Various Kentucky Treatment Centers Findings Letter
The Honorable Brereton C. Jones
Governor of Kentucky
100 State Capitol
Frankfort, Kentucky 40601
Re: Notice of Findings of Investigations: Owensboro Treatment
Center, Green River Boys Camp, Johnson-Breckinridge Treatment Center, Rice-Audubon
Treatment Center, and Central Kentucky Treatment Center
Dear Governor Jones:
On February 9, 1995, and May 1, 1995, we notified you of our intent
to investigate the five above-captioned juvenile treatment centers for
the Commonwealth of Kentucky ("the treatment centers") pursuant to the
Civil Rights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C. §
1997 et seq., and the law enforcement misconduct provisions
of the Crime Bill, 42 U.S.C. § 14141. We toured the Owensboro Treatment
Center ("OTC") and Green River Boys Camp ("GRBC") with expert consultants
on April 26-28, 1995. We toured the Johnson-Breckinridge Treatment Center
("JBTC"), Rice-Audubon Treatment Center ("RATC") and Central Kentucky Treatment
Center ("CKTC") with expert consultants on May 9-13, 1995. Consistent with
the statutory requirements of CRIPA, we now write to advise you of the
findings of our investigation. Throughout the course of the investigation,
the Cabinet for Human Resources staff and facility personnel were fully
cooperative with our investigation and provided us with substantial assistance.
Our consultants express appreciation for this assistance, and we wish to
join them in thanking you for your cooperation.
I. LEGAL FRAMEWORK
CRIPA gives the Department of Justice authority to investigate and take
appropriate action to enforce "rights, privileges, or immunities protected
by the Constitution or laws of the United States . . . ," of the residents
of facilities such as the Kentucky treatment centers. 42 U.S.C. §
1997a. Hence, CRIPA authorizes suit for violation of federal statutes and
regulations as well as for constitutional violations. The Crime Bill similarly
authorizes the Attorney General to obtain appropriate relief to address
systemic violations of constitutional and federal statutory rights by the
"officials or employees of any governmental agency with responsibility
for administration of juvenile justice or the incarceration of juveniles."
42 U.S.C. § 14141.
A. Constitutional Rights
Juveniles in custody have a due process right to adequate treatment,
food, clothing and shelter, as well as freedom from unnecessary bodily
restraint. Youngberg v. Romeo, 457 U.S. 307 (1982). In addition,
a state has the obligation to provide rehabilitative treatment to those
juveniles within its institutions. Gary H. v. Hegstrom, 831
F.2d 1430 (9th Cir. 1987); Alexander S. v. Boyd, 876 F.Supp.
773, 796 (D.S.C. 1995);
Morgan v. Sproat, 432 F. Supp. 1130,
1136 (S.D. Miss. 1977).
Furthermore, under the 14th Amendment, juveniles in custody have equal
rights with juveniles not in custody, especially with regard to public
education. Any restriction of the rights of juveniles in custody must be
related to a legitimate penological interest. Donnell C. v. Illinois
State Board of Education, 829 F. Supp. 1016 (N.D. Ill. 1993).
B. Federal Statutory Rights
The Individuals with Disabilities Education Act ("IDEA"), 20 U.S.C.
§ 1400 et seq., requires States receiving education
funds for special education to develop individualized education plans ("IEPs")
for qualifying children. Board of Education v. Rowley, 458
U.S. 176, 188-89 (1982). The IDEA applies to incarcerated juveniles. Donnell
C. v. Illinois State Board of Education, 829 F. Supp. 1016 (N.D.
Ill. 1993); Green v. Johnson, 513 F. Supp. 965 (D. Mass.
1981). Furthermore, the Americans with Disabilities Act ("ADA"), 42 U.S.C.
§ 12101 et seq., and Section 504 of the Rehabilitation
Act of 1973, 29 U.S.C. § 794, prohibit discrimination on the basis
Based on our investigation, we believe that certain conditions at the
treatment centers violate the constitutional and federal statutory rights
of the juveniles. The facts supporting our determination of constitutional
and legal violations and the necessary remedial measures to correct these
violations are set forth below.
Notwithstanding our serious concerns, we believe there are several positive
aspects to the care and treatment of residents at the treatment centers.
Though currently inadequately implemented, to its credit the Commonwealth
of Kentucky maintains small community focused facilities with a goal of
providing juveniles with the treatment and education necessary to reintegrate
them into the community upon release. The physical plant at Owensboro Treatment
Center is well designed and modern. Although not as modern and in need
of expansion, the physical plant at Rice-Audubon is well maintained and
clean but inadequate for its rated bed capacity and has safety hazards
as noted below.
II. FACTUAL SUMMARY
The following factual summary is derived from the reports of our experts,
our inspections of the five facilities, and the documents provided by the
facilities. The deficiencies discussed below are systematic and must be
corrected statewide at all juvenile treatment centers.
A. Inadequate Abuse Investigations, Neglect, and Harm
1. Abuse Investigations
The procedures for reporting and investigating abuse and neglect are
inadequate, convoluted, ill designed and ineffective. The abuse investigation
system functions to suppress complaints. An initial abuse complaint is
generated internally. In practice, to file an abuse complaint, a youth
must request a form from staff and complete the form with staff assistance.
Even if the youth obtains a form without staff involvement, the youth must
give the completed form to staff to mail. In either situation, staff are
alerted to an abuse filing. Both youth and staff report that staff pressure
youth to withdraw the complaint, resulting in many complaints being withdrawn
without investigation. More often, complaints are never filed because the
youth fear retribution from staff. The current procedures for filing complaints
are insufficient to provide adequate protection for youth.
For abuse complaints that are filed, the complaints are not processed
with any sense of priority. Minor complaints and infractions receive the
same level of attention as major incidents of physical and verbal abuse.
Consequently, a severe backlog of abuse complaints exists and severe incidents
of abuse remain uninvestigated. When finally investigated, major incidents
of abuse are impossible to corroborate. Key evidence is completely outdated
and often the affected youth has left the facility. Good staff have become
frustrated with the often frivolous nature of many of the complaints actually
investigated and poor staff remain undisciplined within the system. Without
prioritization, the log jam of complaints at the administrative level results
in slow and often unsatisfactory resolutions to serious issues and allegations
of abuse and neglect.
In those instances where complaints of staff misconduct are substantiated,
Kentucky fails to properly discipline and remove such staff from contact
with the youth. Facility superintendents do not have the authority to fire
abusive staff. Consequently, a facility's staff are not truly accountable
to the facility's superintendent. This lack of accountability leads to
a lack of control at the facilities and prevents resolution of facility
problems, thus placing residents in danger of repeated abuse. Problem staff
are simply ignored or shuffled around to other facilities. Many such staff
remain in contact with juveniles. Accountability within the entire Kentucky
system is a severe deficiency resulting in continued abuse and harm to
The above deficiencies in the system of abuse and misconduct investigations
dramatically increase the likelihood of further resident abuse and severely
and negatively impacts the treatment provided at the facilities.
2. Isolation Rooms
The use of isolation rooms at the facilities is improper and potentially
abusive. Staff isolate youth far too frequently and isolation practices
are generally outside the requirements of resident treatment or facility
security. Due process procedures are significantly lacking and youth are
isolated for extended periods of time to suit the staff. One youth was
isolated for fifteen days "for acting out and planning an escape." Another
youth was isolated for three days for "being sarcastic with a smart mouth."
In practice, staff use the isolation rooms to excessively punish youth
or simply when the staff are tired of dealing with a specific youth. With
regard to JBTC specifically, the isolation rooms themselves are in such
disrepair as to be unsafe and inhumane. The rooms have exposed conduits
that could facilitate suicides, pass-throughs that could be used to pass
contraband, and are in general disrepair. One report documented a youth
pulling concrete and glass off of the damaged wall of the isolation room
and throwing it at staff. Finally, the youth in isolation are not monitored
every 15 minutes per facility policy. For example, at JBTC one youth was
not monitored at all for over an hour on the day we toured the facility.
Such lack of monitoring presents an unacceptable suicide risk.
3. Classification and Initial Screening
During our tours, our experts noticed many youth who were improperly
placed in certain facilities. Violent and mentally disturbed youth are
placed in facilities incapable of handling them. This creates a real and
serious danger for both residents and staff. It also disrupts resident
treatment and education. All the facilities we toured, both minimum and
medium security, contained residents transferred from the closed maximum
security Central Kentucky Treatment Center. This practice of transferring
juveniles among facilities of different security classifications presents
a danger to both residents and staff and further disrupts treatment and
educational programming. The lack of proper classification is especially
problematic and potentially dangerous to both residents and staff in those
facilities containing non-secure dormitory style housing.
A large part of the classification problem is due to a lack of proper
mental health screening before a youth is placed into a facility. Without
adequate initial screening, Kentucky will remain unable to properly classify
and segregate its juvenile population and to treat adequately juveniles
with mental health needs, as further explained below.
All facilities, except for GRBC, suffer from staffing shortages. At
OTC and JBTC, the problem is acute. The shortage of staffing is worst among
the direct care staff where sufficient staff does not exist to provide
relief duties when staff are unable to attend work. The facilities often
operate without an adequate complement of direct care staff. Inadequate
staffing patterns negatively impact the facility by overburdening the direct
care staff on duty and increasing the likelihood of physical harm to residents
while decreasing the effectiveness of treatment. Overburdened staff cannot
maintain security and devote adequate time to treatment programming. Staff
informed us that due to lack of adequate staff and the increased numbers
of more violent youth placed in the facilities, several "near-riot" situations
have recently occurred, especially at JBTC. The absence of relief staff
also negatively impacts staff training. Staff do not have time to attend
necessary training without leaving the facility dangerously understaffed.
5. Physical Conditions of Confinement
Johnson-Breckinridge Treatment Center
Johnson-Breckinridge is too small for its rated 34 bed capacity. Many
areas are dirty and in disrepair. Several areas are dangerous. For example,
electrical extension cords are left all over the living unit floors. The
isolation room conditions are horrendous with sharp edges, exposed conduit,
and holes in the wall temporarily closed with sheets of plywood. The indoor
recreation area is poorly lighted and inadequate in size. The dining room
is too small and peeling paint in the kitchen food preparation area is
Rice Audubon-Treatment Center
The Rice-Audubon physical plant is neat and clean but inadequate in
size for its rated 42 bed capacity. The sleeping area allows for little
privacy, the dining area is far too small, the gym shared with JBTC needs
to be replaced or renovated and enlarged, and the indoor recreation room
and showers need to be enlarged. In addition, exposed lightbulbs throughout
the facility create a dangerous hazard.
Central Kentucky Treatment Center
Although under renovation, several of the safety features being added
to the Central Kentucky physical plant are deficient and potentially dangerous.
The razor wire spiralled around the perimeter fencing is so poorly installed
as to potentially assist escape. The barred gates at the entrance of both
ends of the living space could render the facility a firetrap without an
accompanying secondary/backup release. The entire electrical system, lighting,
and fire alarm system needs to be replaced.
B. Inadequate Treatment Programming and Aftercare Services
1. Treatment Programs
As a general matter, the Commonwealth of Kentucky has multiple policies
and procedures covering nearly ever aspect of its care and treatment of
the juveniles under its custody. The implementation of these policies,
however, is often inadequate. Every juvenile treatment center we investigated
lacks adequate individual treatment programs for the juveniles. Our consultants
found most ITPs to be superficial and of little use in meaningful treatment.
The ITPs are formula written and boilerplate. The ITPs do not list specific
treatment goals or problem behaviors specific to the individual with defined
consequences or rewards. Because the ITPs are standard formulas, they are
not useful to inform staff of the specific actions that staff should take
when dealing with a particular youth. The ITPs are seldom reviewed, revised,
or updated and few of the youth interviewed even understood their ITPs.
Vague and inadequate ITPs also adversely affect a resident's release from
a treatment center. In Kentucky, release from a treatment program depends
upon successful completion of a treatment program. Without specific and
identifiable treatment goals as contained in a youth's ITP, the decision
to release a child has become arbitrary and capricious. Staff apply no
established set of criteria for release. Release is consequently a function
of arbitrary staff decisions.
Numerous policies and procedures refer to individual and group counseling.
However, these services are not being adequately provided. Counseling is
defined broadly to include any informal conversation with a youth at any
time. Such an understanding of counseling by staff is meaningless. The
formal counseling that does occur is inadequate. Individual counseling
is sporadic and haphazard often involving multiple untrained staff and
providing no continuity for the youth involved. Progress notes are also
poorly maintained. Group counseling occurs more frequently but is inadequately
documented and provided by poorly or untrained staff. Essentially, the
system of treatment throughout all facilities investigated functions to
maintain order and does not adequately provide for any meaningful treatment.
Finally, clinical oversight for the treatment programs is inadequate.
There is an almost absolute lack of oversight of the treatment programs
in the facilities by professionally trained or licensed personnel. In sum,
the actual treatment is grossly inadequate, departs from generally accepted
standards, and does not provide the juveniles with needed rehabilitation.
Kentucky facilities provide inadequate aftercare and transitional services
to youth reintegrating into the community. Currently, the youth's transitional
counselors meet with the specific youth and the youth's facility counselors
only infrequently, if at all. Youth do not continue to receive counseling
or follow-up once they have left the facility. This deficiency has a severely
negative impact on the treatment provided at all the facilities.
C. Inadequate Medical and Mental Health Care Services
1. Medical Care
The physician and nurse staffing complement at the facilities is inadequate.
Untrained direct care staff dispense medications and are unqualified to
monitor for side effects of dispensed medications. Moreover, there is little
uniformity in dispensing medications. We witnessed one staff member discover
that the medication log for a youth had not been filled out. He called
the person responsible for administering the medication and asked whether
he should sign the log for him. He then signed the log for the other staff
member. This kind of inexperience and lax control presents a real danger
to residents receiving medications. Finally, non-medical staff routinely
dispense psychotropic medication and repackage designated dosages. Such
a practice is clearly improper. In sum, medication administration practices
at the treatment centers depart significantly from accepted standards of
2. Mental Health Services
Kentucky fails to provide adequate mental health services to its juvenile
treatment center residents. The State does not locate mental health providers
on the facility campuses and does not provide regular mental health consultations.
This is true even when a youth has been identified by his counselor as
needing such services. Staff are not properly trained to recognize the
dangerous side effects of psychotropic medications. Nor are staff adequately
trained to identify youth with self-destructive or suicidal tendencies.
What mental health services are provided are inadequate. For example,
the "Treatment Specialist" assigned to the Western Region is responsible
for consultation to multiple programs and averages two hours per week at
OTC (and these two hours are primarily spent with the residents in the
Sex Offender Treatment Program). This consultant has an MSW but is not
licensed in Kentucky.
The lack of adequate mental health services is a grave cause for concern
given the type of youth placed in many Kentucky juvenile treatment centers.
For example, two OTC youths interviewed by the consultant were seriously
emotionally disturbed with histories of prior psychiatric hospitalizations.
However, these two youths are not being seen by a mental health professional.
At JBTC, where seven youth were on significant doses of psychotropic medications,
the facility contracted a psychiatrist for a mere four hours a month. A
similar situation exists at RATC.
The lack of mental health services results in situations that are potentially
dangerous to the health and safety of both residents and staff. The absence
of adequate mental health services also negatively impacts the treatment
programs for the youth.
Johnson-Breckinridge Treatment Center
The Individualized Education Plans ("IEPs") required under the IDEA
at JBTC are inadequate. The IEPs are primitive and lacking in detail. They
do not adequately identify the youth's educational goals and methods of
achieving these goals. Additionally, the IEPs are not integrated with the
Rice-Audubon Treatment Center
Although the vocational and regular education program at RATC are good,
the IEPs as required under the IDEA are deficient. The IEPs are lacking
in detail and overly generalized. There is little evidence of follow-up,
monitoring, and revision of the IEPs. The juveniles' educational programs
are not integrated into their treatment programs.
III. Minimally Required Remedies
Remedial measures must be taken to ensure that the juveniles confined
in these facilities are not further deprived of their constitutional and
statutory rights. These measures include, at a minimum, the following remedies:
1. Kentucky must provide adequate abuse investigation procedures
for all facilities. Adequate abuse investigation procedures must include
the following measures:
a. Staff must not be involved in filing complaints.
b. Investigations must be prioritized and conducted promptly.
c. The abuse investigation process must be adequately monitored with
proper quality assurance external oversight.
d. Abusive staff must be appropriately and promptly disciplined.
2. Kentucky must adequately protect its facility youth from neglect
and harm. To protect its residents from neglect and harm, the State
must implement the following remedial measures:
a. Ensure that all youth entering the system are adequately evaluated
with current and relevant information and properly classified and placed
within appropriate juvenile facilities.
b. Immediately cease inappropriately using isolation rooms for punishment
and convenience of staff.
c. Only use isolation rooms where placement meets treatment goals or
is necessary for the immediate and short term security of the facility.
d. Further revise and enhance due-process protections for isolation
e. Regularly monitor all youth placed in isolation.
f. Maintain properly trained and adequate staffing and increase line
staffing to levels that allow for staffing relief and attendance at staff
3. Kentucky must provide its confined juveniles with safe conditions
of confinement. To this end, the State must initiate the following
a. Immediately remove all safety hazards.
b. Remove all fire and safety hazards.
c. Provide for adequate exercise opportunities.
d. Renovate isolation rooms where unsafe.
e. Reduce overcrowding.
4. Kentucky must provide adequate treatment plans and after care
services to its juveniles. To this end, the State must initiate the
a. Develop and implement meaningful ITPs.
b. Monitor, evaluate, and revise ITPs as necessary.
c. Ensure that the ITPs are used and understood by staff and residents
and train staff accordingly.
d. Adequately define the concept of counseling and maintain sufficient
and qualified juvenile counselors.
e. Provide transitional counseling services and aftercare to all residents
for whom such treatment is needed.
5. Kentucky must provide adequate medical and mental health care
to protect the health and safety of the juveniles.
a. Provide appropriate medical services including maintaining sufficient
qualified medical staff to safely dispense medication and provide adequate
b. Maintain sufficient qualified mental health staff to evaluate and
monitor all juveniles for mental health problems, develop and implement
an adequate mental health care delivery system of individualized treatment,
and provide adequate clinical oversight.
6. Kentucky must develop and implement meaningful IEPs,integrate
IEPs with ITPs, and monitor, evaluate, and revise IEPs as necessary.
You may wish to contact the regional offices of the United States Departments
of Health and Human Services and Education as well as the National Institute
of Corrections and the Office of Juvenile Justice and Delinquency Protection
to ensure that Commonwealth officials have taken full advantage of any
federal financial assistance which may be available to assist in the correction
of the above listed deficiencies. If we can assist you in this regard,
please contact us.
We appreciate the assistance and cooperation that representatives of
the Commonwealth and the facilities extended to us during this investigation.
My staff will contact appropriate officials in the next two weeks to discuss
this matter further. It is our intent to work cooperatively with State
officials by entering into a consent decree to remedy the deficiencies
we have outlined herein.
Deval L. Patrick
Assistant Attorney General
Civil Rights Division
cc: The Honorable Chris Gorman
Mr. Masten Childers, II
Cabinet for Human Resources
Mr. Leon Farley
Mr. Richard Barnes
Green River Boys Camp
Ms. Carol A. Isham
Central Kentucky Treatment Center
Ms. Pam McFarland
Johnson-Breckinridge Treatment Center
Mr. Scott Britton
Owensboro Treatment Center
Michael Troop, Esquire
United States Attorney
Western District of Kentucky