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 Brevard Regional Juvenile Detention Center Department of Juvenile Justice (State-Operated) 5225 Dewitt Avenue Cocoa, Florida Review Date(s): October 30 - November 1, 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 Brevard Brevard Foradditionalinformationaboutthisfacility,clickhereorvisit htp:// FY (July1,2010-June30,2011) PerformanceMeasures IncidentRate Sex Youthon Staf Youthon StafRate Youthon Youth YouthonYouth Rate c Escapes 0 c Race/Ethnicity Black Hispanic Other White Female Male O fensesleadingtoyouthdetention (Admissions) O fensecategorybreakdown(admissions) 18% O fensesleadingto YouthDetention CourtOrders FelonyOfense 100% Felony OfenseType Misdemeanor MisdemeanorOfense 29% 54% 50% 0% Drug OtherOf Property Violent Drug OtherOf Property Violent 79% 60% 5% 4% 30% 6% 12% 3%

3 NumberofAdmissions AverageDailyPopulation 1,500 1,000 1,469 1,463 1,255 1,141 1, FY06-07 FY07-08 FY08-09 FY09-10 FY10-11 FY06-07 FY07-08 FY08-09 FY09-10 FY10-11 AverageLengthofStay(Days) Brevard 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: Kristen Richardson, Lead Reviewer, DJJ Bureau of Quality Improvement Donna Connors, Program Administrator, DJJ Bureau of Quality Improvement Christine Gurk, Registered Nursing Consultant, Office of Health Services Tracy Hunt, Juvenile Probation Officer Supervisor, DJJ Probation, Circuit 9 Freda Smith, Juvenile Justice Detention Officer Supervisor, Orange Regional Juvenile Detention Center

7 Program Name: Brevard Regional Juvenile Detention Center QI Program Code: 244 Provider Name: Department of Juvenile Justice Contract Number: N/A Location: Brevard County / Circuit 18 Number of Beds: 40 Review Date(s): October 30 - November 1, 2012 Lead Reviewer Code: 115 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 1 # Clinical Staff 2 # Food Service Personnel 2 # Healthcare Staff Documents Reviewed # Maintenance Personnel 3 # Program Supervisors 2 # Other (listed by title): secretary specialist, 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 8 # Health Records 5 # MH/SA Records 5 # Personnel Records 5 # Training Records/CORE 4 # Youth Records (Closed) 5 # Youth Records (Open) 2 # Other: JJIS, Background Screening Unit 5 # Youth 5 # Direct Care Staff # 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 3 (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) 1.05 Protective Action Response (PAR) Limited 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 Protective Action Response (PAR) Office of Program Accountability Page 4 of 4 (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 5 (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 6 (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 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 4.16 Gender-Specific Screening/Examination 4.17 Tuberculosis Screening 4.18 Sexually Transmitted Infection Screening 4.19 HIV Testing 4.20 Sick Call Process - Requests/Complaints 4.21 Sick Call Process - Visits/Encounters 4.22 Restricted Housing 4.23 Episodic/First Aid Care 4.24 Emergency Care 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 Limited 4.38 Infection Control - Exposure Control Plan 4.39 Prenatal Care - Physical Care of Pregnant Youth 4.40 Prenatal Care - Nutrition and Education of Youth 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 Infection Control - Education Office of Program Accountability Page 7 of 7 (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 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). Office of Program Accountability Page 8 of 8 (Revised September 2012)

13 Strengths and Innovative Approaches Brevard Regional Juvenile Detention Center is in the process of decorating a room in each living module for youth who display excellent behavior in all areas, to include keeping their room clean, following rules, attending school daily, and being a model youth. The center had several gallons of paint donated for the project. In addition, pictures, an afghan, and throw pillows have been purchased. Painting has begun in one of the female youth rooms. Once complete, the center will work on a male room in the west module. In conjunction with the Brevard County Public Schools, youth are encouraged to read at least three hundred and fifty pages per week, and submit a book report on the topic. The report is turned in to the teacher; upon review the youth receive a special social hour for their hard work. A volunteer from the community visits the center every Thursday to teach the youth how to play chess. It allows the youth an opportunity to develop strategies, logistics, and concentrating. The youth appear to enjoy this activity. Office of Program Accountability Page 9 of 9 (Revised September 2012)

14 Standard 1: Management Accountability Overview Brevard Regional Juvenile Detention Center, which is located in Cocoa, Florida, is a stateoperated, hardware-secure facility that currently has capacity for forty youth. At the time of the Quality Improvement review, there were twenty-three youth in the center. The center houses both male and female youth who are detained pending adjudication, disposition, or placement into a residential commitment facility. The center provides services for the youth, to include, but not limited to, behavior management, education, mental health, substance abuse, and healthcare services. The center employs a superintendent, one assistant superintendent, seven shift supervisors, thirty juvenile justice detention officers, one maintenance mechanic, one nurse, four food service workers, and three administrative staff. The center also contracts for staff to provide mental health services, psychiatric services, and medical services. At the time of the Quality Improvement review, the center had six staff vacancies; one maintenance mechanic, one food service worker, three juvenile justice detention officers, and one administrative staff. In addition, one staff was out on family medical leave (FMLA), and one staff was out on worker s compensation 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. The center has a written policy requiring compliance with the Department s background screening requirements. The center hired eleven staff since the last Quality Improvement review; all eleven staff had an eligible background screening completed prior to each staff s hire date. The Annual Affidavit of Compliance with Level 2 Screening Standards was completed and sent to the Department s Background Screening Unit on January 23, 2012; the Annual Affidavit of Compliance with Level 2 Screening Standards for school board teachers was sent on this date as well, meeting the annual requirement 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. The center tracks each staff s hire date to complete five-year background rescreenings. The center s personnel staff completed five-year rescreenings on two applicable staff members. Of the two completed, both were completed well within the required time frame 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 10 (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. The detention center utilizes the Department of Juvenile Justice employee handbook, which outlines a code of conduct. Five personnel files were reviewed; each contained documentation that the staff member had received and reviewed the code of conduct. A review of four disciplinary actions taken within the past six months revealed a variety of administrative actions related to violations of the code of conduct. These actions ranged from a verbal reprimand to a suspension. While on site, the Quality Improvement team observed staff communicating with youth in a respectful manner. Five staff responded to the survey; none reported seeing a coworker refusing a youth the opportunity to call the Florida Abuse Hotline. Three staff reported hearing a coworker using profanity when speaking to a youth. One staff indicated hearing a coworker use threats, intimidation, or humiliation when interacting with the youth. Five youth responded to the survey; all five reported that staff were respectful when talking with them. Three youth reported hearing staff use profanity occasionally, and one youth reported hearing a staff threaten another youth. During a follow-up interview, the youth reported that the staff told the youth he could lose his level if his poor behavior continued. All five youth reported they felt safe while at the center Incident Reporting (CCC) 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. The center has written policies and procedures regarding their response to incidents. The center had fifteen incidents reported to the Central Communications Center (CCC) in the last six months. The reports were called in for one of the following reasons: program disruption, youth behavior incident, medical, complaint against staff, and mental health/substance abuse incidents. Five incident reports were reviewed; all five were reported to the CCC in the required time frame. The logbooks reflected each date and time the report was called in, and also indicated which staff member called the report in to the CCC. Office of Program Accountability Page 11 of 11 (Revised September 2012)

16 1.05 Protective Action Response (PAR) Limited 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. The center has written procedures for the use of physical intervention techniques. Five Protective Action Response (PAR) reports were reviewed. All five were completed by the end of each staff member s workday, however, four of the five reports were missing some of the required information. Four of the reports did not contain information reflecting whether a post- PAR interview was conducted with the youth, therefore, there was no information documented whether or not a PAR medical review was necessary. Two of the reports were missing staff statements, four of the reports were not reviewed and signed by a supervisor, and three reports were not reviewed and signed by a PAR instructor or PAR certified supervisory staff. None of the five reports involved the use of mechanical restraints. All five staff responding to the survey reported the staff at the center try to talk with each youth prior to using any physical or mechanical restraints 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. Upon hire, all staff complete phase I training at the center, and then move on to complete phase II training, which is conducted at the juvenile justice training academy. An individual training file is maintained for each staff member, which contains sign-in sheets and certificates. Two training files for newly hired staff were reviewed; both reflected documentation of the staff working on phase I training. Both new staff are scheduled to attend the academy on December 3, 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. In-service training is provided through a combination of the Department s Learning Management System (CORE) and instructor-led courses. Three staff training files, including two supervisors, were reviewed for in-service training requirements. All training files contained an annual training plan detailing which months the required courses should be completed. All three files documented more than the required twenty-four hours of annual in-service training. The files documented between twenty-eight and thirty-eight hours of annual training during the 2011 calendar year. Documentation was absent for one staff receiving a CPR update in There was no documentation in two training files that the staff had received all eight hours of the PAR recertification for the 2011 calendar year; however, the Department s Learning Management Office of Program Accountability Page 12 of 12 (Revised September 2012)

17 System (CORE) reflected all hours completed for the PAR recertification. A review of two supervisory training files revealed each had nine hours of supervisory-related training completed. None of the three staff training files contained documentation that staff were trained annually on the center s exposure control plan 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, 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. The center has a policy regarding logbook maintenance and requirements. The center maintains a separate logbook for master control and each individual living unit. The logbooks contain a record of events and activities in books, which were bound and numbered accordingly. A review of the logbooks for the six months prior to the Quality Improvement review revealed requirements were met, with a limited number of exceptions. An example includes inconsistent documentation of mental health alerts, such as youth placed on suicide precautions or for changes in a youth s level of supervision. One of these alerts was found in the logbook for in the living unit, but not in the master control logbook. A review of the master control logbooks did revealed emergency situations, incidents, drills, population counts at the beginning and end of each shift, as well as population counts throughout shifts, group movement, admissions and releases, presence of law enforcement, and names of youth placed in confinement with the time the confinement began and the time confinement ended were documented, as required 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. Office of Program Accountability Page 13 of 13 (Revised September 2012)

18 A review of the logbooks reflected the superintendent and/or assistant superintendent are reviewing the logbooks on a regular basis. There was also documentation in the logbooks to reflect that supervisory reviews take place daily and on each shift 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. A review of ten alerts revealed all ten were documented in the Juvenile Justice Information System (JJIS), entered in the logbook, and noted on the center s shift reports. The alerts included youth placed on suicide risk, youth with medical issues such as asthma or tuberculosis, youth taking psychiatric or other prescribed medication, and youth requiring a single room. Alerts related to suicide precautions consistently included information relating to the youth s level of supervision, as well as when the youth was being stepped down to close supervision and to standard supervision. The list of JJIS alerts is printed daily, and reviewed and discussed at each shift meeting. This was documented on the center s shift reports 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 list of alerts is shared with all staff during the center s shift change. The list of alerts is also documented on the center s shift report. The alerts shared are entered into the logbooks for the staff to review. The center s healthcare staff and mental health staff enter their applicable alerts into the JJIS system, which are further discussed at the shift change, and entered into the logbooks. Office of Program Accountability Page 14 of 14 (Revised September 2012)

19 Standard 2: Assessment and Performance Plan Overview At Brevard Regional Juvenile Detention Center, the juvenile justice detention officers (JJDO) are responsible for completing the admission process with each new youth entering the center. The admission process takes place in a secure area of the center. The JJDOs are responsible for conducting both a frisk and electronic search of each youth upon their entrance to the center. The staff screen each youth utilizing the Juvenile Justice Information System (JJIS) Admission Wizard. During the orientation process, each youth is provided an orientation brochure to review, which covers numerous topics including the center s key staff at the facility, emergency evacuation plan, contraband policy, admissions process, dress code, youth rights, grievance procedure, information on medical and mental health services, visitation, youth rules and regulations, and behavior management system. The center utilizes a classification process to ensure that each youth is properly placed in a living area. The detention center completes a classification form on each youth, which details the following: the youth s name, physical characteristics, any distinguishing physical characteristics, current offense, any demonstrated behavior, security risk, and a summary and recommendations. The classification form is reviewed by a shift supervisor and a room assignment is given 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. 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. The detention center has procedures in place dictating their admissions process. Upon a youth entering the center, a juvenile detention center officer (JJDO) talks with the youth and reviews all of the information provided by the screener, including the JJIS face sheet, the Detention Risk Assessment Instrument (DRAI), the Suicide Risk Screening Instrument (SRSI), and the youth s Positive Achievement Change Tool (PACT). Each youth is screened using a frisk search and an electronic search, and the youth s personal property is bagged and placed in a safe. Each youth is offered a telephone call to speak to their parent/guardian; following the phone call, the JJDO reviews the orientation brochure with the youth. At this time, a snack or a meal is offered to the Office of Program Accountability Page 15 of 15 (Revised September 2012)

20 youth. The youth are screened for possible mental health/medical issues; should a youth need further observation, the JJDO shift supervisor is contacted and makes the appropriate referral. Five case management files were reviewed; all five contained documentation that the JJDO completed the admission wizard to include a review of the arrest affidavit, a review of the DRAI, and a review of the SRSI. The officer completed the search of each youth, allowed each youth to make a telephone call, offered each youth a meal or snack, and completed the medical, mental health, and substance abuse screening. One admission was observed while the Quality Improvement team was on site, and the admission process was followed according to the center s policies and procedures 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. The center has written procedures in place regarding the orientation process into the detention center. Each youth is oriented within twenty-four hours of admission, both verbally and in writing. Each youth is provided an orientation brochure, which covers numerous topics in detail, including the key staff at the facility, emergency evacuation plan, contraband policy, admissions process, dress code, youth rights, grievance procedure, information on medical and mental health services, visitation, telephone calls, youth rules and regulations, behavior management system, and how to access the Florida Abuse Hotline. Each youth signs these forms to acknowledge their receipt and understanding of the center s policies. Five files were reviewed; each file contained documentation that the youth was provided an orientation to the center within twenty-four hours of admission. Five youth responded to the survey; all five reported being provided information upon their admission regarding the center s rules and regulations, daily schedule, education services, visitation, abuse reporting, and behavior management system 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); Office of Program Accountability Page 16 of 16 (Revised September 2012)

21 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. 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. The center has a policy in place relating to classification of youth. The classification system used at the center promotes the safety and security of the youth and staff. The detention center has created a form, which is utilized by the intake JJDO at each youth s admission, to assist in the classification process. The form captures the youth s name, physical characteristics, distinguishing physical characteristics, current offense, demonstrated behavior, security risk, a summary, and recommendations. The classification form is reviewed by a shift supervisor; this information, coupled with the information in the JJIS Admission Wizard, guides each youth s placement into their assigned room. Five files were reviewed; all five contained a completed classification form, as well as a completed JJIS Admission Wizard form, which were reviewed and signed by the shift supervisor prior to making each youth s room assignment 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. The center s policy requires that each youth, upon admission, be screened for possible gang involvement or an affiliation with any type of criminal street gang. If staff have reason to believe that a youth is involved in gang activity, a referral is made to the center s gang liaison, and an alert is entered into JJIS. This information is also captured when completing the JJIS Admission Wizard. The gang liaison maintains a binder of all suspected gang members within the center and notifies local law enforcement of the gang activity. Five files were reviewed; all five contained documentation of a gang screening being conducted upon each youth s admission to the center. One file indicated the youth admitted to being in a gang; an alert was immediately entered in JJIS, and a referral was made to the center s gang liaison 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 Office of Program Accountability Page 17 of 17 (Revised September 2012)

22 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. The center has designated one staff member to act as the gang liaison. The gang liaison is required to notify local law enforcement when a youth who is involved in gang activity is admitted to the center. While on site, an interview was conducted with the gang liaison. The gang liaison indicated she is responsible for maintaining a notebook where the referrals are logged and maintained. Additionally, the liaison reported that any time she receives information about gang activity it is documented in a logbook, and law enforcement is notified. The liaison also indicated that she logs the dates and times when the information is given, and all of this information was documented in the law enforcement notebook. During the Quality Improvement review, the binder was reviewed; the binder contained information according to the center s policy 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. The center has a policy in place where an itemized personal property receipt form is maintained for each youth who enters the center. Upon admission, each youth s clothing is itemized and placed in a numbered bag by the JJDO. This bag is placed into a locker for the remainder of the youth s stay, with the corresponding number documented on the receipt. Any items of value are placed in a tamper-proof bag, documented with the youth s identifying information, and stored in a safe at the center. Each youth and the staff conducting the admission sign the property receipt form, as well as the tamper-proof property bag. A copy of the property receipt form is placed in the youth s case management file. Five youth files were reviewed; all five files contained documentation of all items that the youth had in his or her possession upon admission to the center. A property receipt form was verified in all five youth files that contained both the youth s signature, verifying the contents of the bag, as well as the staff s signature. Five youth responded to the survey; all five reported that upon admission to the center, their personal property had been inventoried, and they each signed a receipt reflecting the information was correct 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. Upon admission to the center, each youth s property is inventoried and placed either in a locker or safe until the youth is discharged. Each youth is given a form entitled property letter of acknowledgement, which states that youth s property must be claimed within thirty days of discharge from the center, or it will be disposed of by the state of Florida. The form is reviewed Office of Program Accountability Page 18 of 18 (Revised September 2012)

23 with each youth and signed by both the youth and a staff member. The form is located in each youth s active case management file. During the Quality Improvement review, a release of a youth was observed. The staff member was observed returning the property to the youth from his assigned locker. The staff member also provided the youth a copy of the personal property receipt form that listed all of his property. The youth reviewed the list and signed the form indicated that all of his property was accounted for and returned to him. The youth was also provided a copy of the form 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. The center has policies in place regarding youth being released from secure detention. Upon notification of a youth s release, the releasing officer must thoroughly review the documentation received from the assigned juvenile probation officer (JPO) to determine if the youth is in fact to be released, and to whom. This process is approved by a supervisor. Prior to release, each youth s parent/guardian must show proper photo identification, which is photocopied and placed in the youth s file. Of the five files reviewed, one was applicable to review for release, and the release was observed while the Quality Improvement team was on site. At the time of the youth s release, there was a JJDO supervisor present, as well as the assistant superintendent. The youth was able to change her clothes and staff followed policy when providing youth with all of her personal property. The youth was a DCF involved youth, and was therefore being released to her DCF caseworker. The DCF caseworker presented her photo ID and signed all of the necessary paperwork for the youth s release from the center. Three additional files were reviewed; the process was followed with no exceptions 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. Office of Program Accountability Page 19 of 19 (Revised September 2012)

24 The center s policy states that all of a youth s personal property is returned to them upon release from the center. The youth and their parent/guardian are to sign the property receipt form, acknowledging they have received all of the youth s personal property. Of the five files reviewed, one was applicable to review for release of youth s personal property, which was witnessed by the Quality Improvement team. During this release, there were two staff present, which is the center s policy in regards to returning personal property. The staff followed policies without issue. The youth received her property, and both she and her parent/guardian signed for it on the property receipt form. The release documentation for two other youth was reviewed; each youth signed a receipt to acknowledge receiving their personal property. Three additional files were reviewed; each youth received their property, as required Release of Medication, Aftercare Instructions Compliance The program ensures that there are provisions in place to ensure that prescribed medication, along with medical instructions. accompanies detained youth upon release. The center has a policy in place to ensure that youth are properly released to their parent/guardian, and that all pertinent information regarding future court dates and medical and mental health concerns are addressed with the parent/guardian. Of the five youth files reviewed; one was applicable to review for release. The youth s guardian was the Department of Children and Families (DCF), so prior to the release taking place, the DCF caseworker provided the detention staff with a copy of her photo identification. While at the center, the youth was taking prescribed medication; the release of the youth s medication was observed by the Quality Improvement team. The nurse verified the guardian s identification by requesting to view the DCF caseworker s photo identification. Once verification was made, the nurse provided the DCF caseworker with the youth s prescribed medication and the guardian signed a receipt for it. Three additional files were reviewed; each youth and their parent/guardian received any applicable medications and aftercare instructions, as required 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. The center conducts a weekly audit to discuss all youth being detained in secure detention. The detention reviews are conducted every Thursday at the detention center. Those in attendance include the assistant superintendent, home detention representative, education staff, mental health staff, juvenile probation officer supervisors, commitment manager, contract providers, intake screeners, and the chief probation officer for Circuit 18. The Quality Improvement team was able to observe a weekly audit while on site; all youth placed in secure detention were reviewed. Information was shared as it related to upcoming court dates, mental health and/or medical issues, possible release issues, and any other pertinent information pertaining to the youth. A review of the meeting minutes from the past six months revealed the audits take place weekly, and there was consistent participation among the parties. Office of Program Accountability Page 20 of 20 (Revised September 2012)