THE MISSISSIPPI LEGISLATURE

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 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.

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.

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.

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.

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. 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.

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.

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.

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 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 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.

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.

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 monitoring procedures for juveniles in restraints-both for health care staff and other staff. This policy statement can incorporate current practices.

8. 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.

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.

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;

• A policy statement regarding the health treatment of females;

• A policy statement about pregnancy management;

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

2. 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.

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

4. 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.

5. 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 staff to ensure connection between medical observations and treatment.

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.