John Howard Association Report on St Charles Youth Facility 2009
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IYC – St. Charles September 14, 2009 John Howard Association of Illinois Site Visit Summary On September 14, 2009, a team of JHA staff, board members and trained volunteers visited IYC St. Charles with the express purpose of inspecting all living units for safety risks, other maintenance problems, and sanitary conditions. This focused visit was planned as a result of the tragic suicide of a youth in custody at St. Charles on September 1, 2009. While a routine monitoring visit had been scheduled for September 14th, the suicide several weeks earlier and a brief visit to several living units by JHA staff and consultants on September 4, 2009, prompted our decision to focus our observations on living units at the facility. Our areas of concern were thus limited to suicide and other safety risks, other maintenance problems, and sanitation in the living units. The primary focus of this visit was a direct examination of all the sleeping rooms in the facility. Two‐person JHA teams toured each of the ten living units and the confinement unit. We looked in each room, examined conditions and furnishings in sleeping rooms, shower rooms and common/day rooms and assessed the potential for self‐harm of residents. In addition we examined the areas in which staff posts are located and their ability to observe and monitor the actions of youth, particularly once they are locked in their sleeping rooms. Findings 1. Our first major finding is that the living units at St. Charles, and specifically the sleeping rooms and their furnishings, are rife with self‐harm hazards: dangerous beds, toilets, air vent covers and other hazards. The sleeping rooms are arranged down the sides of long narrow halls providing staff absolutely no way of observing behavior within a room other than to approach the door to the room and look in, since no cameras are installed in living units at St. Charles. Each housing unit has two separate corridors (A Wing and B Wing) projecting in different directions and there is no spot in the unit from which a staff member can see into multiple rooms. At night there is only one staff member on duty in each housing unit so only one of the two corridors can be observed at a time. Staff offices are actually located behind glass walls that have no line of sight to either of the corridors. Finally there are no devices to provide auditory monitoring of the sleeping rooms. THE JOHN HOWARD ASSOCIATION OF ILLINOIS SITE VISIT IYC ST. CHARLES 9.14.09 The vast majority of the rooms are configured to house two youth and those rooms almost always are equipped with bunk beds. These metal frame beds (typically bolted to the floor) provide the easiest, most apparent opportunity for suicide by providing a strong, stable base from which a piece of cloth or cord can be suspended. Even those rooms without bunk beds almost always have metal frame beds that are sufficiently high off the ground that they could be used as a hanging post. Bunk Beds Single Bed Safer “Slab Bed” In addition, many beds have dangerous protrusions that offer additional opportunities for self harm. 2 THE JOHN HOWARD ASSOCIATION OF ILLINOIS SITE VISIT IYC ST. CHARLES 9.14.09 Dangerous Protrusions Less than half of the living units have sleeping rooms equipped with the more suicide proof metal toilet/sink units that have no exposed pipes or faucets. The other rooms have porcelain toilets and sinks with exposed pipes, and faucets from which a youth can tie off. Many even have removable toilet seats which pose an additional danger as a potential weapon. Most of the rooms with the porcelain toilets and sinks are constructed with a wooden partition that partially surrounds the sink and separates the toilet area from the sink. These partitions are old and many contain holes that present an additional location from which a youth can tie off. Metal Toilet/Sink Unit Unsafe Porcelain Toilet and Sink 3 THE JOHN HOWARD ASSOCIATION OF ILLINOIS SITE VISIT IYC ST. CHARLES 9.14.09 Exposed Unsafe Sink Pipes Unsafe Sink Faucets Porcelain Toilet with Partition Each room has an air vent above the door at a height of about 10 to 11 feet. These vents are covered with a metal screen called an air vent cover with holes about the size of the tip of one’s little finger. Although a youth can’t reach these covers while standing on the floor, it is possible to reach them by stacking the stools or the property boxes with which each room is equipped, or by standing on some of the beds which are not bolted down. Some youth could also reach them by standing on one another’s shoulders. These covers appear strong enough to pose an additional hanging risk. Many of the rooms have nails or screws that protrude from the walls and some of the metal window frames are pitted producing holes. Air Vent Cover 4 THE JOHN HOWARD ASSOCIATION OF ILLINOIS SITE VISIT IYC ST. CHARLES 9.14.09 Entry to each sleeping room is through a heavy metal door kept closed and locked during much of the day. The view into the room is through a narrow glass window (approximately 4X15 inches) at eye level. Because of the placement of the window and the room’s furnishings it is not possible to view residents who are inside without being immediately adjacent to the door. Sleeping Room Door with Limited View Each wing of a cottage has a communal shower room. These rooms have minimal furnishings: a few shower heads, perhaps a soap dish and a few hooks from which to hang a towel. State of the art correctional design and architecture has produced items which will serve these purposes without providing an opportunity for self‐harm. Shower heads can be constructed of a short sloped piece of metal and hooks can be used which will break off or collapse if significant weight is exerted on them. Soap dishes can be recessed. In most instances the shower rooms at St. Charles have not employed these devices, or in the case of the hooks, the devices are old and seem to have solidified in place and can now support significant weight. Unsafe Shower Control Unsafe Rigid Shower Hooks 5 THE JOHN HOWARD ASSOCIATION OF ILLINOIS SITE VISIT IYC ST. CHARLES 9.14.09 In general, common areas (day rooms and corridors) are themselves free of significant opportunities for self‐harm particularly when coupled with more observation of staff. But even here there can be problems such as hooks used for hanging outerwear particularly with poor sight lines, the existence of partitions to separate areas and staff that spend time in enclosed offices. Unsafe Coat Hooks in Dayroom 2. A second major finding of our visit is that the physical plant at IYC St. Charles has serious, chronic sanitation and maintenance deficiencies. These problems did not occur overnight and are a result of trying to maintain an aging facility with decades of deferred maintenance and quick/cheap fixes to serious problems. One obvious example is the academic building/chapel that is now abandoned due to water damage, mold and mildew. The unfortunate consequence is that youth can no longer worship in the handsome sanctuary which boasts an original mural by world renowned Chicago artist Warner Sallman on the wall behind the alter. Exterior of Academic Building/Chapel Interior of Sanctuary 6 THE JOHN HOWARD ASSOCIATION OF ILLINOIS SITE VISIT IYC ST. CHARLES 9.14.09 First Floor of the Academic Building Formerly the Wood Shop There are additional abandoned buildings, some with roofs that have caved in, buildings with serious roof leaks, mold and mildew on some walls, floor tiles that are cracked or missing, heating and air conditioning systems that require constant maintenance, plumbing lines that need to be replaced and a system of pothole riddled roads that are barely passable. The ten housing units resemble one another in both appearance and construction. They are one story structures constructed economically in the seventies using cinder block coated with wood planking on the exterior set on concrete slabs; unbreakable glass windows which cannot be opened are set in metal frames. Floors in the building are covered with tile. Over the years the tiles have worn and many are cracked or missing. Because the mastic used to affix the tiles to the floor contained asbestos the cost of properly remediating the asbestos and replacing the tiles is high and many floors have not been fixed. The buildings have the original individual heating and air conditioning units; they are energy inefficient and have frequent breakdowns. The downspouts of these buildings were at one time connected to an underground drainage system but have since been disconnected. The result is water damage to some of the cottages which degrades the wood paneling/paint and some pooling of water and creation of muddy areas outside others. Exterior of Williams Cottage 7 THE JOHN HOWARD ASSOCIATION OF ILLINOIS SITE VISIT IYC ST. CHARLES 9.14.09 Most roofs on these buildings show their age with loose shingles and some bowing on a few. Window frames in the housing units are likewise degraded with many showing rusting and pitting. Metal Window Frame “Repaired” Metal Window Frame The combination of moisture and inconsistent heating and cooling has caused the deterioration of the material directly below many of the windows. In some rooms metal plates have been used to fill the spaces. Last December two youth escaped through such a space where they had loosened the screws holding the plate. Sleeping Room with Metal Plate Close‐up of Metal Plate 8 THE JOHN HOWARD ASSOCIATION OF ILLINOIS SITE VISIT IYC ST. CHARLES 9.14.09 The Cottages/Overview St. Charles currently has 10 cottages housing youth of varied populations; ordinarily there are three cottages which house youth who are participating in the reception and classification process (Kennedy, King, and Robinson), two cottages for youth with moderate mental health needs (Adams and Lincoln), two cottages for youth receiving substance abuse treatment (Cleveland and Harding) and three cottages of general population youth (Owens, Pierce and Williams). The two cottages of youth with moderate mental health needs will in part be populated by youth who pose an enhanced risk of self‐harm. (But clearly not all youth with moderate mental health needs pose these issues.) Many youth in Reception and Classification may not pose a particularly high risk of self harm, but since you cannot tell which ones will, and because some youth will be particularly traumatized by having been committed to IDJJ, it is important to treat the R&C population as at risk. This calculation would imply that at least half of the housing units should be designed and equipped with minimal structural risks and with adequate staffing and mechanisms for appropriate surveillance and supervision. Reception & Classification Cottages/Details Kennedy Cottage has 8 rooms configured as singles and 16 configured as doubles. All but one of these double rooms has bunk beds; the exception has two concrete slabs on which mattresses can be placed. The “slab beds” as we have dubbed them appear to present minimal risk of harm. In the single bed rooms all but one (room 20) had beds with places from which to tie off, and which were sufficiently high above the floor to pose a self‐harm hazard. The toilet/sink units are of the newer, safer variety. The shower room has hooks which appear to be capable of supporting significant weight. The day room has a series of wooden hooks on the wall for hanging outerwear. Rooms 22 and 24 had cracked windows and rooms 17, 22 and 23 had holes in the ceiling. The hole in room 22 exposed an overhead pipe. The floors had numerous cracked and missing tiles. King Cottage has 8 rooms configured as singles and 16 configured as doubles. All but one of the double rooms has bunk beds; the exception has the slab beds described above. In the single bed rooms all had beds with places from which to tie off, and which were sufficiently high to pose a self‐harm hazard. The toilet/sink units are of the newer, safer variety. The shower room has hooks which appear capable of supporting significant weight and a door opener presents itself as another hanging opportunity. The day room has a series of wooden hooks on the wall for hanging outer wear. There are cracked light fixtures in rooms 4, 8 and 24, a hole in the ceiling in 14 and an open wall socket in room 9. There was an unpleasant odor in room 19 and peeling paint in room 14. There are missing and cracked floor tiles throughout the cottage, filthy walls in many sleeping rooms and rusted pitted metal window frames throughout. 9 THE JOHN HOWARD ASSOCIATION OF ILLINOIS SITE VISIT IYC ST. CHARLES 9.14.09 Robinson Cottage was the site of the recent suicide. At that time youth from Adams Cottage were being temporarily housed there while Adams was undergoing renovation. At the time of our visit no youth were being housed in Robinson. The cottage has 8 rooms configured as singles and 16 configured as doubles. All but 2 of the double rooms have bunk beds; the 2 exceptions have “slab beds.” The toilet/sink units are of the newer, safer variety. The shower room has rigid hooks which appear capable of supporting significant weight. Some plates used to fix holes in walls are loose enough from the wall to allow youth to tie off. The day room has a series of wooden hooks on the wall for hanging outerwear. There are cracked and missing floor tiles, peeling paint and pitted window sills throughout the cottage. Mental Health Treatment Cottages/Details Adams Cottage has 24 rooms which we were informed have been configured as 11 singles and 13 doubles. The cottage was in the process of being rehabbed at the time of our visit to repair some plumbing problems and to update and upgrade the appearance and level of furnishings. There were no beds in the sleeping rooms. The toilets and sinks in this cottage are of the old porcelain type with exposed pipes and faucets. About half of the toilets had movable toilet seats. Wooden partitions and “vanities” surround the sinks and many of these were in poor repair. The shower room contained shower heads and hooks which appear unsafe. There was exposed conduit in one hallway that appeared strong enough to pose a self‐harm hazard. There are cracked and missing tiles and pitted, rusted window sills throughout. The exterior of this cottage had numerous splintered boards and the roof appears to have loose shingles although no visible leaks were noted on the inside. Lincoln Cottage has 10 rooms configured as singles and 14 configured as doubles. All the doubles have bunk beds. The toilets and sinks in this cottage are of the old porcelain type with exposed pipes and faucets. Most of the wooden partitions have large holes presenting a self‐ harm hazard. The shower room has unsafe hooks and soap dishes both of which could be used for self‐harm. The interior of this building is in better shape than most other cottages but there are cracked and missing floor tiles, windows which require caulking, and damaged panels below windows. The exterior of this building has splintered boards and needs to be sealed and repainted. There are loose shingles on the roof. Substance Abuse Treatment Cottages/Details Cleveland Cottage has 23 rooms configured as doubles. All the doubles have bunk beds. The toilets and sinks in this cottage are of the old porcelain type with exposed pipes and faucets. There are wooden partitions, many of which have large holes. Some rooms (11 and 15) had exposed nails and screws. The shower rooms have unsafe hooks, water valves and soap dishes. One of the shower rooms has open ended cinder block exposing plumbing fixtures and pipes. The windows in resident rooms need to be caulked and there are damaged panels below windows. The wooden exterior of the building needs to be sealed and painted. 10 THE JOHN HOWARD ASSOCIATION OF ILLINOIS SITE VISIT IYC ST. CHARLES 9.14.09 Harding Cottage has 24 rooms, 22 of which have bunk beds. Of these 22, Room 2 is “off line” because water from the shower room floods the room. The room is frigidly cold and has no toilet or sink. Another room, Room 22, is empty because it is uninhabitable (rusted window sills, sink on the floor and exposed tiles.) Room 1 is used as a counselor’s office. The toilets and sinks in this cottage are of the old porcelain type with exposed pipes and faucets. There are wooden partitions, many with holes and some having towel holders. The vent covers in Rooms 5, 16, 17, and 19 have holes, and Room 3 has a metal window latch with a hole, all of which may present increased risk of self‐harm. There are leaking or broken toilets or sinks in Rooms 7, 8, 9, 12, 13, 15, 18, 19, 21 and 23. There are pitted, rusted window sills and cracked and missing floor tiles throughout. There are holes in the floor and walls in Rooms 12 and 19. The shower rooms have shower heads and soap dishes which present a risk of self‐harm. Shower room B has a strong unpleasant odor and visible mold and mildew on the walls. There is water damage to the floor in the common room. The wooden exterior of the building has peeling paint and the roof appears to be buckling as well as missing some shingles. General Population Cottages/Details Owens Cottage has 24 rooms configured as doubles, all with bunk beds. The toilet‐sink units are of the newer, safer variety. The shower rooms contained rusted, rigid metal hooks that appear capable of supporting significant weight, and the dayroom has a row of wooden hooks for hanging outer clothing. There are rusted pitted metal window frames and cracked and missing floor tiles throughout. The exterior of the building has one corner with splintered boards. Pierce Cottage has 24 rooms configured as doubles, all with bunk beds. Room 2 is not occupied because of an eroding floor. (We observed a small frog in the room which appeared to have entered from the outdoors.). Room 3 likewise has an eroding floor, and we were told that insects come in through the cracks. The toilet/sink unit is of the newer, safer variety. The sink in Room 15 leaks water onto the floor and there was no water in the sink in Room 20. A part of the toilet base in Room 10 is missing. Both shower rooms in this building contained rusted rigid metal hooks that appear capable of supporting significant weight, and there was a cracked light fixture in one (B.) There are rusted, pitted metal window frames and cracked and missing floor tiles throughout. Williams Cottage has 24 rooms configured as doubles, all with bunk beds. The toilets and sinks are of the old porcelain variety with exposed pipes and faucets. The wooden partitions and sink vanities are in disrepair with many holes and some protruding nails and screws, all of which present a risk of self‐harm. There are open electrical outlets in sleeping rooms. The shower rooms have rusted, rigid metal hooks which appear capable of supporting significant weight. There is peeling paint, rusted, pitted window sills and cracked and missing floor tiles throughout. 11 THE JOHN HOWARD ASSOCIATION OF ILLINOIS SITE VISIT IYC ST. CHARLES 9.14.09 Conclusions Although many members of the JHA visiting team have considerable experience with juvenile and adult correctional institutions, we were nonetheless appalled at the condition of many of the living units at St. Charles. Although most of the units are 30 – 40 years old, they show the results of years of neglect mitigated only by marginal efforts to perform maintenance. As noted above, several buildings had been vacated for maintenance reasons, but they still displayed more sanitation problems than would be expected or acceptable in a facility housing juveniles. (It is important to note that it is impossible to construct a sleeping room in which no self harm can occur. Short of 24/7 one‐on‐one direct observation of youth by staff one can never guarantee the safety of an individual. However we must always strive to identify those youth who pose an imminent risk of self harm, eliminate the obvious suicide risk opportunities and provide supervision and counseling commensurate with the level of risk a youth presents.) We believe that the state must act immediately to remedy the most egregious physical conditions. Given the increased risk of harm the Mental Health Treatment and Reception and Classification Cottages should be prioritized as should those recommendations which directly affect the safety of residents. Recommended Actions: ¾ Eliminate the practice of double bunking and the use of bunk beds, and replace all beds with the type that is a solid piece with no legs or protrusions from which to tie off and bolt them to the floor. (Norix makes such a bed called the “Attenda floor mount bed.”) ¾ Replace the porcelain sinks and toilets with the steel toilet/sink units. ¾ Replace the vent covers with a break away plastic cover or insure that there are no items in the sleeping rooms that youth can use to climb to reach the covers. (This would involve bolting beds and stools and discarding the property boxes.) ¾ Increase the ratio of staff to kids to 1 to 8 during the waking hours and 1 to 24 during the night. In lieu of increases in staff, and ideally as an additional safe‐guard, install two way auditory devices in all sleeping rooms and cameras in some. ¾ Replace all shower heads, soap dishes and hooks in the shower rooms which pose a risk for self‐harm. ¾ Repair all broken and leaking plumbing in the sleeping rooms and shower rooms. Remove mildew and mold as needed. 12 THE JOHN HOWARD ASSOCIATION OF ILLINOIS SITE VISIT IYC ST. CHARLES 9.14.09 ¾ Repair holes in walls, floors, and window sills. Finally, we urge a more thorough and complete assessment of the overall viability of this institution continuing to serve as a place to hold youth. We are aware of the existence of a Master Plan created for the Department of Juvenile Justice in 2008 by a team of outside experts and never released to the public. We believe it contained an analysis of all existing structures with recommendations for their future use. Although it may need some updating we feel it can serve as the basis of a cost/benefit analysis in moving the facility and the Department forward. 13