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Joint Legislative Committee on Performance
Evaluation and Expenditure Review (PEER)
Report to
the Mississippi Legislature

Health and Safety Issues at the Oakley
and Columbia Youth Training Schools

The PEER Committee reviewed complaints related to health and safety issues at the Oakley and Columbia Youth Training Schools operated by the Division of Youth Services (DYS) of the Mississippi Department of Human Services (DHS). There were nine complaints involving four broad areas in the administration of services: access to medical care, medical supervision, special medical needs, and preventing abuse of juveniles. In these areas, actual practices at the Columbia and Oakley juvenile facilities promote health and safety. However, uniformity of program operations suffers due to the absence of formal policies and procedures to govern critical components of care.

PEER found that although the training schools have qualified health professionals available (medical, dental, mental health), the facilities are not meeting health requirements and/or minimum standards in the areas of medical staff shift coverage and dental services. The facilities also lack policies and procedures governing medical authority to ensure proper medical supervision of youth detained in the facilities. Because the facilities have not formally designated their physicians as the medical authority, it is possible for a juvenile's health needs to go un-
addressed. Qualified health-trained professionals address special needs of training school youth at both facilities; however, lack of coordination and supervision of treatment plans allow mainly dental and drug treatment needs to go unmet.

Other policy areas such as those prohibiting sexual abuse, harassment, or contact are generally effective in preventing sexual misconduct. However, the practices of low staffing in student residences and no pre-service orientation on treatment topics put both students and staff at risk for misconduct.

Despite these specific shortcomings, staff and administrators have taken numerous measures to ensure the health and safety of students. The training schools have a major disconnect between policies and practice. However, there are many more cases of no written policy but actual practice approaching or realizing the performance standards than there are of written policy but no practice, or of the institutions having neither policy nor practice.

May 14, 2002


PEER: The Mississippi Legislature's Oversight Agency

          The Mississippi Legislature created the Joint Legislative Committee on Performance Evaluation and Expenditure Review (PEER Committee) by statute in 1973. A standing joint committee, the PEER Committee is composed of five members of the House of Representatives appointed by the Speaker and five members of the Senate appointed by the Lieutenant Governor. Appointments are made for four-year terms with one Senator and one Representative appointed from each of the U. S. Congressional Districts. Committee officers are elected by the membership with officers alternating annually between the two houses. All Committee actions by statute require a majority vote of three Representatives and three Senators voting in the affirmative.
          Mississippi's constitution gives the Legislature broad power to conduct examinations and investigations. PEER is authorized by law to review any public entity, including contractors supported in whole or in part by public funds, and to address any issues that may require legislative action. PEER has statutory access to all state and local records and has subpoena power to compel testimony or the production of documents.
          PEER provides a variety of services to the Legislature, including program evaluations, economy and efficiency reviews, financial audits, limited scope evaluations, fiscal notes, special investigations, briefings to individual legislators, testimony, and other governmental research and assistance. The Committee identifies inefficiency or ineffectiveness or a failure to accomplish legislative objectives, and makes recommendations for redefinition, redirection, redistribution and/or restructuring of Mississippi government. As directed by and subject to the prior approval of the PEER Committee, the Committee's professional staff executes audit and evaluation projects obtaining information and developing options for consideration by the Committee. The PEER Committee releases reports to the Legislature, Governor, Lieutenant Governor, and the agency examined.
          The Committee assigns top priority to written requests from individual legislators and legislative committees. The Committee also considers PEER staff proposals and written requests from state officials and others.
PEER Committee
Post Office Box 1204
Jackson, MS 39215-1204
(Tel.) 601-359-1226
(Fax) 601-359-1420
(Website)  http://www.peer.state.ms.us

May 14, 2002

Honorable Ronnie Musgrove, Governor
Honorable Amy Tuck, Lieutenant Governor
Honorable Tim Ford, Speaker of the House
Members of the Mississippi State Legislature

On May 14, 2002, the PEER Committee authorized release of the report entitled Health
and Safety Issues at the Oakley and Columbia Youth Training Schools.

Signature
Senator William Canon, Chairman

This report does not recommend increased funding or additional staff.

PEER Report #432                                                 pg ( i )

Table of Contents
Letter of Transmittal    ..…..............................….................................................…I

List of Exhibits         ...……………………….……….......................................…V

Executive Summary  ...............……….........…...............................................…Vii

Introduction                  ...................................................................................1

Authority                      .....……......................................................................1
Scope and Purpose       ...............……………………....................................1
Method                          .....…………………..................................................2

Background                .......………......................................................................3

Committal to a Training School   .....................................….............................3
Description of Intake and Routine Services Provided       ...…..........................4

Conclusions Concerning Health and Safety Issues ......................................7

Policies and Procedures.........................…………........................................7

Access to Medical Care ...............................................................................9
Dental Services            ...............................................................................10
Infirmary Isolation          ..............................................................................11
Privacy for Medical Screenings   ................................................................12

Medical Supervision….....................................................................................13

Medical Authority ............................................................................................13
Medical Supervision Related to Restraint Chair Use.     .................................15

Special Medical Needs of Juveniles.....................................……....................16
Care for Juveniles with Special Needs.......................…...............................16
Medical Needs........................................................……..................................17
Dietary Needs ................................................…..............................................17

Preventing Abuse of Juveniles....................................….................................18
Abuse Control Practice..............................…...................................................18
Abuse Control Policies and Procedures..........................................................19
Direct-Care Staffing ..…...................................................................................20
Pre-Service Training ........................................................…............................20

Summary         . ................................................................................................21

Recommendations  .........................................................................................23

Agency Response ...........................................................................................29

List of Exhibits
Policy and Practice Compliance with Minimum Standards For Health Services...8

Health and Safety Issues at the
Oakley and Columbia Youth
Training Schools

Executive Summary

The PEER Committee reviewed complaints related to
health and safety issues at the Oakley and Columbia Youth Training Schools operated by the Division of Youth
Services (DYS) of the Mississippi Department of Human
Services (DHS).

Complainants outlined nine (9) specific concerns relative
to the health and safety of the youth committed to thesetraining schools. The nine complaints involve four broad
areas in the administration of services, organized as follows:

· Access to Medical Care - including lack of 24-hour, 7-
day-a-week medical access; lack of dental services; lack
of infirmary isolation; and lack of privacy for medicalscreenings;

· Medical Supervision - including lack of assignment of a
medical authority and improper use of restraint chairs;

· Special Medical Needs - including lack of care and services provided to juveniles with special medical
needs;

· Preventing Abuse of Juveniles - including lack of policies, procedures, and practices to prevent sexual
abuse of juveniles.

Health and Safety Concerns

In the areas of medical access, medical supervision, special medical needs, and prevention of abuse, actual practices at the Columbia and Oakley juvenile facilities promote health and safety. However, uniformity of program operations suffers due to the absence of formal policies and procedures to govern critical components of care.

PEER found that the medical services area is without a
formally adopted set of written policies and procedures.
Therefore, the facilities are not ensuring consistency in
procedures, and in meeting minimum standards.
                                       pg ( vii)

Access to Medical Care

Although the training schools have qualified health
professionals available (medical, dental, mental health),
the facilities are not meeting health requirements and/or
minimum standards in the areas of medical staff shift
coverage and dental services.

Neither facility has on-site medical personnel during the
11 p.m. to 7 a.m. shift. However, each facility's access to
hospital emergency services and on-call arrangements with doctors and nurses help compensate for responses to medical needs. Additionally, because the facilities do not provide many routine dental services, some dental
problems are inadequately treated.

Regarding infirmary isolation, PEER found that each
facility has space available for infirmary isolation. However, because none of the infirmary rooms that are used for isolation have negative pressure ventilation systems, contagious conditions have a chance of spreading to the general clinic environment. Regarding medical screenings, the facilities should take added measures to ensure the privacy of youth.

Medical Supervision

The facilities lack policies and procedures governing
medical authority to ensure proper medical supervision of
youth detained in the facilities. Because the facilities have
not formally designated their physicians as the medical authority, it is possible for a juvenile's health needs to go
unaddressed. PEER found, however, that medical decisions at each facility are usually made by medically qualified personnel on a timely basis, rather than by administrative staff.

A lack of training and medical oversight for restraint of youth in the violent offender's chair can yield negative outcomes for youth and staff. Both facilities have policies regarding the restraint chair in their facility manuals that are consistent with correctional standards. However, these policies are not fully followed in practice. Policies also require medical authority and supervision of youth placed
in the restraint chairs.

Special Medical Needs

Qualified health-trained professionals address special
needs of training school youth at both facilities. However,
based on an examination of about 300 cases of current
residents, treatment did not match special medical needs
                                              pg. viii

identified in approximately 5% of individual treatment
plans. In general, the facilities do not ignore students with
special medical needs. However, lack of coordination and
supervision of treatment plans allow mainly dental and drug treatment needs to go unmet. PEER found that other
special medical needs such as prenatal care for pregnancies and special dietary considerations for diabetics are addressed.

Both facilities need improvements in the following areas:

· Require licensed psychologists to supervise treatment
plans rather than associate psychologists;

· Conduct monthly progress meetings;

· Make counselors at Oakley part of staffings (meetings
that assign youth to particular staff and dormitories);
and,

· Require nurses at Columbia to be present at staffings.

Preventing Abuse of Juveniles

Policies and procedures prohibiting sexual abuse, harassment, or contact are generally effective in preventing sexual misconduct. However, the practices of low staffing in student residences and no pre-service orientation on treatment topics put both students and staff at risk for misconduct.

The facilities' use of various methods to increase security decreases the likelihood of misconduct. In fact, from FY 1998 through FY 2000, the MDHS Office of Special Investigation carried out investigations of five cases of some kinds of inappropriate sexual conduct by employees at the training schools. None of the five allegations (including two involving Juvenile Correctional Officers and juveniles) were substantiated.

Summary

Actual health care practices conform to applicable policy
standards, but the written institutional policies and procedures are out of date and do not reflect the current practices. Columbia and Oakley need a major update of their Policies and Procedures Manuals in general, but particularly in the health care area in ways that are specified in the recommendations.
                                       pg. ix

Recommendations

Access to Medical Care

Policies and Procedures

1. The facilities should adopt and distribute an official version of the medical manual. All of the health service areas in the final medical manual should be reflected in the overall facility Policies and Procedures Manual. The Division of Youth Services should amend the Policies and Procedures Manuals for Columbia and Oakley, particularly for health care, to reflect all health care areas. The Division of Youth Services should substantively review the draft manual in light of this report, circulate it to the health care and administrative staffs of Columbia and Oakley, and set a date for its adoption under the authority of the physicians and the facility administrators.

2. Columbia and Oakley should develop a formal system
for processing juvenile complaints about health care matters for the Policies and Procedures Manuals. This complaint system can incorporate the informal system currently in use.

3. The Division of Youth Services should develop and implement (at the facility level) a program to monitor medical area needs and the delivery of health services, and a program to assess and assure quality for all health care services at both Columbia and Oakley.

24-hour, 7-day-a-week Medical Access

4. In order to meet the Morgan v. Sproat standard, the Department of Human Services and its Division of Youth Services should facilitate the timely hiring and retention of personnel to fill all positions allocated for medical personnel who staff the health care clinics at Columbia and Oakley on a priority basis. Both facilities should either change the work schedule of nurses to allow coverage during the 11 p.m. to 7 a.m. shift or hire nurses for this shift.

5. Division of Youth Services should significantly update the Columbia and Oakley Health Care Policies and Procedures Manuals to incorporate a number of accessibility practices already being used. These include nursing services, labs and x-rays, emergency health services, and in-patient hospitalization.
                                        pg. x

6. The Division of Youth Services should modify its health care policies and procedures to include use of nurse practitioners or physician assistants, as is currently the practice.

7. Each of the training schools should formally adopt a written agreement with a local hospital regarding admission of juveniles and provision of medical services that cannot be provided in the facility. Dental Services
8. The Division of Youth Services should require the dentist for Oakley to document the results of the dental examination for each juvenile entrant on a dental chart, include it in the juvenile's medical file, and monitor files for compliance.
9. Columbia and Oakley should immediately provide a
full continuum of dental services in order to meet the Morgan v. Sproat standard of care. Minimum standards require diagnosis and treatment that includes non-emergency, preventive, and maintenance dental care. The Division of Youth Services should assure that the program addresses all aspects of dental care including: initial examination; hygienic and prophylactic services; preventive education; non-emergency services (such as fillings for cavities; and emergency services. Dental services may be provided either on-campus at the dental rooms that are in various stages of being equipped and fixed to operate (this will mean some modernizing of equipment such as the dental chair's tools and acquisition of dental treatment supplies), or at dental offices off-campus, or a combination. DYS should contract with available dentists in Columbia rather than with dentists in
Jackson to provide dental services.

10. In the program of dental services at Columbia and
Oakley, the providers should pay particular attention to the matter of the status and treatment of wisdom teeth, especially in the older juveniles at Oakley. There are notations by the nursing staff on a number of "clinic pass" complaints of painful wisdom teeth at Oakley, and invariably all that was done was to administer temporary pain relievers to sore gums.

11. Columbia and Oakley should specifically include in the
annual training of all staff having contact with juveniles the proper means of preserving and transporting avulsed (ripped or severed) teeth.

12. All entities (Division of Youth Services, Oakley,
Columbia) should contract more service time with
                                        pg xi

dentists so that the dentists can perform necessary
procedures such as fillings, and also have time for more thorough charting of dental conditions. Infirmary Isolation

13. The Division of Youth Services should ensure that the
new clinic that will begin construction this summer will have a true isolation room as outlined in the construction plan.

14. The Division of Youth Services should develop a policy statement on the use of the infirmary and isolation beds.
15. The Division of Youth Services should update the
Columbia and Oakley Policies and Procedures Manuals
to incorporate current infirmary and clinic practices.

Privacy for Screenings

16. The Division of Youth Services should specify in the
Columbia and Oakley Policies and Procedures Manuals current practices regarding clinic facilities, privacy, verbal consent from patient (for rectal or pelvic examinations), and the conduct of examinations.

17. Columbia and Oakley should move as many aspects as possible of the screening process to private areas.
Columbia should consider the use of a partition next to the nurse's station where screenings occur in order to keep the process out of view of those in the waiting area.

Medical Supervision

Medical Authority

1. The Division of Youth Services should include a written policy in the Health Care Policies and Procedures Manual that standards of medical care and access to that care are decided by qualified medical personnel, and not by any other institutional staff.

2. The Columbia and Oakley Policies and Procedures Manuals need an explicit statement of policy regarding
the primacy of qualified health professionals making
final medical judgments in all cases. The policy statement should clarify the role of the directors and duty administrators in decisions to transport juveniles to off-campus health care facilities, as they must be accompanied by security personnel and use training school vehicles in many instances.
                                        Pg  xii

3. At a minimum, the facility directors should formalize
the role of the physician as the medical authority through policy or distribution of memoranda to staff.

4. Facility directors should meet with the physicians on a
quarterly basis to review medical services and medical
needs.

Restraint Chair Use

5. The facilities should establish monitoring procedures
for juvenile in restraints, provide appropriate training, and require reporting of restraint use to a physician or psychologist.

6. The Division of Youth Services should clarify statements in the facilities' Policies and Procedures Manuals concerning the conditions under which various types of restraints, including the restraint chair, will be used. The Division should define procedures guiding the use of fixed restraint and how long, when, where, and how restraints are to be used.

7. The Division of Youth Services should include a written statement in the facilities' Policies and Procedures Manuals regarding emergency distribution of restraint equipment. Written records should be maintained of those who routinely and non-routinely receive restraint equipment, for accountability purposes.

9. The Division of Youth Services should include a written statement in the facilities' Policy and Procedures Manuals that specifies annual training for the appropriate staff in the safe and appropriate use of physical, mechanical, and chemical restraints.

10. The Division of Youth Services should include a written statement in the facilities' Policies and Procedures Manuals that specifies policy on direct-care staff receiving annual training on de-escalation techniques.
                                          Pg. xiii

Special Needs

1. Columbia and Oakley staff responsible for the Individualized Treatment Program (ITP) for each juvenile should make sure there is a meaningful medical/health care component to each one, and that appropriate health care staff contribute to progress reports on meeting ITP goals.

2. The Division of Youth Services should thoroughly update the Columbia and Oakley Policies and Procedures Manuals regarding the treatment of all categories of special needs students. Areas that need to be addressed specifically include:

· A complete policy statement about dietary practices;

· A policy statement about nutritionally adequate diet incorporating the Food Guide Pyramid;

· The process for using special medical and dental diets;

· Policy recognition of the greater risk of suicide and other psychological problems among incarcerated girls than among boys.

3. Licensed psychologists should meet with counselors
on an intermittent basis to discuss the needs of youths, and to ensure the treatment plans are followed. Medical personnel should also be present at "staffings" to ensure that special medical needs are accurately represented on the treatment plans.

4. Programmatically, licensed psychologists and health
care staff should participate in monthly progress report meetings on the juveniles prior to parole reports.

5. Columbia should bring written policy regarding suicide
precautions in line with practice. Columbia should use
the same written policy that Oakley uses regarding
treatment for students on the suicide precaution list. The policy calls for counseling rather than using punitive or disciplinary measures.

6. Registered nurses should give medical counseling
pertaining to mastering special medical conditions
(perhaps group sessions in the dormitories) to affected
youth. This should be coordinated with the counseling
                                            Pg xiv
staff to ensure connection between medical observations and treatment.

Preventing Abuse of Juveniles

1. The Department of Human Services should ensure that
the budgets for both facilities support staffing all living areas with at least two counselor aides or juvenile correctional officers at all times.

2. In addition to the informal system currently in operation, the Columbia and Oakley health care policy should have a formal grievance procedure for youth to lodge complaints about abuse, including sexual abuse.

3. The Division of Youth Services should include a written statement in the facilities' Policies and Procedures Manuals to inform juveniles and staff that those who report alleged abuse will be protected from retaliation.

4. The facilities should revise student handbooks to incorporate policies regarding appropriate staff contact with students.

5. Upon hiring, new employees should receive an additional 32 hours of pre-service orientation on topics that would promote the treatment and understanding of youth. These topics should include, but should not be limited to, stages and pathways of adolescent development, communication skills that include verbal de-escalation techniques, behavior management, basic training related to medical care, effects of drug use, and potential negative effects of isolation. The facilities should consider pairing new counselor aides and juvenile correctional officers with counselors for this orientation.

Health and Safety Issues at the
Oakley and Columbia Youth
Training Schools

The PEER Committee authorized a review of complaints
related to health and safety issues at the Oakley and
Columbia Youth Training Schools operated by the Division of Youth Services of the Mississippi Department of Human Services (MDHS) pursuant to the authority granted by MISS. CODE ANN. Section 5-3-57 et seq. (1972).

PEER sought to determine whether health and safety
measures practiced at the Oakley and Columbia Youth
Training Schools are sufficient to assure that juveniles
receive necessary medical services and are protected from harm. Complainants cite a number of concerns, including the following:

· Lack of 24-hour, 7-day-a-week medical access;

· Lack of dental services;

· Lack of infirmary isolation;

· Lack of privacy for medical screenings;
· Ignoring students with special needs;

· Allowing medical decisions to be made by administrative
staff rather than doctors;

· Placing students in restraint chairs without proper
medical supervision;

· Correctional guards participating in sexually
inappropriate conduct with juveniles; and,

· Lack of a comprehensive manual of policies and
procedures to govern the conduct of facility employees.
PEER has organized these concerns in such a way as to
determine the following:
                                                                                   Pg 1

· Whether medical services are available and provided to
assure that juveniles in each facility are healthy and safe;

· Whether the administrators of the facilities provide for
proper medical supervision of juveniles;

· Whether the facilities meet the needs of juveniles who
have special needs (for example, disabilities, diabetes);

· Whether facility procedures and practices reduce the
risk of sexual abuse of juveniles by facility personnel or
other juveniles.

PEER conducted a file review in February 2002, of current
juveniles committed to the Oakley and Columbia Training
Schools through December 31, 2001. This enabled the
treatment plans to be in effect for at least six weeks. The
review consisted of an analysis of the individual treatment
plans and medical files of each resident. PEER also reviewed procedures for obtaining hospital care of juveniles from FY 1999 through the first half of FY 2002. PEER inspected the facilities, interviewed staff, reviewed policies, procedures, and practices of each facility, and reviewed budget and appropriation information.

PEER also reviewed the 1977 health and safety requirements promulgated by the federal district court case, Morgan vs. Sproat class action lawsuit, against the Oakley facility. The judgment for the case resulted in court-ordered minimum standards for programs of the Oakley facility. These standards also apply to other facilities operated by MDHS. The Oakley and Columbia Juvenile Training Schools are not accredited by juvenile correctional standards. However, where minimum standards promulgated by Morgan vs. Sproat did not exist, PEER used standards from other sources. These include the American Correctional Association (ACA), the National Commission on Correctional Health Care (NCCHC), the Office of Juvenile Justice and Delinquency Prevention (OJJDP), and the Civil Rights for Institutionalized Persons Act (CRIPA).
                                                                                  Pg 2

Mississippi's two state-operated juvenile training schools
provide services to juvenile offenders who have been
committed by the state's Youth Courts. One, the Oakley
Training School (more recently referred to as the Mississippi Youth Corrections Complex) currently holds male offenders between the ages of 15 and 18 years of age. This facility is located in northeastern Raymond (southern Hinds County). The second facility, the Columbia Training School, holds female offenders from the age of ten to 18, and male offenders between the ages of ten and 14. The Columbia Training School is located in northern Columbia (Marion County).

Both campus-based facilities offer juveniles who have been committed there as a result of offenses, an opportunity to receive various rehabilitative and correctional services under the care of administrative and professional staff.

Statutory Authority for Commitments

Under MISS. CODE ANN. Section 43-21-605, any of Mississippi's youth courts may transfer custody of a juvenile offender to the Department of Human Services for committal to one of the training schools. Commitment of youth to a correctional training institution entails provision of specialized treatment services. This treatment involves several components; namely, health care, education, counseling, vocational, recreational, nutritional, and optional religious services. The Columbia and Oakley Training Schools have also instituted a training component based on a regimented military model of discipline as an integral aspect of the training and rehabilitation experience. This report focuses on the health and safety components within the institutional programs.

Types of Dispositions

The health, safety, and rehabilitation of youth committed
to the state's training schools are primary concerns in providing treatment to juvenile offenders. Commitment to the training schools is only one of many dispositional alternatives that Youth Court judges employ. Other alternatives include restitution to the victims, warnings, supervision, fines, special services, suspension of licenses, counseling, referrals to agencies or institutions, transfer of
                                                                                    Pg 3
custody to other individuals or agencies, or wilderness
programs.

Type of Offenses and Number of Youth Committed

According to the 1999 annual statistical report of the
Division of Youth Services, cases are classified according to three categories of disposition: delinquent offenses (for example, disorderly conduct/disturbing the peace, assault -all except aggravated assault, and larceny - shoplifting);

· status offenses (for example, ungovernable
behavior/incorrigibility, truancy/educational neglect,
and running away); and,

· "other" offenses (for example, drug offenses, aggravated assault, rape, manslaughter by negligence, and
murder/negligent homicide).

Delinquent and status offenses account for approximately 97% of cases whereas "other" offenses account for less than three percent. The report notes that the most reported age of offenders was sixteen years of age.

According to the Division of Youth Service's 2000 annual report, approximately 10% (or 2,320) of the 22,806 cases disposed of during CY 2000 resulted in commitment to the Youth Training Schools. The Columbia Training School served approximately 900 youths in 2001, and Oakley served approximately 1,400. During 2001, the 200-bed Columbia facility maintained an average daily population of 195, and the 465-bed Oakley facility maintained an average daily population of 337.

Intake Services (Provided during Commitment)

Intake Screenings: General health, dental, vision, inoculations,
STD/HIV, pregnancy

On their first day of residence at the training school, the
juvenile is received through an intake process that includes receipt of the youth from the escorting law enforcement officer with appropriate court documents;
photographing and indoctrinating the youth on the rules
and customs of the facility; assessments in education,
psychology, dentistry, and physical fitness.
                                                                                    Pg 4
The youth is escorted to the clinic for another part of the
intake procedure, the health screening. The nurse on-duty
checks and records the vital signs on a form, then records
the youth's self-reported health history on the same form.
The nurse makes notation of any unusual markings on the
body such as cuts or tattoos, then diagrams these markings on a pictorial representation of the body. A complete blood count and urinalysis are also conducted.

Medical and Dental Examinations (Conducted by Doctors)

Within two weeks of residence, youths see a physician for
a physical examination, and a dentist for a dental exam.
The physician checks for many conditions such as lung
clarity, presence of hernias, and/or prior medical conditions to determine regimens and activity restrictions.

Routine Services (Provided during Commitment)

Routine Care (Doctors, Nurses, Lab Work, Special Needs)

Once the youths have completed the full intake process,
they receive medical attention for health concerns that
arise. For example, nurses administer prescribed medications at appropriate intervals and respond to sick call requests of the youths on a daily basis. The physicians visit one day a week to respond to major health concerns. Such medical attention may require x-rays, lab work, or other tests to determine the diagnosis. Community resources are used for these tests including local hospitals and medical specialists. Physicians also prescribe special diets for diabetics and recommend activity levels for the military and recreational training areas.

Emergency Care (Hospitals)

If a physician is not available to make medical determinations, or the youth is experiencing pain that requires immediate attention, security guards and available medical personnel transport the youth to a local hospital for diagnosis and treatment.

Aspects of Care Designed to Assure Safety of Juveniles

Security Officers

Each facility employs security officers for a number of
functions. Their primary duties are to guard the entrance
and exit to the facility; to conduct surveillance of the
campuses by driving around the facilities; and to intervene
in situations where staff needs extra assistance.
                                                                                    Pg 5

Security Levels

The Columbia facility is a minimum-security facility. Each
residence has open-bay dormitory rooms, with ease of
entry and exit within the dormitory. The Oakley facility
has three levels of security within the housing units -
minimum, medium, and maximum. Minimum-security
dormitories are located on the open campus. These units
have open-bay rooms with a common living area. The
medium-security housing units are within an enclosed,
fenced structure that also contains the school and
recreation area. The rooms within these units are situated
around pods. Each pod has about 25 cells to which
juvenile correctional officers control entrance and exit to
individual cells. The maximum-security unit is located on
the Oakley campus, but is shared with the Columbia
facility. Security officers supervise the living quarters in
this facility, and control the entrance and exit to the
facility and rooms at a central location.

Security Checks

Security officers and duty administrators conduct routine
checks and spot checks on all buildings during evening,
night, and morning hours. Routine checks happen on
regular intervals, whereas spot checks are unannounced
and random.
                                                                                    Pg 6

Conclusions Concerning Health and Safety Issues
--------------------------------------------
In the areas of medical access, medical supervision, special medical needs, and prevention of abuse, actual practices at the Columbia and Oakley juvenile facilities promote health and safety; however, uniformity of program operations suffers due to the absence of formal policies and procedures to govern critical components of care.

Factors that affect health and safety within the Oakley and
Columbia Youth Training School environments range from
adequate policies and procedures to availability of
services.

Complainants outlined nine (9) specific concerns relative
to the health and safety of the youth committed to these
training schools. The nine complaints involve four broad
areas in the administration of services, organized as
follows:

· Access to Medical Care - including lack of 24-hour, 7-
day-a-week medical access; lack of dental services; lack
of infirmary isolation; and lack of privacy for medical
screenings;

· Medical Supervision - including lack of assignment of a
medical authority and improper use of restraint chairs;

· Special Medical Needs - including lack of care and
services provided to juveniles with special medical
needs;

· Preventing Abuse of Juveniles - including lack of
policies, procedures, and practices to prevent sexual
abuse of juveniles.

This report makes careful distinction between what the
facilities have in policy, and what they are actually doing
in practice. PEER found that policies and procedures were
generally lacking throughout most areas governing the
provision of services to the juvenile population, which we
chose to address first in the following.

PEER found that the medical services area is without a formally adopted set
of written policies and procedures. Therefore, the facilities are not ensuring
consistency in procedures and in meeting minimum standards.
                                                                                                         Pg 7

Both facilities have manuals that address all aspects of the training schools. However, the medical sections of the facilities' manuals cover only two areas - dental and
sexually transmitted disease/human immunodeficiency
virus (STD/HIV). It is not clear why only these two
particular areas are highlighted in the facilities' manuals.
The medical section mentions nothing about medical
services available through nursing or physician staffs,
referrals for medical treatment, or emergency services.
Both facilities have departmental manuals addressing
limited components of care that give further guidance to
employees. While Columbia has a nurses' manual, Oakley has a draft medical services manual. This manual was circulated to medical personnel at Columbia and Oakley for input, but has not been seen by or distributed to the staff of either facility. At the time of the review, a health authority had not signed the draft medical services
manual. Therefore, PEER did not consider the policies of
the draft medical manual for this review.

NOTES: No = Facility has no written policy or practice offering guidance on the minimum standard. Partial = Facility practices some aspects of minimum standard. Yes = Facility has a written policy or practice offering guidance on the minimum standard.

SOURCE: Final Judgment for the 1977 Morgan vs. Sproat Case
                                                                                                                         Pg 8

Actual practice varies by complaint area. There are many more instances where practice exists without policies, and fewer instances where policies exist without practice (see Exhibit 1). In two major areas, 24 hour medical staffing and progress meetings, there is neither policy nor practice in compliance with minimum standards.

Although the training schools have qualified health professionals available (medical, dental, mental health), the facilities are not meeting health requirements and/or minimum standards in the areas of medical staff shift coverage and dental services.

24-hour, 7-day-a-week Medical Access

The first project objective is to determine if medical services are available (accessible) and provided at Columbia and Oakley to assure that juveniles in each facility are healthy and safe. This area, in particular, shows the necessity of obtaining both written policy and procedures information and observation of policy practice as well. Minimally, the court order requires the facilities to provide qualified medically-trained professionals (physicians, nurses, dentists, and psychiatrists or psychologists) who are available to address a variety of youths' medical needs; complete health screenings (hearing, vision, dental, and inoculations); complete medical and dental examinations, diagnosis, and treatment; sufficient medical staff to allow at least one medical nurse or licensed practical nurse to be on duty at all times, 24 hours a day; and, the establishment of an overnight infirmary.

Each training school contracts with a physician who visits
the campus one day a week to perform physicals and to
respond to sick call requests that are beyond the scope of nursing services. The physician, who has admitting
privileges at a local hospital, also sees youths if they
require medical services at the hospital. Youths also receive other necessary medical attention - outpatient and inpatient care, labs, and x-rays. Nurses have a variety of duties, including administering scheduled medications, and administering various non-prescription medications such as fever reducers, pain relievers, and anti-bacterial
ointments. Nurses also maintain pharmaceuticals, monitor changes in conditions, and contact physicians for
consultation or emergencies.
                                                                                 pg 9

Neither facility has on-site medical personnel during the 11 p.m. to 7
a.m. shift. However, each facility's access to hospital emergency services
and on-call arrangements with doctors and nurses help compensate for
responses to medical needs.

A potential shortcoming concerns the 24-hour, 7-day-aweek access to medical care for the juveniles at both
institutions. Shortfalls in medical staff (for example,
Columbia currently has three of six nursing positions
filled) mean that the third shift is usually covered by "on
call" arrangements. The two clinics located on the Oakley
campus are staffed by a total of eight nurses. Two registered nurses (RNs) and two licensed practical nurses
(LPNs) staff the Unit I (medium security) clinic. Four licensed practical nurses (LPNs) currently staff the Unit II
(open campus) clinic.

If juveniles use the clinics' infirmaries, nurses make
arrangements to be physically present overnight as
needed. Medical staff constantly juggles rotations to
increase coverage as much as possible, depending on
availability of staff, needs of the juveniles, and holidays. A collateral problem in the 24-hour/7-day coverage by
medical staff is that none are paid overtime. When
medical staff cover an overnight shift, they are given
compensatory time as compensation, which, because of
medical staff shortages, they are rarely able to use. Half of the nursing staff at both facilities are either at or near the limit of accrued compensatory of 240 hours imposed by the Fair Labor Standards Board. The facilities must pay
these nurses for any time over this level, and find ways to allow leave in order to lower this accrued time.

Dental Services

Because the facilities do not provide many routine dental services, some dental problems are inadequately treated.

Routine dental services, such as prophylactic and other
non-emergency treatment, are not available to juveniles at either Columbia or Oakley. The dental treatment available is mostly emergency tooth extraction, with little else.
Minimum standards outlined by Morgan v. Sproat require
complete dental care. Everything from dental screenings
to dental care for all indicated problems would be part of
a complete dental program. Policy statements in the area
of medical access are in compliance with applicable
standards.

Dental screenings and dental examinations are separate
functions carried out by separate medical staff. During
the intake procedure, nurses screen dental needs by
interviewing the youth. Self-reports by the youth reveal
that about 80% consider themselves to have dental ( pg-10) problems. Dentists conduct dental examinations. PEER found that the dentist for Oakley does not use a dental examination form that diagrams teeth and demonstrates which teeth need attention (Columbia's dental contract has not been enacted during FY 2002). Results of the review of juvenile files invariably showed that the youth had been examined; however, no findings were recorded on the form. Furthermore, the treatment plan invariably stated that the youth would receive "routine dental care." Currently, the dentist on contract for Oakley visits the campus once a week for half a day. PEER found rare occurrences of dental procedures performed in his private practice office. Therefore, it is evident that the dentist only addresses the most serious presenting problems. Routine care for dental pain involves the administration of Ora-gel by the nurse to the tooth or gum.

Infirmary Isolation

Each facility has space available for infirmary isolation. However, because none of the infirmary rooms that are used for isolation have independent ventilation systems, contagious conditions have a chance of spreading to the general clinic environment.

Infirmary isolation is comprised of two major factors.
First, persons with conditions that necessitate medical
care apart from the general population require physically
separate medical supervision and bed rest. Second, true
isolation reduces the chance of any contagions from
entering the general population.

The clinic for the Columbia campus, built in the 1970's,
contains four infirmary rooms with two beds in each
room. On occasions where a juvenile has a contagious
condition, and should be isolated, the facility uses one of
the rooms for single occupancy isolation. Each of these
rooms is also equipped with toilet areas for ease of access of the infirmed. There are two separate clinics on the Oakley campus. The clinic on the open campus (minimum security) was built in the 1940's. The infirmary is one large room capable of holding eight beds. This large room has a separate toilet room for the convenience of the infirmed. A separate room that contains one bed is available, but is currently used for storage. This room is not equipped with a separate toilet area or room. The area that is used as a clinic in the medium security unit was built in 1998. This area was designed as an intake unit, not a clinic. During construction of the medium security facility, the clinic was not constructed due to costs involved. Therefore, the rooms that are used for infirmary isolation are typical cells with toilets in the cell room. None of the rooms on either campus operate on a negative pressure ventilation system to prevent circulation of contagions. Oakley is currently planning the construction of a modern health clinic that will have two isolation rooms with negative ventilation.              Pg-11

Privacy for Medical Screenings

PEER found that some aspects of the medical screening process requiring disrobing do not assure privacy because a juvenile can be viewed by others.

Minimum standards do not address the issue of privacy
for medical screenings. These standards only require that medical screenings take place upon the entry of the youth to the facility. However, standards from Juvenile Justice and Delinquency Prevention require privacy during interviews, exams, and treatment in order to promote the youth's trust in the medical care process.

Medical screenings and medical examinations occur at
both training schools. While nurses and other responsible staff conduct screenings during the intake process on the student's first day, physicians conduct medical exams
within two weeks of the student's commitment. The
physician conducts physicals in a private examining room. However, screenings usually occur next to the nurse's station. Additionally, security officers and military
training instructors instruct youth on delousing and changing their everyday clothing to facility uniforms.

There are two occasions requiring disrobing, during the
screening process that may compromise privacy.
Screenings are conducted next to the nurse's stations at
both facilities. Frequently, other students and staff are in
the waiting area just outside of the screening areas. When the nurse takes note of unusual markings on the body during the intake screening, the youth will have to allow the nurse to see areas where the markings exist. Nurses document the location and form of the markings (tattoos, gang signs, bruises, cuts, etc.) on a form reflecting the front and back of the human body. The second occasion that requires disrobing is when the student showers, and makes a change of clothing to facility uniforms. The military instructor or the security officer who escorts youth to the shower area instructs and supervises students in placing a delousing lotion on their bodies to get rid of insects (such as lice) that they might bring into the environment with them. Whenever groups of youth are escorted as a group for the change into uniform, there will be a compromise in privacy. Although both of these areas that may compromise privacy are conducted under the supervision of responsible staff, consideration of privacy in the foregoing areas should be reflected in a comprehensive Policies and Procedures Manuals.                                                         Pg. 12

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