The Victor Cullen Academy ("VCA"), located in Sabillasville, Maryland, is a State-owned, committed-care facility which provides care and treatment in a medium-security environment for up to 225 male youth who have been committed to the Department of Juvenile Justice. The typical length of stay is six months in the program which is operated by Youth Services International, Inc., a subsidiary of Correctional Services Corporation. The Department of Juvenile Justice ("The Department" or "DJJ") administers the contract and pays the Contractor on a fixed-cost per-diem basis for youth placed in the facility by a Maryland judge or master. The Department licenses the facility operations for 225 youth. Over Fiscal Years 1998 through 2000, the facility had an average daily population of 200, 225, and 222, respectively.

By Order of the Secretary, the Department's Office of Audits has coordinated and performed a Performance Audit of VCA which also utilized technical expertise of other Department staff. As a result of this audit numerous required corrective actions and other recommended changes are identified throughout this report and the attached findings of the technical specialists. A summary of the findings and recommendations is included in the appendix. The Performance Audit is broken into Administrative Operations and three main areas of performance: Security and Basic or Direct Care, Education, and Treatment Screening and Services.

Staffing Vacancies
VCA is not meeting the staffing levels required by the contract. VCA must take aggressive steps to fill its vacancies. Also, VCA must ensure that all posts are covered in accordance with the contract by appropriate personnel. The examination of Fiscal Years 1998, 1999, and 2000, shows a continual pattern of under staffing in direct care positions as well as in specialized positions such as teachers, nurses, and clinicians. It was learned that staff are routinely requested or required to work overtime and that non-line staff, such as Case Managers and Night Shift Supervisors, are used to provide coverage in the living units. It was also learned that teachers at are considered line staff. Among direct care staff such as Group Leaders and Youth Counselors, the vacancy rate was to 22.5% (86 of 111 FTE positions filled) which is nearly one quarter of all positions needed to staff the facility.

With the knowledge of the staff vacancies, the actual employee attendance at VCA was reviewed as indicated on sign in sheets, time cards, and log books for all three shifts on Monday, 18 September 2000 to determine how and if all posts were being covered. These findings, which are detailed in Exhibit 1, reveal that of the 225.70 positions, only 132.75 worked that day. That means, on this day, there was 93 positions that was either vacant or did not work that day. It was found that of the required 88 direct care posts in the youth housing units, 7 posts were not covered.Typically post coverage included teachers, night youth workers, and case managers. In addition it was noted that the night shift supervisor worked a double shift in one of the housing units.

The Department's monitor stated that DJJ is aware of VCA's staffing vacancies. While the Department does monitor staffing vacancies it has failed to calculate or assess liquidated damages. The auditor's assessment of liquidated damages for Fiscal Years 1998 through 2000 has been calculated in the section of the report, titled "Post Coverages".

Administrative and Financial Management
VCA is operated by a subsidiary of a publicly-traded for-profit corporation. A review of available financial information shows that the Contractor realized approximately nine million dollars in revenue for each of the past three fiscal years. The facility-related expenditures for each fiscal year were approximately eight million dollars, leaving one million dollars per year as a management fee and operating profit for the Contractor.

Aftercare for Maryland DJJ Youth Fund
The contract provides for VCA to maintain an Aftercare for Maryland DJJ Youth Fund ("Aftercare Fund") which is funded by $1.00 per youth per day from the Department's per diem payment to the Contractor. This Aftercare Fund, unique to VCA, is used with the advance approval of the Department to provide assistance in attending school or as a salary stipend in an on-the-job training program. For Fiscal Years 1998 through 2000 the Department's per diem payments included Aftercare Funding of $236,554 for 236,554 youth days.

The Contractor has failed to adequately control the Aftercare Fund. Bank reconciliations are not being performed, deposits are not being made timely and as of 30 June 2000 the Fund is under funded by $37,872.70.

The Department is not doing an adequate job of monitoring this fund. The Department's Assistant Administrator for Placement & Management ("AAPM"), who authorizes Aftercare Fund expenditures, does not maintain sufficient documentation of her decisions in order to allow her to determine if payments made by VCA were authorized. The Department is not monitoring the Aftercare Care Fund to determine whether the payments made from the Fund were actually authorized.

Employee Training
The Contractor has not materially complied with training requirements of the contract. An examination of the training records of all employees at VCA during Fiscal Years 1998, 1999 and 2000 revealed that 158 employees did not receive their required training. The contract authorizes the assessment of liquidated damages of $100 per employee for each year the training requirements are not met; VCA should be assessed $15,800 in liquidated damages.

Use of Minority Business Enterprises
The Contractor is not meeting its Minority Business Enterprises (MBE) goal. VCA operates under a contract with a certified subcontracting and/or purchasing goal for MBE of 15% of the total contract amount. Due to the Contractor reported unavailability of willing MBE providers and the small portion of the contract amount eligible for subcontracting, VCA will be hard-pressed to achieve more than 1%.

Custody of Youth-Owned Assets
The Contractor has failed to adequately administer youth-owned assets. The contract provides for inappropriate personal property of youths arriving at VCA to be confiscated, inventoried, and provided safe keeping. It was found that VCA has not returned confiscated valuables belonging to discharged youth. Furthermore, for several youth, it appears that VCA's use of vague release forms indicates that possessions have been returned when they have not.

Use of Concession Revenue
The Contractor has failed to adequately administer concession revenue. Vending machines located on the VCA campus generate concession revenue. The revenue generated from vending sales should be used to benefit the general youth population.

There are a total of eight vending machines on campus which are used by youth, guests and staff and from which profits are received from the concessionaire. These funds are used to pay for employee recognition awards and various operating expenses as well as youth rewards. Concession revenues earned from youth should be maintained in a "Juvenile Welfare Fund," and used for items outside the obligations of the facility (i.e., pizza parties, etc.).

Employee Incentive / Bonus Payments
VCA has an Employee Incentive Awards Program policy and procedure in place which provides for employees to be recognized as employee of the month, quarter, or year and receive cash of $50 - $150. It also disburses other bonuses. VCA was unable to provide policies or procedures for Christmas or other performance incentive payment programs.

Direct Care and Security Services
Post Coverages
Because of the number of post coverage shortages and other vacancies, there is a major program impact that needs to be assessed. For the Fiscal Years 1998 through 2000 a review of a total of 77 work shifts revealed 219 apparent contract violations for which liquidated damages of $54,750 exist. Annualizing the post coverage violations for each Fiscal Year over the total number of work shifts in each Fiscal Year results in a total of 67,264 hours that were not provided and liquidated damages totaling $2,102,000 for the three year period. Also, the Department has failed to document testing of post coverage compliance and, also has failed to calculate or assess liquidated damages.

The Department has failed to document testing of post coverage compliance and, also has failed to calculate or assess liquidated damages.

Staffing
The contractor has too many vacant positions. Because of the number of vacancies, there is a major program impact that needs to be assessed. It was found that the facility had an 18.2% vacancy rate excluding part-time/on-call positions; among direct care staff such as Group Leaders and Youth Counselors, the vacancy rate rises to 22.5% or nearly one-quarter of all positions needed to staff the living areas. Staff are routinely requested or required to work overtime and that non-line staff, such as case managers and teachers, are used to provide coverage in the living units. An examination of management positions revealed that the acting Facility Administrator was the fourth person to fill that position in less than six months and his appointment had not yet received final approved from the Department. The Human Resources Manager, Clinical Services Director (filled 18 September), Program Director, and Special Education Coordinator positions were also currently vacant.

The current staffing structure has several variations from the proposed structure and no documentation of a request or granting of approval for these changes could be found.

The Department, according to the Monitor, was aware of staffing vacancies. While the Department does monitor staff vacancies it has failed to calculate or assess liquidated damages.

Physical Security - DOC Security Audit
The Department of Public Safety and Correctional Services' Division of Corrections ("DOC") performed a Security Audit of VCA. This audit dated 27 August 1999 noted a need for extension of the security fence to cover the mess hall, recreation area and administration building. Other recommendations for improving the VCA physical plant security included a need for a security lighting survey, tree pruning, and the installation of razor wire. In addition the Security Audit recommended that DJJ review the contractor's training program and have a security monitor make unannounced visits to observe the contractor in practice. It was learned that the Department of General Services has budgeted, for Fiscal Year 2001, $250,000 for an extension of the perimeter fencing with an alarm system.

The facility has twelve vehicles of which eight are used for transporting youth to and from the secure facility. It was noted that those eight vehicles do not contain metal security "cages" to contain the youth and separate them from the vehicle operator. While there is no regulation which requires this security measure, the Department mandates its own vehicles be so equipped to protect staff and insure public safety. It also does not appear that VCA has enough vehicles available should an emergency situation occur requiring the immediate evacuation of all youth and staff. Its emergency plan for mass evacuation does not indicate specifically how it would acquire additional transportation or where they would be transported (one suggested relocation site, Fort Ritchie, is closed).

The Contractor has failed to submit a plan on how it will bring families to VCA for visits. The Contractor has committed to provide "a plan of how it will van or apply ways to bring families up to the institutions who by themselves cannot accommodate that." The Department has not received or request this plan. VCA has stated to the auditors that they do not have a plan.

The Contractor has too many vacant positions in food service. The contractor also has failed to institute a Culinary Arts Program. Because of the number of vacancies and because the Culinary Arts Program has not been instituted, there is a major program impact that needs to be assessed.

The food service department had 5 vacant positions at the time of the auditor's visit out of 9 FTE food service positions plus a Culinary Arts Teacher. At the present staffing level, the Food Service Director has to cook; as of 2 August she had worked 17 days straight to provide coverage. Present staffing levels do not permit adequate supervision of the youth working in the kitchen area. The Culinary Arts Program, proposed as a way to educate youth working in the kitchen, has never been developed. The auditor's assessment of damages for the failure to provide a Culinary Arts Teacher has been calculated in the section of the report, titled "Food Services".

Prior to issuing a license, the Department conducts a biannual licensing audit to determine compliance with COMAR. Other than this licensing audit, the Department does not do any ongoing monitoring of the food services.

Educational and Recreational Services
VCA has failed to provide all the Educational Services required under the contract. The VCA education program lacks the appropriate instructional materials and equipment, library media, and computer lab. Although almost half of the total student population is identified as special education eligible, there are no special education teachers on staff. There are no vocational education programs.

World of Work Program
The Contractor has failed to adequately administer the World of Work Program records. The bank accounts is not reconciled to actual wage records. Inconsistencies and errors were found resulting in double credit for hours worked for some youth while other youth were not paid uniformly for all hours worked.

VCA is reporting as Community Service all hours worked by the youths - it is unclear if certain services to the VCA community, or services for which reimbursement was received, fit the Schools', the Courts', or DJJ's definitions of community service.

Prior to issuing a license, the Department conducts a biannual licensing audit to determine compliance with COMAR. Other than this licensing audit, the Department does not do any ongoing monitoring of the educational and recreational services.

Treatment Screening and Services
Substance Abuse Services
The Contractor has failed to sufficiently provide Substance Abuse Services. Due to the severity of staff vacancies VCA has not been able to screen youth for substance abuse issues within five days of admission, provide campus wide substance abuse education/prevention, provide substance abuse consults in other cottages, provide individual and group counseling for youth classified as chemical dependent and abusing and not waiting for admission into substance abuse treatment on Silver Charm. Problems were found in the timeliness, existence and documentation of treatment plans, master problem lists, HIV/AIDS Risk Assessments, Admission Summarys, supervisory client record reviews, and Substance Abuse Subtle Screening Inventories ("SASSI").

On 25 July 2000 thirteen youth are awaiting (on Count Fleet, the orientation cottage) admission into Silver Charm, the substance abuse treatment program at VCA. The first youth on the waiting list as of 9 August 2000 was admitted to VCA 31 May 2000. (From youth interviews and VCA documentation there appears to be approximately a 90 day wait for admission into substance abuse treatment on Silver Charm.) VCA should open another substance abuse treatment cottage. Since March 2000 youth on the rest of the campus have not received substance abuse education of at least one hour per week for groups no larger than 20 due to staff vacancies (four addictions counselor positions).

While the Department conducts a biannual licensing audit to determine compliance with the Department's Substance Abuse Policy and Standards, and Standards set by the SASSI Institute, there is no on-going Departmental monitoring of the substance abuse services.

Mental Health Services
The Contractor has failed to sufficiently provide Mental Health Services. Except for the Clinical Director (position now vacant) and the Mental Health Associate who functions under the direction of the Clinical Director, VCA does not have any other clinical staff to deal with the psychotherapeutic needs. Upon admission to VCA, youth are receiving diagnostic services for substance abuse, but not for mental health services. While there is an admissions interview, mental health protocols for determining the mental health status of youth do not appear to be formalized in any appreciable way. There is a psychiatric referral form that is used by VCA personnel to refer youth to the consulting psychiatrist. No similar arrangement is apparent for referral to the clinical staff for psychotherapeutic clinical services. Referrals for individual psychotherapy appear to be done on a haphazard basis. Counseling is done by unit staff on their respective units who may have no more education and training than a high school diploma.

In the medical records that were reviewed, recommendations were not made by the psychiatrist consultant for concurrent psychotherapeutic services to augment medication regimens. There appears to be marked imbalance in the use of psychotropic medication regimens without the concurrent use of psychotherapy services. Those youth whose records were reviewed would benefit greatly from clinical psychotherapy services. If there are any clinical services occurring for a given youth, the medical staff are not often aware of it, including the psychiatrist. There is a breakdown in the formal connection among clinical services, unit staff, and the Medical Department for coordination of mental health needs of youth.

Prior to issuing a license, the Department conducts a biannual licensing audit to determine compliance with COMAR. Other than this licensing audit, the Department does not do any ongoing monitoring of the Mental Health Services.

Medical Services
The Contractor is not doing an adequate job of Medical Services. Five of ten nurses had expired licenses. First Aid Kits throughout the campus, including vehicles, were not consistently stocked with appropriate, clean supplies. Back-up medical supplies to accommodate a disaster had not been checked since 1998 and contained many expired medications and supplies. In Youth Health Record Files and other documentation, numerous and significant procedural problems were found, ranging from documentation to follow-up care to a large supply of unsecured over-the-counter medication in the gymnasium to expired medication in the active inventory.

Prior to issuing a license, the Department conducts a biannual licensing audit to determine compliance with COMAR. Other than this licensing audit, the Department does not do any ongoing monitoring of the Medical Services.

Contract Administration
The review of post coverages and employee training indicated that the Department does not routinely examine (and document the examination of) areas identified by the Department as so essential to contract performance that liquidated damages is assessed for non-compliance. The Department needs to establish and implement standards for the review of essential contract deliverables.

The Request for Proposals required that methodologies for measuring program objectives be detailed and that DJJ receive and approve the evaluation design and methodology of the objectives. VCA has submitted to the Contract Monitor an annual report compiling data for the minimum 5 program objectives, but no evidence was found that DJJ has approved the evaluation design and methodology underlying the reported figures or reviewed and analyzed the reported figures. As such it is unclear if the reported figures are relevant. The Department needs determine if and how it will use this information and then review and approve the evaluation design and methodology.

The Department provides secure residential services at the Cheltenham Youth Facility and has a cost-plus-fixed-fee contract for similar services at CHHJS. Decisions to contract-out and to utilize a fixed-cost per-diem structure were reportedly discussed and analyzed prior to the issuance of the most recent RFP, but no documentation of such analysis was found.

The remainder of this Performance Audit Report includes the complete report on all areas examined, exhibits, as well as appendices containing original reports submitted by those with technical expertise. Additional detail and documentation of exceptions involving specific employees, such as training levels or post coverages, will be provided, if requested, to the Contractor under separate cover.