u. S. Department of Justice
Civil Rights Division

Off/a of the Assistant Allorllev General

Washington, D.C. 20530

January 23, 2004

The Honorable Janet Napolitano
Governor of Arizona
1700 West Washington
Phoenix, Arizona 85007
Re:

CRIPA Investigation of Adobe Mountain School and
Black Canyon School in Phoenix, Arizona; and
Catalina Mountain School in Tucson, Arizona

Dear Governor Napolitano:
I am writing to report the findings of the Civil Rights
Division's investigation of conditions at the State of
Arizona's Adobe Mountain School ("Adobe"), Black Canyon School
("Black Canyon"), and Catalina Mountain School ("Catalina").
On June 6, 2002, we notified then-Governor Jane Hull of our
intent to conduct an investigation of Adobe, Black Canyon, and
Catalina (collectively, "the facilities") pursuant to both the
Civil Rights of Institutionalized Persons Act ("CRIPA"), 42
U.S.C. § 1997, and the Violent Crime Control and Law
Enforcement Act of 1994, 42 U.S.C. § 14141 ("Section 14141")
As we noted, both CRIPA and Section 14141 give the Department
of Justice authority to seek a remedy for a pattern or
practice of conduct that violates the constitutional~r
federal statutory rights of children in juvenile justice
institutions.
Between October 1, 2002 and January 13, 2003, we
conducted on-site inspections of the facilities with expert
consultants in juvenile justice, suicide prevention,
education, mental health, and medical care. We visited Adobe
October 1-4, 2002 and January 5-9, 2003.
We visited Black
Canyon School October 22-25, 2002, and January 10-13, 2003.
We visited Catalina Mountain School December 3-6 and December
17-20, 2002.
While at the facilities, we interviewed staff,

-2-

youth residents, medical and mental health care providers,
teachers, and school administrators.
Before, during, and
after our visits, we reviewed an extensive number of
documents, including policies and procedures, incident
reports, medical and mental health records, grievances from
youth residents, Internal Affairs investigations, unit logs,
communication logs, orientation materials, staff training
materials, and school documents. As promised at the onset of
our investigation, we also conducted exit conferences with
facility and central office staff at the conclusion of each
tour, during which time our consultants described their
initial impressions and concerns.
We commend the staff of the facilities and the central
office staff of the Arizona Department of Juvenile Corrections
("ADJC") for their helpful and professional conduct throughout
the course of the investigation.
Staff and administrators
cooperated fully with our investigation.
We also appreciate
the ADJC's receptiveness to our consultants' on-site
recommendations.
Consistent with our statutory obligation under CRIPA, we
now write to advise you of the findings of our investigation,
the facts supporting them, and the minimum remedial steps that
are necessary to address the deficiencies set forth below. As
described more fully below, we conclude that certain serious
deficiencies at these facilities violate the constitutional
and federal statutory rights of the youth residents.
In
particular, we find that children confined at Adobe, Black
Canyon, and Catalina suffer harm or the risk of harm from
constitutional deficiencies in the facilities' suicide
prevention measures, correctional practices, and medical and
mental health care services.
In addition, we find that the
facilities fail to provide required education services
pursuant to the Individuals with Disabilities Education Act
("IDEA"), 20 U.S.C. § 1401 et ~., and Section 504 of the
Rehabilitation Act of 1973 ("Section 504"), 29 U.S.C. § 794.
I.

BACKGROUND

Adobe Mountain School is a 430-bed 1 secure facility for
boys that also serves as the Reception, Assessment and

Adobe has a physical capacity of 544 beds, but ADJC
considers its operational capacity to be limited to 430.

-3-

Classification ("RAC") center for newly-committed boys from
Maricopa County. After completing a 28-day RAC process, boys
are assigned to one of three secure facilities: Adobe, Eagle
Point School in Buckeye, or Catalina in Tucson. Approximately
426 youth between the ages of 13 and 17 were confined at Adobe
at the time of our tours. Adobe has 14 housing units,
including specialized housing units for youth with sexual
behavior offenses, violent offenses, substance abuse offenses,
and a specialized mental health unit, Triumph. 2 Adobe also
has a ten-bed Separation Unit.
Black Canyon School is a 182-bed secure facility for
female juvenile offenders.
It is the only facility for girls
committed to ADJC custody and operates its own RAC unit.
This
institution confined approximately 108 girls between the ages
of 14 and 17 at the time of our tour in October 2002; the
population decreased to around 90 during our tour in January
2003. Black Canyon has seven housing units, including a
special treatment unit for violent offenders, a substance
abuse unit, a mental health treatment unit, Maya, and a parole
violator unit. A ten-bed Separation Unit exists for girls who
require segregation from the rest of the population.
Catalina Mountain School is a 140-bed secure facility for
boys and is the initial intake location for Pima, Santa Cruz,
and Cochise Counties. 3 Approximately 136 youth between the
ages of 13 and 17 were confined at this facility at the time
of our tours.
Catalina has six housing units, including three
general housing units, a violent offenders unit, a sex
offenders unit, and a substance abuse unit.
Catalina Mountain
also has a ten-bed Separation Unit.

2
The Triumph Unit, located on the campus of Adobe, and
the Maya Unit, located on the campus of Black Canyon, together
constitute ADJC's specialized mental health program called
Encanto.
This program has its own superintendent and staff.
It shares education, food, medical, and security services with
Adobe and Black Canyon.

Catalina has a physical capacity of 150 beds, but ADJC
considers its operational capacity to be limited to 140.

-4-

II.

FINDINGS
A.

SUICIDE PREVENTION

Between April 2002 and March 2003, three youth at Adobe
committed suicide, all three by hanging, and two in the same
housing unit.
On April 11, 2002, a youth was found dead in the Freedom
Cottage at Adobe with a sheet tied around his neck.
On July 11, 2002, a youth committed suicide by hanging
himself with a sheet in the Enterprise Unit at Adobe.
On March 23, 2003, a youth strangled himself to death
with his own belt in the Freedom Cottage at Adobe.
This number of suicides in a 12-month period is extremely high
for any juvenile justice facility.
Indeed, according to a
recent survey of 3,800 juvenile facilities throughout the
United States covering the five-year period from 1995-1999,
only two other facilities (.0005%) have had three or more
completed suicides during a 12-month period.
Our
investigation revealed that the Adobe suicides are emblematic
of the inadequate suicide prevention measures and practices
throughout the facilities.
As a general matter, States must provide confined
adjudicated juveniles with reasonably safe conditions of
confinement.
See Youngberg v. Romeo, 457 U.S. 307, 315-24
(1982) i Bell v. Wolfish, 441 U.S. 520, 535-36 & n.16 (1979) i
Gary H. v. Hegstrom, 831 F.2d 1430, 1432 (9th Cir. 1987).
Such constitutionally mandated conditions include the right to
adequate medical care, a concept that embraces both mental
health treatment and suicide prevention measures.
See Hott v.
Hennepin County, 260 F.3d 901, 905 (8th Cir. 2001) i Hare v.
City of Corinth, 74 F.3d 633, 644-45 (5th Cir. 1996) (en
banc) i Young v. City of Augusta, 59 F.3d 1160, 1169 (11th Cir.
1995) i Horn v. Madison County Fiscal Court, 22 F.3d 653, 660
(6th Cir. 1994) i Gordon v. Kidd, 971 F.2d 1087, 1094 (4th Cir.
1992) i Hoptowit v. Ray, 682 F.2d 1237, 1253 (9th Cir. 1982).
The State has clearly fallen well short of this constitutional
obligation.
As described in detail below, the suicide prevention
procedures employed at all three facilities we examined were

-5-

grossly inconsistent with generally accepted professional
standards. 4 Although the facilities adequately screen youth
to identify those at risk for suicide, the youth who are
identified are inadequately monitored by mental health staff,
inadequately supervised by direct care staff who also lack the
training and tools necessary to intervene in the event of an
attempted suicide, and are not safely housed. 5
1.

Inadequate Monitoring by Mental Health Staff

Generally accepted professional standards require that
youth who are identified as potentially suicidal and who have
been placed on suicide precaution, be monitored by mental
health professionals. Appropriate monitoring is necessary to
provide consistent and adequate services. Our investigation
revealed that appropriate monitoring of youth on suicide
precaution does not occur in any of the three facilities.
We found that youth who were initially identified as at
risk for suicide were not placed on suicide precaution or seen
in a timely manner by mental health staff.
For example, a
youth with a history of depression and self-harm, who made
threats of suicide on July 13 and 17, 2002, was not placed on
suicide precaution or monitored by mental health staff.
On
August 1, 2002, this youth was found wrapping a belt around
his neck. Moreover, we found that even when mental health
professionals do monitor youth, in many cases they fail to
document their clinical assessments.
This deficiency in the

4
In assessing whether the constitutional rights of the
confined juveniles have been violated, the governing standard
is the Due Process Clause of the Fourteenth Amendment.
See
Gary H., 831 F.2d at 1431-32. Accordingly, the proper inquiry
focuses on whether the conditions substantially depart from
generally accepted professional judgment, practices, or
standards.
See Youngberg, 457 U.S. at 323.
5
In July 2003, the State provided us with a summary of
recent measures reportedly taken to address some of our
concerns relating to suicide prevention. Although a number of
these reforms have yet to be implemented or are only in the
embryonic stage, we do acknowledge the State's efforts.
It is
our hope, as it is surely the State's, that these measures
will allow the State to make significant strides in correcting
its institutional deficiencies.

-6-

monitoring process places potentially suicidal youth at risk
by denying them necessary mental health services.
Communication about the mental health status of
potentially suicidal youth is a necessary aspect of monitoring
suicidal youth. ADJC staff fail to communicate effectively
among themselves regarding the management needs of suicidal
youth.
Communication deficiencies are particularly acute at
Adobe. Adobe fails to maintain a daily listing of youth on
close observation status.
Incident reports describing the
events which resulted in placing a youth on suicide precaution
are not consistently completed.
The psychiatrist at Adobe
only sporadically attends the weekly treatment meetings during
which each youth's status is discussed, and, at the time of
our tours, had been absent from these meetings for the
previous five months. Adobe mental health staff, who also
service youth at Encanto (the specialized mental health unit) ,
do not interact routinely with the Encanto direct care staff.
While communication practices are somewhat better at
Black Canyon and Catalina than at Adobe, overall, the
facilities all practice inadequate information management of
suicidal youth.
For instance, all three facilities fail to
integrate the medical and mental health files of youth.
We
were informed that mental health staff are not permitted
access to the medical files, which is where the psychiatrist's
notes are placed. As a result, mental health personnel lack
access to information necessary to understand fully a youth's
mental health status.
Further, mental health staff at the
facilities informed us that they sometimes fail to keep any
clinical notes regarding their interaction and assessment of
suicidal youth.
Mental health staff also stated that where
clinical notes are maintained on youth, these notes are not
retained in either the youths' medical files or a central
mental health file, but in the staff person's personal files.
In addition, psychology associates (masters level mental
health professionals), who attend to suicidal youth, do not
receive any clinical supervision, an important aspect of
effective communication. These communication voids deny
suicidal youth appropriate treatment.
The communication failures within ADJC are exemplified by
the July 11, 2002 suicide of a youth at Adobe.
On June 25,
2002, this youth was placed on close observation status based
upon his high suicide ideation rating.
We found no indication
of any formal mental health assessment or in-person physical

-7-

assessment by a psychiatrist of this youth.
While his mental
health records were reviewed by a psychiatrist on June 26
there was no indication that the youth/s close observation
status was communicated to the psychiatrist.
The youth was
not seen by mental health staff until July 3 when he was seen
by a psychology intern.
1

1

Between July 3 and 11 ADJC/s Community Family Services
Division conducted an in-home evaluation and discovered that
this youth had previously threatened and/or attempted suicide.
In addition his court file which accompanied him to Adobe
contained information regarding his attempted suicide while he
was in detention.
This information which could have assisted
in the addressing this youth/s mental health needs was not
timely communicated tO I or reviewed bYI staff. On July 11
this youth committed suicide.
1

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2.

Inadequate Supervision by Direct Care Staff

In addition to appropriate monitoring by mental health
professionals potentially suicidal youth require appropriate
supervision by direct care staff who are the only staff in
the facilities on duty 24 hours a daYI to ensure their safety.
We found that supervision of suicidal youth by direct care
staff throughout the facilities was inadequate.
For example
during our on-site tour a youth at Black Canyon attempted to
choke herself with her clothing. At the time of this
incident the youth was on suicide precautions that required
direct care staff to check on her every 15 minutes but the
required checks had not been made for two hours.
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Direct care staff at all three facilities especially
those on night dutYI admitted to difficulty in consistently
supervising youth on suicide precaution because of staff
shortages.
In some cases we found that reports documenting
suicide precaution observations by staff were filled out even
though staff admitted that the observations were not actually
being performed.
On the Enterprise Unit at Adobe we found
suicide precaution reports that had not been completed for
several hours for eight youth who were placed on suicide
precaution.
In other instances we observed suicide
precaution reports filled in at precise 15-minute intervals
for extended periods of time.
This level of precision seemed
highly improbable given the other responsibilities of direct
care staff and chronic staff shortages.
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-8-

Further, we found that youth who are placed in exclusion
(confined to their rooms for periods of time) for disciplinary
purposes, were not supervised appropriately. While ADJC
policy requires staff to interact with youth in exclusion
every 15 minutes, direct care staff readily admitted that
these checks were not regularly performed.
This failure is
significant because of the strong correlation between
involuntary locked room confinement and suicidal behavior. 6
Indeed, two of the suicides that occurred at Adobe in 2002
involved cases in which the youth had been involuntarily
confined to their rooms prior to their suicides.
Appropriate supervision by direct care staff also
includes the referral of potentially suicidal youth to mental
health professionals. Our investigation revealed instances
where direct care staff failed to refer potentially suicidal
youth to mental health professionals.
For example, on
September 28, 2002, upon hearing of his father's attempted
suicide, a youth at Adobe informed direct care staff that he
would kill himself.
Later that day, the youth acted upon the
threat by wrapping earphone wires around his neck.
Rather
than refer the youth to mental health professionals, direct
care staff instructed two other youth to watch the boy to make
sure he did not harm himself. No follow-up action or mental
health assessment was undertaken until the youth was
transferred to another facility two weeks later.
In another
instance, a youth who self-mutilated on July 28, 2002 was
placed on 15-minute watch by direct care staff, but was not
referred to mental health staff for assessment.
Adequate supervision also contemplates that direct care
staff will follow the orders of mental health professionals.
Our investigation revealed several instances in which direct
care staff, who have no specialized mental health training,
downgraded the level of suicide precaution that youth were

6
It is well-established in the field of corrections that
there is a strong correlation between inmate suicide and
isolation.
See Lindsay Hayes, National Study of Jail
Suicides; Seven Years Later, 60 Psychiatric Quarterly, NO.2,
7-29 (1989). According to a forthcoming report for the U.S.
Department of Justice, Office of Juvenile Justice and
Delinquency Prevention, over 50 percent of juvenile suicides
occur while youth are in involuntary room confinement status.

-9-

placed on without the authority of mental health
professionals.
3.

Inadequate Training and Intervention Tools for
Direct Care Staff

Staff training in suicide prevention measures similarly
departs substantially from the generally accepted professional
standards in this area.
Experts all agree that staff who
interact with potentially suicidal youth must be trained to
detect, assess, and, if necessary, intervene to prevent a
suicide.
Yet our review of training records for 2002 (a year
in which there were two suicides at Adobe) revealed that 61.8%
of Adobe staff had received no suicide prevention training.
At Catalina, 56.3% of medical and mental health staff at
Catalina had not received the annual refresher training and
40% of non-medical staff had not received cardiopulmonary
resuscitation ("CPR") refresher training.
The failure to have emergency equipment readily available
to staff trained to use it can make the difference between
life and death.
We found that emergency intervention measures
throughout the facilities were wholly inadequate. At Adobe,
first aid kits, microshields for CPR, and rescue tools (e.g.,
blades to cut ligature from a hanging victim's neck) were not
available. During our January 2003 tour of Adobe, we found
oxygen tanks, which are often vital to resuscitating a hanging
victim, were stored haphazardly without indication of which
ones were full and which ones were empty.
Nursing staff did
not even know how to operate these tanks, and the facility had
no regular system in place to monitor the readiness of this
emergency equipment.
These deficiencies were demonstrated
during the July 25, 2002 suicide by hanging at Adobe. When
the youth was discovered hanging, staff reportedly did not
have the appropriate rescue tool to cut the noose and had
difficulty removing it from the boy's neck. Medical staff
were reportedly delayed in responding without explanation.
When they did arrive, the oxygen tank they brought with them
to help resuscitate the youth was reportedly empty.
Another example of staff unpreparedness to respond to an
emergency occurred on October 23, 2002 at Black Canyon. DOJ
investigators and our suicide prevention consultant were
coincidentally visiting a housing unit when a youth attempted
to choke herself with her clothing. After the initial alarm
was raised, security staff responded promptly.
However, when

-10the nurse responded, she was not directed to the victim by
staff.
Indeed, staff generally appeared uncertain as to what
actions to take, and our suicide prevention consultant had to
alert the nurse to the location of the victim.
4.

Unsafe Housing of Suicidal Youth

Generally accepted professional standards further require
that potentially suicidal youth be housed in living quarters
that are suicide resistant.
Suicidal youth are housed in two
places in the facilities -- the Separation Units and the
living units. While Separation cells were largely free of
potential suicide hazards, we found physical features
throughout the remainder of the facilities' housing units that
pose substantial risks to suicidal youth.
For example, the
Alpha, Challenge, Crossroads, Enterprise, January, Nova,
Phoenix, and Separation Units at Adobe have ventilation
grilles and ceiling vents that are potentially dangerous
because sheets or other objects could be anchored to them.
Nova and January also have exposed bolts attached to the desk
that present a similar risk.
The Estrella{ Genesis{ Hope{
Oasis{ and Encanto units all have horizontal bars on the room
windows that provide sufficient space between the bars and the
glass to allow for the anchoring of a sheet or other material.
Indeed{ this was the anchoring device utilized by the youth
who committed suicide in April 2002.
At Black Canyon, four of the seven functioning housing
units have dangerous suicide risk physical plant issues
similar to those at Adobe. For instance, the Recovery and
Success units have room doors containing grilles with large
gauge openings, and the Maya and Pride units have rooms with
both wall and ceiling ventilation grilles with large openings.
Large gauge openings pose risks for tying off hanging devices.
At Catalina{ five of the seven functioning housing units
have rooms with dangerous anchoring points.
The Chiricahua{
Crossroads{ and Recovery units have rooms with ceiling
ventilation grilles with large gauge openings { as well as
holes in the bunk bed platforms that could be utilized as
anchoring devices. All five housing units have rooms with
window grilles with large gauge openings in the doors.

-11B.

JUVENILE JUSTICE

Youth are denied constitutional protections because the
facilities fail to:
(i) protect youth from sexual and
physical abusei (ii) provide adequate due process protections
before isolating youthi and (iii) maintain safe and sanitary
living conditions.
1.

Sexual Abuse at Adobe

Our investigation revealed that sexuql abuse of youth by
staff and other juveniles occurs with incredibly disturbing
frequency at Adobe r and that ADJC management does not
effectively address this serious problem.?
Several examples are illustrative.
In December 2002 r a
female staff member admitted to internal investigators that
she had engaged in sexual acts with a youth r including oral
copulation r sexual touching r and sex talk over a period of
months.
It appears that facility management failed to detect
these alleged acts r which occurred over an extended period of
time.
In April 2001 r an internal investigation revealed that
another female staff member wrote at least 12 sexually
explicit letters to a youth.
In February 2002, a male staff member was accused
repeatedly of inappropriate sexual contact with youth,
including touching boys on their buttocks.
Reportedly, 13
boys and five staff members voiced complaints about this
behavior and three youth filed formal grievances within a one
month period.
In response to one of the grievances, a unit
supervisor responded that he had spoken to this staff person
three times and that ~it is his lifestyle and personality to
be physically affectionate." Youth Grievance dated 2/21/02.
In response to a written request for an investigation by the
youth rights advocate, Adobers Assistant Superintendent stated
that the matter had been taken care of and that "usually when
something like this is found out it goes to the

7
It is difficult to assess the full extent of the sexual
abuse occurring at Adobe, in part because of the dysfunctional
grievance system and ineffective abuse investigation processes
described below.

-12manager .
u8
Despite the seriousness of these
complaints/ the allegations were never investigated by a
neutral party.
Rather/ the staff member was simply counseled.
At the time of our tour/ this staff member continued to work
directly with youth.
We notified management of this matter.
In addition to sexual abuse committed by staff/ our
investigation revealed many examples of youth-on-youth sexual
violence.
Documentation revealed that sexual intimidation is
occurring in the facilities.
In numerous interviews during
our tours/ youth revealed their fears and concerns about being
sexually intimidated by other youth.
An incident report from October 2002 reveals that a youth
informed a staff member that youth were threatening him to
perform sexual acts or risk being beaten up or raped.
In
another case/ an Internal Affairs investigation includes
strong evidence that three Adobe youth attempted to place a
pepper shaker in the anus of another youth. Another
investigation disclosed that a youth engaged in sex with other
youth in exchange for their friendship or for such items as
soap.
Incident reports also indicate a prevalence of sexual
activity among the girls at Black Canyon/ including the
characterization of some youth as "sexual predators. u
These
reports highlighted the fact that much of the sexual activity
consisted of inappropriate actions between "girlfriends u due
to competition among the girls for affection. We found no
evidence of any action taken by the facilities to address
these reports.
2.

Physical Abuse

Equally disturbing to us/ our investigation revealed that
some Adobe staff physically abuse youth/ and that other Adobe
staff purposefully do not intervene to protect juveniles from
attacks by fellow youth.
These practices not only harm youth
but make efforts to rehabilitate them extraordinarily
difficult.
They also are obviously unconstitutional.
See
Redman v. County of San Diego/ 942 F.2d 1435/ 1441 n.7 (9th
Cir. 1991) (en banc) i White v. Roper/ 901 F.2d 1501/ 1503 (9th
Cir. 1990).

8
This deficient practice of referring serious complaints
from a unit back to the same unit for resolution is discussed
in detail below.

-13-

Interviews conducted with both staff and youth during our
tour of Adobe revealed that a sizable number of unit and
security staff physically abuse youth by hitting them or
slamming them to the ground in an overly-aggressive fashion.
We also found that some staff exposed youth to entirely
unnecessary risks of physical injury.
For example, in
September 2002, Mr. V., a staff person from the RAe unit,
required youth under his supervision to crawl on their
stomachs through a drainage ditch in order to receive their
"responsibility time" (free time) later that day.
Two youth
received minor injuries in the activity.9 On the very day we
toured Adobe, we even observed a staff member slap an Encanto
youth hard on the side of his head because he was moving "too
slowly" back to the housing unit after dinner.
Our investigation also revealed numerous allegations of
physical abuse that were never investigated and, in fact,
remain unresolved to this day. One youth at Adobe reported
that staff literally assaulted him for failing to return a
pencil that was given to him by another staff member. Another
Adobe youth reported that a correctional officer put his knee
on the youth's head while the youth, who was offering no
resistance whatsoever, was lying down on the bed of the small
pick-up truck used to transport individuals to disciplinary
confinement. We found no evidence that these allegations of
abuse had been investigated.
Our review also revealed staff complicity in a number of
fights between youth.
Youth at Adobe reported that, at times,
staff allowed youth to fight with each other and, incredibly,
permitted and even encouraged youth to enforce physical
discipline on other youth. A report dated August 20, 2002
stated that during a group session with the entire cottage
present, a staff member allowed two youth to beat another
youth.
In another instance, a youth reported that he was
"brutally assaulted" in September 2002 by two youth who were
permitted by staff to run into his room.
This grievance was
never resolved.
In a further incident, a youth received a
serious eye injury that an Internal Affairs investigation
determined was the result of a staff member "setting-up" and
allowing a youth-on-youth fight.
It was further determined

9

Mr. V. was demoted.

Mr. V's initial has been

fictionalized here; his identity will be provided by separate
cover.

-14-

that the involved staff member was setting up other fights
between youths, allowing them to occur and watching them.
3.

Dangerous Lack of Supervision

Sexual and physical assaults are more likely to occur
because the facilities lack sufficient staff to supervise
youth adequately, thus exposing youth to danger. ADJC Policy
4002.05 calls for a minimum of three staff for up to 48
juveniles during the day and one staff at night.
Our review
indicates that none of the three facilities meet the ADJC's
own staff-to-youth target ratios. Moreover, the prescribed
ratios deviate substantially from generally accepted
professional practices. Many states require one staff per
eight youth during waking hours, and one staff per 16 youth at
night.
Indeed, at Adobe, we observed one staff person
supervising an entire cottage of 20-28 youth in the afternoon
and another single staff person supervising 48 youth during
the overnight shift.
Documentation that room checks were
being done regularly during the night could not be provided.
At Catalina, the staffing deficiency is similarly acute.
There, we observed during the overnight shift that there was
only one staff person to supervise both the ten-bed Separation
Unit and the 22-bed Agave Unit, which share a common building.
Youth who are at acute risk for suicidal behavior and those
segregated from the general population for disciplinary
reasons are housed in Separation; older youth with more
serious behavioral problems are housed in Agave.
The one
staff person on duty at the time of our tour literally had to
dart between these two units to attend to youth in both units
and readily admitted that it was not possible for him to
supervise the youth adequately.
The absence of adequate supervision is clearly resulting
in harm to the youth.
For example, an April 2002 Internal
Affairs investigation found that a youth received a serious
eye injury when he was assaulted by another youth.
The only
staff member on duty at the time was on a bathroom break when
the fight occurred.
The lack of supervision is particularly
dangerous on the overnight shift.
Youth are double-bunked and
fights, assaults, and other "acting out" occur in the absence
of appropriate supervision. Adobe staff reported that fights
are commonplace in the youth rooms at night and often go
unreported. A lack of supervision also allows youth to
victimize other youth.
Staff in the Triumph cottage at Adobe

-15related that sexual "acting out" was "rampant"
there.
One youth complained of being sexually
by his roommate. A review of Internal Affairs
of youth-on-youth sexual assaults demonstrated
victimizations occur regularly.
4.

among youth
propositioned
investigations
that these

Inadequate Grievance and Abuse Investigation
Systems.

Both the grievance system and abuse investigation process
at all three facilities are extremely dysfunctional.
These
deficiencies incubate the dangerous institutional environment
described above, where incidents of sexual and physical abuse
are not appropriately reported or investigated, and where
youth are not protected adequately from harm.
a.

Inadequate Grievance Systems

The Constitution mandates that incarcerated individuals
have readily available access to the institution's grievance
process.
See Bradley v. Hall, 64 F.3d 1276, 1279 (9th Cir.
1995). Based on our interviews with youth and staff in all
three facilities, it is apparent that the grievance system
does not operate fairly.
Youth and some staff reported that
youth are frequently prevented from speaking with "youth
rights" staff, and that, in some cases, at the discretion of
staff, written grievances are not accepted. When youth are
permitted to submit written grievances, youth rights staff
simply collect the grievances, assign a tracking number, and
return the completed forms to the cottage supervisor for
handling.
The obvious problem with this approach is that many
grievances include allegations of abuse against the very
cottage staff for whom the supervisors are responsible. Not
surprisingly, youth widely reported that this process made
them reluctant to file a grievance out of fear of retribution.
Furthermore, throughout the facilities, grievances are
not responded to in a timely fashion.
At Catalina, a review
of 150 grievances filed between September and November 2002
revealed that nearly one third had not been addressed. Among
these were the denial of access to an asthma inhaler and
allegations of inappropriate racial comments made by a staff
person.
Similarly, grievances at Adobe and Black Canyon were
not addressed in a timely fashion.
Youth throughout the
facilities reported that the grievance system was "a joke" and
that they rarely received responses to any grievances they

-16-

filed.
Youth rights staff also expressed frustration with the
process for grievance resolution and the lack of response from
other ADJC personnel.
b.

Inadequate Abuse Investigations

Youth who witness or experience potential abuse at one of
the facilities may file a grievance. 1o At the same time! staff
who witness potential abuse are required to report the matter
to the facility superintendent. There are several problems -both systemic and practical -- with this abuse investigation
system.
As an initial matter! two administrative screening
processes must be utilized before an objective investigation
even begins. Once a grievance is submitted! the
superintendent makes a case-by-case determination as to
whether the allegation will be investigated by his/her own
facility staff or referred to the Deputy Director of the
agency for investigation.
If the matter is referred to the
Deputy Director! a second inquiry is conducted to determine
whether an Internal Affairs investigator will be assigned to
investigate the matter. Unfortunately! there are no written
criteria to determine which allegations of abuse are to be
investigated by Internal Affairs or by institution staff.
Determinations are made on a case-by-case basis! a wholly
subjective! time consuming! and cumbersome process.
In addition! it appears that incidents that should be
referred for investigation by Internal Affairs are not being
referred.
For instance! in June 2002! a new staff member
completing on-the-job training at Black Canyon reportedly
"threw" a girl to the ground! slapping her several times! and
choking her.
This incident was reportedly witnessed by
numerous youth who provided consistent accounts of the events!
and the incident was reported to facility administrators by
the youth rights advocate. Nonetheless! we could locate no
documentation to indicate that an independent investigation of
this matter had been conducted by Internal Affairs.

10
Very few abuse investigations are generated by youth
grievances apparently because youth lack faith in the
grievance system and fail to utilize it.

-17-

Investigations that are undertaken are generally very
untimely, often occurring weeks or even months after an
alleged incident.
This is problematic because it allows for
the possibility of further harm to youth by an abusive staff
member while waiting for a formal finding.
In a case
involving allegations of sexual misconduct that allegedly
occurred during the months of November and December 2001, and
were reported in January 2002, the investigation was not
completed until March 2002. Despite the seriousness of the
allegations, there was no indication whether the involved
staff member was relieved of direct contact with youth during
the time it took to complete the investigation.
There is also no system in place allowing youth a direct
method by which to report abuse other than by filing a
grievance. Under the present system, youth grievances are
collected by the youth rights staff and returned to the
housing unit supervisor for resolution.
This practice
necessarily involves a staff person with supervisory
responsibility for the housing unit in the resolution of a
grievance.
Objectivity in this situation is highly
questionable, particularly where the allegations may include
physical or sexual abuse.
For example, from September 6, 2002
to October 26, 2002, 15 youth grievances alleging abusive use
of force in Encanto were made.
One particular staff member
was repeatedly identified by youth for allegedly aggressive
take downs and verbal threats.
The Director of Encanto,
however, only responded to two of the grievances and both
responses noted that the Director would seek resolution by
bringing the involved youth and the staff member together.
The other grievances had no resolution or outcome noted.
5.

Inappropriate Use of Disciplinary Confinement

The facilities employ three different disciplinary
measures that result in the disciplinary confinement of youth.
First, youth can be confined to their rooms, either
individually or with roommates, in a practice known as
"exclusion." Second, entire housing unit populations can be
locked in their rooms in a practice known as "large group."
Third, youth can be placed in Separation Units, which are
single-celled housing units where youth are placed in
isolation in individual, locked rooms.

-18While the facilities provide adequate due process
protections as they relate to the initial placement in
Separation Units, youth are kept in isolation for extended and
inappropriate periods of time that fly in the face of
generally accepted professional standards.
For example, over
the explicit objections of mental health staff, one Catalina
youth was confined in a Separation Unit for 33 days.
Four
other youth were confined in a Separation Unit for more than
18 days, again over the objections of the mental health staff.
Another disturbing practice is the decision to lock
entire unit populations in their rooms because of the
misbehavior of two or three youth.
This practice is known as
"large group." Clinical staff can authorize "large group"
lock downs, which consist of locking every youth in a
particular cottage in his room for several days or weeks with
very limited time outside their room or cottage. We do not
suggest that these lock downs are facially unconstitutional or
unwarranted in all circumstances.
But the State's
institutions appear to ignore completely the adverse
psychological side effects of prolonged isolation and, more
importantly, seem to have adopted no standards governing when
such lock downs may be validly employed.
Our review of Adobe documentation revealed that staff
have almost unfettered discretion to impose lock down. A
review of lock down practices in the Freedom Unit at Adobe
revealed numerous lock downs of the entire unit, during which
time youth acted out in their rooms, engaging in sexual
behavior and fights.
In another unit, youth rights staff
reported that youth were locked down for more than 14
consecutive days.
Despite objections raised by the youth
rights staff, lock down continued in this unit, during which
time youth were limited to only ten minutes of exercise per
day and were not permitted to attend school, eat in the dining
hall, or attend religious services. Notably, one of the
suicides discussed earlier involved a youth whose unit had
been locked down for over 30 days in a "large group" status.
In addition to the abusive practices noted above, we
found other troubling examples of disciplinary confinement.
For instance, at Adobe in March 2002, a youth was placed for
several days straight on "Security Status" in locked room
isolation.
Log notes indicate that the youth was permitted to
talk only with certain designated staff and, even then, only
for five minutes in the morning and five minutes in the

-19evening, at which points he could "request toilet paper." The
log also denotes that the youth's day was to be spent in
silence, yet offers no explanation or justification for such
treatment.
This condition of confinement raises serious
constitutional questions in that it potentially precluded this
youth from alerting staff about, and securing necessary
treatment for, serious medical issues.
See LeMaire v. Mass,
12 F.3d 1444, 1458-59 (9th Cir. 1993).
Although disciplinary practices were not as extreme at
Black Canyon, we observed some inappropriate isolation
practices there as well.
For example, a girl who spoke
Spanish and very limited English and who was very upset about
the recent death of her mother was confined in the Separation
Unit for three consecutive days.
There was no documented
justification for her isolation and, when we asked facility
staff about this incident, no explanation whatsoever was
offered. Unfortunately, this incident was not unique.
Large
group lock downs lasting as long as ten days were reported in
the Maya Unit at Black Canyon, and some girls reported that
during these times they received virtually no opportunity to
shower.
6.

Unsanitary Living Conditions

At Adobe and Catalina, most of the rooms for boys lack
toilets. Moreover, due to staff shortages at night, youth
often are not allowed out of their rooms to use the restroom
unless additional security staff are present. As a
consequence, youth frequently have no access to bathroom
facilities and must relieve themselves in their rooms.
Shockingly, youth reported urinating and defecating in laundry
bins and plastic bottles. During one evening tour at Adobe,
we observed youth emptying their laundry bins in the toilets
and rinsing them out; other youth were observed darting from
their rooms to the bathroom to relieve themselves when
security arrived and their doors were unlocked.
Grievances and interviews with youth revealed numerous
complaints about a lack of access to toilet facilities at
night.
One youth was told by staff to "hold it" for two and
one-half hours; reportedly, he ultimately relieved himself in
a plastic bottle in his room. Another youth indicated that
one night when he requested to go to the bathroom, it took
nearly an hour and a half before someone arrived.
In another
instance, a youth stated that the night staff member would not

-20call security for a bathroom break, so the youth was forced to
defecate in a plastic bin in his room.
Staff at Catalina
reported that the odor that results from these unsanitary
practices is particularly pungent in the summer months. 11
7.

Inadequate Security at Catalina

Juveniles confined at ADJC facilities are entitled to
reasonable safety.
Security practices at Adobe and Black
Canyon were acceptable and comport with generally accepted
professional practices.
Security practices at Catalina,
however, were significantly deficient.
During our tours, we
observed that there was virtually no screening of visitors.
There was no operating metal detector and visitors were not
required to sign a log or subjected to any type of search.
Our investigation also revealed a fair amount of contraband at
Catalina.
Key control was incredibly lax.
Indeed, during our
tours, we were provided with two sets of master keys that
opened almost all facility doors. At the conclusion of our
tour, we were asked to return four sets of keys even though we
only had two sets to return.
This discrepancy was apparently
not reconciled.
The failure to screen visitors for contraband
and to control the possession of keys places youth at an
unreasonable risk of harm.
C.

EDUCATION

Turning to the education provided to the confined youth,
the facilities are in clear violation of the statutory rights
of residents with disabilities by failing to provide these
juveniles adequate special education instruction and
resources.
1.

Inadequate Special Education Services

In states that accept federal funds for the education of
children with disabilities, as does Arizona, the requirements
of the IDEA apply to juvenile correctional facilities.
See 20 U.S.C. § 1412 (a) (1) (A) i 34 C.F.R. § 300.2 (b) (1) (iv).
The deficiencies in special education services we observed at

Youth at Catalina have recently been issued plastic
urinals like those utilized in hospital settings.
11

-21three Arizona facilities result from inadequate screening and
identification of students for special education services,
inadequately developed Individualized Education Plans
("IEPs"), inadequate special education staffing, a lack of
related services 12 for special education students, and the lack
of Section 504 plans for students with disabilities.
a.

Inadequate Screening and Identification

The IDEA requires that all children with disabilities who
are in need of special education and related services be
identified, evaluated, and served.
The IDEA requires that
schools conduct a full and complete an assessment of students
suspected of having disabilities and that the assessment be
done by an appropriate evaluation team that includes
specialists in the areas of the students' suspected
disabilities.
Proper screening should include systematic
observation of students, interviews, and an assessment of
entering students to determine either a prior history of
special education or the necessity of a referral for special
education eligibility.
Youth who enter the facilities we examined are not
sufficiently screened for identification of special education
needs.
The primary test that is administered to all incoming
students is the Test of Adult Basic Education ("TABE").
This
test is intended for use with an adult population and is an
inadequate tool for assessing the educational needs of youth. 13
Moreover, the TABE can only determine the grade level at which
someone is functioning; it cannot assess individual skill
deficiencies.
Thus, it is an inappropriate and inadequate
12
Related services are defined in the IDEA to include
supportive services as are required to assist a child with a
disability to benefit from special education.
Examples of
related services include psychological services; physical
therapy and occupational therapy; recreation, including
therapeutic recreation; counseling services, including
rehabilitation counseling; and social work services in
schools.
20 U.S.C. § 1401(17).

13
The youngest age for which the TABE is normed is 17,
and the average age of youth committed to ADJC is 15 and a
half.

-22assessment tool for meeting the requirements of the IDEA. At
the time of our tour, program administrators were developing a
different process to screen and identify students eligible for
special education services.
The development of this new
process, however, was hampered by a lack of adequate personnel
and delays in receiving school records.
At the time of our visits, 19% of students at Adobe were
identified as eligible for special education services, 27% at
Black Canyon, and 37% at Catalina.
Program administrators
consistently estimated the true prevalence of students
eligible for special education services in ADJC to be between
35-40%.
Key education staff acknowledged that Adobe had
under-identified the number of youth in need of special
education services.
b.

Inadequate Individualized Education Plans

The IDEA requires that each youth classified as eligible
for special education services have an Individual Education
Plan (IEP) that:
(i) states the student's present level of
performance; (ii) specifies short term instructional
objectives that are measurable and within the individual
student's capabilities; (iii) sets objective criteria and a
timetable for measuring achievement; (iv) outlines the special
education and related services to be provided; (v) describes
the extent to which the student will be able to participate in
the general education program; and (vi) sets forth projected
dates for the initiation and duration of services.
The
facilities fail to develop adequate IEPs for each youth
determined to be eligible for special education services.
Facility IEPs were not individually tailored to address the
special education needs of youth.
Rather, the IEPs had
generic and broadly stated goals and objectives, making
progress on these goals difficult if not impossible to assess.
Nor were related services described in the IEPs. 14
The IDEA also establishes safeguards to protect the
rights of children with disabilities, including parental
participation and consent in the IEP process.
For the special
education student whose parent cannot be located, a surrogate
may be appointed to advocate for the child. At ADJC, rather

14
As discussed below, our review found no evidence that
any youth actually received related services.

-23-

than appoint a surrogate when a youth's parents cannot or will
not participate in the IEP process, the facilities simply have
adults who have never even met the youth sign the IEP.
c.

Inadequate Special Education Staff

To the extent that general education teachers do try to
address the goals and objectives of IEPs, they are hampered by
a shortage of qualified special education staff, particularly
at Adobe. At the time of our tour, Adobe had a total student
population of 426.
Eighty students had been identified as
needing special education services. These 80 students were
served by just three special education teachers, each of whom
carries a caseload from 16 to 36 students.
To achieve the 1:8
teacher to student ratio that is required by ADJC policy, and
commonly viewed as adequate, seven additional teachers would
be required. Although most special education students are
served in general education classrooms, a number of classroom
teachers we interviewed informed us that they receive no
consultation from special education teachers for their
students on consultative IEPs.
The high demands placed on the
limited number of special education teachers make it difficult
for them to provide meaningful consultation to general
education teachers. As discussed in further detail below, the
lack of substitute teachers when regular classroom teachers
are absent also compounds the difficulty in providing adequate
instruction to special education students.
d.

Lack of Related Services

The facilities fail to provide necessary related services
to help special education students benefit from their
educational experiences.
Few of the IEPs that we reviewed
indicated any related services, although the need for such
services was readily apparent. At Catalina, two youth with
IEPs had recently attempted suicide, but neither was receiving
any special therapy. Another teenage youth at Catalina, who
had reading and math skills at the third grade level, a
history of both antagonizing other youth and being disruptive
and defiant to his teachers, and who had spent considerable
time in school detention, was also receiving no related
services. When queried, special education teachers indicated

-24that Limit and Lead 15 is the only "related service" that
students with disabilities receive.
While Limit and Lead may
provide some structure to ADJC's rehabilitative program, it
does not qualify as a related service. Moreover, given that
this program is geared to the seventh grade reading level, its
benefit to students eligible for special education services is
suspect.
Further, our investigation revealed that 14 youth at
Catalina required speech therapy, a related service commonly
provided to special education students, but there was no
indication that any were receiving such services.
e.

Lack of 504 Plans

Section 504 of the Rehabilitation Act of 1973 prohibits
discrimination against persons with a disability by any agency
receiving federal funds.
The protections of this law, which
apply to state prisons, see Pennsylvania Dep't of Corrections
v. Yeskey, 524 U.S. 206 (1998) (holding that the terms of
Title II of the Americans with Disabilities Act, the relevant
provisions of which are identical to Section 504, are
applicable to the states), are extended to any person who
(1) has a physical or mental impairment that substantially
limits one or more of such person's major life activities,
(2) has a record of such impairment, or (3) is regarded as
having such impairment.
The law requires that an
accommodation plan be developed for students who qualify for
services under Section 504.
Throughout the facilities, we could find no student for
whom a Section 504 accommodation plan was provided, although
many youth would qualify for such plans.
There is no formal
process or identified coordinator to facilitate development or
implementation of Section 504 accommodation plans and, as a
result, accommodation plans are not developed for students,
which reduces their potential benefit from the education
program.

15
Limit and Lead is the primary treatment program at the
facilities and consists of a curriculum designed to "change
delinquent thinking." ADJC's version is modified from the
Limit and Lead therapeutic program originally designed for
treatment with sexual offenders that is discussed in greater
detail below.
The program includes reading and writing
components.

-25-

f.

Failure to Provide Accommodations for Youth
with Disabilities.

As discussed above, the core component of the treatment
program at use in the facilities is the Limit and Lead
treatment curriculum.
This program consists of four different
levels.
To be released from custody, youth must progress
through the different levels. While the treatment program
includes workbooks that are written at a seventh grade reading
level, data supplied by the school superintendent at the time
of our tours indicated that a sizeable percentage of the youth
at Adobe and Black Canyon, and nearly half of the youth at
Catalina, read below the seventh grade level.
The following
chart summarizes the data:

Facility

Youth who read
below the 7 th grade
level

Youth who read
below the 2 nd grade
level

Adobe

28%

10%

Black Canyon

38%

3%

Catalina

48%

6%

Thus, many students are unable to read the required treatment
program materials independently. Moreover, treatment staff,
who are not trained or expected to make accommodations in
instruction or materials for youth with reading difficulties,
did not appear prepared to help those students struggling to
read.
Thus, students with reading difficulties, including
many students receiving special education services, are
significantly challenged to complete the treatment program
successfully. Because completion of the program is a
prerequisite for release from the facilities, the failure to
provide accommodations for disabled youth has particularly
adverse consequences.
D.

INADEQUATE MEDICAL CARE

Juveniles in the facilities are entitled to adequate
medical care.
See Sharp v. Weston, 233 F.3d 1166, 1172 (9th
Cir. 2000).
However, the medical services actually provided
to youth at Adobe, Black Canyon, and Catalina is grossly

-26-

deficient and exposes youth to significant risks of harm.
The
deficiencies result from inadequate nursing care, dangerous
medication administration practices, inadequate quality
assurance and infection control programs, inadequate pharmacy
services, and inadequate dental care services at Catalina.
1.

Inadequate Nursing Care

Generally accepted professional standards dictate that
nurses document a description and assessment of an
individual's medical problem in the progress notes in the
medical chart.
The taking and documenting of vital signs
(heart rate, blood pressure, respiratory rate, and body
temperature) are among the most basic of nursing practices;
the failure to obtain such basic information significantly
limits the ability of a medical practitioner to assess a
youth's medical condition and places the youth at risk of
harm.
Moreover, appropriate documentation serves as a record
of treatment received and the efficacy of any treatment given.
Absent appropriate medical documentation, it is nearly
impossible for health care staff at the facilities to
ascertain whether appropriate medical treatment is being
rendered.
Our review of nursing care throughout the
facilities demonstrated substantial deficiencies.
The
following examples are illustrative.
At Adobe, the medical record of one particular youth
reveals four separate, serious errors in nursing care in a
six-week period. Notes indicate that, when the youth was seen
by a nurse in August 2002, he expressed suicidal thoughts.
Yet there was no documentation of the youth's mood, mental
status, sleep patterns, past mental health issues, or history
of prior suicide attempts.
In the area where an assessment
should have been documented, a line was drawn, indicating that
no assessment was done.
The absence of an assessment of a
youth verbalizing suicidal ideation demonstrates a lack of
basic, clinical nursing knowledge.
In September 2002, the
youth was seen following a "take down" by security, at which
time he complained that he "sees stars." Once again, however,
there was no neurological exam noted or vital signs
documented.
The youth was also seen for a sore throat but,
while the nurse's note indicated swelling of his tonsils and a
strep culture was ordered, no vital signs were obtained and
the strep was not taken for almost two weeks.
Ultimately, the
results were positive for strep, a painful and highly
contagious condition.

-27-

Additional examples of deficient nursing care include:
• A youth was seen by medical staff because he hit his
head on a door on two occasions in September 2002 resulting
in lacerations. Although it is standard medical practice to
obtain vital signs and conduct a neurological check in such
cases l the nursing notes for N.O. lacked any vitals or
neurological exam.
1

• A youth was seen for a possible hand fracture.
Nursing
notes indicate that a re-evaluation would occur in one to two
days but there was no follow-up entry documenting that the
follow-up occurred.
I

• A youth was seen on November 2 2002 for vomiting that
morning. Although obtaining vital signs on a youth
experiencing vomiting is basic nursing carel none were
obtained.
1

• A youth was seen for headache and blurred vision
following an injury to his right eye.
No vital signs or
neurological check was noted.
• A nursels note dated June 51 2002 stated that a youthls
mother reported that he was allergic to Lithium.
This
information was not added to his medical staffing sheet under
~Allergiesll so that medical providers would be immediately
alerted to this allergYI which could have life-threatening
side effects.
Because adolescent girls experience significant changes
in their bodies as they go through pubertYI monitoring them
for regular menstrual cycles is a standard medical practice l
as the absence of menses could be brought about by various
conditions including pregnancy emotional disturbances
medications l poor nutrition l weight lossl anemia l or
tuberculosis.
Our review indicated the absence of a system
for monitoring menses.
For example a youth was admitted to
Black Canyon on December 51 2002. Her medical record
indicated that she had had a miscarriage on July 19 2002 but
had not had a regular menses since that time.
On December 24
2002
she was referred due to an abnormal Papanicolaou (pap)
test.
On January 7 2003 the medical record indicated that
she was having ~long periods ll and bleeding heavilYI but there
was no indication that her menses was being monitored.
I

I

I

1

1

1

1

1

1

-28-

Another youth was admitted to Black Canyon on February
10, 2002. A health care request dated in July 2002 from W.S.
stated that she was having pains in her breasts and that she
had not had her menses in over a year. Until the girl
submitted a sick call request five months after her arrival at
the facility, medical staff were not aware of this condition.
Nursing coverage at the facilities is provided from 5
a.m. until 10 p.m. During the overnight shift, the Director
of Nursing provides medical consultation, as needed, by phone.
Unit staff are not trained to take basic vital signs, and,
during the night, decisions regarding whether medical
attention is sought are made by unit staff.
The absence of
medical staff during the overnight shift, coupled with the
lack of training for unit staff, places youth at serious risk.
An example of the dangerous management of serious medical
issues during the overnight shift due to the absence of a
trained nurse on-site coupled with the lack of training of
unit staff is illustrated most acutely by an incident from
June 29, 2002.
That night, a youth at Black Canyon slipped
and hit her head.
She was seen by medical staff just before
the overnight shift began.
The medical staff recommended that
the youth be checked by unit staff every 30 minutes. At 11:30
p.m., one and one-half hours after medical staff had left the
facility, the youth was found disoriented and difficult to
arouse.
The on-call medical provider instructed that a female
unit staff perform breastbone thrusts to rouse her.
Such an
over-the-phone medical consult ordering chest thrusts is a
clinically unacceptable practice and a potentially dangerous
treatment for the youth. Once the chest thrusts were done,
the youth became more alert, but within 25 minutes began
vomiting and shaking.
The youth was then transported to the
community hospital.
Our review revealed no documentation that
the youth was checked every 30 minutes. Moreover, because
unit staff lacked training to take vital signs, they were
unable to provide that relevant information to the on-call
medical provider.
In still another case, a youth at Catalina sustained a
cut over his eye. Because there were no medical staff onsite, the on-call nurse was notified, but did not respond for
more than an hour and a half.
Even when nurses are supposed to be on-site, nursing
directors in all three facilities reported that they are

-29-

frequently short-staffed and must rely upon registry nurses
who are often unfamiliar with the facilities' policies and
procedures.
2.

Dangerous Medication Administration Practices

Generally accepted medical practices, not to mention
basic logic, advise that prescribed medication should be taken
only by the person to whom the medication is prescribed, only
in the dose prescribed, and, if administered by a health
professional, appropriately documented. Medication
administration practices at the youth facilities in Arizona,
however, are woefully inadequate.
As part of our on-site investigation, we observed nurses
administering medication to youth in all three facilities.
Nursing staff did not uniformly follow the "watch/swallow"
procedure designed to assure that youth actually take their
prescribed medications.
Several examples illustrate
deficiencies in medication administration and the risk posed
to youth. After a youth at Black Canyon swallowed some
unknown medication, a search of her housing unit revealed pink
pills in the cushion of her unit's day room.
This youth was
transported to the hospital where she had her stomach pumped.
Another youth at Black Canyon was found in her room in the
fetal position crying.
She disclosed to staff that she had
swallowed ten pills that she had obtained from another youth.
She was also transported to the hospital for treatment. At
Catalina, a youth informed staff that he had "cheeked" his
anti-depressant medications with the intent of stockpiling it
for subsequent use or disseminating it to other residents.
Another youth reported that he was having trouble breathing
after snorting the contents of a capsule given to him by
another youth. At Catalina, numerous incident reports also
documented that youth had hoarded psychotropic medications and
later gave/sold them to other youths.
Youth are also at risk of harm at the facilities because
they do not always receive the medications prescribed to them.
A review of 30 medical records from Catalina revealed that in
19 cases, there was no documentation that medications were
given as ordered. A similar pattern was evident at Black
Canyon, where a review of 30 medical records revealed an
absence of documentation for 20 youths.
Standards of nursing
practice dictate that medications be administered as
prescribed and appropriately documented.

-303.

Inadequate Dental Care at Catalina

With the exception of Catalina, the facilities are
meeting their obligation to provide adequate dental care to
youth. At Catalina, dental services are provided on an
irregular basis and used only generally for emergency dental
needs or initial admission exams. At the time of our tour,
there was a significant backlog of youth in need of dental
procedures.
The Director of Nursing informed us that numerous
youth had been placed on antibiotics to prevent infection
while awaiting needed dental services.
It was unclear when
these services would be provided. At the time of our December
2002 tour, at least 15 youth required follow-up dental care
that had not been scheduled.
4.

Lack of a Quality Assurance Program

Quality assurance protocols are standard in institutional
healthcare settings and necessary for monitoring, tracking,
identifying trends, and/or recognizing need for corrective
actions.
The facilities have no quality assurance program in
place for nursing care. As noted above, medication errors
occur with some frequency in the facilities, yet when
questioned, the Directors of Nursing were either unaware of
the rates of medication errors or grossly underestimated the
rate.
In addition, nursing directors do not conduct regular
chart audits.
One nursing director had completed only five
chart audits in the last yearj the other two had completed
none. As a result, the deficiencies in nursing care discussed
herein are not identified or corrected.
5.

Inadequate Infection Control Program

Generally accepted medical practices require that
facilities like Adobe, Black Canyon, and Catalina have an
infection control program to track incidents of communicable
diseases and ensure effective responses to infections.
The
absence of a program, given the close quarters of a juvenile
justice facility, puts youth and staff at risk of illness.
Our review revealed that the facilities lack an infection
control program.
6.

Inadequate Phar.macy Services

Pharmacy services throughout the facilities fail to
comport with generally accepted professional standards. ADJC

-31-

employs a single pharmacist who is based at Black Canyon and
fills prescriptions for Adobe r Black Canyon r and Catalina.
There is no indication r however r that this pharmacist performs
any functions other filling prescriptions.
It iS r for example r standard practice for pharmacists to
participate on a facilityr s Pharmacy and Therapeutics ("P&T")
Committee. 16 Yet our investigation revealed no functioning P&T
Committee in the facilities and no review of medication errors
by the pharmacist.
The purpose of a P&T Committee is to
ensure safe medication practices and the committeers
responsibilities typically include reporting and monitoring
adverse medication reactions and errors r making decisions on
the facility formularYr developing and reviewing treatment
guidelines and protocols r developing medication policies and
procedures to meet regulatory standards r and conducting drug
use evaluations of requests for off-label medications.
ClearlYr the P&T Committee serves a vital purpose in the
overall management of medication issues r particularly in
monitoring and correcting medication errors.
The virtual
complete absence of a functioning committee in the facilities
fails to ensure safe medication practices and places youth at
risk of harm.
The pharmacist is also generally responsible for
maintaining the inventory of emergency medical kits.
But we
observed that the medical boxes did not contain an inventory
list r as required by professional standards r and that in one
kit r some medication had expired. Our review revealed no
evidence that these boxes were checked within the six months
prior to our tour.
E.

MENTAL HEALTH/REHABILITATIVE SERVICES

Mental health services r to which incarcerated individuals
are constitutionally entitled r see Sharpr 233 F.3d at 1172 r
are inadequate to address the individual needs of the youth at
each of the three facilities. ,The shortfalls are seen in the
areas of rehabilitative services r including inadequate group
and individual therapy; interventions; interdisciplinary
communication; and discharge planning.

We found evidence of only one P&T Committee meeting r
conducted on January lOr 2002.
16

-321.

Inadequate Rehabilitative Services

Youth in juvenile justice facilities are entitled to
adequate rehabilitative services, including individualized
treatment.
See Sharp, 233 F.3d at 1172 (quoting Ohlinger v.
Watson, 652 F.2d 775, 778 (9th Cir.1980)). Without a program
of individual treatment juveniles are much more likely to
become long-term wards of the State and simply "warehoused" in
the facility.
Arizona fails to meet its constitutional
obligations in this area.
The programs at both Adobe and Black Canyon consist
largely of standardized group therapy in which little attempt
is made to address the individualized needs of the youth.
Therapeutic groups, led by a qualified group leader with
formal training and supervision in group dynamics, can be a
highly useful tool for developing skills.
From our
observations of group sessions and interviews of group
leaders, however, it was painfully apparent that, while the
facilities' staff were well meaning, they did not have
sufficient training to lead groups in a therapeutic manner.
There is also a lack of adequate and appropriate
individual therapy at Adobe and Catalina.
For example, a
youth at Adobe attempted suicide by cutting both of his arms.
After treatment in the emergency room, he was placed in the
Separation Unit, but he received no individual therapy.
Another youth struck himself with a pipe from the sink, yet
there was no indication that he received any individual
therapy. After one youth's godfather died, and communication
logs indicated that he was upset over the death, staff were
merely instructed "to keep him busy" rather than providing him
an appropriate therapeutic intervention. At Catalina, we
found a youth who was in the Separation Unit for cutting
himself, who reported to us that he did not have a regular
therapist with whom to talk. While this youth stated that he
had received a few visits from a mental health staff person
while in the Separation Unit, he noted that he did not know
this person and, therefore, would not be able discuss his
problems with her.
This youth appeared to be extremely
depressed and in need of individual therapy.
The psychology associates and psychologists we
interviewed reported that individual therapy is not a
treatment supported by the facilities' administration.
Rather, the facilities rely on Limit and Lead, a therapeutic

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program originally designed for treatment with sexual
offenders.
Mental health staff reported that much of the
Limit and Lead program is inappropriate for the youth, and one
psychologist reported that this program actually undermined
the limited individual therapy that was provided. Mental
health staff throughout the facilities reported their belief
that youths' therapy needs were not being met.
Clinical staffing shortages at the facilities exacerbate
a "one size fits all" approach to the therapeutic program.
The wide variety of girls assigned to the Pride Unit
exemplified the deficiency.17 Residents of Pride Unit included
girls who were almost 18 years old and, therefore, close to
mandatory release. Others were younger and sexually
aggressive, or younger and physically aggressive.
Still
others were lower functioning girls who had spent, in some
cases, years at Black Canyon without advancing through the
level system necessary for their release.
Girls with
disparate needs received therapy together and, not
surprisingly, to little effect.
2.

Inadequate Mental Health Interventions

The facilities claim to provide a therapeutic milieu, but
in reality do not.
Milieu therapy is a treatment mode in
which the staff deliberately plan and structure a youth's
interpersonal and physical environment.
The purpose of a
therapeutic milieu is to create the structure necessary for
the development of independence, responsibility, and a healthy
sense of self, traits which delinquent youth often lack.
The
staff in a therapeutic milieu use every interaction with youth
as an opportunity to encourage growth.
Our review of records,
interviews with staff and youth, and on-site observations
revealed the absence of a therapeutic milieu in the
facilities.
Staff spend most of their time responding to incidents
and crises, focusing attention on youth who injure themselves.
Some staff reflected unsympathetic attitudes inconsistent with

17 We understand that following our tour of Black Canyon,
the Pride Unit was closed and youth were re-assigned to other
housing units.
While this change in environment may have some
salutary effect, we have not been apprized of substantive
programmatic changes.

-34-

any therapeutic approach.
One staff member stated that a
youth had been saying he wanted to kill himself for months,
but the staff member did not take the threats seriously
because the youth had not made any attempt so far.
Another
staff member stated that if a youth was serious about killing
himself, he should get a knife or a rope and "just do it."
Yet another staff member told a youth who had recently made a
suicidal gesture that he "needed to be a man and take it." In
light of the three suicides that have occurred at Adobe since
April 2002, these attitudes are nothing short of alarming.
3.

Inadequate Interdisciplinary Communication

Communication among the various disciplines at the
facilities is fragmented.
No formal system exists for
information to cross all areas to ensure that consistent care
is provided. Medical records, mental health records, and
treatment notes are not integrated.
There is no sequential
documentation of events.
This deficiency deprives the
treating psychiatrist of feedback from professional and nonprofessional staff to remain informed of the status of the
symptoms being treated, medication refusals, injuries, changes
in behavior, medication side effects, or educational issues.
4.

Inadequate Discharge Planning

Discharge planning is an essential component of a
rehabilitative plan because this helps to identify the
individual treatment goals for a youth.
Our investigation
revealed inadequate discharge planning throughout the
facilities.
Discharge plans consisted of the date of the last
physical examination, any medications the youth was taking,
any chronic illnesses (e.g., asthma), and the need for any
follow-up medical appointments. Discharge plans failed to
consider information regarding a youth's mental status,
educational level, placement, or progress summary.
The
discharge summaries provided extremely limited information
about a youth's treatment at the facility and are inconsistent
with professional standards of treatment.
5.

Psychiatric Services

Psychiatric services at the facilities were generally
adequate. Appropriate psychiatric evaluations were being
conducted and clinical justifications for most diagnoses were
evident.
We noted one area of deficiency regarding the

-35-

monitoring of youth on atypical antipsychotic medications.
Youth taking these types of medications should be regularly
evaluated for Tardive Dyskenisia, a serious potential side
effect of neuroleptic (antipsychotic) medication that is
manifested by involuntary, rhythmic movements of the tongue,
mouth, jaw, or limbs.
Screening for this irreversible side
effect should be conducted and documented through the use of
the Abnormal Involuntary Movement Scale ("AIMS") or the
Dyskenisia Identification System, Condensed User Scale
("DISCUS").
Our review of medical charts of youth receiving
atypical antipsychotics did not show that the AIMS or DISCUS
were regularly conducted.
III. REMEDIAL MEASURES

In order to rectify the identified deficiencies and
protect the constitutional and statutory rights of the youth
confined at Adobe, Black Canyon, and Catalina, these
facilities should implement, at a minimum, the following
measures:
1.
Ensure adequate housing, monitoring, and documentation of
youth identified as potentially suicidal.
Ensure that current
environmental conditions which pose risks for potentially
suicidal youth are eliminated.
2.
Ensure that all staff who are in contact with youth are
adequately trained in suicide identification, prevention,
supervision, and intervention.
3. Develop and implement procedures to ensure that
interdisciplinary communication occurs between all direct care
staff and mental health staff who are in contact with
potentially suicidal youth.
4.
Ensure that there are sufficient numbers of adequately
trained direct care and supervisory staff to safely supervise
youth and protect youth from harm.
Ensure that there are
adequate staff to permit youth to use the bathroom facilities
in a timely manner.
5.
Develop and implement adequate grievance procedures to
ensure youth have access to a functional and responsive
grievance process.

-36-

6.
Ensure that investigations of abuse are conducted thoroughly
and in a timely fashion by appropriately trained investigators.
Develop and implement a policy for youth to directly report
allegations of abuse independent of the grievance process.
7.
Develop and implement policies that eliminate the use of
disciplinary confinement without adequate due process
protections.
8.
Ensure that appropriate remedial security measures are
implemented at Catalina Mountain School to address security
lapses.
9.
Provide adequate special education services in all
facilities, including complying with all requirements of the
IDEA.
10. Comply with all requirements of Section 504 of the
Rehabilitation Act and the Americans with Disabilities Act.
11.
Provide adequately trained staff, resources, and quality
assurance programs to ensure access to adequate medical care,
including dental services at Catalina.
12. Develop and implement appropriate an appropriate quality
assurance program for medical care.
13. Develop and implement an effective infection control
program.
14. Ensure that professional standards for medication
administration are followed by all medical staff, including
pharmacy services for the regular review of medication regimens
for youth, regular inventorying of medications, and regular
Pharmacy & Therapeutics meetings.
15. Ensure that adequate mental health services are provided to
all youth, including appropriate individual and group therapy and
that appropriate interdisciplinary communication to facilitate
mental health treatment occurs.
16.

Ensure that appropriate discharge planning is conducted.

* * * * *

/s/ R. Alexander Acosta

-38-

Ms. Judy Dyess
Superintendent, Black Canyon School
Ms. Vicky Bradley
Superintendent, Catalina Mountain School
Mr. Paul K. Charlton, Esquire
United States Attorney
District of Arizona
The Honorable Roderick R. Paige
Secretary
United States Department of Education
Mr. Robert H. Pasternack
Assistant Secretary
Office of Special Education and Rehabilitative Services
United States Department of Education
Ms. Stephanie S. Lee
Director
Office of Special Education Programs
United States Department of Education