PERFORMANCE AUDIT REPORT Glen Mills Schools June 2020 Commonwealth of Department of the Auditor General Eugene A. DePasquale Auditor General This page left blank intentionally June 15, 2020 The Honorable Tom Wolf Governor Commonwealth of Pennsylvania Room 225 Main Capitol Building Harrisburg, PA 17120 Dear Governor Wolf: This report contains the result of the Department of the Auditor General’s (Department) performance audit of the Glen Mills Schools (GMS), a child residential facility licensed by the Department of Human Services, regarding child abuse prevention and proper reporting. This audit was conducted under the authority of Sections 402 and 403 of The Fiscal Code, 72 P.S. §§ 402 and 403, and in accordance with applicable Government Auditing Standards, issued by the Comptroller General of the United States. 1 Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Our performance audit covered the period July 1, 2017 through March 11, 2020, unless otherwise noted, with updates through the report date, and included the following four objectives: 1 • Determine if GMS complied with the Child Protective Services Law (CPSL), 23 Pa.C.S. § 6301 et seq., and its associated regulations, including 55 Pa. Code § 3800.15. • Determine the extent to which GMS complies with all legal and/or policy and procedural requirements under the CPSL regarding state and federal background clearances for employees and others (e.g., volunteers) who are in contact with its child residents. U.S. Government Accountability Office. Government Auditing Standards. 2011 Revision. The Honorable Tom Wolf June 15, 2020 Page 2 • Determine if GMS has policies and effective procedures to prevent child resident abuse. • Determine what avenues child residents have to report incidents of abuse. As noted in Finding 1, we found that GMS management, in some instances, did not obtain and maintain required background clearances from its employees, contractors, and volunteers, which potentially put GMS students at risk of harm. Additionally, GMS did not have all required justification forms on file for hiring/retaining employees whose background clearances listed offenses. GMS permitted four new employees to continue working with GMS students despite not obtaining their federal background clearances within the required provisional time period. GMS also did not run an Adam Walsh check for one non-Pennsylvania resident employee, and we were unable to determine if Adam Walsh checks should have been obtained for four other GMS employees. Additionally, GMS did not maintain a centralized list to track and monitor the status of background clearances of all its contractors and volunteers nor does it require supervisory review of those background clearances to ensure that follow-up is performed, if necessary. Finally, background clearance dates for several employees were not accurately recorded in GMS’ training tracking system. We reported in Finding 2 that GMS management did not ensure that some of the employees, contractors, and volunteers who may have direct contact with its students received all of the required training related to the prevention of child abuse and the mandatory reporting of suspected abuse. Specifically, we found the following: GMS lacks adequate written training policies and procedures; weaknesses exist involving the completion of required training and the failure to properly maintain training records; and significant deficiencies were identified related to tracking completion of developmental training and on-the-job orientation. Finally, in Finding 3 we outlined the avenues available for students to report incidents of abuse; however, we found that GMS failed to communicate the importance of the mandatory reporter requirement to report suspected abuse during the first day of the student’s orientation process. This is concerning because the student might not know that reaching out to a mandatory reporter is a critical avenue for reporting instances of abuse. Regarding the grievance process for students and staff to follow when reporting and investigating violations of student rights, we summarized and highlighted key differences between the process in place at the beginning of our audit period versus the process after an update made on March 15, 2019. While updates to the grievance policy were made during our audit period, we found that the March 2019 update still did not sufficiently address abuse of a student. Additionally, GMS did not have a specific retaliation policy regarding non-sexual related abuse. Overall, we offer 35 recommendations for GMS to consider implementing to help ensure the health, safety, and well-being of students placed at GMS in the future. GMS agrees with our findings and has indicated that it is committed to and in the process of implementing most of the recommendations. The Honorable Tom Wolf June 15, 2020 Page 3 In closing, we would like to thank GMS for its cooperation and assistance during the audit. We will follow up at the appropriate time to determine whether and to what extent all recommendations have been implemented. Sincerely, Eugene A. DePasquale Auditor General A Performance Audit Glen Mills Schools TABLE OF CONTENTS Executive Summary ............................................................................................................. 1 Introduction and Background .............................................................................................. 5 Finding One: Glen Mills Schools’ management in some instances did not obtain and maintain required background clearances from its employees, contractors, and volunteers, which potentially put students at risk of harm ................................................................................................................13 Recommendations ........................24 Finding Two: Glen Mills Schools did not ensure that some individuals who may have direct contact with its students received all of the required training related to the prevention of child abuse and the mandatory reporting of suspected abuse ..............................................................................................27 Recommendations ........................36 Finding Three: Avenues available to Glen Mills Schools’ students to report incidents of abuse ................................................................................................................38 Recommendations ........................45 Glen Mills Schools’ Response and Auditor’s Conclusions .......................................................46 Appendix A – Objectives, Scope, and Methodology ....................................................................65 Appendix B – Timeline of Events Regarding an Alleged Assault Against a Glen Mills Schools Student by Glen Mills Schools Staff That Led to the Pennsylvania Department of Human Services Order to Remove all Students and Revocation of Glen Mills Schools’ Licenses to Operate a Child Residential Facility ...................................76 Appendix C – Training Timeline for Glen Mills Schools Employees, Contracted Staff, and Volunteers ..............................................................................................................79 Appendix D – Glen Mills Schools Student’s Rights .....................................................................83 Appendix E – GMS Policy 12.6 – Student Grievance and Appeal Process .................................86 i A Performance Audit Glen Mills Schools TABLE OF CONTENTS (continued) Appendix F – Glen Mills Schools Policy 8.20 – Compliance with Pennsylvania Child Protective Services Law ..........................................................................................................92 Appendix G – Distribution List ....................................................................................................94 ii A Performance Audit Glen Mills Schools Executive Summary This report presents the results of our performance audit of the Glen Mills Schools (GMS). Our performance audit was conducted under the authority of Sections 402 and 403 of The Fiscal Code. 2 We initiated this audit as a result of an alleged assault against a GMS student in July 2018, the dismissal of six GMS staff, and the subsequent investigative reports by a Philadelphia newspaper detailing decades of alleged abuse at GMS (further discussed in Appendix B). Our performance audit had four objectives and covered the period of July 1, 2017 through March 11, 2020, unless otherwise noted, with updates through the report date. Refer to Appendix A of this report for a detailed description of the audit objectives, scope, and methodology. GMS was originally founded in 1826 and moved to its present location in Delaware County, Pennsylvania in 1892 on a campus situated on nearly 800 acres. 3 Most recently, GMS enrolled both in-state and out-of-state students in its residential program from agencies dealing with adolescents such as adjudicated delinquent and adjudicated dependent males between the ages of 14 and 18, with an I.Q. of 70 or higher, and operated non-residential programs including community based services and shelter care. Additionally, GMS operated the Alternative Education for Disruptive Youth Program. In this program, students were provided with alternative education services designed to provide educational services for students who have had significant challenges in previous school placements. Removal of students from GMS by their respective Pennsylvania county or state began on February 22, 2019. 4 The Pennsylvania Department of Human Services (DHS) further issued an emergency removal order of GMS students on March 25, 2019, requiring that all residents at GMS be removed as promptly as could be safely accomplished. On April 8, 2019, DHS issued a decision to revoke all 14 of GMS’ licenses to operate a Child Residential Facility. Our audit results are contained in three findings, summarized below, and include 35 recommendations directed to GMS. GMS agrees with each finding and is committed to, and in the process of, implementing most of the recommendations. 72 P.S. §§ 402 and 403. https://www.delcotimes.com/opinion/guest-column-what-will-happen-to-glen-mills--acre/article_f20445f4-60fb11e9-9a4f-63d5602cecf8.html (accessed February 24, 2020). The 800 acres was in addition to the Glen Mills Golf Course, opened in 2001 as an outdoor vocational classroom for troubled youth. https://www.top100golfcourses.com/golf-course/glen-mills (accessed February 24, 2020). 4 Students were removed by California (Kern, Alameda, San Bernardino, and Santa Clara counties) and Pennsylvania (Washington, Dauphin, and Westmoreland Counties). 2 3 1 A Performance Audit Glen Mills Schools Finding 1 – Glen Mills Schools' management in some instances did not obtain and maintain required background clearances from its employees, contractors, and volunteers, which potentially put students at risk of harm. We conducted procedures to determine if GMS timely obtained and retained the required state (PSP), federal (FBI), and Child Abuse background clearances, as well as the Adam Walsh check, if applicable. 5 We found that GMS did not have procedures and management controls in place to ensure that all background clearances were obtained timely nor were they maintained and available for our review. As a result, we were not able to verify that all of the 67 employees, 10 contractors, and 60 volunteers selected for testing obtained the required background clearances necessary to have direct contact with GMS students. Our audit procedures related to our selection of 67 employees found that while GMS maintained all three required background clearances for 63 of the 67 GMS employees, the following issues were identified for the remaining four GMS employees’ background clearances: • • • One employee was missing the FBI clearance. One employee was missing the FBI and PSP clearances. Two new employees were terminated prior to GMS receiving their FBI clearances. In addition to the issues previously described for the four GMS employees, we also identified the following concerns: • • • • • GMS permitted two new employees to continue working with GMS students despite not obtaining their FBI clearances within the required provisional time period. Background clearance dates were not accurately recorded in GMS’ tracking system for 14 employees. GMS did not have all required justification forms on file for five employees whose background clearances listed offenses. An Adam Walsh check was not run for one employee that lived outside of Pennsylvania at the time the application to work at GMS was completed. GMS did not obtain addresses for all five years preceding employment at GMS; therefore, we were unable to determine if GMS should have obtained Adam Walsh checks for four GMS employees. Additionally, GMS management stated that although not formalized into written policy, due to the sensitive nature of information in background clearances and based upon security awareness training presented by the Pennsylvania State Police in June 2016, GMS is only maintaining the Although not required under the Child Protective Services Law, GMS also utilizes the “Adam Walsh State Contacts and Procedures for Child Abuse Registry Checks” to check on its employees or applicants that are nonPennsylvania residents or applicants that have lived outside of Pennsylvania in the last five years prior to applying to work at GMS. We will refer to this as the Adam Walsh check. 5 2 A Performance Audit Glen Mills Schools most recent background clearances for employees, contractors, and volunteers. GMS is also purging background clearances one year after they end their employment or stop providing services to GMS students. It is important, however, for GMS management to formalize in written policy the process it has in place regarding retaining background clearances. Regarding our audit procedures to determine if GMS obtained and retained the three required background clearances for the 10 contractors and 60 volunteers selected for testing, we found that GMS accepted two contractors’ Child Abuse clearances that were only certified for volunteer purposes. GMS also did not have all the required background clearances on file for eight GMS volunteers. Additionally, we found that GMS did not require supervisory review of the results and did not maintain centralized lists which are necessary to track and monitor the status of background clearances. We offer 18 recommendations to GMS to improve how it processes, maintains, and tracks the background clearances required for its employees, contractors, and volunteers to help ensure the safety and security of GMS students. Finding 2 – Glen Mills Schools did not ensure that some individuals who may have direct contact with its students received all of the required training related to the prevention of child abuse and the mandatory reporting of suspected abuse. The Child Protective Services Law (CPSL), DHS regulations, and GMS require employees, contractors, and volunteers to complete training relating to Child Abuse Recognition and Reporting (CARR) as well as to the health, safety, and well-being of its students. Based on our audit procedures, we identified several deficiencies within GMS’ training program and with the maintenance of training records. These deficiencies included the lack of adequate written training policies and procedures, weaknesses involving the completion of required training and the failure to properly maintain training records, and issues related to developmental training and on-the-job orientation. Specifically, our testing of training records for 65 employees (12 new hires and 53 existing employees) found that GMS did not maintain documentation to support that the required CARR training was completed for three employees. GMS also did not have record that one employee selected for testing attended the abbreviated mandatory reporter training offered after the July 2018 alleged incident of abuse. Additionally, we found three newly hired GMS employees did not receive one of either CARR training or Prison Rape Elimination Act (PREA) training timely. We also identified numerous clerical errors such as incorrect training dates and the number of training hours recorded in the employees’ training records, and GMS staff did not date sign-in sheets to indicate when the training was received. GMS further was unable to provide documentation to support that two of the ten contractors tested completed CARR training. GMS also failed to maintain CARR certificates for 21 of the 60 3 A Performance Audit Glen Mills Schools volunteers tested and could not provide a face-to-face orientation acknowledgement form for one volunteer. Finally, we found significant deficiencies relating to the tracking of the number of hours of required annual developmental training that GMS direct care employees completed. GMS’ tracking system automatically recorded one hour per week of annual developmental training in each employees’ record rather than a GMS staff member entering the actual number of training hours received. This process, however, provides no assurance that the training recorded actually took place. Additionally, the process of documenting the completion of on-the-job orientation was not designed properly. GMS staff instructed employees to sign the staff orientation acknowledgment form, which acknowledged the completion of the on-the-job orientation, upon hire rather than waiting until after the 21 day on-the-job orientation training was completed. We offer eight recommendations to GMS including updating its training policy and ensuring that all employees, contractors, and volunteers complete required training to help prevent abuse and recognize the signs of child abuse and the reporting requirements for suspected abuse in the commonwealth. Finding 3 – Avenues available to Glen Mills Schools’ students to report incidents of abuse. During our audit, we identified various avenues, both written and verbal, for students to use to report incidents of abuse. These avenues included communicating with other GMS students, GMS staff, as well as individuals outside of the GMS campus such as parents/guardians and probation officers. GMS management indicated that staff would have made students aware of these opportunities as part of new student orientation; however, we found GMS established no written procedures to ensure that students were made aware of GMS staff’s role as mandatory reporters during the first day of the orientation process. In addition, we describe GMS’ policy related to its student grievance and appeal process. Our review of the grievance process in place at the beginning of our audit period and its update on March 15, 2019, found that the revised process now also allows the student’s parent/guardian to file a grievance allegation. The revised process also added a Grievance Panel, which is another level to review the grievance allegation. GMS policy, however, does not provide for what actions should occur if the grievance reported is abuse related. For example, it does not address specific steps that should be taken to ensure the safety of the student and to seek medical attention for the student. Further, GMS does not have a retaliation policy specific to non-sexual related abuse to ensure individuals reporting abuse are protected from retaliation. Within this finding, we offer nine recommendations including measures to ensure GMS students are aware of all avenues for reporting incidents of abuse and to promote a culture of full transparency. 4 A Performance Audit Glen Mills Schools Introduction and Background This report presents the results of our performance audit of the Glen Mills Schools (GMS), which is a child residential facility under the purview of the Pennsylvania Department of Human Services’ (DHS) Bureau of Human Services Licensing, which licenses facilities based on evaluations of compliance with minimum health and safety requirements. 6 This performance audit was conducted under the authority of Sections 402 and 403 of The Fiscal Code and in accordance with applicable Government Auditing Standards, issued by the Comptroller General of the United States, 2011 Revision. 7 Our performance audit had four objectives and covered the period of July 1, 2017 through March 11, 2020, unless otherwise noted, with updates through the report date. Refer to Appendix A of this report for a detailed description of the audit objectives, scope, and methodology. This performance audit was initiated as the result of an alleged assault against a GMS student in July 2018, the dismissal of six GMS staff, two of whom were also charged with crimes related to the incident, and the subsequent investigative reports by a Philadelphia newspaper detailing decades of alleged abuse at GMS. 8 Details regarding the events that occurred subsequent to the alleged assault against the GMS student are provided in a below section and in a timetable included in Appendix B. In the sections that follow, we present the following background information related to GMS: • • • • • GMS background and student census information. GMS administration and staff complement. Background clearance requirements. Mandated reporters and prevention of abuse training requirements for individuals that have contact with GMS students. Abuse reporting requirements. GMS is subject to the state Human Services Code (relating to DHS’ powers and duties as to supervision and licensing) and DHS’ regulations pertaining to child residential and day treatment facilities. See 62 P.S. §§ 901-922, 1001-1088, and 55 Pa. Code Ch. 3800. See also 2013 DHS Regulatory Compliance Guide, https://www.dhs.pa.gov/providers/Clearances-andlicensing/Documents/Child%20Youth%20Residential%20Licensing/p_023326.pdf (accessed February 24, 2020). 7 72 P.S. §§ 402 and 403. 8 The Philadelphia Inquirer, “’I can’t breathe’: Probe underway at Glen Mills after staffer attacks boy.” dated August 31, 2018, and “Beaten, then silenced. At the oldest U.S. reform school for boys, leaders of the prestigious Glen Mills Schools in Pennsylvania have hidden a long history of violence.” dated February 20, 2019 (both articles accessed March 15, 2019). Five of the employees were terminated by GMS and one resigned two weeks prior to GMS’ intention of terminating his employment. 6 5 A Performance Audit Glen Mills Schools GMS Background and Student Census Information The Glen Mills Schools, originally founded in 1826, was moved to its present location in Delaware County, Pennsylvania in 1892 on a campus situated on nearly 800 acres. 9 It was originally incorporated as the Philadelphia House of Refuge to address the plight of delinquent children in the City of Philadelphia. More recently, GMS enrolled students, both residents and non-residents of Pennsylvania, in its residential program from agencies dealing with adolescents, for example, but not limited to the following: adjudicated delinquent and adjudicated dependent males between the ages of 14 and 18, with an I.Q. of 70 or higher. 10 GMS is a tax-exempt nonprofit 501(c)(3) child residential facility governed by a Board of Managers charged with fiduciary duties and received approximately $40 million of annual revenue prior to the removal of all of the GMS students in April 2019. 11 The GMS residential program included room and board, clothing, behavior management, counseling, academic and vocational programming, medical and dental services, as well as athletic and recreational opportunities. 12 During the audit period, GMS also provided a variety of non-residential services to delinquent and non-delinquent male and female youth including community based services and shelter care. 13 In addition to the three programs previously discussed, for which census information is included in a below table, GMS operated the Alternative Education for Disruptive Youth Program, which was licensed by the Pennsylvania Department of Education. As part of this program, GMS staff provided academic day-program alternative education services designed to provide educational services for students who have had significant difficulties in previous school placements. These services were offered both on campus at GMS and at an off-site location. 14 This program provided services to students from a total of 20 local school districts and served 61 students https://www.delcotimes.com/opinion/guest-column-what-will-happen-to-glen-mills--acre/article_f20445f4-60fb11e9-9a4f-63d5602cecf8.html (accessed February 24, 2020). The 800 acres was in addition to the Glen Mills Golf Course, opened in 2001 as an outdoor vocational classroom for troubled youth. https://www.top100golfcourses.com/golf-course/glen-mills (accessed February 24, 2020). 10 https://www.delcotimes.com/opinion/guest-column-what-will-happen-to-glen-mills--acre/article_f20445f4-60fb11e9-9a4f-63d5602cecf8.html and https://www.delcotimes.com/news/pa-revokes-all-operating-licenses-for-glenmills-schools/article_d6cfce4e-5a24-11e9-b189-bb602cf8d4ca.html (accessed February 24, 2020). 11 Ibid. 12 http://www.glenmillsschools.org/admissions/programs-offered (accessed September 13, 2019, and January 21, 2020). 13 The Community Based Programs offered a variety of services including electronic monitoring, career and technical education, weekend respite, community service and restitution, as well as a truancy diversion program for male and female youth. The shelter care unit offered an environment for those adolescents needing temporary housing arrangements and provided such necessities as meals, clothing, and health services. 14 Academic day-program services, for students that had significant difficulty in previous school placements such as services to change a student’s inappropriate behavior and develop life skills necessary to sustain this change, were provided by GMS staff on the GMS campus during the audit period July 1, 2017 through September 3, 2019. At that time, services were then provided off campus until December 23, 2019, when the program was dissolved. 9 6 A Performance Audit Glen Mills Schools during the 2017-2018 school year, 41 students during the 2018-2019 school year, and 9 students during Fall 2019. After the investigative report was published by a Philadelphia newspaper regarding allegations of abuse of GMS students (further discussed in Appendix B), students began being removed from GMS by their respective Pennsylvania county or state on February 22, 2019. 15 Furthermore, DHS issued an emergency removal order of GMS students on March 25, 2019, requiring that all residents at GMS be removed as promptly as could be safely accomplished. On April 8, 2019, DHS issued a decision to revoke all 14 of GMS’ licenses to operate a Child Residential Facility. The student census at GMS for our audit period was as follows: Population Type Residential Students Shelter Care Community Based Services Division July 1, 2017 436 3 0 July 1, 2018 397 1 36 January 1, 2019 273a/ 3b/ 0d/ - The last residential student was removed from GMS on April 5, 2019, and there continued to be no residential students at GMS through the end of our audit procedures. b/ - The last shelter care student was removed on March 27, 2019, and there continued to be no students served by this program through the end of our audit procedures. d/ - There continued to be no students served by this program through the end of our audit procedures. Source: Produced by the Department of the Auditor General staff based on information provided by GMS management. a/ GMS’ Administration and Staff Complement GMS’ Administration is headed by its Executive Director, hired by the GMS’ Board of Managers, which consists of 18 members and includes a Board President, two Vice-Presidents, a Secretary, and Treasurer. The Executive Director is responsible for all aspects of the management and supervision of GMS’ day-to-day operations. Additionally, prior to the removal of the GMS students, the Executive Director was assisted by a Group Living Director, Admissions Director, Special Service Director, Education Director, Support Services Director, Culinary Services Director, and support staff who provided services to the GMS students. Students were removed by California (Kern, Alameda, San Bernardino, and Santa Clara counties) and Pennsylvania (Washington, Dauphin, and Westmoreland Counties) on February 22, 2019. 15 7 A Performance Audit Glen Mills Schools As the result of the removal of the GMS students, GMS began layoffs of its staff complement. The employee complement of GMS during our audit period is reflected in the table below: GMS Staff Complement July 1, 2017 July 1, 2018 July 1, 2019 December 31, 2019 Direct Care Staff 452 433 102 78a/ Non-Direct Care Staff 62 53 24 22 514 486 126 100 Total a/ - GMS staff considered to be direct care, and are part of the direct care staff that were employed as of December 31, 2019, including some positions such as administration, maintenance, and facility operations. Source: Produced by the Department of the Auditor General staff based on information provided by GMS management. Background Clearance Requirements Pursuant to the Child Protective Services Law (CPSL), individuals having contact with students of GMS are required to submit background clearances to confirm that they are eligible to be in contact with children below 18 years of age. 16 For purposes of this report, we will discuss these individuals in three categories: (1) employees, those employed directly by GMS; (2) contracted employees, those that provided services such as medical and dental care; and (3) volunteers, generally college students that provided tutoring services. 17 GMS employees, contracted employees, and volunteers are required to submit the following three background clearances: 1. A report of criminal history record information from the Pennsylvania State Police (PSP) or a statement from the PSP that the State Police central repository contains no such information relating to that person. We will refer to this background clearance report as a PSP clearance within this report. 2. A certification from the DHS ChildLine and Abuse Registry, ChildLine Verification Unit, as to whether the applicant is named in the Pennsylvania statewide child abuse database as an alleged perpetrator in a pending child abuse investigation or as the perpetrator of a founded report or an indicated report. We will refer to this background clearance as a Child Abuse clearance within this report. 3. A report of Federal criminal history record information. The applicant shall submit a full set of fingerprints to PSP for the purpose of a record check and PSP, or its authorized agent, shall submit the fingerprints to the Federal Bureau of Investigation (FBI) for the purpose of verifying the identity of the applicant and obtaining a current record of any 23 Pa.C.S. § 6344(b). Under the CPSL, the definition of “Child” is: “[a]n individual under 18 years of age”. See 23 Pa.C.S. § 6303. 17 Ibid. and 23 Pa.C.S. § 6344.2 (relating to Volunteers having contact with children). 16 8 A Performance Audit Glen Mills Schools criminal arrests or convictions. We will refer to this background clearance report as an FBI clearance within this report. 18 A background clearance that indicates a conviction or a record of an offense that did not result in a conviction does not automatically/necessarily preclude an individual from working with GMS students. The CPSL outlines which specific offenses precludes working with children. 19 Although not required under the CPSL, GMS also utilizes the “Adam Walsh State Contacts and Procedures for Child Abuse Registry Checks” to check on its employees or applicants that are non-Pennsylvania residents or applicants that have lived outside of Pennsylvania in the last five years prior to applying to work at GMS. 20 We will refer to this as the Adam Walsh check. 21 The CPSL requires the PSP, Child Abuse, and FBI clearances to be obtained every five years. 22 It is the policy of GMS, however, to obtain new CPSL-required clearances for each employee, contracted employee, and volunteer as well as the Adam Walsh check for employees, if applicable, every three years. As previously reported, only certain offenses will preclude an individual from working with students at GMS. At GMS, prospective and current employees’ background clearances are initially received and reviewed by one employee, an Administrative Assistant. This Administrative Assistant is also the same employee responsible for posting the background clearance dates to Filemaker which is the software utilized by GMS to track the dates of employees’ background clearances and when they are due for renewal. GMS management stated that if an individual’s background clearance has no offenses listed, then the Administrative Assistant will file the background clearance in a locked filing cabinet in the personnel office and notify the respective supervisor that the individual is cleared for work. Conversely, although not formalized in written policies or procedures, if there are any offenses on a background clearance, other than a CPSL disqualifying offense, GMS management stated that it has been their practice since January 1, 2016, for the Administrative Assistant to notify the employee, the employee’s supervisor, and the personnel director of the offenses, which would prompt them to complete a “Criminal History Assessment Document” (justification form) that is Ibid. 23 Pa.C.S. § 6344(c)(2) and (3). 20 On July 27, 2006, President George W. Bush signed into law The Adam Walsh Child Protection and Safety Act (Adam Walsh Act). Also known as the Sex Offender Registration and Notification Act, the Adam Walsh Act establishes a comprehensive national system for the registration of sex offenders and offenders against children. The Act also integrates the information in State sex offender registry systems and ensures that law enforcement has access to the same information across the United States. 21 Please note that the Adam Walsh check requirement was added to the CPSL through Act 47 of 2019, effective September 19, 2019 but it solely applies to employees or volunteers at a child day-care center, group day-care home, or family child-care home. See 23 Pa.C.S. § 6344(c)(4)(ii) relating to the National Crime Information Center National Sex Offender Registry or on a state's sex offender registry. 22 23 Pa.C.S. § 6344.4(1). 18 19 9 A Performance Audit Glen Mills Schools then signed by each of those individuals. This document contains a written account from the employee regarding the offense listed on the background clearance and indicates the basis for GMS’ decision to either hire or retain the individual. Mandated Reporters and Prevention of Abuse Training Requirements for Individuals that have Contact with GMS Students The CPSL requires employees who have direct contact with children to receive three hours of child abuse recognition and reporting (CARR) training within 90 days of hire and three hours every five years thereafter. 23 Additionally, the CPSL requires the Pennsylvania Department of State to make training and educational programs and materials available for all professional licensing boards that oversee mandated reporters within the commonwealth. Under the CPSL, mandated reporters, which would include GMS-contracted employees, such as dentists and clinical social workers, are required to submit documentation to their professional licensing board showing the completion of at least three hours of approved CARR training when applying for their certification. Those mandated reporters who are applying to renew their certification must complete at least two hours of approved training and submit the required documentation. 24 In addition to the applicable sections of the CPSL, GMS must follow the directives set forth in regulations enacted to protect the health, safety, and well-being of children receiving care in child residential and day treatment facilities. 25 The regulations include the following training requirements pertinent to our audit objectives relating to compliance with the CPSL and preventing child abuse: • Prior to working with children, each staff person who will have regular and significant direct contact with children, including part-time and temporary staff persons and volunteers, shall have an orientation to the person’s specific duties and responsibilities and the policies and procedures of the facility, including incident reporting as well as discipline, care, and management of children, and use of restrictive procedures. 26 • Prior to working with children and within 120 calendar days after the date of hire, the director and each full-time, part-time, and temporary staff person who has regular and significant direct contact with children, shall have at least 30 hours of training to include at least the following areas: 27 23 Pa.C.S. § 6383(c). 23 Pa.C.S. § 6383(b). 25 55 Pa. Code § 3800. 26 55 Pa. Code § 3800.58(a). 27 55 Pa. Code § 3800.58(b). 23 24 10 A Performance Audit Glen Mills Schools o Recognition of the signs of child abuse and mandatory reporting. 28 o Behavior management. 29 o Special issues affecting the population. 30 • After initial training, the director and each full-time, part-time, and temporary staff person who will have regular and significant direct contact with children, shall have at least 40 hours of training annually relating to the care and management of children. This requirement for annual training does not apply for the initial year of employment. 31 GMS has issued policies and procedures related to training for employees and volunteers; however, during discussions with GMS management, we found that not all training requirements were documented within its training policies and procedures. 32 Due to the lack of clarity, as discussed in Finding 2, GMS provided us with a timeline detailing the training requirements in place for newly hired employees and existing employees, contracted employees, and volunteers that were utilized during our testing of training records. 33 See Appendix C for a copy of the training timeline provided by GMS management. Abuse Reporting Requirements The CPSL requires individuals considered mandated reporters, which would include GMS employees, contracted employees, and volunteers, to make a report of suspected child abuse if the individual has reasonable cause to suspect that a child is a victim of child abuse. 34 The mandated reporter shall immediately make an oral report to ChildLine and a written report within 48 hours. 35 The CPSL also defines penalties for those mandated reporters who fail to report suspected child abuse. 36 55 Pa. Code § 3800.58(b)(2). See also CPSL, 23 Pa.C.S. §§ 6301-6386 and 55 Pa. Code Chapter 3490 (relating to Protective Services). 29 55 Pa. Code § 3800.58(b)(5). 30 55 Pa. Code § 3800.58(b)(6). 31 55 Pa. Code § 3800.58(d). 32 Glen Mills Schools Policies and Procedures, Policy Number 3.15: Training and Training Criteria and Policy Number 3.17: Orientation Training, both issued January 5, 2001 and re-issued April 2015. 33 For the purposes of this audit report, the timeline refers to the document provided by GMS management, utilized during our testing further discussed in Finding 2 that listed the training requirements for GMS employees, contracted employees, and volunteers, including initial training, if applicable, and recertification requirements. 34 23 Pa.C.S. § 6311(a). 35 23 Pa.C.S. § 6313(a)(1). ChildLine is part of a mandated statewide child protective services program designed to accept child abuse referrals and general child well-being concerns, and transmit the information quickly to the appropriate investigating agency. Individuals can contact ChildLine’s toll-free hotline, which is available 24 hours a day, seven days a week. 36 23 Pa.C.S. § 6319. 28 11 A Performance Audit Glen Mills Schools GMS has issued policies and procedures related to GMS staff members’ responsibilities as mandatory reporters of suspected child abuse; Student’s Rights stating that a child may not be abused; an employees’ Code of Ethics that lists abusing a student or students as unacceptable behavior; and the Student Grievance and Appeals Process. Finding 3 includes details on what avenues students had to report grievances including incidents of abuse. 12 A Performance Audit Glen Mills Schools Finding 1 – Glen Mills Schools’ management in some instances did not obtain and maintain required background clearances from its employees, contractors, and volunteers, which potentially put students at risk of harm. As part of our audit objective to determine if Glen Mills Schools (GMS) complied with the Child Protective Services Law (CPSL) regarding obtaining background clearances for GMS employees, contractors, and volunteers having contact with GMS students, we conducted audit procedures to determine if GMS timely obtained and retained the required state (PSP), federal (FBI), and Child Abuse background clearances, as well as the Adam Walsh check, if applicable. 37 The CPSL requires each of the three required background clearances (PSP, FBI, and Child Abuse) to be obtained every five years. 38 It is the policy of GMS, however, to obtain new reports for the three required background clearances, for each employee, contractor, and volunteer and the Adam Walsh check for employees, if applicable, every three years. 39 As described in detail in this finding, our audit found that GMS did not have procedures and management controls in place to ensure that all background clearances were obtained timely nor were they maintained and available for our review. As a result, in some instances, we were not able to verify that employees, contractors, and volunteers selected for testing obtained the required background clearances necessary to have direct contact with GMS students. 40 The following chart provides information regarding the total number, as provided by GMS management, of the three types of individuals providing services at GMS that require background clearances, and the number of individuals we selected for testing: 37 23 Pa.C.S. §6344(b); as noted earlier in the report, the Adam Walsh Act, which was enacted on July 27, 2006, establishes a comprehensive national system for the registration of sex offenders and offenders against children. The Act also integrates the information in State sex offender registry systems and ensures that law enforcement has access to the same information across the United States. GMS requires Adam Walsh checks for employees and applicants that are non-Pennsylvania residents or have lived outside of Pennsylvania in the last five years prior to applying to work at GMS. 38 23 Pa.C.S. §6344.4(1). 39 GMS employees and contractors: GMS Policy Number 19.1, “Prison Rape Elimination Act” issued June 16, 2014 and re-issued February 26, 2018. Volunteers, who generally are local college students providing tutoring services, change frequently and GMS Policy Number 14.2, “Assignment of Interns and Volunteers” issued January 5, 2001 and re-issued May 2016 requires background clearances prior to assignment. 40 As noted in the Introduction and Background, a background clearance that indicates a conviction or a record of an offense that did not result in a conviction does not automatically/necessarily preclude an individual from working with GMS students. The CPSL outlines which specific offenses precludes working with children. 13 A Performance Audit Glen Mills Schools GMS Employees, Contractors, and Volunteers Population per GMS and Total Number of Each Selected for Testing Type Total Population per GMS Total Selected for Testing Employees 698a/ 67b/ c/ Contractors 35 10d/ Volunteers 285e/ 60f/ 1,018 137 Totals - The list of employees provided by GMS management was generated from Filemaker as discussed in the Data Reliability section of Appendix A. The employees (including both direct care [i.e., counselors and teachers, those that work directly with the students on a daily basis] and non-direct care staff [i.e., administrative positions]) on the list were employed at GMS at some point during the time period of July 1, 2017 through May 13, 2019. b/ - Of the 67 employees tested, 60 (15 employees hired on or after July 1, 2017 and 45 hired prior to July 1, 2017) were randomly selected and the remaining seven employees were selected based upon GMS incident reports that indicated they were involved in some manner with the July 2018 allegations of abuse sustained by a student while under the care of GMS staff. See Introduction and Background for details on the July 2018 incident. c/ - GMS management provided us with a list of the 35 individuals contracted by GMS at some point during the period of July 1, 2017 through August 3, 2019. As discussed in the Data Reliability section of Appendix A, we deemed the list of contractors to be of undetermined reliability; however, this is the best data available. Although this determination may affect the precision of the information we present, there is sufficient evidence in total to support our findings, conclusions, and recommendations. d/ - Of the 10 contractors tested, six were randomly selected from the list provided by GMS management and four were haphazardly selected from the contractor background clearance hard copy files maintained at GMS. Two of the four contractors selected from the hard copy files were not included in the list of 35 contractors provided to us by GMS management. The issue of GMS not maintaining a centralized list of contractors is addressed later in this finding. e/ - GMS management provided us with a list of 285 individuals that volunteered at GMS at some point during the period of July 1, 2017 through August 9, 2019. As discussed in the Data Reliability section of Appendix A, we deemed the list of volunteers to be of undetermined reliability; however, this is the best data available. Although this determination may affect the precision of the information we present, there is sufficient evidence in total to support our findings, conclusions, and recommendations. f/ - Of the 60 GMS volunteers tested, 40 were randomly selected from the volunteer list provided by GMS management and 20 were haphazardly selected from the volunteer background clearance hard copy files maintained at GMS. Source: This table was compiled by the staff of the Department of the Auditor General from data received from GMS management. While the population of employees was confirmed to GMS payroll records, the total populations provided for contractors and volunteers are of undetermined reliability as noted in Appendix A. Although this determination may affect the precision of the numbers we present, there is sufficient evidence in total to support our findings and conclusions. a/ The discussion of our test results will be separated by type of direct care worker and will be grouped as follows: (1) GMS employees; and (2) contractors and volunteers. In addition to determining whether direct care workers had the proper background clearances, we also evaluated related management’s controls, which includes whether GMS formalized its practices into written standard operating procedures and the adequacy of management controls in place to ensure compliance with GMS’ policies and procedures. 14 A Performance Audit Glen Mills Schools Test Results Related to GMS Employees PSP, FBI, and Child Abuse Background Clearances With regard to the three required background clearances, we performed audit procedures to determine various conclusions as discussed in the sections that follow. Most background clearances were on file at GMS. Of the 67 GMS employees selected for testing, we found that GMS maintained all three required background clearances for 63 employees. For the remaining four employees, we found the following: • One employee was missing the FBI clearance. GMS stated that this clearance was done, but the employee took the clearance when he resigned and GMS did not maintain a copy. • One employee was missing the FBI clearance and the PSP clearance. GMS stated that these documents were prematurely purged after the employee separated employment. • Two new employees were terminated prior to GMS receiving their FBI clearances. As discussed in a later section of this finding, these employees, along with two of the other 67 employees, were hired, as many new hires are, on a provisional basis pending receipt of their background clearances. Upon further inquiry into these responses, we found two concerns regarding GMS maintaining background clearances: • GMS only maintains the most recent background clearances for each individual. GMS management stated that although not formalized into written policy, due to the sensitive nature of information in background clearances and based upon security awareness training presented by the Pennsylvania State Police in June 2016, GMS is only maintaining the most recent background clearances for each individual. 41 On January 23, 2017 (and as reissued on August 30, 2019), however, the Pennsylvania Department of Human Services (DHS) issued an announcement stating that child care facilities’ directors are responsible for keeping copies of background clearances permanently in an employee’s file. 42 Although GMS is not designated as a child care facility under the 41 Individuals includes GMS employees, contractors and volunteers. Also, this decision did not affect the auditors from reviewing current background clearances. 42 DHS Announcement C-17-01 issued to clarify the requirements in the Pennsylvania Code to meet the CPSL requirements. ISSUE DATE: September 18, 2018 REISSUE DATE: August 30, 2019. The announcement was reissued pursuant to Act 47 of 2019, effective September 19, 2019, which as previously noted, added the Adam 15 A Performance Audit Glen Mills Schools CPSL and its associated regulations we believe this is a best practice that GMS should implement. 43 Retaining older background clearances would allow for review to confirm that prior background clearances had been obtained and would provide the means to verify report dates and when background clearances should be renewed to comply with requirements. • In 2017, GMS’ intention was to put into practice the purging of background clearances one year after individuals ended their employment or stopped providing services to GMS students. According to GMS management, the Pennsylvania State Police security awareness training noted above also resulted in GMS management, in 2017, to begin purging employees’ background clearances one year after their separation date and background clearances of contractors and volunteers one year after their services at GMS ended. GMS management also cited guidance from the United States Equal Employment Opportunity Commission (EEOC) to make this decision. 44 We found, however, that this decision was not formalized in policy and, in fact, regarding GMS employees, it was not consistent with current policy, which states that the records of former employees shall be retained in the inactive files of the Personnel Office. 45 Based on our review of the background clearances for 67 employees selected for testing, we also found that this decision was not consistently put into practice. Although 14 employees had a separation date more than one year before our test date, GMS had not purged any of their background clearances. This lack of compliance however, allowed us to perform our testing for these 14 employees. Conversely, as previously stated in the finding, GMS was unable to provide the PSP or FBI clearances for 1 of the 67 employees whose separation date was twelve days less than one year prior to our test date. GMS management stated that the documents had mistakenly been purged. We, therefore, were unable to validate the eligibility of this employee to have direct contact with GMS Walsh check requirement to the CPSL applicable solely to employees or volunteers at a child day-care center, group day-care home, or family child-care home. 43 While GMS is within the general category of “Child-care services” under the CPSL, GMS is within the specific category of a "Child Residential Facility” under the CPSL and DHS’ regulations and is clearly not a “Child Care Facility”. Under Section 6303 (relating to Definitions) of the CPSL, GMS falls in to the category of: “‘Child-care services.’ Includes any of the following:…(13) Other child-care services that are provided by or subject to approval, licensure, registration or certification by the department….” Under Section 3800.5 (relating to Definitions) of the DHS’ regulations, a “Child residential facility” is a “premise or part thereof, operated in a 24-hour living setting in which care is provided for one or more children who are not relatives of the facility operator” with some exemptions under Section 3800.3 including “child day care centers”. See 23 Pa.C.S. §§ 6303(13) and 6344(a)(1) and (b); see 55 Pa. Code Chapter 3800, specifically, 55 Pa. Code §§ 3800.3(10) and 3800.5. 44 U.S. Equal Employment Opportunity Commission, “Background Checks What Employers Need to Know” section entitled, “Disposing of Background Information.” A joint publication of the Equal Employment Opportunity Commission and the Federal Trade Commission. 45 GMS Policy 3.8, “Personnel Records.” 16 A Performance Audit Glen Mills Schools students. The remaining 52 employees, whose background clearances were still on file at GMS, had either separated employment from GMS less than one year from our test date or were still employed at GMS. It is important for GMS management to establish, through formal policy and subsequent training, the appropriate timeframes for retaining background clearances for former employees. As part of establishing appropriate timeframes, consideration must be given that would allow independent third parties to be able to evaluate the background clearances of former employees for a reasonable amount of time. GMS permitted four new employees to continue working with GMS students despite not obtaining their FBI clearances within the required provisional time period. Pursuant to the CPSL and DHS’ regulations and related guidance in effect during the audit period, employees may be hired on a provisional basis pending receipt of the required background clearances if certain conditions are met. 46 The DHS’ regulations allow provisional employees to be hired for a period of time that does not exceed 30 days for Pennsylvania residents or 90 days for non-Pennsylvania residents. If the provisional employee does not submit the required clearances within 30 or 90 calendar days of employment, whichever is applicable, the facility must do one of the following: • • • Dismiss the provisional employee until the required clearances are received. Lay off or place the provisional employee on leave with or without pay until the clearances are received. Retain and reassign the provisional employee to a position that does not involve direct contact with children. 47 As part of our audit, we determined that 29 of the 67 employees selected for testing were within their initial three-year employment period and therefore, GMS only had to obtain their background clearances at the time of hire. 48 For these 29 employees, we performed procedures to determine if GMS had obtained the background clearances within the previously reported required time-frame of 30 or 90 calendar days of employment. We found that GMS did not obtain the FBI clearance within the required timeframe for 4 of the 29 employees, ranging from 23 Pa.C.S. § 6344(m), 55 Pa. Code § 3490.127, and DHS Regulatory Compliance Guide, 55 Pa. Code Chapter 3800, January 1, 2013 Edition. As discussed in a later section, the CPSL was subsequently amended by Act 47 of 2019, effective December 31, 2019 and facilities like GMS are no longer permitted to hire employees on a provisional basis. 47 55 Pa. Code § 3490.127 and DHS Regulatory Compliance Guide, 55 Pa. Code Chapter 3800, January 1, 2013 Edition. 48 These employees may have been hired prior to the beginning of the audit period on July 1, 2017, but the three year background clearance renewal time period had not yet expired as of the date of our audit procedures. 46 17 A Performance Audit Glen Mills Schools 6 to 38 days late. 49 GMS management stated that they allowed these four employees to continue to work with GMS students because these employees’ PSP and Child Abuse clearances did not indicate a record that would preclude them from working with children and did not have any knowledge or information that would disqualify the individuals from employment. However, allowing the four employees to continue to work with GMS students is in direct violation of the previously cited section of the DHS’ regulations. Although we confirmed that the PSP and Child Abuse clearances for these four employees did not contain disqualifying information, GMS should not have assumed that a disqualifying offense would not be on the FBI clearance. Further, after the end of our audit period, the CPSL was amended effective December 31, 2019, to no longer allow facilities, like GMS, to employ applicants on a provisional basis. 50 As a result, individuals that do not have all three required background clearances are no longer allowed to be hired and have direct contact with children. This update to the CPSL supports our concern that during the audit period GMS allowed employees that did not have all of their required background clearances to have direct contact with GMS students, therefore potentially putting the students at risk of harm. GMS did not have all required justification forms on file for employees whose background clearances listed offenses. The Introduction and Background describes the process of reviewing the background clearances and, if offenses are reported, how the offenses are vetted through a justification form that documents the basis for GMS’ decision to either hire or retain the individual. 51 Although we determined that this process appears to be sufficiently designed based on our test work described in the next paragraph, we note that this process is not documented in a policy and/or in written procedures. GMS should formalize this process in either a policy or written procedures to help ensure that justification is properly documented and approved for each employee whose background clearance contains a non-disqualifying offense. Two of these four new employees were previously noted in the finding as employees whose FBI clearances were not obtained within the required provisional hiring period; however, GMS management allowed them to continue to work until they were terminated. GMS management confirmed that the cause for the employees’ termination was not related to the lack of their FBI clearances. Regarding the other two employees, GMS did receive their clearances but not until after their provisional hiring periods had expired. The number of days late for the two employees that were terminated was calculated based upon each of the employee’s respective termination dates. 50 Act 47 of 2019. Please see current 23 Pa.C.S. § 6344(m) which now states, in part: “(m) Provisional employees for limited periods.--Employers, administrators, supervisors or other persons responsible for employment decisions may not employ applicants on a provisional basis, except that the department is authorized to grant a waiver of this provision upon request from a child day-care center, group day-care home or family child-care home. If a child day-care center, group day-care home or family child-care home is granted a waiver, an applicant may be employed on a provisional basis for a single period not to exceed 45 days…” under certain conditions. (Emphases added.) 51 GMS management stated that when background clearances are renewed for employees, if a new offense is reported on a background clearance then a justification form will be prepared; however, if the offense was reported on a previous background clearance then the justification form that was prepared at that time will be used. 49 18 A Performance Audit Glen Mills Schools Of the 67 employees selected for testing, we identified 12 employees who had a total of 17 background clearances that listed offenses and requested to review the justification forms used by GMS to document the decision to either hire or retain an individual with offenses reported on their respective background clearances. Based on our review of the available justification forms, it appears that the justification forms were adequately documented and properly approved. However, GMS management stated that they were unable to locate justification forms for the following: • • Four employees whose FBI clearance indicated offenses. One employee whose PSP and FBI clearances indicated offenses. Without the justifications, we could not confirm that GMS management reviewed the offenses listed on the employees’ background clearances or what GMS management based its decision on to hire the individuals. While our review of the background clearances in question did not reveal any offenses which would prohibit the employee from working with children, the lack of approved justification forms on file increases the risk that a person potentially could be hired without proper consideration being given to ensure students are not being put at risk of harm. Background clearance dates for several employees were not accurately recorded in GMS’ tracking system. GMS utilizes the tracking system software Filemaker to record background clearance dates and to monitor when background clearances should be renewed for employees, based on GMS’ policy of background clearance renewals every three years. To determine whether data in Filemaker was accurate, we compared the actual background clearances for the 67 employees selected for testing to the information recorded in Filemaker and found that the records for 14 employees had an incorrect background clearance date entered for one of their background clearances. 52 The difference in the date of the background clearance to the date entered into Filemaker ranged from one to thirty days. Although GMS’ policy for renewing background clearances is more stringent than that of the CPSL, it is still important that dates be accurately entered into Filemaker to ensure background clearances are obtained in a timely manner according to GMS policy and also within the time period required by the CPSL. GMS management stated that one staff member is assigned the responsibility of recording background clearance dates in Filemaker and her work is only reviewed “as needed” by her supervisor. As the renewal of background clearances is prompted by the background clearance dates in Filemaker, a review by a supervisor, which should be documented, after background clearance dates have been recorded in Filemaker at least on a sample basis should improve the accuracy of the background clearance dates. 53 Background clearances included five Child Abuse, seven PSP, one FBI, and one Adam Walsh check. While we consider the list of employees contained in Filemaker to be sufficiently reliable, due to the clerical errors found, we do not consider the information included in the records for each employee within Filemaker to be sufficiently reliable and do not place reliance on this data, as discussed in Appendix A. 52 53 19 A Performance Audit Glen Mills Schools Adam Walsh checks As noted in the Introduction and Background section of this report, GMS requires Adam Walsh checks for employees and applicants that are not Pennsylvania residents or have lived outside of Pennsylvania within the last five years prior to applying to work at GMS. 54 To determine if GMS complied with its policy, we reviewed the background clearances on file for the 67 employees selected for testing and found the following: • • GMS acknowledged that an Adam Walsh check was not run for one employee that lived outside of Pennsylvania at the time of application. We were unable to determine if GMS should have obtained Adam Walsh checks for four GMS employees because GMS did not obtain in writing the individuals’ addresses for all five years preceding their employment at GMS. 55 As the result of our audit procedures and inquiries, GMS management stated that in order to ensure that it obtains the information necessary to determine if an Adam Walsh check should be conducted, they have updated the job application to include a section requesting the residential addresses of the applicant for the prior five years. We did not, however, review the updated job application as part of our audit procedures. Test Results Related to Contractors and Volunteers Contractors With regard to the PSP, FBI, and Child Abuse background clearances, we performed audit procedures for 10 selected contractors and found the following: • GMS maintained background clearances for eight contractors that were current and valid for the contractors to work with students during the period of our review. • GMS accepted two contractors’ Child Abuse clearances that were only certified for volunteers. For two contractors, their PSP and FBI clearances were current and valid; however, GMS accepted Child Abuse clearances with certification purposes indicating Volunteer instead 54 As noted in previous footnotes, the Adam Walsh check requirement was added to the CPSL through Act 47 of 2019, effective September 19, 2019, but it solely applies to employees or volunteers at a child day-care center, group day-care home, or family child-care home. See 23 Pa.C.S. § 6344(c)(4)(ii). 55 Two of the four employees were staff that GMS investigated as being involved with the alleged abuse incident on July 19, 2018 and were subsequently terminated. 20 A Performance Audit Glen Mills Schools of Employee, which is in violation of the CPSL. 56 GMS management stated that it accepted a Volunteer Child Abuse clearance for the two contractors because the clearances were in good standing and the certification purpose does not affect the results of the Child Abuse clearances. We noted, however, that in addition to being a violation of the CPSL, the DHS web-site, through which an individual obtains a Child Abuse clearance, indicates that clearances obtained for volunteer purposes cannot be used for employment purposes. 57 Therefore, GMS should not have accepted Volunteer type Child Abuse clearances for these contractors. Based upon our further audit procedures, we found two additional weaknesses in management controls regarding lack of review and monitoring of contractor background clearances, as follows: • GMS does not maintain a centralized list of its contractors, who have direct contact with GMS students, to track and monitor the status of background clearances. As noted in the table at the beginning of this finding, although GMS provided us with a list of contractors who contracted with GMS at some point during the period July 1, 2017 through August 3, 2019, we found that the list was incomplete. 58 Specifically, we haphazardly selected four contractors from hard copy files and identified that two of these contractors were not included on the list. GMS acknowledged that this list was created based on our request because it did not have a centralized list of all contractors who had direct contact with GMS students in order to track their background clearances. Instead, prior to our request, GMS only maintained a list and tracked background clearances of those individuals that contracted directly with GMS, which did not include the names of individuals that worked for vendors that contracted with GMS. GMS management additionally stated that for those individuals that work for a GMS contracted vendor, it was GMS’ expectation that the contracted vendor would monitor the background clearance dates and provide GMS with the most recent clearances. It is, however, the responsibility of GMS to ensure that all background clearances are current and contain no improper convictions that prevent the contractor from having contact with its students. 23 Pa.C.S. § 6344(b.3) Volunteer certification prohibition. According to GMS management, one of the contractors was only on GMS campus for one day and did not return to work on campus after that day. 57 http://keepkidssafe.pa.gov/cs/groups/webcontent/documents/document/c_135246.pdf (accessed December 2, 2019). 58 See also the data reliability assessment in Appendix A regarding the issue of the incomplete list of contractors provided by GMS management. 56 21 A Performance Audit Glen Mills Schools • GMS does not require supervisory review of contractors’ background clearances to ensure that follow-up is performed, if necessary. GMS management stated that the majority of contractors submit their background clearances to the personnel department at the time of their orientation and that it was the personnel departments’ responsibility to review the background clearances. In the instances where the contractors did not bring their background clearances to orientation, the contractor would provide the clearances to their contact person prior to providing services. The GMS contact person would then submit the clearances to the personnel department, whose staff would review and file the background clearances. 59 There is, however, no supervisory review performed to confirm that there are no offenses reported that require follow-up. Without supervisory review to determine if offenses are reported that would preclude the individuals from having direct contact with GMS students, GMS is at greater risk of allowing contractors, who are not cleared, to work with GMS students. GMS should develop written procedures to help ensure that these steps are followed regarding obtaining and reviewing contractor background clearances, including documenting the supervisory review. Volunteers With regard to the PSP, FBI, and Child Abuse background clearances, we performed audit procedures for 60 selected volunteers and found the following: • GMS maintained the three types of required background clearances for 52 volunteers selected for testing. • GMS did not have all the required background clearances on file for eight GMS volunteers. GMS management was unable to locate 13 background clearances for 8 of the volunteers selected for testing, and therefore, we could not validate the eligibility of these eight volunteers to have direct contact with GMS students. 60 GMS management responded that they could not provide an answer as to why the background clearances were missing, and we were unable to determine if GMS ever obtained the background clearances or if they were obtained but not properly filed/maintained. GMS management further explained and provided us with orientation training slides to support that volunteers receive training to The GMS contact person for contractors would depend on the type of service being provided. Two volunteers were missing all three types of background clearances; one volunteer was missing two background clearances (PSP and FBI); and five volunteers were each missing one background clearance (one was missing the Child Abuse, three were missing the FBI, and one was missing the PSP). 59 60 22 A Performance Audit Glen Mills Schools inform them that they are not permitted to be alone with GMS students and must always work in the presence of a full-time GMS staff member. 61 As described in the next section of the finding, GMS did not maintain a centralized list of volunteers prior to us requesting a list, which may have contributed to the issue of the missing background clearances. Based upon our further audit procedures, we found two additional weaknesses in management controls regarding lack of review and monitoring of volunteer background clearances, as follows: • GMS does not maintain a centralized list of its volunteers to track and monitor the status of background clearances. Similar to the previously discussed issue with its contractors, GMS does not maintain a centralized list of its volunteers to track and monitor the status of background clearances. 62 GMS management stated that personnel department staff are responsible for the formal tracking of volunteer background clearances. GMS management further stated that the personnel department used multiple sign-in sheets from volunteer orientation training as the sources for the names of the volunteers scheduled to work with GMS students for that particular semester. In relying upon sign-in sheets, the personnel department risked not tracking volunteers that either did not attend or did not sign in at orientation training. The lack of a centralized list may have contributed to why, as previously reported, GMS did not have all of the background clearances on file for eight volunteers. • GMS does not require supervisory review of volunteers’ background clearance results to ensure that follow-up is performed, if necessary. Similar to contractor background clearances, GMS does not require supervisory review of the results of volunteer background clearances to ensure that follow-up is performed for those whose background clearances list offenses. Management stated that the majority of the volunteers submit their background clearances to the personnel department staff at the time of their orientation. In instances where a volunteer did not bring his/her background clearances to orientation, the background clearances would be given to their GMS contact person who would then submit them to the personnel department, whose staff would 61 Although we performed testing to determine if those that volunteered during the audit period received orientation training and found documents to support that 59 of the 60 volunteers selected for testing had received the training (further discussed in Finding 2), we could not validate that the volunteers’ training included the specific training slides described by GMS management. 62 See also the data reliability assessment in Appendix A regarding the issue of the incomplete list of volunteers provided by GMS management. 23 A Performance Audit Glen Mills Schools review and file the background clearances. 63 Without supervisory review to determine if offenses are reported that would preclude the volunteers from having direct contact with GMS students, GMS is at greater risk of allowing volunteers, who are not cleared, to work with GMS students. GMS should develop written procedures to help ensure that these steps are followed regarding obtaining and reviewing volunteer background clearances, including documenting the supervisory review. Conclusion Overall, improvements are needed in the way in which GMS tracks all individuals that have contact with any GMS students and how it processes, maintains, and tracks the background clearances required for its employees, contractors, and volunteers. In particular, the lack of a centralized list for both the contractors and volunteers increases the risk that GMS may not obtain the required background clearances for individuals that have direct contact with its students. Additionally, GMS must develop or update written policies and procedures that formalize these processes. After completion of our audit procedures, GMS management provided us with copies of updated GMS policies to reflect some of the improvements that we discussed are needed in this finding; however, we did not review the updated policies as part of our audit procedures nor do we comment on the appropriateness/effectiveness of the new policies. It is critical that the safety and security of GMS students be maintained. Every effort needs to be made to ensure that GMS students are protected and not put at risk of harm. Each background clearance that GMS management does not obtain and review could potentially contain information that may disqualify an individual from having direct contact with GMS students. Even just one potential instance that increases risk of harm is one too many. Additionally, moving forward with what is now required by recent updates to the CPSL, GMS must ensure that individuals that do not have all the required background clearances are not permitted to have any contact with any GMS students. Recommendations for Finding 1 We recommend that GMS: 1. Consider, in consultation with the Pennsylvania State Police, discontinuing the practice of only maintaining the most recent background clearances obtained for employees, contractors, and volunteers and developing an appropriate timeframe for retaining noncurrent background clearances for GMS employees, contractors, and volunteers. The contact person for volunteers was either the GMS Academic Coordinator or the Special Education Coordinator. 63 24 A Performance Audit Glen Mills Schools 2. Formalize in written policy how long non-current background clearances should be maintained after a determination has been made. 3. Consider, in consultation with the Pennsylvania State Police, lengthening the timeframe for purging all background clearances after an individual separates from GMS to ensure that an independent party can evaluate whether former GMS employees, contractors, and volunteers were permitted to have direct contact with GMS students. 4. Formalize in written policy the length of time after a determination is made that background clearances should be purged. 5. Maintain centralized, up-to-date lists of all contractors and volunteers in order to help facilitate the following: a) Ensuring that all required background clearances have been obtained. b) Ensuring that all of these individuals have the required background clearances necessary to have contact with GMS students. 6. Formalize in written policy and/or standard operating procedures who is responsible for maintaining a centralized list of contractors and volunteers and monitoring to ensure that all background clearances necessary to have direct contact with GMS students have been obtained and reviewed. 7. Implement a review process to help ensure the accuracy of the background clearance information, in particular report dates, posted to the Filemaker tracking system. 8. Formalize in written policy and/or standard operating procedures the process of requiring a supervisor to review the accuracy of background clearance information recorded in Filemaker. 9. Do not allow employees, contractors, and volunteers that do not have all of the required background clearances on file at GMS to have any contact with GMS students. 10. Maintain approved justification forms on file for all GMS employees with offenses listed on their background clearances. 11. Formalize in written policy and/or standard operating procedures the process of preparing, approving, and retaining justification forms for all GMS employees with offenses listed on their background clearances. 25 A Performance Audit Glen Mills Schools 12. Implement documented supervisory review of GMS employees, contractors, and volunteer background clearance results to ensure that: a) Follow-up is performed if a background clearance indicates an offense. b) A correct determination is made regarding the eligibility of the individual to have direct contact with GMS students. 13. Formalize in written policy and/or standard operating procedures the process of reviewing all background clearances, including having a second level of review to ensure follow-up is performed on any offenses listed. 14. Obtain from all applicants their residential addresses for all five years preceding their application for employment at GMS. 15. Obtain and review Adam Walsh checks for all applicants who were not Pennsylvania residents in any of the five years preceding their request for employment at GMS. 16. Obtain Adam Walsh checks for all GMS employees who are not Pennsylvania residents. 17. Formalize in written policy and/or standard operating procedures the requirement and process for Adam Walsh checks for all GMS employees and applicants that are not Pennsylvania residents and applicants that were not Pennsylvania residents in any of the five years preceding their request for employment at GMS. 18. Do not accept “Volunteer” type Child Abuse clearances obtained from the Pennsylvania Department of Human Services for “Employee” purposes. 26 A Performance Audit Glen Mills Schools Finding 2 – Glen Mills Schools did not ensure that some individuals who may have direct contact with its students received all of the required training related to the prevention of child abuse and the mandatory reporting of suspected abuse. The Child Protective Services Law (CPSL) requires Glen Mills Schools’ (GMS) employees who have direct contact with children and individuals applying for a professional license or certification, including contractors such as medical, dental, and therapy staff, all of whom are legally mandated reporters, to complete training addressing the recognition of the signs of child abuse and reporting requirements for suspected abuse in the commonwealth. 64 Pennsylvania Department of Human Services’ (DHS) regulations and GMS management also require direct care employees, contractors, and volunteers to receive training related to the prevention of child abuse and mandatory reporting. Collectively, we are referring to this required prevention of child abuse and mandated reporter training as “required training” throughout this report. 65 Completion of this required training is critical because it provides the necessary foundation to help ensure a safe and secure environment for all students, especially since GMS provided residential programming to adjudicated male youth, among other non-residential services provided to both male and female youth. 66 Additionally, as noted in Appendix B, GMS has appealed DHS’ orders to remove the students and revoke its licensing certificates; therefore, it is of utmost importance that GMS ensures that all individuals that may come into direct contact with students receive all the required training if the school reopens. See CPSL 23 Pa.C.S. § 6383(c)(4)(i) which provides for “Education and Training” for all persons subject to DHS’ regulation for the prevention of child abuse and mandatory reporting including, among others: “(4) Training curriculum shall be approved by…[DHS] and shall address, but not be limited to, the following: (i) Recognition of the signs of abuse and reporting requirements for suspected abuse in this Commonwealth.” See also CPSL 23 Pa.C.S. § 6303 that defines the term “Mandated reporter” as “[a] person who is required by this chapter to make a report of suspected child abuse.” Such reporters are immediately required to make a report of suspected child abuse. ChildLine is part of a mandated statewide child protective services program designed to accept child abuse referrals and general child well-being concerns, and transmit the information quickly to the appropriate investigating agency. Individuals can contact ChildLine’s toll-free hotline, which is available 24 hours a day, seven days a week. Direct care employees include individuals that do have regular and significant contact with students, such as counselors and teachers, while non-direct care employees include individuals who do not have regular and significant direct contact with students, such as administrative staff. 65 Training requirements and GMS policies and procedures related to training are outlined in the Introduction and Background section and Appendix C of this report and discussed in further detail in this finding. 66 The programs provided by GMS are discussed in the Introduction and Background section of our report. 64 27 A Performance Audit Glen Mills Schools Based on our audit procedures, we identified several weaknesses within GMS’ training program for employees, contractors, and volunteers as well as with the maintenance of training records categorized within the following areas: • • • GMS lacks adequate written training policies and procedures. Training testing results identified weaknesses involving the completion of required training and the failure to properly maintain training records. Significant deficiencies identified related to developmental training and on-the-job orientation. The above weakness areas are addressed in detail in the following sections. GMS lacks adequate written training policies and procedures. Based on interviews and correspondence with GMS management and review of GMS’ written training policies and procedures, we found that GMS’ policies and procedures do not align with current practices and, therefore, are not adequate. 67 This deficiency increases the risk that employees, contractors, or volunteers will not receive the required training or receive it timely. Specifically, GMS’ current written training policies and procedures do not include the following: • • • Child Abuse Recognition and Reporting (CARR) training that addresses how to recognize the signs of child abuse and reporting requirements for suspected child abuse for employees as required by the CPSL and for volunteers as required by GMS. Specifics such as the number of required training hours and completion timeframes for training, such as behavioral intervention and restrictive procedures and Prison Rape Elimination Act (PREA) instruction. 68 Requirements for contractors that include providing copies of valid professional licenses as support for their completion of CARR training. Training policies and procedures should include more clarity regarding the training required, including allowable timeframes for completion. 69 Further, the training policies and procedures should include all training requirements, not just for employees, but also for contractors and volunteers. Because these specifics were not included in GMS’ policies and procedures, we asked GMS to prepare a detailed list of the training required for employees, contractors, and Glen Mills Schools Policies and Procedures, Policy Number 3.15: Training and Training Criteria. Issued January 5, 2001 and re-issued April 2015 and Glen Mills Schools Policies and Procedures, Policy Number 3.17: Orientation Training. Issued January 5, 2001 and re-issued April 2015. 68 Glen Mills Schools Training and Training Criteria Policy did include the required number of hours of on-the-job orientation (120 hours) and annual developmental training (40 hours) for direct care staff. 69 In lieu of not having an up-to-date policy, GMS provided us with an additional document, entitled the “GMS Training Designs Summary.” The “GMS Training Designs Summary” however only lists available training for employees and is not referenced within the GMS’ actual training policy. 67 28 A Performance Audit Glen Mills Schools volunteers and the respective timeframes each type of training was required to be completed. GMS provided this information in a document entitled “Training Timeline” which is presented in Appendix C. We utilized the “Training Timeline” along with training requirements established in the CPSL and DHS guidelines as the criteria to conduct our testing of training records. Training testing results identified weaknesses involving the completion of required training and the failure to properly maintain training records. This section of our finding discusses the results of our review of training records for GMS employees, contractors, and volunteers that have direct contact with GMS students. 70 GMS Employees The following table summarizes our test results for a selection of 65 of the 698 employees working at GMS within the time period of July 1, 2017 through May 13, 2019. 71 The first three columns of the table include the results of the testing of 12 employees that were hired after the beginning of our audit period of July 1, 2017 (new hires) and the last four columns of the table covers the refresher courses that includes the results of both the new hires and the remaining 53 employees that were hired prior to July 1, 2017 (existing employees). The seven employees involved in some manner with the July 2018 alleged student abuse incident are included in our selection of the 53 existing employees. 72 While GMS maintains hard copies of employee training support documents, such as training sign-in sheets and training certificates, and tracks employee training (such as training course title, date of training, and number of completed hours) in its tracking system software, Filemaker, we found deficiencies as noted in the table below and described in further detail in the following sections. Information regarding the total number, as provided by GMS management, of the three types of individuals that may have had direct contact with GMS students is included in Appendix A, Objectives, Scope and Methodology. 71 We selected 67 employees to test, however, two were non-direct care employees in which the training requirements we tested did not apply. We, therefore, only included the testing results of 65 direct care employees. Of the 65 employees, 48 were randomly selected, 10 were judgmentally selected to ensure coverage across different types of direct care employees, and 7 were selected based upon GMS incident reports that indicated they were involved in some manner with the July 2018 allegations of abuse sustained by a minor/child while under the care of GMS staff. 72 See Appendix B for timeline of events regarding an alleged assault against a GMS student by GMS staff that led to the DHS order to remove all students and revocation of GMS licenses to operate a child residential facility. 70 29 A Performance Audit Glen Mills Schools Employee Training Test Results Orientation/Initial Training Refresher Courses New Hires New Hires and Existing Employees Child Abuse Recognition and Reporting (CARR)a/ Behavioral Intervention Training (BIT) & Restrictive Proceduresa/ Prison Rape Elimination Act (PREA)a/ Child Abuse Recognition and Reporting (CARR)a/ Behavioral Intervention Training (BIT) & Restrictive Proceduresa/ Prison Rape Elimination Act (PREA)a/ September 2018 Abbreviated Mandatory Reporterb/ Total number 12 12 12 65 65 65 65 selected for testing Lack of evidence to support completion of required 0 0 0 3 0 0 1 training Training not 2 0 1 0 0 0c/ 0 completed timely Complied with training requirements; however, clerical 1 0 4 6 0 0 37 errors foundd/ Complied with training 9 12 7 44 55 50 12 requirements 0 0 0 12e/ 10f/ 15f/ 15g/ Not applicable a/ - Training is required by either the CPSL or DHS. b/ - Training was not required; however, after the July 2018 incident and DHS’ investigation that found that staff failed to report an incident of abuse, GMS management partnered with an outside consultant to present employees with an abbreviated mandatory reporting training that focused on the care of students and emphasized identifying and reporting child abuse. c/ - While we report no exceptions to completion of the refresher for the PREA training within the required timeframe during our audit period, we did find one employee who received training in July 2018, but GMS did not have a record to support that required refresher training was completed in 2016. The last training on record prior to July 2018 was completed in June 2014. d/ - Clerical errors included either an incorrect date or number of training hours being posted to an employees’ training record, training hours received were not posted to the employees’ training record, or employee signed but did not date the training sign-in sheet to indicate the date training was received. Due to the clerical errors found, we do not consider the records for each employee within Filemaker to be sufficiently reliable and do not place reliance on this data, as discussed in Appendix A. e/ - Employees were new hires and, therefore, did not yet require recertification of CARR training. f/ - Employees were terminated prior to the date the refresher was required. g/ - Employees were not employed by GMS at the time the training was provided. Lack of evidence to support completion of required training We found that GMS did not maintain documentation to demonstrate that the required three hour CARR training was completed for three employees. Specifically, no CARR certificates were provided for two employees and only a two hour CARR certificate was provided for the third employee. GMS management indicated that these were isolated oversights. 30 A Performance Audit Glen Mills Schools With regard to the abbreviated mandatory reporter training offered after the July 2018 alleged incident of abuse, one employee did not have any record of completing the training. GMS management was unsure as to why one employee did not attend the training. Training not completed timely We also found that three newly hired GMS employees did not receive either their CARR or PREA training timely, resulting in non-compliance with the CPSL or DHS regulations, respectively. CPSL requires CARR training to be completed within 90 days of an employee’s hire date and DHS regulations require PREA training to be completed within 120 days of the employee’s hire date. Two employees received their CARR training 22 and 35 days late, respectively, and one employee was 16 days late in receiving his/her PREA training. GMS management indicated that they could not speculate as to why the two employees did not receive their CARR training within the required 90 days. Regarding the employee who did not timely attend PREA training, GMS management indicated that the employee did not attend his/her originally scheduled PREA training and the next available training date, which he/she attended, was after the required 120 days. Given the importance of the issues covered in CARR and PREA training, such as recognizing the signs of child abuse and mandated reporting requirements, as well as preventing, detecting, and investigating sexual abuse, GMS should ensure that training is completed within the required time frames prior to allowing employees to work alone with the students. 73 Clerical Errors During our testing of employee training records, we found numerous clerical errors which included the following: 74 • One employee had only one hour credit for his initial CARR training recorded in Filemaker; however, the CARR certificate indicates that he actually received the required three hours. According to GMS management, the erroneous entry in Filemaker was an oversight. • Four employees received four hours credit each for PREA training in Filemaker, when PREA training is actually only three hours in length per GMS. This was a result of the sign-in sheet incorrectly indicating that the PREA training was four hours in length. CPSL 23 Pa.C.S. § 6383(c)(4)(i) providing for “Education and Training” for all persons subject to DHS’ regulation for the prevention of child abuse and mandatory reporting and Glen Mills Schools Policies and Procedures, Policy Number 19.1: Prison Rape Elimination Act. Issued June 16, 2014 and re-issued February 26, 2018. 74 Note that due to the clerical errors found, we do not consider the data records for each employee within Filemaker to be sufficiently reliable and do not place reliance on this data, as discussed in Appendix A. 73 31 A Performance Audit Glen Mills Schools • Of the six employees with clerical errors related to refresher CARR training, five had the CARR training listed in their training records in Filemaker, but no hours were noted; and one employee did not have the course listed in his/her training records. All six employees had certificates noting that they had completed the three hour training course. • Thirty-seven errors were recorded in Filemaker relating to the posting of the September 2018 abbreviated mandatory reporter training. These errors included instances of the wrong training date recorded in Filemaker, and instances in which we could not verify whether GMS staff posted the correct completion date in the employees’ Filemaker records due to employees signing but not dating the respective sign-in sheets. We followed-up with GMS management to determine whether GMS had procedures in place to review the postings made to employees’ training records to ensure compliance with training requirements. According to GMS management, the postings were reviewed to ensure that employees received credit for the training but there was not a procedure in place to check that the dates were entered correctly and certificates were maintained demonstrating completion. Based on our test results, however, we noted one instance where an employee who completed refresher CARR training did not have it recorded in his/her training records. This instance indicates that this management control was not working as it was intended. As a result of our audit, GMS management stated that they are in the process of implementing new procedures for checking the accuracy of recording training in Filemaker. Contractors GMS contractors, including but not limited to dentists, psychiatrists, and therapists, are required to have CARR training. If the contractor is licensed by the Pennsylvania Department of State (DOS), the CPSL requires DOS to make training available for all professional licensing boards whose licensees are charged with responsibilities for reporting child abuse. 75 Each licensing board with jurisdiction over professional licensees identified as mandated reporters must require all individuals applying for a license to submit documentation of the completion of at least three hours of CARR training and all individuals applying for the renewal of a license to submit proof of completion of approved continuing education. As a result, in lieu of obtaining CARR training certificates, GMS management stated that it requires contractors to provide to GMS their current active license. To determine if GMS had current active licenses of contractors to ensure completeness of CARR training, we randomly selected 10 of the 35 contractors who were contracted by GMS at some point during the period of July 1, 2017 through August 3, 2019 to provide services to GMS students. 76 While GMS tracks the contractors’ licensing status in a spreadsheet, we found that CPSL 23 Pa.C.S. § 6383(b) Duties of Department of State. We randomly selected six contractors from the list provided by GMS management and randomly selected four from the contracted employee hard copy files maintained at GMS. As discussed in the Data Reliability section of Appendix A, we deemed the list of contractors to be of undetermined reliability, however, this is the best data 75 76 32 A Performance Audit Glen Mills Schools only eight contractors had current licenses issued by DOS. The remaining two contractors were hired as yoga instructors whose professional licenses are not issued by DOS. As a result, we requested, but GMS was unable to provide, documentation to support that the two contracted yoga employees completed CARR training prior to providing services for GMS during the audit period. Given the importance of the completion of CARR training for those contractors whose professional license is not issued by DOS, GMS should ensure that the individual completed the required CARR training and maintain documentation for record keeping purposes. Volunteers Volunteers are generally students from local universities that provide tutoring services to GMS students. According to the training timeline prepared by GMS at our request, all volunteers are required to complete CARR online training in accordance with GMS’ unwritten procedures and a face-to-face orientation training provided by the GMS personnel department as required by DHS and included in GMS’ training policy. 77 GMS indicated that it maintains hard copies of volunteer training records using a manual filing system. Specifically, training records for volunteers who had completed CARR and face-to-face orientation training were placed in the back of a file box and training records for volunteers who had not completed all training were placed in the front of a file box. We randomly selected 60 of the 285 volunteers that GMS indicated provided services at GMS at some point during the period of July 1, 2017 through August 9, 2019. 78 We reviewed the training records for these 60 volunteers and found that GMS failed to maintain CARR certificates for 21 volunteers. GMS management stated that they were unable to locate all of the volunteer CARR certificates. Additionally, GMS could not provide a face-to-face orientation acknowledgement form for one of the 60 volunteers. GMS management attempted to obtain copies of the CARR certificates from the local university that provided the volunteers; however, the university responded that they no longer had the certificates but confirmed that the students received the CARR training. Without GMS having the CARR certificates or the face-to-face available. Although this determination may affect the precision of the information we present, there is sufficient evidence in total to support our findings, conclusions, and recommendations. 77 55 Pa. Code Chapter 3800.58(a) Staff Training, and Glen Mills Schools Policies and Procedures, Policy Number 3.15: Training and Training Criteria. Issued January 5, 2001 and re-issued April 2015. 78 The 60 volunteers selected for testing were the same individuals selected for background clearance testing with the exception of one volunteer who subsequently did not provide volunteer services to GMS. We replaced that one volunteer with a volunteer that did provide volunteer tutoring services. See Appendix A for methodology regarding the selection of the 60 volunteers. As discussed in the Data Reliability section of Appendix A, we deemed the list of volunteers to be of undetermined reliability, however, this is the best data available. Although this determination may affect the precision of the information we present, there is sufficient evidence in total to support our findings, conclusions, and recommendations. 33 A Performance Audit Glen Mills Schools acknowledgement form, we could not independently verify that all the volunteers we selected for testing had the required training. 79 If training records for volunteers were tracked using a formal mechanism, such as a spreadsheet or software program, and then reviewed for accuracy and compliance, GMS may have avoided not having the aforementioned documents to support that its volunteers received the required training. Significant deficiencies identified related to developmental training and onthe-job orientation. In addition to the initial and refresher training exceptions previously addressed, we also identified significant deficiencies in how GMS is recording developmental training and how GMS is having employees document the completion of on-the-job orientation. These deficiencies are discussed in detail below. Developmental Training DHS regulations require direct care employees of child residential and day treatment facilities to receive 40 annual hours of developmental training relating to the care and management of children. 80 GMS management indicated that these training hours are obtained by staff through weekly meetings held between staff and their supervisors. Based on our audit procedures, we found a flaw as to how GMS records this training. According to GMS management, GMS’ tracking system software, Filemaker, was set up by GMS to automatically record one hour per week of developmental training to each employee’s training record rather than entering the actual number of training hours received. 81 According to GMS management, having Filemaker automatically record this training allows GMS a way to “conservatively document the minimum of one hour per week for a large number of staff.” Although we agree that this automatic recording process may be efficient, this process provides no assurance that the training actually took place, when it took place, and who actually attended the training each week despite it being recorded in Filemaker for each direct care employee. GMS management also indicated that supervisors who provide the developmental training during weekly meetings identify who attended on staff developmental training logs, which are maintained in the living units. Therefore, these training logs if maintained could possibly be used as a source document to record actual developmental training hours to each employee’s record. CPSL 23 Pa.C.S. § 6383(c)(4)(i) providing for “Education and Training” for all persons subject to DHS’ regulation for the prevention of child abuse and mandatory reporting. 80 55 Pa. Code Chapter 3800.58(d) Staff Training. 81 See Appendix A regarding data reliability assessment of Filemaker. 79 34 A Performance Audit Glen Mills Schools In order to determine if available source documents supported GMS management’s assertion that employees received the required 40 hours of developmental training on an annual basis, we judgmentally selected five of the 65 direct care GMS employees selected for training testing. For those five employees, we requested the staff developmental training logs for calendar year 2018 in order to determine if records indicated that each had received at least the 40 hours of required training. Based on our review of the logs provided by GMS, we found the following: • For one employee, no logs were provided; therefore no evidence was provided demonstrating that the employee had completed any developmental training in 2018. According to GMS, training logs were not maintained by the Admissions Department, where this employee worked. • For two employees, we were provided a sufficient amount of logs demonstrating that these employees met the requirement for the 40 hours of developmental training. • For two employees, we were provided logs that demonstrated these employees had some developmental training in 2018 as follows: o One employee had 38 hours recorded on 33 logs. o One employee had 33.25 hours recorded on 28 logs. GMS management stated that they are confident that those two employees far exceeded the 40 hours required annually since some of the developmental training logs could not be located and the logs in general do not capture undocumented individual training, which supervisors conducted with their staff daily. Without the logs, however, we could not validate management’s assertion. GMS management acknowledged that it needs to do a better job with documenting and retaining proof of developmental training hours provided to employees. GMS management additionally explained that as part of GMS’ annual performance evaluation where an employee was evaluated by a supervisor for the year prior, employees signed a staff developmental training acknowledgement form indicating that the employee received developmental training. GMS management stated that this acknowledgement form indicates that the employee both received the required developmental training and may also reflect additional developmental trainings needed going forward. We found, however, that the form does not state that the employee actually received the training, nor does the form include a timeframe to which the training acknowledgement applies. Nevertheless, we reviewed the staff developmental training acknowledgement forms completed during the 2018 performance evaluations. GMS was able to provide staff developmental training acknowledgement forms for all but one of the 65 employees that should have had a form on file. 35 A Performance Audit Glen Mills Schools On-the-Job Orientation Another significant deficiency we identified relates to the documentation of the completion of on-the-job orientation. 82 Based on correspondence with GMS management, we found that GMS staff instructed employees to sign the staff orientation acknowledgment form, indicating the orientation was complete, upon hire rather than waiting until after the on-the-job orientation was actually completed. Then after the employee worked for 21 days, GMS staff recorded the completion of the on-the-job orientation in Filemaker. In addition, the staff orientation form did not require a signature from the employee’s supervisor confirming that the on-the-job orientation was completed. According to GMS management, the process of having the employee sign the staff orientation form ahead of time was done out of expediency and accessibility. This flawed process, however, invalidates the staff orientation acknowledgement form as adequate evidence that this training took place. GMS management should not have assumed the on-the-job orientation would be completed. After our inquiry, GMS management indicated that it intends to change its process and have the supervisor, as well as the employee, sign the orientation acknowledgement form after the 21 days has been completed. Overall Conclusion Moving forward, if DHS reinstates GMS’ licenses and the school was to reopen its doors and enroll students, it is critical that all individuals that may come into direct contact with students timely complete required training to understand their roles as mandated reporters for reporting suspected child abuse and preventing all types of child abuse on campus. Ensuring that all GMS employees, contractors, and volunteers meet all training requirements relating to safeguarding the students’ health, safety, and well-being is especially important if GMS were to once again provide residential programming to students. Recommendations for Finding 2 We recommend that GMS: 1. Update the GMS training policy to ensure that it encompasses all of the required training and the frequency of training for GMS employees, contractors, and volunteers, both upon hire as well as for ongoing training. 55 Pa. Code Chapter 3800.58(a) Staff Training, which notes that on-the-job orientation includes topics such as reportable incident reporting, care and management of children, and use of restrictive procedures. 82 36 A Performance Audit Glen Mills Schools 2. Establish responsibility for appropriate personnel to ensure that all employees, contractors, and volunteers complete all required training within the required time frame. 3. Develop procedures for monitoring compliance with all training requirements. 4. Maintain documents to demonstrate that the appropriate training was completed and completed timely for each employee, contractor, and volunteer. This includes the current professional licenses of contractors. 5. Ensure the accuracy of the training information recorded in Filemaker by requiring a supervisor or another employee, who is not responsible for data entry, to review the training record information for reasonableness, as well as to compare, on at least a sample basis, the recorded information to the training certificate or other source documentation. 6. Develop a tracking system to document training completed by volunteers to ensure all training requirements have been met. 7. Discontinue the automatic recording of one hour of developmental training per employee each week in Filemaker and instead, record the completion of developmental training into Filemaker based on documentation (i.e., weekly training log) showing the actual hours of training completed by each employee. This would require that supervisors ensure that all information is accurately documented in the weekly training logs. 8. Require the supervisor, as well as the employee, to sign the orientation acknowledgement form after the 21 days of on-the-job orientation has been completed. 37 A Performance Audit Glen Mills Schools Finding 3 – Avenues available to Glen Mills Schools’ students to report incidents of abuse. This performance audit was initiated as the result of the following: • • • • An alleged physical assault against a Glen Mills Schools (GMS) student in July 2018. The dismissal of six GMS staff, two of whom were also charged with crimes related to the incident. 83 The subsequent investigative report by a Philadelphia newspaper detailing decades of alleged abuse at GMS. 84 The Pennsylvania Department of Human Services’ (DHS) orders on March 25, 2019, and April 8, 2019, respectively, to remove all students from GMS and to revoke all 14 of GMS’ licenses to operate a child residential facility. While the Child Protective Services Law (CPSL) does not include any requirements for providing child residents of a child residential facility, such as GMS, with a formal reporting method regarding abuse, DHS Title 55, Chapter 3800 regulations contain a requirement for such grievance procedures. 85 Therefore, one of our audit objectives was to determine what avenues child residents at GMS (GMS students) had to report incidents of abuse. 86 In addition to incidents of abuse, we also include in this finding information regarding the process for students to report any violations of a student’s rights. 87 This process is outlined in the Student Grievance and Appeal Process established by GMS which, according to GMS management, was amended during our audit period. 88 As there was more than one process in place during our audit period, we include both within this finding. Five of the employees were terminated by GMS and one resigned two weeks prior to GMS’ intention of terminating his employment. See also the December 2018 Children’s Rights and Education Law Center’s publication of: Unsafe and Uneducated: Indifference to Dangers in Pennsylvania’s Residential Child Welfare Facilities which discusses GMS on page 12. Please note that the DHS’ Regulatory Compliance Guide; A Tool for Child Residential Regulators, Operators, and Stakeholders was issued in 2013. 84 “‘I can’t breathe’: Probe underway at Glen Mills after staffer attacks boy,” The Philadelphia Inquirer, August 31, 2018 and “Beaten Then Silenced: At the Oldest U.S. Reform School for Boys, Leaders of the Prestigious Glen Mills Schools in Pennsylvania Have Hidden a Long History of Violence,” The Philadelphia Inquirer, February 20, 2019. 85 See 55 Pa. Code § 3800.31 (relating to Notification of rights and grievance procedures), § 3800.32 (relating to Specific Rights), and § 3800.31 (relating to Prohibition against deprivation of rights). 86 For purposes of this finding, when referencing abuse, unless otherwise indicated, we are referring to physical abuse, not sexual abuse. Students are generally placed at GMS by court order and according to the GMS web site, most students are placed there for nine to twelve months. While at GMS, a student may be granted a home pass based on factors such as meeting the requirements established by GMS and the jurisdiction that placed him at GMS, student behavior, and parental/guardian permission. http://www.glenmillsschool.org/resources/faqs (accessed March 2, 2020). 87 See Appendix D for a full listing of student’s rights. 88 GMS Policies and Procedures, Policy Number 12.6, Student Grievance and Appeal Process. Issued January 5, 2001 and re-issued May 2016 and again on March 15, 2019. See Appendix E for both versions of the policy. 83 38 A Performance Audit Glen Mills Schools Due to the timing of the audit and the removal of students from GMS, we were unable to interview GMS students as part of our audit procedures and therefore, information for this objective was primarily obtained from statements made by GMS management, GMS policy, and the GMS Student Handbook (handbook). We emphasize that even with the policies and procedures that GMS had in place, which we describe in this finding, we were unable to determine how strictly they were followed by GMS management and/or staff and what practices may have been condoned or overlooked in the interactions of students and staff. Further, we did not assess the culture or environment of GMS regarding student abuse. We have summarized our results into the following areas: • • • • • Communication to students regarding reporting abuse Avenues GMS students have for reporting abuse Student grievance and appeal process Changes in the Student Grievance and Appeal Process policy GMS’ policy regarding abuse Communication to students regarding reporting abuse As described to us by GMS management, upon a student’s arrival at GMS, an orientation process begins that includes discussions with their admissions counselor and living unit counselor, as well as members of GMS’ offices of admissions, education, medical, and the Prison Rape Elimination Act (PREA) coordinator. GMS management stated that when students met with admissions staff, they were given a copy of the handbook. This handbook is a source for students to find information such as: • • • A listing of student’s rights, which includes students not being “abused, mistreated, and threatened, harassed or subject to corporal punishment”. The telephone number to contact ChildLine to report incidents of abuse. 89 The grievance process in place when violations of student’s rights occur. GMS management stated that admissions staff discussed the student’s rights and the grievance process with each student prior to requiring the student to sign an acknowledgment form stating that they received a copy of the handbook. We discuss the grievance process later in this finding. This acknowledgment form, however, only indicates that the student received the handbook. It does not state that the grievance process and student’s rights, particularly those related to student abuse, were actually explained and discussed with the student or that the student understood them. ChildLine is part of a mandated statewide child protective services program designed to accept child abuse referrals and general child well-being concerns, and transmit the information quickly to the appropriate investigating agency. Individuals can contact ChildLine’s toll-free hotline, which is available 24 hours a day, seven days a week. 89 39 A Performance Audit Glen Mills Schools Additionally, GMS management stated that a copy of the student’s rights, the policy for processing concerns and grievances, and notification that the student received these documents in the handbook were sent to the parent/guardian of the student along with an acknowledgement form and a postage-paid envelope with a request that the parent/guardian sign the form and return it to GMS. We inquired of GMS staff that participated in the student orientation process as to whether students were made aware during orientation that pursuant to the CPSL, the individuals that GMS students primarily encounter while at GMS (GMS employees, contracted employees, and volunteers) are all mandatory reporters and what reporting responsibilities mandatory reporters must follow. 90 Staff from the medical department stated that they explained to students the medical staff’s role as a mandatory reporter if the student were to report abuse to them. GMS management stated that GMS staff shared with students the avenues for them to report abuse by other GMS staff throughout the orientation process; however, the words “mandatory reporter” may not have been used. While GMS management indicated that staff would have made students aware of the avenues for reporting abuse, there are no written procedures to ensure that students are made aware of GMS staff’s role as mandatory reporters during the orientation process until the student meets with the PREA coordinator which is required to occur within 10 days of the student’s arrival on campus. GMS’ failure to stress the importance of the mandatory reporter requirement during the first day of the orientation process is troublesome because if students were not made aware of and understand the role and responsibilities of a mandatory reporter, then the student likely did not know that speaking to a mandatory reporter was one of the critical avenues for them to report incidents of abuse in order to prompt an investigation. Avenues GMS students have for reporting abuse Regarding avenues available for students to report incidents of abuse, GMS management indicated that students were able to discuss issues/report abuse at various opportunities to the following individuals: • Other students and/or counseling staff of GMS during individual or group meetings. A mandatory reporter, as defined in 23 Pa.C.S. Part VII, Chapter 63 Child Protective Services, is a person who is immediately required to make a report of suspected child abuse. Please see 23 Pa.C.S. § 6311 (related to Persons required to report suspected child abuse) which provides: “(a)…the following adults shall make a report of suspected child abuse, subject to subsection (b), if the person has reasonable cause to suspect that a child is a victim of child abuse [among others]: (1) A person licensed or certified to practice in any health-related field under the jurisdiction of the Department of State….(5) An employee of a child-care service [which includes GMS staff] who has direct contact with children in the course of employment….(7) An individual paid or unpaid, who, on the basis of the individual's role as an integral part of a regularly scheduled program, activity or service [such as volunteers], is a person responsible for the child's welfare or has direct contact with children….(12) An individual supervised or managed by a person listed under paragraphs (1)…(5)….(7)… and (13), who has direct contact with children in the course of employment. (13) An independent contractor….” 90 40 A Performance Audit Glen Mills Schools • • • • • Parents/guardians during visitations or phone calls. Probation officers during private monthly meetings. Health care providers at GMS. Teachers in the GMS Education Department. Tutors that provided educational support to students on the GMS campus. We also made inquiries regarding the students’ phone privileges in order to determine if telephone calls could be made to report incidents of abuse to individuals outside of those that students interact with on the GMS campus. Both GMS policy and the handbook indicate that telephones are available in the Student Union building. 91 GMS policy further indicates that the telephones are available to the students 35.5 hours per week which includes hours during each day of the week. GMS management also stated that in addition to the written policies, each student’s counselor was required to allow the student at least one 15 minute unmonitored phone call every week. The handbook also indicates that students were provided writing materials and free postage and that outgoing mail shall not be opened or read by staff except in the cases of a written court order. Student Grievance and Appeal Process The grievance policy in place at the beginning of our audit period, July 1, 2017, was implemented in May 2016. According to GMS management, the policy was updated on March 15, 2019; however, a pilot program for the current version of the policy began in January 2019 in one of the living units. 92 For purposes of this finding, we will refer to the two versions of the policy as the former policy and the current policy. These policies are both included, in their entirety, in Appendix E. Both versions of the grievance policy include several levels, or steps, that were designed by GMS which the student and GMS staff must follow when reporting and investigating a grievance. These levels escalate following the chain of command to provide the student an opportunity for the grievance allegation to be resolved. As previously reported, GMS management stated that if a grievance reported was related to suspected child abuse, as mandatory reporters, they are required to report the incident to ChildLine. Although a claim of the abuse of a student is subject to the grievance policy, GMS management stated that the grievance process is “stayed” internally while DHS conducts its investigation. Although GMS management stated that the grievance process is “stayed”, this practice has not been formalized in writing in the grievance policy, nor does the grievance policy contain language to specifically provide for what actions should occur if the grievance reported GMS Policies and Procedures, Policy Number 7.11, Telephone Access. Issued January 5, 2001 and re-issued March 2016; and Policy Number 12.27 Confidential Access to Court System and Attorney. Issued January 5, 2001 and re-issued May 2016. 92 As of January 1, 2019, the living unit housed 24 of the total 273 GMS students. 91 41 A Performance Audit Glen Mills Schools is abuse related. For example, the grievance policy does not address specific steps that should be taken to ensure the safety of the student and to seek medical attention for the student. Both the former and current grievance policies contain language stating that GMS students have the right to lodge a grievance without fear of retaliation. Additionally, according to GMS management, the grievance process could be used to address any retaliation claims related to a claim of abuse. GMS does not, however, have a “stand alone” retaliation policy specific to nonsexual related abuse. 93 GMS management agreed on the importance of such a policy and stated that moving forward, it would look to create a policy, or add language to an existing policy, regarding the handling of retaliation specific to allegations of abuse. In addition to GMS management ensuring that there are written policies and practices in place regarding what should occur when claims of student abuse are made, it is critical that GMS management establish an environment at GMS to facilitate students and staff being comfortable in reporting incidents of abuse so they will know that the claims will be investigated without fear of retaliation for reporting the abuse. Changes in the Student Grievance and Appeal Process Policy The current grievance policy states, “Students and the Student’s family shall have the right to initiate grievance procedures with The Glen Mills Schools to address any alleged violation of specific or civil rights without fear of retaliation.” It also indicates that the grievance policy be included in the handbook that is to be given to each student upon arrival at the school. We confirmed that the current handbook provided to us by GMS management contains the grievance process as outlined in the former policy; however, GMS management indicated, and we confirmed, that the handbook does not include the current policy because it was not approved until March 15, 2019, and GMS did not have an opportunity to update the handbook prior to the removal of students from GMS. According to GMS management, a copy of the handbook is also posted and available to students in the living units and posters listing the grievance process have also always been posted in the living units. During our campus tour, we observed a grievance poster posted in a living unit. GMS management stated that although they did not update the handbook to reflect the new policy, they did provide training on the new policy to all GMS staff and to those students that still remained on campus. Included in both the former and current policies are the names and mailing addresses of four external agencies for students to contact if GMS resources are not successful in resolving the We noted that GMS Policy 19.1 “Prison Rape Elimination Act” with a re-issue date of February 26, 2018, regarding sexual abuse does include a section on protection from retaliation if an incident of sexual abuse is reported by a student. 93 42 A Performance Audit Glen Mills Schools student’s grievances. 94 Although the names and mailing addresses of the agencies are listed, the contact telephone numbers and email addresses are not. Having the telephone numbers and email addresses would enable students and parents/guardians to contact the agencies more easily, if necessary. 95 While both the former and current policy are similar, there are a few key differences. Under the former policy, the language only referred to a grievance allegation initiated by the affected student; however, the current policy also allows the student’s parent/guardian to file a grievance allegation on his behalf. The other major change in the current policy is the creation of a Grievance Panel to review the grievance allegation. The Grievance Panel is the last level of the grievance process before an appeal can be filed with the Executive Director. When asked, GMS management did not yet have a process in place to select members for the Grievance Panel; however, they did inform us that it would most likely include members from external resources who are involved in the student’s treatment plan, as well as at least one GMS staff member from the GMS Grievance Committee. Both policies indicate that assistance by a counselor or teacher will be provided if the student wishes to submit a written grievance and needs assistance doing so. Additionally, if during the grievance investigation a resolution is reached, the student shall sign the grievance form to verify a satisfactory conclusion to the grievance allegation. Notification of the grievance allegation and any outcome of the investigation will be sent to the student’s family and the student’s jurisdiction that ordered the student to GMS, if applicable. 96 Although the grievance policy was updated during the audit period, as previously indicated, it does not sufficiently address abuse of a student. GMS’ policy regarding abuse GMS management stated that if an incident related to suspected child abuse was reported to GMS staff, as mandatory reporters, staff are required to report the incident to ChildLine. GMS’ policy regarding compliance with the CPSL outlines four steps for GMS staff to follow in cases of suspected abuse. 97 These steps, however, are very general and are limited to only the reporting responsibilities of staff and implementing plans to ensure the safety of the student. The policy The external agencies include the Department of Human Services, Bureau of Equal Opportunity in both the Harrisburg and Philadelphia offices, the U.S. Department of Health and Human Services, Office of Civil Rights in Philadelphia, and the Pennsylvania Human Relations Commission in Philadelphia. 95 The addition of email addresses would be for the benefit of parents/guardians to contact agencies since GMS students do not have email access. 96 Under the former policy, a Grievance Tracking Form was used and under the current policy, a Grievance Allegation Form is used. The most significant differences between the two forms are that only the old form included a section for the student to sign when filing the grievance and the new form includes a section to allow for more detail to be documented as it occurred at each level of the grievance process. 97 GMS Policy 8.20, “Compliance with Pennsylvania Child Protective Services Law” with a re-issue date of May 2016. See Appendix F for a copy of the policy. 94 43 A Performance Audit Glen Mills Schools does not include information regarding specific steps that should be taken in emergency-type situations, such as seeking medical assistance for the student either at GMS’ health center or at an off-site medical facility, as necessary. Additionally, the policy does not discuss the protection of staff, contracted employees, volunteers, and interns from retaliation if they report an incident of abuse. 98 It is critical that a policy with sound and robust provisions is in place to ensure individuals are protected from retaliation and that it is made part of the GMS culture to assure individuals that they will not be retaliated against if they do report incidents of abuse. Conclusion It is critical that GMS provide sufficient opportunities and avenues for students to report instances of abuse in compliance with DHS Title 55, Chapter 3800 regulations. It could be very difficult for a male teenager, in particular one that has been placed into a facility such as GMS, to admit or confide in someone that they are being physically, emotionally, or sexually abused. That is why it is imperative that GMS staff ensure students are aware of ALL avenues available to them to report incidents of abuse and encourage use of these avenues, if necessary. It is equally important that GMS take these reports seriously and ensure the safety of each student reporting an incident. Unlike students in a traditional school who have regular access to and support from teachers, counselors, family, and friends, most students residing at GMS are at the facility 24/7 based on a court order and are much more isolated from the outside world. Reporting abuse is not easy for any student, but it is inherently more difficult for students residing at GMS to report abuse because of an increased fear to report due to the absence of outside support and the potential of being brought back to court for additional appearances before a judge. Moving forward, if GMS’ licenses are reinstated to allow students to be placed at GMS, GMS needs to be fully transparent with staff, students, and parents as to the process for reporting abuse and promote a culture that will not only prevent abuse from happening but also ensure that incidents of abuse will be investigated. While our audit objective was only to determine, not evaluate, what avenues GMS students have to report incidents of abuse, in conducting our audit procedures we identified areas for improvements and make recommendations accordingly. We noted that GMS Policy 19.1 “Prison Rape Elimination Act” with a re-issue date of February 26, 2018, regarding sexual abuse does include sections on student education and student reporting and steps regarding how student’s rights will be communicated to them and protection from retaliation if an incident of sexual abuse is reported by a student, staff, contracted staff, volunteers, and interns. 98 44 A Performance Audit Glen Mills Schools Recommendations for Finding 3 We recommend that GMS: 1. Develop written procedures for the orientation process that include topics to be discussed with students on their first day at GMS including the need to explicitly explain the role of GMS employees, contracted employees, and volunteers as mandatory reporters and to ask the students if they understand the process. 2. Develop a policy to specifically address the protection of students from retaliation for reporting cases of suspected non-sexual related abuse and ensure that this policy is explicitly explained to students. 3. Update the Student Grievance and Appeal Process policy to reflect the actual practice of delaying its investigation of abuse-related grievances while DHS conducts an investigation. 4. Include language in GMS policy 8.20 “Compliance with Pennsylvania Child Protective Services Law” regarding specific steps that should be taken when abuse is reported, such as seeking medical treatment for the student and protection from retaliation for a mandatory reporter that reports suspected abuse. 5. Ensure the student handbook is continually updated to reflect GMS’ current Student Grievance and Appeal Process policy regarding the grievance process. 6. Ensure that any future GMS students are informed of and understand their rights, as well as the avenues available to them, and that reporting abuse can be done without fear of retaliation not only during the orientation process but also on an ongoing basis. 7. Amend the GMS student handbook acknowledgment form to be signed by students to not only verify the receipt of the handbook, but also to verify that the grievance process and student’s rights, in particular those related to student abuse, were explained to the student and that he understands his rights and the grievance process. 8. Include telephone numbers and email addresses associated with the names and addresses of the external agencies listed in GMS policies that are provided for students and parents to contact if GMS resources are not successful in resolving the student’s grievances. 9. Promote a culture of full transparency with GMS employees, contracted employees, volunteers, parents, and students that demonstrates that any abuse against students will not be tolerated, the protection and safety of the students is of the utmost importance, and that every case of abuse or potential misconduct against a student is taken seriously. 45 A Performance Audit Glen Mills Schools Glen Mills Schools’ Response and Auditor’s Conclusions We provided copies of our draft audit findings and related recommendations to Glen Mills Schools (GMS) for its review. On the pages that follow, we included GMS’ response in its entirety. Following GMS’ response is our auditor’s conclusions. 46 A Performance Audit Glen Mills Schools Audit Response from Glen Mills Schools Dr. Christopher R. GLEN MILLS SCHOOLS Acting Executive Director Service to youth since The Honorable Eugene A. DePasquale Auditor General Commonwealth of Harrisburg. Pa. 19120 Dear Auditor General DePasquale. Attached is the reaponse of The Glen Mills Schools to the ?ndings and reenn?uttendations reSulting from your performance audit of our organization. We share in the goal of providing a high quality of service to the youth served in our organization. The new administration of The Glen Mills Schools has a strong desire to implement controls, policies, and systems that support the highest level of compliance possible. I appreciate the professionalism of your staff throughout this process, their attention to detail, and the many recommendations that were provided to us. We will undoubtedly utilize these recommendations to enhance our program and to improve the overall operations of The Glen Mills Schools. We have fully embraced the need to improve our practices related to clearances. backgroUnd checks, and training compliance as we look to restore public con?dence in our organization. As you can see in our response, we are making systemic changes to address the ?ndings and to move our organization forward. Thank you for your commitment to helping The Glen Mills Schools improve its operations We will utilise the baseline provided to reach a level of compliance that aligns with the expectations of the Commonwealth. Sincerely. Car/6W Carolyn Seagraves Board President PD. Box Concordville. 1933I (610)459?8l?? 47 A Performance Audit Glen Mills Schools The Glen Mills Schools Response to the Performance Audit Report from the Auditor General The Glen Mills Schools Mission Statement: The Glen Mills Schools, the oldest existing school of its kind, was founded in on the belief that at-risk youth have unlimited potential. We assess the unique needs of each student. teach tools for success, and offer meaninng opportunities for personal growth. We do this to transform students? lives and offer students a future ?lled with new opportunity, hope, and resilience. The Glen Mills eels Evolving New Program i'vladel: 111a Glen Mills Schools has developed a Trauma-informed program model that is starkly different from the model that was previously employed. This Trauma [nforrned program model provides an enhanced approach to the protection, safety, and well-being of every student that we serve, and provides a rehabilitative envimnment that is even more conducive to the positive growth of our youth. The new model is designed based on best practices in the ?eld, research, consultation with experts, consideration for Governor Executive order, and the recommendations from the Council on Reform. The new administration has partnered With West Chester University to provide therapeutic supports for students, under the new program model. We have consulted with the Massachusetts Advocates for Children, and the Harvard Law School in establishing the framework for a Trauma lnforrned program model outlined in Helping l'l'aamatised Children Learn, a report and policy agenda. We have also partnered with UKERU Systems to provide a safe and restraint. free way to deal with behavioml management. This new program model includes many more enhancements and is designed to provide a positive experience for you?t on our campus, where they can grow and develop the skills necessary to become positive conuibuting members of society. Introduction The new administration at The Glen Mills Schools has worked diligently in the last [3 months to establish a new program model, after the closure of our residential program. lt?itur plans for improvement and the steps we have taken to rebuild the program cannot move forward without the results of the Auditor Ge neral?s evaluation of our organisation. The evaluation of our organization was done respectfully and professionally, and we are eager to implement all of the recommendations, as a way to demonstrate the highest level ofcompliance possible. 48 A Performance Audit Glen Mills Schools The Glen Mills Scheels shares a let ef the same espectatiens as the Auditer General and has the same geal ef l??l?rir cempliance related In backgreund checks and training. The Auditer General?s perfermanee audit ef eur erganisatien. has led The Glen lvlills Scheels te take a deeper leek at hew we gather, stere, and review much et' its required decumentatien. ?ts seme areas that needed imprevement became apparent during the perferrnanee audit. we teek beld and immediate preactive measures te eerrect these pelicics, precedures, and precesses prier te receiving this repert. Te that endI EilvlS has already addressed the majerity ef the recemmendatiens. and we have every intentien ef achieving full cempliance as we leek te meve fet'ward as an erganiaatien. Finding Glen Mills Schenls management in same instances did net ebtuin and maintain required clearances frent its cnepleyees, centracters. and veluntcers, which peten'lially put students at risk el? harm. The Glen Mills Scheels thi'viE} respectfully disagrees with the last part ei? this ?nding1 which states ?which students at risk Altheugh it is cur understanding that this language is standard fer perfennance audits related tn scheelsI lelS dees net believe there is any evidence In suggest that any students were petentially put at risk el? harm as the result ef' missing backgmund checks. As per the huditer General?s assessment. ?nest backgreund clearances were an ?le at Additienally. it is the practice at GMS that ND empleyee, centraeter, er velunteer is te week alerts with students until all back greuttd checks and clearances are received by the erganizatien. Thus, individuals whe have net received the preper decumentatien must week with an empleyee whe has all the required clearances and trainings. In fact. velunteers are trained that they are never te be alene with students. up matter the status ef their clearances. Hewever, we acknewledge there is teem i'er imprevement with the fellewing ?ndings item the Auditer General. I eemplia nee with empleyee clearances {?iti?l'i I 36% celnpliance with velnnteer clearances [sweet I Ellis?: cent plianee with centracter clearances {arts} 1 h?hile lelSr already empleys a practice that is mere stringent than the Child Fretectivc Services Law by evaluating empleyee clearances every 3 years instead et?j years. we recegniae that imprevements in ear eperatiens were needed. Therel?ere, leiS has made changes in pelicies. premdures, hiring practices. enhearding. trainings1 and keeping te address the cencems raised within this ?nding. Further. GMS censulled with the State Felice te ensure that we are meeting the etepectatien ef the Cemntenwealth Law Eni'ercement assistant Hetwerk training, and that we are in centpliance with the speci?ed tinteframe fer maintaining backgreund clearances. 49 A Performance Audit Glen Mills Schools The Glen Mills Schools? response to recommendations associated with Finding I: Recommendations for Finding I l. Consider, in consultation with the State Police discontinuing the practice oi'onIy maintaining the most recent background clearances obtained for employees, contractors, and volunteers and developing an appropriate timefrarne for retaining non-current background clearances for EMS employees, contractors, and volunteers. EMS consulted again with the State Police about discontinuing the practice of only maintaining the most recent background clearances obtained for employees, contractors, and volunteers and was advised via email1 that: 1. Clearances should be destroyed upon termination of employment. 2. Did clearances should be destroyed when new ones are ran and received by Fortnaliec in written policy how long non-current background clearances should be maintained after a determination has been made. The i'ollowi ng policies fonnaiised how long non~current background clearances should be maintained: I Policy number New Empioyee Popenirori: ("New as ot? Policy number 3.2 a ddo?iriortoi Popenvorit 1hr Staff-"lies {New as of I Policy number 3. Cris-rind.I Record Check [Revised on errors} - Policy number 3.3 Pei-umnneti Records [Revised on Eild??l?f Consider, in consultation with the State Police, lengthening the timei'rame for purging all background clearances alter an individual separates from CHIS to ensure that an independent party can evaluate whether former EMS employees, contractors, and volunteers were permitted to have direct contact with EMS students. EMS consulted again with the State Police about discontinuing the practice of only maintaining the most recent background clearances obtained for employees, contractors, and volunteers and was advised via email3 that: l, Clearances should be destroyed upon termination of employment. 2. Did clearances should be destroyed when new ones are ran and received by EMS. 5' The email from the PSP on May men that advises EMS about clearancea is available for review from the Auditor General. 1 Throughout this document, EMS references notices that have either been developed or revised In re-sponse to the Auditor Eeneral?s report- EMS will make these policies available [or review and verification upon request {tom the Auditor General. 50 A Performance Audit Glen Mills Schools Adhering tn the reennunendatien nt'the PEP, EMS revised the palieies: I Puliey number l3 Criminal .ii'eenna'T Cheek {Revised un 2H ??tl2l'l} I Peliey number 3.3 Ferrennei Rees-rats {Revised nn 2M #2020] . Fennalize in written pulley the length nf Lime after a determinatinn is made that baekgrnund elearanees she-uld be purged. The pnlieies funnal'ue the length nf time baeltgraurszl elearanees shnuld be maintained befnre purging: I Peliey number 3.21 New Earp-?eyes Papernerrs [New as of li21i2?2?} I Pulley ntunber 3.2la Papenvnrefer Surf Files {New as of 122322020} Pulley number 3.13 Criminal Reenra' Cheek {Revised nn 2! $21326} Pnliey number 3.3 Persennei ileum-ab [Revised nn 2? snare} . Maintain eentralized. up?tn-date lists nt? all eentraetnrs and vnlunteers in nrder tn help faeilitate the fellewing a] Ensuring that all required elearanees have been nbtained. b} Ensuring that all at? these individuals have the required baelrgreund elearanees tn have enntaet with Elvis. students. this time we dn net have any euntraetnrs er valunteers at EMS. Hewever, in August 2019 we did begin tn develnp. install, and test the necessary database in Filelvlalrer tn eapture the baelsgreu nd elearanees of all ennrraetnrs and velunte-ers upun ineeptinn nfserviees with EMS. The fallnwing pulieies were either develepetl er revised ta maintain a eentralised and up-tn-date list at all eantraetnrs and vnlunteers: Pnliey number 3.23 Intern and linirrnreer Prunes: {New as at l?gil?l?} Feliey number 3.22 Centre-erred Stuff {New as nt' 322tl2?l Feliey number l4.l interns [Revised en Pnliey number lsl.2 Assignment nfinrerns and i'biumeers {Revised en ll'29i2-ll'2l1} I Paliey number 3.3 Persennel Reese-its {Revised 2213:2021?) . Fnrmalize in written naliey andfur standard nperating prneedures whu is respensible fer maintaining a eentraliaed list af enntraetars and valunteers and tn ensure that all baeltgruund elearanees tn have direct enntaet with (3M3 students have been nbtained and reviewed. The fullnwing pnlieies were either develnped er revised tn formalise whu is maintaining a eentralieed list nf'enntraetnrs and vnlunteers. and mnnitnri ng tn ensure all elearanees tn have direet enntaet wi?t students have been nbtained and reviee'ed: I Pulley number 3.23 intern and Fninnreer Prneess {New as nf 1?9i2?2?] I Puliey ntunber 3.22 Sinftl'iew as at" I Pnliey number 14.l Interns Feinnreers [Revised en 1i29i'2?2?} 51 A Performance Audit Glen Mills Schools T- I Policy number [4.2 .dsrr'grrarent efforeror onrr? Volunteers [Revised on I Policy number 3.3 Renter-tool Records {Revised 21'] Implement a review process to help the accuracy of the background clearance information, in particular report dates, posted to the Filehiaker tracking system. The Personnel Department will perform quarteriy quality asurance reviews on all staff paper files and electronic ?les stored in ilelvlaker related to background clearances as stated in Policy 3.3 Ransom-ref Records {Revised 2! Forrnaliae in 1written policy and or standard operating procedures the process of requiring a supervisor to review the accuracy of background clearance infennation recorded in ilel'vlaker. These fennel policies address a supervisor reviewing the accuracy of background clearance information and it subsequently being recorded in Filehiaker. They are as follows: I Policy number 3.3 Personnel Records [Revised 1! Willie] I Policy number 3.21 New Employee Paperwork [New policy it?? fl?l?j {Revised Do not allow em ployecs, contractors, and volunteers that do not have all the required background clearances on ?le at EMS to have any contact with Elvis snrdents. EMS will not allow employees, contractors, and volunteers that do not have all the required background clearances on file at lelE to have any contact with EMS students. ll}. Maintain approved justi?cation forms on ?le for all lel? employees with offenses listed on their background clearances. On January a. a, ores began to maintain justi?cation forms {criminal amessment document} to comply with the slate of Michigan audit requirements. EMS will continue to maintain these forms for all employees with offenses listed in their background clearances. Fonnaliae in written policy andtor standard operating procedures the process of preparing, approving, and retaining justi?cation forms for all EilvlS employees with offenses listed on their background clearances. Gl'le formalised in written policy the process of preparing, approving. and retaining justi?cation forms in the following policies: I Policy number 3 .El New Employee Paperwork mew as of I [Revised Policy number 3. 3 Criminal Recornl Check [Revised sorcerer I Policy number 3.3 Personnel Records- (Revised Er'lEfE Dill] . Implement documented supervisory review of (EMS employees, contractors, and volunteer background clearance results to ensure that: 52 A Performance Audit Glen Mills Schools lit. 14. 15. a] Follow-up is performed if a background clearance indicates an offense. b] ?t correct determination is made regarding the eligibility ol'tl'te individual to have direct contact with EMS students. En January 2 I, 1020 EMS implemented documented supervisory reviews of EMS employees, contractors, and volunteer background clearance results. The policies that support the supervisory review are as follows: I Policy number 3.11 New Employee Paparworl: [New as of it: Revised I Policy number 3.2! Contractors? Sro?tfl?lcw as of I S??l?i Forntaliae in written policy and or standard operating procedures the process of ret'iewing all background clearances, including having a second level of review to ensure follow-up is perfumed on any offenses listed, The Following formal wrinen policies were implemented to formalise the process of reviewing. all background clearances, including having a second level of review to ensure Follow-up is performed on any offenses listed: I Policy number 3.3i New Employee Paperwork {New as at" [Revised town are} I Policy number 3. I Criminal Recon-atT Cheek {Revised Ebtain from all applicants their residential addresses for all ?ve years preceding their application for employment at EMS. EMS developed the following policy to ensure that all applicants? residential addresstes] tor all ?ve years preceding their application for employment are obtained. in addition, EMS created a new application to include the question of whether you have lived outside ofPA in the last 5 years. I Policy number 3.24 Interview and Hiring mew as of Obtain and review Adam Walsh checlrs for all applicants who were not residents in any oFthe ?ve years preceding their request for employment at EMS. Although Adam Walsh checks are not required by the Department othunan Services under regulations, EMS will continue to obtain Adam Walsh checks on all applicants who were not Pa residents in any of the ?ve years preceding their request for employment. . Ebtain Adam Walsh checks for all EMS employees who are not residents- As stated above in the response to recommendation 15, Adam Walsh checks are not required by the Department of Human Services under 3WD regulations; however, EMS will continue to obtain Adam Walsh eheclts on all applicants who are not Fa. residents preceding their request for employment. 17". Formaliac in written policy andfor standard operating procedures the requirement and process for Adam Walsh checks for all EMS employees and applicants that are not 53 A Performance Audit Glen Mills Schools residents and applicants tltat were not residence in say of the ?ve years preceding their request for em at EMS. The following policies were implemented or revised to respond to recommendation l5, lb. and Policv number s. Criminoi Record {Titer-i- {Revise-d 1:1 steosot 1' Policy number 3.3 Pentonoei Records [Revised Itl?tl?l?} II Policy number 3.21 New Fupenvori' {New as of it? Policy number 3.24 interw'mr and Hiring {New as ot? IE. Do not accept ?b'oIUnteer?? type Child Abuse clearances obtained from the Department of Human Services t?or?En1ployee" purposes. will ensure we accept the proper type of child abuse clearance for all employees, contractors, and volunteers. Finding Gl?ttl? did not ensure that some individuals who may have direct contact with its students received all of the required training related to the prevention of child abuse and the mandatory reporting ol' suspected abuse. EMS ?illy understands the importance of training related to child abuse and mandatory reporting of suspected abuse. EMS ensured that the vast majority of individuals who may have had direct contact with its students. received all the required training related to the prevention of child abuse and the mandatory reporting of suspected abuse. In addition, individuals working with students were aware of their duties as mandatory reporters and had signi?cant training related to the prevention ol'child abuse. its a whole. over ?ght: of the staff unining tiles reviewed demonstrated the completion of required trainings within the required time frame. 1While in some areas we scored very well with training compliance, we acknowledge that there is room for improvement. The new administration at EMS is eontrnitted to achieving the highest level of compliance possible. [if the seven trainings evaluated by Auditor General below. Elvis. acknowledges that improvements were needed in three of the trainings that did not meet the threshold. The organisation shares in the goal of limit. compliance and is responsive to the recommendations. as to improve upon these numbers. Further, EMS is improving training policies, enhancing developmental training, and making systemic changes to assure that every training area reached the lump compliance threshold. 54 A Performance Audit Glen Mills Schools The areas of training evaluated by the Auditor General?s of?ce are as follows: itial Traiui 33% compliance with CARR [Ii] 2} l??'iir compliance with BIT {l Iii?) 923-3 compliance with PREA. i1 lilE) I I in 94% compliance with CARR. 1&th compliance with BIT {55:55} Hill-?rim compliance with FREE. [senor 933i- compliance with Mandatory Reporting {4950} The Glen lvlills 3chools* response to recommendations associated with Finding 2.- Recommendations for Finding 3 go Update the EMS training policy to ensure that it encompasses all of the required training and the ?equency of training for EMS employees, contractors, and volunteers, both upon hire as well as for ongoing training. The Following policy was updated to crtsurts that it encompasses all of the required training and the frquueocy of training for ones employees, contractors, and volunteers {up-on hire and ongoing training]: - Policy number 3. 5 Training ti Training Criteria {Updated on lil Establish responsibility for appropriate personnel to ensure that all employees, contractors, and volunteers complete all required training within the required time frame. The following policies were implemented or revised to establish responsibility for appropriate personnel to ensure that all employees, contractors and volunteers complete all required training Within the required time frame: I Policy number 3.25 New Empioyee ?nhoorritng [New as of I Policy number 3.3 Personnci Records [Revised 2! I Hi - Policy number 3.15 Training In Training Criteria [Revised EMS also created, through the Fichaiter system, a daily report for several trainings and all employee clearances to alert personnel staff to ensure that all employees. contractors, and volunteers complete all required training within the required time frame to remain in compliance. We continue to update this process to be able to ensure all trainings are completed in the appropriate time frame. Develop procedures for monitoring compliance with all training requirements. As stated in recommendation number two, the following policies were developed for monitoring compliance with all training requirements 55 A Performance Audit Glen Mills Schools i Policy number 3.25 New Entpi'ayee [New as of - Policy number 3.3 Pet-sonnetr Records [Revised 2il?t2ft2ti} I Policy number it. [5 i'i-aining dr Training Criteria {Revised 2i] some} 4. Maintain documents to demonstrate the appropriate training was completed and completed timely for each employee, contractor, and volunteer. This includes the current professional license ofcontractots. The following policies were implemented or revised to ensure the appropriate training was completed and completed timely for each employee, contractor, and volunteer: I Policy number 3.25 New Employee Dnoaartiing {New as of 1i22t'2?2?) Policy ntunber 3.3 i'z'ersonnetr Records {Revised 21130031} Policy 3.15 Training ii Training Criteria {Revised 2i Policy number 3.22 Contracted Sta?'tfl?tew Policy as of Hi Er2?2ti] Also, as stated in recommendation number two, the Filelvlalter syslern for performing daily rep-ens are saved and can be reviewed and retrieved at any time. 5. Ensure the accuracy of the training infonnaticn recorded in Fileh'lalter by requiring a supentisor or another employee, who is not responsible for data eon-y, to review the training record infonnation for reasonableness, as well as to compare, an at least a sample basis, the recorded in formation to the uaining certi?cate or other source documentation. The Personnel Department will perfonn quarterly quality assurance reviews on all staff paper ?les and electronic ?les stored in Fitehlalter as stated in the following: - Policy number 3.3 Personnei Resort-is [Retdsed 2H lli2?2ft} I Policy number 3.15 Training ti Training Criteria {Revised 2i Eill??} Addresses the recording accuracy oftraining information. I5. Develop a tracking system to document training completed by volunteers to ensure all training requirements have been met. its stated in recommendation number two, GMS created, through the Filelvlaher system, a daily report for several trainings and all employee clearances to alert personnel staff to evaluate that all employees, contractors, and volunteers have complete all required training within the required time ?'ame. This system will also ensure that everyone remains in compliance. We continue to update this process to be able to ensure all trainings are completed in the appropriate time frame. The following policies support this recommendation: - Policy number 3-3 Personnei Renal-ails {Revised 2i'l $2020} Policy number 3.15 Training dis Training Criteria {Revised i Bi2tl2t'tl Discontinue the automatic recording ofone hour of developmental training per employee each week in Filelvlalter and instead, record the completion of developmental training into Fileh'lalter hard on documentation weekly training log} showing the actual 56 A Performance Audit Glen Mills Schools hours of training completed by each employee. This would require that supervisors ensure tltat all information is accurately doe urnented in the weekly training log. EMS will discontinue the automatic recording of one hour of developmental training per employee each week in Filetvlaker and begin to record the completion of developmental training based on documentation, showing the actual hours of training completed by each employee. Supervisors will ensure that all information is accurately documented in the weekly training log. 3. Require the supervisor, as well as the employee, to sign the orientation acknowledgement form after the II days of on-the-job orientation has been completed. EMS will require the supervisor, as well as the employee to sign the orientation acknowledgement form after the 2 days of on-Ihe-job orientation has been completed. The following policy has language to ensure compliance with this recommendation: 1- Folicy number 3.21 New Employee Popenvorit {New policy l?El'E?l?} [Revised Finding lit-Avenues available to ltilen Mills Schools? students to report incidents ofabnse. Gverall, EMS is in agreement with this ?nding and believes the information provided depicts an accurate assessment of avenues available in which students can report incidents of abuse. The report describes that due to the timing of the performance evaluation, the auditors had to rely primarily on statements made by EMS management. EMS policy, and the EMS Student Handbook to obtain information on this objective. The Auditor General also relied on the previous and revised grievance process that was in place during the audit period. The report accurately states the in formation ems provided to students within their handbook at the time cfarrival. The iniiormation described included the list ofstudentis rights, the telephone number to EhiIdLine, and the grievance process. These handbooks were also posted within every residential unit. The report also correctly explains how these are reviewed with the incoming student by the admissions staff. The acknowledgement form not only recognizes that they received the handbook, but also that the information stated above is also included within it. The new process now includes a copy of a grievance n-acking form for every new student. In addition, the acknowledgement form also calls to attention other important information provided in the handbook, such as the nondiscrimination in services policy, visitation policy, and access to 24-hour emergency medicalrdental provisions. EMS fully acknowledges the importance of making students aware of the avenues available to them to report abuse. The report accurately states that [ii'vIS staff share such avenues with students throughout the orientation process. EMS will also use the term ?mandatory reporter" when describing those avenues in the future. tats accepted by the report, shortly after their arrival and during the student?s FREE education, the words ?mandatory reporter? are used when 57 A Performance Audit Glen Mills Schools reiterating the avenues students have te repert abuse. Altheugh they may net be given the technical term en the ?rst day, they are made aware ef it within a shert per-led cf time. Student Grievance and Appeet Precess d: Changes in the Student Grievance and Appeal Precess Peiicy The student grievance precess is an area lelE takes very serieusly. EMS had a precess in place. but as stated within the repert, we had recently updated the precess at the time the perfennance audit began, and we have made additienal updates since. It is a gcal te mahe students as centl'ertable as pessihle in the reperting precess and te ensure each student?s safety. The repert describes grievances being ?stayed? internally when a claim cf chase is made. This requirement ftem DHS was put in place an erganiaatiens de net interfere with any DHS investigatien. The eflelS during an investigatien waste ensure student safety. This ceuld be accemplished by n'teving the student?s unit, having the student meet with a medical prefessienal, putting a staff en leave, er having them werlt with supervisien. In additien te the changes eutliced in the repert, EMS alse hired a fenner DHS supervises as a censultant when updating the precess. EMS staff and students were trained en the new precess prier te the start cf this perfermance aadiL Either additiens made te assure the safety cf students and help in the grievance precess that are netewerthy are: l. The grievance precess is pested in each residential unit and centmen area. 2. Each grievance will new be put inte an elech'enic pertal te assist in tracking and expediting the prccess. 3. Alerts will he sent regularly and autematlcally threugh email te lteep leadership infenped that there is a grievance and at what level ef the precess it is at. 4. {ille has alse installed carneras tn the areas within the living units as well as many ef the high traffic areas an campus, such as the cafe, gym, and rec center. ?ts stated aheve, lel? has centinued te werlt en the grievance precess, taking in in acceunt made by the Auditer General staff, in erder te make it as dtereugh and as student friendly as pessible. EMS 'peiicy regarding chase As stated within this scetien, all staff are mandatery reperters and are required te repert incidents related te suspected child abuse tc ChildLine. This includes all empleyees, centracters. and velunteers- The EMS pelicy regarding cempliance with the Child Pretectjve Services Law eutlines the fear steps fer 5 le stali'tc fellew in case efsuspected abuse. These fear steps are prescribed by CPSL. Each allegatien cf abuse is fellewcd by a safety plan that is reviewed and apprevcd by DHS. Althcugh there was net a pelicy related te dealing with retaliatien fer repetting abuse speci?cally, Git-i5 has a 1 i'tihistleblcwer Pelicy as well as separate pclicies that eever harassment and empleyee discriminatien. Tc that end, EMS did add language 58 A Performance Audit Glen Mills Schools speci?c to the Whistleblower Policy and our Code of Ethics for the protection of individuals against retaliation for reporting child abuse. We share in the thought that it can be difficult for students to confide in someone concerning alleged abused. EMS will continue to ensure that students are aware of ALL avenues available to report alleged abuse within the organization. The Glen Mills Schools? response to recommendations associated with Finding 3: Recommendations For Finding 3 l- I-J Develop written procedures for the orientation process that include topics to he discussed with students including the need to explicitly as plain the role of EMS employees, contracted employees, and volunteers as mandatory reporters and to ask the students if they understand the process- For several years, EMS has addressed, during the student PREA presentation within 1G days ol?student?s admission, that all EMS employees an: mandatory reporters. We will ensUre that all resources are utilized during the beginning ofa student's commitment to explain the role of mandatory reporters and salt the students if they understand the process- Develop a policy to speci?cally address the protection of students from retaliation for reporting cases ol'suspected nonvsertual related abuse and ensure that this policy is explicitly explained to students. The following policies have been revised to address employee conduct and protection of students from retaliation from reporting cases of suspected non?sexual related abuse: I Policy number 3. I4 Code afEtlrr'es {Revised l?lS?lE?lS] [Revised 1- Policy number [2.6 Student Grievance at: Appeal Process {Revised {Revised Ill ilS?Ell} {Revised Update the Student Grievance and Appeal Process policy to re?ect the actual practice of delaying its investigation oi" abuse related grievances while DHS conducts an investigation. The following policy was updated to re?ect the actual practice of delaying its investigation of abuse related to grievances while DHS is conducting an investigation: - Policy nturtber llo Sta-dear Erlemace Appeal Process {Revised {Revised 3i] Illill?] {Revised {Revised include language in EMS policy with Child Protective Services Law? regarding speci?c steps that should be talren when abuse is reported, such as seeking medical treatment for the student and protection from retaliation for a mandatory reporter that reports suspected abuse. Policy number Slit Compliance with FA CPSL {Revised will be revised to include language regarding speci?c steps that should be taken when abuse is reported, such as seeking medical treatment For the student. Policy number 3. 59 A Performance Audit Glen Mills Schools Pulley [Revised l?tll?? was revised and prevides language pretecting empleyces l'rem retaliatien frern any repert et?stal't? miscenduct. . Ensure the student handbeelt is cuntinually updated te re?ect lelS current Student Grievance and Appeal Precess pelicy regarding the grievance precess. Pelicy number 12.6 Student Grievance Appeat? (Revised lt?ldtit?E? {Revised 3tl It? are) [Revised Stl?ttl??l?} is currently in the new Studenttl?arent Handbeett that is being updated. EMS will centinne te ensure that the student bandbeelt is centinually updated te re?ect ?lvlS cunent Student ?rievanee and Appeal pulley. Ensure that any future EMS students are int'unned et' and understand their rights. as well as the avenues available In them, and that repertiug abuse can be dune withuut fear ef retaliatiun net enly during the erientatien but else an an engeing basis. It is a prierity uflelS te ensure that all students are inferrned at and understand their rights. as well as the avenues available te them Studenttl-?arent Handbeelt], and that reperting abuse can be dune witheut fear ef retaliatien. net enly during the uricatatiun precess but alsu an an engeing basis. The revisiun ei' Felicy number 12.15 Student Grievance Appeal Praeess and the transparency ef the peliey and precess ef inferming the students and their parenttguardian will be explained during erieutatien and threugheut they time spent at EMS . Amend the 131le student handbeett achnewledgentent fern-t te be signed by students te net enly verify the receipt ef the handbeelt. but alse te verify that the grievance precess and students rights. in particular these related te student abuse. were explained te the student and that he understands his rights and the grievance precess. EMS is currently updating the aclcnewledgetnent farm and is including veri?eatien that the grievance precess and students rights. in particular these related te student abuse, are caplained tn the student and that he understands his rights and the grievance precess. This precess will talte place upen a studeutls arrival te campus at car new welceme center. The student?s parenttguardians are enceuraged te take part in this precess te minimise the trauma l'ur bath the student and parenttguardian. . Include telephene numbers and email addresses asseciated with the names and addresses at the estental agencies listed in EMS pelieies that are previded l?er students and parents te eentact reseurees are net successful in reselving the student's grievances. Phene ntunbers were previded te Peliey number llti Student Grievance a alppetti Prunes-r [Revised [Revised 3t] lt'Iil-Illj {Revised Stll??Z?} fer students and parents te cuntaet it?lelS reseurees are net success?rl in reselving the student?s grievances. . Prernete a culture ef full transparency with EMS empleyees. centracted empleyeea velunteers., parents, and students that demensttates that any abuse against students will 60 A Performance Audit Glen Mills Schools not be tolerated, the protection and safety of the students is of the utmost importance, and that every case of abuse or potential misconduct against the student is talten seriously. In order to promote a culture of full transparency EMS has provided the following: A. To add an additional measure of oversight and safety, GMS utilizes an fin-Site Safety Review Process. The {in-Site Safety Review process provides direct oversight on behavioral interventions, ?ghts, and assaults or any incident that threatens the safety and security of the students and staff at EMS. This review is conducted by an interdepartmental team of trained employees. The review of these incidents commences within an hour and evaluates all aspects of the event. Safety and security are paramount in this process and are the primary focus- The review of other factors such as staf?ng, procedures, intervention techniques, training adherence, ete., is subsequently evaluated to ensure future safety and security through professional development and a feedback loop. Dn- Site remediation is provided to enhance staff development and to address areas that need improvement. Recognising staff for adherence to the behavioral intervention expectations will also be a part of this process. El. Consistent with our Trauma Informed approach, the number one priority of EMS is ensuring the physical and emotional safety of the students. For that reason, the staff are expected to conduct themselves respectfully and professionally at all times, in each and every interaction, with every student. We encourage students to share any grievance or concern, in the least traumatic fashion, as set forth in the Student Grievance and Appeal Process policy. It is our commitment that a student's grievance be hilly heard and fairly considered in a timely manner, viewing and reviewing each incident, through a Trauma-informed lens. The student Will be an active participant in the consideration of the grievance, and there will be a full, fair, and timely appeal process if a grievance is determined to be without merit and a student disagrees with that finding. EMS decisions 1tvill be conducted with transparency, with the goal ofbuilding and maintaining trust with the student and family members, among staff, and others involved with the treatment services of each student. Ftu'thermore, there will not be any fortn of retaliation towards a student who utilizes the grievance process. C- in addition to the unit staff, lelS has Regulatory Compliance personnel in each residential facility duri waking hours. The compliance personnel are independent of the Student Support Department staff and management. They ensure student safety and program compliance with state regulations and a Trauma?lnformed approach. in addition, they also provide additional support to our vulnerable population to avoid re-traumatiaation. The staff measure compliance, student safety, and staff professionalism by utilizing an instrument that documents observations and recommendations. The daily compliance tool includes. but not be limited to, random student safety checlts, physical plant inspections, staff interviews, and medication administration compliance. 61 A Performance Audit Glen Mills Schools . EMS has bolstered transparency by installing video cameras in the living units and in many common areas on the campus. The video footage will be randomly monitored and also utilized for staff development- Poliey number I34 Smyeiltaaee Comer-or {New Pulley 4t2'9l'2l12?] was approved for transparency. the safety and security of students, and employees. . Poliey number 3.14 Code was update-cl and provided to all employees for review and signature- . All current employees have completed CARR training and Trauma lnfonned Care trainings in line with our ?new program model." . There is a new family visitation and welcome center. Pnlieies used in above recommendations 1 ulv'i'tistlelzlluwer Policy [Revised 9) 3.3 Personnel Records {Revised 2H 3.14 Code of Ethics {Revised runwaala} [Revised arenas} 3.15 Training 43: Training Criteria {Revised 2? 3:21.320} 3.13 IZri minal Record Cheek {Revised 2113t'2lil2?'j 3.21 New Employee Papenvorlt [New policy lt?2H2?2?] [Revised lf29t2?2?jl 3.21a Additional for Staff Files {New PoJioy U23t?2l32?] [Revised 2lnt2?2?} 3.22 Contraeteti Staff [New Policy 2? $20213} 3.23 Intern and Volunteer Process [New Policy 139221320} 3.24 Interview and Hiring {New poliey ?2212020) 3.25 New Employee l[Ilnlroarrling [New policy It?l2t2?2?] 3.2? Compliance with FA CPEL {Revised 2:2 ?20} I235 Student Grievanee Appeal Process [Revised lt24f2?2?} [Revised 3t1lt2?2?] 13.4 Surveillance llil?arneras {New Policy 4t29f2?2?} 14.] lntems 3r. Volunteers {Revised Ir29i2?2l3} [4.2 Assignment of Interns E: Volunteers [Revised [?ll-?020} 62 A Performance Audit Glen Mills Schools Auditor’s Conclusions to Glen Mills Schools’ Response Overall, Glen Mills Schools (GMS) agrees with each of our three findings and stated that GMS is eager to implement the recommendations. GMS’ proactive efforts were seen during the audit as GMS management either updated or developed policies regarding some of the areas that the auditors brought to its attention. We did not, however, review the new or updated policies noted in management’s response as part of our audit procedures. We provide further points of emphasis and clarifications based on our evaluation of management’s response to our findings and recommendations below. As to GMS’ expressed disagreement with the language in Finding 1 pertaining to our belief that the potential effect of GMS not timely obtaining background clearances for even just one case could increase the risk of putting students at risk of harm, we reiterate the vital importance of these requirements. Our General Assembly has continually refined and enhanced these background clearance requirements first enacted in the mid-1990s and related child protection provisions by enacting more than 20 pieces of legislation since 2013, including improved reporting and mandated reporter requirements, to ensure that individuals do not have criminal offenses on their record that would preclude them from having direct contact with students and to prevent and decrease child abuse in Pennsylvania. 99 Therefore, every effort must be made to ensure that GMS students are protected by obtaining timely background clearances. Regarding language in Finding 1 related to how long GMS retains background clearances, we believe the recommendations that we made would be beneficial to allow for review to confirm that prior background clearances had been obtained and would provide the means to verify report dates and when background clearances should be renewed to comply with requirements. We do, however, acknowledge the need for GMS to be compliant with direction provided by the Pennsylvania State Police to ensure they are meeting the expectation of the Commonwealth Law Enforcement Assistant Network training. We appreciate GMS management’s timely consultation with the Pennsylvania State Police on this matter. GMS management stated in its response that it was 94 percent compliant regarding obtaining GMS employee clearances. We should note, however, GMS does not take into consideration two new employees that GMS allowed to continue to work with GMS students without obtaining all of their background clearances by the time their provisional hiring period had expired. It also does not take into consideration the issues noted with regard to GMS either not obtaining an Adam Walsh check for an employee or not obtaining enough information from employees to determine if GMS should have obtained an Adam Walsh check that is required according to GMS policy. 99 http://www.keepkidssafe.pa.gov/about/cpsl/index.htm (accessed June 12, 2020). 63 A Performance Audit Glen Mills Schools Regarding Finding 2, while GMS responded that over 95 percent of the staff training files reviewed demonstrated the completion of required training within the required time frame, GMS did not acknowledge the numerous clerical errors we identified during our testing. Ensuring that the training courses, dates, and number of hours are properly recorded into the training records is imperative given the critical importance of the issues, such as mandatory reporting and prevention of abuse, covered during the training and to guarantee that required training refreshers are completed on a timely basis. Additionally, GMS’ response did not reference that we found GMS failed to maintain Child Abuse Recognition and Reporting (CARR) certificates for 2 of the 10 contractors, or 20 percent, and 21 of the 60 volunteers, or 35 percent, selected for testing. While GMS management informed us that volunteers are not permitted to be alone with students, given the importance of CARR training, it is important for GMS to maintain documentation and ensure that all required training is completed. 64 A Performance Audit Glen Mills Schools Appendix A Objectives, Scope, and Methodology The Department of the Auditor General (DAG) conducted this performance audit of the Glen Mills Schools (GMS), regarding child abuse prevention and proper reporting, under the authority of Sections 402 and 403 of The Fiscal Code of the Commonwealth of Pennsylvania. 100 We conducted this audit in accordance with applicable Government Auditing Standards, issued by the Comptroller General of the United States, 2011 Revision. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Objectives Our audit objectives were to: 1. Determine if GMS has complied with the Child Protective Services Law (CPSL), 23 Pa.C.S. § 6301 et seq., and its associated regulations, including 55 Pa Code § 3800.15. 2. Determine the extent to which GMS complies with all legal and/or policy and procedural requirements under the CPSL regarding state and federal background clearances for employees and others (e.g., volunteers) who are in contact with its child residents. 3. Determine if GMS has policies and effective procedures to prevent child resident abuse. 4. Determine what avenues child residents have to report incidents of abuse. Scope The audit objectives covered the period July 1, 2017 through March 11, 2020, unless otherwise noted, with updates through the report date. GMS management is responsible for establishing and maintaining effective internal controls to provide reasonable assurance of compliance with applicable laws and regulations, contracts, grant agreements, and administrative policies and procedures related to its programs. In conducting our audit, we obtained an understanding of GMS internal controls, including any information system controls, if applicable, that we considered to be significant within the context of our audit objectives. 100 72 P.S. §§ 402 and 403. 65 A Performance Audit Glen Mills Schools For those internal controls that we determined to be significant within the context of our audit objectives, we also assessed the effectiveness of the design and implementation of those controls as discussed in the Methodology section that follows. Any deficiencies in internal controls that were identified during the conduct of our audit and determined to be significant within the context of our audit objectives are included in this report. Methodology Items selected for testing within this audit were based on a combination of random selection and auditor’s professional judgment. The results of our testing, therefore, cannot be projected to, and are not representative of, the corresponding populations. To address our audit objectives, we performed the following procedures: • Interviewed and corresponded with GMS management and staff including the Director of Special Services/Regulatory Compliance, Lead Trainer, Special Services Department Administrative Assistant, one of the Team Leaders, Prison Rape Elimination Act (PREA) Coordinator, Lead Nurse, and Admissions Coordinator in order to:  Gain an understanding of how GMS obtains, reviews, maintains, and tracks state (PSP), federal (FBI), Child Abuse background clearances for employees, contractors, and volunteers that had direct contact with GMS students, as well as the Adam Walsh check, if applicable.  Gain an understanding of the training provided to employees, contractors, and volunteers that had direct contact with GMS students related to their roles as mandated reporters for reporting child abuse and to the prevention of abuse as well as how training is recorded, tracked, and monitored in the tracking system software.  Determine what avenues GMS students had to report incidents of abuse; how GMS staff informed the students of how to report abuse; and obtain an understanding of the process for students to report any violations of a student’s rights including abuse. • Reviewed the following laws, regulations, Governor’s Executive Order, Pennsylvania Department of Human Services (DHS) guidance, U.S. Equal Employment Opportunity Commission guidance, and written GMS policies, procedures, and training related documents to determine compliance requirements of GMS regarding background clearances, preventing and reporting child abuse, and avenues GMS students had to report incidents of abuse: 66 A Performance Audit Glen Mills Schools  CPSL, 23 Pa.C.S. o § 6303. Definitions. o § 6311. Persons required to report suspected child abuse. o § 6313. Reporting Procedure. o § 6319. Penalties. o § 6344. Employees having contact with children; adoptive and foster parents. o § 6344.2. Volunteers having contact with children. o § 6344.4 Recertification. o § 6383. Education and Training.  55 Pennsylvania Code Chapter 3800 Child Residential and Day Treatment Facilities and associated Pennsylvania Department of Human Services Regulatory Compliance Guide, January 1, 2013 Edition: o o o o o o § 3800.15 Child abuse. § 3800.52 Child abuse and criminal history checks. § 3800.58 Staff training. § 3800.31 Notification of rights and grievance procedures. § 3800.32 Specific rights. § 3800.33 Prohibition against deprivation of rights.  55 Pennsylvania Code Chapter 3490 Protective Services Section 127 Information relating to prospective child care personnel.  Glen Mills Schools Policies and Procedures: o Policy Number 3.15: Training and Training Criteria. Issued January 5, 2001 and re-issued April 2015. o Policy Number 3.17: Orientation Training. Issued January 5, 2001 and reissued April 2015. o Policy Number 19.1: Prison Rape Elimination Act. Issued June 16, 2014 and re-issued February 26, 2018. o Policy Number 3.8: Personnel: Personnel Records. Issued January 5, 2001 and re-issued December 2014. o Policy Number 14.2: Volunteers and Interns: Assignment of Interns and Volunteers. Issued January 5, 2001 and re-issued May 2016. o Policy Number 12.6: Student Grievance and Appeal Process. Issued January 5, 2001 and re-issued May 2016. o Policy Number 8.20: Compliance with Pennsylvania Child Protective Services Law. Issued January 5, 2001 and re-issued May 2016. o Policy Number 12.34: Student Rights. Issued January 5, 2001 and reissued August 2018. 67 A Performance Audit Glen Mills Schools o Policy Number 7.11: Telephone Access. Issued January 5, 2001 and reissued March 2016. o Policy Number 12.27: Confidential Access to Court System and Attorney. Issued January 5, 2001 and re-issued May 2016.  GMS Training Designs Summaries dated January 5, 2016, March 2019, and October 2019.  “Training Timeline” prepared by GMS management, at our request, detailing the training required for employees, contractors, and volunteers and the respective timeframes each type of training was required to be completed.  The Adam Walsh Child Protection and Safety Act of 2006.  DHS Announcement C-17-01 relating to the maintenance of background clearances for employees in child care facilities with a reissue date of September 19, 2019.  U.S. Equal Employment Opportunity Commission, “Background Checks: What Employers Need to Know” entitled, “Disposing of Background Information.”  Act 47 of 2019, effective December 31, 2019 relating to provisional hiring.  DHS’ Employees Having Contact with Children Frequently Asked Questions document accessed on December 2, 2019.  Commonwealth of Pennsylvania Governor’s Office Executive Order 2019-05 Protection of Vulnerable Populations. • Reviewed DHS licensing inspection summary reports issued to GMS after complaint investigations during our audit period and after the annual licensing inspections conducted in May 2017 and May 2018, along with the plans of correction filed in response to the reports, and corresponded with management from DHS’ Office of Children, Youth, and Families, in order to determine whether DHS identified any instances of non-compliance by GMS related to our audit objectives that required further review. • Reviewed DHS’ orders on March 25, 2019 and April 8, 2019 to determine what orders were given regarding the removal of all students from GMS and to revoke all 14 of GMS’ licenses to operate a child residential facility as well as reviewed the related GMS’ appeals. 68 A Performance Audit Glen Mills Schools • Reviewed orders by the Pennsylvania DHS Bureau of Hearings and Appeals to determine the status of appeals regarding GMS’ licensure and removal of students from GMS campus. • Reviewed news articles to determine information published describing instances of alleged abuse of GMS students. • Reviewed the December 2018 Children’s Rights and Education Law Center’s publication of : Unsafe and Uneducated: Indifference to Dangers in Pennsylvania’s Residential Child Welfare Facilities to obtain information regarding the alleged physical assault against a GMS student in July 2018 and the dismissal of GMS staff involved in the incident. • Toured the GMS campus and numerous buildings frequented by students including, but not limited to, the recreation center, cafeteria, dental center, and one of the student living units to determine if signage was posted indicating students’ rights and the student grievance policy and if locked student grievance boxes were present for students to submit written complaints. • Reviewed GMS Incident Reports documenting the alleged assault against a GMS student to determine the timeline of the incident and subsequent investigation performed as well as the GMS staff involved in the incident. • Reviewed documents regarding security awareness training and correspondence between GMS management and a member of the Pennsylvania State Police regarding retaining GMS employees’ background clearances. • Obtained from GMS management a listing of 698 GMS employees, generated from Filemaker, that included direct care staff and non-direct care staff for the period July 1, 2017 through May 13, 2019, to utilize for the testing related to our first three audit objectives. • Selected a total of 67 of the 698 GMS employees for background clearance testing:  Seven employees were selected based upon GMS incident reports that indicated they were involved in some manner with the July 2018 allegations of abuse sustained by a student while under the care of GMS staff.  Forty-five employees were selected from the 518 of the remaining 691 employees hired prior to the beginning of our audit period of July 1, 2017 by randomly selecting a starting point on the list and then systematically selecting every eleventh employee. 69 A Performance Audit Glen Mills Schools  Fifteen employees were selected from the 173 of the remaining 691 employees hired on or after the beginning of our audit period of July 1, 2017 by randomly selecting a starting point on the list and then systematically selecting every eleventh employee. • For each of the 67 employees selected for testing, we performed the following:  Determined if GMS timely obtained and retained the required state (PSP), federal (FBI), and Child Abuse background clearances, as well as the Adam Walsh check, if applicable.  If offenses were reported on any of the background clearances, we performed the following: o Reviewed the “Criminal History Assessment Documents” (justification forms) on file to determine if the justification forms were completed and approved indicating the basis for GMS’ decision to either hire or retain the individual. o Reviewed the offenses reported on the background clearances to determine if any of the offenses, pursuant to the CPSL, were ones that would have precluded the individual from having direct contact with GMS students.  Reviewed the employees’ job applications and current addresses in their personnel files to determine if the applicant currently resides or resided outside of Pennsylvania within the prior five years in order to determine if Adam Walsh checks should have been conducted. • Obtained from GMS management a listing of the 35 individuals contracted by GMS at some point during the period of July 1, 2017 through August 3, 2019, who had direct contact with GMS students and selected 6 of the 35 contractors for testing by randomly selecting a starting point on the list and then systematically selecting every sixth employee. Due to concerns with the completeness of the contractor list, we haphazardly selected an additional 4 contractors’ records from the hard copy files maintained at GMS for a total of 10 contractors selected for testing. • Obtained from GMS management a listing of 285 individuals that volunteered on GMS’ campus at some point during the period of July 1, 2017 through August 9, 2019, and selected 40 volunteers from the listing by randomly selecting a starting point on the list and then systematically selecting every seventh employee. Due to concerns with the completeness of the listing of volunteers, we haphazardly selected an additional 20 volunteers’ records from the hard copy files maintained at GMS for a total of 60 volunteers selected for testing. 70 A Performance Audit Glen Mills Schools • For each of the 10 contractors and 60 volunteers selected for testing, we determined whether GMS timely obtained, reviewed, and retained the required state (PSP), federal (FBI), and Child Abuse background clearances. • Tested training records for a total of 65 GMS employees by randomly selecting 48 employees, judgmentally selecting 10 employees to ensure coverage across different types of direct care employees, and selecting the seven employees that GMS incident reports indicated were involved in some manner with the July 2018 allegations of abuse sustained by a minor/child while under the care of GMS staff. Twelve employees were hired from July 1, 2017 through May 13, 2019, and the remaining 53 were hired prior to July 1, 2017. Our original intent was to test the same 67 employees selected for background clearance testing discussed in Finding 1, however, due to varying training requirements for non-direct and direct care employees and turnover timeframes of newly hired direct care employees, we selected replacements, as necessary, and did not test two non-direct care employees since the training requirements we tested did not apply. • With regard to our testing of training records of the 12 employees hired from July 1, 2017 through May 13, 2019, we reviewed supporting documentation, such as sign-in sheets, certificates, staff orientation acknowledgement forms, and Filemaker (tracking system software) training records, to determine if the employees completed:  Three hours of Child Abuse Recognition and Reporting (CARR) training within 90 calendar days of hire.  Four hours of Behavioral Intervention Training (BIT) & Restrictive Procedures training within 120 calendar days of hire.  Three hours of Prison Rape Elimination Act (PREA) training within 120 calendar days of hire.  Twenty-one days of on-the-job orientation. • With regard to our testing of training records of the 53 employees hired prior to July 1, 2017, and newly hired employees, where applicable, we reviewed supporting documentation, such as sign-in sheets, certificates, developmental logs, staff developmental training acknowledgment forms, and Filemaker training records, to determine if the employees completed:  Three hours of CARR training every five years.  One hour yearly and two hours yearly beginning in September 2018 of BIT & Restrictive Procedures training.  One hour every two years of PREA training.  One-time mandatory reporter training held in September 2018.  Forty annual hours of developmental training relating to the care and management of children. 71 A Performance Audit Glen Mills Schools • For all 65 employees, compared the dates recorded on the supporting documentation, such as sign-in sheets, certificates, and staff orientation acknowledgement forms, to Filemaker training records for accuracy. • Tested the training records of 8 of the 10 contractors selected for background clearance testing discussed in Finding 1. Two contractors were replaced due to GMS management subsequently indicating that the two contractors did not have direct contact with GMS students. For each of the 10 contractors, we reviewed their professional licenses or certificates to determine if they had completed the three hours of required CARR training or approved continuing education related to CARR training. • Tested the training records of 59 of the 60 volunteers selected for background clearance testing discussed in Finding 1. The remaining one volunteer was replaced for testing since the individual subsequently did not obtain training because the individual did not return to campus to tutor. Test procedures included reviewing certificates and acknowledgement forms to determine if the volunteers completed:  Three hours of CARR training.  One hour face-to-face orientation training. • Reviewed the GMS Student Handbook to determine what information is provided to students such as student rights and the grievance process. • Reviewed information/documents such as student rights, the policy for processing concerns and grievances, and notifications of documents provided to students and their parents/guardians upon admission to GMS to determine if they contained information relating to student rights and the grievance process. Additionally, we reviewed an example of the acknowledgment forms that GMS students and their parent/guardian sign to determine what information students and their parent/guardian acknowledge that they have received. • Reviewed Frequently Asked Questions information posted on GMS’ website to determine information published on home passes granted to GMS students. • Compared GMS’ grievance policy in place at the beginning of our audit period, July 1, 2017, implemented in May 2016, to the policy updated on March 15, 2019 with a pilot program for one of GMS’ living units in January 2019 to determine what the differences were between the policies and what avenues were available to students for reporting incidents of abuse and the procedures in place for processing grievances filed. 72 A Performance Audit Glen Mills Schools • Reviewed examples of a Grievance Tracking From and a Grievance Allegation Form to gain an understanding of what is documented regarding each level of the student grievance process. Data Reliability Government Auditing Standards requires us to assess the sufficiency and appropriateness of computer-processed information that we used to support our findings, conclusions, and/or recommendations. The assessment of the sufficiency and appropriateness of computer-processed information includes considerations regarding the completeness and accuracy of the data for the intended purposes. 101 In addition to the procedures described in the remainder of this section, as part of our overall process in obtaining assurance of the reliability of computer-processed information and data files, obtained from GMS, we obtained a management representation letter from GMS. This letter, signed by GMS management, included a confirmation statement indicating that the information and data provided to us had not been altered and was a complete and accurate duplication of the data from its original source. To assess the completeness and accuracy of the listing of GMS employees during the period July 1, 2017 through May 13, 2019 provided to us by GMS management that was generated from Filemaker, software utilized by GMS staff, we conducted audit procedures as follows: • Obtained an understanding of the information technology environment and controls for Filemaker. • Interviewed GMS management responsible for maintaining the listing. • Obtained three payroll reports during our audit period (April 5, 2019, June 29, 2018, and June 30, 2017), and compared the names on the payroll reports to the listing provided by GMS management. A limited number of variances were investigated and ultimately we determined the listing to be complete. In accordance with Government Auditing Standards and based on the above procedures, we concluded that the GMS employee listing was sufficiently reliable regarding completeness and accuracy of the population of employees. In order to further assess the accuracy of information maintained for each employee in Filemaker used to determine when background clearances should be renewed and when training refresher courses are required, we conducted audit procedures as follows: 101 U.S. Government Accountability Office. Government Auditing Standards. 2011 Revision. Paragraph 6.66. 73 A Performance Audit Glen Mills Schools • Obtained and reviewed background clearance reports for selected GMS employees to determine if the correct report dates had been posted to each of the employees’ background clearance file. • Obtained and reviewed training certificates, training logs manually maintained by GMS staff, and training sign-in sheets completed by employees at the time of their training to determine if the correct training dates and the number of associated training hours had been accurately posted to each of the selected GMS employees’ training record in Filemaker. Based on the above procedures, we determined that there were errors made when background clearance and training related information was posted to some GMS employees’ files. We therefore deemed the background clearance and training information maintained in Filemaker to not be sufficiently reliable and did not place any reliance on this information. Instead, we used the hard copy source documents (background clearance reports and training related documents) tested during our audit procedures to determine if GMS obtained the required background clearances for employees and if GMS employees received the required training. The errors found during our audit procedures are reported on in Findings 1 and 2 along with recommendations for GMS to improve its use of Filemaker as a tracking tool for renewal of background clearances and mandatory training for GMS employees. To assess the completeness and accuracy of the listings provided to us by GMS management of contractors at GMS during the period July 1, 2017 through August 3, 2019, we conducted audit procedures as follows: • Interviewed GMS management responsible for maintaining the listing. • Obtained detailed invoices of services provided by the contractors and compared the names on the invoices to the listing. During our review, we found contractors that provided services that were not included on the listing provided by GMS management. After we brought the discrepancies to the attention of GMS management, they provided a revised contractor listing. • In order to verify the completeness of the revised contractor listing, we haphazardly selected four contractors from hard copy background clearances on file at GMS and found that two of those contractors were not included on the revised listing. GMS acknowledged that this list was created based on our request because it did not have a centralized list of all contractors who had direct contact with GMS students in order to track their background clearances. See Finding 1 for details on GMS’ lack of maintaining a centralized list of contractors. 74 A Performance Audit Glen Mills Schools The listings of contractors were generated by GMS management based on information from various GMS staff that maintained files on the contractors. For example, the names of contractors providing medical related services were provided by GMS health center staff. Based on the above procedures, we deemed this information to be of undetermined reliability; however, this is the best data available. Although this determination may affect the precision of the numbers we present, there is sufficient evidence in total to support our findings, conclusions, and recommendations. To assess the completeness and accuracy of the listing provided to us by GMS management of volunteers at GMS during the period July 1, 2017 through August 9, 2019, we conducted audit procedures as follows: • Interviewed GMS management responsible for maintaining the listing. • Obtained sign-in sheets for the month of April 2018 evidencing that volunteers were on the GMS campus and compared the signatures to the volunteer listing. We found numerous volunteers who signed the sign-in sheets that were not included on the listing. After we brought the discrepancies to the attention of GMS management, they provided a revised volunteer listing. • In order to verify the completeness of the revised volunteer listing, we haphazardly selected 20 volunteers from hard copy background clearances on file at GMS and found that one volunteer was not included on the revised listing. GMS stated that the volunteer attended GMS orientation training and provided background clearances in anticipation of returning to GMS campus as a tutor; however, the volunteer never returned to campus and never provided services to students. Therefore, the individual was not included on the listing. GMS acknowledged that this list was created based on our request because it did not have a centralized list of all volunteers who had direct contact with GMS students in order to track their background clearances. See Finding 1 for details on GMS’ lack of maintaining a centralized list of volunteers. The listing of volunteers was generated by GMS management based on information provided by two GMS academic staff that maintained their own volunteer lists aligned with their own separate academic programs. Based on the above procedures, we deemed this information to be of undetermined reliability; however, this is the best data available. Although this determination may affect the precision of the numbers we present, there is sufficient evidence in total to support our findings, conclusions, and recommendations. 75 A Performance Audit Glen Mills Schools Appendix B Timeline of Events Regarding an Alleged Assault Against a Glen Mills Schools Student by Glen Mills Schools Staff That Led to the Pennsylvania Department of Human Services Order to Remove all Students and Revocation of Glen Mills Schools’ Licenses to Operate a Child Residential Facility The below timetable provides information regarding the events that occurred relating to an alleged assault by Glen Mills Schools (GMS) staff against a GMS student in July 2018. The information contained in the below timeline was obtained from various sources including The Philadelphia Inquirer and The Delaware County Daily Times news articles, incident reports filed by GMS, interviews and correspondence with GMS management, Pennsylvania Department of Human Services (DHS) correspondence to GMS, and documents filed by GMS to appeal DHS orders/decisions. July 19, 2018 3:08 PM July 20, 2018 9:32 AM July 20, 2018 1:15 PM July 20, 2018 July 23, 2018 July 24, 2018 Alleged assault against GMS student. After interviewing the student and staff that witnessed the alleged assault and reviewing video footage of the event, a GMS Team Leader (Team Leader) called ChildLine to report the alleged occurrence as an incident of suspected abuse by a GMS Counselor/Teacher. The Team Leader also notified the student’s parent, a Philadelphia Admissions Supervisor, a Philadelphia Human Services Program Administrator, and the Chief of Juvenile Probation of the incident. GMS student allegedly assaulted was examined by a doctor at the GMS Health Center. GMS terminated employment of the Counselor/Teacher for going outside of established GMS Behavioral Intervention Techniques. The Team Leader who notified external agencies on July 20, 2018, was removed from his position and placed on administrative duties for failing to meet standards of his job. A GMS Group Living Director contacted ChildLine to inform them that after reviewing video footage of the July 19, 2018, incident it was determined that a second GMS staff member, a Senior Counselor, was involved in the same alleged incident and that he also went outside of the GMS Behavioral Intervention Techniques. The Senior Counselor was reassigned to an administrative position and was to have no contact with students until the investigation was concluded. 76 A Performance Audit Glen Mills Schools February 22, 2019 February 28, 2019 The Group Living Director also reported the incident to the Pennsylvania State Police and turned over video footage. Four additional Counselors/Teachers were reassigned to administrative duty and were to have no contact with students until the investigation was concluded. The Team Leader, via telephone, notified the student’s parent and, via email, a Philadelphia Admissions Supervisor and a Philadelphia Human Services Program Administrator that a second counselor was involved in the incident. GMS terminated employment of the Senior Counselor for going outside of established GMS Behavioral Intervention Techniques. Philadelphia Inquirer publishes the article “‘I can’t breathe’: Probe underway at Glen Mills after staffer attacks boy.” GMS received a DHS Licensing/Approval/Registration Inspection Summary with inspection dates of July 19, 2018 through September 12, 2018, and reported that GMS failed to protect the health, safety, and well-being of youth in their care and that a student was physically abused by staff. GMS responded to DHS’ Licensing/Approval/Registration Inspection Summary with its response and plan of correction that included but was not limited to employees being either terminated or demoted and the provision of additional training for all GMS staff. DHS accepted and approved GMS’ plan of correction provided in response to DHS’ December 17, 2018 Licensing/Approval/Registration Inspection Summary. The Philadelphia Inquirer publishes the article “Beaten Then Silenced: At the Oldest U.S. Reform School for Boys, Leaders of the Prestigious Glen Mills Schools in Pennsylvania Have Hidden a Long History of Violence.” Four counties in California and three counties in Pennsylvania began to remove students from GMS. The Philadelphia Inquirer reported that GMS Executive Director, Dr. Randy Ireson, took a leave of absence. 102 March 8 and March 19, 2019 Further, according to the Delcotimes, Dr. Christopher Spriggs named Assistant Executive Director and assumed all responsibilities of the Executive Director. Carolyn Seagraves became President of the Board of Managers upon the resignation of the prior President, Joe Hand, Jr. 103 DHS staff visited the GMS campus and met with representatives from GMS to discuss implementation of GMS’ plan of correction accepted by DHS on February 13, 2019. July 25, 2018 July 27, 2018 August 31, 2018 December 17, 2018 January 15, 2019 February 13, 2019 February 20, 2019 https://www.inquirer.com/news/glen-mills-schools-pa-abuse-resign-randy-ireson-joe-hand-investigation20190228.html (accessed February 25, 2020). 103 https://www.delcotimes.com/news/glen-mills-appoints-new-leadership-team-during-transition/article_62e99940946e-11e9-b2cf-9b05d9f8341f.html (accessed February 25, 2020). 102 77 A Performance Audit Glen Mills Schools March 25, 2019 April 2, 2019 April 4, 2019 April 5, 2019 April 8, 2019 April 11, 2019 April 16, 2019 May 6, 2019 June 5, 2019 July 31, 2019 December 11, 2019 March 4, 2020 DHS issued an Emergency Removal Order requiring that all residents at GMS be removed as promptly as can be safely accomplished. This was based on a determination that the conditions at the 14 licensed facilities at GMS constitute gross incompetence, negligence, and misconduct in operating a facility, including mistreatment and abuse of clients, likely to constitute immediate and serious danger to the life or health of the children in care. As the result of the DHS order to remove students from GMS, GMS began laying off staff with 86 employees initially affected. (The most recent layoff associated with the removal of students was on August 20, 2019, bringing the total to 252 employees laid off.) GMS filed an appeal regarding DHS’ Emergency Removal Order to remove all residents at GMS. The last student remaining at GMS was removed. DHS issued a decision to revoke all 14 of GMS’ licenses to operate a Child Residential Facility. The Juvenile Law Center, Education Law Center, and Dechert LLP filed a lawsuit against certain state departments, officials, and others seeking financial damages on behalf of young people who were sent to GMS by the courts. This followed the December 2018 Children’s Rights and Education Law Center’s publication of: Unsafe and Uneducated: Indifference to Dangers in Pennsylvania’s Residential Child Welfare Facilities which reported that GMS was known for its maltreatment of its child residents long before the July 19, 2018 incident. (See page 12.) 104 GMS filed an appeal regarding DHS’ revocation of the 14 licenses held by GMS. The Bureau of Hearings and Appeals ordered a six-month stay of the appeal regarding GMS’ licensure and emergency removal, but the licenses remain invalid until such time as a hearing is conducted. Dr. Randy Ireson retired as GMS Executive Director. Dr. Christopher Spriggs named as the Acting Executive Director. Governor Wolf signed Executive Order 2019-05 Protection of Vulnerable Populations and established the Office of Advocacy and Reform, the position of Child Advocate, and the Council on Reform. A Bureau of Hearings and Appeals’ status conference regarding the sixmonth stay was scheduled; however, due to technical difficulties the conference was canceled. Subsequently, in February 2020, the case was stayed an additional 30 days and a status conference with the Administrative Law Judge was scheduled for March 4, 2020. The Administrative Law Judge lifted the six-month stay of the appeal. A Hearing on the Merits has been scheduled for August 3, 2020. https://www.elc-pa.org/resource/report-highlights-dangers-lack-of-educational-opportunity-in-pa-residentialchild-welfare-facilities/ (accessed March 6, 2020). 104 78 A Performance Audit Glen Mills Schools Appendix C Training Timeline for Glen Mills Schools Employees, Contracted Staff, and Volunteers As discussed in Finding 2, the following timeline detailing Glen Mills Schools’ (GMS) training requirements in place during our audit period for newly hired employees, existing employees, contracted employees, and volunteers was utilized during our testing of training records. Training requirements are included in the Child Protective Services Law pertaining to Child Abuse Recognition and Reporting and Department of Human Services (DHS) regulations at Title 55, Chapter 3800 of the Pennsylvania Code which were promulgated to protect the health, safety, and well-being of children receiving care in child residential and day treatment facilities. 105 Since GMS policies did not adequately include all necessary information, this document, as included verbatim below, was prepared by GMS to provide us with a list and the timing of all the training courses provided. The timeline includes references to “DPW” which has been renamed the Department of Human Services (DHS). Training Timeline GMS follows the guidelines set forth in the 3800 regulations. The difference between non-direct care and direct care staff is defined in section 3800.58. Staff Training. Because our non-direct care staff do not have regular and significant direct contact with children and because they don’t work alone with the children, they are not required to be trained in the same areas as the direct care staff. Background clearances are required for all staff (Direct/Non-Direct Care, Contractor, Volunteer, and Intern). New Hire: Non-Direct Care (Full and Part Time) Orientation Training was an on the job training (21 days=120 hrs.) provided by the supervisor and veteran staff within the unit/department during a new employees probationary period. 105 See 23 Pa.C.S. § 6383 and 55 Pa. Code Ch. 3800. 79 A Performance Audit Glen Mills Schools New Hire: Direct Care (Full and Part Time) Orientation Training was an on the job training (21 days=120 hrs.) provided by the supervisor and veteran staff within the unit during the first 21 days of a new employees probationary period. In March 2018, we implemented a face to face Orientation Training (1 hr.), provided by the personnel department. This training was added to inform the new employee, prior to starting their job, pertinent information about the school and job requirements in a formal training format. Prior to having contact with the child, all new employees are offered the face to face training and continued to receive the on the job training (21 days=120 hrs.) during their probationary period. Within a 120 calendar days of the new employee start date, each employee receives training in the following areas: Training: (Unless noted, delivery was live face to face by Personnel Department staff) • • • • • • • • • • • • Pa. DPW Child Abuse Recognition and Reporting Training (CARR within 90 days) (3 hrs) o On-line training through http://tinyurl.com/p4fmt8v Behavioral Intervention and Restrictive Procedures Training (4 hrs) o In September 2018, a proposal was submitted for Behavioral Intervention training to be expanded (8hrs). The proposal expanded instruction on early intervention and de-escalation. We also proposed to add in simulated live practice in the hands on techniques of Handle with Care. Suicide Prevention and Suicide Recognition (1 hr) Search and Seizure (1 hr) Sexual Orientation Gender Identity Cultural Diversity and Sensitivity (1 hr) Cardiopulmonary Resuscitation (C.P.R.) (3 hrs) First Aid Training (2 hrs) Automated External Defibrillator (A.E.D.) (1 hrs) Bloodborne Pathogen Training (1 hr) MRSA / CA–MRSA Training (1 hr) Fire Safety and Hazard Communication Training (4 hrs) o includes OSHA Training Prison Rape Elimination Act Training (PREA) (3 hrs) Recertification: (Unless noted, delivery was live face to face by Personnel Department staff) • • Pa. DPW Child Abuse Recognition and Reporting Training (CARR) (3 hrs every 5 yrs) o On-line training through http://tinyurl.com/p4fmt8v Behavioral Intervention and Restrictive Procedures Training (1 hr annually) 80 A Performance Audit Glen Mills Schools • • • o In September 2018, recertification changed (2 hr annually). There was an expanded instruction on early intervention and de-escalation. We also provided more practice in the hands on techniques of Handle with Care. This was to coincide with the proposed expansion of the initial BIT training. Cardiopulmonary Resuscitation (C.P.R.)/ Automated External Defibrillator (A.E.D.) (1 hr every 2 yrs) First Aid Training (1 hr every 2 yrs) Prison Rape Elimination Act Training (PREA) (1 hr every 2 yrs) Contracted Staff: (Full and Part Time) Our contracted staff are licensed in the field which they are contracted to work at GMS. We require staff to supply their current active license to work with our kids. All contracted staff are required to submit to background clearance checks. Contracted staff received on the job orientation from the supervisors in their area. In March 2018, any new contracted staff also received a face to face orientation training (1hr) provided by the personnel department as well as their on the job orientation. Volunteer/Intern Staff: (Full and Part Time) All volunteers are required to provide background clearance checks prior to working with our kids. All volunteers are required to complete the Pa. DPW Child Abuse Recognition and Reporting Training (CARR) (3 hrs.) online training to work with our kids. Volunteer staff receive a face to face orientation training (1hr) provided by the personnel department prior to working with our kids. Following 3800 regulations, Glen Mills requires 40 hours of Developmental Training for staff. This training is delivered by the supervisor during the weekly meetings conducted in each area. There is a developmental log in each unit/department to record the information discussed. All trainings provided for staff are documented in our filemaker online database. Each training is documented with sign in sheets that are kept in the Personnel office. The following trainings are documented and kept in staff personnel files either through acknowledgement forms, or certificates: Acknowledgment Forms: • • • Face to Face Orientation BIT Suicide Prevention 81 A Performance Audit Glen Mills Schools • • Fire Safety PREA • • • • CARR CPR First Aid AED Certificates: 82 A Performance Audit Glen Mills Schools Appendix D Glen Mills Schools Student’s Rights As discussed in Finding 3, the following is a list of a student’s rights that is included in the GMS Student Handbook (handbook). The most recent version of the handbook was issued on March 11, 2019. 106 GMS management stated that the handbook is provided to all new students and a copy is posted in each of the living units. Additionally, a copy of the student’s rights is provided to the each student’s parent/guardian. There were several versions of the handbook during our audit period, which appear to be the result of changes due to staff listings. We confirmed that the student rights remained unchanged throughout the different versions during the audit period. 106 83 A Performance Audit Glen Mills Schools I-J em UI 11]- El Ne student shall he discriminated against hecause ef celer: religieus creed. disability: handicap: ancestry. sexual erienta1ien. natienal erigin. age er sen. Ne student shall he ahused.. untreated and threatened. harassed er suhject tr- cerperal punishment. Ea-m student shall he treated with fairness, dignity and respect. Ea-m student shall he infermed efthe nernss efthe Erl- Echeels. A student has the rightte cerumunicate with ethers hy telephene suhjectte reasenahle facility pelicy regarding circumstances: ?'equency. time. payment and p1itacy. Each student may pritately cemmunicate with ether: hy um eftelephenes le?cated in the Student Unit-n. Private phene cenversatiens te er Err-m a Prehatien U?'icer. ?ildh Attemey. clergy: are cens'Etent with the student's legitimate need fer pritacy and his right fer cenfidentiality. A mild shall have the right te visit'irith family at least ence every 2 weeks: at a time and lecatien cenveni-t fer the family: the child and the facility, unless visits are restricted hy ceurt erder. This right dees net restrict mere frequent family visits. Ea-m student tisit with his family in a designated area en the greunds efthe Glen lv?lh Echeels. The scheduling efan appeintnieut fer tisi1atien en the weekend days ef Saturday 3r Sunday is required te insure the availability efthe student. Ea-m student may receive and send mail- There shall he ne charge tn the studut te mail letters. Cl'utgeing mail shall net he epened er read by slaffpersens except in the existence efa written ceurt erder se autherizing. Inceruing n1ail frem Federal, State er Ceuuty ef?cials: er Err-n: the studenfs atterrley shall net he epened er read hy s1a?' persens- Inceruing n1ail frem persens ether than these speci?ed aheve shall net he epened er read hy slaffpersens. Ifthere reasenahle suspicien that centlahand er ether inferniatien er matedal that mayjeepardize the student's health. safety er wellheing is enclesed in the letter er package, the letten'paclrage shall he epened hy the student in the presence efa slaffpersen. A Performance Audit Glen Mills Schools ll- 13-- 14. 15- 1+5- 13. A mild has the right tc- cc-mmunicate and visit his attemey and clergy. A student may cemmunicate and visit privately sri?s atterne'j.r and clergr presided thatthe and-'c-r clergy veri?cation nftheir relatinnship ferthe student's recnrd E?Eitatic-n shall occur at a nautuallyagreed upon ccnt?enient nrue seizure- A facility may cencluct search and seizure precedures: subject tc- reasr-nahle facility pelicy. Ferthe purpose at safety, upon arrival ea-m studentshall unpack his and pessessiens in view nfa staff persen. Thereafter. a stud-t shall searched if there reasenah-le suspicinn that he is in pns?sinn cf centsahand?weape-ns- A mild has the right tc- plactice the religion c-ri'aith cf chc-ice. ernnt tn pracnce religic-n curl'aith. A studut may practice the religicnn er faith nfhis chnice as lung as the pact-ice there-1f dues net infringe ri A student shall nnth-e required tn practice a religicnn cr Faith. A student shall have the right tn apprc-priate medical hehat'ielal health and dental treatment. A student shall have the right tn rehabilitatinn and treatment. A student shall have the right te be free item excessive medicatien A student shall nnth-e suhjectedtn unusual nr extreme nae?mds nf dimipline schi?a may cause at physical harm tn the child A student has the right tn clean seas-anal clething thatis age and gender App-repriate masnnal will he presided h-ythe Glen Llills ?che-ch- 15 85 A Performance Audit Glen Mills Schools Appendix E GMS Policy 12.6 – Student Grievance and Appeal Process As discussed in Finding 3, the following policies detail the process by which students (or their parent/guardian) may file a grievance with GMS to address an alleged violation of their student rights. GMS management updated the policy on March 15, 2019 during our audit period; therefore, there are two versions of the policy, which we refer to as the former and current policies in Finding 3. The major differences between the two versions are that the current policy allows for parents/guardians to file a grievance on behalf of their student, and the current policy also establishes a Grievance Panel as another level in the process to review a student’s grievance. 86 A Performance Audit Glen Mills Schools Policies and Prue-Idem l?nliesr Numb-er @Mig Glen Sehnnh 116 - Chapter: 11 - Fragrant Subject: Student Grievance it Appeal Prueess humanity: Dr. Randy A. Iresnn. Executive Director [late of Issue: Dale nl' lie-issue: Still-IE I. IL Students at the Iiilen l?v'lills shall have the right tn initiate grievance procedures to address an}.r viniatinn n?r'their "student rights". This ptueess shall he initiated with-ant fear at" retaliatinn er an}; adverse eclien. PHDCEDURE: A- The grievance policy shall be included in each cnpy nf1he Glen Mills Schnels which is given tn each Student upun arrival at the El. Retaliati?n: ND let?liatinn nl?any kind shall he directed tnward an}r student initiating the grievnnee prneess- C. Grievances may be ?led for any vielatien ei'a "student right". The rights are specified in the "smtlent rights" sectien nfthe Glen Mills helmets student I-lantib-nnlt- D- Levels 1. Level One The student may Liiseuss his grievance with peer. The student may ?1er this during 3 peer 1t} peer cnnversatinn. Guided Grnup lnteractinn meetings. unit meetings nr Unit Battling Bulls Club Meetings. Student's can use the nptinn in gen directly In Level Twn. Level Twin The student may discuss his grievance with his individual unit munseler. 'l'his sheuld he dnne within five days {if the ineident, in which the student felt his rights were if the cnunselnr is unable tn resnlve the concern. the student sheuld speak in the unit Senier The Seninr shall :I'ccn-rcl the grievance en a ticvance Tracking an?n"- Level 3 1f the student feels the grievance was unresnlveti at Level 2. the "Grievance Tracking Farm" shall he passed the unit Team Lender. The student shall have the appertunitv 1n sneak tn the team Lender sheet the grievance. 87 A Performance Audit Glen Mills Schools 4. Level 4 - ll'the grievance is unrcsulvecl at Level 3, the "Grievance 'l'raeltini,r will he passe-d en tn the Greup Living Direeter in regards as the grievance- Ln Level 5 - 11" the grievanee remains unrestelvecl Il'Ie "Grievance Tracking Ferm" Shall be unseen un tn the EHECtLtive Direetnr. The student shaJI have the tu speak with the Exeeutive Direeler regarding the grievanee. IEI. Level ti - ll'the grievance is unresnlveel despite the el't'erts efall the individuals invelvecl in the grievance prucess, the student shall have the eppertunity In ape-alt tn his prebatien el'iicer. werker er relerral agency representative- at Reseiutiun - ll?during the grievance piecess1 a reseJutien is reached, the student shall sign the "Grievance Tracking Femt" te a eenclusien tn the lirecess. F. Neti?catiens tn the student?s Email}r andjunsdiclien will be made- (3. Assistance by a Ceunseler-Teaclter I.vill be previded in the event the student wishes te- raaltc a written grievance. and needs assistance cleing su. H. The grie vanee and appeal prueess will he centpleted within 5 days. 1. tn the event that tlte afereinenliened internal reseureea are net in requving student grievanees the I'elluwing external reseurees are available fer their use. Department Services Bureau at" Equal Crepe rtunilv Health at Wellare Building Rm 225 Harrisburg. Pa. Diapartmenl at" l'lul'r?ienl Serviees Bureau at" Equal Upp?l?tunitjr' SnuTlte-?at Regienal ?f'fiee Suite SHE-4 3i.? St. Philadelphia, PA US. Department at" Health Human Services ?ffiee efL?ivil Eighla Fi? lndepetidertee Mal] West-Suite 372 Philadelphia. P?t Iluman Relations N- 5L Suite SUI Philadelphia, PA Will? Id 88 A Performance Audit Glen Mills Schools I'Hlicies and Precedures Pnliele Number @Mg Glen Mills Scheels lid Chapter: II Program Subject: Student Grievance ti Appeal Frneess Autherity: Dr. Randy .di. lresen, Executive Director Date uf Issue: 13531001 Date of lie?issue: 19 POLICY: Students and tlte Student?s family shall have the right In initiate grievance with The Glen Mills Selma-ls te address an}.r alleged t-?ielatien efspecific ur civil rights witheut fear aftetaliatinn. These speci?c rights include but are net limited In, t'inlatien el' lewcring et'the student's Itchacier rating in the residential living unit! staff misceuduct er any acti-ans by stathhat the student at the student's parent-guardian tines net agree with Student miseenduct. and speci?c health and safe-t}? issues. PRDCEDIJRE: A. The grievance shall he included in each copy nt'the Glen Mills Selrnels Fitutlern i-Iandbeek, 1which is git-en in each student and the Student?s paran-?guardian upalt arrival at the schea-l- Each student and the student's parentiguardian shall receive a Grievance a?iileg?ti?n upttri arrival. should the student or the student?s parenc?guardittn feel the need tn ?le a grievance allegatien 1.eitlt the t3 Ien Mills Scheets- The er the student?s parentt'guardian shell eeinplete the Grievance Allegatien Farm and depesit the cempletcd fann in an}- grict-?anct: ceileetien link: in the units and-"er titreuglteut the cernrnen arena ?n W'ithin E4 lteurs alt eleetmnic grievance record will bi: created the Team Leader {er designee} to initiate the intrestigatien of alleged g1 iet'ance. Each student and lite student?s parent-guardian shall hat-e the right te lite a grievance allegatien 1.tritlt the Glen Mills Scheels l'h?l??l'ly' alleged i-?ielatinn et'specit'ie er civil rights with eut the fear el'rctaliatian- Grievances may he filed fer alleged t-inlatiu-n nt'a "student right". As Stated abet-e. these rights include but are net limited in. alleged t-?ia-latiens nFthe student?s behavie-ral rating in the residential living unit. staf'i'rniscenduet er anyaCtinns by staff nersens that the student er the student?s pal-eiteguarnian dues net agree with. student ntiseenduet, and specific health and safer}.r Issues. The student?s speci?c rights are in the "student rights" scetintt nl'lhe Glen Mills Student Handheld-it. 89 A Performance Audit Glen Mills Schools E. Levels Le eel Cine - The student 1arill the Erie 'n'ill'l?? Ftllegatien Farm and depesit the fin-r111. in any grieve nel: eelleetieh hes tllreuglniut campus. Team lead ers will elteelt tlte grit vanee eelle etien heses daily. The Team Leader (er desighee} 1still eteate the eleetrenie {er the grieL-anee allegatien in the penal within 24 lie-hrs. er next business dag.? elf at" a gt'iet'att ee allegalien. The 14 hnur time eluelt starts enee the eleetre-nie grie s'anee is created. The student mag.-I diseuss his alleged grieve nee With a peer. The student tea}I de this dating is student te- student eereatien, Guided Greup Interactien meetings. unit meetings or unit Battling Bulls Cluh The student may.r alse discuss his gries?anee allegatien 1with his individual unit euunseler {er any eeunseler]. Level 'l'we - lfthe student is enable :rese-Isle the grievance allegatien at level ?ne. the student sheuld rtteet Iwith the unit Se nier Cettnseler regarding the grievanee allegatien. 'l'he Senier CeunseIe-r shall reentel the investigatien et?tlte grte vanee allegatien and euteeme in the eleetrenie [at eaeh level an eleetrenle at the investigation and nut: eme et'alleged grievance investigatien shall he eampleted by the responsible petseh?i. Lew?'1 Three - lfthe student FEEIF. that the griet'anee allegalien was unresnlvetl at Level Twe. the student shall have the nppertunity te meet with the Team Leader ngarding the gries?anee allegation. Les-e] Feur [I'the grievanee allegatien is unresolved at Level Three, the student shall have the eppununity te meet with the Green Living Dire eler regarding the nee allegatitnl. Let-e] Five - lflhe grievanee allegatinn is unreselved despite the e?'eree in Levels Due threugh the student sltall hat-e the epper?lunity te meet and!? speak with external res eurees in valued in child's treatment plan. This shall inelude. hut net lintite-tl ten his pruhatien et'?eer, semal er re Femll agency-r rep-tese ntatit-e. his parentsr'guardian, at his atlerney. 01' any eftlte agenejes listed helew- It'due pttJ-eess has been afferded the student, the deeisien el?the Eseeutive Direeter is final. Department at Human Ser vices Bureau at Equal Health at: Welfare Building Hm 22:1 Harrishurg, PA li? Department at! lumen Serviees Bureau uquual 90 A Performance Audit Glen Mills Schools Regional Df'?ee Suile SDI-ail SCH Market St. Philadelphia. PA Igll? US. Department er] lealth 3: Human Service-5 Dfl?tee {it?ll?lie ll Rights 51] S. ln-tlepenele nee I'v'lall West-Suite Philadelphia, PA I l-Iumati Relatiens N. St. Suite 5m Philadelphta, PA 1910? I Level Sitt? If the grievance allegatien is er the attendant is net eatitt?etl with the rest] ease tn the grievance allegalinn Levels-1 {?ne Ihreugh Five, the student will have the eppertunity te have his grievance allegatten reviewed in them ef'a Grievance Panel. The panel wt? be made up til varieus. stakeheIel-ere {as available] invelvetl in the ehiltl'e. treatment. If clue has. been after-tied the Student. the deeisien el"the Exeeutive Dir-eater is. ?nal. 1- Level Seven - grievance allegatiun remaiIe-z er the student is net satiefled tlte rettpnase 1n the grin: vanee allegatie-n. the student ehall have the ?pp?l?lunily Le ?le an appeal With the Executive Direeler regarding the grit.- vanee allegati-en euteeme. Renalutiun - Ifduring the grievance investigat'ten. a is reae he1tl, the student shall sign the "Grievance ?tllegat?ten Fertn" te- verify a eenelt-sien he the grieve nee allegatinn. Hetil'teatiert el'lhe grievance allegatien and any eLtIL-urne el'the ef the grievance allegalien will be sent te the student's-2 pareltt..?gtiartlian and jurietlietien il' app-lie able. Meietaitee by Ceunselert'l'eaeher be prevideti in the event the Studem has limited writlen eetnmunieatien skills and needs help cemeleting the grievance allegaliun Term. Within 24 heunt at" the grit; vanee reentt?l being created, the griEva nee allegatien and inveetigatien will be reviewed by the Greup Living DireeIe-r. T2 hears ef' the grievance ree-erel being created. IJII: gtievartee allegetiert and investigation Iwill be reviewed by [he Exeeulive Direttmr. Appeal- lt'the srutlenepatent guardian is net satis?ed with the deeisien eeneerrting the grievance allege-tines. an app-ea] can be made In the Executive Directer. Within Tl 1I21th5 et' receipt at the eeneem, the Flt-t eeutive Direetnr er the deeignee will reap-end in writing. 91 A Performance Audit Glen Mills Schools Appendix F Glen Mills Schools Policy 8.20 – Compliance with Pennsylvania Child Protective Services Law As discussed in Finding 3, in accordance with the Pennsylvania Child Protective Services Law (CPSL), Glen Mills Schools (GMS) staff are mandatory reporters. The following policy outlines the steps GMS shall follow in cases of suspected abuse. This policy was originally issued in 2001 and was re-issued in May 2016. 92 A Performance Audit Glen Mills Schools Fallciu Pram-durum Piliny Numb-Ir un- Hill: Eight-II- 11'} - Elm:- uni may-Icy 'Ehjm: cud I mull-HE llr. Hull] 4.1mm. Emmi?- nit-mum TD-lltull'uum Him-m . [gunning-mug: 5511116 T11: Ell-En- =I1n l fulluw'l'i?: 55 child Etnu'un Edna-glam WW ul" 51mm child ahm. II- 1'11: Elm luliJla Ema-uh will lake 1hr:- maps in nmsufatupncludalm: A. Amlel?JH-n?h! Ell-=11 Milla 5:11am: will im?iimly mum-I1 Dre] rcpn-rc [If luau-Em! :I'nlld alum ?im?y [It mummhm Jm-pucl mum-child hi5 ?ab-m. ll'lh: ram: hmlven imrmd'mdy impleml: :Ir uII:rn:1I:lIn- mum-mu Lu mum I11: may "Tl?r??l'i?i?d wiltmuti'rl: ?gummswill bl: In ?pp-mvcd tL'l ll'lt Chill] Emmi-H: agency. C. CDM?lm?lsllE frith die-121mm: Sen-inu- dml'mnr: IfanmlEn-ml immigurlnu ?'I-nul? b?jrli 2iB EIIL D. Mal-cu FnIl-ucliul Etm'm hres?gnning agar-qr n?lirl lull-nun. Emu the rim: lh: il'llm ul'lh: sump-culled Elan-c.1111: umlL-m MPH-I1 will be am the 515mm Farm. pra'rinl-nd hymn: [I'll-pm'lmcr? ut'E-lum Liming. 93 A Performance Audit Glen Mills Schools Appendix G Distribution List This report was distributed to the following Commonwealth officials: The Honorable Tom Wolf Governor The Honorable Carolyn Seagraves President, Board of Managers Glen Mills Schools The Honorable Thomas Murt Majority Chair House Human Services Committee Dr. Christopher Spriggs Acting Executive Director Glen Mills Schools The Honorable Angel Cruz Democratic Chair House Human Services Committee Mr. Herb Pace Director of Special Services/Regulatory Compliance Glen Mills Schools The Honorable Michelle Brooks Majority Chair Senate Human Services Committee Joseph McHale, Attorney Stradley, Ronon, Stevens & Young, LLP The Honorable Art Haywood Democratic Chair Senate Human Services Committee The Honorable Teresa D. Miller Secretary Department of Human Services The Honorable Jen Swails Secretary of the Budget Office of the Budget The Honorable Carolyn Ellison Deputy Secretary Office of Administration Department of Human Services The Honorable Joseph M. Torsella State Treasurer Pennsylvania Treasury Department The Honorable Josh Shapiro Attorney General Office of the Attorney General Ms. Tina Long Director, Bureau of Financial Operations Department of Human Services Mr. William Canfield Director Bureau of Audits Office of Comptroller Operations Mr. Alexander Matolyak, CPA Director, Division of Audit and Review Department of Human Services 94 A Performance Audit Glen Mills Schools Ms. Mary Spila Collections/Cataloging State Library of Pennsylvania This report is a matter of public record and is available online at www.PaAuditor.gov. Media questions about the report can be directed to the Pennsylvania Department of the Auditor General, Office of Communications, 229 Finance Building, Harrisburg, PA 17120; via email to: News@PaAuditor.gov. 95