FINDINGS

This investigation revealed numerous deficiencies at CJTS in numerous areas. This is especially troubling since CJTS is a brand new facility, having opened in August 2001, which cost the State of Connecticut $57 million to build and which was supposed to be a “state of the art” facility.   Even Kristine Ragaglia, Commissioner of the Department of Children and Families, admitted to the Hartford Courant on June 25, 2002 that the conditions at CJTS were such that “the 240-bed Middletown facility probably would not get a state license if it were privately run.” A concise summary of our concerns is set forth below.

Suicide Prevention

Safety and Security

Generally, restraints are only supposed to be used when necessary to protect youth from injury to themselves or from injuring others. Restraints are specifically not supposed to be use for punishment, for convenience or as a substitute for programming. We found the following:

• Restraints were significantly over-utilized by staff at CJTS. At one point this even included utilization of restraints at the specific written direction of CJTS Superintendent Lesley Mara for youth threatening to or actually setting off the facility sprinkler system. We also learned of one instance of a 15-year-old youth in restraints 24 hours a day for 5 continuous days.
• The actual use of restraints was significantly underreported in facility records. This makes it appear as though restraints are used less than they are actually used. It also makes it extremely difficult to monitor what is going on at the facility.
• Seclusion is only supposed to be used to prevent immediate or imminent injury to the youth or others, to prevent escape, or in an individual treatment plan. We found the following:
• Seclusion was used routinely at CJTS for inappropriate reasons. We found, for example, that seclusion was regularly used in the following manner: (1) youth were regularly locked in their rooms after school; (2) youth were regularly locked in their rooms during shift change; (3) youth were regularly locked in their rooms during treatment meetings; (4) youth were regularly locked in their rooms during morning and evening hygiene and shower periods; and, (5) youth in the general population unit were routinely secluded during their daily schedules for over one hour.
• The actual use of seclusion was significantly underreported in facility records. Seclusion used for administrative convenience was invariably never recorded in facility records. There were also examples of disciplinary seclusions not being recorded or reported. This makes it appear as though seclusion is used less than it really is at the facility.  As with restraints, often this underreporting makes it extremely difficult to monitor what is actually going on at the facility.

Clinical Services

Clinical services are extremely important for adjudicated delinquents placed at CJTS. Many of them have serious problems — especially substance abuse. Clinical services are crucial to enabling these youth to function in the real world when they are eventually released. Serious shortcomings at CJTS include the following:

• CJTS has not had an adequate facility wide behavior management system from the time that it opened.
• Youth, staff, and supervisors do not appear to understand the point level system that has been in use.
• Clinical programs in place at CJTS, such as Aggression Replacement Therapy and Cognitive Behavioral Therapy have been implemented very poorly.
• Substance abuse treatment is not being provided for a high number of youth at CJTS who require such treatment.
• A huge number of staff vacancies have made it impossible to provide needed clinical services to youth. This has forced clinicians to focus their time and attention on crisis intervention and pulled them away from providing clinical services to CJTS residents in general. As a result there are significant gaps in programming and follow through.
• There is insufficient space at CJTS for therapy and insufficient space for clinicians to meet with youth. Workstations in units with open desks are clearly not appropriate for clinical services. Despite all of the time and resources that have been invested, planning did not take into account what the needs for clinical space would be.  There is simply no excuse for a brand new custom designed facility to be missing adequate space for clinical services.
• CJTS managers who are not themselves clinicians are setting clinical policy even though they are simply not professionally qualified to do so.

Education

Education is a crucial element of CJTS — the Connecticut Juvenile Training School. Although the youth placed there are in custody, they are still children who need a proper education. Many of them cannot read or read well below grade level. It has not been possible to provide basic education at CJTS for reasons including the following:

• Although all of the boys at CJTS have significant risk for learning disabilities and behavior problems that are disruptive to learning, they are not all fully evaluated for educational supports as required by federal law.
• Basic items like desks and chairs were not in place when CJTS opened. Although CJTS opened in August 2001, books and supplies were not generally available until December and many were still not in place at the time this report was drafted. By February 2002, only a portion of the library books had arrived and only 5 of 12 computers intended for use in the library had arrived (a related problem is that the new computers went to administrative staff with students getting hand me downs).
• The general educational atmosphere is chaotic. Teaching is significantly disrupted.
• Educational administration is in disarray with constantly changing policies and conflicting policy announcements.
• Educational services at CJTS are supposed to be under the special school district in DCF with licensed educational professionals and administrators making decisions about curriculum and educational services. However, CJTS management who are not certified teachers or administrators have taken over educational administration and permitted security and behavioral modification issues to predominate over education.

Recreation

Recreation is extremely important. Youth should be kept productively occupied and should have a range of activities available to them. This has not been the case at CJTS.

• Recreation often gets canceled. Youth do not get sufficient recreation time and rarely go outside, sometimes as little as once a week.
• Recreational opportunities are inconsistent among units with some complaining of other units getting more recreation. This inconsistency is itself a source of tension in the facility.

Staff

CJTS would not be functioning at all without the dedicated staff it has.  In fact, the most positive aspect of the facility is the commitment of the staff toward the boys. However, staff morale is very poor and numerous staff have been placed in a position where it is virtually impossible to do their job effectively. There are a number of contributing factors to this including the following:

• A huge number of staff vacancies have resulted in excessive utilization of overtime and excessive workers’ compensation claims. Extraordinary overtime leads to significant stress and strain on the staff.
• Changes in clinical coverage to the second shift (3pm to 11pm) prompted numerous resignations by clinicians. This resulted in the remaining clinicians being asked to do far more than they could possibly do, causing significant stress and strain. Additional conflict was created by CJTS managers, who are not themselves clinicians, setting clinical policy.
• Educational staff are very frustrated that they could not do their jobs since critical items like desks, computers, textbooks and supplies were not available, notwithstanding their having requested them months before.
• CJTS administrators did not involve direct care staff in the process of change in order to enable them to have some sense of responsibility for, and commitment to, new policies necessary for functioning in the new environment. As a result there is conflict between staff and CJTS administration that severely impedes the correction of deficiencies at CJTS.
• CJTS staff have not had sufficient training in deescalation techniques. Insufficient clinical staff are available at CJTS to assist in situations where direct care staff are unable to deescalate situations themselves.

Management

The inevitable conclusion flowing from all of the deficiencies at CJTS is that DCF management, both at CJTS and in the Central Office, failed to properly plan for and implement the transition of youth from Long Lane School to CJTS. This is unconscionable for a brand new “state of the art” facility that cost the State of Connecticut $57 million.

• Proper policies and procedures describing all of the programs that should have been in place were not in place when CJTS opened.
• Adequate clinical services were not provided at CJTS.
• Adequate education was not provided at CJTS, including needed furniture, textbooks, library materials, computers and supplies not being available when the facility opened in August 2001, and were not available for a considerable time thereafter
• Staff assigned to CJTS were not properly prepared for the transition and did not have proper training.
• Due to the lack of preparation and training, policies and procedures are being implemented inconsistently and inappropriately at times.   This was particularly evident in similarly situated youth being treated differently regarding strip-searching procedure.
• Record keeping at CJTS, specifically including records of restraints, seclusion and strip searches, has been very poor. Without accurate records it is simply not possible to properly oversee the facility.
• CJTS has no clearly defined vision, mission or identity by which to guide its programming in rehabilitating youth.       

 Quality Assurance

• Internal quality assurance by the facility was virtually non-existent. Until fairly recently, no DCF staff were specifically assigned to perform this function at CJTS. Even without dedicated quality assurance staff, some of the problems should have been obvious to CJTS managers just by walking through the facility.  Youth being locked in rooms or not allowed out of rooms on pain of being sanctioned were obvious to Office of Child Advocate personnel on visits to CJTS and should also have been obvious to CJTS management.
• Most recently DCF administrators assigned a Quality Assurance staff person to assume to the responsibility of “Risk Manager” for only a ninety-day period at CJTS.
• External quality assurance — independent oversight — by DCF was also virtually non-existent until very recently. Although CJTS was opened in August 2001 it was not until March 2002, following the Child Advocate and Attorney General expressing concerns to Commissioner Ragaglia, as well as considerable public attention, that DCF performed a program review at the facility. While DCF did a commendable job in performing that review, recognizing numerous deficiencies and requiring a corrective action plan, the DCF oversight came as a result of pressure by other state officials as well as considerable public attention. Clearly lacking was a truly independent oversight process. A brand new facility should have been independently reviewed prior to opening in August 2001 and several times since then, as an ordinary part of an independent oversight process rather than many months later as a reaction to developing concerns.

RECOMMENDATIONS

1. Proper protocols should be put in place for the assessment of risk of suicide and for suicide prevention in order to ensure that no child at the Connecticut Juvenile Training School is at risk for attempting or committing suicide.
2. Connecticut Juvenile Training School policy and practice regarding the use of restraint and seclusion must immediately be brought into compliance with Connecticut law.
3. All staff at all levels at the Connecticut Juvenile Training School should immediately receive training in their “mandatory reporter” obligations under Connecticut law.
4. The leadership of the Department of Children and Families should articulate a clear vision and mission for the Connecticut Juvenile Training School, and then enforce their expectations and rules.
5. The Connecticut Juvenile Training School leadership must take immediate steps to provide for the individualized needs of the children in their care. This will include the provision of appropriate treatment and education.
6. DCF administration must ensure that management at CJTS is on site and accessible to all staff at all times and that such management fully understands all aspects of the facility and its programs.
7. The Connecticut Juvenile Training School administration must define, develop and implement protocols for tracking and following up on “critical incidents.”
8. The Connecticut Juvenile Training School administration must improve the process of imposing and reviewing sanctions on children at the facility.
9. The actions of officials and employees of the Department of Children and Families should be reviewed to determine whether or not disciplinary action is warranted.
10. Oversight of state operated facilities serving children, such as the Connecticut Juvenile Training School, should be truly independent from DCF functions associated with program development and program administration in order to ensure that DCF decision making is objective.
11. An effective internal quality assurance program is necessary at the Connecticut Juvenile Training School.
12. The management structure and protocols for internal communication at the Department of Children and Families must be revamped so timely and accurate information is presented to responsible managers.
13. The Department of Children and Families should develop a long term planning unit that operates separately from program administration.

For all of the foregoing reasons we conclude that the Department of Children and Families failed in its obligations to the children at the Connecticut Juvenile Training School. The Department of Children and Families failed to properly plan for the opening of the Connecticut Juvenile Training School and failed to meet the needs of the children there. This is all the more problematic since the facility is a brand new facility that was supposed to be a state of the art “model” facility which has already cost nearly $90 million to develop and operate. Appropriate steps, such as those outlined in our recommendations, should be taken immediately to ensure that the needs of the children at the Connecticut Juvenile Training School are met in the future.