Youth Treatment Center
November 1995
EXECUTIVE SUMMARY
The state of Wyoming funds a variety of community-based and
residential treatment programs for at-risk youth. According to
statutes, adolescents in need of services are required to be placed
in the least restrictive setting considered appropriate for their
individual needs.
Young persons generally enter the youth services system through the
courts. Multi-disciplinary teams at the community level advise
juvenile court judges regarding appropriate placements.
The Youth Treatment Center (YTC) is one component of the continuum
of services available for at-risk youth in Wyoming. YTC is a
long-term residential program providing education, health, and
social services to address the multiple problems of high-risk
youth.
According to YTC's management, treating traumatized children is at
the forefront of its service mission, and many of the residents
have been emotionally, physically, or sexually abused. Some
residents have mental illnesses such as severe depression, while
others exhibit behavior disorders. Many of the youth also have a
history of abusing substances.
For FY 1995, we estimate that it cost an average of $140 per day to
provide services for each resident admitted to YTC. Based on a
median stay of 8.5 months, an average treatment cost would be more
than $35,000. YTC has an average census of 38.7, and in the course
of a year, serves 90 to 100 adolescents.
Finding 1 Planning and Coordinating Weaknesses
Limit YTC's Effectiveness
Although YTC's accomplishments are not well documented,
knowledgeable individuals we interviewed generally agreed that
treatment at the Center can have a positive impact on youth.
However, these individuals also recognized a need for improved
planning and interagency coordination. The combination of
ineffective treatment planning and weak coordination of transitions
tends to extend time for treatment and also limit sustainable
benefits of therapy.
Although YTC has been a part of DFS since reorganization in 1991,
DFS has not clearly outlined for YTC its expectations regarding
residents' treatment planning and coordination of transitions.
This lack of management direction has allowed problems to develop
and go unaddressed.
Recommendation: DFS should develop and implement a comprehensive
strategy to strengthen planning for treatment, transitions, and
aftercare.
Treatment outcomes for YTC residents can be improved if DFS
develops a strategy to address system problems in the areas of
treatment, transitioning, and aftercare. The resulting strategy
should require DFS and YTC to establish management controls which
guarantee that new planning and coordinating procedures are
effectively carried out.
Finding 2 Human Resources Management Problems Have
Resulted in High Staff Turnover
Ineffective human resources management at YTC has resulted in an
excessive staff turnover rate. YTC's turnover rates for 1994 and
1995 were 36.8 percent and 39.7 percent respectively. These rates
were more than triple the turnover rate for all state employees,
and more than double the rates at either the Girls' or Boys'
Schools.
YTC has not effectively identified and addressed the causes of its
high staff turnover rates. Current and former employees attributed
turnover primarily to management practices, not to pay. Several
former employees told us they were so dissatisfied that they
resigned without having new employment to go to.
Recommendation: DFS should review human resources management
practices at YTC and take appropriate actions to resolve problems.
Specific steps to improve human resources management could include
some of the following: improving internal communications,
establishing an ongoing team building training program, reviewing
YTC's organization structure to determine if there are an
appropriate number of staff at the various levels, developing an
employee recognition program for all levels of employees, and
developing employee incentives which may include recognition and
award features.
Finding 3 YTC Has Not Addressed Critical Facility
Problems
YTC's aging and inappropriately designed facilities limit staff's
ability to supervise residents. Consequently, the state cannot be
assured that YTC is providing a safe living and treatment
environment for youths placed at the Center.
The Center has not presented policymakers with a plan to
incrementally address the most critical needs in the existing
buildings. YTC has identified cottage design as presenting the
greatest risks to the residents and the state. Therefore, it has
an obligation to continue informing policymakers of those specific
risks and to justify funding requests for upgrades. YTC's capital
outlay requests have not reflected this focus.
Recommendation: DFS should conduct a systematic assessment of
YTC's facilities to identify and prioritize its most critical
needs.
DFS should obtain an independent condition assessment of YTC's
facilities to identify critical building needs. Using the
assessment as a guide, YTC should develop a five to seven year plan
to reduce critical facility deficiencies.
Finding 4 YTC Has A Serious Runaway Problem
We found that YTC has an ongoing and severe runaway problem, but
has not identified the causes or effectively addressed the issue.
As a result, YTC has exposed its runaways, the community, and the
state to unnecessary risks. YTC does not have a systematic process
to review runaways from the Center. It lacks a system to determine
the number of youths who run away, to ascertain the causes of
runaways, and to strengthen its program and security procedures to
reduce the number of runaways.
Recommendation: YTC should develop a process to reduce runaways.
YTC should develop a system to track the number of residents who
run away, to determine the causes of runaways, to provide staff
training on prevention, and to strengthen security procedures.
These steps should contribute to reduced runaway rates.
DFS should require YTC, through rules or written policy, to report
all cases of runaways immediately. In addition, YTC should be
required to provide follow up reporting on steps taken and the
disposition of these cases.
Finding 5 Customers Are Dissatisfied With YTC
Responsiveness
Interviews with judges, caseworkers, county attorneys,
multi-disciplinary team members, and families depicted a great deal
of dissatisfaction with the timeliness and substance of YTC
contact. Many local officials told us they had problems
communicating with YTC prior to an admission, during treatment, and
at the time of release. Ineffective communication diminishes the
ability of local workers and the courts to effectively meet the
needs of local youth treated at YTC.
As a state facility operating within DFS, YTC has an obligation to
work within DFS to meet the needs of youth, and also to serve the
needs of local communities. However, due to communication problems
with YTC, officials in several counties have refused to work with
YTC. They opt instead to place youth with private providers.
Recommendation: YTC should improve responsiveness to its broad
range of customers.
YTC needs to recognize it has many customers, including the local
officials who are responsible for youth in treatment. YTC should
take steps to identify its diverse clientele, in ways that enhance
rather than diminish focus on the residents.
YTC should develop rules concerning admission criteria, so
placement officials can have more information about the process.
It should develop a systematic approach for communicating with, and
obtaining feedback from, key groups prior to admission, during
treatment, and at release.
Finding 6 Quality Control Systems Are Lacking at
YTC
YTC operates largely without external oversight and internal
quality assurance systems which can promote program quality. YTC
undergoes no external quality control review by the state or by
independent accrediting entities. Also, YTC lacks an internal,
formalized quality assurance system to continually assess and
improve operations.
Without these systems, YTC is isolated from the mainstream of
residential treatment for adolescents. Residents and their
families, the Legislature, and the public have no independent
assurance that treatment provided at YTC is appropriate and safe.
Recommendation: DFS should develop and implement a plan for
providing effective oversight and internal review at YTC.
To protect the interests of its residents and of the state, YTC
needs to be made part of a larger framework. As part of the
strategic planning process, DFS could establish a goal of
developing performance measures related to effective oversight for
YTC. All parties stand to benefit from external and internal
quality assurance programs at YTC.
Because the Management Audit Committee requested a focused study
emphasizing YTC, not the larger youth services system, our findings
and recommendations are intended to strengthen the Center's
operations. However, they necessarily will need to be considered
in a broader context.
Policy makers need to be working toward resolution of a number of
related and over-arching public policy matters. Questions for
consideration, some of which have been noted in prior studies of
the youth services system, include:
What are the state's expectations for court-ordered
placements?
How can YTC best fit into the state's youth services
system?
Should the YTC continue to provide services which are
also available in the private sector?
Which agency should run the state's mental health system?
The Legislature faces a fundamental decision regarding YTC: should
it continue to operate according to status quo, be changed, closed,
or is another policy direction desirable?
Regardless of which decision is made, we believe the
recommendations in thisreport have implications for the entire
youth services system. They speak to the state's obligation to
ensure that youth treatment is delivered in an environment and
manner which promote high quality treatment, safety for residents,
retention of skilled staff, and attainment of desired outcomes.
Introduction
A. Scope
W.S. 28-8-107 (b) authorizes the Legislative Service Office to
conduct program evaluations and performance audits. The general
purpose of a program evaluation is to provide a base of knowledge
from which policy makers can make informed decisions.
In February 1995, the Management Audit Committee chose the Youth
Treatment Center in Casper, which is a part of the Department of
Family Services, as the subject of a review. The Committee
requested that research focus on the Center and its operations,
but, to the extent possible, that its operations be reviewed in the
context of the youth services system.
The research in this report centered around the following
questions:
What is YTC's purpose and how effective is it in carrying
out that purpose?
Are YTC's facilities appropriate to its mission?
How are placement decisions made?
How comparable are YTC's treatment strategies to accepted
practices?
What is known about outcomes for YTC residents?
What supervision and oversight does YTC receive from DFS?
B. Methodology
This evaluation was conducted according to statutory requirements
and appropriate program evaluation standards and methods. We
conducted our research between June and October 1995.
We reviewed relevant Wyoming statutes, rules, YTC policies, annual
reports, budget requests, academic literature, agency records, and
a variety of other state and federal reports and studies. We
contacted the Department of Health, the Department of Education,
and several mental health centers for information. We selected a
random sample of former residents at YTC and reviewed records
pertaining to their placement and release.
We interviewed current and former staff at YTC and DFS, as well as
former participants in the program and parents. We traveled
throughout the state to interview District Court judges and members
of multi-disciplinary teams. We toured private residential
treatment centers, the Girls' and Boys' Schools, and several
community based programs for troubled youth.
Finally, we conducted telephone interviews and reviewed
documentation from several neighboring and western states,
including Alaska, Colorado, and Nebraska.
C. Acknowledgements
The Legislative Service Office would like to express appreciation
to all the individuals who assisted us in our research on this
project, and especially to staff at the Youth Treatment Center and
the Department of Family Services.
Background
Description of the Problem of At-Risk Youth
Wyoming, like all states, faces difficult challenges in deciding
how best to approach the problem of youth whose behavior places
them at risk of not becoming self sufficient members of society.
The Youth Treatment Center (YTC) is one facet of Wyoming's approach
to dealing with at-risk youth.
One study has estimated that more than 10 percent of the nation's
youth aged 10 to 17 engage in three or more of the four behaviors
most commonly associated with this risk: poor performance in
school, substance abuse, delinquency, and early unprotected sexual
activity. Many of these children come from troubled families and
have experienced neglect or physical, sexual, or emotional abuse.
They may internalize or act out their problems through behaviors
that range from depression to delinquent acts.
Two Basic Approaches to the Problem
One way to serve high-risk youth is through nonresidential
community-based programs. Such programs serve youths at home, at
school, or through other community locations.
Another way of addressing youths' problems is through out of home
placements. Options range from short-term crisis centers to
comprehensive, long-term (6 to 18 months) residential programs.
YTC is a long-term residential program providing education, health,
and social services to address the multiple problems of high-risk
youth.
Wyoming's Approach to At-Risk Youth
The state of Wyoming funds a variety of community-based and
residential treatment programs for at risk youth. According to
statutes, adolescents in need of services are required to be placed
in the least restrictive setting considered appropriate for their
individual needs.
Young persons generally enter the youth services system through the
courts. Juveniles can come under the protection of the courts in
cases of neglect or abuse. They can be adjudicated delinquent if
they have broken the law or have violated the terms of a court
order. Juveniles who are out of parental control, such as habitual
truants, chronic runaways, and status offenders can be adjudicated
as children in need of supervision (CHINS). The state gains
custody of those youth ordered to out of home placements.
Local and private options for out of home placements include family
members, foster care, specialized foster care, therapeutic foster
care, group homes, and private residential treatment facilities
(RTFs). There are 13 RTFs in Wyoming providing long-term
residential mental health care and special education services.
These RTFs have capacities ranging from 14 to 70 beds.
The state operates several institutions for youth. DFS is
responsible for the Youth Treatment Center -- a treatment facility
for adolescents, and two correctional institutions -- the Girls'
School and the Boys' School. The Department of Health is
responsible for the State Hospital, which has an adolescent
psychiatric unit.
Three agencies are involved in funding court-ordered placements.
Generally, DFS pays for room, board and treatment; the State
Department of Education (SDE) pays for educational costs; and the
Department of Health (WDH) pays for medical expenses and certain
mental health services. As shown below, both the number of
court-ordered placements and expenditures for placements have been
increasing in recent years.
Exhibit 1: Court-Ordered Placements FY91 through FY94
Fiscal Year Placements Expenditures
1991 572 $7,728,838
1992 632 $8,519,865
1993 682 $10,452,141
1994 747 $11,206,008
Source: LSO analysis of data from DFS, WDH, and SDE
Placement Decisions are Made Locally
According to state statutes, multi-disciplinary teams (MDTs) at the
community level advise juvenile court judges regarding appropriate
placements. The composition of these teams varies somewhat from
community to community, but must consist of at least four members,
some specified in statutes. Teams often consist of parents or
guardians, the youth's legal counsel, school officials, state or
local social service workers, county attorneys, or other
professionals.
In making recommendations, MDTs typically consider factors such as
the availability of appropriate local services, immediate
availability of space in preferred facilities, and individual
members' impressions of program effectiveness. Although MDT
members consider the cost of various placement options, many do not
believe this to be their primary consideration. Typically, local
DFS offices are responsible for paying for placements, while
juvenile court judges have the ultimate placement authority.
To initiate the process of making a placement at YTC, a local DFS
office generally contacts YTC directly. They discuss the
appropriateness of placement and the availability of a bed. Some
placements are made immediately, while other youth are put on a
waiting list until a bed is available. YTC may advise against
placement if, for example, staff believe they cannot serve the
treatment needs of the particular youth.
Overview of the Youth Treatment Center
The Youth Treatment Center is one component of the continuum of
services available for at-risk youth in Wyoming. YTC and privately
operated RTFs in the state accept youth with similar problems and
provide similar treatment and educational services.
W.S. 25-7-101 authorizes DFS to operate the YTC for the purpose of
providing special care or treatment for children not otherwise
adequately served. YTC is a residential treatment facility located
near the center of the state in Casper, on a 24-acre open campus.
YTC typically serves male and female adolescents 12 to 18 years old
who have been adjudicated as delinquent or CHINS. Although
statutues allow the placement of delinquents up to age 21, YTC
rarely serves individuals over age 18. Many of these adolescents
have experienced several other treatment placements prior to coming
to YTC.
According to YTC's management, treating traumatized children is at
the forefront of its service mission, and many of the residents
have been emotionally, physically, or sexually abused. Some
residents have mental illnesses such as severe depression, while
others exhibit behavior disorders. Many of the youth also have a
history of abusing substances. The Center provides long-term care
with the goal of enabling children to return home or to an
alternative living situation, able to manage life in a constructive
fashion.
YTC's program offers mental health services and special education
programs. Each resident participates in group therapy and may also
request individual therapy sessions. The residents work through
the program on a "level" system, under which they progress toward
release at individual speed. According to YTC management, the
focus of group therapy and the level system is to empower residents
to help each other through the program. Residents are not required
to complete the program within a designated time period.
Agency officials report that current placement trends involve
adolescents requiring more and more acute psychiatric care. They
say over 50 percent of the youth served at YTC have previously
received acute psychiatric hospital care. Approximately 30 to 40
percent of the residents are on psychotropic medications, which are
dispensed through a self-administered program.
History of the Institution
YTC's facilities date to the 1930s when they served as the State
Children's Home for orphans. In 1983, YTC changed its focus from
a state orphanage to that of a clinically-focused residential
treatment center and special education school. YTC reported to the
Board of Charities and Reform until 1991, when
it became part of DFS.
Budget and Staffing
The Center's budget for the 1995-96 biennium is $3.8 million, which
is a two percent increase over the previous period. The General
Fund is the source of more than 98 percent of the Center's funds,
with Federal Funds contributing less than two percent.
As shown in Exhibit 2, nearly 86 percent of FY 95 expenditures were
for residents' room and board, therapeutic services, and education.
Exhibit 2: YTC Expenditures by Category Fiscal Year 1995
Total Expenditures = $1.9 million
Source: LSO analysis of YTC data
YTC is authorized 58 employees: 56 full-time and 2 part-time.
They fill a variety of positions which support a program designed
around four residential cottages, staffed 24 hours per day. Many
of the staff work rotating shifts.
Each cottage has an assigned therapist who manages the cottage and
conducts group and individual therapy sessions. Each cottage also
has a supervisor who is responsible for day-to-day operations. The
Center is authorized 24 full-time and one part-time youth service
workers. These staff act in a parental role and are responsible
for such tasks as meal preparation and monitoring and supervising
residents.
Within educational services, YTC employs an education director,
five teachers, a Chapter One aide, and a recreation director. YTC
also contracts with a psychiatrist and a physician for mental and
medical health services.
Program Costs and Descriptive Statistics
For FY 1995, we estimate that it cost an average of $140 per day to
provide services for each resident admitted to YTC. Additionally,
for the FY95/96 biennium, the Legislature appropriated $352,000 for
capital improvements to the facility. Admissions and releases
occur throughout the year, with some youth staying only a short
while and others for extended periods. Based on a median stay of
8.5 months, an average treatment cost would be more than $35,000.
YTC has an average census of 38.7, and in the course of a year,
serves 90 to 100 adolescents.
As a state facility, YTC is a resource to youth from all counties,
although admissions are more likely to come from some counties than
from others. For the four-year period FY 1992 through FY 1995, YTC
admitted adolescents from 21 of Wyoming's 23 counties. During that
time, 30 or more youths were admitted from two counties, Natrona
and Sweetwater. By contrast, only seven admissions came from each
of the following counties: Albany, Campbell, and Laramie [see
Appendix B].
Placements After Release
After successfully completing the fourth and final program "level,"
residents may progress to a new placement on a 60-day extended
pass. During this period, YTC still has legal custody of the youth
even though they are no longer in the Center's physical custody.
Those youth who are not making progress in the program are
transferred out of the facility to someone else's custody.
Residents can be released to any of a variety of settings, ranging
from less to more restrictive than YTC. Youth may go to group
homes, therapeutic foster care, back to their families, to
independent living, other residential facilities, psychiatric
hospitals, or correctional facilities. Based on our file review,
we found that 38 percent of the youth released from YTC returned to
their families.
Once released, it is widely accepted that youth need provision for
aftercare, or ongoing support and service. As one comprehensive
Government Accounting Office (GAO) study found, "a number of
research efforts have suggested that a youth's environment after
discharge is crucial to sustaining the effects of residential
treatment."
High-risk youth are not necessarily "cured" or "fixed" by
residential treatment. In addition, there may be ongoing family
problems which require counseling and monitoring. Some examples of
aftercare are: continued therapy, substance abuse support groups,
home visits by social workers, counseling to help ensure completion
of schooling, and assistance in obtaining jobs.
Many Earlier Reports Point to System Deficiencies
During the past 15 years, Wyoming has studied its youth services
system many times, through consultant studies, committee reviews,
and task forces. Cumulatively, these efforts have produced at
least 13 reports, and many of them contain similar findings about
Wyoming's system:
There is no early identification of risk or assessment system in
place.
Community resources are limited and not effectively used.
There is no consistent process for evaluation of the need for
placement or treatment.
There is a lack of clearly defined missions for state agencies and
facilities.
There needs to be a clearly defined continuum of care to serve each
type of child in the system.
Because our research was not directed at the youth services system
as a whole, we did not attempt to re-verify these findings.
Nevertheless, it is fair to state that we found nothing to
contradict the findings listed above. In addition, it appears that
few of the recommendations made in these reports have been acted on
in the intervening years.
None of these reports focused exclusively on YTC's role in serving
youth. The Management Audit Committee, in an effort to shed light
on an as yet unstudied aspect of the system, chose to focus on YTC
and its role within the youth services system. Consequently, our
findings and recommendations focus on what exists at YTC, with a
view to how operations might improve.
In this report, we identify several areas in which YTC and DFS can
improve: coordination and treatment strategies, staff turnover,
deficiencies in the physical plant, the rate of runaways,
responsiveness to customer concerns, and oversight and independent
scrutiny.
Finding 1 Planning and Coordinating Weaknesses Limit
YTC's Effectiveness
Although YTC's accomplishments are not well documented,
knowledgeable individuals we interviewed generally agreed that
treatment at the Center can have a positive impact on youth.
However, these individuals also recognized a need for improved
planning and interagency coordination. The combination of
ineffective treatment planning and weak coordination of transitions
tends to extend time for treatment and also limit sustainable
benefits of therapy.
To gain an understanding of YTC's operations, we talked to a broad
range of current and former employees and residents, parents,
public officials, and professionals in related fields. We
questioned them about various aspects of the Center's operations,
obtained their views concerning its effectiveness, and asked some
of them to compare YTC to standards we found in the literature
about residential programs.
In addition, we examined a randomly selected sample of 25 cases
admitted to YTC between September 1, 1992 and August 31, 1994.
None of these cases involved current residents. For this sample,
we found:
The median length of stay was 255 days, or about 8.5 months.
The median time from admission until the completion of a written
individual treatment plan was 110 days, or about 3.7 months.
There was no evidence that any of these plans, once completed, had
been revised during treatment to reflect modified goals.
17 of our sample of 25 residents (68 percent) were released without
completing their treatment plans.
12 of our sample of 25 residents (48 percent) were released to
placements that were equally or more restrictive than YTC.
Research Shows Key Characteristics of Effective Programs
We reviewed pertinent literature and program evaluations from other
states to gain an understanding of residential care for at-risk
youth. The U.S. General Accounting Office has identified key
elements believed to be important for the success of residential
treatment programs. A description of these characteristics is
shown in Exhibit 3.
Exhibit 3: Characteristics of Effective
Residential Treatment Programs
Developing Individual Treatment Plans. Nearly all residential
treatment programs develop individual treatment plans for each
youth. Plans, in some cases, are updated at specific intervals,
such as monthly.
Participation of a Caring Adult. The presence of a caring adult,
such as a counselor or other staff member, was considered important
in many youths' successful experiences in residential programs.
Self-Esteem Building. According to officials from most programs,
it is important for residential programs to provide opportunities
to build self-esteem so that youths can develop a sense of success.
Planning for Post-Program Life. Planning for transitions may begin
as soon as youths enter the program. Some programs connect youths
to community services and work with families to strengthen
relationships and resolve problems such as substance abuse.
Teaching Social, Coping, and Living Skills. One important purpose
of residential care is to prepare youths for the everyday world.
Youths are taught good work habits, handling confrontations, and
preparing nutritious meals.
Coordination of Services. Program officials viewed coordination of
services as important, whether the services were provided by a
single caseworker or a team.
Involving the Family. Programs acknowledge that youths' behaviors
are often related to family problems and dysfunction. Several
programs contacted involved families in their formal treatment
approach, although this is not always feasible.
Positive Peer Culture. Peer influence is used to effect healthy
behavior changes in youths. Program staff work with peer groups to
foster desirable values and behavior patterns.
Enforcing a Strict Code of Discipline. Program officials believe
a strict code of discipline for residents was of great importance.
Post-Program Support. Research efforts suggest that a youth's
environment after discharge is crucial to sustaining the effects of
residential treatment. Accordingly, some programs continue
services after the youths are discharged from residential care.
Providing a Family-Like Atmosphere. Because many at-risk youths
have not grown up in constructive family environments, several
programs helped youths develop skills and relationships in a
healthy family-like setting.
Source: U.S. General Accounting Office
DFS Has Not Provided YTC With Clear Directions
Although YTC has been a part of DFS since reorganization in 1991,
DFS has not clearly outlined for YTC its expectations regarding
residents' treatment planning and coordination of transitions.
This lack of management direction has allowed problems to develop
and go unaddressed.
Specifically, we found YTC has not developed written policies or
management controls necessary to ensure that individual treatment
plans are consistently prepared in a timely manner and regularly
updated. YTC managers told us they have a goal to complete plans
within 30 to 45 days of a resident's admission. They said
treatment plans are continuously reviewed and changes noted in the
monthly updates sent to courts, parents, and social workers.
However, they acknowledged that actual treatment plans are not
revised. Without up-to-date treatment plans, we believe staff and
residents may not fully understand and be working toward the same
specific treatment goals.
Opportunities Exist to Improve YTC's Effectiveness
Our review showed that many features of YTC's treatment program
resemble those of other highly effective residential treatment
programs. Several individuals we interviewed commended YTC for its
highly qualified staff and, in September 1995, DFS recognized a YTC
job training program as exemplary. Despite its strengths, however,
we also found that opportunities exist to improve YTC's
effectiveness through better planning and interagency coordination.
Although it is extremely difficult to prove that planning and
coordinating problems have specific effects, we believe there are
strong indications that these difficulties tend to increase the
cost of care. This occurs because the length of stay at YTC is
extended due to delays in developing personalized therapeutic
treatment plans.
In the 25 cases we reviewed, we found the median time to complete
a written treatment plan was 110 days, or about 3.7 months. This
delay in establishing formal goals amounted to nearly half of the
8.5 month median length of stay for this group. By contrast,
private treatment facilities told us they produce treatment plans
in no more than 40 days -- which is 70 days earlier than YTC
-- as is required by state standards for RTF licensure.
Based on this information, we concluded that YTC takes an
unreasonably long amount of time to complete individual treatment
plans. The likely effect is to extend treatment periods.
Moreover, until plans are completed, residents may not be receiving
care sufficiently tailored to meet their individual needs.
Our sample analysis also showed that more than two out of three
residents left YTC without completing their treatment programs. No
objective criteria exist to show the number who should be expected
to complete specified treatment plans, and data was not available
to determine completion rates for private RTFs. Nevertheless, we
believe the large percentage of residents who do not complete the
program suggests that YTC's treatment plans may not be sufficiently
tailored to individual residents' needs.
Finally, almost half of the residents in our sample were
transferred to facilities that were equally or more restrictive --
and potentially as expensive. This data also suggests a need for
improvement.
Recommendation: DFS should develop and implement a comprehensive
strategy to strengthen planning for treatment, transitions, and
aftercare.
Treatment outcomes for YTC residents can be improved if DFS
develops a strategy to address system problems in the areas of
treatment, transitioning, and aftercare. The resulting strategy
should require DFS and YTC to establish management controls which
guarantee that new planning and coordinating procedures are
effectively carried out.
The strategy should require a more timely development of individual
treatment plans at YTC than has occurred in the past. Regular
reviews and appropriate revisions of plans, based on progress
toward treatment goals, should ensure that more residents complete
their planned treatment.
The strategy should also require DFS social workers and YTC
treatment staff to ensure that appropriate post-program support is
in place prior to releasing the resident. One approach would be to
require that written plans for transitions and aftercare be
incorporated into individual residents' treatment plans. Whenever
possible, the strategy should provide for appropriate family
interventions, especially when family reunification is being
considered.
Finding 2 Human Resources Management Problems Have
Resulted in High Staff Turnover
Interviews with current and former YTC employees revealed a
widespread sense of disillusionment and job dissatisfaction,
resulting in high staff turnover. Although many staff we
interviewed expressed a deep-seated pride in the value of their
work, they frequently were critical of YTC's human resources
management practices.
Ineffective human resources management at YTC has resulted in an
excessive staff turnover rate. YTC's turnover rates for 1994 and
1995 were 36.8 percent and 39.7 percent respectively. As shown in
Exhibit 4, YTC's turnover rate has been two to three times higher
than the turnover rate for all state employees and the Boys' and
Girls' Schools.
Exhibit 4: State Employee Turnover During 1994 and 1995
Organization: Employees Turnover Percent
1994 1995 1994 1995 1994 1995
State
Government 7,014 n/a 865 n/a 12.3% n/a
Boys' School 88 88 8 11 9.1% 12.5%
Girls' School 53 54 10 3 18.9% 5.6%
YTC 57 58 21 23 36.8% 39.7%
Source: Department of Family Services and Department of
Administration and Information.
YTC acknowledges that staff turnover rates increase expenditures
and decrease productivity. Their estimates place one-time costs
for recruitment and training of a new employee at $335.
Additionally, YTC estimates its new employees are 20 percent less
productive than seasoned staff. Using these assumptions, YTC
estimates that during calendar year 1994, its total turnover costs
were $362,180.
Although it is unrealistic to believe YTC could entirely eliminate
turnover and associated costs, it could reduce them. By moderating
its turnover rate to a level similar to the overall state employee
turnover rate, we estimate YTC could achieve annual budget savings
in excess of $200,000.
Our review showed there are other less quantifiable effects of
staff turnover. Numerous sources indicated that turnover has
hampered residents' care. YTC suggests this consequence in a
document which states the key to successful treatment programs for
these individuals (residents) is consistency and stability in
staff.
Staff told us they believe turnover is disruptive and prevents
residents from bonding with staff. They felt that a lack of
continuity among staff results in longer treatment periods and also
decreases the effectiveness of treatment. They told us that
turnover is especially difficult for residents who are already
trying to come to grips with abandonment issues in their own lives.
Some residents view turnover as their fault.
As one staff member put it, "you lose time and you lose kids."
Another stated, "kids fall apart when they hear a staff member is
leaving. Common sense says that it's not healthy to have this kind
of turnover."
Good Management Practices Require Stable Staffing
One popular reference volume describes effective human resources
management practices. The practices described in this book
include: making people feel they are part of a team; encouraging
open communication, informing people of new developments and
encouraging them to offer suggestions and complaints; reducing the
distinctions of rank between the top management and those in
entry-level jobs; and expanding the skills of personnel through
training programs and reimbursement of tuition for outside courses.
DFS itself has recognized the need for effective human resources
management. Its draft strategic plan for 1996 includes an
objective to attract, develop, and retain highly professional
employees. This draft plan suggests that to retain highly
professional employees, DFS divisions and institutions should
reduce staff turnover, develop an employee recognition and awards
program, increase the percentage of staff receiving training, and
increase employee satisfaction through non-monetary recognition of
above average effort and efficiency in job performance. DFS' draft
plan would also establish staff turnover as a department outcome
measure.
The GAO study of residential care found that the presence of a
caring adult, such as a counselor or other staff member, was
important in many youths' successful experiences in residential
treatment programs. GAO stated that behavioral change can only
take place in the context of a caring relationship -- youth will
listen and learn only from adults they believe care about them.
Excessive staff turnover at YTC makes it less likely that residents
will form these kinds of relationships.
Management Has Not Addressed the Causes of Turnover
YTC has not effectively identified and addressed the causes of its
high staff turnover rates. Current and former employees attributed
turnover primarily to management practices, not to pay. Several
former employees told us they were so dissatisfied that they
resigned without having new employment to go to.
In addition, YTC has not established formal feedback channels, such
as performance measures, which are necessary to improve its human
resources management program. Specific causes of employee
dissatisfaction cited in staff interviews included the following:
Limited communication between administrators and staff members.
After reorganization, DFS conducted a survey of staff at all the
youth institutions, to ascertain the root causes of some morale
problems. At YTC, this study found a large degree of separation
between various work groups, strong staff dissatisfaction with the
administration at YTC, and communication problems. More recent
statistics show that YTC's turnover during 1994 and 1995 occurred
among non-administrators. This is a likely indication that a
communication breakdown continues and is most critical at the staff
level, as was also indicated in our interviews.
Lack of recognition and respect for staff problems, thoughts, and
suggestions. Many staff felt administrators have a singular focus
that does not always include their concerns. Current and former
staff told us they believe their opinions do not count and they are
considered expendable resources. One told us, "we're told what,
when, and how. We're punished for disagreements. When we ask why,
we're told, just because." A DFS official stated, "there is a huge
gap between administrators and workers, involving such matters as
trust and teamwork."
Lack of management support for staff decisions. Staff we talked to
were frustrated because they believed that YTC's management
consistently did not support their decisions. As one said, "We try
to help each other out and stick together. It's important that we
do this because we aren't supported by management." Another said,
"Management subverts, demeans, and belittles staff by arbitrarily
making changes that render (our) work ineffective." Generally, our
interviews showed that many staff are discouraged because they are
addressing the same issues over and over, with no results.
YTC management has identified staff turnover as a problem in its
strategic plan and other documents. They attribute turnover to
several factors including too few staff for the number of
residents, rotating shift work, and an improved local economy which
provides better paying career alternatives. While these may be
valid contributing factors, staff we interviewed said they are not
the most important reasons. Overwhelmingly, current and former
employees cited negative management attitudes toward them and a
perceived lack of respect for the value of their contributions to
the Center.
Other similar state institutions, such as the Girls' and Boys'
Schools, do not have turnover rates as high as YTC's. Regardless
of the causes, we believe YTC's turnover rate is excessively high
and it is affecting the Center's ability to do its job well. The
evidence points to a need to address this problem decisively.
Recommendation: DFS should review human resources management
practices at YTC and take appropriate actions to resolve problems.
Specific steps to improve human resources management could include
some of the following: improving internal communications,
establishing an ongoing team building training program, reviewing
YTC's organization structure to determine if there are an
appropriate number of staff at the various levels, developing an
employee recognition program for all levels of employees, and
developing employee incentives which may include recognition and
award features.
Additionally, so that decision makers can monitor this situation
over time, YTC should establish staff turnover rates as a
performance measure for strategic planning purposes, and report
this information biennially to the Legislature.
Finding 3 YTC Has Not Addressed Critical Facility
Problems
YTC's aging and inappropriately designed facilities limit staff's
ability to supervise residents. Consequently, the state cannot be
assured that YTC is providing a safe living and treatment
environment for youths placed at the Center. YTC operates in a
facility which originally housed the state orphanage. The
administration and school building dates back to 1935, while the
four residential cottages were built over a 30-year period: one in
1952, one in the late 1960s, another about 10 years later, and the
latest in 1982.
Inadequate Cottage Designs
Numerous risks are associated with inadequate supervision of
residents. Residents are at risk of harming themselves by engaging
in dangerous activities such as drug use and suicide attempts.
Residents are also at risk of harm from other residents, through
fights and sexually aggressive behavior. Additionally, the state
is at risk because it is responsible for protecting the youths in
its custody.
The floor plans of two of the four cottages make it difficult for
staff to maintain visual contact with residents. The two cottages
have several right- angled hallways which block the view. It is
not possible for staff to observe each bedroom entrance, the living
room, and the kitchen from a central location. As a result, it is
difficult to adequately monitor, protect, and supervise residents.
YTC Has Not Prioritized Critical Needs
YTC has not conducted a systematic evaluation of its facilities in
order to identify and prioritize its most critical needs. In 1988,
the Legislature funded a feasibility study to compare the costs and
benefits of either remodeling or replacing YTC's facility. Without
presenting a detailed analysis of individual building deficiencies,
the study concluded:
The Center's most critical deficiencies were with the four
residential cottages. Two needed substantial remodeling. The
other two needed to be demolished and rebuilt.
The administration building was adequate, although the heating,
ventilation and air conditioning systems needed updating. The
school was acceptable, but a new gym, locker area, and recreation
room were needed.
The study recommended that YTC not continue to operate in the
facilities as they existed. To mitigate the facility risks, it
suggested the state should either renovate, build a new facility,
or place youths with other providers.
In 1991, a bill sponsored by individual legislators to fund
construction of a new YTC facility was defeated. YTC did not
present a capital outlay request to the Governor for the 1993/1994
biennium. Recently, YTC was able to use federal funds to improve
one of the cottages. However, this construction was not undertaken
as part of a systematic plan designed to address the Center's
critical facility needs.
The Center has not presented policymakers with a plan to
incrementally address the most critical needs in the existing
buildings. For example, in the 1995/1996 capital outlay request,
DFS proposed three options for YTC:
$8 million to build a new facility.
$5 million to completely renovate the facility.
$352,000 to remove and repair the curbs, gutters, and paving;
to remove and replace soffits on the administration/school
building; to construct two therapist offices; and to construct
four time-out rooms.
In justifying the first two options, YTC did not articulate the
specific risks associated with cottage design. The Governor
recommended and the Legislature approved the smallest request. As
a result, YTC is currently working on road projects, rather than on
projects intended to reduce risks to residents.
YTC has identified cottage design as presenting the greatest risks
to the residents and the state. Therefore, it has an obligation to
continue informing policymakers of those specific risks and to
justify funding requests for upgrades. YTC's capital outlay
requests have not reflected this focus.
Recommendation: DFS should conduct a systematic assessment of
YTC's facilities to identify and prioritize its most critical
needs.
DFS should obtain an independent condition assessment of YTC's
facilities to identify critical building needs. The study should
include a point by point enumeration of building and facility
deficiencies, including:
The appropriateness of the buildings for current use.
Any specific inadequacies.
Risks associated with any inadequacies.
The study should also prioritize those risks from most to least
critical.
Using the assessment as a guide, YTC should develop a five to seven
year plan to reduce critical facility deficiencies. Initial
capital outlay requests should focus on the most serious health and
safety issues. Once these projects have been funded and completed,
YTC should incrementally and systematically request funding for
other facility needs.
Finding 4 YTC Has A Serious Runaway Problem
We found that YTC has an ongoing and severe runaway problem, but
has not identified the causes or effectively addressed the issue.
As a result, YTC has exposed its runaways, the community, and the
state to unnecessary risks.
Runaway Rates
Our review of 25 randomly selected resident files revealed:
52 percent, or 13 of the 25, ran away from YTC at least once.
6 of the 13 who ran away did so more than once: 4 ran away
twice and 2 ran away three times.
For the purposes of this evaluation, we refer to a "runaway" as an
unauthorized departure from the Center, accompanied with the intent
not to return. We are not referring to cases where residents fail
to get permission to leave the Center, yet intend to return.
In numerous interviews around the state, we heard that runaways
continue to occur at YTC. In late August 1995, three youths ran
away from YTC. As of this writing, only two of them had been
located and returned to YTC; one remains unaccounted for.
Expected Runaway Rates
We did not find a standard for what would be considered an
acceptable or reasonable runaway rate at RTFs. However, runaway
rates are generally expected to be higher at less secure
facilities. Since YTC is a non-secure facility and is located near
downtown Casper, it is relatively easy for residents to walk away.
Thus, YTC must rely on programs and staff, not locks and fences, to
maintain residents at the Center.
DFS does not require reporting from RTFs on the number of runaways.
Thus, we were unable to determine runaway rates for other
non-secure RTFs in Wyoming. However, many judges, county
attorneys, and MDT members told us that other non-secure RTFs in
Wyoming also have a high number of runaways. In our sample of 25
from YTC, 52 percent had run away. We found that similar
non-secure facilities in Tennessee reported runaway rates ranging
from 1 to 21 percent, with an average of 18 percent.
Risks Created by Runaways
Residents who run away from YTC create risks for themselves, the
community, the state, and YTC. Although some runaways may only be
gone for a few minutes, others are gone much longer, and some may
never be located.
In most of the cases we reviewed, youths were located and returned
to YTC. However, in our sample, two of the 13 who ran away were
never located. These youths represent a vulnerable population.
Away from YTC supervision and protection, they are at risk of
becoming victims of crime or engaging in dangerous behaviors.
Also, they are not receiving needed treatment.
Runaways create risks to the community when they carry out criminal
activities. In our sample of 25, two of the 13 runaways stole
vehicles. MDT members and others told us of numerous similar cases
in which runaways had stolen vehicles or had been caught breaking
and entering.
The state is liable for the damages caused by youths who run away
from YTC. When a court orders a young person into treatment at
YTC, the state becomes the custodian of the youth; consequently,
the state is legally responsible for protecting the youth in its
custody.
Finally, high runaway rates have the potential of eroding
confidence in YTC's ability to manage, protect, and treat the youth
in its custody. Very few of the individuals we interviewed were
aware of YTC's runaway rate. However, they were hesitant to place
youths with some private providers who are believed to have high
runaway rates.
No Process to Reduce Runaways
YTC does not have a systematic process to review runaways from the
Center. It lacks a system to determine the number of youths who
run away, to ascertain the causes of runaways, and to strengthen
its program and security procedures to reduce the number of
runaways.
Our file review indicated that 56 percent of the youth, or 14 of
the 25, had run away prior to being placed at YTC. Thus, youths
placed at YTC are known to be high runaway risks. Nevertheless, it
does not appear that YTC has adjusted its program or security
procedures to accommodate this population.
YTC officials attribute runaway problems to deficiencies in their
facility. Specifically, they point out that YTC is a non-secure
facility and thus, a certain number of runaways are to be expected.
Also, they note that the design of the facility impairs staff's
ability to monitor the residents.
These arguments have some merit, in that they relate to areas
beyond YTC's immediate control. However, YTC is directly
responsible for program content and delivery and also for creating
an effective security system. We believe YTC could reduce the
number of runaways if it had a process to strengthen its programs
and security procedures.
Recommendation: YTC should develop a process to reduce runaways.
Since YTC serves a high-risk youth population in a non-secure
facility, it is unreasonable to expect staff to prevent all
runaways. Nevertheless, YTC can take steps to moderate risks
associated with this problem.
YTC should develop a system to track the number of residents who
run away, to determine the causes of runaways, to provide staff
training on prevention, and to strengthen security procedures.
These steps should contribute to reduced runaway rates.
DFS recently requested informally that YTC report runaway cases to
the Juvenile Services Division administrator. However, because YTC
has not been routinely notifying DFS when residents run away, we
believe DFS may not be fully aware of the extent of YTC's problem.
Due to the size and seriousness of the problem, we believe more
stringent measures are called for.
DFS should require YTC, through rules or written policy, to report
all cases of runaways immediately. In addition, YTC should be
required to provide follow up reporting on steps taken and the
disposition of these cases.
Finding 5 Customers Are Dissatisfied With YTC
Responsiveness
Interviews with judges, caseworkers, county attorneys, MDT members,
and families depicted a great deal of dissatisfaction with the
timeliness and substance of YTC contact. Many local officials told
us they had problems communicating with YTC prior to an admission,
during treatment, and at the time of release. Ineffective
communication diminishes the ability of local workers and the
courts to effectively meet the needs of local youth treated at YTC.
Many Counties Refuse to Work With YTC
As a state facility operating within DFS, YTC has an obligation to
work within DFS to meet the needs of youth, and also to serve the
needs of local communities. However, due to communication problems
with YTC, officials in several counties have refused to work with
YTC. They opt instead to place youth with private providers.
Some told us they simply grew tired of trying to place youth at
YTC, only to be refused every time. YTC has not promulgated rules
or developed policies for admission criteria, and placement
officials said YTC does not provide a clear explanation when they
deny an admission. Others stopped contacting YTC because they were
not receiving feedback about a youth's treatment, or were not
consulted about developing plans for release.
Of the 31 local officials and parents we interviewed, 94 percent
were dissatisfied with YTC's responsiveness. Eight of the
officials either refuse to work with YTC, or rarely recommend
placements there. One DFS worker said, "We don't call YTC anymore.
We gave up on them."
YTC's Unresponsiveness Directly Affects Local Officials
Local officials are responsible for intervening in the lives of
troubled youth, and the immediacy of these youths' needs are
apparent at the local level. YTC's unresponsiveness impacts
judges, county attorneys, MDT members, and DFS social workers in
several ways.
Initially, MDTs and the courts are under pressure to find
placements for troubled youth, and often need a quick and
definitive response to placement inquiries. During the course of
an individual's treatment, local officials need to assess the
effectiveness of treatment and make changes in placement, if
necessary. Their ability to do this is limited without feedback
from YTC. Finally, it is difficult to coordinate aftercare
services for the youth without effective communication processes.
Aftercare Should Be Adequately Planned
Because admissions to YTC come from all over the state, YTC's
ability to directly provide post-program support services is
limited. Thus, an exchange of information between YTC and
communities is essential to ensure that appropriate aftercare
services are developed. Without aftercare, residents still return
to the community, but the state has no assurance that the money
spent in treatment will have lasting effects.
YTC's annual operating budget is approximately $1.9 million. Based
on an average length of stay, we estimate it costs more than
$35,000 to treat an adolescent at YTC. The time and expense
invested in youth during treatment need to be capitalized on when
they return to the community. Establishing communication channels
between local authorities and YTC is critical to this outcome.
There is a lack of scientific data regarding the effectiveness and
long-term outcomes of residential treatment for youth.
Nevertheless, without service coordination between YTC and local
authorities, it is clear that some youth may be "lost in the
shuffle" when they are released from YTC.
YTC Has Not Defined All of Its Clientele
YTC has not recognized or defined all of its clientele. According
to the superintendent, YTC operates under a Total Quality
Management (TQM) philosophy. According to TQM principles, an
organization should have a customer focus and should recognize that
it may serve many customers, including members of the same
organization. Establishing adequate feedback mechanisms for the
customer is another important TQM principle.
In its strategic plan, DFS identified the need to strengthen
communication with internal and external customers. However, YTC
views residents as its primary customers. While the youth they
serve are certainly key clients, YTC has not fully acknowledged
other clientele within the system. Consequently, YTC does not have
a process in place to communicate with, or obtain feedback from,
its diverse customer base at the following stages:
Communication Prior to Admission. Eighty percent of the local
officials we interviewed said that YTC's mission and admission
criteria were unclear to them. One county attorney said, "We can
call YTC with a number of kids with a variety of problems, and they
tell us that none of our kids are appropriate for their program.
It really makes us wonder who they do take."
Several local officials also stated that it often took a week or
two for YTC to decide to accept an adolescent. By comparison, they
said private providers usually responded on the same day the
request was made. Even after YTC accepted a youth, there were
often waiting lists to get into the facility. One judge related
that a youth had to wait six weeks to start the program.
A delayed admission is of concern to local officials because it
increases the time the youth goes without treatment. One said,
"The amount of time it takes them to decide whether to accept a kid
is a problem. We're trying to coordinate court dates, prepare
social summaries, and we need their decision so the MDTs can make
recommendations. If we can't get a kid in, we need to find
somewhere else."
Communication During Treatment. Many local officials who have
placed youth at YTC believe the staff did not include them as an
integral part of the youth's treatment. Most said they were not
informed about the youth's progress during treatment. Others said
they made repeated attempts to obtain feedback on the progress of
youth at YTC, and would often not get a response for months. One
judge stated, "We don't use YTC a lot. Kids get lost in their
system.
We had one kid there for six months, without hearing a word. We
requested information, and didn't receive any. Ten months later we
found out he'd been sent to the Boys' School, and we weren't even
consulted."
In our file review, we found that YTC initiated a median of only
three written contacts with local officials during a resident's
stay at the Center. YTC recently revised its written communication
procedures and now sends monthly progress checklists to judges,
DFS, and parents. However, our interviews indicate there is little
support for the new format. We were told that, while the new
procedure provides for more frequent feedback, the reports do not
have much substance. Many parents perceived they were not welcome
at YTC, and felt that YTC staff did not encourage them to
participate in the treatment program.
While some parents may not desire contact, or contact may be
detrimental to the youth's treatment, other parents are invested in
their child's life. One family related that for five months, they
were given almost no information about their daughter's diagnosis,
treatment, or prognosis, even though they showed a great deal of
interest.
Other parents had concerns because YTC staff did not consult them
about the course of their child's treatment. Specifically, several
parents raised concerns about the use of psychotropic medicines to
treat their children. One mother said YTC staff did not notify her
when her daughter was placed on several psychotropic medications,
to discuss with her the need for medications and the potential side
effects. She stated, "I wanted more input, but felt left out of
the process."
Communication at Release. YTC does not have effective procedures
for notifying local authorities of residents' impending release.
Local DFS social workers are responsible for arranging appropriate
placements and aftercare for youths released from YTC. W.S.
14-6-303(b) states that no youth shall be granted a home leave
until the institution makes a reasonable effort to notify the
Department of Family Services' office nearest the site of the
home leave. However, judges and social workers alike told us they
frequently do not receive enough advance notice of a resident's
impending release.
As a result, they reported being rushed to consider new
arrangements. One judge said he was shocked to see a former YTC
resident on the streets of his community before receiving any
notice of the resident's release. Similarly, DFS workers told us
of instances where YTC residents were returned to their communities
with little or no advance notice to them. Local authorities need
adequate advance notice to ensure that appropriate placements are
made and transition and aftercare services are in place.
YTC Has Few Monetary Incentives to Please Their Customers
Private providers must be responsive to placement officials if they
wish to stay in business. They receive payment for each youth they
are serving from funds allocated to local DFS offices; thus, their
income is based on the number of residents served. YTC's funding,
on the other hand, is determined by the Legislature two years in
advance and is guaranteed, regardless of the number of youth
served.
Since DFS pays directly for private RTF placements, but considers
placements at YTC to be "free," YTC is an attractive option.
However, the result is also that YTC has no need to actively
recruit residents for the program, and little incentive to maintain
contact with placing officials once a youth is in treatment. One
such official said, "If DFS had to pay for YTC slots, the Center
wouldn't be full. This is due to their marketing process and
administrative procedures."
Recommendation: YTC should improve responsiveness to its broad
range of customers.
YTC needs to recognize it has many customers, including the local
officials who are responsible for youth in treatment. YTC should
take steps to identify its diverse clientele, in ways that enhance
rather than diminish focus on the residents.
YTC should develop rules concerning admission criteria, so
placement officials can have more information about the process.
It should develop a systematic approach for communicating with, and
obtaining feedback from, key groups prior to admission, during
treatment, and at release.
YTC should also track customer satisfaction over time, and report
their efforts as part of the strategic planning process. YTC
should consider developing the following as part of a
customer-focused process:
Surveys. YTC could periodically survey customers regarding their
satisfaction with YTC operations and to identify areas for
improvement.
Follow-up. YTC could routinely poll customers to see
whether service changes actually yield desired results.
Councils or Focus Groups. YTC could create a permanently
established council, or convene focus groups,
representing many levels of customers to work toward
service improvements.
Employee Training. YTC could offer customer service
training to all levels of employees, delineating their
responsibilities to the Center's broad range of
customers.
Complaint Tracking Systems. YTC could develop complaint
tracking systems, one for residents and another for
external customers, to ensure access to an impartial
source for complaint resolution.
YTC can achieve a more customer-oriented focus under the current
funding structure. However, if administrative measures do not
produce this change, DFS may wish to examine other options. It
could consider alternative funding mechanisms which would hold YTC
more accountable for services and outcomes. Some alternative
funding mechanisms include:
Contracting for a specific number of beds. DFS could
contract for a certain number of beds at YTC, and provide
a block grant for those services. YTC would compete with
private providers to fill the remaining slots.
Funding treatment on a per diem basis. DFS could divide
YTC's budget among regional DFS offices. YTC would then
need to compete for admissions with private providers
and, like them, would receive funding on a per diem
basis. This mechanism would eliminate "free" placements
at YTC.
Finding 6 Quality Control Systems Are Lacking at YTC
YTC operates largely without external oversight and internal
quality assurance systems which can promote program quality. YTC
undergoes no external quality control review by the state or by
independent accrediting entities. Also, YTC lacks an internal,
formalized quality assurance system to continually assess and
improve operations.
Without these systems, YTC is isolated from the mainstream of
residential treatment for adolescents. Residents and their
families, the Legislature, and the public have no independent
assurance that treatment provided at YTC is appropriate and safe.
Protections Are Lacking
YTC residents lack the protections afforded by quality control
systems. Institutionalized individuals are commonly recognized as
being at risk in numerous ways. They might receive substandard or
unnecessary treatment, be harmed by inappropriate treatment, be
subjected to abuse or neglect, or not be helped by expensive and
extended placement in an institution.
YTC appears to have a number of informal protections for residents
in place. For example, it has a core of caring, committed staff,
it generally hires licensed therapists, and it provides staff
training.
As important as these protections are, however, YTC should also
have a formal system of quality control in place. Without such
assurance, the state may not be properly discharging its duty to
provide appropriate care. Also, it may be spending money on
unnecessary or inadequate treatment.
Negative Perceptions About YTC's Treatment Program
We asked former residents, parents, judges, MDT members, and staff
about YTC's treatment program. They acknowledged YTC staff for
their dedication to helping young people, and while the program
received both praise and criticism, the criticisms tended to be of
a very serious nature. For example, we heard allegations about
residents abusing substances while on campus, engaging in
inappropriate sexual contacts, and being too heavily medicated.
It was not our task to investigate such remarks in order to
substantiate or disprove them. Instead, we note these negative
perceptions as an area needing DFS attention. If true, the
comments indicate a need for program improvement. If not, they
need to be dispelled with facts, because unchallenged, they will
erode YTC's credibility. As an unregulated, uninspected
residential treatment facility, YTC is very susceptible to
criticism and needs to safeguard its reputation.
The lack of external oversight mechanisms and internal controls has
created an "island atmosphere" at YTC. Because YTC does not
actively solicit feedback, administration and staff at the Center
may not even be aware that such concerns exist.
Sources for External Review
To protect vulnerable individuals in institutional settings,
facilities often adhere to externally developed standards for
services and treatment. Some sources for external quality review
are: independent accrediting entities, insurance reimbursement
programs such as Medicaid, and peer reviews. Although YTC has
requested funds in the past to explore independent accreditation,
the requests were denied. YTC does not currently participate in
these programs and therefore cannot benefit from the rigorous
reviews and requirements for improvement they impose.
W.S. 14-4-101(a)(vi)(O) exempts YTC from state inspection and
licensure requirements for residential treatment facilities. These
requirements include a brief inspection, a review of certain
records, and a check for minimum health and safety standards.
Program oversight is not a part of the process. Private RTFs must
be licensed by the state, but YTC is not required to meet even
these minimal standards.
Internal Review Process is Weak
YTC has not developed its own rigorous program of quality
assurance. YTC uses a loose process based on TQM principles. YTC
administrators identify problems and areas needing improvement, and
then appoint teams to study and make recommendations.
This approach is not as likely to generate the same results as
would a formal, systematic internal assessment process. Without a
thorough and ongoing self-assessment process, YTC cannot assure
that its program provides quality treatment. Furthermore, many
staff members told us they had worked hard on these teams, but were
discouraged by the lack of administrative follow through.
DFS Exercises Insufficient Management Authority
Since reorganization, DFS has offered YTC what might best be
characterized as benign neglect: no structured oversight, and no
plan to fit YTC into an identified role in the state's continuum of
youth services. DFS has allowed YTC to continue operating largely
as it did before reorganization, as an independent institution and
self-contained operating entity.
DFS officials told us they maintain regular contact with YTC, but
provide supervision only on an as-needed basis. As one DFS
official stated, the agency desired to "evolve them into our
organization instead of forcing them...." Numerous DFS employees
told us that YTC has not been enthusiastic about its inclusion in
DFS. They see YTC as a rather unwilling partner.
DFS administration has not ensured a consistent agency-wide
approach to transitioning residents out of YTC. DFS and YTC appear
to have incongruent philosophies regarding placement for residents
who are about to complete the program. YTC focuses almost
exclusively on the child's needs and preferences, and these may not
center around returning home. DFS strongly advocates family
reunification as the primary mechanism for meeting youths' needs.
Many of the DFS workers we interviewed spoke of the difficulty of
reconciling these two points of view when residents leave YTC.
Finally, DFS does not require YTC to report serious incidents
involving residents and staff to the director or a designee. Thus,
serious incidents such as suicide attempts, runaways, and medical
emergencies could go unreported or could be misrepresented to DFS.
If such circumstances were to occur, DFS would not have the
opportunity to exercise its management discretion and intervene,
and residents could be at risk. We believe this is an important
enough aspect of management oversight to merit written rules.
Recommendation: DFS should develop and implement a plan for
providing effective oversight and internal review at YTC.
Prior to reorganization of state government and the repeal of the
Board of Charities and Reform, the five elected officials visited
state institutions annually. BCR's successor organization, DFS,
has not carried on this "inspection" custom, nor has it developed
alternative means of supervising YTC.
Consequently, YTC operates without the state oversight and
independent scrutiny that would help ensure quality of care. At
this time, the Center appears to be respected for its caring staff
and commitment to youth. However, continuing to operate as an
independent, isolated entity could seriously undermine the
program's effectiveness.
To protect the interests of its residents and of the state, YTC
needs to be made a part of a larger framework. As part of the
strategic planning process, DFS could establish a goal of
developing performance measures related to effective oversight for
YTC. All parties stand to benefit from external and internal
quality assurance programs at YTC.
Conclusion
Because the Management Audit Committee requested a focused study
emphasizing YTC, not the larger youth services system, our findings
and recommendations are intended to strengthen the Center's
operations. However, they necessarily will need to be considered
in a broader context.
We identified a number of specific operating problems which DFS
and YTC can address now. At the same time, policy makers also need
to be working toward resolution of a number of related and
over-arching public policy matters. Questions for consideration,
some of which have been noted in prior studies of the youth
services system, include:
What are the state's expectations for court-ordered
placements?
How can YTC best fit into the state's youth services
system?
Should the YTC continue to provide services which are
also available in the private sector?
Which agency should run the state's mental health system?
The state's youth services system, with its various components, has
evolved over a period of many years to meet specific local needs.
However, those needs are changing and new stresses to this system
appear to be driving a demand for change. One significant factor
is sharply rising expenditures for court-ordered placements.
Another is the increasing number of youth entering the system, as
well as the severity of their problems. In 1995, the Legislature
appointed a Select Committee on Court-Ordered Placements to explore
these and other issues.
For several years, the Wyoming Department of Health has been
discussing whether to close the adolescent treatment unit at the
State Hospital. This debate brings to the forefront the question
of how the state will diagnose and treat psychiatrically needy
children and adolescents in a secure setting. As of this writing,
a comprehensive proposal has not emerged, but certainly one
possibility would involve redefining YTC's mission and upgrading
its facilities in order to accommodate this population. Another
would be to explore the benefits and costs of privatizing these
services.
The Legislature faces a fundamental decision regarding YTC: should
it continue to operate according to status quo, be changed, closed,
or is another policy direction desirable?
Regardless of which decision is made, we believe the
recommendations in this report have implications for the entire
youth services system. They speak to the state's obligation to
ensure that youth treatment is delivered in an environment and
manner which promote high quality treatment, safety for residents,
retention of skilled staff, and attainment of desired outcomes.
These are some of the fundamental principles on which the
Legislature and DFS must base any system of managing inpatient
treatment for at-risk youth. Whether that will include a YTC as we
know it today remains for the Legislature to determine.
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