BUREAU OF QUALITY IMPROVEMENT PROGRAM REPORT FOR

Transcription

1 S T A T E O F F L O R I D A D E P A R T M E N T O F J U V E N I L E J U S T I C E BUREAU OF QUALITY IMPROVEMENT PROGRAM REPORT FOR Alachua Regional Juvenile Detention Center Department of Juvenile Justice (State-Operated) 3440 NE 39 th Avenue Gainesville, Florida Review Date(s): November 13-15, 2012 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES W A N S L E Y W A L T E R S, S E C R E T A R Y J E N N I F E R R E C H I C H I, B U R E A U C H I E F

2 SELECTADETENTIONCENTER Alachua Alachua Foradditionalinformationaboutthisfacility,clickhereorvisit htp:// FY (July1,2010-June30,2011) PerformanceMeasures IncidentRate Sex Youthon Staf Youthon StafRate Youthon Youth YouthonYouth Rate c Escapes 0 c 1, Race/Ethnicity Black Hispanic Other White Female Male O fensesleadingtoyouthdetention (Admissions) O fensecategorybreakdown(admissions) 14% O fensesleadingto YouthDetention CourtOrders FelonyOfense MisdemeanorOfense 80% 60% Felony OfenseType Misdemeanor 33% 54% 40% 20% 0% Drug OtherOf Property Violent Drug OtherOf Property Violent 55% 64% 6% 4% 35% 7% 14% 15%

3 NumberofAdmissions AverageDailyPopulation 2,000 1,865 1, ,500 1,000 1,455 1,266 1, FY06-07 FY07-08 FY08-09 FY09-10 FY10-11 FY06-07 FY07-08 FY08-09 FY09-10 FY10-11 AverageLengthofStay(Days) Alachua Statewide 10 FY06-07 FY07-08 FY08-09 FY09-10 FY FY06-07 FY07-08 FY08-09 FY09-10 FY % ofsecuredetention Populationinfor DomesticViolence % ofdraiscoreswith AnyFirearm-Related Charges Utilization FY06-07 FY07-08 FY08-09 FY09-10 FY10-11 ScoredIn HadFirearm 80% 60% 40% Didn'tscorein,buthad nootheroption NoFirearm 20% 0%

4 FY (July1,2010-June30,2011) DRAI Screening- Actual Outcome % Home 95% Secure 5% DRAIDecision-ActualOutcomesofYouthScreened (TotalNumber&Percent) DRAIF_N

5 DEFINITIONSOFMEASURES Demographics-Thetotalnumberofmales,females,whiteyouth,blackyouth,Hispanicyouth,andotheryouthadmittedto thefacility. Escapes-Numberofindividualwhoescapedfrom afacility. IncidentType-Rateofyouthonstafbatteryisthenumberofincidentsper100,000servicedaysincalendaryear2007.This methodisappliedtoyouthonyouthbatteryrate.seethemethodologysectionformoreinformation. OffensesLeadingtoYouthDetention -ThehighestpresentingchargeassociatedwiththereferralIDlinkedtothedetention stayisusedtodeterminethedetentionadmissionofense(orreasonfordetention). CourtOrders-include5categories:FailuretoAppear,Abscond,Contempt,violationofprobation,andgeneralcourtorders (likecourtorder-detentionorder). OffenseCategories-Feloniesareanynew chargewhoseofenselevelisafelony.misdemeanorsareanynew chargewhose ofenselevelisamisdemeanor.itisimportanttonotethatthemajorityoftheseyoutharethemisdemeanordomesticviolenceyouth,althoughanothergroupofthemisdemeanorkidsarescoredonanunderlyingchargeonthedraiforwhichthey arecurrentlyonsometypeofactivesupervision.forbothfeloniesandmisdemeanors,subgroupingsareperson,property, drug,andother. NumberofAdmissions-Totalnumberofyouthadmittedtothesecuredetentionfacility.Ayouthiscountedonceforeach admissiontoadetentioncenterforaseparatereferral(case). AverageDailyPopulation -Theaveragedailypopulationofyouthinthefacilityforthefiscalyear.ADPissimplycalculated byaddingthetotalnumberofservicedaysforaparticularcenteranddividingbythetotalnumberofdaysinthestudyperiod (typicaly365). AverageLengthofStay(Days)-Statewidelengthofstayinsecuredetentioniscalculatedseparatelyfrom individuallengths ofstay.thestatewidefigureincorporatestheentiretimeayouthspentinsecuredetentionincludingstaysinmultiplefacilities, whereasindividualfacilitylengthofstayonlyaccountsforthecontinuoustimespentatasinglecenter. Utilization -Percentageofthefacilitiesbedsthatwere,onaverage,filed.Whentheutilizationrateisunder100%,thedetentioncenteris,onaverage,operatingbelow itsdesignedcapacity.whenthisrateisover100%,thedetentioncenteris,onaverage,operatingaboveitsdesignedcapacity. DRAI(Detention RiskAssessmentInstrument)-Youthunderage18takenintocustodybylaw enforcementarescreened withthedraitodetermineiftheyshouldbedetainedinasecuredetentionfacility. DomesticViolence-Thepercentofthesecuredetentionpopulationinfordomesticviolence,andofthattotal,thepercent thatscoredinandthepercentthatdidnotscoreinbutdetentionwastheyouth'sonlyoption. Firearms-ThepercentofDRAIscoreswithanyfirearm-relatedcharges. DRAIDecision(ActualOutcome)-UsingalyouthwithDRAIrecords,thetotalnumberandpercentofalyouthscreenedin aparticularcountythathadanactualoutcomeofrelease,homedetention,andsecuredetention.thisincludesalyouthadministeredadraiscreening.individualyouthmayhavebeenscoredmultipletimesduringthestudyperiod. DRAIAggravating/MitigatingFactors-Indicatethenumberofpointsofdiscretionaryaggravatingandmitigatingfactors usedforaldetainedyouthinaparticularcountywithnon-zerodraiscores.

6 Rating Definitions Ratings were assigned to each indicator by the review team using the following definitions: Compliance Limited Compliance Failed Compliance No exceptions to the requirements of the indicator; or limited, unintentional, and/or non-systemic exceptions that do not result in reduced or substandard service delivery; or systemic exceptions with corrective action already applied and demonstrated. Systemic exceptions to the requirements of the indicator; exceptions to the requirements of the indicator that result in the interruption of service delivery; and/or typically require oversight by management to address the issues systemically. The absence of a component(s) essential to the requirements of the indicator that typically requires immediate follow-up and response to remediate the issue and ensure service delivery. Review Team The Bureau of Quality Improvement wishes to thank the following review team members for their participation in this review, and for promoting continuous improvement and accountability in juvenile justice programs and services in Florida: Janet Hampton, Lead Reviewer, DJJ Bureau of Quality Improvement Kevin Greaney, Review Specialist, DJJ Bureau of Quality Improvement Bryan Harrison, Senior Juvenile Probation Officer, DJJ Probation, Circuit 5 Mike Marino, Program Administrator, DJJ Bureau of Quality Improvement Christi Stua, Acting Superintendent, Marion Regional Juvenile Detention Center

7 Program Name: Alachua Regional Juvenile Detention Center QI Program Code: 89 Provider Name: Department of Juvenile Justice Contract Number: NA Location: Alachua County / Circuit 8 Number of Beds: 48 Review Date(s): November 13-15, 2012 Lead Reviewer Code: 90 Methodology This review was conducted in accordance with FDJJ-1720 (Quality Improvement Policy and Procedures), and focused on the areas of (1) Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention Standards (August 2012). Persons Interviewed Program Director DJJ Monitor DHA or designee DMHA or designee # Case Managers # Clinical Staff # Food Service Personnel 1 # Healthcare Staff Documents Reviewed 1 # Maintenance Personnel # Program Supervisors 2 # Other (listed by title): Asst. Superintendent, Teacher Accreditation Reports Affidavit of Good Moral Character CCC Reports Confinement Reports Continuity of Operation Plan Contract Monitoring Reports Contract Scope of Services Egress Plans Escape Notification/Logs Exposure Control Plan Fire Drill Log Fire Inspection Report Fire Prevention Plan Grievance Process/Records Key Control Log Logbooks Medical and Mental Health Alerts PAR Reports Precautionary Observation Logs Program Schedules Sick Call Logs Supplemental Contracts Table of Organization Telephone Logs Surveys Vehicle Inspection Reports Visitation Logs Youth Handbook 18 # Health Records 9 # MH/SA Records 17 # Personnel Records 8 # Training Records/CORE 5 # Youth Records (Closed) 6 # Youth Records (Open) # Other: 5 # Youth 5 # Direct Care Staff NA # Other: Observations During Review Admissions Confinement Facility and Grounds First Aid Kit(s) Group Meals Medical Clinic Medication Administration Posting of Abuse Hotline Program Activities Recreation Searches Security Video Tapes Sick Call Social Skill Modeling by Staff Staff Interactions with Youth Comments Staff Supervision of Youth Tool Inventory and Storage Toxic Item Inventory and Storage Transition/Exit Conferences Treatment Team Meetings Use of Mechanical Restraints Youth Movement and Counts Items not marked were either not applicable or not available for review. Office of Program Accountability Page 3 of 42 (Revised September 2012)

8 Standard 1: Management Accountability Detention Rating Profile Indicator Ratings Standard 1 - Management Accountability 1.01 * Initial Background Screening 1.02 Five-Year Rescreens 1.03 Staff Code of Conduct 1.04 * Incident Reporting (CCC) Limited 1.05 Protective Action Response (PAR) 1.06 * Pre-Service/Certification Requirements 1.07 In-Service Training 1.08 Logbook Maintenance 1.09 Logbook Reviews 1.10 * Entering Alerts (JJIS) 1.11 Sharing of Alert Information * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). The following limited and/or failed indicators require immediate corrective action Incident Reporting (CCC)* Office of Program Accountability Page 4 of 42 (Revised September 2012)

9 Standard 2: Youth Management Detention Rating Profile Indicator Ratings Standard 2 - Youth Management 2.01 Admission 2.02 Orientation 2.03 Classification 2.04 Classification of Gang Members 2.05 Notification of Law Enforcement 2.06 Admission of Youth Personal Property 2.07 Storage of Youth Personal Property 2.08 Release 2.09 Release of Youth Personal Property 2.10 Release of Medication, Aftercare Instructions 2.11 Review of Youth in Secure Detention 2.12 Review of Youth on Home Detention 2.13 Daily Activity Schedule 2.14 Adherence to Daily Schedule 2.15 Educational Access 2.16 Vocational Programming 2.17 Behavior Management System 2.18 * Unauthorized Use of Punishment 2.19 Grievances 2.20 Trauma-Informed Care * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 5 of 42 (Revised September 2012)

10 Standard 3: Mental Health and Substance Abuse Services Detention Rating Profile Indicator Ratings Standard 3 - Mental Health and Substance Abuse Treatment 3.01 Designated Mental Health Authority (DMHA) 3.02 * Licensed Mental Health and Substance Abuse Clinical Staff 3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff 3.04 Mental Health and Substance Abuse Admission Screening 3.05 Mental Health and Substance Abuse Assessment/Evaluation 3.06 Mental Health and Substance Abuse Treatment 3.07 Treatment and Discharge Planning 3.08 * Psychiatric Services 3.09 * Suicide Prevention Plan 3.10 * Suicide Prevention Services 3.11 * Suicide Precaution Observation Logs 3.12 * Suicide Prevention Training Limited 3.13 * Mental Health Crisis Intervention Services 3.14 * Crisis Assessments 3.15 * Emergency Care Plan 3.16 * Baker and Marchman Acts * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). The following limited and/or failed indicators require immediate corrective action Suicide Prevention Training* Office of Program Accountability Page 6 of 42 (Revised September 2012)

11 Standard 4: Health Services Detention Rating Profile Indicator Ratings Standard 4 - Healthcare Services 4.01 * Designated Health Authority/Designee 4.02 * Psychiatrist/Designee 4.03 Facility Operating Procedures 4.04 Authority for Evaluation and Treatment 4.05 Parental Notification Limited 4.06 Notification - Clinical Psychotropic Progress Note 4.07 Immunizations 4.08 Healthcare Admission Screening Form 4.09 Medical Alerts 4.10 Suicide Risk Screening Instrument 4.11 Youth Orientation to Healthcare Services 4.12 Designated Health Authority/Designee Admission Notification 4.13 Healthcare Admission Rescreening 4.14 Health Related History 4.15 Comprehensive Physical Assessment Limited 4.16 Gender-Specific Screening/Examination 4.17 Tuberculosis Screening 4.18 Sexually Transmitted Infection Screening 4.19 HIV Testing Limited 4.20 Sick Call Process - Requests/Complaints 4.21 Sick Call Process - Visits/Encounters Limited 4.22 Restricted Housing 4.23 Episodic/First Aid Care Limited 4.24 Emergency Care Limited 4.25 Off-Site Care/Referrals 4.26 Chronic Illness/Periodic Evaluations 4.27 Medication Management - Verification 4.28 Medication Management - Orders/Prescriptions 4.29 Medication Management - Storage 4.30 Medication Management - Medication and Sharps Inventory 4.31 Medication Management - Controlled Medications 4.32 Medication Management - Medication Administration Record 4.33 Medication Management - Medication Administration By Licensed Staff 4.34 Medication Management - Medications Provided By Non-Licensed Staff 4.35 Medication Management - Psychotropic Medication Monitoring 4.36 Infection Control - Surveillance, Screening, and Management 4.37 Infection Control - Education 4.38 Infection Control - Exposure Control Plan 4.39 Prenatal Care - Physical Care of Pregnant Youth Non-Applicable 4.40 Prenatal Care - Nutrition and Education of Youth Non-Applicable 4.41 Prenatal Staff Education * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). The following limited and/or failed indicators require immediate corrective action Parental Notification 4.15 Comprehensive Physical Assessment 4.19 HIV Testing 4.21 Sick Call Process - Visits/Encounters 4.23 Episodic/First Aid Care 4.24 Emergency Care Office of Program Accountability Page 7 of 42 (Revised September 2012)

12 Standard 5: Safety and Security Detention Rating Profile Indicator Ratings Standard 5 - Safety and Security 5.01 * Active Supervision of Youth 5.02 * Ten-Minute Checks 5.03 Census Counts and Tracking 5.04 Key Control 5.05 Vehicles and Maintenance 5.06 Tool Inventory and Management 5.07 Kitchen Tools 5.08 * Youth Access & Use of Tools, Cleaning Items 5.09 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items Limited 5.10 * Access to all Flammable, Toxic, Caustic, and Poisonous Items 5.11 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items 5.12 Confinement Under Twenty-Four Hours 5.13 Confinement Over Twenty-Four Hours 5.14 Continuity of Operations Planning (COOP) Drills 5.15 Escape Drills 5.16 Fire Drills * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). The following limited and/or failed indicators require immediate corrective action Inventory of Flammable, Toxic, Caustic, and Poisonous Items Office of Program Accountability Page 8 of 42 (Revised September 2012)

13 Strengths and Innovative Approaches The center has stability in key mental health staff positions. A psychiatrist and a psychologist have provided mental health and substance abuse treatment services at the center for a number of years. The center has implemented staff training on trauma-informed care practices. Murals have been painted in the living and common areas, which soften the appearance of the facility. The murals were painted by volunteers from the University of Florida. A vacant living area is being converted into a soft room, where youth may spend quiet time. Office of Program Accountability Page 9 of 42 (Revised September 2012)

14 Standard 1: Management Accountability Overview There have been changes in key management positions since the last Quality Improvement review. The superintendent was promoted from assistant superintendent in July 2012; he served as the acting superintendent up until his promotion. The assistant superintendent was hired in May One assistant superintendent position is still vacant. There are three lieutenants and three juvenile detention officer supervisors employed at the center. The center had a number of staff on family medical leave or workman s compensation during the past year. At the time of the review, two staff were on extended family medical leave and one staff was out on workman s compensation. There was one juvenile justice detention officer (JJDO) position vacant at the time of the review Initial Background Screening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. The background screening process is completed prior to hiring an employee or utilizing the services of a volunteer, mentor, or intern. An Annual Affidavit of Compliance with Level 2 Screening Standards is completed annually. Seven staff were hired since the last Quality Improvement review. Each staff was background screened by the Department before their date of hire. The Annual Affidavit of Compliance with Level 2 Screening Standards was submitted to the Department on January 5, 2012, meeting the annual requirement. Three teachers are employed by North American Family Institute and provide educational services at the center. Each teacher received a background screening from the Department as well. The Affidavit of Compliance with Level 2 Screening Standards for the teachers was submitted to the Department on January 4, 2012, meeting the annual requirement. According to a Central Communications Center (CCC) printout, two contracted staff from Correct Care Solutions were not background screened according to Departmental policy. The superintendent discovered this information before these staff came in contact with youth Five-Year Rescreening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. Employees and volunteers are rescreened every five years from the initial date of employment. Ten staff required a five-year background rescreening from the Department. Nine staff received their rescreening within the required time frame. One staff s hire date was March 9, The rescreening request was sent to the Department s Background Screening Unit on February 22, 2012; it was returned to the center on March 12, Staff Code of Conduct Compliance Program staff adheres to a code of conduct that prohibits any form of abuse, profanity, threats, harassment, intimidation, horseplay, or personal relationships with youth. Office of Program Accountability Page 10 of 42 (Revised September 2012)

15 Officers shall maintain the confidentiality afforded to all youth, and shall not release any information to the general public or the news media about any youth in detention or who has been in the custody of the department. Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use profanity in the performance of their job. Officers shall not engage in or allow horseplay, either verbal or physical with and/or between any youth. Officers shall not engage in personal relationships nor discuss personal information related to themselves or other officers with any youth. Management takes immediate action to investigate or address all allegations or violations of the code of conduct. Five personnel files were reviewed for a signed code of conduct form. Each personnel file had a code of conduct form, which was signed by the staff. None of the staff received disciplinary action during the past six months for improper conduct. This was supported in a review of the Central Communications Center (CCC) printout. The center conducted an investigation into an allegation of one staff acting inappropriately by horse playing with three youth; the center requested termination of employment with the Department and it was upheld. Five youth completed surveys. Three youth said the staff treat them respectfully and professionally. Two youth said they have never heard staff use profanity. Four youth said they have never heard staff threaten youth. Informal interviews were conducted with each youth. Overall, each youth had positive comments about staff. There were two exceptions, with two youth reporting issues with one staff Incident Reporting (CCC) Limited Compliance Whenever a reportable incident occurs, the program notifies the Department s Central Communications Center (CCC) within two hours of the incident, or within two hours of becoming aware of the incident. Thirteen incidents were reported to the Central Communications Center (CCC) during the past six months. Eleven incidents were reported within the required two-hour time frame. The remaining two incidents were reported to the CCC within twenty-four hours. The incidents were for injuries requiring off-site medical care, medication errors, and two contracted staff not receiving background screening clearance from the Department. One detention staff was cited on two occasions for not reporting an incident within the required time frame. In both cases, a youth was taken off-site for medical care and returned to the detention center Protective Action Response (PAR) Compliance The program uses physical intervention techniques in accordance with Florida Administrative Code. Any time staff uses a physical intervention technique, such as countermoves, control techniques, takedowns, or application of mechanical restraints (other than for regular transports), a PAR Incident Report is completed and filed in accordance with the Florida Administrative Code. Office of Program Accountability Page 11 of 42 (Revised September 2012)

16 Six Protective Action Response (PAR) reports were reviewed from the past six months. The reports were reviewed by all required parties within the required time frames. No youth were injured as a result of a PAR, however, one staff was injured and it was reported to the CCC. The post-par interview form was not filed in the medical records. The center s policy states the post-par interview is to be conducted by the designated health authority (DHA) or designee. In practice, the JJDOSs are primarily conducting the interview, which is allowable by administrative rule Pre-Service/Certification Requirements Compliance Detention staff are trained in accordance with Florida Administrative Code. Detention staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. Two staff training files were applicable for pre-service certification since the last Quality Improvement review. Each staff was certified within the 180-day requirement and completed all training requirements In-Service Training Compliance All detention staff completes twenty-four hours of in-service training, including mandatory topics specified in Florida Administrative Code, each calendar year, effective the year after preservice/certification training. Supervisory staff completes eight hours of training (as part of the twenty-four hours of in-service training) in the areas specified in Florida Administrative Code. Six staff training files were reviewed for in-service training topics. All of the staff had current first aid, CPR, and AED certifications. Four staff had PAR update training within the required time frame. One staff had PAR update training on January 3, 2010; the next PAR update training was completed on March 24, Each staff received over twenty-four hours of training in the 2011 calendar year; the training hours ranged from thirty-three to 132 hours. One administrator had eight hours of training in management topics. One supervisor did not receive eight hours of training in management topics. The center has an annual training plan. Each month, staff are required to complete courses on the Department s Learning Management System (CORE). Topics include suicide prevention, fire safety and awareness, gang awareness, and information security awareness Logbook Maintenance Compliance The program maintains a chronological record of events, incidents, and activities in logbooks maintained at master control and in each living area in accordance with Florida Administrative Code. Each logbook is a bound book with numbered pages. If electronic logbook software is used by the facility, it is password-protected and configured to prevent entries from being deleted or altered after they are saved. At a minimum, each logbook entry includes the date and time of the event, the names of staff and youth involved, a brief description of the event, the initials of the person making the entry, Office of Program Accountability Page 12 of 42 (Revised September 2012)

17 and the date and time of the entry. Logbook entries are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are obliterated or removed; errors are struck through with a single line and initialed by the person correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts, or other issues that may impact facility safety and security shall be highlighted. Multiple logbooks were reviewed. There are separate logbooks for each of the three living units and master control. Each logbook was bound with numbered pages. All entries included the date and time of the event. Placements on precautionary observations were routinely documented in the logbooks. Changes in supervision levels were also recorded. Youth counts were consistently documented at the beginning and end of each shift, after movement, and for emergency situations. Counts were documented when youth return from transports. Fire drills were documented in the logbooks. It was difficult to find entries documenting the superintendent and assistant superintendent s presence on the living units at least once per day Logbook Reviews Compliance The superintendent or designee reviews all logbooks on a weekly basis. The supervisor(s) reviews the facility logbook maintained at master control when he/she accepts responsibility for the facility. The Juvenile Justice Detention Officer (JJDO) Supervisor(s) reviews logbooks maintained in each living area daily. The JJDO(s) reviews the logbook maintained in his/her assigned living area when he/she accepts responsibility for the living area at shift change. Logbooks were reviewed from the past six months. The juvenile justice detention officer supervisors (JJDOS) are the superintendent s designees for the review of all logbooks. The JJDOSs reviewed the unit logbooks on a daily basis and their reviews were written in the body of the pages. Each JJDOS signed their name and documented their review of the logbooks with the date and time of the entry. Additionally, each JJDOS reviewed the logbooks at the beginning of their shift. There were no issues with the supervisory reviews of the master control logbook Entering Alerts (JJIS) Compliance Superintendents shall ensure that Critical and Special Alerts are reviewed and responded to appropriately. Upon completion of the Admission Wizard, the officer shall ensure that the all Critical and Special Alerts are listed in JJIS. The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure that it correctly reflects the status of youth. If the electronic system is inoperable, for any reason, the JJDO Supervisor shall ensure that the last hard copy of the alerts shall have a written notification or update of the recent admissions or changes to existing alerts on the alert sheet and distribute to all staff within the facility immediately. Office of Program Accountability Page 13 of 42 (Revised September 2012)

18 Five confinement files were reviewed for admission wizards. In each case, the staff noted critical issues, which required a Juvenile Justice Information System (JJIS) alert. Suicide risk, prescribed medications, diagnosed disorders, and single room status were identified as issues. A review of the critical alert report found all critical issues were entered on JJIS Sharing of Alert Information Compliance JJDOS s shall inform staff of alerts during shift briefing. When a JJDOS receives changes to the alert list, he or she shall notify the staff affected by changes and add the information to the shift briefing for the oncoming shift upon receipt of the information. Medical and mental health staff shall review alerts to ensure each alert is correctly tracked and managed. The responses and updates by medical, mental health and other staff should be documented in JJIS alerts as they pertain to that critical alert. The critical alert report is printed and shared at each shift exchange meeting. This was supported in a review of fifteen shift reports and an observation of a shift exchange meeting. Five youth required some type of critical alert on JJIS. Five youth were placed on precautionary observation at intake. When their status was changed to standard supervision, the mental health staff closed out the alerts on JJIS appropriately. Standard 2: Assessment and Performance Plan Overview When youth are arrested, they are brought to the center for screening purposes. Youth are initially screened by juvenile probation officers (JPO). If they meet the criteria for placement in secure detention, juvenile justice detention officers (JJDO) complete the intake process. A JJDO review each youth s JJIS face sheet for their arrest history and any critical alerts. Interviews are conducted with each youth. Once all the information is gathered, youth are classified and assigned to a living unit. Each youth is searched and his/her clothing is inventoried by a JJDO Admission Compliance All youth are admitted to the program in accordance with Florida Administrative Code through a process that, at a minimum, addresses the following: 1. Review of required paperwork from law enforcement and screening staff. 2. Review of inactive files shall be conducted, if available, to obtain useful information. 3. All youth shall be electronically searched, frisk searched, and stripped searched by an officer of the same sex as the youth. 4. All youth shall be allowed to place a telephone call at the facility s expense to his/her parent/guardian and the call shall be documented on all applicable forms, or document refusal to make a telephone call. 5. If the admission process is completed two hours or more before the serving of the next scheduled meal, youth shall be offered something to eat. Office of Program Accountability Page 14 of 42 (Revised September 2012)

19 6. All youth shall be screened to identify medical, mental health, and substance abuse needs. Any youth identified as at risk of suicide shall be placed on Precautionary Observation until evaluated by the licensed mental health provider. Five files were reviewed. Each file contained documentation of compliance with the requirements. Each admission wizard contained documentation of searches. There was documentation of each youth speaking with their parent/guardian by telephone. Each youth was also offered a meal or snack during the admission process. The reviewed files documented that each youth was informed of their rights and how to access needed services. All five youth were at risk of suicide at admission and each youth was placed on precautionary observation pending review by a mental health professional. One applicable youth was appropriately provided medical treatment prior to admission to the center Orientation Compliance Program orientation process shall occur within twenty-four hours of a youth being admitted into detention and documented according to Facility Operating Procedures. During the orientation process, youth must be advised, both verbally and in writing, at a minimum, the following: 1. Facility rules and regulations; 2. Grievance procedures; 3. Visitation; 4. Telephone calls; 5. Available medical, mental health and substance abuse services and how to access them; 6. How to access the Florida Abuse Hotline; 7. Expectations for behavior and related consequences; 8. Possible new law violations for destruction of property; and 9. Youth rights. Five files were reviewed for documentation of orientation. All files contained a signed copy of the orientation acknowledgement form. Each youth received a copy of the center s rules and regulations, as well as consequences for violations. All youth completed orientation immediately upon admission Classification Compliance All youth admitted to the detention center shall be classified to provide the highest level of safety and security. Considerations shall include, at a minimum: 1. Physical characteristics (e.g. sex, height and weight); 2. Age and level of aggressiveness; 3. Special needs (mental illness, developmental disabilities, and physical disabilities); 4. History of violent behavior; 5. Gang affiliation; 6. Criminal behavior; 7. History of sexual offenses; 8. Vulnerability to victimization; and 9. Suicide risk identified or suspected. Office of Program Accountability Page 15 of 42 (Revised September 2012)

20 Youth shall be assigned to a room based on their classification and are reclassified if changes in behavior or status are observed. Youth with a history of committing sexual offenses or a victim of a sexual offense are not to be placed in a room with any other youth. Youth with a history of violent behavior shall be assigned to rooms where it is least likely that they will be able to jeopardize safety and security. Five files were reviewed for classification instruments. The required review for classification was completed in each file and documented on the admission wizard. The classification process included interviews with parents/guardians, and a review of each youth s JJIS face sheet, arrest history, and critical alerts. The detention staff also documented the demographic information for each youth. Prior history of abuse or neglect allegations were noted on the Detention Risk Screening Instrument Classification of Gang Members Compliance All newly admitted youth are screened to determine if he or she is a criminal street gang member or is affiliated with any criminal street gang. Each facility shall identify a staff person to serve as a gang representative who shall review identified youth for suspected gang involvement or gang activity. Five files were reviewed for classification of gang members. Each file contained a completed gang identification form. One applicable file contained an alert entered into JJIS, as required Notification of Law Enforcement Compliance A referral on a youth for suspected gang involvement shall be shared with local law enforcement and educational providers or local school districts providing educational services at the facility, as well as with the youth s Juvenile Probation Officer (JPO) and, if identified, their post residential services counselor. Facility staff shall share pertinent gang-related information, as appropriate, with the Florida Department of Law Enforcement, local law enforcement, Department of Corrections, school districts, the judiciary, and social service agencies, as well as with a youth s JPO. Due to staff changes, the superintendent currently makes notifications of suspected gang members. Information from the gang identification form is entered in JJIS, as appropriate, and a notice is sent to each youth s assigned juvenile probation officer (JPO). The JPO is responsible for conveying gang information to the appropriate law enforcement agency Admission of Youth Personal Property Compliance The program takes possession of each youth s personal property during admission. In the presence of each youth, staff inventories all personal property in the youth s possession and records each surrendered item on the Property Receipt Form. Five files were reviewed for property receipt forms. Each file contained a signed property receipt form. Office of Program Accountability Page 16 of 42 (Revised September 2012)

21 2.07 Storage of Youth Personal Property Compliance The program safeguards each youth s personal property until it can be returned to the youth and/or legal guardian. The center has a locked drop box, which is used to temporarily house valuable personal property until it can be placed in the safe. The safe is located in the administrative office and only the superintendent and the assistant superintendent have access. Personal property, including clothing, is stored in individual bags with a copy of the inventory form. The bags are kept in a locked room in a secure area of the center Release Compliance When releasing youth from detention, the releasing officer shall verify the court s authorization to release the youth. Care must be taken to ensure all case file information is reviewed to prevent the negligent release of a youth. All releases from the program are court-ordered, with the exception of deaths, escapes, and expirations of detention time period. In the absence of a written order, documentation of a verbal order in open court may be used for release. The on-duty JJDO Supervisor reviews all paperwork prior to release. The JJDO Supervisor is responsible for ensuring that there are no holds, court orders, or other legal reasons not to release the youth. Questions concerning release are presented and addressed by the Superintendent, or designee, prior to release. The releasing officer shall verify the identification of the youth. Five files were reviewed for release documentation requirements. All five files contained a court order authorizing each youth s release from detention. Additionally, there was a fax confirmation from local law enforcement confirming there were no outstanding warrants for the five reviewed youth. Each youth s parent/guardian signed a release form. One release was observed during the review; all requirements were completed appropriately Release of Youth Personal Property Compliance Upon the youth s release from detention and retrieval of personal property, the releasing officer, the youth, and the youth s legal guardian shall review and sign the Property Receipt Form and account for all of the youth s personal property. Five files were reviewed for release of youth personal property. Four files contained a release of property form signed by each youth. One file did not contain a signed release form, but the return of the youth's property was indicated on the release wizard and was signed by the parent/guardian. One release was observed during the review. The personal property was opened in front of the youth and his parent/guardian. All items were accounted for and the youth signed the property receipt form Release of Medication, Aftercare Instructions Compliance Office of Program Accountability Page 17 of 42 (Revised September 2012)

22 The program ensures that there are provisions in place to ensure that prescribed medication, along with medical instructions. accompanies detained youth upon release. Four files were reviewed for youth released with medications. Each youth had prescribed medications at the center. In three cases, there was documentation on a release form of the parent/guardian receiving the medications. This was not documented on the Health Discharge Summary. The fourth youth was released to commitment and a copy of the receipt from the commitment program was reviewed Review of Youth in Secure Detention Compliance Detention reviews are conducted by the program on a weekly basis to ensure proper management of youth placed in secure detention and appropriate sharing of information. The superintendent appoints an appropriate staff person to coordinate detention reviews. Secure detention reviews are conducted each week by the superintendent and a screening unit staff member. Juvenile probation officer supervisors (JPOS) are involved in the staffing by telephone. The results of the reviews are recorded in the Facility Management System (FMS). The superintendent forwards any issues or requests to the respective circuit chief probation officers for follow-up. A review of the FMS and hard copies found reviews were documented for twenty-four of twenty-six applicable weeks. Notes made on the review sheets indicated followup calls or s were completed, as needed Review of Youth on Home Detention Compliance Detention reviews are conducted by the program on a weekly basis to ensure proper management of youth placed in home detention and appropriate sharing of information. The superintendent appoints an appropriate staff person to coordinate detention reviews. Home detention reviews are conducted by the superintendent and a screening unit staff member. Reviews were documented for twenty-four of twenty-six applicable weeks Daily Activity Schedule Compliance Youth are provided the opportunity to participate in constructive activities that will benefit the youth and the program. The Superintendent or Designee develops a daily activity schedule, which is posted in each living area and outlines the days and times for each youth activity. The daily schedule was posted in each living unit. The schedule provides time for all required activities. Information about the daily schedule was provided at orientation to each of the five reviewed youth. Five youth completed surveys and all said the center has a daily schedule Adherence to Daily Schedule Compliance Facility staff shall adhere to the daily activity schedules. Documentation of all activities shall be made in all applicable logs. The on-duty supervisor must approve any significant changes in the activity schedule and shall document the reason for the change(s) in the shift report. Any cancellation of visitation shall be approved by the superintendent. Office of Program Accountability Page 18 of 42 (Revised September 2012)

23 Activities were observed during the review; the daily schedule was followed consistently. Five youth completed a survey and all said the daily schedule is followed Educational Access Compliance The facility shall integrate educational instruction (career and technical education, as well as academic instruction) into their daily schedule in such a way that ensures the integrity of required instructional time. Educational services are provided by three teachers employed by the North American Family Institute (NAFI). Educational classes are held Monday through Thursday. Youth receive 375 minutes of instruction each day. One teacher was informally interviewed during the review. The teacher said Ed Options, a computer-based, credit retrieval program, is used for instructional purposes. The teachers also provide traditional classroom instruction Vocational Programming Compliance Staff shall develop and implement a vocational competency development program. The center provides Type A/Level 1 vocational programming services. The last class period of each school day is spent on life skills instruction. Youth are taught skills that would assist them in finding employment, which includes completing job and college applications. There was documentation that guest speakers, including speakers from the military, have given talks on their occupations Behavior Management System Compliance The program provides a system of rewards, privileges, and consequences to encourage youth to fulfill the program s expectations. Each facility shall implement and maintain a behavior management system to meet the needs of the youth and the facility. The system shall be approved by the regional director and shall include rewards for positive behavior and consequences for inappropriate behavior. The behavioral norms and expectations for youth shall be posted in all living areas and shall clearly specify appropriate and inappropriate behaviors. The center s behavior management system is based on two levels. All youth are placed on level one upon admission. Five files were reviewed for documentation of an explanation of the behavior management system. Each file documented youth received information on the behavior management system through the orientation process. Each youth signed a rules and regulations form at admission. Five youth completed surveys; all rated the behavior management system as fair Unauthorized Use of Punishment Compliance The center s behavior management system restricts certain types of penalties on youth who demonstrate negative behaviors. Group punishment shall not be used as a part of the facility s behavior management plan. However, corrective action taken with a group of youth is appropriate when the behavior of a Office of Program Accountability Page 19 of 42 (Revised September 2012)

24 group jeopardizes safety or security, and this should not be confused with group punishment. Corporal punishment shall not be used in detention facilities. All allegations of corporal punishment of any youth by facility staff shall be reported to the Florida Abuse Hotline, pursuant to Chapter 39, F.S., and the Central Communications Center. The use of drugs to control the behavior of youth is prohibited. This does not preclude the proper administration of medication as prescribed by a licensed physician. Youth are advised at orientation, in writing, of the center s policy prohibiting any type of corporal punishment. A review of the logbooks found no instances of unauthorized punishment, which was also supported in a review of the CCC reports and youth grievance forms. Five youth completed surveys. Each youth said they are not allowed to punish their peers Grievances Compliance The grievance procedures establish each youth s right to grieve and ensure that all youth are treated fairly, respectfully, without discrimination, and that their rights are protected. The process includes: 1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with the youth using effective communication skills; 2. Formal phase, wherein the youth submits a written grievance that results in a response from a JJDO Supervisor by the end of the shift (if possible), or otherwise within twentyfour hours; and 3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the superintendent or designee. Seven grievances were reviewed. Each grievance was forwarded to the on-duty supervisor within two hours and notations on the forms indicated each youth s satisfaction or dissatisfaction with the findings by the end of shift. Each grievance was reviewed by the superintendent within seventy-two hours. The grievances were maintained on the FMS. The center s policy stated a hard copy of the grievance forms would be maintained in a separate file. Two of the seven grievances were available as a hard copy with youth signatures Trauma-Informed Care Compliance The facility is incorporating trauma-informed practice into current operations to deliver services and to provide care to youth in custody that acknowledge the role that violence and victimization play in the lives of most of the youth entering the facility. Trauma-informed practice has many characteristics, which include the following: A recognition of the high prevalence of trauma Assessment for traumatic histories and symptoms Recognition of culture and practices that may be re-traumatizing Collaboration of caregivers Training of staff to improve trauma knowledge and sensitivity Increased staff understanding of the function of behavior (rage, self-injury, etc.) as an expression of trauma Office of Program Accountability Page 20 of 42 (Revised September 2012)

25 Use of objective and neutral language (avoids labeling of youth) The center is tastefully decorated with wall panels and wall murals located in both common areas and living areas. Staff have been trained in the use of trauma-informed care techniques and several staff recently attended a trauma-informed care seminar. The center is in the process of redecorating a vacant living area to use as a soft room, where youth can go to spend quite time, when needed. Standard 3: Mental Health and Substance Abuse Services Overview The center has a contract with a psychologist to serve as the designated mental health authority (DMHA). The DMHA provides twenty-four hours of service each week, Monday through Wednesday, and is on call twenty-four hours per day, seven days per week. A licensed mental health counselor (LMHC) provides sixteen to seventeen hours of service each week. The LMHC is responsible for mental health and substance abuse services on the weekends. The LMHC also works on Monday or Tuesday, and Thursday. A registered mental health counselor intern is employed at twenty hours per week and works Wednesday through Friday. The schedule allows for coverage seven days per week. The center also has a contract with a psychiatrist. The psychiatrist is on site for four hours every two weeks. At the time of the review, a psychiatric advanced registered nurse practitioner (ARNP) was not contracted or employed at the center. The mental health staff are responsible for the completion of Assessments of Suicide Risk, reviewing Suicide Precautions Observation Logs, developing initial and individual treatment plans, and participating in mini-treatment team meetings Designated Mental Health Authority (DMHA) Compliance A Designated Mental Health Authority (DMHA) is required in each detention center. The DMHA is responsible and accountable for ensuring appropriate coordination and implementation of mental health and substance abuse services in the facility and shall promote consistent and effective services and allow the facility superintendent and staff a specific source of expertise and referral. The designated mental health authority (DMHA) is a licensed psychologist. The DMHA s license is clear and active. The DMHA is on site Mondays, Tuesdays, and Wednesdays, and is on call twenty-four hours per day, seven days per week Licensed Mental Health and Substance Abuse Clinical Staff Compliance The facility superintendent is responsible for ensuring that mental health and substance abuse services are provided by individuals with appropriate qualifications. Clinical supervisors must assure that clinical staff working under their supervision are performing services that they are qualified to provide based on education, training, and experience. There is one licensed mental health counselor (LMHC) working at the center. The LMHC s license is clear and active. Office of Program Accountability Page 21 of 42 (Revised September 2012)