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Wa Special Civil Commitment Center Audit August 2008

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Final
INSPECTION OF CARE
Program Standards

Evaluation Tool

-

The Special Commitment Center
Department of Social and Health Services
State of Washington

March 2008 Survey
Augusl4, 2008 Final Report

Final Report
Inspection of Care Survey Tool March 3 -7, 2008
Washington State Special Commitment Center

Staff Competence, Training, Supervision
I-A
1-8
I-C

II

Treatment Program
II-A
11-8
II-C
11-0
Il-E
II-F
II-G
II-H
11-1
II-J
ll-K
II-L

III

1II~8

III-C
III+D
III-E
III-F
III-G
III-H

Staff training, licensure
Staffing
Facility
Pharmaceutical services
Documentation, confidentiality
Routine. preventive, emergent care
Support services
Psychiatric services

Program Oversight
IV-A
IV-B

V

Treatment program components
Treatment phases
Treatment plans
Measures of progress
Transition to community living
Management, restraint, use of force
Treatment-oriented environment
Space and group separation
Professional staff behavior
Consistent policy enforcement
Respect and grievances
Long-term care needs

Health Care Services
III-A

IV

Administrative and clinical supervision
Residential program staff supervision
Staff training

External oversight, incident investigation
Internal quality, protections, review, investigation

New Admissions
V-A Intake and orientation
V-B Health screening upon admission
V-C Determination of risk and needs
V-D Initial treatment planning

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Final Report
Inspection of Care Survey Tool March 3 - 7, 2008
Washington State Special Commitment Center

VI

Food Service
VI-A
VI-B
VI-C
VI-D

VII

Safety and Emergency Preparedness
VII-A

VIII

Standards and practices
Menu planning
Health and safety standards
Special health or religious diets

Fire safety, hazardous materials, natural disasters

Security
VIII-A Adequate security
VIII-B lricident documentation and follow-up
VIII-C Investigation of alleged criminal violations

IX

Resident Information
IX-A
IX-B

X

Resident records
Medical research

Physical Plant
X-A
X-B
X-C

Building and safety codes
Housing for residents with physical disabilities
Indoor air quality

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Final Report
Inspection of Care Survey Tool March 3 - 7, 2008
Washington State Special Commitment Center

STANDARD I:
I-A

Staff Competence, Training, Supervision

Qualified professionals provide consistent administrative and clinical direction
and supervision.

CONCLUSIONS:

o Meets expectations.
Meets minimum expectations - requires improvement in some areas.
o Does not meet expectations - requires significant improvement.

121
D

Not Reviewed.

Reviewer(s}
IOCTeam
Comments
1. Most of the elements of this standard are being met by sec. The areas where this is not the cases
are in the clinical program. Given the significance of the clinical program to the central mission of sec,
the Team decided to heavily weigh these specific shortfalls in forming our overall evaluation of this
standard.
2. The areas where the Team believes that sec is not currently meeting this standard include: (A) It
appears that the Clinical Director's experience in supervising clinical staff in a mental health or forensic
selling has occurred only at sec since her appointment as Clinical Director. It is unclear that this is
consistent with the elements of this standard, since the experience has been at SCC. It is, however,
important to acknowledge that the clinical supervisory experience gained at SCC is clearly relevant in
assessing qualifications. (2) The Assistant Clinical Director does not have clinical experience in
providing sex offender treatment. (3) The direct supervision of the Psychological Associates is provided
by the Assistant Clinical Director who does not have the experience specified in the elements under this
standard. (D) Forensic Therapists apparently do not allend the central Clinical Staff meetings (they do
participate in team meetings associated with individual residents/units), which is not consistent with the
standard.
3. The Team recognizes that the area of clinical staffing, supervision, structure, etc., are in flux at SCC.
ThUS, the Team does not want to overemphasize the above cited deficiencies, but the application of the
standard's elements dictate this finding. Also, given the current state of treatment participation and the
difficulties that SCC faces in recruiting clinical staff, the Team concluded that these issues associated
with the current management are worthy of note.

Evidence/Observations upon which conclusions & recommendations were based
Staff interviews.
Recommendations

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Final Report
Inspection of Care Survey Tool March 3 -7, 2008
Washington State Special Commitment Center

1. sec should continue with its efforts to foster professional development among all of
its clinical program managers. In particular, given the key role that the Assistant Clinical
Director plays in the direct supervision of the Psychological Associates who provide the
sex offender treatment, it is essential that SCC foster and facilitate the development of
sex offender specific knowledge and skills by this position. (Note: The ICC Team heard
many very positive statements about the Assistant Clinical Director, so .tho prec9ding
comment is not intended as a criticism of her performance. Rather, it reflects the belief
. of the Team that the development of sex offender expertise will further enhance the
ability of the incumbent to perfonn the major responsibilities assigned to her.)

SCC Response

sec acknowledges the loce Tea,,?'s findings.
I-A; Comment 3.
This comment associates current management with the issues of resident treatment participation and
staff recruitment difficulties. Treatment participation is affected by many factors, most significantly the
residents willingness to participate given their attitudes and beliefs about civil commitment and
acceptance of their need for treatment. Staff recruitment is affected by many factors, including the Island
location. pay and challenging work_
IOC Team Final Comments
The IOC Team acknowledges that the issues of resident treatment participation and staff recruitment
difficulties are very complex issues, and we did not intend to attribute the issues to only one factor. The
factors cited in the sec response undoubtedly are key issues. In fact, the IDe Team has made a
number of recommendations in this and past inspections intended to assist sec in responding to these
other factors (e.g., assignment pay for psychologists involved in treatment programming on the island and
programmatic incentives for residents to participate in treatment). We recognize that there is no one
"silver bullet" that will resolve these t'NO major challenges facing sec (and most if not all civil commitment
programs).

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Final Report
Inspection of Care Survey Tool March 3 - 7, 2008
Washington State Special Commitment Center

STANDARD I:
I-B

Staff Competence, Training, Supervision

Residential program staff are qualified, adequately supervised and trained to
provide residential care and treatment components.

CONCLUSIONS:

o Meets expectations.
o Does not meet expectations - requires significant improvement.
o Not Reviewed.

~ Meets minimum expectations - requires improvement in some areas.

Reviewer(s)
IOCTeam
Comments
1. As noted in the comments in Standard I-C, there were a number of isolated circumstances where
residential staff members were not able to answer specific fundamental questions about their
role/performance expectations,
2. A key component ot'an effective supervision model is the formal documentation of employee
performance and providing that assessment to the employees. The IOC Team's audit of see personnel
records indicated that only 60% of the files met the standard of documented annual evaluations.
3. The personnel records audit also indicated that 95% of the same files included documentation of
completion of Ihe mimdatory training.
4. The loe Team believes that the rating for this standard is a close call, However, ultimately, the
combination of the failure to document annual performance reviews and the episodes where residenlial
staff members were nol able 10 answer certain basic questions led the Team 10 the conclusion that the
most appropriate rating was needs improvement (as opposed to meeting the standard).

Evidence/Observations upon which conclusions & recommendations were based
Staff interviews.
Recommendations

1. see should continue with its improvement efforts (presented in response to the
Team's last inspection report) in the area of employee evaluations being completed on
time.
SCC Response
SCC acknowledges the IDee Team's findings.
Standard 1-8; Comment 2
The acknowleded deficiency in the percentage of employees receiving annual evaluations does not mean
that employees are not receiving routine performance feedback, For example, sec provides written

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Final Report
Inspection of Care Survey Tool March 3 - 7,2008
Washington State Special Commitment Center

feedback to RRC employees in the form of monthly performance feedback sessions and as necessary,
corrective and disciplinary actions.

IOC Team Final Comments
No further comment.

I-e

Staff are adequately trained to competently provide treatment, residential care and
security.

CONCLUSIONS:

D

Meets expectations.

[2J Meets minimum expectations - requires improvement in some areas.

D
D

Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOC Team
Comments
1. see has recently initiated an effort to improve its staff training through the addition of a director for its
training academy. While it will take some time for this to have an impact, the Team supports this initiative.
2. The areas of concern where the Team would recommend a review of past and current training
practices include: (A) A need for greater training on sex offender treatment, issues, etc. This applies both
for front-line slaff and clinical staff. (B) A concern that current in-service training for slaff is not
adequately meeting the organization's needs. For example, there is not an annual update on restraint
and seclusion issues.

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Final Report
Inspection of Care Survey Tool March 3 - 7, 2008
Washington State'Special Commitment Center

3. During unit tours/visils, IOC Team memb~rs asked residential slaff about an array of
issuesfprocedures. Generally, staff were able to provide adequate responses, but there were several
occasions where residential staff were not able to answer fundamental questions about their
roles/responsibilities (e.g .. how frequently rounds are done. procedures of what to do during rounds. who
would you report certain incidents 10, etc.).
4. II also should be noted that a number of Ihe residential slaff were outstanding in terms of their
responses, and when asked to demonstrale that they had actually performed the sort of tasks that they
had explained verbally, they were able to present examples (e.g., they explained whal they would create
a progress note on, bul more importantly, they were able 10 locate thai sort of charting in their own work).

Evidence/Observations upon which conclusions & recommendations were based
Staff interviews, training records.
Recommendations
1. In consultation with
managers and staff, the new traning academy director
should conduct a needs assessment for training. A comprehensive training strategy
should then be developed with staged implementation.

see

see

2. As part of the needs assessment process,
should seriously consider the
feasibility/desirability of providing a substantial increase in the ongoing in-service
training for treatment providers in the areas of sex offender assessment, treatment and
other issues. A part of this strategy should be an assessment of the feasibility of
providing this training through the services of external experts and lor internal
experts. Given the lack of sex offender specific expertise on the part of most of the
psychological associates, it is essential for the further development of the treatment
programming at the facility that staff be better trained and prepared for their
responsibilities.

sec

SCC Response
sec acknowledges the loce Team's findings.

IOC Team Final Comments
No further comment.

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Final Report
Inspection of Care Survey Tool March 3 - 7, 2008
Washington State Special Commitment Center

STANDARD II:
II-A

Treatment Program

The treatment program offers the components that are typically provided in
inpatient programs for sexually violent offenders.

CONCLUSIONS:

o MeGts &xpectations.

[ZI MeGts minimum expectations - requires improvoment in some areas.

D

o

Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IQCTeam
Comments
1. (Note: Comment deleted and moved to Report Addendum.)
2_ The treatment program includes the components typically provided in inpatient treatment programs for
sexual offenders. However, based on discussions with staff and r.esidents, there appears to be a lack of
any sort of comprehensive view of the total treatment program. Residents, residential staff, and a number
of clinical staff expressed a lack of understanding about the components of the treatment program and
how they are related to the prospects of earning release from the facility.
3. In the sample of treatment records reviewed by the IOC Team, each of the resident records included a
treatment plan. However, one-third of the plans were more than 6 months old, and of that group, one-half
(or 17% of the total) were over one year old.
4. In the sample of records, treatment plans did not follow a consistent formal.
5. During a walk-through of the facility. IDe Team members observed two residents playing a sniper
video game in the gymnasium. In a subsequent discussion with recreational staff, it was clarified that the
game system in the gym is prOVided by the facility, but that the games played on it are owned by the
residents. When asked why a resident would be allowed to possess a violence-themed game, the
recreation staff indicated that those decisiOflS are made by Forensic Therapists on an individual resident
basis and recreation staff members are not involved in those decisions. This incident raises several
concerns: (A) It is unclear how a video game such as a sniper action game could be viewed as
therapeutically appropriate for any sec resident. (8) Even if one accepts that such a game may be
appropriate for an individual resident, recrealion staff indicated that they have no idea as to who can or
can not play an individual game-i.e., if individualized judgments are being made to allow only certain

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Final Report
Inspection of Care Survey Tool March 3 - 7, 2008
Washington State Special Commitment Center

specific residents to use/possess certain games/property/etc., there does not appear to be any
mechanism in place 10 ensure compliance with those decisions_ This issue raises concerns about the
overall coordination of the treatment environment at Ihe facility.
6_ see continues 10 struggle in its efforts to recruit psychologists for the treatment program. Only one of
ils five psychologist positions was filled at the time of the inspection. This is a significant issue in the
context of the institution's plan for treatment delivery-Le., the planned reliance on psychologists and
Psychology Associates.

Evidence/Observations upon which conclusions & recommendations were based
Staff Interviews, resident interviews, treatment records, treatment program documentation.
Recommendations

1. see should continue with its efforts to ensure that current treatment plans exist for all
see residents and that consistent formats are used in treatment plans.
2. Ongoing training for clinical and residential staff relative to the structure and content
of the treatment program is recommended.
3. see should assess the process for the review of individual video games and other
property that are allowed into the facility. It may be possible that the observation of a
violence-themed video game was an outlier and the staff members responsible for
reviewing and making these sorts of decisions are much more diligent and consistent
than this one example would indicate. However, the presence of a predatory video game
in a treatment environment intended to address predatory behavior is particularly
troubling to the loe Team.
4. see should assess a number of current practices in an effort to enhance the quality
of the treatment environment throughout the facility: (A) It is imperative that staff
members responsible for supervising resident activities in different areas of the
institution be aware of specific restrictions, limitations, privileges, etc., that Individual
residents may have. For example, staff members supervising the activities in the gym
need to be aware of who mayor may not use certain games. There does not appear to be
any mechanism available to ensure this sort of coordination between different
components of the treatment environment. (B) sec should assess the impact of its
approach of individualizing most <;>f the decisions relative to property. Specifically, in an
environment where property is actively borrowed and loaned by residents to each other,
it appears to be a highly ineffective strategy to make a series of individualized decisions
approving Items for some and denying the same item for others. sec may wish to
consider expanding these sorts of decisions on certain types of items (e,g., movies,
games, etc.) to be institution-wide decisions for all residents.
5. Given the specific recruitment issues facing sec, it is evident that continued efforts at
resolving the psychologist staffing issue through standard recruiting efforts is destined
for failure. Accordingly, the IOC Team endorses the concept of designating psycho.logist
positions at sec for assignment pay.

see Response
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Final Report
Inspection of Care Survey Tool March 3 - 7, 2008
Washington State Special Commitment Center

SCC acknowledge.s the IOCC Team's findings.
II-A. Comment 1.
SCC requests that this comment be deleted from this standard and be included as an item in the
addendum.The level of resident treatment participation is not part of the standard.
II-A. Comment 5.
The IOC observation is acknowledged as a valid concern; however, in relation to the standard, SCC
believes that the recreational component meets the standard ("The program provides residents with
opportunities for treatment in ....therapeutic recreation activities~).

IOC Team Final Comments
The IOC Team agrees that treatment participation is not a part of the wrillen standard, and accordingly
we have deleted this comment from this standard and instead have included it in the Report Addendum.
The 'lDC Team agrees that SCC provides ample opportunity for residents to engage in therapeutic
recreation activities and in that sense meets the recreational component of this slandard. The IDC
Team's comment was intended to address the logical corollary of this component by raising a concern
that perhaps sec policies/procedures/practices do not adequately restrict residents from engaging in
non-therapeutic recreational activities. sec's response acknowledges this as a valid concern, and
therefore there does not appear to be any significant difference between the perspectives of the loe
Team and sec.

11-8

The treatment program has identifiable phases sequentially progressing from
orientation to transition to community living.

CONCLUSIONS:

IZI

Meets expectations.

o Meets minimum expectations - requires improvement in some areas.
o Does not meet expectations - requires significant improvement.
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Final Report
Inspection of Care Survey Tool March 3 - 7, 2008
Washington State Special Commitment Center

D

Not Reviewed.

Reviewer(s)
IOCTeam
Comments
1. The phases of lhe treatment program are clearly delineated in program documentation.
2. The relatively small number of residents who have advanced through treatment to the point of
community living is likely the single biggest factor in shaping residents' generally negative views of the
treatment program.
Evidence/Observations upon which conclusions & recommendations were based
Staff interviews, resident interviews, treatment program documentation.
Recommendations

None.
SCC Response
SCC acknowledges the IOCC Team's comments.
IOC Team Final Comments
No further comment.

STANDARD II:

Treatment Program

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Final Report
Inspection of Care Survey Tool March 3 -7, 2008
Washington State Special Commitment Center

II-C

Treatment plans are individualized and comprehensive.

CONCLUSIONS:

D

C2J

D
D

Meets expectations.
Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOC Team
Comments
1. There are two issues in terms of compliance with this standard: (A) As noted in II~A. treatment plans
are not consistent in format. (6) The goals typically included in the plans are not measurable
2. Plans do typically address the range of domains established in the program standards.

Evidence/Observations upon which conclusions & recommendations were based
Resident treatment records.
Recommendations

see

1. As part of its in-s~rvice training program,.
should include training in the
preparation of treatment plans, with an emphasis on the development of measurable and
meaningful goals that residents can achieve in their current living situation.
SCC Response
SCC has an established format for treatment plans and acknowledges the IOCC's findings of
discrepancies.
IOC Team Final Comments
No further comment.

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Final Report
Inspection of Care Survey Tool March 3 - 7, 2008
Washington State Special Commitment Center

11-0

Systematic measures of progress are used; feedback is regularly provided to
participants.

CONCLUSIONS:

GJ

o
o
o

Meets expectations.
Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
lOG Team
Comments
1. In the sample of charts, it was difficult to find the progress notes prepared by Iherapisls on a consistent
basis_ However, the lOG Team concluded that this was more a function of inconsislent filing than it was a
measure Ihat such notes were not prepared.
Evidence/Observations upon which conclusions & recommendations were based
Resident treatment records.
Recommendations

None.
SCC Response
sec acknowledges the IDee Team's findings.
IOC Team Final Comments
No further comment.

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Final Report
Inspection of Care Survey Tool March 3 - 7, 2008
Washington State Special Commitment Center

STANDARD II:
II·E

Treatment Program

Too program has a component to assist residents in systematically preparing for
transition to community living.

CONCLUSIONS:

[2:J Meets expectations.

0
0

o

Meets minimum expectations· requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s}
IOC Team
Comments
1 The State of Washington's civil commitment program has established a high bar for attaining release
from the inpatient portion of the program (a standard that undoubtedly reflects the policy preferences of
the State's policy makers). Within the parameters established by this polley/practice, see has a
developed system for facilitating transition back to the community.

Evidence/Observations upon which conclusions & recommendations were based
Staff interviews, document review.
Recommendations

None.
SCC Response
see acknowledges the

loee Team's findings_

IOC Team Final Comments
No further comment.

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Final Report
Inspection of Care Survey Tool March 3 -7. 2008
Washington State Special Commitment Center

STANDARD II:
II-F

Treatment Program

The program has adequate policies and procedures on the intensive management
of residents, use of seclusion or restraint of residents, and graduated intervention
and the use of force.

CONCLUSIONS:

D
D
ISJ
D

Meets expectations.
Meets minimum expectations - requires improvement·in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
lOeTeam
Comments
1 The lOG team has extensively commented on this standard during our previous inspections. Atthis
point, there have not been any changes in see policies and procedures relative to restraint and
seclusion.

2. see has fonned a team to assess and revise their policies and procedures in this area. A
presentation was made to the IOC team about the facility's progress in producing a comprehensive policy
and procedure for the use of seclusion and restraint. This was a concentrated in-depth effort thai required
a great deal of participation by several different components of the program. The draft document was
comprehensive and when complete will be a great improvement.
3. Related to the previous point, there was a general discussion with the team working on restraint and
seclusion about the use of the restraint chair. From the perspective of community standards of care in

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Final Report
Inspection of Care Survey Tool March 3 - 7, 2008
Washington State Special Commitment Center

most licensed care settings, il is questionable that the use of the restraint chair would be acceptable.
However, the IDe Team is sensitive to the unique legal status of sec and some of the unique challenges
that a small portion of its residents present.

Evidence/Observations upon which conclusions & recommendations were based
Staff interviews,· presentation by see on status of team's progress on this issue.
Recommendations
1. The sec team reviewing and assessing policies and procedures should continue with
their current effort. Hopefully, any revisions recommended by the team will be made and
in effect prior to the interim IOC inspection schduled for the Fall of 2008.
sec Response

sec acknowledges the IDee Team's findings.
IOC Team Fin_a_'C_o_m_m_e_"_'s

_

No further comment.

STANDARD II:
II-G

Treatment Program

Residents are housed in a facility that provides a treatment-oriented environment.

CONCLUSIONS;

o

D
D
D

Meets expectations.
Meets minimum expectations - requires improvement in some areas,
Does not meet expectations - requires significant improvement.
Not Reviewed,

Reviewer{s)
IOC Team

Comments
1. sec provides a pleasant environment for living and functioning, and therefore the elements of this
slandard are generally meL
2. There are, however, several observations that the IDe Team made during the site survey which are
worthy of note: (A) There appears to be a general lack of a treatment milieu throughout the facility.
Undoubtedly. this perception is magnified by the relatively low level of treatment participation that
currently occurs at see, bulthe lack of any overarching ethos of treatment on the units and throughout

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Final Report
Inspection of Care Survey Tool March 3 - 7,2008
Washington State Special Commitment Center

the facility is a clearly observable characteristic of the sec environment. (B) On one of the units visited
by the laC Team (in Program Area 3), the corridor that led to resident rooms was noticeably dark to the
extent that the ability to see clearly from one end of the corridor 10 the other was compromised. When
staff was asked about why the hallway was kept that dark, the response was that the residents preferred
the low level of lighting. II would appear that the level of illumination in a common area would be more
appropriately determined by facility needs as opposed to relying on resident preferences.

Evidence/Observations upon which conclusions & recommendations were based
Resident interviews, staff Interviews, unit visits.
Recommendations

1. sec units should assess environmental needs (such as the level of lighting) to meet
the goals of operating safely and meeting therapeutic needs. Any changes in current
practices should be discussed with residents prior to the changes actually being made.
SCC Response
sec acknowledges the lace Team's findings.
IOC Team Final Comments
No furlher comment.

II·H

Adequate space is provided for resident living, treatment, other activities, and
separation among resident groups.

CONCLUSIONS:

[2J Meets expectations.

o
o
o

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOeTeam

Comments
1. Current census levels have required the institution to make any number of unit assignments for
residents thai are less than ideal. However, given these census pressures, see has no alternative but to
make these sorts of decisions. Based on discussions with sec management, it is evident that see is
very thoughtful about lhese sorts of difficult assignments.

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final Report
Inspection of Care Survey Tool March 3 - 7,2008
Washington State Special Commitment Centef"

2. Census pressures are anticipated to continue to build within the program, which means that sec will
soon exceed Its functional capacity_ sec has a plan and funding for the creation of 38 temporary beds
within existing facility space. see also is pursuing budget authority for the construction of additional
permanent bed space. Based on these plans-and assuming legislative enactment of the funding for the
construction of an sec expansjon~- it appears that the capacity of see will be sufficient to meet
projected census levels for the foreseeable future. On the other hand, if legislative approval is not
attained in a timely manner, it is likely that see will eventually face at least some period of time where
census levels will result in a situation where the Washington's civil commitment program will no longer
have sufficient space to meet this standard.

3. A review of space available for support activities generally supports the conclusion that adequate
space is available. One area of possible exception is seC's library, which occupies a quite small space.
At the same time, there are certain areas of the facility's workshop (especially the woodworking shop),
which consume a considerable amount of space that are utilized by a very small number of residents.
According to staff involved in the area, only about five residents make consistent use of the woodworking
shop.

Evidence/Observations upon which conclusions & recommendations were based
Briefing on facility census, staff interviews, facility tour.
Recommendations

1. sec should continue with its plans for meeting projected bed needs, including both
the temporary bed space modifications and the proposal to permanently expand the
number of available beds.
2. see should assess its current use of space for resident activites to determine if
expanded space can be created for the library.
see Response
sec acknowledges the IDee Team's findings.
loe Team final Comments
No further comment.

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Final Report
Inspection of Care Survey Tool March 3 - 7, 2008
Washington State Special Commitment Center

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Final Report
Inspection of Care Survey Tool March 3 - 7, 2008
Washington State Special Commitment Center

STANDARD II:
II-I

Treatment Program

Staff are trained to, and held accountable for, professional and therapeutic
conduct.

CONCLUSIONS:

D

Meets expectations.

[2J Meets minimum expectations· requires improvement in some areas.

D
D

Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IDe Team
Comments
1. The loe Team has no question as 10 the commitment of the institution to train staff appropriately, and
to hold staff accountable for professional and therapeulic conduct. We oelieve that as a general rule, this
commitment manifests itself on a daily basis at sec.
2. There are, however, several specific observations that the IDe Team made that indicate that see has
some shortfalls in the area of a number of specific elements that require some improvements in order for
the institution to be evaluated as meeting this overall standard:
(A) Based on staff interviews, it is evident thaI there still remain some significant issues with the new
treatment program delivery model that sec moved to last year (i.e., Forensic Therapists being shifted oul
of SOT, with that role being assumed by Psychological Associates). Specifically, there remains a
significant morale problem within the ranks of the FT's, and it is evident that there is limited coordination
between the management of the clinical program and the ranks of the FT's. Given that the Frs provide
case management for 65% of sec's population, this division within clinical staff creates a very real
problem for the institution.
(B) Based on comments by both residential staff and residents, and also confirmed by the limited
observations of tt1e IOC Team members during unit walk-throughs, clinical staff members do not generally
.
appear to maintain a significant presence on the living units.
(C) As noted in II-C, the IDe Team had interactions with residential staff where institution
policyfpractice could not be described. The Team does not wish to overemphasize the significance of a
limited number of staff interactions. Thus, we cite this factor only as supporting detail for the evaluation of
SCC as needing improvement in this area.

Evidence/Observations upon which conclusions & recommendations were based
Satff interviews, resident interviews.
Recommendations

1. see needs to evaluate whether the current structure for the direction of sec's overall
clinical resources provides the level of coordination and consistency that is needed in an

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Inspection of Care Survey Tool March 3 - 7, 2008
Washington State Special Commitment Center

inpatient setting. In particular, the key issues which n99d to b9 considered are: (A) How
can the staffing resources of the Forensic Therapists be more effectively used in the
delivery/coordination of a consistent treatment program? (8) What steps can be taken to
reduce the level of division between the various components of the treatment program?
(C) How can the 24-hours a day staffing on the units and their observations be more
closely integrated into the treatment program?
SCC Response

sec acknowledges the teams commments and recommendations.
IOC Team Final Comments
No further comment.

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II-J

Program policies are consistently enforced.

CONCLUSIONS:

o Meets expectations.

.lZJ
O

o

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOCTeam
Comments
1. As a general rule, program policies are consistenUy enforced at SCC, and there is no evidence Ihat
there is any sort of discrimination, favoritism or arbitrary decision~making as a common sorl of occurrence
at sec.
2. The elements of this standard include a consideration of the administrative process for resident
disciplinary cases, and the standard makes specific reference to the residents having access to the
services of an advocate to represent their constructive interests. IOC Team members observed an
admi':lislrative hearing involving a resident. At the hearing, the resident indicated that he wanted an
advocate to attend the hearing and participate in the process. The hearing coordinator stated al the
hearing Ihat an advocate was not available, and the hearing would proceed. This statement directly
contradicls sec Policy 238 which states: "Residents participating in an administrative review hearing are
entitled to have advocacy." The decision to proceed with the hearing notwithstanding the resident's
request is a dear and concrete example of a program policy not being consistenlly enforced.
Accordingly, per the elements of this standard, this incident precludes the IOC Team from evaluating that
program policies are consistently enforced.
Evidence/Observations upon which conclusions & recommendations were based
Observation of an administrative review hearing, SCC policy.
Recommendations

1. see should evaluate its practices and policy relative to the participation of an
advocate at an adminsitrative review hearing. Given that these hearings are scheduled in
advance, it is unclear to the loe Team why an advocate can not always attend these
sessions. However, if that can not be arranged, sec should either create an alternate
process for advocacy for a resident at these hearings when requested, or the institution's
policy establishing this right should be revisited.
SCC Response
sec acknowledges the loee Team's findings.
iOC Team Final Comments
No further comment.

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II·K

Residents are treated with respect and have opportunities to have their
grievances addressed.

CONCLUSIONS:

[SJ Meets expectations.

D
D
D

Meets minimum expectations· requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOCTeam
Comments
.1. sec policy and practice has established a very elaborate and detailed process for the investigation
and resolution of resident grievances. (Note: the issue of advocacy at a hearing was addressed under
the previous standard and accordingly is not being reflected under this standard.)
Evidence/Obse.....ations upon which conclusions & recommendations were based
sce policy. staff interviews, specific case reviews.
Recommendations

None.
sec Response

sec acknowledges the IDee Tearn's findings.
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IOC Team Final Comments
No further comment.

STANDARD II:
II-L

Treatment Program

The program addresses the long-term care needs of residents who do not choose
to participate in sex offender specific treatment activities.

CONCLUSIONS:

l:8J

o
o
o

Meets expectations.
Meets minimum expectations - requires improvement in some areas.
Does nat meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
loe Team
Comments
1. As in the past, the loe Team is struck by the lack of incentives within sec 10 encouragefreward
treatment participation. sec has implemented one rather innocuous reward for treatment participation.
A plan to develop a more significant incentive was placed on hold pending litigation.
2. During the inspection, the Washington Legislature was considering a proposal that would restrict
computers at sec only to those residents who are participating in treatment.
Evidence/Observations upon which conclusions & recommendations were based

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Staff interviews, resident interviews, SCC status report on previous IOC recommendations.
Recommendations

1. see should continue to explore meaningful incentives that could be created to
encourage treatment participation.
2. If the legislation concerning computers passes, see will need to establish a set of
criteria to evaluate the quality of treatment participation--i.e., it would appear likely that
some residents may change their stated intent to particpate in treatment without
changing their actual commitment to treatment.
SCC Response

sec acknowledges the IDee Team's comments and recommendations.
IOC Team Final Comments
No further comment.

STANDARD III:
III-A

Health Care Services

Health care services staff are trained and licensed to provide care adequate to
meet the routine and emergency medical needs of residents.

CONCLUSIONS:

IZl

D
D
D

Meets expectations.
Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

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Reviewer(s)
IDe Team
Comments

1. Since the last inspection, there has been a clear and marked improvement in the organization and
culture of nursing care at sec. This has resulted in a noticeable improvement in the quality of nursing
care at the facility.
2. The nurse manager now has the designation of clinical nurse specialist and is the acting Health
Services Administrator. She presented the need to access assignment pay for the positions filied by
contract nurses. This would enable these experienced nurses to become permanent employees. This
change would improve the stability of staff and quality of care.
3. There is still a lack of adequate training for the nursing staff and nurses are asking for more training in
sex offender treatment to enable them to assist with the resident treatment plans.
4. A posilion has been established for a nurse trainer. There is a plan to include mock codes in the
future.
5. Two issues have been identified with the implementation of advance directives for the residents: (A)
The first issue is that apparently security staff make the determinations of medical emergencies of
residents. They lack the necessary training to assess the medical status of a resident. Medical staff
should assume this responsibility. (B) The second issue is that security staff and residential staff believe
that they musl always start CPR (cardia-pulmonary-resuscitation) regardless of the residents DNR (do not
resuscitate) status contained in the advance directives. Further, there is not a standard method to notify
program area staff if there is a valid DNR in place. Interviews with staff confirmed the belief they must
perform CPR in all cases.
Evidence/Observations upon which conclusions & recommendations were based
Staff Interviews, SCC policies, clinic visit.
Recommendations

1. The IOC Team endorses the concept of changing position designations to make
nursing staff permanent employees in an effort to support the quality of the nursing care.
2, The ICC Team recommends that the staff psychiatrist provide training about sex
offenders with the nursing staff via regularly scheduled in-services. This would enhance
nursing knowledge and facilitate improved communication between the programs.
3. A facility-wide plan should be developed to address the issue of medical emergency
determinations and how to implement the use of advance directives. It is essential to
address this issue in a timely manner. It is a serious resident right violation to perform
CPR when it is contrary to the individual's wishes and directive.

see Response
sec acknowledges the loce Team's comments and recommendations.
Facility psychiatric staff attend regular medical slaff meetings and present vignettes regarding sex
offender subject matler to enhance clinic staff understandings of etiology and safely/security methods
while interacting with sex offenders.

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IOC Team Final Comments
The IOC Team acknowledges the clarification concerning ongoing training of clinic staff relative to sex
offender issues.

STANDARD III:
111-8

Health Care Services

Health care services staffing is sufficient to provide residents wtth routine and
emergent medical care.

CONCLUSIONS:

I3J

Meets expectations.

o Meets minimum expectations - requires improvement in some areas.
o Does not meet expectations - requires significant improvement.
o Not Reviewed.

Reviewer(s)
IOCTeam
Comments
1. While there are a number of issues or areas of potential improvement in the delivery of health
services, the level of staffing does not appear to be an issue.
Evidence/Observations upon which conclusions & recommendations were based
Staff interviews, clinic visit.
Recommendations

None.
SCC Response
sec acknowledges the loce Team's comment.
IOC Team Final Comments
No further comment.

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III-C

Health care facility is sufficiently equipped to provide routine and emergent health
care services to residents.

CONCLUSIONS:

[gI Meets expectations.

D
D
D

Meets minimum expectations - requires improvement in some areas.
Does not m99t expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOC Team
Comments
1. see's medical clinic is adequately equipped to provide the level of care expected in this sort of
setting.
Evidence/Observations upon which conclusions & recommendations were based
Clinic visit.
Recommendations

None.

see Response

sec acknOWledges the IDee Team's comment.
IOC Team Final Comments
No further comment.

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111-0

Pharmaceutical services are sufficient to meet residents' routine and emergent
health care needs.

CONCLUSIONS;

D
D

Meets expectations.
Meets minimum expectations - requires improvement in some areas.
[8] Does not meet expectations - requires significant improvement.
D Not Reviewed.

Reviewer(s)
IOCTeam
Comments
(1) There are signifICant problems with the quality of pharmaceutical services at sec. The issues
identified indude: (A) There have been problems with drug errors-i.e., the number of ordered
medications in the containers delivered by the pharmacy service were fewer than had been ordered,
including cases involving controlled substances. (B) There was one incident where aspirin was
substituted for an ordered medication. (C) There have been regular issues with getting timely
prescription refills. (0) The contracted pharmacy provides minimal consultative assistance with
pharmaceutical issues. (E) sec medical staff reports that when issues are identified, the pharmacy has
not been responsive.
(2) In addition to the quality of services provided by the pharmacy, there are several issues rooted in
(A) see does not have an automatic medication refill program in place that aggravates
the situation concerning prescription refills. (B) see does not have a complete list of medication orders
in the records.

sec practices:

(3) There are regUlatory restrictions that have caused a number of challenges for sec in terms of the
development of a medication delivery system at the facility. see has consulted with the state board of
pharmacy to allow completion of a plan to have a complete medication delivery system on the island, but
a resolution of the issue has not been achieved.
Evidence/Observations upon which conclusions & recommendations were based
Staff interviews. medical records
Recommendations

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1. The loe Team endorses the plan to seek another contract pharmacy, and the new
contract should specifiy that pharmacy consultation must be provided when necessary.
2. When a new pharmacy service is arranged, the loe Team recommends that see
require the implementation of an automatic refill program. Also, sec should retain a
complete list of medication orders in the records.
3. The loe Team recommends that see continue its discussions with the pharmacy
board with the goal of resolving the issues about the development of a medication
delivery system at the facility.
SCC Response

sec acknowledges the IDee Team's comments and recommendations.
IOC Team Final Comments
No further comment.

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STANDARD III:
III-E

Health Care Services

Resident health care records include information essential to the residents' health
care needs and are prepared and maintained in a manner that supports the
residents' treatment and respects confidentiality.

CONCLUSIONS:

o Meets expectations.
o Does not meet expectations - requires significant improvement.
o Not Reviewed.

[2J Meets minimum expectations· requires improvement in some areas.

Reviewer(s)
IOCTeam
Comments
(1) There has been a definite improvement in the quality of the resident health care records maintained
by sec. History and physical examinations were essentially current.
(2) There were several areas where the medical records need improvement: (A) Medical treatment plans
were not current in most records revie.rved. (8) There was a lack of current nursing care plans for
resident care.

Evidence/Observations upon which conclusions & recommendations were based
Record reviews, staff interviews.
Recommendations

1. The loe Team recommends that sec consider establishing a system/process that
would develop an initial nursing care plan upon admission to the facility. The plan
should be as comprehensive as needed by the resident. Nursing care plans are a
standard of nursing practice and should be present at sec.
2. The loe team recommends that an effort be made to update medical treatment plans
for residents receiving active medical care.

sec Response

sec acknowledges the lOGe Team's comments and recommendations.
IOC Team Final Comments
No further comment.

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STANDARD III:
III-F

Health Care Services

Residents receive adequate routine. preventive. and emergent health care
services.

CONCLUSIONS:

[.8J Meets expectations.

o

D
D

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IDe Team
Comments
. (1) While there-are some issues in the area, the IOC Team has concluded that the level of medical care
at sec is adequate in terms of meeting resident needs.
(2) The issue of second opinions was discussed by the IDe Team and sec's management. (This issue
was also raised by the ombudsman.) This is a difficult issue to find a simple and cost effective approach,
but sec is reviewing the issue.
(3) The IDe Team supports the concept that residents with financial resources should pay for their own
over the counter medications. However, there does appear to be a legitimate complaint expressed by
residents about the delays that exist between ordering the medication and actual receipt of it by the
resident. In cases where a resident is seeking relief from symptoms of common ailments, it does not
appear that the current process provides a timely enough response.
(4) Limitations imposed by MiCe on the number of sec residents who may go off-island on any given
day for non-emergent medical services appear 10 have an occasional impact on the level of services
provided to ~ee residents. For example, because a number of residents are going off island for cancer
treatments, the ability to provide certain preventative services to other residents has been adversely
impacted. Significant delays in preventative procedures can mean the difference between early diagnosis
of a treatable condition with good prognosis for the re"Sidenl compared to a lale diagnosis of an advanced
condition with a poor prognosis.
Evidence/Observations upon which conclusions & recommendations were based
Staff interviews, residet interviews, medical record reviews.
Recommendations

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see

1.
should review the process for resident over-the-counter medications purchases
with the goal of speeding up the delivery of these products when needed by the
residents.
2. see should assess how widespread the impact of the Mlee policy on limiting the
number of sec residents off island for non~emergentmedical services has been. If there
is an issue that extends beyond minor re-sheduling for this sort of care, see should
discuss and negotiate the issue with Mlee in an effort to reach a modification in the
current policy.
3. sec should continue to review the issue of second medical opinions. However, given
the potential significance of this issue from both a fiscal and resident rights perspective,
the loe Team defers to the jUdgement of sec management on this issue.
SCC Response
sec acknowledges the IOCC Team's comments and recommendalions.
The number of scheduled off-island medical visits is not controlled by MICC; it is a matter of contract.
sec receives the level of support from MiCe that is contracted for. The apparent bottleneck on
appointments can be addressed through scheduling and contract changes.
IOC Team Final Comments
The IOC Team acknowledges the clarification that off-island trips are done pursuant to a contract with
MiCe. The potential resolutions mentioned in the sce response are consistent wilh the loe
recommendation.

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IlI-G

Health Care Professionals will provide consultation and other services to
residential program areas.

CONCLUSIONS:

IZ1

Meets expectations.

o Meets minimum expectations - requires improvement in some areas.
o Does not meet expectations - requires significant improvement.
o Not Reviewed.
Reviewer(s)
IOeTeam
Comments
(1) The Program Area Nurse concept that was implemented in the last several years continues to be very
successful.
Evidence/Observations upon which conclusions & recommendations were based
Staff interviews.
Recommendations

None.
SCC Response
see acknoWledges the loee Team's comment.
IOC Team Final Comments
No further commen~I.==='------ - - - - - - - - - - - - - - - - - - - - - - - -

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STANDARD III:
III-H

Health Care Services

Residents receive adequate psychiatric services necessary to support their
progress in treatment.

CONCLUSIONS:

[ZJ Meets expectations.

o Meets minimum expectations - requires improvement in some areas.
o Does not meet expectations - requires significant improvement.
o Not Reviewed.
Reviewer(s)
lac Team
Comments
1. The working relationship between medical and psychiatry at sec has improved since the lac Team's
last site visit. Given the importance of an integrated team approach in these areas, this working
relationship needs to continue to be improved and supported.
2. The assignment of a nurse to support the psychiatrist has significantly improved the organization of
this service through the tracking of appointments, medication reviews, and other coordination issues.
3. Record reviews indicate thai the psychiatrist has good follow·up with residents, sometimes seeing
difficult or unstable patients on a weekly basis.
4. There are several areas where future improvement is needed: (A) Psychiatric intakes are not
documented in many patient charts, despite the fact that these patients are receiving psychiatric services
at SCC. (B) Chart reviews indicated that there stili are occasions where a patient has been seen by the
psychiatrist, but it is not documented in the patie.nt's chart.

Evidence/Observations upon which conclusions & recommendations were based
Staff interviews, resident interviews, chart reviews.
Recommendations

1. It is recommended that relative to the issue of psychiatric intake: (A) see must ensure
that each resident that is followed by psychiatry has an initial psychiatric intake (or
updated detailed psychiatric evaluation) with five axis diagnosis and treatment plan
completed and in the patient's chart. (B) In those cases where the initial intake
assessment is old, the psychiatrist should complete a more thorough evaluation in order
to update the medical record.
2. It is essential that the psychiatric services that are provided to individual residents be
documented by timely psychiatric notes in the patients' charts. see may wish to

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consider addressing this issue through a QA project-i.e., reviewing a sample of the
charts for patients seen by seen by the psychiatrist over a specific period of time to
determine whether this situation is an ongoing issue that needs further attention.

see Response
see acknowledges the IDee Team's comments and recommendations.
IOC Team Final Comments
No further comment.

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STANDARD IV:
IV-A

Program Oversight

The program has external oversight, either through a licensing organization or
other entities (a governing body; inspections by outside professionals,
ombudsman services, and external investigation of incidents).

CONCLUSIONS:

l:8J

Meets expectations.

o Meets minimum expectations - requires improvement in some areas.
o Does not meet expectations - requires significant improvement.
o Not Reviewed.
Reviewer(s)
IOCleam
Comments
1. see has developed a very comprehensive oversight structure for its operations.
EvidencefObservations upon which conclusions & recommendations were based
SCC policies, minutes.
Recommendations

None.
SCC Response

see acknowledges the loee Team's comment.
IOC Team Final Comments
No further comment.

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IV-B

The program has internal review procedures covering quality assurance,
protection of residents' rights, policy review and compliance, and internal
investigation of incidents.

CONCLUSIONS:

o

Meets expectations.
[8] Meets minimum expectations - requires improvement in some areas.
0 Does not meet expectations - requires significant improvement.
Not Reviewed.

o

Reviewer{s)
lac Team
Comments
1. The basic structures/processes required by this standard are present in sec. However, the lac
Team concluded that there are some significant issues with a number of these elements, which led to the
evaluation that only minimum expectations were being met
2. sec has a designated QA staff person, and a variety of QA products and reports are generated.
However, the IDe Team believes that sec lacks an effective QA infrastructure. For example, wh~e the
institution has a OA committee, it appears to be relatively inactive. Also, various QA reports have
identified the same sorts of issues that have been pointed out by the IDe reports in the past, but in any
number of cases there did not appear to be any follow-up on those sorts of efforts.
3. As noted elsewhere in this report, nerther of the resident advocates were available to attend the
disciplinary hearing attended by members of the IDe Team. According to staff interviewed who were
involved in that process, it is a fairly common situation for no advocate to attend and participate in these
hearings.
4. see has a full-time investigator, who also has two· assistants_ It appears that this operation is an
effective unit for investigating major incidents, especially those incidents that may have involved criminal
activity. The full-time investigator appears to be very skilled and experienced. However, based on the
IDe Team's review of the institution's resident disciplinary process, the rationale for the role assigned to
investigative staff in these routine cases is unclear. It appears that the assistant investigators only serve
as someone to contact the resident and ask for the resident's statement on the incident. The "report"
submilled by the assistant investigator is a brief recitation of the resident's description/explanation of the
incident. It is not dear if the limited nature of these reports is a function of design (i.e., it has been
determined that these assistant investigators are the appropriate parties to talk to the resident to get that
side of the story), or if it is a function of a lack of training in how to conduct a more comprehensive
investigation.
Evidence/Observations upon which conclusions & recommendations were based
Staff interviews, SCC policies, SCC reports.
Recommendations

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1. see should review and assess its QA infrastructure, with the goal of establishing an
active and effective process for detennining priorities for QA staff, reviewing QA reports,
and taking action on these reports.

2. see should work with the chain of command for the resident advocates with the goal
of ensuring that resident advocacy is available for residents during administrative
hearings when requested by the residents (assuming that the see policy on this issue is
not changed).
3. see should review its "investigative process" for standard resident grievances with
an emphasis placed on evaluationg whether the current role of the assistant
investigators should be modified-·perhaps the role should be reassigned, dropped, or
otherwise modified. If the role is intended to complete an actual investigation, it is
'recommended that the staff be provided the necessary training to complete a more
comprehensive investigation.
SCC Response

sec acknowledges the IOCC Team's comments and recommendations.
lV-B Comment 4
The assistant investigators are two individuals with three primary responsibilities which are divided
between them:
1.
Pertaining to Resident Misbehavior. they compile all relevent paperwork and records pertaining to
the incident of misbehavior and they offer the miscreant(s) an opportunity to make a statement for the
record. All of which is submitted to the hearings officer. They do not generally investigate the
misbehavior. The resident can speak for him/her self at the hearing, witnesses can be interviewed as
needed and the reports submitted at the lime of the incident are used 10 adjudicate the matter.
2.
Pertaining to Resident Abuse, they perform work necessary to support abuse investigation and
coordinate with others to conduct components of the investigation and ensure the process is tracked to
comply with our standards.
3.
Pertaining to Resident Grievences, they review the complaint, interview the complainent, contrast
Ihe complaint against the policy, procedure. or rule alleged to be viotated, interview staff members named
or subject matter experts in the·matter and provide the resident with feedback. More often than not the
matter is nol an issue of substance, bul each grievence requires follow-through and investigation.

IOC Team Final Comments
The IOC Team acknowledges the explanation of the role fot assistant investigators.

STANDARD V:
V-A

New Admissions

Residents are involved in a comprehensive intake and orientation process upon
admission to the program.

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CONCLUSIONS:

[2] Meets expectations.
Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

o
o
o

Reviewer(s)
loe Team
Comments
1. sec has a very detailed policy and associated procedures for the intake of new admissions, and the
practice of the inslilution is to follow these policies and procedures.

2. The issue of the comprehensive summary admission report is somewhat in flux at SCC. Previous
practices have required the preparation of a very detailed and lengthy admission report by a Forensic
Therapist. sec is now considering reducing the scope of that report in order to make it a more easily
prepared document.
Evidence/Observations upon which conclusions & recommendations were based
Staff Interviews, SCC policies, admission reports.
Recommendations

1. sec should assess the utility of a comprehensive admission report in the context of
whether the resources required to produce these reports can be justified. The loe Team
does not have a specific recommendation on this issue, but believes that the final
decision on this issue should be made in a broad context that assesses the long-term
utility of the comprehensive report for all parts of the institution.
SCC Response

sec acknowledges the roee Team's comments and recommendation.
IOC Team Final Comments
No further comment.

V-B

Residents receive a health screening upon admission to the program.

CONCLUSIONS:

o Meets expectations.
o Meets minimum expectations - requires improvement in some areas.
D Does not meet expectations - requires significant improvement.
o Not Reviewed.
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Reviewer(s)
laC Team
Comments
1. Admission physical exams are being done on new admissions.
EvidencelObservations upon which conclusions & recommendations were based
Staff interviews, resident medical charts.
Recommendations
None.
SCC Response
SCC acknowledges the IOCC Team's comment.

IOC Team Final Comments
No further comment.

v-c

The program follows an established process for determining each resident's risk
level, housing and treatment needs.

CONCLUSIONS:
~ Meets expectations.

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D
D

o

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOCTeam
Comments
1. Resident special needs are assessed prior 10 and during the course of the admission.
Evidence/Observations upon which conclusions & recommendations were based
Staff interviews.
Recommendations
None.
SCC Response
sec ackno'NIedges the loce Team's comment.
IOC Team Final Comments
No further comment.

V-D

An initial treatment plan is developed for each resident following his/her
admission to the program.

CONClUSIONS",:_ _

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IZJ
D
D
D

Meets expectations.
Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOCTeam
Comments
TThe charts for the more recent admissions that were reviewed

by sec included

treatment plans.

Evidence/Observations upon which conclusions & recommendations were base_"d'-Chart reviews.
--- --Recommendations

None.
SCC Response
see acknowledges the

loce Team's comment.

IOC Team Final Comments
No further comment.

STANDARD VI:
VI-A

.Food Service

The program's food services department is managed by experienced staff who
follow established standards and practices.

CONCLUSIONS:

42

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[ZI Meets expectations.

o Meets minimum expectations· requires improvement in some areas.
o Does not meet expectations - requires significant improvement.
o Not Reviewed.
Reviewer(s)
IOCTeam
Comments
1. SCC's food service department is a professionally managed operation.
Evidence/Observations upon which conclusions & recommendations were based
Staff interviews.
Recommendations

None.
SCC Response
SCC acknowledges the loce Team's comment.
JOC Team Final Comments
No further comment.

VI-B

The food service program meets established health and safety standards.

CONCLUSIONS:

f2] Meets expectations.
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o
D
o

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOC Team
Comments
1. The kllchen and dining areas were clean, well lit, and properly ventilated.
2. The residents staffing the kitchen were knowledgeable about their tasks and the operations of the
kitchen.
3. Appropriate sanitary conditions were evident.
4. The painting of the tables in the dining room has greatly improved the appearance of the dining room
and the ability to adequately clean the table surfaces.
5. Cracks are evident in certain portions of the flooring in the dining room.
6. Concern was expressed about occasional fecal droppings of animals in the general vicinity of the
kitchen and dining area. However. adequate processes are in place to address these issues when they
occur.
Evidence/Observations upon which conclusions & recommendations were based
Kitchen inspection, resident interviews, staff interviews.
Recommendations

1. It is recommended that the issue of repairing/replacing the flooring in the dining area
be assessed by the institution. It is difficult to adequately clean a floor with breaks in the
surface.
SCC Response

VI-B Comment 5.
The kitchen and dining areas are undergoing a 2-phase $1.5 million renovation, $800 thousand has been
spent to date. The floors are scheduled to be resurfaced as part of the 200 phase of this renovation
project.
IOC Team Final Comments
The roc acknO\v1edges the planned repair of the food service area floors.

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STANDARD VI:
VI-C

Food Service

The program's menu planning is adequate to meet the residents' needs.

CONCLUSIONS:

[8J

Meets expectations.

o Meets minimum expectations - requires improvement in some areas.
o Does not meet expectations - requires significant improvement.
o Not Reviewed.
Reviewer(s)
IOC Team
Comments
1. The program's menu planning has been greatly enhanced by the addition of a Registered Dietitian who
works three days a week. She provides consultation to the food service manager and the medical staff.
She also meets with residents to discuss dietary issues.

Evidence/Observations upon which conclusions & recommendations were based
Staff interviews, menus.
Recommendations

None.
SCC Response
sec acknowledges the IOeC Team's comment
IOC Team Final Comments
No further comment.

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Final Report
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VI·D

The program provides adequate and appropriate meals for residents with special
diet needs because of health or religious reasons.

CONCLUSIONS,

t8J

Meets expectations.

o Meets minimum expectations - requires improvement in some areas.
D Does not meet expectations - requires significant improvement.
o Not Reviewed.
Reviewer(s)
IOC Team
Comments
1. This standard is adequately mel by the inslilution.
Evidence/Observations upon which conclusions & recommendations were based
Staff interviews, menus.
Recommendations

None.
SCC Response

sec acknowledges the faCe Team's comment.
IOC Team Final Comments
No further comment.

STANDARD VII:
VII·A

Safety and Emergency Preparedness

The program has adequate procedures for managing fire safety, handling and
disposing of hazardous materials and natural disasters_

CONCLUSIONS:

o Meets expectations.
o Meets minimum expectations - requires improvement in some areas.
t8J

Does not meet expectations - requires significant improvement.

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Final Report
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o

Not Reviewed.

Reviewer(s)
IOe Team
Comments
1. sec h'~a~S~I~h~e~a~p~p~co~p~'~ia~lC-eemergency plans to respond to various emergencies.
2. Since the last IOe inspection, sec has had two serious incidents involving arson or attempted arson
by residents. sec residents continue to have unabated access to matches.
Evidence/Observations upon which conclusions'& recommendations were based
Staff Interviews, incident reports, facility tour.
Recommendations

1. Access to matches remains a critical Issue for thel0C Team (as stated in previous
inspection reports), and the recent incidents in the institution further emphasize how
important this issue is. Accordingly, the IDe Team repeats its standing recommendation
that matches be removed from the facility.
sec Response
see acknowledges the loce Team's comments and recommendation.

loe Team Final Comments
In our initial comments on this standard, the loe Team did not acknowledge the overall excellent work
that see has done in terms of emergency planning. During the reviewed period of time, sec faced a
number of significant emergencies associated with severe weather, and the institution very successfUlly
handled these' challenging situations. This success is a testimony to the quality of emergency planning
that sec has done. Our original comments failed to recognize this successful experience and excellent
work due to our emphasis on the issue of matches and fire safely in the institution. In hindsight, we
believe that our comments were not sufficiently balanced, which is why we concluded that this postscript
is appropriate/necessary_

STANDARD VIII:

Security

VIII-A The program's security measures and practices adequately protect residents,
staff, and the community.

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CONCLUSIONS:

[3J Meets expectations.

o Meets minimum expectations - rsquires improvement in some areas.
o Does not meet expectations - requires significant improvement.
o Not Reviewed.
Reviewer(s)
IOC Team
Comments
1_ sec has a Ouick Response Team to respond to security issues within the facility_The ORT is
equipped with the appropriate protective gear to respond to these sorts of situations.
2. sec reports that it has used the chemical spray oe (pepper spray) in two incidents inside the facility.
IOC Team members reviewed the official videotape of one of these exposures (which was provided by a
resident to support his claim of facility abuse). The lOC Team members who viewed the videotape did
not view the facility's actions in this incident as abusive, and it was noted that the 09 use assisted in the
safe resolution of the incident. The IOC Team did nole that the specific tactics used in the incident may
have been done in a manner that did not conform to the standard protocol that would appear to be
appropriate in this sort of incident. Specifically, the OC was sprayed into a seclusion room though the
room's trap door (commonly used for handcuffing a resident or passing a meal tray); given the specifics of
the incident that appears to have been an appropriate tactic; however, the ORT member who spayed the
OC did so by extending his arm through the trap door in a manner th~t appears questionable from a
review of the videotape. The staff member extending his arm through the trap for the administration of
OC placed himself in some degree of jeopardy from a personal safety perspective (Le., if the resident
had charged the door, it may have been possible for the resident to grab his arm), and this particular
approach could have placed institutional security in some degree of jeopardy (i.e., the resident may have
been able to knock the canister of OC oUt of the staff member's hand or the staff member may have
knocked it out of his own hand if he had been required to quickly 'Nithdraw his arm back through the trap).
Another aspect of this incident that also was un~onvenlionaJ was the tactical decision to spray the
resident on his buttocks with OC when the resident used his bare buttocks to altemptto block the trap.
While the IOC Team did not view this as abusive, it does raise further questions about the tactical
decisions that were made by the ORT team during this incident. (The IOC Team notes that directions for
the use of DC specify that the intended target zone for the spray is the ''face aiming at the eyes and
brow.
M

)

3. SCC continues to face an ongoing battle with a variety of contraband issues. Pornography and street
drugs are reportedly relatively easily accessible within the institution (per statements by residents). Also,
the prosecut!ons that have occurred at sec confirm that these issues do exisl.
4. Staff from the McNeil Island Correctional Center provide a variety of services for SCC, including
escorting residents into the community for medical appointments and fire protection services. Certain
issues exist in this relationship that sce should explore with the Department of Corrections. For
example, the escorting by MICC staff apparently establishes a limit on the number of SCC residents who
can go off-island for medical appointments on any given day. This appears to be a problem from the
perspective of the requirement that SCC meet the medical needs of its residents. Also, there may be
areas where it makes sense for there to be further cooperation with Mice; for example, the security .

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resources of MICe may be a logical part of the array of responses that sec would want to have available
for certain issues that arise.

5. sec does not do random room searches, but instead does room inspections only on a for cause
basis.
Evidence/Observations upon which conclusions & recommendations were based
Staff interviews, resident interviews, videotape of security incident, facility tour, SCC policy.
Recommendations

1. In light of its ongoing issues with contraband, sec should assess whether
modifications in its standard security practices are appropriate. Legislation on the issue
of resident possession of computers may address a major portion of this issue. sec
may want to assess other potential enhancements in its security practices-for example,
the possibility of implementing a program of random room searches.
2. sec shoul.d assess its training program relative to the use of oe spray in the facility.
In particular, this training should include handsaon training done in the context of
potential scenarios. Per policy, it is assumed that sec reviews all uses of oe and
feedback is given to the staff about lessons that may have been learned from these
incidents.
3. sec should assess its working relationship with Mice and determine if potential
changes in this relationship may be necessary in order for sec to operate more
effectively/safely. It may be necessary for authorizing legislation to be passed in order to
attain the goals/needs of sec.
SCC Response
sec acknowledges the IDee Team's comments and recommendations.
security staff receive on-going training on use of force tactics. Staff who were involved in the aoovedescribed incident conducted a de-briefing which resulted in further training in use of pepper spray to
ensure staff and resident safety.
sec currently conducts 5 weekly random room inspections per shift per Program Area to control, locate
and seize any contraband items Ihat may have passed through our various security systems.
Residents are no longer able 10 purchase a choice of computers. As of 2007. residents who want to
purchase a computer can only purchase one type of computer that has limited capabiUties. This new
procedure was enacted to severely restrict and limit the entry of contraband pornography and illicit datasharing between residents.
As previously mentioned in Standard III-F. the quantity of medical trips provided to sec residents is a
matter of contracting, not a matter of independienl decisions by MiCe staff members.

IOC Team Final Comments
The loe Team acknowledges the clarifICations provided relative to use of force training, random room
inspections. and permissible new computer equipment One point of clarification relative to Ihe original
recommendation relative 10 the working relationship with MleC: This recommendation was not made in
the context of medical trips. Rather, the loe Team was speaking to emergency security situations that

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Final Report
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Washington State Special Commitment Center

may arise at sec where
emergency situation.

MICe resources may be essential to the safe and timely resolution of such an

VIII-B The program documents incidents and takes appropriate follow -up action.
CONCLUSIONS:
~ Meets expectations.

o
o
o

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IDe Team
Comments
1. The IDe Team reviewed incident reports and investigation reports from a number of incidents. These
reports present clear documentation of the incident.
Evidence/Observations upon which conclusions & recommendations were based
SCC reports, see policy, staff interviews.
Recommendations

None.
see Response

see acknO\vledges the IDee Team's comment.
IOC Team Final Comments
No further comment.

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VIII-C The program assures that incidents involving allegations of criminal violations are
properly investigated..
CONCLUSIONS:

[Z1 Meets expectations.

o
o
o

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOC Team
Comments
1. sec refers criminal activities to law enforcement, and occasional prosecutions occur.
2. sec maintains an evidence room that includes a considerable amount of items in storage for possible
investigation and prosecution. This room and its contents are organized such that chain of custody for
law enforcement purposes is maintained.
Evidence/Observations upon which conclusions & recommendations were based
Staff interviews, facility tour.
Recommendations

None.
SCC Response
sec acknowledges the

IDee Team's comments.

IOC Team Final Comments
No further comment.

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Final Report
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STANDARD IX:
IX-A

Resident Information

The program adequately compiles, maintains and protects resident records.

CONCLUSIONS:

o Meets expectations.
!81 Meets minimum expectations - requires improvement in some areas.
o Does not meet expectations - requires significant improvement.
o Not Reviewed.
Reviewer(s)
IOC Team
Comments
1. see is HIPAA compliant in its management, storage and use of resident records.
2. sec's medical records have improved considerably in the last year in terms of organization and
therefore their utility for medical staff.

3. During the IDe Team's review of clinical records, the Team concluded that there is a certain level of
disorganization that is prevalent throughout the records. For example, the definition of what is filed under
the Progress Notes section and the Treatment Notes section do nol appear to be uniformly applied.
Thus, in one chart, notes bya clinical staff member about'a treatment group may be found in either
section of the charI.
Evidence/Observations upon which conclusions & recommendations were based
Record reviews.
Recommendations
1. sec should ensure that clear standards/procedures exist for determining where

various forms of documentation will be stored in the residents' charts. Compliance with
these standards should then be assessed through SCC's quality assurance process.
sec Response
sec acknowledges the loce Team's comments and

_

recommen=d~a~l;~on~.-------------

IOC Team Final Comments
No further comment.

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IX-B

The program has a policy regarding medical research.

CONCLUSIONS:

[8J Meets expectations.

D
D
D

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOCTeam
Comments
1. see has a policy in this area.

sec

Forensic Evalualion unit has collected data relative to the utility of the Rorschach test to sex
2.
offender assessment.

Evidence/Observations upon which conclusions & recommendations were based
SCC policy, staff interviews.
Recommendations

None.
SCC Response
sec acknowledges the

IDee Team's comments.

IOC Team Final Comments
No further comment:

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Final Report
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STANDARD X:
X-A

Physical Plant

The facility meets all appiicable building and safety codes.

CONCLUSIONS:

r2l

Meets expectations.

o Meets minimum expectations· requires improvement in some areas.
o Does not meet expectations - requires significant improvement.
o Not Reviewed.
Reviewer(s)
IDe TEam
Comments
1. AppropO;ri:Ca,i::.-=di::ocumentalion of inspections was available 10 the IOC Team.
Evidence/Observations upon which conclusions & ,recommendations were based
Staff interviews, fire inspection reports.
Recomme"n"da"''''io'''n,,s'---

------------------

None.
SCC Response
sec acknowledges the

IDee Team's comment.

IOC Team Final Comments
No further comment.

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Final Report
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X-B

The program assures that the facility's indoor air quality is adequate.

CONC~USIONS'

l3J

Meets expectations.

o Meets minimum expectations· requires improvement in some areas.
o Does not meet expectations - requires significa.nt improvement.
o Not Reviewed.
Reviewer(s)
IOCTeam
Comments
1. No issues appear to exist in this area.
Evidence/Observations upon which conclusions & recommendations were based
Facility tour/inspection.
Recommendations

None.

sec Response

see acknowledges the lOGe Team's comment.

IOC Team Final Comments
No further comment.

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Final Report
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STANDARD X:

x-c

Physical Plant

The program provides adequate and appropriate housing for residents with
physical disabilities.

CONCLUSIONS:
~ Meets expectations.

o Meets minimum expectations - requires improvement in some areas.
o Does not meet expectations - requires significant improvement.
o Not Reviewed.
Reviewer(s)
roc Team
Comments
1. Facility is designed to allow integration of individuals with physical disabilities into the general
population.
Evidence/Observations upon which conclusions & recommendations were based
Facility tour, staff interviews.
Recommendations
None.

sec Response

sce acknowledges the IDee Team's comment.
IOC Team Final Comments
No further comment.

57

Addendum to the April 2008 Inspection of Care Report

This addendum is prepared as a supplement to the "lnspection ofCarc Evaluation Tool"
completed by the Inspection of Care Team for the April 2008 report. This docwnent,is
intended to allow the Team to explain or comment on "big picture" issues/themes which
may not be evident from just reviewing the report documented in the "Inspection of Care
Evaluation 1'001."
The Team wants to comment on three general issues:
1. The 2008 IOC Report may he perceived as being somewhat more critical
than this Team's previous JOC reports. We believe that such a perception is
accurate. Howeycr, it is important to recognize that this change in tone is the
result of a number of different factors. First, the 2008 inspection consisted of
five on-site days, which facilitated a more extensive and detailed review by the
Team of the standards. Second, and elosely related to the first point, the IOC
Team members have become more familiar with sec organization and operations
through our multiple exposures to the facility. Finally, the fact that the Team has
been involved for multiple years allows the Team to track the direction (i.e.,
progression or regression) of certain aspects of the program. The bottom line is
that we believe that this year's report is an accurate and reasonable assessment of
the institution's current status, but we want to acknowledge that as the Team
becomes more familiar with issues and trends at sce, this knowledge inevitably
is going to have an influence on OUf assessment.
2. SCC has undertaken an institutional self-assessment and improvement
program that it has labeled as the Transformational Leadership Program.
This effort is intended to fundamentally change the nature of how the
institution does its business on a day-by-day basis by moving toward a model
of continuous quality improvement with less reliance on hierarchical
structures. This effort is in its relatively early stages, so the Team has not
attempted to draw any conclusions about this project. However, to the extent
that this initiative addresses certain fundamental weaknesses that appur
present in SCC-such as a lack of data driven decision-making, delays in
making decisions and taking action, instilling in staff a greater sense of
participation in a common set of goals, a lack of a common big picture
perspective, etc.-the Team endorses the goals of this effort. At the same
time, the Team is concerned about certain challenges that this effort is going to
encounter. First, given the all too frequent short-lived efforts of governmental
entities to adopt and implement "organizational improvements," it is not
surprising that there is a certain amount of skepticism that exists within SCC
about this effort. It is always a challenge to get buy-in to a process that staff may
tend to view as only the latest trend. Second, SCC needs to be careful to not use
the TLP project as a device that facilitates/perpetuates some of the problematic
behavior within the institution. In other words, the integrity of the TLP project

will be undennincd if institutional perfonnance in terms of collecting and using
data, making decisions and taking actions, etc., is not consistent with thc
philosophy that the TLP project is working towards-i.e., the classic issue of
needing to walk-the-walk and not just talk-the-talk.
3. There is a considerable amount of negativity evident in the resident and staff
environments at sec. Given the legal context tllat sec operates in, a
certain amount of negative expressions is inevitable. However, from an
outsider's perspective, these negative feelings are prevalent throughout much
of the institution. The end result of this factor is that it is very difficult to
establish and maintain a therapeutic culture given this dominant
characteristic of the environment.
Residents appear to reflect some
combination ~f hopelessness/despair, while at the same time presenting with a
very heavy dose of entitlement. This combination establishes a difficult and
challenging population to treat and manage. In terms of the staff culture, therc
appear to be any number of different staff camps, each with their own set of
issues/perspectives. In discussions with staff, a theme that emerges on a regular
basis is a question as to. whether they are respected/valued by the institution. The
staff issues presumably are one of the targets of the previously discussed TLP
initiative.

2008 Inspection of Care Team

 

 

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