Colorado Department of Human Services

Division of Youth Services

Response to CJJA Report dated July 22-25, 2019

1. Recommendation: Increase support for facility managers and direct care staff through
regular site visits. DYS has experienced difficult times in the past year that have included issues
around retention. These crisis situations often lead to staff feeling overworked and not
supported by upper management. While most facility managers stated they felt supported by the
DYS Executive Team, the suggestion was offered to increase the Executive Team’s presence at
the facilities through regular site visits. It is important that these site visits not be conducted only
in response to serious incidents but also as part of routine “check-ins” to take advantage of
opportunities to praise the good work being done with youth. These positive visits will
demonstrate support for facility leadership, mid-level managers, and direct care staff and
consequently increase staff morale.

In addition, when a post-incident visit must occur, the Executive Team should be aware of its
communication style and messaging. Consistent with the agency’s trauma-informed care and
strengths-based approach, the team should highlight what facility staff did well in handling the
significant event (i.e. staff using de-escalation strategies; staff “tapping out” and asking another
staff to step in when s/he was not effective in de-escalating youth, etc.). While it is important to
provide constructive feedback, it is critical for leadership to remember that significant incidents
are traumatic for both youth and staff and staff are doing their best with the skills they have. The
Executive Team is encouraged to make a concerted effort to find opportunities to praise
managers and direct care staff.

Response to Recommendation: DYS Executive Team has increased site visits at Lookout
Mountain over the last 9 months, which includes times of struggle and times of praise. The DYS
Associate Director was placed at Lookout Mountain full-time in May 2019 and is currently the
interim director until which time a replacement is hired. The DYS Executive Team will continue
with regular site visits and will ensure that programming is observed and operating to standard,
in addition to providing the opportunity to hear from staff and praise their work.

2. Recommendation: Increase cohesiveness among all levels of facility staff through open
dialogue during regular monthly meetings, specific team building exercises, activities, retreats,
etc. Consider implementing cycle-trainings that include staff from the different sites and/or
programs, this would allow an opportunity to build comradery and support, while obtaining
necessary training. This will increase understanding and support for one another as well as
break down any myths that currently exist (i.e. certain units are the “gang” units while others do
not hold youth accountable, etc.)
Response to Recommendation: In July 2019, the Lookout Mountain Interim Director
implemented a thorough shift briefing process for all staff, weekly treatment team and staff
business meetings, quarterly all-day retreats for each housing unit, quarterly roundtable
meetings by job class, and a full-day opportunity for any staff to come and meet and discuss
any topic of their choice with the Interim Director. DYS also facilitated two trainings in the last 12
months specific to creating a trauma responsive environment with the youth center leaders.
Lastly, DYS administration has routinely been involved in being present in youth centers to talk
with youth and staff.

3. Recommendation: Develop specific strategies for overcoming staff resistance to change and
increasing staff engagement or “buy-in.” This work can be done using a brainstorming exercise
with facility staff during a monthly meeting and developing a formal action plan on how to
implement these strategies (i.e. lead, specific activity, target dates, etc.)

Response to Recommendation: The interim director, along with her leadership team, has
reinstituted several routine meetings that allow for staff input, creation of ideas and systems,
and to effectively work through change management issues. Specifically, routine weekly
leadership team meetings, weekly unit-based team meetings, quarterly roundtables by job
class, an official open door policy to administration, routine all-staff meeting, maintaining the
Employee Advisory Council, and ongoing town hall style meetings with DYS administration.
These meetings function as an avenue for leadership to communicate change issues and staff
to have their valued input. The meetings were reinstituted in August 2019.

4. Recommendation: Create a formal communication plan around the agency policy on staff
recognition. If DYS chooses to implement this recommendation it will be critical to gather ideas
from all levels of staff to include direct care staff on what they view as meaningful rewards and
ways to communicate. This discussion should also include ideas on the frequency of formal
recognition.

Response to Recommendation: Formal communication will go out to DYS staff outlining the
policy on staff recognition. A survey will be provided to staff asking what they see as meaningful
rewards. This will be completed by April 2020.

5. Recommendation: The agency should create and/or re-create youth and family program
manuals to ensure all language is reflective of the agency’s trauma-informed care approach. For
example, one manual describes restraints as a “take down” which may be perceived as punitive
or at the very least physically violent. Language should reflect a staff’s responsibility and effort
to protect youth from harm and do so without violence.
Response to Recommendation: DYS administration created a committee to review the youth
and family program manuals and updated the manuals to be congruent with a trauma-
responsive organizational approach. This was completed in August 2019. The manuals will be
reviewed yearly and updated.

6. Recommendation: It is suggested that all facilities develop a communication plan to further

explain the agency mission, core principles, agency treatment philosophy and approach, and
juvenile rights in the youth and family manuals. If the facility also has a facility-specific mission
statement, it is suggested that they include both the agency and facility missions in these
handbooks. This reminds staff and youth that the facility is part of a larger DYS system - a
network of facilities which operate together with the same goals in mind.

Response to Recommendation: DYS has a single Vision and Mission approach for
consistency across the organization. A single communication plan will be developed by DYS
Communications and sent to each youth center on a periodic basis. In addition, DYS will
continue to maintain posted and visible posters that outline DYS Vision, Mision, Strategies, and
Commitments in each youth center. During the DYS Administrator town hall meetings staff were
updated on all recent policy or practice changes and continued focus on creating safe trauma
responsive environments. Ongoing communication plan is in place through ongoing town hall
meetings within DYS youth centers.

7. Recommendation: Develop a comprehensive plan detailing strategy for promoting staff

wellness and retention. This planning process should include input from staff at all levels of the
agency, especially direct care staff. This is an important exercise to support staff retention.

Response to Recommendation: DYS is part of a three state grant award that is focused on
staff recruitment, hiring, and retention. This is a grant that was provided through the Council of
Juvenile Justice Administrators. In addition, DYS is in the process of fully implementing a
trauma responsive organizational approach and there are clear techniques to support a staff
culture for resiliency and staff retention. These techniques include safety and self-care plans for
staff. Safety plans have been in place for approximately 3 years and staff attach these to their
badges. The safety plans are specific to strategies staff can use in the moment to assist with
emotional regulation in working with the DYS population. The DYS Sanctuary Integration Team
within our youth centers developed a Staff Wellness Plan and accompanying documents to be
used as they integrate the DYS trauma responsive supervision model, Reflective Supervision.
The majority of DYS supervisors were trained by June 30, 2019 and implemented the Reflective
Supervision Model beginning July 1, 2019. DYS also has a group working on creating trauma
responsive teams within all of our youth centers to more actively support staff after difficult
incidents.

8. Recommendation: Hire a permanent new director with proven experience in a secure long-
term commitment program similar to LMYSC.
Response to Recommendation: DYS immediately put in place an interim director with proven
experience in secure long-term commitment. This happened in May 2019. That individual has
remained there for the past 9 months. DYS will be moving to a new model at Lookout Mountain
and that will allow for smaller and separate youth centers on the campus. This change will
mandate that DYS hire four new directors, who will lead programs that range from 16 to 36
beds. Two of the four directors have been hired as of February 2020.

9. Recommendation: Evaluate on-site leadership and their ability to appropriately function in

their assigned position.

Response to Recommendation: The previous Director resigned their position in April 2019.
DYS immediately put in place an Interim Director at Lookout Mountain who has 25 years of
secure-residential/community residential experience, with the vast majority in secure care as an
administrator. She is a Licensed Clinical Social Worker and a proven leader within DYS youth
centers. Over the past several months the interim director has been able to fully evaluate all on-
site leadership positions. In addition, DYS made a decision to move towards a new model of
creating four separate and distinct youth centers on the campus. This move allows for the
decentralization of administration while also creating smaller youth centers, less youth per
center, and direct on-site administration in each building. The first two youth centers will be
opened no later than April 1, 2020.

10. Recommendation: Identify a formal supervision protocol to support and engage staff and to
have a means for staff to immediately bring concerns and receive assistance in operationalizing
solutions.

Response to Recommendation: A formal supervision structure has been created for each
staff member. In an effort to fully support this recommendation, DYS will need to continue to
work with Human Resources to fill several vacant supervisory positions. The recommendation
will be difficult to fully accomplish until the allocation of supervisors to oversee subordinate staff
is adequately staffed, however an interim structure has been created to support the staff.
Implementation of the DYS Reflective Supervision Model has also begun at Lookout Mountain.

11. Recommendation: Maintain the current reduction in the number of youth from 148 to the
current census of approximately 75-96 youth. This is important as it relates to staffing ratios,
staff vacancies and turnover rates.

Response to Recommendation: DYS has maintained an average daily population of 65 youth

for the past nine months. As mentioned above, DYS will be moving to a new model which will
allow for smaller and separate youth centers on the campus. These smaller youth centers will
house between 16 and 36 youth each. The first two centers are set to open by April 1, 2020 and
the remaining two are projected to open by July 1, 2020.

12. Recommendation: Consider implementing the Diana Screen tool across the division. This
instrument screens for vulnerability of new hires to cross boundaries and pose a risk of sexually
victimizing youth.

Response to Recommendation: DYS will not be implementing the Diana Screen at this time.
An internal review of the research associated with this instrument determined that it’s not in the
best interest of DYS at this time. Instead, DYS submitted a budget request to fully implement
the Corrections Selection Inventory for staff on all prospective new hires who will have direct
contact with youth. The assessment screens for the following:

● Characteristics critical to job success

● Respect for Authority
● Work Ethic
● Cooperation/Teamwork
● Dependability
● Retention
● Communication Skills
● Attention to Detail
● Principled Behavior
● Judgement

The funding will become available July 2020 and DYS plans to fully implement the screen
by August 2020.

13. Recommendation: Consider reviewing and increasing minimum qualifications for direct-
care staff.

Response to Recommendation: DYS does not have the authority to change minimum
qualifications for direct-care staff. This is a process that happens at the Department of
Personnel and Administration. Human Resources met with the Department of Personnel and
Administration. After lengthy discussion the outcome of that meeting was that it would be much
faster, and have a more immediate impact, for the DYS job postings to be focused on the
Preferred Qualifications for each job. From that meeting the DYS team revised the job postings
to highlight the preferred qualifications that would help increase the number of applicants with
the qualified background needed. These questions can be scored by the Applicant Tracking
System and allowed the HR and Program staff to cut out a significant number of low scoring
applicants and decreased the time it took to review applications. DYS has piloted this program
in 3 locations and will now expand to all locations. The focus of job postings and
advertisements as well as pipelining of future candidates will focus on the Preferred
Qualifications in order to continue attracting candidates.

In addition, Human Resources was able to achieve an out-of-state waiver to hire for direct care
positions in October 2019.

14. Recommendation: Consider changing position description for the unit managers from a
Youth Services Counselor III to a Program Manager I.

Response to Recommendation: DYS will be moving away from the Unit Manager model that
was based on a centralized administration and individuals that managed each unit. As
described previously, DYS will be moving to four separate youth centers at the campus at
Lookout Mountain and providing each youth center with their own administration. This move
meets and exceeds the recommendation.

15. Recommendation:

Response to Recommendation:

16. Recommendation: Re-establish routine meetings, such as the Youth Advisory Council
meetings and staff Roundtable meetings, to increase the voice and participation of all that live
and work at Lookout Mountain.

Response to Recommendation: Youth Advisory Council monthly meetings have been

reestablished and allows youth from across the campus to participate. Also, Student Council
meetings have been established in the school. Roundtable meetings for staff have also been
reestablished, by job class quarterly. Both of these meetings allow for youth and staff to be
heard directly by the administration and further allows buy in from all that work and live at the
youth center. These meetings were reinstituted in August 2019.

17. Recommendation: Evaluate legislation for aggravated offender sentences.

Response to Recommendation: DYS has thoroughly evaluated this recommendation and

does not believe at this time that legislation is needed to address individuals committed to DYS
under the aggravated offender sentencing structure. Ongoing review will continue, in
partnership with stakeholders, on individuals sentenced to DYS for upwards of 7 years.
Response to Recommendation:

22. Recommendation:

Response to Recommendation:

23. Recommendation: Ongoing evaluation protocols for assessment of staff appropriate

professionalism and boundaries. Have a supervision protocol to help determine which staff are
appropriate to remain employed in direct care services at Lookout Mountain.

Response to Recommendation: A lot of progress has been made in this area in the last 9
months. The Lookout on-site administration has moved forward to ensure that staff are
performing at the utmost of professionalism. Several staff have either resigned or have been
discharged. This culture move is a positive sign as Lookout Mountain moves towards a safe,
secure and therapeutic environment. A boundaries and culture training was facilitated for all
staff. In addition, all supervisory staff attended leadership training and training in effective
supervision of staff. There have been numerous opportunities for the on-site administration to
bring staff in to talk directly about boundaries and concerns with professionalism, focus on
providing direct feedback and increasing accountability.
24. Recommendation: Facility leaders should eliminate safety hazards on the living units and
increase the “homelike” feel of the units (make them more welcoming and warmer).

Response to Recommendation: DYS is committed to creating a homelike environment. The

Lookout Mountain Aspen building (pilot program) was completely updated with bright paint,
wood floors, bedroom furniture, and homelike (non-correctional) furniture in 2018. The Juniper
East building has followed with new paint colors and wood floors. The Cedar and Spruce
building have been painted with bright colors and flooring is being or has been installed in the
common areas and youth sleeping areas. Lookout has focused on cleaning up the community
inside our buildings and on the grounds, and the goal is to continue creating a homelike
approach. Lastly, DYS has put forward a budget request in December 2019 to increase the
homelike environment (painting, furniture, flooring, rugs, pictures, doors) at Lookout Mountain.
DYS anticipates hearing the outcome of that proposal in April 2020.

25. Recommendation: DYS should ensure all units have formal post orders to provide
guidance and direction for staff working throughout the facility. Although all staff receive on-the-
job training, some staff may not handle a crisis as effectively as others which may lead to staff
forgetting steps in the response process. It is critical that staff react immediately, consistently,
and effectively to all situations that may arise. Creating post orders will provide staff with
guidance needed during crisis situations. Staff must be appropriately and regularly trained on
crisis and emergency management response.

Response to Recommendation: Post descriptions and operational orders have been provided
for all direct care staff as of September 2019. The focus at Lookout Mountain has been ongoing
training on safe practices. In addition, quarterly training is provided to all direct care staff specific
to verbal de-escalation, physical response, motivational interviewing, and crisis management to
include code calling.

26. Recommendation: DYS should work with local law enforcement to develop procedures to
have a drug dog onsite to patrol the parking lot and stand by the door on random visitation days
and during various work shifts and shift change.

Response to Recommendation: DYS secured a K9 contract in October, 2019. This contract is

specifically utilized in DYS youth centers. This is a safety and security issue so further details
will not be provided.

27. Recommendation: As part of the incident review process and to supplement review of
video footage, the agency should consider requiring regular review of facility video in all-staff
meetings a minimum of quarterly (in addition to post-incident reviews). These reviews serve to
identify what went well, areas for improvement, team training needs, and lessons learned. This
is an important process for ongoing professional development.

Response to Recommendation:

28. Recommendation: DYS should consider formalizing the practice of regular video review
(not only after incidents) into agency policy and/or the program operations manual. The
policy/procedure should explain when to conduct these reviews, what to look for (the positive
and negative actions taken), how to use the information obtained from these video observation
sessions, and how this information will be documented.

Response to Recommendation: The DYS policy committee in conjunction with the facility
administrators will develop a policy to support ongoing video review to celebrate positive actions
and to address areas for development. This policy is projected to be completed by July 2020. In
addition, the DYS Office of Staff Development is in the process of putting together training
based on do's and don'ts from video to be utilized in the new employee academy and in
refresher training.

29. Recommendation: Continue to formally address staff fear for safety concerns and the use
of isolation. At the time of the onsite visit several facilities had identified the goal of decreasing
the use of isolation and fear for safety concerns of staff. Although most facilities are currently
below the national average on isolation and seclusion, staff fear for safety is a major concern.
Staff routinely voiced concerns that the mandate to reduce seclusion became more important
than the safety of youth and staff. This certainly is contributing to the rise in fear for safety
concerns.

They are encouraged to continue to regularly review data with staff

and to work with their teams to identify barriers and strategies to successfully reduce the use of
isolation while working to provide staff with appropriate training to ensure for their and youth
safety (i.e. alternatives to isolation, documentation, etc.). Staff need additional training and skills
to respond to behavior incidents in a different manner while ensuring for the safety of all.

Response to Recommendation: DYS agrees that staff feeling safe is a top priority and is
committed to working towards that end. DYS takes the use of seclusion seriously. It can only be
utilized in accordance with state law. The youth must be a serious, imminent and probable risk
to self or others and the present ability to do so. Seclusion can not be used past that point. DYS
has made great strides in the reduction and use of seclusion over the past few years and will
continue to train staff in alternate interventions to support them feeling safe in their work
environment. As many other states come to this juncture, reducing the use of seclusion, it is
imperative that Colorado continue to network to determine best practice approaches. In
addition, DYS is supportive of the Council of Juvenile Justice Administrators position statement
on the use of seclusion. It further agrees that one of the most important tools is staff and youth
relationships. DYS continues to work hard in this area in order to create a relationship-based
and therapeutic environment where both youth and staff feel safe. Lookout Mountain has
created teams with the hope that the same staff are working with the same youth to facilitate the
building of relationships through consistent interactions. Lastly, data is made available to all
staff and specifically the use of seclusion. The October 2019 PbS data collection, in the Safety
14-Percent of staff who report they fear for their safety decreased from 77% in April 2019 to
63%.

30. Recommendation:

Response to Recommendation:

31. Recommendation:

Response to Recommendation:
32. Recommendation:

Response to Recommendation:

33. Recommendation: The agency should revise its grievance procedures and the youth and
family manuals to align with federal Department of Justice PREA (Prison Rape Elimination Act)
standards. The revised policy and program manuals should clearly state: • Youth are not
required to talk with the staff member who is the subject of the grievance • Youth may submit a
grievance anonymously or on behalf of another youth • A parent and/or guardian may file a
grievance on behalf of a youth and describe how a third-party report is made • Designated
facility staff must check the locked grievance boxes a minimum of once daily (including
weekends) • How submitted grievances are resolved – i.e. with grievances that allege sexual
abuse, a thorough investigation will be conducted and a written response provided to youth by
the YS3’s within 48 hours but no later than five calendar days • Staff are prohibited from asking
youth about the contents of the grievance • Staff must provide the tools necessary for youth to
file a grievance and are not allowed to refuse youth the right to file a grievance • The facility will
provide stamps for letters to advocacy agencies as needed (no maximum limit)

Response to Recommendation: The grievance procedure and the youth and family handbook
align with the federal Department of Justice standards. Additionally, DYS has reviewed the
relevant procedures as well as the youth and family handbook as outlined in the
recommendation. The handbook covers the specific areas of the recommendation. Lookout
Mountain passed their federally mandated federal Department of Justice audit with a 100%
rating in February 2018.

34. Recommendation: DYS should secure an agreement with a local advocacy or rape crisis
center to provide support to youth who may be victims of sexual abuse and/or assault. Once this
Memorandum of Understanding is secured, youth and family manuals should be updated to
provide this contact information (i.e. mailing address and telephone number). Federal PREA
standard 115.351 requires facilities to youth to “report abuse or harassment to a public or
private entity or office that is not part of the agency and that is able to receive and immediately
forward resident reports of sexual abuse and sexual harassment to agency officials, allowing the
resident to remain anonymous upon request.” And, signage is posted throughout the units to
provide instructions.

Response to Recommendation: Since 2007, Lookout Mountain has utilized St. Anthony’s
Hospital SANE unit. This information is noted in the Emergency Response Guide at control
stations and other key locations throughout Lookout so that staff know what hospital should be
accessed. DYS BHS staff are also accessed as support resources to guide victims to the
appropriate services and hospital.

35. Recommendation: Ensure all units have a locked grievance box on the living units and in
the school classrooms. This will ensure youth can submit a grievance at any time throughout the
day and on weekends. And, ensure proper communication is provided to youth and staff on the
process.

Response to Recommendation: DYS implemented locked grievance boxes in 2010. There are
also locked grievances boxes in the school building and central dining. Grievance forms are
readily available and a youth can access a grievance without asking a staff member. Lookout
Mountain has a grievance officer who reviews all grievances so that there is not a conflict of
interest with a staff working directly with the youth. At the time of the consultation with CJCA,
the locked grievance box in one residential unit had been damaged and taken down. It has
since been replaced. This happened in July 2019.

36. Recommendation: Adopt and implement a vulnerability risk tool to measure risk for sexual
victimization and/or perpetration for all youth at intake. This safety information should be used to
make bedroom assignments. It is recommended that DYS revise existing policy and/or
procedures to reflect this new practice. (I think that a lot of this is done at the assessment unit.
Maybe check on this in case it is already happening.)

Response to Recommendation: DYS already completes this recommendation. The

vulnerability risk tool has been in place since 2007 and utilized across the DYS system, as
outlined in policy. Each time a youth is admitted to a youth center, transferred within the youth
center, or engages in a specific act of violence the assessment is completed to ensure each
youth is appropriately housed within the youth center.

37. Recommendation: Revise agency policies, procedures, and facility youth manuals to more
clearly describe how strip searches are conducted to ensure privacy and meet security
concerns. It is important to explain in the youth and family manuals that searches are done with
two staff – one staff member conducts the search, while the other watches the staff (and cannot
see the exposed youth).

Response to Recommendation: The youth search process was updated and implemented
September 1, 2019. All required staff were provided a two-hour training prior to implementation.
Additionally, video training was completed and staff will review two times per year. Letters were
sent to families, stakeholders and staff on the changes to the youth search policy and talking
points were generated so that staff could meet with all youth to update them on the change.

38. Recommendation:

Response to Recommendation:

39. Recommendation:

Response to Recommendation:

40. Recommendation: The agency should consider developing a weekly room confinement
report to be reviewed by DYS leadership each week (to include all room confinement). This will
ensure all facilities operate consistent with agency expectations and use room confinement only
in limited and exigent circumstances. Consider establishing a monthly metrics report which
focuses on PbS critical outcome measures so that the data for these measures can be reviewed
monthly.
Response to Recommendation: DYS closely reviews the use of seclusion monthly with the
Department. The collection and analysis of seclusion data is in alignment with the internal and
external stakeholders’ goal of reducing its use. Room confinement, such as shift briefing or the
debrief of a physical management episode, is congruent with policy and state statute. DYS
continues to work with their PbS coach to develop ways to limit the time a youth is subject to
their bedroom outside sleeping hours.

41. Recommendation: Consistent with federal PREA standards, DYS should consider
implementing ongoing education about zero tolerance for sexual abuse and sexual harassment.
The facility may consider having youth watch a video at intake and lead a discussion monthly.
One video to consider is one created by the Idaho Department of Juvenile Corrections
(https://youtu.be/TRqJd_tZh1A). Included in these regular discussions with youth should be the
youth’s right to contact an advocacy center and/or the State of Colorado sexual abuse hotline
number. This contact information should be displayed on zero tolerance posters throughout all
facilities.

Response to Recommendation: A PREA video for youth to watch has been in place since the
passing of the federal law. Youth also receive this information in their Handbook and posters
are posted within the youth center providing a telephone number they can call to make any
confidential allegations. In addition, all DYS staff are trained in PREA at the time of hire and
receive mandated annual refresher training. DYS maintains a zero tolerance for sexual abuse
and sexual harassment. DYS will continue to use the PREA video for youth to watch and regular
discussions will be conducted between youth and staff on the youth’s right to an advocacy
telephone number, to a center, to ask questions or report concerns/incidents.

42. Recommendation: Develop a detailed response protocol for allegations of sexual abuse
and provide formal training to all staff. This protocol should include separating the victim and
perpetrator; preserving the scene (and evidence); contacting the rape advocacy center;
transporting youth to hospital for a SANE exam (Sexual Assault Nurse Examiner), etc. Having a
detailed protocol ensures allegations of sexual abuse and sexual assault are handled effectively
and ensures the safety of all staff and youth.

Response to Recommendation: The elements of this recommendation have been in place

since 2007 and are outlined clearly in DYS policy. All staff are trained in PREA upon hire and
receive mandated annual refresher training. As of January, 2020 new employees spend 7
hours covering PREA (Policy 9.19), boundaries and mandatory reporting in the new employee
academy. The test, new employees complete, covers all of the topics addressed during the 1st
week of the academy. Out of the 30 questions on the test, 5 are specific to PREA and
boundaries. DYS has a sign off form specific to PREA and employees sign off that they have
read the policy. Prior to January, new employees spent 3 hours going over PREA, mandatory
reporting and boundaries. DYS had an acknowledgement form which covered several topics
and only referenced that the employee received access to the policy. Employees continue to
sign it but now DYS includes an additional sign off letter. As for ongoing training, youth centers
and regions are required to use one of the two training modules available. One focuses on
PREA and the other on boundaries. The expectation is to switch off yearly to meet the 2-hour
requirement.

43. Recommendation: The agency may consider adopting or creating additional

assessments/questionnaires to measure other responsivity factors such as personality
characteristics, hobbies, and interests for both staff and youth. Assessing staff professional
skills, goals, and personal hobbies coupled with having youth complete a short questionnaire
inquiring about their interests, hobbies, and personality characteristics will allow the program to
more effectively match youth to their staff advocate. Doing so, will help establish a working
relationship between two individuals with shared interests. In addition, understanding staff’s
professional goals and interests will allow the program to support staff in achieving these goals
by providing them personal growth opportunities (i.e. co-facilitating specific treatment groups).

Response to Recommendation: DYS will establish a committee of DYS direct care, clinical
and supervisors staff to develop this process. This is in line with our philosophy of creating
strength-based and therapeutic relationships between youth and staff. DYS will be reaching out
to the Council of Juvenile Justice Administrators for support in this area. DYS anticipates this
will be concluded by July 2020.

44. Recommendation: The behavior management system is not working as it should and is
ineffective in reducing incidents of violence and/or providing adequate incentives to improve
youth behaviors. In fact, it was discovered the previous facility director discontinued the
behavior management system all together. The BMS needs to be reinstituted and staff re-
trained on the program. DYS should offer several incentives to encourage youth progress in
treatment, facilities should continue to work with youth and staff to increase the number and
types of reinforcers/incentives. Youth needs are ever-changing and incentives must be
individualized. Ideas to consider are an individual lunch with the facility Superintendent (takeout
from a favorite restaurant); special hair products; one day to wear his favorite personal t-shirt;
first choice seat selection during movie night, etc.

Response to Recommendation: DYS is retraining all staff in the behavioral management

program and implementing the systems and process to allow it work effectively. In July 2019,
staff were trained on the level system, group processes, and a program that addresses major
rule violations, weekly reinforcers and longer reinforcers.

45. Recommendation: The agency should work to create a program schedule with meaningful
activities that does not require youth to be in their rooms during shift change, shower time,
and/or during other regular operational activities. Room confinement time seems to be
significant as it relates to these operational confinement periods. This is another area where
community volunteers could be helpful. Research shows separation from the group on a regular
basis can trigger trauma and lead to acting out behaviors. Finally, the PbS data related to the
daily activity logs, needs to be tracked more efficiently and in a manner, which ensures data
integrity.

Response to Recommendation: DYS is actively reviewing the use of room time across youth
centers and is developing an action plan to address any issues related to operational
confinement periods. Additionally, Lookout Mountain is actively working to engage youth in
intramurals and weekly engaging incentives. The program schedule was updated and
implemented in August 2019. The room time periods are continued to be reviewed and an
action plan will be completed by January 2021.

46. Recommendation: Due process is lacking or is non-existent within the youth disciplinary
process. Due process has been replaced with the “intervention and sanctions” process. Agency
leadership should review and restore due process to the disciplinary procedures. Finally, there
is a lack of consequences for youth, particularly those involved in serious incidents, such as a
staff assault. The agency needs to review the disciplinary sanctions and consequences to
ensure adequate sanctions for serious offenses.

Response to Recommendation: DYS has established a committee to review and develop

well-functioning, transparent, and fair due process procedures for youth. Lookout Mountain
specifically restructured the entire discipline process whereby a supervisory staff will ultimately
assign interventions specific to the behavior. Interventions include assignments specific to the
development of skills and restorative community justice. This will be completed by July 2020.

47. Recommendation: It is suggested that the agency immediately reinstitute Religious

Services. The consultants were told that Religious Services were placed on hold for several
weeks. However, this is a constitutional right and needs to be the highest priority.

Response to Recommendation: Religious services were reinstated at Lookout Mountain in

July 2019. Lookout currently partners with Youth for Christ and Straight Ahead Colorado.
Lookout Mountain also has a chaplain who works directly with all youth to meet their religious
needs.

48. Recommendation: Work to enhance family engagement practices. Family engagement is

an important element for facility and youth success. Families have extraordinary strengths and
help create healthier facility environments.

Response to Recommendation: DYS believes that family engagement and the two-
generation process is extremely important to the success of the youth and their family. DYS and
Lookout Mountain have routinely involved families in the treatment review meetings,
graduations, and other sanctioned and supervised events. DYS will continue to support family
engagement and opportunities for youth and families to come together. Lookout supports an
evidence based curriculum for youth who have children called New Beginnings which is
facilitated by direct care staff. In addition, behavioral health staff complete family sessions when
indicated by the requirements outlined in DYS Policy.

49. Recommendation: It is suggested that all facilities adopt the practice of providing monthly
training refreshers during all-staff meetings. PowerPoint presentations and corresponding
talking points could be developed for and used by Leadership or designees each month. Topics
to consider include adolescent brain development, verbal de-escalation, teaching youth skills,
positive youth development, staff positioning, etc. These training sessions should include
experiential learning exercises whenever possible.

Response to Recommendation: Lookout Mountain reinstituted all day team training days in
July 2019 and training days continue to be held on a quarterly basis. In addition, there is a
process in team meetings where staff receive information specific to the youth served,
diagnosis, and interventions specific to supporting the youth. Lookout will continue to train to the
SOAR Program, the behavior management program to include the trauma responsive tools that
have been developed through the Sanctuary Integration Team for Youth Centers in all days and
team meetings.

50. Recommendation: Continue to devote resources to implementing vocational certification

programs for youth in DYS facilities (i.e. plumbing, carpentry, etc.). Trade certifications greatly
increase the likelihood a youth will find employment and consequently, continue to engage in
prosocial activities. The agency is in the process of increasing the vocational opportunities at
Lookout Mountain. The consultants would encourage including vocational programs such as
welding, robotics, landscaping, and construction (i.e. sheet rocking, tiling, flooring, etc.) as well
as for DYS to continue to explore vocational programs that will allow youth to earn certification
in specific trades.

Response to Recommendation: DYS continues to devote resources to vocational education

programs. DYS has completed a Facility Master Plan with an outside architecture firm. A central
goal of this plan is to increase space for career technical opportunities in all commitment youth
centers. Specifically at Lookout Mountain, youth have the opportunity to participate in culinary
arts, hairstyling, construction trades, silk-screening and large kitchen cafeteria work. These
programs have been in place for several years.

51. Recommendation: DYS should ensure that a formal structure exists requiring active youth
participation in the treatment planning process. Youth engagement may include youth
advocating for level advancement and/or presenting to the treatment team evidence of
behavioral progress. These expectations should be clearly described in the youth and parent
manuals. Best practices show programs with the best outcomes are those in which youth are
actively involved in the development and tracking of their treatment goals. At the time of the
onsite visit, some facilities required youth to be actively engaged in advocating for their behavior
level and privileges, while others did not.

Response to Recommendation: DYS utilizes the Multi-Disciplinary Team (MDT) process and
has since 2011. The MDT process includes the youth and their family and utilizes the
consensus based decision process. It has been implemented and utilized throughout the
system. Lookout Mountain had a lapse in effective MDT practice. It was fully reinstituted in
August 2019.

52. Recommendation: Facilities may benefit from additional training and guidance on how best
to work with gang-affiliated youth. During the onsite visit, staff identified this as an area of need.

Response to Recommendation: DYS is currently participating in an initiative between the

University of Colorado and the Gang Reduction Initiative in Denver. The goal of the strategic
planning initiative is to review collective efforts to reduce gang violence, identify and discuss
successes and challenges, and create a framework for continued efforts over the next five
years. In addition, the Office of Staff Development actively searches for updated curricula and
best practice to share at staff meetings.

53. Recommendation: DYS should reconsider whether the implementation of their current
model is the best model given the facility make-up. It should also be noted that both staff and
youth are confused about the model and it appears to be having a negative impact throughout
the facility. Staff reported that the model was introduced poorly and was implemented poorly.
Staff and youth are confused as to which behavioral model they are supposed to be following
and which rules apply.

Response to Recommendation: DYS is actively working towards the creation of smaller

youth centers that are single-purpose, which supports relationships and a safe environment.
DYS believes in a strength-based and relationship based approach in working with youth. In
addition, DYS believes in sound evidence-based and trauma responsive programming that
identifies risk, needs and protective factors and facilitates effective treatment to lower risk in the
youth we serve. DYS has been allocated funding by the legislature to stand up four separate
facilities on the Lookout Mountain Campus beginning July, 2020.

54. Recommendation: Ensure all youth and family manuals are written using language that is
easily understood by most individuals and not simply a mirror image of agency procedures. All
manuals should clearly explain the program’s philosophy; type and purpose of treatment
groups; the behavioral level system and daily ratings; privileges and consequences; and other
important program information.
Response to Recommendation: DYS has already completed this recommendation.
Additionally, the youth and family manuals are readily available to recipients and are on the
website.

55. Recommendation: Although all DYS facilities participate in Performance-based Standards

and collect isolation data twice a year, the consultants encourage DYS to require its facilities to
collect, report, and discuss isolation and other critical outcome measures a minimum of monthly.
This will ensure facilities adhere to agency expectations and assist in maintaining a culture of
using isolation as a last resort. Most importantly, by establishing a monthly critical outcomes
measure report, agency and facility leadership will be better able to monitor these outcomes and
to respond to them in a more efficient and effective manner. Create an automated report to
capture isolation, use of restraint, assaults, fights, youth without incident, and other critical
incident measures and data points regularly and share this information with staff to reduce
uninformed myths about the facility.

Response to Recommendation: DYS already completes this recommendation. In addition, the

Department has a robust data collection and review process monthly that examines similar data
points as DYS.