POLICY

SUBJECT: Incident Reporting –Private Residential Child Care Programs and Child

Placement Agencies

NUMBER: OPS-901-15

APPLICABLE TO: Employees of Residential Child Care Programs

APPROVED: /s/ signature on original

Sam Abed, Secretary

EFFECTIVE DATE: 4/9/15

I. POLICY

Employees of privately operated Residential Child Care Programs (RCCP) or Child Placement Agencies (CPA) serving youth under DJS supervision shall report incidents involving a youth to DJS. Employees of private residential child care programs also shall notify the appropriate law enforcement agency and Child Protective Services at the local Department of Social Services of incidents as required by law.

II. AUTHORITY

A. Md. Code, Hum. Srvcs., §8-707 B. Md. Code Ann., Hum. Srvcs., §9-203 and §9-204 C. Md. Code Ann., Family Law, §5-701 to §5-715

D. COMAR 07.02.07

E. COMAR 14.31.05

F. COMAR 14.31.06

G. COMAR 14.31.07

III. DIRECTIVES/POLICIES RESCINDED

A. Incident Reporting, MGMT-03-07 B. Photographing of Injuries, RF-11-05 C. Videotaping of Incidents, RF-05-07

IV. FAILURE TO COMPLY

Failure to comply with the Department’s Policy and Procedures may be grounds for suspension or termination of the contract agreement or a moratorium on placements of youth.

V. STANDARD OPERATING PROCEDURES

All Residential Child Care Programs shall develop standard operating procedures to implement this policy and its procedures.

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Department of Juvenile Services

Successful Youth • Strong Leaders • Safer Communities

Incident Reporting –Private Residential Child Care Programs and Child Placement Agencies

OPS-901-15

April 9, 2015

VI. REVISION HISTORY

DESCRIPTION OF REVISION DATE OF

REVISION

New policy issued. 4/9/15

PROCEDURES

SUBJECT: Incident Reporting –Private Residential Child Care Programs and Child Placement Agencies

APPLICABLE TO: Employees of Private Residential Child Care Programs

APPROVED: /s/ signature on original

Linda McWilliams, Deputy Secretary

EFFECTIVE DATE: 3/31/15

I. PURPOSE

The Department of Juvenile Services (DJS or Department) establishes these procedures for the notification and documentation of all incidents that disrupt the good order and discipline of the privately-operated Residential Child Care Programs (RCCP) and Child Placement Agencies (CPA) or that threaten the safety and security of youth, staff, volunteers, and visitors. This procedure applies to all staff employees of private residential child care programs or child placement agencies serving youth under DJS supervision.

II. DEFINITIONS

Addendum - a supplemental report for an Incident Report to provide follow-up or additional information regarding the original incident or to document a pattern of behavior for a particular youth (i.e., SIB).

Allegation Against Staff: Referred - any non-sexual action on the part of staff, volunteers, or visitors which is referred to the local Child Protective Services (CPS), State Police, and/or the Office of the Inspector General (OIG) for investigation.

Accusations of a sexual nature that may be referred to the previously referenced entities are categorized separately in this procedure.

Allegation Status

• Substantiated (Indicated) – the event was investigated and determined to have occurred based on a preponderance of the evidence.

• Unsubstantiated – the investigation concluded that the evidence was insufficient to determine whether the event occurred.

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• Unfounded (Ruled Out) – the investigation determined that the event did NOT occur.

• Investigation Ongoing – evidence is still being gathered, processed or evaluated, and a final determination has not yet been made.

Alleged Abuse - a suspected act of physical injury or sexual molestation or exploitation of a youth. Note: Incident category is not captured in the DJS Incident Reporting database and is used only for DHR or DHMH purposes.

Alleged Neglect – – a suspected act in which the caregiver has failed to give proper care and attention to a child including leaving a child unattended where the child’s health or welfare is harmed or the child is placed in substantial risk of harm; or an act in which the caregiver’s actions or failure to act results in identifiable and substantial impairment of a child’s mental or psychological ability to function. Note: Incident category is not captured in the DJS Incident Reporting database and is used only for DHR or DHMH purposes.

Arrest - is any arrest of a youth and any arrest of a staff, volunteer or visitor for an alleged felony or a misdemeanor.

Assault – a provoked or unprovoked attack, which may or may not result in physical retaliation or injury. Distinctions should be made between assaults and fights where fights are defined as mutual physical attacks. Assaults are categorized based on the level of injury sustained.

• Assault: Level 0 – no visible injury or articulated pain.

• Assault: Level 1 – injury or pain requiring in-facility medical treatment only.

• Assault: Level 2 – an injury sustained that requires assessment and/or treatment as an outpatient at an outside medical facility or emergency room.

• Assault: Level 3 – an injury sustained that requires assessment and/or treatment as an inpatient at an outside medical facility or emergency room.

ASSIST – a DJS database that establishes an electronic case record on each youth beginning at the initial contact with the court and continuing until the youth’s release from supervision. The database also serves to generate a variety of reports using the information collected on the youth.

AWOL (Absent Without Leave) –any youth who, without authorization, leaves the boundaries of a facility designated as a residential child care program.

Business Day - 8:00 a.m. until 5:00 p.m. every day excluding Saturday, Sunday, declared state emergencies, service reduction days, and holidays.

Class “A” Tools - devices considered extremely hazardous to the security of the facility, e.g. bolt and wire cutters, ladders, files. These items must be securely stored in locations outside the facility’s secure perimeter or youth residences.

Class I Incident – any event which presents a significant disruption to the orderly operation of the facility.

Class II Incident - any event which results or may result in a major disruption to a program, results or may result in significant harm to youth or employees while on duty, or may have a negative impact on the Department, the RCCP or the CPA.

Class III Incident – any event or situation that is severe in nature and may present a risk to public safety, threatens or critically affects staff or youth, and/or may attract media attention at a facility.

Emergency Petition – a petition to the court to request emergency evaluation, care and treatment of a youth because the youth has shown symptoms of a mental disorder and presents a danger to the life or safety of the youth or others. Note: Incident category is not captured in the DJS Incident Reporting database and is used only for DHR or DHMH purposes.

Fight – a fight is a mutual physical assault or altercation between two (2) or more youth. The associated level of injury will be reported as follows.

• Fight: Level 0 – no visible injury or articulated pain.

• Fight: Level 1 – injury sustained requires in-facility medical treatment only.

• Fight: Level 2 – injury sustained requires assessment and/or treatment as an outpatient at an outside medical facility or emergency room.

• Fight: Level 3 – injury sustained requires assessment and/or treatment as an inpatient at an outside medical facility.

Fire – an incident of fire extinguished by staff or the fire department.

Group Disturbance – the disruption or interference of normal program operations resulting from 3 or more youth participating in actions, threats, demands or suggestions to advocate disruption. (Definition is from the National Alliance of Gang Investigators Association.) A group disturbance may require assistance from a law enforcement agency.

Group Home - a residential child care program, includes, but is not limited to privately owned and operated:

• Shelter care, including emergency or structured;

• Mother-baby programs;

• Programs for adolescent girls who are pregnant;

• Psychiatric respite care;

• Secure care;

• Programs for children who are medically fragile;

• Programs for children with developmental disabilities;

• Residential crisis services;

• Residential respite care services;

• Wilderness programs; and

• Diagnostic evaluation treatment programs.

Hostage Taking - one or more persons being held against their will.

Incident - an event or happening outside the ordinary routine which disrupts or threatens the security, good order, and discipline of the facility or that threatens the safety of youth, staff, volunteers and visitors.

Injury/Illness: A youth’s or staff’s level of injury or illness will be determined by medical staff. Assessments of injury are defined as the following:

• Injury/Illness - Level 0 – no visible injury or articulated pain.

• Injury/Illness - Level 1 – injury or pain requiring in-facility medical treatment only.

• Injury/Illness - Level 2 – injury or pain requiring assessment and/or treatment as an outpatient at an outside medical facility or emergency room.

• Injury/Illness - Level 3 – injury or pain requiring assessment and/or treatment as an inpatient at an outside medical facility or emergency room.

Office of the Inspector General (OIG) Administrator – the DJS administrator/ supervisor of the OIG who receives notification of and investigates incidents.

Other - any incident that may result in adverse media attention and/or potential litigation should be reported. Any incident that should be reported but is not defined in the categories identified in this procedure, to include, youth interfering with staff in the performance of their duties.

Physical Restraint – a non-mechanical behavior management technique involving the use of a physical hold as a means of restricting a youth’s freedom of movement. Only physical restraint techniques approved by the Governor’s Office for Children as part of the Behavioral Interventions, Strategies and Support program, may be used by program employees who have completed training and earned certification.

Physical Plant Problem – a broken or malfunctioning system that significantly disrupts operations, and/or physical plant damage that poses a breach of security, or a health and/or safety risk to youth, employees, and visitors.

Precipitating Event – the factors that occurred just before the incident/first reportable action.

RCCP/CPA Incident Information Sheet – the form used to make the one-hour notification of a critical incident or AWOL.

RCCP/CPA Incident Reporting Form – the form used to document an incident as defined in this procedure.

RCCP/CPA Program Administrator - the individual, regardless of title who is designated as having the day-to-day responsibility for the overall administration and operation of a program and for assuring the care, treatment, safety, and protection of children.

Seclusion - the confinement of a youth alone in a room from which the youth is physically prevented from leaving. Use of seclusion is prohibited in residential child care programs in Maryland. Use of seclusion is allowed in Residential Treatment Centers (RTC) and Development Disability Administration (DDA) residential facilities.

Security Contraband - an unauthorized item found in, on, or around the grounds of the program or confiscated from a staff, youth, or visitor that has the potential to threaten the security of the program. For the purposes of this procedure, these items have been designated in the following categories:

• Level 2 includes, but is not limited to: cigarettes, lighters, matches, gang material, batteries, money or items not approved by the RCCP/CPA.

• Level 3 includes, but is not limited to: any weapon – homemade or manufactured; illegal, controlled or unknown substances; explosives or explosive substances, money not approved by the RCCP/CPA, escape plans, maps, and/or provisions.

Self-Injurious Behavior (SIB) - an action taken by an individual to harm oneself although not indicating a conscious intent to commit suicide (non-life threatening self-mutilation, e.g., cutting).

Sexual Abuse Allegations:

Staff-on-Youth Incidents Staff–on-youth incidents include an employee, volunteer, contractor, official visitor or other agency representative and exclude family, friend or other visitors.

• Staff-on-Youth Indecent Exposure - the intentional display by a staff of his or her uncovered genitalia, buttocks, or breast in the presence of a youth.

• Staff-on-Youth Sexual Harassment - repeated verbal statements or comments of a sexual nature to a youth by a staff member. Such statements include but are not limited to making references to gender, sexual orientation, genitalia, sexually suggestive or derogatory comments about the body or clothing, or repeated profane or obscene language or gestures.

• Staff-on-Youth Sexual Misconduct - threatened or requested sexual acts by a staff to a youth.

• Staff-on-Youth Sexually Abusive Contact - non-penetrative touching (either directly or through the clothing) of the genitalia, anus, groin, breast, inner thigh, or buttocks of a youth by a staff that is unrelated to official duties.

• Staff-on-Youth Sexually Abusive Penetration – Penetration by staff of a youth. The sexual acts included are contact between the penis and vagina or the anus; contact between the mouth and penis, vagina, or anus; or, penetration of the anal or genital opening of another person by hand, finger, or other object.

• Staff-on-Youth Voyeurism – An invasion of a resident’s privacy by staff for reasons unrelated to official duties or when otherwise not necessary for safety and security reasons, such as but NOT limited to peering at a youth who is using the toilet; requiring a resident to expose his or her buttocks, genitals, or breasts; or taking images of all or part of a youth’s naked body or of a youth performing bodily functions.

Youth-on-Youth Incidents

• Youth-on-Youth Indecent Exposure - the intentional display by a youth of his or her uncovered genitalia, buttocks, or breast exhibited towards another youth.

• Youth-on-Youth Sexual Harassment - any unwelcome and repeated sexual advances, requests for sexual favors, verbal comments, or gestures or actions of a derogatory or offensive sexual nature by one youth directed toward another.

• Youth-on-Youth Sexual Contact - any non-penetrative touching (either directly or through the clothing) of the genitalia, anus, groin, breast, inner thigh, or buttocks by a youth of another youth with or without consent.

• Youth-on-Youth Sexual Penetration - any sexual penetration by youth of another youth. The sexual acts included are contact between the penis and vagina or the anus; contact between the mouth and penis, vagina, or anus; or, penetration of the anal or genital opening of another youth by hand, finger, or other object.

• Youth-on-Staff Sexual Misconduct - deliberate acts of a sexual nature performed by a youth in the presence of a staff or towards a staff, to include but not limited to public masturbation and indecent exposure.

Suicide Attempt - a potential or actual self-injurious act committed with at least some wish to die or which could result in death because of actions taken. There does not have to be any injury or harm resulting from action taken, just the potential for injury or harm.

Suicidal Ideation – expressed thoughts of wanting to end one’s life with or without intent to act or a plan to commit suicide.

Vehicle Accident - an incident involving a vehicle operated by a RCCP/CPA employee that result in injury to any DJS youth involved in the accident and/or results in damage to any vehicle involved in the accident.

Violation of Youth Rights – the failure by a private residential child care provider or child placement agency to provide services designed to meet the youth's needs for guidance, learning, and personal development according to the Residents’ Bill of Rights as set forth in Md. Code, Hum. Srvcs., §8-707. Note: Incident category is not captured in the DJS Incident Reporting database and is used only for DHR or DHMH purposes.

III. PROCEDURES

A. Incidents are classified into three categories based on level of severity and associated periods for reporting.

1. CLASS I INCIDENTS

Class I must be reported to DJS by the next business day. Class I incidents are as follows:

• Alleged Abuse (Not in DJS custody/supervision)

• Assault: Youth on Staff –Level 0

• Assault: Youth on Staff –Level 1

• Assault: Youth on Youth –Level 0

• Assault: Youth on Youth –Level 1

• Fight: Level 0

• Fight: Level 1

• Restraint

• Violation of Youth Rights

• Suicidal Ideation

• Youth Injury/Illness – Level 1

2. CLASS II INCIDENTS

Class II must be reported to DJS by the next business day. Class II incidents are as follows:

• Arrest: Staff, Volunteer, or Visitor

• Arrest: Youth

• Assault – Youth on Youth: Level 2

• Assault – Youth on Staff Level 2

• AWOL – Youth Apprehended or Returned

• Fight: Level 2

• Loss of Keys

• Physical Plant Problem

• Security Contraband: Level 2

• Self-Injurious Behavior

• Sexual Abuse Allegation:

Staff-on-Youth Sexual Harassment Staff-on-Youth Sexual Misconduct Youth-on-Youth Sexual Harassment

• Staff Injury or Illness (on the job): Level 2

• Youth Injury or Illness: Level 2

3. CLASS III INCIDENTS

Class III incidents shall be verbally reported immediately through the appropriate chain of command within the RCCP/CPA. These incidents also shall be reported to DJS within 1 hour of the incident. Class III incidents are as follows:

• Alleged Abuse (in DJS custody/supervision)

• Alleged Neglect

• Allegation Against Staff: Referred (non-sexual)

• Assault - Youth on Youth: Level 3

• Assault - Youth on Staff: Level 3

• AWOL

• Death of staff, visitors, volunteers, or youth at a program or during the course of conduction program business

• Emergency Petition

• Fight: Level 3

• Fire

• Group Disturbance

Not requiring assistance from law enforcement Requiring assistance from law enforcement

• Hostage Taking

• Loss of a Class “A” Tool

• Physical Plant Problem

• Security Contraband: Level 3

• Sexual Abuse Allegation:

Staff on Youth Indecent Exposure Staff-on-Youth Sexually Abusive Contact Staff-on-Youth Sexually Abusive Penetration Staff-on-Youth Voyeurism Youth on Youth Indecent Exposure Youth-on-Staff Sexual Misconduct Youth-on-Youth Sexual Contact Youth-on-Youth Sexual Penetration

• Staff Injury or Illness (on the job): Level 3

• Suicide Attempt

• Vehicle Accident

• Youth Injury or Illness: Level 3

• Other

B. Reporting Process – Private Residential Child Care Program or Child Placement Agency

1. Class III Incidents

For all Class III incidents,

a. The employee involved in or having knowledge of a Class III

Incident shall immediately notify the designated RCCP/CPA management staff.

b. Within 1 hour of the incident occurring, the RCCP/CPA management staff shall notify the DJS Office of the Inspector General (OIG) of the incident by completing the RCCP/CPA Incident Information Sheet (Appendix 1) and submitting it to the DJS staff listed on the Sheet.

c. The RCCP/CPA management staff shall immediately report all incidents related to child abuse or neglect verbally to the local Department of Social Services’ Child Protective Services (CPS) unit and the local law enforcement agency and within 48 hours send a written report to CPS and the local law enforcement agency and a copy to the State’s Attorney’s Office in accordance with state law and the DJS Reporting and Investigating Child Abuse and Neglect Policy A copy of the completed DJS Incident Report shall be forwarded to CPS upon request.

d. The RCCP/CPA management staff shall complete a RCCP/CPA Incident Reporting Form (Appendix 2) and email it to OIG at DJS.incidents@maryland.gov by the next business day. Instructions for completing the form can be found in the Step-by-Step Guide to Completing the RCCP/CPA Incident Reporting Form (Appendix 3).

2. Class I and II Incidents

The employee involved in or having knowledge of a Class I or II Incident shall immediately notify the designated RCCP/CPA management staff; and complete the RCCP/CPA Incident Reporting form and submit it to OIG at DJS.incidents@maryland.gov by the next business day.

C. DJS Office of the Inspector General

1. If an incident occurs in a DJS licensed facility, OIG may investigate the incident; and if the incident occurs in a non-DJS licensed facility, OIG may report the incident to the licensing agency.

2. The OIG shall report incidents to the DJS Public Information Officer that may draw adverse media attention.

mailto:DJS.incidents@maryland.gov mailto:DJS.incidents@maryland.gov

IV. RESPONSIBILITY

The RCCP/CPA Program Administrator is responsible for implementation and compliance with this procedure. The RCCP/CPA Program Administrator also must provide ongoing monitoring for compliance.

V. DIRECTIVES/POLICIES REFERENCED

DJS Reporting and Investigating Child Abuse and Neglect Policy

VI. APPENDICES

1. RCCP/CPA Information Sheet

2. RCCP/CPA Incident Reporting Form

3. Step-by-Step Guide to Completing RCCP/CPA Incident Reporting Form

DJS POLICY AND STANDARD OPERATING

PROCEDURES

Statement of Receipt and Acknowledgment of Review and Understanding

SUBJECT: Incident Reporting –Private Residential Child Care Programs and Child

Placement Agencies

APPLICABLE TO: Employees of Private Residential Child Care Programs

I have received and reviewed a copy (electronic or paper) of the above titled policy and procedures. I understand the contents of the policy and procedures.

I understand that failure to sign this acknowledgment form within five working days of receipt of the policy shall be grounds for disciplinary action up to and including termination of employment.

I understand that I will be held accountable for implementing this policy even if I fail to sign this acknowledgment form.

NAME OF PROGRAM OR AGENCY

SIGNATURE TITLE

DATE

Send the original, signed copy to the DJS Procurement Director at 120 W. Fayette St., Baltimore, MD 21201.

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Revised September 12, 2018 Page 1 of 2

RCCP/CPA INCIDENT INFORMATION SHEET

I. Program Information

Program Name:

Program Address:

Program Phone #:

II. Incident Information

Type of Incident:

Date and Time of Incident:

III. Youth Information

Youth Name:

Youth Assist #:

Youth DOB:

Youth Admitting Charge:

Youth Residence and County:

IV. Program Director/Supervisor Information Director Name:

Director Phone #:

V. Notification Information

Date and Time DJS Notified:

Name and Title Notification made by:

DJS Case Manager:

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Revised September 12, 2018 Page 2 of 2

VI. Law Enforcement Notification Date and Time:

Police Report #:

Contact Name:

Contact Phone #:

VII. Additional Youth Information

Color of Clothing:

Height:

Weight:

Other Addresses (if known):

Parent Name:

Parent Phone #

For AWOL notifications ONLY, email the above information to DJS.emonitor@maryland.gov and cc: Sonya White–Norman, sonya.white-norman@maryland.gov , Jeffrey Kessler, jeffrey.kessler@maryland.gov, Salithea Eubanks, salithea.eubanks@maryland.gov and the youth (s) DJS Case Manager.

For all other Class III notifications, email the above information to Sonya White–Norman, sonya.white-norman@maryland.gov , Jeffrey Kessler, jeffrey.kessler@maryland.gov, Salithea Eubanks, salithea.eubanks@maryland.gov and the youth (s) DJS Case Manager.

NOTE: This information should be forwarded within one hour of the event. This notification does not preclude you from completing a DJS RCCP Incident Reporting Form and forwarding to DJS by the next business day.

mailto:DJS.emonitor@maryland.gov http://aryland.gov/ http://aryland.gov/ http://aryland.gov/ http://aryland.gov/

Incident Report Form RCCP/CPA

Level Category –Incident Revised January 2015 Page 1 of 10

Date of Incident:

Organization Name:

Program Name: Program Type:

Program Address:

Staff Filing Report:

Youth Involved/Date of Birth:

Staff or Foster Parent Involved:

Class I

Significant in nature, however, do not rise to the level of seriousness as Class III and Class II. Class I incidents shall be reported to OIG by the next business day.

Class II Incidents which are serious in nature but do not present a significant risk to the facility, public safety, or attract media attention shall be considered Class II incidents and shall be reported to OIG by the next business day.

Class III Incidents, which are severe in nature, present a risk to public safety, and/or may attract media attention. A written notification shall be provided to OIG for Class III incidents within one hour of the incident utilizing the DJS Information Sheet. Class III incidents shall be reported to OIG immediately.

Alleged Abuse (Not in DJS custody/supervision) Arrest: Staff, Volunteer, or Visitor Allegation Against Staff Referred (non-sexual)

Assault: Youth on STAFF - Level 0 Arrest: Youth Alleged Abuse (In DJS custody/supervision)

Assault: Youth on STAFF - Level 1 Assault: Youth on STAFF - Level 2 Alleged Neglect

Assault: Youth on Youth – Level 0 Assault: Youth on Youth - Level 2 Assault: Youth on STAFF - Level 3

Assault: Youth on Youth - Level 1 AWOL/ Apprehension or Return Assault: Youth on Youth - Level 3

Fight: Level 0 Fight: Level 2 AWOL

Fight: Level 1 Loss of Staff Keys Death

RESTRAINT Guided Intervention Physical Plant Problem Emergency Petition

RESTRAINT Standing Security Contraband - Level 2 Fight: Level 3

RESTRAINT Take Down Self-Injurious Behavior Fire

Violation of Youth Rights Sexual Abuse Allegation - STAFF on Youth Sexual Misconduct

Group Disturbance –Law Enforcement Required

Suicidal Ideation Sexual Abuse Allegation - STAFF on Youth Sexual Harassment

Group Disturbance – No Law Enforcement Required

Youth Injury or Illness - Level 1 Sexual Abuse Allegation Youth on Youth Sexual Harassment

Hostage Taking

STAFF Injury or Illness (OTJ)-Level 2 Loss of a Class “A” Tool Youth Injury or Illness - Level 2 Physical Plant Problem

Security Contraband - Level 3 Sexual Abuse Allegation

STAFF on Youth Sexually Abusive Contact Sexual Abuse Allegation STAFF on Youth Sexually Abusive Penetration Sexual Abuse Allegation STAFF on Youth Indecent Exposure

Sexual Abuse Allegation STAFF on Youth Voyeurism Sexual Abuse Allegation Youth on STAFF Sexual Misconduct Sexual Abuse Allegation Youth on Youth Sexual Contact Sexual Abuse Allegation Youth on Youth Sexual Penetration Sexual Abuse Allegation Youth on Youth Indecent Exposure

STAFF Injury or Illness (OTJ): Level 3 Vehicle Accident Suicide Attempt Youth Injury or Illness - Level 3

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Level Category –Incident Revised January 2015 Page 2 of 10

Location within the program:

Description\Comment regarding the location (optional):

Date and time of the incident:

Reported By:

Date Reported:

Staff Involved:

DESCRIPTION OF INCIDENT

What happened just before the incident?

Who was there when the incident occurred? Number of youth present?

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Level Category –Incident Revised January 2015 Page 3 of 10

What happened during the incident? (Note length of restraint if applicable)

Begin with the day, date and time. Use full names of youth and staff.

What occurred after the incident?

Level Category –Incident Revised January 2015 Page 4 of 10

Youth Involved:

Role in Incident - check one: Youth Witness Aggressor Victim

Physical Restraint Type Used (select one): Duration of Physical Restraint Guided Intervention - Directive Touch 01 – 15 Minutes

Guided Intervention - Pivot and Parry 16 – 30 Minutes

Restraint – Standing: Shoulder Support 31 – 45 Minutes

Restraint – Standing: Cradle Standing 46 – 60 Minutes

Restraint – Standing: Cradle Wrap Greater than 60 minutes, EXPLAIN:

Restraint – Standing: Passive Restraint Restraint – Standing: Therapeutic Restraint

Restraint – Standing: Therapeutic Escort

Restraint – Standing: Passive Escort

Restraint – Standing: Multiple Team Intervention

Restraint – Standing: Two-Man Therapeutic Escort

Restraint – Take Down: Cradle Seated

Restraint – Take Down: Passive Restraint Seated

Restraint – Take Down: Side Restraint

Reason for Physical Restraint:

Intervention Leaving Supervision Prevention

Mechanical Restraint Used:

Flex Cuffs Handcuffs AND Leg Irons

Handcuffs Leg Irons

Duration of Mechanical Restraint 01 – 15 Minutes 61 – 75 Minutes Greater than 120 minutes, EXPLAIN:

16 – 30 Minutes 76 – 90 Minutes 31 – 45 Minutes 91 – 105 Minutes 46 – 60 Minutes 106 – 120 Minutes

Staff involved in restraint:

De-escalation Efforts Made: YES NO Seen by Medical? YES NO Injury Sustained YES NO Injury Severity Rating Level 1 Level 2 Level 3 Injury resulting from restraint? YES NO

Seclusion:

YES NO

Duration of Seclusion:

01 - 30 Minutes 2 – 4 Hours Gang Involvement\ Name of Gang:

30 - 60 Minutes 4 – 6 Hours 1 – 2 Hours 6 – 8 Hours

Contraband Found: Drugs Weapons Other

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Level Category –Incident Revised January 2015 Page 5 of 10

Additional Youth Involved:

Role in Incident - check one: Youth Witness Aggressor Victim

Physical Restraint Type Used (select one): Duration of Physical Restraint Guided Intervention - Directive Touch 01 – 15 Minutes

Guided Intervention - Pivot and Parry 16 – 30 Minutes

Restraint – Standing: Shoulder Support 31 – 45 Minutes

Restraint – Standing: Cradle Standing 46 – 60 Minutes

Restraint – Standing: Cradle Wrap Greater than 60 minutes, EXPLAIN:

Restraint – Standing: Passive Restraint Restraint – Standing: Therapeutic Restraint

Restraint – Standing: Therapeutic Escort

Restraint – Standing: Passive Escort

Restraint – Standing: Multiple Team Intervention

Restraint – Standing: Two-Man Therapeutic Escort

Restraint – Take Down: Cradle Seated

Restraint – Take Down: Passive Restraint Seated

Restraint – Take Down: Side Restraint

Reason for Physical Restraint:

Intervention Leaving Supervision Prevention

Mechanical Restraint Used:

Flex Cuffs Handcuff AND Leg Irons

Handcuffs Leg Irons

Duration of Mechanical Restraint 01 – 15 Minutes 61 – 75 Minutes Greater than 120 minutes, EXPLAIN:

16 – 30 Minutes 76 – 90 Minutes 31 – 45 Minutes 91 – 105 Minutes 46 – 60 Minutes 106 – 120 Minutes

Staff involved in restraint::

De-escalation Efforts Made: YES NO Seen by Medical? YES NO Injury Sustained YES NO Injury Severity Rating Level 1 Level 2 Level 3 Injury resulting from restraint? YES NO

Seclusion:

YES NO

Duration of Seclusion:

01 - 30 Minutes 2 – 4 Hours Gang Involvement\ Name of Gang:

30 - 60 Minutes 4 – 6 Hours 1 – 2 Hours 6 – 8 Hours

Contraband Found: Drugs Weapons Other

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Level Category –Incident Revised January 2015 Page 6 of 10

Primary Staff Involved Name:

Staff Assaulted? YES NO

Injury Sustained? YES NO

Injury Severity Rating: Level 1 Level 2 Level 3

Additional Staff Involved Name:

Detail Tab Gang Related - Explain:

Was the incident videotaped? YES NO

Supporting Evidence

Juvenile Services

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Level Category –Incident Revised January 2015 Page 7 of 10

Physical Restraint Notification

Name: _______________________________________________________________________________________

Title: _______________________________________________________________________________________

Contact Information: ____________________________________________________________________________

Date: ________________________________________ Time: _________________________________________

Notes: _______________________________________________________________________________________

Mechanical Restraint Notification

Name: _______________________________________________________________________________________

Title: _______________________________________________________________________________________

Contact Information: ____________________________________________________________________________

Date: ________________________________________ Time: _________________________________________

Notes: _______________________________________________________________________________________

Seclusion Authorization

Name: _______________________________________________________________________________________

Title: _______________________________________________________________________________________

Contact Information: ____________________________________________________________________________

Date: ________________________________________ Time: _________________________________________

Notes: _______________________________________________________________________________________ lVl.ARYL.A~D Department of

Level Category –Incident Revised January 2015 Page 8 of 10

Parent/Guardian:

Date:

Time:

Executive Director:

Program Administrator:

On-Call Administrator:

Licensing Agency:

DJS Case Management Specialist:

Legal Representative:

OIG Investigator:

Law Enforcement:

Child Protective Services:

Other:

Level Category –Incident Revised January 2015 Page 9 of 10

Statements

Statements of ALL youth and ALL staff involved or witnessing the incident should be attached separately to this report. Attached? Yes No If not, please explain below.

This incident report is true and accurate to the best of my knowledge.

Staff Member Completing Report Date

SUPERVISOR COMMENTS

Must include critique of how staff handled the incident including, whether decisions\actions could have been improved or whether staff did an exceptionally good job. These comments will be used to as a tool for staff to learn from this incident.

Supervisor Date

Checklist

1. All sections filled out completely? Yes No (If no, attach an explanation.)

2. Supervisor Comments filled out? Yes No (If no, attach an explanation.)

3. All youth\witness statements are attached? Yes No (If no, attach an explanation.)

4. Notifications made? Yes No (If no, attach an explanation.)

5. Nurses Report of Injury attached? (Including any photos.) Yes No (If no, attach an explanation.)

6. Signed and dated? Yes No (If no, attach an explanation.)

7. Checked for spelling, grammar and adequate details? Yes No (If no, attach an explanation.)

8. Description\Comment regarding the location (optional): Yes No (If no, attach an explanation.)

9. Additional Supporting documentation attached, if applicable?

Copies of seclusion sheets, suicide watch forms, etc.

Yes No (If no, attach an explanation.)

10. Incident report submitted to Child Protective Services?

If applicable.

Yes No (If no, attach an explanation.)

Administrative Review Completed by (sign & date) _____________________________________________

Level Category –Incident Revised January 2015 Page 10 of 10

WITNESS STATEMENT

Name:

Youth Staff

Signature: Date:

Department of

A STEP-BY-STEP GUIDE TO

COMPLETING THE RCCP/CPA INCIDENT

REPORTING FORM

This manual provides guidance to all staff that may have the responsibility of reporting incidents of staff misconduct, youth-on-youth violence, uses of force and other types of incidents in compliance with the Department’s Incident Reporting policy.

MARYLAND

STEP-BY-STEP GUIDE TO COMPLETING DJS INCIDENT REPORTING FORM

Appendix 2 – DJS Incident Reporting Policy –RCCP/CPA, OPS–901–15

Table of Contents What is the Purpose of an Incident Report?

When should Incident Reports be written?

Who might have access to Incident Reports?

How can RCCP/CPA staff improve the quality of Incident Reports?

Completing the Incident Report (Step-by-Step)

Page 1 of the Incident Reporting Form

Page 2 of the Incident Reporting Form

Page 3 of the Incident Reporting Form

Page 4 of the Incident Reporting Form

Page 5 of the Incident Reporting Form

Page 6 of the Incident Reporting Form

Page 7 of the Incident Reporting Form

Page 8 of the Incident Reporting Form

Page 9 of the Incident Reporting Form

Page 10 of the Incident Reporting Form

Where should Incident Reports be submitted?

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What is the Purpose of an Incident Report?

Successful juvenile detention work is a function of good information upon which teams can make insightful plans for troubled youth. Good information permits staff to monitor and adjust daily interventions with youth to maximize effectiveness. Good information helps staff operate a consistent program, which simultaneously reduces the need for sanctions. For direct care staff, the foundation of good information is proficiency in behavior observation and recording.

One of the most important purposes of documentation is to help staff solve problems when serious, dangerous or criminal behaviors occur. Documentation serves as evidence that action was taken. It may be the critical factor in helping reduce liability among direct care staff.

Complete and accurate documentation can help staff:

Provide clear documentation of the incident;

Be proactive in creating a safe environment for youth and staff;

Fulfill legal and ethical obligations;

Provide accountability for actions;

Predict behaviors;

Make quality based decisions;

Monitor changes in behavior;

Evaluate effectiveness of strategies;

Provide a baseline for evaluating program development;

Improve communication between staff and co-workers;

Improve timeliness and effectiveness of intervention strategies;

Facilitate interpersonal interactions that create trust;

Reinforce positive behaviors;

Minimize staff control measures;

Encourage positive youth involvement; and Promote therapeutic relationships.

When should Incident Reports be written?

Memory and accuracy deteriorate over time; it is best to complete the incident report with a precise description of behavior as soon as possible. The DJS Incident Reporting Policy for Residential Child Care Providers (RCCP) and Child Placement Agencies (CPA) requires that incident reports be completed by the end of the shift in which the incident occurred.

Who might have access to Incident Reports?

Incident reports are confidential. However, incident reports may be released in accordance with state laws governing confidentiality. Information is available to DJS employees, supervisors, monitors, and investigators. With proper authority, reports may be released to law enforcement agency personnel, medical personnel, mental health professionals, attorneys, judges, members of the press, and others.

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How can RCCP/CPA staff improve the quality of Incident Reports?

1. Describe the factors that precipitated the event.

2. Provide a detailed account of the incident in words that describe behaviors or actions.

3. Provide a clear explanation with sufficient detail on what the individual both did and saw.

4. Identify the exact role that each staff played in the restraint.

5. Identify the particular hold used and describe the physical restraint used.

6. Provide enough information so that an independent party, when reading it, can re-enact the event and can then determine whether the use of force was appropriate.

7. Ensure that youth who were involved or are witnesses to an incident provide a statement (or their written refusal to provide a statement).

8. Notify licensing agency, placing agency, parents, program administrators, child protective services, and law enforcement, as required.

Completing the Incident Report (Step-by-Step) Write neatly and legibly in pen. Complete all applicable sections. Do not leave any section blank.

Provide details that justify the incident type and injury severity rating.

The primary staff who was involved in the incident must complete pages 1 - 8. Supervisors must complete page 9 if they were not involved in the incident. All youth and staff who witnessed the incident must complete the Witness Statement. The supervisor shall ensure that all witnesses complete a Witness Statement.

Page 1 of the Incident Reporting Form

1. Date of Incident: Insert the date of the incident: month, day, year

2. The Incident Report number is automatically generated by the database after the “create incident record” is clicked. Enter the IR number generated by the database.

3. Organization Name: Insert the name of the parent organization.

4. Program Name: Insert the name of the program.

5. Program Type: Insert the type of program (e.g., ALU, Diagnostic, Group Home High Intensity

Respite, Independent Living, Mother-Child, Shelter, Residential Treatment Center, Therapeutic Group Home, and Treatment Foster Care.) Note: Program type is not captured in the DJS Incident Reporting database and is used only for DHR or DHMH purposes.

6. Program Address: Insert the address of the program that the youth is placed

7. Youth involved and Staff involved. List names of youth and staff involved.

8. Type of Incident: Incidents shall be categorized based on the precipitating event, in accordance with the guidelines designated in the standard operating procedures. Exception:

All allegations against staff referred (physical abuse, neglect, sexual abuse) are reported in a separate incident report.

Page 2 of the Incident Reporting Form

1. Location within Facility: Identify where the incident occurred within the program.

2. Description\comment regarding the location (optional). For example, the floor was wet, the chairs were stacked or near the television.

3. Date and time of the incident: insert the day and date (Tuesday, August 27, 2013) and the time must include a.m. (ante meridiem, meaning "before midday") or p.m. (post meridiem, meaning "after midday)

January 14, 2015 Page 4 of 8

4. Reported by: Staff completing the report, print your first and last name if you are the primary staff person writing the report (this is not the data entry person).

5. Staff Involved: Print the name of any other staff involved in the incident

6. Description of the incident: Describe the incident in detail. Include who, what, where and when. Use additional sheets if necessary.

• What happened just before the incident? Describe what happened just before the incident that the youth might be responding to. Was there a situation that the youth might have responded to? Was there a break in routine? Was there any indication that the youth(s) might become involved in a physical or verbal fight? Explain.

Respond to this question by explaining what the youth were doing just prior to the incident (e.g., 18 youth in Unit A were watching television in the dayroom). If applicable, explain specifically, by name, if any youth or staff were becoming loud, using profanity, making accusations, having a verbal altercation, or otherwise indicating that an incident might occur. Identify who intervened at this time and what the intervention(s) were.

These might include a verbal warning, a separation of youth, staff moving next to a youth, etc.

If there were no indications, explain what the youth were doing just prior to the incident and state that there were no observable indications that an incident might occur.

(Example: All 18 youth in Unit A were watching television in the dayroom. There were no observable indications of an incident. The incident appeared to be unprovoked.)

• Who was there when the incident occurred? Where was staff posted? What youth were present? Where were they located? Include youth and staff if they were or were not involved in the incident.

Respond to this question by identifying youth who were involved in the incident by first and last name, staff who were present by first and last name, and any witnesses who were present. State exactly where the youth were when the incident occurred. (Example: Youth John Johnson and youth Tom Smith were sitting across from each other at the small table playing cards in the dayroom, the rest of Unit A were sitting around the room watching television.)

Identify staff who were present when the incident occurred by first and last name and title, and state where they were posted. Example: RA Mary Johnson was standing by the hallway door, RA James Jones was playing cards with the two youth, and RA Karen Smith was sitting by the kitchen door.

Page 3 of the Incident Reporting Form

• What happened during the incident? Provide a detailed account of the incident, including what youth did and said and how staff responded. If restraint was used, what type? What was the duration of the restraint? Include any crowd control or de-escalation techniques used. What was the duration of the incident? How did the youth respond and comply?

The reader should have the ability to actually visualize and even re-create an event after reading the response to this question. It is essential that staff actions are detailed in response to this question.

January 14, 2015 Page 5 of 8

Respond to this question by stating what you observed and heard. Explain the incident in chronological order, using words like “first, then, next, finally,” to allow the reader to envision what happened in sequence.

Use language that clearly explains observable behaviors, not vague words. (Example:

“Youth James Jones called me a [use the exact words] and spit on my hand” not “youth was disrespecting me.”)

If a fight or assault occurred, indicate if there was punching, kicking, exchanging blows, throwing something, spitting, etc.

Repeat the language used by staff or youth. Express profanity by quoting directly, not by saying “youth used profanity.”

Identify the volume of the language. (Example: “Youth was screaming, “I’m going to get you!”) Identify the staff who intervened, and in what way. Cite the specific physical hold or restraint used (e.g., passive restraint, side restraint, etc.) stating exactly the role each staff played in the restraint. (Example: R.A. James Jones held Tom’s right arm while R.A. Mary Smith held Tom’s left arm in a two-man escort.)

State the duration (length of time) of the restraint (Example: “the restraint lasted about two minutes”; or “Because the youth continued to be extremely combative, trying to yank away, I restrained the youth using the cradle wrap using the least amount of force necessary for less than five minutes”)

• What occurred after the incident? Identify the exact time of seclusion and details of other results for youth. Identify the observable medical care needed for anyone.

Respond to this question by explaining what happened after the incident occurred. Identify who escorted youth away and state where the youth was taken. (Example: “Shift Commander Joan King arrived with mechanical restraints and placed them on youth James Jones. King took youth Jones to the nurse.”)

Page 4 of the Incident Reporting Form Primary Youth Involved: Insert the youth’s name.

Role in Incident: Circle the role the primary youth played in the incident.

Physical Restraint Type Used: Select one if applicable.

Duration of Physical Restraint: Select one if applicable.

Reason for Physical Restraint: Select one if applicable.

Mechanical Restraint Used: Select one if applicable.

Duration of Mechanical Restraint: Select one if applicable.

Reason for Mechanical Restraint: Select one if applicable.

Staff Involved in restraint: List the names and titles of each staff person involved in the restraint.

De-escalation efforts made: Answer yes or no.

Seen by Medical: Answer yes or no.

Injury Severity Rating: Check the appropriate Injury Level.

Injury resulting from restraint: Answer yes or no.

Seclusion: Answer yes or no.

Duration of Seclusion: Select one if applicable Contraband found: Select one if applicable Gang involvement\Name of gang: Insert the name of the gang(s) if the incident was gang related.

January 14, 2015 Page 6 of 8

Page 5 of the Incident Reporting Form Additional Youth involved. Make as many copies of this page as required.

Additional Youth Involved: Insert the youth’s name.

Role in Incident: Circle the role the primary youth played in the incident.

Physical Restraint Type Used: Select one if applicable.

Duration of Physical Restraint: Select one if applicable.

Reason for Physical Restraint: Select one if applicable.

Mechanical Restraint Used: Select one if applicable.

Duration of Mechanical Restraint: Select one if applicable.

Reason for Mechanical Restraint: Select one if applicable.

Staff Involved in restraint: List the names and titles of each staff person involved in the restraint.

De-escalation Efforts Made: Answer yes or no.

Seen by Medical: Answer yes or no.

Injury Severity Rating: Check the appropriate Injury Level.

Injury resulting from restraint: Answer yes or no.

Seclusion: Answer yes or no.

Duration of Seclusion: Select one if applicable Contraband found: Select one if applicable Gang involvement\Name of gang: Insert the name of the gang(s) if the incident was gang related.

Page 6 of the Incident Reporting Form Primary Staff Involved Name: Insert the name of the primary staff involved.

Staff Assaulted Answer yes or no.

Injury Sustained: Answer yes or no.

Injury Severity Rating: Select one based on an assessment by Medical.

Additional Staff Involved Name: Insert the name of the additional staff involved.

Staff Assaulted Answer yes or no.

Injury Sustained: Answer yes or no.

Injury Severity Rating: Check the appropriate Injury Level.

Repeat additional staff entries if necessary.

Gang Related – Explain: Insert a narrative to explain why the incident is considered gang related.

Was the incident videotaped: Answer yes or no. If no, explain why the incident was not videotaped.

Supporting Evidence: Provide any additional information not previously stated that could be considered evidence.

Description of location: Description or comments about the location not previously stated (optional.)

January 14, 2015 Page 7 of 8

Page 7 of the Incident Reporting Form Complete the required information for notification and authorization for use of physical restraint, mechanical restraint and seclusion. For each, write the name of the person who authorized, the date and time authorized, and any notes that may provide additional information needed for review.

Page 8 of the Incident Reporting Form Complete the required information for incident notification.

Page 9 of the Incident Reporting Form The Supervisor shall complete this page. This should be a critique of the staff’s performance, not be a summary of the incident. It should include comments on more effective interventions that may be indicated. These comments should include a critical examination of staff ratios, postings, de-escalation actions, environmental issues, and any violations of policy or procedures.

Checklist: The Supervisor shall complete the…