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Continues from previous Page   Joint Legislative Committee on Performance
Evaluation and Expenditure Review (PEER) Health and Safety Issues at the Oakley
and Columbia Youth Training Schools  Page 13 to 36 End

Report to
the Mississippi Legislature

Complainants voiced two primary concerns over medical supervision for juveniles. These involve the assignment of authority to make medical decisions and supervision of juveniles when confined to a restraint chair.

Medical Authority

The facilities lack policies and procedures governing medical authority to ensure proper medical supervision of youth detained in the facilities.

The second project objective is to determine if the training school facilities exercise proper medical supervision over the juveniles housed there. Minimum standards
promulgated by the court order do not directly outline
standards for a medical authority. However, the standards do require that the facility have a physician either on staff or through a contractual relationship. Other sources of standards for juvenile corrections, including the American Correctional Association and the National Commission on Correctional Health Care, clearly speak to the necessity of a designated medical authority. These include coordination of health services, quarterly meetings with the facility administrator and submission of statistical reports, and final medical judgments resting with a licensed physician.

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.

Both campuses have physicians on contract to DHS to
provide diagnosis and treatment to students of the
training schools. Although both facilities contract with a
physician to provide medical care, neither written policy
nor procedures formally designate the physician as the
health authority. Whereas the administrator for the
Columbia facility has allowed all medical decisions to be made by the facility's medical staff, the administration of the Oakley facility has participated in medical decisions. The administrator stated that the notification procedure was recently changed to calling the physician first. (The director did not provide PEER with a policy statement to that effect). The physicians direct the nursing staffs in the matter of medical treatment decisions for juveniles. Each campus has a registered nurse (RN), who supervises the licensed practical nurses (LPNs) making up the rest of the staff. However, other procedures that would ascertain the physicians as the health authority are lacking. Medical authority would be ascertained by: making the final decision for medical treatment clearly be the physicians'; having quarterly meetings between the facility directors
(Pg 13) and the physicians; and, authorizing physicians to make decisions regarding such issues as placement of students in restraint chairs. The facilities need improvement in these areas regarding policies and practices.

Although the facilities have not formally designated physicians as the
medical authority, medically qualified personnel, rather than administrative staff, tend to be responsible for making medical decisions at each facility on a timely basis.

Interviews with medical staff on both campuses elicited no
complaints from them of administrative interference with
medical decisions, or of administrative staff's denial of
juvenile access to medical services. There is a youthinitiated
process for access to the Health Clinics on both campuses; all staff honor that process. Health emergency case history chronologies in juveniles' medical files (all of those necessitating hospitalization in the last 30 months) corroborated the interviews; there were no cases of unexplained or unwarranted delays in getting youths to the proper places for emergency medical care, and no documentation of non-medical staff intrusion into or preemption of the medical decision-making. What is lacking is a written policy making these procedures clear. Duty administrators and facility directors were often involved in the emergencies, either by being notified by health care professionals, or in helping to coordinate the necessary personnel to respond to the emergency (e.g., assigning security personnel to drive/accompany juvenile offcampus).

Policies of each facility require documentation of services/decisions and maintenance of a medical record, thereby yielding orderly care.

According to ACA and NCCHC standards, health records for juveniles in the facilities should include files on the completed receiving screening form, diagnoses and treatments, labs and x-rays, prescribed medications, health service reports (for example, dental, mental health, and consultations), consent forms, and discharge summary of hospitalization. The standards also state that the active health record should be maintained separately from the confinement record to ensure confidentiality. The medical files for every juvenile are thorough and complete, from the entering examinations through routine complaints (and responses to them) to hospital or other specialization (including laboratory) reports. All medications administered are recorded. Often there is some record of prior health treatment, especially if it is germane to an on-going health condition or problem, also included in the medical file. Medical personnel maintain active health records separate from confinement records. (pg 14)

Medical Supervision Related to Restraint Chair Use

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.

Minimum standards only mention training staff in deescalation techniques. However, other juvenile correctional standards, ACA in particular, require the approval of the health authority for placement of a student in a restraint chair. 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 require the medical or mental health service areas to provide training for the proper supervision of students placed in restraint chairs. Policies also require medical authority and supervision of youth placed in the restraint chairs. Neither facility contacts their physicians when staff places a youth in the chair. Oakley nurses stated they have no involvement in supervision of the restraint chair. Columbia nurses only check tightness of restraints around wrists and ankles, but they do not conduct medical checks such as blood pressure. On the other hand, nurses of both facilities check on and document the condition of students who are placed in the timeout cells.

Oakley and Columbia officials report using the restraint
chair (violent offenders chair) on rare occasions. Reportedly, these occasions involve the same person who
has habitual violent behaviors. This chair has at least six areas of restraint (wrists, ankles, torso, and lap), one of which involves a key lock. Training records show no evidence of training by medical or mental health
professionals. Although staff did not mention any medical complications from youth placed in the restraint chair, staff reported other unexpected behaviors. Nurses mentioned that youth restrained in the chair often spit at staff. However, nurses do not conduct medical checks and physicians are not notified when students are placed in restraint chairs.

Policy and procedure for each facility embodies the state standard of 32 hours of in-service training annually. Training records indicate this standard is being met, but the substance of the training is a matter of concern. Training records indicate that the nursing staffs are often training themselves, and often going over internal procedures. Medical supervisors could do much more in developing the content of in-service training. (pg 15)

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 identified in approximately 5% of individual treatment plans.

Care for Juveniles with Special Needs

The third project objective is to determine if the facilities
meet the needs of juveniles with special medical
conditions (e.g., disabilities, diabetes, etc.). Minimum
standards put forth by Morgan vs. Sproat require that the
facilities have treatment plans for each youth, and that the
treatment plans are supervised by a licensed psychologist. Once physicians identify special medical needs, a plan for care and treatment is recommended by the physician, and should be accurately reflected in the treatment plan.

Special medical needs are identified in the Individual
Treatment Plans or in medical files. Medical records indicate referrals to health specialists when necessary, including hospital laboratories for diagnostics and psychiatrists for mental health assistance. Female juveniles are tested for pregnancy, and pregnant girls have the full range of prenatal care, including regular ob-gyn visits, diet and dietary supplements (vitamins, etc.), and exercise restrictions to walking. Color-coded wristbands worn by juveniles identify physical restrictions for program purposes. A set of protocols guides staffs' attention to and treatment of juveniles who are suicide risks. There are two needs not being met. One is dental treatment, described above. The second, particularly on the Oakley campus, is a systematic treatment regimen for drug and alcohol abuse. Around 80% of juveniles committed to Oakley enter with some level of drug use and/or abuse. Counselors try their best, and are able to offer group sessions on drug and alcohol abuse education. But short time stays and the other elements of the program make it difficult to address the experience of drug abuse in meaningful ways.

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.

Minimum standards for the facilities state that residents'
treatment plans are to be monitored by a licensed
psychologist. Other sources for juvenile corrections
available through the American Correctional Association
(ACA) as well as the National Commission on Correctional Health Care (NCCHC) also clearly state that special needs of juveniles must be met. There are several standards from (pg 16) these and other sources concerning special needs (physical, including pregnancy; mental, including suicide; and dietary, including diabetes).

Medical Needs

The existence of policies and procedures for
accommodating juveniles with special needs varies by
need. Departmental policies for mental health are the
most comprehensive for treatment of these special needs.
Suicide prevention and intervention procedures are
outlined (treatment is often obtained by practitioners in
the community), as well as drug and alcohol counseling
(though treatment is not available). In practice, the
physician recommends restricted activities for juveniles
with conditions such as heart murmurs and asthma, and
medical personnel write dietary schedules for diabetics.
However, the overall facility policy manual contains only
one standard for dietary content. It states, "All meals
served to students and staff must be exactly the same."
The facilities do not contract with a licensed dietician for
consultation on meals. However, training records indicate
that the food service supervisors attend sessions on
special meal preparation.

Dietary Needs

Both facilities provide special diets for juveniles with
diabetes or other dietary needs. The medical staff specify
the appropriate diet, send a written "dietary consult" to the
cafeteria staff who produce the specified diet, and monitor
the diet's results (through glucose measuring, or other
observations) and adjust as necessary. The medical files of current juveniles who are diabetic show prescribed diets between 1,800 and 2,200 calories per day. There are
further medical notes prescribing appropriate snacks
daily, and forbidding the consumption of certain foods.
There is a clearly established process on both campuses to accommodate special dietary needs among the juveniles. What is missing is a written policy reflecting these
practices.

Although medical examination results are translated into an individualized treatment plan, there are several occasions where the juvenile's treatment plan does not reflect their special needs.

The medical examination form used by the physician
indicates special restrictions the doctor determines are
necessary for special needs juveniles. PEER found that lack of monitoring results in some needs (such as activity
restrictions for asthmatics, and certain physical and mental problems) not being accurately recorded in individual treatment plans. Both facilities conduct "staffing" meetings in order to ensure all information  (pg.17) needed for the juveniles have been received and to assign the student to a counselor and dormitory. However, "staffings" at the Oakley campus do not include the counselor. (Counselors at the Columbia campus are an integral part of the "staffings"). Medical personnel at Columbia rarely attend "staffings" due to workload and availability of nurses. However, they do send medical information on the student to the meetings. Neither facility has intermittent team meetings to discuss progress of the students. Additionally, the licensed psychologists do not provide direct supervision over the treatment plans for the students. Lack of cohesive procedures for monitoring treatment plans will allow inconsistencies between medical findings and treatment of special needs students.

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

No clear evidence
exists of juvenile
correctional officers
engaging in sexual
misconduct with
students.

The fourth program objective is to determine whether facility procedures and practices prevent sexual abuse of juveniles by facility personnel or other juveniles. All of the structural elements of such a system are in place. DHS and DYS have codes of ethics for their employees that are incorporated into the Policies and Procedures Manuals for the training schools. Written codes of ethics prohibit employees from using their official positions to secure privileges for themselves or others and from engaging in activities that constitute a conflict of interest. Facility Policy and Procedures Manuals include a strict prohibition
against any sexual contact by employees with juveniles.
The manuals also address student protection from juvenile-on-juvenile violence and sexual abuse at several points including student discipline; enumeration of student minor, serious, and major violations of conduct;
and the student disciplinary code.

Abuse Control Practices

The DHS Division of Program Integrity, Office of Special
Investigations, is the enforcement arm responsible for
investigating any case of employee-juvenile sexually
inappropriate conduct. A Mississippi Child Abuse Central
Registry keeps the names of known child abusers, which
assists DHS (and others) from knowingly hiring a child (pg 18 ) abuser. There is not a formal complaint system that juveniles can use to report such abuse, but interviews with staffs at both schools strongly suggest that informal
complaints in such an instance would be made and be
heard. In fact, from FY 1998 through FY 2000, the DHS
Office of Special Investigation carried out investigations of
five cases of some kind 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. Much of the
program at the training schools for the juveniles aims at
developing respect, self-discipline, and order. The Policies and Procedures Manuals and Cadet Handbooks define student discipline, minor, serious, and major violations of conduct, and the process for investigation and treatment of disciplinary violations. While incidents happen, they are identified and dealt with in appropriate ways.

Abuse Control Policies and Procedures

The court order offers no minimum standards regarding
ethical behavior between what was then referred to as
"cottage parents" and juveniles under their care and supervision. However, minimum standards from Morgan
vs. Sproat address staffing levels for the dormitories.
These standards require one caregiver to every 20
juveniles. Although this minimum is being met, all staff
that PEER interviewed believe this level is dangerously low, and that at least two caregivers should be present at all times in the dormitories.

The training schools are residential facilities that employ
juvenile correctional officers and counselor aides to
supervise and reinforce the program goals for youths
during the evening, night, and early morning. Policies and
procedures must exist to minimize, if not eliminate,
misconduct that has the added opportunity to occur in a
residential facility. The facilities have numerous policies
and procedures that reinforce appropriate interactions
among staff and students, and to control misuse of
position or misconduct in general. The facility policy
manual clearly outlines policies against and procedures for handling sexual harassment and rape. The facilities also use other methods to increase security and decrease the likelihood of misconduct. According to the facility
directors, the training schools conduct security checks
throughout the night. Security officers conduct 24-hour
checks throughout the campus, and duty administrators
conduct both routine and spot checks from the afternoon
to early morning hours on week days, and 24-hours during the weekend. PEER was not able to ascertain the effectiveness of the checks. However, procedures require
that these checks be logged and documented if something unusual is found. Staff believes the "culture" of the
(Pg. 19) training schools also helps to decrease the likelihood of exploitation. Varying staff told PEER that youths would tell if a staff or student is behaving inappropriately. The dormitories have a variety of designs that could give more or less opportunity for exploitation. Some dormitories are built with an open bay design, some have individual rooms, and some have cells within pods (or suites) within the residential structure.

Direct-Care Staffing

Although these factors may determine the effectiveness of
personal safety, one factor was most evident in compromising security for all. PEER found that low staffing in the residential areas increases opportunities for misconduct. Low staffing of the facilities does not permit housing pods to be staffed by a minimum of two counselor aides or juvenile correctional officers during all shifts. The facilities currently meet minimum staffing
requirements of 1 staff to 20 students for student housing. However, staff uniformly believes that the dorms need a minimum of two staff per shift for security purposes.

Compensatory time accrual is a collateral issue that could
result from low staffing. Next to the nursing staff, the dormitory staff has accrued the second highest amount of compensatory time on average. Neither nurses nor the dormitory staffs are exempt from payments for compensatory time over 240 hours. Because staff in exempt positions often must cover a shift or part of a shift due to low staffing, they, too, may eventually accrue enough compensatory time for payment.

Pre-Service Training

Although both facilities conduct basic pre-service training programs, the programs do not incorporate topics that could reduce the potential for abuse.

Minimum standards established by Morgan v. Sproat and
other professional standards require facilities that employ
direct-care staff to provide pre-service training Furthermore, a decision based on the Civil Rights of Institutionalized Persons Act (CRIPA) requires three times as many hours of pre-service training for direct-care employees than for non-direct care employees. That is, 120 hours of pre-service training for direct-care employees, which includes a variety of treatment topics.

Standards of the Office of Juvenile Justice and Delinquency Prevention view both pre-service and inservice
training as preventive measures pertaining to safety and security within direct-care facilities. (Pg. 20)

Additionally, pre-service orientation on topics that
promote understanding of youth can potentially reduce
risks of harm, increase safety, and improve treatment by
having staff trained to care for juveniles beyond job
procedures.

According to facility administrators, direct-care
supervisors, the policy manuals, and training records,
orientation only requires new employees to read facility
policies and review topics related to job duties the first
eight hours of orientation. New employees receive further
training by observing experienced employees in various
location assignments the next 80 hours. Standards require orientation on topics that would aid caregivers in their understanding and subsequent treatment of youth.
Treatment topics should include, but not be limited to,
stages and pathways of adolescent development,
communication skills, behavior management, basic
medical care, effects of drug use, and potential negative
effects of isolation.

Interviews with counselors indicate a consensus among
them that more training is needed, both pre-service and inservice. Other staff we spoke with stated that they are
taking psychology and other courses on their own in order
to gain an understanding of adolescents and their behavior. Both facility directors mentioned the need for more training, but cited restrictions on their ability to bring direct-care staff together at one time. A quality preservice
training program could also alleviate some inservice
training concerns.

Policies and procedures adhere to standards for provision
of medical services in a juvenile correctional environment.
According to the Division of Youth Services director, the
policies and procedures at Columbia and Oakley were
developed with the Morgan v. Sproat court order standards
in mind first (since the court order applied to Mississippi
institutions). Other actions (e.g., construction of Unit 1 at
Oakley) reflect other applicable standards (such as
American Correctional Association (ACA) standards in this
case). Still, the age and condition of some of the buildings
(e.g., the 1948 Health Clinic for Unit 2 at Oakley -which is
to be replaced with a new medical facility within the year),
the understaffing in a number of service areas, the nonfunctioning of the dental clinics, would all preclude either
facility from being accredited by ACA standards.

With respect to physical and mental health care needs,
medical access (to both routine and emergency care) is by
(Pg. 21)  and large there for all juveniles housed by Columbia and Oakley. Nursing staffs make every effort to provide 24/7 coverage when needed; contract physicians and contract psychiatrists are "on call" to both institutions at all times; a psychologist is on staff at the Oakley facility, and one is on contract at the Columbia facility; hospitals with
emergency rooms and laboratory services are accessible to
the institutions, and are used by juveniles; and medical
staff refer juveniles to requisite health care specialists
when necessary. The dental program, however, is clearly
lacking in the provision of expected services for both facilities.

Site data collection identified other problems. One is
primarily illustrated by the lack of dental services. In this
case, the policy statements governing the service, and the
existence of contracts with dentists, would lead to the conclusion that dental services are being satisfactorily performed. But site visits found dental clinic rooms at both Columbia and Oakley non-functional for months or years. One dentist has delivered no services to Columbia at all under his contract. The other dentist at Oakley reports his contract cut in half and provides no services beyond a cursory entrance examination and the emergency extraction of teeth. In this case, the policy statements are adequate, but the service is inadequate. In a number of other service areas (documented above), the opposite is true-written policies lag behind actual practice at both Columbia and Oakley. Actual health care practices adhere to applicable policy standards, but the written institutional health policies and procedures are insufficient and do not reflect current practices. Columbia and Oakley need a major update of their Policies and Procedures Manuals in the health care area to clearly state the facilities' current practices regarding intake screenings and examinations, nursing care, and hospitalization procedures. Modifications in these areas are further specified in the recommendations. (Pg. 22)

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.

6. The Division of Youth Services should modify its health care policies and procedures to include use of (Pg. 23)
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 dentists so that the dentists can perform necessary (Pg. 24) procedures such as fillings, and also have time for more thorough charting of dental conditions.