  to	  the	  PU	  “due	  to	  the	  youth’s	  continued	  assaultive	  behaviors	   despite	  staff’s	  efforts.”	  	  This	  case	  is	  concerning	  as	  the	  potential	  presence	  of	  a	  thought	  disorder	  is	   an	  automatic	  exclusion	  to	  PU	  acceptance.	  	  At	  the	  time	  this	  report	  was	  authored,	  documentation	   indicated	  that	  this	  youth	  had	  transferred	  to	  the	  PU	  on	  2/1/13	  and	  remained	  on	  Phase	  1	  as	  of	   3/8/13.	  	  Over	  time,	  ODYS	  should	  monitor	  the	  length	  of	  stay	  on	  the	  phases	  for	  youth	  with	  mental	   health	  disorders.	  	  Regardless,	  this	  youth’s	  record,	  inclusive	  of	  the	  Administrative	  Psychiatrist’s	   review,	  should	  be	  reviewed	  closely	  given	  his	  admission	  to	  the	  PU	  with	  a	  potential	  thought	   disorder,	  which	  should	  have	  been	  ruled	  out	  prior	  to	  admission.	   	   	   	   	  

	  

9.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 10 of 34 PAGEID #: 2571

Youth	  	   Diagnoses	  

Phase	  One	  

Phase	  Two	  

TB	   Rule	  out	  psychotic	  disorder,	  NOS;	  Conduct	   Transfer	  2.1.13	  

	  

Disorder;	  Oppositional	  Defiant	  Disorder;	   Per	  roster	  of	  3.8.13	  

Cannabis	  Dependence	  

youth	  remains	  on	  P1	  

	  

35	  days	  

KD	   Current	  Diagnoses:	  	  ADHD	  and	  BIF.	  	  

Transfer	  12.31.12	  

	  

Prior	  diagnoses:	  	  Rule	  out	  Bipolar	  Mood	   Last	  documentation	  on	  

disorder,	  NOS;	  Conduct	  Disorder;	  

unit	  2.16.13	  and	  youth	  

Oppositional	  Defiant	  Disorder;	  Alcohol	  

remained	  on	  P1	  

Abuse;	  Cannabis	  Abuse;	  Antisocial	  

	  

Personality	  Disorder	  

	  

47	  days	  (minimum,	  stay	  

may	  have	  been	  longer,	  

do	  not	  have	  record	  of	  

date	  of	  transfer	  to	  

another	  facility)	  

DG	   Adjustment	  Disorder;	  PTSD;	  Conduct	   Disorder;	  Cannabis	  Abuse	  

Transfer	  2.1.13.	   Promoted	  2.20.13	   	   19	  days	  

Promoted	  2.20.13	  

	   	   The	  table	  above	  suggests	  that	  youth	  with	  certain	  mental	  health	  diagnoses	  (e.g.,	  TB	  and	  KD)	   require	  an	  increased	  amount	  of	  time	  to	  progress	  through	  the	  phases.	  	  This	  should	  be	  reviewed	   by	  ODYS	  on	  a	  continuous	  basis.	   	   While	  the	  facility	  has	  a	  process	  for	  reviewing	  and	  screening	  youth	  prior	  to	  admission,	  a	  few	   youth	  were	  admitted	  with	  “rule	  out”	  diagnoses.	  If	  these	  diagnoses	  were	  finalized	  and	  “ruled	  in,”	   they	  would	  have	  precluded	  the	  youth	  from	  admission.	  Youth	  should	  not	  be	  admitted	  to	  the	  PU	   with	  these	  pending	  diagnoses.	  	   	   Recommendations.	  	   In	  order	  to	  meet	  the	  standard	  associated	  with	  Admissions	  Screening,	  a	  Quality	  Improvement	   Plan	  should	  be	  developed	  to	  address	  the	  following	  issues:	  
1. Expanding	  the	  scope	  of	  data	  that	  are	  available	  for	  review	  by	  the	  QA	  auditor	  (e.g.,	   youth’s	  complete	  mental	  health	  record;	  Administrative	  Psychiatrist’s	  notes).	  	  
2. Ensuring	  that	  youth	  referred	  for	  admission	  to	  the	  PU	  are	  screened	  with	  regard	  to	  the	   presence	  or	  absence	  of	  a	  mental	  health	  condition	  that	  would	  preclude	  admission.	  	  For	   these	  youth,	  alternate	  placements	  should	  be	  considered	  (e.g.,	  a	  referral	  to	  the	  mental	   health	  unit).	  
3. For	  youth	  with	  mental	  health	  conditions	  who	  are	  accepted	  to	  the	  PU,	  reviewing	  their	   length	  of	  stay	  on	  each	  level	  to	  determine	  whether	  youth	  with	  mental	  health	  conditions	   experience	  difficulty	  progressing	  through	  the	  stages	  on	  the	  PU,	  further	  informing	  the	   referral	  and	  screening	  process.	  	  	  
	  
	  

	  

10.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 11 of 34 PAGEID #: 2572

[II.10]	  	  Daily	  Schedule	  [reviewed	  by	  Dr.	  Dedel]	   Status:	  Not	  in	  Substantial	  Compliance	  [Note:	  see	  issues	  regarding	  large	  muscle	  activity	   while	  in	  restraints	  and	  a	  written	  plan	  for	  graduate	  programming	  during	  school	  hours.]	  
	   (1)	  Standard:	  Out-­‐of-­‐Room	  Time.	  	  	   Youth	  on	  the	  PU	  have	  as	  much	  out-­‐of-­‐room	  time	  as	  youth	  in	  the	  general	  population,	  which	   ensures	  their	  access	  to	  the	  rehabilitative	  treatment	  necessary	  to	  address	  the	  behaviors	  and	  skill	   deficits	  that	  resulted	  in	  their	  placement	  on	  the	  PU.	  In	  general,	  PU	  youth	  are	  out	  of	  their	  rooms	   from	  7am	  to	  7pm,	  except	  during	  shift	  change	  (40	  minutes	  daily),	  medication	  pass	  (30	  minutes	   daily),	  Treatment	  Team	  (3	  to	  4	  hours	  per	  week),	  and	  seclusion	  time	  that	  is	  ordered	  as	  a	  sanction	   for	  major	  rule	  violations.	  The	  PU	  is	  not	  a	  lock-­‐down	  unit	  that	  relies	  on	  isolation	  to	  suppress	   youth	  behaviors.	   	   Methodology.	  	   The	  following	  information	  is	  used	  to	  determine	  compliance	  with	  the	  standard:	  
• Youth	  Activity	  Tracking	  sheets	  that	  indicate	  the	  youth’s	  activities	  throughout	  each	  day,	   separated	  according	  to	  whether	  the	  youth	  is	  in	  his	  room	  or	  out	  of	  his	  room.	  	  
• Youth	  and	  staff	  interviews	   	   Analysis	  and	  Interpretation.	  	   The	  DYS	  provided	  Youth	  Activity	  Tracking	  (YAT)	  logs	  for	  the	  4-­‐week	  period	  from	  January	  20	   through	  February	  16,	  2013.	  Each	  week,	  a	  random	  sample	  of	  4	  youth	  was	  selected	  for	  a	  total	  of	   16	  youth	  and	  107	  days.	  Of	  the	  107	  days	  reviewed,	  youth	  were	  in	  seclusion	  for	  8	  of	  them.	  In	   other	  words,	  on	  92%	  of	  the	  days	  reviewed,	  the	  youth	  were	  out	  of	  their	  rooms	  and	  engaged	  in	   the	  program.	  About	  half	  of	  the	  youth	  spent	  one	  day	  in	  seclusion	  during	  the	  week	  reviewed.	  	   	   The	  Order	  requires	  youth	  to	  be	  out	  of	  their	  rooms	  on	  non-­‐IDT	  days	  for	  at	  least	  10	  hours	  and	  50	   minutes	  (allowing	  70	  minutes	  for	  shift	  change	  and	  med	  passes	  during	  the	  12	  waking	  hours).	  This	   minimum	  was	  exceeded	  for	  approximately	  90%	  of	  the	  non-­‐IDT	  days	  in	  the	  sample.	  On	  11	  of	  the	   107	  days	  (10%),	  times	  in	  excess	  of	  70	  minutes	  were	  recorded	  for	  shift	  change/med	  pass.	  This	  is	  a	   reasonable	  rate	  of	  exception.	  	   	   	  
Technical	  Assistance	  Note:	  Activity	  Tracking	  
Until	  very	  recently,	  the	  days	  on	  which	  IDT	  meetings	  were	  held	  were	  not	  identified	  in	  the	  YAT.	  While	  there	   are	  other	  ways	  to	  verify	  that	  IDT	  meetings	  are	  held	  as	  required	  (and	  the	  data	  confirm	  that	  they	  are),	  it	  is	  of	   concern	  that	  the	  YAT	  data	  reflected	  that	  youth	  were	  out	  of	  their	  rooms	  during	  times	  when	  they	  were	  not.	  
	   It	  is	  worth	  highlighting	  the	  significant	  change	  in	  practice	  that	  has	  occurred	  over	  the	  past	  few	   months.	  Previously,	  youth	  spent	  most	  of	  their	  waking	  hours	  locked	  inside	  their	  rooms.	  Now,	   they	  have	  similar	  out-­‐of-­‐cell	  time	  to	  the	  general	  population,	  which	  creates	  the	  opportunity	  to	   provide	  the	  intensive	  programing	  that	  these	  youth	  sorely	  need.	   	   Recommendations.	  	   A	  Quality	  Improvement	  Plan	  is	  not	  necessary	  to	  meet	  the	  standard	  regarding	  out-­‐of-­‐room	  time	   on	  the	  Daily	  Schedule.	  	   	  

	  

11.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 12 of 34 PAGEID #: 2573

(2)	  Standard:	  Daily	  Activities.	  	   Each	  day,	  youth	  on	  the	  PU	  participate	  in	  the	  following	  activities,	  out	  of	  their	  rooms:	  	  
• Meals;	   • 330	  minutes	  of	  education,	  except	  during	  intersession;	   • One	  hour	  of	  large	  muscle	  activity	  (without	  restraints);	   • Individual	  and	  group	  treatment	  conducted	  by	  Behavioral	  Health	  Staff;	   • Structured	  activities	  led	  by	  Youth	  Specialists	  or	  Volunteers;	   • Leisure	  time	  (one	  hour	  on	  school	  days,	  two	  hours	  on	  non-­‐school	  days).	  	   	   Methodology.	  	   The	  following	  information	  is	  used	  to	  determine	  compliance	  with	  the	  standard:	   • Youth	  Activity	  Tracking	  sheets	  that	  indicate	  the	  youth’s	  activities	  throughout	  each	  day,	  
separated	  according	  to	  whether	  the	  youth	  is	  in	  his	  room	  or	  out	  of	  his	  room.	  	   • Observations	  of	  PU	  activities	   • Youth	  and	  staff	  interviews	   	   Analysis	  and	  Interpretation.	  	   The	  DYS	  provided	  Youth	  Activity	  Tracking	  (YAT)	  logs	  for	  the	  4-­‐week	  period	  from	  January	  20	   through	  February	  16,	  2013.	  Each	  week,	  a	  random	  sample	  of	  4	  youth	  was	  selected	  for	  a	  total	  of	   16	  youth	  and	  107	  days.	  Across	  the	  days:	   • Three	  meals	  were	  provided	  to	  each	  youth,	  each	  day	  (100%).	  Youth	  who	  were	  not	  in	  
seclusion	  ate	  outside	  of	  their	  rooms.	   • A	  full	  day	  of	  education	  was	  provided	  to	  youth	  who	  were	  not	  in	  seclusion	  (100%)	  
[Chancery	  attendance	  records	  should	  be	  used	  to	  verify	  these	  data.].	  	   • Recreation	  was	  provided	  on	  all	  but	  12	  days	  (89%;	  4	  non-­‐seclusion	  and	  8	  seclusion	  days).	  
Although	  recreation	  was	  provided	  consistently,	  the	  PU	  practice	  continues	  to	  require	  P1	   youth	  to	  attend	  recreation	  while	  wearing	  restraints	  if	  they	  choose	  to	  go	  to	  the	   gymnasium	  or	  the	  outdoor	  recreation	  area.	  True	  large	  muscle	  activity	  is	  nearly	   impossible	  while	  wearing	  these	  devices,	  particularly	  for	  taller	  youth.	  Furthermore,	  youth	   in	  seclusion	  do	  not	  receive	  recreation,	  which	  goes	  against	  the	  generally	  accepted	   practice	  in	  the	  field.	  	   • Group	  and	  individual	  treatment	  was	  recorded	  for	  all	  but	  12	  of	  the	  99	  non-­‐seclusion	  days	   (88%).	  It	  is	  likely	  that	  IDTs	  were	  held	  on	  these	  days	  but	  were	  not	  recorded.	  On	  most	   days,	  multiple	  treatment	  activities	  were	  recorded.	  	   • Structured	  activities	  were	  recorded	  on	  all	  of	  the	  non-­‐seclusion	  days	  (100%).	   • Leisure	  time	  was	  recorded	  for	  only	  6	  of	  the	  99	  non-­‐seclusion	  days	  (6%).	  	   	   	  
Technical	  Assistance	  Note:	  Activity	  Tracking	  
“Structured	  activity”	  and	  “leisure	  time”	  appear	  to	  be	  used	  somewhat	  interchangeably.	  In	  November	  2012,	   youth	  had	  a	  large	  amount	  of	  leisure	  time	  recorded,	  about	  which	  the	  Monitor	  expressed	  concern.	  Since	   then,	  the	  pattern	  in	  the	  data	  has	  shifted	  to	  register	  a	  high	  volume	  of	  “structured	  activity”	  and	  relatively	  no	   “leisure	  time.”	  This	  issue	  should	  not	  be	  one	  of	  semantics;	  the	  distinguishing	  feature	  should	  be	  one	  of	   interaction	  with	  staff.	  The	  precise	  term	  used	  does	  not	  concern	  the	  Monitor,	  but	  DYS	  should	  construct	  a	   way	  to	  verify	  that	  staff	  and	  youth	  are	  interacting	  during	  the	  majority	  of	  time	  when	  youth	  are	  not	  in	  school	   or	  participating	  in	  a	  treatment	  activity.	  Experience	  has	  shown	  that	  excessive,	  unstructured	  leisure	  time	   leads	  to	  increases	  in	  misconduct.	  	  

	  

12.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 13 of 34 PAGEID #: 2574

	   Overall,	  the	  Monitor	  is	  concerned	  that	  the	  amount	  of	  staff	  time	  and	  effort	  used	  to	  construct	  the	  daily	   activity	  records	  may	  be	  overkill	  and	  thus	  not	  sustainable	  for	  the	  purposes	  of	  QA.	  There	  may	  be	  a	  simpler	   way	  to	  verify	  that	  youth	  are	  out	  of	  their	  rooms	  and	  engaged	  in	  the	  required	  activities.	  Some	  combination	   of	  tracking	  in-­‐room	  time	  (which	  is	  far	  less	  voluminous),	  structured	  questioning	  during	  IDT	  meetings	  (e.g.,	   “did	  you	  get	  meals/shower/rec	  every	  day	  this	  week?”),	  and	  a	  targeted	  effort	  to	  document	  structured	   programming	  and	  leisure	  time	  activities	  may	  be	  more	  practical.	  	   	   Finally,	  the	  on-­‐site	  visit	  conducted	  by	  the	  S.H.	  Lead	  Monitor	  and	  his	  Assistant	  reinforced	  the	  importance	  of	   posting	  a	  current	  daily	  schedule	  on	  each	  Unit.	  The	  schedule	  for	  the	  Transition	  Unit	  was	  outdated,	  which	   led	  to	  complaints	  from	  youth	  that	  staff	  were	  not	  following	  the	  program	  with	  regard	  to	  bedtime.	  Not	  only	   are	  current	  schedules	  essential	  to	  inform	  youth	  expectations,	  but	  are	  also	  important	  to	  ensure	  that	  relief	   staff	  properly	  implement	  the	  program.	  On	  a	  positive	  note,	  both	  youth	  and	  staff	  were	  very	  cognizant	  of	  the	   schedule—they	  know	  what	  should	  be	  happening	  at	  all	  times	  and	  youth	  could	  recite	  the	  schedule	  without	   looking	  at	  it.	  	  
	   	   Recommendations.	  	   In	  order	  to	  meet	  the	  standard	  associated	  with	  activity	  component	  of	  the	  Daily	  Schedule,	  a	   Quality	  Improvement	  Plan	  should	  be	  constructed	  to	  address	  the	  following	  issues:	  
1. Identifying	  ways	  to	  engage	  youth	  in	  large	  muscle	  activities	  without	  the	  use	  of	  restraints.	   DYS	  contends	  that	  youth	  are	  offered	  indoor	  recreational	  opportunities	  that	  do	  not	   require	  restraints,	  but	  that	  youth	  choose	  options	  in	  which	  DYS	  has	  determined	  restraints	   must	  be	  worn.	  Setting	  up	  situations	  in	  which	  youth	  cannot	  actually	  participate	  in	   meaningful	  activity	  seems	  contrary	  to	  the	  agency’s	  commitment	  to	  recreation.	  	  	  	  	  
2. Providing	  daily	  large	  muscle	  recreation	  to	  youth	  in	  seclusion.	  	   3. Efficient	  methods	  for	  tracking	  out	  of	  room	  time,	  receipt	  of	  basic	  services	  (meals,	  
showers,	  recreation)	  and	  engagement	  in	  structured	  activities.	  Any	  new	  methods	  should	   provide	  sufficient	  details	  to	  substantiate	  compliance	  with	  the	  standard,	  but	  should	  also	   be	  simple	  enough	  to	  ensure	  DYS	  continues	  to	  utilize	  them	  for	  the	  purpose	  of	  Quality	   Assurance.	  	   	   	   (3)	  Standard:	  Graduate	  Programming.	  	   Youth	  on	  the	  PU	  who	  have	  graduated	  from	  high	  school	  participate	  in	  out-­‐of-­‐room	  structured	   activities	  throughout	  the	  time	  that	  non-­‐graduates	  are	  in	  school.	  	   	   Methodology.	  	   The	  following	  information	  is	  used	  to	  determine	  compliance	  with	  the	  standard:	   • List	  of	  youth	  who	  have	  graduated	  from	  high	  school	   • Youth	  Activity	  Tracking	  sheets	  that	  indicate	  the	  youth’s	  activities	  throughout	  each	  day,	   separated	  according	  to	  whether	  the	  youth	  is	  in	  his	  room	  or	  out	  of	  his	  room.	  	   • Youth	  and	  staff	  interviews	   	   Analysis	  and	  Interpretation.	  	   The	  DYS	  submits	  weekly	  Youth	  Activity	  Tracking	  logs	  that	  record	  how	  youth	  spend	  their	  waking	   hours.	  A	  specific	  data	  collection	  and	  analysis	  protocol	  has	  not	  been	  established	  for	  youth	  who	   have	  graduated	  from	  high	  school	  or	  obtained	  their	  GEDs.	  One	  such	  youth	  was	  identified	  via	  the	  

	  

13.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 14 of 34 PAGEID #: 2575

IDT	  minutes,	  and	  his	  YAT	  consistently	  revealed	  that	  he	  spent	  the	  hours	  when	  other	  youth	  were	  

in	  school	  outside	  of	  his	  room	  in	  “structured	  activities.”	  The	  specific	  activities	  in	  which	  the	  youth	  

engaged	  are	  unknown.	  Youth	  in	  the	  general	  population	  have	  access	  to	  college	  courses,	  

vocational	  programming	  and	  campus	  jobs.	  Given	  that	  PU	  youth	  cannot	  travel	  around	  campus,	  

the	  traditional	  options	  are	  not	  available.	  However,	  a	  plan	  should	  be	  developed	  to	  advance	  the	  

youth’s	  career	  interest	  and	  job	  readiness	  while	  on	  the	  PU,	  but	  that	  also	  addresses	  the	  legitimate	  

safety	  concerns	  posed	  by	  these	  youth.	  The	  Order	  allows	  DYS	  60	  days	  from	  the	  date	  of	  signing	  to	  

develop	  such	  a	  plan,	  which	  expires	  on	  March	  18,	  2013.	  DYS	  submitted	  the	  Unit	  Handbook	  within	  

the	  required	  timeline,	  but	  outside	  of	  the	  period	  of	  review	  for	  this	  report.	  The	  substance	  and	  

outcomes	  associated	  with	  graduate	  programming	  will	  be	  discussed	  in	  the	  next	  status	  report.	  	  

	  

Recommendations.	  	  

In	  order	  to	  meet	  the	  standard	  associated	  with	  graduate	  programming	  on	  the	  Daily	  Schedule,	  a	  

Quality	  Improvement	  Plan	  should	  be	  developed	  to	  address	  the	  following	  issue:	  

1. Occupying	  graduates’	  time	  when	  other	  youth	  are	  in	  school.	  While	  they	  are	  currently	  

able	  to	  spend	  this	  time	  outside	  their	  rooms,	  structured	  activities	  that	  promote	  career	  

interest	  or	  job	  readiness	  should	  be	  considered.	  At	  a	  minimum,	  the	  plan	  should	  include	  a	  

mechanism	  to	  identify	  graduates	  housed	  on	  the	  PU	  and	  should	  indicate	  how	  the	  hours	  

that	  other	  youth	  spend	  in	  school	  will	  be	  occupied.	  	  

	  

	  

	  

	  

	  

	  

14.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 15 of 34 PAGEID #: 2576
[II.11]	  Staffing	  [monitored	  by	  Dr.	  Dedel]	   Status:	  Not	  in	  Substantial	  Compliance	  [see	  issues	  related	  to	  identifying	  which	  staff	  are	   permanent	  versus	  relief	  and	  staff	  training]	  
	   (1)	  Standard:	  Staff	  Numbers	  and	  Training.	  	   A	  sufficient	  number	  of	  adequately	  trained	  supervisory	  and	  line	  staff	  are	  available	  to	  implement	   the	  PU	  program	  as	  designed.	  	  
• A	  Unit	  Manager	  (UM)	  works	  during	  all	  waking	  hours,	  seven	  days	  per	  week.	  	   • All	  assigned	  PU	  Youth	  Specialists	  have	  completed	  required	  training	  within	  three	  months	  
of	  their	  assignment.	   • All	  Youth	  Specialists	  (whether	  assigned	  or	  relief)	  read	  and	  sign	  the	  relevant	  Post	  Orders.	   	   Methodology.	  	   The	  following	  information	  should	  be	  used	  to	  determine	  compliance	  with	  the	  standard:	   • Average	  daily	  populations	  for	  Sycamore,	  Cedar	  and	  Buckeye	   • UM	  schedule	   • Youth	  Specialist	  staffing	  reports	   • Youth	  Specialist	  training	  records	   • PU	  Post	  Orders	  and	  signature	  pages	   • Staff	  interviews	   	   Analysis	  and	  Interpretation.	  	   The	  DYS	  submitted	  work	  schedules	  for	  the	  four	  Unit	  Mangers	  (UM)	  assigned	  to	  the	  PU	  for	  the	   months	  of	  January	  and	  February	  2013.	  Throughout	  the	  two-­‐month	  period,	  UM	  coverage	  met	   the	  requirements	  of	  the	  Order	  (i.e.,	  UM	  available	  during	  all	  waking	  hours,	  7	  days	  per	  week).	  On	   Monday,	  Tuesday	  and	  Thursday,	  all	  four	  UMs	  were	  on	  duty	  with	  staggered	  start	  times	  which	   provided	  extensive	  UM	  coverage	  throughout	  waking	  hours.	  On	  Wednesdays,	  Fridays	  and	   weekend	  days,	  two	  unit	  managers	  were	  on	  duty	  with	  staggered	  schedules	  that	  provided	  for	   overlap	  between	  11a	  and	  3:30p	  and	  one	  UM	  on	  duty	  during	  the	  remaining	  waking	  hours.	  	   	   	  
Technical	  Assistance	  Note:	  Unit	  Manager	  Schedules	  
A	  review	  of	  each	  individual	  UM’s	  schedule	  indicated	  that	  all	  of	  the	  UMs	  rotate	  days	  off	  (either	   Sunday/Friday	  or	  Wednesday/Saturday).	  While	  this	  provides	  everyone	  with	  one	  weekend	  day	  off	  per	  week,	   the	  UMs	  never	  have	  two	  days	  off	  in	  a	  row.	  This	  may	  be	  entirely	  to	  the	  preference	  of	  currently	  assigned	   UMs.	  But,	  if	  problems	  with	  morale	  or	  retention	  develop,	  re-­‐examining	  the	  schedule	  is	  advised.	  Experience	   with	  other	  positions	  at	  DYS	  (e.g.,	  social	  workers)	  indicates	  that	  scheduling	  is	  an	  essential	  component	  of	  the	   ability	  to	  attract	  and	  retain	  highly	  qualified	  staff.	  	  
	   The	  Youth	  Specialists’	  (YS)	  schedule	  was	  provided	  at	  the	  end	  of	  February	  2013	  for	  the	  Sycamore	   and	  Cedar	  Units.	  [Staffing	  data	  were	  not	  provided	  for	  the	  Transition	  Unit.]	  The	  YS	  shift	   assignments	  are	  as	  follows:	  5	  staff	  on	  1st	  shift,	  4	  staff	  on	  2nd	  shift,	  and	  3	  staff	  on	  3rd	  shift	  on	  each	   unit,	  for	  a	  total	  of	  24	  positions.	  There	  is	  currently	  one	  vacancy	  on	  Cedar,	  1st	  shift.	  Each	  of	  the	  24	   staff	  is	  assigned	  to	  1st,	  2nd,	  or	  3rd	  shift	  and	  has	  two	  days	  off	  per	  week.	  In	  all	  cases,	  the	  staff	  have	   two	  days	  off	  in	  a	  row.	  As	  stated	  in	  the	  Technical	  Assistance	  Note,	  above,	  this	  may	  be	  preferable	  

	  

15.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 16 of 34 PAGEID #: 2577

to	  currently	  assigned	  staff,	  but	  DYS	  should	  consider	  how	  the	  staff’s	  days	  off	  are	  sequenced	  if	   problems	  with	  morale	  or	  retention	  are	  encountered.	  	   	   DYS	  also	  provided	  weekly	  staffing	  reports	  for	  November	  and	  December	  2012,	  which	  show	  the	   number	  of	  staff	  who	  actually	  reported	  to	  work	  each	  day.	  [YS	  staffing	  data	  were	  not	  submitted	   for	  January	  2013.]	  This	  report	  does	  not	  list	  the	  names	  of	  the	  staff,	  so	  it	  was	  not	  possible	  to	   determine	  whether	  the	  staff	  who	  reported	  were	  those	  who	  were	  regularly	  assigned	  to	  the	  PU,	   or	  if	  relief	  staff	  were	  utilized.	  	   	   The	  Order	  requires	  staff	  assigned	  to	  the	  PU	  to	  complete	  training	  “specifically	  relating	  to	  working	   with	  youth	  on	  the	  PU	  and	  implementing	  the	  PU	  as	  designed”	  within	  3-­‐months	  of	  their	   assignment.	  DYS	  is	  required	  to	  submit	  training	  records	  for	  staff	  assigned	  to	  the	  PU	  within	  three	   months	  of	  the	  date	  the	  Order	  was	  signed.	  These	  records	  are	  due	  on	  April	  18,	  2013	  and	  will	  be	   discussed	  in	  the	  subsequent	  Status	  Report.	  	   	   Staff	  who	  are	  not	  regularly	  assigned	  to	  the	  unit	  (i.e.,	  relief	  staff)	  are	  required	  to	  read	  and	  initial	   the	  PU	  Post	  Orders	  whenever	  they	  are	  scheduled	  to	  work	  the	  unit.	  The	  PU’s	  Post	  Orders	  are	   severely	  outdated	  (last	  revised	  in	  March	  2012,	  prior	  to	  the	  significant	  program	  changes	   described	  in	  this	  report).	  In	  order	  to	  maintain	  the	  integrity	  of	  the	  reforms,	  even	  when	  regular	   staff	  are	  on	  vacation,	  out	  sick	  or	  otherwise	  unavailable	  to	  work,	  these	  Post	  Orders	  need	  to	  be	   updated	  to	  accurately	  reflect	  the	  job	  responsibilities	  of	  a	  YS	  assigned	  to	  the	  PU.	  	   	   Determining	  whether	  staffing	  levels	  are	  “adequate”	  requires	  knowledge	  of	  the	  size	  of	  the	   population	  the	  staff	  are	  supervising	  on	  any	  given	  day.	  Average	  daily	  populations	  (ADP)	  are	   normally	  calculated	  by	  adding	  the	  number	  of	  youth	  on	  a	  unit	  each	  day,	  and	  dividing	  the	  sum	  by	   the	  number	  of	  days	  in	  the	  month.	  Daily	  population	  levels	  were	  not	  available	  to	  the	  Monitor,	  but	   weekly	  unit	  rosters	  provided	  a	  snapshot	  of	  population	  levels	  that	  could	  be	  used	  to	  estimate	  the	   ADP.	  	   	  
Population	  Averages,	  per	  unit	  

Unit	  

Nov/Dec	  

Jan/Feb	   Average	  

Sycamore	  (P1)	  

7.0	  

5.75	  

6.375	  

Cedar	  (P2)	  

8.0*	  

4.5	  

6.25	  

Buckeye	  (Transition)	  

6.4	  

8.25	  

7.325	  

Total	  PU	  

21.4	  

18.5	  

19.95	  

*Note:	  There	  were	  several	  days	  in	  December	  when	  P2	  boys	  were	  housed	  on	   Buckeye	  with	  the	  Transition	  youth.	  They	  are	  included	  in	  the	  P2	  count.	  	  
	   As	  shown	  in	  the	  table	  above,	  the	  average	  number	  of	  youth	  assigned	  to	  the	  PU	  decreased	  by	   approximately	  14%	  over	  the	  4-­‐month	  period.	  Within	  the	  PU	  as	  a	  whole,	  the	  population	  across	   the	  three	  units	  fluctuated	  (decreasing	  on	  Sycamore	  and	  Cedar,	  but	  increasing	  on	  Buckeye).	  In	   real	  numbers,	  the	  average	  PU	  population	  decreased	  by	  about	  3	  youth	  over	  the	  4-­‐month	  period.	  	   	   	  

	  

16.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 17 of 34 PAGEID #: 2578

The	  weekly	  staffing	  reports,	  coupled	  with	  the	  estimated	  ADP	  permit	  an	  assessment	  of	  the	   typical	  staff—youth	  ratio	  on	  Sycamore	  and	  Cedar.	  1st	  and	  2nd	  shifts	  normally	  had	  3	  staff	  on	  each	   unit,	  while	  3rd	  shift	  normally	  had	  2	  staff.	  About	  10%	  of	  the	  time,	  1st	  and	  2nd	  shifts	  had	  4	  or	  5	  staff	   and	  3rd	  shift	  had	  3	  staff.	  	   	   A	  staff-­‐youth	  ratio	  was	  calculated	  for	  all	  three	  shifts	  on	  each	  unit	  for	  each	  of	  the	  66	  days	   reviewed.	  On	  Sycamore,	  1st	  and	  2nd	  shifts	  were	  staffed	  at	  1:2.33	  or	  better	  every	  day,	  and	  3rd	  shift	   was	  staffed	  at	  1:3.5	  or	  better	  every	  day.	  On	  Cedar,	  1st	  and	  2nd	  shifts	  were	  staffed	  at	  1:2.66	  or	   better	  every	  day,	  and	  3rd	  shift	  was	  staffed	  at	  1:4	  or	  better	  every	  day.	  These	  staffing	  levels	  are	   appropriate	  for	  an	  intensive	  programming	  unit	  with	  high-­‐risk	  youth,	  such	  as	  the	  PU.	  As	  noted,	   staffing	  data	  were	  not	  submitted	  for	  the	  Transition	  Unit,	  so	  staff—youth	  ratios	  could	  not	  be	   calculated.	  	   	  
Technical	  Assistance	  Note:	  Staffing	  
DYS	  data	  submissions	  have	  not	  included	  staffing	  levels	  on	  the	  Transition	  Unit.	  Being	  as	  the	  Transition	  Unit	   is	  part	  of	  the	  PU,	  these	  data	  are	  required	  by	  the	  Court	  Order.	  Furthermore,	  staffing	  data	  for	  January	  and	   February	  has	  not	  yet	  been	  submitted.	  	  
	   	   Recommendations.	  	   While	  the	  DYS	  meets	  some	  of	  the	  requirements	  related	  to	  staffing	  (e.g.,	  UM	  scheduling,	  staff— youth	  ratio)	  a	  few	  issues	  remain.	  The	  DYS	  should	  develop	  a	  Quality	  Improvement	  Plan	  related	  to	   the	  following	  issues:	  
1. Calculating	  a	  monthly	  ADP	  for	  each	  unit	  so	  that	  staff	  ratios	  can	  be	  tracked	  easily.	   2. Including	  Transition	  staff	  in	  the	  Quality	  Assurance	  process	  surrounding	  staffing	  (e.g.,	  
schedules,	  daily	  staffing	  levels,	  training,	  etc.).	   3. Amending	  staffing	  reports	  to	  identify	  whether	  any	  of	  the	  staff	  who	  worked	  on	  a	  given	  
day/shift	  were	  relief	  staff.	   4. Developing	  a	  mechanism	  to	  certify	  that	  all	  assigned	  staff	  have	  completed	  PU-­‐specific	  
training	  within	  3	  months	  of	  their	  assignment.	  	   5. Updating	  the	  Post	  Orders	  for	  the	  PU	  to	  reflect	  current	  procedures.	  	  
	   	   (2)	  Standard:	  Impact	  on	  Safety.	  	   Recognizing	  there	  are	  many	  contributing	  factors	  to	  youth	  violence,	  staffing	  levels	  on	  the	  PU	  are	   sufficient	  to	  ensure	  that	  a	  lack	  of	  supervision	  does	  not	  contribute	  to	  the	  opportunity	  for	  youth	   to	  commit	  violence	  against	  other	  youth	  or	  staff.	  	   	   Methodology.	  	   The	  following	  information	  should	  be	  used	  to	  determine	  compliance	  with	  the	  standard:	  
• Rate	  of	  youth-­‐on-­‐youth	  violence	  for	  past	  12	  months	   • Rate	  of	  youth-­‐on-­‐staff	  violence	  for	  past	  12	  months	   • Disaggregated	  list	  of	  AOVs	  committed	  by	  youth	  that	  includes	  the	  youth’s	  name,	  date	  
and	  type	  of	  violence.	  	   	   	   	  

	  

17.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 18 of 34 PAGEID #: 2579

Analysis	  and	  Interpretation.	  	   The	  DYS	  has	  provided	  a	  spreadsheet	  each	  month	  since	  November	  2012	  listing	  the	  youth	  who	   have	  been	  involved	  in	  AOV	  during	  the	  month.	  Spreadsheets	  from	  November	  2012	  through	   January	  2013	  (the	  last	  month	  for	  which	  data	  are	  available)	  were	  analyzed	  to	  identify	  the	  number	   of	  youth	  involved	  in	  AOV	  against	  staff	  and	  other	  youth.	  The	  table	  below	  presents	  the	  number	  of	   youth-­‐staff	  assaults	  and	  youth-­‐youth	  assaults.	  In	  the	  future,	  the	  DYS	  should	  include	  data	  on	  the	   ADP	  each	  month	  and	  calculate	  a	  rate	  for	  each	  type	  of	  violence	  (rate	  =	  number	  of	  incidents/ADP).	   Using	  a	  rate	  will	  neutralize	  the	  impact	  of	  the	  fluctuating	  population	  on	  the	  units	  and	  will	  permit	   long-­‐term	  comparisons.	  While	  it	  appears	  that	  the	  rate	  of	  violence	  is	  decreasing	  in	  the	  PU,	  the	   population	  of	  the	  PU	  has	  also	  decreased	  during	  this	  same	  time	  period.	  This	  makes	  the	  need	  to	   use	  a	  rate	  particularly	  pronounced.	  	   	   The	  estimated	  unit-­‐level	  ADP	  used	  in	  the	  staffing	  discussion	  above	  is	  not	  sensitive	  enough	  for	   these	  calculations	  given	  that	  a	  complete	  set	  of	  weekly	  data	  were	  not	  available	  for	  each	  month.	   However,	  ADPs	  of	  21	  (Nov),	  20	  (Dec)	  and	  19	  (Jan)	  are	  reasonable	  estimates	  and	  are	  used	  for	   illustrative	  purposes.	  These	  rates	  should	  be	  recalculated	  when	  the	  actual	  ADP	  is	  known.	  	   	  
Rates	  of	  Violence	  on	  the	  PU	  

Month	  

Youth—Staff	  

Youth—Youth	  

Number	   ADP	   Rate	   Number	   ADP	   Rate	  

Nov	  12	  

8	  

21	  

.381	  

5	  

21	   .238	  

Dec	  12	  

6	  

20	  

.285	  

1	  

21	   .048	  

Jan	  12	  

5	  

19	  

.263	  

1	  

19	   .053	  

	   The	  same	  youth	  was	  involved	  in	  early	  all	  of	  the	  youth-­‐youth	  assaults.	  This	  youth’s	  treatment	   plan	  should	  be	  reviewed	  to	  determine	  whether	  there	  are	  sufficient	  therapeutic	  and	   environmental	  supports	  to	  help	  him	  to	  refrain	  from	  violent	  behavior.	  	   	   Clearly,	  the	  rate	  of	  youth-­‐staff	  assaults	  is	  much	  higher	  than	  the	  rate	  of	  youth-­‐youth	  assaults.	  In	   order	  to	  ensure	  a	  safe	  environment	  for	  the	  staff	  posted	  to	  the	  PU,	  the	  types	  of	  violence	  and	  the	   underlying	  causes	  of	  these	  assaults	  should	  be	  further	  analyzed	  and	  addressed.	  As	  noted	  in	   subsequent	  sections	  of	  this	  report,	  reducing	  the	  rate	  of	  youth-­‐staff	  assaults	  will	  also	  shorten	   youth’s	  length	  of	  stay	  and	  shrink	  the	  PU’s	  population,	  as	  youth-­‐staff	  assault	  is	  one	  of	  the	  main	   reasons	  why	  youth	  are	  recycled	  through	  the	  phases.	  	   	  

Technical	  Assistance	  Note:	  Rates	  of	  Violence	  

While	  DYS	  has	  invested	  considerable	  resources	  in	  creating	  a	  robust	  staffing	  plan	  for	  the	  PU,	  the	   ability	  to	  demonstrate	  that	  the	  enhanced	  staffing	  levels	  translate	  to	  a	  safer	  environment	  for	   youth	  and	  staff	  (as	  required	  by	  the	  Order)	  is	  hampered	  by	  the	  lack	  of	  unit-­‐specific	  data	  on	  AOV	   and	  ADPs.	  The	  safe	  environment	  may	  be	  easy	  to	  substantiate	  once	  the	  data	  are	  in	  order.	  	  	  
	   	   Recommendations.	  	   In	  order	  to	  meet	  the	  standard	  associated	  with	  the	  Impact	  of	  Staffing	  on	  Safety,	  the	  DYS	  should	   create	  a	  Quality	  Improvement	  Plan	  to	  address	  the	  following	  issues:	  

	  

18.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 19 of 34 PAGEID #: 2580

1. Developing	  the	  ability	  to	  track	  rates	  of	  violence	  by	  collecting	  the	  number	  of	  AOVs	  and	  

the	  ADP	  each	  month	  for	  the	  PU,	  specifically.	  	  

2. Analyzing	  the	  incidents	  involving	  violence	  against	  youth	  to	  identify	  any	  patterns	  in	  unit,	  

location,	  youth	  involved,	  etc.	  Enact	  specific	  strategies	  to	  address	  these	  patterns.	  	  

3. Analyzing	  the	  types	  of	  violence	  perpetrated	  against	  staff,	  their	  underlying	  causes	  and	  

any	  environmental	  conditions	  that	  create	  the	  opportunity	  for	  violence	  to	  occur	  (e.g.,	  

sufficient	  staff	  support	  during	  restraints?	  Ability	  to	  collect	  liquids	  and	  throw	  them?	  

Tensions	  between	  individuals	  that	  should	  be	  mitigated?).	  Develop	  and	  implement	  

specific	  strategies	  to	  address	  these	  issues.	  	  

	  

	  

	  

	  

19.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 20 of 34 PAGEID #: 2581

[II.12]	  Treatment	  Planning	  [monitored	  by	  Dr.	  Glindmeyer]	   Status:	  Not	  in	  Substantial	  Compliance	   	  
(1)	  Standard:	  Clinical	  Staffing	  [this	  standard	  is	  derived	  from	  paragraph	  II.C.3	  of	  the	  SH	  Order]	   Clinical	  staffing	  is	  sufficient	  to	  implement	  youth’s	  treatment	  plans	  and	  to	  conduct	  Inter-­‐ Disciplinary	  Team	  (IDT)	  meetings	  (e.g.,	  with	  20	  youth	  on	  the	  PU,	  “sufficient	  staffing”	  is	  three	   psychologists,	  one	  psychiatrist,	  one	  psychiatric	  nurse	  and	  three	  social	  workers).	  The	  staffing	   levels	  are	  adjusted	  when	  the	  population	  fluctuates	  or	  upon	  reasonable	  professional	  judgment.	  	   	   Methodology.	  	   The	  following	  information	  should	  be	  used	  to	  determine	  compliance	  with	  the	  standard:	  
• PU	  clinical	  staffing	  plan	   	   Analysis	  and	  Interpretation.	  	   Sufficient	  data	  were	  not	  submitted	  in	  order	  to	  demonstrate	  compliance	  with	  this	  standard.	  	   	   	  
Technical	  Assistance	  Note:	  Clinical	  Staffing	  
The	  clinical	  staffing	  plan	  was	  not	  submitted	  for	  review	  at	  the	  time	  this	  report	  was	  authored.	  DYS	  needs	  to	   develop	  a	  mechanism	  to	  track	  the	  number	  and	  type	  of	  clinical	  staff	  and	  the	  ratio	  to	  the	  PU	  population	  for	   each	  position.	  	  
	   	   Recommendations.	  	   In	  order	  to	  meet	  the	  standard	  associated	  with	  Clinical	  Staffing,	  a	  Quality	  Improvement	  Plan	   should	  be	  created	  to	  address	  the	  following	  issues:	  
1. Reporting	  the	  clinical	  staffing	  levels	  and	  hours	  of	  clinical	  activity	  on	  a	  periodic	  basis.	   2. If	  ratios	  are	  found	  to	  be	  insufficient	  once	  the	  data	  have	  been	  assembled,	  ensuring	  
appropriate	  staff	  to	  meet	  the	  clinical	  needs	  of	  youth	  on	  the	  PU.	   	   	   (2)	  Standard:	  Treatment	  Planning.	  	   Treatment	  plans	  are	  individualized	  and	  include	  concrete,	  realistic,	  measurable	  goals	  and	   objectives	  that	  are	  designed	  to	  address	  the	  specific	  behaviors	  that	  led	  to	  the	  youth’s	  placement	   on	  the	  PU.	  Specific	  interventions	  are	  prescribed	  in	  order	  to	  assist	  youth	  in	  accomplishing	   treatment	  goals.	  Progress	  toward	  treatment	  goals	  results	  in	  promotion	  through	  the	  PU’s	  phases	   and,	  ultimately,	  back	  to	  the	  general	  population.	  	  
• Phase	  1	  (P1)	  goals	  focus	  on	  acquiring	  skills	  to	  move	  safely	  about	  the	  unit	  without	  the	  use	   of	  restraints	  once	  promoted.	  Skill	  acquisition	  is	  demonstrated	  by	  meeting	  behavioral	   expectations.	  	  	  
• Phase	  2	  (P2)	  goals	  focus	  on	  acquiring	  skills	  needed	  to	  refrain	  from	  aggressive	  behavior	   once	  returned	  to	  the	  general	  population.	  	  
	   	   	   	  

	  

20.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 21 of 34 PAGEID #: 2582

Methodology.	  	   The	  following	  information	  should	  be	  used	  to	  determine	  compliance	  with	  the	  standard:	  
• Content	  analysis	  of	  Treatment	  Plans	  for	  youth	  on	  P1	  and	  P2	  including	  the	  presence	  of	   measurable	  goals	  and	  objectives	  with	  targeted	  interventions.	  
• Data	  on	  the	  frequency	  and	  type	  of	  treatment	  services	  provided,	  via	  the	  CaseNotes	   database.	  
• Progress	  notes	  to	  demonstrate	  how	  treatment	  goals	  are	  addressed	  within	  each	   treatment	  activity.	  
	   Analysis	  and	  Interpretation.	  	   ITP	  documents	  were	  available	  for	  five	  youth	  (AE,	  DS,	  DS2,	  BD,	  and	  WH).	  	  These	  ITP	  documents	   were	  provided	  in	  early	  January	  2013.	  More	  recent	  documents	  were	  not	  made	  available	  for	   review,	  so,	  in	  the	  interest	  of	  providing	  guidance	  and	  feedback,	  the	  early	  January	  documents	   were	  audited.	  Improvements	  were	  noted	  in	  the	  goals	  and	  objectives	  recorded	  in	  the	  ITPs	   compared	  to	  those	  reviewed	  in	  October	  2012	  during	  the	  most	  recent	  DOJ	  site	  visit,	  but	  the	  lack	   of	  focus	  on	  skill	  building	  continues	  to	  be	  problematic	  (and,	  encouragingly,	  has	  been	  a	  focus	  of	   the	  feedback	  from	  the	  Central	  Office	  Review	  Board).	   	   Furthermore,	  the	  prescribed	  type	  and	  frequency	  of	  treatment	  was	  not	  always	  clear	  in	  the	   description	  of	  the	  intervention.	  This	  lack	  of	  specificity	  precluded	  an	  assessment	  of	  the	  extent	  to	   which	  treatment	  services	  were	  provided	  (per	  the	  CaseNotes	  data)	  as	  prescribed	  on	  the	  ITP.	  	   	   	  
Technical	  Assistance	  Note:	  Treatment	  Planning	  
The	  Court	  Order	  requires	  ITP	  documents	  to	  be	  provided	  within	  30	  days	  of	  the	  youth’s	  admission	  to	  the	   facility	  and	  subsequently	  upon	  any	  changes	  to	  the	  ITP.	  	  Documentation	  showed	  that	  a	  number	  of	  youth	   were	  admitted	  to	  the	  unit	  in	  late	  December	  2012	  and	  early	  February	  2013;	  however,	  initial	  ITP	   documentation	  was	  not	  received.	  In	  the	  future,	  timely	  submission	  of	  initial	  and	  subsequent	  ITPs	  is	  essential	   for	  comprehensive	  monitoring	  and	  quality	  assurance.	   	   CaseNotes	  data	  are	  regularly	  submitted	  and,	  despite	  some	  mis-­‐categorization	  of	  activities,	  appear	   sufficient	  to	  identify	  the	  type	  and	  amount	  of	  treatment	  youth	  receive.	  However,	  without	  current	  ITPs,	  the	   CaseNotes	  data	  cannot	  be	  cross-­‐referenced	  with	  the	  ITP	  prescription.	  Finally,	  the	  QA	  process	  should	  also	   include	  a	  review	  of	  Progress	  Notes	  to	  ascertain	  whether	  treatment	  sessions	  are	  appropriately	  anchored	  to	   the	  youth’s	  treatment	  goals.	  These	  data	  should	  all	  be	  submitted	  to	  the	  Monitor.	  	   	   ODYS	  has	  conducted	  several	  audits	  to	  improve	  the	  quality	  of	  treatment	  planning.	  These	  reviews	  provided	   excellent	  feedback	  and	  will	  be	  an	  essential	  component	  of	  DYS’	  Quality	  Improvement	  Plan.	  
	   	   Whether	  youth	  were	  prescribed	  psychotropic	  medication	  was	  difficult	  to	  determine	  given	  the	   content	  of	  the	  treatment	  plans.	  Youth	  who	  are	  prescribed	  medication	  must	  have	  an	  ITP	  goal	   referring	  to	  this	  treatment	  intervention.	   	   Other	  goals,	  while	  appropriate,	  were	  variable	  with	  regard	  to	  appropriate	  interventions	   indicated.	  	  Two	  specific	  examples	  are	  discussed	  here,	  but	  the	  pattern	  was	  evident	  throughout	   the	  IDT	  documents.	  In	  the	  case	  of	  BD,	  one	  of	  his	  treatment	  goals	  was	  “I	  will	  not	  expose	  my	  penis	   to	  any	  female	  for	  the	  next	  14	  days.	  	  This	  will	  be	  monitored	  by	  not	  receiving	  any	  YBIR’s	  for	  sexual	  

	  

21.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 22 of 34 PAGEID #: 2583

conduct	  within	  that	  14	  days.”	  	  The	  intervention	  indicated,	  “If	  I	  feel	  the	  urge	  to	  expose	  myself	  or	   masturbate	  in	  front	  of	  a	  female…I	  will	  complete	  a	  Decisional	  Balance	  worksheet	  and	  process	  the	   information	  with	  my	  social	  worker	  during	  individual	  sessions.	  	  I	  will	  talk	  to	  my	  behavioral	  health	   [staff]	  at	  least	  one	  time	  per	  week	  regarding	  my	  sexual	  misconduct	  urges.”	  This	  youth	  had	   diagnoses	  documented	  as	  ADHD	  and	  Conduct	  Disorder.	  	  There	  was	  no	  IDT	  goal	  regarding	   psychotropic	  medication,	  and	  therefore,	  it	  was	  unclear	  if	  he	  was	  prescribed	  medication	  at	  the	   time	  this	  ITP	  was	  authored.	   	   In	  this	  case,	  a	  more	  appropriate	  treatment	  protocol	  would	  be	  to	  consider	  the	  youth’s	  motivation	   for	  exposing	  himself	  (e.g.	  anxiety,	  sexual	  aggression,	  impulsivity,	  to	  repel	  others,	  hypersexuality,	   control	  of	  his	  environment,	  attention	  seeking,	  etc.)	  or	  specific	  triggers,	  which	  precipitated	  his	   self-­‐exposure.	  	  Then,	  treatment	  interventions	  should	  be	  developed	  focusing	  on	  specific	  skills	  the	   youth	  will	  need	  to	  acquire	  in	  order	  to	  address	  the	  underlying	  cause	  of	  the	  maladaptive	  behavior.	   	   Documentation	  provided	  revealed	  a	  review	  of	  this	  youth’s	  treatment	  plan	  performed	  by	  ODYS	   central	  office	  2/15/13.	  	  There	  were	  excellent	  suggestions	  provided	  via	  this	  review	  document.	  	   Unfortunately,	  the	  ITP	  revisions	  performed	  as	  a	  result	  of	  this	  review	  were	  not	  provided	  prior	  to	   the	  completion	  of	  this	  status	  report.	   	   Other	  examples	  included	  the	  case	  of	  RB.	  	  Per	  the	  IDT	  minutes	  dated	  2.26.12,	  his	  treatment	  goals	   included,	  “I	  will	  reduce	  acts	  of	  violence	  or	  cruelty	  towards	  people.”	  	  IDT	  documentation	   indicated,	  “this	  is…weakest	  area…he	  earned	  two	  primary	  YBIR’s	  for	  fighting…peers	  target	  him	   and	  taunt	  him…he	  appeared	  to	  allow	  these	  insults	  to	  fester	  to	  the	  point	  where	  he	  would	   fight…shows	  an	  increased	  ability	  to	  ignore	  and	  control	  his	  temper,	  but	  he	  is	  still	  fighting…not	   meeting	  this	  behavioral	  requirement.”	  	  The	  document	  further	  stated,	  “in	  light	  of	  the	  fights,	   there	  may	  be	  a	  recommendation	  to	  return	  to	  the	  PU	  where	  he	  does	  well	  because	  of	  the	   structure	  on	  the	  unit	  and	  in	  school…another	  option	  is	  that	  …earn	  his	  way	  to	  general	  population	   and	  possibly	  transfer	  to	  another	  facility.	  	  	  Youth	  Specialists	  expressed	  concern	  for…safety	   because	  of	  the	  behaviors	  of	  his	  peers.”	  	  	   	   This	  documentation	  is	  concerning	  as	  there	  are	  apparently	  concerns	  for	  this	  youth’s	  safety,	  he	  is	   being	  targeted	  and	  taunted,	  and	  then	  penalized	  for	  fighting.	  	  The	  IDT	  must	  explore	  ways	  to	   ensure	  this	  youth	  is	  safe	  and	  not	  provoked	  by	  other	  youth.	  	  In	  addition,	  there	  were	  no	  notations	   regarding	  skills	  he	  may	  need	  to	  develop.	  	  The	  document	  indicated,	  “team	  members	  encouraged	   him	  to	  stop	  fighting,	  continue	  to	  work	  on	  expressing	  his	  anger	  differently	  and	  asked	  if	  they	  could	   assist	  him	  to	  reach	  these	  goals.	  	  [He]	  did	  not	  identify	  any	  needs	  from	  the	  team.	  	  It	  was	   considered	  that	  the	  youth’s	  primary	  need	  is	  safety.”	   	   Recommendations.	  	   In	  order	  to	  meet	  the	  standard	  associated	  with	  Treatment	  Planning,	  a	  Quality	  Improvement	  Plan	   should	  be	  developed	  to	  address	  the	  following	  issues:	  
1. Ensuring	  that	  ITP	  goals	  and	  objectives	  are	  measurable,	  strength-­‐based	  and	  include	  the	   specific	  skill	  development	  needed.	  	  
2. Ensuring	  that	  ITP	  interventions	  are	  documented	  and	  appropriate	  to	  the	  stated	  goals	  and	   objectives,	  via	  clinicians’	  Progress	  Notes.	  
3. Verifying	  that	  youth	  receive	  the	  type	  and	  intensity	  of	  the	  services	  prescribed	  on	  the	  ITP.	  	   	   	  

	  

22.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 23 of 34 PAGEID #: 2584

	   (3)	  Standard:	  Progress	  Reporting	  and	  Promotion.	   Progress	  toward	  treatment	  goals	  and	  behavioral	  expectations	  is	  assessed	  on	  a	  weekly	  basis.	   Youth	  are	  promoted	  to	  the	  next	  higher	  phase	  when	  they	  have	  met	  their	  treatment	  goals	  and	   behavioral	  expectations.	  Behavior	  not	  related	  to	  AOV,	  serious	  STG	  activity,	  possession	  of	  major	   contraband,	  or	  repeated	  verbal	  threats	  to	  cause	  serious	  harm	  are	  not	  used	  as	  a	  basis	  to	   withhold	  promotion.	  	   	   Methodology.	  	   The	  following	  information	  should	  be	  used	  to	  determine	  compliance	  with	  the	  standard:	  
• Behavior	  Expectation	  Tracking	  Sheets	   • Treatment	  Plans,	  and	  updates	   • Progress	  Note	  entries	  in	  the	  CaseNotes	  database	   • IDT	  Minutes	   	   Analysis	  and	  Interpretation.	  	   IDT	  minutes	  were	  received	  throughout	  the	  monitoring	  period,	  clearly	  demonstrating	  that	  the	   IDTs	  on	  all	  three	  units	  meet	  weekly	  as	  required.	  Youth	  are	  regularly	  promoted	  when	  they	  have	   accomplished	  the	  behavioral	  objectives.	  However,	  the	  discussion	  surrounding	  why	  Phase	  1	   youth	  did	  not	  or	  could	  not	  meet	  the	  behavioral	  objectives	  often	  lacked	  substance.	  Furthermore,	   progress	  toward	  treatment	  goals	  was	  not	  discussed	  with	  enough	  detail	  to	  determine	  which	   objectives	  may	  have	  been	  met	  and	  which	  remained	  incomplete.	  	   	   In	  general,	  the	  discussion	  surrounding	  treatment	  plans	  (ITPs)	  during	  the	  2/26/13	  IDT	  meetings	   were	  much	  improved	  over	  previous	  submissions.	  	  The	  revised	  format	  reviews	  the	  youth’s	  ITP	   goals	  and	  a	  brief	  summary	  of	  his	  progress	  toward	  said	  goals.	  However,	  it	  was	  difficult	  to	  discern	   the	  skills	  that	  the	  team	  believed	  were	  necessary	  for	  the	  youth	  to	  develop	  in	  order	  to	  meet	  their	   goals.	   	   For	  example,	  in	  the	  case	  of	  youth	  CC,	  the	  IDT	  minutes	  revealed	  the	  youth	  “received	  a	  primary	   violation	  for	  sexual	  misconduct…last	  week…since	  this,	  he	  has	  had	  three	  secondary	   violations…has	  not	  met	  his	  behavioral	  expectations…team	  members	  reported	  youth’s	  positive	   participation	  in	  group	  and	  in	  school…[but]	  he	  continues	  to	  sit	  alone	  in	  the	  corner…observing	  unit	   activity.	  [Psychology	  staff]…continues	  to	  process	  his	  feelings	  of	  dissonance.”	  This	  IDT	  case	   summary	  lacks	  clarity	  with	  regard	  to	  specific	  skills	  this	  youth	  needs	  to	  develop	  in	  order	  to	  avoid	   behavioral	  challenges,	  including	  sexual	  misconduct.	  This	  youth	  was	  noted	  to	  have	  strengths	  with	   regard	  to	  participation	  in	  group	  and	  in	  school,	  but	  was	  reported	  to	  isolate	  on	  the	  unit.	  While	  it	   was	  suggested	  that	  the	  youth’s	  observation	  served	  a	  purpose,	  it	  is	  unclear	  what	  this	  purpose	  is	   and	  how	  it	  will	  be	  addressed	  with	  regard	  to	  skill	  acquisition.	  This	  discussion	  was	  not	  anchored	  to	   the	  youth’s	  treatment	  goals,	  and	  thus	  the	  youth’s	  progress	  toward	  them	  was	  never	  quite	   articulated.	  	   	   In	  the	  case	  of	  youth	  RB,	  it	  was	  noted	  that	  acts	  of	  violence	  toward	  others	  was	  this	  youth’s	   “weakest	  area.”	  There	  was	  information	  that	  “peers	  target	  him	  and	  taunt	  him…shows	  an	   increased	  ability	  to	  ignore	  and	  control	  his	  temper,	  but	  he	  is	  still	  fighting…not	  meeting	  this	   behavioral	  requirement.”	  	  There	  was	  a	  notation	  that	  the	  team	  encouraged	  this	  youth	  to	  “stop	   fighting”	  but	  it	  was	  unclear	  what	  skills	  this	  youth	  needed	  to	  develop	  in	  order	  to	  achieve	  this	   goal.	  

	  

23.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 24 of 34 PAGEID #: 2585

	   With	  regard	  to	  youth	  TB,	  the	  lack	  of	  progress	  toward	  treatment	  goals	  may	  be	  due	  to	  a	  potential	   psychiatric	  illness.	  This	  youth	  had	  diagnoses	  on	  admission	  to	  the	  PU	  of:	  	  Rule	  out	  psychotic	   disorder,	  NOS;	  Conduct	  Disorder;	  Oppositional	  Defiant	  Disorder;	  Cannabis	  Dependence.	  	  His	   family	  reportedly	  refuses	  to	  consent	  to	  psychotropic	  medication,	  and	  his	  behavior	  has	  been	   “odd”	  and	  included	  the	  requirement	  for	  suicide	  watch	  due	  to	  his	  tying	  “	  jumpsuit	  around	  his	   neck”	  covering	  “himself	  with	  his	  mattress	  and	  was	  unresponsive	  to	  staff.”	  This	  youth	  has	   reportedly	  not	  met	  any	  of	  his	  treatment	  goals	  and	  has	  not	  been	  promoted.	  Given	  what	  appear	   to	  be	  significant	  mental	  health	  symptoms,	  consideration	  of	  a	  transfer	  to	  the	  mental	  health	  unit	   would	  be	  expected.	   	   Recommendations.	  	   In	  order	  to	  meet	  the	  standard	  associated	  with	  Progress	  Reporting	  and	  Promotion,	  a	  Quality	   Improvement	  Plan	  should	  be	  developed	  to	  address	  the	  following	  issues:	  
1. Ensuring	  that	  ITP	  and	  IDT	  documentation	  clearly	  outlines	  the	  skills	  that	  the	  youth	  needs	   to	  develop	  in	  order	  to	  meet	  identified	  treatment	  goals.	  
2. Ensure	  that	  the	  ITP	  clearly	  outlines	  the	  steps	  that	  will	  be	  utilized	  to	  assist	  the	  youth	  in	   skill	  development.	  
3. Documenting	  the	  progress,	  or	  the	  lack	  thereof,	  on	  the	  ITP	  goals	  and	  how	  the	   interventions	  will	  be	  adjusted	  in	  order	  to	  assist	  the	  youth	  in	  achieving	  said	  goals	  (note:	   this	  may	  be	  documented	  in	  weekly	  IDT	  minutes).	   	  
	   (4)	  Standard:	  Inter-­‐Disciplinary	  Team.	  [Note:	  this	  standard	  applies	  only	  to	  the	  S.H.	  Agreement.]	   A	  psychiatrist	  or	  psychologist	  facilitates	  an	  Inter-­‐Disciplinary	  Team	  (IDT)	  meeting.	  Attendees	   include	  social	  workers,	  psychologists,	  occupational	  therapists,	  medical	  staff,	  educators,	   recreation	  staff,	  Unit	  Managers	  and	  Youth	  Specialists.	  If	  a	  member	  of	  the	  IDT	  cannot	  attend,	   written	  input	  is	  provided	  to	  the	  IDT	  Chair.	  	   	   Methodology.	  	   The	  following	  information	  should	  used	  to	  determine	  compliance	  with	  the	  standard:	  
• IDT	  Minutes	   	   	  
Technical	  Assistance	  Note:	  IDT	  
While	  the	  Monitors	  have	  not	  yet	  engaged	  in	  this	  type	  of	  monitoring,	  any	  Quality	  Assurance	  protocol	   should	  include	  direct	  observation	  of	  IDT	  meetings	  in	  order	  to	  form	  conclusions	  about	  whether	  they	  meet	   the	  relevant	  standards.	  	  
	   	   Analysis	  and	  Interpretation.	  	   The	  IDT	  minutes	  available	  for	  the	  majority	  of	  the	  monitoring	  period	  did	  not	  include	  the	  names	  or	   positions	  of	  the	  staff	  members	  present.	  	  The	  one	  exception	  to	  this	  was	  the	  IDT	  documentation	   from	  2/26/13.	  These	  minutes	  revealed	  an	  improvement	  in	  documentation	  surrounding	  the	   participants	  in	  the	  meetings,	  although	  it	  did	  not	  always	  specify	  the	  individual’s	  role.	  The	  contract	   psychiatrist	  was	  present	  for	  IDT	  on	  Phase	  1	  and	  Phase	  2,	  and	  the	  psychologist	  was	  present	  for	   the	  IDT	  on	  the	  Transition	  Unit.	  Prior	  to	  these	  minutes,	  it	  was	  not	  possible	  to	  verify	  whether	  the	  

	  

24.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 25 of 34 PAGEID #: 2586

required	  participants	  attended	  or	  not,	  and	  it	  did	  not	  appear	  that	  non-­‐attending	  members	   submitted	  written	  input	  for	  consideration	  by	  the	  team.	  	  	  	   	   Recommendations.	  	   In	  order	  to	  meet	  the	  standard	  associated	  with	  the	  Inter-­‐Disciplinary	  Team,	  a	  Quality	   Improvement	  Plan	  should	  be	  created	  to	  address	  the	  following	  issues:	  	  
1. Documenting	  staff	  attendance	  (i.e.,	  name	  and	  role)	  at	  IDT	  via	  the	  IDT	  minutes.	   2. Ensuring	  an	  appropriate	  complement	  of	  staff	  at	  the	  IDT	  meetings.	   3. If	  staff	  are	  not	  in	  attendance,	  providing	  written	  input	  to	  the	  IDT	  chair	  for	  review.	   	   	   (5)	  Standard:	  IDT	  Substance.	  	   Youth	  appear	  before	  an	  Inter-­‐Disciplinary	  Team	  (IDT)	  at	  least	  bi-­‐weekly.	  IDT	  meetings	  for	  each	   youth	  involve	  a	  structured	  and	  specific	  discussion	  of	  each	  youth’s	  goals	  and	  objectives,	   behavioral	  expectations	  and	  progress	  toward	  meeting	  them.	  	   • When	  goals	  and	  expectations	  are	  met,	  the	  youth	  is	  promoted.	  	   • If	  goals	  and	  expectations	  are	  not	  met,	  the	  IDT	  identifies	  the	  areas	  in	  need	  of	  
improvement	  so	  the	  youth	  know	  what	  is	  required	  for	  promotion.	  The	  IDT	  also	  revises	   the	  treatment	  plan	  or	  its	  implementation	  to	  better	  address	  the	  underlying	  causes	  of	  the	   youth’s	  unwanted	  behaviors.	  	   	   Methodology.	  	   The	  following	  information	  should	  be	  used	  to	  determine	  compliance	  with	  the	  standard:	   • IDT	  Minutes	   • Treatment	  Plans,	  and	  updates	   	   	  
Technical	  Assistance	  Note:	  IDT	  
While	  the	  Monitors	  have	  not	  yet	  engaged	  in	  this	  type	  of	  monitoring,	  any	  Quality	  Assurance	  protocol	   should	  include	  direct	  observation	  of	  IDT	  meetings	  in	  order	  to	  form	  conclusions	  about	  whether	  they	  meet	   the	  relevant	  standards.	  	  
	   	   Analysis	  and	  Interpretation.	  	   IDT	  minutes	  reviewed	  for	  this	  status	  report	  revealed	  documentation	  that	  youth	  meet	  with	  the	   IDT	  bi-­‐weekly	  as	  required.	  There	  was	  notation	  that	  the	  youth	  were	  engaged	  in	  the	  treatment	   planning	  process	  and	  that	  treatment	  interventions	  were	  discussed	  with	  them.	  	  As	  noted	  in	  the	   discussions	  above,	  there	  needs	  to	  be	  increased	  attention	  to	  skill	  development	  with	  regard	  to	   those	  skills	  needed	  to	  meet	  specific	  treatment	  goals.	  Furthermore,	  only	  some	  of	  the	  youth	   reviewed	  in	  the	  most	  recent	  set	  of	  IDT	  Minutes	  includes	  a	  structured	  review	  of	  the	  youth’s	  ITP	   goals	  and	  objectives.	  	   	   	  
Technical	  Assistance	  Note:	  IDT	  
The	  Court	  Order	  requires	  youth	  to	  attend	  the	  IDT	  only	  every	  other	  week.	  It	  is	  likely	  that	  feedback	  on	  the	   youth’s	  performance	  is	  more	  powerful	  when	  delivered	  to	  the	  youth	  by	  the	  team.	  	  In	  order	  to	  facilitate	  

	  

25.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 26 of 34 PAGEID #: 2587

progress	  through	  the	  program,	  as	  is	  the	  goal,	  DYS	  should	  consider	  reviewing	  each	  youth	  in	  person	  every	   week.	  This	  may	  be	  feasible	  given	  that	  the	  PU	  population	  is	  lower	  than	  it	  has	  been	  in	  the	  past.	  	  
	   	   There	  was	  documentation	  of	  the	  IDT’s	  awareness	  of	  the	  need	  to	  be	  clear	  and	  consistent	  with	   youth	  when	  discussing	  promotions	  (or	  retention	  on	  a	  specific	  level).	  	  For	  example,	  in	  the	  case	  of	   DS	  reviewed	  in	  IDT	  on	  2/26/13,	  “it	  was	  suggested	  that	  in	  the	  future,	  the	  team	  needs	  to	  be	  clear	   with	  youth	  that	  they	  need	  to	  complete	  all	  ITP	  goals	  for	  a	  youth	  on	  Phase	  2	  to	  qualify	  for	   transition,	  and	  if	  behavioral	  expectations	  need	  to	  be	  carried	  over	  from	  Phase	  1,	  that	  they	  need	   to	  be	  put	  in	  the	  form	  of	  a	  measurable	  objective	  on	  their	  ITP…Phase	  2	  youth	  move	  to	  transition	   based	  strictly	  on	  their	  ITP	  goals.”	   	   Recommendations.	  	   In	  order	  to	  meet	  the	  standard	  associated	  with	  the	  IDT	  Substance,	  a	  Quality	  Improvement	  Plan	   should	  be	  crafted	  to	  address	  the	  following	  issues:	  
1. Ensuring	  that	  IDT	  documentation	  reveals	  a	  structured	  and	  specific	  discussion	  of	  each	   youth’s	  goals	  and	  objectives.	  
2. Ensuring	  that	  IDT	  documentation	  includes	  discussion	  of	  behavioral	  expectations	  and	   progress	  toward	  meeting	  expectations.	  
3. If	  goals	  and	  expectations	  are	  not	  met,	  identifying	  the	  areas	  in	  need	  of	  improvement	  so	   the	  youth	  know	  what	  is	  required	  for	  promotion.	  
	   	   (6)	  Standard:	  Length	  of	  Stay	  [this	  standard	  is	  monitored	  by	  Dr.	  Dedel;	  the	  other	  standards	  in	  the	   Treatment	  Planning	  section	  are	  monitored	  by	  Dr.	  Glindmeyer]	   	   A	  Length	  of	  Stay	  (LOS)	  record	  is	  maintained	  for	  each	  youth	  to	  document	  the	  date	  placed	  on	   Phase	  1,	  promoted	  to	  Phase	  2,	  promoted	  to	  Transition,	  and	  transferred	  to	  the	  general	   population.	  Youth	  are	  expected	  to	  promote	  to	  the	  next	  phase	  within	  30	  days	  (or	  be	  referred	  for	   review,	  as	  described	  by	  Standards	  7-­‐8,	  below).	  Across	  the	  three	  phases,	  the	  outer	  limit	  is	  90	   days.	  	   	   Methodology.	  	   The	  following	  information	  should	  be	  used	  to	  determine	  compliance	  with	  the	  standard:	  
• LOS	  Records	  which	  are	  currently	  captured	  on	  the	  Youth	  Activity	  Tracking	  form	   	   Although	  21	  youth	  spent	  time	  on	  the	  PU	  during	  the	  period	  of	  review,	  LOS	  data	  were	  available	   for	  only	  the	  17	  youth	  housed	  on	  the	  unit	  as	  of	  February	  25,	  2013	  (see	  Technical	  Assistance	  note,	   below).	  Each	  youth’s	  Youth	  Activity	  Tracking	  (YAT)	  record	  begins	  with	  a	  synopsis	  of	  their	   movement	  across	  the	  phases.	  [Note:	  DYS	  began	  capturing	  LOS	  data	  on	  October	  1,	  2012.	  As	  a	   result,	  LOS	  data	  for	  youth	  who	  entered	  the	  PU	  prior	  to	  that	  date	  will	  underestimate	  their	  actual	   LOS.]	  Data	  on	  overall	  LOS	  and	  LOS	  within	  each	  phase	  were	  calculated	  for	  each	  youth,	  and	  then	   aggregated	  across	  the	  17	  youth	  in	  the	  sample.	  	   	   	   	   	  

	  

26.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 27 of 34 PAGEID #: 2588

Technical	  Assistance	  Note:	  
Given	  that	  DYS	  does	  not	  capture	  YAT	  data	  for	  youth	  on	  in	  Transition,	  it	  may	  not	  be	  prudent	  to	  house	  LOS	   data	  within	  these	  records.	  End	  dates	  for	  Transition	  are	  not	  included	  among	  the	  data	  provided	  to	  the	   Monitor	  and	  so	  the	  LOS	  could	  not	  be	  calculated	  for	  the	  four	  youth	  who	  returned	  to	  the	  general	  population	   during	  the	  sampling	  timeframe.	  DYS	  should	  develop	  the	  ability	  to	  compile	  stand-­‐alone	  LOS	  records	  that	   capture	  the	  beginning	  and	  end	  date	  for	  all	  phases.	  
	   	   Analysis	  and	  Interpretation.	  	   The	  youth	  housed	  on	  the	  PU	  as	  of	  February	  25,	  2013	  had	  been	  there	  for	  an	  average	  of	  118	  days	   (about	  4	  months).	  Because	  outliers	  (i.e.,	  youth	  who	  have	  a	  very	  short	  LOS	  or	  a	  very	  long	  LOS)	   distort	  a	  mathematical	  average,	  the	  median	  was	  also	  calculated.	  The	  median	  was	  142	  days	   (about	  5	  months),	  which	  means	  50%	  of	  the	  youth	  on	  the	  PU	  had	  been	  there	  for	  less	  than	  142	   days	  and	  50%	  of	  the	  youth	  on	  the	  PU	  had	  been	  there	  for	  more	  than	  142	  days.	  Put	  simply,	  the	   average	  youth	  currently	  on	  the	  PU	  has	  been	  there	  for	  about	  4	  or	  5	  months.	  Note	  that	  these	   youth	  have	  not	  yet	  completed	  the	  program—this	  statistic	  refers	  only	  to	  the	  length	  of	  time	  they	   have	  currently	  been	  on	  the	  PU.	  	  	   	   The	  LOS	  on	  Phases	  1	  (P1)	  and	  2	  (P2)	  were	  also	  calculated.	  These	  calculations	  used	  only	  stays	  that	   had	  been	  completed—if	  a	  youth	  is	  currently	  on	  a	  phase,	  that	  data	  was	  not	  used	  because	  there	  is	   no	  end	  date.	  Across	  the	  20	  P1	  stays,	  the	  average	  LOS	  was	  35	  days,	  and	  the	  median	  was	  19.5	   days.	  For	  the	  17	  stays	  on	  P2,	  the	  average	  was	  22	  days	  and	  the	  median	  was	  16	  days.	  The	  median	   for	  both	  P1	  and	  P2	  was	  significantly	  shorter	  than	  the	  average,	  which	  means	  that	  the	  average	   was	  distorted	  by	  a	  small	  number	  of	  youth	  who	  spent	  an	  extraordinarily	  long	  time	  on	  the	  phase	   (e.g.	  one	  youth	  spent	  134	  days	  on	  P1,	  another	  spent	  64	  days	  on	  P2).	  	   	   The	  number	  of	  times	  the	  30-­‐day	  benchmark	  for	  external	  review	  was	  exceeded	  was	  also	   calculated.	  Across	  the	  20	  completed	  stays	  on	  P1,	  7	  exceeded	  the	  30-­‐day	  maximum	  limit	  (35%).	   Across	  the	  17	  completed	  stays	  on	  P2,	  3	  exceeded	  the	  30-­‐day	  maximum	  limit	  (18%).	  In	  other	   words,	  65%	  of	  the	  P1	  episodes	  were	  completed	  within	  30	  days	  and	  82%	  of	  the	  P2	  episodes	  were	   completed	  within	  30	  days.	  	   	   Finally,	  the	  frequency	  with	  which	  youth	  recycled	  through	  the	  phases	  was	  calculated.	  Across	  the	   17	  youth,	  all	  but	  5	  youth	  had	  repeated	  the	  P1-­‐P2-­‐T	  cycle	  (or	  part	  of	  it)	  at	  least	  once.	  In	  other	   words,	  70%	  of	  the	  youth	  currently	  on	  the	  PU	  have	  not	  progressed	  cleanly	  from	  P1	  to	  P2	  to	   Transition,	  but	  rather	  have	  recycled	  through	  the	  phases,	  sometimes	  more	  than	  once.	  	   	   Thus,	  while	  many	  of	  the	  individual	  LOS	  on	  P1	  (65%)	  and	  P2	  (82%)	  fall	  within	  the	  30-­‐day	   maximum	  limit,	  the	  fact	  that	  youth	  often	  cycle	  back	  through	  the	  phases	  accounts	  for	  the	   significantly	  longer	  LOS	  than	  these	  data	  would	  suggest.	  In	  fact,	  all	  but	  three	  of	  the	  17	  youth	   currently	  housed	  on	  the	  unit	  	  (82%)	  have	  already	  exceeded	  the	  90-­‐day	  maximum	  limit,	  and	  they	   have	  yet	  to	  complete	  the	  PU	  program.	   	   Recommendations.	  	   In	  order	  to	  meet	  the	  standard	  associated	  with	  Length	  of	  Stay,	  the	  DYS	  should	  develop	  a	  Quality	   Improvement	  Plan	  to	  address	  the	  following	  issues:	  

	  

27.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 28 of 34 PAGEID #: 2589

1. Develop	  stand-­‐alone	  LOS	  records	  that	  provide	  definitive	  end	  dates	  for	  all	  phases,	   including	  the	  Transition	  phase.	  Consider	  divorcing	  the	  LOS	  record	  from	  the	  YAT	  records.	  	  
2. Investigate	  the	  reasons	  that	  youth	  are	  being	  returned	  to	  lower	  phases	  at	  such	  high	   frequencies.	  While	  the	  obvious	  reason	  is	  that	  they	  have	  displayed	  behavior	  that	   warrants	  demotion	  (i.e.,	  AOV,	  using	  STG	  to	  direct	  the	  harm	  of	  another	  person,	  major	   contraband,	  repeated	  verbal	  threats),	  the	  QIP	  should	  look	  for	  the	  underlying	  reason	  that	   these	  youth	  have	  not	  adopted	  or	  are	  not	  displaying	  the	  skills	  needed	  to	  control	  their	   impulses,	  manage	  anger,	  improve	  decision-­‐making	  etc.	  	  
	   	   (7)	  Standard:	  Central	  Office	  Review	  Board	  Composition	  and	  Timelines.	  	   A	  Central	  Office	  Review	  Board	  (CORB)	  conducts	  a	  review	  of	  any	  youth	  who	  has	  been	  on	  any	   phase	  of	  the	  PU	  for	  more	  than	  28	  days.	  At	  a	  minimum,	  the	  CORB	  consists	  of	  an	  Administrative	   Psychiatrist,	  the	  Bureau	  Chief	  of	  Facility	  Programs,	  and	  Behavioral	  Health	  Administrator.	  The	   CORB	  review	  is	  completed	  by	  the	  42nd	  /35th	  day	  on	  the	  phase.	  	   	   Methodology.	  	   The	  following	  information	  should	  be	  used	  to	  determine	  compliance	  with	  the	  standard:	  
• CORB	  review	  packets	   	   Analysis	  and	  Interpretation.	  	   Of	  a	  total	  of	  seven	  CORB	  review	  documents,	  six	  included	  signatures	  of	  a	  minimum	  of	  three	  staff	   members,	  including	  the	  Administrative	  Psychiatrist.	  	  One	  did	  not	  include	  the	  signature	  of	  the	   Administrative	  Psychiatrist.	  	  For	  other	  members	  present,	  it	  was	  difficult	  to	  determine	  the	   individual	  and	  their	  role,	  as	  in	  some	  cases,	  the	  signatures	  were	  illegible,	  and	  there	  was	  no	   notation	  included.	   	   A	  review	  of	  the	  documents	  revealed	  inconsistencies	  with	  regard	  to	  the	  required	  timelines	  for	   review.	  For	  example,	  BD	  was	  admitted	  to	  the	  PU	  11/9/12,	  he	  was	  placed	  on	  his	  current	  phase	   1/2/13,	  and	  the	  date	  of	  the	  review	  was	  2/15/13,	  however	  two	  board	  members	  signatures	  were	   dated	  2/19/13.	  There	  was	  notation	  of	  a	  previous	  review	  12/21/12,	  but	  documentation	  of	  this	   meeting	  was	  not	  reviewed	  given	  the	  timeframe	  for	  this	  status	  report.	  This	  timeline	  was	   confusing:	  this	  youth	  had	  a	  period	  of	  56	  days	  between	  the	  first	  and	  second	  review;	  however,	   documentation	  did	  not	  clarify	  the	  reason	  for	  this	  delay.	  Review	  of	  other	  cases	  revealed	  similar	   issues	  with	  regard	  to	  timelines.	  	  Documentation	  should	  provide	  a	  clear	  history	  of	  the	  youth’s	  PU	   stay	  including	  the	  number	  of	  days	  on	  a	  particular	  level,	  promotions	  and	  demotions.	  Special	   attention	  should	  be	  given	  to	  youth	  who	  “recycle”	  through	  the	  system.	   	   Recommendations.	  	   In	  order	  to	  meet	  the	  standard	  associated	  with	  the	  CORB	  Composition	  and	  Timelines,	  a	  Quality	   Improvement	  Plan	  should	  be	  developed	  to	  address	  the	  following	  issues:	   1. Ensuring	  that	  the	  full	  complement	  of	  CORB	  staff	  participate	  in	  the	  review	  and	  sign	  the	  
document.	  Clearly	  indicate	  the	  individual’s	  title.	  	   2. Ensuring	  documentation	  of	  the	  youth’s	  history	  on	  the	  PU	  including	  the	  number	  of	  days	  
on	  a	  particular	  level,	  promotions	  and	  demotions,	  and	  ensuring	  that	  the	  CORB	  review	  is	   performed	  within	  the	  required	  timelines.	   	   	  

	  

28.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 29 of 34 PAGEID #: 2590

	   	   (8)	  Standard:	  Central	  Office	  Review	  Board	  Substance.	  	   The	  CORB	  utilizes	  a	  comprehensive	  summary	  of	  the	  youth’s	  clinical	  formulation,	  treatment,	   progress	  and	  challenges	  to	  date.	  The	  summary	  is	  reviewed	  by	  each	  CORB	  team	  member	  prior	  to	   the	  case	  review.	  The	  CORB	  issues	  specific	  recommendations	  for	  refocusing	  the	  youth’s	   treatment	  and	  sets	  specific	  timelines	  for	  subsequent	  reviews.	  Recommendations	  are	   communicated	  to	  the	  IDT,	  which	  notifies	  the	  youth	  if	  the	  treatment	  plan	  has	  been	  modified.	  	   	   Methodology.	  	   The	  following	  information	  should	  be	  used	  to	  determine	  compliance	  with	  the	  standard:	  
• CORB	  review	  packets	   • IDT	  Minutes	   	   Analysis	  and	  Interpretation.	  	   A	  review	  of	  seven	  examples	  of	  CORB	  documentation	  revealed	  that	  in	  most	  cases,	  all	  of	  the	   required	  documentation	  was	  not	  reviewed.	  For	  example,	  in	  the	  case	  of	  BD,	  the	  psychological	   services	  summary	  and	  the	  IDT	  monthly	  progress	  report	  were	  not	  reviewed.	  In	  the	  case	  of	  RB,	   the	  IDT	  monthly	  progress	  report	  was	  not	  reviewed.	  In	  the	  case	  of	  DH,	  the	  psychological	   summary	  was	  not	  reviewed,	  nor	  were	  behavioral	  health	  assessments.	  In	  the	  case	  of	  KD,	  the	  IDT	   monthly	  progress	  report	  was	  not	  reviewed.	  In	  the	  case	  of	  JC,	  behavioral	  health	  assessments	   were	  not	  reviewed.	  In	  only	  two	  cases	  was	  there	  indication	  that	  all	  data	  were	  reviewed.	   	   	  
Technical	  Assistance	  Note:	  
The	  CORB	  review	  should	  not	  proceed	  without	  a	  comprehensive	  packet	  of	  information	  for	  the	  youth.	   Reviewing	  a	  youth’s	  progress	  with	  incomplete	  information	  is	  counterproductive.	  Furthermore,	  the	  fact	   that	  treatment	  has	  been	  ongoing	  without	  some	  of	  these	  essential	  treatment	  documents	  raises	  serious	   concern	  about	  the	  quality	  of	  treatment	  provided.	  	  
	   	   It	  was	  concerning	  that	  in	  some	  cases,	  there	  was	  a	  failure	  on	  the	  part	  of	  the	  IDT	  to	  follow	  through	   with	  recommendations	  in	  a	  timely	  manner.	  For	  example,	  in	  the	  case	  of	  KA,	  documentation	   indicated	  that	  during	  a	  previous	  review	  dated	  11/19/12,	  the	  CORB	  recommended	  an	  increase	  in	   the	  frequency	  of	  sessions	  to	  focus	  on	  the	  youth’s	  anger	  management	  and	  plans	  for	  additional	   psychological	  testing.	  	  With	  regard	  to	  the	  increase	  in	  frequency	  of	  sessions,	  there	  was	   documentation	  of	  the	  sessions	  with	  the	  youth,	  specifically,	  four	  individual	  psychotherapy	   sessions	  in	  January	  2013,	  but	  overall,	  this	  was	  a	  decrease	  over	  the	  number	  of	  individual	  sessions	   in	  the	  month	  of	  December	  2012,	  where	  there	  were	  six	  noted.	   	   It	  was	  noted	  that	  although	  the	  focus	  of	  the	  sessions	  was	  “to	  explore	  the	  youth	  becoming	  more	   open	  with	  the	  psychologist	  and	  to	  exercise	  better	  methods	  of	  self	  control”	  and	  the	  CORB	  had	   recommended	  anger	  management,	  it	  was	  not	  documented	  that	  anger	  management	  techniques	   were	  being	  addressed	  with	  this	  youth.	  Moreover,	  psychological	  testing	  remained	  pending,	   almost	  three	  months	  after	  it	  was	  recommended.	  	  	   	  

	  

29.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 30 of 34 PAGEID #: 2591

In	  general,	  documentation	  did	  not	  indicate	  specific	  skills	  that	  the	  youth	  would	  need	  to	  develop	  

in	  order	  to	  progress.	  For	  example,	  in	  the	  case	  of	  KA,	  the	  CORB	  noted,	  “will	  connect	  his	  thoughts	  

regarding	  being	  aggressive	  towards	  others	  by	  completing	  a	  decisional	  balance	  worksheet.”	  	  	  

Assaultive	  behavior	  has	  been	  a	  significant	  issue	  for	  this	  youth.	  The	  CORB	  document	  does	  not	  

opine	  regarding	  the	  reason	  the	  youth	  has	  not	  been	  able	  to	  acquire	  the	  necessary	  skills	  to	  

address	  his	  impulsivity	  (outside	  of	  the	  recent	  prescription	  of	  psychotropic	  medication).	  	  

	  

In	  the	  case	  of	  RB,	  the	  CORB	  indicated	  that	  the	  youth	  had	  routine	  contact	  with	  social	  work,	  

psychology,	  OT,	  nursing,	  and	  psychiatry.	  Information	  regarding	  the	  content	  of	  these	  contacts	  

and	  the	  need	  to	  alter	  treatment	  modalities	  in	  order	  for	  this	  youth	  meet	  his	  treatment	  goals	  was	  

not	  included.	  	  In	  addition,	  recommendations	  to	  the	  IDT	  were	  vague,	  for	  example,	  “continue	  to	  

focus	  on	  managing	  anger	  and	  teaching	  positive	  coping	  skills.”	  As	  this	  youth	  apparently	  cycled	  

from	  P1	  to	  P2	  on	  several	  occasions,	  more	  focus	  should	  have	  been	  placed	  on	  what	  skills	  the	  

youth	  needed	  to	  progress	  and	  the	  manner	  in	  which	  these	  skills	  were	  being	  

taught/modeled/reinforced	  with	  the	  youth.	  	  

	  

	  

Recommendations.	  	  

In	  order	  to	  meet	  the	  standard	  associated	  with	  the	  CORB	  Substance,	  a	  Quality	  Improvement	  Plan	  

should	  be	  developed	  to	  address	  the	  following	  issues:	  

1. Ensuring	  that	  all	  information	  is	  available	  to	  the	  CORB	  so	  that	  the	  members	  can	  perform	  

a	  quality	  review	  and	  make	  appropriate	  recommendations.	  

2. Ensuring	  that	  specific	  recommendations	  for	  refocusing	  the	  youth’s	  treatment	  are	  

provided.	  Consider	  soliciting	  feedback	  from	  the	  IDT	  on	  the	  utility	  of	  the	  CORB	  

document.	  

3. Ensuring	  that	  ITP	  documentation	  addresses	  specific	  recommendations	  of	  the	  CORB.	  

	  

	  

	  

	  

	  

30.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 31 of 34 PAGEID #: 2592

[II.13]	  	  Phase	  Demotions	  [monitored	  by	  Dr.	  Dedel]	   Status:	  Not	  in	  Substantial	  Compliance	  
	   (1)	  Standard:	  Phase	  Demotion.	  	   A	  deliberative	  process	  is	  utilized	  to	  demote	  youth	  to	  a	  lower	  phase.	  Demotions	  are	  imposed	  only	   for	  the	  following	  reasons:	  an	  act	  of	  violence,	  STG	  activity	  that	  promotes	  or	  directs	  an	  individual	   to	  carry	  out	  an	  act	  of	  violence,	  possession	  of	  major	  contraband,	  repeated	  verbal	  threats	  to	   cause	  serious	  physical	  harm	  to	  staff	  or	  other	  youth.	  All	  demotions	  are	  approved	  by	  the	  facility	   Superintendent.	  	   	   Methodology.	  	   The	  following	  information	  should	  be	  used	  to	  determine	  compliance	  with	  the	  standard:	  
• AMS	  reports	   • IDT	  Meeting	  minutes	   • IH	  documentation,	  including	  appeals	   • Interviews	  with	  youth,	  DYS	  and	  Scioto	  administrators	   • Phase	  Demotion	  Summary	  Form	  (currently	  under	  development)	   	   DYS	  submitted	  a	  list	  of	  four	  youth	  in	  response	  to	  a	  request	  for	  “a	  list	  of	  youth	  who	  were	   demoted	  between	  January	  18	  and	  February	  28,	  2013.”	  Three	  of	  these	  demotions	  were	   overturned	  just	  before	  this	  report	  was	  issued.	  Four	  additional	  demotions	  (one	  of	  which	  was	   overturned)	  were	  identified	  via	  the	  IDT	  minutes.	  	   	   IDT	  minutes	  and	  other	  documents	  were	  reviewed	  to	  ascertain	  the	  reason	  for	  demotion	  and	  how	   the	  decision	  to	  demote	  was	  deliberated.	  IDT	  Minutes	  were	  also	  reviewed	  to	  ascertain	  whether	   the	  teams	  use	  alternative	  consequences	  to	  sanction	  youth,	  even	  when	  their	  behavior	  may	  have	   qualified	  them	  for	  a	  demotion.	  	   	   	  
Technical	  Assistance	  Note:	  
Although	  the	  Monitor	  was	  provided	  with	  data	  regarding	  youth	  who	  were	  demoted,	  the	  data	  were	  often	   incomplete	  and	  required	  additional	  follow-­‐up	  questions,	  memos	  and	  conference	  calls.	  Moving	  forward,	   DYS	  should	  develop	  a	  form	  for	  the	  Superintendent’s	  signature	  that	  clearly	  delineates	  1)	  whether	  the	   youth’s	  behavior	  fits	  into	  the	  four	  criteria	  listed	  in	  the	  standard;	  2)	  the	  evidence	  that	  is	  available	  to	  support	   that	  conclusion;	  and	  3)	  why	  phase	  demotion	  is	  considered	  the	  best	  response	  (i.e.,	  why	  a	  less	  severe	   sanction	  is	  considered	  to	  be	  inadequate;	  why	  Phase	  1	  and	  not	  Phase	  2;	  what	  skills	  the	  youth	  needs	  in	  order	   to	  prevent	  similar	  behavior	  from	  re-­‐occurring	  and	  how	  to	  best	  teach	  him	  those	  skills).	  Such	  a	  document	   would	  likely	  reduce	  the	  need	  for	  DYS	  to	  respond	  to	  follow-­‐up	  questions	  from	  Monitors,	  public	  defenders,	   and	  other	  interested	  parties.	  At	  the	  time	  this	  report	  was	  drafted,	  DYS	  had	  begun	  to	  create	  this	  form.	  It	   should	  be	  completed	  for	  all	  youth	  who	  are	  demoted,	  whether	  or	  not	  their	  demotions	  are	  later	  rescinded	  or	   overturned.	  The	  extent	  to	  which	  this	  form	  provides	  the	  required	  information	  will	  be	  discussed	  in	   subsequent	  Status	  Reports.	  	  
	   	   Analysis	  and	  Interpretation.	  	   During	  the	  period	  of	  review,	  eight	  youth	  were	  slated	  for	  demotion	  to	  a	  lower	  phase.	  The	   demotion	  was	  overturned	  for	  one	  of	  these	  youth	  due	  to	  a	  technical	  violation	  of	  his	  due	  process	  

	  

31.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 32 of 34 PAGEID #: 2593

rights	  (the	  YBIR	  was	  not	  served	  within	  24	  hours;	  he	  was	  accused	  of	  using	  his	  position	  within	  an	  

STG	  to	  direct	  other	  members	  to	  harm	  a	  female	  staff	  if	  she	  refused	  to	  bring	  in	  contraband).	  

Among	  the	  other	  seven	  youth,	  one	  assaulted	  a	  Unit	  Manager	  on	  the	  Transition	  Unit;	  one	  

engaged	  in	  an	  AOV	  (details	  were	  not	  provided);	  one	  had	  a	  promotion	  rescinded	  because	  he	  was	  

found	  in	  possession	  of	  tobacco	  during	  the	  unit	  transfer;	  one	  sexually	  assaulted	  a	  Youth	  Specialist	  

by	  grabbing	  her	  crotch;	  and	  the	  other	  three	  allegedly	  engaged	  in	  verbal	  threatening	  and	  

intimidation	  of	  medical	  staff	  during	  an	  emergency	  response	  (although	  this	  was	  reported	  by	  

medical	  staff	  only	  after	  the	  fact,	  not	  in	  their	  written	  witness	  statements).	  After	  several	  weeks,	  

the	  phase	  demotions	  for	  these	  last	  three	  youth	  were	  overturned	  via	  the	  IH	  Appeal	  process,	  just	  

prior	  to	  this	  report	  being	  issued.	  The	  IH	  ruling	  stated	  that	  “the	  youth’s	  behavior	  did	  not	  amount	  

to	  a	  primary	  rule	  violation.”	  	  

	  

While	  on	  the	  surface,	  some	  of	  these	  youths’	  behaviors	  may	  meet	  the	  requirements	  of	  the	  Court	  

Order,	  documentation	  of	  the	  deliberative	  process	  (whether	  an	  Intervention	  Hearing,	  IDT	  

meeting	  or	  other	  group	  decision-­‐making	  process)	  was	  not	  provided	  to	  identify	  the	  relevant	  facts	  

and	  whether	  they	  supported	  the	  youth’s	  eligibility	  for	  demotion.	  The	  youth’s	  perspective	  is	  also	  

not	  represented	  anywhere.	  Similarly,	  no	  information	  was	  provided	  to	  indicate	  why	  the	  group	  

believed	  demotion	  to	  Phase	  1	  to	  be	  the	  most	  appropriate	  response.	  In	  one	  case,	  the	  IDT	  had	  

recommended	  a	  demotion	  from	  Transition	  to	  P2,	  but	  the	  Superintendent	  overrode	  the	  IDT	  

decision	  and	  demoted	  the	  youth	  to	  P1.	  The	  reason	  for	  this	  override	  was	  not	  provided.	  The	  Court	  

Order	  requires	  active	  deliberation	  to	  ensure	  that	  phase	  demotions	  are	  used	  only	  in	  response	  to	  

egregious	  behavior	  and	  to	  ensure	  that	  other,	  less	  severe	  sanctions	  have	  been	  considered.	  	  

	  

IDT	  minutes	  from	  January	  18	  through	  February	  28,	  2013	  were	  reviewed	  to	  identify	  instances	  in	  

which	  alternative	  sanctions	  were	  imposed,	  even	  when	  a	  youth’s	  behavior	  may	  have	  met	  the	  

demotion	  criteria.	  During	  the	  review	  period,	  three	  instances	  were	  noted	  where	  youth	  engaged	  

in	  behavior	  that	  appeared	  to	  qualify	  them	  for	  demotion,	  but	  a	  less	  punitive	  sanction	  was	  

imposed.	  These	  included:	  two	  Transition	  youth	  who	  engaged	  in	  a	  fight	  in	  school	  (both	  were	  put	  

on	  extended	  Behavior	  Contracts	  on	  the	  Transition	  Unit)	  and	  a	  youth	  who	  was	  put	  on	  a	  Behavior	  

Contract	  for	  serious	  threatening	  behavior	  (although	  he	  was	  later	  demoted	  for	  an	  AOV).	  

	  

Moving	  forward,	  DYS	  needs	  to	  provide	  additional	  information	  regarding	  the	  nature	  of	  the	  

youth’s	  misconduct	  and	  evidence	  of	  a	  deliberative	  process	  to	  determine	  the	  most	  appropriate	  

sanction.	  Though	  not	  required	  by	  the	  Court	  Order,	  it	  would	  be	  helpful	  for	  the	  DYS	  to	  assess	  the	  

extent	  to	  which	  youth	  who	  engage	  in	  serious	  misconduct	  are	  sanctioned	  without	  the	  use	  of	  

phase	  demotion.	  	  

	  

Recommendations.	  	  

In	  order	  to	  meet	  the	  standard	  associated	  with	  Phase	  Demotions,	  a	  Quality	  Improvement	  Plan	  

should	  be	  developed	  to	  address	  the	  following	  issues:	  

1. Ensuring	  that	  documentation	  supports	  the	  requirement	  that	  a	  deliberative	  process	  was	  

used	  to	  determine	  whether	  the	  facts	  of	  the	  incident	  support	  the	  youth’s	  eligibility	  for	  

demotion	  and	  why	  phase	  demotion	  was	  selected	  from	  among	  the	  other	  available	  

sanctions.	  	  

	  

	  

	  

	  

32.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 33 of 34 PAGEID #: 2594

[II.C.3]	  Quality	  Assurance	  [monitored	  by	  both	  Dr.	  Dedel	  and	  Dr.	  Glindmeyer;	  this	  standard	   applies	  only	  to	  the	  S.H.	  Agreement]	   Status:	  Not	  in	  Substantial	  Compliance	  
	   (1)	  Standard:	  Quality	  Assurance	  Process.	  	   The	  Quality	  Assurance	  (QA)	  program	  establishes	  specific	  standards	  for	  the	  operation	  of	  the	  unit	   and	  a	  specific	  methodology	  for	  measuring	  the	  level	  of	  performance	  on	  each	  standard.	  When	   deficits	  are	  identified,	  a	  Quality	  Improvement	  (QI)	  plan	  is	  created	  to	  identify	  the	  underlying	   causes	  of	  the	  problem	  and	  to	  construct	  specific	  strategies	  designed	  to	  remediate	  the	  deficit.	  The	   QI	  plan’s	  effectiveness	  is	  measure	  on	  a	  monthly	  basis.	  Findings	  from	  the	  QA/QI	  process	  are	   articulated	  in	  a	  written	  document	  at	  least	  twice	  per	  year.	  	   	   Methodology.	  	   The	  following	  information	  should	  be	  used	  to	  determine	  compliance	  with	  the	  standard:	  
• Written	  reports	  that	  include	  QA	  standards,	  methodologies	  and	  results	   • Written	  QI	  plans	  and	  monthly	  progress	  reports	   	   Analysis	  and	  Interpretation.	  	   While	  the	  DYS	  has	  amassed	  a	  large	  volume	  of	  data	  relevant	  to	  the	  daily	  operation	  of	  the	  unit	   and	  the	  substance	  of	  the	  treatment	  delivered	  on	  the	  PU,	  it	  has	  yet	  to	  organize	  these	  data	  in	  any	   meaningful	  way.	  To	  date,	  the	  Monitors	  have	  borne	  the	  responsibility	  of	  analyzing	  and	   interpreting	  the	  data,	  and	  making	  recommendations	  for	  program	  improvements.	  While	  this	   ensures	  that	  the	  Monitors	  are	  fully	  informed	  about	  the	  PU’s	  operation,	  it	  comes	  at	  significant	   expense	  to	  the	  State.	  Perhaps	  more	  importantly,	  it	  does	  not	  carry	  an	  exit	  strategy.	  DYS	  needs	  to	   develop	  a	  rigorous	  Quality	  Assurance/Quality	  Improvement	  process	  that	  is	  capable	  of	   identifying,	  analyzing	  and	  solving	  problems	  that	  will	  inevitably	  occur	  in	  the	  operation	  of	  a	   complicated	  program	  with	  very	  challenging	  youth.	  Only	  when	  this	  occurs	  will	  external	   monitoring	  by	  the	  Monitors	  become	  unnecessary.	  	   	   Recommendations.	  	   In	  order	  to	  meet	  the	  standard	  associated	  with	  Quality	  Assurance,	  a	  Quality	  Improvement	  Plan	   should	  be	  developed	  to	  address	  the	  following	  issues:	   1. Developing	  a	  set	  of	  standards	  or	  performance	  objectives	  that	  describe	  what	  each	  
component	  of	  the	  program	  aspires	  to	  do.	  To	  assist	  in	  this	  effort,	  the	  Monitors	  drafted	   the	  standards	  used	  in	  this	  report	  to	  reflect	  the	  various	  subsections	  of	  the	  Court	  Order.	   These	  should	  be	  considered,	  modified	  if	  necessary,	  and	  supplemented	  with	  standards	   that	  address	  important	  issues	  that	  may	  not	  be	  adequately	  addressed	  in	  the	  Court	  Order	   (e.g.,	  SBBMS).	  	   2. Developing	  an	  audit	  methodology	  for	  each	  standard.	  Identify	  existing	  data	  that	  speak	  to	   the	  performance	  on	  each	  standard.	  DYS	  appears	  to	  possess	  most	  of	  the	  data	  it	  needs	  to	   assess	  the	  unit’s	  performance	  (exceptions	  are	  noted	  throughout	  this	  status	  report).	   Develop	  a	  schedule	  for	  audits	  (e.g.,	  quarterly,	  semi-­‐annually)	  and	  a	  sampling	  strategy	   (i.e.,	  what	  proportion	  of	  the	  cases/days/occurrences/incidents	  will	  be	  reviewed?	  For	   things	  that	  don’t	  happen	  often	  (e.g.,	  phase	  demotions),	  all	  cases	  should	  be	  reviewed.	   For	  things	  that	  occur	  regularly	  (e.g.,	  daily	  activities),	  a	  random	  sample	  should	  be	   identified).	  	  

	  

33.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 34 of 34 PAGEID #: 2595
3. Analyzing	  and	  interpreting	  the	  data	  that	  is	  produced	  by	  the	  audits.	  Identify	  patterns	  that	   speak	  to	  the	  challenges	  in	  meeting	  a	  particular	  standard.	  Memorialize	  these	  efforts	  in	   writing,	  in	  the	  form	  of	  a	  written	  Quality	  Assurance	  Report	  that	  includes	  the	  standard,	   the	  methodology	  used	  to	  audit	  performance,	  and	  the	  analysis	  and	  interpretation	  of	  the	   data	  that	  was	  collected.	  	  
4. Developing	  a	  Quality	  Improvement	  Plan	  for	  each	  area	  in	  which	  the	  standard	  is	  not	  met.	   An	  interdisciplinary	  team	  of	  staff	  who	  can	  dissect	  the	  problem	  to	  determine	  its	   underlying	  causes	  should	  develop	  this	  plan.	  Once	  known,	  specific	  strategies	  to	  address	   the	  underlying	  causes	  need	  to	  be	  developed.	  The	  strategies	  should	  be	  fleshed	  out	  into	   specific	  tasks,	  responsible	  parties,	  and	  timelines.	  	  
5. Conducting	  targeted	  reviews	  for	  each	  QIP	  to	  determine	  whether	  the	  strategies	  are	   working	  to	  improve	  performance	  toward	  a	  specific	  standard.	  These	  should	  be	  in	   addition	  to	  regularly	  scheduled,	  comprehensive	  audits.	  Document	  the	  results	  of	  the	   targeted	  reviews	  on	  the	  QIP	  and	  make	  adjustments	  to	  the	  strategies	  if	  the	  desired	   results	  are	  not	  being	  obtained.	  	  
	   	   	   	  

	  

34.	  

 
 U.S. Department of Justice Civil Rights Division

Assistant Attorney General 950 Pennsylvania Avenue, NW - RFK Washington, DC 20530
May 9, 2007
The Honorable Ted Strickland Governor State of Ohio 30th Floor 77 South High Street Columbus, OH 43215-6117
Re: Investigation of the Scioto Juvenile Correctional Facility, Delaware, Ohio
Dear Governor Strickland:
I am writing to report the findings of the Civil Rights Division’s investigation of conditions at the Scioto Juvenile Correctional Facility (“Scioto”), located in Delaware, Ohio. On March 16, 2005, we notified you of our intent to conduct an investigation of Scioto, pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997 (“CRIPA”), and the pattern or practice provision of the Violent Crime Control and Law Enforcement Act of 1994, 42 U.S.C. § 14141 (“Section 14141”). We informed you that our investigation of Scioto would focus on protecting residents from harm, medical care, mental health care, grievances, and provision of special education.1 As we noted, both CRIPA and Section 14141 give the Department of Justice authority to seek a remedy for a pattern or practice of conduct that violates the constitutional or federal statutory rights of children in juvenile justice institutions.
We note that the State has worked cooperatively and, under the leadership of Director of Ohio Youth Services Thomas Stickrath, has unequivocally indicated its clear desire to improve both facilities since being placed on notice of possible constitutional deficiencies. Prior to the Department of Justice investigations of Scioto and Marion, the State hired a team of expert consultants, led by Mr. Fred Cohen, to evaluate the

1

Shortly thereafter, on April 15, 2005, we notified you

of our intent to conduct an investigation of the Marion Juvenile

Correctional Facility in Marion, Ohio (“Marion”) regarding

similar issues. Our findings regarding Marion are addressed in a

separate letter.

- 2 -
constitutional conditions at the girls’ section of the Scioto facility.2 Mr. Cohen issued an Interim Report on August 16, 2004 and an Action Plan on September 28, 2004. In each of these documents, Mr. Cohen found constitutional deficiencies in the areas of protection from harm, medical care, mental health care, grievances, and provision of special education. The State agreed to adopt and stipulate to Mr. Cohen’s findings, for the purpose of our investigation, and to apply those findings to the entire Scioto facility and the Marion facility.
Given the State’s stipulation that the conditions identified in our March 16, 2005 notice letter are constitutionally deficient, we agreed to conduct limited facility tours.3 On June 29-July 1, 2005, we conducted an on-site inspection of Scioto, accompanied by expert consultants in mental health care and medical care. During our inspections, we interviewed mental health providers, medical providers, other staff, youth residents, and facility administrators. Before, during, and after our visit, we reviewed an extensive number of documents, including policies and procedures, mental health records, youth detention records, unit logs, and orientation materials. Consistent with our commitment to provide technical assistance and conduct a transparent investigation, we conducted an exit conference with facility staff and Ohio Department of Youth Services officials upon the conclusion of the tour, during which our expert consultants conveyed their initial impressions and concerns.

2

Although the main Scioto facility houses female youth,

a separate section of the facility acts as state-wide intake for

all male youth.

3

This investigation is anomalous because Mr. Cohen's

2004 factual findings regarding the conditions of confinement at

Scioto revealed significant deficiencies in each of the areas

that were the subject of our investigation and because the State

has stipulated to all of Mr. Cohen's generally well-supported

findings. Together, these factors created the unusual

circumstance in which it was not necessary for the Department to

conduct a facility tour regarding each of the specific subject

areas of our investigation. However, we did tour Scioto

regarding areas in which we required additional factual

information to make a thorough and complete finding or to frame

appropriate corrective measures. For example, as Mr. Cohen's

2004 report is admittedly not thorough regarding its assessment

of medical and mental health care, we reviewed these subjects on-

site with expert consultants before issuing our findings.

- 3 -
We commend the Scioto staff for their helpful, courteous, and professional conduct throughout the course of this investigation. We also wish to express our appreciation for the cooperation of Ohio Department of Youth Services officials and staff.
Consistent with our statutory obligation under CRIPA, we set forth below the findings of our investigation, the facts supporting them, and the minimum remedial steps that are necessary to address the deficiencies we have identified. As described below, we conclude that youth confined at Scioto suffer harm or the risk of harm from constitutional deficiencies as to: protecting residents from harm; certain discrete elements of medical care; mental health care; grievances; and special education services. Notwithstanding the foregoing, we are pleased to report that our review indicates that Scioto’s general medical programs are, for the most part, good. In particular we find that Scioto’s medical quality improvement program, environmental conditions, and management of special dietary needs for youth are appropriate. However, certain discrete aspects of medical care, identified below, substantially depart from generally accepted professional standards of care and expose youth to harm.
I. BACKGROUND
The State of Ohio, through its Department of Youth Services, owns and operates Scioto, located approximately 15 miles north of Columbus, Ohio. Scioto is the reception center for all juvenile males entering Department of Youth Services’ juvenile justice facilities and serves as Ohio’s sole facility for girls adjudicated, of felony-level crimes, in juvenile courts. Reportedly, many of these girls were in the State’s foster care system before being confined. The facility has a rated capacity of 192 and currently houses approximately 185 males and 120 females, aged 12 to 21.
II. FINDINGS
As a general matter, States must provide confined juveniles with reasonably safe conditions of confinement. Youngberg v. Romeo, 457 U.S. 307 (1982); Nelson v. Heyne, 491 F.2d 352 (7th Cir. 1974); see also Miletic v. Natalucci-Persichetti, No. C-3-89-299, 1992 WL 1258522, *2, *4 (S.D. Ohio Feb. 6, 1992) (holding, in a case against the Ohio Department of Youth Services, that “a juvenile who is involuntarily committed to a correctional as opposed to mental health facility has a right to treatment under the Fourteenth Amendment similar to that which was recognized in Youngberg . . . .”).

- 4 -
A. PROTECTION FROM HARM
Juveniles in state custody have a constitutional right to reasonable safety. See Youngberg, 457 U.S. at 315-16 (“personal security constitutes a historic liberty interest protected substantively by the Due Process Clause”) (internal quotation omitted).
Our review of conditions of confinement at Scioto reveals significant constitutional deficiencies regarding use of physical force, grievance investigation and processing, and use of seclusion. For purposes of our investigation, the State has stipulated to Mr. Cohen’s August 2004 findings, agreeing to the applicability to Scioto’s intake program of Mr. Cohen’s findings for each of the above-mentioned subject areas. In addition, our experts concur with Mr. Cohen's findings and suggested remedies.
1. Use of Physical Force
Juveniles at Scioto have a right to be free from unnecessary restraint and the use of excessive force. Youngberg, 457 U.S. at 315-16. Since 2003, 14 Scioto staff have been indicted on charges relating to physical and sexual abuse of youth at Scioto. In response to this crisis, the State hired Mr. Cohen and a team of experts in 2004 to review protection from harm issues in Scioto’s Girls’ Program. For purposes of our investigation, the State has stipulated to Mr. Cohen’s August 2004 findings, agreeing to the applicability of Mr. Cohen’s findings to Scioto’s intake section.
In his report, Mr. Cohen concludes that “there has been (and remains) a culture of violence among the uniformed staff, that verbal and physical abuse are common, [and] sexual misconduct by staff occurs . . . .” Mr. Cohen indicates that he and his team of experts “have the most serious reservations as to whether [the State’s] investigators are presently able to produce the quality of investigative work required to identify those use of force incidents that merit corrective actions for staff who violate the [Department of Youth Services’] use of force policy.” Finally, Mr. Cohen concludes that “there can be no debate on the constitutional obligation under the Fourteenth Amendment to provide a safe environment. Scioto has not met its obligations to provide such an environment . . . .”
In reviewing Scioto’s use of force incidents, Mr. Cohen reported that “verbal and physical abuse are common” at Scioto. Since 2003, five defendants have been convicted of various charges such as sexual battery, attempted sexual battery,

- 5 -
assault, falsification, and dereliction of duty. In addition, as of July 2006, one defendant awaits trial on charges of assault, child endangerment, falsification, dereliction of duty, and tampering with evidence.4
One officer was convicted of attempted sexual battery as a result of allegations that he ordered a female youth to undress while he watched and engaged in inappropriate sexual touching. Another officer pled guilty to misdemeanor assault for slapping and punching a youth, and then kicking the youth after she fell to the floor. A female officer pled guilty to dereliction of duty as a result of allegations that she ordered a male youth to expose himself and engage in inappropriate sexual touching. Another officer tendered an Alford plea5 to misdemeanor assault and falsification charges for striking a youth during an altercation, puncturing her eardrum. Finally, an officer was convicted of sexual battery and attempted sexual battery for forcing one youth to perform sex acts on him and for inappropriately sexually touching another female youth.
In his report, Mr. Cohen stated that he and his team “found countless examples of situations where no force at all should have been used and others where the force used was excessive.” Further, according to Mr. Cohen, verbal abuse is rampant and often serves, perhaps intentionally, to precipitate physical confrontations with juveniles.
Finally, we note that Scioto currently allows use of a physical restraint technique directing staff to place an arm across a youth’s chest below the neck and push on the cheek with the back of the hand. As our medical expert observed during the tour, use of any technique calling for an arm to be placed across the neck during a physical altercation or other incident exposes the youth to a significant risk of harm. This practice is especially problematic in light of allegations that we have received that youth have been choked by staff during altercations.
Based on these assessments and the State’s stipulation as to the applicability of Mr. Cohen’s findings, we agreed that it was

4

One defendant was acquitted and seven other defendants

were indicted, but the charges were later dismissed.

5

In an Alford plea a defendant does not admit the act,

but admits that sufficient evidence exists with which the

prosecution could likely convince a judge or jury to find the

defendant guilty. North Carolina v. Alford, 400 U.S. 25, 38

(1970).

- 6 -
not necessary to perform additional fact-finding regarding use of force at Scioto and we conclude that youth at Scioto are subject to use of excessive physical force and physical abuse.
2. Grievances (Investigations and Processing)
Just as prisoners and juvenile detainees have a constitutional right of access to the courts, they have a right to a grievance system that does not carry risk of punishment as a price for using it. See Thaddeus-X v. Blatter, 175 F.3d 378, 394 (6th Cir. 1999); see also Bounds v. Smith, 430 U.S. 817, 822 n.17 (1977) (“Our main concern here is protecting the ability of an inmate to prepare a petition or complaint.”) (internal quotation marks and citations omitted).
We adopt the following findings by the State’s experts. As part of Mr. Cohen’s assessment, the State’s experts conducted a review of Scioto’s incident investigation and grievance process,6 finding that several factors contribute to its inadequacy. In particular, Mr. Cohen’s report finds that Scioto investigations are “pedestrian, time consuming, and full of errors or oversights.” The State’s experts also determined that, with the exception of a few cases, investigators rarely attempt to determine if officers followed existing protocol.
In his report, Mr. Cohen found that investigations contain few facts other than repetition of the complaint and denials by involved individuals. The investigations reveal a trend of repetitive questioning of involved youth, as though questioning was to continue until the youth provided the “correct” answer. Incidents involving physical aggression contained no evaluation of events preceding the incident, nor questions regarding use or attempted use of lesser physical interventions.
Although Scioto grievances contain serious allegations, such as verbal harassment and abuse, use of physical force, loss of programs and privileges, sexual harassment, and medical issues, such investigations rarely result in corrective action for staff or youth or any attempt to recognize or identify patterns of behavior requiring intervention.
Finally, given the facility’s population, the number of grievances filed appears low and, when examined in conjunction with the above, supports the conclusion that Scioto youth view the grievance process as ineffective. We note that some investigations completed by the Department of Youth Services'

6

Mr. Cohen’s team reviewed the 984 incidents filed from

January 1, 2003 through August 18, 2004.

- 7 -
Bureau of Chief Inspector contained more facts than those completed by Scioto personnel. However, these investigations varied widely in quality and accuracy and were not completed in a timely manner necessary to sustain a proper incident review and grievance system and implement warranted corrective actions.
The dysfunctional grievance system at Scioto contributes to the State’s failure to ensure a reasonably safe environment. An adequately functioning grievance system ensures that youth have an avenue for bringing serious allegations of abuse and other complaints to the attention of the administration. It also provides an important tool in evaluating the culture at the facility, and alerting the administration about dangers and other problems in the facility’s operations.
3. Seclusion
The State's experts reviewed over 200 seclusion reports regarding Scioto girls from May 2004 to June 2004. In his report, Mr. Cohen concluded that staff use seclusion as a “knee-jerk, prolonged first response” and often hold youth in seclusion for hours even though they do not pose an imminent threat. For example, many Scioto youth are held in seclusion for lengthy periods for refusing breakfast, cursing, and talking in class. In one instance, Scioto held a youth in seclusion for 14 hours for being “argumentative” and using a racial epitaph. Additionally, the State's expert found that Scioto's routine use of seclusion as immediate punishment is often accompanied by use of force. We adopt Mr. Cohen's findings.
B. MEDICAL AND MENTAL HEALTH CARE
Juveniles in state custody have a due process right to adequate mental health care. The Supreme Court in Youngberg broadly labeled health care as “medical care,” but recognized that this would include care provided by various disciplines, including persons with appropriate training in psychology. See id., 457 U.S. at 322-323, n.30. The Sixth Circuit also has recognized that medical care encompasses mental health care. See Horn v. Madison County Fiscal Court, 22 F.3d 653, 660 (6th Cir. 1994) (“A detainee’s psychological needs may constitute serious medical needs, especially when they result in suicidal tendencies.”).
1. Medical
We are pleased to report that our review indicates that Scioto’s general medical programs are, for the most part, good. In particular we find that Scioto’s medical quality improvement program, environmental conditions, and management of special

- 8 -
dietary needs for youth are appropriate. However, certain discrete aspects of medical care, identified below, substantially depart from generally accepted professional standards of care and expose youth to harm.
a. Identification of Health Problems and Initial Health Assessments
Based on our review, Scioto’s health records are inadequate insofar as they do not contain problem lists identifying all active health problems. Problem lists are necessary tools in monitoring youth health status and providing adequate health care. Scioto’s initial health assessments are similarly inadequate, due to the absence of problem lists. These lists and plans of care should be reviewed and approved by a physician after reviewing all relevant assessment information.
b. Evaluation and Treatment of Sick Residents
Scioto’s sick call procedures make youth access to medical care dependent upon line staff and force youth to submit requests through line staff in a non-confidential manner. It is a generally accepted professional standard of care that youth should be able to submit sick call requests confidentially and independent of the line staff.
c. Dental Care
Scioto’s dental program fails to meet the dental needs of its youth. We found numerous instances of youth with significant, untreated, dental health needs.
We find that Scioto dentists' practice of not providing crowns and rarely replacing missing or damaged front teeth conflicts with Department of Youth Services policies and generally accepted professional standards of care requiring that such services are to be provided, as needed, upon the dentist's recommendation. We also note that Scioto’s dental program for the girls’ section of the facility fails to provide timely restorative care for youth with cavities. As a general matter, Scioto must develop a system for tracking the dental needs of its youth and providing services in a timely manner. The treating dentist should determine the necessity of dental care on a patient-by-patient basis.
We also found that documentation of oral surgery procedures and recommendations of post-operative management of youth was missing in the files we reviewed.

- 9 -
Finally, Scioto has no dental assistant or dental hygienist. Consequently, its dentists are forced to choose between foregoing basic dental care that such practitioners provide, or delaying or ignoring more significant dental needs.
d. Special Services for Chronically Ill and Disabled Youth
We find Scioto’s care provided to patients with asthma substantially departs from generally accepted professional standards. The facility must acquire peak flow meters to properly assess patients when healthy and ill, to determine the effectiveness of treatment. Scioto nurses also do not clinically assess youth when administering rescue inhalers, and youth who use such inhalers frequently are not referred to the physician for more intense treatment. Scioto’s current treatment approach results in preventable asthma hospitalizations due to inadequate treatment of active asthma.
e. Disease Prevention and Health Promotion
Fifteen percent of Scioto’s youth had incomplete immunizations, and youth are not fully immunized for their age. This is a substantial departure from generally accepted professional standards.
In addition, Scioto’s blanket discontinuation of all oral contraception for youth entering the facility and Scioto’s failure to offer emergency contraception conflict with applicable standards of care, exposing female youth to harm.
f. Medical Quality Improvement Program
While we find that Scioto’s current medical quality improvement program is adequate, we suggest that Scioto begin to place more emphasis on health outcomes and use the topics identified in this section to establish such a system.
g. Environmental Conditions
As a matter of technical assistance, Scioto youth should be provided opportunities to practice appropriate hygiene in order to reduce transmission of communicable diseases.
h. Special Dietary Needs for Youth
Scioto adequately manages food allergies and special medical diets.

- 10 -
i. Abuse Reported By Medical Professionals
While nurses at Scioto assess youth after a use of physical restraint, they only report suspected abuse to the facility administration, rather than to State child abuse authorities. This reporting scheme is a substantial departure from generally accepted standards of practice and, in light of the State’s stipulation regarding use of excessive force, is especially problematic.
2. Mental Health Care
The Constitution requires that youth in juvenile justice institutions receive adequate mental health care. Youngberg, 457 U.S. at 323, n.30; Nelson, 491 F.2d at 360; see also K.H. v. Morgan, 914 F.2d 846, 851 (7th Cir. 1990); A.M. v. Luzerne County Juvenile Detention Center, 372 F.3d 572, 585 n.3 (3d Cir. 2004). We find that mental health care at Scioto’s intake facility and girls’ facility is constitutionally inadequate.
As a threshold matter, we note the assessment of the State’s expert that the girls’ mental health unit “is little more than a residence for girls with mental disorders” and that “[m]ental health care is so deficient” that it was not feasible to comment on the various elements of such care, indicating that “[a] more refined analysis must await another day – a day when constitutionally required, minimally acceptable care is instituted.” Given this assessment, we conducted an independent review of mental health care at the facility and found significant deficiencies in almost every aspect of mental health care encompassed within screening and assessment services and the provision of treatment.
a. Scioto Intake
1. Screening and Assessment Services
Upon arrival at Scioto, all male juveniles receive an assessment in the reception area. The assessment includes a review of the youth’s offense history, his behavior in the reception facility, his scores on various assessments, and a social worker’s recommendations for specific programming. We found that assessments were implemented in a consistent manner and often contained an impressive range of information collected from sources outside the facility (i.e., court records, previous mental health records). Nevertheless, we conclude that there are a number of constitutional deficiencies with respect to the assessment of youth for mental illness.

- 11 -
(i) Reception Assessments: We found that many reception assessments were incomplete, failing to address numerous factors important to an accurate and complete assessment of a youth’s mental condition. In addition, the assessments are primarily deficit oriented, focusing little on strengths or family functioning. As a result, they fail to identify important bases for treatment interventions. We also note that assessment records are poorly integrated and that there is no reliable system of communication among various contributors to the assessment. Furthermore, the assessments do not include structured consideration of data to determine placement or appropriate programming. In this regard, placement and planning recommendations are often made with no justification. As a result of these weaknesses, placement decisions and specific treatment plans for youth are arbitrary in important respects and are otherwise excessively generic.
(ii) Mental Health Assessments: In addition to the reception assessment, youth entering Scioto receive a mental health assessment. A social worker administers the Massachusetts Youth Screening Instrument (“MAYSI”) checklist to each youth and the MAYSI is scored by a psychologist. Youth answering positive to questions regarding suicidal thinking or behavior on the MAYSI, or on medical screening questions, meet with a psychologist or psychologist assistant for a mental health assessment. Youth receiving psychiatric medication upon arrival at Scioto and youth whose psychological assessment reveals serious acute psychopathology are referred to a psychiatrist for psychopharmacological assessment and treatment.
Like the reception assessment, the mental health assessment follows a consistent, reliable format. Nevertheless, the process suffers from poor data gathering and recording. In this regard, we note that assessments often fail to address important considerations such as cognition problems, impact of trauma, school history, past treatment experiences, past treatment responses, and dysphoric (i.e., anxious or despairing) moods. Moreover, we found that data collection regarding positive adaptions, peer relationships, developmental information, and family history and functioning is completely inadequate. As a result, the assessment lacks information that is fundamental to making appropriate recommendations.
In addition, Scioto’s mental health assessments do not employ validated structured instruments for diagnosis or functional assessment. Without such instruments, assessments tend to be arbitrary as to identifying clinical disorders and appropriate treatment. Additionally, the assessments rely heavily on a structured interview of the youth, which provides questionable information and fails to make use of information

- 12 -
regarding current behavior adaption or school functioning. Lastly, Scioto’s use of checklists to be read and completed by youth is problematic, because these checklists are used without establishing that the youth can read and comprehend them.
Scioto’s psychological assessments are also inadequate. Most assessments we reviewed rarely include specific treatment recommendations or consider multiple concurrent conditions, despite the prevalence of such conditions among the facility’s population. The assessments fail to contain differential diagnoses (considering alternative diagnostic hypotheses) and do not link the diagnoses to likely functional problems, such as socialization problems and aggressiveness. As a result, Scioto’s assessments do not provide information and opinions adequate for coherent treatment planning.
We found similar problems with Scioto’s psychiatric assessments, in that the assessments appeared perfunctory, with little follow-up. Also, we noted that a number of obvious candidates for psychiatric care were not referred for psychiatric assessment.
Finally, we found that Scioto’s overall mental health staffing is inadequate, allowing for only superficial assessment without any routine follow-up. We also could not find any explicit criteria used for determining who should receive ongoing mental health treatment while in reception.
As a consequence of these deficiencies, youths’ mental health needs are often untreated or inappropriately treated, resulting, among other things, in no treatment, counterproductive treatment, exposure to inappropriate or unnecessary medications posing serious physical and other side effects, longer periods of confinement, and needlessly greater potential for recidivism.
b. Scioto Girls’ Program
Girls come to Scioto only after failing to complete a number of other, less restrictive, state-sponsored juvenile programs. Given the Scioto girls’ prior programming failures, and that our consultants have estimated the prevalence of mental disorders among female juvenile offenders to be as high as 87 percent, a female youth at Scioto without significant mental health problems would be in the minority. Nevertheless, it was evident from our expert’s review of randomly selected files that Scioto’s current process for identifying youth with mental illness is inadequate, and that girls’ significant mental disorders often go unidentified and untreated. For example, in three randomly selected cases our consultant reviewed, each youth showed clear signs of mental health issues. Two of the youth were identified

- 13 -
as having mental health issues within nine months (one was only identified after undergoing multiple risk assessments in response to several instances of self-injurious behavior and reports of hallucinations instructing her to hang herself).7 The third youth showed clear signs of mental distress but did not complain of specific symptoms, and she received no mental health followup. Scioto’s failure to reliably identify girls in its custody with significant mental health concerns is a substantial departure from generally accepted standards of practice that exposes girls to risk of significant harm, in the form of serious, untreated mental disorders.
1. Provision of Treatment
Scioto’s attempt to establish and implement individual treatment plans for its residents is clearly in its beginning stages. We noted that few records of girls with identified mental disorders included a treatment plan. Records containing such plans provided no indication that the treatment services provided to the girl were linked to a specific plan. In addition, we found no regularly scheduled treatment meetings involving clinicians and residents with clearly identified treatment needs. In fact, apparently because of current inadequate staffing, most Scioto youth with mental health disorders do not receive regular, scheduled treatment sessions, allowing these disorders to go neglected. As a result, the quality and effectiveness of the treatment provided is deficient, resulting in an ongoing risk of self harm and disruptive behavior, and lack of progress in rehabilitation, which, in turn, can lead to an extended period of confinement.
While we note that Scioto provides psychopharmacological treatment in a more consistent manner, our record review indicates underutilization of applicable medications for attention problems and impulse control disorders. In addition, we noted a lack of collaboration between psychiatry and psychology regarding psychopharmacological treatment. Such lack of collaboration causes the psychiatrist to be less informed regarding youth behavior, thus reducing the effectiveness of psychiatric treatment regarding attention and impulse control problems.

7

Although these two youth were eventually identified as

having mental health problems, the significant delay was a factor

causing each youth to spend additional time in the program, to

suffer behavioral and emotional instability over a longer period

of time resulting in impairment in their growth and

rehabilitation, to remain at increased risk for self harm, and to

create considerable disruption in the program.

- 14 -
Indicative of many of these problems, Scioto’s Special Needs Unit for girls with heightened mental health or behavioral needs provides no improvement in the intensity, specificity, or consistency of mental health care in comparison to other units, other than having a better youth-to-social worker ratio and a dialectical behavioral therapy skills group. In this regard, we note that the State’s expert determined that Scioto’s Special Needs Unit “is little more than a residence for girls with mental disorders.”
We do note that Scioto’s risk assessment procedures have resulted in preventing self-harm among its population. However, as implemented, these procedures contribute to Scioto’s current crisis atmosphere (teaching youth that the way to get attention is to engage in, or to threaten, self-harm) and divert psychologists from providing consistent treatment to other youth.
In summary, Scioto does not provide supports and services adequate to meet the needs of its population, in contravention of generally accepted professional standards, exposing girls to harm or a significant risk of harm in the form of significant, untreated mental health disorders, and leading to heightened emotional distress, longer periods of confinement, and greater potential for recidivism.
C. SPECIAL EDUCATION SERVICES
Students with disabilities have federal statutory rights to special education services under the Individuals with Disabilities Education Act (IDEA), 20 U.S.C.A. §§ 1400-1482 (West 2000 & Supp. 2006).8 As part of the review conducted by the State’s expert, Mr. Cohen, the Ohio Department of Youth Services retained Ms. Ava Crow to review special education services at Scioto.9 Ms. Crow conducted an exhaustive study, including two three-day site visits, numerous interviews, classroom observation, and document review. In her August 31, 2004 report, Ms. Crow concluded that Scioto’s special education program suffers from systemic failure and violates residents’ rights under the IDEA by failing to provide adequate special

8

We note that the IDEA was reauthorized and amended by

the Individuals with Disabilities Education Improvement Act of

2004, Pub. L. No. 108-446, 118 Stat. 2647 (2004), effective

July 1, 2005.

9

The IDEA provisions cited herein are substantively the

same as those in force at the time of Ava Crow’s review. At the

time of Ms. Crow’s tour, slightly less than half of Scioto

residents had been identified as qualifying for special education

services under the IDEA.

- 15 -
education.10 As indicated earlier, the State has stipulated, for the purpose of resolving this investigation, to the following deficiencies identified in Ms. Crow’s report. In addition, our expert consultant concurs with Ms. Crow's findings and recommendations.
1. Child Find
The IDEA requires that states implement systems to identify all students who are eligible for special education services and provide such services to all those identified as having disabilities. 20 U.S.C. § 1412. The State’s expert determined that Scioto does not meet “Child Find” requirements of the IDEA. In this regard, school guidance counselors acknowledge that Scioto does not comply with “Child Find.”
2. Parental Involvement
Parental involvement is an essential element of the IDEA, which requires parental consent for decisions about eligibility, evaluation, and placement. 20 U.S.C. § 1414.
However, based on the State expert’s review of a sample of youth files, Scioto often fails to contact parents, sometimes sending parental notices and consent forms to social services agencies. In one instance, a consent form was signed by a “former social worker.” In the same manner, two additional files revealed students whose placements were restricted in scope without parental consent or notification, in clear violation of the IDEA.
3. Provision of Transition Services
The IDEA requires schools to actively attempt to involve outside agencies in transition plan meetings to help students progress from school to adult life. The State’s expert found that Scioto’s transition plans are inadequate: students do not have written transition plans, and there is no indication of any outside agency involvement or any evidence of sustained efforts to involve outside agencies.
4. Implementation and Monitoring of Individualized Education Plans
The IDEA requires that each student with a disability have an IEP (“Individual Education Plan”), and describes the IEP components required to ensure that each student receives adequate special education services. The State’s expert determined that
10 Scioto's school program is called the William K. Willis School.

- 16 -
IEPs developed at Scioto do not ensure that students with disabilities receive required special education services.
For example, all Scioto IEPs reviewed by Mr. Cohen’s team contain an identical, barely exploratory list of services. Document review also revealed a pattern in which Scioto adopts IEPs from local education authorities but fails to implement them. In addition, while the IDEA requires consideration of positive behavioral interventions for students whose behaviors interfere with their learning or that of other students, document review revealed almost no individualized interventions for any Scioto student. Given the makeup of the Scioto population, lack of such clearly relevant interventions is telling. Finally, classroom observations indicate that there is substantially no difference in Scioto regular education classrooms versus special education classrooms and no indication that special education students were expected to perform less work or offered extended time to complete projects.
Separately, the IDEA requires a multidisciplinary team reevaluation of the information included in a youth’s multifactored evaluation, which is the basis for the IEP, every three years. We find that Scioto failed to update its multifactored evaluations for more than one-third of its special education population within the required three-year period.
The IDEA also requires that all IEPs are to be reviewed periodically and at least annually. The State’s expert found that Scioto failed to complete the required reviews and that 60 percent of Scioto’s IEPs had expired.
Lastly, the State’s expert found that Scioto has no appropriate system to monitor specific IEP goals. Document review indicated that some teachers at Scioto use weekly reporting forms to attempt compliance with IDEA monitoring requirements. However, such forms appear inadequate to document specific IDEA goals and fail to inform parents of students’ progress as required by the IDEA. Even if Scioto’s current forms were adequate, they are not sent to parents for review as required.
In light of these findings by the State’s expert and of the State’s stipulation, we find that the State fails to comply with the IDEA in the areas set forth above.
III. REMEDIAL MEASURES
In order to rectify the identified deficiencies and protect the constitutional and statutory rights of the youth confined at Scioto, the facility should implement, at a minimum, the following measures:

- 17 -
A. Protection from Harm
1. Ensure that youth are provided with safe living conditions and are protected from abuse, use of excessive force, undue seclusion, and undue restraint.
2. Develop appropriate policies and procedures that govern the use of force, requiring reliable documentation and limiting use of force to situations where a youth is physically violent and poses an immediate danger to himself and/or others or the youth is physically resisting institutional rules and the institution has attempted a hierarchy of nonphysical alternatives.
3. Prohibit verbal and physical punishment, and use of force practices that are incompatible with minimum actions necessary to prevent harm or obtain compliance with reasonable orders, including practices such as shoving, pushing, kicking, striking, or using inappropriate holds on youth.
4. Monitor and supervise staff, maintaining appropriate staff ratios and holding staff accountable for the use of excessive force or abuse.
5. Develop policies and procedures to ensure that seclusion and restraint are only used in appropriate, documented, instances by trained staff.
6. Provide youth with an effective and reliable process to raise grievances, without exposing them to retribution from staff, ensuring that all grievances are reviewed and addressed in a timely matter that provides youth with notification of the final resolution.
7. Employ sufficiently trained and independent investigators to ensure that all incidents of violence, use of force, or serious injury are adequately investigated, and documented, and that appropriate personnel actions are taken in response to substantiated findings.
B. Medical and Mental Health Care
1. Ensure that youth receive routine, preventative, and emergency medical and dental care consistent with current, generally accepted professional standards, including identification, assessment, diagnosis, and treatment of health problems.
2. Develop policies and procedures to ensure that youth are provided with: complete and accurate health records, access to confidential health care, a complete initial health

- 18 -
assessment, appropriate access to health services, appropriate medications and care to manage chronic illness, access to specialty consults, proper immunizations, and female reproductive health care managed according to generally accepted medical standards.
3. Maintain appropriate dental staffing and require that generally accepted professional standards are followed to ensure that: youths’ restorative needs are met in a timely manner, youth are not denied appropriate pain medication, needed prosthetic dental services are provided, and health records contain adequate documentation of outside dental consults.
4. Provide mental health and rehabilitative treatment consistent with generally accepted professional standards and ensure that there are an adequate number of qualified mental health professionals to provide mental health and rehabilitative services in a timely manner to all youth who require such services.
5. Develop and implement policies, procedures, and practices to ensure that, consistent with generally accepted professional standards of care, youth are: (1) comprehensively screened by appropriately trained personnel for mental disorders, including substance abuse, depression, and serious mental illness within 24 hours of admission; (2) systematically evaluated in response to problem indicators to address potential manifestations of mental or behavioral disorders in youth who have not been previously identified as requiring treatment; and (3) provided appropriate mental health care, substance abuse care, and treatment services.
6. Ensure that any youth determined at screening to be at immediate risk is immediately referred to a qualified mental health treatment professional for: assessment, treatment, and other appropriate actions, including facility transfer when necessary.
7. Implement policies, procedures, and practices according to generally accepted professional standards to ensure that: mental health assessments, including health, risks, strengths, and needs are performed within two weeks of a youth’s arrival at Scioto; youth identified in screening receive timely, comprehensive, and accurate assessments by qualified mental health professionals; and assessments are designed to incorporate data necessary to identify youth with mental disorders and contribute to a plan for managing the youth’s risk.
8. Develop and implement policies and procedures consistent with generally accepted professional standards of care to:

- 19 -
(1) ensure that treatment determinations are made by an interdisciplinary team through integrated treatment planning; (2) create and implement treatment plans that are current and individualized; (3) maintain readily accessible records containing meaningful, accurate and coherent assessments of the individual’s treatment plan progress, goals, and objectives.
9. Develop and implement a system to ensure that mental health issues are adequately considered in making housing decisions and that mentally ill youth receive appropriate housing.
10. Prior to administration of prescribed psychoactive medication, Scioto must: (1) ensure that youth and their parents (or guardians, if parents have lost custody due to abuse or neglect) are provided with goals, risks, benefits, and potential side effects of the medication, along with the potential consequences of not treating with the medication; (2) follow state law in order to administer such medication without consent.
11. Develop and implement policies, procedures, and practices to ensure that psychoactive medications are prescribed, distributed, and monitored properly and safely, consistent with generally accepted professional standards of care.
12. Provide training to all staff who interact directly with youth regarding mental health information, developmental disabilities, recognition of signs and symptoms of trauma, teenage development, strength-based treatment strategies, suicide risks, and (for staff working with female youth) female development.
13. Develop and implement policies and procedures that comply with generally accepted professional standards for the management of suicidal youth.
14. Create transition plans for youth leaving the facility that are consistent with generally accepted practice standards.
15. Develop and implement polices and procedures to maintain oversight of mental health services and ensure that such services are provided consistent with generally accepted professional standards of care.
C. Special Education
1. Provide prompt and adequate screening, and ongoing rescreening and referral, of youth for special education needs and ensure that all students requiring special education services receive services in compliance with the IDEA within a reasonable time following intake.

- 20 -
2. Ensure that all eligible youth have current, accurate IEPs that are developed and implemented consistent with IDEA requirements.
3. Create and implement a system to routinely develop, implement, and monitor youths' IEPs, with involvement of parents and guardians, as required by the IDEA.
4. Develop and implement a staffing plan that allows for a sufficient number of certified special education teachers and staff to provide all youth with the opportunity to attend school full-time and to obtain adequate educational services while providing teachers with sufficient time to plan lessons, grade assignments, and participate in special education meetings.
5. Develop a quality assurance program to ensure the quality of IEPs, compliance with the IDEA, and monitoring of teaching staff on compliance issues.
6. Ensure that special education staff receive in-service training and maintain current educator licenses appropriate to the courses they teach.
* * *
As stated above, we appreciate the cooperation we have received from Ohio Department of Youth Services officials and facility staff throughout this investigation. We hope to be able to continue working with the State in an amicable and cooperative fashion to resolve the deficiencies found at Scioto. Provided that our cooperative relationship continues, we will forward our expert consultant reports under separate cover. Although this report is our consultants’ work – and does not necessarily reflect the official conclusions of the Department of Justice – the observations, analyses, and recommendations contained in the reports provide further elaboration of the issues discussed in this letter and offer practical assistance in addressing them.
In the unexpected event that we are unable to reach a resolution regarding our concerns, the Attorney General is empowered to institute a lawsuit pursuant to CRIPA to correct the deficiencies of the kind identified in this letter 49 days after appropriate officials have been notified of them. 42 U.S.C. § 1997b(a)(1).
We would prefer, however, to resolve this matter by working cooperatively with you. We have every confidence that we will be able to do so in this case. The lawyers assigned to this matter will be contacting your attorneys to discuss this matter in further detail. If you have any questions regarding this letter,

- 21 -
please contact Shanetta Y. Cutlar, Chief of the Civil Rights Division’s Special Litigation Section, at (202) 514-0195.
Sincerely,
/s/ Wan J. Kim Wan J. Kim Assistant Attorney General
cc: The Honorable Marc Dann Ohio Attorney General Department of the Attorney General
Thomas J. Stickrath Director Ohio Department of Youth Services
Amy Ast Superintendent Scioto Juvenile Correctional Facility
The Honorable Gregory G. Lockhart United States Attorney Southern District of Ohio

 
 Case: 2:08-cv-00475-ALM-MRA Doc #: 161 Filed: 12/09/15 Page: 1 of 5 PAGEID #: 3271

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

EASTERN DIVISION 


S.H., a minor child and all others similarly situated, et al., Plaintiffs, v.
HARVEY J. REED, Defendant.
UNITED STATES OF AMERICA, Plaintiff,
v. THE STATE OF OHIO, et al.,
Defendants.

:

:

:

Case No. 2:04-CV-1206

:

:

JUDGE ALGENON L. MARBLEY

:

:

Magistrate Judge Kemp

:

:

:

:

:

:

:

:

:

Case No. 2:08-CV-00475

:

:

JUDGE ALGENON L. MARBLEY

:

:

:

:

:

ORDER This matter is before the Court on the Parties’ Joint Motion to Terminate the Consent Decree. (Doc. 410.) The Court-appointed monitors, Will Harrell and Kelly Dedel (“the Monitors”), have submitted final reports on the Department of Youth Services’ (“DYS”) facilities for boys and DYS-contracted facilities for girls, finding DYS in substantial compliance with the remaining quality assurance measures under monitoring. All parties now agree that this case should be terminated. The Monitors have also submitted a final report entitled “The Ohio Model: A Report on the Transformation of the Ohio Department of Youth Services, 2007-2015,” which details the remarkable improvement in conditions of confinement in DYS juvenile
1 


Case: 2:08-cv-00475-ALM-MRA Doc #: 161 Filed: 12/09/15 Page: 2 of 5 PAGEID #: 3272
facilities over the last seven years. They hope to use this report in part to “memorialize the agency’s major policy and practice decisions for the benefit of others in the field.” (Doc. 411.) The Court will briefly summarize the history of the litigation and highlight some of the remarkable improvements at DYS facilities since this case began.
I. HISTORY OF THIS LITIGATION On December 20, 2004, Plaintiffs in S.H. v. Reed, No. 2:04-cv-1206, filed a complaint challenging conditions at DYS juvenile correctional facilities. The Court later entered an order certifying the S.H. case as a class action. (Doc. 67.) The S.H. plaintiffs challenged the application by staff of unnecessary force; arbitrary and excessive use of isolation and seclusion, arbitrary and excessive discipline; inadequate mental health, medical, and dental care; inadequate educational services; inadequate structured programming; broadly inadequate training of staff; an unsafe living environment; and a dysfunctional grievance system. (Doc. 76 at 6.) On May 16, 2008, the United States filed a similar complaint in the companion case United States v. Ohio, No. 2:08-cv-475. On May 18, 2007, the Court approved a case management plan under which the parties agreed to a joint fact finding team, and that team’s report was filed on December 31, 2007. On May 21, 2008, the parties agreed to a Stipulation of Injunctive Relief which incorporated that Report and established that the conditions of confinement for youth in DYS facilities violated the constitutional and statutory rights of those youth. (Doc. 108.) The Stipulation provided for a period of oversight by a Court-appointed monitor for five years. (Id. at 87.) On February 18, 2014, the S.H. Plaintiffs filed a motion for specific performance and alleged a failure to provide adequate treatment to youth who are or have been on the mental health caseload, in particular faulting the excessive periods of seclusion to which these youth
2 


Case: 2:08-cv-00475-ALM-MRA Doc #: 161 Filed: 12/09/15 Page: 3 of 5 PAGEID #: 3273
were subjected. The United States also filed a supplemental complaint renewing its motion for a temporary restraining order. Through settlement negotiations, the parties reached an agreement on the resolution of Plaintiffs’ claims, which the Court approved. (Doc. 401.)
This settlement established a Grid that detailed the actions Defendants committed to undertake to improve mental health services and reduce seclusion of youth on the mental health caseload. (Doc. 401-1.) The remaining areas to be monitored included quality assurance and peer review for mental health and psychiatry, case formulation, fidelity of treatment provided to treatment model, treatment planning and treatment terms, behavior contracts, suicide prevention, and discipline for youth on the mental health caseload through the intervention hearing process. (Doc. 400 at 3.) Starting on July 31, 2014, DYS agreed to provide to the Monitors quarterly reports on its seclusion practices. The parties agreed that Defendants’ compliance with the Grid would be monitored by Mr. Harrell and Dr. Dedel until DYS maintained substantial compliance with all provisions and performance measures for six months. Although the order indicated that the Grid applies only to youth at facilities directly managed by DYS, it also specified that “youth at other facilities shall receive mental health services consistent with those described [in the Grid] but appropriately tailored for such non-DYS managed facilities.” (Doc. 401-1 at 9.) These other facilities include the contracted facilities which house girls.
II. CURRENT CONDITIONS AT DYS FACILITIES In June 2015, the Monitors filed a Compliance Report for the DYS boys’ facilities (“Boys Report”). (Doc. 407.) In November 2015, the Monitors also filed a review of the DYS contracted programs for girls (“Girls Report”). The Boys Report, and the memos that followed it in August 2015, concluded that DYS is now in substantial compliance with all of the provisions and performance measures incorporated in the Grid. The Girls Report concluded that the
3 


Case: 2:08-cv-00475-ALM-MRA Doc #: 161 Filed: 12/09/15 Page: 4 of 5 PAGEID #: 3274
practices at the contracted girls’ facilities were functionally equivalent to services prescribed by
the Grid for boys at DYS facilities, including significant progress in quality of treatment and
further restrictions on the use of seclusion. The improvements documented by the Ohio Model
Report include the following:
 The video recording and review of all applications of the use of force, and intensive staff training and oversight for compliance with the use-of-force policy
 A meaningful grievance system and easy access to attorneys to address concerns related to fact, duration, and conditions of confinement
 Abolition of the practice of disciplinary seclusion and dramatic reductions in pre-hearing seclusion
 Fully staffed and well-managed educational programming and the elimination of school suspensions and school-day reductions
 Improved systems for health assessments, physical exams, maintenance of medical records, and more thorough documentation, as well as chronic care and medication administration that is now consistent with national guidelines
 New Program Administrator positions at each facility; expanded access to work programs (for high school graduates); Youth Councils that offer youth a meaningful role in decision-making; positive behavior incentive programs for youth; cognitive behavioral therapy program to target youth at risk of reoffending or gang involvement
 Video conferencing technology and bus transportation to increase family visitation and a policy of seven-day-a-week visitation
 Vastly improved mental health treatment including group treatment sessions; quality oversight of staff; easy accessibility of treatment professionals; and the replacement of punitive Special Management Plans that relied excessively on seclusion with Behavior Contracts, tailored plans with incentives and consequences
 Development of standardized criteria to deny a youth’s release rather than making such decisions without any criteria, as well as a meaningful process to appeal a release denial
 Reducing the incarcerated population from over 2000 youth several years ago to less than 500 today through the initiative RECLAIM, whereby DYS partnered with juvenile courts throughout the state to increase their capacity effectively to supervise and serve youth at the county level, which has led to less school interruption, more family engagement, and better behavioral outcomes for youth.
4 


Case: 2:08-cv-00475-ALM-MRA Doc #: 161 Filed: 12/09/15 Page: 5 of 5 PAGEID #: 3275

III. CONCLUSION 


The Court concludes that the Defendants have complied with the terms and modifications

of the Stipulation for Injunctive Relief in Case No. 2:04-cv-1206 and the consent decree in Case

No. 2:08-cv-475. The Joint Motion to Terminate the Consent Decree is GRANTED. The

consent decree is hereby TERMINATED.

IT IS SO ORDERED.

DATED: December 9, 2015

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

5 


 
 Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 1 of 39 PAGEID #: 3200
The Ohio Model 

A Report on the Transformational Reform of the 
 Ohio Department of Youth Services, 2007 ‐ 2015 

Will Harrell, J.D., LL.M. & Kelly Dedel, Ph.D, Federal Court Monitors and Terry Schuster, J.D., Special Assistant to the Monitors 12/7/2015

Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 2 of 39 PAGEID #: 3201
The Ohio Model
A Report on the Transformational Reform of the
 Ohio Department of Youth Services, 2007 ‐ 2015

By Will Harrell, Kelly Dedel, and Terry Schuster
 Video footage recorded and produced by Roger Cohen

Introduction
Ohio is well known among juvenile justice practitioners for its RECLAIM and Targeted RECLAIM initiatives, which have reduced the population of youth placed in the state’s juvenile facilities through financial incentives and significant advanced planning with the counties. Less well known is the story of how, with a reduced population, Ohio has transformed the conditions and culture inside the state’s juvenile facilities. This report tells that story. Comparing conditions today with those found unconstitutional in 2008, this report describes how the focused efforts of the state juvenile corrections agency, spurred by litigation, have resulted in what is in many ways a model system – and what we are calling The Ohio Model.
All juvenile correctional agencies have areas in which they can improve, and Ohio’s Department of Youth Services (DYS) is no exception. Higher concentrations of youth with serious behavioral challenges and mental health disorders remain in DYS facilities after downsizing, as they have in other states. This group of youth often includes those who have exhausted county resources and placement options, and most if not all juvenile corrections agencies struggle to provide them with appropriate programming and behavioral interventions. We have reported over the last several years on areas of progress and ongoing deficiencies. We continue to find that DYS’s leaders are vested in examining and improving their practices. The purpose of this report is not to make the case that DYS is a perfect agency. Rather, it is to applaud their significant improvement in conditions of confinement, and memorialize the agency’s major policy and practice decisions for the benefit of others in the field. All findings in this report reflect the Department’s practices at the time monitoring of the relevant subject matter was terminated.
Authors
Will Harrell, J.D., LL.M. was appointed Lead Monitor for the remedy stage of the S.H. v. Reed litigation by Federal District Judge Algenon Marbley. Mr. Harrell is the Founder and Director of the Justice Collaborative, a consulting firm on criminal and juvenile justice reform initiatives. He also serves as Ombudsman for the New Orleans juvenile detention center, and Southern Regional Policy Director for the ACLU doing criminal justice reform work throughout the South. As Director of the Justice Collaborative, he provides technical assistance to jurisdictions around the country to strengthen justice reform initiatives, improve conditions of confinement, and expand alternatives to confinement. He has previously served as Public Policy Director for the Southern Poverty Law Center; the Independent Ombudsman for the Texas Youth Commission; the Executive Director of the ACLU of Texas; and the Executive Director of the National Police Accountability
1


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 3 of 39 PAGEID #: 3202
Project. As Legal Director for the Centro Para La Accion Legal En Derechos Humanos, he developed and managed an international human rights law clinic in Guatemala; investigated Guatemalan jails and prisons for the United Nations Human Rights Verification Mission; and brought litigation against the Ecuadoran prison system before the Inter‐American Commission on Human Rights. Mr. Harrell began his legal career in criminal justice reform as a Thurgood Marshall Law Fellow at the ACLU National Prison Project in 1991 under the wings of the late Al Bronstein.
Kelly Dedel, Ph.D was appointed Lead Monitor in the U.S. v. Ohio litigation. She is an independent consultant and Director of One in 37 Research, Inc. For the past 17 years, she has worked as a monitor and investigator in juvenile conditions of confinement litigation, with subject matter expertise in protection from harm, use of seclusion, special education, and quality assurance. While litigation is rarely a pleasant experience for those involved, Dr. Dedel embraces the opportunity to help defendants accomplish the reforms in a way that best suits their philosophy, resources, and staff and youth cultures. Her monitoring strategy comes with a commitment to technical assistance and to helping systems develop an internal capacity to identify and respond to their problems so that oversight becomes unnecessary.
Terry Schuster, J.D., was Special Assistant to Monitor Will Harrell from 2011 to early 2014. He is a senior associate at The Pew Charitable Trusts’ Public Safety Performance Project, where he has provided technical assistance on sentencing and corrections reform efforts in Utah, Arkansas, and Alaska. He has previously worked as an attorney for Juvenile Law Center; and as a law clerk for the Special Master in the juvenile conditions of confinement case Farrell v. Cate, the Ombudsman for the Texas Youth Commission, the Travis County Juvenile Court, and the Texas RioGrande Legal Aid Public Defender’s Office.
The collaborative monitoring model
Our monitoring model has created a framework to shift from an adversarial process to a more collaborative remedy process. We have aimed to be efficient and cost‐effective, empowering to the parties and community stakeholders, and focused on collaborative resolutions to the problems identified through the litigation. We have streamlined site visits and information requests, and created shared electronic filing systems for the parties and monitoring team. We developed a fact‐finding and reporting protocol to ensure timely comprehensive monitoring, to avoid conflicting findings regarding compliance with the stipulated agreements, and to triage concerns and recommendations for change. We worked with the Department and interested parties to outline a plan to achieve compliance and reach closure of the case in a short period of time. We moderated disputes and made every effort to resolve them informally and collaboratively. We also provided quick and thorough national research to guide the parties toward resolution.
We believe in transparency, and have gone out of our way to keep the parties and the Court informed of the monitoring team’s work. Understanding the overlapping, but sometimes differing perspectives of private counsel and the Department of Justice, we have been cautious to approach our work with those perspectives in mind, and to regularly seek input and consensus.
2


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 4 of 39 PAGEID #: 3203
This monitoring model is a coaching model that has included a heavy emphasis on quality assurance and continuous quality improvement. The subject matter experts on the team have worked with DYS to develop and continually revise internal monitoring tools, to ensure that as DYS has achieved compliance with the stipulated agreements, they are also prepared to take over the work of monitoring conditions of confinement themselves – monitoring that will continue long after the remedial phase of the cases have ended. DYS has taken ownership of the reforms, and we applaud their outstanding accomplishments.
A note on the multi‐media content of this report
Throughout this report we have included video segments of youth describing changes they have witnessed and benefitted from during the term of their confinement in DYS facilities. Video footage was recorded and produced by Roger Cohen as one among many measures of DYS’s progress over time. Youth who were interviewed were asked general, non‐leading questions about subject matters under Court supervision (use of force, education, mental health care, etc.), and were not promised any rewards for saying favorable things about the agency. All of those portrayed in this report have given written legal permission for their words and images to be shared publicly. To view the video segments, click on the hyperlinks in the body of the report or in the Table of Contents.
Acknowledgements
The class of youth placed in DYS secure facilities has benefitted from extraordinarily skilled counsel since 2004. The S.H. case was filed by Kim Tandy, Director of the Children’s Law Center. Along with Al Gerhardstein of Gerhardstein & Branch, LPA, Kim led the legal team through the negotiations in 2004 and through implementation of the decree during the reform years until 2015. They were ably assisted at various times by Jennifer Kinsley, Marc Schindler, Maria Ramiu, Mark Soler, Joseph Scantlebury, David Singleton, Janet Moore, Jessica Gingold, and Angelina Jackson. They have represented the S.H. class in federal court hearings and negotiations, and secured among other things a Stipulated Consent Order unique in scope and specificity. Over the same period of time, DYS has received outstanding representation from several Assistant Attorneys General, including Judy Goldstein, Tom Anger, Mindy Worly, Rich Cholar, Eric Holloway, Joseph Mancini, Philip King, Sharon Jennings, Frank Strigari, Janet Hill Arbogast, Brian Laliberte, Lisa Eschbacher, and Zachary Swisher; as well as in‐house counsel Kelly Castle, Anthony Pierson, Marla Burton, and Dustin Calhoun; and private counsel Geoffrey Moul, James Burnes and Laura Anthony.
Presiding over the S.H. v. Reed (previously S.H. v. Stickrath) case, the Honorable Algenon Marbley has overseen both the litigation and eight years of efforts to remedy the unconstitutional conditions found in 2008. His attention to this case, his guidance to the monitoring team, and his compassion for system‐ involved youth have helped mold and strengthen the reforms. Judge Marbley has inspired movement and momentum at times when reform efforts were stalled. He has served the parties as a mediator, a problem‐ solver, and an agent for change. His judicial clerks, Natalie McGlaughlin, Soren Aandahl, Sara Belton, Elizabeth Gerber, Lauren Hilsheimer, Rob Szykowny, and Adam Rusnak have also contributed immensely to the S.H. reforms.
3


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 5 of 39 PAGEID #: 3204
Above all, the authors and drivers of reform in DYS facilities have been the Department’s staff and administrators. Their leadership, innovation, experimentation, and tireless work have dramatically improved the environment for youth in state custody, and altered the course of many youths’ lives. While there are far too many individuals to name here, the reforms were brought about under the leadership of Directors Harvey Reed, Tom Stickrath, Christine Money, Martha Spohn, and Geno Natalucci‐Persichetti, each of whom worked closely with Governors Bob Taft, Ted Strickland, and John Kasich. In the final years of monitoring, Governor Kasich’s engagement with the Department and active support helped sustain and build on the previous years’ efforts. Significant credit must also be paid to Assistant Directors Linda Janes, Damita Peery, Bonnie Sweeney, and Brenda Cronin; Bureau Chiefs Amy Ast, Laura Dolan, Ginine Trim, MT Schwartz, Wendi Faulkner, Ryan Gies, Linda Modry, and Kevin Shepherd; Chief Inspector Jennifer Fears; Superintendents Katie Neeham, Jim Darnell, Ron Edwards, Andrea Jones, Gwen Randall, Chris Baker, Dave Blackburn, Earl Myles, Marci Sutherland, Dave Pigman, Dion Norman, Thomas Teague, and Fred Nelson; central office administrators Jodi Slagle, Shelly Fitzhugh, Christy Hauck, Kim Kehl, Jeff Spears, Tony Panzino, Cedric Collins, Rochele Jones, Joan Olivieri, Shari Wolf, Brandon Strange, Edward Dachowski, John Bradley, Jacqueline Carter, Pam Robbins, Pam Gulley, Latoya Gregory, Mike Gordon, Peter Huling, Ernie Moore, Maryalice Turner, Jerry McGlone, Jennifer Sanders, Cynthie McIntosh, Connie Blair, Burger Penrod, Mark Thompson, Dave Dutton, Kim Parsell, Andrea Kruse, Nan Hoff, Aaron Bauer, Shannon Komisarek, Pat Hurley, Chris Freeman, Jim Ferrell, Keith Willliams, Clifford Smith, and countless others both in central office and at the facilities.
An exceptionally talented group of experts and consultants have served as members of the court‐appointed monitoring team. They have each played a dual role – part fact‐finder for the Court and part coach and consultant for their counterparts at DYS. Our monitoring model has been very hands‐on and collaborative. Over the last three years, we have focused intensively on helping the agency develop internal quality assurance tools, ensuring that DYS could conduct systematic internal monitoring as a step toward phasing out our external monitoring. The expertise and guidance of these monitoring team members have been invaluable for the Court and the parties, and the legacy of The Ohio Model is, in part, their legacy. In addition to ourselves, members of the S.H. monitoring team have included Monitors Fred Cohen and Vince Nathan; and subject matter experts Ava Crow, Anne Flynn, Ron Shansky, Barb Peterson, Shay Bilchik, Steve Martin, Daphne Glindmeyer, Andi Weisman, Orlando Martinez, David Roush, Cheryl Wills, Don Sauter, and Nick Makrides. Two of these experts as well as Michelle Staples Horne also served as members of the monitoring team for U.S. v. Ohio, a parallel suit brought by the U.S. Department of Justice regarding conditions at two DYS facilities. We would like to acknowledge their outstanding work and also recognize the attorneys for the United States who have played a vital role in system reforms, Bo Tayloe, Silvia Dominguez Reese, Rashida Ogletree, Jackie Cuncannan, Grace Chung Becker, Shanetta Cutlar, Gregory Gonzalez, and Vincent Herman.
A number of other consultants, including many leading national experts, contributed to the S.H. remedial efforts. We owe a debt of gratitude to the Vera Institute of Justice, the Juvenile Detention Alternatives Initiative, the Center for Juvenile Justice Reform at Georgetown University, Ed Latessa, Brian Lovins, Larry Travis and other researchers at the University of Cincinnati School of Criminal Justice, the Schubert Center for Child Studies at Case Western Reserve University, the PREA Resource Center, the Moss Group, the Project Addressing Prison Rape at the American University Washington College of Law, Leta Smith, Kathy Burns, Ned Loughran, Robert Prentky, Jim Austin, John Boston, Julian Ford, Amanda Yurick, Lindsay Hayes, Stuart
4


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 6 of 39 PAGEID #: 3205
Grassian, Patrick Canary, and Lisa Boesky. Juvenile justice stakeholders and other state and county agencies in Ohio have influenced DYS policy and practice through participation in the Ohio Interagency Task Force on Mental Health and Juvenile Justice, the Interagency Task Force on Sexual Misconduct, the RECLAIM Ohio and Targeted RECLAIM initiatives, and the Behavioral Health / Juvenile Justice Initiative. Ohio also benefits from a uniquely robust community of youth advocates and external oversight bodies that will remain long after the S.H. case ends. The Office of the Ohio Public Defender provides legal assistance to youth housed in DYS facilities on matters relating to the fact, duration, or conditions of their confinement. For several years, legal services were also provided by Emma Setta and the law office of Marc Mezibov. The state’s Correctional Institution Inspection Committee regularly audits each facility and reports its findings to the legislature. Disability Rights Ohio serves as the state’s Protection and Advocacy organization for youth with mental health disorders and other disabilities. Facilities are also monitored by a citizen oversight group, the Juvenile Justice Coalition. Additionally, the Children’s Law Center, Voices for Ohio’s Children, Children’s Defense Fund, the ACLU of Ohio, and the National Campaign to Reform State Juvenile Justice Systems continue to advocate for the rights and protection of youth in DYS facilities.
5


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 7 of 39 PAGEID #: 3206
Table of Contents
Executive Summary……………………………………………………………………………………………………………………………….……8 Protection from Harm………………………………………………………………………………………………………………………….……13
Dangerous conditions and practices in 2007…………………………………………………………………………………………..13 Changes to use‐of‐force practices…………………………………………………………………………………………………………..13 Improved documentation and video recording of applications of force ……………………………..………………….14 Better oversight and investigations…………………………………………………………………………………………………………14 Improved grievance system and access to attorneys ……………………………………………………………………………..15 Enhanced efforts to prevent and address sexual victimization.…………………………………………………………….…15 Development of a youth classification and housing system…………………………………………………………………….16 Development of internal quality assurance practices………………………………………………………………………………17 Video segment: Click here to hear from youth about improvements in protection from harm………….….17 Discipline and Seclusion……………………………………………………………………………………………………………………………17 Dangerous conditions and practices in 2007…………………………………………………………………………………………..17 Reduced reliance on pre‐hearing seclusion…………………………………………………………………………………………….17 Abolishing seclusion as a disciplinary sanction………………………………………………………………………………………..18 Alternatives to formal discipline……………………………………………………………………………………………………………..18 Increased oversight of seclusion practices………………………………………………………………………………………………18 Creation of a new Youth Advocate program……………………………………………………………………………………………19 Elimination of Special Management Units………………………………………………………………………………………………19 Education………………………………………………………………………………………………………………………………………………….19 Conditions in 2007………………………………………………………………………………………………………………………………….19 Better collaboration between school and facility staff………………………………………………………………………….…20 Meeting the needs of youth who can’t read……………………………………………………………………………………………20 Improvements in staffing and classroom space………………………………………………………………………………………20 Improvements in classroom management and school safety………………………………………………………………….21 Compliance with Special Education law………………………………………………………………………………………………….22 Providing education to youth on specialty housing units and youth in seclusion…………………………………….22 More vocational training, college courses, and transition planning…………………………………………………………23 Internal quality assurance monitoring for education………………………………………………………………………………24 Video segment: Click here to hear from youth about improvements in educational services………………..24 Video segment: Click here to learn more about the Inside‐Out program…………………………………………….…24 Medical and Dental Care…………………………….…………………………………………………………………………………………….24 Conditions in 2007………………………………….………………………………………………………………………………………………24 Improvements in medical assessments...………………………………………………………………………………………………..25 Improvements in medication, chronic care, and emergency care.…………………………………………………………..25 Improvements in medical records………………………………………………..…………………………………………………………26 Continuous Quality Improvement and peer review of doctors and nurses……………………………………………..26 Improvements in dental care………………………………………………………………………………………………………………….26 Cultural and Environmental Changes………………………………………………………………………………………………………..27 Conditions in 2007………………………………………………………………………………………………………………………………….27 Changing the role of direct care staff………………………………………………………………………………………………………27
6


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 8 of 39 PAGEID #: 3207
More activities, more staff, and fewer youth………………………………………………………………………………………….27 Identifying and addressing youths’ criminogenic needs……………………………………………………………………….…28 Family Engagement…………………………………………………………………………………………………………………………………..29 Finding new and innovative ways to engage family members during a youth’s stay at DYS…………………….29 Video segment: Click here to hear from youth about improvements in family engagement..……………….30 Mental Health and Psychiatry Services……………………………………………………………………………………………………..30 Conditions in 2007………………………………………………………………………………………………………………………………….30 Providing proactive rather than reactive mental health services…………………………………………………………….31 Improved care for youth with the most serious mental health symptoms………………………………………………31 Treatment‐based interventions for youth with disruptive behavior……………………………………………………..…32 Improved psychiatry services……………………………………………………………………………………………………….…………32 Quality assurance monitoring and peer review……………………………………………………………………………………….33 More continuity of care for youth returning home…………………………………………………………………………………33 Video segment: Click here to hear from youth about improvement in mental health services..…………….33 Release from Secure Custody……………………………………………………………………………………………………………………33 Release practices in 2007………………………………………………………………………………………………………………….…….33 Clear‐cut criteria for denying release……………………………………………………………………………………………..……….34 Conducting internal quality assurance monitoring……………………………………………………………………………..…..34 Reducing the Incarcerated Population………………………………………………………………………………………………………35 Downsizing the juvenile prison system by increasing effective local alternatives……………………………………35 Risk assessment tools used to inform placement decisions…………………………………………………………………….35 JDAI and DMC initiatives…………………………………………………………………………………………………………………………35 Improvements to parole and reentry efforts…………………………………………………………………………………………..36 Dramatically improved outcomes and cost savings…………………………………………………………………………………36 Additional Accomplishments…………………………………………………………………………………………………………………….36 Conclusion………………………………………………………………………………………………………………………………………………..37
7


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 9 of 39 PAGEID #: 3208
Executive Summary
Protection from Harm
The Ohio Department of Youth Services (DYS) put in place several measures to protect youth in their custody from harm. DYS intensified staff training and oversight, responding to findings that use of force in the facilities was excessive and reckless. Today, staff members consistently engage in verbal strategies to deescalate violent and threatening behavior among youth, and use minimal amounts of force when necessary, only as a last resort. Every application of force is now recorded on video and reviewed by administrators for compliance with policy. The staff members engaged in incidents get immediate, detailed feedback from those administrators. DYS now also has a state of the art process for investigating allegations of excessive force.
Youth have a meaningful grievance system, and have easy access to attorneys who help them address concerns related to the fact, duration, or conditions of their confinement. An improved security classification system and quality assurance system have contributed to a steady decline in youth‐on‐youth violence. With assistance from a wide range of national experts, DYS has also greatly expanded its efforts to prevent and address sexual victimization of youth in its facilities.
Discipline and seclusion
Excessively punitive consequences for youth who violated facility rules have been revised. Rather than utilizing a formal disciplinary system, interventions to respond to rule violations are constructed by youths’ treatment teams. DYS has abolished the practice of disciplinary seclusion, has achieved dramatic reductions in the use of pre‐hearing seclusion, and has put in place a robust oversight process to monitor placement in seclusion, length of stay, and frequency of staff contacts with youth. Youth report that the disciplinary process is more fair, in part due to the agency’s placement of a Youth Advocate at each facility who assists youth during hearings.
DYS has removed all youth from Special Management Units, which previously relied excessively on seclusion and restraints. They revised the program so that, if utilized in the future, those housed on the unit will be out of their rooms and engaged in programming for the entire day.
Education
Education has vastly improved in DYS facilities. Schools that were plagued by violence, teacher shortages, lack of instruction, and ineffective classroom management, are now fully staffed, safe, and well‐managed. Teachers receive professional development and mentoring to better manage challenging student behavior and engage more effectively with youth. Students are no longer suspended from school. Those housed on mental health units are no longer deprived of a
8


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 10 of 39 PAGEID #: 3209
full school day. Special Education services are now compliant with federal and state law, and responsive to individual student needs. Additionally, DYS now has a unique quality assurance system for Special Education that should serve as a model for other schools around the country.
Medical and dental care
Medical and dental services in DYS facilities are now closely monitored through clinician peer review and Continuous Quality Improvement systems. DYS hired a Dental Director whose oversight and guidance have significantly improved the quality and timeliness of dental care. Dental staffing has improved, as have exams, cleanings, and restorative dental care. Medical services, which previously lacked adequate assessments and documentation, and which provided no systematic care for youth with chronic diseases, are now significantly improved. Health assessments are timely and complete. Chronic care and medication administration are consistent with national guidelines. Nurses who assess youth for injuries after fights or applications of force now take appropriate histories. They conduct physical exams in a clinical space rather than through the youth’s door. Central office also closely monitors practices related to intake, lab and diagnostic services, vital sign monitoring, sick call, emergency services, and family engagement in treatment.
Medical records are up‐to‐date and chronological. They contain thorough notes on clinical findings, treatment plans, patient encounters, and responses to treatment. At the time monitoring of medical care terminated, DYS was working toward the roll‐out of an electronic medical record system that would combine medical, dental, mental health, psychiatry, and social work files into a single fully‐integrated record.
Cultural and environmental changes
Much of DYS’s reform efforts have focused on changing the culture and environment in the institutions. A 2007 investigation found that direct care staff in the facilities were overly confrontational and violent. Their approach created a hostile environment, and negatively affected youths’ behavioral outcomes. DYS expanded the job duties of direct care staff, ensuring that they would be highly involved in programming, treatment teams, and mentoring of youth, rather than just acting as guards. Each facility now has a core group of staff who have good relationships with a wide range of youth, and whose approaches to problem behaviors are based on a positive rapport that they have built over time with the youth.
The creation of new Program Administrator positions at each facility has increased the quantity and quality of programming and activities. High school graduates now benefit from an expanded work program to constructively occupy the portion of their day that other youth spend in school. Each facility also has a Youth Council, which offers youth a meaningful role in facility decision‐ making.
9


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 11 of 39 PAGEID #: 3210
All youth earn points through a positive behavior incentive program, and spend those points on commissary items, additional phone calls, and entry into special events. The reduced population has allowed staff more time to interact with youth and engage them in programming. These changes have helped improve perceptions of safety among both youth and staff. Because fewer staff members call off work due to stress and injuries, these cultural changes have also helped alleviate chronic staffing shortages.
DYS adopted the Ohio Youth Assessment System (OYAS), which helps staff determine the types of interventions that will be most effective with youth, based on their risk to reoffend and their criminogenic treatment needs. The agency also adopted a Cognitive Behavioral Therapy modality that targets these criminogenic factors, and helps teach and reinforce pro‐social ways to cope with stressful situations. DYS changed their approach to gang intervention as well. Rather than attempting to simply sanction all gang‐related behavior, which has not been successful in the past, DYS’s new approach aims to disengage youth from gang activity by understanding why they are getting involved in the first place. They manage gang problems by creating a safe place for youth to talk about them; and providing alternatives, incentives, and supports for youth who want to disengage. These approaches have helped to shift staff responses away from labelling youth as troublemakers, and toward interventions that are based on meeting their criminogenic needs.
Family engagement
DYS now uses video conferencing technology and provides bus transportation to increase family visitation, which in turn has improved youth behavioral and educational outcomes. They have also implemented a policy that facilitates family visitation seven days a week. Through a partnership with the Vera Institute of Justice, DYS has developed staff members’ abilities to find and engage family members and supportive community members in youths’ treatment, and plan for reentry back to the youth’s home community.
Mental health and psychiatry services
In the area of mental health care, DYS’s efforts transformed a profoundly understaffed and disorganized system in which mental health needs went largely undiagnosed and untreated, into a proactive system that provides individualized treatment planning and progress monitoring for each youth in their custody. A 2007 investigation found grossly inadequate services for youth with the most serious mental health needs, and barriers to inpatient hospitalization for those in acute crisis. Today, specially trained staff provide intensive treatment services on Mental Health Units, and all youth have access to inpatient care when needed. The agency has drafted and revised a comprehensive set of policies and procedures governing mental health and psychiatry services. Social workers, psychologists, occupational therapists, and psychiatric nurses work as an integrated behavioral health team, are easily accessible to youth on all housing units, and provide more than adequate clinical coverage.
10


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 12 of 39 PAGEID #: 3211
Treatment teams meet monthly to review each youth’s progress toward their goals. Group treatment sessions are provided nearly every day and individual sessions are provided as needed. Psychiatrists meet regularly with youth who are treated with psychotropic medications to monitor treatment efficacy and side effects. The agency has begun monitoring services and staff performance through quality assurance measures and clinician peer review. They have also improved continuity of care for youth returning home, by securing a policy change that makes youth presumptively eligible for Medicaid coverage upon release from the institution.
Behavior management for youth whose disruptive behavior stems from underlying mental health disorders has also changed. DYS stopped using punitive Special Management Plans that relied excessively on seclusion, and replaced them with Behavior Contracts. These contracts offer incentives and consequences tailored for each youth to incrementally improve behavior. Mental health clinicians review incidents in which youth on the mental health caseload engage in violent or disruptive behavior. This process allows them to divert youth away from formal disciplinary hearings or offer guidance to hearing officers regarding appropriate interventions.
Release from secure custody
The release process, which youth and staff previously found confusing and exasperating, has become much more fair and consistent. The 2007 investigation found release decisions being made without clear‐cut criteria. At times, youth were denied release due to staff members’ failure to complete paperwork or due to other factors beyond the youth’s control. Not knowing when they were going home or how that decision was being made caused youth act out, which undermined the agency’s behavior incentive program. DYS has since defined a limited set of barriers that would warrant denying a youth’s release. These barriers are invoked sparingly, and each quarter between 70 and 90 percent of youth reviewed are released by their minimum sentence expiration date. Youth now also have a meaningful process to appeal a release denial. Additionally, DYS reviews the performance of Release Authority panel members and facility staff members involved in release reviews through an internal quality assurance system.
Reducing the incarcerated population
Finally, DYS is best known for its extraordinary success in downsizing the juvenile prison population. The agency partnered with juvenile courts throughout the state to increase capacity to effectively supervise and serve youth at the county level. They provided financial incentives to use those dispositional alternatives rather than commit youth to state‐run correctional facilities. This initiative, called RECLAIM Ohio, was bolstered by the Targeted RECLAIM initiative that expanded evidence‐based alternatives in the state’s six largest counties. Both this initiative and a similar project focused on increasing local mental health resources at the county level have since been expanded to many more counties. DYS reduced its juvenile prison population from over 2000 youth several years ago to less than 500 today. These downsizing efforts
11


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 13 of 39 PAGEID #: 3212
resulted in enormous cost savings for the state, and were supported by studies showing that low‐ and moderate‐risk youth had lower recidivism rates if they were not placed in the state’s secure facilities. Youth diverted from confinement in DYS facilities also had less school interruption, more family engagement in treatment, and better behavioral outcomes. DYS also closed its girls’ unit at the Scioto Juvenile Correctional Facility, and transitioned the youth housed there to the community with aftercare plans or to one of three small contract placements, two of which are licensed to provide mental health and addiction services.
12


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 14 of 39 PAGEID #: 3213
Protection from Harm
Dangerous conditions and practices in 2007. An investigation conducted in 2007, with findings reported in January 2008, revealed a pattern and practice of excessive staff use of force in DYS facilities. Direct care staff engaged in reckless and malicious practices, disregarding obvious risks of harm to youth.1 The degree of force applied was unnecessary and often life‐threatening. The investigation report described several examples of chokeholds and other restraints that created extreme risks of asphyxia to youth in DYS custody.2 Staff were untrained, confrontational, quick to apply physical restraints and excessive force, and often strategic in the location of incidents in order to avoid cameras. Staff supervisors became directly and unnecessarily involved in applications of force rather than managing the incidents and overseeing the involved staff.3
Staff documentation regarding applications of force lacked detail sufficient to determine the nature of the force used. Staff often used terms such as “fight break‐up” without fully describing the actions they took. Other reports were incomplete or entirely false. The investigation report included examples of incidents in which many staff members witnessed (and video captured) youth being choked for extended periods of time or kicked in the head multiple times, but where none of the witness reports documented these details.4 Most administrative reviews of incidents did not involve viewing video footage, and both staff and youth described abuse of youth in areas without video coverage.5 Facility administrators had no reliable set of criteria to review the propriety of applications of force or the need for an abuse investigation by the Chief Inspector’s Office. Abuse investigations at the facility level were of very questionable quality, often resulting in facially unreliable findings. Moreover, employee disciplinary sanctions for engaging in abusive practices were often too lenient compared with the seriousness of the violation, or were not imposed at all.6
Youth also reported being scared of peer violence. Psychology staff reported dramatic numbers of youth making suicidal gestures or statements in order to be placed in protective custody.7 Youth grievances related to peer violence (as well as sexual harassment, staff retaliation, and unmet medical needs) often received no response. Youth with low levels of literacy were not provided any assistance in writing grievances. Furthermore, the Grievance Coordinators at each facility had no clearly defined role or special training.8
Changes to use‐of‐force practices. Staff now receive quarterly training on appropriate techniques for de‐escalation and managing youth resistance. Throughout DYS facilities, staff members engage in verbal strategies to de‐escalate violent and threatening behavior among youth, and resort to force only
1 Fred Cohen, Final Fact‐Finding Report, S.H. v. Stickrath (Jan. 2008), pp. 24‐25.
 2 Id. at pp. 35‐37.
 3 Id. at pp. 37‐38, 133.
 4 Id. at pp. 33‐38, 41.
 5 Id. at pp. 26‐27, 37‐38, 82.
 6 Id. at pp. 26‐27, 37‐38.
 7 Id. at pp. 76‐77.
 8 Id. at pp. 186‐191.

13


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 15 of 39 PAGEID #: 3214
as a last resort.9 The rates of physical restraints have declined. When they do occur, they are planned and captured by hand‐held video cameras. The levels and intensity of force now applied are minimal with very few injuries occurring to youth and staff.10 Mechanical restraints occur at very modest levels, and for minimal lengths of time.11 Supervisory staff at the facilities are also effectively managing incidents of force rather than becoming directly involved.12
Improved documentation and video recording of applications of force. Staff members’ written documentation of use of force incidents has significantly improved. Staff record applications of force on hand‐held video cameras, and preserve the videos for review by supervisors and investigators. In recent months, an additional 40‐70 stationary cameras were installed at each facility to increase DYS’s surveillance capabilities in vulnerable areas. The video camera coverage enhances the monitoring of use of force and other potential abuse.13
Better oversight and investigations. DYS created a new administrative position at each facility called the Facility Intervention Administrator (FIA), who is responsible for reviewing every incident involving physical or mechanical restraints, and determining whether the staff members’ actions complied with policy. The FIA provides staff with immediate, detailed feedback to refine their skills and improve incident management. The facility FIAs are diligent in taking corrective action. They are not hesitant to refer incidents to the Chief Inspector’s Office (CIO) for investigation into potential abuse. Where policy violations fall short of abuse, they address staff performance through “teachable moments” or direct coaching.14 DYS is unique among juvenile corrections agencies for creating a role like the FIA. The position has had a dramatic impact on use of force practices, and serves as a model for agencies struggling with violent conditions. Each month, a Facility Resource Administrator (FRA) from Central Office reviews the FIA’s decision‐making for a sample of incidents. The FRA provides comprehensive assessments, and meets with facility officials to improve the use‐of‐force review process.15 When abuse has been alleged, the CIO conducts thorough and timely investigations, sustains the allegations when supported by the evidence, and imposes appropriate staff disciplinary action.16
9 See Steve Martin, CJCF site visit report (Jan. 2013), pp. 3‐4; Steve Martin SJCF site visit report (Jan. 2013), p. 4;
 Steve Martin, CHJCF site visit report (Sept. 2012), p. 3.
 10 Id.; Kelly Dedel, et al., Monitor’s Fourth Report, U.S. Department of Justice v. The State of Ohio (June 2013), p. 12
 (Hereinafter “Monitor’s Fourth Report”).
 11 See Steve Martin, CJCF site visit report (Mar. 2012), p. 7.
 12 See Steve Martin, CJCF site visit report (Jan. 2013), pp. 3‐4; Steve Martin & Amy Ast, Fifth Year Plan for Bureau of
 Facility Operations (Nov. 2012), p. 2.
 13 Steve Martin, IRJCF site visit report (Sept. 2012), p. 3; Steve Martin, CJCF site visit report (Jan. 2013), p.4;
 Message from DYS Director Harvey Reed, Facility Developments (Sept. 6, 2013).
 14 Steve Martin, CJCF site visit report (Jan. 2013), pp. 3‐4; Steve Martin, CHJCF site visit report (Sept. 2012), p. 3;
 Steve Martin, IRJCF site visit report (Sept. 2012), pp. 3‐4; Steve Martin, CJCF site visit report (Mar. 2012), p. 5; Kelly
 Dedel, et al., Monitor’s Fourth Report (June 2013), p. 10.
 15 Steve Martin, SJCF site visit report (Jan. 2013), p. 4; Steve Martin, IRJCF site visit report (Sept. 2012), pp. 3‐4;
 Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), p. 10.
 16 Steve Martin, CJCF site visit report (Jan. 2013), pp. 4‐5; Steve Martin, CHJCF site visit report (Sept. 2012), p. 3.

14


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 16 of 39 PAGEID #: 3215
Improved grievance system and access to attorneys. Youth receive a handbook and a thorough orientation covering the grievance system and their legal rights.17 Grievance Coordinators at each facility are easily accessible to youth. They respond to grievances in a timely and substantive manner, and effectively resolve youth complaints.18 The CIO reviews all grievances on an ongoing basis, requesting follow‐up action from the Grievance Coordinators if additional information is needed, and imposing corrective action when grievances are not resolved appropriately. The CIO audits the grievance process, directly observing interaction between the Grievance Coordinator and youth. The CIO also regularly surveys youth to identify ways in which the grievance system could be improved. As a result of these surveys, youth now receive a notification letter advising them of the outcomes of abuse investigations triggered by one of their grievances.19 Youth now have easy access to attorneys through the Ohio Public Defender’s office, which helps youth address concerns related to the fact or duration of their confinement; and which also operates the Legal Assistance Program, focused on resolving or litigating youth concerns related to their living conditions. The Public Defender’s degree of access to youth in custody and their ability to troubleshoot problems largely without litigation is rare in the United States, and should serve as a model for independent ombudsman offices nationwide.20
Enhanced efforts to prevent and address sexual victimization. In response to a Bureau of Justice Statistics report listing DYS among the juvenile corrections agencies with the highest reported incidence of sexual victimization, Governor Kasich convened an Interagency Task Force on Sexual Misconduct. The Task Force made unannounced visits to each facility, and developed recommendations related to implementation of the Prison Rape Elimination Act (PREA) regulations, improving reporting and investigation protocols, and data collection and analysis related to sexual misconduct. DYS received a two‐year grant to enhance training efforts and modify the facility physical plants, with technical assistance from the National PREA Resource Center. They identified areas in the facilities vulnerable to sexual misconduct, completed restroom and shower renovations to provide youth with more privacy, installed locks on school restrooms to eliminate the opportunity for youth to enter without staff knowledge, rearranged furniture to improve visibility and safety, and installed over 200 additional cameras. They developed a new more sophisticated system for daily rounds and random security checks at multiple levels to deter misconduct, and enhanced the protocols for monitoring camera footage. Cultural assessments lasting four days and nights at each facility were conducted to identify factors contributing to victimization and reporting problems. DYS reviewed its training for current staff and new hires with assistance from the PREA Resource Center and the Project Addressing Prison Rape at the Washington College of Law. They developed a four‐hour training for all staff based on evidence‐based practices and strategies to address sexual misconduct, with materials provided by the National Institute of Corrections, Washington College of Law, Just Detention
17 Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), p. 39.
 18 See Steve Martin, CHJCF site visit report (Sept. 2012), pp. 5‐6; Steve Martin, IRJCF site visit report (Sept. 2012),
 pp. 3, 7; Steve Martin, SJCF site visit report (June 2011), p. 8; Kelly Dedel, et al., Monitor’s Fourth Report (June
 2013), p. 35.
 19 Steve Martin, CJCF site visit report (Jan. 2013), p. 7; Steve Martin, CJCF site visit report (Mar. 2012), pp. 9‐10;
 Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), p. 36.
 20 See 51 Ohio Rev. Code § 5139.04(H); Memorandum of Understanding between Ohio Public Defender and Ohio
 Department of Youth Services (Jan. 2006); State of Ohio Inter‐Departmental Agreement, Department of Youth
 Services and Ohio Public Defender (Aug. 2013).

15


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 17 of 39 PAGEID #: 3216
International, and the Center for Children’s Law and Policy. Investigators of sexual misconduct and harassment incidents participated in a training provided by The Moss Group and the PREA Resource Center on conducting quality investigations, and additional training was provided to behavioral health staff on identifying warning signs and behavioral indicators of abuse. DYS also developed an excellent policy to protect and provide for the special needs of lesbian, gay, bisexual, transgender, and intersex youth.21
DYS put in place a Tip Line, a direct line to central office, for staff, youth, and family members to report any issues related to sexual harassment or abuse. Messages left on the Tip Line can be anonymous, and are reviewed within 24 hours by DYS’s new Youth Ombudsman at central office. The Tip Line number is posted in all housing units, and has been delivered to the families of youth currently in DYS facilities and on parole. DYS conducted interviews with staff and youth to collect input on how to address sexual victimization issues. Town hall meetings and labor‐management meetings were held with staff in which all staff were encouraged to read the BJS report, and asked to provide input through suggestion boxes and a special email account for suggestions. House meetings were conducted on every housing unit to discuss the desire to keep youth safe and to review with youth the ways they can report incidents of misconduct through the grievance process, trusted staff members, the Chief Inspector’s Office, the Legal Assistance Program, or the Correctional Institution Inspection Committee. All youth received a letter from the Director and a special training on their rights to be free from sexual abuse, harassment, and retaliation, DYS’s zero tolerance policy, and their avenues for reporting. Youth are interviewed upon leaving DYS and reentering the community, and youth on parole have been encouraged to report any sexual activity or abuse that they experienced or witnessed while in custody. Youth and staff surveys are also being developed to assess whether new interventions are working.22
Development of a youth classification and housing system. In collaboration with the University of Cincinnati, DYS developed and validated an assessment tool that designates youth as appropriate for minimum, medium, or close security housing; and that allows for reclassification of youth based on their demonstrated behavior while in custody. This security classification system has contributed to a steady decline in youth‐on‐youth violence.23
21 Ohio Department of Youth Services, Message from DYS Director Harvey Reed (Dec. 17, 2013); Ohio Department
 of Youth Services, Message from DYS Director Harvey Reed (Oct. 3, 2013); Ohio Department of Youth Services,
 Message from DYS Director Harvey Reed (Sept. 6, 2013); Ohio Department of Youth Services, Message from DYS
 Director Harvey Reed (Aug. 12, 2013); Ohio Department of Youth Services, Message from DYS Director Harvey
 Reed (July 17, 2013); Ohio Department of Youth Services, Message from DYS Director Harvey Reed (June 18, 2013);
 ODYS Standard Operating Procedure 304.02.01; Memorandum from Will Harrell and Terry Schuster to Gwen
 Randle, Linda Janes, Laura Dolan, and Jodi Slagle re: Comments on ODYS SOP 304.02.01 regarding LGBTI youth
 (July 17, 2013).
 22 Email from Kim Parsell to DYS Stakeholders (Oct. 15, 2013); Ohio Department of Youth Services, Message from
 DYS Director Harvey Reed (Sept. 6, 2013); Memorandum from Director Reed to All Youth (July 11, 2013);
 Memorandum from Director Reed to All Youth on Parole (July 11, 2013); Ohio Department of Youth Services,
 Message from DYS Director Harvey Reed (July 10, 2013); Email from Danny Turek, DYS Training Academy, to Dustin
 Calhoun, DYS General Counsel (Sept. 30, 2013).
 23 See Steve Martin, Report on Stipulation Paragraph 47 re: Classification and Housing (Mar. 2011), pp. 1‐4;
 Orlando Martinez & David Roush, CJCF site visit report (Feb. 2012), p. 11; Kelly Dedel, et al., Monitor’s Fourth
 Report (June 2013), p. 10.

16


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 18 of 39 PAGEID #: 3217
Development of internal quality assurance practices. Each facility collects and analyzes extensive data on youth violence and applications of force. DYS created a quality assurance system to identify increases or decreases in youth violence and to respond thoughtfully to those trends. Local monitoring of force is reviewed regularly by central office, and the Bureau Chief over facility operations meets monthly with the facility Superintendents to discuss the influences on youth violence and strategies to improve safety and security outcomes.24
Video segment: Click here to hear from youth about improvements in protection from harm.
Discipline and Seclusion
Dangerous conditions and practices in 2007. The 2007 investigation found that consequences for youth who violated facility rules were excessively punitive and not effective at making the facility safer for youth and staff. DYS placed youth in seclusion too frequently and for far too long.25 DYS was not using oversight tools to monitor youth placed in seclusion or trends in seclusion data, allowing excessive stays to go unchecked. The agency’s Youth Advocate had no clear job description, and did not have the resources or staff to assist youth during the disciplinary process, which meant youth were routinely exposed to harsh disciplinary sanctions with no one to assist them, to explain the potential consequences, or to assess whether underlying mental health conditions contributed to their rule‐ breaking behavior.26
DYS also operated special management housing units (SMUs) that held youth in lockdown 23‐hours a day, 7‐days a week. Monitor Fred Cohen reported that they resembled “supermax” housing units found in adult prisons. Youth on the SMUs were held for weeks or months at a time in prolonged isolation under stark conditions, without any substantive treatment or programming.27
Reduced reliance on pre‐hearing seclusion. Prior to the Consent Order, DYS utilized a structured decision‐making tool to determine the severity of the rule violation and the resulting length of stay in pre‐hearing seclusion. Youth accused of serious rule violations were held in pre‐hearing seclusion for between 56‐72 hours. Following the Consent Order, DYS implemented its new seclusion policy, which required all youth to be assessed for release no later than 4 hours following their placement in pre‐ hearing confinement, and every 3 hours thereafter if continued seclusion was justified based on the youth’s current behavior. The “safe‐to‐release” check involves a structured interview designed to help youth identify the circumstances that led to his misconduct and opportunities to respond differently in
24 Steve Martin & Amy Ast, Fifth Year Plan for Bureau of Facility Operations (Nov. 2012), p. 1; Kelly Dedel,
 Compliance Review, Quality Assurance for Safe Living Conditions and Structured Programming (May 2013), p. 7;
 Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), p. 9.
 25 Fred Cohen, Final Fact‐Finding Report, S.H. v. Stickrath (Jan. 2008), pp. 28, 39, 84.
 26 Id., at pp. 39, 192‐195.
 27 Id., at pp. 32‐33.

17


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 19 of 39 PAGEID #: 3218
the future. Between March and July 2015, over 90 percent of the pre‐hearing seclusion episodes were terminated within 4 hours, with an average length of stay of just 2.83 hours.28
Abolishing seclusion as a disciplinary sanction. Prior to the Consent Order regarding the use of seclusion, DYS conducted Intervention Hearings to determine whether youth were culpable for serious misconduct and whether to impose Intervention Seclusion as a sanction for the youth’s behavior, which could last up to five days for serious rule violations. Youth who engaged in frequent misconduct accumulated time in seclusion that represented a significant portion of their time in custody.29 On January 1, 2015, DYS issued a policy that abolished the use of seclusion as a disciplinary sanction. Rather than placing youth in isolation and increasing the risk of self‐harm and decompensation of their mental health, disciplinary sanctions now rely on restricting youth’s access to privileges available through its behavior management system and, in some cases, adding days to their time in custody (i.e. Intervention Time). Changes to practices regarding the imposition of Intervention Time were also reformed, resulting in significant reductions to historically excessive time‐adds. In the six months prior to the new seclusion policy taking effect, a total of 38,203 days of Intervention Time were imposed. During the six months following the implementation of the new policy, only 4,100 days were imposed, for a decrease of 89 percent.30 Not only does DYS’s new policy for responding to youth misconduct prohibit the harmful practice of seclusion, but it also protects against the imposition of excessive Intervention Time.
Alternatives to formal discipline. DYS facilities now screen incident reports in an effort to identify those infractions that can be addressed by treatment teams rather than by formal disciplinary hearings. This referral process has led to a significant decrease in hearings and, as a result, in seclusion hours. Treatment teams generally design alternative interventions that are more responsive to the underlying causes of the youth’s behavior. These include treatment assignments and Behavior Contracts, combined with sanctions like commissary restrictions and suspension of other privileges.31 DYS has also implemented a process to divert youth away from the formal disciplinary process when their rule‐breaking behavior is related to underlying mental health conditions. [This process is described in more detail under the section of this report titled Mental Health and Psychiatry Services.]
Increased oversight of seclusion practices. DYS has developed several quality assurance practices to internally identify and respond to problems related to seclusion of youth. The Superintendent at each facility reports seclusion hours monthly and must explain any increase or decrease in the various categories of seclusion. Every month, facility administrators compile monthly statistical summaries and a Facility Resource Administrator (FRA) from central office analyzes seclusion events at each facility. The FRA provides a compliance score and when that score falls below 80%, also provides recommendations for a performance improvement plan. With regard to pre‐hearing seclusion, for example, the FRA reviews the initial placement decision, the frequency of contacts while a youth is in seclusion, and the continued justification for seclusion. Deficiencies noted by the FRA in the past have
28 Kelly Dedel, Memorandum (Aug. 16, 2015).
 29 Kelly Dedel, et al., Monitors’ 6‐Month Report on Compliance with The Grid (June 2015).
 30 Id.
 31 Steve Martin, CJCF site visit report (Jan. 2013), pp. 7‐8; Steve Martin, IRJCF site visit report (Sept. 2012), p. 8; Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), p. 24.
18


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 20 of 39 PAGEID #: 3219
been corrected, suggesting that the internal compliance monitoring has been effective at improving practices at the facilities.32
Creation of a new Youth Advocate program. DYS reinvented the Youth Advocate position, and placed one Youth Advocate at each facility. The new position is tasked with assisting youth who are charged with rule violations that may result in serious disciplinary sanctions. They ensure that youths’ rights are protected throughout the disciplinary process. They explain to the youth what his rights are, help write a statement, call witnesses, and use the avenues available to the youth to tell his or her side of the story during the hearing. They also help with appeals. Youth have overwhelmingly reported that the disciplinary process is fair, due in large part to the assistance they get from their Youth Advocate. Rather than being intimidated during the hearing, youth are more likely to defend or explain themselves, and are often able to help the Hearing Officer see a bigger picture of what happened during a particular incident. The Youth Advocate also acts as a check on the Hearing Officer, and may push back against a potential sanction that seems too harsh in relation to the youth’s behavior.33
Elimination of Special Management Units. No youth have been housed on a Special Management Unit (SMU) since July of 2013. These housing units have existed in various forms and under various names over the last several years. They have relied excessively on seclusion and restraints to manage disruptive behavior among youth. Initially, in place of SMUs, DYS created a two‐phase program (“PROGRESS”) that offers intensive clinical intervention for the most challenging youth, along with separation from the general population in the first phase of the program. When this program was in place, youth on PROGRESS were out of their rooms for the entire day, engaged in programming, and were not subjected to seclusion or restraints any more than youth are in the general population. The program benefits from intensive oversight, data collection, and quality assurance measures, and those youth who did not transition quickly through the phases were provided with a review from central office administrators. The PROGRESS program is no longer utilized at any DYS facility. Instead, DYS now manages all youth either in the general population or on mental health units.34
Education
Conditions in 2007. The investigation report found that students with the most severe need for remedial reading assistance received no services to help them learn to read.35 Chronic shortages in
32 Steve Martin, Final Report on Seclusion and IRAV Quality Assurance Monitoring (May 2013), pp. 1‐3; Steve
 Martin & Amy Ast, Fifth Year Plan for Bureau of Facility Operations (Nov. 2012), pp. 1‐2; Kelly Dedel, et al,
 Monitor’s Fourth Report (June 2013), p. 9, 21‐22.
 33 Terry Schuster & Will Harrell, S.H. v. Reed Youth Advocate Program (July 2012), pp. 1‐3, 10‐11.
 34 See Ohio Department of Youth Services Standard Operating Procedure 303.01.07 (effective date Oct. 7, 2013);
 Consent Order, S.H. v. Reed (Dkt. 359‐2) (Jan. 18, 2013); Ohio Department of Youth Services, Second PROGRESS
 Unit Status Report (Sept. 2013); Kelly Dedel & Daphne Glindmeyer, Monitor’s PROGRESS Unit Compliance Report
 (Dec. 2013); Terry Schuster, 13 Good Ideas from Other Jurisdictions That May Help Improve Outcomes on the
 PROGRESS Units (Aug. 2012); Terry Schuster, Chart of Special Management Unit Models from other Jurisdictions
 (Aug. 2012) (on file with author).
 35 Fred Cohen, Final Fact‐Finding Report, S.H. v. Stickrath (Jan. 2008), pp. 101, 120.

19


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 21 of 39 PAGEID #: 3220
teaching and substitute teaching staff as well as limited classroom space caused youth to receive less than a full day of school. Students and faculty expressed high levels of fear for their personal safety in the school buildings, and teachers regularly took extended leave due to stress, fear, and injuries from assaults.36 Classroom management and discipline were not consistent, and too many classrooms were found to have little or no instruction occurring at all.37
The 2007 investigation revealed that DYS was also not complying with federal Special Education law. Faculty did not develop appropriate Individualized Education Programs (IEPs) for Special Ed students. They did not teach to the youth’s IEP goals or monitor the youth’s progress toward meeting those goals. Agency and facility administrators often made decisions limiting youths’ access to education based on security concerns without consulting the school principals or faculty. Students were disciplined and suspended from school for behavior related to their disabilities in violation of the law. Youth who were housed on mental health units received only three hours of education per day, and those in protective custody or in seclusion for acts of violence received no education at all.38
Better collaboration between school and facility staff. The schools are now far more integrated into the identity and purpose of DYS facilities. Communication between the school principals and the facility superintendents is excellent, as is communication between the principals and central office. Teachers integrate the concepts and language of the agency’s Cognitive Behavioral Therapy program into their lesson plans and classroom activities. Facility social workers participate in IEP meetings for Special Ed students and teachers attend inter‐disciplinary treatment teams along with clinical and direct care staff. Youth Specialists who are posted in the school building attend meetings with the school staff. The school’s transition coordinator also works closely with facility social workers, the Release Authority, and the regional parole offices to assure that students’ educational needs are met when they return to their home communities.39
Meeting the needs of youth who can’t read. DYS adopted a computerized software program called My Reading Coach to teach reading to students with pre‐literacy skills. The program has an established record with non‐readers and students who have very low literacy levels. It is now available in all DYS facilities on computers in Special Education, English, and Title I classrooms, and is also used by speech therapists providing services to Special Ed students.40
Improvements in staffing and classroom space. Students are no longer missing classes because of teacher absenteeism and vacancies. DYS’s staffing plan provides for a principal and assistant principal
36 Id., at pp. 101, 105‐107, 121‐122, 129.
 37 Id., at pp. 113‐114, 131‐132.
 38 Id., at pp. 101, 103‐105, 108‐113.
 39 Ava Crow & Anne Flynn, CHJCF site visit report, Luther E. Ball High School (June 2011), pp. 1‐2; Ava Crow & Anne
 Flynn, IRJCF site visit report, Indian River High School (Feb. 2011), p. 2; Ava Crow & Anne Flynn, site visit report,
 Scioto William K. Willis High School & Circleville Ralph C. Starkey High School (Jan. 2013), pp. 7‐9; Ava Crow & Anne
 Flynn, site visit report, Cuyahoga Hills Luther E. Ball High School & Indian River High School (Sept. 2012), pp. 5, 21,
 34‐35; Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), p. 56.
 40 See Ava Crow & Anne Flynn, CHJCF site visit report, Luther E. Ball High School (June 2011), p. 19; Ava Crow &
 Anne Flynn, IRJCF site visit report, Indian River High School (Feb. 2011), p. 15.

20


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 22 of 39 PAGEID #: 3221
at each school, two guidance counselors, three administrative assistants, a librarian, two teachers in each of the four core classes, an art teacher, a teacher for P.E. and health, a permanent substitute and five intermittent substitutes, a Title I teacher, as well as career tech positions. Because of the smaller youth population, the current complement of staff is sufficient to provide all core subjects, vocational courses, and electives even when vacancies arise. Virtually all students are now receiving a full school day with no repeating classes due to short staffing. Sufficient space now also exists at all DYS facilities to ensure that no students are deprived of a full school day due to lack of classroom space.41
Improvements in classroom management and school safety. Teachers in DYS schools now receive professional development in classroom management and behavioral intervention with challenging students. DYS has contracted with a behavioral analyst to mentor and provide one‐to‐one modeling with teachers who are having difficulty. School principals also now conduct frequent walk‐throughs to observe teaching staff and become familiar with their strengths and weaknesses. They utilize improvement plans and face‐to‐face conferences as part of their efforts to supervise faculty and improve teacher performance. In the past, youth who exhibited non‐compliant behavior in the classroom could be suspended from school and returned to their living units where they did not receive education services of any kind. DYS stopped this practice in June 2011, and now relies instead on its in‐school suspension room, the Academic Behavior Classroom (the ABC room), where youth have an opportunity to regain control of their behavior, work on an assignment, and return to their regular classroom after a short period of time. Assistant principals have placed increased emphasis on following appropriate protocol for referring students to the ABC room. Moreover, teachers across the board have shown marked improvement in classroom management. Students are more actively engaged in learning activities, more youth are remaining in the classroom, and fewer youth are being sent to the ABC room. Teachers differentiate their instruction so that some students may be working on a computer‐generated assignment while others in the same classroom are engaged in a teacher‐ generated assignment. They provide instruction and walk around assisting students both on the computer and on other assignments. Student achievement and good behavior is also recognized in the classrooms, and in special assemblies and award ceremonies.42
Each school is well‐staffed with Youth Specialists and an Operations Manager who work with teachers to anticipate and prevent gang activity in the school, and who respond to any fights quickly and with little or no disruption to the normal course of the day. On a monthly basis, the school principals also analyze violence reduction data and develop plans to address increases in violence. At Scioto JCF, for example, cooperative efforts between school staff and facility staff to adjust the school schedule,
41 Ava Crow & Anne Flynn, CHJCF site visit repot, Luther E. Ball High School (June 2011), pp. 3, 5; Ava Crow & Anne Flynn, IRJCF site visit report, Indian River High School (Feb. 2011), p. 3; Ava Crow & Anne Flynn, site visit report, Scioto William K. Willis High School & Circleville Ralph C. Starkey High School (Jan. 2013), pp. 10, 12, 15; Ava Crow & Anne Flynn, CHJCF site visit report, Luther E. Ball High School (Sept. 2012), pp. 8‐9; Ava Crow & Anne Flynn, CJCF site visit report, Ralph E. Starkey High School (Aug. 2011); Orlando Martinez & David Roush, CHJCF site visit report (Aug. 2012); Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), pp. 56‐57. 42 Ava Crow & Anne Flynn, CHJCF site visit report, Luther E. Ball High School (June 2011), pp. 12, 16, 19‐20; Ava Crow & Anne Flynn, IRJCF site visit report, Indian River High School (Feb. 2011), pp. 2, 13‐14; Ava Crow & Anne Flynn, site visit report, Scioto William K. Willis High School & Circleville Ralph C. Starkey High School (Jan. 2013), pp. 8‐9, 18‐20; Ava Crow & Anne Flynn, site visit report, Cuyahoga Hills Luther E. Ball High School & Indian River High School (Sept. 2012), pp. 18, 20‐23; Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), pp. 56‐57.
21


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 23 of 39 PAGEID #: 3222
increase the number of staff posted in the school building, and change some physical features of the classrooms reduced violence and disruption in the school building.43
Compliance with Special Education law. DYS now provides Special Education services that are responsive to individual student’s needs and that are compliant with the IDEA. The Special Education program is overseen by well‐qualified assistant principals at each facility and by central office. DYS has implemented Special Ed policies and procedures, developed an excellent Special Ed manual, and provided teaching staff with relevant professional development. DYS’s “child find” process is conducted by Intervention Assistance Teams at each facility that meet regularly and seek out students in need of additional interventions related to behavioral, academic, and attendance issues. These teams make referrals for special education evaluations as needed.44
All Individualized Education Programs (IEPs) are developed and implemented in a timely manner, and appropriate representatives attend IEP meetings. DYS has created checklists and tools for teaching staff that assist with drafting IEP goals and measuring progress toward those goals. Students’ IEPs are individualized, and contain measurable, achievable goals. IEP teams consider a broad range of services and arrangements to meet the students’ needs. Teachers have also made significant improvements in using data to track students’ progress toward IEP goals. All Special Ed teachers are Highly Qualified Teachers, and all teachers’ caseloads are under the state‐mandated cap of 12. Vocational programs are available to all Special Ed students, and related services are provided by occupational therapists, speech therapists, and school psychologists.45
Providing education to youth on specialty housing units and youth in seclusion. Special Education teachers serve all specialty units, and unit classrooms are wired for computer learning. These teachers also get weekly reports from medical staff on any medication changes that may affect the students’ behavior or alertness during school hours. Educational placement decisions for Special Ed students housed on specialty units are dictated by the terms of their IEPs, and even students with the most severe impairments and disabilities are provided with at least one class in the school building.46
43 Ava Crow & Anne Flynn, Status of Quality Assurance Program, Buckeye United School District (May 2013), p. 3;
 Ava Crow & Anne Flynn, site visit report, Scioto William K. Willis High School & Circleville Ralph C. Starkey High
 School (Jan. 2013), pp. 8‐9, 18; Ava Crow & Anne Flynn, site visit report, Cuyahoga Hills Luther E. Ball High School &
 Indian River High School (Sept. 2012), pp. 7, 21; Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), p. 56.
 44 Ava Crow & Anne Flynn, CHJCF site visit report, Luther E. Ball High School (June 2011), p. 10; Ava Crow & Anne
 Flynn, IRJCF site visit report, Indian River High School (Feb. 2011), pp. 7‐8; Ava Crow & Anne Flynn, site visit report,
 Scioto William K. Willis High School & Circleville Ralph C. Starkey High School (Jan, 2013), pp. 28‐29; Kelly Dedel, et
 al., Monitor’s Fourth Report (June 2013), pp. 63‐64.
 45 Ava Crow & Anne Flynn, CHJCF site visit report, Luther E. Ball High School (June 2011), pp. 9, 12; Ava Crow &
 Anne Flynn, IRJCF site visit report, Indian River High School (Feb. 2011), pp. 7‐8; Ava Crow & Anne Flynn, site visit
 report, Scioto William K. Willis High School & Circleville Ralph C. Starkey High School (Jan. 2013), pp. 28, 30‐33; Ava
 Crow & Anne Flynn, site visit report, Cuyahoga Hills Luther E. Ball High School (Sept. 2012), pp. 17‐18; Kelly Dedel,
 et al., Monitor’s Fourth Report (June 2013), pp. 61‐64.
 46 Ava Crow & Anne Flynn, site visit report, Scioto William K. Willis High School & Circleville Ralph C. Starkey High
 School (Jan. 2013), pp. 17, 25; Ava Crow & Anne Flynn, site visit report, Cuyahoga Hills Luther E. Ball High School &
 Indian River High School (Sept. 2012), pp. 17, 35.

22


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 24 of 39 PAGEID #: 3223
DYS no longer suspends students from school. Students who commit acts of violence and are placed in seclusion are provided with education on the unit. At the time that monitoring of education was terminated, hearing officers who imposed seclusion as a disciplinary sanction for violent behavior often limited seclusion hours to the weekend in order to minimize the impact of the sanction on the student’s education. For those secluded during the week, teachers visited them on the housing units four times per day and offered unit instruction for at least 30 minutes during each visit. They were also available to assist students on the unit during all six school periods. These students got individualized assignments from their regular teachers, were counted as present, and receive credit for completed work. Instruction for students on the housing units was closely monitored by the school’s administrators for compliance with agency policy.47
More vocational training, college courses, and transition planning. Each DYS school has a transition team that guides every student through an array of reentry skills, beginning at least six weeks before they return to their home communities. The team consists of the transition coordinator, the transition class teacher, the Career Based Instruction (CBI) teacher, and teachers to supervise online college classes or industry certification classes. CBI students spend two hours each day doing class work on job skills and career exploration. This is followed by work experience on campus for which the youth interviews. The transition coordinator continues reentry services after release by working with the parole officer, home schools and potential employers. The program tracks the transition of DYS youth at 30, 60, and 90 day intervals after release.48
Youth are given a career interest assessment and allowed to transfer to other DYS facilities that have vocational programming of interest to them. These programs include graphic design; horticulture; auto technology; healthy living, which offers a ServSafe certificate recognized by the restaurant industry; and administrative office technology, which offers an industry‐recognized Microsoft Office certificate. DYS secured a grant that offers off‐campus training and work experience for students returning to Franklin County. This initiative is focused on solar energy, and computer and electrical skills. Students in all grade levels are allowed to participate in and receive credit for vocational programming, and a very large percentage of students do in fact participate. At Scioto JCF, for example, more than 70 percent of students participated in vocational education.49
Through a partnership with Ashland University, DYS offers college courses in English, History, Business, Financial Literacy, Entrepreneurship, Sociology, and Psychology. These online courses are team‐taught
47 Ava Crow & Anne Flynn, CHJCF site visit report, Luther E. Ball High School (June 2011), p. 3; Ava Crow & Anne
 Flynn, IRJCF site visit report, Indian River High School (Feb. 2011), p. 3, n. 4; Ava Crow & Anne Flynn, site visit
 report, Scioto William K. Willis High School & Circleville Ralph C. Starkey High School (Jan. 2013), pp. 9, 11‐12, 17,
 25; Ava Crow & Anne Flynn, site visit report, Cuyahoga Hills Luther E. Ball High School & Indian River High School
 (Sept. 2012), pp. 9‐11; 17‐18, 35; Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), pp. 57‐58.
 48 Ava Crow & Anne Flynn, site visit report, Scioto William K. Willis High School & Circleville Ralph C. Starkey High
 School (Jan. 2013), pp. 21‐22; Ava Crow & Anne Flynn, site visit report, Cuyahoga Hills Luther E. Ball High School &
 Indian River High School (Sept. 2012), p. 25.
 49 Ava Crow & Anne Flynn, site visit report, Scioto William K. Willis High School & Circleville Ralph C. Starkey High
 School (Jan. 2013), p. 24; Ava Crow & Anne Flynn, site visit report, Cuyahoga Hills Luther E. Ball High School &
 Indian River High School (Sept. 2012), pp. 8, 26‐28, 30; Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), pp.
 65‐67.

23


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 25 of 39 PAGEID #: 3224
by DYS teachers and Ashland professors. DYS has also taken youth off campus for visits to colleges and for community service projects.50 Another course provided intermittently through a partnership with Wooster college combines DYS students and free world college students in a criminal justice course taught on‐site at Indian River JCF.51 Students and teachers involved in this course, called the Inside‐ Out Program, are featured in the video segment below.
Internal quality assurance monitoring for education. The quality assurance system developed by DYS to review their Special Education program is unique and impressive. Because there are few, if any, national models or tools that measure the quality and effectiveness of Special Education services, DYS’s practices now serve as a model for schools both in correctional facilities and in the community. The individual schools and central office conduct monthly and quarterly reviews of Individualized Education Programs (IEPs) to identify whether the goals and objectives are appropriate for the student and whether they incorporate positive behavioral strategies to assist the student. The schools and central office also conduct monthly and quarterly compliance reviews to monitor a host of other Special Education issues, identifying problems that might otherwise be missed and remedying those concerns both for individual students and systemically. Teachers whose paperwork requires frequent correction are placed on performance improvement plans and provided with coaching. Principals also submit monthly reports to central office that address staffing, violence reduction, and other administrative issues. Each school is also audited annually by DYS and by the Ohio Standards Committee, as well as tri‐annually by the Ohio Department of Education.52
Video segment: Click here to hear from youth about improvements in educational services.
Video segment: Click here to learn more about the Inside‐Out program.
Medical and Dental Care
Conditions in 2007. Initial medical assessments for youth coming into DYS facilities were incomplete, lacked any conclusions about the health or medical problems of the youth, and contained no documentation of follow‐up by a physician. The 2007 investigation found abnormal vital signs that were not reported to or assessed by the physician, and lab results that were delayed and inaccurate. The problems with health assessments and documentation resulted in delays in treatment and delays in recognizing chronic disease. In 2007, there was no chronic care program at all. Youth with chronic
50 Ava Crow & Anne Flynn, IRJCF site visit report, Indian River High School (Feb. 2011), p. 14; Ava Crow & Anne
 Flynn, site visit report, Scioto William K. Willis High School & Circleville Ralph C. Starkey High School (Jan. 2013), p.
 22; Ava Crow & Anne Flynn, site visit report, Cuyahoga Hills Luther E. Ball High School & Indian River High School
 (Sept. 2012), pp. 25, 27‐28.
 51 See Anne M. Nurse, Juveniles and College: Inside Out as a Way Forward 93 The Prison Journal 234‐247 (Jan.
 2013), available at http://tpj.sagepub.com/content/93/2/234.full.pdf+html; Orlando Martinez & David Roush,
 IRJCF site visit report (Dec. 2011), pp. 20‐21; Orlando Martinez & David Roush, IRJCF site visit report (Aug. 2012), p.
 17.
 52 Ava Crow & Anne Flynn, Status of Quality Assurance Program, Buckeye United School District (May 2013), pp .1‐ 6; Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), p. 62.

24


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 26 of 39 PAGEID #: 3225
diseases were not seen regularly for status checks, which led to episodic treatment at higher levels than might otherwise have been avoided. Medical information was not shared when youth were transferred between facilities or sent off‐site for scheduled or emergency medical treatment. Youth were also not properly assessed for injuries following fights or applications of force by staff. Medical and mental health information was not integrated. This, plus incomplete medical documentation generally compromised the quality of care being provided to youth. DYS did not monitor medical records and data for quality or completeness. There was no tracking of clinical outcomes or peer review process to ensure that doctors and nurses were meeting medical practice standards. There was also no peer review process for dentists providing services to DYS youth. Youth with dental pain were not being seen and stabilized in a timely manner. Cavities were not always treated and documented, and there was no system for triaging care. Dental staffing was inadequate, as was dental treatment planning, documentation, x‐rays, and infection control.53
Improvements in medical assessments. Initial health screens, physical exams, hearing and vision exams, lab testing, and review of immunization status are now timely and complete. Parents are contacted to provide information relevant to initial medical assessments. Intake information is integrated by care providers into a comprehensive assessment and plan, and physicians now follow up on problems and abnormal findings in a timely manner. Care providers respond appropriately to abnormal vital signs. They provide information to youth in a manner that the youth can understand, and have increased efforts to involve family members throughout the youth’s stay in the provision of care.54
Improvements in medication, chronic care, and emergency care. DYS’s administering of medications has improved. Meds come in pharmacy‐prepared blister packs, are checked against the doctor’s order and the pharmacy manifest, and are checked again when given to the youth. The medication is recorded as given only after the youth has taken it, or it is recorded as refused or missed. “As needed” medications are available at meal times and at other times if directed by the physician. DYS has developed chronic care clinics consistent with national guidelines. Patients enrolled in the chronic care clinics receive timely, appropriate care. A database has also been developed that allows tracking of chronic disease encounters. Nurses assessing youth for injuries following fights or applications of force are now taking appropriate histories, and performing complete physical exams in the clinic rather than through the youth’s door. Additionally, the transfer of information and the continuity of care for youth receiving off‐site medical services are much improved.55
53 Fred Cohen, Final Fact‐Finding Report, S.H. v. Stickrath (Jan. 2008), pp. 139‐173. 54 Barb Peterson & Ron Shansky, CJCF site visit report (Jan. 2013), pp. 2, 4, 6; Barb Peterson & Ron Shansky, SJCF site visit report (Jan. 2013), pp. 3‐4; Barb Peterson & Ron Shansky, CHJCF site visit report (Sept. 2012), p. 11; Barb Peterson & Ron Shansky, IRJCF site visit report (Sept. 2012), p. 10; Barb Peterson & Ron Shansky, SJCF site visit report (Dec. 2010), p. 2; Barb Peterson & Ron Shansky, IRJCF site visit report (Dec. 2011); Michelle Staples‐Horne, et al., Monitor’s Fourth Report, U.S. Department of Justice v. The State of Ohio (June 2013), p. 49 [hereinafter referred to as “Monitor’s Fourth Report”]. 55 Barb Peterson & Ron Shansky, CJCF site visit report (Jan. 2013), pp. 1, 7; Barb Peterson & Ron Shansky, SJCF site visit repot (Jan. 2013), p. 4; Barb Peterson & Ron Shansky, CHJCF site visit report (Sept. 2012), pp. 1, 4, 6‐7; Barb Peterson & Ron Shansky, IRJCF site visit report (Sept. 2012), pp. 1, 5; Barb Peterson & Ron Shansky, CJCF site visit report (Aug. 2011), p. 1; Barb Peterson & Ron Shansky, IRJCF site visit report (Dec. 2011), Michelle Staples‐Horne, et al., Monitor’s Fourth Report (June 2013), pp. 49‐50, 53.
25


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 27 of 39 PAGEID #: 3226
Improvements in medical records. Medical records are now chronological, organized into clearly identified sections, have easy‐to‐find and up‐to‐date problem lists, and thorough notes on clinical findings, treatment plans, patient encounters, and responses to treatment. Medical records contain both medical and mental health diagnoses. Physical plant renovations in the medical and mental health service areas have improved collaboration and access to information among providers. At the time monitoring of medical services was terminated, DYS was also rolling out an electronic medical record that would combine medical and dental files, mental health and psychiatry files, and social work files into a single integrated system. This would allow for more collaborative treatment planning. It would also be able to interface with community providers and pharmacies, which will improve continuity of health care for youth upon release.56
Continuous Quality Improvement and peer review of doctors and nurses. Both the on‐site Health Services Administrator and the central office Medical and Nursing Directors now monitor a variety of health services provided. The Continuous Quality Improvement (CQI) system includes paper monitoring tools and an electronic database. It gathers both quantitative and qualitative information on patient intake, lab and diagnostic services, vital sign monitoring, chronic care programs, medication management, sick call, youth injury assessments, specialty and emergency services, intra‐system transfers, and parental notifications. Data is analyzed for trends at the institution level and across institutions. The central office Nursing Director also meets with the on‐site Health Services Administrator at each facility to ensure consistency in compliance monitoring. Peer review is now routinely conducted for nurses and physicians. This process identifies areas in need of improvement and provides action plans and increased monitoring until the provider’s performance has improved.57
Improvements in dental care. Dental staffing has improved, and all DYS youth now have complete dental exams, initial cleanings, routine preventative and restorative dental care, and oral hygiene instruction. Youth receive radiographs adequate to diagnose carious lesions (cavities), and are provided with individualized treatment plans for sealants and other services. Youth who have complaints of dental pain are assessed and stabilized within one day. Youth in need of crowns, dentures, or oral surgery all have access to these services as well. DYS has hired a Dental Director who has implemented a Continuous Quality Improvement (CQI) program, and who conducts peer review of
56 Barb Peterson & Ron Shansky, SJCF site visit report (Jan. 2013), p. 6; Barb Peterson & Ron Shansky, CHJCF site visit report (Sept. 2012), pp. 1‐2, 8; Barb Peterson & Ron Shansky, IRJCF site visit report (Sept. 2012), pp. 5, 7; Barb Peterson & Ron Shansky, SJCF site visit report (Dec. 2010), p. 5; Barb Peterson & Ron Shansky, IRJCF site visit report (Dec. 2011), p. 9; John Bradley, Jacqueline Carter, Barb Peterson & Ron Shansky, ODYS Fifth Year Plan for Medical Care (Oct. 2012), pp. 1‐2; Email from John Bradley to Terry Schuster (Dec. 20, 2013); Michelle Staples‐Horne, et al., Monitor’s Fourth Report (June 2013), pp. 49, 53. 57 John Bradley, Medical Program Compliance Progress Report (April 2013); Jacqueline Carter, Quality Assurance Review / Report (April 2013), pp. 1‐8; John Bradley, Jacqueline Carter, Barb Peterson & Ron Shansky, ODYS Fifth Year Plan for Medical Care (Oct. 2012), p. 1; Barb Peterson & Ron Shansky, CJCF site visit report (Jan. 2013), pp. 4, 6; Barb Peterson & Ron Shansky, SJCF site visit report (Jan. 2013), pp. 4, 9; Barb Peterson & Ron Shansky, CHJCF site visit report (Sept. 2012), pp. 3, 5; Barb Peterson & Ron Shansky, IRJCF site visit report (Sept. 2012), pp. 1‐2, 4, 7‐9; Barb Peterson & Ron Shansky, IRJCF site visit report (Dec. 2011), p. 6.
26


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 28 of 39 PAGEID #: 3227
the facility dentists. His oversight and guidance have significantly improved the quality and timeliness of dental care in DYS facilities.58
Cultural and Environmental Changes
Conditions in 2007. The 2007 investigation found that direct care staff, at the time called Juvenile Correctional Officers (JCOs), functioned almost exclusively as guards. They did not participate in or lead youth programming or activities, and there was no mention in their performance objectives of encouraging youth, reinforcing behavior, or being a role model for youth in DYS custody. Rather staff were trained to find problems and to sanction them. This confrontational approach created a hostile and violent culture in the facilities and negatively affected youth behavioral outcomes.59
Changing the role of direct care staff. In 2009, DYS changed the title of the direct care staff position to Youth Specialist. The agency expanded Youth Specialist job duties to include participating in and leading recreation activities, group discussions and treatment sessions; mentoring youth; mediating conflicts; acting as a member of the youth’s treatment team; implementing a strength‐based behavior management system; and serving as a pro‐social role model for youth. DYS expanded and improved training for Youth Specialists. These staff members are now highly involved in programming and treatment teams. At each facility, there are a core group of Youth Specialists who have good relationships with a wide range of youth. Youth are enthusiastic about naming and describing those staff members who they like and respect, and who they believe are genuinely trying to help them. Youth perceptions of safety in the facilities are also significantly improved, in large part because they believe there are people on staff who listen to them, look out for their best interests, and take action to protect them from harm. Each facility has implemented mentoring programs in which staff members adopt a youth as a mentee and meet with that youth regularly for informal and structured activities. These mentoring programs have provided an opportunity for youth to build a relationship with a special adult, which improves their confidence and helps them aim for and achieve higher aspirations. Importantly, mentor relationships have also helped change the attitudes and approaches of staff toward youth who are exhibiting problem behavior. Their interventions, framed within trusting relationships and an understanding of what motivates the youth, are more likely to de‐escalate volatile situations than those based solely on correctional security and control.60
More activities, more staff, and fewer youth. A new Program Administrator position was created at each facility to expand the range of programs and services for youth. The facilities have seen a marked
58 Don Sauter, CJCF site visit report (June 2011), pp. 2‐4, 7‐10, 12, 14; Don Sauter & Nick Makrides, CJCF site visit
 report (Apr. 2012), pp. 2‐9; Don Sauter & Nick Makrides, IRJCF site visit report (Apr. 2012), pp. 2, 4, 9; Don Sauter &
 Nick Makrides, CHJCF site visit report (Dec. 2011), pp. 2, 4, 6.
 59 Fred Cohen, Final Fact‐Finding Report, S.H. v. Stickrath (Jan. 2008), pp. 25, 38, 73, 96‐97, 133‐135.
 60 Orlando Martinez, CJCF & SJCF site visit report (Jan. 2013), pp. 3, 6; Orlando Martinez & David Roush, IRJCF site
 visit report (Aug. 2012), pp. 7, 14, 16‐17, 19, 23; Orlando Martinez & David Roush, CHJCF site visit report (Aug.
 2012), pp. 13‐14, 18, 20; Orlando Martinez & David Roush, CJCF site visit report (Feb. 2012), pp. 13, 16, 18, 28‐29,
 37‐38; David Roush, Report on DYS Bureau of Professional and Organizational Excellence and Human Resources
 (Sept. 2011), pp. 5‐6.

27


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 29 of 39 PAGEID #: 3228
increase in the quantity and quality of programming and activities, particularly on weekends and during school intersessions. In addition to programming focused on anger management and victim awareness, DYS facilities now offer a wide range of recreational activities (fitness activities, gardening, movie nights, concerts, game rooms, etc.), youth empowerment activities (Youth Council, house meetings, etc.), and community service activities. The Youth Council, which offers youth a meaningful role in facility decision‐making, is particularly noteworthy. DYS has implemented an outstanding teen‐ parenting program (the Baby Elmo project) designed to help incarcerated youth develop parenting skills and bond with their infants and toddlers. DYS has also expanded the work program for youth who have graduated from high school to constructively occupy the portion of their day that other youth spend in school. Youth interview for positions in the cafeteria, school, storeroom, with the maintenance staff, or with programming and recreation staff, and are paid by the hour. The ability to participate in activities and work opportunities incentivizes positive behavior. The reduction in youths’ idle time has also helped curtail gang activity. DYS sets benchmarks for participation in programming and recreation, and has recently begun auditing facilities to measure the quality and quantity of activities measured against those performance benchmarks.61
The increase in activities is paired with an incentive program in which youth earn points for engaging in positive behavior. They can spend those points on commissary items, additional phone calls, or entry into special events. The reduction in DYS’s youth population has allowed staff more time to interact with youth, and has made it easier for staff to engage youth in programming. It has also allowed for greater surveillance of youth, a safer climate on the housing units, and better opportunities to address gang‐related issues before they escalate. Fewer staff call off work due to stress or injuries. The reduced population and more positive environment have thus helped alleviate the chronic staffing shortages experienced by DYS in the past.62
Identifying and addressing youths’ criminogenic needs. The Ohio Youth Assessment System (OYAS), which the State has used to divert low‐ and moderate‐risk youth away from secure confinement, also provides a tool for use inside DYS facilities. The facility‐based OYAS tool helps DYS staff determine the types of interventions that will be most effective with youth, based on their risk to reoffend and their criminogenic treatment needs. This assessment along with various others (educational, medical, psychological, etc.) provide staff with the information needed to develop individualized treatment plans for youth. Cognitive Behavioral Therapy (CBT), DYS’s treatment modality, targets these criminogenic factors and helps to restructure or change the way youth think and respond in various situations. This is accomplished through learning and practicing pro‐social skills and behaviors. The introduction of CBT has provided a uniform language for Youth Specialists and behavioral health staff, and has helped to increase positive interactions between staff and youth. DYS has also adopted a promising gang intervention program and created a Security Threat Group Coordinator staff position at
61 Kelly Dedel, Compliance Review, Quality Assurance for Safe Living Conditions and Structured Programming (May 2013), pp. 2, 4‐5, 8‐11; Orlando Martinez & David Roush, IRJCF site visit report (Aug. 2012), p. 16; Orlando Martinez & David Roush, CHJCF site visit report (Aug. 2012), pp. 15‐16; Orlando Martinez & David Roush, CJCF site visit report (Feb. 2012), pp. 19‐20, 28; Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), pp. 40‐44. 62 Orlando Martinez & David Roush, IRJCF site visit report (Aug. 2012), pp. 10, 14, 16, 22; Orlando Martinez & David Roush, CHJCF site visit report (Aug. 2012), pp. 14, 19; Orlando Martinez & David Roush, CJCF site visit report (Feb. 2012), pp. 13, 24, 27, 29; Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), p. 14.
28


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 30 of 39 PAGEID #: 3229
each facility. The program creates a major shift in approach to gang‐involved youth. Rather than attempting to simply sanction all gang‐related behavior, which has not been successful in the past, the program aims to disengage youth from gang activity by understanding why they are getting involved in the first place. The program and the coordinator manage gang problems by creating a safe place for youth to talk about them; and providing alternatives, incentives, and supports for youth who want to disengage. At one DYS facility a survey to assess the perceived needs of gang members has gone even further to shift staff responses away from labelling these youth as troublemakers, and toward interventions that are based on their criminogenic needs.63
Family Engagement
Finding new and innovative ways to engage family members during a youth’s stay at DYS. In February 2010, DYS began the Families as Partners program with the Vera Institute of Justice. The project sought to promote better outcomes for youth in DYS custody by encouraging visits and correspondence between youth and their families and increasing family involvement in youth’s treatment and reentry plans. Staff have been trained in using the Vera Institute’s Juvenile Relational Inquiry Tool (JRIT) to recognize and reinforce the connections youth have to family members, mentors, and other supportive people in their social networks during and after incarceration. The State now provides free bus transportation every month to DYS facilities to promote family visitation. This is a remarkable development that has helped families overcome distance and transportation barriers that previously prevented them from visiting. In Ohio, increased family visitation led to improved youth outcomes. A study conducted by the Vera Institute, for example, found that more frequent family visitation was associated with fewer rule violation incidents and improved grade point average (controlling for race, age, school attendance and other variables). Facility staff members and juvenile parole officers (JPOs) also use video conferencing technology to conduct family visits, reentry conferences, and inter‐agency staffings. Video conferencing capability has expanded to all parole regions in the state and has helped youth stay in more frequent contact with supportive family and community members. Additionally, family members often participate by phone in youths’ monthly treatment team meetings. DYS has trained JPOs to conduct family coaching sessions, and continues to contract with monitoring team member Shay Bilchik to enhance JPOs’ family engagement efforts. The agency also adopted a Family Finder tool that has vastly increased the agency’s ability to identify family members who may serve as post‐release placement alternatives for youth, or as supportive individuals to help youth transition back into the community.64
63 Orlando Martinez, CJCF & SJCF site visit report (Jan. 2013), pp. 2, 4; Orlando Martinez & David Roush, IRJCF site visit report (Aug. 2012), pp. 9, 14, 18, 24‐26; Orlando Martinez & David Roush, CHJCF site visit report (Aug. 2012), pp. 13, 21; Orlando Martinez & David Roush, CJCF site visit report (Feb. 2012), p. 11; Orlando Martinez & David Roush, SJCF site visit report (Jan. 2012), p. 8. 64 Shay Bilchik, Regionalization and Reentry Monitoring Report (Jan. 2012), p. 5; Shay Bilchik, Regionalization and Reentry Monitoring Report (Dec. 2012), pp. 7‐9; see also Orlando Martinez & David Roush, CHJCF site visit report (Aug. 2012), p. 13; Vera Institute of Justice, Tools and Methods Used by the Family Justice Program, available at http://www.vera.org/centers/family‐justice‐program/tools‐and‐methods‐used‐family‐justice‐program; Vera Institute of Justice, Issue Brief, The Impact of Family Visitation on Incarcerated Youth’s Behavior and School
29


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 31 of 39 PAGEID #: 3230
Video segment: Click here to hear from youth about improvements in family engagement.
Mental Health and Psychiatry Services
Conditions in 2007. The 2007 investigation found that DYS facilities lacked even rudimentary mental health care and basic rehabilitation efforts. In most major areas of mental health service delivery, DYS lacked adequate policies and protocols. The agency had no core curriculum, no special training for clinical staff, and no unifying model of psychotherapeutic intervention. Mental health services were profoundly understaffed given the prevalence and severity of mental health disorders present in the youth population. Staffing levels did not permit opportunities for adequate assessment or regular group and individual therapy because of the frequency and urgency of crisis interventions. Mental health needs went largely undiagnosed and untreated, and related risks (preventable deterioration, self‐harm, etc.) increased due to the understaffing. The investigation found virtually no proactive mental health services. Treatment was essentially “on demand” through verbalizing intent to harm oneself or actually engaging in self‐injurious behavior. Youth used the threat of suicide simply to get an opportunity to speak with a psychologist, and the relatively few clinical staff members spent most of their time responding to crises.65
Access to inpatient psychiatric care was not available for youth under the age of 18, meaning those who experienced acute psychiatric symptoms were managed in DYS facilities rather than in the hospital. In the facilities, youth remained on suicide watch for unreasonably long periods of time (weeks or months) without clear behavioral plans to intensify or modify treatment interventions in order to get them off watch and back to routine activities. The agency’s intensive Mental Health Units were little more than housing units. There was essentially no mental health program above that available to any other youth housed in the general population. Staff on those specialty units had no additional mental health training, and services for those with the most serious levels of mental health need were grossly inadequate.66
Staff members of the various disciplines (social work, psychology, psychiatry) did not function as a team or provide consistent direction for youth treatment. There was no single mental health clinical treatment plan. Fragmented documentation and communication impeded the sharing of information needed to address youths’ symptoms and behaviors. Psychiatric services were extremely limited and did not include much more than medication monitoring every 30 days. Youth were subjected to inappropriate and harmful punishments for behaviors driven by mental health disorders. Special Management Plans for youth exhibiting disruptive behavior were not developed or approved by clinical staff, and involved excessive seclusion. The plans provided no defined goals that the youth should
Performance: Findings from the Families as Partners Project (Apr. 2013), available at
 http://www.vera.org/pubs/impact‐of‐family‐visitation‐on‐incarcerated‐youth.
 65 Fred Cohen, Final Fact‐Finding Report, S.H. v. Stickrath (Jan. 2008), pp. 44‐45, 47‐52, 54, 58‐59, 61, 64, 66‐68, 74,
 76, 84, 97‐99, 152, 155‐156.
 66 Id., at pp. 50, 52, 55, 57‐58, 62, 65, 76, 83.

30

Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 32 of 39 PAGEID #: 3231
work toward, or acceptable behaviors the youth should engage in as alternatives to disruptive behaviors. The quality of mental health care and psychiatry was not monitored internally. DYS did not have the capacity to identify and address problems with service delivery in a systematic manner, nor did they assess the performance of clinical staff members.67
Providing proactive rather than reactive mental health services. Since 2007, DYS has drafted and revised a comprehensive set of policies and procedures governing mental health and psychiatry services. The reduced youth population and increased clinical staffing has allowed for more than adequate behavioral health coverage. Clinical staff‐to‐youth ratios at the remaining DYS facilities range from 1:9 to 1:11. Clinical staff also work evenings and weekends, and psychologists are available after hours when necessary. Social workers, psychologists, occupational therapists, and psychiatric nurses now work as an integrated behavioral health team at each facility. Both social workers and psychologists work out of offices on the housing units, which has dramatically increased youths’ access to treatment providers. Youth are also now thoroughly screened and assessed at intake for treatment needs related to mental health and trauma symptoms. An individualized treatment plan is developed for each youth in DYS custody, and clinical staff meet monthly with Unit Managers, direct care staff, and the youth to review the youth’s progress in meeting treatment goals. The agency has also increased efforts to involve family members and other staff disciplines (medical, education, recreation) in these treatment team meetings. Clinical staff and direct care staff now engage youth in group sessions nearly every day (cognitive behavioral therapy, substance abuse treatment, sexual behavior treatment, occupational therapy, victim awareness, managing anger and violence, etc.), and have improved over time in their group facilitation skills. Social workers, psychologists, and psychiatrists also meet individually with youth as needed.68
Improved care for youth with the most serious mental health symptoms. DYS adopted appropriate suicide prevention policies and practices, and developed a plan to conduct relevant quality assurance monitoring and data analysis around suicidal incidents. The Mental Health Units now provide intensive treatment services for youth according to a well‐articulated trauma informed program. The roles and responsibilities of direct care staff and clinical staff are clearly defined, and all staff working on these units as well as the Life Skills Units (for youth with developmental disabilities) receive additional training to work with these special needs populations. The program includes meaningful leadership roles for youth, including the opportunity to serve as peer mentors. The efforts of staff and administrators overseeing services on the Mental Health and Life Skills Units have resulted in fewer fights and assaults, and dramatically less disciplinary seclusion. Youth on these specialty units also show improvement in symptoms related to trauma and depression, as measured by pre‐ and post‐tests on various assessment tools. Any youth needing inpatient psychiatric care can now be hospitalized and
67 Id., at pp. 29, 31, 45, 53, 61, 66‐67, 74‐75, 78, 153.
 68 Andi Weisman, CJCF site visit report (Jan. 2013), pp. 2, 4; Andi Weisman, SJCF site visit report (Jan. 2013), pp. 14,
 18; Daphne Glindmeyer, Monitor’s Fourth Report, Addendum – Mental Health Provisions, U.S. Department of
 Justice v. The State of Ohio (June 2013), pp. 5, 7, 9, 11, 13‐14, 18‐22, 25 [hereinafter “Monitor’s Fourth Report,
 Addendum”]; Andi Weisman, CHJCF & IRJCF site visit report (Sept. 2012), pp. 26‐27, 32, 36, 43, 45‐46.

31


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 33 of 39 PAGEID #: 3232
treated for acute symptoms, and DYS is exploring alternative placement options for youth who need long‐term residential treatment.69
Treatment‐based interventions for youth with disruptive behavior. Having determined that the use of seclusion as a disciplinary sanction was ineffective and harmful to both youth and staff, DYS created a more intensive clinical process for youth who engage in acts of violence (AOVs). In collaboration with the subject matter experts and other stakeholders, DYS committed to two essential clinical requirements following AOVs. The first was a review and potential revision of the individual treatment plan following each AOV. The second requirement was a formalized process to address the mental health needs of youth who engage in repeated AOVs. Within DYS secure facilities for boys, youth who engage in repeated AOVs are managed by Special Review Teams (SRTs) consisting of the youth, his primary clinician, Unit Manager, and social worker. The purpose of the SRT is to identify the causes and functions of the AOVs, to prescribe more intensive interventions aimed at addressing the root causes of the behavior, and to recommend updates to the Individualized Treatment Plan (ISP). The SRT meets with the youth until his challenges have been resolved.70
The girls’ contract facilities are not enjoined in the lawsuit and their practices and documentation are not obligated to mirror the processes in place in facilities operated by DYS. However the subject matter experts’ review of practice and documentation for the contract facilities makes clear that they are all functionally equivalent to what is provided within DYS. The partnership DYS has established with the girls’ contract programs is exemplary. Girls are now served in softer, more resource‐rich environments. The collaboration among the facilities and with the Department’s central office has led to robust clinical oversight of the treatment girls are receiving.71
Improved psychiatry services. Psychiatrists in DYS facilities conduct extensive reviews of available clinical information in preparation for psychiatry clinic. They meet regularly with youth who are treated with psychotropic medications and monitor for treatment efficacy and side effects. The clinicians appropriately document the plan and rationale for treatment interventions. Youth who require treatment with psychotropic medications are identified, with medications prescribed as necessary. Medication regimens are appropriate and do not include excessive dosing or polypharmacy. The psychiatrists are supported by psychiatric nurses at each facility who assist with the informed consent process, and who conduct chronic care monitoring (weight, body mass index, vital signs, lab results, etc.) for prescribed psychotropic medications.72
69 Daphne Glindmeyer, CJCF site visit report (Jan. 2013), p. 5; Daphne Glindmeyer, Monitor’s Fourth Report,
 Addendum (June 2013), p. 7; Andi Weisman, CHJCF & IRJCF sit visit report (Sept. 2012), pp. 16, 18‐21, 28, 34;
 Daphne Glindmeyer, Report on DYS Compliance with Psychiatry Provisions of S.H. Consent Order (Dec. 2013), pp.
 4, 6.
 70 Kelly Dedel, et al., Monitors’ 6‐Month Report on Compliance with The Grid (June 2015).
 71 Kelly Dedel, et al., Monitors’ Review of DYS’ Contracted Programs for Girls (Nov. 2015).
 72 Daphne Glindmeyer, CJCF site visit report (Jan. 2013), pp. 1‐3, 6, 9‐10, 13; Daphne Glindmeyer, IRJCF site visit
 report (Sept. 2012), pp. 1‐4, 6‐7, 10; Daphne Glindmeyer, Monitor’s Fourth Report, Addendum (June 2013), p. 32;
 Daphne Glindmeyer, Report on DYS Compliance with Psychiatry Provisions of S.H. Consent Order (Dec. 2013), p. 8
 (revised Jan. 2014).

32


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 34 of 39 PAGEID #: 3233
Quality assurance monitoring and peer review. DYS has improved its internal quality assurance monitoring since the 2007 fact‐finding investigation. Supervisors now observe behavioral health staff leading group sessions and conducting treatment team meetings. They provide feedback based on their observations and reviews of clinical documentation. Psychologists now conduct peer review for one another, and DYS’s administrative psychiatrist conducts peer review for facility psychiatrists. DYS has used this quality assurance monitoring and peer review system to place clinical staff on Performance Improvement Plans and to terminate staff when appropriate.73
DYS is now able to identify and respond to issues within the system, determining whether additional staff training, alterations to policy, or increased clinical supervision for a provider is necessary. Their quality assurance monitoring creates a structure to assure and maintain the clinical quality of mental health services provided to the youth in their care, and has been expanded to include reviews of the mental health treatment provided to girls in contract facilities. The contract facilities have been open to the quality assurance monitoring by DYS and receptive to technical assistance when necessary. Their collaborative relationship has been evidenced by improvements in documentation of the treatment occurring at contract facilities. Mental health services for girls in the contracted facilities are commensurate with those services provided to boys in DYS facilities.74
More continuity of care for youth returning home. For youth returning to their home communities, DYS now provides documentation summarizing their diagnoses, course of treatment while in custody, medications and dosages, and any notes on need for follow‐up treatment in the community. Youth return home with a 30‐day supply of medications, and are now presumptively eligible for Medicaid coverage, because of a policy change recommended by Ohio’s Interagency Task Force on Mental Health and Juvenile Justice. This change in state Medicaid law has helped countless youth overcome financial barriers to treatment upon reentry, which in turn has contributed to lower recidivism rates.75
Video segment: Click here to hear from youth about improvement in mental health services.
Release from Secure Custody
Release practices in 2007. Youth and staff in 2007 expressed confusion and exasperation over the release decision process. Decisions made by the Release Authority were inconsistent with one another. They were made without clear‐cut criteria for releasing youth back to their communities or extending their stays in DYS custody. The fact that youth did not know when they were going home or how that decision was being made undermined the effectiveness of DYS’s behavioral incentive system and rehabilitative efforts. Youth stays were also extended because of factors beyond their control, like
73 Andi Weisman, SJCF site visit report (Jan. 2013), pp. 17‐18; Andi Weisman, CHJCF & IRJCF site visit report (Sept.
 2012), pp. 48‐50; Daphne Glindmeyer, CJCF site visit report (Jan. 2013), p. 15; Daphne Glindmeyer, Report on DYS
 Compliance with Psychiatry Provisions of S.H. Consent Order (Dec. 2013), p. 3 (revised Jan. 2014).
 74 Kelly Dedel, et al., Monitors’ Review of DYS’ Contracted Programs for Girls (Nov. 2015).
 75 Daphne Glindmeyer, Monitor’s Fourth Report, Addendum (June 2013), p. 43; Ohio Interagency Task Force on
 Mental Health and Juvenile Justice, Report and Recommendations (Sept. 2012), p. 8.

33


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 35 of 39 PAGEID #: 3234
delays in programming or staff members’ failure to complete paperwork. Extensions like these made the release process seem not only arbitrary, but unfair.76
Clear‐cut criteria for denying release. DYS developed a Standard Operating Procedure that directs the Release Authority to release youth at their minimum sentence or parole eligibility date unless the panel members determine that one or more barriers to release exist. The procedure narrowly defines three specific barriers. Youth may be denied release when a clinical assessment and risk assessment provide sufficient evidence that the youth, if released, will present a risk to public safety. They may be denied release if they have recently engaged in serious (usually violent) rule violations in the institution. And they may be denied release if they have not completed necessary treatment. This third barrier may only be applied if the treatment is known to be effective, is available in the institution, and cannot be provided safely in the community. For situations that do not fit into one of the defined barriers, but that do warrant denial of release (for example, an alleged assault on a staff member without sufficient time to investigate before a youth’s release date), the procedure allows for the rare use of administrative overrides. Some problems persisted with implementation of this release procedure into 2011. For example, the Release Authority continued to deny release without sufficient facts to support any of the defined barriers, or concluded that there was a treatment barrier to release even though alternative treatment was available in the community. These problems have since been corrected, and the Release Authority now consistently follows the Standard Operating Procedure. Barriers to release are invoked sparingly, and each quarter between 70 and 90 percent of youth reviewed are released on their minimum sentence expiration date. Both youth and staff now increasingly report that the release process is fair and consistent. Youth also have a meaningful process now to appeal denials of release.77
Conducting internal quality assurance monitoring. DYS collects and analyzes a significant amount of data related to the activities of the Release Authority. This monitoring ensures that release plans are developed in a timely manner, that release reviews are timely and follow procedural requirements, that youth and their family members are present for reviews, and that the panel complies with the rules regarding release denials. Decisions of the Release Authority are monitored monthly to identify and correct problems with individual panel members and to address systemic issues. Panel members have received training on communicating with youth who have mental health disorders. DYS facilities and the youth’s treatment team are assessed for their compliance with procedures, their assistance to youth during release reviews, and the quality of their documentation. DYS also monitors treatment teams to ensure that they offer youth assistance with appeals.78
76 Fred Cohen, Final Fact‐Finding Report, S.H. v. Stickrath (Jan. 2008), pp. 19‐20, 98, 174‐176, 178‐179, 183.
 77 Vince Nathan, First Report on Requirements Relating to the Release Authority (June 2011), pp. 17‐18, 22‐23, 28,
 40, 55; Vince Nathan, Supplemental Report on Requirements Relating to the Release Authority (Aug. 2011), pp. 2,
 6; Vince Nathan, Third Report on Requirements Relating to the Release Authority (Jan. 2013), pp. 4‐5, 8‐12, 16‐17;
 ODYS Standard Operating Procedure 704.01.04.
 78 Vince Nathan, Report on the Quality Assurance Plan for the Release Authority (Apr. 2013), pp. 3‐4; ODYS Release
 Authority Quality Assurance Plan Narrative (Apr. 2013), pp. 1‐4.

34


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 36 of 39 PAGEID #: 3235
Reducing the Incarcerated Population
Downsizing the juvenile prison system by increasing effective local alternatives. Drawing significant national attention for its efforts, Ohio safely downsized its juvenile prison population from over 2000 youth several years ago to less than 500 today. DYS partnered with juvenile courts throughout the state to increase the capacity at the county level to effectively supervise and serve youth. The project expanded the availability of local treatment options (residential and non‐residential) and the use of small (12‐24 bed) community‐based facilities. The state provided counties with financial incentives to use those dispositional alternatives rather than commit youth to state‐run correctional facilities. This initiative, called RECLAIM Ohio, was bolstered by the Targeted RECLAIM initiative, which expanded evidence‐based disposition alternatives in the state’s six largest counties. Targeted RECLAIM has been extremely successful, and has since been broadened to include an additional eight counties. DYS also partnered with the largest counties on a similar project – the Behavioral Health / Juvenile Justice Initiative – focused on increasing local mental health resources for youth whose involvement in the juvenile justice system stems from underlying mental health disorders. This initiative has recently been expanded to six additional counties. Ohio’s downsizing efforts have succeeded in large part due to extensive advanced planning between DYS and local courts, a level of collaboration which is unique among states with bifurcated (local and state) juvenile justice authority.79
Risk assessment tools used to inform placement decisions. DYS and the University of Cincinnati developed and implemented a risk assessment tool (the Ohio Youth Assessment System) state‐wide, dividing youth into low‐, moderate‐, and high‐risk categories. Tracking outcomes for each category of youth, DYS and its partners found that placement in secure facilities increased recidivism rates for low‐ and moderate‐risk youth. These youth reoffended at far lower rates when they were served in evidence‐based community alternatives. Armed with this data, juvenile justice practitioners in Ohio have been better able to push for deinstitutionalization of low‐ and moderate‐risk youth as a public safety measure.80
JDAI and DMC initiatives. DYS has provided support to five of the state’s biggest counties as they have become involved in the Juvenile Detention Alternatives Initiative (JDAI). The JDAI methodology has been proven to reduce the unnecessary detention of youth without increasing pre‐trial offending, and has also helped reduce commitments to DYS facilities. Additionally, with the support of federal funding, DYS joined forces with 24 county courts to address the over‐representation of minority youth in the state’s juvenile justice system. Working in concert with the Ohio State University, DYS assisted with the planning and implementation of strategies to reduce disproportionate minority confinement
79 Shay Bilchik, Report on Stipulations 13, 14, and 15 of the S.H. Stipulation (May 2011), pp. 1‐3, 6; Shay Bilchik, Regionalization and Reentry Monitoring Report (Jan. 2012), pp. 2, 4; Shay Bilchik, Regionalization and Reentry Monitoring Report (Dec. 2012), pp. 2‐4, 13; Ohio Department of Youth Services, Message from Director Harvey Reed (Jan. 22, 2014). 80 See Comments of Ed Latessa, Director of the University of Cincinnati School of Criminal Justice, at the DYS Annual Stakeholder Retreat (Sept. 25, 2013); Ed Latessa, et al., The Ohio Youth Assessment System, Final Report (July 2009), available at http://www.uc.edu/content/dam/uc/ccjr/docs/reports/project_reports/OYAS_final_report.pdf.
35


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 37 of 39 PAGEID #: 3236
(DMC). Independent evaluations confirm that these projects have been effective at reducing disparities, diverting youth away from the juvenile justice system, and lowering rates of re‐offending.81
Improvements to parole and reentry efforts. In response to data analyses showing that low‐ and moderate‐risk youth were not benefitting from lengthy periods of parole, DYS shortened parole terms. This left the agency adequate time to help youth transition back to the community, while not keeping youth on parole for such long periods that they would likely incur technical violations. This change, plus the reduced facility population, has led to a decline in Juvenile Parole Officer (JPO) caseloads. DYS continues to contract with subject matter expert Shay Bilchik to ensure that with these smaller caseloads, JPOs engage more productively with youth and their families before and after release, spend more time in joint case management with facility staff, and partner with community resources to improve reentry services.82
Dramatically improved outcomes and cost savings. Formal program evaluations found that youth who were diverted away from state‐run juvenile facilities had lower recidivism rates, less school interruption, more family engagement in treatment, and better behavioral health outcomes. Numerous S.H. monitoring reports support the assertion that the lower institutional population has helped to decrease violence in the facilities. One cost‐benefit analysis found that every dollar spent on RECLAIM Ohio saved the state between $11 and $45 in confinement and recidivism costs (depending on youth risk levels). Additionally, the closure of five state‐operated facilities saves the state millions of dollars each year in operational costs.83
Additional Accomplishments
Despite its length, this report cannot and has not captured all of the Department’s accomplishments during the last eight years. Whether outside the scope of monitoring, or occurring after the termination of monitoring in a particular subject area, these additional accomplishments are part of the Department’s culture, operations, and legacy, and are worthy of special mention. They include: providing apprenticeships that combine work‐based learning with related classroom instruction, as well as other advancements in educational and employment programs;84 establishing the Office of
81 Shay Bilchik, Report on Stipulations 13, 14, and 15 of the S.H. Stipulation (May 2011), p. 5; Shay Bilchik,
 Regionalization and Reentry Monitoring Report (Dec. 2012), pp. 15‐16.
 82 Shay Bilchik, Report on Stipulations 13, 14, and 15 of the S.H. Stipulation (May 2011), p. 3; Shay Bildhik,
 Regionalization and Reentry Monitoring Report (Dec. 2012), pp. 9‐10.
 83 See Shay Bilchik, Report on Stipulations 13, 14, and 15 of the S.H. Stipulation (May 2011), p. 2; Shay Bilchik,
 Regionalization and Reentry Monitoring Report (Dec. 2012), p. 3; Ohio Department of Youth Services, Targeted
 RECLAIM, available at http://www.dys.ohio.gov/dnn/Community/TargetedRECLAIM/tabid/211/Default.aspx.
 84 See Ohio Department of Youth Services Fiscal Year 2015 Annual Report, available at
 http://www.dys.ohio.gov/DNN/LinkClick.aspx?fileticket=F%2bdUC7IbbIw%3d&tabid=102&mid=544; Ohio
 Department of Youth Services, Message from DYS Director Harvey Reed, Apprenticeships Prepare Youth for
 Workforce (Nov. 2015), available at
 http://www.dys.ohio.gov/DNN/LinkClick.aspx?fileticket=pFVSDl%2bySgE%3d&tabid=176&mid=897.

36


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 38 of 39 PAGEID #: 3237
Quality Assurance & Improvement to increase accountability and improve processes and outcomes;85 adopting the performance‐driven grant program, Competitive RECLAIM, to incentivize local communities in Ohio to develop evidence‐based services to meet the needs of youth and their families;86 expanding the Juvenile Detention Alternatives Initiative to additional counties to create alternatives to the use of secure detention and reduce the disproportionate confinement of youth of color;87 implementing the Baby Elmo Visitation Program to help youth who have children of their own build relationships with, and learn to care for, those children;88 participating in new violence prevention efforts, including the 40‐day Power of Peace Project;89 creating virtual tour videos to allow youth and families to see facilities prior to a youth’s arrival, and expanding efforts to encourage family involvement in youth’s treatment and programming;90 establishing core values for the Department through a series of town hall meetings with Department staff on all shifts;91 and many more.
Conclusion
The State of Ohio has accomplished a transformational change in the culture and daily operations of their juvenile corrections system. The toxic conditions that once existed in DYS facilities are not uncommon in juvenile corrections systems across the country. But they should be. This model system – the Ohio Model – came about because state leaders and stakeholders committed to reinventing a system based on the best research and practices in the field. The Department’s administration and line staff could have become trapped in the whirlpool of fears about abandoning old practices, particularly the use of disciplinary seclusion and notions about punishing juvenile offenders. Instead they demonstrated courage, resolve, and compassion to create a more humane and safe environment for both youth and staff. Furthermore, the monitoring model that offered up technical assistance from national experts opened up the possibility of tracking progress and outcomes across a variety of measures. As the Court withdraws its oversight, the Department is well equipped to monitor itself through quality assurance processes and to work with
85 See Ohio Department of Youth Services Fiscal Year 2014 Annual Report, available at http://www.dys.ohio.gov/DNN/LinkClick.aspx?fileticket=RcOcYya1FM8%3d&tabid=102&mid=544; Department of Youth Services Office of Quality Assurance and Improvement, http://www.dys.ohio.gov/dnn/InsideDYS/OfficeofQualityAssuranceandImprovement/tabid/219/Default.aspx. 86 See Ohio Department of Youth Services, Director’s Monthly Brief (Feb. 2015), available at http://www.dys.ohio.gov/DNN/LinkClick.aspx?fileticket=QRzTgx6ignw%3d&tabid=80&mid=540. 87 See Ohio Department of Youth Services, Director’s Monthly Brief, Juvenile Detention Alternatives Initiative Expands (Mar. 2014), available at http://www.dys.ohio.gov/DNN/LinkClick.aspx?fileticket=1UeYmDu7zkQ%3d&tabid=80&mid=540. 88 See Incarcerated Fathers Learn How To Be Better Parents, WKYC (June 2015), available at http://www.dys.ohio.gov/DNN/LinkClick.aspx?fileticket=s9Va3pukgYQ%3d&tabid=78&mid=542. 89 See Ohio Department of Youth Services, Director’s Monthly Brief, Teaching Youth to Pursue Peace (Apr. 2015), available at http://www.dys.ohio.gov/DNN/LinkClick.aspx?fileticket=o9YKpfBH1L0%3d&tabid=80&mid=540. 90 See Ohio Department of Youth Services, Message from DYS Director Harvey Reed, Virtual Tour of DYS Facilities (Nov. 12, 2014), available at http://www.dys.ohio.gov/DNN/LinkClick.aspx?fileticket=WJhHYwlpL8c%3d&tabid=176&mid=897. 91 See Ohio Department of Youth Services, Director’s Monthly Brief, Rising to the Next Level with DYS Core Values (May 2015), available at http://www.dys.ohio.gov/DNN/LinkClick.aspx?fileticket=eTwHNJRJ0Mo%3d&tabid=80&mid=540.
37


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 39 of 39 PAGEID #: 3238
stakeholders, youths’ families, and advocates to continually improve. Ohio is now a model not just for other states facing litigation, but for all jurisdictions examining the best practices in the field of juvenile corrections. To those who have put years of hard work into these systemic reforms, we applaud you. You’ve accomplished an immense change. Sustaining this change – this legacy – will require your ongoing commitment. We know you take great pride in this work. On behalf of the Court, we take great pride in this work too. Thank you and congratulations.
38


 
 Case: 2:08-cv-00475-ALM-MRA Doc #: 148 Filed: 05/21/14 Page: 1 of 6 PAGEID #: 3130

UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF OHIO EASTERN DIVISION

S.H., et aIl.,
Plainttiffs,
v.
HARVEY J. REED, Defeennddant.

) ) ) ) ) CIVIL ACTION NO. 2:04-cv-1206 ) ) )

UNITED STATES OF AMERICA, Plaintiff,
v.
THE STATE OF OHIO, etaaL, Defenndants.

)

)

)

)

)

CIVIL ACTION NO. 2:08-cv-475

)

)

)

JUDGE ALGENON L. MARBLEY

)

)

AGREED ORDER On February 18,,22014, Plaintiffs in S.H v. Reed filed a motion for specific performance (Doc 389), and alleged a failure "to provide adequate treatment to youth who are or have been on the mental health caseload. As a result many of these youth are experiencing excessive periods of seclusion ...." lId at p. 1L. On March 12, 2014, the United States filed a motion for a temporary restraining order in United States v. Ohio raising concerns about Defendants' use of seclusion for all youth with an identified mental health disorder. (Doc 1311). The United States also filed a supplemental complaint. (Doc 140). Shortly thereafter, the parties engaged in settlement negotiations aimed at addressing the issues raised in those filings. The Court hereby consolidates these actions under Fed R. Civ. Proc. 42. They shall retain their separate status but be consolidated for the purpose of case

- - - ---- ------

Case: 2:08-cv-00475-ALM-MRA Doc #: 148 Filed: 05/21/14 Page: 2 of 6 PAGEID #: 3131

management and monitoring. The terms of this Order are intended to be implemented consistent with Docs 108 and 359 in S.H v. Reed and with Doc 85 in United States v. Ohio.
Attached as Exhibit A to this Order is the agreed grid that details the actions Defendants will undertake to improve mental health services and reduce seclusion of youth who are on the mental health caseload. The actions and deadlines included in the attached grid are hereby incorporated into this Order. Defendants' compliance with those terms will be co-monitored by Mr. Will Harrell and Dr. Kelly Dedel under the Court's jurisdiction, and monitoring will continue until Defendants have maintained substantial compliance with all provisions and performance measures for six months.
Upon entry of this Order, Plaintiffs in S.H v. Reed agree to withdraw their pending motions (Docs 389 and 390) without prejudice. The United States agrees to withdraw without prejudice its renewed motion for a temporary restraining order. (Doc 145). Because Defendants have committed to the eventual elimination of disciplinary seclusion for all youth housed in a DYS facility and to engage with the monitors and subject matter experts within six months hereof to formulate steps to reach that goal, the United States also agrees to withdraw without prejudice the claims in its supplemental complaint concerning youth who are not on the mental health caseload. (Doc 140). The United States agrees that it may not renew those claims until one month after the effective date of a request that this Court conduct a conference with the United States and the Defendants regarding a resolution oftthe United States' claims and that the effective date for a conference request shall be no sooner than seven months from the date of this Order.
On a quarterly basis starting July 31, 2014, DYS will provide AMS reports for youth not on the MHCL, but who were held in seclusion for an act of violence, that will contain a narrative
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 148 Filed: 05/21/14 Page: 3 of 6 PAGEID #: 3132

of the incident resulting in seclusion, the AMS number, the date and time the youth went into seclusion and the date and time the youth was released from seclusion, the date the youth entered DYS, the date the youth was released from DYS (if youth has been released) and the type of seclusion. On July 31, 2014, DYS shall send the monitors such documents from May 1, 2014 to July 30, 2014. These documents will be provided quarterly until DYS reaches substantial compliance with regard to seclusion, or the lawsuit terminates, whichever occurs first. The monitors may share this information with counsel for the United States and S.HH. Plaintiffs.
The following areas are hereby removed from monitoring: psychotropic medication, sufficiency of psychiatric resources, and equitable treatment. The remaining areas of monitoring (QAl/QI and peer review for mental health and psychiatry, case formulation, fidelity of treatment provided to treatment model, treatment planning and treatment teams, behavior contracts, suicide prevention, and discipline for youth on the mental health caseload through the intervention hearing process) are addressed by the grid and will be monitored in accordance therewith.
This Order is necessary to address and redress ongoing constitutional violations already found, and the relief set forth herein is narrowly drawn, extends no further than necessary, and is the least intrusive means to do so. Defendants may seek to terminate this Order no earlier than July 15,,2015 at which time the SS.HH. Plaintiffs and United States shall bear the burden of proof to demonstrate the existence of an ongoing violation of federal law and that the current order reflects narrowly drawn relief which extends no further than necessary and is the least intrusive means to remedy that violation.
IT IS SO STIPULATED AND AGREED FOR S.H. PLAINTIFFS:
DATE: May 20,2014
3

Case: 2:08-cv-00475-ALM-MRA Doc #: 148 Filed: 05/21/14 Page: 4 of 6 PAGEID #: 3133


sfAlphonse A. Gerhardstein ALPHONSE A. GERHARDSTEIN (Ohio Bar No. 0032053) Trial Attorney for Plaintiffs Gerhardstein && Branch Co. LPA 432 Walnut Street, Suite 400 Cincinnati, Ohio 45202 (513) 621-9100 (513) 345-5543 fax agerhardstein@gbfIirm.com

s/fKim Brooks Tandy KIM BROOKS TANDY (Ohio Bar No. 0076173) Attorney for Plaintiffs Children's Law Center, Inc. 104 East 7th Street Covington, Kentucky 41011 (859) 431-3313 ktandy@childrenslawky.org
Attorneys for Plaintiffs

4

Case: 2:08-cv-00475-ALM-MRA Doc #: 148 Filed: 05/21/14 Page: 5 of 6 PAGEID #: 3134


IT IS SO STIPULATED AND AGREED FOR THE UNITED STATES:

DATE: May 20,,220014
CARTER STEWART United States Attorney Southern District of Ohio

JOCELYN SAMUELS Acting Assistant Attorney General Civil Rights Division United States Department of Justice

lIsi/ Deborah F. Sanders
DEBORAH F. SANDERS (0043575) Assistant United States Attorney Southern District of Ohio 303 Marconi Boulevard, Suite 200 Columbus, Ohio 43215 (614) 469-5715 {(T) (614) 469-5653 (F) Deborah. Sanders@usdoj. gov

EVE HILL Deputy Assistant Attorney General Civil Rights Division
JONATHHAANNM. SMITH Chief Special Litigation Section
lIsi/ Benjamin 0O. Tayloe., Jr. BENJAMIN 0O. TAYLOE, JR. Deputy Chief Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 (202) 514-8103 (T) (202) 514-4883 (F) Benjamin.Tayloe@usdoj.gov SILVIA J. DOMINGUEZ-REESE CYNTHIACOE ALEXANDRA L. SHANDELL Trial Attorneys Special Litigation Section
Attorneys for Plaintiff

5

Case: 2:08-cv-00475-ALM-MRA Doc #: 148 Filed: 05/21/14 Page: 6 of 6 PAGEID #: 3135

IT IS SO STIPULATED AND AGREED FOR DEFENDANTS REED AND THE STATE OF OHIO, ET AL.:

DATE: May 20,2014

/Is/ Judith Goldstein JUDITH GOLDSTEIN (Ohio Bar No. 0069655) Assistant Attorney General Criminal Justice Section 150 East Gay Street, 16th Floor Columbus, Ohio 43215 (614) 644-7233 Fax: (614) 728-9327 Judith. goldstein@ohioattorneygeneral. gov

/Isl/ Thomas Anger THOMAS ANGER (Ohio Bar No. 0088577) Assistant Attorney General Criminal Justice Section 150 East Gay Street, 16th Floor Columbus, Ohio 43215 (614) 644-8742 (877) 584-2041 Thomas.anger@ohioattorneygeneral. gov

Attorneys for Defendants

:bL WHEREFORE, for good cause shown, this ORDER shall be entered this ~ day of
~2014

6

Case: 2:08-cv-00475-ALM-MRA Doc #: 148-1 Filed: 05/21/14 Page: 1 of 9 PAGEID #: 3136
EXIDBIT A
YOUTH ON THE MENTAL HEALTH CASE LOAD: PROPOSAL TO REDUCE VIOLENCE AND IMPROVE THE RESPONSE TO VIOLENCE IN DYS FACILITIES

A..1l1l Vrcrrlfy Trcqtmcot 'lnfmfty

eCLLJlIJ Reduce RcIlIlqnq po SuullI1ll1liippo

• Quality Assurance (QOA) will be put in place to ensure that individual treatment is aligned with

• No intervention seclusion {(IS) for High Severity (e.g., fight, consensual sexual activity), unless the victim requires off­

treatment goals. Each month, the PsyycchhoololoBgYy Supervisor will sample 2 files per clinician. Monitors will review the cases sampled and the completed QOA audit tools.
• Timel;jne: o Tools are developed; o Will be implemented by May 1, 2014.

grounds emergency medical treatment (and then up to 24 hours can be imposed).
• Interdisciplinary Team {(lIODT) determines sanction.
• Timelines: o Policy changes to be completed by June 30, 2014. o OQA for Performance Measure by July 15, 2014. o Training Completed by August 31, 2014.

• OQA will be put in place to verify that group treatment displays fidelity to design. Each month,

o Implementation by September 1, 2014.

a sample of groups {(MManaging Anger and

Violence, Cognitive Behavioral Therapies overlays,

etc.) will be audited using a OQA tool that has been drafted. Monitors will review the completed OQA

tools.

• Timeline: o Tools are under development, will be sent to

Monitors immediately for input; o Will be implemented by May 1, 2014.
Perdformanccee MMeeasure A.l

I Pediforrmmoance MMeeasure B8..1l • Proportion of youth who commit High Severity infractions
who were given intervention seclusion (should be 0%,

• 90% of all cases reviewed showed correspondence between content of individual sessions and treatment goals.

unless victim required off-grounds emergency medical treatment).

• 90% of all groups included in the sample score 80% or better on a measure of treatment fidelity.

'C1111 TmzJmmt Plgqn RBmmCcWw
• Within 2 days of every AOV, the treating clinician/lOT will review the treatment plan to identify antecedents and function of the behavior; review treatment goals and interventions. If implementation of existing plan has not been sufficient, it will be fortified. If existing plan was propertly implemented yet ineffective, it will be revised to include additional skill-development or environmental changes. May use Behavior Contract if appropriate.
• Intensity of treatment will be increased to 3x/week individual sessions for two weeks; daily homework will be assigned.
• Timeline: Implemented by July 1, 2014.
Perforcmmqqnncce MMeeasure (C,1.l • 90% of youth involved in AOV have Treatment
Plan Review within 2 days of the incident. o % of cases in which implementation was
fortified. o % of cases in which interventions were
revised. o These should total 100%, not an option to
do nothing.

1

Case: 2:08-cv-00475-ALM-MRA Doc #: 148-1 Filed: 05/21/14 Page: 2 of 9 PAGEID #: 3137

A. Prevention S5ttt:att..a.t.e.s
A.lIl OQmmllOqRp 8Sl1o0PPsmycbbpSSqqcdlql Assmmvmncnt that
lnduda Qalfanflcma'l qgand Qlqqn9oSstfk fEqqaannuullqqrrllooan • Initial BioPsychoSocial Assessment includes a
broad range of informational sources and culminates in a clinical formulation and diagnostic formulation, which is reflected in the youth's treatment plan.
• Tjmeljone:
o Guidance on the formulation concept for Department of Youth Services (DYS) staff will be fully developed ASAP, with input from DYS clinicians and Monitors;
o TraininB for all clinicians will occur within 60 days of entry of this Order;
o QA tools will be developed and implemented by May 1, 2014.

8:tmmediate lnterverati~·strateates

8S..2l1l fRkedduuq" DyrpptIlon qpfS,dusslqo • Interim Measure: Effective no later than July 15, 2014, and
ending on September 1, 2014, any youth on seclusion (intervention or pre-hearing) for over 72 hours in a rolling 30-day period must be reviewed by the Treatment Teearmn and any continued seclusion must first receive approval from the Bureau Chief for Facilities or the Deputy Director before the seclusion continues past 72 hours in a rolling 3O0--day period. • TDImmeelijne for ijnterijm measure: Effective July 15, 2014.
• DYS will decrease the minimum length of stay (LOS) for youth engaged in AOVs to two to four hours, not to exceed 24 hours.
• The Safe to Release (STR) process will be initiated between two and four hours and if the youth refuses to engage or the suitability of the climate indicates safety concerns, staff will attempt to engage the youth every two to three hours thereafter, up to the 24 hour period.
• If the 24 hour period is reached and the youth continues to refuse or the suitability of the climate indicates safety concerns, the Superintendent must approve any further seclusion.
• TDImmeellines: o Poljicy changes to be completed by June 30, 2014. o QA for Performance Measure by July 15, 2014. o Training Completed by August 31, 2014. o Implementation by September 1, 2014.

C.ll SRCddgqll8Rccyy1fcw Tcqm (CSSSRD • Within 2 days of a youth's 2rnwdJ Severe or 3rnd1
High Severity AOV, he will be referred to the SRT for a clinical staffing, led by the psychologist and specifically focused on understanding and addressing the AOV behavior. • The SRT will function as the lIODT until the youth's behavior improves.
• The SRT will explore the causes and functions of the behavior and will prescribe interventions designed to address those causes and functions (e.g., Intensive Behavior Contract; staff mentor; change unit; skill building work; referral to Mental Health faciljity).
• Tijmeljine: Implemented by July 1, 2014.

• Decrease intervention seclusion time imposed for Severe AOVs (e.g., assault, sexual exposure/assault; imposed by Hearing Officer, not consecutive to pre-hearing seclusion (PHS)). o 1sstt gets Credit for TIime Served.
o 2trwwJJ gets up to 4 hours.
o 3nn1l gets up to 8 hours. o 4th gets up to 12 hours. o 5Sth+ gets up to 24 hours. o Unless victim requires off-grounds emergency medical
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 148-1 Filed: 05/21/14 Page: 3 of 9 PAGEID #: 3138

;:-·:·-- ,;·~\.'.:!-'

-~; -~~j

A. ·Prevention Stri~;

Pedocrmgqnce MMeqsure A 2 • 90% of initial assessments include a solid
clinical/diagnostic formulation. Every month, a sample of cases will be reviewed by the Monitor andQQAA. • 90% of treatment plans reflect information from the formulation. Every month, a sample of cases will be reviewed by the Monitor and QA.

treatment, then up to 24 hours. o For the purposes of calculating how many previous
"Severe" rule violations youth have committed, the number of "Severe" rule violations is considered zero if a youth goes 30 days without a "•Severe" rule violation unless the superintendent decides otherwise; and, if so, the youth will be reviewed again in 30ddaays. o Served on Saturday and Sunday. o The State shall not substitute physical restraints for seclusion. • IDimmelijnes: o Policy changes to be completed by June 30, 2014. o QA for Performance Measure by July 15, 2014. o Training Completed by August 31, 2014. o Implementation by September 1, 2014.
Pedormoance MMeasure 8B.2 • Proportion of youth released at 4 hours or less. • 100% of youth were sanctioned according to the IS
graduated scheme. • 0% of youth spent more than 72 hours in seclusion in a
rolling 3£0k-dtay period (except in rare circumstances with approval from the Bureau Chief for Facilities or the Deputy Director).

Perforrmmance MMeasure C.2 • Number of youth involved in 2 Severe or 3 High
AOVs (descriptive). o SRT was convened within 2 days for 100%. o 90% of the SRTs explored the causes and
functions of the behavior. o 90% of the SRTs prescribed interventions
that addressed those causes and functions.

3

Case: 2:08-cv-00475-ALM-MRA Doc #: 148-1 Filed: 05/21/14 Page: 4 of 9 PAGEID #: 3139
8..331' Rnlusc Hqpcamn Apqclqtcd with Seudfustlqo
• Intervention seclusion is imposed only on Saturday & Sunday, to reduce interference with core programming.
• For IS, provide 1 hour out for every 4 hours in seclusion, during waking hours.
• Youth in IS participate in treatment activities, school and recreation out of their room and time counts toward seclusion hours if behavior is appropriate.
• Timelines: o Policy changes to be completed by June 30, 2014.
o OA for Performance Measure by July 15, 2014.
o Training Completed by August 31, 220014. o Implementation by September 1, 2014.
Performance Measure 8.3
• 90% of youth in intervention seclusion spent 4 inn//1loouut during waking hours.
• 90% of youth in intervention seclusion participated in all programming (e.g., recreation, treatment) that was scheduled during seclusion time.
8.441. Rnlusc Amulmnulqgtiqo qfSSeudfUwllqo
• To apply more than 72 hours of seclusion in a 30-day period: o Conduct Treatment Plan Review (see Strategy C.l1)). o Obtain approval from Bureau Chief for Facilities or the Deputy Director. o Monitors/Plaintiffs will be provided with information on youth reviewed on a monthly basis.
• UTImmeeljnes:
o Policy changes to be completed by June 30, 2014.
o OA for Performance Measure by July 15, 2014.
o Training Completed by August 31, 2014. o Implementation by September 1, 2014.
Performance Measure 8.4
• Number of youth secluded each month and number of
4

Case: 2:08-cv-00475-ALM-MRA Doc #: 148-1 Filed: 05/21/14 Page: 5 of 9 PAGEID #: 3140

A. PPrreveevnteionntStirloifnt!Sl~~.·

hours in seclusion (Monthly-for all youth on MHCL, provide date, type of AOV, PHS and IS). • Number of youth who spent more than 72 hours in 30day period (descriptive). o 90% received Treatment Plan Review. o 90% receive approval for exception to the 72 hour
rule. • TDImelipe:
o To be implemented by July 15,,22014.
8..551' Pcpyffddc, Cd"R, lntf!YYcotfqo Whlile In PHS • STR process will be initiated with every youth engaged in
an AOV between two and four hours. • STR process will include a structured interview by Social
Worker/Unit Manager/Operations Manager that discusses triggers, decision-making, external influences on behavior. • Timeline: o Obtain input from Monitor on STR interview guide by
Aprriill1, 2014. Completed. • Timelines:
o STR Interview Form developed and Policy changes to be completed by June 30, 2014.
o QA for Performance Measure by July 15, 2014. o Training Completed by August 31, 220014. o Implementation by September 1, 2014.
PPedorrmmaannce MMeeaasure 8.5 • STR process was initiated with 90% of youth within 4
hours. • 90% of STR checks examine the underlying causes of the
youth's behavior, both internal and external.
8.61J EEYRCantu_qtltvv Elllimmfianqatec Usc ofSu/lusilon
• DYS is committed to the eventual elimination of disciplinary seclusion for all youth housed in a DOYS facility. Thus, six months from the acceptance of this proposed settlement, DYS will engage the monitors and subject matter experts in formulating steps to take, and the timeline for completing those steps, to eliminate disciplinary seclusion.
5

Case: 2:08-cv-00475-ALM-MRA Doc #: 148-1 Filed: 05/21/14 Page: 6 of 9 PAGEID #: 3141

Stnlteltft"''
Omqll Pcdppccmmqqnnwq MMAgsuvCrCc;i Vlolcnq Rd"'ucctf1lqp • Increase proportion of youth who do not engage
in Acts of Violence (AOV) (baseline: February 14, 2014, 83% system-wide). • Decrease number and proportion of Mental Health Case load (MHCl) youth who engage in 3 or more AOVs each month (any severity). • A 10% reduction goal each month based upon the previous month's total.

• Timeline: o Six (6) months from the entry of this Order.
0OmvmqIf1l Pcdpnnqq"m" MMuawwt,!,;i W BcruJW uq Tfq*tq#f Su/luslop Hours
• Reduce the number of youth who serve 72+ seclusion hours per month by 10% each month, compared to previous month. o DYS to calculate pre-policy change total.

6

Case: 2:08-cv-00475-ALM-MRA Doc #: 148-1 Filed: 05/21/14 Page: 7 of 9 PAGEID #: 3142
DEFINITIONS "AOV" means act of violence.
"BioPsychoSocial Assessment" means an assessment of all biological, psychological, and social factors present for an individual in order to inform that individual's treatment.
"Disciplinary Seclusion," also known as "Intervention Seclusion," means a period of confinement in a locked room that is used as a disciplinary sanction following a Severe Rule Violation.
"DOJ" means the United States Department of Justice, which represents the United States in this matter.
"DYS" means the Ohio Department of Youth Services.
"Effective Date" means the date by which this Agreed Order has been signed by representatives for each of the parties to this Agreed Order and issued as this Court's Order.
"Facilities" or "Facility" means Scioto Juvenile Correctional Facility, Circleville Juvenile Correctional Facility, Cuyahoga Hills Juvenile Correctional Facility and Indian River Juvenile Correctional Facility, including any DYS facility that replaces or supplements any of those named facilities.
"High Rule Violation" means actions that create immediate and direct threats to the security, safe and order of the facility, its staff, visitors or youth.
"IlODT" means Interdisciplinary Team.
"Implement" means to give practical effect and ensure actual fulfillment by concrete measures, including appropriate training of relevant staff.
"Intervention Grid" means a DYS.grid of sanctions for rule violations ranging in severity from Low, to Moderate, High and Severe.
"Intervention Hearing" means a disciplinary hearing that is conducted, consistent with due process, to determine by a preponderance of the evidence whether a Severe Rule Violation has been proven or not proven.
"Intervention Seclusion," also known as "Disciplinary Seclusion," means a period of confinement in a locked room that is used as a disciplinary sanction following a Severe Rule Violation.
"LOS" means Length of Stay.
7

Case: 2:08-cv-00475-ALM-MRA Doc #: 148-1 Filed: 05/21/14 Page: 8 of 9 PAGEID #: 3143
"Mental Health Caseload" or "MHCL" means all youth with an identified mental health disorder, including those youth who have a psychiatric disorder, including but not limited to psychoses, schizophrenia, bipolar with psychotic features, depression with psychotic features, severe post-traumatic stress disorder, or schizoaffective disorders and who, consistent with reasonable professional judgment, DYS believes require psychiatric or psychological care.
"Monitor" means Will Harrell and Dr. Kelly Dedel, including anyone else the court or parties by agreement may designate as their replacements.
"Monitoring" at facilities other than Indian River, Circleville, Cuyahoga Hills, and Scioto means a review of youth files or other materials requested by the monitor or subject-matter experts. The parties agree to meet and confer should additional access be requested and a good faith effort will be made to resolve any such requests. Monitoring at Indian River, Circleville, Cuyahoga Hills, and Scioto shall otherwise be conducted in accordance with Doc 359 in SH v. Taft 04 cv 1206 and with Doc 85 in United States v. Ohio..
"Order" means this agreed order.
"Pre-hearing Seclusion" means placement of an out-of-control youth or a youth whose behavior poses an immediate threat to himself or others, in a locked room for a period of time until he or she regains control of his or her behavior and can be safely returned to the general population
"Quality Assurance/Improvement Program" or "QA" means a system of self-auditing and improvement to assess the implementation and effectiveness of all remedies instituted pursuant to this Order, to identify deficits that may exist, and to effectuate new measures to cure deficits identified.
"Restraints" means any chemical or mechanical device used to control the behavior of a youth.
"Safe to Release" means a determination pursuant to DYS guidelines that a youth should be released from Pre-hearing Seclusion.
"Seclusion," "seclude," and "secluding" mean isolating a youth in a room from which the youth's ability to egress is blocked. The term seclusion does not apply to locking a youth in a room during normal hours of sleep.
"Severe Rule Violation" means actions that have potential to create immediate and direct harm to the security, safety and order of the Facility, its Staff, visitors or youth, including assault, escape, sexual assault or riot/disturbance.
"Staff' means employees who work at any of the Facilities.
"Subject Matter Experts" means Dr. Daphne Glindmeyer, Dr. Andi Weisman, and anyone else the court or parties by agreement may designate as their replacements.
8

Case: 2:08-cv-00475-ALM-MRA Doc #: 148-1 Filed: 05/21/14 Page: 9 of 9 PAGEID #: 3144
"State" means the State of Ohio, Harvey Reed, Director of the Ohio Department of Youth Services, the Ohio Department of Youth Services, and their successors, contractors and agents.
"Treatment Fidelity" means strategies that monitor the implementation of a behavioral health intervention (e.g., group treatment) to ensure it is delivered according to design/curriculum/theory and that it is delivered in a comparable manner across all youth.
"Youth" means any juvenile or juveniles committed by a court to, and residing at, the Facilities during the pendency of this Agreed Order. The specific terms set out in the grid only apply to youth at facilities directly managed by DYS. Youth at other facilities shall receive mental health services consistent with those described herein but appropriately tailored for the such non-DYS managed facilities.
9

 
 Case: 2:04-cv-01206-ALM-TPK Doc #: 400 Filed: 05/20/14 Page: 1 of 6 PAGEID #: 12833

UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF OHIO EASTERN DIVISION

S.H., et al.,

)

)

Plaintiffs,

)

)

v.

)

)

HARVEY J. REED,

)

Defendant.

)

____________________________________

UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

)

v.

)

)

THE STATE OF OHIO, et al.,

)

)

Defendants.

)

____________________________________)

CIVIL ACTION NO. 2:04-cv-1206
CIVIL ACTION NO. 2:08-cv-475 JUDGE ALGENON L. MARBLEY

JOINT MOTION FOR ENTRY OF AGREED ORDER The Parties in the above-entitled cases jointly move this Court to enter as its Order the attached Agreed Order and Exhibit A thereto, which embody the Parties’ agreement for a resolution of the Plaintiffs’ claims in these actions. In support of this motion, the Parties state as follows: 1. On December 20, 2004, the S.H. Plaintiffs filed a complaint (Doc 1 in S.H. v. Reed, 2:04-cv-1206) challenging conditions at Defendants’ juvenile correctional facilities. On May 16, 2008, the United States also filed a complaint (Doc 2 in U.S. v. Ohio, 2:08-cv-475) challenging conditions at Defendants’ juvenile correctional facilities. 2. On February 18, 2014, the S.H. Plaintiffs filed a motion for specific performance (Doc 389) and alleged a failure “to provide adequate treatment to youth who are or have been on

Case: 2:04-cv-01206-ALM-TPK Doc #: 400 Filed: 05/20/14 Page: 2 of 6 PAGEID #: 12834
the mental health caseload. As a result many of these youth are experiencing excessive periods of seclusion . . . .” Id at p. 1.
3. On March 31, 2014, the United States filed a supplemental complaint to include claims relating to Indian River Juvenile Correctional Facility, Circleville Juvenile Correctional Facility, and Cuyahoga Hills Juvenile Correctional Facility. (Doc 140). On April 29, 2014, the United States renewed its motion for a temporary restraining order in United States v. Ohio, raising concerns about Defendants’ use of seclusion for all youth with an identified mental health disorder (Doc 145).
4. Thereafter, the Parties engaged in settlement negotiations aimed at addressing the issues raised in those filings, and the parties have now reached agreement on a resolution of Plaintiffs’ claims. The Parties’ agreement is embodied in the Joint Proposed Order and Exhibit A thereto, which is attached to this motion.
ACCORDINGLY, the Parties request that the Court enter the attached Joint Proposed Order and Exhibit A thereto as its Order. Subject to the conditions in the Joint Proposed Order, the S.H. Plaintiffs request that the Court dismiss without prejudice their motion for specific performance, and the United States requests that the Court dismiss without prejudice the United States’ renewed motion for a temporary restraining order and the claims in the United States’ supplemental complaint concerning youth who are not on the mental health caseload.
2

Case: 2:04-cv-01206-ALM-TPK Doc #: 400 Filed: 05/20/14 Page: 3 of 6 PAGEID #: 12835

DATE: May 20, 2014
s/ Alphonse A. Gerhardstein ALPHONSE A. GERHARDSTEIN (Ohio Bar No. 0032053) Trial Attorney for Plaintiffs Gerhardstein & Branch Co. LPA 432 Walnut Street, Suite 400 Cincinnati, Ohio 45202 (513) 621-9100 (513) 345-5543 fax agerhardstein@gbfirm.com

s/Kim Brooks Tandy KIM BROOKS TANDY (Ohio Bar No. 0076173) Attorney for Plaintiffs Children’s Law Center, Inc. 104 East 7th Street Covington, Kentucky 41011 (859) 431-3313 ktandy@childrenslawky.org
Attorneys for Plaintiffs

3

Case: 2:04-cv-01206-ALM-TPK Doc #: 400 Filed: 05/20/14 Page: 4 of 6 PAGEID #: 12836

DATE: May 20, 2014
CARTER STEWART United States Attorney Southern District of Ohio
/s/ Deborah F. Sanders DEBORAH F. SANDERS (0043575) Assistant United States Attorney Southern District of Ohio 303 Marconi Boulevard, Suite 200 Columbus, Ohio 43215 (614) 469-5715 (T) (614) 469-5653 (F) Deborah.Sanders@usdoj.gov

JOCELYN SAMUELS Acting Assistant Attorney General Civil Rights Division United States Department of Justice
EVE HILL Deputy Assistant Attorney General Civil Rights Division
JONATHAN M. SMITH Chief Special Litigation Section
/s/ Benjamin O. Tayloe, Jr. BENJAMIN O. TAYLOE, JR. Deputy Chief Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 (202) 514-8103 (T) (202) 514-4883 (F) Benjamin.Tayloe@usdoj.gov SILVIA J. DOMINGUEZ-REESE CYNTHIA COE ALEXANDRA L. SHANDELL Trial Attorneys Special Litigation Section
Attorneys for Plaintiff

4

Case: 2:04-cv-01206-ALM-TPK Doc #: 400 Filed: 05/20/14 Page: 5 of 6 PAGEID #: 12837

DATE: May 20, 2014
/s/ Judith Goldstein JUDITH GOLDSTEIN (Ohio Bar No. 0069655) Assistant Attorney General Criminal Justice Section 150 East Gay Street, 16th Floor Columbus, Ohio 43215 (614) 644-7233 Fax: (614) 728-9327 Judith.goldstein@ohioattorneygeneral.gov

/s/ Thomas Anger THOMAS ANGER (Ohio Bar No. 0088577) Assistant Attorney General Criminal Justice Section 150 East Gay Street, 16th Floor Columbus, Ohio 43215 (614) 644-8742 (877) 584-2041 Thomas.anger@ohioattorneygeneral.gov

5

Case: 2:04-cv-01206-ALM-TPK Doc #: 400 Filed: 05/20/14 Page: 6 of 6 PAGEID #: 12838
Certificate of Service I HEREBY CERTIFY that this date, May 20, 2014, I caused the foregoing to be electronically filed with the Clerk of the Court using the CM/ECF system, which will simultaneously serve notice of such filing to counsel of record and the Court Monitor to their registered electronic mail addresses.
/s/ Thomas Anger THOMAS ANGER (Ohio Bar No. 0088577) Assistant Attorney General Criminal Justice Section 150 East Gay Street, 16th Floor Columbus, Ohio 43215 (614) 644-8742 (877) 584-2041 Thomas.anger@ohioattorneygeneral.gov
6

 
 Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 1 of 18 PAGEID #: 2898

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

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

)

)

)

)

)

)

CIVIL ACTION NO:

)

2:08-cv-475

)

)

)

)

UNITED STATES’ MOTION FOR LEAVE TO FILE SUPPLEMENTAL COMPLAINT The United States moves the Court for leave to file a Supplemental Complaint in this
matter, under Fed. R. Civ. P. 15(d). The grounds for this motion are set forth in the attached Memorandum of Points and Authorities. The United States requests an expedited ruling on this motion in order to expedite consideration of the accompanying Motion for a Temporary Restraining Order.
Respectfully Submitted,

s/ Silvia J. Dominguez-Reese SILVIA J. DOMINGUEZ-REESE Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 (202) 616-8547(T) (202) 514-4883 (F) Silvia.Dominguez-Reese@usdoj.gov
Attorney for Plaintiff

Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 2 of 18 PAGEID #: 2899
MEMORANDUM OF POINTS AND AUTHORITIES IN SUPPORT OF THE UNITED STATES’ MOTION FOR LEAVE TO FILE SUPPLEMENTAL COMPLAINT
The United States seeks to supplement its Complaint in this case under Fed. R. Civ. P. 15(d) to enforce the constitutional and federal statutory rights of youth confined in Ohio’s juvenile justice facilities, including youth in Circleville Juvenile Correctional Facility (“Circleville”), Cuyahoga Hills Juvenile Correctional Facility (“Cuyahoga”), Indian River Correctional Facility (“Indian River”), and Scioto Juvenile Correctional Facility (“Scioto”) (collectively, the “DYS Facilities”). The United States alleges that the State of Ohio (the “State”) is engaging in a pattern or practice of harming youth in its custody through its unnecessary use of seclusion. The United States also alleges that the State is engaging in a pattern or practice of denying adequate mental health care and rehabilitative treatment to youth in its custody, particularly youth the State has harmed through unwarranted seclusion. Finally, the United States alleges that the State’s use of seclusion exceeds the point that the use is reasonably related to a legitimate governmental objective and is tantamount to punishment and a violation of youths’ due process rights. See U.S. Supplemental Compl. (Attach. A). The United States discovered this conduct recently, and subsequent attempts to resolve the violations without litigation have failed. The United States notified the State of its intention to seek leave to file a Supplemental Complaint on March 7, 2014. On March 10, 2014, the United States contacted the State to ascertain whether it would consent to the motion, and the State replied that it would object to this motion.
I. INTRODUCTION The United States has pursued reform of unlawful conditions at the DYS Facilities since May 2007, when it issued findings of unlawful conditions at Scioto and the since-closed Marion
1

Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 3 of 18 PAGEID #: 2900
Juvenile Correctional Facility (“Marion”). The United States entered into a stipulation with the
State regarding Scioto and Marion in June 2008 in this case, U.S .v. Ohio, ECF No. 8, and has
participated as an interested party in the related case, S.H. v. Reed, No. 2:04-cv-1206 (S.D.
Ohio), since that time. Thereafter, the parties and the monitoring teams in each case worked
toward resolving the unconstitutional conditions, and the United States understood that the
litigation was working its way toward a final resolution.
That understanding changed beginning in November 2013. Recent developments have
made it increasingly clear that certain unconstitutional conditions exist at Scioto as well as the
other DYS Facilities, placing Scioto boys and other youth at risk of continued harm, with no
signs from the State that it intends to remedy these conditions. In particular, these developments
include: • The discovery in November 2013 that the State is excessively secluding youth at Scioto who have significant mental health needs, see K. Dedel, Results of Seclusion Analysis (Nov. 8, 2013) (Attach. B); • The State’s announcement in November 2013 that it is closing Scioto and moving the 20 boys there to other DYS Facilities by May 2014, see Letter from Harvey Reed, DYS Director, to Stakeholders (Nov. 21, 2013) (Attach. C); • The State’s attempt on December 18, 2013, to end the stipulation in U.S. v. Ohio via the Prison Litigation Reform Act (“PLRA”) rather than correct its unlawful practices, see U.S. v.Ohio, ECF No. 121; • The discovery on January 17, 2014, that the State is also excessively secluding youth with mental health needs at its other DYS Facilities, as reflected in records the State produced that day, see United States’ Seclusion Hours Summary Table (Attach. D); • The failure of mediation in January 2014 to resolve concerns about the State’s seclusion of, and provision of mental health services to, youth with mental health needs; and • The S.H. plaintiffs’ filing on February 18, 2014, of a motion for specific performance on these issues, see id. at ECF No. 389.
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 4 of 18 PAGEID #: 2901
It is thus appropriate for the United States to supplement its Complaint in this matter in order to ensure full and appropriate relief for Scioto boys and other youth in all DYS Facilities. The United States seeks to supplement its Complaint to include these new events: the State’s closure of Scioto, the State’s transfer of boys subject to excessive seclusion at Scioto to other DYS Facilities where the same unconstitutional conditions exist, and the State’s pattern and practice of harming Scioto boys and other youth through excessive seclusion and insufficient mental health treatment at the other DYS Facilities. As discussed below, the United States’ motion to supplement its Complaint should be granted because the inclusion of the new facts will avoid piecemeal litigation, allow a prompt and efficient resolution of the entire controversy between the parties, and impose no prejudice on the State. In particular, the State will not be prejudiced by allowing the United States to add the new facts because they are timely filed, relate to the same legal theories underlying the original Complaint, will not impose undue delay or trial inconvenience, and the State has received ample notice of its constitutional violations. More fundamentally, this Court should grant the United States’ motion to supplement its Complaint so that the United States can promptly vindicate the federal rights of youth that the State is violating by excessively isolating them and denying them access to mental health care.1
1 The United States Attorney General is tasked with protecting the rights of juveniles in custody pursuant to the Violent Crime Control and Law Enforcement Act of 1994, 42 U.S.C. § 14141. A national enforcement priority of the United States is preventing the use of unlawful seclusion on persons in custody who have significant mental health needs. The United States can best fulfill these responsibilities to protect the public interest by resolving the unconstitutional conditions at all DYS Facilities in a single action.
3

Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 5 of 18 PAGEID #: 2902
II. BACKGROUND A. The State Has Inflicted Extraordinary Levels of Seclusion on Scioto Youth. On November 8, 2013, the United States learned that the State was inflicting extraordinary rates of seclusion on youth, particularly youth with mental health needs. On that day, the monitor in this case2, Dr. Kelly Dedel, reported that the State had secluded a number of youth for over 10 percent of their total time in custody over a recent six-month period. See Attach. B. She noted “that there are a number of [Scioto] youth who spent a considerable amount of time (20, 30, 40, nearly 50 days) in seclusion.” Id. at 1. All of the youth identified in her report also suffered mental health issues. Id. at 2. The monitor also reported that the State was denying mental and behavioral health treatment to the same Scioto youth with mental health disorders whom it was secluding, thereby effectively withholding the interventions these youth needed to address the causes of the behaviors triggering their seclusion. See Fifth Compliance Report, U.S. v. Ohio, ECF No. 127. The monitor’s subject matter expert reviewed the mental health records of the youth identified in the monitor’s report, and this review revealed that these youth were not receiving mental health treatment via group during their seclusion period. Instead, they received visits by mental health staff limited to “brief checks per protocol, [that] were not treatment oriented.” Id. at 60.
2 The Consent Order addresses violations of federal rights including, but not limited to, failures to protect youth from harm, inadequate provision of mental health care, and the excessive use of seclusion. U.S. v. Ohio, ECF No. 8.
4

Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 6 of 18 PAGEID #: 2903
B. The Other Three DYS Facilities Similarly Impose Seclusion and Withhold Mental Health Care.
The State’s unconstitutional treatment of youth in its custody is not limited to Scioto youth. In January 2014, the State provided the United States and S.H. plaintiffs with seclusion data for youth with mental health disorders at all four DYS Facilities for the period July 1, 2013December 31, 2013. The State’s data were clear: It imposed 59,865 seclusion hours on 229 youth with mental health disorders during this six month period. See Attach. D.
In December 2013, Dr. Andrea Weisman, a member of the S.H. monitoring team, confirmed that the excessive use of seclusion at Scioto was present at the other DYS Facilities. Specifically, Dr. Weisman explained:
It is clear to me that the deficiencies in behavioral health care led to the high rates of seclusion for youth at Scioto, and that the same deficiencies exist at the other three DYS facilities. . . . Given the recent closure of the [Scioto special management unit] and Scioto JCF, plaintiffs’ question regarding whether youth with behavioral challenges at other facilities spend a significant portion of their DYS stays in seclusion is a valid one. See Report by Andrea Weisman, S.H. “Compliance with Consent Order Provisions Regarding Mental Health” (Dec. 16, 2013) (Attach. E). In early January 2014, Dr. Weisman reviewed the mental health records for youth at Circleville, Indian River, and Cuyahoga and found that youth with mental health disorders were disproportionately engaging in behaviors likely to result in their being secluded. S.H. v. Reed, ECF No. 388. C. The State Has Refused to Address the Seclusion and Mental Health Care
Problems at the Facilities. The parties have been unable to resolve the problems Dr. Dedel identified. Following her November 8, 2013, seclusion report, both the United States and Dr. Dedel invited the State to engage in substantive discussions about its seclusion practices. Instead, the State filed a PLRA
5

Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 7 of 18 PAGEID #: 2904
motion on December 18, 2013, to terminate this case. U.S. v. Ohio, ECF No. 121. Settlement discussions broke down at a joint January 29, 2014 court-mediated settlement conference. The S.H. plaintiffs moved for specific performance on February 18, 2014, and the United States promptly sought leave to supplement its Complaint.
D. The Proposed Supplemental Complaint. The proposed Supplemental Complaint is attached for the Court’s review. Attach. A. As with the allegations in the United States’ original Complaint, the Supplemental Complaint includes allegations concerning newly discovered events involving Defendants’ pattern or practice of harming youth through unnecessary seclusion and the denial of adequate mental health care and rehabilitative treatment. Specifically, the new events detailed in the Supplemental Complaint include the State’s closure of Scioto, the State’s transfer of boys subjected to excessive seclusion at Scioto to other DYS Facilities where the same unconstitutional conditions exist, and the State’s pattern and practice of harming Scioto boys and other youth through excessive seclusion and insufficient mental health treatment at the other DYS Facilities. These new allegations are based upon information revealed by the monitors in this case and the S.H. case. Despite significant efforts to reach a resolution outside of litigation, it has become evident that the State has not remedied these violations. Consequently, the United States seeks to supplement its Complaint to vindicate the rights of Scioto youth who have been, or will be transferred to the State’s other Facilities, and the rights of other youth at these Facilities whom the State has excessively secluded and prevented from receiving adequate mental health care.
6

Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 8 of 18 PAGEID #: 2905
E. The United States’ Dismissal Without Prejudice. On May 16, 2008, the United States moved to intervene in S.H. v. Reed. See S.H. v. Reed, ECF No. 99. On June 5, 2008, the United States entered into a stipulation with the State to remedy the conditions at Scioto and Marion and stipulated to the conditional dismissal of its original Complaint as to the other DYS Facilities. See U.S. v. Ohio, ECF No. 6. The S.H. plaintiffs separately entered into a consent decree with the State to remedy conditions at all DYS Facilities. The order conditionally dismissing the United States’ Complaint in intervention was without prejudice. U.S. v. Ohio, ECF No. 7. Federal Rule of Civil Procedure 41(a)(2) instructs that a court-ordered voluntary dismissal is without prejudice unless the order of dismissal states otherwise. Following the conditional dismissal, the United States participated in S.H. as an interested party. On February 18, 2014, the S.H. plaintiffs moved for specific performance to secure compliance with the S.H. consent decree. S.H. v. Reed, ECF No. 388. The S.H. plaintiffs argue that the State must provide adequate mental health treatment to address youth’s misconduct and respond in a manner that reduces recurrence – not simply resort to seclusion again and again. Id. The S.H. plaintiffs allege that the conditions for youth on the DYS Facilities’ mental health caseload violate both the S.H. consent decree and the Eighth and Fourteenth Amendments to the Constitution. Id.
III. ARGUMENT The United States seeks leave to supplement its Complaint pursuant to Fed. R. Civ. P. 15(d), which provides that “the [C]ourt may, on just terms, permit a party to serve a
7

Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 9 of 18 PAGEID #: 2906
supplemental pleading setting out any transaction, occurrence, or event that happened after the date of the pleading to be supplemented.” Fed. R. Civ. P. 15(d). The Sixth Circuit has instructed that Rule 15(d) should be given a “liberal construction,” so as “to permit amendments freely.” McHenry v. Ford Motor Co., 269 F.2d 18, 24, 25 (6th Cir. 1959).
“The purpose of Rule 15(d) is to promote as complete an adjudication of the dispute between the parties as possible by allowing the addition of claims which arise after the initial pleadings are filed.” William Inglis & Sons Baking Co. v. ITT Cont’l Baking Co., 668 F.2d 1014, 1057 (9th Cir. 1981) (citing Case-Swayne Co. v. Sunkist Growers, Inc., 369 F.2d 449, 462 (9th Cir. 1966); 6 C. Wright & A. Miller, Federal Practice and Procedure § 1504 (1971)). Rule 15(d) allows a party to seek additional relief where, as here, events occurring subsequent to the original complaint justify such relief. See Griffin v. Cnty. Sch. Bd., 377 U.S. 218, 226-27 (1964) (finding grant of leave to file supplemental complaint proper where original complaint challenged racial segregation in public schools and, ten years later, supplemental complaint challenged the same county’s subsequent funding of segregated private schools in a “continued, persistent effort[]” to avoid desegregation). Courts normally grant leave to file a supplemental complaint if there is no substantial showing of prejudice to the defendant. See McHenry, 269 F.2d at 25.
Consistent with this lenient standard, the Court should grant the United States leave to file a supplemental complaint under Fed. R. Civ. P. Rule 15(d) because it would avoid piecemeal litigation and allow a prompt and efficient resolution of the entire controversy between the parties without prejudice to the State.
8

Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 10 of 18 PAGEID #: 2907
A. Supplementation Will Allow a Prompt and Efficient Resolution of the Entire Controversy Between the Parties and Will Avoid Piecemeal Litigation.
Consistent with the purpose of Rule 15(d), the United States’ Supplemental Complaint will promote the prompt, efficient, and full resolution of all of the claims at issue here regarding excessive seclusion of youth with mental health disorders. This Court has stated that “[a]s a matter of judicial economy, and for the sake of providing a complete and adequate remedy, if plaintiff prevails on the merits, the plaintiff should present any and all additional allegations concerning the defendants’ illegal conduct, occurring subsequent to the filing of the . . . [c]omplaint.” Selelyo v. Drury, 508 F. Supp. 122, 128 (S.D. Ohio 1980) (urging plaintiff to file a supplemental complaint). The alternative is for the United States to initiate a separate action, which would involve needless expense, delay, and waste of judicial resources. This would also result in piecemeal litigation in which the parties would litigate the issue of excessive seclusion at Scioto in this case while separately litigating the same issues at the other DYS Facilities in another case. “[P]iecemeal litigation should be discouraged, not only because it is antagonistic to the goals of public policy, but also because it is prejudicial to the rights of individual litigants.” Troxel Mfg. Co. v. Schwinn Bicycle Co., 489 F.2d 968, 970 (6th Cir. 1973). Allowing the United States to file a supplemental complaint would avoid piecemeal litigation between the same parties on substantially similar issues.
Hearing the additional violations now – rather than in new litigation – is particularly appropriate because of the public interest at stake. The United States seeks to supplement its Complaint in order to fully protect the federal rights of youth confined in the DYS Facilities, especially youth who have been, or will be, moved to other DYS Facilities from Scioto. This interest arises out of the United States’ efforts in this case to safeguard the federal rights of youth
9

Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 11 of 18 PAGEID #: 2908
who have experienced unlawful conditions at Scioto. Those youth are now being transferred to
other DYS Facilities where they are experiencing harm resulting from the same type of unlawful
conditions. The State cannot avoid its obligations in this suit to the Scioto youth simply by
transferring them to other DYS Facilities. Cf. Griffin, 377 U.S. at 226-27 (explaining that grant
of leave to file supplemental complaint was proper to address a “continued, persistent effort[]” to
avoid court-mandated desegregation). It is vital that these issues be resolved in the most
expeditious manner available to the parties and the Court. Until then, the State will continue to
harm youth in its custody by subjecting them to excessive seclusion and denying them adequate mental health care.3
B. Supplementation Will Not Prejudice the State.
The Court should freely grant leave to supplement the Complaint where, as here, there is
no substantial showing of prejudice to the State. See McHenry, 269 F.2d at 25. In the similar context of a motion to amend a complaint, 4 the opposing party must make a “significant
showing of prejudice to prevail.” Sec. Ins. Co. v. Tucker & Assocs., 64 F.3d 1001, 1009 (6th Cir.
1995). The State cannot show it will be prejudiced, because it has received ample notice of the
3 For this reason, the United States intends to seek a temporary restraining order when its motion to supplement is granted, to stop the most egregious aspects of the State’s unlawful conduct. 4 Courts have recognized that the same factors and rationale may apply to motions to supplement pleadings under Fed. R. Civ. P. 15(d) as to motions to amend under Fed. R. Civ. P. 15(a). See Marshall v. Columbus, No. 2:05-cv-484, 2008 WL 4334616, at *2 (S.D. Ohio Sept. 17, 2008) (citing Spies v. Voinovich, No. 00-4015, 48 Fed. Appx. 520, 527 (6th Cir. Sept. 20, 2002)). Factors to be considered in deciding a motion to amend include “[u]ndue delay in filing, lack of notice to the opposing party, bad faith or dilatory motive on the part of the moving party, repeated failure to cure deficiencies by previous amendments, undue prejudice to the opposing party by virtue of allowance of the amendment, and futility of the amendment.” Foman v. Davis, 371 U.S. 178, 182 (1962). As discussed herein, the United States has timely filed this motion, the State received sufficient notice of the violations, and the State will not be prejudiced by any delay or impairment of discovery or trial preparation. The other factors – bad faith, repeated failure to cure deficiencies by previous amendments, and futility – are plainly not at issue here.
10

Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 12 of 18 PAGEID #: 2909
unconstitutional conditions at the DYS Facilities, the United States has acted in a timely manner in filing its Supplemental Complaint, and the litigation will not be unduly delayed or otherwise impaired.
1. The State Has Been on Notice of its Constitutional Violations and the United States’ Supplemental Complaint Is Timely.
The State has had ample notice that the conditions in the DYS Facilities are unconstitutional and that the United States would seek to remedy these conditions. The United States’ initial Complaint put the State on notice that unnecessary and excessive seclusion and failure to provide adequate mental health treatment to youth in custody constituted constitutional violations for which the United States could seek relief. U.S.v. Ohio, ECF No. 2. Thus, the State has known since 2007 that the United States could bring claims for these types of conditions. The State itself has been in the best position to know whether these conditions actually existed at the DYS Facilities.
As soon as the United States became aware of the present unconstitutional conditions, it contacted the State and subsequently made several attempts to resolve its concerns outside of litigation. Following calls and email exchanges in which the United States attempted to discuss the State’s use of seclusion at Scioto, the State responded to these concerns by moving to terminate the parties’ Stipulation under the PLRA on December 18, 2013. U.S. v. Ohio, ECF No. 121. At a December 19, 2013 status conference, the Court encouraged the parties to negotiate a settlement of these issues, and the parties agreed to temporarily refrain from litigating. S.H. v. Reed, ECF No. 387. Throughout this entire period, the United States – and the S.H. plaintiffs – sought to negotiate with the State to resolve their concerns regarding seclusion and mental health care. On January 29, 2014, the parties engaged in court-directed mediation, at
11

Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 13 of 18 PAGEID #: 2910
which the United States raised all of its concerns regarding the use of excessive seclusion at Scioto, the closure of Scioto, the transfer of the Scioto boys to other DYS Facilities, and the existence of unconstitutional conditions in the form of excessive seclusion at the other DYS Facilities and denial of mental health care to youth there, particularly youth subjected to seclusion. All attempts to resolve these issues ended without success.
On March 7, 2014, the United States notified the State that, in light of the failed settlement negotiations, it intended to seek leave to file a supplemental complaint regarding these issues. On March 10, 2014, the United States contacted the State in an attempt to ascertain its position and, when the State did not consent, the United States promptly filed this motion. Thus, the State has received sufficient notice of the unconstitutional conditions at DYS Facilities and the United States has timely sought to supplement its Complaint in this matter.
2. The Allegations in the Supplemental Complaint Are Related and Substantially Similar to the United States’ Original Complaint.
“[W]here facts set forth in the original complaint relate to and support the new cause of action in the amended complaint, the amended cause of action ‘is not so different as to cause prejudice to the defendant.’” Belle v. Ross Prods. Div., No. 2:01-CV-677, 2003 WL 133242, at *3 (S.D. Ohio Jan. 2, 2003) (quoting Tefft v. Seward, 689 F.2d 637, 639 (6th Cir. 1982)). Here, the United States seeks to advance new facts that are related and substantially similar to the claims presented against the State in the United States’ original Complaint.5 The allegations in
5 Courts have found supplementation appropriate where the supplemental complaint alleges new facts that relate to the cause of action in the original complaint, and where the supplemental complaint alleges a course of conduct that has continued from the filing of the original complaint. See, e.g., Griffin, 377 U.S. at 226-27 (explaining that the supplemental pleading added new parties and relied on events that occurred since the action began, which were “alleged to have occurred as a part of continued, persistent efforts” to circumvent the Court’s prior holding requiring desegregation of public schools); McHenry, 269 F.2d at 25 (finding that where
12

Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 14 of 18 PAGEID #: 2911
the Supplemental Complaint relate to facts that the United States has recently discovered,
regarding violations of youths’ federal rights at all four DYS Facilities. But these allegations are
factually similar and related to the claims in the original Complaint. Moreover, the
Supplemental Complaint arises out of the United States’ continued interest in protecting the
rights of former Scioto youth.
The original Complaint and the proposed Supplemental Complaint share core questions
of law and fact:
• Whether the State has deprived youth in DYS Facilities of their rights under the Fourteenth Amendment to the Constitution, Compl. at ¶ 20; Supplemental Compl. at ¶ 24;
• Whether the State fails to provide adequate mental health care and rehabilitative treatment to youth with mental health needs at the DYS Facilities, Compl. at ¶ 24; Supplemental Compl. at ¶ 20; and
• Whether the State fails to ensure that youth at the DYS Facilities are adequately protected from harm and from undue risk of harm, especially harm due to unnecessary and excessive seclusion, Compl. at ¶ 22; Supplemental Compl. at ¶ 21.
Accordingly, the State cannot show prejudice, because the Supplemental Complaint is related
and substantially similar to the claims and facts in the original Complaint.
3. Supplementation Will Not Cause Undue Delay or Impair the State’s Trial Preparation.
The State cannot show that any delay will ensue if the United States’ motion is granted,
nor can the State show that its ability to litigate these issues will be impaired. “[P]rejudice is
demonstrated when a party has insufficient time to conduct discovery on a new issue raised in an
untimely manner. Allowance of the amendment would then force that party to go to trial without
new allegations described a continuing trespass, supplementation “should be allowed almost as a matter of course”). Moreover, “a change in legal theory of the action is not the test of propriety of an amendment to a pleading, particularly in view of the prevailing practice of making final disposition of actions on the evidence rather than the pleadings.” McHenry, 269 F.2d at 25 (allowing supplementation where supplemental complaint stated a new cause of action).
13

Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 15 of 18 PAGEID #: 2912
adequate preparation on the new issue.” Estes v. Ky. Utils. Co., 636 F.2d 1131, 1134 (6th Cir. 1980) (quoting Garrison v. Balt. & Ohio R.R. Co., 20 F.R.D. 190 (W.D. Pa. 1957)); see also Hageman v. Signal L.P. Gas, Inc., 486 F.2d 479, 484-85 (6th Cir. 1973) (quoting Green v. Wolf Corp., 50 F.R.D. 220, 223 (S.D.N.Y. 1970)). Here, the dispute over the State’s use of seclusion and provision of mental health care at the DYS Facilities has just begun. There is presently no discovery schedule or trial date set. There has been no litigation taking place because parties have been working to resolve the issues outside of court. With the filing of the Supplemental Complaint, the parties and the Court will have the opportunity to set a schedule for discovery on these issues, providing the State sufficient time to conduct any discovery and trial preparation it deems necessary. Discovery will be followed by a full hearing and decision by the Court. See McHenry, 269 F.2d at 25 (“A full hearing and decision on the merits can do injustice to neither party.”). The State thus cannot show that it will be prejudiced by any delay or inability to conduct discovery or prepare for trial.
IV. CONCLUSION Supplementation of the United States’ Complaint, rather than prejudice the State, will advance judicial economy for the benefit of the parties and the Court. More fundamentally, it will accelerate the adjudication of the United States’ claims that the State is currently violating the most basic federal rights of youth in its custody by excessively secluding them and withholding mental health care from them. These claims warrant this Court’s immediate attention. Accordingly, the Court should grant the United States’ Motion for Leave to File a Supplemental Complaint.
14

Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 16 of 18 PAGEID #: 2913

DATE: March 12, 2014
CARTER STEWART United States Attorney Southern District of Ohio
/s/ Deborah F. Sanders____________ DEBORAH F. SANDERS (0043575) Assistant United States Attorney Southern District of Ohio 303 Marconi Boulevard, Suite 200 Columbus, Ohio 43215 (614) 469-5715 (T) (614) 469-5653 (F) Deborah.Sanders@usdoj.gov
STEVEN M. DETTLEBACH United States Attorney Northern District of Ohio
/s/ Michelle L. Heyer___________ MICHELLE L. HEYER, Reg. No. 0065723 Assistant United States Attorney Northern District of Ohio 801 West Superior Avenue, Suite 400 Cleveland, Ohio 44113 (216) 622-3686/(216) 622-3781 (T) (216) 522-2404 (F) michelle.heyer@usdoj.gov

Respectfully submitted,
JOCELYN SAMUELS Acting Assistant Attorney General Civil Rights Division United States Department of Justice
JONATHAN M. SMITH Chief Special Litigation Section
BENJAMIN O. TAYLOE, JR. Deputy Chief Special Litigation Section
CYNTHIA COE ALEXANDRA L. SHANDELL Trial Attorneys Special Litigation Section
/s/ Silvia J. Dominguez-Reese________ SILVIA J. DOMINGUEZ-REESE Trial Attorney Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 (202) 616-8547(T) (202) 514-4883 (F) Silvia.Dominguez-Reese@usdoj.gov
Attorneys for Plaintiff

15

Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 17 of 18 PAGEID #: 2914
CERTIFICATE OF SERVICE I HEREBY CERTIFY that this date, March 12, 2014, I caused the foregoing to be electronically filed with the Clerk of the Court using the CM/ECF system, which will simultaneously serve notice of such filing to counsel of record and the Court Monitor to their registered electronic mail addresses.
/s/ Silvia J. Dominguez-Reese SILVIA J. DOMINGUEZ-REESE Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 (202) 616-8547 (T) (202) 514-4883 (F) Silvia.Dominguez-Reese@usdoj.gov Attorney for Plaintiff
16

Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 18 of 18 PAGEID #: 2915

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

)

)

)

)

)

)

CIVIL ACTION NO:

)

2:08-cv-475

)

)

)

)

[PROPOSED] ORDER GRANTING UNITED STATES’ MOTION FOR LEAVE TO FILE SUPPLEMENTAL COMPLAINT

Upon consideration of the parties’ submissions and the applicable law, the Court hereby grants the United States’ Motion for Leave to File Supplemental Complaint. It is so ordered.

Signed this ____ day of ____________, 2014

___________________________________ HONORABLE ALGENON MARBLEY UNITED STATES DISTRICT JUDGE

17

 
 Case: 2:08-cv-00475-ALM-MRA Doc #: 6 Filed: 06/05/08 Page: 1 of 5 PAGEID #: 23

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

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

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

JOINT MOTION AND [PROPOSED] ORDER FOR ENTRY OF STIPULATION AND FOR CONDITIONAL DISMISSAL OF COMPLAINT
The Parties jointly move this Court to enter as its Order the attached Stipulation resolving the United States’ claims in this matter as to Scioto Juvenile Correctional Facility (“Scioto”) and Marion Juvenile Correctional Facility (“Marion”) and, separately, to conditionally dismiss the United States’ complaint in this matter (Docket (“Dkt.”) # 2) as to the remaining six state-operated juvenile correctional facilities that are subject to this litigation (collectively, “State-Operated Juvenile Correctional Facilities”).1 In support of this motion, the Parties state as follows: 1. On May 16, 2008, the United States filed a complaint alleging the existence of ongoing
violations of federal law regarding conditions of confinement in all eight State-Operated Juvenile Correctional Facilities.

1

The six remaining facilities are: Circleville Juvenile Correctional Facility; Indian

River Juvenile Correctional Facility; Cuyahoga Hills Juvenile Correctional Facility; Mohican

Juvenile Correctional Facility; Ohio River Valley Juvenile Correctional Facility; and the

Freedom Center.

Case: 2:08-cv-00475-ALM-MRA Doc #: 6 Filed: 06/05/08 Page: 2 of 5 PAGEID #: 24
-22. Also on May 16, 2008, in the related case of S.H. v. Taft, No. 2:04-cv-1206, also pending
before this Court, the United States filed a Motion to Intervene and Request for Continuance of the May 21, 2008 Fairness Hearing (“Intervention Motion”). On May 18, 2008, plaintiffs in S.H. filed Plaintiffs’ Response to Department of Justice Motion to Intervene (“Plaintiffs’ Response”), (S.H. Dkt # 102) stating that plaintiffs did not oppose the United States’ intervention in S.H. but did oppose a continuance of the fairness hearing. Plaintiffs’ Response at 1. On May 20, 2008, plaintiffs in S.H. amended their position and filed a Supplemental Memorandum, in which plaintiffs opposed the United States’ Intervention Motion (S.H. Dkt # 107). Also on May 20, 2008, the defendant in S.H. filed its Memorandum in Opposition to the United States of America’s Motion to Intervene & Motion to Continue Fairness Hearing (S.H. Dkt # 106). 3. Before the filing of the complaint herein, the United States and Defendants had engaged in negotiations to resolve the United States’ claims. After the filing of the complaint in this matter and the Intervention Motion in S.H., the Parties, assisted by class counsel in S.H., engaged in Court-facilitated negotiations that led to the Parties’ agreement resolving the complaint herein and the Intervention Motion in S.H. Pursuant to that agreement, the United States withdrew its Intervention Motion on May 21, 2008, during the fairness hearing in S.H., subject to the following terms, which were confirmed at the fairness hearing by the Defendants: A. The Court approve and enter as its Order the attached Stipulation, resolving the
United States’ claims herein as to Scioto and Marion; and

Case: 2:08-cv-00475-ALM-MRA Doc #: 6 Filed: 06/05/08 Page: 3 of 5 PAGEID #: 25
-3B. The Court conditionally dismiss the United States’ complaint as to the remaining
State-Operated Juvenile Correctional Facilities, subject to the following terms: i. The Defendants shall provide the United States, for review and comment,
all DYS policies associated with conditions of confinement at the StateOperated Juvenile Correctional Facilities; ii. The United States shall have unfettered access to the Monitor and to the DYS Compliance Coordinator in S.H.; iii. The Defendants shall provide the United States with copies of all performance data gathered by the Monitor in S.H.; and iv. The Defendants shall provide the United States with copies of any reports prepared by the Monitor in S.H. ACCORDINGLY, the Parties request that the Court enter the attached Stipulation as its Order and, subject to the foregoing terms, conditionally dismiss the United States’ complaint as to Circleville Juvenile Correctional Facility, Indian River Juvenile Correctional Facility, Cuyahoga Hills Juvenile Correctional Facility, Mohican Juvenile Correctional Facility, Ohio River Valley Juvenile Correctional Facility, and the Freedom Center.

Case: 2:08-cv-00475-ALM-MRA Doc #: 6 Filed: 06/05/08 Page: 4 of 5 PAGEID #: 26

FOR THE UNITED STATES:

-4DATE:

June 5, 2008

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

GRACE CHUNG BECKER Acting Assistant Attorney General Civil Rights Division
SHANETTA Y. CUTLAR Chief Special Litigation Section
S/ Gregory Gonzalez BENJAMIN O. TAYLOE, JR. Special Counsel Special Litigation Section GREGORY GONZALEZ STACEY K. GRIGSBY Trial Attorneys U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 Telephone: (202) 514-6255 Facsimile: (202) 514-0212 Email: Gregory.Gonzalez@usdoj.gov

Case: 2:08-cv-00475-ALM-MRA Doc #: 6 Filed: 06/05/08 Page: 5 of 5 PAGEID #: 27
-5WHEREFORE, for good cause shown, it is SO ORDERED.
ALGENON L. MARBLEY United States District Court Judge

 
 Compliance Report Regarding DYS’ PROGRESS Unit at the Scioto Juvenile Correctional Facility
Civil Actions 2:08‐cv‐00475 and 2:04‐cv‐01206
Submitted by:
 Kelly Dedel, Ph.D., Lead Monitor, U.S. v State of Ohio, and Subject Matter Expert
 One in 37 Research, Inc.
 16 Rock Street Cody, WY 82414
 (503) 799‐0915 kelly.dedel@gmail.com
Daphne Glindmeyer, M.D., Subject Matter Expert 229 Bellemeade Boulevard Suite 420 Gretna, Louisiana 70056 (504)666‐1600 dglindmeyer@gmail.com
Reviewed by: Will Harrell, J.D., LL.M, Lead Monitor, S.H. v Reed 1221 Kerlerec New Orleans, LA 70117 (512)695‐7519 shmonitor.harrell@gmail.com
Terry Schuster, J.D., Assistant to the Monitor 1037 Neil Ave., Apt. C Columbus, Oh 43201 (512)468‐4486 shmonitor.schuster@gmail.com
September 22, 2013

Introduction
In October and November 2012, pursuant to the United States v. Ohio and S.H. v. Reed Stipulations, the U.S. Department of Justice (DOJ) and the S.H. plaintiff class each initiated a process for dispute resolution to address concerns regarding the purpose, structure, and operation of the PROGRESS Unit at the Scioto Juvenile Correctional Facility (the PU). The Monitors and Plaintiffs in both cases have expressed on‐going concerns about DYS’ operation of special management units since at least 2007. The Ohio Department of Youth Services (DYS) and DOJ negotiated and agreed upon a proposed Consent Order, filed with the Court on December 19, 2012. The Court did not sign the Order until January 18, 2013 when it was also incorporated into a broader settlement between DYS and the S.H. plaintiff class. The Consent Order sets standards related to PU policies, admissions screening, programming, out‐of‐room time, staffing, treatment planning, length of stay, and promotion and demotion between phases. The S.H. settlement supplements the Consent Order with additional standards related to PU behavioral health staffing and quality assurance.
Drs. Kelly Dedel and Daphne Glindmeyer were tasked with monitoring DYS’ compliance with the Consent Order. In order to facilitate compliance in a more efficient manner than the standard 6‐ month monitoring period, the Monitors decided to issue status reports on a more frequent basis. The 1st Status Report, covering the period November 2012 through February 2013, was issued to the Parties on March 27, 2013 and filed with the Court simultaneously with the DOJ Monitor’s Fourth Monitor’s Report on June 18, 2013.
In response to the 1st Status Report, the Parties made some agreements designed to facilitate DYS’ progress toward compliance, while also ensuring that the integrity of the monitoring process. Subsequent status reports would assign compliance ratings to each of the 17 subsections of the seven core areas of the Consent Order so that progress with component parts could be better recognized and deficits in other areas could be highlighted for additional attention. In addition, the requirements for satisfying the Consent Order were clarified. In order to reach substantial compliance with the Consent Order, DYS must first come into compliance with all of the core areas and subsections and then must maintain that level of performance for an additional six months. Once this threshold is obtained, monitoring of the PU’s operation will once again be subsumed under the larger DOJ Agreement.
The Consent Order requires DYS to develop a Quality Assurance mechanism, designed to rigorously examine each of the PU’s component parts using multiple sources of data so that program areas not meeting the requirements of the Order can quickly be identified and remediated. In March 2013, DYS took a major step toward meeting this requirement by agreeing to produce the 2nd Status Report internally. For the March through June 2013 reporting period, using the same data submitted to the Monitors for review as required by the Consent Order, DYS constructed its first quality assurance report regarding the operation of the PU. [DYS’ Status Report is attached to this Compliance Report.]
A draft was submitted to the Monitors and Plaintiffs for review and feedback. The Monitors reviewed the relevant data on their own to determine whether DYS’ analysis and interpretation met generally accepted practices for quality assurance. Extensive feedback was provided to DYS
2.


to improve the clarity, rigor and coherence of the Status Report. In nearly all cases, DYS accepted the Monitors’ and Plaintiffs suggestions.
The assignment of compliance ratings remains the Monitor’s responsibility, and thus is the purpose of this Compliance Report. For each of the 17 subsections, the Monitors indicate whether they agree or disagree with DYS’ assessment of its level of compliance. In areas of disagreement, the Monitors explain the rationale for their compliance ratings.
Overall, DYS has made significant progress complying with the requirements of the Consent Order. Of the 17 subsections, 8 are in substantial compliance (47%) and 9 (53%) are in partial compliance. Many of the changes required to bring other parts into substantial compliance should be relatively simple to address.
Recent changes to DYS’ use of the PU have brought into question whether the Consent Order still applies. Although DYS is currently using only the least restrictive of the PROGRESS units, the structure for the more restrictive units remains active in DYS policy and procedure. Absent a written commitment to decommission the entire Unit, or to remove the more restrictive units with the attendant permission to use programmatic restraints in a self‐contained program environment, the Monitor will continue to conduct periodic reviews of DYS’ compliance with the Consent Order, as it pertains to whichever of the PROGRESS Units are currently in use.
Over the next couple of months, for each component in partial compliance, DYS should craft a written Quality Improvement Plan (QIP) that addresses the underlying causes of the subpar performance. For example, youth in seclusion are not receiving the required one‐hour of daily recreation. This could occur for many reasons—insufficient numbers of recreation staff; insufficient space; lack of interest or incentives among youth; etc. DYS’ challenge is to accurately identify what is driving the problem and to craft strategies to address these contributing factors. The Monitor expects to receive QIPs for the following subparts rated in partial compliance:
 Daily Activities  Graduate Programming  Staff Numbers  Treatment Planning  IDT Composition  IDT Substance  Length of Stay  CORB Substance Technical assistance with crafting and implementing the QIPs is available from the Monitors if desired. Once the QIPs have been implemented, the 3rd Status Report can be drafted to determine whether the problems identified in the current report have been remediated.
What follows is a list of the 17 subsections and the compliance rating assigned to each one. In any area where the Monitors do not agree with DYS’ self‐assessment, the rationale for the Monitor’s compliance rating is provided. Even where agreement exists, key issues related to each partial compliance rating are briefly summarized. The reader is referred to the attached 2nd Status Report for details surrounding the program’s operation in areas where DYS and the Monitor agree on the level of compliance.
3.


II.9 Admissions Screening
The Monitor agrees with DYS’ assessment that it is in substantial compliance with this provision.
II.10(1) Daily Schedule: Out of Room Time
The Monitor agrees with DYS’ assessment that it is in substantial compliance with this provision.
II.10(2) Daily Schedule: Daily Activities
The Monitor agrees with DYS’ assessment that it is in partial compliance with this provision. In order to reach substantial compliance, DYS needs to ensure that structured activities are led by an adult; that leisure time is provided each day; and that youth in seclusion are afforded the opportunity for one‐hour of recreation per day. [Note: this last component, regarding recreation for youth in seclusion, was not included among DYS’ list of issues in need of remediation.]
In addition, the Monitor noted a calculation error regarding the “structured activities” component of the analysis. The report should read that “in the first group of cases sampled, 54% of activities were not led by an adult” and “in the second group of cases, 43% of the activities were not led by an adult.”
II.10(3) Daily Schedule: Graduate Programming
The Monitor agrees with DYS’s assessment that it is in partial compliance with this provision. While there was only one graduate on the PROGRESS Unit during the period of review, his schedule was followed only 65% of the time.
II.11(1) Staffing: Staff Numbers and Training
The Monitor does not agree with DYS’ assessment that it is in substantial compliance with this provision; rather, the Monitor believes the DYS is in partial compliance with this provision, absent additional data analysis. DYS asserted that time Unit Managers spend in training should be included in the calculation of Unit Manager coverage because, since they are on campus, “they can respond if needed.” The Monitor disagrees. Presumably focused on the content of the training session, Unit Managers cannot provide active supervision of the Youth Specialist (YS) staff assigned to the Unit. While they may be able to respond to a call for assistance, the negotiations surrounding the Consent Order emphasized the need for hands‐on mentoring and oversight of YS staff, which clearly cannot occur if the Unit Manager is not physically present. It is possible that DYS’ Unit Manager coverage exceeds the 80% minimum threshold for substantial compliance even once the training hours are subtracted out, but DYS did not provide these data and so compliance cannot be substantiated at this time.
4.


The Monitor does agree that the level of YS staffing meets the requirements of the provision, though recommends that in future Status Reports, DYS should combine the ADP data with the staffing data to calculate a specific YS—youth ratio for each unit, each shift.
II.11(2) Staffing: Impact on Safety
The Monitor agrees that DYS is in substantial compliance with this provision. While the level of youth‐on‐staff violence remains a concern, it does not appear to be related to insufficient numbers of staff, which was the key caution behind this section of the Order.
II.12(1) Treatment Planning: Clinical Staffing
The Monitor agrees with DYS’ assessment that it is in substantial compliance with this provision.
II.12(2) Treatment Planning: Treatment Planning
The Monitor agrees with DYS’ assessment that it is in partial compliance with this provision. In the data analysis, DYS reviewed youth treatment planning goals and objectives. While goals and objectives were appropriately measurable and realistic, there were marked deficits in strengths based and skills focused objectives. In addition, a review of treatment documentation indicated that treatment (and its documentation) needed to utilize interventions that were more focused on the goals and objectives outlined in the treatment plan. In order to reach substantial compliance, these areas must be addressed.
Throughout the 2nd Status Report, skills acquisition is discussed. The Monitors acknowledge that deficits in skill acquisition are likely the precipitating factor in youth recycling through the PU phases. Skills acquisition must be addressed via a process that includes:
 Identifying skills that a particular youth requires;  Outlining necessary skill development via treatment planning (i.e., goals, objectives,
interventions);  Implementing interventions that addresses the development of these skills in
treatment;  Documenting the interventions and the youth’s progress with regard to skill
development; and  Addressing a lack of progress toward skill development via the treatment planning
process in order to identify alternate interventions that may be beneficial.
II.12(3) Treatment Planning: Progress Reporting and Promotion
The Monitor agrees with DYS’ assessment that it is in substantial compliance with this provision.
5.


II.12(4) Treatment Planning: Interdisciplinary Treatment Team
The Monitor agrees with DYS’ assessment that it is in partial compliance with this provision. In their review of the data, DYS recognized issues with staff attendance at Interdisciplinary Treatment Team (IDT) meetings. In order to reach substantial compliance, the facility plans to develop a Program Improvement Plan to address issues of attendance at IDT meetings. Furthermore, representatives from all disciplines must consistently attend and provide input on all Progress Units.
II.12(5) Treatment Planning: IDT Substance
The Monitor agrees with DYS’ assessment that it is in partial compliance with this provision. In order to achieve substantial compliance, DYS must ensure that the IDT appropriately and regularly reviews the youth’s behavioral expectations and treatment goals, focusing on skill acquisition. Both the IDT and the youth must be aware of the youth’s progress (or lack thereof) toward meeting the treatment goals. When youth are not meeting treatment goals or are not acquiring necessary skills, the IDT must recommend alternate strategies for consideration.
II.12(6) Treatment Planning: Length of Stay
The Monitor agrees with DYS’ assessment that it is in partial compliance with this provision. Using a 30‐day maximum threshold for each of the three phases, 22% of the stays across all of the phases lasted longer than 30 days. Furthermore, 10 of the 16 youth reviewed (63%) had a total length of stay in excess of 90 days. Finally, “recycling” (being demoted to a lower phase) continues to be prevalent and brings into question whether youth are acquiring the skills they need to refrain from violent behavior.
II.12(7) Treatment Planning: Central Office Review Board (CORB)
The Monitor agrees with DYS’ assessment that it is in substantial compliance with this provision.
Several months ago, the Monitors’ gave their approval for DYS to cease completing CORB reviews for youth on the Transition Unit so that they could prioritize the reviews of Phase 1 and Phase 2 youth and complete them in a timely manner. However, the Monitors gave this permission without first consulting the Plaintiffs, who feel strongly that youth on the Transition Unit should be reviewed if they have not been promoted within 30 days. Moving forward, in order to maintain substantial compliance, the CORB will need to review Transition youth, as described in the Consent Order.
6.


II.12(8) Treatment Planning: CORB Substance
The Monitor agrees with DYS’ assessment that it is in partial compliance with this provision. In order to achieve substantial compliance, DYS must ensure that the IDT reviews with the youth the results of the CORB review and that CORB recommendations are implemented at the facility level.
II.13 Phase Demotions
The Monitor agrees with DYS’ assessment that it is in substantial compliance with this provision.
II.14 Policies and Procedures
The Monitor agrees with DYS’ assessment that it is in substantial compliance with this provision.
In order to maintain substantial compliance, DYS must update the SOP and Youth Handbooks to keep pace with the recent evolution of the program (i.e., a narrowing of the program that utilizes only the least restrictive of the PROGRESS Units, the Transition Unit). If, as DYS asserts, youth will no longer be admitted or demoted to the more restrictive units (i.e., Phase 1 on Cedar or Phase 2 on Sycamore), the written documentation for the program must be updated to reflect this significant change. As of the writing of this report, the policy and handbook revisions are in progress.
III.C.3 Quality Assurance
As noted in the Introduction, DYS took a major step toward complying with the consent order when it agreed to produce the 2nd Status Report internally. For this reason, DYS is in partial compliance with this provision. While the Monitor had feedback and suggestions about the content of the report, most of the comments were stylistic and intended to better communicate the information rather than to correct a misleading analysis. Moving forward, DYS should strive to improve the organization of the report (e.g., ensuring that all component parts are included and eventually synthesized into a single document that will provide the reader with a concise assessment of the PU’s operation).
In order to reach substantial compliance with this subsection, DYS needs to actively engage in the process of remediating the identified deficits, via the Quality Improvement Planning (QIP) process. As noted in the Introduction, within the next couple months, the Monitor expects to receive written QIPs that address the underlying causes of the performance problems. QIPs need to be developed for the following subparts rated in partial compliance:
7.


 Daily Activities  Graduate Programming  Staff Numbers  Treatment Planning  IDT Composition  IDT Substance  Length of Stay  CORB Substance Technical assistance with crafting and implementing the QIPs is available from the Monitors if desired. Once the QIPs have been implemented, the 3rd Status Report can be drafted to determine whether the problems identified in the current report have been remediated.
8.


 
 Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 1 of 26 PAGEID #: 2939

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

UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

)

v.

)

)

THE STATE OF OHIO, et al.,

)

)

Defendants.

)

____________________________________)

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

UNITED STATES’ MOTION FOR A TEMPORARY RESTRAINING ORDER
Plaintiff, the United States, moves the Court for a temporary restraining order against
Defendants, the State of Ohio, et al. (the “State”), and requests a hearing. The grounds for this
motion are set forth in the attached Memorandum of Points and Authorities.
The United States notified the State on March 12, 2014, that it planned to file this motion.
Respectfully Submitted,
_s/Silvia J. Dominguez-Reese_ SILVIA J. DOMINGUEZ-REESE Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 (202) 616-8547(T) (202) 514-4883 (F) Silvia.Dominguez-Reese@usdoj.gov
Attorney for Plaintiff

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 2 of 26 PAGEID #: 2940
MEMORANDUM OF POINTS AND AUTHORITIES IN SUPPORT OF THE UNITED STATES’ MOTION FOR A TEMPORARY RESTRAINING ORDER
The State has systematically violated the substantive due process rights of boys with mental health disorders at four of its juvenile correctional facilities (the “Facilities”)1, and this Court must act immediately to protect these boys from mounting and irreparable harm. The State punishes the boys with seclusion (i.e., solitary confinement) for days on end, often also depriving them of education, exercise, programming and crucial mental health care. When the State returns them to the general population, the State often does not adjust their mental health care treatment to address the harm from seclusion or the misconduct that led to seclusion in the first place. Even when the boys are not secluded, the State deprives them of appropriate mental health care, instead providing cut-and-paste treatment plans that bear little relationship to the mental health needs of a particular boy.
Seclusion has become the State’s modus operandi for handling boys with mental illness. In the second half of 2013, the State imposed almost 60,000 hours of seclusion on boys at the Facilities. Ten boys at Circleville and Indian River spent over 1,000 hours in seclusion over a six month period, and another 17 boys spent over 500 hours in seclusion. At least ten boys at Scioto spent over 10 percent of their time in custody in seclusion from April to September 2013.
Those statistics are disturbing, but the youth at the Facilities are not statistics. They are troubled boys coping with mental health disorders who are suffering real, irreparable harm from tremendous time in seclusion. A few examples from just six months of the State’s records:
1 The Facilities are Cuyahoga Juvenile Correctional Facility, Circleville Juvenile Correctional Facility, Indian River Juvenile Correctional Facility and Scioto Juvenile Correctional Facility.
1

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 3 of 26 PAGEID #: 2941
• K.R. (218520) at Circleville is taking significant psychiatric medications. He bangs his head frequently, and he had fresh head injuries during a recent visit.2 Yet K.R. spent 1,964 hours in seclusion over six months. His longest episode of seclusion was about 19 days. Eleven times, he was secluded for five or more days at a time. Three times, he received a five-day penalty of extra seclusion during a time when he was already serving seven days in seclusion. While secluded, he was on “Suicide Watch,” had “Suicide [Ideation],” and displayed “Self Injurious Behavior.”
• A.E. (217241) at Circleville spent 1,504 hours in seclusion over six months. At one point, he was given 21 consecutive days in seclusion, with five of those days tacked on while he was already in seclusion.
• J.H. (218144) at Circleville spent 1,146 hours in seclusion over six months. In September 2013, he received 120 hours of seclusion, and then an additional 179 hours that same day, for over 12 days of seclusion. On November 17, 2013, he received 143 hours of seclusion; the next day the State tacked on 108 more.
• N.H. (217322) at Indian River spent 90 hours in seclusion, followed by an additional 120 hours. A week later, he received 92.5 hours. The day after that, the State imposed another 144 hours. One observation during his seclusion was “Self Injurious Behavior.”
• M.L. (218660) at Cuyahoga spent 164.58 hours in seclusion over three months, culminating in “Suicidal Ideation.”
• N.O. (218428) at Indian River spent 752 hours in seclusion. During 158 hours of seclusion, he demonstrated “Self Injurious Behavior.” Another 81 hours yielded a notation of “Suicide Watch”; two days later, he received 91.5 hours of seclusion and another notation of “Suicide Watch.”
• J.S. (218396) at Circleville spent 1,585 hours in seclusion. “Self Injurious Behavior” marred his last 48 hours of seclusion.3
The State has had every opportunity to address the rampant use of seclusion on boys with
mental health disorders, but it has made little or no improvement and may actually be losing
2 See Email from Alphonse Gerhardstein to Thomas Anger (Jan. 11, 2014) (Attach. A). 3 Monitor Dr. Dedel found additional instances of lengthy seclusion at Scioto from April through September 2013. C.C. spent 16 consecutive days in seclusion with only one 24-hour period in the general population. T.B. spent eight consecutive days in seclusion. Fifth Compliance Report at 29-30, U.S. v. Ohio, ECF No. 127.
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 4 of 26 PAGEID #: 2942
ground. Indeed, the State does not view seclusion at the Facilities as a problem at all. At one
point, counsel for the State brushed aside a boy’s seclusion of 142 hours in a single month as “not alarming.”4 When the State was advised that K.R. (1,964 seclusion hours in six months)
was in immediate and extreme distress, the State’s lawyers responded with a demand for the
resignation of the subject matter expert who tried to look into K.R.’s situation at the monitor’s request.5 One thing is certain: The State will continue the excessive seclusion of boys with
mental health disorders unless this Court steps in.
The United States requests an immediate temporary restraining order to stop the seclusion
of boys with mental health disorders and to avoid the irreparable harm these boys are suffering
and will continue to suffer absent Court protection. Specifically, the United States seeks a
temporary restraining order as follows:
I. This Court, as an interim response to the State’s infliction of unlawful and irreparable harm on boys through its seclusion and mental health practices, should immediately issue a temporary restraining order that the State:
A. Stop secluding any boy with an identified mental health disorder for more than 24 hours without providing him, outside of his confinement area and during normal facility programming times, at least four hours of programming, exercise, education, or combinations thereof;
B. Stop imposing more than three consecutive days of seclusion in any form (e.g., prehearing seclusion and intervention seclusion) on any boy with an identified mental health disorder;
C. Stop imposing more than three days of seclusion in any form within a 30-day period on any boy with an identified mental health disorder without first:
1. Conducting a comprehensive mental health treatment review of the boy that
4 See Email from Dustin Calhoun to Silvia Dominguez and Benjamin Tayloe (Dec. 4, 2013) (Attach. B). 5 See Email from Will Harrell to Alphonse Gerhardstein (Jan. 15, 2014) (Attach. C).
3

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 5 of 26 PAGEID #: 2943
includes the treatment team meeting and reviewing the boy’s mental health treatment plan to consider and address potential problems with the plan and its implementation;
2. Obtaining the prior written approval of the Deputy Director of the Department of Youth Services (“DYS”) responsible for Facility programming; and
3. Providing written notice to the United States and monitor within 24 hours of a youth exceeding three days of seclusion within a single month, describing the amount of seclusion, reason for seclusion, treatment provided in response to seclusion, whether the youth’s behavior intervention plan was modified or created, and alternatives to seclusion that were rejected.
D. Provide monthly to the monitor an AMS printout of monthly seclusion hours for boys at the Facilities; and
E. Refrain from substituting restraints for seclusion.
II. The Court should hold an expedited hearing to determine the United States’ entitlement to a preliminary injunction.
III. The Court should set an expedited schedule for discovery and further briefing in preparation for a hearing on a permanent injunction. At the permanent injunction hearing, the Court should determine the circumstances and limitations governing the use of seclusion (or restraints as a substitute for seclusion) on boys with mental health disorders at the Facilities, particularly given that the proposed temporary restraining order’s terms do not extend far enough to address the extent of the State’s violations;
IV. Such other and further relief as the Court deems necessary to prevent the boys with mental health disorders at the Facilities from suffering additional irreparable harm.6
BACKGROUND
A. U.S. v. Ohio.
Following an investigation of the Scioto Juvenile Correctional Facility (“Scioto”) in
Delaware, Ohio, the United States found “significant constitutional deficiencies regarding use of
6 The United States seeks a temporary restraining order permitting the State to use up to three days of seclusion as an interim measure only, until the State implements reasonable programmatic changes enabling it to constrain further its seclusion use and comply with constitutional standards. The United States will delineate those programmatic changes in a subsequent request for relief, after conducting discovery with its experts.
4

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 6 of 26 PAGEID #: 2944
physical force, grievance investigation and processing, and use of seclusion.” See Letter from Wan J. Kim, Assistant Att’y Gen., Ohio Att’y Gen., to Ted Strickland, Governor, State of Ohio, “Investigation of the Scioto Juvenile Correctional Facility, Delaware, Ohio” (May 9, 2007) (on file with author). Thereafter, on May 16, 2008, the United States filed suit against the State (including the Governor, DYS, and various officials associated with DYS), alleging among other things that the State engaged in a pattern or practice of failing adequately to protect boys from undue risk of harm by failing to “protect[] from the unwarranted use of seclusion” and failing to provide adequate mental health care and rehabilitative treatment to boys through “the provision of adequate screening and assessments . . . adequate treatment planning . . . and adequate psychological services.” Compl., ¶¶ 22, 24, U.S. v. Ohio, ECF No. 2.
On June 28, 2008, the United States and the State entered into a Consent Order to resolve the identified violations of federal rights. U.S. v. Ohio, ECF No. 8. Three years later, the United States and the State negotiated an Amended Stipulation for Injunctive Relief, reflecting that progress had occurred in certain areas but violations related to seclusion and mental health care continued. U.S. v. Ohio, ECF No. 85. In January 2012, this Court issued as its order a proposed stipulation between the United States and the State intended to resolve the State’s use of excessive seclusion on Scioto youth housed on special management units. U.S. v. Ohio, ECF No. 109 (the “Progress Unit Consent Order”).
Less than six months after the Progress Unit Consent Order was filed, it became apparent the State was forcing Progress Unit boys to wear restraints for an average of 12-14 hours per day. Essentially, the boys in the Progress Unit who had been subjected to prolonged periods of seclusion were now being forced to wear restraints virtually every waking moment. Only after an exchange of letters and the threat of litigation did the State, on August 22, 2013, announce
5

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 7 of 26 PAGEID #: 2945

that it would discontinue use of programmatic restraints. See Letter from Thomas Anger, Ohio Asst. Att’y Gen., to Benjamin Tayloe (Aug. 22, 2013) (Attach. D).

1. The Monitor’s Discovery of Excessive Seclusion at Scioto. On November 8, 2013, Dr. Kelly Dedel, the monitor, investigated the accumulation of seclusion hours among some Scioto boys. She found the State had secluded ten boys for over 10 percent of their time in custody and that one boy spent almost 40 percent of his time in seclusion:

Youth
O.J. B.D. A.F. T.R. D.H. J.A. T.H. M.G. R.B. K.A. D.S.

Days in Custody during Monitoring Period (max 184)
74 184 184 184 184 141 109 137 184 184 184

Days in Seclusion during Monitoring Period 28.54 49.56 43.83 35.36 33.59 24.56 16.27 17.55 23.24 20.57 17.62

% days spent in Seclusion
38.57% 26.93% 23.82% 19.21% 18.25% 17.42% 14.92% 12.81% 12.63% 11.18% 9.6%

See Memorandum from Kelly Dedel, Lead Monitor, U.S. v. Ohio, to Tom Anger, Ohio Asst. Att’y Gen., “Results of Seclusion Analysis” (Nov. 8, 2013) (Attach. E) (“Seclusion Report”).

Faced with this evidence of seclusion, Dr. Dedel expressed her “serious concerns.” She

invited the State to consider “how to mitigate these risks for the youth who have chronic,

aggressive misconduct.” She urged the State to participate in a “problem-solving discussion.”

She proposed that the State consult the mental health subject matter expert for recommendations.

Id. at 1-2.

6

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 8 of 26 PAGEID #: 2946
All of this fell upon deaf ears. The State has not identified any policy change or other course of action to mitigate the harm of seclusion for the boys named in the Seclusion Report or any other boys at the Facilities. On the contrary, counsel for the State cited the November seclusion hours for B.D. (142.3 hours) and A.F. (80.93 hours) and stated, “As you can see, the seclusion hours are not alarming for these youth.” Attach. B.
2. The Closure of Scioto and the PLRA Motion. On November 21, 2013, the State announced its intent to close Scioto on May 3, 2014. Citing the declining population there, the Director of Ohio DYS wrote, “As of [November 20, 2013], there were 38 youth at [Scioto] (20 males and 18 females who reside separately). Male youth will be gradually reassigned to the remaining facilities according to their security, educational and programming needs.” See Letter from Harvey Reed, DYS Director, to Stakeholders (Nov. 21, 2013) (Attach. F) (emphasis added). On December 18, 2013, the State filed a motion under the Prison Litigation Reform Act, 18 U.S.C. § 3626(b) (“PLRA”), to terminate U.S. v. Ohio. The next day, December 19, 2013, the United States filed a preliminary opposition. Also that day, the Court held a joint status conference with counsel in this case and S.H. v. Reed, No. 2:04-cv-01206 (filed Dec. 20, 2004) and set a joint settlement conference for January 29, 2014. The State withdrew its PLRA motion without prejudice to renew its motion should the parties fail to settle, and the United States withdrew its PLRA opposition without prejudice.7
7 The State’s PLRA motion and United States’ response triggered the consent order’s dispute resolution process, which culminated in a court-ordered mediation on January 29, 2014. The dispute resolution period ended on February 27, 2014, meaning the parties are free to submit this dispute to the Court.
7

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 9 of 26 PAGEID #: 2947

True to its word, the State gradually assigned the Scioto boys to other Facilities. The United States has learned that there are at least six boys who were once at Scioto and are now elsewhere in DYS custody. Discovery has been limited, which prevents the United States from learning the extent to which former Scioto boys are still experiencing high levels of seclusion. The United States expects that updated discovery and records for boys not on the mental health caseload will reveal that boys at the Facilities are still experiencing excessive seclusion.
B. Excessive Seclusion Is Harming Boys with Mental Health Disorders. On January 14, 2014, the State provided data revealing the depth of the seclusion problem. In the second half of 2013, the State imposed almost 60,000 seclusion hours on boys on the mental health caseload at the Facilities:

Prehearing And Intervention Seclusion Hours Cuyahoga
Scioto
Indian River
Circleville
Total

July 2013
434.45 102.05 277.92 336.00 2,025.13 1,657.33 930.38 2,256.17 8,019.43

Aug 2013
624.37 47.88 528.14 984.17 1,938.72 3,072.00 1,319.01 2,448.00 10,962.29

Sept 2013

Oct 2013

1,027.85 16.10 108.75 72.00 2,091.99 2,105.60 1,444.17 1,752.00 8,618.46

1,433.47 143.78 403.52 457.75 1,908.29 997.20 2,775.69 4,919.33 13,039.03

Nov 2013
864.97
232.44 240.00 1,475.24 384.00 3,048.87 6,420.10 12,665.62

Dec 2013

Totals

629.34 5,324.26

286.83 72.00 1,763.57 816.00 850.71 2,141.73 6,560.18

3,999.52 20,235.07 30,306.16 59,865.01

That may be only the tip of the iceberg. The State did not provide records covering the

first six months of 2013, any part of 2014, or any boys who are not on the mental health caseload

– about half of the population at the Facilities. Even this limited data the State provided shows

that seclusion remains unchecked at the Facilities.

8

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 10 of 26 PAGEID #: 2948
As poor as the State’s track record has been, its overreliance on seclusion is getting worse, not better. In June 2013, Dr. Dedel found that Scioto boys who committed an act of violence received seclusion as a sanction 72 percent of the time. See Fourth Compliance Report at 25, U.S. v. Ohio, ECF No. 114. By September 2013, that number had grown to approximately 90 percent, which is a “significant increase.” See U.S. v. Ohio, ECF No. 127 at 27.
None of this should come as a surprise to the State. Dr. Andrea Weisman, a subject matter expert in the S.H. case, found that the DYS head psychologist, Dr. Hamming, noted that “half of the kids are in seclusion (on Buckeye) a good majority of the time.” See Report by Andrea Weisman, S.H. “Compliance with Consent Order Provisions Regarding Mental Health,” at 6 (Dec. 16, 2013) (“Weisman Report I”) (Attach. G). Dr. Weisman further explained that Dr. Hamming’s note “raises concern that the youth who have transitioned out of the Progress Unit are still being managed with long stays in seclusion, by way of the IRAV and sanction seclusion processes rather than by way of a maximum security unit.” Id. at 6.
Three facts are beyond dispute: The State secludes boys with mental health disorders at the Facilities a tremendous amount, the State knows it, and the State won’t address it. If these boys are to be protected from the irreparable harm of excessive and repeated seclusion, it is up to this Court to protect them.
C. Boys with Mental Health Disorders Suffer Tremendous Harm from Seclusion. The harm from seclusion falls disproportionately on boys with mental illness – the very boys least able to cope with repeated and extended isolation. Dr. Weisman found that the State places mentally ill boys into seclusion more often than general population boys, and “mentally ill youth are disproportionately engaging in behaviors likely to result in their being secluded.” See
9

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 11 of 26 PAGEID #: 2949
“Compliance with Consent Order Provisions Regarding Mental Health,” S.H. v. Reed, ECF No. 388-2.
The State’s excessive reliance on seclusion is rooted in the deficiencies in its mental health care treatment. Dr. Weisman explained, “It is clear to me that the deficiencies in behavioral health care led to the high rates of seclusion for youth at Scioto, and that the same deficiencies exist at the other three DYS facilities.” See Weisman Report I at 6 (emphasis added). Dr. Dedel also warned that seclusion suppresses a boy’s negative behavior during the time that he is behind a locked door but denies him access to the very treatment programs needed to change his behavior. See U.S. v. Ohio, ECF No. 127 at 29.
Indeed, the State does not modify boys’ treatment plans or adjust their mental health treatment following misconduct, so the cycle of violence leading to seclusion continues. When a boy with a mental health disorder is placed in seclusion, “it is incumbent on the practitioners to modify the [Integrated Treatment Plan] to extinguish the behavior.” See Weisman Report I at 5. If there is no corresponding modification of the treatment plan, Dr. Weisman predicted that the “seclusion will just exacerbate the behavioral problems DYS is seeking to extinguish.” See Weisman Report I at 5 (emphasis added).
D. The State Can Operate the Facilities Safely and Securely Without the Use of Excessive Seclusion or Restraints.
The State can operate a safe, secure facility without resorting to seclusion. Dr. Dedel has conducted reviews of approximately 60 juvenile correctional facilities. She has repeatedly informed the parties that, in her experience, juvenile facilities routinely maintain control over youth while using minimal levels of seclusion, levels significantly below those that the State uses. Separately, Paul DeMuro, the former Pennsylvania Commissioner of Children and Youth
10

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 12 of 26 PAGEID #: 2950
and a nationally recognized expert on the operations of juvenile justice facilities, opines that it is possible to maintain security and deliver effective programming while using minimal levels of seclusion. In fact, Mr. DeMuro confirms that high rates of seclusion, such as those used by the State, impede the delivery of effective programming and worsen the very behaviors that seclusion targets. See Decl. of Paul DeMuro at ¶¶ 4-6 (Attach. H).
DYS’ disciplinary policies contribute to the seclusion problem at the Facilities. Dr. Dedel noted, “DYS’ continued use of disciplinary seclusion remains outside the norm. The Monitor’s experience in the field suggests that most jurisdictions limit the length of stay in seclusion to 72 hours, compared to the 120 hours permitted by DYS policy.” U.S. v. Ohio, ECF No. 127 at 31. In the most recent monitoring period, 27 percent of instances of intervention seclusion at Scioto were for the maximum 120 hours. Id. at 29. That is five straight days of isolation, depriving the boys of mental health care treatment the entire time.
Seclusion at the Facilities must be addressed for the best possible reason: It is hurting these boys. “Solitary confinement can cause serious psychological, physical, and developmental harm, resulting in persistent mental health problems or, worse, suicide. . . . These risks are magnified for children with disabilities or histories of trauma and abuse.” ACLU, “Alone & Afraid: Children Held in Solitary Confinement and Isolation in Juvenile Detention and Correctional Facilities” (Nov. 2013). “[D]ue to their ‘developmental vulnerability,’ adolescents are particularly at risk of adverse reactions from prolonged isolation and solitary confinement.” American Academy of Child & Adolescent Psychiatry, “Policy Statements: Solitary Confinement of Juvenile Offenders” (April 2012).8
8 See also Lindsay Hayes, Office of Juvenile Justice and Delinquency Prevention, Juvenile 11

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 13 of 26 PAGEID #: 2951
Dr. Dedel agrees that seclusion of youth in correctional facilities should be a thing of the past. She noted, “Recent publications by the ACLU/Human Rights Watch, the United Nations’ General Assembly, and other scholars suggest an evolving standard around the practice. Indeed, the upcoming revision of the Juvenile Detention Alternative Initiatives’ standards will prohibit the practice of disciplinary seclusion.” See U.S. v. Ohio, ECF No. 127 at 31.
ARGUMENT Fed. R. Civ. P. 65 allows issuance of a temporary restraining order if there is notice to the adverse party and an opportunity for a hearing. Certified Restoration Dry Cleaning Network v. Tenke Corp., 511 F.3d 535, 552 (6th Cir. 2007) (reversing denial of preliminary injunction for failure to hold a hearing). Issuance of injunctive relief is a matter for the trial court’s discretion. Galper v. U.S. Shoe Corp., 815 F. Supp. 1037, 1043 (E.D. Mich. 1993) (granting preliminary injunction prohibiting plaintiff’s eviction from her place of business).
A. This Court Should Grant a Temporary Restraining Order to Prevent the Excessive Seclusion of Boys with Mental Health Disorders. Granting a temporary restraining order involves an evaluation of four factors: (1) Whether the movant has a strong likelihood of success on the merits; (2) Whether the movant would suffer irreparable injury without the injunction; (3) Whether the issuance of the injunction would cause substantial harm to others; and (4) Whether the public interest would be served by issuance of the injunction.
Suicide in Confinement: A National Survey at 3 (2009) (“Although little research has been conducted regarding youth suicide in custody, the information that is available suggests a high prevalence of self-injurious behavior in juvenile correctional facilities. . . . The study found that almost 22 percent of confined youth seriously considered suicide, 20 percent made a plan, 16 percent made at least one attempt, and 8 percent were injured in a suicide attempt during the previous 12 months.”).
12

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 14 of 26 PAGEID #: 2952
Welch v. Brown, No. 13-1476, 2014 WL 25641 (6th Cir. 2014) (granting preliminary injunction preventing city from changing terms of retirees’ benefits package) (citations omitted).
These considerations are “factors to be balanced, not prerequisites that must be met.” Washington v. Reno, 35 F.3d 1093, 1099 (6th Cir.1994) (affirming issuance of injunction prohibiting prison officials from using trust fund proceeds to fund a new phone system). The district court need not make specific findings regarding each of the four factors if fewer factors are dispositive of the issue. See Six Clinics Holding Corp., II v. Cafcomp Sys., Inc., 119 F.3d 393, 400 (6th Cir. 1997) (“A preliminary injunction is customarily granted on the basis of procedures that are less formal and evidence that is less complete than in a trial on the merits.”).
In this case, the balancing of these factors weighs heavily in favor of enjoining the State’s continued use of excessive seclusion at the Facilities on boys with mental health disorders.
1. The United States Has Demonstrated a Likelihood of Success on the Merits. To show a likelihood of success on the merits, it is enough that the movant raises “questions going to the merits so serious, substantial, difficult and doubtful, as to make them a fair ground for litigation and thus for more deliberate investigation.” Brandeis Mach. & Supply Corp. v. Barber-Greene Co., 503 F.2d 503, 505 (6th Cir. 1974) (preliminary injunction granted against illegal tying arrangement) (quotation omitted). The United States can demonstrate likelihood of success on the merits. Excessive seclusion of juveniles is inherently punitive and violates the Fourteenth and Eighth Amendments to the Constitution. Courts have held that the “use of isolation [on children] was not within the range of acceptable professional practices and constitutes punishment in violation of the plaintiffs’ Due Process rights.” R.G. v. Koller, 415 F. Supp. 2d 1129, 1155 (D. Haw. 2006)
13

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 15 of 26 PAGEID #: 2953
(relying on expert testimony that “[p]rolonged isolation or seclusion . . . can cause serious psychological consequences”). Numerous courts have recognized the harm to juveniles from isolation and have found it violates Due Process. See generally H.C. v. Jarrard, 786 F.2d 1080, 1088 (11th Cir. 1986) (“Juveniles are even more susceptible to mental anguish than adult convicts.”); Santana v. Collazo, 714 F.2d 1172 (1st Cir. 1983) (experts’ testimony on lack of therapeutic and disciplinary benefits from isolation sufficient to warrant remand for further factual findings); Feliciano v. Barcelo, 497 F. Supp. 14, 35 (D.P.R. 1979) (“Solitary confinement of young adults is unconstitutional.”); Lollis v. N.Y. State Dep’t of Soc. Servs., 322 F. Supp. 473, 480 (S.D.N.Y. 1970) (concluding that the extended use of isolation on children is “cruel and inhuman,” and “counterproductive to the development of the child”).
The United States has established that boys with mental health disorders at the Facilities are secluded for weeks at a time, even when they demonstrate suicidal ideation or actions. Despite the concerted efforts of monitoring teams of subject matter experts for many years, the State continues to impose seclusion on boys with mental health disorders as a matter of course. The State does not deny the extent to which it secludes boys at the Facilities; when confronted with over 100 hours of seclusion in a single month, it dismissed that as “not alarming.” Attach. B. Even as evidence mounted that boys with mental health disorders were suffering, the State turned its resources and attention toward terminating this case under the PLRA rather than addressing the problems at the Facilities. There can be no factual dispute that the State is handing out thousands of seclusion hours and that is hurting boys at the Facilities.
Based on the undisputed evidence of the State’s relentless use of seclusion on boys with mental health disorders, the United States has demonstrated a likelihood of success sufficient to justify a temporary restraining order.
14

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 16 of 26 PAGEID #: 2954
2. The Boys at the Facilities Will Suffer Irreparable Injury Without a Temporary Restraining Order. The United States can demonstrate irreparable harm to boys with mental health disorders at the Facilities. “Irreparable harm” means that the plaintiff is unlikely to be made whole by an award of damages at the end of the trial. Farnam v. Walker, 593 F. Supp. 2d 1000, 1012 (C.D. Ill. 2009) (granting preliminary injunction requiring prison to provide medical care for inmate). Here, a monetary award would be cold comfort for the tremendous mental and physical harm the boys at the Facilities are suffering. They have endured days and even weeks of seclusion at the Facilities, to the point where some boys threaten suicide or are driven to hurt themselves. Their Fourteenth Amendment and Eighth Amendment rights have been impaired, and money damages cannot possibly fix that. These boys should not have to suffer needlessly while the United States, the United States v. Ohio and S.H. monitors, and the monitors’ subject matter experts try to persuade the State to change its ways. See, e.g., Farnam, 593 F. Supp. 2d at 1013 (“[M]oney hardly seems an adequate remedy for . . . significant pain and suffering.”). To substantiate a claim that irreparable injury is likely to occur, a movant “must provide some evidence that the harm has occurred in the past and is likely to occur again.” See Mich. Coal. of Radioactive Material Users, Inc. v. Griepentrog, 945 F.2d 150, 154 (6th Cir. 1991) (finding irreparable harm in state’s refusal to allow access to sites for dumping of radioactive waste). Here, the State’s own records prove excessive seclusion has occurred in the past. Moreover, the State’s own words prove excessive seclusion will occur in the future. When Dr. Dedel discovered that some Scioto boys had been secluded for at least 10 percent of their time in custody, the State dismissed her findings as “not alarming.” Attach. B. When the monitor sought help for one boy who showed extreme distress, visible injuries, and suicidal
15

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 17 of 26 PAGEID #: 2955
behavior during numerous episodes of seclusion, the State sought the resignation of the subject matter expert who investigated. The State’s active resistance to efforts to reduce the suffering of secluded boys with mental health disorders shows irreparable harm will continue unless this Court steps in.
3. A Temporary Restraining Order Would Not Cause Substantial Harm to Others. To determine whether the temporary restraining order would cause harm to others, the Court should balance the hardships by comparing relevant harms to plaintiff and defendant. Hughes Network Sys., Inc. v. InterDigital Commc’ns Corp., 17 F.3d 691, 693 (4th Cir. 1994) (vacating denial of preliminary injunction where district court failed to balance relative harms). Here, the harm to the boys with mental health disorders is significant and immediate. They are isolated for long periods, they are denied exercise outside of their rooms, and they often cannot receive essential programming, education and mental health care. At least one boy (K.R.) has hurt himself, and several more displayed suicidal tendencies. Isolation of juveniles greatly increases the risk of suicide or self-harm. Dr. Dedel warned, “The risk of self-harm increases when youth are isolated. Approximately ½ of the suicides that occur in juvenile correctional facilities occur among youth who are in disciplinary seclusion.” See Seclusion Report at 1. In contrast, the potential harm to the State from the proposed relief is minimal and speculative if there is any harm at all.9 As expert DeMuro explained, it is possible to run a safe
9 Reducing seclusion may actually yield cost savings for the State. A recent study found, “[s]ubstantial savings can result from effectively changing the organizational culture to reduce and prevent the use of restraint and seclusion.” Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, The Business Case for Preventing and Reducing Restraint and Seclusion Use, at 4 (2011).
16

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 18 of 26 PAGEID #: 2956
and secure facility without the State’s current overreliance on seclusion. DeMuro Decl. at ¶¶ 46, Attach. H. Under the proposed temporary restraining order, the State would retain authority and discretion to run the Facilities consistent with this Court’s order. For instance, the State could use seclusion as a temporary cool-down device or to restore order for a short time after an episode of chaos. What the State could not do is continue to use lengthy and repeated seclusion as its default, one-size-fits-all method for handling disciplinary issues. See Farnam, 593 F. Supp. 2d at 1016 (in Eighth Amendment challenge alleging deliberate indifference to serious medical needs, potential harm from erroneously granting a preliminary injunction was slight compared to the potential harm from erroneously denying it); see also Beerheide v. Zavaras, 997 F. Supp. 1405, 1411 (D. Colo. 1998) (balance of harms favored prisoners requesting kosher diet despite prison’s objection based on cost and security concerns).
When the overwhelming harm to the boys at the Facilities from excessive seclusion is weighed against the possible inconvenience to the State of temporarily changing its seclusion practices pending a final determination of what those practices should be, the balance of hardships weighs heavily in favor of the United States.
4. A Temporary Restraining Order to Prevent the Excessive Seclusion of Boys with Mental Health Disorders Would Serve the Public Interest. The Court should evaluate whether “the public interest that would be served by the granting of a preliminary injunction outweighs any public interest that would be served by denying it.” United Food & Commercial Workers Union v. Sw. Ohio Reg’l Transit Auth., 163 F.3d 341, 363 (6th Cir. 1998) (public had an interest in free expression of ideas in bus ads, and transit authority failed to prove impact on safe and efficient transportation supporting advertising
17

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 19 of 26 PAGEID #: 2957
ban); see Galper, 815 F. Supp. at 1044 (preventing plaintiff’s eviction from her office served the
public interest because eviction “would disrupt the service she provides to [5,000] patients”).
Protecting the constitutional rights of juveniles is in the public interest. The Violent
Crime Control and Law Enforcement Act of 1994, 42 U.S.C. § 14141, explicitly grants the
Attorney General the authority to bring suit against any governmental entity that has engaged in
a pattern or practice of depriving juveniles of their rights secured by the Constitution or federal
statute. In addition, the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997,
authorizes the United States to investigate and remedy unconstitutional conditions in juvenile
facilities. 42 U.S.C. § 1997a(a). The existence and enforcement of these federal statutes
demonstrates a substantial and compelling public interest in protecting the rights of boys with
mental health disorders from the harm of excessive seclusion.
Further, a national enforcement priority of the United States is preventing the use of
unlawful seclusion on persons in custody who have significant mental health needs. In the past
ten months alone, the United States has issued investigative findings and statements of interest in pursuit of this priority.10 The compelling public interest, combined with the United States’
10 For example, on May 31, 2013, and February 24, 2014, the United States issued findings that the manner in which the Pennsylvania Department of Corrections used prolonged isolation on inmates with serious mental illness subjected those inmates to a risk of serious harm and violated the Eighth Amendment of the U.S. Constitution and Title II of the Americans with Disabilities Act (“ADA”), 42 U.S.C. §§ 12131-34. On February 13, 2014, the United States filed a Statement of Interest in G.F. v Contra Costa County, No. 3:13-cv-03667-MEJ (N.D. Cal.), arguing that a juvenile detention facility is obligated under the ADA, 42 U.S.C. § 12101, to provide reasonable programming modifications enabling youth with disabilities to avoid imposition of seclusion due to their disability-related behaviors and to receive education and related programming while in seclusion. On August 9, 2013, the United States filed a Statement of Interest in Coleman v. Brown, No. 2:90-cv-0520 (E.D. Cal.), reaffirming, in a case challenging California’s use of prolonged isolation on prisoners with serious mental illness, the United States’ broad interest in preventing the unlawful use of solitary confinement. See Special
18

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 20 of 26 PAGEID #: 2958

showing of irreparable harm, likelihood of success on the merits, and balancing of harms, justifies a temporary restraining order.

B. The Temporary Restraining Order Satisfies the PLRA.

The Prison Litigation Reform Act (“PLRA”) bears on the scope of the prospective relief

this Court can order. It states:

Preliminary injunctive relief. . . . Preliminary injunctive relief must be narrowly drawn, extend no further than necessary to correct the harm the court finds requires preliminary relief, and be the least intrusive means necessary to correct that harm. The court shall give substantial weight to any adverse impact on public safety or the operation of a criminal justice system caused by the preliminary relief and shall respect the principles of comity set out in paragraph (1)(B) in tailoring any preliminary relief.
18 U.S.C.A. § 3626(a)(2) (emphasis added).

As described in the Proposed Order, the United States seeks a temporary restraining order

to enjoin the State from imposing excessive amounts of seclusion on boys with mental health

disorders. This targeted relief complies with the PLRA requirements because:

•

It extends no further than necessary to correct the harm because it allows the State

to use seclusion in a controlled fashion where necessary while preserving boys’

access to essential education, exercise, programming and mental health care;

•

It is narrowly tailored because it encompasses only boys at the Facilities with

mental health disorders, as they are the ones who suffer the most from excessive

seclusion; and

•

It is the least restrictive means necessary because it vests in the State discretion to

decide when seclusion is unavoidable and what offenses will result in seclusion.

The United States’ requested relief is an appropriate exercise of the Court’s equitable

powers, so the Court should issue a temporary restraining order and set an expedited hearing on

issuance of a preliminary injunction, followed by expedited discovery and a hearing on the

Litigation Section, Civil Rights Division, United States Department of Justice, cases and statements of interest, at http://www.justice.gov/crt/about/spl/findsettle.php.
19

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 21 of 26 PAGEID #: 2959 United States’ request for a permanent injunction. CONCLUSION The United States has established that the State is excessively secluding boys with mental health disorders, that boys are suffering irreparable harm, and that the State has not changed its practices. This Court should act now and grant an immediate temporary restraining order, a preliminary injunction hearing and, after expedited discovery and briefing, a hearing on the issuance of a permanent injunction to protect the constitutional and federal rights of these boys.
20

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 22 of 26 PAGEID #: 2960

DATE: March 12, 2014
CARTER STEWART United States Attorney Southern District of Ohio
/s/ Deborah F. Sanders____________ DEBORAH F. SANDERS (0043575) Assistant United States Attorney Southern District of Ohio 303 Marconi Boulevard, Suite 200 Columbus, Ohio 43215 (614) 469-5715 (T) (614) 469-5653 (F) Deborah.Sanders@usdoj.gov
STEVEN M. DETTLEBACH United States Attorney Northern District of Ohio
/s/ Michelle L. Heyer___________ MICHELLE L. HEYER, Reg. No. 0065723 Assistant United States Attorney Northern District of Ohio 801 West Superior Avenue, Suite 400 Cleveland, Ohio 44113 (216) 622-3686/(216) 622-3781 (T) (216) 522-2404 (F) michelle.heyer@usdoj.gov

Respectfully submitted,
JOCELYN SAMUELS Acting Assistant Attorney General Civil Rights Division United States Department of Justice
JONATHAN M. SMITH Chief Special Litigation Section
BENJAMIN O. TAYLOE, JR. Deputy Chief Special Litigation Section
CYNTHIA COE ALEXANDRA L. SHANDELL Trial Attorneys Special Litigation Section
/s/ Silvia J. Dominguez-Reese ___ SILVIA J. DOMINGUEZ-REESE Trial Attorney Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 (202) 616-8547(T) (202) 514-4883 (F) Silvia.Dominguez-Reese@usdoj.gov
Attorneys for Plaintiff

21

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 23 of 26 PAGEID #: 2961
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that this date, March 12, 2014, I caused the foregoing to be
electronically filed with the Clerk of the Court using the CM/ECF system, which will
simultaneously serve notice of such filing to counsel of record and the Court Monitor to their
registered electronic mail addresses.
/s/ Silvia J. Dominguez-Reese SILVIA J. DOMINGUEZ-REESE Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 (202) 616-8547 (T) (202) 514-4883 (F) Silvia.Dominguez-Reese@usdoj.gov
Attorney for Plaintiff

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 24 of 26 PAGEID #: 2962

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

UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

)

v.

)

)

THE STATE OF OHIO, et al.,

)

)

Defendants.

)

____________________________________)

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

[PROPOSED] ORDER GRANTING UNITED STATES’ MOTION FOR TEMPORARY RESTRAINING ORDER, SETTING A PRELIMINARY INJUNCTION HEARING, AND GRANTING
EXPEDITED DISCOVERY FOR A PERMANENT INJUNCTION HEARING

Upon consideration of the parties’ submissions and the applicable law, the Court hereby

grants the United States’ Motion for a Temporary Restraining Order and sets a schedule for the

United States’ request for a Preliminary and Permanent Injunction as follows:

I. This Court, as an interim response to the State’s infliction of unlawful and irreparable harm on boys through its seclusion and mental health practices, hereby issues a temporary restraining order that the State:

A. Stop secluding any boy with an identified mental health disorder for more than 24 hours without providing him, outside of his confinement area and during normal facility programming times, at least four hours of programming, exercise, education, or combinations thereof;

B. Stop imposing more than three consecutive days of seclusion in any form (e.g., prehearing seclusion and intervention seclusion) on any boy with an identified mental health disorder; and

C. Stop imposing more than three days of seclusion in any form within a 30-day period on any boy with an identified mental health disorder without first:

1. Conducting a comprehensive mental health treatment review of the boy that includes the treatment team meeting and reviewing the boy’s mental health treatment plan to consider and address potential problems with the plan and its implementation;

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 25 of 26 PAGEID #: 2963

2. Obtaining the prior written approval of the Deputy Director of DYS responsible for Facility programming; and

3. Providing written notice to the United States and monitor within 24 hours of a youth exceeding three days of seclusion within a single month, describing the amount of seclusion, reason for seclusion, treatment provided in response to seclusion, whether the youth’s behavior intervention plan was modified or created, and alternatives to seclusion that were rejected.

D. Provide monthly to the monitor an AMS printout of monthly seclusion hours for boys at the Facilities; and

E. Refrain from substituting restraints for seclusion.

II. The Court will hold an expedited hearing to determine the United States’ entitlement to a preliminary injunction.

III. The Court hereby sets an expedited schedule for discovery and further briefing in preparation for a hearing on a permanent injunction. At the permanent injunction hearing, the Court will determine the circumstances and limitations governing the use of seclusion (or restraints as a substitute for seclusion) on boys with mental health disorders at the Facilities, particularly given that the proposed temporary restraining order’s terms do not extend far enough to address the extent of the State’s violations.
The Court hereby adopts the following schedule for expedited discovery:

Hearing on TRO Motion Hearing on Motion to Supplement Parties Serve Requests for Production of Documents and Interrogatories Parties Identify Experts Parties File Briefs on Issuance of Preliminary Injunction Hearing on Issuance of Preliminary Injunction Responses to Requests for Production of Documents and Interrogatories Plaintiff’s Experts Tour Facilities Monitor Team Reports Filed by Dedel and Glindmeyer Plaintiff Deposes DYS Staff Parties Serve Requests for Admission Parties Respond to Requests for Admission Parties’ Serve Expert Reports

March 21, 2014 March 21, 2014 March 24, 2014
March 25, 2014 March 28, 2014 April 2, 2014 April 4, 2014
April 6-11, 2014 April 21, 2014 April 28, 2014 April 28, 2014 May 5, 2014 May 5, 2014

2

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 26 of 26 PAGEID #: 2964

Depositions of Experts Pre-Hearing Briefs for Permanent Injunction Hearing to Determine Permanent Injunction

May 12-16, 2014 May 27, 2014 June 7, 2014

It is so ordered.
Signed this ____ day of ____________, 2014
___________________________________ HONORABLE ALGENON MARBLEY UNITED STATES DISTRICT JUDGE

3

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 1 of 37 PAGEID #: 2965
Attachment A

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 2 of 37 PAGEID #: 2966

Coe. Cynthia (CRT)

From: Sent: To: Cc:
Subject:

Alphonse Gerhardstein [AGerhardstein@gbfirm.com] Saturday, January 11, 2014 3:25 PM Thomas N. Anger Judith B. Goldstein; Terry Schuster; Kim Tandy; Tayloe, Benjamin (CRT); Cae, Cynthia
DomirlQLlez··R"ese, Silvia (CRT); Will Harrell; Andrea Weismann; daphne glindmeyer FM'""."lrm needed

Tom - Thanks for the cooperation Kim and I got at CJCF yesterday. [write to urge prompt action regarding • • •

_ . I am not a clinician but I have been representing mentally ill inmates for 37 years. Mr.

strikes me as

extremely mentally iii. More importantly, he seems to be experiencing excessive seclusion - particularly in the

Observation Cell on Oak - which appears to make him worse.

I do not have his file. Only my interview. He reports that he is taking significant psych meds. Staff and the client both reported that he bangs his head frequently. He had fresh head injuries as I spoke to him. Something drives him to self destructive behavior and whatever has been tried so far does not seem to be working. I certainly got the impression that he remains at a current risk of seriously harming himself. I ask that DYS, Dr. Weisman and Dr. Glindmeyer take a careful look at this young man and act promptly to ensure his safety and adequate treatment. Thanks very much.

Alphonse A. Gerhardstein Gerhardstein & Branch Co LPA
432 Walnnt Street, Suite 400 Cincinnati, OR 45202 Office 513.621.9100 FAX 513.345.5543
www.gbfirrn.com

From: Judith B. Goldstein [mailto:Judith.Goldstein@ohioattorneygeneral.gov] Sent: Friday, January 10, 2014 1:37 PM To: Terry Schuster; Thomas N. Anger; Calhoun, Dustin; Alphonse Gerhardstein; Kim Tandy; Tayloe, Benjamin (CRT); Cae, Cynthia (CRT); Dominguez-Reese, Silvia (CRT); Will Harrell; Andrea Weismann; daphne glindmeyer Subject: RE: Summary of parties' agreement re: follow-up to Glindmeyer and Weisman reports
I will certainly check into this asap. I do know that for the documents requested by Dr. Weisman (which were listed in 'tour summary as due on Jan. 6th), we were following her mid-January deadline because we were working under the understanding that she needed documents for a report and plaintiff's counsel needed different documents for the Jan.
29th conference. I'll get back to you with a response.
Judith B. Goldstein
Uuit Coordinator - Criminal Justice Section/Corrections Litigation Unit
Office of Ohio Attorney General Mike DeWine 150 East Gay Street, 16th Floor Columbus, Ohio 43215 Office number: 614-644-8685
Judith.Goldstein@OhioAttorneyGeneral.gov

1

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 3 of 37 PAGEID #: 2967
Confidentiality Notice: This message is intended for use only by the individual or entity to whom or which it is addressed and may contain information that is privileged, confidential and/or otherwise exempt from disclosure under applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify me immediately by telephone.
From: Terry Schuster [mailto:shmonitor.schuster@qmail.coml Sent: Friday, January 10, 2014 1:33 PM To: Judith B. Goldstein; Thomas N. Anger; Calhoun, Dustin; Alphonse Gerhardstein; Kim Tandy; Tayloe, Benjamin (CRT); Coe, Cynthia (CRT); Dominguez-Reese, Silvia (CRT); Will Harrell; Andrea Weismann; daphne glindmeyer Subject: Fwd: Summary of parties' agreement re: follow-up to Glindmeyer and Weisman reports
Hi Judy,
We need some further explanation from you. You said in your recent email that Defendant has provided all of the documents and met all of the deadlines agreed to in chambers. I am forwarding the email that I sent out to everyone on Dec. 22nd. It includes an attached summary of the parties' agreement in chambers.
As far as we can tell, DYS has not provided any of the documents and information on the second page of the attached summary.
Additionally, DYS has not provided the items listed on the first page under the heading "QAlQI and peer review for mental health" or under the heading "discipline for youth on the mental health caseload". [Note that we agreed with Dustin's alternate definition of "frequent flyers," which he included in an email response to this Dec. 22nd emaiL]
I have also attached a short memo that Dr. Weisman wrote up for Will explaining what she is able to report on (by Monday) based on what she's been provided so far, and what she's not able to report on.
It seems as though DYS has overlooked quite offew of the items that were included in this summary. Can you please explain what happened?
Thanks, Terry and Will
---------- Forwarded message ---------From: Terry Schuster <shmonitor.schuster@gmail.com> Date: Sun, Dec 22, 2013 at 8:28 PM Subject: Summary ofparties' agreement re: follow-up to Glindmeyer and Weisman reports To: "Judith B. Goldstein" <Judith.Goldstein@ohioattorneygeneraLgov>, "Thomas N. Auger" <thomas.anger@ohioattorneygeneraLgov>, "Calhoun, Dustin" <dustin.calhoun@dys.ohio.gov>, "Reed, Harvey" <Harvey.Reed@dys.ohio.gov>, "linda.janes@dvs.ohio.gov" <linda.janes@dys.ohio.gov>, "Trim, Ginine" <ginine.trim@dys.ohio.gov>, Will Harrell <shmonitor.harrell@gmaiLcom>, Alphonse Gerhardstein <AGerhardstein@gbfirm.com>, Kim Tandy <ktandy@childrenslawkv.org>, "Dominguez-Reese, Silvia (CRT)" <Silvia.Dominguez-Reese@usdoj.gov>, "Tayloe, Benjamin (CRT)" <Benjarnin.Tayloe@usdoj.gov>, "Coe, Cynthia (CRT)" <Cvnthia.Coe@usdoj.gov>, daphne glindmeyer <dglindmever@gmaiLcom>, Audrea Weismann <Aweisman@aoLcom>, Kelly Dedel <kelly.dedel@gmaiLcom>
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 4 of 37 PAGEID #: 2968
Dear DYS administrators, DYS counsel, S.H. counsel, and DOJ, On Thursday we discussed various follow-up items from the reports written by Dr. Glindmeyer and Dr. Weisman. I have attached a sunnnary. If anyone needs clarification on any ofthe items in the sunnnary, please let us know by close of business on Monday, The deadline for the documentation itemized in the attached sunnnary is January 6th. If you need a couple of extra days, let us know -- we have some wiggle room on that deadline, but we are aiming to circulate our final mental health and psychiatry reports on Jan. 13th, so we'll need all of the documentation sometime on the week of January 6th. We plan to file the final reports with the Court before January 25th. Thanks, Terry
Terry Schuster, Esq. Special Assistant to the Federal Court Monitor S.H v. Reed Monitoring Team (512) 468-4486 sbmonitor.schuster@grnail.com
Terry Schuster, Esq. Special Assistant to the Federal Court Monitor S.H v. Reed Monitoring Team (512) 468-4486 shmonitor.schuster@gmail.com
3

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 5 of 37 PAGEID #: 2969
Attachment B

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 6 of 37 PAGEID #: 2970

Coe. Cynthia (CRT)

From: Sent: To: Subject:

Dominguez-Reese, Silvia (CRT) Thursday, March 06, 2014 5:48 PM Cae, Cynthia (CRT) FW: Seclusion concems at SJCF

From: Calhoun, Dustin [mailto:Dustin,Calhoun@dys.ohio.gov] Sent: Wednesday, December 04, 2013 11:59 AM To: Tayloe, Benjamin (CRT); Dominguez-Reese, Silvia (CRT)
Cc: 'Thomas N. Anger'; Judith B. Goldstein
Subject: Seclusion concems at SJCF

Silvia and Bo,

It was a pleasure speaking with the two of you this morning and I believe our conversation was very productive. Before I addressed the potential for contracting with Kelly with Director Reed, I wanted to drill down and see exactly what we are dealing with and looked at the numbers for November.

Out of the 10 young men that were referenced in Kelly's report, the following five are all that remain at Scioto:

• • • • • • • • • • • • • • • • with the caveat that

is scheduled to be released tomorrow.

The following represents the seclusion HOURS for the month of November for the above youth:

4.5 hours 1.45 hours 142.3 hours (Act of Violence) 80.93 hours (Act of Violence) 1.0 hour
As you can see, the seclusion hours are not alarming for these youth. After reviewing this email, please advise if your
has changed.

Thanks,

Dustin J. Calhoun· Chief Legal Counsel Ohio Department of Youth Services 30 West Spring Street, Sth Floor Columbus, Ohio 43215 614.728.7353 (Office) 614.752.9078 (Fax) Dustin.Calhoun@dys.ohio.gov

This message, and any response to it, may constitute a public record and thus may be publicly available to anyone who requests it in accordance with Chapter 149 of the Ohio Revised Code,
1

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 7 of 37 PAGEID #: 2971
Attachment C

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 8 of 37 PAGEID #: 2972

Coe, Cynthia (CRT)

From: Sent: To: Subject:

Alphonse Gerhardstein [AGerhardstein@gbfirm.com] Wednesday, January 15, 2014 2:24 PM Tayloe, Benjamin (CRT); Coe, Cynthia (CRT); Dominguez-Reese, Silvia (CRT)
FW: Request that Dr. Weisman resign

fyi

From: Will Harrell [mailto:shmonitor.harrell@gmail,com]
Sent: Wednesday, January 15, 2014 12:02 PM To: Alphonse Gerhardstein
Cc: Judith B. Goldstein; ktandy@childrenslawky,org; Thomas N. Anger; dustin.calhoun@dys.ohio.gov; Terry Schuster; Andi Weisman
Subject: Re: Request that Dr. Weisman resign

Judy:

I've reviewed your letter and the email from AI. I've also discussed the allegations with Dr. Weisman. Here is my opinion.

1. Andi did not step outside of her monitor boundaries in following up on this kid's situation as reported to us by

.AJ. In fact, I explicitly asked her to do so. Al reported his concerns about youth

and requested that DYS

and the monitors look into it. The concerns Al reported relate precisely to

ssue that remains in this

c.ase--seclusion ofyouth with mental health disorders. Al informed us that _mother was actively

involved with him and therefor she would be a good source of information

s. We are authorized to

gather information from any source we deem necessary such as staff, youth, advocates, oversight bodies and

family members. We have done so throughout the span of this case and we will continue to do so.

2. Andi maintains that she didn't release private medical information to anyone without the youth's consent. I have no reason to believe she did. Andi didn't have any private medical information to release.

3. Andi maintains that she didn't render psychological services or a psychological evaluation. I have no reason to believe she did. She never spoke with this youth. And when she spoke with his mother, she was merely gathering information relevant to her review ofthe seclusion of youth on the mental health case load.

5. There is nothing slanderous about Andi's statement in her report. She is reporting what _mother stated

to her. However, we will adjust the tone of that statement before submitting the report to t

for the

record.

There have been many situations in the past where in the course of our monitoring we have uncovered an individual case that required urgent attention or that an urgent case is brought to our attention by plaintiffs council or other individuals. When that happens, we try to get it to the attention ofthe appropriate DYS officials as soon as we can. This was simply another one of those instances and it appears that this youth is now getting the attention he needed. How is that not a good thing? I assure you that is what Judge Marbley expects of us.

I am willing to seek Judge Marbley's opinion on this matter or you can bring it to him directly. But I advise you to drop this distraction and get refocused on resolving the remaining substantive issues in the case. The Attorney General's office has been trying to get Dr. Weisman removed from this case for over a year. Rather than shoot the messenger, I suggest you address the message.

1

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 9 of 37 PAGEID #: 2973
Regards, Will Harrell
On Wed, Jan 15,2014 at 8:30 AM, Alphonse Gerhardstein <AGerhardstein01gbfirm.com> wrote: Dear Judy - Will shared with us your letter requesting Dr. Weisman's resignation. Plaintiffs do not agree to your request. As you may know from previous disputes the agreement of Plaintiffs' counsel is necessary in order to remove a member of the monitoring team. We have not even been advised ofthe facts of the underlying dispute.
Here is what I know. Because of concern for one youth's safety, I requested DYS and the monitor team experts to look into the circumstances of a specific youth I interviewed last Friday. The youth called his mother who in turn called me. She had information on his history. I passed her name and number to Will and the monitor experts and it is my understanding that Will requested that Dr. Weisman talk to the mother. There is absolutely nothing wrong with those actions. It is not unusual. It has always been our practice to permit members of the monitoring team to access information from persons with knowledge. See e.g., Doc. 108 at page 82 where Monitors are allowed "unobstructed access to staff and youth and other persons having information relevant to the implementation ofthis Stipulation." I spoke with the youth's mom this morning and she reports that she speaks with her son by phone frequently and visits at least once a month. She seems genuinely excited that he will get effective treatment as result ofthe current efforts. It seems to me everyone is working to make that happen.
As far as I know the needs ofthe youth are now being evaluated. That was the goal. There is no basis here for DYS to seek anyone's resignation. Please call me to discuss the matter.
Alphonse A. Gerhardstein Gerhardstein & Branch Co LPA 432 Walnut Street, Suite 400 Cincinnati, OH 45202 Office 513.621.9100 FAX 513.345.5543 www.gbfirm.com
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 10 of 37 PAGEID #: 2974
Attachment D

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 11 of 37 PAGEID #: 2975

Office (614) 644"7233

Fax (614) 728-9327

.

150 East Gay Street, 16th Floor

Oolumbus, Ohio 43215

www.OhloAttorneyGeneral.gov

August 22, 20:1.3

Benjamin 0. Tayloe Jr., Esq. U. S. Department of Justice Civil Rights Division
950 Pennsylvania Avenue NW Washington, DO 20530

Alphonse Gerhardst.,in, Esq. Gerha'rdsteln & Bra rich Co., LPA 432 Walnut street, Suite 400 Clnolnnati, OH 45202

Kim Tandy-Brown, ·Esq.
Ohlldren's Law Center 1002 Russell Street
Covington, KY 410:11

RE: Use of Programmatlo Restraints and Restructuring of Progress Unit

Dear Attomeys for S.H. and the Department of Justice:

DYS has decided to make the following ohanges to th_e Progress Unit:

First, the Progress Unit wlll be restructured In such a way that any youth admitted to
Progress will be placed on Transition Phase I. Further, any youtb demoted from Transition Phase II will be demotedonly to Transition Phase I. No youth will be demoted from Transition Phase I.
Second, incidental to this ohange, DYS will no longer be using programmatic restraints:

These ohanges will be formalized and incorporated Into polioy as SOOIl as possible. During

this transition time, DYS will neither admit nor demote youth into Phase I, nor will It use

programmatio restraints.

.

Thank you for your continued input and patlenoe as DYS makes these ohanges.

Very truly yours,

MIKE: DeWINiO Ohio Attomey General
s[fhomas N. Anger THOMAS N_ ANGER Ms1stentAttomey General

TNA:mcc
cc: Jackie Ouncannan Kelly Dedel SIlvia Dominguez Will Harrell Rashida ogletree Terry Schuster

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 12 of 37 PAGEID #: 2976
Attachment E

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 13 of 37 PAGEID #: 2977

MEMORANDUM

TO:
FROM: RE: DATE:

Tom Anger, Linda Janes, Amy Ast-Ohio DYS Bo Tayloe, Silvia Dominguez-U.S. DOJ Kelly Dedel, Ph.D., Lead Monitor U.S. v State of Ohio Results of Seclusion Analysis
November 8, 2013

As you know, while I was on site at Scioto during the week of October 14,2013, I became curious about the accumulation of seclusion hours for certain youth. While on site, I noted that the IH Officer and Superintendent used a tempered approach in the number of seclusion hours ordered as a sanction for individual AOVs (e.g., they did not order the maximum permissible, but more often something less). However, I also noticed that the same youth's names kept coming up in the documentation, over and over again.
I did not have time to further investigate this while I was on site, so upon returning home, I requested additional documents to examine this "accumulation" question. Using the AMS seclusion reports for the entire 6-month monitoring period, I calculated the number of hours/days each youth spent in seclusion. At first, I simply estimated the number of days the youth was in custody during that time, e.g., if he had any seclusion time during the month of June, I assumed he was there for the entire month. Once I obtained the preliminary results, I felt the need to make the analysis more precise and requested the exact admission and release dates for each youth so that I could know the precise number of days in custody, and therefore the proportion of that time that the youth spent in seclusion.
The results of this analysis are summarized in the table below. It includes youth whose total seclusion hours/days was 10% or more of their time in custody during the 6-month period. [Note: the total time in seclusion was not consecutive.] Of course, the AMS records show that there are some youth who spent very little time in seclusion. However, the AMS records also show that there are a number of youth who spent a considerable amount of time (20, 30, 40, nearly 50 days) in seclusion. Depending on how long the youth was in custody, this could amount to significant proportions of his time at Scioto.
As you know, I have serious concerns about the use of seclusion as a sanction:
• The risk of self-harm increases when youth are isolated. Approximately Y, of the suicides that occur in juvenile correctional facilities occur among youth who are in disciplinary seclusion.
• Isolation has the potential to exacerbate mental illnesses.
• Seclusion suppresses violent behavior in the moment, but does nothing to address the underlying causes of it. Instead, youth often emerge from seclusion feeling angry, frustrated and irritable-likely the very emotions that triggered their violent behavior in the first place.

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 14 of 37 PAGEID #: 2978
• Seclusion disengages youth from the people and programs that they need to access in order to develop the awareness, skills and desire to control their violent behavior.
Although I believe it to be ineffective, when youth experience seclusion in very small doses, I don't necessarily believe it is harmful. However, when youth's exposure to seclusion accumulates, as it has forthe youth listed in the table below, I believe the risk of harm is much more significant.
I offer these data as a starting point for a conversation about how to mitigate these risks for the youth who have chronic, aggressive misconduct. Obviously, preventing the misconduct via effective treatment is the best solution. Dr. Glindmeyer is reviewing these youth's mental health records and may be able to make some recommendations toward that end. When treatment is not sufficient, finding ways to address the youth's behavior that are compatible with, rather than counterproductive to, the goal of rehabilitation seems essential.
I plan to summarize these results in the upcoming Monitor's Report, but hope that we can initiate a problem-solving discussion about where to go from here in the meantime.
Respectfully,
Kelly Dedel, Ph.D. Lead Monitor, U.S. v. State af Ohia

[OJ.]

74

[B.D.]

184

[A. F.]

184

[T.R.]

184

[D.H.]

184

[J.A.]

141

[T.H.]

109

[M.G.]

137

[R.B.]

184

[K.A.]

184

[0.5.]

184

28.54 49.56 43.83 35.36 33.59 24.56 16.27 17.55 23.24 20.57 17.62

38.57% 26.93% 23.82% 19.21% 18.25% 17.42% 14.92% 12.81% 12.63% 11.18%
9.6%

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 15 of 37 PAGEID #: 2979
Attachment F

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 16 of 37 PAGEID #: 2980
Ohio I Department of Youth Services
John R. Kasich, Governor Harvey J. Reed, Director

November 21,2013

TO: FROM: RE:

Stakeholders Director Reed Facility Closure

I want to inform you of the Department's decision to close the Scioto Juvenile Correctional Facility (SJCF) on May 3, 2014. Over the course of the past two years, the DYS population has dropped from an average of 685 youth in October 2011 to 525 youth in October 2013. With a 23 percent drop in population, closing the facility improves the efficiency of our operations.
As of yesterday, there were 38 youth at SJCF (20 males and 18 females who reside separately). Male youth will be gradually reassigned to the remaining facilities according to their security, educational and programming needs. I am confident that our staff is well-equipped to handle these youth safely and effectively. We are evaluating the appropriate placement options for our female youth, including placement at private residential facilities and Community Corrections Facilities (CCFs), and will certainly keep you informed as the plan advances.
We are required to follow all layoff procedures according to union contracts and the Ohio Revised Code; however, we will offer a DYS position to all staff impacted by this closure and who are not ready to retire. During the next few weeks, we will work closely with the affected bargaining unit and exempt staff to identifY positions for which they are qualified.
Thank you for your cooperation and support. Please do not hesitate to contact us with any questions or concerns by emailing guestions@dys.ohio.gov.

Cenlra! Office 30 W. Spring Sireet, 51h Floor
Columbus, Ohio 43215-2256

6141466-4314 www.dys.ohio.gov

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 17 of 37 PAGEID #: 2981
Attachment G

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 18 of 37 PAGEID #: 2982
S.H. v. Reed
Re: Compliance with Consent Order Provisions regarding Mental Health Submitted by: Andrea Weisman, PhD. December 16,2013
Sub-topic II.C.1.a. QAjQI and peer review for mental health and psychiatry
Mental Health Compliance Rating - Partial Compliance
Methodology: Peer Review forms were received from each facility: CJCF - N=6, CHJCFN=8, Scioto - N=7, IRJCF - N=6.
Observations: These reviews are titled Clinical File Reviews and reflect provider's assessment of 14 areas of concern including, whether the ITP is strength-based, whether there is evidence that parents/guardians have been communicated with, whether the SOAP format was utilized in the documentation of group and individual sessions, etc. The newly created form provides check boxes (Compliant, Non-Compliant and N/A). Problems noted include: when non-compliant or N/A is checked there frequently is no narrative explaining why the rating was given. In addition, there are numerous examples of unchecked boxes or multiple responses to the same question. This check box approach does not really get at the quality oftreatment provided or the clinical efficacy of their interventions. In order to determine the efficacy of treatment, DYS would, for example, need to look at such issues as whether the Sex Offender program is working, and for which populations of youth is it working? Are there racial, intelligence, psychiatric diagnostic factors that correlate with youth's ability to complete the program in a timely way. DYS would also need to examine such issues as what subgroups of youth are effectively participating in their CBT curriculum or individual therapy, as evidenced by youth engaging in fewer acts of violence or meeting treatment objectives. And DYS would be advised to look at whether group and individual services are being offered at the recommended frequency, also by the demographic variables identified above.
In addition, Behavioral Health Peer Review forms specifically focused on ITPs were received from CJCF (N=16). These forms assess the ITP objectives in terms ofthe acronym SMART: Specific (What do we want them to accomplish?), Measurable (Concrete criteria established to measure progress. How much, how many, how will I know when it is accomplished), Attainable (Plan the steps and associated timeframe wisely), Realistic (Is the youth willing and able to meet the objective?) and Timely (Are
1

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 19 of 37 PAGEID #: 2983
the time frames associated with objective). This is a form that collects provider's responses on 5 separate Likert scales which range from strongly disagree to strongly agree (with "neutral" in the center of the scale. Most providers rated the ITPs as meeting SMART expectations.
Since ITPs were also presented for review, it was possible to determine the accuracy of ratings on the SMART Peer review forms. For example, one form which rated the ITP positively on all indicators, in fact contained an objective that read "Learn and practice Skill Card #12: Following instructions and Skill Card #1: Listening over the next 30 days." In still another, the objective read "(Youth) and I will continue working together in individual sessions to identify his coping skills, coping strategies, common thinking errors and his goals, dreams and hopes for the future. This social worker plans on continuing to provide regular support, encouragement and advice in order to aid (youth) in balancing his thinking. We will complete the CBT packet entitled "Functional Behaviors - Making Choices that Work." Neither of these objectives identifies the new skill the youth will learn. I have provided consistent feedback over the years: Talking about completion of skill cards or CBT packets is not the same thing as skill acquisition. If the objective is completion of an assignment, the providers aren't measuring whether the problem behavior has decreased when they monitor for progress. And referencing what the social worker will do to provide support and encouragement is also not appropriate for inclusion in the statement of an objective. As a consequence, this peer review process has not meaningfully addressed the integrity of the ITPs.
There are additional problems with the Peer Review process. Many ofthe SMART Review forms are inaccurately filled out. With some providers rating that they "strongly disagree" that an objective meets the SMART indicators while the accompanying narrative would suggest the provider actually found the objectives to be compliant in the context of SMART. Also, where "neutral" is provider's rating, there is frequently no narrative to explain the rating. It is substantially unclear what value is added with this rating, particularly if it has no narrative clarifying what the rating means.
While there are continuing difficulties with the QI processes, there is evidence that . psychology supervisors are focused on improving ITPs. Both Drs. Dunphy and Hamning should receive particular praise for their efforts to improve the quality of ITPs as evidenced by their thoughtful feedback to clinicians in both Behavioral Health Staff Meeting minutes and on their supervision notes. However their efforts are not reflected in the documentation provided for review.
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 20 of 37 PAGEID #: 2984
Required Action: DYS needs to provide additional training on the writing of ITPs and on the forms in used for their peer review process.
Sub-topic II.C.l.e. Case formulation, fidelity to treatment provided to treatment model, treatment planning and treatment teams
Compliance Rating: Partial Compliance - Case formulation, treatment planning and treatment teams
Compliance Rating: Non- Compliant - Fidelity to treatment provided to treatment model
Methodology:Four Individual Treatment Plans (ITP) from each ofthe four facilities were reviewed. CJCF presented an additional 13 ITPs along with their Peer Review documentation. This documentation was sufficient to comment on case formulation, treatment planning and treatment teams. There was no documentation offered for review of fidelity to treatment provided to treatment model.
Observations: Treatment planning and ITPs continue to be a challenge for all facilities. Although we'd previously identified problems with the conceptualization and encoding of ITPs, and asked DYS to produce ITPs that was responsive to this observation, none of the currently reviewed ITPs are strength-based, nor do they present goals or objectives in concrete, measurable terms. Examples across facilities include: Goal: "{Youth will address his pro criminal identify mindset and work towards identifying a non criminal identity." The corresponding objective is "{Youth and 1will complete the packet "Problems with Authority in our individual sessions." Goal: "(Youth) will be able to maintain control over disturbing thoughts and feelings and related impulses that contribute to criminal behavior." The corresponding objective reads: "I will use CBT techniques to develop an understanding of and be able to identify in everyday situations, the ways in which thoughts feelings, behaviors and consequences are connected and related to each other." Goal: "Correct irrational thinking, which leads to anger and interpersonal problems." And again, the corresponding objective reads: "I will use materials from MAV and CBT groups, including thinking reports, to review the last 5 incidents of angry outbursts and all future incidents to identify the specific triggers that were connected with these incidents."
As has been discussed previously, a case formulation is the essential framework for the development of Individual Treatment Plans (ITP). Treatment goals need to reflect real world concerns - issues that must be addressed in order for the youth to return to the community. Objectives should be designed to develop and measure skill acquisition. Plans need to be assessed in terms oftheir efficacy in helping the youth acquire the desired skills, and revised monthly - or more often - if it becomes clear that the ITP is not working. Articulating objectives as the completion of paper and pencil tasks or
3

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 21 of 37 PAGEID #: 2985
studying Skill Cards does not address the development of new replacement behaviors. These are rather, strategies being employed in the service ofthe development of new skills, they are not in and of themselves, evidence of skill acquisition.
Required Action: UntillTPs are made more meaningful, mental health service delivery is compromised. The ITP is a roadmap, and if it doesn't outline what the staff is trying to achieve with the youth, there's no way for providers to assess whether the youth is improving. If DYS is to receive an improved compliance rating with regard to fidelity monitoring, they will have to produce evidence that they are engaging in such monitoring. This is a recommendation that has been made repeatedly over the years.
Sub-topic II.C.l.f. Behavior contracts
Compliance rating - Partial Compliance Methodology: Five Intensive Behavior Contracts from each facility were reviewed.
Comments: As a general matter, there is noted improvement in the Intensive Behavior Contracts. There is consistency across facilities in their use of a newly revised Intensive Behavior Contract format. The Contracts now evidence only one or two target behaviors, some document the frequency of occurrence of the noxious behavior, and all offer both incentives and consequences. All Contracts are now scheduled for review 7 days from the date of its signing, and, Contracts evidence attempts to articulate goals in incremental steps: "I (youth) agree I will perform the following behavior: maintain a distance of an arm's length when upset, use respectful language when discussing my issue, and maintain a low voice volume lout of 3 times," "I will maintain an arm's length of space between myself and all female staff lout of 2 times."
There are however, some continuing challenges with the Contracts. In particular, the incentives are not sufficiently incentivizing: "I will earn an extra snack provided by the UM or SWat a predetermined time," "I can listen to 15 minutes of music in my SW or psychologist's office," "15 minutes with an MP3 player on her unit," "I will earn 10 minutes in my room." As has been noted previously, incentives should be both proximate to the production ofthe desired behavior and should be sufficiently incentivizing so as to be rewarding to the youth. An extra 10 minutes in one's room at the end of a week of not engaging in target behaviors just not enough of a carrot for an adolescent. Incentives should be meaningful and determined in collaboration with the youth. In order to be maximally rewarding, as previously noted, they should also be more proximate to the production of desired behavior -like daily.
In addition, all Contracts begin with the statement that "I (youth) enter into the following contract in order to create and maintain order and harmony in the facility." In point of fact, Behavior Contracts are entered into in order to enhance the youth's ability to engage in replacement behaviors - that is, new behaviors that replace the target
4

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 22 of 37 PAGEID #: 2986
behaviors. If and when successful, it is likely that it will facilitate "order and harmony in the facility," however, that is not the purpose of the Contracts.
Contracts reviewed were developed from July through October. None were signed by the youth, clinician, UM, or supervisory behavioral health staff. No evidence was provided that any ofthe Contracts were reviewed. As such, itis impossible to know whether these Contracts were implemented, or if revising these Contracts was just a training exercise for the practitioners. As a consequence, it is impossible to determine if these Contracts are more efficacious than their predecessors. To determine the efficacy of the Contracts, DYS would have to track whether the youth met the goal and got the reward, or didn't meet the goal and got the consequence.
Required Action: DYS needs to provide documentation that reviews ofthe behavior contracts is occurring and that they are reducing the target behaviors.
Sub-topic II.C.l.h. Discipline for youth on the mental health caseload through the intervention hearing process
Compliance Rating - Partial Compliance
Since my preliminary recommendations in November, 2013, no new documentation has been presented for review regarding discipline for youth on the mental health caseload. We were advised that DYS has revised their policy "Intervention Procedures for Youth with Mental Illness, Cognitive or Development'll Disabilities (policy 303.01.04). Policy now requires that clinicians attend intervention hearings if: there are mental health and/or developmental issues that may have impacted the youth's behavior at the time ofthe rule violation, and ifthere are mental health and/or developmental issues that should be considered regarding disposition of the youth iffound proven.
This was recommended in our earlier Mental Health findings report, and it is all to the good that DYS is incorporating this recommendation into their operating procedures.
I have substantial concern however, that DYS is continuing to seclude mentally ill youth who are charged with rule infractions. While some amount of room confinement may be appropriate in some instances, when mentally ill youth are secluded, especially for protracted periods, they suffer harmful consequences. When a mentally ill youth winds up in secluSion, it is incumbent on the practitioners to modify the ITP appropriately to extinguish the behavior. If the youth continues in seclusion without a corresponding modification of his/her ITP,.the seclusion will just exacerbate the behavior problems DYS is seeking to extinguish.
5

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 23 of 37 PAGEID #: 2987
In a Behavioral Health Staff Meeting note from Dr. Hamning at Scioto (8/21/13)' he documents that "half ofthe kids are in seclusion (on Buckeye) a good majority of time." In particular, I have concern about how youth who were transferred off the Progress Units - all of whom were on the mental health case load - are being managed in their new units. Historically - before DYS undertook drastic reforms to change the PROGRESS Unit program design - the PROGRESS Unit and SMUs before it exacerbated challenging youth behavior by keeping youth locked in their cells for most or all of the day, for weeks or months on end. Dr. Hamning's note raises concerns that the youth who have transitioned out ofthe PROGRESS Unit are still being managed with long stays in seclusion, by way of the IRAV and sanction seclusion processes rather than by way of a maximum security housing unit. If DYS's treatment interventions have not evolved enough to identify why these youth and others with serious mental health issues are behaving in the ways that they are, it is more likely that these youth will spend significant lengths oftime in seclusion, an intervention that actually undermines the effectiveness of treatment.
In order to establish whether or not this is occurring, it will be necessary to review AMS logs, ITPs, Behavior Management Plans and seclusion hours for all the youth who transferred off Progress to other units.
Of course the concern extends to other mentally ill youth in DYS facilities.
Since DYS's announcement regarding the closure of Scioto, plaintiffs have expressed their concern "that youth on the mental health caseload who did not receive adequate treatment in the PROGRESS Unit will now be dispersed to the remaining institutions and continue to have deficient case formulation, treatment planning, behavior contracts, excessive diSCipline and excessive segregation. Similar youth who would have otherwise been transferred to the PROGRESS unit may be facing the same problem." It is clear to me that the deficiencies in behavioral health care led to high rates of seclusion for youth at Scioto, and that the same deficiencies exist at the other three DYS facilities. What I do not know from the documentation I have been provided is whether youth with mental illnesses are experiencing high rates of seclusion at the other three DYS facilities. Given the recent closures of both the PROGRESS Unit and Scioto JCF, plaintiffs' question regarding whether youth with behavioral challenges at other facilities spend a significant portion oftheir DYS stays in seclusion is a valid one. Such a determination, however, could be made only after a more thorough review of the AMS data and treatment files of mental health caseload youth who have experienced multiple Intervention Hearings over the last six months.
Required Action: By mid-January DYS should produce documentation that identifies the seclusion hours for "frequent fliers" and indicate whether they are on the mental health caseload. This, along with their ITPs and Intensive Behavior Management Plans will help to determine if IDTs are addressing the behavior that has led to seclusion, and the harmful effects of seclusion itself.
6

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 24 of 37 PAGEID #: 2988
Attachment H

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 25 of 37 PAGEID #: 2989

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

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

)

)

)

)

)

)

CIVIL ACTION NO:

)

2:08-cv-475

)

)

)

)

DECLARATION OF PAUL DEMURO

Paul DeMuro declares as follows under penalty of perjury:

L My name is Paul DeMuro. I submit this declaration in support of the United States' motion for a temporary restraining order. My address is 1201 Futch Creek Rd., Wilmington, N.C. 28411. I have been retained by the United States to, among other things, provide my opinion whether limitations proposed by the United States on the use of seclusion ofjuveniles are reasonable, appropriate, and capable of being implemented rapidly without causing significant disruption to security and operations in a juvenile justice facility.

2. I have over forty-three years of experience in juvenile justice and child welfare services. I have been superintendent of a large urban, secure juvenile detention center, as well as superintendent of a large training school for juvenile delinquents. I have served as Assistant Commissioner of the Massachusetts Department of Youth Services, overseeing all parole supervision for adjudicated juveniles h'1 Massachusetts. In the late 1970's, I was appointed by the Governor of Pennsylvania to serve as the Commissioner of Children and Youth in Pennsylvania. As the Commissioner, I supervised the superintendents of Pennsylvania's juvenile justice institutions, including all of the state's secure institutions for the most violent juvenile offenders. As Commissioner, I developed state regulations that governed the operation of secure county juvenile detention centers. I have developed public and contract residential and nonresidential programs for delinquent youth, including model secure treatment programs for violent offenders.

3. I am knowledgeable about contemporary juvenile justice and child welfare program standards, policies and practices. For over six years I served as the

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 26 of 37 PAGEID #: 2990
Federal Court monitor in a class action case in Florida, overseeing on a regular basis conditions of confinement in Florida's secure juvenile correctional institutions. I held a similar appointment for the Federal District Court in Oklahoma. As Federal Court monitor, I monitored Florida's and Oklahoma's secure institntional and community programs for youths and reported to the Federal Court. More recently, I have served as a Federal Court monitor in a New Orleans secure juvenile detention case, and I presently serve as a Federal Court Monitor in Mississippi in a case involving a secure commitment program for youth tried and convicted as adults. The use of disciplinary seclusion is severely limited in both the New Orleans and Mississippi secure programs. I have been appointed as a mediator in a number of cases to help resolve class action juvenile justice and child welfare cases. As a consultant, I routinely evaluate juvenile justice and child welfa.'"C programs and services. I have reviewed juvenile justice institntions, including juvenile justice secure institntions and child welfare programs in Alabama, Arizona, California, Florida, Georgia, Kentncky, Illinois, Louisiana, Maryland, Mississippi, New Jersey, New York City, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, South Dakota and Texas. I have evaluated a variety of state and COllllty run juvenile correctional institntions, including secure juvenile facilities, for the United States Department of Justice (the "DOJ"). My clients have included state juvenile justice agencies, state child welfare agencies, county juvenile justice agencies, the U.S. Department ofJustice, the National Juvenile Detention Association (now part ofthe National Partnership for Juvenile Services), and private Foundations. I have co-edited an anthology regarding violent offenders (Violent Juvenile Offenders, I984) and have co-authored a book regarding the problems of overcrowding in the California Youth Authority's secure institutions (Reforming the CYA, 1988). I have written a number of reports and articles concerning young offenders and secure institntional and alternative programs designed to serve them. Exhibit I contains my cv and my consulting prospectus, which contains a list ofmy publications. Exhibit II identifies court cases in which I have served as an expert witness or court-appointed expert/monitor.
4. The opinions expressed in this declaration are based on my experience in the field and my knowledge ofjuvepile justice standards, policies and practices. I have not reviewed Ohio Department ofJuvenile Corrections' ("DYS") policies or practices, nor have I reviewed DYS data or records or interviewed Ohio staff or juveniles. However, it is clear that the use ofseclusion in juvenile institutions causes more harm than good and, therefore, the use of and the duration of seclusion should be limited to the absolute minimum degree possible.1 Youth in isolation cannot participate in programs designed to address their problems. In
I See, "The Use of Seclusion IS Not Evidence Based Practice", The Journal of Child Abuse and Adolescent Psychiatric Nursing, Oct -Dec. 2001. Linda Finke, the author ofthis article, concludes that "the scientific evidence available illustrates that the use of seclusion with children is not therapeutic and is, in fact, hannfuL .." Also consider what a non-academic expert John Me Cain says about isolation: an awful thing, solitary... .It crushes your spirit and weakens your resistance more than any other form of mistreatment." The New Yorker, March 30, 2009, Atul Gawande, "Annals ofHuman Rights: Hellhole".
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 27 of 37 PAGEID #: 2991
essence youth who are perceived as being most in need of rehabilitative services are, when they are in isolation, denied access to those supportive interventions. In addition, isolation has direct negative consequences. Youth in isolation are more likely to commit suicide and/or to self mutilate than youth in the general population. Youth in isolation often become depressed; many youth in isolation become angry and more agitated and thus even more resentful of staff. The use of isolation is counterproductive. Isolated yonth often feel more depressed and desperate. Locking a youth in a cell does not reduce a youth's acting out. Its use only makes matters worse.
5. I understand that the United States has proposed the following limitations on the use of seclusion at facilities operated by DYS. (My specific observations regarding them are set forth in italics):
A. Refrain from secluding any boy with an identified mental health disorder for more than 24 hours without providing hlln, outside of his confinement area 811d during normal facility prograJUmiug times, at least four hours of programming (e.g., mental health counseling, exercise, education or combinations thereof);
B. Refrain from imposing more than three consecutive days of seclusion in any form (e.g., prehearing seclusion and intervention seclusion) on any boy with an identified mental health disorder. In fact, the pre-hearing time should be limited to the degree possible. Youth should not be placed in
seclusion on a pre-hearing basis ifthey are in control. All youth in
seclusion either on a pre-hearing basis or on a diSCiplinary basis should be out ofthe confinement area/cellfor at leastfour hours in any given twenty-:four hour period during normal programming time. There is no evidence to suggest that longer periods ofseclusion improve a youth's behavior. In fact the available evidence strongly pOints in the exact opposite direction, for all youth, andparticularlyfor youth with mental health problems.
C. Refrain from imposing more than three days of seclusion in any form \vithin a 30-day period on any boy with an identified mental health disorder without first:
1. Conducting a comprehensive mental health treatment review of the boy that includes the treatment team meeting and reviewing the boy's mental health treatment pl8l1 to consider and address potential problems with the plan 8l1d its in1plementation. The treatment review should include the key staffresponsible for the youth (including the security, clinical and educational stafJ). In all possible cases the specific youth shouldparticipate in the treatment review. The purpose ofthe review/meeting would be to develop a specific and detailed behavioral plan that is designed to
3

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 28 of 37 PAGEID #: 2992

safely supervise the youth in the program - without relying on seclusion/isolation;
2. Obtaining the prior written approval ofthe Deputy Director of DYS responsible for Facility programming; and
3. Providing written notice to the United States and monitor within 24 hours of a yonth exceeding three days of seclusion within a single month, describing the amount of seclusion, reason for seclusion, treatment provided in response to seclusion, whether the youth's behavior intervention plan was modified or created, and alternatives to seclusion that were rejected.
D. Refrain from imposing restraints as an alternative to seclusion.
6. In my opinion, these limitations are reasonable, appropriate, and capable of being implemented in a short period of time without causing significant disruption to security and operations.

I declare under penalty of perjury that the foregoing is true and correct.

Executed on March 7, 2014

C!dtJ eM
Pl(ul DeMuro

4

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 29 of 37 PAGEID #: 2993
Exhibit I, Consulting Prospectus
DeMuro: CONSULTING PROSPECTUS
PROFESSIONAL EXPERIENCE
Forty-three years experience managillg people, programs, budgets and processes for youth serving programs; extensive experience providillg a wide range of consultiilg services to support progressive efforts to improve programs for troubled youth and families. Examples: Functions as a senior consultant to the Annie E. Casey Foundation's child welfare and juvenile justice initiatives; helps plan and evaluate innovative child welfare and juvenile justice projects. Experienced at conductiilg fact-findiilg evaluations of community-based and illstitutional programs; retained by public illterest attorneys in a variety of federal and state court cases. Experienced expert witness.
Developed mediated settlements ill child welfare and juvenile justice class action litigation ill Oklahoma, Tennessee and Hamilton County, Ohio. Appoillted by Federal Courts ill Florida and Oklahoma and New Orleans to monitor consent decrees designed to improve services for children, youth and families. Designed case management systems for Hawaii's and Missouri's state youth services organization; conducts risk assessment studies and other policy studies for a variety of states; designs and conducts training seminars for child welfare and juvenile justice staff. Editor, Violent Juvenile Offenders: An Anthology, 1984; co-author, Reforming the California Youth Authority, 1988; author of Annie E. Casey training monographs and several articles; former Vice-president, National Council on Criine and Delillquency. Held a variety of leadership positions withiil state governments: e.g., Pennsylvania Commissioner of Children and Youth. Curriculum vitae available.
CONSULTING SERVICES
Developing and Monitoring Court Ordered Settlements
Designs, implements and monitors step-by-step plans to comply with court ordered mandates, usually as a result of class action litigation. Examples: Developed settlement agreements/court ordered implementation plans for class action law suits ill Florida, Indiana, New Mexico, New Orleans, Oklahoma, Tennessee and Hamilton County, Ohio. Appoillted by Federal District Courts to serve on Court appointed Panels to develop and negotiate settlement agreements, and ill Oklahoma and Florida to monitor class action settlements. Able to develop agreements among parties regardillg settlillg class action litigation.
Fact Finding, Negotiating and Expert Witness Services
Organizes and implements fact-findillg investigations to help resolve litigation involving
1

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 30 of 37 PAGEID #: 2994
Exhibit I, Consulting Prospectus
public and private youth serving agencies. Expert in assessing conditions of confinement. Identifies and leads highly qualified teams of professionals to evaluate community based and institutional programs. Able to enter adversarial situations, discover the facts, and assist in either resolving/mediating the case or preparing for trial. Experienced at interviewing children, youth and staff involved in law suits. Has helped develop settlement agreements and has testified at numerous trials in Federal and state courts. Examples: Retained by the Civil Rights Division of U.S. Justice Department and public interest law firms to investigate and document alleged unconstitutional conditions in a number of private and public institutions throughout the country.
Policy Oriented Research
Over forty years experience writing and directing policy studies, articles, reports, evaluations and other materials designed to analyze public policy questions and present alternative courses of action. Examples: Directed risk assessment studies of institutional populations in five states; these studies often help bring about major organizational change. Retained by state legislative committee in Tennessee to conduct studies on juvenile justice issues, child welfare and managed health care issues. Co-authored book analyzing California's juvenile justice system. Co-edited a book on violent juvenile offenders and published a number of reports and articles concerning troubled youth and public policy.
Evaluation and Technical Assistance
Conducts management and program evaluations of public & contracted youth serving programs and agencies. Analyzes problems and develops specific recommendations. Examples: Foundation supported evaluation of Hawaii's juvenile justice system (nopportunity for Refo=n, 1987) and program evaluation of Toledo, Ohio's substance abuse programs; developed mediated settlement in a New Mexico conditions of confinement case (2009). Conducts comprehensive evaluations of detention centers and training schools. Examples: evaluation of Maryland training school (Hickey) which led to the refo= and privatization of that institution; evaluation of Cleveland's detention center and Toledo's detention system. Conducts program and systemic reviews of public youth serving programs for state legislative committees. Example: Review of Iowa's residential programs for delinquent youth. Provides technical assistance/planning to Directors of state agencies. Examples: Senior consultant to the Annie E. Casey's highly successful initiative aimed at reforming juvenile detention (JDAl) in several public jurisdictions. Helped develop case management and day treatment services in Missouri. Assisted public interest law firm in Mississippi to close a refo= school for girls (Columbia).
Plan and Conduct Staff Training
Plans, directs and offers a variety of training workshops, seminars and other training efforts designed to improve the skill level and knowledge of direct service staff.
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 31 of 37 PAGEID #: 2995
Exhibit I, Consulting Prospectus
Examples: designed and conducted team-building and case management training for executive staff ofthe Missouri and Alabama Departments of Youth Services. Plans and conducts skill-building workshops for public defenders sponsored by the American Bar Association; plans and conducts training workshops for child welfare staff sponsored by the Anuie E. Casey Foundation: Conducts child welfare training: e. g. ,"Team Decision Making" in a number ofjurisdictions.
Direct Services -- Program Development
Plans, organizes and implements innovative and cost effective, youth services within gove=ent and non-profit organizations at the local, state and national levels. Examples: Developed statewide system ofnon-residential interventions in Massachusetts for adjudicated delinquents. Planned and directed nationally recognized community-based program model for adjudicated delinquents in Cook County. Planned crisis intervention program for Toledo, Ohio. Implemented model correctional program for the U.S. Department of Justice, developing multi-site, state-of-the-art, intensive, secure programs for violent juvenile offenders.
PARTIAL CLIENT LIST Government Agencies:
U. S. Justice Department, Civil Rights Division, Washington, DC.
State Human Service Departments, Child Welfare & Juvenile Justice Agencies: (e.g., Hawaii, Indiana, Missouri, New Jersey, Oklahoma, Pennsylvania, Tennessee & Texas)
State Legislative Committees: Iowa & Tennessee
County Human Service, Child Welfare & Juvenile Justice Agencies: (e.g. Cook, Ill.; Cuyahoga, Hamilton, Lucas Counties, Ohio; Jefferson County, Ala.; Multnomah, Oregon.)
County Juvenile Probation: (e.g.. Lucas Co. Ohio; Tarrant County, Fort Worth, Texas)
Federal Courts:
Federal District Courts: Tallahassee, Fl.; Oklahoma City, OK. & Washington, DC
Private Foundations:
The Anuie E Casey Foundation, Baltimore, Maryland. The MacArthur Foundation, Chicago, Ill.
3

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 32 of 37 PAGEID #: 2996
Exhibit I, Consulting Prospectns
Public Interest Law:
The American Bar Association's Juvenile Justice Center Juvenile Law Center, Philadelphia, PA National Center for Youth Law, San Francisco Public Defenders Office, Dade Co" Fl Youth Law Center, San Francisco. The Southern Poverty Law Center, AL
Private Attorneys:
Goldstein & McGroder, Phoenix, Arizona Robert Link, Jacksonville, Fla. Covington & Burling, Washington, DC
Research, Policy & Technical Assistance Centers:
The National Juvenile Detention Association The John Howard Association The Urban Institute.
List of Publications and Reports As of 1/31114
Books
Violent Juvenile Offenders: An Anthology, National Council on Crime and Delinquency, 1984. Co-editor.
Reforming The California Youth Authority, Common Knowledge Press, 1988. Co-author.
Articles and Reports [some co-authored]
"Preliminary Plan: Reducing the Population in Florida's Training Schools", March 1986. Report to the Federal District Court, Tallahassee, Fl.
"Report of the Jerry M. Panel", March, 1987. Submitted to Washington, D.C. Superior Court.
"Adjudicated Youth in Delaware Who Need Secure Care", National Council on Crime And Delinquency, 1987.
"Hawaii's Juvenile Justice System: Opportunity for Reform", August 1987. Funded by the Clark Foundation, New York, NY.
"Resisting the Adultification of Juvenile Corrections: Rational Programs for Violent Juvenile
4

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 33 of 37 PAGEID #: 2997
Exhibit I, Consulting Prospectns
Offenders", American Psychological Association Newsletter, Winter, 1988.
"At the Crossroads: A Population Profile of Youth Committed to the Alabama Department of Youth Services", 1989. Funded by the Clark Foundation, New York, NY.
"Population Profile and Risk Assessment Study: Mississippi Department of Youth Services", February 1989, Center for Study of Youth Policy, University of Michigan.
"Risk Assessment of Adjudicated Delinquents, Division for Children and Youth Services, State of New Hampshire," December 1989, Center for Study of Youth Policy, University of Michigan.
"Framework for Dispositional Decisions", Alabama Division of Youth Services, 1990.
"In Search of Excellence: Reflections Regarding the Improvement of the Missouri Division of Youth Services", April 1990.
"Comprehensive Services for Oklahoma's Delinquent, Deprived, lNT & lNS Children: The Terry D. Panel Report", December 1990. Submitted to the Federal District Court, Oklahoma City, Oklo
Final Report of the Alabama Detention Project", July 1991. Prepared for the State of Alabama, Juvenile Detention Advisory Committee.
"Final Report: Iowa's Service Delivery System For China & Delinquent Youth", June 30, 1993. Study conducted for the Iowa State Legislature.
"OverCrowding in Juvenile Detention: Some Concrete Suggestions", June 1996.
"Conditions of Confmement Review: Cuyahoga County Juvenile Detention Center", NJDA, September 1997.
"Developing Partnerships with Neighborhoods and Local Co=unities", the Family to Family Initiative, the Casey Foundation, 1997.
"Team Decision-making: Involving the Family and Co=unity in Child Welfare Decisions", the Family to Family Initiative, the Casey Foundation, 1997.
A Reasonable Alternative to Locking More Kids Up: The Development of Jurisdictional Core Groups, [with Earl Dunlap], Special Edition: Journal for Juvenile Justice Issues. and Detention Services, NJDA, Spring, 1998.
Crowding in Juvenile Detention Centers: A Problem Solving Manual, [with Sue Burrell, Earl Dunlap, Carl Sanniti and Loren Warboys], OJJDP, December 1998.
Consider the Alternatives: Planning & Implementing Non-Secure Detention Alternatives", the Casey Foundation, November, 1999.
5

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 34 of 37 PAGEID #: 2998
Exhibit I, Consulting Prospectus
"Be All You Can Be - Reflection on Leadership Development & Staff Training", Spring 2003, Journal for Juvenile Justice and Detention Services, Spring 2003. "Good News From Toledo: Real Improvements in Detention", Journal for Juvenile Justice and Detention Services, Fall 2003. "Boot Camps Revisited", Journal of Juvenile Justice Services, National Partnership for Juvenile Services, Vol. 22, # 1,2008. "Why Child Welfare Agencies Should Limit the Role of Residential Care", Journal of Juvenile Justice Services, National Partnership for Juvenile Services, Vol. 22, # 1,2008. "Toward Abolishing the Use ofDisciplinary Isolation in Juvenile Justice Institutions: Some Initial Ideas", January 22,2014. Published on the web.
6

CEaxshei:bi2t :I0, c8v-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 35 of 37 PAGEID #: 2999
Paul DeMuro: 1201 Futch Creek Rd., WilnringtonNC2841l. 91O-681-378l. e-mail: PDeMuro@aol.com
Paul DeMuro
PROFESSIONAL STRENGTHS
* Providing a wide variety of consulting services to youth serving agencies
* Planning and conducting fact-finding and dispute resolution efforts
* Planning and directing program and policy oriented research and evaluation efforts * CommUnicating effectively to staff, the public and media
* Planning and implementing successful programs
* Providing imaginative and cost effective leadership for innovative youth policy
initiatives
* Managing complex contract, budget, personnel and program interventions * Planning & providing a variety of stafftraining initiatives * Supervising, developing and motivating staff * Producing successfully under intense financial, political and time pressures
BACKGROUND
Forty three experience managing staff, programs, budgets and processes designed to improve a wide variety of youth serving agencies. Experienced at conducting fact-finding evaluations. of community-based and institutional programs; expert on conditions of confinement. Retained by the US Justice Department and public interest attorneys in a variety of federal and state court cases. Experienced expert witness. Developed mediated settlements in child welfare class action litigation in Oklahoma, Tennessee and Hamilton County, Ohio. Appointed by Federal Courts in Florida and Oklahoma to monitor statewide consent decrees designed to improve services for children, youth and families. Designed case management systems for Hawaii's and Missouri's state youth services organizations; conducted risk assessment and policy studies for state and county agencies; designed and conducted trai..iJ.i.ng seminars for child welfare and juvenile justice staff. Presently serves as a senior consultant for the Annie E. Casey Foundation and the National Juvenile Detention Association. Consulting prospectus, list of publications and references available upon request. Married with four children. Interests include reading, tennis and music.
1

CEaxshei:bi2t :I0, 8cv-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 36 of 37 PAGEID #: 3000
Paul DeMuro: 1201 Futch Creek Rd., Wilmington NC 28411. 910-681-3781. e-mail: PDeMuro@aol.com
EDUCATION
BA, Villanova University, 1963.
MA, Villanova, 1965.
EMPLOYMENT HISTORY'
1983 - to present. Founder andprincipal staffof a small, flexible consulting fi= that provides a variety of policy, program, management and conflict resolution services to private and public youth serving agencies. Clients include the US Justice Department, federal Courts, state and county agencies, private foundations, public interest attorneys and the private Bar,
1979 - 1983. Vice-Presidentfor Program Services, National Council on Crime and Delinquency. Responsible for field related activities of nationally prominent criminal justice agency. Managed national projects, maintained liaison with other national and state organizations; conducted policy and evaluation studies; supervised and delivered technical assistance to state and local juvenile justice agencies. Prepared and delivered testimony to US Congress and state legislative bodies. Prepared publications; developed and offered training to professional staff. While with NCCD, directed two national juvenile justice projects: (1) Citizen Advocacy Network project, a $1.5 million dollar, four state effort to involve local citizens in efforts aimed at improving their juvenile justice systems; (2) Violent Juvenile Offender Research and Development Project, a $3.5 million dollar project aimed at testing innovative interventions for violent offenders: developed program models and request for proposals; supervised competitive bidding process; and oversaw all fiscal and program reporting to the US Justice Department.
1978 - 1979. Commissioner ofChildren and Youth, Pennsylvania Department ofPublic Welfare. Responsible for $300 million dollars of state funding to provide management and program supports for services to over 35,000 children and youth. Policy and program responsibilities included the state's day care, child welfare and juvenile justice programs. Prepared budgets, developed regulations, drafted legislation and represented the Governor's office in local, state and national negotiations. Supervised the state training school system.
2

CEaxshei:bi2t :I0, 8cv-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 37 of 37 PAGEID #: 3001
Paul DeMuro: 1201 Futch Creek Rd., WihuingtonNC2841I. 910-681-3781. e-mail: PDeMuro@aoI.com
1975 - 1978. Director, Office ofCorrections Education. Created and directed this office which had fiscal, planning and evaluation responsibility for educational programs in the state's run adult and juvenile correctional institutions which held over 9,000 offenders.
1973 - 1975. Director, Unified Delinquency Intervention Services, Illinois Department ofChildren and Family Services. Planned and implemented this nationally recognized model that serves adjudicated youth. UDIS diverts youth from institutional placement by using a network of community-based placements and strong case management.
1970 - 1973. Massachusetts Department ofYouth Services (DYS). With DYS held three positions of increasing responsibilities: Assistant Commissioner for Aftercare (1972 - 73), supervised all non-institutional programs for adjudicated youth (e.g., parole, group homes, non-residential interventions, etc.). Supervised seven regional offices with 220 staff and a purchase of service budget of $5 million; Director ofNon-Residential Programs ( 1971 - 72), developed and administered a statewide network of non-residential interventions providing educational, vocational, counseling and mentoring supports to more than 1000 youth living at home or in foster care. Sponsors of programs included churches, community groups and traditional youth serving agencies. Superintendent, Shirley Industrial School (1970- 71), responsible for 125 bed refonn school for "hard core" delinquents aged 14 - 18.
1963 - 1970. University English Instructor, Ohio State University (1965 - 70); Villanova (1963 -1965).
3

 
 Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 1 of 32 PAGEID #: 3239
Monitors’ Review of DYS’ Contracted Programs for Girls
S.H. v Reed (Civil Action No. 2:04-cv-1206) U.S. v State of Ohio (Civil Action No. 2:08-cv-475)
Submitted by: Kelly Dedel, Ph.D., Lead Monitor, U.S. v State of Ohio Will Harrell, J.D., Lead Monitor, S.H. v Reed Daphne Glindmeyer, M.D., Subject Matter Expert Andrea Weisman, Ph.D., Subject Matter Expert Submitted November 30, 2015

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 2 of 32 PAGEID #: 3240
Table of Contents
Introduction .................................................................................................................... 3
 Column A: MH Assessment, Treatment Planning and the Provision of Services .. 8
 Column B: Use of Seclusion in Response to Aggressive Behavior ......................... 15
 Column C: MH Response to Youth who Engage in Aggressive Behavior ............. 20
 Summary and Conclusions ........................................................................................... 32

2.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 3 of 32 PAGEID #: 3241
Introduction
On May 20, 2014, the Parties to S.H. v Reed (Civil Action No. 2:04-cv-1206) and U.S. v State of Ohio (Civil Action No. 2:08-cv-475) filed a joint motion for entry of an agreed order to resolve the issues remaining in both Settlement Agreements. The resulting Court Order required DYS to undertake specific actions, outlined in “The Grid” (Exhibit A to the Order), to improve mental health services and reduce the seclusion of male youth on the mental health caseload at three DYS facilities. Compliance with the Grid at Circleville, Cuyahoga Hills and Indian River is discussed in a separate report.
The Court Order clearly indicates that the Grid applies only to “youth at facilities directly managed by DYS,” but goes on to specify that “youth at other facilities shall receive mental health services consistent with those described [in the Grid] but appropriately tailored for such non-DYS managed facilities.” In other words, DYS needs to ensure that comparable services are delivered to girls who are served at facilities contracted by DYS.
The parameters for monitoring the provision of services at non-DYS facilities are also clearly articulated in the Court Order. Rather than monitoring that includes the extensive activities discussed in Doc 359 in S.H. v Reed or in Doc 85 in United States v Ohio, monitoring for the girls facilities was limited to “a review of youth files or other materials requested by the monitor or subject matter experts” (i.e., a paper review). If the Monitor or subject matter experts identified a troubling practice among the documents they reviewed, the Parties would then meet and confer to negotiate additional access. Fortunately, this did not occur during the review of documents or the various explanatory discussions held among the Monitors, subject matter experts and DYS staff.
Our findings should be viewed within the context of the limited access granted by the Court Order. Although the review of documents was ultimately reassuring (i.e., the documents did not reveal troubling practices that warranted more in-depth access to the facilities), the methodology specified in the Court Order limited what the Monitor and subject matter experts could know about the facilities and thus what the Team is able to say about the delivery of services. On one hand, the documentation and data surrounding seclusion practices (Column B of the Grid) were sufficient for the Monitor to conclude that the girls’ facilities have comparable (in some cases, better) practices to what the Team has seen in the DYS facilities for boys. Conclusions about mental health treatment were slightly more difficult given that the subject matter experts were not able to interview youth or staff or observe group treatment, which would normally be a central part of their program assessments. Fortunately, given their greater access to the facilities, DYS provided the Monitoring Team with extensive documentation flowing from a variety of quality assurance and technical assistance activities. These documents were very helpful in assessing the quality of care and also cause the Monitoring Team to feel confident in DYS’ capacity to conduct robust quality assurance activities designed to continue to improve the quality of services to girls.
3.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 4 of 32 PAGEID #: 3242
Ultimately, the Monitoring Team found sufficient evidence to state that quality mental health treatment was occurring at all three facilities.
Originally, the Team reviewed records, data and other documentation for girls housed in the facilities between September 2014 and February 2015 (i.e., the same review period used for our most recent assessment of DYS’ facilities for boys). In June 2015, one of the three facilities (CAS) was placed on a Corrective Action Plan by DYS to remedy problems associated with the use of seclusion and the quality of mental health treatment. In order to assess the magnitude of improvements, the Team reviewed a second set of records, data and other documentation for girls housed in the facilities during July, August and September 2015. Our opinions about the extent to which services for girls are comparable to those available to DYS boys are based on data from both time periods.
DYS’ Contracted Facilities for Girls
In mid-2014, DYS closed its Girls’ Unit at the Scioto Juvenile Correctional Facility. The girls housed at Scioto were either released to the community on an aftercare plan or were transferred to one of three facilities that DYS contracted to provide services for girls committed to DYS custody. The facilities include:
• Center for Adolescent Services (CAS) operates a 15-bed unit exclusively for girls committed to DYS. Upon completion of a 3-day clinical intake, the Clinical Intake Assessment is sent to the DYS Administrator for Female Placements and Programs. When a girl is identified with a mental health diagnosis, referrals are sent to one of the two residential mental health facilities (below). Girls who do not transfer to the mental health facilities remain at CAS.
• Applewood is licensed by the Ohio Department of Mental Health and Addiction Services (ODMHAS) as a Type I facility, providing room and board, personal care and certified mental health services to adolescent girls, age 12 to 18. DYS contracts for six beds at Applewood. Applewood’s ODMHAS license is current until 8/23/17.
• Pomegranate is also licensed by the Ohio Department of Mental Health and Addiction Services (ODMHAS) as a Type I facility and provides the same type of care as Applewood to adolescent girls, age 12 to 20. DYS contracts for 10 beds at Pomegranate. Pomegranate’s ODMHAS license is current until 1/26/2016.
Combined, these three facilities served a total of 53 DYS girls between September 1, 2014 and September 30, 2015. Six girls had more than one admission during that period of time. On September 1, 2014, there were 14 girls at CAS, 6 girls at Pomegranate and 4 girls at Applewood (total, 24 girls). On October 15, 2015, there were 6 girls at CAS, 9 girls at Pomegranate and 6 girls at Applewood (total, 21 girls).
4.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 5 of 32 PAGEID #: 3243
DYS Oversight of Contract Facilities for Girls
DYS fortified its regular contract monitoring (predominantly a financial audit) to include a monitoring process to oversee the quality of services delivered (“DYS monitoring”). DYS staff make frequent (i.e. 2-3 times per month) visits to the facilities and a formal monitoring report is also produced every 6 months. The first DYS monitoring reports were issued in April/May 2015 and the second round was issued in October 2015. Components include:
• Youth involvement in programming • Grievance, legal assistance, and PREA protections • Physical plant assessment • Licensure and certifications • Treatment services, including whether interventions are evidence-based and whether
families are engaged, as well as the frequency of individual and group sessions • Youth File Reviews to assess intake assessment and treatment planning, case notes,
and discharge planning • Education and Medical services • Incident reporting, crisis management and disciplinary practices, including the use of
seclusion and the use of physical restraints • Youth and staff interviews
CAS: DYS staff visited the facility at least 3 times per month during both review periods, and met monthly with Court Administrators and CAS administrators. The May 2015 DYS monitoring report did not identify any deficiencies related to services required by the Court Order. However, in the Monitor’s opinion, the report could have benefitted from a more quantitative, detailed focus with regard to the extent to which treatment plans and case notes were judged to be adequate and the extent to which the seclusion policy was being followed. The first DYS monitoring report described what should happen, but did not delve into whether practices are conforming to policy. Seclusion data are now available to DYS through the AMS system, which should facilitate this type of analysis.
Shortly after the first DYS monitoring report was issued, data regarding the implementation of CAS’ revised seclusion policy became available. While DYS noticed a significant decrease in the duration of seclusion episodes, an increase in the frequency with which seclusion was also evident. As a result, DYS placed CAS on a Corrective Action Plan to ensure that seclusion was used only as a last resort and only in response to an imminent threat to safety of youth or staff. As required by the Plan, as of July 31st, the policy was revised slightly and all CAS staff were retrained to limit the situations in which seclusion is used. DYS conducts on-going targeted reviews to ensure that seclusion is used appropriately. In addition, in June 2015, DYS became concerned about a lack of documentation that reflected the delivery of individual and group treatment that DYS knew to be occurring. A Corrective Action Plan was implemented to ensure existing databases were utilized to capture progress notes from all providers, with the results to be reviewed with DYS on August 31, 2015. Subsequent
5.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 6 of 32 PAGEID #: 3244
information provided by DYS showed that the seclusion policy has now been implemented as designed and that the quality of mental health services has improved considerably.
The October 2015 DYS monitoring report indicated that the new Director appears to have energized the facility. New activities have been implemented (e.g., field day, contests, recreation activities) and the physical environment had been upgraded with new furniture and room decorations. The University of Cincinnati has been providing technical assistance to improve the quality of treatment planning. While the DYS monitoring report indicates that seclusion practices “closely mirror DYS practices,” summary data on the use of room restriction would be useful in future reports to provide a baseline against which subsequent review periods can be measured.
Pomegranate: DYS staff visited the facility at least 3 times per month during both review periods (occasionally as often as 7 times per month) and met with both the CEO and Clinical Director of the program. The May 2015 DYS monitoring report describes a program that is safe and treatment-focused and did not identify any deficiencies related to the services required by the Court Order. During the review period for this report, the facility hired a Compliance Manager to ensure that policies were properly implemented, to handle grievances and to manage licensure. Just before the first review period for this report began, concerns about the Alternative Program (discussed in more detail, below) were identified by one of the Plaintiff’s counsel. While the problems were resolved during the review period, it would have been helpful for the DYS monitoring report to include both the history and the current practices for the Alternative Program as a response to violent behavior in order to illustrate that, in its current form, it is not a seclusion-based intervention. [As a result, the Alternative Program was not monitored during the July/August/September 2015 period.]
The October 2015 DYS monitoring report indicated that DYS girls had all been moved to one unit, which made managing the schedule easier and prevented many of the treatment disruptions that were caused by multiple clinicians serving this population (i.e., individual treatment and group treatment appointments sometimes overlapped). The physical environment of the facility had improved and furnishings had been upgraded. The substance use treatment curriculum was upgraded, and work continued on improving the specificity of substance use related treatment goals. The facility, at DYS’ suggestion, is working to establish a treatment team process.
Applewood: DYS staff visited the facility once per month during the first review period, and the frequency increased to two or three times per month during the second review period. The April 2015 DYS monitoring report describes a program that is focused on safety and treatment and did not identify any deficiencies related to the services required by the Court Order. The October 2015 DYS monitoring report noted an expansion of the substance use treatment options, now provided by a full-time AOD counselor. Services were previously contracted. DYS monitors also noted that treatment files are extensive due to the high volume of treatment youth receive (e.g., 3 to 4 hours of group treatment per day, plus
6.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 7 of 32 PAGEID #: 3245
individual sessions). The DYS monitoring report also applauded Applewood staff’s interactions with the Release Authority on behalf of DYS girls.
In addition to overall program monitoring, DYS also deploys behavioral health resources to monitor the quality of treatment being provided by each of the three girls’ programs (“QA process/reports”). Using the same quality assurance tools used to review treatment at DYS’ boys’ facilities, DYS behavioral health staff review treatment plans and case notes for two girls on each clinician’s caseload. A QA summary of the September-October 2015 reviews was provided to the Monitoring Team, along with the score sheets for each file that was reviewed. The recommendations resulting from these QA reviews focused mostly on improving the individualization of goals and objectives and ensuring the correspondence between goals and objectives and the content of treatment sessions. When deficiencies were noted (and not many were), DYS provided targeted technical assistance and observed rather immediate improvements among some of the clinicians.
In summary, DYS has developed a solid protocol for overseeing the girls’ programs and has implemented a robust quality assurance process that goes well beyond traditional “contract monitoring.” Not only did the Monitoring Team conclude that treatment services and seclusion practices are, for the most part, comparable to the boys’ programs, but also that DYS’ process for assessing quality and improving program performance is as robust as what is implemented in DYS’ boys’ facilities.
In the next sections of this report, the Monitor and subject matter experts briefly describe what the Grid requires of the DYS facilities and then discuss the services that are provided to the girls in the contracted facilities and whether they are comparable to what the Grid requires. The discussion is organized around the Columns that were the defining feature of the Grid: Column A refers to the quality of mental health assessments, treatment planning and the provision of mental health services (reviewed by Dr. Glindmeyer); Column B refers to the use of seclusion as a response to youth’s aggressive behavior (reviewed by Dr. Dedel); and Column C refers to the mental health response to youth who engage in violent behavior (reviewed by Dr. Weisman).
7.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 8 of 32 PAGEID #: 3246
Column A. (Reviewed by Dr. Glindmeyer)
Mental Health Assessments, Treatment Planning and the Provision of Mental Health Services
What the Grid requires of DYS facilities.
 Column A of the Grid was developed to ensure that youth receive adequate mental health
 assessments, appropriate treatment planning with goals derived from the assessments, and
 mental health treatment that is consistent with stated treatment goals.

This portion of the Grid has two parts. The first is to verify treatment integrity. The Grid requires that quality assurance tools are developed and that audits are conducted to ensure that individual treatment is aligned with treatment goals, and that group therapy treatments display fidelity to design. As such, it would be necessary for case review or record review to reveal correlation between the content of individual sessions and treatment goals. It would also be necessary for group therapy interactions to be reviewed to ensure treatment fidelity.
The second potion of Column A focuses on mental health assessments. The Grid requires that quality assurance tools are developed and audits are conducted to ensure that an initial BioPsychoSocial assessment, inclusive of a broad range of information from a variety of sources that is summarized in a clinical diagnostic formulation, is developed. Then the clinical issues identified via the assessment must be reflected in the youth’s treatment plan. As such, it would be necessary for case review or record review to assess the quality of the diagnostic formulation and the treatment plan developed as a result.
The following review assesses the extent to which the contracted girls’ facilities: 1) exhibit treatment integrity with regard to correlation between the content of individual sessions and treatment goals; 2) have group therapy interactions that reveal treatment fidelity; 3) develop appropriate BioPsychoSocial assessments that are appropriately summarized in a clinical diagnostic formulation; and 4) develop treatment plans that are based on the issues identified via the clinical diagnostic formulation.
Methodology In order to determine the level of compliance with Column A for facilities housing female youth, multiple documents were reviewed. As the subject matter expert for Column A was not able to make site visits per the Court Order, DYS provided extensive information obtained via their own on-site monitoring. This included the following:
• DYS provided descriptive information regarding the units at CAS, Applewood, and Pomegranate. This included the process by which each youth is assessed and transferred from CAS to a mental health destination facility (i.e. Applewood or Pomegranate) if mental health treatment is determined to be necessary.
8.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 9 of 32 PAGEID #: 3247
• As Applewood and Pomegranate would not provide copies of policies to the Monitoring Team, DYS conducted an in-depth review of policy and procedure from each program and responded to specific questions from the Monitoring Team. With regard to Column A, this included: o The structure of mental health services at both Applewood and Pomegranate. o Individual treatment planning process at both Applewood and Pomegranate. o Provision of mental health treatment at both Applewood and Pomegranate. o Documentation of mental health services at both Applewood and Pomegranate.
• DYS provided detailed information regarding mental health treatment services at each of the facilities. This included the names and the schedules of each of the mental health providers at the facility, the mental health treatment schedule (i.e. number of groups each youth received weekly, and the amount of individual therapy each youth received weekly). Information also included the types of groups that were provided to the girls (i.e. DBT, stress reduction, emotional regulation).
• A list of all girls who were housed in any of the three facilities between September 2014 and February 2015. This included information regarding which facilities each girl was housed in.
• Results of surveys for residential services performed by their state licensing agency, the Ohio Department of Mental Health and Addiction Services. o The Applewood survey was performed September 4, 2013. This survey was essentially a quality assurance review that included a review of the youth’s personal care plan and progress notes. It was noted that the license renewal for Applewood was approved August 24, 2014 with an expiration date of August 23, 2015, and then extended to August 23, 2017. o Pomegranate was reviewed October 28, 2014. While the review of Applewood noted above included a review of mental health documentation, this documentation was not included for Pomegranate. Regardless, the Pomegranate survey was performed October 28, 2013 and the current license expires January 26, 2016.
• While the programs declined to release information regarding facility-generated quality assurance, DYS performed multiple monitoring site visits to the programs and provided reports of their ongoing contract monitoring, which included a review of mental health treatment services. As such, although the subject matter expert was not able to independently visit and observe treatment, ODYS provided reports of their observations of the services rendered.
These summaries were based on multiple site visits as described below:
9.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 10 of 32 PAGEID #: 3248
o Pomegranate was visited by DYS reviewer, Nan Hoff, on eighteen occasions between January 12,2015 and April 27, 2015. An additional twenty visits occurred between May 15, 2015 and September 30, 2015.
o CAS was visited by DYS reviewer, Nan Hoff, on twenty occasions between October 2, 2014 and April 29, 2015. An additional seventeen visits occurred between May 7, 2015 and September 17, 2015.
o Applewood was visited by DYS reviewer, Nan Hoff, on eight occasions between October 15, 2014 and March 24, 2015. An additional twelve visits occurred between April 9, 2015 and October 5, 2015.
• Medical records for specific youth were provided: o At CAS, many of the girls only remained there a short time pending referral and transfer to either Applewood or Pomegranate. As such, a summary of assessments, orientation, group attendance, and progress was provided for a total of seven youth (TL, AL, DT, JM, AW, AY and CS). For the second review period, documentation was provided for youth LB, JW, and KR. In addition, two conference calls regarding the treatment/treatment planning of youth LB were held. o Three youth records from Applewood were provided for review (AL, CS, and TL). For the second review period, documentation was provided for youth VW and AS. o Six youth records from Pomegranate were provided for review (AW, AY, BE, DT, JM, and RLB).
• Given reviews at CAS where DYS determined inadequacies existed, action plans were authored. The action plan pertinent to Column A was regarding documentation of treatment services. In the initial document request, information from CAS, specifically treatment documentation was missing. While there was notation that treatment occurred, it was included in the daily log. As such, DYS made the decision to draft an action plan which has reportedly been both well received and implemented by CAS. Conversations with DYS behavioral health staff indicated that interim reviews of treatment documentation indicated improvement. Ultimately, DYS determined that ongoing quality assurance monitoring would occur at all three facilities.
• On July 29, 2015 an interim review of the progress toward compliance with the CAS action plan for documentation of mental health treatment was conducted by DYS. Per this review, treatment specialists had been entering progress notes effective June 12, 2015. Furthermore, DYS, via the Chief of Behavioral Health Services, provided a detailed review of CAS documentation dated July 31, 2015. Per this review: o Group notes regarding nine different youth were reviewed, individual progress notes from South Community Behavioral Health Care regarding four different youth were reviewed, and individual progress notes regarding two different youth from Wright State University School of Professional Psychology were
10.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 11 of 32 PAGEID #: 3249
reviewed. This review included a qualitative analysis of the CAS documentation inclusive of documents provided via contracted providers (South Community Mental Health Center and Wright State University School of Professional Psychology). This document included areas in need of improvement and indicated plans to address areas in need of improvement via staff training. There was also documentation of plans for ongoing quality assurance reviews to determine ongoing improvement and compliance with the corrective action plan.
• Subsequent QA reviews were performed at all three facilities. The review for the month of August (completed October 5, 2015) and for September (completed November 2, 2015) revealed in-depth quality assurance monitoring of the integrated treatment plan and case notes at all three facilities. Group therapy was observed at both Pomegranate and CAS. Applewood group therapy could not be observed due to confidentiality issues. Youth who were not assigned to DYS also participate in these groups. In addition, treatment team meetings were observed at all three facilities. o Quality assurance monitoring indicated that DYS is identifying issues at all facilities; specifically, areas where cross-training and technical assistance are necessary. This is the goal of quality assurance. What is most important is that DYS is able to identify areas where improvement is necessary and develop technical assistance to address weaknesses.
What the documents revealed is provided to girls at the facilities contracted by DYS.
CAS With the initiation of this monitoring review, DYS developed program monitoring and quality assurance reviews for CAS. In doing so, weaknesses were identified at CAS and corrective action plans were developed. Action Plan 4 specifically addresses the documentation of treatment services provided at CAS.
While it is noted that CAS is not technically a mental health facility, diagnostic assessments, treatment plans, individual therapy, and group therapy are provided. Action Plan 4 requires that the youth’s treatment and progress in treatment is recorded in the JCS (Juvenile Court System) database. In addition, progress notes from outside providers must be included in the youth’s record. This Action Plan requires a joint review by CAS and DYS by August 31, 2015. In the interim, the Chief of Behavioral Health Services of DYS conducted a review of CAS documentation dated 6.1.15 through 7.15.15. This review revealed areas of improvement in that CAS is now documenting group therapy via case notes, and documenting the specific CBT skill taught in the group. The review also identified additional areas in need of improvement. For example, the review noted the need for individualization of progress notes, better descriptions of the methods utilized to teach CBT skills, documentation of the youth’s understanding of a specific skill, documentation of the youth’s progress in treatment
11.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 12 of 32 PAGEID #: 3250
(or the lack thereof), and better correlation with the individualized service plan (treatment plan).
In an effort to ensure ongoing progress, CAS and DYS have developed a QA plan, and DYS plans to implement a QA process at CAS similar to that present in the facilities that house boys. This would reportedly include a review of group therapy interaction, file review using QA tools, with onsite training and coaching as necessary. In conversation with DYS staff, it was noted that CAS administration is willing and open to improvement efforts.
Documents inclusive of seven youth records were provided for review. These records predated the improvements noted in the DYS review documented above. The strength of the CAS program is the initial youth assessments. These were individualized, generally detailed, and provided information to allow for the development of an individualized service plan, or as titled at CAS, the personal program plan.
However, the personal program plan was essentially a checklist and not individualized. Goals were not measurable, nor were specific interventions identified outside of a checklist of available group interactions. Progress notes regarding group and individual therapeutic interactions were included in shift notes and did not describe the group therapy or individual therapy adequately. As noted above, these documentation issues were being addressed via ongoing QA review by DYS with corrective action plans developed as needed to include staff training and mentorship.
For the second review period, additional youth records and quality assurance monitoring results were reviewed. This revealed marked improvements in the documentation of treatment including individual and group therapies. Quality assurance monitoring is ongoing. While there remain issues in documentation, (e.g. the need for consistent treatment goals, consistent use of SOAP note format for documentation of group therapy), what is important is that improvements are apparent and DYS is able to identify the weaknesses and has plans for ongoing technical assistance to address these.
Applewood DYS performs contract monitoring site visits at this facility. Between 10.1.14 and 4.1.15, eight visits were conducted. Documentation received from this facility included three youth records containing mental health assessments, individualized service plan, group counseling notes, and individual counseling notes. While checklists were utilized to populate some sections of the mental health assessments, a case formulation was included. These were individualized and provided information to allow for the development of the treatment plan (service plan).
Service plan goals did not appear to be individualized, with similar goals noted in different records. There was a need for improvement in documentation in both group and individual therapy progress notes. For example, improvements in goal development would allow for these goals to be addressed in individual therapy with progress toward specific goals
12.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 13 of 32 PAGEID #: 3251
outlined in the progress notes. However, even with the documentation issues, it was apparent that treatment was occurring at this facility.
QA is also performed by the facility, although these data were not available for review. DYS reported plans to obtain the records of girls receiving treatment at this facility and to perform their own record reviews for QA purposes on a regular basis.
For the second monitoring period, an additional twelve DYS contract monitoring visits occurred between April 9, 2015 and October 5, 2015. In addition, DYS has implemented in depth quality assurance of treatment team meetings, individualized treatment plans, and case notes. As group therapy at this facility includes youth not assigned to DYS, group therapy encounters were not observed. Quality assurance monitoring for this facility revealed that goals and objectives for treatment planning were written in template format; however, other information, specifically the specific needs of the individual youth with regard to mental health treatment was individualized.
Pomegranate DYS performs contract monitoring site visits at this facility. Between 1.12.15 and 5.12.15, 18 visits were conducted. Documentation received from this facility included six youth records containing the diagnostic assessment, individualized service plan, group therapy progress notes, and individual therapy progress notes. While the group and individual counseling notes were descriptive of the treatment provided, there was a need for improvement in the case formulation development. However, even with the documentation issues, it was apparent that treatment was occurring at this facility.
QA is also performed at this facility, although these data were not available for review. DYS reported plans to obtain the records of girls receiving treatment at this facility and to perform their own record review for QA purposes on a regular basis.
For the second monitoring period, an additional twenty DYS contract monitoring visits occurred between May 15, 2015 and September 30, 2015. In addition, DYS has implemented in-depth quality assurance of the individualized treatment plan, case notes, group therapy observations, and treatment team meetings. Quality assurance monitoring for this facility revealed that goals and objectives were similar for all girls and that some therapy notes were superficial. There were also therapists who demonstrated therapy notes that were well written.
Whether the services received by the girls at facilities contracted by DYS are comparable to those delivered to the boys at DYS facilities, and therefore, whether DYS is in substantial compliance with the Court Order.
Please note that this review has limitations, as the monitors and subject matter experts were not able to visit the facilities, meet with clinicians, interview youth, observe group therapies,
13.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 14 of 32 PAGEID #: 3252
or conduct other activities typical of a facility review. As such, it was necessary to rely on a review of youth records and other reviews conducted by DYS behavioral health staff. In the DYS facilities housing boys, DYS has done a good job of developing quality assurance (QA) tools, using these tools to identify weaknesses in the system, and developing corrective action plans to address these weaknesses. This has resulted in an adequate quality assurance program. Admittedly, the early QA activities conducted via DYS have been staff dependent; however, over time, it is hoped that these activities will become routine, and utilized at both the central office and facility level to effect change in the system.
Per the DYS quality assurance review of CAS, it was reported that mental health services were occurring commensurate with what is occurring at the boy’s facilities. While in the initial review, this was not directly seen in the documents reviewed by the subject matter expert, DYS has reviewed the documentation and expressed confidence in the treatment being provided. DYS also has pledged to continue QA monitoring of this facility. For the second review period, treatment documents revealed improvements. In addition, DYS quality assurance monitoring has continued on a monthly basis. Again, while this has revealed improvements, there remain issues that have been identified and are being addressed via technical assistance. As such, to the extent possible given the limits of the methodology for this review, services appear to be commensurate to those provided to the boys.
At Applewood and Pomegranate, it was apparent that treatment was occurring. Both of these facilities have their own QA process, although the results were not available for review by the Monitoring Team. In addition to the current site visit monitoring that DYS is conducting, DYS Behavioral Health staff review the treatment records for youth receiving treatment in these facilities for QA purposes. Although the need for improvements in documentation was noted, there was no question that treatment was occurring. As a result, to the extent possible given the limits of the methodology for this review, services appear to be commensurate to those provided to the boys. For the second review period, ongoing quality assurance monitoring revealed results consistent with the first review for both of these facilities.
14.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 15 of 32 PAGEID #: 3253
Column B. (Monitored by Dr. Dedel)
Use of Seclusion in Response to Youth’s Aggressive Behavior
What the Grid requires of DYS facilities.
Column B of the Grid was designed to reduce the reliance on seclusion as a response to youth’s aggressive behavior. Ultimately, DYS was required to prohibit the use of disciplinary seclusion (which it did as of January 1, 2015) and to significantly reduce the length of time that youth remained in pre-hearing seclusion immediately following a violent incident. The length of stay could no longer be pre-determined and was to be based on the youth’s readiness to safely return to regular programming. A regular schedule of opportunities for youth to process their behavior with staff is required, starting at the 4-hour mark, and then repeating every 3 hours if the youth initially refuses. Pre-release interviews (i.e., Safe to Release interviews) are designed to inquire about the underlying causes of the youth’s behavior and how the youth might respond differently in the future.
The following review assesses the extent to which the contracted girls’ facilities: 1) impose seclusion as a disciplinary sanction for violent misconduct; and 2) utilize seclusion as an immediate response to a youth’s violent behavior and how long that seclusion lasts.
What the documents revealed is provided to girls at the facilities contracted by DYS.
Applewood and Pomegranate Per ODMHAS licensing requirements, seclusion is not permitted at either facility. Nothing in the documents received indicated that the practice is ever used at Applewood. DYS staff reported that the doors to the youth’s rooms do not lock and the facility does not have “seclusion rooms.” Furthermore, the Quality Assurance review indicated that youth who are agitated may be placed on 1x1 status, where a staff person remains with the youth at all times, including sitting outside the open doorway if the youth is in her room.
While seclusion is also not permitted at Pomegranate, just before the first review period began (August 2014), one of the Plaintiff’s attorneys received reports from girls that they were being placed in “Alternative Program” (AP) for several days at a time and that AP consisted of serving time in a hallway where the doors at both ends and rooms on the sides were locked. Girls had little interaction with staff and program services were not continued during this time. While it was not imposed in the traditional way (i.e., hallway versus resident’s room), Plaintiffs counsel and the Monitoring Team felt that AP had the essential features of “seclusion.”
Subsequent discussions with DYS led to shared concern and DYS administrators took immediate steps to change the practice. In early September 2014, DYS administrators visited the program and communicated their concerns to the program’s CEO, who also took
15.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 16 of 32 PAGEID #: 3254
immediate action. Following staff meetings on all three shifts, the Alternative Program policy was immediately revised (effective 9/9/14), staff were re-trained and youth were informed about what they should expect. AP was immediately adjusted to remove the features that created the greatest concern and now does not include any type of seclusion in a locked room or area.
Currently, youth may be placed on AP immediately following an aggressive incident in order to separate them from potential victims. They are in a hallway, but are permitted free access to their rooms and have a place to sit, eat, and do treatment and school work. Staff are present at all times and are constantly interacting with the youth. DYS staff have been invited back multiple times to observe the program and to talk to girls who’ve spent time in it and have found that it is being implemented as designed.
Although it is troubling that these problems were not discovered by the program itself, or by DYS during the course of its program monitoring, both the facility and DYS enacted procedures to ensure that disciplinary practices continued to be aligned with DYS policies and program licensing requirements. The facility hired a Compliance Manager and one of her tasks is to monitor the AP. DYS is also informed every time a youth is placed in AP, for what reason and for how long. These incidents are compiled in a running log, which was provided to the Monitor. During the 1st 6-month review period for this report, AP was used 7 times, with an average length of stay of 25 hours (range 11-39 hours).
As noted above, youth are no longer secluded while on AP, so the various provisions required by the Grid for DYS facilities do not apply. As a result, AP was not monitored during the 2nd review period.
CAS CAS is part of a community corrections facility, not a mental health facility, so it is not subjected to the same licensing requirements regarding seclusion as Applewood and Pomegranate. During an August 2014 site visit, one of the Plaintiff’s attorneys indicated that several girls indicated that they’d been placed in seclusion for either 24- or 48-hour periods. While these lengths of stay were commensurate with what DYS permitted in its facilities at the time, in a conversation with the Monitoring Team in September 2014, DYS noted that it intended to ensure that CAS’ policies and practices regarding seclusion evolved alongside DYS’.
CAS drafted a new policy (3C-11) in mid-September 2014 that included all of the major components required by the Grid. The policy:
• Prohibits the use of room confinement as a punishment and permits its use only for the purpose of de-escalation/imminent threat;
• Requires 30-minute assessments/justifications if the restriction is going to be
 continued;

• Gives the line staff authority to release the youth once calm;
16.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 17 of 32 PAGEID #: 3255
• Requires the Program Director to become involved if the youth has not been released at the 8-hour mark;
• Includes an insight-oriented component (requires a Thinking Error Report); and • Is fortified by the “Rules of Conduct” policy, which does not list room confinement as a
permissible sanction for any of the rule violations.
Since then, DYS has pushed further to ensure that CAS’ policy reflects the best practices identified in the DYS-managed facilities. Currently, DYS and CAS are working to implement a Corrective Action Plan that includes: 1) ensuring that room confinement is used only as a last resort; 2) better structuring the assessment of the youth’s readiness for release; 3) referring all youth placed on room confinement to the clinical team; 4) reviewing room restriction data on a weekly basis to ensure compliance with policy; and 5) reviewing all AMS reports on a daily basis at DYS Central Office.
While the policy was drafted in September 2014, it was not implemented until March 1, 2015 due to distractions caused by County and Court Administrator program audits. That said, the table below show a declining average length of stay and increasingly larger proportions of youth who were released within 4 hours (the threshold set by DYS’ new policy and the Grid).
Of the 45 seclusion episodes during the 1st review period (October 2014-April 2015), 56% (n=25) were completed in 4 hours or less, 13% (n=13) were completed in 4-8 hours, 11% (n=5) were completed in 8-12 hours, and 20% (n=9) lasted longer than 12 hours (all of which included an overnight stay). The average length of stay during the 1st review period was 6.06 hours and the longest length of stay was 26.1 hours. These data are comparable to the durations observed at the DYS-managed facilities during the review period.
Of the 49 seclusion episodes during the 2nd review period (May 2015 through September 2015), 92% (n=45) were completed in 4 hours or less. Only 3 episodes (6%) were between 4 and 8 hours, and only 1 episode (2%) was between 8 and 12 hours. The average length of stay during the 2nd review period was 1.84 hours and the longest length of stay was 8.80 hours. These lengths of stay are significantly shorter than those witnessed in the DYS boys’ facilities at the conclusion of the monitoring period for boys (August 2015).
As noted in the introduction to this report, DYS closely oversees the use of seclusion at CAS by reviewing AMS reports on a daily basis and providing feedback to the site about whether the use of seclusion appeared to be justified or whether alternative strategies could have been effective. This oversight, coupled with a additional policy revisions completed in July 2015 have decreased the frequency of seclusion to levels that approximate what occurs in DYS’ boys facilities.
17.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 18 of 32 PAGEID #: 3256

CAS: Use of Seclusion, October 2014 through September 2015

Oct Nov Dec Jan Feb Mar Apr May June July

ADP

6.7

8.9 11.5 10.3 10.1 10.0 9.2 6.8

9.3 9.9

# episodes

~

5

10

5

1

11 13

5

12

16

% less than 4 hrs.

~

20% 30% 20%

~ 91% 77% 100% 100% 88%

% 4 to 8 hrs.

~

60%

~

40% 100% ~

~

~

~ 13%

% 8-12 hrs.

~

~

20%

~

~

~ 23% ~

~

~

% 12+ hrs.**

20% 50% 40%

~

9% ~

~

~

~

ALOS

0.0

7.3 12.29 12.2 6.0 3.07 1.6

1.3 1.24 1.89

LOS range

~

2.017.5

1.221.5

1.526.1

~

0.5- 0.5- 0.519.2 11.9 1.5

0.5- 0.53.0 5.37

*Most of the seclusion episodes lasting more than 8 hours included an overnight stay (8.75 hours of total time were sleeping hours).

Aug 9.2 9 89% 11% ~ ~ 1.9 0.55.75

Sept 8.7 7 71% 14% 14% ~ 2.88 0.428.80

One of the concerns that led to the Grid’s development was the accumulation of seclusion hours on certain youth with high-frequency aggressive behaviors. During the 1st review period, two girls had a significantly higher number of seclusion episodes than the others. One (S.S.) had 8 total episodes with a total seclusion time of 120.5 hours over a 5-month period. This translates to her spending approximately 3.3% of her time in custody in seclusion. The other (S.J.) had 7 total episodes with a total seclusion time of 42.50 hours over a 2-month period. This translates to her spending approximately 3.0% of her time in custody in seclusion. During the 2nd review period, one girl (L.B.) accounted for 23 of the 32 seclusion episodes (72%) in July, August and September. Her total time in seclusion (53.3 hours) translated to only 2.5% of her time in custody. These rates of accumulation are significantly below the levels that originally generated concerns about the use of seclusion at the DYS boys’ facilities.
The key mechanism for shortening the length of stay in seclusion is the use of a robust process for assessing the youth’s readiness for return to the regularly scheduled activities of the unit. CAS has implemented a process that is as strong as any reviewed by the Monitor across the country. CAS’ Room Restriction Form requires a detailed description of the youth’s behavior that qualifies as a threat to self or others and supervisory approval of the initial placement in seclusion. Every 30 minutes thereafter, staff members must provide a narrative description of the youth’s mood, attitude, behavior, statements, non-verbal cues, etc. that justify either the continued use of room restriction or the youth’s removal. After one hour, the On-Duty Administrator interviews the youth and determines whether she can safely return to scheduled programming or whether she remains a threat to self or others and must remain in room restriction.

18.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 19 of 32 PAGEID #: 3257
The Monitor reviewed the Room Restriction forms for all 32 youth who were placed in Room Restriction during July, August and September 2015. Only very small and very infrequent errors were noted among them (e.g., a single missing or late 30-minute check; justifications for continuing room confinement that could have used some additional information). It’s worth highlighting that it is not CAS’ protocol or format for review that makes its process so outstanding, but rather the level of detail and richness of descriptions that are provided by CAS’ staff about the girls’ situations at any given time.
Whether the services received by the girls at facilities contracted by DYS are comparable to those delivered to the boys at DYS facilities and therefore, whether DYS is in substantial compliance with the Court Order.
Currently, neither of the two facilities licensed by ODMHAS utilizes any behavior management practice that includes secluding a girl alone in a locked room. While prior to the beginning of the review period, implementation problems with the Alternative Program at Pomegranate did result in girls being secluded in a locked hallway, once the problem was brought to the program administrator’s attention, the practice ceased. This has been verified by DYS staff who make frequent on-site visits to the facility. The Alternative Program remains an option, but the girls are not secluded and continue to be engaged in programming throughout their time in AP. In summary, the document review completed by the Monitor indicated that current behavior management practices at Applewood/Pomegranate are aligned with what was required by the Grid at the DYS-managed boys’ facilities.
CAS uses seclusion to de-escalate a youth who is out of control, but the new policy drastically shortened the length of stay. Data from the past 12 months reveal that the frequency and duration of the seclusion episodes (even before the new policy was put into effect) are very short, compatible with what is commonly necessary to de-escalate a youth who is a threat to self or others, and are similar to what has been witnessed at the DYS boys’ facilities. Furthermore, the process for assessing youth’s readiness to return to regular programming is outstanding. Youth are assessed very frequently (i.e., every 30 minutes) and staff provide rich, detailed narratives about the youth’s current state of mind at each interval. Taken together, CAS’ use of seclusion easily satisfies the requirements of Column B of the Grid.
In all three facilities, a structured quality assurance process has been implemented to ensure that services meet the needs of the girls housed at the facilities. DYS is encouraged to include quantitative seclusion data in its QA reports for CAS. DYS’ close oversight of the use of seclusion at CAS, coupled with its demonstrated willingness to use the Corrective Action tool to ensure that practices are aligned with DYS managed facilities, create considerable confidence that continued external oversight around the use of seclusion from the Monitoring Team is not necessary.
19.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 20 of 32 PAGEID #: 3258
Column C. (Monitored by Dr. Weisman)
Mental Health Response to Youth’s Aggressive Behavior
This report provides observations of each of the girls’ facilities during two distinct monitoring periods. The first monitoring period covered the six months between January and June 2015. The second monitoring period covered the three months between July and September 2015. Findings for each facility for these distinct time frames will be noted in the text as Review One (January – June, 2015) and Review Two (July – September, 2015).
What the Grid requires of DYS facilities.
There are two essential requirements of Column C, and while the girls’ facilities do not have to provide identical services, they must provide comparable services. The first requirement is a review and potential revision of the individual treatment plan following each AOV. In reviewing this documentation it was clear that each of the facilities provided both individual and group interventions in a timely manner following each girl’s involvement in a single AOV. Documentation does not specifically identify the AOV in the intervention notes, however the focus of these sessions is on emotional regulation which is clearly a clinical issue informing the girls’ behavioral dyscontrol.
This report will not dissect these interventions. It must be assumed that the facilities are providing appropriate care given their licensing requirements by the Department of Mental Health and the fact that the girls only engaged in one AOV. This speaks to the effectiveness of their interventions.
The second requirement of Column C is a formalized process in place to address the mental health needs of youth who engage in repeated acts of violence (AOV). Within DYS secure facilities for boys, youth who engage in repeated AOVs are managed by Special Review Teams (SRT) consisting of the youth, the youth’s primary clinician, Unit Manager and social worker. The purpose of the SRT is to identify the causes and functions of the AOVs, to prescribe more intensive interventions aimed at addressing the root causes of the behavior, and to recommend updates to the Individual Service Plan (ISP).
The focus of this report will be on the facilities’ clinical management of girls’ who engage in repeated AOVs.
Methodological Note.
The facilities did not provide their policies for the auditors to review. We were also unable to make site visits to the facilities, observe programming or speak with the girls. As a result, this report relies heavily on the extensive analysis and on-going QA activities by ODYS and the subject matter expert’s thorough review of the following documents:
20.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 21 of 32 PAGEID #: 3259
v For Round Two, the Monitoring Team received DYS Behavioral Health Quality Assurance summary (dated 11/2/15) and the underlying score sheets for each record reviewed. This QA protocol mirrors that implemented in the DYS boys’ facilities. This Behavioral Health QA review was summarized in the introduction to this report.
v For each monitoring period, the Monitoring Team received Nan Hoff’s monitoring reports as follows:
• Review One – CAS (5/15/15); Pomegranate (5/12/15); Applewood (4/1/15) • Review Two – CAS, Pomegranate and Applewood (10/13/15)
Information contained in these documents is summarized in the introduction to this report.
v For each monitoring period, the Monitoring Team received facility-specific Incident Tracking forms detailing the dates, incident descriptions and consequences of AOVs for individual youth:
• Review One – Pomegranate (2– 7/15); Applewood (1/15 – 6/15)1 • Review Two - CAS, Pomegranate and Applewood (7/15 – 9/15)
This information was used to identify the number of girls who met the AOV threshold so that the subject matter expert could ascertain whether they received services comparable to what is required by the Grid. It should be noted at the outset that there were a total of 28 youth in residence at the three facilities during the first review period. During this period, seven youth met the SRT threshold, or 25%. During the second review period there were 21 youth in residence. Of these, only three met the SRT threshold, or 14%. This speaks to the relative infrequency of a youth engaging in multiple AOVs, and to the overall improvement in the facilities’ management of some of the most challenging behavior.
v For each monitoring period the Monitoring Team received youth-specific treatment plans and progress notes.
v Since the Monitoring Team did not have access to the facilities’ policies, on August 14, 2015, the Chief of Behavioral Health Services provided the Monitoring Team with a detailed memo describing the processes in place at each of the facilities for their management of youth who engaged in AOVs.
1 The Monitoring Team did not request a specific listing of AOVs for Round 1, relying instead on DYS’ identification of girls who engaged in AOVs. In Round 2, the Team requested and received this list so that the identification of girls who engaged in AOVs was made independently.
21.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 22 of 32 PAGEID #: 3260
Given the small number of youth involved in the review from each of the three facilities, calculation of compliance ratings in terms of percentages makes little sense. Instead, evidence of compliance, when it occurs, is noted for each youth.
Pomegranate
Review One (1/15 – 6/15): DYS provided the following background on Pomegranate policies based on their site visits, document reviews and interviews with staff and youth. The following processes are in place to respond to and address AOVs:
• In-the-moment processing of AOVs; • CBT Packets as part of the Alternative Placement intervention2; • Critical Incident Reviews following incidents in which a youth causes or sustains a
serious injury (though none of the DYS girls have been involved in an incident which would trigger such a review); • Monthly SAVE Committee (i.e., Staff Against Violent Environments) in which the underlying causes of restraints are examined and specific interventions are prescribed.
The subject matter expert reviewed the mental health records for six girls. Of these, five had had altercations that met the SRT threshold. In each instance, the therapist met with the youth immediately following the incident to process the event, and the youth was subsequently returned to programming. In one instance, a youth (JM) received an extra 90 days due to her altercation. Pomegranate has no requirement that the ISP be reviewed and revised or modified following AOVs.
DYS provided substantial information to help us better understand how the other interventions, listed above, provide services that are functionally equivalent to the SRT process that is available to DYS boys. To summarize the information the Monitoring Team received from DYS:
According to policy, after each act of violence, there is a Critical Incident Review (CIR), that includes staff, a shift supervisor and administrative staff. Monthly there is a Staff Against Violent Environments (SAVE) committee meeting which reviews all AOVs. It is within this forum that Root Causes of the AOVs are addressed. While there is no formal written policy to govern this, programming operates from a CBT/DBT model, which dictates that any behavioral concerns are reviewed, discussed and worked into the client’s individual case
2 As noted previously in this report, Pomegranate uses what they refer to as Alternative Programming for some youth who engage in AOVs. AP does not have a pre-determined duration. Programming is taken to youth who are on AP and staff is always present. With regard to Column C requirements, one of the requirements while on AP is to complete a CBT packet related to the event leading to AP and to process the information in the packets with staff. The youth’s primary clinician is required to meet with the youth while on AP.
22.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 23 of 32 PAGEID #: 3261
conceptualization. That conceptualization of the case translates into interventions within the client’s program and related to the client’s ISP goals. Safety plans are used as needed. By policy, treatment team meetings are to be held “no less than once a month and at clinical junctions,” though the current practice is to have weekly team meetings and clinical staffings are scheduled more frequently if needed.
DYS conducted in-depth reviews of CIR and SAVE meeting minutes and talked about the process with program staff. In their summary report provided to the monitors, DYS stated, “CIRs are triggered by a youth causing or sustaining serious injuries, etc., and are targeted to ascertain the cause of the incident / outcome and to learn from the incidents to avoid critical incidents in the future. No DYS girls have needed a CIR in the recent past.” DYS reported that the SAVE committee minutes focuses on institutional reforms that responded to trends noted in AOVs and other undesirable occurrences. For example, DYS noted that ”The July 2015 SAVE minutes included the following: revamp the coping skills, addressing what the youth need to be successful, providing tangible items for the youth to use, implementing a pilot program, and creation of behavior management plans.”
In addition, DYS reported that, “The SAVE Committee did a day-by-day break down of restraints in June. They discovered some trends as it related to days of the week and addressed staffing levels on those days. The Committee also reviewed a list of kids who had the highest number of restraints and the Restraint Reduction Group was assigned to meet and further discuss those youth.”
Although DYS’ information suggested that the CIR and SAVE Committee meetings had been implemented as prescribed in policy, the Monitoring Team was also interested in whether these interventions were effective in reducing violence among girls with mental health issues. On 8/13/15, DYS provided the following outcome data:
• Five girls would have met the criteria for SRT at some point over the past 16 months; • The range of days the SRT would’ve been active ranged from 14 to 73 days. [Note that
by policy, the minimum active time is 14 days.] The median was 25 days. • No girl would have met the SRT criteria in the month immediately following her initial
SRT, though one girl would have again met criteria 4 months later.
Subject Matter Expert’s Assessment: Review One.
Although the subject matter expert was not personally able to review some of the documentation related to Column C, DYS made every effort to fill in the blanks by going on site and reviewing the substance of the relevant documentation. The Monitoring Team was provided with detailed findings from the DYS staff conducting these reviews. The documents the subject matter expert personally reviewed, along with the summaries received from DYS, suggest that although Pomegranate does not have an SRT per se, the immediate intervention following the AOV, ongoing clinical interactions and the CIR and SAVE meetings combine to form a comparable process to what is in place for boys at DYS. Outcome data suggest that
23.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 24 of 32 PAGEID #: 3262
these have been effective in limiting the girls’ involvement in AOVs.
Review Two (7/15 – 9/15): Pomegranate had no youth who engaged in repeated AOVs during this monitoring period. To be clear, none of the girls met the threshold for an SRT. There was one AOV in July, two in August and two in September. Only one girl had two AOVs within this time frame, but those were spaced so as to not meet the requirements.
This is remarkable progress. As DYS noted in their report (8/13/15), five girls had met the SRT threshold in the prior 6 months. In the subsequent three months reviewed, no girls met the threshold. This certainly suggests improvement in Pomegranate’s management of these events.
In her Monitoring report of 10/13/15, Nan Hoff notes the many changes that have been implemented at Pomegranate. According to her report:
• DYS girls are now housed on one unit making it easier to provide programming. • The unit the girls are housed on has been softened. All girls painted murals on the
walls of their rooms, and a mural for the common area is underway. • Girls are able to attend community activities such as weekend home passes, shopping
with staff, going to museums, walking in the neighborhood and going out for dinner. • Educational achievement of the girls is going well with two girls having graduated
high school and one attending college. • A Treatment Team model that meets monthly with each youth is being implemented. • The Director of Pomegranate has scheduled refresher training for all staff on trauma
informed care.
These changes are huge and no doubt account for the calming of the youth on the unit. The collaboration between DYS and Pomegranate resulting in Pomegranate’s use of strategies now commonly in use in DYS facilities is to be commended. Issues such as the softening of the environment, implementing treatment teams, community-outings and a greater focus on trauma-informed care are clearly having a positive impact on the behavior of the girls.
Subject Matter Expert’s Assessment: Review Two.
Pomegranate has made significant progress in their ability to provide meaningful services to the DYS youth in their care. Evidence of this is the reduction of youth with repeated AOVs from the first to the second review. At the time of Nan Hoff’s review, there were 9 girls in residence at Pomegranate. None of the girls at Pomegranate met the threshold for an SRT. The benefits of the collaborative relationship between DYS and Pomegranate are clearly in evidence.
However, a concern remains about the lack of individualization of treatment plans for girls at Pomegranate. The plans reviewed by the subject matter expert were nearly identical. It is
24.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 25 of 32 PAGEID #: 3263
recommended that going forward DYS and Pomegranate work on improving the girls’ treatment plans. DYS has noted the similarity in goals and objectives (as stated in their 11/2/15 Quality Assurance Summary) and plans to continue to work with the clinicians on this issue.
Applewood
Review One (1/15 – 6/15): DYS provided the following background on Applewood’s policies based on their site visits, document reviews and interviews with staff and youth, the following process are in place to respond to and address AOVs:
• In-the-moment processing of AOVs; • Addressing AOVs during regularly scheduled treatment interventions; • Reviewing AOVs during weekly clinical rounds and prescribing necessary

interventions;
 • Monthly team meetings that include summaries of issues that can be then integrated
into youth’s treatment, reflected in progress notes; and • 90-Day Review Meetings.
These interventions are all prescribed by policy, and DYS’ oversight verified their implementation. Although the program did not provide policies to the Monitoring Team, DYS responded to a series of structured questions from us about the substance of policies. DYS reported that according to policy, acts of violence should be processed with staff in the moment, if feasible. Client cases should be reviewed weekly in clinical rounds. Participants in clinical rounds should consist of the entire treatment team. At this time any/all incidents should be reviewed, as well as the youth’s response to interventions and progress in treatment. Additionally, clients should be individually reviewed monthly with the treatment team and community stakeholders (i.e., probation officers, legal guardians, custodians, etc.).
The subject matter expert personally reviewed mental health records for three girls. Of these, two had engaged in AOVs that met the SRT threshold. The mental health records consisted of Group Therapy Notes, Individual Therapy Notes, Partial Hospitalization notes and an Intake Mental Health Assessment.
For the period 1/31 – 3/2, Applewood reported five serious incidents. Youth AL was responsible for four of these incidents. ISP goals and interventions, developed upon intake, were focused on “emotional regulation” and substance abuse. There was evidence that AL’s AOV were addressed in the context of a group on two separate occasions (3/5 and 3/6/15).
Applewood may use a “shut down” intervention and/or a “cottage restriction.” In policy, these practices are defined as follows: “Shut Down: Failure to follow transition rules i.e., remaining in assigned hallway during hygiene routine or causing a significant bedtime disruption,
25.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 26 of 32 PAGEID #: 3264
continually out of area, or using doorway that sounds an alarm. Client will be restricted to sitting in their room during all transition periods. (2) Cottage Restriction: Attempted or successful AWOL as defined as leaving campus without permission will result in 72-hour cottage restriction.” It is said that these are used in rare circumstances. However, all three of the girls had experienced these or other consequences following their AOV: Youth AL – Separation Plan, Youth CS – Shut Down, Youth TL – Unit Restriction.
Youth TL was placed on Unit Restriction for a lengthy period due to her unrelenting selfinjurious behavior. During this time she was not able to attend groups in an abundance of caution for her safety. She did however, receive focused individual therapy during this period. She was also placed on a Safety Plan that was reviewed weekly. It is clear from reviewing the Safety Plans developed between 4/16/15 and 6/8/15 that the strategies Applewood was implementing had the desired effect because over this period TL was able to earn back restricted items and begin attending groups.
Although DYS’ information suggested that the various interventions had been implemented as prescribed in policy, the Monitoring Team was also interested in whether these interventions were effective in reducing violence among girls with mental health issues. On 8/13/15, DYS provided the following outcome data:
o Five girls met criteria for an SRT at some point in time over the last 16 months. o The range of days the girls would have been on an SRT ranged from 14 to 29 days
(Note: the minimum is 14 days since a person is kept on the SRT for a minimum of 14 days following the date they meet the threshold). The median was 19 days. o Only one girl would have gone back on an SRT after coming off her first SRT. o No girls would have met the criteria for an SRT in the month following the month she came off an SRT (i.e., in consecutive months).
Subject Matter Expert’s Assessment: Review One.
There is sufficient evidence to assert that Applewood addresses AOVs in a manner consistent with Column C requirements. Some of the supporting documentation that would have provided additional evidence that their formalized processes are in place seems to be attributable to their manner of documentation. Meetings in which more than one youth is discussed do not appear in the individual notes of the youths’ in question, and thus were not provided to the Monitoring Team in response for our request for individual treatment records.
Applewood’s treatment plans are not individualized. The treatment plans for the three girls reviewed were nearly identical – this despite the fact that the girls presented with some of the same, but some distinct issues. It is recommended that DYS monitor the adequacy of Applewood’s case formulations and their relationship to service provision. As with Pomegranate, it is recommended that DYS work with Applewood to improve the girls’
26.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 27 of 32 PAGEID #: 3265
treatment plans.
Review Two (7/15 – 9/15): Applewood had two youth who met the SRT threshold during this review period:
• TL - AOVs: 7/24 (H), 7/27 (S) and 8/3 (S) • TW - AOVs: 9/19 (S) and 9/28 (S)
TL is the same youth reviewed in Round One, and she remained unsafe during the second review period. Following TL’s AOV on 8/3/15, she received individual or group counseling everyday from 8/6/15 through 8/15/15.
There are two notes indicating that TW directly addressed the restraint episode related to her AOV during an individual therapy session on 9/23; the second note states that TW brought up her AOV during group on 9/24. Thereafter, TW received a daily combination of individual and group therapies from 10/1 -10/15/15.
Subject Matter Expert’s Assessment: Review Two.
Applewood’s policies and practices conform to the requirements of Column C. While Applewood’s documentation does not exactly mirror what is required of clinicians at the boys’ facilities, there is ample evidence that the girls are receiving services which are at least as intensive as those the boys’ receive.
The subject matter expert again notes the lack of individualization of treatment plans. The treatment plans for both girls are nearly identical and do not seem to be reviewed or revised following an AOV.
CAS
Review One (1/15 – 6/15): The subject matter expert personally reviewed the mental health records for six youth. There was considerable overlap of youth who were presented at Pomegranate and Applewood. The following youth appeared in multiple settings:
• AL (CAS and Pomegranate) • AW (CAS and Applewood) • AY (CAS then Pomegranate then CAS) • TL (CAS and Applewood)
This is because, as noted previously, CAS serves as both the receiving facility for girls to be served in any of the three facilities and as a provider of services for those youth determined not to be in need of more specialized mental health services. If the youth evidences mental health concerns, she is referred to either Applewood or Pomegranate. On occasion, girls who do not do well in these more therapeutic programs, or who are determined not to have
27.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 28 of 32 PAGEID #: 3266
mental health concerns of sufficient severity to require their maintenance in these programs, are returned to CAS.
Of the six girls reviewed by the subject matter expert, three had engaged in AOVs. None of these met the threshold for an SRT. The only information provided regarding CAS’ response to these events indicated that:
• Youth AW: placed in her room on 15 minute checks • Youth DT: physically restrained, placed in room and on Unit Restriction • Youth AY: placed on a behavior contract
In addition to the types of interventions that were provided and whether they were functionally equivalent to what is provided to the DYS boys, the Monitoring Team was also interested in whether CAS’ services were effective in reducing violence among the girls. According to data reviewed by ODYS (8/21/15): “CAS went 11 consecutive months with no girl meeting the criteria for an SRT. One girl met the criteria in July (that was the first one to meet the criteria in 11 months). Since then, a medication consultation has occurred for her. Medication adjustments have been made. SOPP is providing individual therapy. Family members have been brought in and family sessions are starting. (In addition), a case conference with Pomegranate was held to see about the possibility of them getting involved.”
This youth will be discussed in greater detail in the second review.
Subject Matter Expert’s Assessment: Review One.
Documentation provided from CAS was insufficient to comment on their processes in addressing youth who engage in repeated AOVs and the extent to which they may be comparable to what occurs in the ODYS facilities for boys.
CAS has entered into a Corrective Action Plan with DYS to ensure that their documentation is more robust:
• The Treatment Specialists have been entering JCS notes effective June 12, 2015. These notes reflect the resident’s progress in CBT groups. These notes are continuously being reviewed to ensure they are clear and individualized to the resident
• CAS has begun providing copies of Individualized Service Plans, Diagnostic Assessments and therapeutic goals for all residents on their caseload. As of August 1, 2015 they will be providing notes regarding each therapy session.
28.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 29 of 32 PAGEID #: 3267
• The psychiatrist will provide weekly updates on youth seen and monthly psychiatric notes.
Review Two (7/15 – 9/15): One youth (LB) accounted for nine of the 14 AOVs that occurred during this time frame (63%). LB engaged in three Severe AOVs in July, four Severe AOVs in August and two Severe AOVs in September. She is the only youth to have met the SRT threshold. It should be noted that she is the first youth to have met this threshold in 11 months.
LB is a very complicated case and managing her assaultive, oppositional behavior has been a huge challenge for all concerned. DYS Central Office’s involvement in this case and general oversight of CAS’ clinical management of DYS youth in their care has been extensive and impressive. There have been multiple case conferences and visits between DYS and CAS to jointly development a clinical strategy to address her needs. On 9/23, Dr. Dachowski (who participated in all case conferences) spoke directly with Dr. Hart about LB’s diagnoses and medications. There have been two case conferences that involved staff from CAS, DYS Central Office, and the mental health subject matter experts. All this clinical dialogue resulted in articulation of a set of strategies to address her behavior and underlying issues, among which was a decision to place LB on a behavior management plan. On 10/6, Dr. Stinson shared a draft behavior management plan with CAS for their input and on 10/7 he went to CAS to present the plan to LB.
The level of clinical attention devoted to LB meets or exceeds the requirements of Column C.
There have been remarkable improvements in the quality of clinical service provision at CAS. Perhaps most importantly, in the time since the first review, CAS has a new director with a treatment focus. According to Nan Hoff’s monitoring report (10/13/15), the following improvements have been implemented at CAS:
• Monthly clinical meetings which the youth attends (analogous to a treatment team); • University of Cincinnati Is working with the CAS clinical staff In the development
individualized goals and objectives for the girl; • Inclusion of girls in all levels of decision-making regarding the changes that are
occurring.
• Colorful, softer furniture has replaced the harder institutional furniture; • Colorful artwork and posters are now displayed in the main hallway greeting all who
enter; • Girls are now able to hang pictures and quotes on the walls of their rooms;
Nan Hoff notes in her monitoring report that, “with the arrival of a treatment focused director and changes, there’s a major culture change going on.”
29.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 30 of 32 PAGEID #: 3268
Subject Matter Expert’s Assessment: Review Two.
CAS has demonstrated remarkable improvement in their delivery of treatment services for DYS girls. This is undoubtedly a result of the hugely successful collaboration between CAS and DYS Central Office, and the newly appointed treatment oriented director. The hoped for outcome of the CAP, and oversight by DYS has occurred. CAS is now functionally equivalent to the DYS boys’ with regard to Column C requirements.
Other Services Provided to DYS Girls at Contracted Facilities.
Pomegranate While not directly related to Column C indicators, surely it can be said that the groups, programs and activities offered at a facility play a role in engaging youth and reducing the likelihood of AOVs. Pomegranate offers a rich array of groups and activities, including:
• Values in Ourselves • Art Making Studio • Breaking the Ice • Decision Making • Team Building • Life Skills • Self-Esteem • Positive Skills • Life Skills • Understanding Symptoms • Behavior • Team Building • Decision Making While the groups have different foci, in all, basic Dialectical Behavioral Therapy (DBT) skills are emphasized. In reading through group notes, the array of strategies used to engage youth appears thoughtful and accessible.
Applewood Among the groups offered at Applewood are:
• CBT • Social Awareness • Emotional Healing through Art • Stress Reduction • Emotional Regulation • Nurture and Grow • Creative Cultural Art • Bibliotherapy • Resiliency
30.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 31 of 32 PAGEID #: 3269
• Self-Care/Hygiene • Anger Management • Relational Aggression • Boundaries • Needs, Wants and Expectations • Communication • Beyond the Violence • Empathy and Compassion • Conflict Resolution • Me, Myself and I • How to Train Your Dragon • Healthy Habits • Independent Living Once again, this is a rich array of groups and activities that engage youth in a variety of modalities focused essentially on emotional regulation.
CAS The groups offered at CAS are:
• Motivation to Change • DBT Emotional Regulation • EQUIP • Girls Moving On • Strengthening Families
Girls may be enrolled in two different groups at any given time.
Whether the services received by the girls at facilities contracted by DYS are comparable to those delivered to the boys at DYS facilities, and therefore, whether DYS is in substantial compliance with the Court Order.
Both Applewood and Pomegranate are licensed mental health facilities that provide a rich array of programming to DYS girls. Information obtained directly from the providers and summaries from DYS about information they collected while on site suggest that the programming received by girls in these facilities following an AOV is comparable to what boys in ODYS facilities receive. DYS oversight and technical assistance to these facilities is excellent.
CAS is not a mental health facility and so the level of therapeutic programming is contemplated to be somewhat reduced. While programming at CAS is not comparable to what is offered at Pomegranate and Applewood, overall CAS has made enormous gains in their clinical service provision and documentation. The corrective action plan that DYS placed CAS on is having its intended effect.
31.

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 32 of 32 PAGEID #: 3270

Summary & Conclusion
The following chart illustrates that practices at the contracted girls facilities were assessed as being functionally equivalent to services prescribed by the Grid for boys at DYS facilities. Our second review revealed significant progress at CAS with the quality of treatment, documentation in clinical progress notes, and further restrictions on the use of seclusion—all of which were products of a very effective Corrective Action Plan.

Are Services Functionally Equivalent to Services for Boys at DYS Facilities?

Facility

Column A: quality of MH assessments,
treatment planning and provision of MH services

Column B: use of seclusion as a response
to youth’s aggressive behavior

Applewood

✓

✓

Pomegranate

✓

✓

CAS

✓

✓

Column C: MH response to youth who engage in aggressive
behavior
✓
✓
✓

32.

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

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

:

:

Case No. 2:08-CV-00475

:

:

JUDGE ALGENON L. MARBLEY

:

:

Magistrate Judge Abel

:

:

:

OPINION & ORDER This matter is before the Court on Plaintiff United States of America’s Motion for Leave

to File Supplemental Complaint (Doc. 130). The United States seeks leave to supplement its

Complaint in order to reassert its claims with regard to various Department of Youth Services

Detention Facilities, based on newly-discovered evidence of wide-spread overuse of seclusion of

youths with mental health needs. Defendants oppose (Doc. 134), on the grounds that the United

States improperly seeks, effectively, to change the terms of the Consent Decree in this case, that

the dismissal of the United States’ previous claims was an adjudication on the merits, and that

Defendants would be prejudiced by supplementation.

For the reasons set forth herein, the United States’ Motion is hereby GRANTED.

I. BACKGROUND The United States commenced this action against the State of Ohio, its Governor, its

Department of Youth Services (“DYS”), and various DYS officials on May 16, 2008, alleging

constitutional violations at eight juvenile correctional facilities in Ohio: Circleville, Cuyahoga

Hills, Indian River, Marion, Mohican, Ohio River, Scioto, and the Freedom Center. (Complaint,

Doc. 2, ¶ 1). In particular, the United States alleged a pattern or practice of failing to protect

youths from harm and undue risk of harm, meet youth medical needs, provide adequate mental

health care, and offer adequate special education services, in violation of federal constitutional and statutory rights. (Id., ¶¶ 22-32). Among the allegations in the original Complaint was the charge that Defendants failed adequately to protect youths at the Facilities from harm or risk of harm due to “unwarranted use of seclusion.” (Id., ¶ 22(b)).
On June 5, 2008, the Parties filed a Joint Motion for Entry of Stipulation and Conditional Dismissal of the Complaint, resolving the United States’ claims as to the Scioto and Marion Facilities, and asking the Court conditionally to dismiss its claims as to the remaining six stateoperated Facilities. (Joint Motion for Stipulation, Doc. 6). The Court entered the agreed Stipulation for Injunction Relief on June 24, 2008. As an integral part of the Stipulation was a provision that the State would development and implement policies, procedures, and practices to guide the use of seclusion (as defined in the Stipulation), including documentation and review of its use. (Stipulation, Doc. 8 at 5, 7). On December 15, 2009, in response to the closing of the Marion Facility, the Stipulation was amended to address only the Scioto Facility. (Doc. 27 at 1).
On May 20, 2011, the Parties again moved to amend the Stipulation (Doc. 80), which the Court granted on June 6, 2011 (Doc. 81), and which ultimately resulted in the Amended Stipulation for Injunctive Relief, entered June 28, 2011 (Doc. 85). This Amended Stipulation terminated 20 provisions under the Stipulation’s “Substantive Remedial Provisions”; the provision regarding “seclusion” was not removed. (See Doc. 85 at 3-4, 7). The Stipulation also appointed a new Monitor, Dr. Kelly Dedel, and modified the monitoring process. (Id. at 18-22).
In December 2012, the United States initiated a dispute-resolution procedure, pursuant to the terms of the Amended Stipulation, with regard to the use of seclusion for youth on the “PROGRESS Unit” at the Scioto Facility. On December 19, 2012, it sought a Consent Order resolving this issue (Doc. 107), which the Court entered on January 18, 2013 (Doc. 109).
2

On November 21, 2013, in a letter from DYS Director Harvey Reed, DYS announced that it would close the Scioto Facility, and move any boys remaining at Scioto to other Facilities by May 2014. (Doc. 130-1 at 14).
On December 18, 2013, Defendants moved to terminate this case under Paragraph VII(E) of the Amended Stipulation, and pursuant to the Prison Litigation Reform Act of 1995, 18 U.S.C. § 3626 et seq. (“PLRA”) (Doc. 121). As a result of negotiations with all stakeholders held in the Court’s chambers, however, Defendants withdrew their Motion on December 24, 2013 (Doc. 125). Further negotiations were held on January 29, 2014. (See Doc. 128).
According to the United States, “recent developments” since the events of late 2013 have revealed further allegedly unconstitutional conditions at the Scioto Facility, as well as other DYS Facilities. (Doc. 130 at 3). In particular, the United States alleges that it was discovered in November 2013 that Defendants were “excessively secluding youth at Scioto who have significant mental health needs.” (Id. at 5). The United States also cites the planned closure of the Scioto Facility, and the aborted December PLRA Motion as other troubling recent developments. (Id. at 6-7). Furthermore, the United States alleges that records produced by Defendants on January 17, 2014, demonstrate that Ohio “is also excessively secluding youth with mental health needs at its other DYS facilities.” (Id. at 3, 6).
The United States thus insists that, after the breakdown of negotiations in January 2014, and the failure of the Parties to reach any further agreement, it was compelled to file the Motion sub judice, as well as the companion motion seeking a temporary restraining order regarding the use of seclusion on youths with mental health needs at DYS facilities (Doc. 131).
II. STANDARD OF REVIEW Under Fed. R. Civ. P. 15(d), upon motion and “reasonable notice,” the Court may permit a party to serve a supplemental pleading setting out “any transaction, occurrence, or event that
3

happened after the date of the pleading to be supplemented.” When a party “assert[s] additional claims for relief,” however, “[a] Rule 15(a) motion for leave to amend the complaint, not a Rule 15(d) motion to supplement the pleading, is the appropriate mechanism.” Michael v. Ghee, 498 F.3d 372, 386 (6th Cir. 2007). Rule 15(a) permits a party to amend a pleading with the Court’s leave, which should be “freely given[] . . . when justice so requires.” Fed. R. Civ. P. 15(a)(2). The purpose of Rule 15 for amended and supplemental pleadings is “to provide maximum opportunity for each claim to be decided on its merits rather than on procedural technicalities.” Roger v. Lehman Bros. Kuhn Loeb, Inc., 621 F. Supp. 114, 119 (S.D. Ohio 1985) (citing McHenry v. Ford Motor Co., 269 F.2d 18 (6th Cir. 1959)).
The same standard of review and rationale apply under both Rules 15(a) and 15(d). Spies v. Voinovich, 48 F. App’x. 520, 527 (6th Cir. 2002) (citing Glatt v. Chicago Park Dist., 87 F.3d 190, 194 (7th Cir. 1996)); Maclin v. Holden, No. 12-CV-12480, 2013 WL 4521124, at *2 (E.D. Mich. Aug. 27, 2013). The grant or denial of a motion to supplement a pleading is left “to the discretion of the trial court.” Allen v. Reynolds, 895 F.2d 1412, at *2 (6th Cir. Feb. 13, 1990). In exercising its discretion, the Court may consider such factors as “undue delay, bad faith or dilatory motive on the part of the movant, repeated failure to cure deficiencies by amendments previously allowed, undue prejudice to the opposing party by virtue of allowance of the amendment, [and] futility of the amendment.” Foman v. Davis, 371 U.S. 178, 182 (1962). In the absence of any such “apparent or declared reason,” however, leave sought should be “freely given.” Id. In determining prejudice to a party, the Court should take into account whether the assertion of the new claim or defense would “require the opponent to expend significant additional resources to conduct discovery and prepare for trial[,] significantly delay the resolution of the dispute[,] or prevent the plaintiff from bringing a timely action in another
4

jurisdiction.” Phelps v. McClellan, 30 F.3d 658, 662-63 (6th Cir. 1994). In general, “[a] trial court does not abuse its discretion in refusing to allow supplementation of a complaint which would add extraneous matter late in the case.” Tesfa v. Am. Red Cross, No. 2:12-CV-0397, 2013 WL 5722808, at *2 (S.D. Ohio Oct. 21, 2013); see also McCormack v. Frank, 34 F.3d 1068, at *5 (6th Cir. Aug. 10, 1994) (court did not abuse its discretion when it denied a motion to supplement, where granting would require re-opening discovery and further delay trial). Nor does a Court abuse its discretion by “deny[ing] a motion for leave to amend a complaint if such complaint, as amended, could not withstand a motion to dismiss.” Neighborhood Dev. Corp. v. Advisory Council on Historic Preservation, 632 F.2d 21, 23 (6th Cir.1980) (citation omitted).
III. ANALYSIS The United States seeks leave to file its Proposed Supplemental Complaint, which, it argues, “including allegations concerning newly discovered events involving Defendants’ pattern or practice of harming youth through unnecessary seclusion and denial of adequate mental health care and rehabilitative treatment.” (Doc. 130 at 7). The United States asserts that its Proposed Supplemental Complaint details allegations of Ohio’s closure of the Scioto Facility, its transfer of boys to other DYS Facilities where the same conditions exist, and its pattern or practice of harming youths through excessive seclusion and inadequate treatment at those other Facilities. (Id.). These new allegations, it explains, are based upon information revealed by the Monitor in this case, as well as the associated S.H. case.1 (Id.). In support of its Motion, the United States argues, first, that its conditional dismissal with regard to the DYS Facilities other than Scioto and Marion (see Doc. 6; Doc. 7) was without prejudice, and therefore does not bar its Proposed Supplemental Complaint. (Doc. 130 at 8). It further argues that leave to supplement should be freely granted, since its Supplemental
1 S.H. v. Reed, No. 2:04-CV-1206 (S.D. Ohio).
5

Complaint properly concerns events that took place after the filing of the original Complaint, and moreover that supplementing the Complaint would avoid piecemeal litigation and allow for the complete and efficient adjudication of the entire controversy between the Parties. (Id. at 9-11).
The United States emphasizes its fear that Ohio could seek to “avoid its obligations in this suit to the Scioto youth simply by transferring them to other DYS facilities,” and it should therefore be granted leave to prevent this end-run by the State. (Id. at 11). The United States additionally argues that Ohio would not be prejudiced by the new Complaint, since it has “received ample notice,” because these claims were part of the original Complaint, and because the United States acted as soon as it was aware of the present conditions. (Id. at 11-12). The United States adds that supplementation will not cause delay, since there is presently no discovery schedule or trial date set. (Id. at 14-15). Finally, the United States insists that its new allegations are “related and substantially similar” to the original Complaint, since they “share core questions of law and fact,” and are thus “not so different as to cause prejudice to the defendant.” (Id. at 13-14) (quotation omitted).
Defendants oppose the United States’ request on several grounds. First, Defendants argue that the January 18, 2013 Consent Order governs this case. (Doc. 134 at 2). Defendants maintain that the United States cannot unilaterally alter the Consent Order, absent an unanticipated change in fact or law, which, Defendants argue, has not occurred here, given that the closure of Scioto was anticipated well in advance, and follows in the wake of the closure of other DYS Facilities, such as Marion and Mohican. (Doc. 134 at 2). Defendants also argue that the current increase in seclusion hours is also not unanticipated, since “[s]eclusion hours go up and down,” and Ohio has been in at least Partial Compliance in this regard. (Id. at 3).
6

Defendants further assert that because the United States’ Complaint has been dismissed twice—first, by stipulation, on June 12, 2008 (Doc. 7), and again, by the Amended Stipulation, on June 28, 2011 (Doc. 85)—the second dismissal “operates as an adjudication on the merits.” (Doc. 134 at 3) (citing Fed. R. Civ. P. 41(a)(1)(B)). Defendants add that the claims asserted by the United States are time-barred, since under any theory, the statute of limitations relevant to the claims is not more than two years, which elapsed at least by 2012. (Doc. 134 at 4-5).
Defendants also argue that they would be prejudiced by the United States’ supplementation. Because the United States knew about the use of seclusion since at least 2008, Defendants insist, but has waited nearly six years and twice dismissed most of the DYS Facilities from the case, the delay should not be excused by granting leave to supplement. (Id. at 5-6). Defendants also point to the prejudice that would result if the United States were allowed to alter the burden of proof: Defendants oppose supplementation that would “hold all DYS facilities to the standard set out in the Consent Decree,” which is limited by its terms to Scioto and which exceeds minimum constitutional guarantees. (Id. at 6). Thus, Defendants argue that the United States should instead file a new Complaint, as the original Complaint already address seclusion, and accordingly the Supplemental Complaint cannot meet Rule 15(d)’s standard of transactions or occurrences “that happened after the date” of the original Complaint. (Id. at 6-7).
A. Procedural Bars to Supplementation or Amendment Defendants raise three procedural bars to the United States’ Motion: (1) the January 18, 2013 Consent Order; (2) the “two dismissal rule” of Fed. R. Civ. P. 41(a)(1)(B); and (3) the statute of limitations. The Court considers each in turn.
1. The Consent Order First, the January 18, 2013 Consent Order (Doc. 109) is inapplicable here. Indeed, neither the Consent Order, nor the Amended Stipulation (Doc. 85), address the allegations raised
7

by the United States in its Proposed Supplemental Complaint, both because those earlier Orders address different facilities, and because they address different substantive conduct. The Stipulation (Doc. 7) and Amended Stipulation concern the United States’ original claims, with regard to the Scioto and Marion Facilities, not the Circleville, Cuyahoga Hills, and Indian River Facilities targeted here. Moreover, while the Proposed Supplemental Complaint undoubtedly contains some allegations touching on the Scioto Facility (see Doc. 1301-1, ¶¶ 19-21, 23), these new allegations specifically concern conduct occurring in 2013 and 2014.
The State’s suggestion that the United States “now seeks to hold all DYS facilities to the standard set out in the Consent Decree” (Doc. 134 at 6) is difficult to reconcile with the actual language of the United States’ Proposed Supplemental Complaint and Motion to Supplement. Nowhere does the Proposed Supplemental Complaint reference the Consent Order. Moreover, as it acknowledges, the United States retains the burden of “prov[ing] the allegations in the supplemental complaint.” (Doc. 136 at 2).
2. Rule 41(a) Defendants also mistakenly rely on Fed. R. Civ. P. 41(a). Rule 41(a)(1)(B) mandates that voluntary dismissal, by notice filed by a plaintiff before service of an answer or motion for summary judgment, or by a joint stipulation of dismissal, is generally without prejudice; except that a dismissal of a “previously dismissed . . . federal- or state-court action based on or including the same claim” has the effect of an adjudication on the merits. Fed. R. Civ. P. 41(a)(1)(A), (B). In this case, however, dismissal of the United States’ claims relating to the other DYS Facilities was accomplished by Court Order. The Parties jointly moved the Court “to enter as its Order” the Stipulation resolving the United States’ claims as to Scioto and Marion, “and, separately, to conditionally dismiss the United States’ complaint” as to the other Facilities. (Doc. 6 at 1). On June 12, 2008, the Court so ordered. (Doc. 7 at 1). Thus, the relevant
8

provision of the Federal Rules is Rule 41(a)(2). Under this Rule, unless the Court’s Order states otherwise, dismissal is without prejudice. The Court’s Order here did not state otherwise.
Moreover, it is difficult to discern the “second” dismissal referenced by Defendants. Defendants suggest that the United States “again dismissed” its Complaint on June 28, 2011. (See Doc. 134 at 3). In fact, this Amended Stipulation had the effect of “terminat[ing] 20 provisions under section III [of the Stipulation],” appointing a new monitor, and modifying the monitoring process. (Doc. 85 at 4). As the original Stipulation that was modified by this amendment concerned only the Scioto Facility, no claims were “again dismissed” at this time with regard to the other facilities, and, even with regard to Scioto, the Amended Stipulation could not dismiss claims based on events which did not occur until 2013.
3. Statute of Limitations Lastly, Defendants’ reliance on the applicable statute of limitations for the claims referenced in the Proposed Supplemental Complaint is unavailing. The Court need not decide whether O.R.C. § 2305.19’s limitations period governs, since the Proposed Supplemental Complaint alleges conduct which occurred since 2013, and is alleged to be ongoing. Moreover, it is axiomatic that when the United States sues in its own right on behalf of the public interest, it is not subject to state statutes of limitations. Occidental Life Ins. Co. of California v. E.E.O.C., 432 U.S. 355, 382 (1977); E.I. DuPont De Nemours & Co. v. Davis, 264 U.S. 456, 462 (1924) (“An action by the United States in its governmental capacity . . . is subject to no time limitation, in the absence of congressional enactment clearly imposing it.”); United States v. City of Columbus, No. 2:99-CV-1097, 2000 WL 1133166, at *10 (S.D. Ohio Aug. 3, 2000).
B. Prejudice to Defendants In assessing prejudice from a motion to supplement or to amend, the Court must assess whether granting the motion would cause undue delay, require the opponent to expend
9

significant additional resources to conduct discovery or prepare for trial, significantly delay final resolution, or prevent the plaintiff from bringing an action in another jurisdiction. Phelps, 30 F.3d at 662-63. Delay alone is not a ground for denying leave. Dana Corp. v. Blue Cross & Blue Shield Mutual, 900 F.2d 882, 883 (6th Cir. 1990). Rather, the opposing party “must demonstrate significant prejudice.” Brown v. Worthington Steel, Inc., 211 F.R.D. 320, 323 (S.D. Ohio 2002) (citing Duggins v. Steak ‘N Shake, Inc., 195 F.3d 828, 834 (6th Cir. 1999); Moore v. City of Paducah, 790 F.2d 557, 562 (6th Cir. 1986)).
In general, the longer the period of unexplained delay, the lesser the burden of demonstrating prejudice. Phelps, 30 F.3d at 662-63. Courts have focused particularly, however, on the phase of litigation during which the motion was filed. Thus, courts have frequently found prejudice where the motion is filed after the discovery deadline has passed, Duggins, 195 F.3d at 843, or where only a month remained before trial, United States v. Midwest Suspension and Brake, 49 F.3d 1197, 1202 (6th Cir. 1995). Nevertheless, “even amendments made on the eve of trial are permissible when there is no demonstrable prejudice.” Brown, 211 F.R.D. at 323 (citing United States v. Wood, 877 F.2d 453, 456–57 (6th Cir.1989)).
Defendants here have failed to demonstrate that they will be prejudiced if the United States is permitted to supplement its Complaint. Although Defendants argue, correctly, that the United States was aware of the use of seclusion at DYS Facilities since the start of this litigation, the Proposed Supplemental Complaint clearly alleges new and more serious violations of the constitutional rights of youth via the excessive use of seclusion and denial of adequate mental health treatment at DYS Facilities. (Doc. 130-1, at 5-7, ¶¶ 18-29).
Defendants also misconstrue the burden that the Supplemental Complaint will place upon the Parties. As explained above, the United States does not argue that the other DYS Facilities,
10

beyond only Scioto, should be governed by the Amended Stipulation or the Consent Decree.

Indeed, the United States concedes that it will bear the burden of proof as all plaintiffs do, and it

“intends to litigate its claims regarding the other Facilities to a final judgment.” (Doc. 136 at 7).

Beyond this burden-shifting argument, Defendants do not explain how they would be

prejudiced by the United States’ Proposed Supplemental Complaint: they cannot point to any

discovery deadlines that have lapsed, or any trial schedule that would be delayed; nor can they

direct the Court to any additional, burdensome discovery they will be compelled to undertake

that is not already a part of the ongoing monitoring process in this case. Instead, Defendants

suggest that the United States ought to file a separate lawsuit to address the alleged ongoing

violations. (Doc. 134 at 6). This is precisely the sort of piecemeal litigation and needless waste

of judicial resources that Rule 15 was designed to avoid. In short, the Court cannot conclude that

granting leave here, well before trial or close of discovery, would be the sort of supplementation

that “would profoundly alter and expand the scope and nature of plaintiffs’ claims” or “result in

significant delay of th[e] litigation.” Marshall v. City of Columbus, No. 2:05-CV-484, 2008 WL

4334616, at *2 (S.D. Ohio Sept. 17, 2008).

IV. CONCLUSION The United States has succeeded in pleading further transactions, occurrences, and events

taking place after the date of the original Complaint, and demonstrating good cause for leave to

supplement under Fed. R. Civ. P. 15(d). Defendants have established no procedural bar,

prejudice, or other reason to show why leave should not be freely given in accordance with the

Rule. Accordingly, the United States’ Motion (Doc. 130) is hereby GRANTED.

IT IS SO ORDERED. DATED: March 28, 2014

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

11

 
 Case: 2:08-cv-00475-ALM-MRA Doc #: 140 Filed: 03/31/14 Page: 1 of 9 PAGEID #: 3050

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

UNITED STATES OF AMERICA,
Plaintiff,
v.
THE STATE OF OHIO; The Honorable John Kasich The Ohio Department of Youth Services Harvey Reed, Director of Ohio Youth Services Indian River Juvenile Correctional Facility Cuyahoga Hills Juvenile Correctional Facility Circleville Juvenile Correctional Facility Scioto Juvenile Correctional Facility,
Defendants.

)

)

)

)

)

CIVIL ACTION NO:

)

2:08-cv-475

)

)

)

)

)

)

)

)

)

)

)

SUPPLEMENTAL COMPLAINT

THE UNITED STATES OF AMERICA (“Plaintiff”), by its undersigned attorneys,

hereby files this Supplemental Complaint and alleges upon information and belief:

1. The United States files this Supplemental Complaint in the above captioned

matter pursuant to the pattern or practice provision of the Violent Crime Control and Law

Enforcement Act of 1994, 42 U.S.C. § 14141, to enjoin the named Defendants from depriving

youth confined in the Circleville Juvenile Correctional Facility, Cuyahoga Hills Juvenile

Correctional Facility, Indian River Juvenile Correctional Facility, and Scioto Juvenile

Correctional Facility (collectively, the “DYS facilities”) of rights, privileges, or immunities

secured or protected by the Constitution and laws of the United States.

Case: 2:08-cv-00475-ALM-MRA Doc #: 140 Filed: 03/31/14 Page: 2 of 9 PAGEID #: 3051
Jurisdiction, Standing and Venue 2. This Court has jurisdiction over this action pursuant to 28 U.S.C. §§ 1331 and 1345. 3. The United States is authorized to initiate this action pursuant to 42 U.S.C. § 14141. 4. Venue in the United States District Court for the Southern District of Ohio is proper pursuant to 28 U.S.C. § 1391.
Defendants 5. Defendant State of Ohio (“State”) is responsible for the administration of juvenile justice in the State and operates, or contracts for the operation of, all juvenile justice facilities in the State. This action concerns the administration of the DYS facilities, which house youth in State custody who are confined for periods of time established by juvenile county courts. 6. Defendant John R. Kasich is the Governor of Ohio and, in this capacity, heads the executive branch of Ohio’s government. The Governor of Ohio, as chief of the executive branch, has the duty to ensure that the departments that compose the executive branch of Ohio government guarantee the federal constitutional and statutory rights of all of the citizens of Ohio, including the youth confined in the DYS facilities. 7. Defendant Ohio Department of Youth Services (“DYS”) establishes the general policy to be followed by its juvenile institutions and contractors; provides leadership in developing programs to rehabilitate youth committed to State custody; and is responsible for the promulgation of all rules and regulations necessary and appropriate to the administration and operation of the DYS facilities.
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 140 Filed: 03/31/14 Page: 3 of 9 PAGEID #: 3052
8. Defendant Harvey J. Reed is Director of the DYS and, in this capacity, exercises administrative control of, and responsibility for, the DYS Facilities.
9. Circleville Juvenile Correctional Facility is a juvenile correctional facility within the State of Ohio, a part of DYS, and under the administrative control of and responsibility of Director Harvey J. Reed.
10. Cuyahoga Hills Juvenile Correctional Facility is a juvenile correctional facility within the State of Ohio, a part of DYS, and under the administrative control of and responsibility of Director Harvey J. Reed.
11. Indian River Juvenile Correctional Facility is a juvenile correctional facility within the State of Ohio, a part of DYS, and under the administrative control of and responsibility of Director Harvey J. Reed.
12. Scioto Juvenile Correctional Facility is a juvenile correctional facility within the State of Ohio, a part of DYS, and under the administrative control of and responsibility of Director Harvey J. Reed.
13. The individual Defendants named in Paragraphs 6 and 8 above are officers or agents of the State of Ohio and are sued in their official capacity only.
Factual Allegations 14. Defendants are legally responsible, in whole or in part, for the operation of the DYS facilities and for the health and safety of the youth confined at the DYS facilities. 15. Defendants are governmental authorities with responsibility for the administration of juvenile justice or the incarceration of juveniles within the meaning of 42 U.S.C. § 14141. 16. Defendants are obligated to operate the DYS facilities in a manner that does not infringe upon the federal rights, as protected by the Fourteenth and Eighth Amendments to the
3

Case: 2:08-cv-00475-ALM-MRA Doc #: 140 Filed: 03/31/14 Page: 4 of 9 PAGEID #: 3053
Constitution of the United States and by other federal law, of individuals confined at the DYS facilities.
17. At all relevant times, Defendants have acted or failed to act, as alleged herein, under color of state law.
18. On or about November 8, 2013, the lead monitor in United States v. Ohio, 2:08-cv-475, investigated the accumulation of seclusion hours among some youth at the Scioto Juvenile Correctional Facility. She wrote that she found the State had secluded ten youths for over 10 percent of their time in custody during a six-month period in 2013.
19. On or about January 17, 2014, DYS released information showing that youths on the mental health caseload at Cuyahoga Hills Juvenile Correctional Facility, Indian River Juvenile Correctional Facility, Circleville Juvenile Correctional Facility and Scioto Juvenile Correctional Facility had spent approximately 59,865 hours in seclusion from approximately July 2013 through December 2013.
20. On November 21, 2013, DYS announced it would close Scioto Juvenile Correctional Facility and the youths would be gradually reassigned to the remaining facilities. Plaintiff believes that some Scioto youth were transferred to Cuyahoga Hills Juvenile Correctional Facility, Indian River Juvenile Correctional Facility and/or Circleville Juvenile Correctional Facility.
21. On or about January 17, 2014, DYS released information showing that some youth on the mental health caseload at Indian River Juvenile Correctional Facility, Circleville Juvenile Correctional Facility and Scioto Juvenile Correctional Facility had been placed in seclusion for long periods of time, including seclusion of 19 days for one youth and 21 days for another youth.
4

Case: 2:08-cv-00475-ALM-MRA Doc #: 140 Filed: 03/31/14 Page: 5 of 9 PAGEID #: 3054
22. On or about January 17, 2014, DYS released information showing that one youth on the mental health caseload at Cuyahoga Hills Juvenile Correctional Facility had been placed in pre-hearing seclusion for 4.88 days, in contravention of DYS policy concerning the maximum length of pre-hearing seclusion.
23. On or about January 17, 2014, DYS released information showing that some youth on the mental health caseload at Cuyahoga Hills Juvenile Correctional Facility, Indian River Juvenile Correctional Facility, Circleville Juvenile Correctional Facility and Scioto Juvenile Correctional Facility had been placed in seclusion despite DYS’ observation that the youths had displayed suicidal ideation, self-injurious behavior or were on suicide watch.
24. Numerous national studies have established that seclusion of youth with mental health disorders even for short periods of time can severely harm youth. ACLU, “Alone & Afraid: Children Held in Solitary Confinement and Isolation in Juvenile Detention and Correctional Facilities” (Nov. 2013); American Academy of Child & Adolescent Psychiatry, Policy Statements: Solitary Confinement of Juvenile Offenders” (April 2012); Lindsay Hayes, Office of Juvenile Justice and Delinquency Prevention, Juvenile Suicide in Confinement: A National Survey (2009).
25. On or about January 10, 2014, the lead monitor in United States v. Ohio, 2:08-cv-475, found that Scioto youths who spent long periods of time in seclusion often were not receiving mental health treatment via group during their seclusion time. She found instead that these youths were receiving daily visits by mental health staff during the seclusion period, but these visits were documented as brief checks per protocol, and were not treatment oriented.
26. On or about December 16, 2013, a subject matter expert in S.H. v. Reed, No. 2:04-cv-1206, stated that if a youth with a mental health disorder is placed in seclusion, it is
5

Case: 2:08-cv-00475-ALM-MRA Doc #: 140 Filed: 03/31/14 Page: 6 of 9 PAGEID #: 3055
incumbent on DYS to modify the youth’s integrated treatment plan. If a youth with a mental health disorder is placed in seclusion and DYS does not modify the youth’s integrated treatment plan, seclusion may exacerbate the youth’s behavioral problems. On information and belief, DYS has not so modified youths’ treatment plans.
27. Defendants have engaged, and continue to engage, in a pattern or practice of failing to provide adequate mental health care and rehabilitative treatment to youth at the DYS facilities in the following specific respects, among others:
a. the provision of adequate screening and assessments; b. the provision of adequate treatment planning; and c. the provision of adequate psychological services. 28. Defendants have engaged, and continue to engage, in a pattern or practice of failing to ensure that youth with mental health disorders at the DYS facilities are adequately protected from harm and from undue risk of harm in the following specific respects, among others: a. protection from the unnecessary use of seclusion; and b. protection from the use of seclusion as a barrier or obstacle to receiving adequate mental health care and rehabilitative treatment at the DYS facilities. 29. Defendants have engaged, and continue to engage, in a pattern or practice of subjecting youth with mental health disorders at the DYS facilities to unnecessary periods of seclusion with: a. the specific intent to punish; or b. no reasonable relation to a legitimate governmental objective and instead as a form of punishment.
6

Case: 2:08-cv-00475-ALM-MRA Doc #: 140 Filed: 03/31/14 Page: 7 of 9 PAGEID #: 3056
Violations Alleged 30. The United States incorporates by reference the allegations set forth in Paragraphs 14 through 29 as if fully set forth herein. 31. The acts and omissions alleged in Paragraphs 18 through 29 constitute a pattern or practice of conduct that violates the federal rights, as protected by the Eighth and Fourteenth Amendments to the Constitution of the United States, of youth confined at the DYS Facilities. 32. Unless restrained by this Court, Defendants will continue to engage in the acts and omissions set forth in Paragraphs 18 and 29 that deprive youth confined at the DYS facilities of rights, privileges, or immunities secured or protected by the Constitution of the United States and federal law, and will cause irreparable harm to these youth.
PRAYER FOR RELIEF 33. The Attorney General is authorized, pursuant to 42 U.S.C. § 14141, to seek equitable and declaratory relief. WHEREFORE, the United States prays that this Court enter an order: a. Declaring that the acts, omissions, and practices of Defendants set forth in Paragraphs 18 through 29 above constitute a pattern or practice of conduct that deprives the DYS facilities’ youth of rights, privileges, or immunities secured or protected by the Constitution or laws of the United States, and that those acts, omissions, and practices violate the Constitution and laws of the United States; b. Permanently enjoining Defendants, their officers, agents, employees, subordinates, successors in office, and all those acting in concert or participation with them from continuing the acts, omissions, and practices set forth in Paragraphs 18 through 29 above, and
7

Case: 2:08-cv-00475-ALM-MRA Doc #: 140 Filed: 03/31/14 Page: 8 of 9 PAGEID #: 3057

requiring Defendants to take such actions as will ensure that lawful conditions of confinement are afforded to youth at the DYS Facilities; and
c. Granting such other and further equitable relief as the Court may deem just and proper.

DATE: March 31, 2014
CARTER STEWART United States Attorney Southern District of Ohio
/s/ Deborah F. Sanders____________ DEBORAH F. SANDERS (0043575) Assistant United States Attorney Southern District of Ohio 303 Marconi Boulevard, Suite 200 Columbus, Ohio 43215 (614) 469-5715 (T) (614) 469-5653 (F) Deborah.Sanders@usdoj.gov

Respectfully submitted,
JOCELYN SAMUELS Acting Assistant Attorney General Civil Rights Division United States Department of Justice
JONATHAN M. SMITH Chief Special Litigation Section
BENJAMIN O. TAYLOE, JR. Deputy Chief Special Litigation Section
CYNTHIA COE ALEXANDRA L. SHANDELL Trial Attorneys Special Litigation Section
/s/ Silvia J. Dominguez-Reese SILVIA J. DOMINGUEZ-REESE Trial Attorney Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 (202) 616-8547 (T) (202) 514-4883 (F) Silvia.Dominguez-Reese@usdoj.gov
Attorneys for Plaintiff

8

Case: 2:08-cv-00475-ALM-MRA Doc #: 140 Filed: 03/31/14 Page: 9 of 9 PAGEID #: 3058
CERTIFICATE OF SERVICE I HEREBY CERTIFY that this date, March 31, 2014, I caused the foregoing to be electronically filed with the Clerk of the Court using the CM/ECF system, which will simultaneously serve notice of such filing to counsel of record and the Court Monitor to their registered electronic mail addresses.
s/Silvia J. Dominguez-Reese SILVIA J. DOMINGUEZ-REESE Trial Attorney Special Litigation Section Civil Rights Division U.S. Department of Justice 950 Pennsylvania Avenue, NW Washington, DC 20530 Telephone: (202) 616-8547 Facsimile: (202) 514-4883 Email: Silvia.Dominguez-Reese@usdoj.gov Attorney for Plaintiff
9

 
 Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 1 of 34 PAGEID #: 3159
	  

	  

	  

	  

	  

	  

	  

	  

	  

	  

	  

	  

Monitors’	  6-­‐Month	  Report	  on	  Compliance	  with	  The	  Grid	  

	  

S.H.	  v	  Reed	  	  (Civil	  Action	  No.	  2:04-­‐cv-­‐1206)	  

U.S.	  v	  State	  of	  Ohio	  (Civil	  Action	  No.	  2:08-­‐cv-­‐475)	  	  

	   	   	   	   Submitted	  by:	   	   Kelly	  Dedel,	  Ph.D.,	  Lead	  Monitor,	  U.S.	  v	  State	  of	  Ohio	   Will	  Harrell,	  J.D.,	  Lead	  Monitor,	  S.H.	  v	  Reed	   Daphne	  Glindmeyer,	  M.D.,	  Subject	  Matter	  Expert	   Andrea	  Weisman,	  Ph.D.,	  Subject	  Matter	  Expert	   	  

	  

	  

Submitted	  June	  10,	  2015	  

	  

	  

1.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 2 of 34 PAGEID #: 3160
	  
Table	  of	  Contents	   	  
Introduction	  and	  Executive	  Summary	.   .........................................................................................................	 3  	   Column	  A:	  Prevention	  Strategies	  .................................................................................................................	 6  	  
Overall	  Performance	  Measures	  (A)	.   ................................................................................................	 6  	   Verifying	  Treatment	  Integrity	  (A.1)	 .  ................................................................................................	 8  	   Developing	  BioPsychoSocial	  Assessments	  (A.2)	.  ...........................................................................	 1  3	   Other	  Information	.   ........................................................................................................................	 1  5	   Compliance	  Assessment	.  ...............................................................................................................	 1  6	   Column	  B:	  Immediate	  Intervention	  Strategies	.  ..........................................................................................	 1  7	   Reduce	  Reliance	  on	  Seclusion	  (B.1)	.  ..............................................................................................	 1  7	   Reduce	  Duration	  of	  Seclusion	  (B.2)	.  ..............................................................................................	 1  7	   Reduce	  Harm	  Associated	  with	  Seclusion	  (B.3)	 .  .............................................................................	 1  9	   Reduce	  Accumulation	  of	  Seclusion	  (B.4)	.  ......................................................................................	 2  0	   Provide	  Crisis	  Intervention	  while	  In	  PHS	  (B.5)	.  ..............................................................................	 2  1	   Eventually	  Eliminate	  the	  Use	  of	  Disciplinary	  Seclusion	.   ................................................................	 2  5	   Other	  Information	.   ........................................................................................................................	 2  5	   Compliance	  Assessment	.  ...............................................................................................................	 2  8	   Column	  C:	  Strategies	  for	  the	  Aftermath	.  ....................................................................................................	 3  0	   Treatment	  Plan	  Review	  (C.1)	.  ........................................................................................................	 3  0	   Special	  Review	  Team	  (C.2)	  ............................................................................................................	 3  1	   Other	  Information	.   ........................................................................................................................	 3  3	  
Compliance	  Assessment	.  ...............................................................................................................	 3  4	  

	  

2.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 3 of 34 PAGEID #: 3161
	  
Introduction	  and	  Executive	  Summary	  
	   On	  May	  20,	  2014,	  the	  Parties	  to	  S.H.	  v	  Reed	  	  (Civil	  Action	  No.	  2:04-­‐cv-­‐1206)	  and	  U.S.	  v	  State	  of	   Ohio	  (Civil	  Action	  No.	  2:08-­‐cv-­‐475)	  filed	  a	  joint	  motion	  for	  entry	  of	  an	  agreed	  order	  to	  resolve	   the	  issues	  remaining	  in	  both	  Settlement	  Agreements.	  The	  resulting	  Court	  Order	  required	  DYS	  to	   undertake	  specific	  actions,	  outlined	  in	  “The	  Grid”	  (Exhibit	  A	  to	  the	  Order),	  to	  improve	  mental	   health	  services	  and	  reduce	  the	  seclusion	  of	  youth	  who	  are	  on	  the	  mental	  health	  caseload.	  The	   Court	  also	  consolidated	  the	  civil	  actions	  for	  the	  purpose	  of	  case	  monitoring,	  though	  the	  actions	   retained	  their	  separate	  status.	  This	  report	  discusses	  DYS’	  application	  of	  the	  Grid	  to	  its	  three	   male	  facilities:	  Circleville,	  Cuyahoga	  Hills	  and	  Indian	  River.	  DYS	  does	  not	  operate	  any	  facilities	  for	   girls—these	  services	  are	  contracted	  out	  to	  private	  providers.	  The	  extent	  to	  which	  DYS	  girls	  in	   these	  facilities	  have	  access	  to	  comparable	  mental	  health	  treatment	  and	  protection	  from	  harmful	   seclusion	  practices	  will	  be	  discussed	  in	  a	  separate	  report.	  	   	   The	  Grid	  is	  the	  product	  of	  a	  collaborative	  effort	  between	  DYS	  and	  the	  Monitoring	  Team.	  It	   prescribes	  specific	  practices	  designed	  to	  improve	  the	  quality	  of	  mental	  health	  services,	  to	   reduce	  the	  potential	  for	  youth	  violence	  and	  to	  reduce/eliminate	  the	  system’s	  use	  of	  seclusion	  as	   a	  response	  to	  youth	  violence.	  Monitoring	  responsibilities	  were	  divided	  up	  according	  to	  the	  Grid,	   with	  each	  column	  assigned	  to	  a	  member	  of	  the	  Monitoring	  Team.	  “Column	  A,”	  monitored	  by	  Dr.	   Daphne	  Glindmeyer,	  prescribes	  strategies	  for	  improving	  the	  quality	  of	  mental	  health	   assessments,	  treatment	  plan	  formulations	  and	  therapeutic	  interventions.	  “Column	  B,”	   monitored	  by	  Dr.	  Kelly	  Dedel,	  prescribes	  strategies	  for	  reducing	  the	  use	  and	  duration	  of	   seclusion	  as	  a	  de-­‐escalation	  tool	  and	  also	  prescribes	  strategies	  for	  limiting/eliminating	  the	   practice	  of	  disciplinary	  confinement.	  “Column	  C,”	  monitored	  by	  Dr.	  Andrea	  Weisman,	  prescribes	   strategies	  to	  fortify	  the	  therapeutic	  response	  to	  youth	  who	  engage	  in	  frequent	  acts	  of	  violence.	  	   	   The	  Grid	  identifies	  key	  performance	  measures	  for	  each	  column	  and	  prescribes	  an	  expected	   performance	  level	  for	  each	  one.	  For	  example,	  measure	  A.1	  requires	  90%	  of	  all	  cases	  reviewed	  to	   show	  correspondence	  between	  the	  content	  of	  individual	  treatment	  sessions	  and	  treatment	   goals.	  Each	  month,	  DYS	  submits	  data	  to	  assess	  the	  level	  of	  performance	  on	  each	  measure	  to	  the	   Monitoring	  Team.	  Once	  analyzed,	  the	  responsible	  Team	  member	  provided	  oral	  or	  written	   feedback	  to	  DYS,	  designed	  to	  recognize	  program	  components	  that	  were	  performing	  at	  the	   expected	  level	  and	  to	  solve	  problems	  related	  to	  underperformance	  when	  it	  occurred.	  	   	   Frequent	  conference	  calls,	  email	  exchanges	  and	  two	  on-­‐site	  visits,	  one	  in	  October	  2014	  and	   another	  in	  March	  2015,	  supplemented	  the	  information	  gleaned	  from	  these	  data.	  This	  report	   compiles	  this	  information	  and	  details	  DYS’	  progress	  on	  all	  components	  of	  the	  Grid	  during	  the	   first	  6-­‐months	  of	  the	  implementation	  of	  the	  new	  Seclusion	  Policy,	  which	  went	  into	  effect	  on	  July	   1,	  2014.	  Several	  of	  the	  new	  mental	  health	  procedures	  were	  in	  place	  before	  that	  date,	  though	   data	  were	  not	  collected	  during	  the	  early	  implementation	  phase.	  	   	   On	  a	  monthly	  basis,	  the	  Monitors	  identified	  whether	  the	  performance	  measures	  were	  met	  at	   the	  level	  required	  by	  the	  grid	  (i.e.,	  in	  most	  cases,	  90%).	  To	  date,	  overall	  compliance	  has	  not	  been	   assessed	  as	  the	  Court	  Order	  requires	  “monitoring	  [to]	  continue	  until	  Defendants	  have	   maintained	  substantial	  compliance	  with	  all	  provisions	  and	  performance	  measures	  for	  six	   months.”	  This	  report	  compiles	  performance	  data	  for	  the	  first	  six-­‐month	  period	  so	  that	  overall	   compliance	  can	  be	  assessed.	  	  

	  

3.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 4 of 34 PAGEID #: 3162
	  
	   	   	  
Column	  A	  Summary:	  Prevention	  Strategies	  
• During	  the	  6-­‐month	  monitoring	  period,	  each	  facility	  increased	  the	  proportion	  of	  youth	   on	  the	  mental	  health	  caseload	  (MHCL)	  who	  were	  not	  involved	  in	  acts	  of	  violence	  (AOV)	   from	  a	  baseline	  (55%	  to	  64%).	  	  
• During	  the	  6-­‐month	  monitoring	  period,	  small	  proportions	  of	  youth	  on	  the	  MHCL	  (6%)	   were	  involved	  in	  frequent	  AOVs.	  The	  majority	  of	  youth	  who	  initially	  met	  the	  3+	  AOV	   threshold	  went	  on	  to	  curb	  their	  aggressive	  behavior	  in	  the	  subsequent	  months.	  This	   indicates	  that	  the	  mental	  health	  interventions—and	  other	  enhancements	  to	  the	  facility	   programs—had	  a	  positive	  effect	  on	  DYS	  youth.	  	  
• Quality	  assurance	  tools	  have	  been	  developed	  and	  implemented	  to	  monitor	  the	  quality	   of	  DYS	  mental	  health	  services.	  	  
• System	  wide,	  DYS	  achieved	  the	  90%	  benchmark	  related	  to	  the	  correspondence	  between	   individual	  treatment	  goals	  and	  the	  content	  of	  individual	  therapy	  sessions.	  
• System	  wide,	  DYS	  easily	  exceeded	  the	  required	  performance	  level	  related	  to	  the	   integrity	  of	  group	  treatment.	  Of	  the	  group	  sessions	  audited,	  98%	  scored	  80%	  or	  better	   on	  the	  quality	  assurance	  tool.	  	  
• System	  wide,	  DYS	  achieved	  the	  90%	  benchmark	  related	  to	  ensuring	  that	  initial	   assessments	  contained	  a	  high-­‐quality	  clinical/diagnostic	  formulation.	  
• System	  wide,	  DYS	  exceeded	  the	  required	  performance	  level	  regarding	  treatment	  plans	   reflecting	  the	  clinical/diagnostic	  formulation.	  Of	  the	  cases	  audited,	  94%	  met	  the	   requirements	  of	  the	  quality	  assurance	  tool.	  	  
• In	  Dr.	  Glindmeyer’s	  opinion,	  DYS	  is	  in	  substantial	  compliance	  with	  the	  requirements	  of	   Column	  A	  of	  the	  Grid.	  	  
	  
	  
Column	  B	  Summary:	  Immediate	  Intervention	  Strategies	  
• DYS	  policy	  prohibited	  the	  use	  of	  disciplinary	  seclusion	  as	  a	  response	  to	  youth	   misconduct	  on	  January	  1,	  2015,	  although	  two	  of	  the	  three	  facilities	  ceased	  the	  practice	   several	  months	  before	  the	  official	  policy	  change.	  As	  a	  result,	  some	  of	  the	  requirements	   of	  the	  Grid	  no	  longer	  applied	  and	  were	  not	  monitored	  throughout	  the	  six-­‐month	  period.	  
• DYS	  drastically	  reformed	  its	  use	  of	  prehearing	  seclusion	  (PHS),	  removing	  predetermined	   lengths	  of	  stay	  ranging	  between	  24	  and	  72	  hours	  and	  replacing	  them	  with	  assessments	   related	  to	  the	  youth’s	  current	  behavior	  and	  his	  willingness	  to	  process	  the	  events	  with	   staff.	  As	  a	  result,	  the	  large	  majority	  (80%)	  of	  PHS	  episodes	  concluded	  within	  4	  hours,	   with	  the	  remaining	  concluding	  within	  8-­‐12	  hours.	  Longer	  lengths	  of	  stay	  were	  typically	   the	  result	  of	  the	  timing	  of	  the	  incident—those	  occurring	  in	  the	  late	  evening	  generally	   result	  in	  an	  overnight	  stay	  on	  PHS.	  Occasionally,	  youth	  refused	  to	  process	  the	  event,	  but	   were	  revisited	  by	  staff	  within	  2-­‐3	  hours.	  Over	  the	  past	  six	  months,	  of	  the	  over	  700	   episodes	  of	  PHS,	  none	  lasted	  beyond	  24	  hours.	  	  
• While	  the	  quality	  of	  the	  processing	  of	  events	  between	  youth	  and	  staff	  was	  slower	  to	   develop	  into	  a	  substantive	  conversation,	  by	  the	  end	  of	  the	  monitoring	  period,	   approximately	  80%	  of	  the	  Safe	  to	  Release	  interviews	  were	  sufficient	  to	  inform	  the	   therapeutic	  conversation	  between	  youth	  and	  behavioral	  health	  staff	  that	  occurred	  

	  

4.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 5 of 34 PAGEID #: 3163
	  

within	  a	  few	  days	  of	  the	  incident.	  Data	  from	  March	  (not	  presented	  in	  this	  report)	   revealed	  that	  all	  three	  facilities	  exceeded	  the	  required	  90%	  performance	  level.	  	   • As	  a	  result	  of	  these	  changes,	  the	  accumulation	  of	  seclusion	  hours	  by	  individual	  youth	   who	  engage	  in	  high-­‐frequency	  AOVs	  is	  nowhere	  near	  the	  levels	  that	  originally	  created	   concern	  (for	  background,	  see	  Dr.	  Dedel’s	  report	  on	  seclusion	  practices	  at	  Scioto	  JCF,	   November	  2013).	  Rather	  than	  the	  hundreds	  of	  hours	  of	  seclusion	  that	  some	  youth	   accumulated	  before	  the	  Grid	  went	  into	  effect,	  since	  the	  Grid’s	  implementation,	  even	   youth	  with	  high-­‐frequency	  AOVs	  accumulated	  only	  20-­‐30	  hours	  of	  seclusion	  each	   month.	   • DYS	  has	  developed	  and	  implemented	  a	  comprehensive	  Quality	  Assurance	  process	  that	   attends	  to	  the	  duration	  of	  seclusion,	  its	  accumulation,	  and	  the	  integrity	  and	  timeliness	   of	  the	  Safe-­‐to-­‐Release	  process.	  This	  process	  is	  a	  suitable	  replacement	  for	  external	   oversight	  from	  the	  Monitor.	  	  	   • In	  Dr.	  Dedel’s	  opinion,	  DYS	  is	  in	  substantial	  compliance	  with	  the	  requirements	  of	  Column	   B	  of	  the	  Grid.	   	   	  
Column	  C	  Summary:	  Strategies	  for	  the	  Aftermath	  
• System	  wide,	  treatment	  plans	  were	  reviewed	  within	  2	  days	  of	  the	  AOV	  in	  77%	  of	  the	   cases	  reviewed.	  Delays	  occurred	  because	  of	  weekend	  coverage	  and	  the	  availability	  of	   clinicians	  involved	  with	  the	  youth.	  The	  small	  number	  of	  cases	  reviewed	  skews	  the	   understanding	  of	  what	  is	  truly	  occurring	  at	  the	  facilities.	  Furthermore,	  compliance	  rates	   improved	  significantly	  in	  recent	  months.	  
• System	  wide,	  the	  treatment	  plans	  were	  fortified	  or	  revised	  in	  84%	  of	  the	  cases	   reviewed.	  Six-­‐month	  averages	  at	  the	  individual	  facilities	  were	  93%	  at	  Circleville,	  84%	  at	   Cuyahoga	  Hills	  and	  76%	  at	  Indian	  River.	  Small	  sample	  sizes	  and	  database	  issues	   obscured	  the	  significant	  gains	  DYS	  has	  made.	  	  
• System	  wide,	  a	  Special	  Review	  Team	  (SRT)	  was	  convened	  within	  2	  days	  of	  a	  youth’s	   meeting	  the	  AOV	  threshold	  (3+	  high	  severity	  or	  2+	  severe	  offenses)	  in	  87%	  of	  the	  cases	   reviewed.	  Six-­‐month	  averages	  at	  the	  individual	  facilities	  were	  95%	  at	  Cuyahoga	  Hills,	   84%	  at	  Circleville,	  and	  83%	  at	  Indian	  River.	  In	  all	  instances,	  the	  SRT	  was	  held	  within	  4	   days.	  Delays	  occurred	  in	  order	  to	  permit	  the	  youth’s	  treating	  clinician	  to	  participate	  in	   the	  meeting.	  	  
• System	  wide,	  the	  SRT	  explored	  and	  provided	  interventions	  relevant	  to	  the	  causes	  and	   functions	  of	  the	  youth’s	  behavior	  in	  only	  72%	  of	  the	  cases	  reviewed.	  Six-­‐month	  averages	   for	  the	  individual	  facilities	  are	  93%	  at	  Indian	  River,	  82%	  at	  Cuyahoga	  Hills	  and	  41%	  at	   Circleville.	  However,	  there	  is	  ample	  evidence	  that	  the	  interventions	  provided	  did	  curb	   instances	  of	  youth	  aggression.	  	  
• In	  Dr.	  Weisman’s	  opinion,	  DYS	  is	  in	  substantial	  compliance	  with	  the	  requirements	  of	   Column	  C	  of	  the	  Grid.	  	  
	   	  

	  

	  

	  

	  

5.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 6 of 34 PAGEID #: 3164
	  

	   Column	  A.	  Prevention	  Strategies	  (Assigned	  Monitor:	  Dr.	  Daphne	  Glindmeyer)	  

What	  the	   Grid	   Requires	  

(A)	  Overall	  Performance	  Measure	  	   • Increase	  proportion	  of	  youth	  who	  do	  not	  engage	  in	  AOV	   • Decrease	  number	  and	  proportion	  of	  MHCL	  youth	  who	  engage	  in	  3+	  AOVs	   each	  month	  by	  10%	  each	  month.	  	  

Monitor’s	   Assessment	  

While	  originally	  attached	  to	  “Column	  A,”	  it	  turned	  out	  that	  the	  data	  required	  to	   assess	  these	  outcomes	  were	  submitted	  to	  the	  Monitor	  for	  “Column	  B,”	  so	   responsibility	  for	  monitoring	  them	  was	  shifted	  to	  Dr.	  Dedel,	  who	  authored	  this	   section,	  “Overall	  Performance	  Measures.”	  	   	   The	  table	  below	  shows	  the	  proportion	  of	  youth	  on	  the	  MHCL	  who	  did	  not	   engaged	  in	  acts	  of	  violence	  (AOV)	  each	  month,	  by	  facility	  and	  system-­‐wide.	  The	   Grid	  requires	  an	  increase	  from	  a	  baseline	  (i.e.,	  average	  Jan-­‐June,	  2014).	  As	  shown,	   while	  the	  month-­‐to-­‐month	  increases	  were	  not	  always	  steady,	  each	  facility’s	  6-­‐ month	  average	  reveals	  an	  increase	  over	  the	  baseline.	  Circleville	  and	  Cuyahoga	   Hills	  both	  increased	  the	  proportion	  of	  youth	  on	  the	  MHCL	  without	  an	  AOV	  by	  5%,	   while	  Indian	  River’s	  proportion	  increased	  18%.	  Overall,	  roughly	  two-­‐thirds	  of	  DYS	   youth	  on	  the	  MHCL	  did	  not	  engage	  in	  acts	  of	  violence	  each	  month.	  Prior	  to	  the	   Grid’s	  implementation,	  only	  about	  half	  remained	  AOV-­‐free	  each	  month.	  	   	  

Proportion	  of	  youth	  on	  the	  MHCL	  with	  no	  AOV	  

	  

Baseline	   Sept	   Oct	   Nov	   Dec	   Jan	   Feb	   AVG	  

Circleville	  

54%	   69%	   58%	   45%	   67%	   59%	   58%	   59%	  

Cuyahoga	  Hills	  

61%	   71%	   75%	   63%	   64%	   59%	   62%	   66%	  

Indian	  River	  

50%	   59%	   72%	   61%	   80%	   68%	   68%	   68%	  

DYS	  AVERAGE	  

55%	   66%	   68%	   56%	   70%	   62%	   63%	   64%	  

	  	   The	  Grid	  also	  required	  decreases	  in	  the	  proportion	  of	  youth	  on	  the	  MHCL	  who	   engaged	  in	  frequent	  acts	  of	  violence	  each	  month	  (i.e.,	  3+	  AOVs).	  A	  baseline	  was	   not	  calculated	  due	  to	  the	  significant	  workload	  involved	  in	  compiling	  historical	   data.	  The	  table	  below	  shows	  each	  facility’s	  performance	  level	  over	  the	  6-­‐month	   period.	  Once	  again,	  the	  decreases	  were	  not	  always	  steady,	  but	  overall,	  the	   proportion	  of	  youth	  with	  high-­‐frequency	  AOVs	  was	  smaller	  toward	  the	  end	  of	  the	   monitoring	  period	  as	  compared	  to	  the	  beginning	  (Sept-­‐Nov	  average	  =	  7.0%;	  Dec-­‐ Feb	  average	  =	  5.3%).	  This	  pattern	  holds	  for	  both	  Circleville	  (Sept-­‐Nov	  average	   11.6%	  versus	  Dec-­‐Feb	  average	  6.6%)	  and	  Cuyahoga	  Hills	  (Sept-­‐Nov	  average	  6.0%	   versus	  Dec-­‐Feb	  average	  4.6%),	  though	  not	  for	  Indian	  River	  (average	  3.3%	  versus	   4.0%)	  due	  to	  the	  low	  number	  of	  youth	  with	  frequent	  AOVs	  throughout	  the	   monitoring	  period.	  	   	   	   	   	   	  

	  

6.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 7 of 34 PAGEID #: 3165
	  

Proportion	  of	  youth	  on	  the	  MHCL	  with	  3+	  AOV	  

	  

Sept	   Oct	   Nov	   Dec	   Jan	   Feb	   AVG	  

Circleville	  

10%	   10%	   15%	   3%	   9%	   8%	   9%	  

Cuyahoga	  Hills	  

3%	   5%	   10%	   3%	   6%	   5%	   5%	  

Indian	  River	  

8%	   0%	   2%	   2%	   5%	   5%	   4%	  

DYS	  AVERAGE	  

7%	   5%	   9%	   3%	   7%	   6%	   6%	  

	   While	  the	  changes	  did	  not	  conform	  to	  the	  rigid	  mathematical	  formula	  originally	   proposed,	  in	  both	  cases,	  the	  data	  suggest	  that	  fewer	  MHCL	  youth	  engaged	  in	   AOVs	  and	  fewer	  engaged	  in	  high-­‐frequency	  AOVs	  than	  before	  the	  Grid	  was	   implemented.	  By	  way	  of	  context,	  note	  that	  the	  MHCLs	  were	  generally	  between	   60-­‐70	  youth	  in	  each	  facility	  each	  month,	  so	  in	  most	  months,	  fewer	  than	  5	  youth	  at	   each	  facility	  were	  engaging	  in	  high-­‐frequency	  AOVs.	  	   	   As	  the	  monitoring	  period	  progressed,	  the	  Monitor	  became	  aware	  that	  the	  rigid	   mathematical	  formula	  prescribed	  by	  the	  grid	  may	  not	  be	  as	  useful	  as	  we	  originally	   hoped,	  due	  mostly	  to	  the	  small	  numbers	  of	  youth	  with	  high-­‐frequency	  AOVs.	  The	   low	  base	  rate	  makes	  continual	  reductions	  very	  difficult	  to	  achieve.	  The	  Monitor,	   DYS	  and	  Plaintiffs	  agreed	  that	  a	  more	  useful	  metric	  would	  be	  the	  extent	  to	  which	   the	  same	  youth	  were	  involved	  in	  high-­‐frequency	  AOVs	  over	  and	  over	  again,	  as	   this	  would	  be	  a	  better	  indicator	  of	  the	  effectiveness	  of	  mental	  health	   interventions	  (see	  “Column	  C”).	  	   	   An	  analysis	  of	  all	  the	  youth	  who	  met	  the	  3+	  AOV	  threshold	  across	  the	  6-­‐month	   period	  revealed	  that	  the	  large	  majority	  of	  DYS	  youth	  who	  initially	  met	  the	   threshold	  went	  on	  to	  curb	  their	  aggressive	  behavior	  in	  short	  order.	  Collectively,	   49	  youth	  met	  the	  3+	  AOV	  threshold	  at	  least	  once	  during	  the	  monitoring	  period,	   and	  only	  12	  youth	  (24%)	  met	  the	  threshold	  multiple	  times.	  This	  suggests	  that	  the	   Special	  Review	  Team	  (SRT;	  see	  “Column	  C”)	  and	  the	  many	  other	  program	   improvements	  that	  are	  part	  of	  DYS’	  Path	  to	  Safer	  Facilities	  have	  been	  effective	  in	   reducing	  youth	  violence.	  Some	  of	  the	  youth	  continued	  to	  engage	  in	  aggressive	   behavior,	  but	  at	  a	  reduced	  frequency.	  Individual	  facility	  data	  is	  presented	  below:	  
• At	  Circleville,	  a	  total	  of	  20	  youth	  met	  the	  3+	  AOV	  threshold	  during	  the	  6-­‐ month	  period.	  Of	  these,	  only	  7	  youth	  (35%)	  met	  the	  threshold	  in	  multiple	   months.	  Among	  the	  7	  youth,	  three	  met	  the	  threshold	  3	  or	  more	  times,	   while	  the	  other	  4	  met	  the	  threshold	  only	  2	  times.	  	  
• At	  Cuyahoga	  Hills,	  a	  total	  of	  18	  youth	  met	  the	  3+	  AOV	  threshold	  during	   the	  6-­‐month	  period.	  Of	  these,	  only	  4	  youth	  (22%)	  met	  the	  threshold	  in	   multiple	  months.	  All	  of	  these	  youth	  met	  the	  threshold	  only	  2	  times.	  	  
• At	  Indian	  River,	  a	  total	  of	  11	  youth	  met	  the	  3+	  AOV	  threshold	  during	  the	   6-­‐month.	  Of	  these,	  only	  1	  youth	  (10%)	  met	  the	  threshold	  in	  multiple	   months	  (3	  months).	  	  
	   In	  summary,	  aggregate	  data	  and	  individual	  analyses	  suggest	  that	  the	  proportion	   of	  MHCL	  youth	  who	  engage	  in	  any	  aggressive	  behavior	  has	  decreased	  throughout	   the	  monitoring	  period,	  as	  has	  the	  proportion	  of	  youth	  who	  engage	  in	  high	  

	  

7.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 8 of 34 PAGEID #: 3166
	  

	  
What	  the	   Grid	   Requires	  

frequency	  aggressive	  behavior.	  The	  interventions	  applied	  to	  those	  with	  high-­‐ frequency	  AOVs	  appear	  to	  be	  effective,	  given	  that	  very	  only	  about	  one-­‐quarter	  of	   these	  youth	  continue	  their	  high-­‐frequency	  AOVs	  in	  subsequent	  months.	  	  
(A.1)	  Verify	  Treatment	  Integrity	   • Quality	  Assurance	  tools	  and	  audits	  that	  ensure	  individual	  treatment	  is	   aligned	  with	  treatment	  goals.	   • Quality	  Assurance	  tools	  and	  audits	  that	  ensure	  group	  treatment	  displays	   fidelity	  to	  design.	  	  
(A.1)	  Performance	  Measures	   • 90%	  of	  all	  cases	  reviewed	  showed	  correspondence	  between	  content	  of	   individual	  sessions	  and	  treatment	  goals.	   • 90%	  of	  all	  groups	  included	  in	  the	  sample	  scored	  80%	  or	  better	  on	  a	   measure	  of	  treatment	  fidelity.	  	  

Monitor’s	   Assessment	  

Quality	  assurance	  tools	  have	  been	  developed	  and	  monthly	  audits	  of	  both	  group	   therapy	  treatment	  and	  documentation	  indicating	  treatment	  is	  aligned	  with	   treatment	  goals	  have	  occurred	  as	  required	  by	  the	  Grid.	  DYS	  provided	  copies	  of	  all	   documents	  used	  to	  conduct	  the	  QA	  reviews	  each	  month.	  Dr.	  Glindmeyer	   reviewed	  approximately	  10-­‐15%	  of	  these	  documents	  in	  order	  to	  validate	  the	   conclusions	  of	  the	  QA	  reviewers.	  In	  general,	  Dr.	  Glindmeyer’s	  assessment	  of	   adequacy	  matched	  the	  QA	  reviewer’s	  assessment.	  	   	   A.1(a)	   	   In	  order	  to	  determine	  the	  integration,	  a	  Behavioral	  Health	  Supervisor	  must	  review	   an	  integrated	  treatment	  plan	  (ITP)	  and	  corresponding	  case	  notes	  for	  two	  youth	   on	  each	  clinician’s	  caseload	  every	  month.	  	  The	  following	  information	  is	  reviewed:	  
• General	  Elements	   o Did	  the	  clinician	  meet	  with	  the	  youth	  face	  to	  face	  within	  7	  days	  of	   arrival	   o The	  ITP	  identifies	  the	  youth’s	  presenting	  issues	   o The	  ITP	  is	  approved	  within	  30	  days	  of	  the	  youth’s	  arrival	  to	  the	   facility	  
• ITP	  Goal	  Key	  Elements	   o Are	  all	  goals	  individualized	   o Are	  all	  goals	  written	  in	  strength	  based	  language	   o Are	  all	  goals	  related	  to	  documented	  presenting	  issues	   o Are	  the	  youth’s	  criminogenic	  needs	  addressed	  
• ITP	  Objective	  Key	  Elements	   o Is	  there	  at	  least	  one	  objective	  for	  each	  goal	   o All	  objectives	  include	  duration	   o All	  objectives	  include	  frequency	   o All	  objectives	  are	  written	  in	  concrete,	  specific	  behavioral	  terms	   o The	  objectives	  are	  written	  in	  a	  language	  that	  the	  youth	   understands	   o Each	  objective	  identifies	  the	  IDT	  member	  responsible	  for	  the	  

	  

8.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 9 of 34 PAGEID #: 3167
	  
service	  delivery	   o If	  the	  youth	  has	  been	  active	  in	  Security	  Threat	  Group	  (STG)	  
activity,	  an	  objective	  has	  been	  developed	  to	  address	  this	  behavior	   • Individual	  Session	  Key	  Elements	  
o Do	  the	  notes	  reflect	  that	  the	  clinician	  addressed	  the	  youth’s	  ITP	   goals	  and	  or	  objectives	  during	  90%	  of	  the	  individual	  sessions	  
o Are	  individual	  session	  notes	  in	  a	  Subjective,	  Objective,	   Assessment,	  Plan	  (SOAP)	  format	  
o Does	  each	  section	  of	  the	  SOAP	  note	  contain	  appropriate	  content	   • Group	  Key	  Elements	  
o Are	  group	  notes	  in	  SOAP	  format	   o Does	  each	  section	  of	  the	  SOAP	  note	  contain	  appropriate	  content	   o Are	  groups	  attended	  by	  the	  youth	  specific	  to	  the	  youth’s	  needs	  as	  
outlined	  in	  the	  ITP	   • Case	  notes	  Key	  Elements	  
o Do	  all	  individual	  session	  notes	  contain	  the	  clinician’s	  name	  and	   credentials	  
o Do	  all	  group	  notes	  contain	  the	  clinician’s	  name	  and	  credentials	   o Was	  session	  length	  documented	  in	  90%	  of	  the	  case	  notes	   o Was	  the	  treatment	  dosage	  documented	  in	  90%	  of	  the	  case	  notes	   o Were	  90%	  of	  the	  notes	  entered	  the	  same	  day	   • Sex	  Offender	  Programming	   o Was	  a	  JSOAP	  completed	  within	  30	  calendar	  days	  of	  arrival	  to	  the	  
parent	  facility	   o If	  the	  youth	  was	  adjudicated	  on	  a	  sex	  offense,	  is	  it	  documented	  in	  
the	  Court	  Request	  section	  of	  the	  ITP	   o If	  the	  youth	  was	  adjudicated	  on	  a	  sex	  offense,	  is	  there	  a	  goal	  and	  
objectives	  that	  address	  Sex	  Offender	  Programming	   o Within	  45	  calendar	  days	  of	  arrival	  to	  the	  parent	  facility,	  the	  youth	  
started	  sex	  offender	  programming	   o Was	  a	  6	  month	  sex	  offender	  reassessment	  completed	   o Was	  a	  comparison	  of	  the	  Scale	  3	  outcomes	  documented	  in	  the	  
narrative	   • Monthly	  Interdisciplinary	  Treatment	  Team	  (IDT)	  Summary	  Process	  
o A	  current	  IDT	  summary	  is	  present	   o Does	  the	  current	  IDT	  summary	  include:	  
§ The	  current	  group	  enrollment	   § The	  number	  of	  individual	  sessions	  attended	  and	  not	  
attended	   § An	  explanation	  for	  unattended	  individual	  sessions	   § Therapeutic	  work	  being	  processed	  in	  individual	  sessions	   § The	  number	  of	  groups	  attended	  and	  not	  attended	   § An	  explanation	  for	  unattended	  groups	   § The	  level	  of	  youth’s	  participation	  in	  group	   § The	  youth’s	  integration	  of	  skills	  acquired	   § Progress	  or	  lack	  thereof	  toward	  ITP	  goals	  and	  objectives	   § Stages	  of	  Change	  as	  it	  relates	  to	  ITP	  goals	  and	  objectives	  

	  

9.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 10 of 34 PAGEID #: 3168
	  

§ New	  programming	  recommendations	   § Family	  engagement/contact	   § Medication	  changes	   § Changes	  to	  mental	  health	  status/updates	   § Education	  progress	   § Employment	  progress	   § Based	  on	  the	  Planned	  Expiration	  Date	  (PED),	  is	  the	  youth	  
on	  track	  to	  complete	  dosage	  hours	  
	  
The	  following	  is	  a	  summary	  of	  quality	  assurance	  audit	  data	  from	  the	  six-­‐month	  
monitoring	  period.	  The	  Grid	  required	  90%	  of	  all	  cases	  reviewed	  to	  show	  
correspondence	  between	  the	  content	  of	  individual	  therapy	  and	  treatment	  goals.	  
	  

Correspondence	  between	  Content	  of	  Therapy	  and	  Individual	  Treatment	  Goals	  

	  

Sept	   Oct	   Nov	   Dec	   Jan	   Feb	   AVG	  

Circleville	  

90%	   69%	   81%	   94%	   85%	   68%	   81%	  

Cuyahoga	  Hills	  

84%	   91%	   89%	   88%	   100%	   100%	   92%	  

Indian	  River	  

96%	   100%	   100%	   100%	   93%	   100%	   98%	  

DYS	  AVERAGE	  

90%	   87%	   90%	   94%	   93%	   89%	   90%	  

Sample	  Size:	  Circleville	  n=112;	  Cuyahoga	  Hills	  n=113;	  Indian	  River	  n=168	  

	   While	  individual	  facilities	  occasionally	  fell	  below	  the	  required	  performance	  level,	   overall	  DYS	  achieved	  the	  90%	  benchmark.	  When	  the	  QA	  review	  indicated	  that	  the	   facility	  did	  not	  meet	  expectations,	  DYS	  took	  appropriate	  action,	  as	  described	   below.	  	   	   Following	  each	  of	  the	  QA	  sections	  outlined	  above,	  the	  Behavioral	  Health	   Supervisor	  is	  given	  the	  option	  to	  recommend	  a	  Performance	  Improvement	  Plan	   (PIP)	  for	  the	  clinician	  under	  review.	  	  As	  noted	  in	  the	  outline	  above,	  the	  quality	   assurance	  measures	  for	  this	  performance	  measure	  are	  detailed.	  	  A	  review	  of	  the	   quality	  assurance	  results	  for	  each	  of	  the	  three	  facilities	  revealed	  that	  two	   facilities,	  CHJCF	  and	  IRJCF	  have	  had	  a	  general	  increase	  in	  compliance	  percentages,	   with	  each	  scoring	  100%	  in	  the	  February	  review.	  	  CJCF	  has	  experienced	  some	   challenges,	  with	  a	  drop	  in	  scores	  from	  85%	  in	  January	  to	  68%	  in	  February.	  	  It	   should	  be	  noted	  that	  the	  decrease	  in	  scores	  at	  CJCF	  in	  the	  month	  of	  February	  was	   due	  to	  some	  clinicians	  experiencing	  difficulties.	  	  	  	   	   There	  were	  a	  total	  of	  three	  staff	  on	  performance	  improvement	  plans	  (PIP)	  at	  CJCF	   in	  the	  month	  of	  February.	  	  One	  of	  these	  staff	  had	  been	  placed	  on	  a	  PIP	  in	   November	  2014.	  	  As	  of	  February,	  this	  staff	  was	  continuing	  to	  experience	  difficulty,	   as	  it	  was	  noted	  that	  only	  half	  of	  the	  youth	  assigned	  to	  this	  staff’s	  caseload	  had	   been	  seen	  for	  individual	  sessions	  during	  the	  month.	  	  Two	  additional	  staff	  were	   placed	  on	  PIP	  in	  the	  month	  of	  February	  2015.	  	  Both	  of	  these	  staff	  were	  noted	  to	   have	  deficiencies	  with	  regard	  to	  meeting	  with	  youth	  for	  individual	  sessions	  on	  a	   regularly	  scheduled	  basis.	  	  The	  PIP	  noted	  that	  these	  individual’s	  would	  be	   reviewed	  on	  a	  monthly	  basis.	  	  Given	  the	  deficiencies	  and	  how	  this	  has	  negatively	  

	  

10.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 11 of 34 PAGEID #: 3169
	  
affected	  the	  outcome	  of	  the	  data,	  and	  more	  importantly,	  the	  potential	  for	   negative	  outcomes	  for	  the	  youth	  in	  their	  care,	  more	  frequent	  (i.e.	  weekly)	   reviews	  are	  recommended	  during	  the	  period	  of	  time	  these	  treatment	  providers	   are	  on	  PIP.	   	   Overall	  marked	  improvement	  in	  both	  treatment	  planning	  and	  documentation	  of	   treatment	  provided	  were	  noted.	  	  In	  general,	  goals	  were	  individualized,	  were	   related	  to	  presenting	  issues,	  and	  included	  objectives	  that	  were	  measurable	  and	   time	  limited.	  	  When	  reviewing	  associated	  individual	  treatment	  progress	  notes,	   there	  was	  greater	  attention	  to	  documenting	  the	  youth’s	  progress	  toward	   treatment	  goals.	  	  There	  was	  an	  overall	  need	  for	  improvement	  with	  regard	  to	   documentation	  of	  reviewing	  skills	  that	  either	  the	  youth	  had	  learned	  and	  was	   implementing	  or	  that	  the	  youth	  needed	  to	  improve.	  	  It	  should	  be	  noted	  that	  this	   is	  a	  very	  difficult	  concept	  for	  clinicians	  to	  integrate	  into	  their	  documentation.	  	  	   	   Although	  it	  was	  not	  always	  found	  in	  the	  record,	  site	  visits	  and	  interviews	  with	  the	   youth	  indicated	  that	  clearly,	  youth	  were	  learning	  skills.	  	  Youth	  were	  noted	  to	  be	   able	  to	  state	  their	  treatment	  goals	  and	  to	  verbalize	  skills	  that	  they	  had	  learned	   and	  how	  they	  were	  using	  these	  skills.	  	   	   Given	  the	  overall	  improvement	  with	  regard	  to	  the	  correlation	  between	  ITP	  goals	   and	  treatment	  provided,	  this	  portion	  of	  provision	  A.1.	  is	  in	  substantial	   compliance.	  	  It	  is	  understood	  that	  some	  quality	  assurance	  scores	  were	  below	  the	   level	  needed	  for	  compliance;	  however,	  what	  is	  most	  important	  is	  that	  the	  quality	   assurance	  process	  is	  in	  place	  at	  the	  facility,	  that	  ODYS	  was	  able	  to	  identify	  these	   deficiencies,	  and	  that	  staff	  were	  working	  to	  improve	  the	  overall	  provision	  of	   mental	  health	  care.	   	   A.1(b)	   	   Quality	  assurance	  monitoring	  for	  group	  therapy	  includes	  a	  review	  of	  elements	  of	   group	  structure,	  content,	  and	  fidelity	  to	  a	  treatment	  manual	  (if	  applicable).	  	  This	   is	  accomplished	  by	  having	  the	  quality	  assurance	  reviewer	  attend	  group	  and	  score	   the	  following	  items:	   	  
• Did	  the	  group	  begin	  on	  time	   • Did	  the	  group	  last	  an	  appropriate	  length	  of	  time	   • Were	  the	  facilitators	  prepared	  for	  group	   • Was	  the	  group	  set	  up	  in	  a	  circle	  or	  a	  U	   • Did	  the	  facilitators	  review	  the	  group	  rules	  at	  the	  beginning	  of	  group	   • Did	  the	  facilitators	  review	  the	  objectives	  at	  the	  beginning	  of	  group	   • Did	  the	  facilitators	  collect	  homework	   • Did	  all	  youth	  role	  play	  or	  practice	  the	  skill	  being	  taught	   • Did	  the	  facilitators	  use	  reflective	  listening	   • Did	  the	  facilitators	  use	  open	  ended	  questions	   • Did	  the	  facilitators	  make	  the	  material	  relevant	  and	  interesting	  to	  the	  
youth	  

	  

11.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 12 of 34 PAGEID #: 3170
	  

• Did	  the	  facilitators	  connect	  the	  group	  discussion	  to	  the	  objectives	  at	  the	   end	  of	  group	  
• Did	  the	  facilitators	  encourage	  all	  youth	  to	  participate	   • Did	  the	  facilitators	  hold	  all	  youth	  accountable	  for	  group	  expectations	  
throughout	  the	  meeting	   • Did	  the	  facilitators	  manage	  the	  group	  effectively	   • Did	  the	  facilitators	  manage	  inappropriate	  youth	  so	  that	  they	  did	  not	  
disrupt	  the	  group	  process	   	   The	  following	  is	  a	  summary	  of	  quality	  assurance	  audit	  data	  from	  the	  six-­‐month	   monitoring	  period.	  The	  Grid	  requires	  90%	  of	  all	  groups	  included	  in	  the	  sample	  to	   score	  80%	  or	  better	  on	  a	  measure	  of	  treatment	  fidelity	  (i.e.,	  the	  QA	  tool).	  	   	  

Treatment	  Fidelity	  for	  Groups	  

	  

Sept	   Oct	   Nov	   Dec	   Jan	   Feb	   AVG	  

Circleville	  

100%	   89%	   100%	   100%	   100%	   100%	   98%	  

Cuyahoga	  Hills	  

100%	   100%	   100%	   100%	   100%	   100%	   100%	  

Indian	  River	  

91%	   100%	   88%	   100%	   100%	   100%	   97%	  

DYS	  AVERAGE	  

97%	   96%	   96%	   100%	   100%	   100%	   98%	  

Sample	  Size:	  Circleville	  n=43;	  Cuyahoga	  Hills	  n=33;	  Indian	  River	  n=48	  

	   	   When	  reviewing	  the	  tabulated	  results	  from	  group	  therapy	  quality	  assurance,	  it	  is	   notable	  that	  for	  the	  last	  three	  months,	  all	  facilities	  scored	  100%	  on	  quality	   assurance	  measures.	  	  	   	   Over	  this	  monitoring	  period,	  two	  onsite	  visits	  were	  performed	  at	  each	  of	  the	   three	  facilities.	  Group	  therapy	  interactions	  were	  observed	  during	  the	  visits.	  	   Overall,	  marked	  improvements	  in	  group	  therapy	  were	  noted.	  For	  example,	  in	   previous	  monitoring	  visits	  there	  were	  occasions	  where	  groups	  were	  disorganized,	   had	  no	  clear	  goals/objectives,	  and	  disruptive	  youth	  were	  allowed	  to	  interrupt	  the	   group	  process.	  	  	   	   In	  the	  last	  two	  visits	  (September	  2014	  and	  March	  2015),	  youth	  were	  observed	  to	   be	  engaged	  in	  the	  group	  therapy	  process	  and	  were	  able	  to	  discuss	  cognitive	   behavioral	  therapy	  techniques	  they	  had	  learned	  as	  well	  as	  how	  to	  implement	   these	  techniques.	  It	  was	  noted	  that	  groups	  were	  more	  interesting	  for	  the	  youth	   and	  held	  their	  attention	  given	  the	  use	  of	  “real	  world”	  examples	  that	  the	  youth	   could	  relate	  to.	  In	  particular,	  “Men’s	  Group”	  observed	  at	  CHJCF	  during	  the	  March	   2015	  monitoring	  visit,	  was	  an	  example	  of	  marked	  improvement	  in	  group	  therapy	   programming.	  Youth	  were	  engaged	  in	  the	  process,	  discussing	  role-­‐plays,	  and	   facilitators	  used	  the	  youth’s	  discussions	  as	  examples	  of	  cognitive	  behavioral	  skills.	   	   Given	  the	  results	  of	  quality	  assurance	  monitoring	  coupled	  with	  group	  therapy	   observations	  performed	  during	  the	  last	  two	  monitoring	  visits,	  this	  portion	  of	  A.1.	   of	  the	  Grid	  is	  in	  substantial	  compliance.	  

	  

12.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 13 of 34 PAGEID #: 3171
	  

What	  the	   Grid	   Requires	  

(A.2)	  Develop	  BioPsychoSocial	  Assessment	  that	  includes	  Clinical	  and	  Diagnostic	   Formulation	  
• Initial	  BioPsychoSocial	  Assessment	  includes	  a	  broad	  range	  of	   informational	  sources	  and	  culminates	  in	  a	  clinical	  formulation	  and	   diagnostic	  formulation,	  which	  is	  reflected	  in	  the	  youth’s	  treatment	  plan.	  	  
• Quality	  Assurance	  Tools	  will	  be	  developed.	  	   (A.2)	  Performance	  Measures	  
• 90%	  of	  initial	  assessments	  include	  a	  solid	  clinical/diagnostic	  formulation.	   • 90%	  of	  treatment	  plans	  reflect	  information	  from	  the	  formulation.	  	  

Monitor’s	   Assessment	  

Quality	  assurance	  tools	  have	  been	  developed	  and	  monthly	  audits	  of	  both	  the	   BioPsychoSocial	  assessment	  and	  the	  resultant	  treatment	  plan	  are	  occurring,	  as	   required	  by	  the	  Grid.	  DYS	  provided	  copies	  of	  all	  documents	  used	  to	  conduct	  the	   QA	  reviews	  each	  month.	  Dr.	  Glindmeyer	  reviewed	  approximately	  10-­‐15%	  of	  these	   documents	  in	  order	  to	  validate	  the	  conclusions	  of	  the	  QA	  reviewers.	  In	  general,	   Dr.	  Glindmeyer’s	  assessment	  of	  adequacy	  matched	  the	  QA	  reviewer’s	   assessment.	  	   	   A.2(a)	   	   In	  order	  to	  determine	  compliance	  with	  standards	  for	  the	  BioPsychoSocial	   assessment,	  the	  QA	  auditor	  reviews	  charts	  to	  score	  the	  following	  metrics:	   	  
• Did	  the	  clinician	  complete	  the	  Mental	  Status	  Examination	  Sections	   o Each	  area	  of	  the	  mental	  status	  examination	  is	  then	  separately	   scored	  
• Summary	  and	  Recommendations	   o Did	  the	  clinician	  describe	  how	  the	  person	  came	  to	  the	  particular	   problems	   o Did	  the	  clinician	  identify	  influences	  involved	   o Did	  the	  clinician	  identify	  the	  youth’s	  strengths	   o Did	  the	  clinician	  identify	  how	  the	  youth	  has	  coped	  thus	  far	   o Did	  the	  case	  formulation	  describe	  the	  relationship	  between	  the	   various	  factors	  and	  the	  problems	  that	  are	  present	   o Did	  the	  clinician	  recommend	  interventions	  and	  behavior	   management	  techniques	  that	  will	  address	  the	  youth’s	  needs	   o Did	  the	  clinician	  identify	  PREA	  needs	   o Did	  the	  clinician	  recommend	  treatment	  and	  programming	   recommendations	  that	  address	  the	  youth’s	  needs	  
	   The	  following	  chart	  summarizes	  the	  quality	  assurance	  data	  from	  the	  six-­‐month	   monitoring	  period.	  The	  Grid	  requires	  90%	  of	  initial	  assessments	  to	  include	  a	  solid	   clinical/	  diagnostic	  formulation.	   	   	   	   	   	  

	  

13.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 14 of 34 PAGEID #: 3172
	  

	  

Initial	  Assessment	  includes	  a	  Quality	  Clinical/Diagnostic	  Formulation	  

	  

Sept	   Oct	   Nov	   Dec	   Jan	   Feb	   AVG	  

Circleville	  

100%	   100%	   88%	   100%	   100%	   100%	   98%	  

Cuyahoga	  Hills	  

33%	   67%	   100%	   67%	   100%	   100%	   78%	  

Indian	  River	  

80%	   100%	   80%	   100%	   100%	   100%	   93%	  

DYS	  AVERAGE	  

71%	   89%	   89%	   89%	   100%	   100%	   90%	  

Sample	  Size:	  Circleville	  n=26;	  Cuyahoga	  Hills	  n=47;	  Indian	  River	  n=23	  

	   	   As	  noted	  in	  the	  table	  above,	  there	  have	  been	  improvements	  in	  the	  mental	  health	   assessments	  performed	  at	  all	  facilities.	  	  For	  the	  last	  two	  months,	  all	  initial	   assessments	  reviewed	  via	  quality	  assurance	  at	  all	  three	  facilities	  have	  scored	   100%.	  	  	   	   In	  an	  effort	  to	  achieve	  compliance	  with	  this	  provision,	  and	  to	  improve	  behavioral	   health	  services	  overall,	  ODYS	  changed	  the	  format	  of	  the	  initial	  mental	  health	   appraisal,	  putting	  focus	  on	  the	  review	  of	  symptoms	  indicating	  a	  mental	  health	   disorder	  and	  on	  the	  development	  of	  the	  case	  formulation.	  These	  changes	  were	   evident	  in	  the	  most	  recent	  monitoring	  visit	  in	  March	  2015.	  Assessments	  were	   noted	  to	  be	  thorough,	  with	  cogent	  case	  formulations	  that	  could	  be	  used	  in	  order	   to	  author	  a	  relevant	  ITP.	   	   Currently,	  the	  mental	  health	  appraisal	  includes	  information	  regarding	  the	  youth’s	   developmental	  history,	  family	  history,	  trauma	  history,	  childhood	  conduct,	   educational	  history,	  work	  history,	  relationship	  history,	  legal	  history,	  medical	   history,	  alcohol	  and	  substance	  use	  history,	  mental	  health	  treatment	  history,	   suicidal/self-­‐injurious	  behavior	  history,	  current	  offense,	  mental	  status	   examination,	  a	  review	  of	  symptoms	  for	  various	  mental	  health	  disorders	   (depression,	  mania,	  anxiety,	  panic,	  post-­‐traumatic	  stress,	  risk	  to	  self	  or	  others),	   psychological	  assessment/screening	  results,	  diagnoses,	  case	  conceptualization,	   and	  recommendations.	  	  	   	   Given	  the	  comprehensive	  nature	  of	  these	  assessments,	  a	  much	  better	  “picture”	   of	  the	  youth’s	  mental	  health	  functioning	  is	  elucidated.	  	  Review	  of	  completed	   mental	  health	  appraisals	  revealed	  vast	  improvements	  over	  the	  course	  of	  the	   monitoring	  period.	  	  As	  such,	  this	  portion	  of	  A.2.	  is	  in	  substantial	  compliance.	   	   A.2(b)	   Review	  of	  the	  Individualized	  Treatment	  Plan	  (ITP)	  is	  completed	  via	  the	  quality	   assurance	  monitoring	  outlined	  in	  provision	  A.1.	  	  That	  data	  is	  then	  utilized	  in	   determining	  compliance	  for	  this	  provision.	  	  Given	  the	  improvement	  in	  the	  quality	   of	  the	  mental	  health	  appraisal,	  behavioral	  health	  staff	  have	  the	  opportunity	  to	   author	  goals	  and	  objectives	  that	  are	  meaningful	  and	  address	  the	  specific	  skills	   that	  youth	  need	  to	  acquire.	  	  	   	  

	  

14.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 15 of 34 PAGEID #: 3173
	  

The	  Grid	  requires	  90%	  of	  ITPs	  to	  reflect	  information	  from	  the	  clinical/diagnostic	   formulation.	  Quality	  assurance	  data	  for	  the	  six-­‐month	  monitoring	  period	  is	   presented	  below.	  	   	  

Treatment	  Plans	  Reflect	  Information	  from	  Diagnostic	  Formulation	  

	  

Sept	   Oct	   Nov	   Dec	   Jan	   Feb	   AVG	  

Circleville	  

80%	   100%	   88%	   78%	   100%	   82%	   88%	  

Cuyahoga	  Hills	  

100%	   82%	   100%	   100%	   100%	   100%	   97%	  

Indian	  River	  

100%	   100%	   100%	   97%	   94%	   94%	   98%	  

DYS	  AVERAGE	  

93%	   94%	   96%	   92%	   98%	   92%	   94%	  

Sample	  Size:	  Circleville	  n=213;	  Cuyahoga	  Hills	  n=117;	  Indian	  River	  n=163	  

	   	   Review	  of	  ITP	  documents	  revealed	  marked	  improvements	  with	  regard	  to	  specific	   goals	  and	  objectives	  developed	  for	  individual	  youth.	  	  Overall,	  DYS	  met	  this	   performance	  measure	  in	  94%	  of	  the	  cases	  reviewed.	  Although	  there	  are	  some	   specific	  staff	  that	  need	  to	  improve	  in	  this	  area,	  what	  is	  important	  is	  that	  ODYS	  has	   developed	  a	  quality	  assurance	  process,	  that	  they	  are	  able	  to	  identify	  issues	  with	   regard	  to	  mental	  health	  services,	  and	  address	  those	  issues	  via	  supervision	  and	   training	  of	  staff.	  	  As	  such,	  this	  portion	  of	  A.2.	  is	  in	  substantial	  compliance.	  

Other	  

The	  Monitors	  regularly	  interacted	  with	  DYS	  administrators	  and	  facility	  staff	  via	  bi-­‐

Information	   weekly	  conference	  calls	  and	  frequent	  email	  exchanges.	  The	  Monitoring	  Team	  also	  

participated	  in	  two	  one-­‐day	  site	  visits	  to	  each	  facility,	  one	  in	  October	  2014	  and	  

one	  in	  March	  2015.	  Contextual	  information	  and	  findings	  from	  site	  visits	  are	  

discussed	  here.	  	  

Monitor’s	   Assessment	  

Following	  the	  initial	  monitoring	  visit	  in	  October	  2014,	  recommendations	  included	   the	  need	  for	  improved	  justification	  of	  diagnoses	  via	  the	  case	  formulation,	   improvements	  in	  ITP	  goals	  and	  objectives,	  and	  improvements	  in	  group	  therapies.	  	   At	  that	  time,	  it	  was	  noted	  that	  two	  of	  the	  three	  facilities	  were	  on	  track	  and	   improving	  as	  expected.	  	  There	  was	  a	  need	  for	  behavioral	  health	  leadership	  at	   CJCF,	  which	  impeded	  this	  facility’s	  progress.	   	   Following	  the	  first	  monitoring	  visit	  of	  this	  reporting	  period,	  ODYS	  and	  the	   monitors	  agreed	  to	  participate	  in	  conference	  calls	  to	  include	  behavioral	  health	   staff.	  	  The	  purpose	  of	  the	  calls	  was	  to	  review	  challenging	  cases	  and	  to	  discuss	   both	  mental	  health	  appraisals	  and	  ITP	  goals/objectives.	  	  These	  conference	  calls	   have	  been	  helpful	  both	  to	  the	  monitors	  and	  to	  the	  behavioral	  health	  staff.	   	   In	  the	  intervening	  period	  between	  the	  two	  monitoring	  visits,	  ODYS	  behavioral	   health	  administration	  focused	  on	  both	  the	  quality	  of	  behavioral	  health	  treatment	   and	  documentation.	  	  This	  focus	  was	  evident	  given	  the	  overall	  improvements	   noted	  during	  the	  second	  monitoring	  visit	  in	  March	  2015.	  	  At	  that	  time,	  groups	   were	  improved	  and	  were	  noted	  to	  reinforce	  CBT	  skills	  that	  youth	  had	  learned	  via	   other	  group	  interactions	  or	  via	  individual	  therapies.	  	  The	  mental	  health	  appraisal	   format	  change	  had	  been	  implemented,	  resulting	  in	  higher	  quality	  assessments	  

	  

15.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 16 of 34 PAGEID #: 3174
	  

with	  case	  formulations	  that	  aided	  in	  the	  development	  of	  ITP	  goals	  and	  objectives.	  	   Although	  there	  were	  areas	  that	  remained	  in	  need	  of	  improvement,	  for	  example,	   the	  documentation	  of	  skill	  acquisition	  and	  implementation,	  it	  was	  apparent	  that	   ODYS	  was	  committed	  to	  ongoing	  quality	  assurance	  monitoring	  and	  staff	   development	  in	  the	  pursuit	  of	  improved	  behavioral	  health	  services.	  

Compliance	   The	  Court	  Order	  requires	  DYS	  to	  meet	  the	  each	  of	  the	  performance	  measures	  at	   Assessment	   the	  required	  level	  each	  month	  for	  six	  months.	  	  

Monitor’s	   Assessment	  

As	  discussed	  in	  the	  individual	  paragraph	  subparts	  above,	  DYS	  has	  demonstrated	   overall	  improvements	  in	  behavioral	  health	  services.	  	  While	  there	  are	  some	  areas	   that	  have	  not	  met	  the	  cut	  off	  for	  quality	  assurance	  monitoring,	  this	  does	  not	   mean	  that	  DYS	  is	  in	  noncompliance.	  	  	   	   It	  is	  notable	  that	  DYS	  has	  developed	  a	  quality	  assurance	  monitoring	  program,	  has	   the	  ability	  to	  identify	  weaknesses	  and	  deficiencies,	  and	  has	  taken	  steps	  to	  address	   these	  issues	  through	  staff	  development	  or	  alterations	  in	  documentation	   requirements	  or	  mental	  health	  programming.	  	  In	  the	  presence	  of	  these	  system	   changes,	  it	  is	  apparent	  that	  current	  administrative	  behavioral	  health	  staff	  have	   both	  the	  desire	  and	  ability	  to	  continue	  to	  self	  monitor	  and	  ensure	  services	   consistent	  with	  this	  Court	  Order.	  

	  

	  

	  

	  

	  

16.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 17 of 34 PAGEID #: 3175
	  

	   Column	  B.	  Immediate	  Intervention	  Strategies	  (Assigned	  Monitor:	  Dr.	  Kelly	  Dedel)	  

What	  the	   Grid	   Requires	  

(B.1)	  Reduce	  Reliance	  on	  Seclusion	   • No	  Intervention	  Seclusion	  (IS)	  for	  high	  severity	  offenses	  (e.g.,	  fight,	   consensual	  sexual	  activity),	  unless	  the	  victim	  requires	  off-­‐grounds	   emergency	  medical	  treatment,	  and	  then	  up	  to	  24	  hours	  can	  be	  imposed.	  	   • Interdisciplinary	  Team	  (IDT)	  determines	  sanction.	  	   • Policy	  to	  be	  implemented	  by	  September	  1,	  2015.	  
(B.1)	  Performance	  Measures	   • Proportion	  of	  youth	  who	  commit	  High	  Severity	  infractions	  who	  were	   given	  IS	  (should	  be	  0%,	  unless	  victim	  required	  off	  grounds	  medical	   treatment).	  	  	  

Monitor’s	   Assessment	  

The	  first	  section	  of	  “Column	  B”	  seeks	  to	  reduce	  the	  use	  of	  seclusion,	  limiting	  its	   use	  to	  “severe”	  rule	  violations.	  DYS	  SOP	  301.01.02,	  “Youth	  Intervention	   Sanctions,”	  signed	  into	  effect	  September	  1,	  2014,	  eliminated	  the	  use	  of	   Intervention	  Seclusion	  (IS)	  for	  high	  severity	  violations,	  unless	  one	  of	  the	   participants	  required	  emergency	  medical	  treatment	  (in	  which	  case	  24	  hours	  could	   be	  imposed).	  High-­‐severity	  violations	  includes	  fights	  and	  consensual	  sexual	   activity,	  which	  are	  violations	  that	  used	  to	  carry	  IS	  time,	  depending	  on	  the	   previous	  number	  of	  infractions.	  	   	   The	  new	  policy	  required	  the	  Interdisciplinary	  Team	  (IDT)	  to	  determine	  the	  youth’s	   sanction,	  which	  could	  include	  privilege,	  commissary	  or	  activity	  restrictions	  or	   restorative	  and	  learning	  activities.	  Between	  September	  and	  December	  2014,	  none	   of	  the	  facilities	  imposed	  IS	  for	  any	  high-­‐severity	  rule	  violation.	  Starting	  January	  1,	   2015,	  DYS	  prohibited	  the	  use	  of	  Intervention	  Seclusion	  for	  a	  rule	  violation	  of	  any	   severity.	  SOP	  301.01.02	  was	  revised	  again	  on	  January	  1,	  2015	  and	  all	  references	   to	  Intervention	  Seclusion	  were	  removed.	  In	  summary,	  DYS	  met	  the	  performance	   measure	  at	  the	  required	  level	  for	  the	  entire	  6-­‐month	  monitoring	  period.	  	  

What	  the	   Grid	   Requires	  

(B.2)	  Reduce	  Duration	  of	  Seclusion	  	  
• Safe	  to	  Release:	  DYS	  will	  decrease	  the	  minimum	  length	  of	  stay	  (LOS)	  for	   youth	  engaged	  in	  AOVs	  to	  two	  to	  four	  hours,	  not	  to	  exceed	  24	  hours.	  	   o The	  Safe	  to	  Release	  (STR)	  process	  will	  be	  initiated	  within	  2	  and	  4	   hours	  and	  if	  the	  youth	  refuses	  to	  engage	  or	  the	  suitability	  of	  the	   climate	  indicates	  safety	  concerns,	  staff	  will	  attempt	  to	  engage	  the	   youth	  every	  2	  to	  3	  hours	  thereafter,	  up	  to	  the	  24	  hour	  period.	  	   o If	  the	  24-­‐hour	  period	  is	  reached	  and	  the	  youth	  continues	  to	   refuse	  or	  the	  suitability	  of	  the	  climate	  indicates	  safety	  concerns,	   the	  Superintendent	  must	  approve	  any	  further	  seclusion.	  	  
• Intervention	  Time	  for	  Severe	  AOV:	  decrease	  IS	  imposed	  for	  Severe	  AOVs	   (e.g.,	  assault,	  sexual	  exposure/assault);	  imposed	  by	  hearing	  officer;	  not	   consecutive	  to	  PHS.	   o 1st	  gets	  credit	  for	  time	  served;	  2nd	  gets	  up	  to	  4	  hours;	  3rd	  gets	  up	   to	  8	  hours;	  4th	  gets	  up	  to	  12	  hours;	  5th	  +	  gets	  up	  to	  24	  hours.	  	   o The	  number	  of	  previous	  severe	  rule	  violations	  is	  considered	  zero	   if	  a	  youth	  goes	  30	  days	  without	  a	  severe	  rule	  violation,	  unless	  the	  

	  

17.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 18 of 34 PAGEID #: 3176
	  

Superintendent	  decides	  otherwise.	  	   o IS	  is	  served	  on	  Saturday	  and	  Sunday.	  DYS	  shall	  not	  substitute	  
physical	  restraints	  for	  seclusion	  time.	  	   (B.2)	  Performance	  Measures	  
• Proportion	  of	  youth	  released	  at	  4	  hours	  or	  less	   • 100%	  of	  youth	  were	  sanctioned	  according	  to	  the	  IS	  graduated	  scheme	   • 0%	  of	  youth	  spent	  more	  than	  72	  hours	  in	  seclusion	  in	  a	  rolling	  30-­‐day	  
period	  (except	  in	  rare	  circumstances	  with	  approval)	  

Monitor’s	   Assessment	  

The	  next	  section	  of	  the	  Grid	  focuses	  on	  reducing	  the	  duration	  of	  seclusion—both	   Pre-­‐Hearing	  Seclusion	  (PHS)	  and	  Intervention	  Seclusion	  (IS).	  	   	   Pre-­‐Hearing	  Seclusion	  (PHS)/Safe	  to	  Release	  (STR)	   Prior	  to	  the	  implementation	  of	  the	  new	  Seclusion	  Policy	  (SOP	  301.05.04,	  effective	   September	  1,	  2014),	  DYS	  utilized	  a	  structured	  decision	  making	  tool,	  Individualized	   Response	  to	  Acts	  of	  Violence	  (IRAV).	  Scores	  on	  this	  instrument	  were	  associated	   with	  minimum	  lengths	  of	  stay	  in	  PHS	  that	  ranged	  between	  24	  and	  72	  hours.	  Most	   youth	  who	  engaged	  in	  violent	  behavior	  spent	  72	  hours	  in	  isolation	  immediately	   following	  the	  event.	  The	  new	  policy,	  implemented	  September	  1,	  2014,	  changed	   the	  metric	  by	  which	  the	  duration	  of	  PHS	  was	  determined.	  Rather	  than	  being	   based	  on	  the	  IRAV	  score,	  the	  length	  of	  time	  in	  PHS	  became	  based	  on	  the	  youth’s	   current	  behavior	  and	  his	  willingness	  to	  process	  the	  event	  that	  escalated	  to	   violence.	   	   The	  Grid	  requires	  facilities	  to	  provide	  an	  opportunity	  for	  release	  within	  4	  hours	  of	   being	  placed	  in	  PHS.	  [The	  process	  for	  release	  is	  discussed	  in	  more	  depth	  in	  B.5,	   below.]	  If	  the	  youth	  is	  not	  ready	  for	  release	  by	  the	  4-­‐hour	  mark,	  subsequent	   opportunities	  for	  release	  must	  be	  provided	  every	  2-­‐3	  hours	  thereafter,	  up	  to	  a	   maximum	  of	  24	  hours.	  	   	   Each	  month,	  DYS	  submitted	  data	  on	  the	  duration	  of	  every	  episode	  of	  PHS	  from	  all	   three	  facilities	  to	  the	  Monitor.	  While	  no	  specific	  performance	  requirements	  were	   imposed	  as	  to	  the	  proportion	  of	  youth	  who	  must	  be	  released	  at	  the	  4-­‐hour	  mark	   (because	  release	  is	  meant	  to	  be	  dependent	  on	  the	  youth’s	  behavior,	  not	   artificially	  determined),	  the	  Grid	  requires	  these	  data	  to	  be	  tracked.	  The	  table	   below	  shows	  the	  proportion	  of	  youth	  in	  PHS	  who	  were	  released	  in	  4	  hours	  or	  less:	   	  

Proportion	  of	  Youth	  in	  PHS	  Released	  in	  4-­‐hours	  or	  Less	  

	  

Sept	   Oct	   Nov	   Dec	   Jan	   Feb	   AVG	  

Circleville	  

88%	   74%	   48%	   77%	   88%	   88%	   77%	  

Cuyahoga	  Hills	  

86%	   94%	   98%	   98%	   98%	   98%	   95%	  

Indian	  River	  

73%	   66%	   55%	   83%	   61%	   67%	   68%	  

DYS	  AVERAGE	  

82%	   78%	   67%	   86%	   83%	   84%	   80%	  

	   In	  contrast	  to	  the	  period	  preceding	  the	  implementation	  of	  the	  new	  seclusion	   policy	  where	  youth	  routinely	  spent	  24-­‐72	  hours	  in	  PHS,	  80%	  of	  the	  youth	  in	  PHS	   during	  the	  6-­‐month	  monitoring	  period	  were	  released	  within	  4	  hours.	  Deeper	  

	  

18.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 19 of 34 PAGEID #: 3177
	  

What	  the	   Grid	   Requires	  

analysis	  of	  the	  data	  revealed	  that	  longer	  periods	  of	  PHS	  were	  associated	  with	   youth’s	  refusal	  to	  engage	  in	  the	  release	  process	  and	  the	  time	  of	  day	  in	  which	  the	   incident	  occurred.	  Incidents	  occurring	  later	  in	  the	  evening	  generally	  required	  an	   overnight	  stay	  in	  PHS,	  though	  youth	  were	  generally	  released	  by	  9am	  the	  following	   morning.	  Across	  the	  6-­‐month	  period,	  which	  included	  706	  episodes	  of	  PHS,	  none	   of	  the	  episodes	  extended	  beyond	  24	  hours.	  	   	   Intervention	  Seclusion	   From	  September	  to	  December	  2014,	  facilities	  were	  permitted	  to	  impose	   Intervention	  Seclusion	  as	  a	  sanction	  for	  “severe”	  rule	  violations	  (e.g.,	  assaults	  on	   youth,	  assaults	  on	  staff,	  sexual	  misconduct).	  The	  new	  seclusion	  policy,	  effective	   September	  1,	  2014,	  drastically	  reduced	  the	  amount	  of	  IS	  time	  that	  could	  be	   imposed.	  Prior	  to	  the	  new	  policy,	  youth	  routinely	  spent	  3	  to	  5	  days	  (72	  to	  120	   hours)	  in	  IS.	  The	  new	  policy	  limited	  IS	  time	  to	  up	  to	  time	  served	  in	  PHS	  for	  the	  1st	   offense	  within	  a	  30	  day	  period,	  up	  to	  4	  hours	  for	  the	  2nd	  offense,	  up	  to	  8	  hours	  for	   the	  3rd	  offense,	  etc.	  	   	   Even	  when	  it	  was	  permitted,	  IS	  was	  not	  used	  very	  often	  during	  the	  monitoring	   period.	  Of	  the	  over	  700	  AOVs	  recorded	  during	  the	  monitoring	  period,	  IS	  was	   imposed	  in	  only	  28	  cases	  (less	  than	  4%	  of	  the	  AOV	  incidents).	  Circleville	  was	  the	   only	  facility	  that	  imposed	  IS	  during	  the	  monitoring	  period.	  Indian	  River	  and	   Cuyahoga	  Hills	  did	  not	  use	  it	  at	  all.	  Although	  used	  infrequently	  and	  restricted	  in	   duration	  by	  the	  Grid/policy,	  Circleville	  made	  frequent	  errors	  in	  the	  amount	  of	   time	  imposed.	  Of	  the	  28	  total	  cases	  of	  IS,	  13	  youth	  (46%)	  were	  sanctioned	  outside	   of	  the	  permissible	  ranges.	  Most	  often,	  youth	  with	  a	  1st	  severe	  offense	  were	  not	   sentenced	  to	  time	  served	  in	  PHS,	  as	  required	  by	  policy.	  All	  of	  the	  28	  youth	   received	  either	  4	  or	  8	  hours	  of	  IS	  time.	  [Note	  the	  contrast	  to	  pre-­‐Grid,	  where	   youth	  routinely	  served	  72-­‐120	  hours.]	  Rather	  than	  belabor	  the	  underlying	  causes	   of	  the	  problems	  with	  using	  the	  grid,	  DYS	  and	  the	  Monitors	  simply	  pushed	  forward	   to	  the	  eventual	  elimination	  of	  the	  practice.	  DYS	  policy	  prohibited	  the	  use	  of	   Intervention	  Seclusion	  on	  January	  1,	  2015.	  Data,	  youth	  and	  staff	  interviews	  all	   confirm	  that	  Intervention	  Seclusion	  is	  no	  longer	  used	  in	  response	  to	  youth	   violence.	  	   	   So,	  in	  summary,	  most	  of	  the	  instances	  of	  PHS	  are	  now	  very	  short	  in	  comparison	  to	   the	  past—80%	  conclude	  in	  4	  hours	  or	  less.	  While	  there	  were	  problems	  with	  the	   imposition	  of	  IS	  for	  the	  small	  number	  of	  cases	  in	  which	  it	  was	  used	  at	  one	  facility,	   the	  practice	  was	  abolished	  entirely	  on	  January	  1,	  2015	  and	  thus	  further	  remedy	  is	   not	  needed.	  	  
(B.3)	  Reduce	  Harm	  Associated	  with	  Seclusion	  	   • Intervention	  Seclusion	  is	  imposed	  only	  on	  Saturday	  &	  Sunday,	  to	  reduce	   interference	  with	  core	  programming	   • For	  IS,	  provide	  1	  hour	  out	  for	  every	  4	  hours	  in	  seclusion,	  during	  waking	   hours	   • Youth	  in	  IS	  participate	  in	  treatment	  activities,	  school	  and	  recreation	  out	   of	  their	  rooms	  and	  time	  counts	  toward	  seclusion	  hours	  if	  behavior	  is	   appropriate	  

	  

19.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 20 of 34 PAGEID #: 3178
	  

(B.3)	  Performance	  Measures	   • 90%	  of	  youth	  in	  Intervention	  Seclusion	  spent	  4	  in/1	  out	  during	  waking	   hours	   • 90%	  of	  youth	  in	  Intervention	  Seclusion	  participated	  in	  all	  programming	   (e.g.,	  recreation,	  treatment)	  that	  was	  scheduled	  during	  seclusion	  time	  

Monitor’s	   Assessment	  

As	  noted	  above,	  Intervention	  Seclusion	  was	  used	  only	  28	  times	  during	  the	   monitoring	  period,	  at	  Circleville	  during	  September-­‐November	  2014.	  Of	  these	   instances,	  only	  8	  of	  the	  28	  (29%)	  imposed	  IS	  for	  longer	  than	  4	  hours.	  For	  these	  8	   cases:	  
• All	  8	  instances	  were	  served	  on	  Saturday	  or	  Sunday;	   • 4	  of	  the	  8	  (50%)	  received	  one-­‐hour	  out	  for	  every	  4	  hours	  in;	  and	   • 4	  of	  the	  8	  (50%)	  participated	  in	  the	  regularly	  scheduled	  programming	  
during	  that	  time	  (most	  often,	  recreation	  or	  leisure	  time).	  	   In	  two	  of	  the	  4	  non-­‐compliant	  cases,	  documentation	  to	  establish	  compliance	  with	   the	  policy	  could	  not	  be	  located.	  In	  the	  other	  two	  cases,	  the	  proper	  procedures	   were	  not	  followed.	  Although	  the	  performance	  levels	  do	  not	  meet	  the	  thresholds	   established	  by	  the	  Grid,	  DYS	  and	  the	  Monitor	  chose	  not	  to	  belabor	  corrective	   action	  given	  that	  the	  practice	  of	  Intervention	  Seclusion	  was	  abolished	  altogether	   on	  January	  1,	  2015.	  	  

What	  the	   Grid	   Requires	  

(B.4)	  Reduce	  Accumulation	  of	  Seclusion	  	   • To	  apply	  more	  than	  72	  hours	  of	  seclusion	  in	  a	  30-­‐day	  period,	  must	   conduct	  Treatment	  Plan	  Review	  (see	  C.1),	  obtain	  approval	  from	  Bureau	   Chief/Deputy	  Director,	  provide	  information	  to	  Monitors.	  
	  (B.4)	  Performance	  Measures	   • Number	  of	  youth	  secluded	  each	  month	  and	  the	  number	  of	  hours	  in	   seclusion	   • Number	  of	  youth	  who	  spent	  more	  than	  72-­‐hours	  in	  a	  30-­‐day	  period	   o 90%	  received	  treatment	  plan	  review	   o 990%	  received	  approval	  for	  exception	  to	  the	  72	  hour	  rule	  

Monitor’s	   Assessment	  

In	  November	  2013,	  Dr.	  Dedel	  (the	  Lead	  Monitor	  on	  the	  DOJ	  case)	  drafted	  a	  memo	   to	  the	  Parties	  that	  examined	  the	  way	  in	  which	  seclusion	  hours	  accumulated	  for	   individual	  youth	  who	  engaged	  in	  high-­‐frequency	  AOVs	  at	  Scioto	  JCF.	  Some	  of	  the	   youth	  included	  in	  the	  analysis	  spent	  well	  over	  200	  hours	  in	  seclusion	  each	  month.	   The	  Grid	  sought	  to	  remedy	  that	  problem	  by	  placing	  limits	  on	  the	  amount	  of	  time	   that	  could	  be	  imposed	  and	  by	  creating	  additional	  protections	  for	  youth	  who	   accumulated	  significant	  seclusion	  time.	  The	  threshold	  for	  additional	  protections	   was	  established	  in	  the	  Court	  Order	  at	  72	  hours	  of	  accumulated	  seclusion	  in	  a	   rolling	  30-­‐day	  period.	  	   	   With	  the	  implementation	  of	  the	  new	  seclusion	  policy	  that	  changed	  the	  maximum	   limits	  for	  PHS	  and	  severely	  restricted	  the	  use	  of	  IS	  came	  significant	  reductions	  in	   the	  accumulation	  of	  seclusion,	  even	  among	  youth	  with	  high-­‐frequency	  AOVs.	  As	   discussed	  in	  “Column	  A	  Overall	  Measures,”	  a	  handful	  of	  youth	  at	  each	  facility	   engaged	  in	  3	  to	  6	  AOVs	  per	  month.	  Prior	  to	  the	  new	  policy,	  it	  would	  not	  have	   been	  uncommon	  for	  youth	  to	  spend	  3	  days	  in	  PHS	  and	  3	  to	  5	  days	  in	  IS	  for	  each	  of	  

	  

20.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 21 of 34 PAGEID #: 3179
	  

these	  offenses.	  In	  other	  words,	  he	  could	  have	  easily	  spent	  the	  majority	  of	  his	  time	   in	  custody	  that	  month	  in	  seclusion,	  separated	  from	  the	  people,	  programs	  and	   relationships	  that	  were	  tasked	  with	  providing	  rehabilitative	  services.	   	   As	  shown	  in	  the	  table	  below,	  during	  the	  monitoring	  period,	  seclusion	  hours	   simply	  did	  not	  accumulate	  with	  the	  same	  magnitude	  that	  created	  concern	  in	  Dr.	   Dedel’s	  November	  2013	  memo.	  The	  table	  below	  shows	  the	  seclusion	  hours	  for	   the	  single	  youth	  in	  each	  facility	  with	  the	  highest	  total	  number	  of	  hours	  each	   month.	  Most	  of	  the	  time,	  the	  youth	  with	  the	  highest	  total	  seclusion	  hours	  spent	   less	  than	  20	  hours	  in	  seclusion	  each	  month.	   	  

Total	  Seclusion	  Hours	  for	  the	  Single	  Youth	  with	  the	  Highest	  Accumulation	  

	  

Sept	   Oct	   Nov	   Dec	   Jan	   Feb	   AVG	  

Circleville	  

25.8	   30.8	   32.4	   12.5	   19.2	   19.3	   23.3	  

Cuyahoga	  Hills	  

11.3	   8.0	   15.3	   10.2	   11.2	   13.5	   11.6	  

Indian	  River	  

29.5	   20.4	   22.8	   17.4	   28.6	   13.4	   22.0	  

	   Because	  DYS	  successfully	  limited	  the	  total	  number	  of	  hours	  that	  youth	  spent	  in	   seclusion,	  the	  protective	  measures	  built	  into	  the	  Grid	  for	  youth	  who	  accumulated	   72+	  hours	  of	  seclusion	  in	  a	  rolling	  30-­‐day	  period	  (e.g.,	  treatment	  plan	  reviews;	   approval	  by	  DYS	  Administrators)	  were	  never	  utilized.	  	   	   In	  summary,	  DYS	  successfully	  limited	  the	  accumulation	  of	  seclusion	  hours,	  even	   for	  youth	  with	  high-­‐frequency	  AOVs.	  Across	  the	  6-­‐month	  period,	  of	  the	  hundreds	   of	  youth	  who	  committed	  AOVs,	  the	  highest	  accumulation	  was	  32.4	  hours	  in	  a	   single	  month,	  compared	  to	  the	  period	  before	  the	  policy	  was	  changed	  when	  youth	   with	  high-­‐frequency	  AOVs	  could	  easily	  accumulate	  200-­‐500	  hours	  in	  seclusion	  in	  a	   single	  month.	  	  

What	  the	   Grid	   Requires	  

(B.5)	  Provide	  Crisis	  Intervention	  while	  in	  PHS	  	   • STR	  process	  will	  be	  initiated	  with	  every	  youth	  engaged	  in	  AOV	  between	   two	  and	  four	  hours;	  subsequent	  checks	  every	  2-­‐3	  hours	   • STR	  process	  will	  include	  a	  structured	  interview	  by	  SW/UM/OM	  that	   discusses	  triggers,	  decision-­‐making,	  external	  influences	  on	  behavior.	  
(B.5)	  Performance	  Measures	   • STR	  process	  was	  initiated	  with	  90%	  of	  youth	  within	  4	  hours	  of	  AOV	   • 90%	  of	  STR	  checks	  examine	  the	  underlying	  causes	  of	  the	  youth’s	   behavior,	  both	  internal	  and	  external	  

Monitor’s	   Assessment	  

In	  order	  to	  better	  calibrate	  the	  youth’s	  length	  of	  stay	  in	  pre-­‐hearing	  seclusion	  to	   when	  he	  could	  safely	  return	  to	  the	  general	  population,	  DYS	  created	  the	  “Safe	  to	   Release”	  process.	  This	  process	  uses	  a	  structured	  interview	  guide	  that	  helps	  youth	   to	  process	  the	  antecedents	  and	  consequences	  of	  his	  aggressive	  behavior.	  The	   interview	  must	  be	  first	  attempted	  within	  4	  hours	  of	  the	  youth’s	  placement	  in	  PHS.	   If	  the	  youth	  engages	  in	  the	  process,	  he	  is	  released.	  If	  the	  youth	  refuses	  the	   process	  or	  provides	  evidence	  that	  he	  continues	  to	  present	  a	  risk	  to	  facility	  safety,	   his	  stay	  in	  PHS	  is	  extended.	  An	  attempt	  to	  engage	  the	  youth	  in	  the	  process	  must	  

	  

21.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 22 of 34 PAGEID #: 3180
	  

be	  made	  at	  least	  every	  2-­‐3	  hours	  thereafter,	  until	  he	  is	  released.	  In	  practice,	  the	   STR	  interviews	  generally	  occur	  well	  within	  the	  required	  timelines.	  Most	  recently,	   facilities	  are	  striving	  to	  engage	  the	  youth	  at	  the	  initial	  2-­‐hour	  mark,	  instead	  of	  the	   4-­‐hour	  mark.	  	   	   STR	  Timeliness	   The	  table	  below	  shows	  the	  extent	  to	  which	  the	  required	  timelines	  were	  met	  each	   month.	  The	  proportion	  of	  cases	  that	  met	  the	  required	  timelines	  includes	  both	   youth	  who	  were	  released	  within	  4	  hours	  (approximately	  80%	  of	  all	  cases,	  as	   discussed	  in	  B.2	  above)	  and	  those	  who	  remained	  in	  PHS	  after	  an	  initially	  refusing	   to	  participate	  in	  the	  process,	  but	  were	  subsequently	  engaged	  in	  an	  STR	  interview	   within	  the	  required	  timelines.	   	  

Proportion	  of	  STR	  Interviews	  Conducted	  within	  Required	  Timelines	  

	  

Sept	   Oct	   Nov	   Dec	   Jan	   Feb	   AVG	  

Circleville	  

94%	   88%	   66%	   86%	   98%	   94%	   88%	  

Cuyahoga	  Hills	  

93%	   97%	   100%	   100%	   100%	   100%	   98%	  

Indian	  River	  

87%	   91%	   100%	   100%	   97%	   93%	   95%	  

DYS	  TOTAL	  

91%	   92%	   89%	   95%	   98%	   96%	   94%	  

	   As	  shown	  in	  the	  table	  above,	  Cuyahoga	  Hills	  and	  Indian	  River	  exceeded	  the	   required	  90%	  performance	  level	  each	  month	  while	  Circleville	  sometimes	   struggled	  to	  meet	  the	  required	  performance	  level.	  Even	  so,	  Circleville	  exceeded	   the	  required	  level	  during	  the	  last	  part	  of	  the	  monitoring	  period,	  with	  a	  6-­‐month	   average	  nearly	  at	  the	  90%	  level.	  	   	   Originally,	  responsibility	  for	  the	  STR	  interviews	  was	  delegated	  entirely	  to	  the	   Operations	  Manager.	  The	  OMs	  at	  each	  facility	  had	  to	  track	  the	  timelines	  for	   multiple	  youth	  on	  PHS,	  while	  at	  the	  same	  time	  ensure	  that	  count,	  movement,	   incident	  report	  recording	  and	  entry,	  and	  other	  facility	  operational	  functions	   occurred	  timely	  and	  on	  schedule.	  This	  turned	  out	  to	  be	  very	  difficult.	  A	  quality	   STR	  requires	  about	  20	  minutes	  to	  conduct.	  If	  the	  STR	  was	  due	  just	  before	  count	  or	   movement,	  the	  OM	  was	  left	  with	  several	  unappealing	  choices.	  The	  OM	  could	   choose	  to	  rush	  the	  interview	  to	  complete	  it	  before	  count	  started,	  or	  could	  start	   the	  STR	  interview,	  interrupt	  it	  for	  count,	  and	  then	  complete	  it	  after	  count	  cleared,	   or	  could	  begin	  the	  STR	  process	  after	  count	  cleared—which	  meant	  missing	  the	  STR	   timeline.	  For	  this	  and	  other	  reasons	  related	  to	  the	  quality	  of	  the	  interviews	   (discussed	  below),	  responsibility	  for	  the	  STR	  interviews	  was	  eventually	  dispersed	   among	  the	  OMs,	  social	  workers,	  behavioral	  health	  clinicians	  and	  Unit	  Managers.	   This	  adjustment	  led	  to	  the	  higher	  rates	  of	  performance	  at	  required	  levels	   witnessed	  at	  the	  end	  of	  the	  monitoring	  period.	  	   	   Although	  one	  of	  the	  three	  facilities	  did	  not	  quite	  meet	  the	  required	  performance	   level	  of	  90%,	  system-­‐wide,	  the	  STR	  interviews	  proceeded	  according	  to	  the	   required	  timelines	  in	  94%	  of	  the	  706	  PHS	  episodes	  occurring	  during	  the	  6-­‐month	   period.	  	  

	  

22.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 23 of 34 PAGEID #: 3181
	  
	   STR	  Quality	   The	  Parties	  and	  the	  Monitoring	  Team	  shared	  the	  same	  intention	  about	  engaging	   youth	  in	  PHS	  in	  an	  interactive	  process	  to	  identify	  the	  underlying	  causes	  of	  his	   behavior	  so	  that	  he	  could	  be	  quickly	  returned	  to	  the	  general	  population	  and	   appropriate	  safety	  or	  therapeutic	  responses	  could	  be	  put	  into	  place.	  Although	  the	   vision	  was	  clear,	  the	  pathway	  for	  getting	  there	  was	  not.	  First,	  as	  noted	  above,	  the	   original	  plan	  to	  make	  the	  OMs	  solely	  responsible	  for	  carrying	  out	  the	  STR	  process	   proved	  to	  be	  impractical.	  Diffusing	  this	  responsibility	  seems	  to	  provide	  the	   flexibility	  needed	  to	  ensure	  that	  timelines	  are	  met,	  and	  also	  provides	  choices	   among	  staff	  doing	  the	  interview,	  some	  of	  whom	  may	  have	  a	  stronger	  rapport	   with	  the	  youth.	  	   	   Second,	  the	  content	  of	  the	  interview	  guide	  needed	  adjustment	  to	  ensure	  that	  it	   cued	  staff	  to	  ask	  specific	  questions	  that	  elicited	  detailed	  answers.	  These	  changes	   were	  articulated	  during	  a	  meeting	  in	  early	  December	  2014	  among	  Central	  Office	   staff,	  OMs,	  and	  UMs	  who	  shared	  their	  experiences	  of	  using	  the	  form	  and	  made	   suggestions	  for	  how	  to	  improve	  the	  quality	  of	  the	  information	  obtained.	  The	  new	   form	  was	  put	  into	  use	  in	  mid-­‐December	  2014.	   	   Third,	  the	  process	  for	  monitoring	  the	  quality	  of	  the	  STR	  interviews	  to	  determine	   whether	  it	  met	  the	  requirements	  of	  the	  Grid	  was	  also	  a	  challenge.	  For	  the	  first	   few	  months,	  each	  STR	  sampled	  was	  rated	  as	  to	  whether	  it	  provided	  sufficient	   answers	  to	  each	  of	  the	  11	  questions	  on	  the	  STR	  form.	  However,	  very	  few	  STR	   forms	  scored	  well	  using	  this	  method,	  and	  at	  times,	  the	  score	  seemed	  at	  odds	  with	   the	  overall	  sufficiency	  of	  the	  STR	  interview.	  Furthermore,	  given	  that	  1)	  the	  vast	   majority	  of	  youth	  were	  being	  released	  at	  the	  4	  hour	  mark	  based	  on	  the	  STR	   interviews	  and	  2)	  very	  few	  youth	  were	  engaging	  in	  AOVs	  proximal	  to	  their	  release	   from	  PHS,	  we	  felt	  that	  the	  OMs	  were	  making	  release	  decisions	  that	  protected	   facility	  safety	  and	  did	  not	  hold	  youth	  in	  PHS	  for	  undue	  periods	  of	  time.	  These	   were	  the	  most	  important	  outcomes	  relevant	  to	  Column	  B,	  but	  somehow	  the	   method	  to	  assess	  the	  quality	  of	  the	  STR	  forms	  was	  missing	  the	  point	  (i.e.,	  so	  many	   were	  scoring	  poorly).	  	   	   In	  an	  effort	  to	  identify	  a	  scoring	  method	  with	  better	  face	  validity,	  the	  Monitor	  and	   DYS	  revised	  the	  monitoring	  strategy.	  Given	  some	  of	  the	  other	  protections	  in	   place—namely,	  that	  Behavior	  Health	  staff	  conducted	  a	  treatment	  plan	  review	   within	  48	  hours	  of	  each	  AOV—there	  was	  less	  pressure	  for	  the	  OM	  to	  obtain	  all	  of	   the	  details	  during	  the	  STR	  interviews.	  Instead,	  we	  wanted	  to	  ensure	  that	  the	  STR	   form	  gave	  the	  BH	  clinician	  sufficient	  information	  to	  start	  the	  conversation	  about	   what	  happened	  and	  why	  in	  their	  meetings	  with	  the	  youth.	  Thus,	  beginning	  in	   November	  2014,	  a	  more	  holistic	  monitoring	  strategy	  was	  utilized—a	  single	  yes/no	   question:	  did	  the	  STR	  provide	  sufficient	  information	  for	  BH	  staff	  to	  start	  a	   discussion	  about	  what	  happened,	  how	  the	  youth	  felt	  about	  it	  at	  the	  time	  of	  the	   incident	  and	  then	  later	  during	  the	  interview,	  and	  what	  the	  youth	  said	  about	  what	   could	  be	  different	  the	  next	  time?	  In	  addition,	  the	  monthly	  reports	  provided	  to	  the	   Monitor	  began	  to	  include	  data	  on	  whether	  the	  treatment	  plan	  reviews	  were	  

	  

23.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 24 of 34 PAGEID #: 3182
	  

occurring	  within	  48	  hours	  as	  required.	  	   	   The	  table	  below	  summarizes	  progress	  in	  this	  area.	  Specific	  percentages	  are	  not	   included	  for	  September	  and	  October	  because	  at	  the	  time,	  the	  Monitor	  was	   scoring	  each	  of	  the	  interview	  questions	  separately,	  and	  had	  yet	  to	  land	  upon	  a	   meaningful	  way	  to	  synthesize	  the	  data.	  However,	  both	  the	  Monitor	  and	  DYS	   agreed	  that	  of	  the	  70	  STR	  forms	  reviewed	  during	  that	  period,	  only	  a	  few	  were	  of	   good	  quality	  and	  the	  vast	  majority	  did	  not	  reach	  the	  standards	  required	  by	  the	   Grid.	  	   	  

Proportion	  of	  STR	  Interviews	  of	  Sufficient	  Quality	  to	  Initiate	  BH	  Treatment	  	  

	  

Sept	   Oct	   Nov	   Dec	   Jan	   Feb	   AVG	  

Circleville	  

~	  

~	   50%	   73%	   93%	   80%	   74%	  

Cuyahoga	  Hills	  

~	  

~	   50%	   45%	   47%	   75%	   54%	  

Indian	  River	  

~	  

~	   60%	   69%	   80%	   93%	   76%	  

DYS	  TOTAL	  

~	  

~	   53%	   62%	   73%	   83%	   68%	  

	   Throughout	  the	  rest	  of	  the	  monitoring	  period,	  overall	  progress	  has	  been	  steady.	   Using	  a	  single	  holistic	  measure	  of	  sufficiency,	  the	  Monitor	  assessed	  180	  additional	   STR	  forms	  and	  reviewed	  the	  assessments	  with	  DYS	  staff	  to	  ensure	  general	   agreement.	  As	  shown	  in	  the	  table	  above,	  progress	  has	  been	  steady.	  Each	  month,	   an	  additional	  10%	  of	  the	  STR	  interviews	  were	  assessed	  as	  being	  of	  sufficient	   quality.	  In	  the	  final	  month	  of	  this	  6-­‐month	  monitoring	  period,	  83%	  of	  the	  STR	   forms	  provided	  sufficient	  detail	  for	  the	  OMs	  to	  make	  a	  safe	  release	  decision	  and	   for	  BH	  staff	  to	  initiate	  a	  treatment	  plan	  review	  with	  the	  youth	  a	  couple	  days	  later.	   March	  data	  (not	  included	  in	  this	  report)	  revealed	  that	  all	  three	  facilities	   performed	  above	  the	  required	  90%	  level.	  	  	   	   One	  of	  the	  things	  that	  became	  particularly	  visible	  toward	  the	  end	  of	  the	   monitoring	  period	  was	  the	  synergy	  created	  among	  disciplines	  as	  they	  tackled	  the	   problem	  of	  youth	  violence.	  Several	  times	  during	  monthly	  conference	  calls	  and	   while	  the	  Monitoring	  team	  was	  on	  site,	  BH	  staff	  noted	  how	  helpful	  they	  found	  the	   information	  in	  the	  STR	  interviews	  to	  be.	  Similarly,	  the	  increasing	  success	  with	   which	  BH	  staff	  were	  conducting	  the	  treatment	  plan	  reviews	  in	  a	  timely	  manner	   helped	  the	  direct	  care	  staff	  to	  feel	  confident	  that	  the	  STR	  process	  had	  come	  full	   circle	  (these	  data	  are	  presented/discussed	  in	  “Column	  C,”	  but	  were	  also	  reviewed	   each	  month	  by	  the	  Monitor	  and	  DYS	  staff	  charged	  with	  implementing	  the	  STR	   process).	  	   	   In	  summary,	  although	  Circleville	  initially	  experienced	  difficulty	  with	  timeliness,	  by	   the	  end	  of	  the	  monitoring	  period,	  all	  three	  facilities	  had	  a	  solid	  track	  record	  of	   initiating	  the	  STR	  process	  within	  required	  timelines.	  Overall,	  94%	  the	  706	   episodes	  of	  PHS	  included	  STR	  interviews	  that	  were	  completed	  within	  required	   timelines.	  	  The	  STR	  administration	  and	  monitoring	  process	  required	  several	   iterations	  to	  land	  on	  a	  structure	  that	  retained	  the	  proper	  focus	  on	  safety	  and	   length	  of	  stay.	  In	  the	  end,	  the	  STR	  interviews	  have	  proved	  to	  be	  a	  valuable	  

	  

24.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 25 of 34 PAGEID #: 3183
	  

contribution	  to	  the	  system’s	  response	  to	  violence.	  While	  the	  facilities	  have	  not	   yet	  consistently	  reached	  the	  90%	  performance	  level	  required	  by	  the	  Grid,	  the	   Monitor	  believes	  that	  the	  process,	  as	  it	  exists	  at	  the	  time	  this	  report	  was	  written,	   is	  sufficient	  to	  satisfy	  the	  objectives	  of	  the	  Grid	  and	  Court	  Order.	  	  	  

What	  the	   Grid	   Requires	  

(B.6)	  Eventually	  Eliminate	  the	  Use	  of	  Disciplinary	  Seclusion	   • DYS	  is	  committed	  to	  the	  eventual	  elimination	  of	  disciplinary	  seclusion	  for	   all	  youth	  housed	  in	  a	  DYS	  facility.	  Thus,	  six	  months	  from	  the	  acceptance	  of	   this	  settlement,	  DYS	  will	  engage	  the	  Monitors	  and	  subject	  matter	  experts	   in	  formulating	  the	  steps	  to	  take,	  and	  the	  timeline	  for	  completing	  those	   steps,	  to	  eliminate	  disciplinary	  seclusion.	  	  	  
(B.6)	  Overall	  Performance	  Measure	   • Reduce	  the	  number	  of	  youth	  who	  serve	  72+	  hours	  in	  seclusion	  per	  month	   by	  10%	  each	  month,	  compared	  to	  the	  previous	  month.	  	  

Monitor’s	   Assessment	  

DYS	  abolished	  the	  practice	  of	  Intervention	  Seclusion	  on	  January	  1,	  2015,	  though	   two	  of	  the	  three	  facilities	  abandoned	  the	  practice	  many	  months	  before	  then.	  	   	   As	  noted	  in	  B.4,	  above,	  none	  of	  the	  youth	  housed	  in	  DYS	  during	  the	  monitoring	   period	  even	  approached	  the	  72-­‐hour	  limit	  imposed	  by	  the	  Grid.	  Throughout	  that	   time,	  the	  youth	  with	  the	  highest	  accumulation	  totaled	  32.4	  hours	  in	  a	  single	   month,	  which	  is	  well	  below	  the	  threshold	  established	  by	  the	  Grid.	  	  

Other	  

The	  Monitors	  regularly	  interacted	  with	  DYS	  administrators	  and	  facility	  staff	  via	  bi-­‐

Information	   weekly	  conference	  calls	  and	  frequent	  email	  exchanges.	  The	  Monitoring	  Team	  also	  

participated	  in	  two	  one-­‐day	  site	  visits	  to	  each	  facility,	  one	  in	  October	  2014	  and	  

one	  in	  March	  2015.	  Contextual	  information	  and	  findings	  from	  site	  visits	  are	  

discussed	  here.	  	  

Monitor’s	   Assessment	  

Rather	  than	  implementing	  the	  requirements	  of	  the	  Grid	  in	  a	  stand-­‐alone	  fashion,	   DYS	  engaged	  in	  a	  process	  to	  examine	  the	  larger	  environment	  in	  which	  the	   reforms	  would	  be	  made.	  This	  examination	  led	  to	  a	  series	  of	  reforms,	  going	  far	   beyond	  the	  requirements	  of	  the	  Grid,	  articulated	  in	  DYS’	  Path	  to	  Safer	  Facilities.	   The	  model	  includes	  enhancements	  to	  mental	  health	  treatment	  and	  changes	  to	   the	  use	  of	  pre-­‐hearing	  and	  disciplinary	  seclusion	  required	  by	  the	  Grid,	  but	  also	   requires	  changes	  in	  the	  facility	  environment	  and	  programming	  needed	  to	  ensure	   successful	  implementation	  of	  the	  reforms	  flowing	  from	  the	  Court	  Order.	  Some	  of	   these	  innovations	  are	  discussed	  below,	  because	  they	  are	  directly	  related	  to	  the	   problem	  of	  youth	  violence	  that	  is	  at	  the	  core	  of	  the	  reforms	  required	  by	  the	  Grid.	  	   	   All	  DYS	  facilities	  utilize	  the	  Strength	  Based	  Behavior	  Management	  System	   (SBBMS)	  to	  ensure	  that	  behavioral	  expectations	  are	  clear	  and	  that	  youth	  are	   appropriately	  incentivized	  to	  meet	  them.	  Youth	  who	  meet	  expectations	  for	   sustained	  periods	  of	  time	  are	  provided	  access	  to	  increasingly	  attractive	  rewards	   and	  incentives	  on	  a	  daily,	  weekly	  and	  long-­‐term	  basis	  by	  being	  promoted	  to	   higher	  phases.	  As	  part	  of	  the	  Path	  to	  Safer	  Facilities	  plan,	  the	  SBBMS	  programs	   were	  enhanced	  with	  more	  robust	  rewards	  to	  ensure	  they	  were	  meaningful	  to	   youth.	  	   	  

	  

25.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 26 of 34 PAGEID #: 3184
	  
In	  addition,	  some	  of	  the	  facilities	  changed	  the	  way	  in	  which	  youth	  are	  housed—by	   need	  rather	  than	  risk,	  as	  determined	  by	  the	  Ohio	  Youth	  Assessment	  System	   (OYAS).	  Housing	  youth	  by	  needs	  means	  that	  youth	  of	  all	  security	  levels	  (Close,	   Medium,	  Low)	  can	  now	  be	  housed	  together.	  SBBMS	  provides	  for	  three	  phases	   within	  each	  security	  level,	  which	  means	  that	  now	  that	  the	  levels	  are	  integrated,	   staff	  are	  tasked	  with	  implementing	  9	  different	  bedtimes	  (one	  for	  each	  of	  the	  3	   phases	  within	  each	  of	  the	  3	  security	  levels).	  This	  is	  just	  one	  example	  of	  how	   SBBMS	  needed	  to	  be	  restructured	  so	  that	  it	  better	  supported	  all	  of	  these	   innovations,	  so	  that	  it	  was	  easier	  for	  staff	  to	  implement	  consistently	  and	  to	   improve	  youth	  and	  staff	  buy-­‐in.	  	   	   Furthermore,	  now	  that	  disciplinary	  seclusion	  is	  no	  longer	  imposed	  in	  response	  to	   youth	  violence,	  consequences	  for	  misconduct	  needed	  to	  be	  found	  among	  the	   options	  available	  via	  SBBMS.	  These	  consequences	  now	  rely	  on	  activity	  restrictions	   and	  time-­‐limited	  suspensions	  of	  various	  incentives	  earned	  under	  the	  program.	   Shifting	  responsibility	  for	  sanctioning	  misconduct	  to	  SBBMS,	  via	  the	  IDTs,	  meant	   that	  the	  facilities	  needed	  new	  procedures	  for	  imposing	  and	  monitoring	  the	   completion	  of	  sanctions.	  The	  Monitor	  recommended	  that	  the	  facility	  identify	   ways	  to	  ensure	  that	  consequences	  for	  misconduct—once	  very	  visible	  because	   youth	  were	  on	  seclusion,	  but	  now	  somewhat	  hidden	  because	  youth	  continued	  to	   be	  engaged	  in	  normal	  programming—were	  evident	  to	  staff	  to	  combat	  the	   sentiment	  that	  youth	  were	  not	  being	  held	  accountable	  because	  they	  were	  no	   longer	  placed	  in	  disciplinary	  seclusion.	  At	  Cuyahoga	  Hills,	  this	  was	  accomplished	   by	  posting	  a	  list	  of	  incidents,	  along	  with	  the	  sanctions	  imposed,	  in	  the	  staff	   briefing	  room	  each	  week.	  This	  strategy	  helped	  staff	  to	  buy-­‐in	  to	  the	  sanctioning	   process	  envisioned	  by	  the	  Grid	  and	  the	  Path	  to	  Safer	  Facilities	  initiative.	  	   	   At	  Indian	  River,	  the	  SBBMS	  Coordinator	  has	  done	  a	  spectacular	  job	  helping	  IDTs	  to	   identify	  sanctions	  that	  involve	  learning	  activities.	  This	  follows	  best-­‐practice	   research	  that	  shows	  that	  deterring	  misconduct	  is	  only	  part	  of	  the	  equation	  and	  is	   unlikely	  to	  create	  lasting	  behavior	  change	  without	  an	  equal	  focus	  on	  teaching	  the	   youth	  “replacement	  behaviors.”	  Stated	  simply,	  the	  Coordinator	  asks	  the	  IDT	  to	   identify	  the	  opposite	  behavior	  and	  to	  require	  the	  youth	  to	  learn	  and	  demonstrate	   it	  over	  a	  period	  of	  time.	  For	  example,	  if	  a	  youth	  threatens	  and	  curses	  a	  staff,	  he	   must	  discuss	  three	  of	  that	  staff’s	  positive	  attributes	  in	  front	  of	  the	  unit	  group	   meeting	  each	  day	  for	  a	  week.	  A	  thorough	  accounting	  of	  SBBMS	  changes	  is	  beyond	   the	  scope	  of	  this	  report,	  but	  the	  process	  of	  its	  reformulation	  is	  mentioned	  to	   highlight	  DYS’	  holistic	  approach	  to	  implementing	  the	  reforms	  required	  by	  the	   Grid.	  	   	   One	  of	  the	  concerns	  that	  came	  with	  abolishing	  the	  practice	  of	  disciplinary	   seclusion	  was	  that	  disciplinary	  hearing	  officers	  might	  begin	  to	  rely	  on	  even	  more	   punitive	  sanctions	  in	  response	  to	  youth	  violence.	  Among	  the	  options	  available	  to	   hearing	  officers	  is	  to	  recommend	  Intervention	  Time	  (IT),	  which	  extends	  the	   youth’s	  length	  of	  stay	  at	  the	  facility	  once	  imposed	  by	  the	  Release	  Authority.	  When	   revising	  the	  Disciplinary	  Policy,	  DYS	  had	  the	  foresight	  to	  place	  limits	  on	  the	  use	  of	   IT	  to	  ensure	  that	  the	  pendulum	  did	  not	  swing	  further	  into	  the	  punitive	  realm.	  

	  

26.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 27 of 34 PAGEID #: 3185
	  

These	  limits	  were	  effective	  in	  combating	  the	  application	  of	  greater	  amounts	  of	  IT	   in	  the	  absence	  of	  disciplinary	  seclusion.	  DYS	  collected	  data	  on	  the	  use	  of	  IT	  six	   months	  before	  and	  after	  the	  Grid	  was	  implemented.	  The	  results	  are	  presented	   below:	   	  

IT	  Recommended	  Before	  and	  After	  Disciplinary	  Policy	  was	  Implemented	  

Facility	  

Before	  (#	  Days)	  

After	  (#	  Days)	  

%	  decrease	  

Circleville	  

10,075	  

927	  

-­‐91%	  

Cuyahoga	  Hills	  

5,978	  

1,753	  

-­‐71%	  

Indian	  River	  

22,150	  

1,420	  

-­‐94%	  

DYS	  TOTAL	  

38,203	  

4,100	  

-­‐89%	  

*Before	  spans	  March	  1,	  2014	  to	  August	  31,	  2014.	  After	  spans	  September	  1,	  2014	  to	  March	  1,	  2015	  
	   As	  shown,	  the	  number	  of	  days	  of	  IT	  recommended	  by	  facility	  hearing	  officers	   decreased	  drastically—89%—in	  the	  six-­‐month	  period	  following	  the	   implementation	  of	  the	  new	  Disciplinary	  Policy.	  These	  data	  are	  offered	  in	  further	   support	  of	  the	  drastic	  changes	  implemented	  in	  DYS’	  approach	  to	  managing	  youth	   behavior	  since	  the	  Court	  Order	  was	  imposed.	  	   	   Finally,	  DYS	  recognized	  that	  while	  Column	  B	  created	  changes	  in	  the	  system’s	   response	  to	  youth	  violence,	  and	  while	  Columns	  A	  &	  C	  addressed	  the	  mental	   health	  issues	  that	  underlie	  some	  youth’s	  involvement	  in	  aggressive	  behavior,	  a	   significant	  proportion	  of	  youth	  violence	  in	  DYS	  facilities	  is	  driven	  by	  youth’s	  gang	   involvement,	  their	  attempts	  to	  recruit	  other	  youth,	  and	  youth’s	  attempts	  to	  resist	   the	  pressure	  imposed	  by	  their	  gang-­‐involved	  peers.	  For	  this	  reason,	  DYS	  beefed	   up	  its	  gang	  intelligence	  and	  intervention	  resources.	  	   	   Every	  facility	  has	  a	  Gang	  Coordinator.	  Because	  the	  individuals	  who	  serve	  this	  role	   at	  each	  facility	  have	  different	  strengths	  and	  challenges,	  they	  were	  asked	  to	   articulate	  goals	  and	  create	  a	  work	  plan	  that	  highlighted	  the	  approach	  to	  be	  taken	   to	  combat	  gangs’	  influence	  in	  own	  facility.	  Circleville’s	  approach	  has	  centered	  on	   ways	  to	  help	  gang-­‐involved	  youth	  identify	  the	  ways	  in	  which	  gang-­‐related	   violence	  stands	  in	  the	  way	  of	  reaching	  their	  goals.	  The	  first	  class	  of	  The	  Power	  of	   Peace	  (POP)	  included	  58	  youth	  who	  had	  influence	  over	  other	  youth	  (e.g.,	  STG	   leaders,	  physical	  dominance,	  cognitive	  edge).	  Throughout	  the	  program’s	  40-­‐days,	   only	  20	  of	  these	  youth	  engaged	  in	  a	  subsequent	  AOV;	  in	  other	  words,	  two-­‐thirds	   abstained	  from	  aggressive	  behavior.	  Interviews	  with	  participating	  youth	  indicated	   their	  incentive	  to	  do	  so,	  in	  large	  part,	  was	  to	  protect	  their	  ability	  to	  participate	  in	   the	  POP	  program.	  A	  lunchtime	  program	  for	  STG	  shot-­‐callers	  was	  also	  created	  to	   interfere	  in	  their	  ability	  to	  communicate	  and	  issue	  orders	  during	  the	  mid-­‐day	   break	  in	  the	  dormitory.	  Finally,	  the	  facility	  plans	  to	  implement	  a	  group	  to	  help	   unaffiliated	  youth	  build	  resistance	  skills	  and	  strategies.	  The	  charisma	  and	  youth-­‐ focused	  approach	  of	  Circleville’s	  Gang	  Coordinator	  is	  an	  enormous	  asset.	  	   	   Indian	  River	  and	  Cuyahoga	  Hills	  were	  similar	  to	  each	  other	  in	  their	  focus	  on	   identifying	  youth	  who	  have	  not	  yet	  affiliated	  and	  who	  are	  targeted	  by	  gang-­‐

	  

27.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 28 of 34 PAGEID #: 3186
	  

involved	  youth’s	  efforts	  to	  recruit.	  Indian	  River	  assigns	  mentors	  to	  these	  youth	  to	   provide	  additional	  support	  for	  their	  resistance	  efforts.	  The	  Gang	  Coordinators	  at	   both	  facilities	  also	  participated	  in	  IDT	  meetings	  in	  order	  to	  ensure	  that	  heavily	   gang-­‐involved	  youth’s	  behavior	  gets	  brought	  into	  the	  treatment	  planning.	  These	   two	  Gang	  Coordinators	  are	  very	  focused	  on	  gathering	  and	  sharing	  information	   about	  gang	  involvement	  so	  that	  IDTs	  and	  individual	  staff	  can	  begin	  to	  handle	  the	   issues	  directly	  in	  their	  interactions	  with	  the	  youth.	  	   	   DYS	  went	  far	  beyond	  the	  parameters	  of	  the	  Grid	  to	  address	  youth	  violence	  and	   the	  system’s	  response	  to	  it.	  In	  so	  doing,	  they	  no	  doubt	  strengthened	  the	   implementation	  of	  the	  new	  policies	  because	  the	  changes	  were	  seen	  as	  part	  of	  a	   much	  larger	  process	  designed	  to	  improve	  staff	  and	  youth	  safety	  and	  to	  improve	   positive	  youth	  outcomes.	  	  

Compliance	   The	  Court	  Order	  requires	  DYS	  to	  meet	  the	  each	  of	  the	  performance	  measures	  at	   Assessment	   the	  required	  level	  each	  month	  for	  six	  months.	  	  

Monitor’s	   Assessment	  

Although	  DYS	  did	  not	  meet	  some	  of	  the	  performance	  measures	  at	  the	  required	   level	  throughout	  the	  entire	  six-­‐month	  period,	  the	  Monitor	  believes	  DYS	  has	   substantially	  complied	  with	  the	  requirements	  of	  Column	  B	  of	  the	  grid.	  	   	   The	  main	  area	  in	  which	  performance	  levels	  were	  not	  as	  high	  as	  expected	  was	  in	   the	  quality	  of	  the	  Safe	  to	  Release	  interviews.	  As	  noted	  in	  section	  B.5,	  above,	  the	   STR	  intervention	  underwent	  several	  changes	  in	  process,	  content	  and	  monitoring	   strategy	  throughout	  the	  six-­‐month	  period.	  The	  final	  product	  appears	  to	  allow	   sufficient	  time	  for	  the	  interviews	  to	  be	  conducted	  by	  staff	  who	  are	  trained	  to	   engage	  youth	  in	  substantive	  discussions.	  The	  interview	  form	  itself	  asks	  pointed	   questions	  designed	  to	  help	  the	  youth	  gain	  insight	  into	  his	  behavior	  and	  how	   future	  aggressive	  behavior	  could	  be	  avoided.	  Those	  overseeing	  the	  process	  at	   both	  the	  Central	  Office	  and	  facility	  level	  clearly	  understand	  the	  overall	  purpose	   and	  goals	  of	  the	  STR	  process	  and	  are	  well	  suited	  to	  continue	  to	  push	  for	  higher	   quality.	  STR	  interviews	  completed	  in	  March	  and	  April	  2015	  met	  the	  90%	   performance	  objective	  at	  all	  three	  facilities.	  For	  these	  reasons,	  the	  Monitor	  does	   not	  feel	  that	  her	  continued	  oversight	  is	  necessary	  to	  ensure	  that	  DYS	  continues	  to	   faithfully	  implement	  the	  reforms	  required	  by	  Column	  B	  of	  the	  grid.	  	   	   Finally,	  DYS	  has	  developed	  and	  implemented	  an	  internal	  Quality	  Assurance	   process	  that	  examines	  the	  duration	  of	  seclusion	  episodes,	  the	  accumulation	  of	   seclusion	  on	  individual	  youth,	  and	  the	  quality	  and	  timeliness	  of	  the	  STR	  process.	   From	  Central	  Office,	  monthly	  data	  are	  reviewed,	  outcomes	  are	  summarized,	  and	   results	  are	  presented	  to	  the	  facility	  Superintendents	  each	  month.	  These	   summaries	  were	  also	  shared	  with	  the	  Monitor.	  All	  three	  facilities	  also	  conduct	  on-­‐ site	  QA	  of	  the	  STR	  forms,	  either	  via	  a	  multi-­‐disciplinary	  team	  during	  morning	   incident	  reviews	  or	  by	  the	  Operations	  Administrator	  in	  the	  daily	  review	  of	  AOVs.	  If	   problems	  are	  identified,	  the	  facility	  Superintendents	  are	  responsible	  for	   constructing	  a	  Corrective	  Action	  Plan.	  Moving	  forward,	  the	  facilities	  will	  utilize	   Performance	  Based	  Standards’	  (PbS)	  Facility	  Improvement	  Plan	  (FIP)	  structure	  to	   make	  improvements.	  	  

	  

28.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 29 of 34 PAGEID #: 3187
	  

	   As	  noted	  above,	  the	  Monitoring	  Team	  participated	  in	  bi-­‐weekly	  calls	  held	  among	   the	  Superintendents	  and	  Central	  Office	  staff	  during	  which	  a	  healthy	  competition	   became	  apparent.	  Bragging	  rights	  are	  given	  when	  large	  proportions	  of	  the	   seclusion	  episodes	  are	  terminated	  within	  4-­‐hours,	  though	  the	  Superintendents	   are	  quick	  to	  up	  the	  ante	  with	  “Well,	  most	  of	  ours	  are	  going	  to	  be	  within	  2	  hours	   next	  month.”	  Furthermore,	  they	  often	  comment	  that	  a	  passing	  grade	  on	  the	   quality	  of	  the	  STR	  interviews	  is	  no	  longer	  sufficient,	  as	  they	  are	  striving	  for	  100%	   perfection,	  “no	  matter	  what	  Shari	  [the	  QA	  auditor]	  says.”	  Thus,	  the	  structured	  QA	   process	  and	  the	  culture	  change	  among	  the	  facility	  staff	  in	  recognizing	  that	  their	   facilities	  are	  safer	  without	  seclusion	  will	  allow	  DYS	  to	  continue	  their	  progress	   without	  external	  oversight	  from	  the	  Monitor.	  	  

	  

	  

	  

	  

	  

	  

29.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 30 of 34 PAGEID #: 3188
	  

Column	  C.	  Strategies	  for	  the	  Aftermath	  (Assigned	  Monitor:	  Dr.	  Andrea	  Weismann)	  

What	  the	   Grid	   Requires	  

(C.1)	  Treatment	  Plan	  Review	   • Within	  2	  days	  of	  every	  AOV,	  the	  treating	  clinician/IDT	  will	  review	  the	   treatment	  plan	  to	  identify	  antecedents	  and	  function	  of	  the	  behavior	  and	   to	  review	  treatment	  goals	  and	  interventions.	  If	  implementation	  of	  the	   existing	  plan	  has	  not	  been	  sufficient,	  it	  will	  be	  fortified.	  If	  the	  existing	  plan	   was	  properly	  implemented	  yet	  ineffective,	  it	  will	  be	  revised	  to	  include	   additional	  skill-­‐development	  or	  environmental	  changes.	  May	  use	   Behavior	  Contract	  if	  appropriate.	  	   • Intensity	  of	  treatment	  will	  be	  increased	  to	  3x/week	  individual	  sessions	  for	   two	  weeks;	  daily	  homework	  will	  be	  assigned.	  	  
(C.1)	  Performance	  Measures	   • 90%	  of	  youth	  involved	  in	  AOV	  have	  a	  Treatment	  Plan	  Review	  within	  2	   days	  of	  the	  incident.	  	   • %	  of	  cases	  in	  which	  implementation	  was	  fortified	   • %	  of	  cases	  in	  which	  interventions	  were	  revised	   o 	  Above	  should	  total	  100%.	  Not	  an	  option	  to	  do	  nothing.	  	  

Monitor’s	   Assessment	  

A	  set	  of	  requirements	  were	  established	  to	  address	  the	  mental	  health	  needs	  of	   youth	  involved	  in	  Acts	  of	  Violence	  (AOV):	  1)	  that	  the	  Individual	  Treatment	  Plan	   (ITP)	  would	  be	  reviewed	  within	  2	  days	  to	  determine	  if	  it	  established	  goals	  and	   objectives	  that	  addressed	  the	  root	  causes	  of	  the	  AOVs;	  and	  2)	  that	  the	  youth	  be	   provided	  intensified	  interventions	  that	  addressed	  the	  root	  causes	  of	  the	  AOVs.	   The	  following	  tables	  represent	  the	  facilities’	  compliance	  with	  these	  requirements.	  	   	  

Treatment	  Plan	  Review	  within	  2	  Days	  of	  Incident	  

	  

Aug	   Sept	   Oct	   Nov	   Dec	   Jan	   Feb	   Mar	   AVG	  

Circleville	  

66%	   86%	   100%	   75%	   100%	   ~	   0%	   25%	   65%	  

Cuyahoga	  Hills	  

~	   100%	   66%	   100%	   66%	   100%	   75%	   100%	   87%	  

Indian	  River	  

50%	   60%	   100%	   100%	   ~	  

~	   66%	   100%	   79%	  

DYS	  AVERAGE	  

58%	   82%	   89%	   92%	   83%	   100%	   71%	   75%	   77%	  

Sample	  Size:	  Circleville	  (n=27),	  Cuyahoga	  Hills	  (n=21),	  Indian	  River	  (n=28);	  TOTAL	  DYS	  n=76	  

	   While	  documentation	  supports	  that	  ITPs	  were	  being	  reviewed,	  this	  did	  not	  always	   occur	  within	  two	  days.	  This	  was	  due	  to	  weekend	  coverage	  and	  the	  availability	  of	   clinicians	  involved	  with	  the	  youth.	  When	  one	  looks	  at	  the	  March	  figures	  for	  CHJCF	   and	  IRJCF,	  there	  is	  no	  question	  that,	  overall,	  there	  has	  been	  improvement.	  	  As	  will	   be	  noted	  elsewhere,	  the	  small	  number	  of	  youth	  the	  grid	  metrics	  apply	  to	  in	  any	   given	  month	  skews	  an	  understanding	  of	  what	  is	  really	  going	  on	  on	  the	  ground.	  	   	   Subject	  Matter	  Expert’s	  assessment:	  This	  Grid	  requirement	  is	  in	  Substantial	   Compliance. 	   	   	   	  

	  

30.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 31 of 34 PAGEID #: 3189
	  

What	  the	   Grid	   Requires	  

	  

Treatment	  Plan	  Intervention	  Fortified	  or	  Revised	  

	  

Aug	   Sept	   Oct	   Nov	   Dec	   Jan	   Feb	   Mar	   AVG	  

Circleville	  

100%	   57%	   100%	   ~	   100%	   ~	   100%	   100%	   93%	  

Cuyahoga	  Hills	  

~	   100%	   100%	   50%	   100%	   100%	   100%	   33%	   84%	  

Indian	  River	  

66%	   50%	   100%	   ~	  

~	  

~	   66%	   100%	   76%	  

DYS	  AVERAGE	  

83%	   69%	   100%	   50%	   100%	   100%	   89%	   78%	   84%	  

Sample	  Size:	  Circleville	  (n=23),	  Cuyahoga	  Hills	  (n=22),	  Indian	  River	  (n=24);	  TOTAL	  DYS	  n=69	  

	   Both	  CJCF	  and	  IRJCF	  achieved	  100%	  compliance	  in	  March.	  Both	  CJCF	  and	  CHJF	   achieved	  100%	  compliance	  in	  February.	  CHJCF	  also	  achieved	  100%	  compliance	  in	   December	  and	  January.	  Once	  again,	  the	  resulting	  percentages	  required	  by	  the	   metrics	  of	  the	  grid	  minimize	  the	  significant	  gains	  DYS	  has	  made,	  which	  have	  been	   substantial.	  

Central	  Office	  has	  acknowledged	  that	  database	  issues	  kept	  them	  from	  accurately	   assessing	  whether	  this	  component	  of	  the	  grid	  was	  being	  complied	  with.	  DYS	   reports	  that:	  	  

“The	  reports	  we	  (now)	  run	  show	  whether	  the	  plan	  was	  fortified	  or	  revised	  AND	   that	  the	  fortification	  /	  revision	  was	  properly	  documented	  in	  our	  database.	  The	   documentation	  of	  that	  in	  the	  database	  was	  not	  entirely	  intuitive.	  As	  such,	  many	   fortifications	  and	  revisions,	  while	  occurring	  upon	  inspection,	  were	  not	  reflected	  in	   the	  database.	  We	  recently	  made	  a	  change	  in	  how	  that	  is	  recorded	  in	  the	   database—changing	  where	  it	  is	  recorded	  so	  the	  user	  does	  not	  have	  to	  leave	  one	   area	  of	  the	  database	  and	  open	  another	  just	  to	  record	  what	  they	  did	  in	  the	  original	   location,	  and	  inserting	  a	  forced	  response	  so	  the	  user	  will	  have	  to	  tell	  us	  what	  they	   did	  or	  that	  they	  did	  nothing	  in	  order	  to	  close	  out.”	  	  

It	  would	  seem	  that	  DYS	  is	  poised	  to	  report	  consistent	  compliance	  going	  forward.	  

Subject	  Matter	  Expert’s	  Assessment:	  This	  Grid	  requirement	  is	  in	  Substantial	   Compliance	  
(C.2)	  Special	  Review	  Team	  (SRT)	   • Within	  2	  days	  of	  a	  youth’s	  2nd	  Severe	  or	  3rd	  High	  severity	  AOV,	  he	  will	  be	   referred	  to	  the	  SRT	  for	  a	  clinical	  staffing,	  led	  by	  the	  psychologist	  and	   specifically	  focused	  on	  understanding	  and	  addressing	  the	  AOV	  behavior.	  	   • The	  SRT	  will	  function	  as	  the	  IDT	  until	  the	  youth’s	  behavior	  improves.	   • The	  SRT	  will	  explore	  the	  causes	  and	  functions	  of	  the	  behavior	  and	  will	   prescribe	  interventions	  designed	  to	  address	  those	  causes	  and	  functions	   (e.g.,	  Intensive	  Behavior	  Contract,	  staff	  mentor,	  change	  unit,	  skill	  building	   work,	  referral	  to	  MH	  facility,	  etc.)	  
(A.2)	  Performance	  Measures	   • Number	  of	  youth	  involved	  in	  2	  Severe	  or	  3	  High	  AOVs	  (descriptive	  data	   only)	   • SRT	  was	  convened	  within	  2	  days	  for	  100%	  

	  

31.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 32 of 34 PAGEID #: 3190
	  

• 90%	  of	  the	  SRTs	  explored	  the	  causes	  and	  functions	  of	  the	  behavior	   • 90%	  of	  the	  SRTs	  prescribed	  interventions	  that	  addressed	  those	  causes	  
and	  functions	  	  

Monitor’s	   Assessment	  

The	  Special	  Review	  Teams	  (SRTs)	  were	  implemented	  as	  the	  strategic	  clinical	   intervention	  for	  youth	  who	  engaged	  in	  multiple	  AOVs	  within	  a	  prescribed	  period	   of	  time.	  The	  purpose	  of	  the	  SRT	  was	  to	  delve	  into	  the	  causes	  and	  functions	  of	  the	   AOVs	  and	  prescribe	  interventions	  that	  would	  address	  the	  root	  causes.	  The	   following	  tables	  represent	  the	  facilities	  compliance	  in	  holding	  SRTs	  within	  2	  days	   of	  the	  incident	  and	  whether	  they	  considered	  the	  causes	  and	  functions	  of	  the	   behaviors	  that	  led	  to	  the	  AOVs.	  	   	  
SRT	  Convened	  within	  2	  Days	  of	  2nd	  Severe	  or	  3rd	  High	  Severity	  AOV	  

	  

Aug	   Sept	   Oct	   Nov	   Dec	   Jan	   Feb	   Mar	   AVG	  

Circleville	  

66%	   71%	   100%	   100%	   75%	   ~	   75%	   100%	   84%	  

Cuyahoga	  Hills	  

~	   100%	   100%	   100%	   66%	   100%	   100%	   100%	   95%	  

Indian	  River	  

50%	   70%	   100%	   100%	   ~	  

~	   100%	   75%	   83%	  

DYS	  AVERAGE	  

58%	   80%	   100%	   100%	   71%	   100%	   92%	   92%	   87%	  

Sample	  Size:	  Circleville	  (n=27),	  Cuyahoga	  Hills	  (n=21),	  Indian	  River	  (n=28);	  TOTAL	  DYS	  n=76	  

	   In	  all	  instances,	  the	  SRT	  was	  held	  within	  3	  –	  4	  days.	  The	  disparity	  in	  the	  timing	  of	   what	  was	  required	  and	  when	  these	  outlying	  instances	  occurred	  is	  explained	  by	   the	  DYS’	  decision	  to	  hold	  SRT	  when	  the	  involved	  clinicians	  were	  on-­‐site	  to	  make	   the	  proposed	  interventions	  more	  meaningful.	  All	  outlying	  instances	  were	  because	   of	  a	  weekend	  (or	  long	  weekend)	  intervening.	  	  Currently,	  DYS	  has	  amended	  their	   process	  so	  that	  SRTs	  are	  being	  held	  6	  days	  a	  week	  at	  each	  facility.	  DYS	  also	  has	  an	  
improved	  system	  for	  identifying	  youth	  who	  have	  met	  the	  SRT	  threshold	  

Given	  the	  small	  number	  of	  youth	  (i.e.,	  4	  –	  5)	  who	  met	  the	  SRT	  threshold	  each	   month,	  the	  metrics	  of	  the	  grid	  seem	  skewed	  when	  applied.	  Even	  one	  “miss”	   brings	  the	  monthly	  percentage	  down	  to	  75%	  -­‐	  80%.	  	   	   Subject	  Matter	  Expert’s	  Assessment:	  This	  Grid	  requirement	  is	  in	  Substantial	   Compliance	   	  

SRT	  Explored/Prescribed	  Interventions	  that	  Addressed	  Causes	  and	  Functions	  of	  Behavior	  

	  

Aug	   Sept	   Oct	   Nov	   Dec	   Jan	   Feb	   Mar	   AVG	  

Circleville	  

33%	   29%	   0%	   50%	   0%	   ~	   75%	   100%	   41%	  

Cuyahoga	  Hills	  

~	   100%	   100%	   100%	   0%	   100%	   75%	   100%	   82%	  

Indian	  River	  

67%	   90%	   100%	   100%	   ~	  

~	   100%	   100%	   93%	  

DYS	  AVERAGE	  

50%	   73%	   67%	   83%	   0%	   100%	   83%	   100%	   72%	  

Sample	  Size:	  Circleville	  (n=27),	  Cuyahoga	  Hills	  (n=21),	  Indian	  River	  (n=28);	  TOTAL	  DYS	  n=76	  

	   While	  interpretation	  of	  some	  documentation	  was	  an	  issue	  regarding	  the	  data	   reviewed,	  there	  is	  ample	  evidence	  that	  interventions	  provided	  did	  curb	  instances	  

	  

32.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 33 of 34 PAGEID #: 3191
	  

of	  youth	  aggression.	  	   	  
• At	  CJCF,	  with	  a	  total	  of	  27	  youth	  meeting	  the	  SRT	  threshold	  over	  the	  six-­‐ month	  period,	  there	  were	  only	  7	  repeaters,	  with	  4	  of	  these	  meeting	  the	   threshold	  for	  two	  months.	  	  That	  means	  that	  of	  the	  27	  youth	  who	  met	  the	   threshold	  for	  one	  month,	  74%	  did	  not	  engage	  in	  AOVs	  subsequent	  to	  	  	  	   receiving	  the	  more	  intensive	  treatment.	  	   	  
• At	  CHJCF,	  a	  total	  of	  20	  youth	  met	  the	  SRT	  threshold	  during	  the	  6-­‐month	   review.	  Of	  these,	  only	  4	  youth	  met	  the	  threshold	  for	  two	  months.	  That	   means	  that	  80%	  of	  the	  youth	  did	  not	  engage	  in	  repeated	  AOVs	  following	   the	  intensive	  interventions.	  	  	  
	   • At	  IRJCF,	  a	  total	  of	  14	  youth	  met	  the	  SRT	  threshold	  over	  the	  6-­‐month	   period.	  Of	  these,	  only	  one	  repeated	  for	  a	  second	  month.	  This	  means	  that	   the	  intensive	  interventions	  were	  successful	  in	  curbing	  youth	  aggression	   93%	  of	  the	  time.	  
	   Although	  it	  is	  impossible	  to	  say	  for	  certain	  how	  many	  AOVs	  are	  attributable	  to	   STG	  activity	  among	  youth	  on	  the	  MHCL,	  it	  is	  fair	  to	  say	  that	  this	  figure	  is	   substantial.	  From	  information	  available	  in	  the	  database,	  it	  would	  appear	  that	  at	   least	  25%	  of	  AOVs	  committed	  at	  CHJCF	  are	  due	  to	  gang	  involvement.	  At	  IRJCF,	  this	   figure	  rises	  to	  86%.	  CJCF	  had	  the	  lowest	  rate	  of	  STG	  activity	  with	  only	  about	  15%	   of	  youth	  involved.	  	  AOV	  figures	  from	  January	  to	  February	  show	  more	  than	  a	  50%	   decrease	  in	  activity	  (from	  56	  in	  January	  to	  25	  in	  February).	  The	  new	  program	   implemented	  at	  CJCF,	  The	  Power	  of	  Peace,	  seems	  to	  have	  made	  a	  critical	   difference	  in	  the	  reduction	  of	  gang	  activity	  and	  endorsement.	  We	  look	  forward	  to	   its	  implementation	  at	  the	  other	  facilities.	  	  
	   	   Subject	  Matter	  Expert’s	  Assessment:	  This	  Grid	  requirement	  is	  in	  Substantial	   Compliance	  

Other	  

The	  Monitors	  regularly	  interacted	  with	  DYS	  administrators	  and	  facility	  staff	  via	  bi-­‐

Information	   weekly	  conference	  calls	  and	  frequent	  email	  exchanges.	  The	  Monitoring	  Team	  also	  

participated	  in	  two	  one-­‐day	  site	  visits	  to	  each	  facility,	  one	  in	  October	  2014	  and	  

one	  in	  March	  2015.	  Contextual	  information	  and	  findings	  from	  site	  visits	  are	  

discussed	  here.	  	  

Monitor’s	   Assessment	  

The	  improved	  quality	  of	  mental	  health	  care	  at	  the	  facilities	  is	  supported	  by	  the	   fact	  that	  very	  few	  youth	  on	  the	  MHCL	  engage	  in	  AOVs	  at	  a	  frequency	  that	  meets	   the	  threshold	  for	  an	  SRT.	  We	  can	  assume,	  as	  noted	  in	  Column	  A,	  that	  between	  60	   and	  70	  youth	  at	  each	  facility	  are	  on	  the	  MHCL.	  With	  only	  approximately	  5	  youth	   per	  month	  engaging	  in	  AOVs	  sufficient	  to	  meet	  the	  SRT	  threshold,	  which	  means	   that	  93%	  of	  youth	  on	  the	  MHCL	  are	  doing	  well	  with	  the	  programs	  and	  activities	   aimed	  at	  addressing	  their	  needs.	  Relatively	  few	  of	  the	  remaining	  7%	  went	  on	  to	   commit	  frequent	  AOVs	  in	  multiple	  months.	  	  	   	  

	  

33.	  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 34 of 34 PAGEID #: 3192
	  
Further,	  opportunities	  to	  sit	  in	  on	  both	  Inter-­‐Disciplinary	  Teams	  (IDTs)	  and	  SRTs	  at	   all	  facilities	  gives	  rise	  to	  the	  observation	  that	  the	  quality	  of	  clinical	  discourse	  has	   been	  enhanced	  significantly	  over	  the	  last	  6	  months.	   	   The	  case	  conference	  process	  that	  was	  implemented	  by	  DYS	  to	  bring	  together	  the	   mental	  health	  subject	  matter	  experts	  from	  the	  Monitoring	  Team	  and	  DYS	   behavioral	  staff	  to	  review	  the	  most	  difficult	  cases	  (i.e.,	  cases	  that	  achieved	  the	   SRT	  threshold	  multiple	  times	  a	  month	  in	  multiple	  months)	  has	  proven	  most	   productive.	  	   	   To	  be	  sure,	  the	  constellation	  of	  strategies	  implemented	  as	  part	  of	  the	  Path	  to	   Safer	  Facilities,	  contributes	  to	  the	  huge	  successes	  now	  being	  experienced	  by	  DYS.	  
Compliance	   The	  Court	  Order	  requires	  DYS	  to	  meet	  the	  each	  of	  the	  performance	  measures	  at	   Assessment	   the	  required	  level	  each	  month	  for	  six	  months.	  	  
Monitor’s	   Individual	  institutions	  have	  come	  into	  substantial	  compliance	  with	  regard	  to	  all	   Assessment	   performance	  measures	  in	  Column	  C	  of	  the	  Grid.	  	   	  

	  

34.	  

 
 Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 1 of 44 PAGEID #: 2661
Second Progress Unit Status Report
Contributors: Amy Ast, Bureau Chief of Facility Operations Laura Dolan, Bureau Chief of Facility Programs Dr. Dachowski, Administrative Psychiatry Dr. Gregory, Behavioral Health Services Administrator Vanessa Tower, Behavioral Health Services Administrator Alexis Witte, Behavioral Health Services Administrator Andrea Jones, Superintendent of SJCF Shannon Komisarek, Direct Deputy of SJCF Jack Vicencio, Program Deputy of SJCF Dr. Hamning, Psychology Supervisor of SJCF
1

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 2 of 44 PAGEID #: 2662
INTRODUCTION The Ohio Department of Youth Services (DYS) and the U.S. Department of Justice (DOJ) negotiated and agreed upon a proposed Consent Order to mediate a process for dispute resolution regarding the PROGRESS Unit at the Scioto Juvenile Correctional Facility, as related to the United Sates v. Ohio and S.H. v. Reed Stipulations. The Consent Order, which was signed by the Court on January 18, 2013 (at which time it was also incorporated into a broader settlement between DYS and the S.H. plaintiff class), sets standards related to PU policies, admissions screening, programming, out‐of‐room time, staffing, treatment planning, length of stay, and promotion and demotion between phases. The first PU Status Report was authored by Drs. Kelly Dedel and Daphne Glindmeyer and was submitted to the court on March 27, 3013.
PURPOSE AND STRUCTURE OF THE REPORT This is the 2nd Status Report and it covers the time period from March 1, 2013 to May 31, 2013. The Parties and Monitors agreed that DYS would be responsible for the data collection, analysis, and completion of this 2nd report. The goal of this report is to act as follow‐up to the first report and to provide documentation and assessment for each of the PU standards, as well as an explanation for standards that are not in compliance. DYS has created action plans for how we will continue to address those areas that are not in Substantial Compliance. DYS was very careful to replicate the Quality Assurance (QA) format of the first report. Our hope with this format is that the State will be able to showcase competency with internal quality assurance through the use of concrete, real time examples. For each of the seven substantive areas in the Order, the report includes the following:
 Status: ODYS used a three‐level system for each substantive area: either substantial compliance, partial compliance or not in substantial compliance. This three‐tiered compliance scheme was agreed to by all Parties, with the recognition that DYS cannot come into compliance with the Consent Order until it has reached substantial compliance with all of the PU standards.
 Standard: A statement of what the State attempted to achieve in the particular area based on the requirements of the Court Order. Each substantive area has multiple standards under it. They are “should be” statements, rather than a current reflection of the PROGRESS Unit.
 Methodology: The source of the data that was used to assess performance toward the standard.
 Analysis and Interpretation: A thorough presentation of the data collected for the timeframe (with the option of providing June data as well) with an interpretation (including trends and red flags) of what the data implies regarding the extent to which the standard is being achieved. Additionally, this section offers an explanation for inconsistencies in the data and reasons behind an apparent lack of compliance in regards to extenuating circumstances.
 Conclusions and Recommendations: Indicates the status of compliance for the standard, by briefly summarizing the findings from the analysis and interpretation. Statements regarding what
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 3 of 44 PAGEID #: 2663
shall occur in order for the standard to be achieved in areas that are not yet compliant are listed as recommendations. An accurate description of DYS’s response to the suggested Quality Improvement Plan (QIP) suggested by the Monitors in the 1st Report is addressed in the discussion for each standard. For areas where the State finds itself still not in compliance with a certain standard, the State’s next steps of action will be apparent. It is DYS’s hope that in doing so, we are demonstrating our ability and acceptance of the responsibility for ongoing internal monitoring of the PU. DYS provided a draft of this report to the Monitors and to the plaintiffs in the S.H. and DOJ cases. The Monitors also had access to the underlying source data DYS used to draft the report. Each party provided comments to DYS, which were then used to revise the draft into this final report. Under separate cover, the Monitors will submit a Compliance Report to the Court that assigns compliance ratings, summarizes feedback and impressions and discusses any ongoing concerns. The State believes that this 2nd report shows significant progress in all standards. Although we were not able to grade ourselves as “substantially compliant” in all areas, we have pinpointed the areas in need of improvement and created a realistic plan to ameliorate those issues. As stated in the 1st report, “the PU is a radically different program than it was a year ago” and with this 2nd report, DYS demonstrates that it has tied up some procedural loose ends and improved the substance and quality of the treatment. Furthermore, this 2nd report provides insight into the future actions that will continue to improve the quality and purpose of this unit. Although this report shows many improvements in the PU from the 1st report, DYS is aware that much work remains. For example, we are still struggling with prolonged length of stay on the PU as well as quality Integrated Treatment Plans and Interdisciplinary Team meeting minutes. Having fixed many of the procedural loose ends, the State has been able to and will continue to focus on the quality of services provided to the youth on the PU. Certain themes, such as ITP goals and objectives and IDT minutes lacking the essential information continued to emerge. Again, although a work in progress, the State believes that this report demonstrates a continuing commitment to and improvement in the quality of provided services. The State sincerely hopes that this report will reveal the seriousness with which we approached this task, incorporated the recommendations of the Monitors, and are committed to continued improvement.
X[II.9] Admissions Screening Status: Substantial Compliance
(1) Standard: Admissions Screening. The PU accepts only those youth who can be reasonably expected to respond positively to the type of program and treatment services on the Unit. As such, their behavior and mental health history is reviewed to ensure that the behaviors are not the symptoms of mental illness (including undiagnosed or untreated mental illness). Youth with the following DSM‐IV diagnoses or conditions are excluded from placement on the PU:
 Thought Disorders  Mood Disorders
3

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 4 of 44 PAGEID #: 2664
 Developmental Disorders  Recurring self‐injurious behavior or suicidal ideation
Methodology: The following information was used to determine compliance with the standard:  PROGRESS Placement Table  Mental Health / Cognitive Skills Screen for Placement on Progress Unit
Analysis and Interpretation. The PROGRESS Placement table included the following information: youth’s name; identification number; facility; date the PU packet was received; adjudicated offense; mental health caseload status; educational program (e.g. regular or special education); DSM‐IV diagnoses; reason for request for PU placement; outcome of request (e.g. either approved or denied); the rationale for the approval/denial of placement; and the date of transfer to the unit.
The Mental Health / Cognitive Skills Screen for Placement on the Progress Unit included the following information: youth’s name; DYS number; referring facility; date of birth; mental health caseload status; primary clinician’s name; DSM‐IV diagnoses; 90 day review of psychotropic medication; synopsis of mental health condition; review of cognitive skills; appraisal of adaptive skills; and recommendations.
Five juveniles were referred to the Administrative Psychiatrist for placement onto the Progress Unit from March to May 2013. Two juveniles (40%) were denied by the Facility Resource Administrator prior to their referral packets reaching the Administrative Psychiatrist (OJ and DH). These 2 youth had diagnoses contained in the exclusionary criteria, and thus were not appropriate for the unit. One of the 2 youth denied for placement was also on an IEP for Emotional Disturbance (ED). Consequently, their information was excluded from this analysis. The remaining 3 youth (60%) were accepted onto the Unit.
The number of referrals remained the same from the previous quarter (there were 5 referrals made during the 1st and 2nd quarters). In addition, the number of juveniles accepted onto the unit remained the same from the previous quarter (there were 3 youth admitted to the unit during 1st and 2nd quarters).
None of the juveniles admitted during the 2nd quarter had the diagnoses contained in the exclusionary criteria and were not on the mental health caseload. None of the youth were prescribed psychotropic medication at the time of admission to the unit. Additionally, none of them had documented cognitive limitations or adaptive functioning impairments that would have contraindicated their placement onto the unit. Two of the youth admitted (66%) did have an IEP for Emotional Disturbance (ED).
Individual profiles of the youth admitted are as follows:
JA was not on the mental health caseload and was not prescribed psychotropic medication at the time of the referral. His diagnoses included; Conduct Disorder, Sexual Abuse of a Child, Cannabis Abuse, and Alcohol Abuse. None of these diagnoses are contained in the exclusion list. In addition, JA does not
4

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 5 of 44 PAGEID #: 2665
have an IEP or difficulties with adaptive skills. Furthermore, there were no contraindications to his placement onto the progress unit.
TH was the 2nd youth admitted to the Progress Unit during 2nd quarter. TH was not on the mental health caseload at the time of the referral and was not prescribed psychotropic medication. His diagnoses were Conduct Disorder and Cannabis Abuse. None of these diagnoses are contained in the exclusionary criteria for placement onto the Progress Unit. In addition, he did not exhibit difficulties with adaptive functioning (with the exception of continued aggressive behaviors towards staff and peers). This youth did have an IEP for Emotional Disturbance (ED). His intellectual functioning was estimated as normative at the time of his admission to the Progress Unit. It was noted that cognitive testing was incomplete due to the youth’s lack of compliance with the assessment process. Additionally, there were no apparent contraindications to TH’s placement on the Progress Unit.
AF was the 3rd youth admitted to the Progress Unit during the 2nd quarter. AF was not on the mental health caseload at the time of the referral. His diagnoses included; Conduct Disorder, Reactive Attachment Disorder, and Antisocial Personality Disorder. None of these diagnoses are contained in the exclusion list for the Progress Unit. AF was on an IEP with the classification of Emotional Disturbance (ED). Results of IQ testing placed AF in the Average Range of intellectual functioning with no significant limitations in adaptive functioning. AF’s weakest area was his aggressive behavior against staff and peers. There were no apparent contraindications for his placement on the Progress Unit at time of admission.
*Please see the chart on the subsequent page.

Youth Diagnoses

Phase One

Phase Two

Transition

5

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 6 of 44 PAGEID #: 2666

JA

Conduct Disorder, Sexual He was placed

Abuse of a Child, Cannabis on P1 5/31/13

Abuse, and Alcohol Abuse.

TH

Conduct Disorder and

Cannabis Abuse.

He was on P1 from 3/14/13 to 3/28/13
14 days

He was on P2 from 3/28/13 to 4/24/13 27 days

He was on T1 from 4/24/13 to 5/25/13 31 days

He returned to P1 on 5/25/13 for an AOV

AF

Conduct Disorder, Reactive He was on P1

He was on P2

Attachment Disorder, and from 3/18/13 to from 4/17/13 to

Antisocial Personality

4/17/13

5/31/13

Disorder.

30 days

44 days

He returned to P1 on 5/31/13 for an AOV
Table: The dates of service are current as of 5/31/13.

JH was one of the 2 youth who were denied placement onto the unit. JH was on the mental health caseload and was prescribed psychotropic medication. His mental health diagnoses included the following: Depressive Disorder Not Otherwise Specified; Post Traumatic Stress Disorder; Conduct Disorder; and Cannabis Abuse. The recommendation was for the treatment providers to continue to work with him around trauma issues and to continue to reinforce his behavior contract.
RB was the 2nd youth who was denied placement onto the Progress Unit. RB was on the mental health caseload and prescribed psychotropic medication. His mental health diagnoses included; Mood Disorder, Not Otherwise Specified; Conduct Disorder; and Attention Deficit Hyperactivity Disorder. RB’s intellectual functioning fell within the Average Range and he did not have adaptive functioning impairments. However, he had an IEP for Emotional Disturbance (ED). RB was not on an intensive behavior contract at the time of the referral. The recommendation was for the treatment providers to develop and implement an intensive behavior contract for him.

Conclusions and Recommendations. The rate of referrals to the Unit has remained stable for the past 6 months (5 youth per quarter). During the current quarter, no youth with exclusionary diagnoses was admitted to the unit. In fact, two youth were denied admission to the unit due to the presence of exclusionary diagnoses. In addition, it was

6

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 7 of 44 PAGEID #: 2667
recommended that the youth’s home facilities exhaust treatment options prior to utilizing a more restrictive placement. The facility is in substantial compliance with this standard.
ODYS shall continue the process of having the Administrative Psychiatrist conduct The Mental Health and Cognitive Screen for Placement onto the Progress Unit. The screening process continues to limit the number of referrals and consequently the number of youth placed onto the Progress Unit. In addition, the Facility Resource Administrator shall continue to deny requests that contain insufficient documentation prior to forwarding them to the Administrative Psychiatrist for review. This process also limits the number of inappropriate referrals to the Progress Unit. Additionally, ODYS shall continue to track and cross‐reference Progress Unit referrals via the Requests for Progress Placement Table maintained by the Facility Resource Administrator.
[II.10] Daily Schedule [reviewed by Shannon Komisarek] Status: Partial Compliance
(1) Standard: Out‐of‐Room Time. Youth on the PROGRESS unit have as much out‐of‐room time as youth in the general population. The ability to be out of their room from 7am to 7pm enables the youth to access to the intensive programming to address the behaviors and skill deficits that resulted in their placement on PROGRESS. The designated times when youth are in their rooms are the following: during shift change (40 minutes daily), medication pass (30 minutes daily), Treatment Team (3 to 4 hours per week), and seclusion time that is ordered as a sanction for major rule violations. The access to rehabilitative services fosters an environment where PROGRESS youth have the opportunity to practice the skills acquired through each Phase and are not in a lock down unit that uses isolation as a means to address youth behaviors.
Methodology. The following information is used to determine compliance with the standard:
 PROGRESS Unit Youth Activity History Report sheets that indicate the youth’s activities throughout each day, separated according to whether the youth is in his room or out of his room.
 The review period was March 1‐ May 31. Data was reviewed only for the month of May and not March or April due to improvements being made in the schedule itself and wanting to provide the most current picture of the Unit’s operation.
Analysis and Interpretation. The PROGRESS Unit Youth Activity History Report for the 4‐week period from May 5‐ May 28, 2013 was reviewed.
Each week, a random sample of 2 youth was selected for a total of 8 youth and 48 days. Of the 48 days reviewed, 1 youth was in seclusion for 1 full day and 6 hours the following day, a total of 30 hours during
7

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 8 of 44 PAGEID #: 2668
the sample time. In other words, on 97% of the days reviewed, the youth were out of their rooms and engaged in the program.
The Order requires youth to be out of their rooms on non‐IDT days for at least 10 hours and 50 minutes (allowing 70 minutes for shift change and med passes during the 12 waking hours). This minimum was exceeded for approximately 89% of the non‐IDT days in the sample. During the 24 day time period review, on 6 of the 56 days (11%), youth were noted to be in their rooms longer than the allotted 70 minutes for shift change/med pass. The in‐ room time exceptions were minimal with time in‐room ranging from 15 to 30 minutes longer than the 70 total minutes permitted by policy. The reasons for the exceptions ranged from a long restroom call to when youth had to go into their rooms because a peer was noncompliant (which averaged 15 minutes). This is a reasonable rate of exception.
The prior Status Report noted concern in the “Technical Assistance Note: Activity Tracking” that the data reflected that youth wee out their rooms during times when they were not, particularly during the IDT meeting times. In reviewing the Youth Activity History reports, the youth were in school approximately for approximately one hour during the IDT meetings. In addition, some youth were in one of the designated recreation rooms on the unit during IDT, which would give them more out of room time than if they were in their rooms during the entire IDT meeting. The discrepancies in the data occurred when the YS’s did document the transfer of youth from school or the recreation room in the unit log once the youth had physically moved locations.
There have been instances where a time period ranging from .3 to 1.5 hours is docuemted as in‐room time without the explanation. The PROGRESS Administrator needs to ensure the staff are including in the narrative if this is due to restroom calls, shift change, med pass, self‐seclusion or any other reason. During these months, the Administrator position was vacant and the clerical staff completing the input did not read the narrative to give the appropriate explanation.
Recommendations. The facility is in compliance with the standard related to out‐of‐room time. The Order’s minimum requirement (10 hours, 50 minutes) was exceeded on 89% of the days reviewed. Although problems with data‐entry and the data collection tool itself make data related to in‐room time difficult to interpret cleanly, the issue is best addressed under the standard related to Quality Assurance. Thus, a Quality Improvement Plan is not necessary to meet the standard regarding out‐of‐room time on the Daily Schedule a Quality Improvement Plan is not necessary to meet the standard regarding out‐of‐room time on the Daily Schedule.
(2) Standard: Daily Activities. Each day, youth on the PU participate in the following activities, out of their rooms:
 Meals;  330 minutes of education, except during intersession;  One hour of large muscle activity (without restraints);  Individual and group treatment conducted by Behavioral Health Staff;
8

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 9 of 44 PAGEID #: 2669
 Structured activities led by Youth Specialists or Volunteers;  Leisure time (one hour on school days, two hours on non‐school days).
Methodology. The following information is used to determine compliance with the standard:
 Youth Activity History that indicates the youth’s activities throughout each day, separated according to whether the youth is in his room or out of his room.
 Review of the Unit Log narrative that details the specific structured program/ activity the youth is involved in.
 Observations of PU activities
Analysis and Interpretation. The Youth Activity History logs for the 4‐week period from May 1‐29, 2013. Each week, a random sample of 2 youth was selected for a total of 8 youth and 58 days. Across the days:
 Three meals were provided to each youth, each day (100%). Youth who were not in seclusion ate outside of their rooms.
 A full day of education was provided to youth who were not in seclusion (100%) [Chancery attendance records were used to verify these data.].
 Recreation was provided on all but 3 days (95%; 3 seclusion days). During March and April Phase 1 youth participated in recreation in gator restraints that had more mobility than the gator restraints used all other instances a Phase 1 youth is out of his room. Starting May 1, Phase 1 youth participated in large muscle recreation in the outside recreation area designated for only Phase 1 youth or in the recreation rooms provided on the unit. The use of the gymnasium for Phase 1 youth is to engage in leisure activities. Youth who are serving Intervention Hearing (IH) seclusion are offered 1 hour large muscle by the GAT leading calisthenics to the youth while they remain in their room. The youth will refuse this recreation time because it is not in the gym or in the recreation room on the unit. Youth are serving other forms of seclusion are not offered large muscle recreation.
 Group and individual treatment was recorded for all but 1 of the 54 non‐seclusion days (98%). The youth was designated to have been in IDT this specific day.
 Structured activities were recorded on all of the non‐seclusion days (100%). One youth was selected each week each week where the schedule, unit log, and documentation were reviewed. The first set of 4 youth who were reviewed had 46% of their activities documented with the staff member leading the activity, but 43% of their activities were not described as being staff led. The second set of 4 youth had 57% of their activities documented with the staff member who led the activity. One youth was selected each week where the schedule, unit log and documentation were reviewed.
 Leisure time was recorded for 19 of the 56 days (66%). Outside leisure recreation was documented 13 times and inside leisure was documented 6 times. The unit schedules are to allow for 1 hour leisure Monday‐Friday and 2 hours Saturday‐Sunday. The Unit Managers have not allotted the 1 hour leisure on the weekdays, but have structured activities as directed by the
9

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 10 of 44 PAGEID #: 2670
prior Superintendent. Within the last few weeks, the Unit Managers have been instructed to allow the youth to have the one hour leisure time that is permitted by policy.
Technical Assistance Note: Activity Tracking “Structured Activity” is captured in the Youth Activity History logs for each youth. This document, however, does not indicate what the structured activity was or who the staff, i.e., Youth Specialist or Unit Manager, was that lead the activity. The Unit Log was cross reference with the Unit Schedule to determine if the youth are engaging in the activities as prescribed by the UM. What was discovered was that the Youth Specialist is logging the activity that is scheduled; however, not detailing who the staff member is leading the activity. Two youth were reviewed each week. The amount of time that it takes the YS’s and clerical to document the out of room time for each youth has decreased due to the staff becoming comfortable and accustomed to documenting in the unit log.
Conclusions and Recommendations. The lack of recreation opportunities for students in seclusion, the lack of leisure time on weekdays, and the fact that what is recorded as “structured activity” is often not led by an adult indicate that the facility remains in partial compliance with this standard. In order for DYS to meet the standard associated with the activity component of the Daily Schedule; a Quality Improvement Plan should be constructed to assist in the following area:
1. The Youth Specialists (YS’s) need to document in the Unit Log the specific Structured Activity the youth is engaged in and who is delivering this service to the youth. The Youth Activity History Log can then provide the daily and overall information to those who need to review and ensure the Unit Schedule is being followed. It is likely that errors in recording “structured activities” may have obscured the fact that leisure time is being provided on the weekdays.
2. At the writing of this report, there are no Phase 1 PROGRESS youth. When there are Phase 1 youth, the PROGRESS Program Administrator will need to ensure that the YS’s and Unit Managers do not become complacent with documenting exactly where the youth are. As the facility staff have become accustomed to the youth being out of their rooms from 7am‐7pm (minus the allotted 70 minutes to be in their rooms) , the staff make the erroneous assumption that the youth simply being out of their rooms is sufficient.
(3) Standard: Graduate Programming. Youth on the PU who have graduated from high school participate in out‐of‐room structured activities throughout the time that non‐graduates are in school.
Methodology. The following information is used to determine compliance with the standard:
 List of youth who have graduated from high school  Youth Activity Tracking sheets that indicate the youth’s activities throughout each day,
separated according to whether the youth is in his room or out of his room.
10

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 11 of 44 PAGEID #: 2671
Analysis and Interpretation. The Youth Activity Tracking logs were reviewed to determine how the graduate youth have their school time hours structured for them. During this time period, one youth was identified as the only graduate in the PROGRESS Units.
The PROGRESS Unit Managers meet with the youth as he progresses through the Phases to produce an updated schedule. As he has progressed, his access to opportunities increases. An 8 day time period was reviewed when the youth was a Phase 2. Of the 8 days reviewed, the schedule was documented to be followed 65% of the time. The circumstances that contributed to the schedule not being followed were: the youth refusing to participate in the activity; a volunteer (community or SJCF) not present; the documentation the Youth Specialists documented in the unit log was not specific and accurately reflect what the youth was engaged in. On one day (day 8) the specific activities the youth was engaged in was not accurately documented in the narrative of the Unit Log. The unit staff, inclusive of the Youth Specialists, Unit Manager, and Behavioral health staff report that they follow the schedule, although the youth’s activities are not always documented properly.
Recommendations. While only one youth who had graduated from high school was housed on the PROGRESS Unit during the period of review, data indicate that his schedule was followed only 65% of the time. A Quality Improvement Plan is necessary to meet the standard associated with graduate programming on the Daily Schedule. This plan should include:
1. Ensuring that all youth activities are carefully tracked by the YS who is supervising the youth at any given time. Furthermore, ensure that all staff who have made a commitment to serving graduate youth are responsible for delivering those services. Finally, a youth’s refusals to participate in programming will be discussed during the subsequent IDT meeting.
[II.11] Staffing Status: Substantial Compliance
(1) Standard: Staff Numbers and Training. A sufficient number of adequately trained supervisory and line staff are available to implement the PU program as designed.
 A Unit Manager (UM) works during all waking hours, seven days per week.  All assigned PU Youth Specialists have completed required training within three months of their
assignment.  All Youth Specialists (whether assigned or relief) read and sign the relevant Post Orders.
Methodology. The following information should be used to determine compliance with the standard:
 Average daily populations for Sycamore, Cedar and Buckeye
11

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 12 of 44 PAGEID #: 2672
 UM schedule  Youth Specialist staffing reports  Staff training records  PU Post Orders and signature pages
Analysis and Interpretation. The Unit Managers The Unit Manager Schedules were reviewed for the time period of March 2013 – June 2013. Unit Manager Coverage was as follows:
 Of the 31 days in March, 25 days met the court requirement, for an average of 81%  Of the 30 days in April, 28 days met the court requirement, for an average of 93%  Although there were 31 days in May, one day was a state holiday so only 30 days were
reviewed. Of the 30 days in May, 23 days met the court requirement, for an average of 77%  Of the 30 days in June, 27 days met the court requirement, for an average of 90%.
Throughout the four month period, time that staff were noted as in “Training”, were counted as coverage because training took place in the facility and the Unit Managers were available if needed. The court order states, “absent minor incidental deviations, the Unit Manager shall work on the PROGRESS Unit during all waking hours (7a‐7p) seven days per week.” The Unit Manager schedule has required that a Unit Manager be available during waking hours, but has not required a Unit Manager on each Progress Unit during waking hours. Training that has occurred within the facility that Unit Managers were required to attend, still allowed for them to be available and to visit the unit throughout the day.
During the month of May, a PROGRESS Unit Manager was placed on Administrative Leave which impacted coverage resulting in seven of the 30 days not covered, therefore not meeting the standard that month. For the month of June, two additional Unit Managers received PROGERESS training and were included in the coverage, resulting in 90% of the days covered. For the four month period, DYS was overall in compliance with the standard.
The Youth Specialists’ The YS shift assignments are as follows: 6 staff on 1st shift, 6 staff on 2nd shift, and 4 staff on 3rd shift for Cedar and Sycamore Units, for a total of 32 positions. The YS shift assignments are as follows for Buckeye Transition Unit: 4 staff on 1st shift, 6 staff on 2nd shift, and 2 staff on 3rd shift for a total of 12 positions. Each of the 44 staff is assigned to 1st, 2nd, or 3rd shift and has two days off per week. In all cases, the staff have two days off in a row. Relief assist in providing coverage for call offs and vacations. In addition, relief staff are often from another shift, or another Progress Unit, and thus are familiar with the policies and procedures of the Progress Unit. Furthermore, all “relief staff” were trained on the Progress Unit Policy.
Youth Specialists Staffing reports for March, April, and May 2013 show the number of staff who actually reported to work each day.
12

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 13 of 44 PAGEID #: 2673

 Of a total of 93 shifts (including 1st, 2nd, & 3rd) on Sycamore Unit during the months of March, there was one shift (March 10th, Sycamore Unit on 1st shift) that did not meet the staffing pattern, therefore 99% of the time, Youth Specialist staffing levels were appropriate.
 Of a total of 90 shifts (including 1st, 2nd, & 3rd) on Sycamore Unit during the month of April, all shifts met the required staffing pattern 100% of the time.
 Of a total of 93 shifts (including 1st, 2nd, & 3rd) on Sycamore Unit during the month of May, all shifts met the required staffing pattern 100% of the time.
 Of a total of 93 shifts (including 1st, 2nd, & 3rd) on Cedar Unit during the months of March, there all shifts met the required staffing patter 100% of the time.
 Of a total of 90 shifts (including 1st, 2nd, & 3rd) on Cedar Unit during the month of April, all shifts met the required staffing pattern 100% of the time.
 Of a total of 93 shifts (including 1st, 2nd, & 3rd) on Cedar Unit during the month of May, all shifts met the required staffing pattern 100% of the time.
 Of a total of 93 shifts (including 1st, 2nd, & 3rd) on Buckeye Unit during the months of March, there all shifts met the required staffing patter 100% of the time.
 Of a total of 90 shifts (including 1st, 2nd, & 3rd) on Buckeye Unit during the month of April, all shifts met the required staffing pattern 100% of the time.
 Of a total of 93 shifts (including 1st, 2nd, & 3rd) on Buckeye Unit during the month of May, all shifts met the required staffing pattern 100% of the time.
Staffing Levels Determining whether staffing levels are “adequate” requires knowledge of the size of the population the staff are supervising on any given day. Average daily populations (ADP) are normally calculated by adding the number of youth on a unit each day, and dividing the sum by the number of days in the month.

Population Averages, per unit

Unit

March

Sycamore (P1)

6

Cedar (P2)

8

Buckeye (Transition)

6

Total PU

20

April 6 8 6 20

May

Average

6

6

8

8

5

5.7

19

19.7

The first Progress Status report showed a decrease in PU population of 14% over the 4 months reviewed (December 2012, Jan.‐Feb., 2013) Review of population averages per unit for March, April, May 2013, shows that the population averages have basically remained the same. First Progress report shows an overall average of 19.95 for all units over a 4 month period. This reporting period the overall average for the 3 month period is 19.7. This is 1% decrease which is not statistically relevant.
13

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 14 of 44 PAGEID #: 2674
The weekly staffing reports, coupled with the estimated ADP permit an assessment of the typical staff— youth ratio on Sycamore and Cedar. 1st and 2nd shifts normally had 3 staff on each unit, while 3rd shift normally had 2 staff. About 10% of the time, 1st and 2nd shifts had 4 or 5 staff and 3rd shift had 3 staff. PROGRESS Training The Order requires staff assigned to PROGRESS Unit complete training “specifically relating to working with youth on the PROGRESS Unit and implementing the PROGRESS Unit as designed” within 3‐months of their assignment. The PROGRESS Unit Policy and Handbook was approved by the DOJ Monitor on April 10, 2013. ODYS officials signed off on them, with an effective date of May 31st. ODYS developed an 8hr training based on the policy and handbook for all PROGRESS Unit staff. There were a total of six training sessions held and 100% of the Youth Specialists that are assigned to the PROGRESS Unit and staff that work as PROGRESS relief staff attended the training. Additionally, 100% of the Unit Managers, Behavioral Health Staff, and Administrative Staff attended the training. Assigned staff who were off on Administrative Leave, Disability, or Military were not considered in these results.
14

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 15 of 44 PAGEID #: 2675

POSITION
William Stump (P) Thomas Polk (P) William Samuels (P)
Kim Williams Dion Baines (P)
David James Jim McWatters (P) Bryant Brown (P)
Nicole Curry Mandy Rafter Deb Powell Glenn Comb Anthony Bordeaux Diane Merritt (P) Jesse Pfalzgraf (P) Katherine Mitchem (P) Justin McGrath (P) Joshua Moss (P) Mathew Sanders
Jessica Jefferson (SW) Keeli Cook (SW)
Gertrude Love (MH Nurse) Marius Igwe (SW)
Alvin Braddy (MH Nurse)

DATE TRAINED
5/8/2013 5/8/2013 5/8/2013 5/8/2013 5/8/2013 5/8/2013 5/17/2013 5/17/2013 5/17/2013 5/17/2013 5/17/2013 5/17/2013 5/17/2013 5/17/2013 5/17/2013 5/21/2013 5/21/2013 5/21/2013 5/21/2013
5/8/2013 5/17/2013 5/17/2013 5/17/2013 5/17/2013

PROGRESS Training May/June 2013

POSITION

DATE TRAINED

YOUTH SPECIALISTS

Tanya Butler (P)

5/21/2013

Marketta Reedus

5/21/2013

Isaiah T. Coleman (P)

5/21/2013

Karl Wilkins Jr

5/24/2013

Fred King

5/24/2013

Malinda Lawrence (P)

5/24/2013

Andrew Bryson

5/24/2013

Tanya Serrell

5/24/2013

Josh Miller

5/24/2013

Melissa Allen

5/24/2013

Victoria A. Tyler

5/24/2013

Dominguez Andres

5/24/2013

Marquetta Dudley

5/24/2013

Adrian Hill (P)

6/14/2013

Saroya Seay (P)

6/14/2013

Jamar A. Hill (P)

6/14/2013

Herman Walker (P)

6/14/2013

Angela King

6/14/2013

Lisa Wynn

6/14/2013

SOCIAL WORKERS / NURSES/PSYCHOLOGY

Princess Cripe (Psychology)

5/17/2013

Irv Jones (Psychology)

5/24/2013

Dr. M.S. Black (Psychology)

6/14/2013

Regina M. Grywalski (OT)

6/14/2013

POSITION
Atha Sanders (P) Yvonne Butler James Littleton (P) Tiffany Logan (P)
Andy Baker Robert Reynolds Chad Boone (P) Grant Zimmerman (P) Stanley Ball (P) Nate Strong (P) Shawn Overstreet Gilbert Cueva (P) Veronica Sellers (P)
Curtis Karn Kehinde Adeyinka (P)
Kevin Judge (P) Velvet Hutchinson (P)
Dedra Johnson (P) Teri Campbell

DATE TRAINED
6/14/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013

15

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 16 of 44 PAGEID #: 2676

POSITION

DATE TRAINED

Becki Williams (SWS)
Ven Evans (OM)
Alfred Brown (OM) Yolanda Frierson (UM) Turon Hairston (OM‐TWL) Laurel E. Jeffreys (UM) Shannon Komisarek (Deputy) Vickie Donahue (HSA)

5/8/2013
5/8/2013
5/8/2013 5/8/2013 5/8/2013 5/8/2013 5/17/2013 5/17/2013

Matt Russell (GAT) Jeffrey Adkins (Asst. Principal)
Melissa Lopes (GAT)

5/8/2013 5/21/2013 5/21/2013

Mindy Worly (AG) Ashleigh Hodge (Intern)
Alexis Witte (Intern) Jim Ferrell (CO) Aaron Bauer (CO)

5/8/2013 5/8/2013 5/8/2013 5/8/2013 5/8/2013

POSITION
MANAGEMENT Michael Waryck (UM)
Lataucia Sweeney (OM)
Keith Williams (OA) Jack Vicencio (Deputy) Joel Nussbaum (OM) Trecia Holdren (SWS)
Carlos Davis (UM) Ian McNamara (Rec. Admin)
RECREATION/EDUCATION Richard B. Sommers (Teacher)
Greyland Williams (GAT) Kelly Wright (OA)
CENTRAL OFFICE/NON‐DYS Dave Pigman (CO) Pat Hurley (CO) Ed Dachowski (CO) Vanessa Tower (CO) Chris Freeman (CO)

DATE TRAINED
5/21/2013
5/21/2013
5/21/2013 5/21/2013 6/14/2013 6/14/2013 6/14/2013 6/18/2013
5/24/2013 6/18/2013 6/18/2013
5/8/2013 5/8/2013 5/17/2013 5/17/2013 5/21/2013

POSITION

DATE TRAINED

Nicole Pace (UMA)
Larry Mallory‐Gang Specialist
Curtis Simms (UM)

6/18/2013 6/18/2013 6/18/2013

The previous PROGRESS Status Report identified that Post Orders were “severely outdated”. In reviewing the current Post Orders, they were updated March 6th, 2013 and accurately reflect current
expectations of the PROGRESS Unit.

Conclusion and Recommendations. In the 1st Progress Status Report the monitor recommended the ODYS develop a QA process to appropriately monitor this standard. ODYS is utilizing the 2nd Progress Status report as a QA tool. The
findings demonstrate that ODYS is in substantial compliance.

In only one area (UM coverage in May 2013) did the staffing levels fall below the requirements of the Court Order. This shortage was due to an unexpected staff departure and did not lead to a chronic shortage in UM coverage. Indeed, in the following month, UM coverage exceeded the threshold of 80%. This, along with the other findings discussed here, demonstrate that ODYS is in substantial compliance.
16

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 17 of 44 PAGEID #: 2677

(2) Standard: Impact on Safety. Recognizing there are many contributing factors to youth violence, staffing levels on the PU are sufficient to ensure that a lack of supervision does not contribute to the opportunity for youth to commit violence against other youth or staff.
Methodology. The following information should be used to determine compliance with the standard:
 Rate of youth‐on‐youth violence for this reporting period  Rate of youth‐on‐staff violence for this reporting period  Disaggregated list of AOVs committed by youth that includes the youth’s name, date and type of
violence.

Analysis and Interpretation The 1st Progress status report showed rates of youth on staff and youth on youth violence for a 3 month
period, November, December and January:

Rates of Violence on the PU

Month

Youth—Staff Number ADP Rate

Nov 12

8

21

.381

Dec 12

6

20

.285

Jan 13

5

19

.263

Youth—Youth

Number ADP Rate

5

21 .238

1

21 .048

1

19 .053

The 2nd Progress Status report reviewed youth on staff and youth on youth violence for a 3 month period, March, April and May 2013:

Rates of Violence on the PU

Month

Youth—Staff Number ADP Rate

Mar 13

3

20

.150

Apr 13

5

20

.250

May 13

2

19

.105

Youth—Youth

Number ADP Rate

0

20 .000

0

20 .000

0

19 .000

17

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 18 of 44 PAGEID #: 2678
Comparisons:  The average rate of youth on staff assaults for the First Status Report was .310; The average rate of youth on staff assaults for the Second Status Report was .168, for an overall decrease of 46%  The average rate of youth on youth assaults for the First Status Report was .113; The average rate of youth on youth assaults for the Second Status Report was 0, for an overall decrease of 100%
Conclusion and Recommendations. The reduction in youth‐on‐youth violence has contributed to an overall safer environment. Although it’s not clear that there is one contributing factor, what is clear is that the reduction of “in room” time, the emphasis on programming, recreation, and structured activities has had a positive impact. ODYS will continue work towards sustaining the progress made thus far and identify areas for continued improvement.
The rate of youth‐on‐staff violence, while significantly reduced from the previous period, still remains higher than desired. As with youth on youth violence, the overall environment has become safer with an emphasis on programming and structured activities. ODYS will continue to sustain the progress made thus far and identify areas for continued improvement.
With a reduction in overall violence, and evidence that sufficient numbers of staff supervise these youth, ODYS is in substantial compliance with this standard.
In order to maintain substantial compliance, ODYS will continue to: 1. Track rates of violence by collecting the number of AOVs and the ADP each month for the PU, specifically. 2. Analyze incidents involving violence against youth to identify any patterns in unit, location, youth involved, etc. 3. Analyze types of violence perpetrated against staff, their underlying causes and any environmental conditions that create the opportunity for violence to occur (e.g., sufficient staff support during restraints? Ability to collect liquids and throw them? Tensions between individuals that should be mitigated?).
[II.12] Treatment Planning Status: Partial Compliance
(1) Standard: Clinical Staffing [this standard is derived from paragraph II.C.3 of the SH Order] Clinical staffing is sufficient to implement youth’s treatment plans and to conduct Inter‐Disciplinary Team (IDT) meetings. The staffing levels are adjusted when the population fluctuates or upon reasonable professional judgment.
18

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 19 of 44 PAGEID #: 2679
Methodology. The following information was used to determine compliance with the standard:
 PROGRESS Unit (PU) policy  Standard Operating Procedures  Case notes from the OK database broken down by treatment type  Integrated Treatment Plans (ITPs) approved between 3/1/13‐5/31/13  A tally of the front line staff and their clinical hours provided  Interdisciplinary Team (IDT) minutes
Analysis and Interpretation.
Ratio of clinical staffing During the March 2013‐May 2013 three month time period, the number of youth on the PROGRESS Unit (PU) varied from as low as 11 youth to as high as 17 youth. During this time, there were 8 full time clinicians and treatment providers, 1 full time mental health nurse, and 1 contracted psychiatrist (.5 FTE) who worked primarily on the PU. This creates a ratio that ranged from a low of staff to youth of 1:1.3 to a high of 1:2.1. The clinicians and treatment providers consisted of three psychology staff, four social workers and one Occupational Therapist (OT) (.5FTE). Collectively, these primary staff (along with treatment provided by three Unit Managers, one Unit Administrator, and 1 youth specialist all assigned to the PU provided treatment to these youth during their time on the PU.
Although more than one Youth Specialist provides treatment, the Case Notes Database is limited in some aspects and therefore does not reflect the name of the Youth Specialist providing such treatment. Detailed limitations are noted below:
 The Case Notes database is not designed to incorporate case notes completed by Youth Specialists who conduct group sessions unless the Youth Specialist’s name is documented as part of the case note.
 The drop box identifying the staff completing the session only lists the clinicians or the Unit Manager. Office assistants completing data entry to document the Youth Specialist’s group session did not identify the group facilitator in the body of the case note. Therefore, the case note would need to be compared with the sign in sheet.
Based upon the data reviewed, psychology staff delivered 39% of the received treatment, social work staff delivered 53% of the treatment and the OT delivered 8% of the treatment. There was also evidence that Scioto JCF ensured necessary treatment was occurring, even when assigned staff were absent. For example, case notes revealed that on occasion, staff who were not normally assigned to the PU conducted and documented treatment provided on this Unit.
19

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 20 of 44 PAGEID #: 2680

Month Lowest Ratio (staff to Highest Ratio (staff to

youth)

youth)

March

1:1.8

1:2.1

April

1:1.4

1:2

May

1:1.3

1:1.6

Research supports the sufficiency of one staff person for every 8 to 10 youth (Deitch, Madore, Vickery and Welch, 2013). Based upon this research, even the highest ratio of 1:2.1 staff:youth ratio identified above is more than sufficient for the provision of behavioral health services.

Another way to demonstrate the effectiveness of the PU staff is to analyze the number of treatments hours they provided. During the 3 month period, the clinicians and treatment providers mentioned above provided 1,432.22 hours of treatment to these youth during the youths’ time on the PU. Of the 8 PROGRESS clinicians and treatment providers, there were 3 psych staff, 4 SW staff, and 1 OT (.5 FTE) staff. Percentage wise, the psych staff contributed to 39% of the received treatment, the SW staff contributed to 53% of the treatment and the OT staff contributed to 8% of the treatment.

According to the data reviewed, the youth received an average of 1.2 hours of treatment a day. The staff provided an average of 15.9 hours of treatment per day, which creates a staff to youth ratio (in treatment hours) of 15.9:1.2. Considering the number of youth on the Unit during this time period (11‐ 17 youth) as well as the expectation that clinicians perform individual and group therapy, this ratio seems to be an accurate reflection of what is occurring. Furthermore, taking into consideration that “treatment” does not include additional programming, such as school, volunteer services, recreation services, or meals, this ratio of treatment is a reasonable expectation.

IDT meetings Of the thirty‐nine IDT meetings that should have been held during the three month period, all 39 meetings occurred. This is a compliance rating of 100%. Furthermore, the IDT was 100% compliant in conducting the weekly meetings as required in the ODYS SOP 404.02.01 “Interdisciplinary Team. “ Please see the discussion below for a more comprehensive outline of staff attendance.

Fluctuations of Rotating Staff During the three‐month period, there were not a high number of fluctuations. Therefore, the number of staff and the amount of treatment provided was adequate to ensure all youth received a consistent level of treatment. Additionally, as there were entries provided by staff members who were not one of the 8 consistent clinicians and treatment providers, it can be interpreted that Scioto JCF has the means and the foresight to ensure that treatment continues, even if there are moments of short staffing. These moments of short staffing include trainings, unexpected call offs, and other unique situations that may occur on any given day.

20

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 21 of 44 PAGEID #: 2681

Conclusions and Recommendations The facility is in substantial compliance with this standard.
Current staffing levels are more than sufficient to meet the requirements of the Court Order and to ensure youth’s consistent access to treatment that is responsive to individual needs. In order to maintain substantial compliance, recommendations include the following:
1. DYS should continue creating data sets in an effort to easily extract data from the Management by Measurement (MbM) database system. The MbM database extracts data from the OK database.
2. DYS should continue evaluating clinical staff:youth to ensure ratios do not exceed 1 clinical staff to 8‐10 youth and to ensure that youth are receiving an adequate average number of treatment hours per day.
(2) Standard: Treatment Planning. Treatment plans are individualized and include concrete, realistic, measurable goals and objectives that are designed to address the specific behaviors that led to the youth’s placement on the PU. Specific interventions are prescribed in order to assist youth in accomplishing treatment goals. Progress toward treatment goals results in promotion through the PU’s phases and, ultimately, back to the general population.
 Phase 1 (P1) goals focus on acquiring skills to move safely about the unit without the use of restraints once promoted. Skill acquisition is demonstrated by meeting behavioral expectations.
 Phase 2 (P2) goals focus on acquiring skills needed to refrain from aggressive behavior once returned to the general population.
Methodology. The following information was used to determine compliance with the standard:
 Integrated Treatment Plans for 10 youths currently on one of the PROGRESS Units  Case notes for 10 youth currently on one of the PROGRESS Units
Analysis and Interpretation.
ITP Goals & Objectives Three of eight primary clinicians were represented in the sample. Objectives written during the period of March, April and May 2013 were reviewed. For this standard, ITP goals and objectives were assessed to determine whether they were measurable, realistic, strength‐based and addressed development of skills needed to change behaviors that led to placement. Based on the ITPs reviewed:

Total 167

Measurable Realistic Strength Based
154 (92%) 167 (100%) 13 (8%)

Skills Focused 39 (23%)

21

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 22 of 44 PAGEID #: 2682

 The use of strengths in objective development has increased slowly.  There appeared to be an increase in objectives being stated in a forward moving way
with an increasing focus on identifying, practicing/acquiring, and demonstrating positive behaviors (as opposed to removing, eliminating, or decreasing negative behaviors).  Although there is a slight increase in objectives with skill development as the focus, the facility is still not meeting ODYS’ standard at this time.  Nearly all objectives being developed are observable, realistic and measurable.
ITP Documentation in Case Notes Interventions were reviewed to determine if they were documented and appropriate to ITP goals and objectives. In addition, the type and intensity of services were reviewed to determine appropriateness to the ITP and the individual youth.
This analysis involved calculating the number of treatment contacts per youth during a 13‐week period (3/1/13‐5/31/13). Once calculated, the average number of each type of contact was averaged across the 10 youth in the sample for the entire 13‐week period and also per week. Results are presented in the table below.

CBT Group Skill OT MH/SA Ind

A and/or B Sets

Group SW

13‐week 8.2

43.7 16 10

11.4

period

Per week .63

3.36 1.23 .77

.88

Ind Psych

15.7 caseload 8 non‐caseload 1.2 caseload

.62

non‐

caseload

Range of Daily treatment contacts 3/1/13 – 5/31/13: 0 – 5

Average number of days on which youth received no treatment contacts 3/1/13 – 5/31/13: 7.4 (2.46 days per month; .56 days per week)

Estimated average daily treatment contacts per youth 3/1/13 – 5/31/13: 1.27

The estimated average daily treatment contacts seem to be an accurate reflection of what is occurring. Furthermore, taking into consideration that “treatment” does not include additional programming, such as school, volunteer services, recreation services, or meals, this ratio of treatment is a reasonable expectation.

22

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 23 of 44 PAGEID #: 2683
With regard to the average daily number, seven out of the ten youth (70%) were on the PU for the full 92 day period between March 1, 2013 and May 31, 2013. The other three youth were on the PU for 1, 74 and 78 days.  Interventions are documented at various levels of detail in all group and individual case
notes with the exception of CBT Core A, Core B Curriculum, and Core B Skill Set groups. Those notes simply identify the date, skill set discussed, and/or lesson covered. CBT Core A, Core B Curriculum and Core B Skill Set are primarily provided by Youth Specialists and facilities were therefore permitted to document the date, skill set discussed and/or lesson covered for these groups.  Documentation of having addressed specific ITP objectives is found in approximately 30‐40% of individual case notes.
o Group notes are dictated by the group subject and focus on details regarding youths’ behavior and apparent investment in the group.
o Individual case notes that do not address specific ITP objectives are, in large part, focused on current youth issues.
Individual and group treatment sessions should always connect back to the youth’s ITP. This is an area that has been addressed and will continue to be addressed as needed.
Based on the case notes reviewed:  Occasionally, a single objective, as phrased, actually represented 2 and sometimes 3 separate objectives. Objectives need to be better focused and limited in scope so that progress toward them can be measured easily.  Over time the number of objectives that focus on skill acquisition has increased, but given that less than ¼ of objectives were skill‐focused, this is an area in need of improvement.  Strength based objectives do not represent a high percentage of objectives written during this period. However, the inclusion of strength based objectives has increased over time, and continued to increase in June and in July to date. However, the percentage remains relatively low and this represents an area for further attention and development. In May 2013, ODYS Central Office reviewed several ITPs and provided written feedback and technical assistance to the facility. The feedback and technical assistance included but was not limited to discussion of SMART goals, strength based goals and objectives, skill acquisition, duration and frequency.  Case notes reference general, broad objectives in most cases. They need to be more specific in order to be more individualized.  Based on clinical expertise, staff is delivering treatment, training and interaction at a high level of frequency. Treatment expectations are guided by OYAS standing, mental health status, and number of other factors. Individual contacts with behavioral health staff identified in policy guidelines for both youths on the mental health caseload and for Progress Unit in general are exceeded. When the total number of treatment contacts are analyzed in terms of time, the ten youths in this sample were provided an average of 90.13
23

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 24 of 44 PAGEID #: 2684
hours of treatment through this 91 day period of time. At this pace, youths with an OYAS level of low will have met their treatment target (100 hours) within 4 months of admission, moderates will have met their target (200 hours) within 6‐7 months, and highs would have met their target (300 hours) within 10‐11 months of admission. These figures and frequencies must be considered in the context of the number of days and hours youths were in seclusion, days and hours youths are available for treatment, and actual number of days on the units (some youths were not on Progress every day through this 3 month period). What looks to be an average of one treatment hour per day would, in fact, turn out to be at least somewhat higher, if not significantly higher, if such an analysis was produced.
Conclusions and Recommendations.
The facility is in partial compliance with this standard based on the following:
1. Substantial compliance with the standard that goals and objectives be realistic and measurable.
2. Partial compliance with the standard that goals and objectives focus on skill acquisition. 3. Partial compliance with the standard that goals and objectives be strength‐based. 4. Substantial compliance with the standard that interventions are documented. 5. Partial compliance with the standard that documentation connects the intervention to ITP
goals and objectives. 6. Substantial compliance with the standard that treatment is at an appropriate level of
intensity.
The following steps are recommended:
1. Continue to focus on writing simple, concrete, measurable objectives. 2. Continue to identify skills to enlist in achieving objectives as well as those that a youth needs
in order to continue moving forward. 3. Identify an instrument BHS staff can utilize to identify strengths in the following areas:
emotional, personality, and character. Ensure these strengths are incorporated into the youth’s ITP goals and objectives. 4. Ensure that group notes are more individualized and have specific references to youth’s individual ITP goals so as to better integrate treatment across providers. 5. Provide continual, frequent, and on‐going training and discussion among BHS staff for developing ITPs.
(3) Standard: Progress Reporting and Promotion. Progress toward treatment goals and behavioral expectations is assessed on a weekly basis. Youth are promoted to the next higher phase when they have met their treatment goals and behavioral
24

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 25 of 44 PAGEID #: 2685

expectations. Behavior not related to AOV, serious STG activity, possession of major contraband, or repeated verbal threats to cause serious harm are not used as a basis to withhold promotion.

Methodology. The following information was used to determine compliance with the standard:
 Movement History  IDT Minutes from March 1, 2013 through May 31, 2013

Analysis and Interpretation.

Promotion/Demotion Compliance A random sample of ten youth who were on the PU between 3/1/13‐5/31/13 was reviewed. Although a random sample was reviewed, several primary and secondary parameters were also considered during the case selection process in an effort to review at least nine cases involving youth who recycled through the PU Phases and at least one case where the youth did not recycle through the PU Phases during the period under review.

A total of 121 IDT discussions occurred during the period under review. Of this number, the PU was 94% compliant with the following: The IDT minutes clearly identified whether the youth was on track for promotion, his promotion was withheld, youth was promoted, or youth was demoted. The table below is a breakdown of the compliance.

ON TRACK FOR PROMOTION, PROMOTION WITHHELD, PROMOTION, DEMOTION

Yes = In compliance No = Out of compliance

#

Question/Issue

Total # of IDT Yes

No

Compliance

Discussions

Percentage

1. IDT action taken complied

with the treatment goals,

121

114

7

94%

behavioral expectations and

four criteria (AOV, major

contraband, STG Activity,

repeated verbal threats to

cause serious harm)**

**The above item was reviewed in reference to policies and standard operating procedures in

effect during the period under review (March 1, 2013‐May 10, 2013)

Based on the data, PU non‐compliance in this area was due to:  Youth demotion from Transition 1 to Phase 2 for sexual misconduct and for not meeting behavioral expectations. Demotions should only occur when a youth has engaged in an Act of Violence, major contraband, STG Activity or repeated verbal threats to cause serious harm.  Several youth were demoted for sexual exposure. The demotion criteria identified above was not met.

25

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 26 of 44 PAGEID #: 2686
 Youth’s promotion from Phase 1 was withheld based on a threatening conduct and four previous secondary violations. Youth had been informed by the IDT during the previous week that he would get promoted if he received no violations that week. However, he received another violation. The youth should not have been promised a promotion to Phase 2 in part because the youth had four prior secondary violations. A Phase 1 youth cannot have primary or secondary violations when being promoted to Phase 2.
 Youth was promoted to Phase 2 even though he did not meet his goals and objectives. A Phase 1 youth must meet his goals and objectives in order to promote to Phase 2.
Although the IDT makes the recommendation for demotion, the facility Superintendent must approve all phase demotions prior to implementation.
On several occasions youth were informed during IDT meetings that they would be promoted the following week if they did not receive any Youth Behavioral Incident Reports (YBIRs) between that time period and the next IDT meeting. Several youth received YBIRs which resulted in a demotion or in a promotion being withheld.
Recycled Cases Nine out of the 10 cases reviewed during this time period (90%) involved youth who recycled through the PU. However, it must be noted that as mentioned earlier these nine cases were specifically selected for review based upon primary and secondary parameters established when determining the random sample criterion. The ten cases were selected to determine if trends for recycling or promotion could be identified.
Based on the data, there was no clear indication why youth recycled through the Phases. The 9 youth who were recycled accumulated a total of 13 demotions. In 8 out of 13 instances (62%), the youth’s goals and objectives were not discussed during the most recent IDT meeting prior to the demotion. This indicates that just prior to demotion, the goals and objectives were only discussed 38% of the time for these youth. As a result of ODYS discovering this trend, it should be explored further to determine if this is one factor which contributes to the youth’s recycling through the Phases.
For the one youth who advanced through the phases without being demoted, his goals and objectives were discussed at all IDT meetings preceding his promotion. This is a 100% compliance rate involving the discussion of goals and objectives immediately prior to the four promotions. When discussing the goals and objectives, the IDT discusses whether the youth has been meeting his goals and objectives. Treatment interventions are also discussed. Further exploration is needed to determine if this may be a factor involving youth who promote through the phases without recycling.
IDT Meeting Compliance During the period under review, a total of 39 IDT meetings were held with each Unit conducting 13. The IDT was 80% compliant in conducting weekly IDT meetings to discuss the youth’s progress. In other words, 2 youth were not reviewed weekly.
26

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 27 of 44 PAGEID #: 2687

For the two non‐compliant cases, one youth was promoted from Phase 2 (Cedar Unit) to Transition 1 (Buckeye Unit) on March 1, 2013 but an IDT meeting was not held for him until March 12, 2013. The second youth was promoted from Phase 2 (Cedar Unit) to Transition 1 (Buckeye Unit) on March 14, 2013 but an IDT meeting was not held for him until one week later on March 21, 2013. These two cases are similar in that when both youth transferred from Phase 2 and Transition 1, there appeared to be a system breakdown and the youth were not integrated into the Buckeye Unit weekly IDT meeting schedule in a timely fashion.

The IDT was 100% compliant in meeting with all ten youth face‐to‐face at least bi‐weekly to discuss the youth’s progress. The table below highlights this data.

IDT WEEKLY & BI‐WEEKLY MEETING COMPLIANCE

Yes = In compliance No = Out of compliance

#

Question/Issue

# of Youth

Yes

No

Reviewed

1. Did the Interdisciplinary Team

(IDT) meet at least once/week

10

8

2

to review youth’s progress?

2. Did the IDT meet face‐to‐face

with the youth at least

10

10

0

twice/month to review the

youth’s progress related to his

ITP?

Compliance Percentage
80%
100%

Documentation of Goals and Objectives in the IDT Meeting Minutes A total of 121 IDT discussions occurred during the review period and the IDT averaged twelve discussions per youth. Discussion of the goals and objectives during the IDT meetings is an area still needing improvement.
A discussion of the goals during the IDT meetings never exceeded 77% for all PU Phases and a discussion of the objectives never exceeded 74%. On several occasions during Phase 1, Phase 2 and Transition 2, the goals were discussed but not the objectives.
Although receiving the lowest rating in both areas of goals and objectives, data reflects that the Buckeye Unit (Transition 1) consistently discussed objectives whenever the youth’s goals were discussed. However, as indicated below, these discussions occurred on very rare occasions.
The table below gives the compliance breakdown for all PU Phases as related to documentation of goals and objectives during IDT meetings. There appeared to be an issue where the goals and objectives were
27

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 28 of 44 PAGEID #: 2688

not routinely reviewed or discussed during IDT meetings when the youth transitioned to the Buckeye Unit. DYS recently addressed this issue with the facility and anticipates improved compliance during the 3rd Quarterly PU report.

GOALS & OBJECTIVES DOCUMENTED IN THE IDT MINUTES

Yes = In compliance No = Out of compliance

GOALS

Unit Name & Phase

Total # of IDT

Yes

No

Discussions

Sycamore (Phase 1):

44

34

10

Cedar (Phase 2):

35

23

12

Buckeye (Transition 1):

30

7

23

Buckeye (Transition 2):

12

5

7

OBJECTIVES

Sycamore (Phase 1):

43

32

11

Cedar (Phase 2):

35

22

13

Buckeye (Transition 1):

31

7

24

Buckeye (Transition 2):

12

4

8

Compliance Percentage
77% 66% 23% 42%
74% 63% 23% 33%

The skills needed to achieve the goals and objectives were either not being discussed during the IDT meetings or were not being documented. There was also limited discussion and documentation on engaging the youths’ families.

The IDTs conscientiously and consistently discussed the youth’s medication compliance rate for those youth taking medication. Documentation of Phase 1 (Sycamore Unit) IDT meetings looked to be the strongest and most detailed. However, significant improvements were made by staff on Transition 1 (Buckeye Unit) during the May 21st and May 28th IDT meetings. The Buckeye Unit began formatting the IDT meeting minutes in the same manner as the Sycamore Unit. Thus, the meeting minutes were more structured. Furthermore, the IDT minutes clearly reflected the status of each youth’s progress with his goals.

Several youth involved in the Phoenix (Gang) program attended the IDT meetings and the IDT discussed youths’ involvement with gang‐related activities. However, the Gang Coordinator was not present to add to this discussion and no information was provided by the Gang Coordinator.

Documentation of Treatment Interventions When Needed In six out of the seven applicable cases reviewed, treatment interventions were adjusted when warranted. This is an 86% compliance rate. On the one case where the treatment intervention was not adjusted, the IDT struggled with identifying new interventions to support the youth.

28

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 29 of 44 PAGEID #: 2689

ADJUSTMENT OF TREATMENT INTERVENTIONS IN THE IDT MINUTES

Yes = In compliance No = Out of compliance

#

Question/Issue

# of Youth Yes No

Not

Compliance

Reviewed

Applicable Percentage

1. Did the IDT weekly

minutes clearly identify

10

6

1

3

86%

adjustments needed to

help the youth achieve

his goals?

Conclusions and Recommendations. The facility is in substantial compliance with this standard.

The IDT was 94% compliant in its action taken related to PU Phase promotions and demotions. Demotion non‐compliance involved sexual misconduct and sexual exposure. Promotion non‐compliance involved a youth being promoted although not meeting his goals and objectives and another youth being promised a promotion from Phase 1 to Phase 2 although he had four prior secondary violations.

There is no clear indication why youth recycled through the PU Phases. However, a trend was discovered which revealed that at the most recent IDT meeting just prior to demotion, the goals and objectives were only reviewed and discussed 38% of the time. The recycling issue should be explored further to determine if this is one factor of possibly several which contributes to the youths’ recycling through the Phases.

Recommendations include the following: 1. Review and comply with SOP 303.01.07 “Unit PROGRESS” to ensure future compliance related to promoting and demoting youth. 2. Comply with SOP 404.02.01 “Interdisciplinary Team” inclusive of engaging the youths’ families and encouraging their participation in the IDT meetings whenever possible. 3. Complete ODYS Form 404.02.01.A “Interdisciplinary Team Agenda/Meeting Minutes” when documenting IDT meeting minutes. 4. Re‐evaluate the practice of promising promotions based on the youth’s anticipated behavior. 5. Develop clinician’s strengths around articulating goals and objectives that are concrete, measurable, strength‐focused and skill‐based. 6. Develop a plan for discussing and documenting, during the IDT meetings, the youth’s ITP goals, objectives and skill development needs. 7. In development of the above plan comply with SOP 404.02.01 “Interdisciplinary Team. 8. Clearly discuss and document during IDT meetings, skill acquisition needed by youth to assist the youth in achieving identified goals and objectives. 9. Continue adjusting treatment interventions as needed. Seek consultation from Central Office when the IDT comes to an impasse related to treatment intervention options.

29

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 30 of 44 PAGEID #: 2690
(4) Standard: Inter‐Disciplinary Team. [Note: this standard applies only to the S.H. Agreement.] A psychiatrist, psychologist or designee facilitates an Inter‐Disciplinary Team (IDT) meeting. Attendees include social workers, psychologists, occupational therapists, medical staff, educators, recreation staff, Unit Managers and Youth Specialists. If a member of the IDT cannot attend, written input shall be submitted to the IDT.
Methodology. The follow information should be used to determine compliance with the standard:
 IDT Minutes
Analysis and Interpretation.
IDT Meeting Facilitation A psychiatrist, psychologist or staff member approved by a psychiatrist or psychologist shall facilitate the IDT meetings. The IDT minutes generated between March 1, 2013 and May 31, 2013 were reviewed. These indicated that the IDT facilitator differed across units (i.e., whether facilitated by a psychiatrist, psychologist or other staff), but that all three units have 100% compliance ratings for this part of the standard. It should be noted that Dr. Ryan, one of DYS’s contracted psychiatrists, attended every IDT meeting on both Sycamore and Cedar with the exception of 1.
IDT Meeting Attendees The staff present for each of the IDT meetings was tabulated for each unit. Monthly attendance rates for each discipline are noted in the tables below, along with an average attendance rate for the 3‐month period reviewed. On the Sycamore Unit, overall, all disciplines were represented in at least 85% of the IDT meetings, except for Recreation staff who did not attend any meetings. In addition, several disciplines’ (OT, medical, education, and Unit Manger) attendance dropped off in May. The underlying reasons for this decrease will be explored to ensure it does not become a pattern.
On the Cedar Unit, all of the disciplines were present for at least 93% of the IDT meetings, except for Recreation staff (0%) and the Unit Manager (62%). There were no significant differences across the three months reviewed.
On the Buckeye Unit, representation across the disciplines was more problematic. Education and social work were represented only 54% and 33% of the time, respectively, and OT, recreation and medical staff never attended.
Below are three tables that depict the information pulled from the sole source of data. It directly relates to the items in question. An analytical breakdown of the raw data is provided below. Further exploration is needed to determine why certain staff was consistently not in attendance during these IDT meetings.
30

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 31 of 44 PAGEID #: 2691

Sycamore Unit: Phase 1 Criteria
Facilitated by a psychiatrist or psychologist or staff member approved by psychiatrist Social worker in attendance Psychologist in attendance Occupational therapist in attendance Medical staff in attendance Educator in attendance Recreation staff in attendance Unit manager in attendance Youth specialist in attendance Written note provided when not in attendance

March rating
100%
100% 100% 100%
100% 100%
0%
100% 100%
0%

April rating
100%

May rating
100%

Average Rating for 3 month period 100%

80% 100% 100%
80% 80% 0%
100% 100%
0%

100% 100% 75%
75% 75% 0%
75% 100%
0%

93% 100% 93%
85% 85% 0%
93% 100%
0%

Cedar Unit: Phase 2 Criteria
Facilitated by a psychiatrist or psychologist or staff member approved by psychiatrist Social worker in attendance Psychologist in attendance Occupational therapist in attendance Medical staff in attendance

March rating
100%
100% 100% 100%
100%

April rating
100%
100% 75% 100%
100%

May rating
100%

Average Rating for 3 month period 100%

100% 100% 100%
100%

100% 93% 100%
100%

31

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 32 of 44 PAGEID #: 2692

Educator in attendance Recreation staff in attendance Unit manager in attendance Youth specialist in attendance Written note provided when not in attendance

100% 0% 50%
100% 0%

75% 0% 75% 100% 29%

100% 0% 60%
100% 0%

93% 0% 62% 100% 10%

Buckeye Unit: Transition Criteria
Facilitated by a psychiatrist or psychologist or staff member approved by psychiatrist Social worker in attendance Psychologist in attendance Occupational therapist in attendance Medical staff in attendance Educator in attendance Recreation staff in attendance Unit manager in attendance Youth specialist in attendance Written note provided when not in attendance

March rating
100%
50% 100%
0%
0% 75% 0% 100% 100% 0%

April rating
100%
60% 100%
0%
0% 60% 0% 80% 100% 0%

May rating
100%

Average Rating for 3 month period 100%

0% 100%
0%
0% 25% 0% 100% 100% 0%

33% 100%
0%
0% 54% 0% 92% 100% 0%

Written Notes Provided When Not in Attendance This is an area needing improvement. Only one unit (Cedar) had any notes with explanation and even that was a compliance rating of only 10%. It should be noted that the complete exclusion of the recreation staff skewed this data especially since the IDT was unaware that recreation staff should have been attending these meetings. Clearly, this is a practice that needs to be greatly improved if DYS is ever to reach substantial compliance with this area.

Conclusion and Recommendations The facility is in partial compliance with this standard.

The significant deficiency noted with this analysis shows that a recreation staff was never in attendance on any of the units. The reason for these absences must be explored.

32

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 33 of 44 PAGEID #: 2693
The second deficiency is that on PU Phase 2 (Cedar Unit) the rate of compliance for the Unit Manager was only at 62%. The reason for such low attendance must be explored.
The third deficiency was the IDT minutes for Transition Phase 1 and Transition 2 (Buckeye Unit) in general. The other concerning aspect of the Buckeye Unit IDT minutes is that there were only 4 categories which reached an acceptable compliance rating (80% and above). The necessary representatives of the various disciplines are clearly not attending the Buckeye Unit’s IDT meetings. This needs to be addressed.
The analysis revealed correctable problems with attendance at IDT meetings. Attendance rates on Sycamore took a downturn in May 2013. Attendance by recreation staff was problematic across all units. Unit Manager attendance on Cedar Unit was inconsistent. Multiple disciplines had attendance problems on Buckeye Unit. As a result, the facility is only in partial compliance with this standard. To resolve these problems, the facility needs to develop a Program Improvement Plan to:
a. Determine why the recreation staff does not attend IDT meetings and develop a plan to ensure compliance.
b. Ensure representatives from all disciplines are consistently present at the IDT meetings on all three units, as required by the Court Order.
(5) Standard: IDT Substance. Youth appear before an Inter‐Disciplinary Team (IDT) at least bi‐weekly. IDT meetings for each youth involve a structured and specific discussion of each youth’s goals and objectives, behavioral expectations and progress toward meeting them.
 When goals and expectations are met, the youth is promoted.  If goals and expectations are not met, the IDT identifies the areas in need of improvement so
the youth know what is required for promotion. The IDT also revises the treatment plan or its implementation to better address the underlying causes of the youth’s unwanted behaviors.
Methodology.
The following information should be used to determine compliance with the standard:  IDT Minutes from March 1, 2013 through May 31, 2013.  Individual Treatment Plans, and updates from March 1, 2013 through May 31, 2013.
Analysis and Interpretation.
IDT minutes completed between March 1, 2013‐May 31, 2013 were reviewed from PU Phase 1 (Sycamore Unit), PU Phase 2 (Cedar Unit) and Transition Unit (Buckeye Unit).
Ten youth cases were reviewed. The IDT minutes revealed 100% compliance with the youth attending IDT bi‐weekly meetings as required.
33

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 34 of 44 PAGEID #: 2694
The IDT was 80% compliant with conducting weekly IDT meetings to discuss the youth’s progress. This is because two youth were not reviewed weekly as required and case documentation and analysis revealed a breakdown in integrating the youth into the IDT meeting schedule when the youth was promoted from Phase 1 (Cedar Unit) to Transition 1 (Buckeye Unit).
Throughout the review of the IDT Meeting process, there are numerous references to new arrivals on the unit, and a tendency to defer seeing such individuals promptly, and instead allowing them to “settle in” to the new environment. Unfortunately, that practice is somewhat contradictory to expectations for treatment planning and execution as listed in ODYS SOP 303.01.07 “Unit PROGRESS.” That SOP, newly approved in May of 2013, specifies certain time requirements for youth to be given their Behavioral Expectations, develop or update their ITP to address problem behaviors that lead their referral for placement on PU in the first place, and meet with the IDT to have this information reviewed and signed off by members of the IDT. The ITP exists now in a version in the electronic behavioral health database that allows for timely updates and revisions, but doesn’t really lend itself to a form where IDT members actually can “sign off” on the document.
IDT minutes indicated that the youth were engaged in the treatment plan process, and that treatment interventions were being discussed with them. However, on one occasion the treatment intervention was not adjusted. Based on the documentation, the treatment intervention was not adjusted because the IDT came to an impasse and was uncertain on what intervention method to introduce next. In this case, the treatment interventions were adjusted in 6 out of the 7 applicable cases when warranted. This is an 86% compliance rate.
Although goals and objectives were reviewed and discussed among the IDT, this is an area still needing improvement. The goals and objectives were discussed on an inconsistent basis and neither Unit exceeded 77% for review and discussion of goals. Moreover, neither Unit exceeded 74% for review of objectives during the IDT meetings.
The IDT consistently discussed the youth’s behaviors and behavior assignments. Conversely, the demonstration of acquisition of skills was discussed less frequently.
The IDT minutes have a structure to them that generally follows the format of listing information by youth individually, including goals / objectives / commentary on progress being made, along with summary paragraphs discussing topics like medication changes and special treatment plans such as Behavioral Contract, Intensive Behavioral Contracts, and Safety Plans. Towards the end of the minutes, there are quick comments on new arrivals on a unit. This is not generally similar to the structure of IDT Minutes as specified in ODYS Form 404.02.01.A, “Interdisciplinary Team Agenda /Meeting Minutes,” which covers many of the same topics, but specifies a different arrangement of information, in which youth are grouped into topics of interests. This difference in the form and format completed by the facility compared to what is in policy needs to be resolved.
34

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 35 of 44 PAGEID #: 2695
SOP 404.02.01 “Interdisciplinary Team” also requires that a youth complete a Juvenile Relational Inquiry Tool. All IDT minutes lacked documentation of the status of this requirement. The SOP also indicates that family members and parole staff should be included in IDT meetings, but these interactions generally are not listed as taking place.
Conclusions and Recommendations.
The facility is in partial compliance with this standard. There is evidence that the IDT minutes for Sycamore and Cedar have vastly improved from the past. The IDT Minutes for these units revealed documentation that youth were meeting with the IDT bi‐weekly as required. There are notations that treatment interventions were being discussed with the youth. Goals and objectives are sometimes presented for report and discussion among the IDT members, and comments about youth’s behaviors and behavior expectations were discussed. However, the minutes contained missing discussion surrounding skill acquisition and relevant interventions. These units are clearly working as a team and are driven to support and assist the youth with whom they work. This is strong evidence that these minutes will be in substantial compliance by the next report.
In order to meet the standard associated with IDT Substance, all three IDTs must: 1. Follow the SOP for documenting IDT meeting minutes. 2. Document in the meeting minutes:
a. Where the youth is in treatment b. Exactly where the youth is in relation to behavior expectations and skill acquisition as
related to his goals and objectives c. That the youth knows exactly what he needs to do in order to get promoted.
(6) Standard: Length of Stay A Length of Stay (LOS) record is maintained for each youth to document the date placed on Phase 1, promoted to Phase 2, promoted to Transition, and transferred to the general population. Youth are expected to promote to the next phase within 30 days (or be referred for review, as described by Standards 7‐8, below). Across the three phases, the outer limit is 90 days.
Methodology. The following information should be used to determine compliance with the standard:
 Youth’s movement history
35

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 36 of 44 PAGEID #: 2696
Analysis and Interpretation.
Promotion to the next phase within 30 days There were 16 youth on the PU during this three month period. One youth was excluded from all analyses due to an extreme outlier which would skew the data (he was on the PU for 1 day during the period under review). A “stay” in the tables below is defined as a finite period of time spent on a single unit.
Four out of the 12 stays (33%) on Phase 1 were over 30 days. In other words, 67% of the Phase 1 stays were shorter than the expected maximum. Three out of the 17 stays on Phase 2 were over 30 days; for a compliance rating of 82% over 30 days. Three out of the 17 stays on Transition were over 30 days; for a compliance rating of 82% over 30 days. There was a total of 10 stays over 30 days (out of 46 total stays), for an overall compliance rating of 78%. Please see the charts at the bottom of this section. Ten out of the 16 youth (63%) had at least one stay over 30 days. Conversely, only 38% of the youth on the PU advanced through all three phases spending less than 30 days on each phase, for a total LOS of 90 days or less.
Finally, it is noteworthy that the average LOSs for all three phases is below 30 days. This suggests that there is significant variability in the length of time youth stay on each phase. As discussed above, some of the youth spend more than 30 days on a phase (33% Phase 1; 18% Phase 2; and 18% Transition), but the remaining youth spend significantly less time on each phase, which brings the average down.
Recycled Cases As previously discussed, ten cases were reviewed to analyze reasons for youth recycling through the PU. Based on the data, there was no clear indication why youth recycled through the Phases. However, it must be noted that the 9 youth who were recycled accumulated a total of 13 demotions. In 8 out of 13 instances (62%), the youth’s goals and objectives were not discussed during the most recent IDT meeting prior to the demotion. This trend should be explored further to determine if this is one factor which may contribute to the youths’ recycling through the Phases.
Conclusions and Recommendations The facility is in partial compliance with this standard.
The primary concern revealed by this analysis is the proportion of youth who do not pass through the PU as quickly as anticipated. Looking at all three phases together for individual youth, about two‐thirds of the youth on the PU get hung up at some point in the process. Most often, the delay occurs on Phase
36

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 37 of 44 PAGEID #: 2697

I. Phase 1 is an adjustment period for the youth, which could explain why this phase is where a delay most often occurs. In order to meet the standard associated with the Length of Stay, a QIP should be developed to address the following issues:
1. Continue streamlining procedures and services on the PU. 2. Continue Quality Assurance/Quality Improvement of ITPs, IDT minutes, and services. 3. Monitor effectiveness of ITPs, IDT minutes and services.
The two tables below depict the information pulled from the primary source of information for the months of March, April, and May 2013. An analytical breakdown of the raw data is provided below.

Phase 1 2 Transition

# of youth 10 16 14

# of stays 12 17 17

Average LOS (days) 26 23 28

Phase
1 2 Transition Total

Over 30 days on a Phase

# of youth # of Total # of

stays

Stays

4

4

12

3

3

17

3

3

17

10

10

46

Compliance Rate 67% 82% 82% 78%

(7) Standard: Central Office Review Board Composition and Timelines. A Central Office Review Board (CORB) conducts a review of any youth who has been on Phases 1 or 2 of the PU for more than 28 days. At a minimum, the CORB must consist of an Administrative Psychiatrist, the Bureau Chief of Facility Programs, and Behavioral Health Administrator. The CORB review is completed by the 35th day on the Phase. As of November 2012, only Phase 1 and Phase 2 are subject to review by the CORB.

Methodology. The following information should be used to determine compliance with the standard:
 Signed reviews from the months of March, April, May  The spreadsheet of timeline deadlines  The movement history Analysis and Interpretation

37

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 38 of 44 PAGEID #: 2698

Reviews completed by the 35th day During the months of March, April, and May 2013, 7 cases were reviewed by the CORB. Of those 7, 6 reviews occurred within the appropriate timeframe, for a compliance rating of 86%. One review was delayed because of a complication with the timeline involving one youth. This youth was on Phase 1 for 78 days. His review was due on 3/4/13. Unfortunately, due to multiple factors, including a lack of communication between the manager of the spreadsheet and the writer of the report, a delay in information received from the facility staff, and timing of an interview opportunity, his review did not occur until 3/29/13. Once the review was held (3/29/13), the youth’s 28 day expectation was re‐initiated and he transitioned prior to meeting the 28 day deadline created by the 3/29/13 meeting.

The table below depicts the information pulled from the three sources of information. It directly relates to the items in question. An analytical breakdown of the raw data is provided below.

Name Phase 35th Day Affected

TB

1

3/7/13

TB

1

4/26/13

CC

1

3/4/13

BD

1

5/6/13

AF

2

5/21/13

DP

2

4/25/13

DS

1

5/22/13

Date review signed
4/2/13 4/26/13 3/21/13, revised 3/29/13 5/3/13 5/21/13 4/26/13 5/21/13

Interviewed
3/26/13

Admin Psych
y y y

Reviewed by Bureau
Chief
y y y

BHSAs
y y y

y

y

y

y

y

y

y

y

y

y

y

y

Administrative Psychiatrist present Of the 7 reviews that occurred during this time period, there was a rating of 100% compliance with the expectation for the Administrative Psychiatrist to be present.

Facility Programs Bureau Chief present Of the 7 reviews that occurred during this time period, the Bureau Chief reviewed all seven of the reviews prior to submission. Due to the demands of the Bureau Chief’s schedule, it is often difficult to attend every meeting, especially when the tight timeframe is taken into account. Therefore, the Bureau Chief consulted with the DOJ monitors and received approval to not attend such meetings as long as the

38

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 39 of 44 PAGEID #: 2699
Bureau Chief reviewed the cases and provided feedback when necessary, which explains why the first and sixth reviews did not appear to meet the 35th day timeframe.
Behavioral Health Administrator Of the 7 reviews that occurred during this time period, there was a 100% compliance rating with the expectation that several Behavioral Health Administrators are present for these meetings. Conclusion and Recommendations. The facility is in substantial compliance with this standard. In order to maintain substantial compliance, the CORB will continue to follow its established process. (8) Standard: Central Office Review Board Substance ‐ Partial Compliance The CORB utilizes a comprehensive summary of the youth’s clinical formulation, treatment, progress and challenges to date. The summary is reviewed by each CORB team member prior to the case review. The CORB issues specific recommendations for refocusing the youth’s treatment and sets specific timelines for subsequent reviews. Recommendations are communicated to the IDT, which notifies the youth if the treatment plan has been modified. Methodology. The following information should be used to determine compliance with the standard:
 Signed CORB reviews from the months of March, April, May 2013  IDT minutes Analysis and Interpretation. A thorough review of 6 CORB reviews was performed to ensure compliance with this standard. Because the sample size is such a small number, the percentages are not quite as meaningful as if it were a larger sample size. The table below provides a breakdown of the data (the “yes” column denotes compliance).
39

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 40 of 44 PAGEID #: 2700

CORB Tasks/Recommendations: CORB review by 35th day Administrative Psych sig Bureau Chief sig BHSA sig Documents Packet reviewed IDT Minutes reviewed Case Review Summary provided PROGRESS Unit History provided (promotions, demotions) Need for difference approach to treatment intervention Need for different treatment goals Contraindicataions for continued placement If Yes, more appropriate placement determined Written recommendations provided Established timeline for next review Primary Clincian and IDT: ITP documentation address CORB recommendations IDT met with youth at next scheduled IDT after Review Youth's summary prepared by Primary Clinician and submitted to CORB Includes Clinical formulation Includes Treatment Progress Includes Challenges to date Includes Youth's history Includes Mental Health diagnoses Includes Past Treatment (including Meds) Includes Psychiatric Progress notes Includes Results of Psychological Testing Includes Treatment Goals Includes Treatment interventions and responses Includes Need treatment delivered Includes IDT's conclusions/reasons youth is not progressing

Yes

No

N/A

4

2

0

6

0

0

1

5

0

6

0

0

5(83%) 1(17%)

0

4 (67%) 2(33%)

0

6

0

0

6

0

0

6

0

0

6

0

0

0

6

0

0

0

6

6

0

0

6

0

0

3(50%) 3(50%)

0

2(33%) 4(67%)

0

6 6 6 6 6 6 6 4 (67%) 5(83%) 5(83%) 2(33%) 3

0 0 0 0 0 0 0 2(33%) 1(17%) 1(17%) 2(33%) 3

0 0 0 0 0 0 0 0 0 0 2(33%) 0

Overall, the results were positive. The CORB is clearly reviewing the documentation prior to writing the reviews, they are providing relevant recommendations that have not been tried by the IDT, and they are creating original comprehensive case conceptualizations before offering recommendations.

For their part, the frontline staff is clearly providing much of the necessary materials to the Central Office Review Board in a timely manner; however there are some definite areas of weakness, as is evident by the chart. There is evidence of genuine attempts to adjust the youth’s treatment prior to the reviews and then also to implement all recommendations provided and to ensure that they are communicating all changes to the youth.
40

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 41 of 44 PAGEID #: 2701
Conclusions and Recommendations As noted in the chart above, there is clear evidence that both parties are working to ensure compliance with this standard. There are some areas that can be improved, such as the IDT meeting with the youth at the next meeting and the CORB following up to ensure that the recommendations offered are followed. Whether this is a failure of actual follow up or documentation of that follow up is not able to be determined from the raw data. Furthermore, because there were only 6 examples used, it will be necessary in the future to continue monitoring these actions.
In order to move from partial compliance to substantial compliance:
1. Central Office must ensure the facility follows through and implements the CORB recommendations.
2. Central Office must take a more supportive role in these reviews by means of communicating with facility frontline staff to determine support needed in order to implement the suggested recommendations and to address any barriers the staff may experience in relation to the recommendations.
[II.13] Phase Demotions Status: Substantial Compliance
(1) Standard: Phase Demotion. A deliberative process is utilized to demote youth to a lower phase. Demotions are imposed only for the following reasons: an act of violence, STG activity that promotes or directs an individual to carry out an act of violence, possession of major contraband, repeated verbal threats to cause serious physical harm to staff or other youth. All demotions are approved by the facility Superintendent.
Methodology. The following information should be used to determine compliance with the standard:
 Phase Demotion Summary Form  AMS reports  IDT Contact and Discussion (via email or summary of verbal discussions with UM, Youth
Specialists, SW, Psychology Staff)  IH documentation
Analysis and Interpretation.
41

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 42 of 44 PAGEID #: 2702
Progress IDT Staff made a total of 25 requests for demotion during the review period of March, April & May of 2013. Of the 25 requests, 11 were denied for demotion (44%) and 14 were approved (56%). During the period of review, the 14 approved for demotion were for the following reasons:
 6 youth (43%) were demoted due to an act of violence (AOV)  6 youth (43%) were demoted due to repeated verbal threats  2 youth (14%) were demoted due to possession of major contraband
o 0 youth were demoted due to possession of STG material The IDT team began addressing possession of STG material as a treatment issue rather than punishment despite the offense being eligible for demotion. This approach resulted in no youth being demoted for possession of STG material.
10 youth accounted for 14 of the demotions as 3 youth had multiple demotions. The following is a breakdown of the youth with multiple demotions:
 Youth MG2 (there are two youth with the initials MG) was demoted three times, once for possession of contraband, once for repeated verbal threats and once for a Youth on Staff assault o On 3/20/13, demoted from Buckeye Transition Phase 2 to Buckeye Transition Phase 1 o On 4/12/13, demoted from Buckeye Phase 1 to Cedar (Phase 2) o On 5/1/13, demoted from Cedar (Phase 2) to Sycamore (Phase 1)
 Youth WH was demoted twice for repeated verbal threats, which included youth walking toward staff with his fist balled up while making threats to physically assault staff o On 3/19/13, demoted from Buckeye Transition Phase 1 to Cedar (Phase 2) o On 3/22/13, demoted from Cedar to Sycamore (Phase 1)
 Youth DS was demoted twice for repeated verbal threats o On 3/19/13, demoted from Buckeye Transition Phase 1 to Cedar (Phase 2) o On 4/17/13, demoted from Cedar to Sycamore (Phase 1)
The following youth were demoted a single time for the following reasons:
 On 4/2, BD was demoted from Buckeye Transition Phase 1 to Sycamore for a youth on staff assault o The team made two recommendations for demotion prior to the 4/2 assault:  On 3/19/13, IDT recommended BD for demotion based on youth receiving YBIRs consistently. The recommendation for demotion was denied and the team was encouraged to address his behaviors through a behavioral contract.  On 3/29/13, BD was involved in a youth on youth fight. IDT recommendation for demotion was denied and the team was encouraged to revise his behavioral contract.
 On 4/2/13, TR was demoted from Buckeye Transition Phase 1 to Sycamore for a youth on staff assault. o On 3/19, IDT recommended TR for demotion for threatening conduct, but was denied. IDT was encouraged to work with TR on how to handle change and his aggression.
 On 5/31/13, AF was demoted from Cedar to Sycamore for a youth on staff assault.
42

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 43 of 44 PAGEID #: 2703
o The team made two recommendations for demotion prior to the 5/31 assault:  On 5/16/13, IDT recommended AF for demotion based on youth receiving YBIRs, refusing programming, and not making progress on his ITP goals. The request was denied and the Superintendent on 5/16/14 because the reason for demotion did not meet the Court Order. The Superintendent subsequently reviewed the Court Order as it related to phase demotions with the Unit Manager.  On 5/24/13, IDT resubmitted their recommendation for demotion stating threatening conduct and the recommendation was denied pending additional documentation illustrating youth’s threatening conduct.
 On 3/19/13, MG1 was demoted from Buckeye Transition Phase 2 to Cedar for having $50 found on his person after a strip search. The IDT recommended the demotion; however, youth was not demoted until youth was proven by the IH process to have had contraband in his possession. o The IDT made a subsequent request for demotion which was denied. On 5/23/13, IDT recommended demotion due to possession of STG material. The recommendation was denied. MG1 was taking a picture during the school graduation party and held up gang signs. He was also found with a STG letter. The letter did not direct anyone to carry out an act of violence. Nor did the letter mention any past violence. The Superintendent encouraged the IDT to address his STG affiliation, poor decision making skills and their impact and how to build positive/healthy relationships.
 On 3/22/13, DP was demoted Buckeye Transition Phase 1 to Cedar (Phase 2) for making repeated threats of harm. This youth was admitted into the program due to his involvement with orchestrating an assault on a unit manager. He was documented as having a conversation with the same youth who carried out the assault on the unit manager. o On 3/28/13, IDT recommended demotion due to threatening conduct. The recommendation was denied because it was one isolated incident and there was no evidence that there were repeated verbal threats.
 On 3/23/13, TB was demoted from Cedar to Sycamore for youth on staff assault.  On 5/25/13, TH was demoted from Buckeye Transition Phase 1 to Sycamore for a youth on staff
assault.
The development and implementation of the Superintendent’s Review for Demotion form assisted in identifying the act(s) that lead to the request for demotion, a description of the incident, the evidence that was reviewed and the deliberative process that was used to justify the decision and the identification of the phase that the youth was being demoted to, if the request for demotion was approved.
Conclusions and Recommendation: The analysis revealed several dynamics in support of a finding of substantial compliance. First, phase demotions were incremental. Youth who committed repeated verbal threats or had possession of contraband/STG material were not demoted all the way to Phase I, but instead were demoted
43

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 44 of 44 PAGEID #: 2704
incrementally to the next more restrictive phase. Only when a youth’s behavior resulted in acts of violence against a staff member were they demoted to Phase 1. Second, nearly half of the demotion requests were denied when the act in question was not of sufficient severity or not properly documented, showing that the Superintendent strictly adheres to the requirements of the Court Order. Finally, occasionally youth have engaged in one of the “big 4” infractions but were not demoted at all; instead, the Superintendent required the IDT to exhaust less punitive sanctions and additional treatment options prior to demotion. In order to maintain substantial compliance, ODYS will continue to ensure that the documentation supports the requirement of a deliberative process to determine whether the facts of the incident support the youth’s eligibility for demotion and why.
[II.14] Policies, Procedures and Handbooks Status: Substantial Compliance
(1) Standard: Policies and Procedures Policies and procedural manuals are current, accurately describe the operation of the PU, and provide guidance to staff in implementing the standards for the Unit. The Youth Handbook accurately describes the operation of the PU so youth know what to expect from the program and what is expected of them.
Methodology. The following information is used to determine compliance with the standard:
 Email from monitor Kelly Dedel, PH.D dated April 10, 2013 stating ODYS is in substantial compliance with this provision.
 PU Policy Effective May 31, 2013  PU Handbook Effective May 31, 2013  PU Handbook Revised 6‐19‐2013 to reflect ODYS Central Office new address so youth could mail
grievance to the correct address
Analysis and Interpretation. The Court Order granted DYS 60 days from the day of signing to submit policies, procedures and Handbooks that accurately describe the operation of the PU. Per the 1st PU Status Report DYS submitted these materials to the Monitor within the required timelines.
Recommendations. In order for ODYS to continue to maintain substantial compliance with this provision DYS will review policy, procedure and handbooks yearly and continue QA/QI to ensure that what is outlined in policy is actual practice on the PU.
44

 
 Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 1 of 22
CLOSED,PROTO
U.S. District Court Southern District of Ohio (Columbus) CIVIL DOCKET FOR CASE #: 2:08−cv−00475−ALM−MRA

United States of America v. Strickland et al Assigned to: Judge Algenon L. Marbley Referred to: Magistrate Judge Mark R. Abel Lead case: 2:04−cv−01206−ALM−TPK Member case: (View Member Case) Cause: 42:1981 Civil Rights Interested Party Kelly Dedel, Ph.D. Lead Monitor
Plaintiff The United States of America

Date Filed: 05/16/2008 Date Terminated: 06/24/2008 Jury Demand: None Nature of Suit: 440 Civil Rights: Other Jurisdiction: U.S. Government Plaintiff
represented by Kelly Dedel, Ph.D. One in 37 Research, Inc. 1608 NW Riverscape Street Portland, OR 97209 503−799−0915 Email: Kelly.Dedel@gmail.com PRO SE
represented by Alexandra L. Shandell U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Ave., NW Washington, DC 20530 202−307−6123 Fax: 202−514−4883 Email: Alexandra.Shandell@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED
Alphonse Adam Gerhardstein Gerhardstein & Branch Co. LPA 441 Vine Street Suite 3400 Cincinnati, OH 45202 513−621−9100 Fax: 513−345−5543 Email: agerhardstein@gbfirm.com LEAD ATTORNEY ATTORNEY TO BE NOTICED
Cynthia Coe 601 D Street, NW Washington, DC 20530 202−353−1121 Fax: 202−514−0212 Email: cynthia.coe@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED
Mark Thomas D'Alessandro United States Attorney's Office − 2 303 Marconi Boulevard 2nd Floor Columbus, OH 43215 614−469−5715 Email: mark.dalessandro@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 2 of 22
Benjamin O Tayloe , Jr. United States Department of Justice 950 Pennsylvania Ave. N.W. Washington, DC 20530 (202) 514−8103 Fax: (202) 514−0212 Email: benjamin.tayloe@usdoj.gov TERMINATED: 07/24/2014
Gregory Gonzalez Department of Justice 601 D Street, NW Room 5920 Washington, DC 20004 202−305−2941 Fax: 202−514−6903 Email: gregory.gonzalez@usdoj.gov TERMINATED: 01/12/2009
Jacqueline K Cuncannan Department of Justice 950 Pennsylvania Avenue, NW SPL, PHB Room 5730 Washington, DC 20530 202−616−2556 Fax: 202−514−4883 Email: Jacqueline.Cuncannan@usdoj.gov ATTORNEY TO BE NOTICED
Judith Preston U.S. Department of Justice 601 D St NW Washington, DC 20004 202−514−5464 Fax: 202−514−0212 Email: judy.preston@usdoj.gov ATTORNEY TO BE NOTICED
Rashida Jamila Ogletree US Department of Justice Special Litigation Section 950 Pennsylvania Avenue NW Washington, DC 20530 202−305−3712 Fax: 202−514−4883 Email: Rashida.Ogletree@usdoj.gov ATTORNEY TO BE NOTICED
Silvia Dominguez U.S. Department of Justice Civil Rights Division 601 D Street, NW Suite 5013 Washington, DC 20530 202−616−8547 Fax: 202−514−4883 Email: Silvia.Dominguez@usdoj.gov TERMINATED: 05/29/2014
Stacy K Grigsby United States Department of Justice 950 Pennsylvania Ave. N.W. Washington, DC 20530 202−514−4151 Fax: 202−514−0212

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 3 of 22
TERMINATED: 01/24/2011 PRO HAC VICE
Vincent Herman 601 D Street, NW Suite 5025B Washington, DC 20004 202−305−3318 Fax: 202−514−0212 Email: vincent.herman@usdoj.gov TERMINATED: 01/24/2011
Deborah F Sanders United States Attorney's Office − 2 303 Marconi Boulevard 2nd Floor Columbus, OH 43215 614−469−5715 Fax: 614−469−5240 Email: Deborah.Sanders@usdoj.gov ATTORNEY TO BE NOTICED

V.
Defendant
Ted Strickland Governor of the State of Ohio

represented by J Eric Holloway Eric Holloway Law Group, LLC 5650 Blazer Parkway Suite 100 Dublin, OH 43017 614−734−8340 Fax: 614−522−6789 Email: Eric@EricHollowayLaw.com TERMINATED: 01/26/2012 LEAD ATTORNEY
Thomas Nathaniel Anger Ohio Attorney General Criminal Justice 150 East Gay Street 16th Floor Columbus, OH 43215 614−644−8742 Fax: 877−584−2041 Email: thomas.anger@ohioattorneygeneral.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED
Dustin J Calhoun Ohio Department of Youth Services 30 West Spring Street 5th Floor Columbus, OH 43215 614−728−7353 Email: Dustin.Calhoun@dys.ohio.gov ATTORNEY TO BE NOTICED
Erin C Reed Office of the Ohio Attorney General BCI&I 1560 State Route 56 SW P.O. Box 365 London, OH 43140 740−845−2204

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 4 of 22

Fax: 740−845−2020 Email: erin.reed@ohioattorneygeneral.gov TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller Ohio Attorney General's Office 150 E. Gay Street 16th Floor Columbus, OH 43215 614−644−8693 Fax: 877−586−0406 Email: jason.fuller@OhioAttorneyGeneral.gov TERMINATED: 03/09/2012

Judith B Goldstein Ohio Attorney General Criminal Justice Section/Corrections Litigation 150 East Gay Street Columbus, OH 43215 614−644−7233 Email: jgoldstein45@gmail.com ATTORNEY TO BE NOTICED

Mindy Ann Worly Ohio Attorney General's Office Criminal Justice Section 150 E. Gay Street 16th Floor Columbus, OH 43215 614−728−0161 Fax: 866−474−4985 Email: mworly@ag.state.oh.us TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. Ohio Parole Board 770 W. Broad Street Columbus, OH 43222 614−752−1200 Email: richard.cholar@odrc.state.oh.us TERMINATED: 03/09/2012

Defendant Ohio Department of Youth Services

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012 LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun (See above for address) ATTORNEY TO BE NOTICED

Erin C Reed (See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 5 of 22

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Judith B Goldstein (See above for address) ATTORNEY TO BE NOTICED

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Defendant
Thomas Stickrath Director of Ohio Youth Services

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012 LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun (See above for address) ATTORNEY TO BE NOTICED

Erin C Reed (See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Judith B Goldstein (See above for address) ATTORNEY TO BE NOTICED

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Defendant
Thomas Teague Superintendent of the Circleville Juvenile Correctional Facility

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012 LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 6 of 22

(See above for address) ATTORNEY TO BE NOTICED

Erin C Reed (See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Judith B Goldstein (See above for address) ATTORNEY TO BE NOTICED

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Defendant
Katie Needham Superintendentof the Cuyahoga Hills JuvenileCorrectional Facility

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012 LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun (See above for address) ATTORNEY TO BE NOTICED

Erin C Reed (See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Judith B Goldstein (See above for address) ATTORNEY TO BE NOTICED

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Defendant
Marci Sutherland Superintendent of the Freedom Center

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 7 of 22

LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun (See above for address) ATTORNEY TO BE NOTICED

Erin C Reed (See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Judith B Goldstein (See above for address) ATTORNEY TO BE NOTICED

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Defendant
Beth Oprisch Acting Superintendent of the Indian River JuvenileCorrectional Facility

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012 LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun (See above for address) ATTORNEY TO BE NOTICED

Erin C Reed (See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Judith B Goldstein (See above for address) ATTORNEY TO BE NOTICED

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 8 of 22

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Defendant
Dion Norman Interim Superintendentof the Marion Juvenile Correctional Facility

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012 LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun (See above for address) ATTORNEY TO BE NOTICED

Erin C Reed (See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Judith B Goldstein (See above for address) ATTORNEY TO BE NOTICED

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Defendant
Larry Gongwer Acting Superintendent of the Mohican Juvenile Correctional Facility

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012 LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun (See above for address) ATTORNEY TO BE NOTICED

Erin C Reed (See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 9 of 22

Judith B Goldstein (See above for address) ATTORNEY TO BE NOTICED

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Defendant
Fred Nelson Superintendent of the Ohio River Valley Juvenile Correctional Facility

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012 LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun (See above for address) ATTORNEY TO BE NOTICED

Erin C Reed (See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Judith B Goldstein (See above for address) ATTORNEY TO BE NOTICED

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Defendant
Chris Money Superintendent of the Scioto Juvenile Correctional Facility

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012 LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun (See above for address) ATTORNEY TO BE NOTICED

Erin C Reed

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 10 of 22

(See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Judith B Goldstein (See above for address) ATTORNEY TO BE NOTICED

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Defendant The State of Ohio

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012 LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun (See above for address) ATTORNEY TO BE NOTICED

Erin C Reed (See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Date Filed 05/16/2008 05/16/2008
05/20/2008

# Docket Text
1 Civil Cover Sheet (sr) (Entered: 05/16/2008)
2 COMPLAINT filed by The United States of America against Dion Norman, Larry Gongwer, Fred Nelson, Chris Money, The State of Ohio, Ted Strickland, Ohio Department of Youth Services, Thomas Stickrath, Thomas Teague, Katie Needham, Marci Sutherland, Beth Oprisch (sr) (Entered: 05/16/2008)
3 MOTION for Leave to Appear Pro Hac Vice of Stacey K. Grigsby U.S. Dept. of Justice (Filing fee $ 200) by Plaintiff The United States of America. (Attachments: # 1 Certificate of Good Standing) (D'Alessandro, Mark) (Entered: 05/20/2008)

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 11 of 22

05/20/2008 05/22/2008 06/05/2008
06/12/2008 06/24/2008 01/09/2009 01/12/2009 06/09/2009 06/09/2009
06/16/2009 09/21/2009 09/29/2009 09/29/2009 10/02/2009 10/05/2009 10/09/2009

4 MOTION for Leave to Appear Pro Hac Vice of Benjamin O. Tayloe, Jr. U.S. Dept. of Justice (Filing fee $ 200) by Plaintiff The United States of America. (Attachments: # 1 Certificate of Good Standing) (D'Alessandro, Mark) (Entered: 05/20/2008)
5 ORDER granting 3 & 4 Motions for Leave to Appear Pro Hac Vice of Stacy K. Grigsby and Benjamin O. Tayloe, Jr. Signed by Mark R. Abel on 05/22/2008. (sr) (Entered: 05/22/2008)
6 Joint MOTION for Settlement as to Scioto Juvenile Correctional Facility and Marion Juvenile Correctional Facility, Unopposed MOTION to Dismiss conditionally the Complaint as to the six remaining state−operated juvenile correctional facilities ( Responses due by 6/30/2008) by Plaintiff The United States of America. (Attachments: # 1 Text of Proposed Order Stipulation for Injunctive Relief) (Gonzalez, Gregory) (Entered: 06/05/2008)
7 ORDER FOR ENTRY OF STIPULATION AND FOR CONDITIONAL DISMISSAL OF COMPLAINT. Signed by Algenon L. Marbley on 06/12/2008. (cw, ) (Entered: 06/12/2008)
8 STIPULATION FOR INJUNCTIVE RELIEF. Signed by Algenon L. Marbley on 6/24/2008. (cw, ) (Entered: 06/24/2008)
9 First MOTION to Substitute Attorney Greg Gonzalez by Plaintiff The United States of America. (Dominguez, Silvia) (Entered: 01/09/2009)
10 ORDER granting # 9 Motion to Substitute Attorney. Attorney Silvia Dominguez added for The United States of America. Attorney Gregory Gonzalez terminated. Signed by Mark R. Abel on 1/12/09. (rew ) (Entered: 01/12/2009)
11 MOTION to Clarify Stipulation by Plaintiff The United States of America. (Tayloe, Benjamin) (Entered: 06/09/2009)
12 Memorandum of Law in Support of its 11 MOTION to Clarify Stipulation by Plaintiff The United States of America. (Attachments: # 1 Exhibit A (Kim May 9, 2007 Letter), # 2 Exhibit B (Swisher April 28, 2008 Letter), # 3 Exhibit C (Cohen Jan 30, 2009 email), # 4 Exhibit D (Cohen Feb 18, 2009 email), # 5 Exhibit E (Cohen April 6, 2009 email), # 6 Exhibit F (Cohen April 23, 2009 email), # 7 Exhibit G (Cohen May 19, 2009 email), # 8 Exhibit H (Cohen March 18, 2009 email), # 9 Exhibit I (Gerhardstein March 26, 2009, 18:38 EST email), # 10 Exhibit J (Gerhardstein March 26, 2009 19:22 EST email), # 11 Exhibit K (Cohen May 12, 2009 email), # 12 Text of Proposed Order) (Tayloe, Benjamin) Modified text and terminate event as motion on 6/9/2009 (er1 ). (Entered: 06/09/2009)
13 NOTICE of Appearance by Vincent Herman Plaintiff The United States of America (Herman, Vincent) (Entered: 06/16/2009)
14 Response Pursuant to Court's Order of Aug 31, 2009 by Plaintiff The United States of America. (Attachments: # 1 Appendix A −− Sept 9, 2009 Letter) (Tayloe, Benjamin) (Entered: 09/21/2009)
15 NOTICE by Plaintiff The United States of America and Parties in S.H. Regarding Monitor's Resignation in U.S. v. Ohio and Motion to Modify Briefing Schedule (Attachments: # 1 Appendix A −− Sept 24, 2009 Letter from Monitor Cohen) (Tayloe, Benjamin) (Entered: 09/29/2009)
16 Position of the Monitor Regarding Joint Notice to the Court Regarding the Monitor's Resignation in U.S. V. Ohio, and Motion to Modify Briefing Schedule (pes1) (Entered: 09/29/2009)
17 NOTICE OF WITHDRAWAL OF DOCUMENT 16 filed by Monitor Fred Cohen. (pes1) (Entered: 10/02/2009)
18 ORDER holding Joint Notice re: Monitor's Resignation and Motion to Modify Briefing Schedule [doc.143] in Abeyance. Signed by Judge Algenon L. Marbley on 10/05/2009. (cw) (Entered: 10/05/2009)
19 NOTICE by Plaintiff The United States of America and Parties in S.H. Regarding Monitor's Resignation in U.S. v. Ohio (Tayloe, Benjamin) (Entered: 10/09/2009)

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 12 of 22

11/06/2009 11/06/2009 11/23/2009 11/23/2009 11/24/2009
11/25/2009 12/01/2009

20 ORDER Setting a Telephonic Status Conference for 11/6/2009 03:30 PM before Judge Algenon L. Marbley. Signed by Judge Algenon L. Marbley on 11/06/2009. (cw) (cw). (Entered: 11/06/2009)
21 ORDER Setting Telephonic Status Conference for 11/16/2009 03:00 PM before Judge Algenon L. Marbley. Signed by Judge Algenon L. Marbley on 11/06/2009. (cw) (Entered: 11/06/2009)
22 NOTICE of Appearance by J Eric Holloway Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio (Holloway, J) (Entered: 11/23/2009)
23 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio of Filing Joint Proposed Modifications to the Stipulation for Injunctive Relief in U.S.A. v. Ohio (Holloway, J) (Entered: 11/23/2009)
24 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio re 23 Notice (Other), Notice (Other) of Filing Exhibit A (Dedel C.V.) to Joint Proposed Modifications to the Stipulation for Injunctive Relief (Holloway, J) (Entered: 11/24/2009)
25 NOTICE of Appearance by Richard Thomas Cholar, Jr Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio (Cholar, Richard) (Entered: 11/25/2009)
26 Transcript of Telephonic Status Conference held on 11/16/2009, before Judge Marbley. Court Reporter/Transcriber Shawna J. Evans, Telephone number 614−719−3316. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.

NOTICE RE: REDACTION OF TRANSCRIPTS: Within 5 business days of this filing, each party shall inform the Court, by filing a Notice of Redaction, of the party's intent to redact personal data identifiers from the electronic transcript of the court proceeding. The policy is located on our website at www.ohsd.uscourts.gov (Forms − Electronic Availability of Transcripts). Please read this policy carefully.

12/15/2009
12/15/2009 02/22/2010 02/26/2010 02/26/2010

For a complete copy of a transcript, please contact the Court Reporter or the Clerk's Office. Redaction Request due 12/22/2009. Redacted Transcript Deadline set for 1/4/2010. Release of Transcript Restriction set for 3/1/2010. (pes1) (Entered: 12/01/2009)
27 ORDER ADOPTING Proposed Modifications to the Stipulation for Injunctive Relief 23 Notice Directing Monthly Payments be made from Prison Account of, ORDER re 23 Notice (Other), Notice (Other) filed by Dion Norman, The State of Ohio, Thomas Stickrath, Fred Nelson, Katie Needham, Ted Strickland, Marci Sutherland, Chris Money, Larry Gongwer, Ohio Department of Youth Services, Thomas Teague, Beth Oprisch. Signed by Judge Algenon L. Marbley on 12/15/2009. (cw) (Entered: 12/15/2009)
28 ORDER finding as moot 11 Motion to Clairfy. Signed by Judge Algenon L. Marbley on 12/15/2009. (cw) (Entered: 12/15/2009)
29 ORDER SETTING Status Conference for 2/24/2010 10:00 AM in Chambers before Judge Algenon L. Marbley. Signed by Judge Algenon L. Marbley on 2/22/2010. (cw) (Entered: 02/22/2010)
30 ORDER. Signed by Judge Algenon L. Marbley on 2/26/2010. (cw) (Additional attachment(s) added on 2/26/2010: # 1 Attachment 1) (cw). (Entered: 02/26/2010)
31 ORDER. Signed by Judge Algenon L. Marbley on 2/26/2010. (Attachments: # 1 Attachment 1) (cw) (Entered: 02/26/2010)

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 13 of 22

02/26/2010 03/03/2010
03/09/2010
03/17/2010 03/17/2010 03/17/2010

Notice of Correction: [doc # 30] removed because it improperly contained confidential information. (cw) (Entered: 02/26/2010)
32 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio re 31 Order of Compliance with Order (Attachments: # 1 Exhibit A, Summaries) (Holloway, J) (Entered: 03/03/2010)
33 MOTION for Order to Grant Relief from Court Order; Motion for Extension of Time in the Alternative by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Attachments: # 1 Exhibit A, Declaration of Chris Money) (Holloway, J) (Entered: 03/09/2010)
34 ORDER granting 33 Alternative Motion for an Extension of Time. Signed by Judge Algenon L. Marbley on 03/17/2010. (cw) (Entered: 03/17/2010)
35 **SEALED** Transcript of Status Conference Proceedings held on 2/24/2010, before Judge Marbley. Court Reporter/Transcriber Shawna J. Evans, Telephone number 614−719−3316. (pes1) (Entered: 03/17/2010)
36 Transcript of Status Conference Proceedings held on 2/24/2010, before Judge Marbley. Court Reporter/Transcriber Shawna J. Evans, Telephone number 614−719−3316. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.

NOTICE RE: REDACTION OF TRANSCRIPTS: Within 5 business days of this filing, each party shall inform the Court, by filing a Notice of Redaction, of the party's intent to redact personal data identifiers from the electronic transcript of the court proceeding. The policy is located on our website at www.ohsd.uscourts.gov (Forms − Electronic Availability of Transcripts). Please read this policy carefully.

04/09/2010
04/09/2010
04/12/2010 04/13/2010
04/13/2010 06/02/2010

For a complete copy of a transcript, please contact the Court Reporter or the Clerk's Office. Redaction Request due 4/7/2010. Redacted Transcript Deadline set for 4/19/2010. Release of Transcript Restriction set for 6/15/2010. (pes1) (Entered: 03/17/2010)
37 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio of Compliance with Court Order (Attachments: # 1 Index of Exhibit B) (Holloway, J) (Entered: 04/09/2010)
38 Unopposed MOTION for Order to Permit Defendants to Manually File Exhibit B by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Holloway, J) (Entered: 04/09/2010)
39 ORDER granting 38 Motion for Order for Leave to File Documents Manually. Signed by Judge Algenon L. Marbley on 04/12/2010. (cw) (Entered: 04/12/2010)
40 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio re 37 Notice (Other), Notice (Other) of Manually Filing Exhibit B to Notice of Compliance with Court Order (Doc. 37) (Holloway, J) (Entered: 04/13/2010)
***Manual Filing of Exhibit B, in CD format, re 172 Notice of Compliance with Court Order has been filed with the Clerk's Office. (er1) Modified on 4/14/2010 to clarify text (kk2). (Entered: 04/13/2010)
41 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio re 37 Notice

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 14 of 22

06/04/2010 06/14/2010 06/17/2010 06/24/2010 06/24/2010 06/24/2010 06/25/2010 06/29/2010 07/01/2010 07/12/2010
07/12/2010 07/12/2010

(Other), Notice (Other) of Supplemental Compliance with Court Order (Attachments: # 1 Exhibit A, Ast Declaration, # 2 Exhibit B, Monitor Cohen Email) (Holloway, J) (Entered: 06/02/2010)
42 ORDER Setting a Show Cause Hearing for 7/1/2010 09:00 AM in Courtroom 1 − Columbus before Judge Algenon L. Marbley. Signed by Judge Algenon L. Marbley on 06/04/2010. (Attachments: # 1 Exhibit 1, # 2 Exhibit 2, # 3 Exhibit 3, # 4 Exhibit 4, # 5 Exhibit 5) (cw) (Entered: 06/04/2010)
43 ORDER re: Show Cause. Signed by Judge Algenon L. Marbley on 06/14/2010. (cw) (Entered: 06/14/2010)
44 ORDER Setting Status Conference for 6/22/2010 @ 3:30 PM in Chambers before Judge Algenon L. Marbley. Signed by Judge Algenon L. Marbley on 06/17/2010. (cw) (Entered: 06/17/2010)
45 MOTION for Order to Grant Protective Order by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Attachments: # 1 Exhibit A, Email of Parties' Agreement) (Holloway, J) (Entered: 06/24/2010)
46 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio re 43 Order of Compliance (Holloway, J) (Entered: 06/24/2010)
47 PROTECTIVE ORDER FOR THE PROTECTION OF CONFIDENTIAL INFORMATION, granting 45 Motion for Order to Grant Protective Order. Signed by Judge Algenon L. Marbley on 06/24/2010. (cw) (Entered: 06/24/2010)
48 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio re 43 Order of Delivery of Documents for In Camera Review (Holloway, J) (Entered: 06/25/2010)
49 Order. Internal documents regarding meal refusal policy, due by June 24, 2010. Rescheduling the hearing on the Order to show cause for 7/14/2010 at 9:00 a.m. before the Honorable Algenon L. Marbley, Courtroom 1. Opening briefs due by 7/2/2010 and memoranda contra due by 7/9/2010. (Attachments: # 1 Attachment 1) (cw) (Entered: 06/29/2010)
50 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio of Filing Pre−Hearing Brief Regarding Show Cause Hearing (Holloway, J) (Entered: 07/01/2010)
51 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio Notice of Supplemental Compliance with the Courts February 26, 2010 Order (Attachments: # 1 Exhibit A, Slagle Declaration, # 2 Exhibit B, Ast Declaration) (Holloway, J) (Entered: 07/12/2010)
52 Response to Plaintiffs Pre−Hearing Brief; Plaintiffs' Motion to File Instanter and Plaintiffs' Motion for Extension to Respond to Monitor's Report by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Holloway, J) (Entered: 07/12/2010)
53 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio of First Supplement to Notice of Delivery of Documents for In Camera Review (Holloway, J) (Entered: 07/12/2010)

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 15 of 22

07/12/2010 07/12/2010
07/13/2010
07/13/2010
07/13/2010 07/16/2010 07/30/2010
09/20/2010 09/21/2010 10/12/2010 10/21/2010 11/22/2010 01/10/2011 01/11/2011 01/13/2011 01/21/2011

54 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio of Recall of Inadvertently Produced Documents (Holloway, J) (Entered: 07/12/2010)
55 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio of Supplement to Pre−Hearing Brief Regarding Show Cause Hearing (Attachments: # 1 Exhibit A, Baker Declaration, # 2 Exhibit B, Daniels Declaration, # 3 Exhibit C, Darnell Declaration, # 4 Exhibit D, French and Clay Declarations, # 5 Exhibit E,Randle Declaration) (Holloway, J) (Entered: 07/12/2010)
56 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio Second Notice of Supplemental Compliance with the Courts Order (Attachments: # 1 Exhibit A, Slagle Declaration) (Holloway, J) (Entered: 07/13/2010)
57 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio Second Supplement to Pre−Hearing Brief Regarding Show Cause Hearing (Holloway, J) (Entered: 07/13/2010)
58 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio of Objections to the Show Cause Hearing (Holloway, J) (Entered: 07/13/2010)
59 ORDER Parties are to submit the new policy by 7/30/2010. Signed by Judge Algenon L. Marbley on 07/14/2010. (cw) (Entered: 07/16/2010)
60 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio of Compliance with the Courts July 16, 2010, Order (Attachments: # 1 Index of Exhibits, # 2 Exhibit A, Policy, # 3 Exhibit B, Training Material) (Holloway, J) (Entered: 07/30/2010)
61 NOTICE by Plaintiff The United States of America First Compliance Report (Attachments: # 1 Compliance Report) (Dominguez, Silvia) (Entered: 09/20/2010)
62 NOTICE by Plaintiff The United States of America re 61 Notice (Other) Expert Reports (Attachments: # 1 Supplement) (Dominguez, Silvia) (Entered: 09/21/2010)
63 NOTICE of Appearance by Erin C Reed for Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio (Reed, Erin) (Entered: 10/12/2010)
64 NOTICE of Appearance by Rashida Jamila Ogletree for Plaintiff The United States of America (Ogletree, Rashida) (Entered: 10/21/2010)
65 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio (Reed, Erin) (Entered: 11/22/2010)
66 First MOTION for Hearing Status Conference by Plaintiff The United States of America. (Dominguez, Silvia) (Entered: 01/10/2011)
67 MOTION to Withdraw 66 First MOTION for Hearing Status Conference by Plaintiff The United States of America. (Dominguez, Silvia) (Entered: 01/11/2011)
68 Mail Returned as Undeliverable. Mail (Doc. 59 Order) sent to Stacy K Grigsby on 7/16/2010. (Attachments: # 1 contents) (kjm1) (Entered: 01/14/2011)
69 MOTION to Withdraw as Attorney by Plaintiff The United States of America. (Herman, Vincent) (Entered: 01/21/2011)

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 16 of 22

01/24/2011 02/02/2011 02/08/2011 02/10/2011 02/16/2011 04/06/2011
04/27/2011 04/27/2011

70 ORDER granting 69 Motion to Withdraw as Attorney. Attorney Stacy K Grigsby and Vincent Herman terminated. Signed by Magistrate Judge Mark R. Abel on 1/24/2011. (er1) (Entered: 01/24/2011)
71 ORDER finding as moot 66 Motion for Hearing; granting 67 Motion to Withdraw. Signed by Judge Algenon L. Marbley on 2/2/2011. (cw) (Entered: 02/02/2011)
72 NOTICE by Plaintiff The United States of America Second Compliance Report (Attachments: # 1 Compliance Report, # 2 Expert Report, # 3 Expert Report, # 4 Expert Report, # 5 Investigation Report) (Dominguez, Silvia) (Entered: 02/08/2011)
73 NOTICE of Appearance by Jason Michael Fuller for Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio (Fuller, Jason) (Entered: 02/10/2011)
74 NOTICE by Plaintiff The United States of America re 72 Notice (Other) Addendum to Second Compliance Report (Attachments: # 1 Compliance Report, # 2 Expert Report, # 3 2007 Findings Letter) (Ogletree, Rashida) (Entered: 02/16/2011)
75 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio re 74 Notice (Other), 72 Notice (Other) Objections to the Second Compliance Report (Fuller, Jason) (Entered: 04/06/2011)
76 Sealed Transcript. Excerpt of Sealed Show Cause Proceedings held on 7/14/2010 before Judge Algenon L. Marbley. (Court Reporter S. Evans) (pes1) (Entered: 04/27/2011)
77 Transcript of Show Cause Proceedings held on July 14, 2010 before Judge Algenon L Marbley. Court Reporter/Transcriber Shawna J Evans, Telephone number 614−719−3316. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.

NOTICE RE: REDACTION OF TRANSCRIPTS: Within 5 business days of this filing, each party shall inform the Court, by filing a Notice of Redaction, of the party's intent to redact personal data identifiers from the electronic transcript of the court proceeding. The policy is located on our website at www.ohsd.uscourts.gov (Forms − Electronic Availability of Transcripts). Please read this policy carefully.

04/27/2011

For a complete copy of a transcript, please contact the Court Reporter or the Clerk's Office. Redaction Request due 5/18/2011. Redacted Transcript Deadline set for 5/31/2011. Release of Transcript Restriction set for 7/26/2011. (kk2) (Entered: 04/27/2011)
78 Transcript of Show Cause Proceedings held on July 15, 2010 before Judge Algenon L Marbley. Court Reporter/Transcriber Shawna J Evans, Telephone number 614−719−3316. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.

NOTICE RE: REDACTION OF TRANSCRIPTS: Within 5 business days of this filing, each party shall inform the Court, by filing a Notice of Redaction, of the party's intent to redact personal data identifiers from the electronic transcript of the court proceeding. The policy is located on our website at www.ohsd.uscourts.gov (Forms − Electronic Availability of Transcripts). Please read this policy carefully.

05/09/2011

For a complete copy of a transcript, please contact the Court Reporter or the Clerk's Office. Redaction Request due 5/18/2011. Redacted Transcript Deadline set for 5/31/2011. Release of Transcript Restriction set for 7/26/2011. (kk2) (Entered: 04/27/2011)
79 NOTICE by Plaintiff The United States of America Third Compliance Report (Attachments: # 1 Supplement Compliance Report, # 2 Supplement PFH Expert Report, # 3 Supplement Spec Educ Expert Report, # 4 Supplement Mental Hlth Expert

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 17 of 22

05/20/2011 06/06/2011 06/17/2011
06/20/2011 06/20/2011
06/28/2011 08/25/2011
08/26/2011 09/01/2011
10/26/2011 10/27/2011 11/02/2011 01/25/2012 01/26/2012 02/06/2012 02/07/2012 02/07/2012

Report, # 5 Supplement Medical Expert Report) (Dominguez, Silvia) (Entered: 05/09/2011)
80 Joint MOTION to Amend/Correct 8 Stipulation and Order by Plaintiff The United States of America. (Attachments: # 1 Memorandum in Support, # 2 Text of Proposed Order) (Dominguez, Silvia) (Entered: 05/20/2011)
81 ORDER AMENDING CERTAIN PROVISIONS OF STIUPLATION; granting 80 Motion to Amend/Correct. Signed by Judge Algenon L. Marbley on 06/6/2011. (cw) (Entered: 06/06/2011)
82 Joint MOTION for Extension of Time to File New date requested 6/20/2011. TO FILE AMENDED STIPULATION by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Holloway, J) (Entered: 06/17/2011)
83 ORDER granting 82 Motion for Extension of Time to File amended stipulation. Signed by Magistrate Judge Mark R. Abel on 06/20/2011. (sr) (Entered: 06/20/2011)
84 NOTICE by Plaintiff The United States of America re 83 Order on Motion for Extension of Time to File, 81 Order on Motion to Amend/Correct Joint Notice of Amended Stipulation for Injunctive Relief (Attachments: # 1 Text of Proposed Order Amended Stipulation for Injunctive Relief) (Dominguez, Silvia) (Entered: 06/20/2011)
85 AMENDED STIPULATION FOR INJUNCTIVE RELIEF. Signed by Judge Algenon L. Marbley on 06/28/2011. (cw) (Entered: 06/28/2011)
86 Unopposed MOTION for Protective Order by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Attachments: # 1 Proposed Protective Order) (Holloway, J) (Entered: 08/25/2011)
87 PROTECTIVE ORDER. Signed by Judge Algenon L. Marbley on 8/26/2011. (pes1) (Entered: 08/26/2011)
88 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio of Amended Certificate of Service to Motion (Doc. 86) (Fuller, Jason) (Entered: 09/01/2011)
Minute Entry for proceedings held before Magistrate Judge Mark R. Abel: Telephone Conference held on 10/26/2011. (Rubey, Rachel) (Entered: 11/03/2011)
89 Unopposed MOTION for Protective Order by Defendant Ohio Department of Youth Services. (Cholar, Richard) (Entered: 10/27/2011)
90 ORDER granting 89 Motion for Protective Order. Signed by Judge Algenon L. Marbley on 11/2/2011. (cw) (Entered: 11/02/2011)
91 MOTION to Authorize Exchange of Information by Plaintiff The United States of America. (Attachments: # 1 Exhibit Memorandum of Understanding) (Ogletree, Rashida) (Entered: 01/25/2012)
92 NOTICE by Defendant The State of Ohio of Substitution of Counsel (Worly, Mindy) (Entered: 01/26/2012)
93 Monitor's First Report on the Amended Stipulation dated 6/282011 by Lead Monitor Kelly Dedel, Ph.D. (pes1) (Entered: 02/06/2012)
94 ORDER re 91 MOTION to Authorize Exchange of Information filed by The United States of America, Responses due by 2/21/2012; replies due by 2/28/2012. Signed by Judge Algenon L. Marbley on 2/7/2012. (cw) (Entered: 02/07/2012)
95 ORDER re 93 Notice (Other) filed by Kelly Dedel, Ph.D., objections due by by 3/8/2012; responses due by 3/22/2012. Signed by Judge Algenon L. Marbley on 2/7/2012. (cw) (Entered: 02/07/2012)

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 18 of 22

02/14/2012 02/28/2012
03/08/2012 03/08/2012
03/09/2012
03/22/2012 04/18/2012
04/25/2012 06/22/2012 11/28/2012
11/29/2012 12/19/2012
12/27/2012
01/18/2013 02/14/2013 02/28/2013 03/07/2013 03/21/2013 06/18/2013 06/18/2013 06/21/2013

96 RESPONSE in Opposition re 91 MOTION to Authorize Exchange of Information filed by Defendant The State of Ohio. (Worly, Mindy) (Entered: 02/14/2012)
97 REPLY to Response to Motion re 91 MOTION to Authorize Exchange of Information filed by Plaintiff The United States of America. (Dominguez, Silvia) (Entered: 02/28/2012)
98 Objection re 93 Notice (Other) Monitor's First Report by Defendant The State of Ohio. (Worly, Mindy) (Entered: 03/08/2012)
99 Objection re 93 Notice (Other) Monitor's First Report by Plaintiff The United States of America. (Attachments: # 1 Exhibit A, # 2 Exhibit B, # 3 Exhibit C, # 4 Exhibit D, # 5 Exhibit E, # 6 Exhibit F) (Ogletree, Rashida) (Entered: 03/08/2012)
100 NOTICE of Appearance by Dustin J Calhoun for Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio (Calhoun, Dustin) (Entered: 03/09/2012)
101 Response re 99 Objection (non motion), to the Monitor's First Report (Doc. 93) by Defendant The State of Ohio. (Worly, Mindy) (Entered: 03/22/2012)
102 NOTICE OF WITHDRAWAL OF DOCUMENT by Defendant The State of Ohio (Attachments: # 1 Memorandum of Understanding) (Worly, Mindy) (Entered: 04/18/2012)
103 NOTICE of Appearance by Jacqueline K Cuncannan for Plaintiff The United States of America (Cuncannan, Jacqueline) (Entered: 04/25/2012)
104 Monitor's Second Report on the Amended Stipulation dated 6/28/2011 by Monitor Kelly Dedel, Ph.D. (pes1) (Entered: 06/22/2012)
105 ORDER SETTING TELEPHONIC STATUS CONFERENCE: Status Conference set for 11/29/2012 11:00 AM before Judge Algenon L. Marbley. Signed by Judge Algenon L. Marbley on 11/28/2012. (cw) (Entered: 11/28/2012)
106 SCHEDULING ORDER. Signed by Judge Algenon L. Marbley on 11/29/2012. (cw) (Entered: 11/29/2012)
107 Unopposed MOTION to Approve Consent Judgment by Plaintiff The United States of America. (Attachments: # 1 Text of Proposed Order Proposed Consent Order, # 2 Exhibit Monitor's Third Draft Report) (Cuncannan, Jacqueline) (Entered: 12/19/2012)
108 RESPONSE to Motion re 107 Unopposed MOTION to Approve Consent Judgment filed by Plaintiff The United States of America. (Gerhardstein, Alphonse) (Entered: 12/27/2012)
109 CONSENT ORDER. Signed by Judge Algenon L. Marbley on 1/18/2013. (cw) (Entered: 01/18/2013)
110 Monitor's Third Report on the Amended Stipulation signed June 28, 2011. (pes1) (Entered: 02/14/2013)
111 ORDER re 110 Notice (Other). Deadline to file objections 3/8/2013 at 12:00 p.m. Signed by Judge Algenon L. Marbley on 2/28/2013. (cw) (Entered: 02/28/2013)
112 Objection re 110 Notice (Other) Defendants Objections to the Monitors Third Report by Defendant The State of Ohio. (Worly, Mindy) (Entered: 03/07/2013)
113 Response re 112 Objection (non motion) to the Monitor's Third Report by Plaintiff The United States of America. (Cuncannan, Jacqueline) (Entered: 03/21/2013)
114 Monitor's Fourth Annual Report. (pes1) (Entered: 06/18/2013)
115 Monitor's First Status Report on Progress Unit. (pes1) (Entered: 06/18/2013)
116 NOTICE of ORDER VACATING 374 Order to Show Cause in related case 2:04CV1206. Signed by Judge Algenon L. Marbley on 6/21/2013. (cw) (Entered: 06/21/2013)

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 19 of 22

06/24/2013 07/30/2013 09/26/2013 09/26/2013 12/18/2013
12/19/2013 12/19/2013
12/20/2013 12/24/2013
12/24/2013 01/14/2014 01/16/2014 03/05/2014 03/12/2014 03/12/2014 03/13/2014
03/20/2014
03/21/2014

117 NOTICE of Appearance by Thomas Nathaniel Anger for Defendant The State of Ohio (Anger, Thomas) (Entered: 06/24/2013)
118 Monitor's Fourth Report Addendum − Mental Health Provisions. (pes1) (Entered: 07/30/2013)
119 STATUS REPORT: Monitors Progress Unit Compliance Report. (cw) (Entered: 09/26/2013)
120 STATUS REPORT: Second Progress Unit Status Report by Defendant Ohio Department of Youth Services. (cw) (Entered: 09/26/2013)
121 MOTION for Order to Terminate Case by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Anger, Thomas) (Entered: 12/18/2013)
122 REPLY to Response to Motion re 121 MOTION for Order to Terminate Case and Request for Postponement of Automatic Stay filed by Plaintiff The United States of America. (Attachments: # 1 Exhibit) (Dominguez, Silvia) (Entered: 12/19/2013)
123 RESPONSE to Motion re 121 MOTION for Order to Terminate Case and Request for Postponement of Automatic Stay filed by Plaintiff The United States of America. (Attachments: # 1 Exhibit Corrected Exhibits ABC) (Dominguez, Silvia) (Entered: 12/19/2013)
124 NOTICE of Appearance by Cynthia Coe for Plaintiff The United States of America (Coe, Cynthia) (Entered: 12/20/2013)
125 NOTICE OF WITHDRAWAL OF DOCUMENT by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio re 121 MOTION for Order to Terminate Case (Anger, Thomas) (Entered: 12/24/2013)
126 NOTICE OF WITHDRAWAL OF DOCUMENT by Plaintiff The United States of America re 122 Reply to Response to Motion for Order to Terminate Case and Request for Postponement of Automatic Stay (Coe, Cynthia) (Entered: 12/24/2013)
127 STATUS REPORT: Monitor's Fifth Report. (cw) (Entered: 01/14/2014)
128 ORDER Setting Settlement Conference for 1/29/2014 10:00 AM in Chambers before Judge Algenon L. Marbley. Signed by Judge Algenon L. Marbley on 1/16/2014. (cw) (Entered: 01/16/2014)
129 NOTICE of Appearance by Alexandra L. Shandell for Plaintiff The United States of America (Shandell, Alexandra) (Entered: 03/05/2014)
130 MOTION Leave to Supplement Complaint re 2 Complaint, by Plaintiff The United States of America. (Attachments: # 1 Exhibit Attachments) (Dominguez, Silvia) (Entered: 03/12/2014)
131 MOTION for Temporary Restraining Order by Plaintiff The United States of America. (Attachments: # 1 Exhibit Attachments) (Dominguez, Silvia) (Entered: 03/12/2014)
132 ORDER SETTING LOCAL RULE 65.1 CONFERENCE re 131 MOTION for Temporary Restraining Order filed by The United States of America, (Status Conference set for 3/26/2014 10:00 AM in Chambers before Judge Algenon L. Marbley.). Signed by Judge Algenon L. Marbley on 3/13/2014. (cw) (Entered: 03/13/2014)
133 AMENDED DOCUMENT by Plaintiff The United States of America. Amendment to 131 MOTION for Temporary Restraining Order , 130 MOTION Leave to Supplement Complaint re 2 Complaint, Declaration. (Attachments: # 1 Exhibit) (Dominguez, Silvia) (Entered: 03/20/2014)
134 RESPONSE in Opposition re 130 MOTION Leave to Supplement Complaint re 2 Complaint, filed by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio.

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 20 of 22

03/21/2014
03/24/2014 03/24/2014 03/25/2014
03/25/2014 03/28/2014 03/31/2014 04/04/2014

(Attachments: # 1 Exhibit Affidavit) (Anger, Thomas) (Entered: 03/21/2014)
135 RESPONSE in Opposition re 131 MOTION for Temporary Restraining Order filed by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Attachments: # 1 Exhibit Affidavit) (Anger, Thomas) (Entered: 03/21/2014)
136 REPLY to Response to Motion re 130 MOTION Leave to Supplement Complaint re 2 Complaint, filed by Plaintiff The United States of America. (Dominguez, Silvia) (Entered: 03/24/2014)
137 Unopposed MOTION to Continue Rule 65.1 Preliminary Conference by Plaintiff The United States of America. (Dominguez, Silvia) (Entered: 03/24/2014)
138 ORDER RESETTING LOCAL RULE 65.1 CONFERENCE. The Court will hold the Local Rule 65.1 preliminary conference on Tuesday, April 1, 2014 at 2:00 p.m. in the Court's Chambers, Room 319. Signed by Judge Algenon L. Marbley on 3/25/2014. (pes1) (Entered: 03/25/2014)
Reset Hearings: Rule 65.1 Conference set for 4/1/2014 at 02:00 PM in Chambers before Judge Algenon L. Marbley. (pes1) (Entered: 03/25/2014)
139 OPINION AND ORDER granting 130 Motion for Leave to File Supplemental Complaint. Signed by Judge Algenon L. Marbley on 3/28/2014. (pes1) (Entered: 03/28/2014)
140 COMPLAINT (Supplemental Complaint) against All Defendants, filed by The United States of America. (Sanders, Deborah) (Entered: 03/31/2014)
141 Transcript of Local Rule 65.1 Conference Proceedings held on 4/1/2014, before Judge Algenon L. Marbley. Court Reporter/Transcriber Shawna J. Evans, Telephone number 614−719−3316. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.

NOTICE RE: REDACTION OF TRANSCRIPTS: Within 5 business days of this filing, each party shall inform the Court, by filing a Notice of Redaction, of the party's intent to redact personal data identifiers from the electronic transcript of the court proceeding. The policy is located on our website at www.ohsd.uscourts.gov (Forms − Electronic Availability of Transcripts). Please read this policy carefully.

04/14/2014 04/17/2014
04/18/2014 04/29/2014 04/30/2014

For a complete copy of a transcript, please contact the Court Reporter or the Clerk's Office. Redaction Request due 4/25/2014. Redacted Transcript Deadline set for 5/5/2014. Release of Transcript Restriction set for 7/3/2014. (er1) (Entered: 04/04/2014)
142 ANSWER to 140 Complaint filed by All Defendants. (Anger, Thomas) (Entered: 04/14/2014)
143 Joint MOTION for Extension of Time to File New date requested 4/25/2014. by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Anger, Thomas) (Entered: 04/17/2014)
144 ORDER granting 143 Motion for Extension of Time to File. The Parties shall file their Agreed Order no later than 4/25/2014. Signed by Judge Algenon L. Marbley on 4/18/2014. (cw) (Entered: 04/18/2014)
145 MOTION for Temporary Restraining Order Renewed by Plaintiff The United States of America. (Dominguez, Silvia) (Entered: 04/29/2014)
146 RESPONSE to Motion re 145 MOTION for Temporary Restraining Order Renewed filed by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Attachments: # 1 Exhibit, # 2 Exhibit) (Anger, Thomas) (Entered: 04/30/2014)

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 21 of 22

05/20/2014
05/21/2014 05/27/2014 05/29/2014 06/03/2014 06/30/2014
07/24/2014 05/07/2015
06/16/2015
06/17/2015 11/05/2015 12/03/2015
12/07/2015
12/08/2015

147 Joint MOTION For Entry of Agreed Order and Grid by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Attachments: # 1 Exhibit, # 2 Exhibit) (Anger, Thomas) (Entered: 05/20/2014)
148 ORDER finding as moot 131 Motion for TRO; finding as moot 145 Renewed Motion for TRO; granting 147 Motion for Entry of Agreed Order. Signed by Judge Algenon L. Marbley on 5/21/2014. (Attachments: # 1 Exhibit A) (cw) (Entered: 05/21/2014)
149 MOTION to Withdraw as Attorney Silvia Dominguez−Reese by Plaintiff The United States of America. (Dominguez, Silvia) (Entered: 05/27/2014)
150 ORDER granting 149 Motion to Withdraw as Attorney. Attorney Silvia Dominguez terminated. Signed by Magistrate Judge Mark R. Abel on 05/29/2014. (sr1) (Entered: 05/29/2014)
151 NOTICE OF WITHDRAWAL OF DOCUMENT by Plaintiff The United States of America Withdrawal Without Prejudice of Motion for Temporary Restraining Order (Coe, Cynthia) (Entered: 06/03/2014)
152 ORDER in case 2:08−cv−00475−ALM−MRA; granting (393) Motion for Leave to File; granting (402) Motion to Withdraw in case 2:04−cv−01206−ALM−TPK. Signed by Judge Algenon L. Marbley on 06/30/2014. Associated Cases: 2:04−cv−01206−ALM−TPK, 2:08−cv−00475−ALM−MRA (cw) (Entered: 06/30/2014)
153 NOTICE of Substitution of Counsel − Judy Preston substituting for Benjamin Tayloe as to Plaintiff The United States of America. (Preston, Judy) (Entered: 07/24/2014)
154 ORDER SETTING STATUS CONFERENCE − Status Conference set for 7/23/2015 10:00 AM in Courtroom 1 − Columbus before Judge Algenon L. Marbley. Signed by Judge Algenon L. Marbley on 5/7/2015. Associated Cases: 2:04−cv−01206−ALM−TPK, 2:08−cv−00475−ALM−MRA (cw) (Entered: 05/07/2015)
155 STATUS REPORT: Compliance Report with The Grid filed by Lead Monitors, Kelley Dedel, Ph.D., William Harrell, J.D., and Subject Matter Experts, Daphne Glkindmeyer, M.D. and Andrea Weisman, Ph.D. Associated Cases: 2:04−cv−01206−ALM−TPK, 2:08−cv−00475−ALM−MRA (cw) (Entered: 06/16/2015)
156 ORDER Resetting Status Conference: reset for 9/3/2015 02:00 PM in Chambers before Judge Algenon L. Marbley. Signed by Judge Algenon L. Marbley on 6/18/2015. Associated Cases: 2:04−cv−01206−ALM−TPK, 2:08−cv−00475−ALM−MRA (cw) (Entered: 06/17/2015)
157 ORDER SETTING FINAL HEARING for 12/8/2015 02:00 PM in Courtroom 1 − Columbus before Judge Algenon L. Marbley. Signed by Judge Algenon L. Marbley on 11/5/2015. Associated Cases: 2:04−cv−01206−ALM−TPK, 2:08−cv−00475−ALM−MRA (cw) (Entered: 11/05/2015)
158 Joint MOTION Terminate Consent Decree re (409 in 2:04−cv−01206−ALM−TPK, 409 in 2:04−cv−01206−ALM−TPK) Order, Set Deadlines/Hearings ( Responses due by 12/28/2015) by Defendants Ohio Department of Youth Services, The State of Ohio, Ohio Department of Youth Services, Harvey J Reed. Associated Cases: 2:04−cv−01206−ALM−TPK, 2:08−cv−00475−ALM−MRA (Anger, Thomas) (Entered: 12/03/2015)
159 FINAL STATUS REPORT: A Report on the Transformational Reform of the Ohio Department of Youth Services, 2007−2015 by Interested Parties William Harrell, J.D., LL.M., Kelly Dedel, Ph.D., Federal Court Monitors and Terry Schuster, J.D. Special Assistant to the Monitors. Associated Cases: 2:04−cv−01206−ALM−TPK, 2:08−cv−00475−ALM−MRA (cw) (Entered: 12/07/2015)
160 FINAL STATUS REPORT: Monitors' Review of DYS' Contracted Programs for Girls Submitted by Kelly Dedel, Ph.D., Lead Monitor, William Harrell, J.D., Lead Monitor, Daphne Glindmeyer, M.D. Subject Matter Expert and Andrea Weisman, Ph.D.,

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 22 of 22

12/09/2015

Subject Matter Expert. Associated Cases: 2:04−cv−01206−ALM−TPK, 2:08−cv−00475−ALM−MRA (cw) (Entered: 12/08/2015)
161 ORDER granting (158) Joint Motion to Terminate the Consent Decree in case 2:08−cv−00475−ALM−MRA; granting (410) Joint Motion to Terminate the Consent Decree in case 2:04−cv−01206−ALM−TPK. Signed by Judge Algenon L. Marbley on 12/9/2015. Associated Cases: 2:04−cv−01206−ALM−TPK, 2:08−cv−00475−ALM−MRA (cw) (Entered: 12/09/2015)

 
 U.S. Department of Justice
Civil Rights Division
Assistant Attorney General 950 Pennsylvania Avenue, NW - RFK Washington, DC 20530
May 9, 2007
The Honorable Ted Strickland Governor State of Ohio 30th Floor 77 South High Street Columbus, OH 43215-6117
Re: Investigation of the Marion Juvenile Correctional Facility, Marion, Ohio
Dear Governor Strickland:
I am writing to report the findings of the Civil Rights Division’s investigation of conditions at the Marion Juvenile Correctional Facility (“Marion”), located in Marion, Ohio. On April 15, 2005, we notified you of our intent to conduct an investigation of Marion, pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997 (“CRIPA”), and the pattern or practice provision of the Violent Crime Control and Law Enforcement Act of 1994, 42 U.S.C. § 14141 (“Section 14141”).1 At that time, we informed you that our investigation of Marion would focus on protecting residents from harm, medical care, grievances, and provision of special education.2 As we noted, both CRIPA and Section 14141 give the Department of Justice authority to seek a remedy for a pattern or practice of conduct that violates the constitutional or federal statutory rights of children in juvenile justice institutions.
We note that the State has worked cooperatively and, under the leadership of Director of Ohio Youth Services Thomas Stickrath, has unequivocally indicated its clear desire to improve both facilities since being placed on notice of possible constitutional deficiencies. Prior to the Department of Justice investigations of Marion and Scioto, the State hired a team of
1 Prior to initiating our Marion investigation, on March 16, 2005, we notified you of our intent to conduct an investigation of the Scioto Juvenile Correctional Facility (“Scioto”).
2 Our Scioto investigation focused on the same issues with the addition of mental health care.

- 2 -
expert consultants, led by Mr. Fred Cohen, to evaluate the constitutional conditions at the girls’ section of the Scioto facility.3 Mr. Cohen issued an Interim Report on August 16, 2004 and an Action Plan on September 28, 2004. In each of these documents, Mr. Cohen found constitutional deficiencies in the areas of protection from harm, medical care, mental health care, grievances, and provision of special education. The State has agreed to adopt and stipulate to Mr. Cohen’s findings, for the purpose of our investigation, and to apply those findings regarding the girls' facility to Marion and the entire Scioto facility.
Given the State’s stipulation that the conditions identified in our April 15, 2005 notice letter are constitutionally deficient, we agreed to conduct limited facility tours.4 On June 27-29, 2005, we conducted an on-site inspection of Marion, accompanied by expert consultants in mental health care and medical care. We returned to Marion on July 19 and 20 for an on-site inspection with our special education consultant. During our inspections, we interviewed mental health providers, medical providers, other staff, youth residents, teachers, and facility administrators. Before, during, and after our visit, we reviewed an extensive number of documents, including policies and procedures, mental health records, youth detention records, unit logs, education records, and orientation materials. Consistent with our commitment to provide technical assistance and conduct
3 Although the main Scioto facility houses female youth, a separate section of the facility acts as state-wide intake for all male youth.
4 This investigation is anomalous because Mr. Cohen's 2004 factual findings regarding the conditions of confinement at Scioto revealed significant deficiencies in each of the areas that were the subject of our investigation and because the State has stipulated to all of Mr. Cohen's generally well-supported findings. Together, these factors created the unusual circumstance in which it was not necessary for the Department to conduct a facility tour regarding each of the specific subject areas of our investigation. However, we did tour Marion regarding areas in which we required additional factual information to make a thorough and complete finding or to frame appropriate corrective measures. For example, we toured Marion with a special education consultant in response to the State's concern that Mr. Cohen's extensive findings regarding special education in Scioto were not reflective of the conditions in Marion.

- 3 -
a transparent investigation, we conducted an exit conference with facility staff and Ohio Department of Youth Services officials upon the conclusion of the tour, during which our expert consultants conveyed their initial impressions and concerns.
We commend the Marion staff for their helpful, courteous, and professional conduct throughout the course of this investigation. We also wish to express our appreciation for the cooperation of Ohio Department of Youth Services officials and staff.
Consistent with our statutory obligation under CRIPA, we set forth below the findings of our investigation, the facts supporting them, and the minimum remedial steps that are necessary to address the deficiencies we have identified. As described below, we conclude that youth confined at Marion suffer harm or the risk of harm from constitutional deficiencies as to: protecting residents from harm; certain discrete elements of medical care; mental health care; grievances; and special education services. Notwithstanding the foregoing, we are pleased to report that our review indicates that Marion’s general medical programs are, for the most part, good. In particular, we find that Marion’s medical quality improvement program, environmental conditions, and management of special dietary needs for youth are appropriate. However, certain discrete aspects of medical care, identified below, substantially depart from generally accepted professional standards of care and expose youth to harm.
I. BACKGROUND
The State of Ohio, through its Department of Youth Services, owns and operates Marion, located approximately 45 miles north of Columbus, Ohio. Marion is Ohio’s only maximum-security juvenile justice facility. Its population consists entirely of juvenile males, aged 12 to 21, adjudicated, of felony-level crimes, in juvenile courts. Marion’s rated capacity is 336. Its facilities include 12 housing units, a mental health unit, a transitional unit, and a super-max unit.
II. FINDINGS
As a general matter, States must provide confined juveniles with reasonably safe conditions of confinement. Youngberg v. Romeo, 457 U.S. 307 (1982); Nelson v. Heyne, 491 F.2d 352 (7th Cir. 1974); see also Miletic v. Natalucci-Persichetti, No. C-3-89-299, 1992 WL 1258522, *2, *4 (S.D. Ohio Feb. 6, 1992) (holding, in a case against the Ohio Department of Youth

- 4 -
Services, that “a juvenile who is involuntarily committed to a correctional as opposed to mental health facility has a right to treatment under the Fourteenth Amendment similar to that which was recognized in Youngberg . . . .”).
A. PROTECTION FROM HARM
Juveniles in state custody have a constitutional right to reasonable safety. See Youngberg, 457 U.S. at 315-16 (“personal security constitutes a historic liberty interest protected substantively by the Due Process Clause”) (internal quotation omitted).
Our review of conditions of confinement at Marion reveals significant constitutional deficiencies regarding use of physical force, grievance investigation and processing, and use of seclusion. For purposes of our investigation, the State has stipulated to Mr. Cohen’s August 2004 findings regarding the Scioto girls' facility, agreeing that Mr. Cohen’s findings for each of the above-mentioned subject areas apply to Marion. In addition, our experts concur with Mr. Cohen's findings and suggested remedies.
1. Use of Physical Force
Juveniles at Marion have a right to be free from unnecessary restraint and the use of excessive force. Youngberg, 457 U.S. at 315-16.
The State has stipulated to apply the findings made by its expert regarding protection from harm issues at Scioto to Marion.5 Because of the State’s stipulation, the Department agreed not to perform a separate fact-finding exercise at Marion regarding protection from harm issues.
In his report, Mr. Cohen concludes that “there has been (and remains) a culture of violence among the uniformed staff, that verbal and physical abuse are common, [and] sexual misconduct by staff occurs . . . .” Mr. Cohen indicates that he and his team of experts “have the most serious reservations as to whether [the State’s] investigators are presently able to produce the quality of investigative work required to identify those use of force
5 In 2004, the State hired Mr. Cohen and a team of experts to review protection from harm issues in Scioto’s Girls’ Program after 14 Scioto staff had been indicted on charges relating to physical and sexual abuse of youth at Scioto.

- 5 -
incidents that merit corrective actions for staff who violate the [Department of Youth Services’] use of force policy.” Finally, Mr. Cohen concludes that “there can be no debate on the constitutional obligation under the Fourteenth Amendment to provide a safe environment. Scioto has not met its obligations to provide such an environment . . . .”
In reviewing use of force incidents at Scioto, Mr. Cohen reported that “verbal and physical abuse are common.” In his report, Mr. Cohen stated that he and his team “found countless examples of situations where no force at all should have been used and others where the force used was excessive.” Further, according to Mr. Cohen, verbal abuse is rampant and often serves, perhaps intentionally, to precipitate physical confrontations with juveniles. Based on these assessments and the State’s stipulation as to their applicability, we conclude that youth at Marion are subject to use of excessive force and physical abuse.
In addition, from document review and youth interviews, our medical consultant found that Marion youth are at significant risk of physical trauma due to youth-on-youth fights. Youth have indicated they believe that staff encourage youth to fight.
Finally, we note that Marion currently allows use of a physical restraint technique directing staff to place an arm across a youth’s chest below the neck and push on the cheek with the back of the hand. As our medical expert observed during the tour, use of any technique calling for an arm to be placed across the neck during a physical altercation or other incident exposes the youth to a significant risk of harm. This practice is especially problematic in light of allegations we have received that youth have been choked by staff during altercations.
2. Grievances (Investigations and Processing)
Just as prisoners and juvenile detainees have a constitutional right of access to the courts, they have a right to a grievance system that does not carry risk of punishment as a price for using it. See Thaddeus-X v. Blatter, 175 F.3d 378, 394 (6th Cir. 1999); see also Bounds v. Smith, 430 U.S. 817, 822 n.17 (1977) (“Our main concern here is protecting the ability of an inmate to prepare a petition or complaint.”) (internal quotation marks and citations omitted).
An adequately functioning grievance system ensures that youth have an avenue for bringing serious allegations of abuse and other complaints to the attention of the administration. It

- 6 -
also provides an important tool in alerting the administration about dangers and other problems in the facility’s operations.
We adopt the following findings by the State’s expert, regarding the Scioto girls' section, based on the State's stipulation as to their applicability at Marion. As part of Mr. Cohen’s assessment, the State’s experts conducted a review of Scioto’s incident investigation and grievance process,6 finding that several factors contribute to its inadequacy. In particular, Mr. Cohen’s report finds that investigations are “pedestrian, time consuming, and full of errors or oversights.” The State’s experts also determined that, with the exception of a few cases, investigators rarely attempt to determine if officers followed existing protocol.
Additionally, investigations contain few facts other than repetition of the complaint and denials by involved individuals. The investigations reveal a trend of repetitive questioning of involved youth, as though questioning was to continue until the youth provided the “correct” answer. Incidents involving physical aggression contained no evaluation of events preceding the incident, nor questions regarding use or attempted use of lesser physical interventions.
In addition, although grievances contain serious allegations such as verbal harassment and abuse, use of physical force, loss of programs and privileges, sexual harassment, and untreated medical issues, such investigations rarely result in corrective action for staff or youth or any attempt to recognize or identify patterns of behavior requiring intervention.
The inadequacies in Marion's grievance system contribute to the State’s failure to ensure a reasonably safe environment. An adequately functioning grievance system ensures that youth have an avenue for bringing serious allegations of abuse and other complaints to the attention of the administration. It also provides an important tool in evaluating the culture at the facility, and alerting the administration about dangers and other problems in the facility’s operations.
3. Seclusion
Based on the State's stipulation as to their applicability at Marion, we adopt the following findings by the State’s expert
6 Mr. Cohen’s team reviewed the 984 incidents filed from January 1, 2003 through August 18, 2004.

- 7 -
regarding the Scioto girls' section. The State's experts reviewed over 200 seclusion reports regarding Scioto girls from May 2004 to June 2004. In his report, Mr. Cohen concluded that staff use seclusion as a first response and often hold youth in seclusion for hours even though they do not pose an imminent threat. Additionally, the State's expert found that Scioto's routine use of seclusion as immediate punishment is often accompanied by use of force.
B. MEDICAL AND MENTAL HEALTH CARE
Juveniles in state custody have a due process right to adequate mental health care. The Supreme Court in Youngberg broadly labeled health care as “medical care,” but recognized that this would include care provided by various disciplines, including persons with appropriate training in psychology. See id., 457 U.S. at 322-323, n.30. The Sixth Circuit also has recognized that medical care encompasses mental health care. See Horn v. Madison County Fiscal Court, 22 F.3d 653, 660 (6th Cir. 1994) (“A detainee’s psychological needs may constitute serious medical needs, especially when they result in suicidal tendencies.”).
1. Medical
We are pleased to report that our review indicates that Marion’s general medical programs are, for the most part, good. In particular, we find that Marion’s medical quality improvement program, environmental conditions, and management of special dietary needs for youth are appropriate. However, certain discrete aspects of medical care, identified below, substantially depart from generally accepted professional standards of care and expose youth to harm.
a. Identification of Health Problems and Initial Health Assessments
Marion’s health records are inadequate insofar as they do not contain problem lists. Such lists document all identified active health problems and are necessary tools in monitoring youth health status and providing adequate health care. Marion’s initial health assessments are similarly inadequate, due to the absence of problem lists.
Separately, as a matter of technical assistance, we note that Marion’s assessments are conducted in a central area of the clinic that is, at best, marginally confidential, as conversations can be easily overheard. Nurses should use

- 8 -
private exam rooms for such assessments and ensure that non-professional staff are unable to overhear the confidential assessment.
b. Evaluation and Treatment of Sick Residents
Marion’s sick call procedures make youth access to medical case dependent upon line staff. Marion’s current system forces youth to submit requests through line staff in a non-confidential manner, breaching youths’ rights to privacy and confidentiality. Marion should implement a system in which youth can submit sick call requests confidentially and independent of the line staff.
Marion’s medication management is well-organized. However, Marion’s policy of discontinuing medication not on the Prison Health Services formulary constitutes a departure from generally accepted professional standards of care, because it requires youth to become unstable before receiving proper medication.
c. Dental Care
Marion’s dental program fails to meet the dental needs of its youth. We found numerous instances of youth with significant, untreated, dental needs. Separately, Marion fails to provide pain medications adequate to relieve severe dental pain, reflecting inadequate dental care. In addition, Marion’s current dentist only works two days per week to meet the needs of its population of approximately 275 youth. This is not adequate.
d. Special Services for Chronically Ill and Disabled Youth
We find that Marion’s care provided to patients with asthma substantially departs from generally accepted professional standards, as youths’ asthma medications are discontinued upon admission to the facility. Marion should continue to provide such necessary medication without delay.
Finally, we note that Marion, through its contractor, Prison Health Services, inappropriately denies youth access to specialist care, such as diagnostic tests and consultations, when such care is clinically indicated. For example, Marion denied a facility physician's request for an echocardiogram, to examine a youth's significant heart murmur, finding the youth to be “asymptomatic” because he was not yet showing disability due to decompensated heart disease. This is a substantial departure from generally accepted professional standards.
e. Disease Prevention and Health Promotion

- 9 -
Thirty percent of Marion’s youth had incomplete immunizations, and youth are not fully immunized for their age. This is a substantial departure from generally accepted professional standards.
f. Medical Quality Improvement Program
While we find that Marion’s current medical quality improvement program is adequate, we suggest that Marion place more emphasis on areas relevant to its population, such as completing immunizations, reviewing grievances, and reviewing hospitalizations.
g. Special Dietary Needs for Youth
Marion adequately manages food allergies and special medical diets.
h. Abuse Reported By Medical Professionals
While nurses at Marion assess youth after a use of physical restraint, they only report suspected abuse to the facility administration, rather than to State child abuse authorities. This reporting scheme is a substantial departure from generally accepted professional standards and, in light of the State’s stipulation regarding use of excessive force, is especially problematic.
2. Mental Health Care
The Constitution requires that youth in juvenile justice institutions receive adequate mental health care. Youngberg, 457 U.S. at 323, n.30; Nelson, 491 F.2d at 360; see also K.H. v. Morgan, 914 F.2d 846, 851 (7th Cir. 1990); A.M. v. Luzerne County Juvenile Detention Center, 372 F.3d 572, 585 n.3 (3d Cir. 2004). We find that mental health care at Marion is constitutionally inadequate.
In 2004, Mr. Cohen, the State’s expert, concluded that the Scioto girls’ facility’s mental health unit “is little more than a residence for girls with mental disorders” and that “[m]ental health care is so deficient” that it was not feasible to comment on the various elements of such care, indicating that “[a] more refined analysis must await another day – a day when constitutionally required, minimally acceptable care is instituted.”
Given the severity of Mr. Cohen’s assessment, and the

- 10 -
State's stipulation applying such findings to Marion, we toured Marion with a mental health expert. We found serious deficiencies in the provision of mental health care regarding the facility’s identification of youth with significant mental health problems (“case finding”), and in the screening, assessment, treatment planning, and monitoring of youth with such problems. In addition, we found discrete or underlying problems regarding the facility’s efforts to involve family in treatment decisions, and regarding staffing, restraints, and environmental conditions.
a. Case Finding
We find that Marion’s efforts to identify youth with mental disorders are significantly lacking. Our observations and interviews with youth indicate that a significant number of youth manifesting mental health disorders are not identified and thus, not treated. Marion’s current 20 percent rate of youth identified as having such disorders is quite probably a significant underestimate. One of Marion’s own staff psychologists estimated that the actual rate of mental disorders within Marion’s population is between 30 and 40 percent (an estimate consistent with current prevailing research). Marion’s failure to adequately detect youth having significant mental disorders is a substantial departure from generally accepted professional standards.
b. Screening, Assessment, Treatment Planning, and Monitoring
Initial screening of all Marion youth is conducted at the intake section of the Scioto Juvenile Correctional Facility. These assessments, which provide the basis for ongoing mental health care at Marion, are addressed in a separate letter. Regarding onsite treatment at Marion, we were unable to find evidence that the facility provides any further assessment of a youth’s adjustment to the new facility, such as systematic rescreening. Additionally, the psychology records we reviewed indicated that Marion does not take into account individuals’ difficulties or strengths when designing and implementing treatment plans. Further, it was evident that clinical team meetings do not review, and modify as warranted, treatment plans in a formal manner or consider whether goals are being met. This is a substantial departure from generally accepted professional standards. Further, Marion does not base determinations on empirical information, making such determinations overly reliant on subjective reporting by line staff.
We find that psychopharmacological treatment at Marion for youth identified as needing such treatment is based on an adequate psychiatric assessment and, a cursory, but explicit,

- 11 -
plan for treatment with medication. We also find that follow-up is adequate, although Marion should ensure that it gathers information from collateral sources when assessing a youth’s target symptoms. Lastly, as a matter of technical assistance, we recommend that the facility reconsider its aversion to prescribing stimulants. Given Marion’s care in monitoring medications, the facility should be comfortable allowing its youth access to the therapeutic benefits of such medications.
c. Mental Health Unit
Marion’s intensive mental health unit appears to be serving an appropriate population and providing adequate care. We suggest that Marion consider using any extra beds in the area for short-term treatment for youth with more acute disturbances.
d. Suicide Prevention Activities
We find that Marion’s plan for assessing acute risk and preventing suicides is thorough and effective.
e. Family Involvement
As a matter of technical assistance, we find that Marion’s efforts to engage youths’ families in their mental health care are lacking. Families are an extremely important source of clinical information, and their support can make an enormous impact on a youth. We understand that some families may live far from Marion or not be responsive to outreach. Nevertheless, we believe that an increased effort by Marion staff will lead to productive outcomes for its youth.
f. Staffing
Marion’s social work staff is not adequate to provide more than superficial care for youth with significant mental health disorders, and this constitutes a substantial departure from generally accepted professional standards. The Psychology Department is severely understaffed at Marion. Such inadequate staffing reduces the ability of mental health staff to collaborate appropriately with other staff in monitoring progress of youth on the mental health list and those without identified disorders. Additionally, poor staff size reduces psychologists’ availability to youth, reduces flexibility in responding to specific treatment needs and designing appropriate responses, and contributes to inconsistent recordkeeping.
Psychiatry staffing is adequate to meet the needs of youth currently identified as having mental health disorders. However, as noted above, the number of youth with significant mental

- 12 -
health disorders is much higher than currently identified by Marion, and the facility will need to maintain adequate psychiatric staff as its mental health caseload changes.
g. Restraints
Marion uses four-point restraints, forced medications, and restraint beds to manage severely mentally ill youth. We urge Marion to work to identify such youth early and transfer them to mental hospitals rather than resorting to the extreme behaviormanagement options listed above.
h. Environmental Conditions
Shower heads in some units pose suicide risks (e.g., hanging hazards) as they are not constructed in a manner that would allow a rope or similar implement to slip free. Easy access to such hazards increases the possibility that potentially suicidal youth will seriously harm themselves. Marion should replace such shower heads.
C. SPECIAL EDUCATION SERVICES
Students with disabilities have federal statutory rights to special education services under the Individuals with Disabilities Education Act (IDEA), 20 U.S.C.A. §§ 1400-1482 (West 2000 & Supp. 2006). Marion serves its special education population though the Hickory Grove High School. The school’s faculty numbers slightly more than 30 individuals, including five special education teachers. As of September 2005, the school served 226 students. Of those, approximately 94 students have been identified as having special education needs. We conducted our own on-site review of the provision of special education at Marion. In addition to our review, our expert consultant reviewed Ms. Ava Crow's findings regarding Scioto and determined that similar concerns exist in Marion.7
1. Child Find
The IDEA requires that states implement systems to identify all students who are eligible for special education services and provide such services to all those identified as having
7 Ms. Crow, acting as part of Fred Cohen's team, reviewed education services provided by Scioto's girls' section. The State has agreed to adopt and stipulate to Mr. Cohen’s findings, for the purpose of our investigation, and to apply those findings to Marion and the entire Scioto facility.

- 13 -
disabilities. 20 U.S.C. § 1412. We find that Marion violates many of these “Child Find” requirements of the IDEA.
When youth enter the Ohio juvenile correctional system, they are inadequately evaluated for special education needs at the Scioto intake facility; this “evaluation” process consists of a document request for special education records from a youth’s prior school. There is no additional direction provided by the Ohio Department of Youth Services to guide intake personnel in conducting a thorough assessment to identify items in a youth’s record that should merit further investigation regarding special education placement. Once placed at Marion, youth appear to receive no additional special education screening; none of the teachers who we interviewed could recount ever having referred a student for such an assessment. In light of the above, we find that Marion is not in compliance with its Child Find obligations under the IDEA.
2. Eligibility Determinations
Under the IDEA, Marion is required to conduct a thorough eligibility evaluation of a child suspected of having a disability. See 20 U.S.C. § 1414 at (b)(4), (b)(5), and (c)(5). The IDEA requires that eligibility decisions are to be reviewed every three years. Approximately six percent of Marion’s evaluations were more than three years old and thus not in compliance with the IDEA. In this regard, the shortage of psychological staff at Marion contributes to the facility’s inability to complete necessary eligibility assessments.
3. Implementation of Individual Education Plans
The IDEA requires that each student with a disability have an Individualized Education Plan (“IEP”), and describes the IEP components required to ensure that each student receives adequate special education services. We find that Marion’s IEP process does not ensure that students with disabilities receive such required special education services.
For example, Marion conducts IEP meetings without the full compliment of professionals who should attend and contribute to the development of the IEP. Although the IEP meeting we observed contained a substitute for the principal or vice principal, it contained no regular education teacher, transition services representative, or psychologist (or other individual with skill in interpreting test results).
Furthermore, the IDEA requires that the IEP be a document containing equal contributions from the school and the parent.

- 14 -
However, at one IEP meeting we observed, although the parent was present via telephone, she had minimal involvement. Throughout the meeting, the special education teacher merely read the “draft” IEP to those present. The parent was not given any opportunity to collaborate in developing the document, and the teacher ratified the IEP upon concluding her oral presentation.
Additionally, the IDEA requires IEPs to be reviewed at least annually. Our document review revealed that at least 12 percent of Marion’s IEPs had not been revised within the IDEA’s time requirements.
Lastly, our document review revealed a clear need for professional development to properly address youth reading problems. The majority of special education records we reviewed revealed substantial deficits in simple reading skills. Moreover, we reviewed a record for one non-special education youth showing lower level reading performance than others currently receiving special education services. This problem reflects the deficiencies described above regarding the special education assessment process.
4. Monitoring of IEPs
We find that Marion’s practices for monitoring progress of students with disabilities is inadequate. Marion should monitor IEPs to ensure that youth receive access to a free and appropriate public education, as required by the IDEA. If monitoring is not conducted frequently and appropriately, educators are unlikely to recognize students' inadequate progress and modify instruction to improve progress.
Our document review and teacher interviews revealed a general lack of knowledge of how to use objective data and quantitative methods to assess students’ progress. All educational records we reviewed consisted of subjective evaluations with little basis supporting the stated conclusions. For example, an estimated 80 percent of the required blocks on the IEP forms uniformly read “quarterly progress reports based upon records reviews and teacher interviews.” Our review raises doubts as to whether such reviews are actually occurring. Marion also does not appear to have adequate professional development for preparing teachers to monitor progress of IEP goals.
In addition, while the IDEA requires consideration of positive behavioral interventions for students whose behavior interferes with their learning or that of other students, our document review revealed only one such individualized intervention, despite the needs of Marion’s youth. Teachers we

- 15 -
interviewed indicated that they believe “only a couple” Marion students have such interventions. This does not comply with the IDEA.
5. Classroom Instruction and Management
Finally, as a matter of technical assistance, we encourage Marion to make maximum use of the instructional time available to provide important educational opportunities for students with disabilities. Furthermore, in order to ensure that students with disabilities are served appropriately, we encourage Marion to increase its school staffing.
III. REMEDIAL MEASURES
In order to rectify the identified deficiencies and protect the constitutional and statutory rights of the youth confined at Marion, the facility should implement, at a minimum, the following measures:
A. Protection from Harm
1. Ensure that youth are provided with safe living conditions and are protected from abuse, use of excessive force, undue seclusion, and undue restraint.
2. Develop appropriate policies and procedures that govern the use of force, requiring reliable documentation and limiting use of force to situations where a youth is physically violent and poses an immediate danger to himself and/or others or the youth is physically resisting institutional rules and the institution has attempted a hierarchy of nonphysical alternatives.
3. Prohibit verbal and physical punishment, and use of force practices that are incompatible with minimum actions necessary to prevent harm or obtain compliance with reasonable orders, including practices such as shoving, pushing, kicking, striking, or using inappropriate holds on youth.
4. Monitor and supervise staff, maintaining appropriate staff ratios and holding staff accountable for the use of excessive force or abuse.
5. Develop policies and procedures to ensure that seclusion and restraint are only used in appropriate, documented, instances by trained staff.
6. Provide youth with an effective and reliable process to raise grievances, without exposing them to retribution from

- 16 -
staff, ensuring that all grievances are reviewed and addressed in a timely matter that provides youth with notification of the final resolution.
7. Employ sufficiently trained and independent investigators to ensure that all incidents of violence, use of force, or serious injury are adequately investigated, and documented, and that appropriate personnel actions are taken in response to substantiated findings.
B. Medical and Mental Health Care
1. Ensure that youth receive routine, preventative, and emergency medical and dental care consistent with current, generally accepted professional standards, including identification, assessment, diagnosis, and treatment of individuals with health problems.
2. Develop policies and procedures to ensure that youth are provided with: complete and accurate health records, access to confidential health care, a complete initial health assessment, appropriate access to health services, appropriate medications and care to manage chronic illness, access to specialty consults, and proper immunizations managed according to generally accepted medical standards.
3. Maintain appropriate dental staffing and require that generally accepted professional standards are followed to ensure that: youths’ restorative needs are met in a timely manner, youth are not denied appropriate pain medication, needed prosthetic dental services are provided, and health records contain adequate documentation of outside dental consults.
4. Provide mental health and rehabilitative treatment consistent with generally accepted professional standards and ensure that there are an adequate number of qualified mental health professionals to provide mental health and rehabilitative services in a timely manner to all youth who require such services.
5. Develop and implement policies, procedures, and practices to ensure that, consistent with generally accepted professional standards of care, youth are: (1) systematically evaluated in response to problem indicators to address potential manifestations of mental or behavioral disorders in youth who have not been previously identified as requiring treatment; and (2) provided appropriate mental health care, substance abuse care, and treatment services.
6. Ensure that any youth determined at screening to be at immediate risk is immediately referred to a qualified mental

- 17 -
health treatment professional for: assessment, treatment, and other appropriate actions, including facility transfer when necessary.
7. Implement policies, procedures, and practices according to generally accepted professional standards to ensure that: youth identified in screening receive timely, comprehensive, and accurate assessments by qualified mental health professionals; and assessments are designed to incorporate data necessary to identify youth with mental disorders and contribute to a plan for managing the youth’s risk.
8. Develop and implement policies and procedures consistent with generally accepted professional standards of care to: (1) ensure that treatment determinations are made by an interdisciplinary team through integrated treatment planning; (2) create and implement treatment plans that are current and individualized; (3) maintain readily accessible records containing meaningful, accurate and coherent assessments of the individual’s treatment plan progress, goals, and objectives.
9. Develop and implement a system to ensure that mental health issues are adequately considered in making housing decisions and that mentally ill youth receive appropriate housing.
10. Prior to administration of prescribed psychoactive medication, Marion must: (1) ensure that youth and their parents (or guardians, if parents have lost custody due to abuse or neglect) are provided with goals, risks, benefits, and potential side effects of the medication, along with the potential consequences of not treating with the medication; (2) follow state law in order to administer such medication without consent.
11. Develop and implement policies, procedures, and practices to ensure that psychoactive medications are prescribed, distributed, and monitored properly and safely, consistent with generally accepted professional standards of care.
12. Provide training to all staff who interact directly with youth regarding mental health information, developmental disabilities, recognition of signs and symptoms of trauma, teenage development, strength-based treatment strategies, and suicide risks.
13. Create transition plans for youth leaving the facility that are consistent with generally accepted practice standards.
14. Develop and implement polices and procedures to maintain oversight of mental health services and ensure that such

- 18 -
services are provided consistent with generally accepted professional standards of care.
C. Special Education
1. Provide prompt and adequate screening, and ongoing rescreening and referral, of youth for special education needs and ensure that all students requiring special education services receive services in compliance with the IDEA within a reasonable time following intake.
2. Ensure that all eligible youth have current, accurate IEPs that are developed and implemented consistent with IDEA requirements.
3. Create and implement a system to routinely develop, implement, and monitor youths' IEPs, with involvement of parents and guardians, as required by the IDEA.
4. Develop and implement a staffing plan that allows for a sufficient number of certified special education teachers and staff to provide all youth with the opportunity to attend school full-time and to obtain adequate educational services while providing teachers with sufficient time to plan lessons, grade assignments, and participate in special education meetings.
5. Develop a quality assurance program to ensure the quality of IEPs, compliance with the IDEA, and monitoring of teaching staff on compliance issues.
6. Ensure that special education staff receive in-service training and maintain current educator licenses appropriate to the courses they teach.
* * *
As stated above, we appreciate the cooperation we have received from Ohio Department of Youth Services officials and facility staff throughout this investigation. We hope to be able to continue working with the State in an amicable and cooperative fashion to resolve the deficiencies found at Marion. Provided that our cooperative relationship continues, we will forward our expert consultant reports under separate cover. Although this report is our consultants’ work – and does not necessarily reflect the official conclusions of the Department of Justice – the observations, analyses, and recommendations contained in the reports provide further elaboration of the issues discussed in this letter and offer practical assistance in addressing them.
In the unexpected event that we are unable to reach a resolution regarding our concerns, the Attorney General is

- 19 -
empowered to institute a lawsuit pursuant to CRIPA to correct the deficiencies of the kind identified in this letter 49 days after appropriate officials have been notified of them. 42 U.S.C. § 1997b(a)(1).
We would prefer, however, to resolve this matter by working cooperatively with you. We have every confidence that we will be able to do so in this case. The lawyers assigned to this matter will be contacting your attorneys to discuss this matter in further detail. If you have any questions regarding this letter, please contact Shanetta Y. Cutlar, Chief of the Civil Rights Division’s Special Litigation Section, at (202) 514-0195.
Sincerely,
/s/ Wan J. Kim Wan J. Kim Assistant Attorney General
cc: The Honorable Marc Dann Ohio Attorney General Department of the Attorney General
Thomas J. Stickrath Director Ohio Department of Youth Services
Dion Norman Superintendent Marion Juvenile Correctional Facility
The Honorable Gregory A. Lockhart United States Attorney Northern District of Ohio

 
 DYS Seclusion Hours Correctional Institution Inspection Committee

February 11, 2015

Seclusion Defined

Under DYS policy 301.05.04, seclusion is the involuntary confinement of a youth alone in his or her own room or in a safe room for a brief period.
 The use of regular seclusion and prehearing seclusion shall be used as a cooling off period and shall be discontinued at the point the youth is able to successfully demonstrate he or she has calmed down and safely able to return to population.
 Youth placed in seclusion are checked visually by staff at least every 15 minutes (recorded on a Youth Intervention Monitoring Log) and are visited daily by personnel from administrative, clinical, social work, religious, and/or medical units.
 Youth placed in seclusion shall be afforded living conditions and privileges approximating those available to the general population. Exceptions shall be justified by clear and substantiated evidence.

CY 2014 Total Seclusion

Hours By Facility

Cuyahoga Hills JCF
12.5%
Scioto JCF 0.8%

Circleville JCF 49.2%

Indian River JCF
37.5%

DOJ Seclusion Litigation Update (Press Release)
Justice Department Settles Lawsuit Against State of Ohio to End Unlawful Seclusion of
Youth in Juvenile Correctional Facilities
“The United States and private plaintiffs announced on May 21, 2014 that it reached an agreement with the state of Ohio, under which the State Department of Youth Services (DYS)
will dramatically reduce, and eventually eliminate, its use of seclusion on young people in its custody. DYS will also ensure that young
people in its juvenile facilities receive individualized mental health treatment to prevent and address the conditions and behaviors that led to seclusion. The order resolves allegations that the state subjects young people with mental health needs in its custody to harmful seclusion and withholds treatment and programming, in violation of their
constitutional rights.”
Key Statistics
In 2014, there were 66,027 reported hours of seclusion, a 64.8% decrease from 2012.
Positively, the DYS system-wide rate of seclusion hours per youth decreased 57.3%
during this period.
The largest number of seclusion hours occurred at Circleville JCF, totaling 32,492
reported hours or 49.2% of all hours.
Circleville JCF also reported the highest rate of seclusion hours per youth, with 255.8
hours.

Correctional Institution Inspection Committee Riffe Center, 77 S. High Street, 15th Floor, Columbus, Ohio 43215, PHONE (614) 466-6649, FAX (614) 466-6929

DYS Seclusion Hour Rates Per Youth CY 2011 - 2014
400

350

300

250

200

380.4

150

358.1

458.8

100 152.8
50

0 2011

2012

2013

2014

* Data was calculated by dividing DYS’ total number of seclusion hours each year (rounded to the nearest whole number) by its average annual population for 2014. NOTE: the data does not take into account whether the same youth was involved in multiple incidents resulting in the use of seclusion. ** Seclusion data was provided by the Ohio Department of Youth Services for 2011 through 2014. Population data was provided by the Ohio Department of
Youth Services for January 2011 through December 2014.

Correctional Institution Inspection Committee Riffe Center, 77 S. High Street, 15th Floor, Columbus, Ohio 43215, PHONE (614) 466-6649, FAX (614) 466-6929

10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0

Total Seclusion Hours by Month CY 2014

CHJCF

CJCF

IRJCF

SJCF*

Settlement Agreement

* Seclusion data was provided by the Ohio Department of Youth Services for 2014. **Please note that seclusion hours were rounded to the nearest whole number.
Correctional Institution Inspection Committee Riffe Center, 77 S. High Street, 15th Floor, Columbus, Ohio 43215, PHONE (614) 466-6649, FAX (614) 466-6929

350,000 300,000 250,000

Total Seclusion Hours by Facility CY 2011-2014
2014 2013 2012 2011

200,000

150,000

100,000

50,000

0

Circleville JCF

Cuyahoga Hills JCF Indian River JCF Ohio River Valley JCF

Scioto JCF

*Data provided by the Ohio Department of Youth Services for 2011 through 2014. **Please note that Ohio River Valley JCF closed September 2011 and Scioto JCF closed May 2014.

Correctional Institution Inspection Committee Riffe Center, 77 S. High Street, 15th Floor, Columbus, Ohio 43215, PHONE (614) 466-6649, FAX (614) 466-6929

Seclusion Hour Rates Per Youth CY 2014
300

250 255.8
200
150

190.3

100

50
0 Circleville JCF

49.1 Cuyahoga Hills JCF

Indian River JCF

80.0 Scioto JCF

* Data was calculated by dividing a facility’s total number of seclusion hours (rounded to the nearest whole number) by its average annual population for 2014. NOTE: the data does not take into account whether the same youth was involved in multiple incidents resulting in the use of seclusion. **Please note Scioto JCF closed in May 2014, therefore affecting the rate and average population.
Correctional Institution Inspection Committee Riffe Center, 77 S. High Street, 15th Floor, Columbus, Ohio 43215, PHONE (614) 466-6649, FAX (614) 466-6929

2014 Seclusion Hour Statistics

Month CHJCF CJCF IRJCF SJCF*

January

1,810

9,514

4,570

117

February

1,497

6,521

4,203

219

March

1,398

7,531

7,252

224

April

1,184

2,926

4,592

0

May

362

2,210

1,184

0

June

368

1,149

641

0

July

371

266

436

0

August

436

452

262

0

September

116

227

499

0

October

159

459

356

0

November

307

829

502

0

December

233

408

237

0

Total 8,241 32,492 24,734 560

Total
Hours
16,011 12,440 16,405 8,702 3,756 2,158 1,073 1,150
842 974 1,638 878
66,027

*Scioto Juvenile Correctional Facility closed May 2014. **Data provided by the Ohio Department of Youth Services for January through December 2014. Data differs slightly from DYS data to ensure agreement within the brief; the differences may be due to rounding issues. ***Please note seclusion hour totals were rounded to the nearest whole number.

Correctional Institution Inspection Committee Riffe Center, 77 S. High Street, 15th Floor, Columbus, Ohio 43215, PHONE (614) 466-6649, FAX (614) 466-6929