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 Bay Regional Juvenile Detention Center Department of Juvenile Justice (State-Operated) 450 East 11 th Street Panama City, Florida Review Date(s): April 18-21, 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: Ken Phillips, Office of Program Accountability, Lead Reviewer (Standard Five) Warren Garrison, Office of Program Accountability, Regional Monitor (Standard One) Jennifer Lowe, DJJ Probation, Circuit 14, Senior Juvenile Probation Officer (Standard Two) Kathy Parrish, Office of Program Accountability, Regional Monitor (Standard Four) Juan Youman, Office of Program Accountability, Regional Monitor (Standard Three)

3 Program Name: Bay Regional Juvenile Detention Center MQI Program Code: 33 Provider Name: Department of Juvenile Justice Contract Number: N/A Location: Bay County / Circuit 14 Number of Beds: 32 Review Date(s): April 18-21, 2017 Lead Reviewer Code: 145 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 1 # Case Managers 1 # Clinical Staff 1 # Food Service Personnel 1 # Healthcare Staff Documents Reviewed 1 # Maintenance Personnel 1 # Program Supervisors 1 # Other (listed by title): lead teacher Accreditation Reports Affidavit of Good Moral Character CCC Reports Confinement Reports Continuity of Operation Plan Contract Monitoring Reports Contract Scope of Services Egress Plans Escape Notification/Logs Exposure Control Plan Fire Drill Log Fire Inspection Report Fire Prevention Plan Grievance Process/Records Key Control Log Logbooks Medical and Mental Health Alerts PAR Reports Precautionary Observation Logs Program Schedules Sick Call Logs Supplemental Contracts Table of Organization Telephone Logs Surveys Vehicle Inspection Reports Visitation Logs Youth Handbook 7 # Health Records 7 # MH/SA Records 7 # Personnel Records 5 # Training Records/CORE 3 # Youth Records (Closed) 7 # Youth Records (Open) # Other: 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 56 (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 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 56 (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 56 (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 Non-Applicable 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 56 (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 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 56 (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 Limited 5.07 Kitchen Tools 5.08 * Youth Access & Use of Tools, Cleaning Items 5.09 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items Limited 5.10 * Access to all Flammable, Toxic, Caustic, and Poisonous Items 5.11 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items 5.12 Confinement Under Twenty-Four Hours 5.13 Confinement Over Twenty-Four Hours 5.14 Continuity of Operations Planning (COOP) Drills 5.15 Escape Drills 5.16 Fire Drills * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 8 of 56 (Revised July 2016)

9 Strengths and Innovative Approaches The Paint a Brick program gives youth the opportunity to leave a permanent, positive mark for others. Once a youth has earned their way to the top tier of the Behavior Management System, they have the opportunity to hand paint a brick in the courtyard area which leaves a positive, permanent mark behind to encourage other youth learn from their experience. Along with educational staff, the facility created a clothes closet for many of the youth who come into the facility with little or no appropriate clothing. The staff and teachers had been spending their own money to ensure youth left the center with shoes, jackets, school uniforms, etc. The facility has a room which houses a ready supply of appropriate, gently used clothing allowing each youth in need to have at least a few changes of clothes to be able to go to school, apply for a job and stay warm upon their release from the facility. Office of Program Accountability Page 9 of 56 (Revised July 2016)

10 Standard 1: Management Accountability Overview Bay Regional Juvenile Detention Center is a thirty-two bed center located in the fourteenth Judicial Circuit in Panama City, Florida. The center houses both male and female youth who have been court ordered to secure detention. The center s administration includes a superintendent and assistant superintendent. Services for youth include education, mental health, substance abuse, and health care. Medical and mental health services are contracted through Correct Care Solutions. Educational services are funded by the Department of Education through local school districts. During the annual compliance review, the superintendent reported having three vacancies for direct care positions. They reported having five staff who were currently in the detention training academy working towards receipt of certification. The center operates twenty-four hours a day, running three shifts each day 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. A background screening was completed for five newly hired staff. Each newly hired staff had an eligible background screening rating prior to their original date of hire. Documentation included the Affidavit of Compliance with Level Two Screening Standards for the center and school submitted to the Department s Background Screening Unit on January 17, Five-Year Rescreening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. Employees and volunteers are rescreened every five years from the initial date of employment. A review of all staff original hire dates revealed one staff was applicable for a five-year rescreening. This rescreening was completed within the allowed time frame and not completed more than twelve-months prior to the employee s five-year anniversary date. The rescreening was submitted to the Background Screening Unit (BSU) at least ten business days prior to the five-year anniversary date. Office of Program Accountability Page 10 of 56 (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. A review of seven staff records included documentation of an acknowledgement of the center s code of conduct. Two staff records had documentation of disciplinary action, including violations of the code of conduct. Corrective action for the violations of the code of conduct included additional training. One staff had a substantiated allegation of improper conduct. Seven surveyed youth indicated staff were respectful when speaking with them or other youth. All seven youth also reported they have never had staff threaten them nor have they heard of other youth being threatened. Four of the seven youth also stated they have never heard staff use any curse words. Two of the seven reported they have heard staff use curse words occasionally and one of the seven reported they have heard this once. All seven surveyed staff reported they have never heard a co-worker using threats, intimidation, or humiliation when interacting with youth. Six of the seven staff stated they have never observed another staff using profanity when speaking with a youth. One of the seven surveyed staff stated they have heard this once 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. A review of four Central Communications Center (CCC) reports over the past six months determined compliance with CCC reporting procedures. A review of internal incidents, grievances, and logbooks determined the incidents coincided with the CCC reports. All surveyed staff reported they have never seen a co-worker tell a youth they could not call the Florida Abuse Hotline. All seven surveyed staff reported youth have access to call the CCC and/or the Florida Abuse Hotline if they choose to make a report. Seven youth were surveyed regarding abuse reporting. Three of seven reported they have never been stopped by staff for reporting abuse. Four of seven stated they have never had to report any abuse. Office of Program Accountability Page 11 of 56 (Revised July 2016)

12 1.05 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 two certified Protective Action Response (PAR) instructors responsible for facilitating PAR certification and refresher training. The center has a written policy which includes a PAR plan with procedures to include a review by a PAR certified instructor or supervisor, a post-par interview with the youth within thirty minutes of the incident occurring by the superintendent or designee, a review of the PAR incident report and the video by the superintendent or designee within seventy-two hours of the incident, statements by all witnesses and participants, PAR reports completed on the same day as the incident occurred, PAR medical on-site/off-site, if needed, and approved techniques applied. A review of nine PAR incidents determined each report included each procedure. Seven staff surveys confirmed staff made an attempt to use verbal techniques prior to using PAR. Upon review of the center s internal incidents, grievances, and logbooks, it was determined no additional PAR incidents had occurred 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. A review of five pre-service staff records showed documentation of each staff being trained in accordance with Florida Administrative Code. Each of the five staff records satisfied the preservice/certification requirements specified by Florida Administrative Code within 180-days of hiring, including Phase One. Each of the five staff records had documentation of showing the completion of Phase One training as follows: Protective Action Response (PAR), Mental Health and Substance Abuse, Suicide Recognition, Prevention, and Intervention, Safety, Security, and Supervision, as well as Detention Facility Operations. All five records had documentation in the Department s Learning Management System (SkillPro) of completing the phase two training which consists of 120 hours of training at the academy 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. A total of eight staff required mandatory training to be completed since the previous annual compliance review and each of the eight were selected for the sample size. The sample size included six juvenile justice detention officer supervisors and two juvenile justice detention officers. Each staff completed training in Protective Action Response (PAR), cardio-pulmonary resuscitation (CPR), automated external defibrillator (AED), first aid, suicide prevention, and Office of Program Accountability Page 12 of 56 (Revised July 2016)

13 professionalism and ethics. Documentation included five of six supervisors completing eight hours of training in the areas of management, leadership, personal accountability, employee relations, communication skills, and fiscal. One of the supervisors was on approved family medical leave during the annual training of 2016 and could not complete all the required training. All training, including instructor-led, was documented in the Department s Learning Management System (SkillPro). The center provided documentation of their annual in-service training calendar. Seven staff were surveyed and asked if they felt they were adequately trained for their job. All seven surveyed staff reported they are adequately trained for their job 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. A review of the center s master control and youth mod logbooks for the past six months reflected documentation of emergency situations including contacts to the Department s Central Communications Center (CCC), incidents, drills, receipt of medical and mental health alerts, population counts at the beginning and end of each shift, population counts throughout the shift as the count changed, population counts following emergency situations, youth group movement, admissions and releases, presence of law enforcement, names of youth placed in confinement along with the time confinement was initiated and the time confinement had ended, and the names of youth placed on precautionary/secure observation along with the time precautionary/secure observation was initiated and the time it ended. Each logbook entry included 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 were made in black or blue ink with no erasures or whiteout areas. No logbook entries were removed and errors were struck through with a single line and initialed by the person correcting the error. Office of Program Accountability Page 13 of 56 (Revised July 2016)

14 1.09 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. Logbook documentation included signatures in red ink to indicate a review by the superintendent and supervisors. A review by the superintendent and supervisor is conducted to ensure each logbook entry was complete and accurate. Documentation of the last six months included weekly reviews of the logbooks by the superintendent and a review by the juvenile detention officers (JDO) to ensure they were aware of all alerts, security risks, and other pertinent issues 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. A review of the center s admission wizard, logbook, and internal alerts revealed eight randomly selected youth alerts were labeled as medical, mental health, and suicide. A review of the Department s Juvenile Justice Information System (JJIS) alert list revealed each randomly selected youth also had an alert appropriately entered in JJIS. Office of Program Accountability Page 14 of 56 (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. A review of the processes in place to ensure alert information is kept up to date and accurate revealed the center had a written policy and procedures to address sharing alert information. Information regarding youth alerts is made available to all center staff. Upon observation of the center s shift briefing, it was determined the center shares information with the oncoming shift of the youth with alerts. Seven staff were surveyed and asked how they were informed of youthspecific alerts. All surveyed staff reported they are informed by review of logbooks, shift briefings, alert forms, the Department s Juvenile Justice Information System (JJIS), and the alert board. No staff indicated they were not informed of youth alerts. When the center receives changes to the alert list, each staff is notified of the changes and information regarding the changes are forwarded to the oncoming shift during the debrief. Standard 2: Assessment and Performance Plan Overview Bay Regional Juvenile Detention Center is a thirty-two bed detention center with one male and one female mod. Youth are admitted into the center if they meet the criteria to be held in secure detention. Each youth is oriented by staff and are provided the rules and regulations of the center, youth rights pamphlet, visitation and telephone schedule, grievance process, and the behavior management system. Youth in the center follow a daily schedule which is posted throughout the center and includes education, meals, and recreational activities. Constant safety and security is provided to all youth who are detained at the center. Office of Program Accountability Page 15 of 56 (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. A review of seven youth case management records found each youth had been admitted into the center, in accordance with Florida Administrative Code, through an admission process. The admission wizard was reviewed in each record. The admission wizard documented the youth were searched and offered a phone call as well as a meal. The seven youth records revealed which medical, mental health, and substance abuse screenings had been conducted upon admission. No youth were accepted if they were in need of emergency medical care, required mental health crisis intervention, or were under the influence of any intoxicant. No admissions were observed during this review 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. A review of seven individual case management records found each youth had received an orientation within the first twenty-four hours of admission. One orientation packet was missing signatures. Six of the seven surveyed youth indicated upon admission, they were provided information about the center regarding the rules, regulations, daily schedule, education services, visitation, abuse reporting, and the behavior management system (BMS). The orientation process included the youth being provided with a copy of the rules and regulations of the center. Office of Program Accountability Page 16 of 56 (Revised July 2016)

17 The youth are informed of visitation times as well as phone calls. The grievance process is discussed upon admission. The youth are also informed of access to medical and mental health services as well as their rights and access to the Florida Abuse Hotline and the Department s Central Communications Center (CCC). The BMS and related consequences are discussed during orientation. The orientation process was not observed during the annual compliance review 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 in place for the youth classification process. A review of seven youth case management records found the admission wizard was able to provide information about the youth, parent/guardian, and past criminal history. All seven reviewed youth case management records contained evidence each youth had been classified utilizing the process of consideration for their sex, height, weight, age, level of aggressiveness, any developmental disability or mental illness, history of violent behavior, any physical disabilities, gang affiliation, and criminal behavior. Youth are also classified by completion of the Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) screening tool. Medical, suicidal, escape, and security considerations are also noted when classifying youth at the center. Youth who had been classified as having a history of committing sexual offenses or may have been a victim of a sexual offense were placed in a room alone. The youth in the center are assigned to a room based on their classification and can be reclassified if changes in behavior or status are observed. All seven youth surveyed during the annual compliance review reported they felt safe in the center. Office of Program Accountability Page 17 of 56 (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. All youth admitted into the center are screened to determine if the youth is a criminal street gang member or affiliated with any gangs. A review of seven youth case management records found each youth was screened, as required. A review of the Department s Juvenile Justice Information System (JJJIS) found none of the youth were applicable for an alert or additional information being entered into JJIS as a result of the gang member screening Notification of Juvenile Probation Officer Circuit Gang Representative Compliance 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 in regards to sharing gang information with law enforcement, educational providers, and juvenile probation officers (JPOs). Interviews were conducted with the center s identified gang liaison and the superintendent to ensure the center had a written policy and procedure in place for gang notification process. The superintendent notifies the JPO designated as the circuit s gang liaison, who then notifies other required parties such as law enforcement, school district, and the youth s JPO. Seven youth case management records were reviewed; however, there were not any gang notifications or alerts required in any of the records. The center was unable to provide a record or a referral for a youth with suspected gang involvement. An interview with the detention superintendent revealed the center has not had any youth admitted who required the referral since the previous annual compliance review 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. Observations of the center found youth personal property stored secured in the sally port area of the center. Property was kept secured in individual lockers with restricted key access. The area was inaccessible to youth. A review of seven youth case management records verified the personal property belonging to each of the youth had been properly secured while at the center. Signatures from both the youth and staff were included on the Personal Property Receipt forms filed in each of the youth s records, verifying their property was properly stored and secured. All Office of Program Accountability Page 18 of 56 (Revised July 2016)

19 seven records included a Letter of Acknowledgement of Unclaimed Property form signed by each youth. None of the seven youth refused to sign the property receipt form. Each of the seven surveyed youth indicated staff had checked their personal property and had them sign a form confirming the personal property was correct upon their arrival to the center. An interview with the detention superintendent revealed each of the youth s personal property is inventoried, verified, and secured in a tamper resistant bag which includes documentation of the date, youth s name, Department of Juvenile Justice identification number, a listing of items, and youth/staff signatures. Valuable property is placed in a drop safe which is under constant video surveillance. Only administration and detention supervisors have access the safe 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 in place which address the storage of youth s personal property. The youth s personal property was observed stored in a secured sally port area of the center and is under video surveillance. Youth s valuables are stored in a tamperproof bag and are placed in a locked safe which is under video surveillance and is located between master control and the entrance to the secure area. A Safe Logbook is located next to the safe. There were not any reports generated to the Department s Central Communications Center (CCC) due to missing or stolen property during this annual compliance review period 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. A review of three closed youth case management records revealed prior to a youth s release, the on-duty supervisor reviewed all release paperwork and verified the identity of the parent/guardian the youth was being released to using a picture identification card. In two out of the three case management records reviewed, the picture ID was photocopied and placed in the youth s record. The third youth was a facility transfer and all appropriate paperwork was completed and signed prior to the youth leaving the center. All applicable parties were required to sign all release forms. Reviewed documentation reflected the date of admission and the date of release was documented within the youth s case management record and correlated with the dates indicated within the Department s Juvenile Justice Information System (JJIS). A youth Office of Program Accountability Page 19 of 56 (Revised July 2016)

20 release was observed during the annual compliance review. Proper release procedures were performed by the center. There were no reports made to the Department s Central Communications Center (CCC) regarding an improper release in the past six months 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. A review of three closed youth case management records showed two of the three youth and parents/guardians had signed the Property Receipt form upon release from the center. The third youth was a facility transfer and all appropriate paperwork was completed and signed. No reports were made to the Department s Central Communications Center (CCC) regarding improper release in the past six months. An interview with the center s administration revealed all youth personal property is secured upon arrival to the center. Prior to release, the juvenile justice detention supervisor will review the personal property inventory, and both youth and staff will sign to indicate the youth received all property. If property is unclaimed, a letter is sent to the youth and parent notifying them of the unclaimed property. The property will be disposed of after ten-days if it remains unclaimed 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. Two of three reviewed closed youth case management records showed documentation of the youth s medication had been released to the youth s parent/guardian with proper identification (ID). The receipt for the youth s medication and the discharge forms were dated, signed, and documented in the youth s record. The third youth was a facility transfer and all appropriate paperwork was completed and signed. There were not any incidents reported to the Department s Central Communications Center (CCC) regarding improper release in the past six months 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. Detention reviews are conducted every Thursday morning for all youth currently placed in secure detention. Representatives for detention reviews include individuals from education, mental health, medical, detention, and probation. During an observation of a detention review, each area s representative spoke on their expertise concerning each youth. Sign-in sheets were maintained as well as documentation of what needed to be followed up on and by whom. All parties present were provided with detention review reports. Detention review documentation is kept in the Department s Juvenile Justice Information System s Facility Management System (FMS) module. Detention review documentation was reviewed within FMS for the previous six months and found all information was accurate. Office of Program Accountability Page 20 of 56 (Revised July 2016)

21 2.12 Review of Youth on Home Detention Compliance Detention reviews are conducted by the program on a weekly basis to ensure proper management of youth placed in home detention and appropriate sharing of information. The superintendent appoints an appropriate staff person to coordinate detention reviews. Home detention reviews are held on Thursdays following the secure detention reviews. A home detention review was observed. Sign-in sheets were maintained as well as documentation of what needed to be followed up on and by whom. Detention review documentation is kept in the Department s Juvenile Justice Information System s Facility Management System (FMS) module. Detention review documentation and minutes from previous detention review meetings were reviewed within FMS for the previous six months and found all information was accurate 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 daily activity schedule which was observed to be posted in youth living areas and hallways throughout the center. The program maintains a separate activity schedule for weekdays and weekends. The daily activity schedule includes the following: personal hygiene, gender-specific programming, restorative justice programming, education, recreational activities, meals, and visitation. An interview with the detention superintendent revealed the center provides a curriculum entitled Wisdom Independence, Nurturance, Guidance, and Self- Confidence (WINGS) as part of the gender-specific programming for female youth. This curriculum addresses independence, nurturance, guidance, and self-confidence for youth. The center also utilizes the Short-Term Group Curriculum for male youth which includes restorative justice practices within the Department of Juvenile Justice (DJJ) curriculum. Youth also participate in gardening activities. The food grown is donated to a local family services program and gives the youth opportunities to give back to their communities. Six of seven surveyed youth reported the center s daily schedule is followed 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. A review of center s logbooks found the staff had been following the daily schedule. Each of the activities were documented in the logbook. The staff were also observed adhering to the daily schedule during the annual compliance review. Seven out of seven surveyed staff reported the center s daily schedule is followed. Six of the seven surveyed youth also reported the center had a daily schedule and it was followed. One of seven surveyed youth reported the center did not have or follow a daily schedule. Office of Program Accountability Page 21 of 56 (Revised July 2016)

22 2.15 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. An interview with the center s lead teacher and a review of the center s daily schedule revealed youth were receiving a total of twenty-five instructional hours a week with the students attending school year round. The interview with the lead teacher and an interview with the center s superintendent further revealed teachers may go to the youth mods for education and instruction during periods where staffing may be limited. There was documentation in the logbooks in reference to the youth in the center attending school with minimal interference. Six of the seven surveyed youth reported they attended school Monday through Friday. Youth surveys also revealed youth are participating in life skills, career choices, math, science, history, reading, social studies, and other educational classes Career Education Compliance Staff shall develop and implement a career education competency development program. An interview with the center s lead teacher was conducted regarding career education. The lead teacher reported the center provides a career education program which is based on age, assessed educational abilities, goals of the youth to be served, and the typical length of stay at the center. The center meets Type One criteria for career educational programming 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 has a behavior management system (BMS) which includes rewards for positive behavior as well as consequences for inappropriate behavior. Staff s implementation of the BMS was observed during daily activities. Seven youth were surveyed regarding the BMS. One youth rated the system as very poor, one youth rated the system as poor, two rated the system as fair, two rated the system as good, and one youth rated the system as very good. Six of the seven youth surveyed felt when they received consequences, the consequences were fair. When asked if they had ever been sent to their room for punishment, five of the seven surveyed youth said yes. Three reported the door was shut and three reported the door was shut and locked. Five of seven surveyed youth stated youth were never allowed to punish other youth, while the other two stated they were. The center has a written policy and procedures which prohibit punishment by other youth. Seven out of seven surveyed youth stated they felt safe in the center. Office of Program Accountability Page 22 of 56 (Revised July 2016)