Common use of Compliance Rating Partial Compliance Clause in Contracts

Compliance Rating Partial Compliance. Discussion Each incident report is reviewed by the Shift Commander. These reviews should critique staff performance in preventing, anticipating, or intervening in the incident. Feedback surrounding the use of de-escalation techniques, staffing ratios and posts, supervision strategies, maintaining security, conflict resolution, environmental hazards, policy and procedures will help to improve staff skill and knowledge and may lead to a decline in youth violence over time. Across the 45 incident reports reviewed, all of the reviewing shift commanders at least attempted to critique the incident—no longer are they simply summarizing the event as they were at the time of the previous Monitors’ Report. However, as a whole, the shift commander reviews are not as adept as they need to be in order to function as an effective strategy to combat youth violence. Over half of the reviews were inadequate in that: ▪ Conclusions are made without foundation (e.g., “good de-escalation” when the narrative made no mention of any staff action other than physical restraint); ▪ Obvious issues are not raised (e.g., the event occurred when the unit was not staffed according to required ratios); ▪ Key pieces of information (e.g. the number and locations of each staff assigned to the unit) are simply noted as “missing” which would preclude a meaningful analysis of the event; and ▪ Inconsistencies across staff witness statements are largely ignored. If these reviews are to be helpful to staff, they must identify the specific decisions made or actions taken that either promoted or compromised youth and staff safety so that staff can refine their responses when next placed in a similar situation. During the current monitoring period, the Group Life Managers took over the auditing function from the Assistant Superintendents. By design, these audits should not only verify the completeness of the incident reporting package, but should also comment on the quality of the staff’s responses to each portion of the incident report and confirm that all of the sources of information hang together without contradiction. In contrast to the last monitoring period, most of the audits were timely, occurring within a few days of the event itself. Most of the audits were well-done, although some missed some of the substantive issues raised in the shift commander discussion above. The major problem however is a lack of responsiveness from staff who were required to undertake some sort of corrective action. Staff often did not respond at all, or else responded to the simpler things to fix, leaving the more complex (but far more potent) issues unaddressed. Not only should these critiques and audits elevate the incident reporting skills of staff, but they should also serve to highlight patterns across incident reports that can be used in targeted violence prevention strategies. There is little point to writing and critiquing incident reports without using the information to reduce youth violence. Recommendation To reach substantial compliance with this provision, the State must: 1. Ensure that Shift Commanders review and critique all incident reports in terms of the way in which staff handled the incident and any contextual factors that could have prevented the incident from occurring. Conclusions should be supported by specific information available in the incident report and therefore Shift Commanders must ensure that all required information is present before undertaking a critique. 2. Hold staff accountable for making corrections to substandard incident reports. It is also recommended that the State: 1. Enact violence prevention strategies grounded in the details, patterns and commonalities across incident reports. Establish a baseline for measurement and use available data to evaluate the effectiveness of these strategies. Evidentiary Basis • Administrator interviews • Incident reports, n=45, randomly selected from those generated January 1 through May 5, 2008 related to youth-on-youth violence and group disturbances.

Compliance Rating Partial Compliance. Discussion Each incident report is reviewed by The policies relevant to this provision include: ▪ Seclusion ▪ Youth Movement and Count Xxxx when they have not verbalized any suicidal ideation or intent, youth are at heightened risk of self-harm when they are isolated in a locked room (e.g., when secluded, overnight, etc.). By checking on youth periodically during these times, staff can respond to any needs or otherwise verify the Shift Commanderyouth’s safety. These reviews should critique Staff interviews confirmed that staff performance are aware of the procedures required for ensuring the safety of youth in preventingseclusion. When interviewed, anticipatingyouth who had been in seclusion confirmed that staff checked on them regularly. In addition to these reports, or intervening the practice of supervision can be assessed using documentation—as such, this review focuses on the adequacy of that documentation to substantiate compliance with the requirements of this provision and DJS policy. Youth in the incidentSeclusion. Feedback surrounding the A total of 44 seclusion episodes, randomly selected from those occurring in January-May, 2008, were audited. The use of deseclusion, and the justification offered for it, was discussed previously (see III.B-1.v). Regardless of the reason for placement, this provision requires the State to adequately supervise youth in seclusion to ensure their safety. Staff are required by policy to make observations at random intervals, no less than six per hour. Of the 44 episodes reviewed, about half revealed that staff were not following required observation procedure (e.g., insufficient number of checks per hour, large gaps in supervision, etc.). This proportion is similar to that observed during the previous monitoring period. Policy also requires medical staff to verify the well-escalation techniquesbeing of youth at two-hour intervals during their stay in seclusion. In approximately two-thirds of the seclusion episodes audited, staffing ratios medical staff missed one or more of these two-hour checks. This proportion increased from the previous monitoring period in which approximately half of the seclusion cases reviewed had this problem. Youth Locked in their Rooms Overnight. Youth at BCJJC are locked into single rooms overnight. The facility is equipped with an electronic GuardTour system that records staff’s routine observations of youth while in their rooms. DJS policy requires staff to verify the well-being of youth at 30-minute intervals, but the facility’s operating policy requires 15- minute intervals. GuardTour reports for 15 days in March and posts, supervision strategies, maintaining security, conflict resolution, environmental hazards, policy and procedures will help April 2008 were reviewed to improve staff skill and knowledge and may lead to a decline in youth violence over timedetermine the level of compliance with overnight check procedures. A total of 180 shifts were reviewed (15 days x 12 units = 180 shifts). Across the 45 incident reports reviewed180 shifts, none of them evidenced proper procedures. On some shifts, no checks were registered at all. The rest of the shifts were plagued by some or all of the reviewing shift commanders at least attempted to critique the incident—no longer are they simply summarizing the event as they were at the time of the previous Monitors’ Report. However, as a whole, the shift commander reviews are not as adept as they need to be in order to function as an effective strategy to combat youth violence. Over half of the reviews were inadequate in thatproblems below: ▪ Conclusions are made without foundation (e.g., “good de-escalation” when the narrative made no mention The onset of any staff action other than physical restraint); ▪ Obvious issues are not raised (e.g., the event occurred when the unit supervision was not staffed staggered according to required ratios); youth’s bedtimes. Instead, safety checks sometimes began for all youth at 11 or 12 at night. ▪ Key pieces The cessation of information (e.g. supervision did not coincide with wake-up times. Instead, checks sometimes stopped at 3 or 4 in the number and locations morning. ▪ Many intervals exceeded the 30 minutes prescribed by policy. Many shifts showed two or more gaps of each staff 60 minutes or more during the shift. Responsibility for auditing the GuardTour reports was recently re-assigned to the unit) are simply noted as “missing” which would preclude a meaningful analysis of the event; and ▪ Inconsistencies across staff witness statements are largely ignored. If these reviews are to be helpful to staff, they must identify the specific decisions made or actions taken that either promoted or compromised youth and staff safety so were asked to sign a form indicating that they understood their responsibilities regarding GuardTour. Administrative staff can refine their responses when next placed indicated that accountability procedures will be put in a similar situation. During the current monitoring period, the Group Life Managers took over the auditing function from the Assistant Superintendents. By design, these audits should not only verify the completeness of the incident reporting package, but should also comment on the quality of the staff’s responses to each portion of the incident report and confirm that all of the sources of information hang together without contradiction. In contrast to the last monitoring period, most of the audits were timely, occurring within a few days of the event itself. Most of the audits were well-done, although some missed some of the substantive issues raised in the shift commander discussion above. The major problem however is a lack of responsiveness from place for staff who were do not follow the required to undertake some sort of corrective actionprocedures. Staff often did not respond at all, or else responded to the simpler things to fix, leaving the more complex (but far more potent) issues unaddressed. Not only should these critiques and audits elevate the incident reporting skills of staff, but they should also serve to highlight patterns across incident reports that can be used in targeted violence prevention strategies. There is little point to writing and critiquing incident reports without using the information to reduce youth violence. Recommendation Recommendations To reach substantial compliance with this provision, the State must: 1. Ensure that Shift Commanders review staff supervise youth in seclusion according to policy and critique all incident reports in terms of require medical staff to assess the way in which staff handled the incident and any contextual factors that could have prevented the incident from occurring. Conclusions should be supported youth’s medical condition at two-hour intervals, as required by specific information available in the incident report and therefore Shift Commanders must ensure that all required information is present before undertaking a critiquepolicy. 2. Hold Ensure that staff accountable for making corrections to substandard incident reportsverify the safety and welfare of youth locked in their rooms at night at 30-minute intervals (or 15-minute intervals, if preferred) and document this verification using the GuardTour system. It is also recommended that the State: 1. Enact violence prevention strategies grounded in the details, patterns Audit GuardTour reports frequently and commonalities across incident reports. Establish a baseline for measurement and use available data to evaluate the effectiveness of these strategiesdiscipline or retrain staff as appropriate. Evidentiary Basis • Administrator interviews Policy review • Incident reports, n=45Seclusion Observation Forms for n=44 youth, randomly selected from those generated placed in seclusion at some point from January 1 through May 5to May, 2008 related • GuardTour reports for 15 days in March and April, 2008 • Youth interviews, n=11 • Staff interviews, n=10 • Administrative interviews ¶ III.C-1.iv Housing for Youth at Risk of Self-Harm. The State shall take all reasonable measures to assure that all housing for youth at heightened risk of self-harm, including holding rooms, seclusion rooms and housing for youth on suicide precautions, is free of identifiable hazards that would allow youth to hang themselves or commit other acts of self-harm. Compliance Rating Substantial Compliance (as of December 31, 2007) Discussion As discussed in the previous Monitors’ Report, in response to the DOJ’s Findings Letter, all rooms were fitted with suicide-resistant bunks; cords were removed from youth-on-’s laundry bags; and suicide resistant towel hooks were installed in all youth violence restroom and group disturbances.shower areas. During the tour of the rooms on each unit, no protrusions or other environmental hazards were observed. These protections were all observed during the facility tour in April 2008. Recommendations The State has been in substantial compliance with this provision for 6 months, beginning December 31, 2007. Evidentiary Basis • Administrative interviews • Tour of all housing units