BUREAU OF MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR

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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 MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR Miami-Dade Regional Juvenile Detention Center Department of Juvenile Justice (State-Operated) 3300 North West 27 th Avenue Miami, Florida Review Date(s): January 30, February 2, 2018 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES

2 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 Monitoring and 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: Teves Bush, Office of Program Accountability, Lead Reviewer (Standard 3) Paula Friedrich, Office of Program Accountability, Regional Monitor (Standard 4) Doug Kane, St. Lucie Regional Detention Center, Assistant Superintendent (Standard 5) Peter Keelan, DJJ Office of Education, Southeast Region Education Coordinator (Education Services) Nancy Romero, DJJ Probation and Community Intervention, Circuit 11, Juvenile Probation Officer Supervisor (Standard 2) Maryann Sanders, Office of Program and Accountability, Deputy Regional Monitoring Supervisor (Standard 1) Launa Wilcox, DJJ Probation and Community Intervention, Circuit 11, Juvenile Probation Officer Supervisor (Standard 2)

3 Program Name: Miami-Dade Regional Juvenile Detention Center MQI Program Code: 490 Provider Name: Department of Juvenile Justice Contract Number: N/A Location: Miami-Dade County / Circuit 11 Number of Beds: 126 Review Date(s): January 30, February 2, 2018 Lead Reviewer Code: 154 Methodology This review was conducted in accordance with FDJJ-2000 (Contract Management and Program Monitoring and 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. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee 2 # Case Managers 1 # Clinical Staff 1 # Food Service Personnel 2 # Healthcare Staff Documents Reviewed 1 # Maintenance Personnel 3 # Program Supervisors # Other (listed by title): 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 9 # Health Records 9 # MH/SA Records 9 # Personnel Records 9 # Training Records/CORE 7 # Youth Records (Closed) 9 # Youth Records (Open) # Other: 9 # Youth 9 # 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 58 (Revised July 2016)

4 Standard 1: Management Accountability Detention Rating Profile Indicator Ratings Standard 1 - Management Accountability 1.01 * Initial Background Screening 1.02 Five-Year Rescreening Limited 1.03 Staff Code of Conduct 1.04 * Incident Reporting 1.05 Protective Action Response (PAR) 1.06 * Pre-Service/Certification Requirements 1.07 In-Service Training 1.08 *Entering Alerts(JJIS) 1.09 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). Office of Program Accountability Page 4 of 58 (Revised July 2016)

5 Standard 2: Youth Management Detention Rating Profile Indicator Ratings Standard 2 - Assessment and Performance Plan 2.01 Admission 2.02 Orientation 2.03 Classification 2.04 Classification of Gang Members 2.05 Notification of JPO Circuit Gang Rep 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 Meds, 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 Career Education 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 58 (Revised July 2016)

6 Standard 3: Mental Health and Substance Abuse Services Detention Rating Profile Indicator Ratings Standard 3 - Mental Health and Substance Abuse Services 3.01 Designated Mental Health Clinician Authority (DMHCA) 3.02 * Licensed MH/SA Clinical Staff 3.03 Non-Licensed MH/SA Clinical Staff 3.04 MH/SA Admission Screening 3.05 MH/SA Assessment/Evaluation 3.06 MH/SA 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 3.13 * Mental Health Crisis Intervention Services 3.14 Emergency Care Plan 3.15 Crisis Assessments 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). Office of Program Accountability Page 6 of 58 (Revised July 2016)

7 Standard 4: Health Services Detention Rating Profile Indicator Ratings Standard 4 - Health Services 4.01 * Designated Health Authority/Designee 4.02 Facility Operating Procedures 4.03 Authority for Evaluation and Treatment 4.04 Parental Notification 4.05 Notification - Clinical Psychotropic Progress Note 4.06 Immunizations 4.07 Healthcare Admission Screening Form 4.08 Medical Alerts 4.09 Suicide Risk Screening Instrument 4.10 Youth Orientation to Healthcare Services Limited 4.11 DHA/Designee Admission Notification Limited 4.12 Healthcare Admission Rescreening 4.13 Health Related History Limited 4.14 Comprehensive Physical Assessment Limited 4.15 Female-Specific Screening/Examination 4.16 Tuberculosis Screening 4.17 Sexually Transmitted Infection Screening 4.18 HIV Testing 4.19 Sick Call Process - Requests/Complaints 4.20 Sick Call Process - Visits/Encounters 4.21 Restricted Housing 4.22 Episodic/First Aid Care 4.23 Emergency Care 4.24 Off-Site Care/Referrals 4.25 Chronic Conditions/Periodic Evaluations 4.26 Medication Management - Verification 4.27 Medication Management - Orders/Prescriptions 4.28 Medication Management - Storage 4.29 Medication and Sharps Inventory 4.30 Medication Management - Controlled Medications 4.31 Medication Administration Record 4.32 Medication Administration By Licensed Staff 4.33 Medications Provided By Non-Licensed Staff 4.34 Psychotropic Medication Monitoring 4.35 Infection Control - Surveillance, Screening, and Management 4.36 Infection Control - Education Limited 4.37 Infection Control - Exposure Control Plan 4.38 Prenatal Care - Physical Care of Pregnant Youth 4.39 Prenatal Care - Nutrition and Education of Youth 4.40 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). Office of Program Accountability Page 7 of 58 (Revised July 2016)

8 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 Logbook Maintenance 5.05 Logbook Reviews 5.06 Key Control 5.07 Vehicles and Maintenance 5.08 Tool Inventory and Management 5.09 Kitchen Tools 5.10 * Youth Access & Use of Tools, Cleaning Items 5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items 5.12 * Access to all Flammable, Toxic, Caustic, and Poisonous Items 5.13 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items 5.14 Confinement Under Twenty-Four Hours 5.15 Confinement Over Twenty-Four Hours 5.16 Continuity of Operations Planning (COOP) Drills 5.17 Escape Drills 5.18 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 58 (Revised July 2016)

9 Strengths and Innovative Approaches The center offers yoga classes to girls in the center. The volunteer who provides yoga instruction, also addresses the importance of meditation, remaining positive, and maintaining an overall healthy lifestyle. The center has partnered with a local farmer who assisted with creating a vegetable and fruit garden at the center. The garden s irrigation system operates automatically by solar powered panels. The garden is cared for and harvested by the youth in the center. Many of the vegetables and fruits are used for meals in the center. The center has implemented a sibling visitation program were level-three youth, who have been in the center for an extensive period of time, can have weekly visits with their siblings. The center also allows special visitation on each youth s birthday, where the parents/guardians can visit and are allowed to bring in a special meal and/or a cake for the youth. The center has a new break room for staff which provides a nice area for staff to eat and relax while on break. Office of Program Accountability Page 9 of 58 (Revised July 2016)

10 Standard 1: Management Accountability Overview The Miami-Dade Regional Juvenile Detention Center is a 126-bed, hardware-secure facility operated by the Department for detained youth. Youth are detained pending adjudication, disposition, or placement in residential commitment facilities. The detention center serves youth who have been detained by various circuit courts, including youth from Miami-Dade, Broward, and Monroe counties. At the time of the annual compliance review, there were 102 youth in the center. All interviewed youth indicated they feel safe in the center. The center provides services to youth which include education, healthcare, mental health, and substance abuse. Healthcare, mental health, and substance abuse services are provided through contracted providers. The center s administrative team includes one superintendent, two assistant superintendents, and twelve supervisors. There were fourteen vacant positions at the time of the annual compliance review, which included two food support workers, seven juvenile justice detention officer II, and five juvenile justice detention officer I. The center has a comprehensive staff development training program, which includes a training officer to ensure the professionalism and competency of the center s staff. Educational and vocational services provided at the center are funded by the Department of Education through the Miami-Dade Public School District (MDPSD). A walk through of the center by the annual compliance review team found all areas were clean and free of graffiti. The superintendent reported the center was approved for funds to update each of the center s restrooms and shower areas. The center has a newly constructed intake area designed to streamline the youth intake process, as well as a new break room for staff 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 detention center has a written policy and procedures for initial background screening. The center hired seventeen new staff since the last annual compliance review. Reviewed documentation in seventeen staff records confirmed each had an initial background screening completed by the Department s Background Screening Unit (BSU) prior to each staff s hire date. None of the reviewed initial background screenings required an exemption. The center had seven new volunteers and/or mentors since the last annual compliance review and reviewed documentation validated all seven received a background screening prior to their start dates. The center hired eleven contracted staff since the last annual compliance review and reviewed documentation confirmed each received a background screening prior to each of their start dates. The Annual Affidavit of Compliance with Level 2 screening standards was submitted to BSU on January 18, 2018, meeting the annual requirement. Office of Program Accountability Page 10 of 58 (Revised July 2016)

11 1.02 Five-Year Rescreening Limited 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 has a written policy and procedures requiring the completion of a five-year background re-screening for staff. There were four staff requiring a five-year re-screening since the last annual compliance review. Reviewed documentation found two of the four required rescreenings were late. One was submitted two months after the staff s anniversary date of hire and the other was submitted three months after the staff s anniversary date of hire. There was no documentation to support the required re-screenings were submitted for the remaining two applicable staff. There were no contracted providers, volunteers, educational staff, medical staff, mental health staff, or interns requiring a five-year background re-screening Staff Code of Conduct Compliance Program staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats, harassment, intimidation, horseplay, or personal relationships with youth. 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 s employee handbook, which contains a code of conduct. Nine applicable staff personnel records were reviewed and each contained the acknowledgement, receipt, and review of the Department s code of conduct. There were three additional reviewed applicable records during the annual review period for disciplinary action. Each of the reviewed additional records contained documentation of disciplinary action. Reviewed documentation in all three staff records validated management took immediate corrective action to address the staff code of conduct when staff violated the policies and procedures. Each written reprimand documented staff received additional training with no other action required. None of the reviewed incidents were applicable to be reported to Department s Central Communications Center (CCC). Internal incidents and CCC reports for the past six months were reviewed and none were applicable for improper conducted by staff. Nine interviewed staff and nine interviewed youth reported never hearing staff use profanity towards youth or one another, or threaten and intimidate a youth. Both staff and youth were able to articulate the center s protocol for reporting abuse. Nine interviewed staff reported the working conditions were either good or very good at the center. Office of Program Accountability Page 11 of 58 (Revised July 2016)

12 1.04 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 detention center has a written policy and procedures addressing incident reporting to the Central Communications Center (CCC). The center had seventy-one incidents reported to the CCC during the last six months and seven reports were reviewed. Documentation found all reportable incidents were called in to the CCC within the mandatory two-hour time frame and in accordance with the CCC reporting procedures. A review of logbooks, grievances, and internal incidents confirmed there were no additional incidents which should have been reported and were not. Six of the seven reviewed CCC reports were documented in the center s CCC logbook. The center maintains a CCC binder which documents all reports made to the CCC 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. The center has a written policy and procedures addressing Protective Action Response (PAR). The center follows the PAR training plan utilized in each of the Department s detention centers. The detention center had 303 PAR reports completed within the past six months and thirty reports were reviewed. Reviewed documentation found each report included a review by a PAR-certified instructor and supervisory staff, a post-par interview with the youth conducted within thirty minutes after the incident, a review of the PAR incident report by the superintendent or designee within seventy-two hours of the incident, and statements completed on the same day. None of the thirty reviewed reports required a PAR medical review or documentation; however, it is the center s protocol to have a medical review conducted for all PAR incidents and documentation confirmed all involved youth were assessed by medical staff. Documentation confirmed each report was reviewed within the mandated time frame and processed by a supervisor and a PAR instructor to determine if use of force was consistent with policy. All thirty reports were reviewed by the superintendent or designee and maintained electronically in the Facility Management System (FMS); subsequently, the center does not generate a monthly summary. None of the reviewed reports required a report to the Central Communication Center (CCC), and there was no documentation to support any involved youth made a report to the Florida Abuse Hotline. Logbooks, internal incidents, and grievances were reviewed and documentation did not reveal any additional PAR incidents occurred. Nine interviewed staff reported being adequately trained to perform their job. Office of Program Accountability Page 12 of 58 (Revised July 2016)

13 1.06 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. The center has a written policy and procedures regarding pre-service certification requirements. Nine staff training records were reviewed and all nine staff were certified within 180-days of hire. Reviewed documentation confirmed staff received and passed Protection Action Response (PAR) training within ninety-days of hire, and the required training which included cardiopulmonary resuscitation (CPR), first aid, automated external defibrillator (AED) certification, mental health and substance abuse, suicide recognition, prevention and intervention, safety, security, and supervision, and Department facility operations. The center utilizes on-site training and all training was completed prior to staff being in the presence of youth. Reviewed documentation reflected all pre-service training was entered into the Department s Learning Management System (SkillPro) 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. The center has a written policy and procedures regarding in-service training. The center provides in-service training to staff through a combination of the Department s Learning Management System (SkillPro) and instructor-led classes. The center has an annual in-service training calendar, which is updated when changes occur. Nine applicable staff training records were reviewed and each exceeded the required in-service training. All nine staff completed the required twenty-four hours of training on Protective Action Response (PAR) update, first aid, automated external defibrillator (AED), and cardiopulmonary resuscitation (CPR). Additionally, each staff received training in professionalism, ethics, suicide prevention training, and all other required training. Five additional supervisors training records were reviewed and documentation found each supervisor exceeded the required eight hours of supervisory training. Each supervisor received training in management, leadership, personal accountability, employee relations, communications skills, and fiscal. All completed training was entered into the Department s Learning Management System (SkillPro). Office of Program Accountability Page 13 of 58 (Revised July 2016)

14 1.08 Entering Alerts (JJIS) Compliance Superintendents shall ensure Critical and Special Alerts are reviewed and responded to appropriately. Upon completion of the Admission Wizard, the officer shall ensure all Critical and Special Alerts are listed in JJIS. The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it correctly reflects the status of youth. If the electronic system is inoperable, for any reason, the JJDO Supervisor shall ensure 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. 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 center has a written policy and procedures regarding entering alerts in the Department s Juvenile Justice Information System (JJIS) and the use of an internal alert system. An interview with the center s superintendent confirmed JJIS alert reports are distributed and reviewed by shift supervisors daily. Upon review of the alert list, the supervisors distribute the alert list to all working direct-care staff, at each shift briefing. Each staff carries the current alert list throughout their shift. The alerts in JJIS are entered as information changes and an updated list is distributed to all direct-care staff. The responses and updates by medical, mental health, and other staff were documented in JJIS, as they pertained to each applicable critical alert. A review of the center s Admission Wizard, logbooks, and internal alerts, and ten youth records found all applicable alerts were documented in JJIS, entered in the appropriate logbook, and noted in 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. The center has a written policy and procedures regarding the sharing of alert information. The center s procedures for sharing alert information to staff is to print the Department s Juvenile Justice Information System (JJIS) alert report daily, prior to each change of shift, and alerts are reviewed by the shift supervisor. The alerts are disseminated to all staff at each shift briefing and all direct care staff are provided with a copy of the list, which they carry with them throughout their shifts. The medical, mental health, and substance abuse staff, as well as the juvenile justice detention officer supervisor enter and update any applicable or critical alerts in the JJIS alert system and the center s Facility Management System (FMS). If a youth with an alert is admitted to the detention center after a shift s briefing, the appropriate entity calls the juvenile justice detention officer supervisor on the telephone to notify of the alert, at which time Office of Program Accountability Page 14 of 58 (Revised July 2016)

15 the information is verbally communicated to direct-care staff until an updated alert list is updated and disseminated. A review of shift briefing minutes for the past six months and an observation of a shift briefing confirmed alerts are discussed at each shift briefing. Nine interviewed staff reported being notified of alerts during shift briefings and by reading the alert board. Each interviewed staff confirmed they each carry the most current alert list with them for the duration of their shift. Standard 2: Assessment and Performance Plan Overview All youth transported to the center are screened and classified by an intake and release officer (IRO), in accordance to their level of risk. All detention paperwork is reviewed to ensure each youth is appropriately admitted into the center. The IRO conducting the admission identifies any significant medical, mental health, substance abuse, allergies, critical, and/or special needs. The IRO places the appropriate alert into the Facility Management System (FMS) and in the Department s Juvenile Justice Information System (JJIS). The superintendent and applicable staff responsible are informed of the youth s status. The IRO determines the youth s risk factors and facilitates a safe and secure assignment of the youth to a specific module. The center s staff notifies or attempts to notify the youth s parent/guardian of their current placement. Detention staff are responsible for conducting the required searches of the youth and ensuring their personal property is accounted for and appropriately secured. Each youth admitted to the center receives an orientation, which includes the explanation of the orientation brochure including staff, services, rules, and procedures. The detention center displays grievance and sick call forms in each module for easy access by the youth. Youth are provided with all personal hygiene items for their use while in center. The center conducts weekly detention reviews for all youth in secure detention and on-home detention/electronic monitoring, to identify youth who may be inappropriately detained, facilitate release, and/or make appropriate placement pending court disposition. The Miami-Dade County Public School District s Juvenile Justice Center School provides teachers and classroom instruction to every youth while in the center. Office of Program Accountability Page 15 of 58 (Revised July 2016)

16 2.01 Admission Compliance All youth are admitted to the program in accordance with Florida Administrative Code through a process, at a minimum, addressing 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 center has a written policy and procedures regarding the admission process. A review of nine youth case management records found each had the appropriate documentation which includes, but is not limited to, an arrest affidavit/custody order, Detention Risk Assessment Instrument (DRAI), Suicide Risk Instrument (SRSI), Positive Change Tool (PACT), and the Department s Juvenile Justice Information System (JJIS) Admission Wizard completed during the admission process. Each youth was allowed a telephone call and a meal or snack during the admission process. Each youth was searched upon admission to identify any medical, mental health, and/or substance abuse needs. None of the reviewed youth case management records identified any youth as being at risk of suicide. Each youth case management record reviewed indicated the admission process was in accordance with program policy 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 a written policy and procedures regarding youth orientation which is to occur within twenty-four hours of the youth being admitted to the center. A review of nine youth case management records revealed each youth received a written and verbal orientation to the center within twenty-four hours of admission. Each youth received a copy of the orientation Office of Program Accountability Page 16 of 58 (Revised July 2016)

17 brochure which addresses visitation, sick call, educational, mental health services, grievance procedures, how to access the Florida Abuse Hotline, procedures for telephone calls, the behavior management system, explanation of the center s rules and regulations, and the fire evacuation plan is reviewed. Nine youth were interviewed and each stated when they were admitted, someone provided information about 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); 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 they will be able to jeopardize safety and security. The center has a written policy and procedures regarding youth classification. All youth admitted to the center are classified to provide the highest level of safety and security. A review of nine youth case management records revealed each contained a copy of the booking classification form, Vulnerability and Sexually Aggressive behavior (VSAB), and the Department s Juvenile Justice Information System (JJIS) Admission Wizard, which are all used to classify youth and to assist with proper placement within the center. One of the nine reviewed youth case management records was identified by the VSAB to warrant a single room placement. An informal interview with staff indicated every effort is made to separate youth with a history of violent behavior from other youth in the center. Staff further stated youth are assigned to a room based on their classification and are re-classified if changes in behavior are observed 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 has a written policy and procedures for youth who have been identified as gang members. A review of nine youth case management records and an observation of a youth admission to the center revealed youth are screened for possible gang involvement or affiliation with any type of gang. Three of the nine reviewed youth case management records were Office of Program Accountability Page 17 of 58 (Revised July 2016)

18 applicable for identification of a gang member and according to the documentation, all three youth were placed appropriately to ensure their safety. Alerts were placed in the center s internal alert system and in the Department s Juvenile Justice Information System (JJIS). An informal interview with the superintendent revealed the center has one staff identified as a gang liaison. Reviewed documentation indicated the staff attend Multi-Agency Gang Task Force meetings monthly. The gang liaison provided evidence of communicating with other gang representatives by way of . The gang liaison indicated the information is updated and provided to staff during the daily debriefing for youth to be appropriately classified Notification of Juvenile Probation Officer Circuit Gang Compliance Representative Each center shall identify the Juvenile Probation Officer designated as the Circuit Gang Representative to communicate suspected gang activity. A referral on a youth for suspected gang involvement shall be shared, via , with the Juvenile Probation Officer designated as the Circuit Gang Representative indicating suspicions of gang activity such as youth flashing gang signs, gang tattoos, gang-related drawings, or related activity. Detention staff should include in the all pictures (when appropriate), copies of written statements, drawings, graffiti, and a description of what gang signs the youth was flashing. The center has a written policy and procedures to ensure the sharing of suspected gang involvement is provided to local law enforcement, sent to the assigned juvenile probation officer (JPO), and an alert is entered into the Department s Juvenile Justice Information System (JJIS). The center has identified one staff member as the gang representative to communicate suspected gang activity to local law enforcement. Three of the nine youth case management records were applicable for gang member or affiliate. A review of the center s daily alerts for the three youth validated the program s practice follows their procedures. The center s gang liaison was informally interviewed and confirmed when a youth is a suspected gang member or affiliate, an alert is entered in the JJIS alert system and information is shared with all parties 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 written policy and procedures to ensure the proper safe handling and security of youth s personal property. All money and personal items of value are verified and placed in a clear tamper-proof property bag. Property is then placed in the drop safe and recorded in the Facility Management System (FMS). A review of nine youth case management records and observations confirmed each youth s personal property was collected and inventoried by the booking officer in the presence of the youth. A review of nine youth case management records revealed each applicable youth and staff signed and dated a property receipt and a valuable receipt. Any personal property unclaimed is deemed abandoned and subjected to disposal, according to the applicable State of Florida guidelines. All nine case management records reviewed had an acknowledgement of unclaimed property signed by each youth. An observation of the storage area revealed each of the bags contained a completed inventory form. Nine youth were interviewed and indicated, upon admission to the center, staff checked their personal property, signed, and received a form listing the property collected was correct. Office of Program Accountability Page 18 of 58 (Revised July 2016)

19 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 written policy and procedures to ensure staff provide control and accountability for youth personal property. Valuable property is placed in two safes, and both areas are under surveillance. Personal items of value are inventoried and placed in clear plastic bags with the youth s information. Non-valuable property is placed in brown paper bags and placed in a secure room. A random review of property logbooks, property bags, and a walk through of the property room revealed the youth s property was inventoried by the booking officer in the presence of the youth and signed by both parties. An interview with the superintendent indicated the shift supervisor documents the youth s property in the safe logbook and secures the valuable property in the safe. An observation of the property room indicated safe guards were in place for each youth s personal property until it is returned to the youth and/or parent/guardian. The property room is under constant video surveillance. A review of the Central Communications Center (CCC) incident reports found there were no incidents of lost or stolen property during the annual compliance review period. The center procedures included a clear process related to disposal of unclaimed property. All nine reviewed case management records contained an acknowledgement of unclaimed property form signed by the youth at the time of admission 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 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 a written policy and procedures for the release of youth. Seven close case management records were reviewed for release documentation. Each record contained the court authorization for release, a copy of photo identification, signatures, dates, youth check list, and notifications. The youth s information was uploaded in the Department s Juvenile Justice Information System (JJIS), by the shift supervisor, at the time of the youth s departure. In the absence of this documentation, the superintendent or designee determines if the person to whom the youth is being released is a parent, legal guardian, or responsible adult. All seven case management records contained signatures of the youth being released, parent/guardian, or staff transporting the youth. A review of the Central Communications Center (CCC) incident Office of Program Accountability Page 19 of 58 (Revised July 2016)

20 reports indicated there were no unauthorized releases during the annual compliance review period 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 parent or legal guardian shall review and sign the Property Receipt Form and account for all of the youth s personal property. The center has a written policy and procedures related to the release of youth property. Procedures for personal property of youth released to their parent/guardian, commitment programs, unclaimed personal property and damaged or missing personal property was also addressed. A review of seven closed youth case management records revealed each contained the required information. All seven case management records contained signatures on the property receipt form of the youth and staff. Reviewed documentation noted each applicable youth, upon release, received their personal property, as evidenced by the property receipt report being signed and dated by the youth and parent/guardian. There were no issues with unclaimed youth property for the seven close case management records reviewed. The superintendent was interviewed and indicated unclaimed youth property is kept secured and if not claimed with in thirty days, it will be considered abandoned, and a notice is mailed to the last known address of the youth Release of Medication, Aftercare Instructions Compliance The program ensures there are provisions in place to ensure prescribed medication, along with medical instructions, accompanies detained youth upon release. The center has a written policy and procedures to ensure prescribed medication, along with medical instructions, is provided to whomever is receiving the youth at the time of release. A review of seven closed youth case management records revealed none of the seven youth had medication prescribed. An informal interview with the advanced registered nurse practitioner (ARNP) indicated at the time of release, the appropriate medication release documentation is placed in the youth case management records which includes the date and signature of the person receiving the youth, as well as the youth s prescribed medication. A discharge summary is provided to the parent at the time of the youth s departure from the center. The Medical Receipt and Transfer and Disposition form from four additional case management records were reviewed and met the criteria. Each form validated prescribed medication and medical instructions accompanied the detained youth upon release 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 has a written policy and procedures in place regarding the detention review process which address youth who are placed in secure detention. The purpose of the weekly reviews is to provide a means to screen all youth who may have physical or behavioral issues, are able to transfer to a less restrictive placement or to their designated commitment placements expeditiously. An observation of the detention review process was conducted along with a review of detention review agendas, minutes, and sign-in sheets for the past six months. It was Office of Program Accountability Page 20 of 58 (Revised July 2016)

21 confirmed meetings were conducted weekly to share information between detention staff, medical, educational, mental health, juvenile probation staff, therapist, and a representative from commitment to determine the most appropriate and least restrictive placement options for each youth in the center. Hard copies of the agendas, follow-up reports, sign-in sheets, and minutes are maintained by the center 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. The center has a written policy and procedures in place regarding the detention review process which address youth who are placed on home detention. The purpose of the weekly reviews is to provide a means to screen all youth who may have physical or behavioral issues, are able to transfer to a less restrictive placement or to their designated commitment placements expeditiously. An observation of the detention review process was conducted along with a review of detention review agendas, minutes, and sign-in sheets for the past six months. It was confirmed meetings were conducted weekly to share information between detention staff, medical, educational, mental health, juvenile probation staff, therapist, and a representative from commitment to determine the most appropriate and least restrictive placement options for each youth on home detention. Hard copies of the agendas, follow-up reports, sign-in sheets, and minutes are maintained by the center 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 center has a written policy and procedures regarding a daily activity schedule. The use of the activities schedule benefits the center by keeping youth constructively involved throughout the day. A review of the center s daily activity schedule revealed the center has a schedule which includes activities for weekdays, weekends, and holidays. Observation of the daily activity schedule indicated a schedule is posted in each module. The schedule outlines the days and times for each youth activity and includes personal hygiene, meals, visitation, educational and recreational services, restorative justice programming, life and social skills competency development. Activities noted include indoor and outdoor services and gender-specific programming for girls. Activities noted included evidence-based groups, volunteer programming, mentoring for girls, library, arts, and gardening. Nine staff were interviewed and each stated the center follows the daily schedule. Nine staff were interviewed on whether the program offers gender-specific programming as part of the daily schedule. Eight staff stated yes and one stated no. Office of Program Accountability Page 21 of 58 (Revised July 2016)