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 Volusia Regional Juvenile Detention Center Department of Juvenile Justice (State-Operated) 3840 Old Deland Road Daytona Beach, Florida Review Date(s): April 4-7, 2017 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: Mike Marino, Office of Program Accountability, Lead Reviewer (Standard 1) Kevin Greaney, Office of Program Accountability, Regional Monitor (Standard 4) Darrell Johnson, DJJ Detention Services, North Region, Chief (Standard 2) Joseph Shuler, Jacksonville Youth Academy, G4S Youth Services, Facility Administrator (Standard 5) Christi Stua, DJJ Detention Services, North Region, Operations and Management Consultant II (Standard 3) Amy Tyson, Office of Program Accountability, Regional Monitor (Standard 1 and Standard 4)

3 Program Name: Volusia Regional Juvenile Detention Center MQI Program Code: 139 Provider Name: Department of Juvenile Justice Contract Number: NA Location: Volusia County / Circuit 7 Number of Beds: 64 Review Date(s): April 4-7, 2107 Lead Reviewer Code: 37 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 # Case Managers # Clinical Staff 1 # Food Service Personnel 1 # Healthcare Staff 1 # Maintenance Personnel 1 # Program Supervisors Documents Reviewed 2 # Other (listed by title): Asst. Superintendent, training coordinator 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 7 # Health Records 7 # MH/SA Records 19 # Personnel Records 12 # Training Records/CORE 4 # Youth Records (Closed) 7 # Youth Records (Open) 1 # Other: JJIS alerts 14 Volunteer files 7 # Youth 7 # 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 51 (Revised July 2016)

4 Standard 1: Management Accountability Detention Rating Profile Indicator Ratings 1.01 Standard 1 - Management Accountability * 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 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). Office of Program Accountability Page 4 of 51 (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 51 (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 Non-Applicable * 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 51 (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 * 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 DHA/Designee Admission Notification 4.13 Healthcare Admission Rescreening 4.14 Health Related History 4.15 Comprehensive Physical Assessment 4.16 Female-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 Conditions/Periodic Evaluations 4.27 Medication Management - Verification 4.28 Medication Management - Orders/Prescriptions 4.29 Medication Management - Storage 4.30 Medication and Sharps Inventory 4.31 Medication Management - Controlled Medications 4.32 Medication Administration Record 4.33 Medication Administration By Licensed Staff 4.34 Medications Provided By Non-Licensed Staff 4.35 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). Office of Program Accountability Page 7 of 51 (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 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 51 (Revised July 2016)

9 Strengths and Innovative Approaches The center continues to maintain a very effective working relationship with the Volusia County School District. In addition, to teachers at the center, the school district has assigned support staff and a guidance counselor to the center. The education staff ensure youth receive credit for schoolwork completed while at the center and transfer records to each youth s assigned school upon release. The center continues to receive grant funding from Very Special Arts of Florida. The grant allows the center to provide art classes one day each week. Youth art projects were prominently displayed throughout the center. Office of Program Accountability Page 9 of 51 (Revised July 2016)

10 Standard 1: Management Accountability Overview The Volusia Regional Juvenile Detention Center is located in Daytona Beach, Florida, and has a designated capacity of sixty-four beds. The center houses male and female youth pending adjudication, disposition, or placement in a commitment facility. There were thirty-seven youth in the center on the first day of the annual compliance review. The center serves Volusia, Flagler, and St. Johns counties. Management staff include the superintendent, two assistant superintendents, nine juvenile justice detention officer supervisors (JJDOS), and a training coordinator. Center staffing includes fifty-one juvenile justice detention officers (JJDO), five food service staff, one maintenance mechanic, and one administrative secretary. Seven JJDO positions were vacant and four JJDO positions were "on hold", at the direction of headquarters, at the time of the annual compliance review. Contracted provider staff provide medical and mental health and substance abuse treatment services. Education services are provided by the Volusia County School District 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 and procedures to address initial background screening. Since the last annual compliance review, the center had ten new staff and fifteen volunteers requiring an initial background screening. All new staff and volunteers were background screened prior to their date of hire or start date, and all were rated as eligible. An Annual Affidavit of Compliance with Level 2 Screening Standards for the center was completed and sent to the BSU on January 5, An Annual Affidavit of Compliance with Level 2 Screening Standards for school board teachers was completed and sent to the BSU on January 10, 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. Eight staff required a five-year background re-screening during the annual compliance review period. Five-year rescreens were completed for all eight staff, but five of the rescreens were completed between one to five-and-a-half months late. The superintendent explained the center based their rescreening dates on previously completed rescreens, rather than staff hire dates, which resulted in rescreens for the five staff being completed more than a year prior to their anniversary of hire date, and thus not in compliance with Department policy. Once BSU notified the center of the error, the center corrected the way they track rescreens, basing them on the date of hire. Office of Program Accountability Page 10 of 51 (Revised July 2016)

11 1.03 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. Seven staff personnel files were reviewed for code of conduct. Each staff signed the code of conduct upon hire. An additional personnel file was reviewed for disciplinary action, a termination, which was the only disciplinary action at the facility during the annual compliance review period. The staff in question was immediately removed from contact with youth, after an incident when he used physical interventions not approved in Protective Action Response (PAR) techniques. Documentation showed administration took appropriate action to review and address the incident, which included involving regional detention staff. The center awards staff with certificates each month when staff have perfect attendance for the month. Seven staff were surveyed and all were able to articulate the process for allowing a youth to call the Florida Abuse Hotline, or Central Communications Center (CCC), if a youth is eighteen years old. Each staff stated the supervisor is notified and responds, if possible. The supervisor then takes the youth to a phone to facilitate the call to the Florida Abuse Hotline or CCC, and allows the youth to make the report. If a supervisor is not available, the staff facilitates the call. Each staff reported they had never heard a youth being denied a call to the Florida Abuse Hotline or CCC. Each staff stated they had never heard co-workers using profanity or threats, intimidation, or humiliation towards youth. Seven youth were surveyed and none of them reported ever being stopped from reporting abuse to the Florida Abuse Hotline or CCC. All seven youth reported staff were respectful when speaking with them. Four youth said they had never heard staff use profanity. Three youth said they had heard staff use profanity once or occasionally, though, it was not directed toward youth. Each youth reported he/she felt safe in the center. Office of Program Accountability Page 11 of 51 (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. There were twenty-one incidents reported to the Central Communications Center (CCC) within the last six months. All were reported to the CCC within two hours of the incident or of staff becoming aware of the incident. A review of logbooks and internal incidents found there were no additional incidents requiring a report 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 detention center had sixty-four Protective Action Response (PAR) incidents in the last six months. Seven PAR reports were reviewed, of which six were completed by the end of the workday, including statements from all staff involved. In the remaining report, one staff statement was completed the next day. The supervisor review was completed after all statements had been completed in five of the seven reports. In one report, the supervisor review was completed prior to one of five staff statements completed in the report. In another report, the supervisor review was documented prior to two staff statements. Each report was reviewed by a PAR instructor, with six of the seven PAR instructor reviews being completed after all staff statements. In one report, the PAR instructor review was completed prior to one staff statement. All seven reports were reviewed by the superintendent or designee after all staff statements, supervisor reviews, and PAR instructor reviews and within seventy-two hours. A post-par interview was conducted within thirty minutes for each PAR incident reviewed. The center s practice is to take all youth involved in a PAR incident to medical to be checked by a nurse, which was documented in six of the seven PAR reports reviews. In the remaining report, the post-par interview clearly documented the youth was not injured and a medical review was not necessary. Seven youth and seven staff were surveyed. All youth and all staff stated staff try to talk to youth prior to using physical restraints. The center s PAR plan was approved for 2017 by the Department s Staff Development and Training Office 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. Seven training files were reviewed for pre-service training. Two of the staff had been employed over 180 days and each had completed the detention officer academy. Five staff were more recent hires and are scheduled to attend the detention officer academy. All seven staff were certified in Protective Action Response (PAR), Cardiopulmonary Resuscitation (CPR), First Aid, and use of an Automated External Defibrillator (AED) within ninety days. All staff had received Office of Program Accountability Page 12 of 51 (Revised July 2016)

13 training in suicide prevention, mental health and substance abuse services, detention operations, and emergency procedures 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. Seven training files were reviewed for in-service training. All staff were current with first aid, cardiopulmonary resuscitation (CPR), and automated external defibrillator (AED) certifications. Each staff completed sixteen hours of Protective Action Response (PAR) update training. All staff received well over twenty-four hours of training in 2016, with training hours completed, ranging from thirty-two to sixty-two hours. Four of seven records documented training in suicide prevention in 2016 and three did not. Two of the staff who did not have suicide prevention training in 2016 were out on extended family medical leave during 2016 and completed suicide prevention training when they returned to work in Four staff had documentation of training in ethics and three did not. Three training files of supervisory personnel were applicable for eight hours of management training. One supervisory staff had twenty-seven hours of training in management related topics and one supervisor had nine hours of training in supervisor related topics. The remaining supervisor completed seven hours of training on supervisory related topics 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 impacting facility safety and security shall be highlighted. Logbooks were reviewed from each module and master control. All logbooks were bound and had numbered pages. There were no missing pages in any of the logbooks reviewed, though the spine binding the pages together was in bad condition for two module logbooks. When errors were made, staff struck through them with a single line. The staff did not use white-out in the logbooks. Each entry had the time of the occurrence and the initials or signature of the staff member who recorded the entry. The dates were recorded at the top of each page. Staff recorded when youth were placed in and released from confinement. All admissions, releases, movements, activities, drills, emergencies, alerts, perimeter checks, visitations, and counts were Office of Program Accountability Page 13 of 51 (Revised July 2016)

14 recorded by staff. Blank lines were noted in master control logbooks, including some with times entered and highlighted. Highlighting was not evident for significant events in the module logbooks Logbook Reviews Compliance The superintendent or designee reviews all logbooks on a weekly basis. The supervisor(s) reviews the facility logbook maintained at master control when he/she accepts responsibility for the facility. The Juvenile Justice Detention Officer (JJDO) Supervisor(s) reviews logbooks maintained in each living area daily. The JJDO(s) reviews the logbook maintained in his/her assigned living area when he/she accepts responsibility for the living area at shift change. Logbooks from the modules and master control were reviewed for supervisory reviews. Supervisors reviewed the logbooks for each module and the master control logbook at the beginning of each shift. The superintendent and assistant superintendents documented at least weekly reviews of module and master control logbooks 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. Seven youth records were reviewed for alerts in the Juvenile Justice Information System (JJIS). Alerts were appropriately entered in JJIS on the date each alert was identified, with one exception. The one exception was one of multiple alerts for one youth. In this case, the youth had a suicide alert already open when he entered the center and staff were not authorized the close it and reopen a new one for the day of admission. Only authorized staff entered and closed alerts. Office of Program Accountability Page 14 of 51 (Revised July 2016)

15 1.11 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. Alert information is shared during each shift briefing. Staff read each alert aloud during the briefing and are issued a copy of the JJIS alerts to carry with them during their shift. Updated alert lists are provided to the kitchen. All staff surveyed said the system for sharing information is good or very good. Office of Program Accountability Page 15 of 51 (Revised July 2016)

16 Standard 2: Assessment and Performance Plan Overview Circuit probation operates a call center to screen youth for detention. Through the call center, law enforcement contacts a juvenile probation to determine if youth qualify for secure detention, home detention, or straight release. If qualifying for secure detention, law enforcement transport the youth to the detention center. Youth are searched by detention staff upon their arrival at intake. Multiple screenings are completed during the intake process, to include screening youth for suicide risk, medical issues, and room assignment. Youth are provided an orientation to the center s rules and expectations and youth property is inventoried and secured during the intake process. Education is provided by the Volusia County School District. The school portables were remodeled during the past year. A guidance counselor, teachers, and support staff are on-site to ensure education services 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 policy and procedures in place addressing the admission of youth. Seven youth files were reviewed and all had the necessary documentation for admissions, including an arrest affidavit or custody order, a Detention Risk Assessment Instrument (DRAI), and Suicide Risk Screening Instrument (SRSI). The admission wizard in all files indicated the youth was searched, allowed to use the phone to contact family, and offered a meal. Office of Program Accountability Page 16 of 51 (Revised July 2016)

17 2.02 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. Seven youth files were reviewed. Each file indicated the youth received orientation. The files indicated the orientation included information on youth rights, visitation, the grievance process, telephone calls, and access to the Florida Abuse Hotline. Seven youth were surveyed, of which six reported they received orientation upon admission to the center and one reported he did not 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. Seven youth files were reviewed to ensure youth were classified using the Secure Detention Admission Wizard. The admission wizard provides basic demographics, such as physical characteristics and age, as well as boxes to be checked to identify special needs, gang affiliation, history of violent behavior, history of sex offenses, and suicide risk. Staff also review intake paperwork, such as the Positive Achievement Change Tool (PACT) and Suicide Risk Screening Instrument (SRSI), to determine appropriate room classification and supervision level for all youth admitted. Office of Program Accountability Page 17 of 51 (Revised July 2016)

18 2.04 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 policy and procedures addressing classification of gang members. A review of seven youth files found each youth was screened for gang affiliation. The center has designated a detention officer as the gang representative. A review of the alert list confirmed the center enters a gang alert in the Juvenile Justice Information System (JJIS) in the event gang affiliation is suspected 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 policy and procedures addressing the notification of the juvenile probation officer of suspected gang involvement by youth in the center. The gang representative was interviewed and indicated the assigned juvenile probation officer is notified by when youth are identified with gang affiliation. The includes the name of the gang and how affiliation was identified (i.e. youth report). Local law enforcement is also notified by 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 and procedures in place addressing the admission of youth personal property. Youth property is inventoried during admission. The items are listed on a property sheet from the Juvenile Justice Information Systems (JJIS). The youth s name, the date, and Department of Juvenile Justice Identification Number appears on the property bag and the property sheet. All money and personal items are verified and secured in a clear tamper proof bag. A review of seven files found each youth signed their property sheet and a letter of acknowledgement regarding unclaimed property. Seven surveyed youth reported they signed property sheets. Office of Program Accountability Page 18 of 51 (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 policy and procedures in place addressing the storage of youth personal property. Youth personal property is stored in plastic, sealed, see-thru bags. Each bag has the youth s name, date, and Department of Juvenile Justice Identification Number on the bag. Valuable property is placed in a safe, to which only designated staff have access. The safe is under video surveillance and there is a logbook to document valuable property is placed in the safe. There have been no Central Communications Center (CCC) reports in the past six months regarding youth property at this detention center Release Compliance When releasing youth from detention, the releasing officer shall verify the court s authorization to release the youth. Care must be taken to ensure all case file information is reviewed to prevent the negligent release of a youth. All releases from the program are court-ordered, with the exception of deaths, escapes, and expirations of detention time period. In the absence of a written order, documentation of a verbal order in open court may be used for release. The on-duty JJDO Supervisor reviews all paperwork prior to release. The JJDO Supervisor is responsible for ensuring 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 policy and procedures addressing the release of youth and a release was observed during this annual compliance review. The supervisor verified a court order was in place to authorize the youth s release and verified the identity of the youth. The supervisor obtained and photocopied identification for the parent/guardian to confirm his/her identity. The supervisor reviewed all the documents pertaining to the release and obtained youth and parent/guardian signatures on applicable release forms. Four closed files were reviewed. A photocopy of the identification for the parent/guardian was in each closed file and documentation showed the youth and parent/guardian were notified of the youth s pending court dates. Each closed file documented youth, parent/guardian, and staff signatures were present on applicable release forms. A review of JJIS found admission and release dates for each youth were accurate. A review of Central Communications Center (CCC) reports found there have not been any unauthorized releases from the center during the past six months. Office of Program Accountability Page 19 of 51 (Revised July 2016)

20 2.09 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 policy and procedures addressing the release youth property. Each of the four closed files contained property forms signed by the youth and his/her parent/guardian to document receipt of the property. One youth release was observed. The releasing officer retrieved the youth property. The youth and the person receiving the youth both signed the property sheet, verifying the property was received. For property left at the center and not claimed for thirty days, notification is sent to the youth s parent/guardian with a copy of the letter signed by the youth acknowledging property left at the center for over thirty days is subject to disposal. The superintendent was interviewed and able to explain the center s procedures and practices related to youth personal property 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 policy and procedure in place addressing the release of medication and aftercare instructions. Three closed files were reviewed for youth who were released with medication. Each file contained an acknowledgment of receipt for the medication and aftercare instructions signed by the parent/guardian or person taking custody of the youth 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 policy and procedures in place to address the review of youth in secure detention. Detention review meetings are held every Wednesday and include a review of all youth in secure detention and youth on home detention. The meeting is attended by representatives from the detention center, probation, the Department of Children and Families (DCF), mental health, medical, and education. A detention review meeting was observed during the review. The meeting included a review of court dates, placement dates, release information, and youth behaviors for each youth in secure detention 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 policy and procedures in place to address the review of youth on home detention. Detention review meetings are held every Wednesday and include a review of all youth in secure detention and youth on home detention. The meeting is attended by representatives from the detention center, probation, the Department of Children and Families (DCF), mental health, medical, and education. A detention review meeting was observed during Office of Program Accountability Page 20 of 51 (Revised July 2016)

21 the review. The meeting included a review of court dates, placement dates, and release information for each youth on home detention 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 policy and procedures addressing the daily activity schedule. The center maintains a master daily activity schedule and a faith-based schedule. All required elements were present on the daily schedule, including time for hygiene, meals, education, and recreation. Gender-specific programming is included in the daily activity schedule. The schedules are posted on each module Adherence to Daily Schedule Compliance Facility staff shall adhere to the daily activity schedules. Documentation of all activities shall be made in all applicable logs. The on-duty supervisor must approve any significant changes in the activity schedule and shall document the reason for the change(s) in the shift report. Any cancellation of visitation shall be approved by the superintendent. Logbooks for the past three months were reviewed and the review team observed several activities during the annual compliance review. The logbooks and review team observations confirmed the daily scheduled is followed, with youth being moved to meals, education, and recreation activities, as well as participating in activities on the dorms at designated times. Seven youth were surveyed, and each youth said the center had a daily schedule and the schedule is followed. Seven staff were surveyed and also said the daily schedules are followed Educational Access Compliance The facility shall integrate educational instruction (career and technical education, as well as academic instruction) into their daily schedule in such a way ensuring the integrity of required instructional time. The school at the center is operated by the Volusia County School District. Youth are able to earn credits towards graduation. Classes are held year round. School is scheduled on weekdays, starting at 8:00 a.m. and ending at 2:30 p.m., with the exception of Wednesdays. On Wednesdays, school ends at 12:05 p.m. Logbooks reviewed and review team observations confirmed youth attended school, as scheduled. Seven youth were surveyed and all stated they attended school daily and took a variety of different classes Career Education Compliance Staff shall develop and implement a career education competency development program. Each youth is given the MyCareerShines assessment tool within the first five days of being admitted. Youth receive Type 1 career education programming daily. Office of Program Accountability Page 21 of 51 (Revised July 2016)

22 2.17 Behavior Management System Compliance The program provides a system of rewards, privileges, and consequences to encourage youth to fulfill the program s expectations. Each facility shall implement and maintain a behavior management system to meet the needs of the youth and the facility. The system shall be approved by the regional director and shall include rewards for positive behavior and consequences for inappropriate behavior. The behavioral norms and expectations for youth shall be posted in all living areas and shall clearly specify appropriate and inappropriate behaviors. The center uses the level system, which consists of three levels. The level system is described in the center policy and procedure manual. All youth enter the center on level two. A youth can be dropped a level for negative behavior and move up a level with positive behavior. Youth on level three get to go to the multi-purpose room to play games and interact with other youth on level three. Seven youth were surveyed of which two youth rated the behavioral management system as fair, three rated it as good, and two rated it as very good. Four youth reported consequences they had received were fair and the remaining three youth stated they had never received consequences. All surveyed youth denied any meals, snacks, clothing, bedding, or sleep was taken away as a consequence. All youth surveyed said youth were never able punish other youth. Seven staff were surveyed, and all said they felt the detention center s behavior management system is effective. All staff reported they discuss consequences with youth prior to imposing them and youth are given the opportunity to explain their behavior. All surveyed staff denied any meals, snacks, clothing, bedding, or sleep was taken away as a consequence. All surveyed staff stated they receive feedback on their implementation of the behavioral management system, with two staff saying weekly and five saying as needed and explaining this routinely occurs at shift briefings Unauthorized Use of Punishment Compliance The center s behavior management system restricts certain types of penalties on youth who demonstrate negative behaviors. Group punishment shall not be used as a part of the facility s behavior management plan. However, corrective action taken with a group of youth is appropriate when the behavior of a group jeopardizes safety or security, and this should not be confused with group punishment. Corporal punishment shall not be used in detention facilities. All allegations of corporal punishment of any youth by facility staff shall be reported to the Florida Abuse Hotline, pursuant to Chapter 39, F.S., and the Central Communications Center. The use of drugs to control the behavior of youth is prohibited. This does not preclude the proper administration of medication as prescribed by a licensed physician. The center has a policy and procedures addressing the unauthorized use of punishment. Corporal punishment is never used at the center. The administration team addresses any form of unauthorized punishment. The center had one officer terminated for the unauthorized use of force. The youth surveys indicated the youth felt safe at the center and the staff surveys indicated the staff did not practice the use of unauthorized punishment. Office of Program Accountability Page 22 of 51 (Revised July 2016)

23 2.19 Grievances Compliance The grievance procedures establish each youth s right to grieve and ensure all youth are treated fairly, respectfully, without discrimination, and their rights are protected. The process includes: 1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with the youth using effective communication skills; 2. Formal phase, wherein the youth submits a written grievance resulting in a response from a JJDO Supervisor by the end of the shift (if possible), or otherwise within twentyfour hours; and 3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the superintendent or designee. The center has a policy and procedures addressing youth grievances. The grievance process includes informal, formal, and appeal phases. The informal phase is for youth to address staff to see if the issue can be resolved. In the formal stage, grievances are entered into the center management system, by the staff, on behalf of the youth. Supervisory staff address the grievances and report their findings to the youth. If the youth wishes to appeal, the grievance is addressed by administration. The center has not reveived a grievance submitted by a youth during the annual compliance review period. Based on the youth surveys, each youth knew about the grievance process. According to staff surveys, the staff has been trained on the grievance process Trauma-Informed Care Compliance The facility is incorporating trauma-informed practice into current operations to deliver services and to provide care to youth in custody, acknowledging the role that violence and victimization play in the lives of most of the youth entering the facility. Trauma-informed practice has many characteristics, which include the following: A recognition of the high prevalence of trauma Assessment for traumatic histories and symptoms Recognition of culture and practices that may be re-traumatizing Collaboration of caregivers Training of staff to improve trauma knowledge and sensitivity Increased staff understanding of the function of behavior (rage, self-injury, etc.) as an expression of trauma Use of objective and neutral language (avoids labeling of youth) The center has a policy and procedures addressing trauma informed care practices. The center receives the Very Special Arts (VSA) grant yearly, through which the girls and boys participate in various art activities. The center has painted the modules and dining hall with murals. The center has also placed positive posters around the center and in the modules for positive reinforcement. The females are allowed to have slippers and pajamas at night and youth on level three are allowed to have sibling visitation. Training files reviewed found all but one staff completed the trauma informed care training. The one staff who did not complete the training was out for a long period of time under the Family Medical Leave Act. (FMLA). Office of Program Accountability Page 23 of 51 (Revised July 2016)