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 Pasco Regional Juvenile Detention Center Department of Juvenile Justice (State-Operated) State Road 52 San Antonio, Florida Review Date(s): March 13-16, 2018 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES

2 Rating Definitions Ratings were assigned to each indicator by the review team using the following definitions: Compliance Limited Compliance Failed Compliance No exceptions to the requirements of the indicator; or limited, unintentional, and/or non-systemic exceptions that do not result in reduced or substandard service delivery; or systemic exceptions with corrective action already applied and demonstrated. Systemic exceptions to the requirements of the indicator; exceptions to the requirements of the indicator that result in the interruption of service delivery; and/or typically require oversight by management to address the issues systemically. The absence of a component(s) essential to the requirements of the indicator that typically requires immediate follow-up and response to remediate the issue and ensure service delivery. Review Team The Bureau of Monitoring and Quality Improvement wishes to thank the following review team members for their participation in this review, and for promoting continuous improvement and accountability in juvenile justice programs and services in Florida: Toni Del Regno, Office of Program Accountability, Lead Reviewer (Standard 1) Felicia Goldstein, Office of Program Accountability, Regional Monitor (Standard 2 & 3) Stephanie Lobzun, Office of Program Accountability, Regional Monitor (Standard 2) Scott Luciano, Office of Program Accountability, Regional Monitor (Standard 4) Margie McKinney, Brevard Regional Juvenile Detention Center, Superintendent (Standard 5) Joey Nice, DJJ Office of Education, West Region Education Coordinator (Standard 2) Lynda Zweibach, Licensed Mental Health Counselor, Eckerd Connects (Standard 3)

3 Program Name: Pasco Regional Juvenile Detention Center MQI Program Code: 363 Provider Name: Department of Juvenile Justice Contract Number: N/A Location: Pasco County / Circuit 6 Number of Beds: 36 Review Date(s): March 13-16, 2018 Lead Reviewer Code: 147 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 2 # Clinical Staff # Food Service Personnel # Healthcare Staff Documents Reviewed 1 # Maintenance Personnel 2 # Program Supervisors # Other (listed by title): Accreditation Reports Affidavit of Good Moral Character CCC Reports Confinement Reports Continuity of Operation Plan Contract Monitoring Reports Contract Scope of Services Egress Plans Escape Notification/Logs Exposure Control Plan Fire Drill Log Fire Inspection Report Fire Prevention Plan Grievance Process/Records Key Control Log Logbooks Medical and Mental Health Alerts PAR Reports Precautionary Observation Logs Program Schedules Sick Call Logs Supplemental Contracts Table of Organization Telephone Logs Surveys Vehicle Inspection Reports Visitation Logs Youth Handbook 8 # Health Records 5 # MH/SA Records 5 # Personnel Records 10 # Training Records/CORE 3 # Youth Records (Closed) 5 # Youth Records (Open) # Other: 5 # Youth 5 # Direct Care Staff # Other: Observations During Review Admissions Confinement Facility and Grounds First Aid Kit(s) Group Meals Medical Clinic Medication Administration Posting of Abuse Hotline Program Activities Recreation Searches Security Video Tapes Sick Call Social Skill Modeling by Staff Staff Interactions with Youth Comments Staff Supervision of Youth Tool Inventory and Storage Toxic Item Inventory and Storage Transition/Exit Conferences Treatment Team Meetings Use of Mechanical Restraints Youth Movement and Counts Items not marked were either not applicable or not available for review. Office of Program Accountability Page 3 of 75 (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 *Entering Alerts(JJIS) 1.09 Sharing of Alert Information * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 4 of 75 (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 Limited 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 Limited 2.15 Educational Access Failed 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 75 (Revised July 2016)

6 Standard 3: Mental Health and Substance Abuse Services Detention Rating Profile Indicator Ratings Standard 3 - Mental Health and Substance Abuse Services 3.01 Designated Mental Health Clinician Authority (DMHCA) 3.02 * Licensed MH/SA Clinical Staff 3.03 Non-Licensed MH/SA Clinical Staff 3.04 MH/SA Admission Screening 3.05 MH/SA Assessment/Evaluation 3.06 MH/SA Treatment 3.07 Treatment and Discharge Planning 3.08 * Psychiatric Services 3.09 * Suicide Prevention Plan 3.10 * Suicide Prevention Services 3.11 * Suicide Precaution Observation Logs 3.12 * Suicide Prevention Training 3.13 * Mental Health Crisis Intervention Services 3.14 Emergency Care Plan 3.15 Crisis Assessments 3.16 * Baker and Marchman Acts * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 6 of 75 (Revised July 2016)

7 Standard 4: Health Services Detention Rating Profile Indicator Ratings Standard 4 - Health Services 4.01 * Designated Health Authority/Designee 4.02 Facility Operating Procedures 4.03 Authority for Evaluation and Treatment 4.04 Parental Notification 4.05 Notification - Clinical Psychotropic Progress Note 4.06 Immunizations 4.07 Healthcare Admission Screening Form 4.08 Medical Alerts 4.09 Suicide Risk Screening Instrument Non-Applicable 4.10 Youth Orientation to Healthcare Services 4.11 DHA/Designee Admission Notification 4.12 Healthcare Admission Rescreening 4.13 Health Related History 4.14 Comprehensive Physical Assessment 4.15 Female-Specific Screening/Examination 4.16 Tuberculosis Screening 4.17 Sexually Transmitted Infection Screening 4.18 HIV Testing 4.19 Sick Call Process - Requests/Complaints 4.20 Sick Call Process - Visits/Encounters 4.21 Restricted Housing 4.22 Episodic/First Aid Care 4.23 Emergency Care 4.24 Off-Site Care/Referrals 4.25 Chronic Conditions/Periodic Evaluations 4.26 Medication Management - Verification 4.27 Medication Management - Orders/Prescriptions 4.28 Medication Management - Storage 4.29 Medication and Sharps Inventory 4.30 Medication Management - Controlled Medications 4.31 Medication Administration Record 4.32 Medication Administration By Licensed Staff 4.33 Medications Provided By Non-Licensed Staff 4.34 Psychotropic Medication Monitoring 4.35 Infection Control - Surveillance, Screening, and Management 4.36 Infection Control - Education 4.37 Infection Control - Exposure Control Plan 4.38 Prenatal Care - Physical Care of Pregnant Youth 4.39 Prenatal Care - Nutrition and Education of Youth 4.40 Prenatal Staff Education * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 7 of 75 (Revised July 2016)

8 Standard 5: Safety and Security Detention Rating Profile Indicator Ratings Standard 5 - Safety and Security 5.01 * Active Supervision of Youth 5.02 * Ten-Minute Checks 5.03 Census Counts and Tracking 5.04 Logbook Maintenance 5.05 Logbook Reviews 5.06 Key Control 5.07 Vehicles and Maintenance Failed 5.08 Tool Inventory and Management 5.09 Kitchen Tools 5.10 * Youth Access & Use of Tools, Cleaning Items 5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items 5.12 * Access to all Flammable, Toxic, Caustic, and Poisonous Items 5.13 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items 5.14 Confinement Under Twenty-Four Hours Limited 5.15 Confinement Over Twenty-Four Hours Limited 5.16 Continuity of Operations Planning (COOP) Drills 5.17 Escape Drills 5.18 Fire Drills * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 8 of 75 (Revised July 2016)

9 Standard 1: Management Accountability Overview The (DJJ)-maintains and operates the Pasco Regional Detention Center (RJDC). The center is a thirty-six bed, hardware-secure facility purposed with providing essential services to youth who are detained by court orders awaiting court disposition, delinquency adjudication, or placement in a residential commitment center. The center is located in San Antonio, Florida and primarily serves youth who reside in Pasco County. Youth from neighboring counties (Pinellas, Polk, and Orange) are routinely transported and housed at the center when determined necessary and appropriate. The facility is divided into three dormitory areas - with separate single rooms. Alpha module, is the module currently designated for female youth. The other two modules (Bravo and Omega) are for male youth. On the first day of the annual compliance review, the census indicated there were thirty youth detained in the facility to include six females and twenty-four males. The center delivers a variety of required services to ensure detained youth access a safe and secure environment, including contracted medical and mental health services, as well as, specialized dietary, educational and transport services all provided under the direct supervision of trained staff. The responsibility for the center s management and operations belongs to the facility superintendent and an assistant superintendent. However, for the past several months, the superintendent position has been vacant and the assistant superintendent has served as the interim superintendent. Recently, the assistant superintendent took an extended leave. At the time of this annual compliance review, the leadership at the center included an acting superintendent and an acting assistant superintendent. These individuals provide oversight to the contracted service providers for medical, mental health, and education, as well as, to seven juvenile justice detention officer supervisors who manage thirty-seven juvenile justice detention officers over three shifts, to ensure appropriate supervision of youth. Notably, due to significant staff turnover during the past year, many of the detention officer staff are new to their current positions. Also employed by the center; a fiscal secretary, a full-time training coordinator, a maintenance manager, a food service manager, and three food service workers. On the first day of the annual compliance review, there were four staff vacancies, specifically, the superintendent, the fiscal secretary, one juvenile justice detention officer I and one juvenile justice detention officer II 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 outlining the required background screening process. A review of documentation verified the center conducts background screenings on all new staff, volunteers, mentors, and interns who will have access to the youth and/or their confidential information. The center uses the Department s Background Screening Unit, which operates under the auspices of the Office of the Inspector General to conduct the standardized, level 2 screenings. Required in Florida Statute , these stringent screening requirements are applied to all potential personnel prior to hire. A review of sixteen applicable background screenings found all individuals hired to work on-site at the center since the last annual Office of Program Accountability Page 9 of 75 (Revised July 2016)

10 compliance review in February 2017, had been appropriately screened prior to their date of hire. Additionally, all twenty-four new volunteers had undergone level 2 background screenings before they were permitted contact with youth on a more than intermittent basis. A review of documentation/background screens indicated all five contracted staff hired to provide services at the center since the last annual compliance review in February 2016 were screened prior to interacting with youth or having access to confidential youth records. All reviewed documentation of staff and volunteers indicated each had received eligible ratings during the background screening process and none required an exemption. The detention center, Pasco County School Board, and the contracted providers for mental health and medical services submitted their Annual Affidavit of Compliance with Level 2 Screening Standards to the Background Screening Unit, prior to January 31, Five-Year Rescreening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. Employees and volunteers are rescreened every five years from the initial date of employment. The center complies with written state-wide policy and procedures for background rescreening for all applicable staff, volunteers, mentors, and interns every five years from the date of hire. Four Department staff and three contracted staff were eligible for five-year re-screening during the annual compliance review period. All rescreens conducted on the Department s staff were completed three to eleven months prior to the individual s anniversary date. Two of three contracted staff rescreens were also completed in a timely manner. There was one exception in the rescreening of a contracted staff member. The rescreen was conducted just over three months late from the original date of hire in However, because rescreenings were conducted at two other times during the contracted staff member s employment, (in 2011 and 2012) there were no gaps longer than five years in the individual s screening history. All reviewed five-year rescreens yielded eligible ratings. Office of Program Accountability Page 10 of 75 (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. The Detention Facility Operating Procedures (FOP), section 1.06 articulates a staff code of conduct which prohibits any form of abuse, intimidation, harassment, or the use of profanity when interacting with a youth. Physical abuse of youth is prohibited by law and a suspicion or knowledge of abuse must be presorted to the Florida Abuse Hotline and the Department s Central Communications Center (CCC). The code also states when interacting with youth, officers shall maintain professional behavior and relationships. Staff are not to engage in or allow horseplay, either verbal or physical with and/or between youth or any other staff member. The code further mandates officers must maintain youth confidentiality at all times, and are not to have personal relationships or discuss any personal information regarding themselves or other staff with the youth. Officers shall not enter the occupied sleeping quarters or confinement room of a youth unless accompanied by another officer the same gender as the youth, nor shall officers have any physical contact with a youth except in the necessary application of Protective Action Response techniques or other emergency response measures. During the annual compliance review, a sample of five personnel records were selected to verify documentation of staff signatures accepting their responsibility to adhere to the Department s Code of Conduct. Augmenting center policy in the Detention Facility Operating Procedures, the center uses the Code of Ethics for Public Officers and Employees and other information documented in the Department of Juvenile Justice Employee Handbook, as the staff code of conduct. All five randomly selected personnel records contained a signed acknowledgement form verifying staff receipt of the employee handbook. There was also a form documenting the staff s taking an Oath of Loyalty and a Statement of Personal Responsibility indicating acknowledgement and agreement to abide by Department regulations as specified in the Code of Conduct. The team also reviewed personnel records and other documentation provided by administration to determine staff response to allegations of staff violations of the Code of Conduct including disciplinary actions. The administrative staff reported there has not been any disciplinary suspensions or termination of staff since the last annual compliance review in February However, there was documentation reviewed indicating one staff was disciplined with dismissal for failure to satisfactorily complete the probationary period in March An observation Office of Program Accountability Page 11 of 75 (Revised July 2016)

12 found signed memo s regarding two disciplinary actions were not recorded in the staff s respective personnel records. The center provided requested documentation of the staff s misconduct which resulted in disciplinary actions including oral reprimands relating to instances of staff tardiness, failure to make a timely report to the Central Communications Center (CCC), conduct unbecoming of a public employee, and violation of a youth s confidentiality related to inappropriate postings on a social media web site. In addition to addressing disciplinary incidents, though rarely observed in reviewed personnel records, documentation provided to the review team indicates administrative staff seek opportunities to recognize staff who display leadership, initiative, and other praise-worthy behaviors. The center has an employee of the month program designed to recognize and reward outstanding staff. The previous facility superintendent documented letters of commendation to six staff related to staff outstanding performance during a hurricane and its aftermath. Additionally, though again, not documented in the individual personnel records, center staff were awarded Food Service Worker for central region and Juvenile Detention Office of the Year. Reviewed documentation indicates administrative staff respond appropriately to allegations of staff misconduct in a timely manner while also positively reinforcing and commending positive staff efforts and behavior. During the annual compliance review, interviews were conducted with five youth and five staff. When asked regarding their experiences/observations of staff/youth interactions in the center, all five youth indicated staff are respectful when talking with youth and they have never been threatened by a staff member, or observed another youth being threatened by staff in the center. Three of five interviewed staff reported they had never observed a co-worker using threats, intimidation, or humiliation when interacting with a youth. One staff recalled a year ago, there was staff whose voiced tone was very intimidating, then added this individual no longer works at the center. Another staff acknowledged having witnessed staff once or twice using threats, intimidation, or humiliation when interacting with a youth. The staff member then commented the incidents occurred a few years ago prior to the annual compliance review. Three of the five interviewed youth indicated they had heard a staff member use profanity occasionally. One youth reported hearing staff use profanity once. None of the four youth who had heard staff use profanity perceived the language as abusive, directed towards them, or provocative. Three of five staff reported hearing co-workers use curse words when speaking with youth or in the presence of youth. The staff indicated the profanity was either an accidental conversational slip, a repeat of what a youth said to them to clarify a verbal warning, or loss of points but not stated with the intent to be abusive or humiliating of the youth. The remaining two staff indicated they had never heard a staff utter profanity in the presence of a youth Incident Reporting (CCC) Compliance Whenever a reportable incident occurs, the program notifies the Department s Central Communications Center (CCC) within two hours of the incident, or within two hours of becoming aware of the incident. The center maintains a written policy and procedures addressing incident reporting to the Department s Central Communications Center (CCC) in accordance with Florida Administrative Code (F.A.C.) 63F-11. The center had thirty-five incidents reported to the CCC during the last six months. A review of the center s logbooks, incident reports, and youth grievances did not reveal any additional CCC reportable incidents which were not reported. The review of all thirtyfive CCC reports was conducted to determine accuracy, timeliness, and the completion of follow-up reporting, as applicable. The reported incidents included medical and mental health incidents, program disruption and youth behavior incidents, as well as, complaints against staff. Office of Program Accountability Page 12 of 75 (Revised July 2016)

13 A review of the CCC reports confirmed it is the center s practice to contact the CCC to report incidents in a timely manner. Twenty-seven of the thirty-five reviewed CCC reports were reported within the required two-hour time frame. One incident was impossible to determine if the call was completed within the time frame as there was no documentation of the time the incident occurred. Three incidents were reported less than an hour late. The remaining four incidents were reported to the CCC between twenty-one minutes and six hours and twentyseven minutes late. Reviewed documentation reflected staff documented each call reported to the CCC in the center s unit and/or master control logbooks typically at the time the CCC was contacted 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 maintains a written policy and procedures outlining the use of physical intervention techniques as indicated under the Department s approved Protective Action Response (PAR)matrix in accordance with the Florida Administrative Code. When an incident occurs during the use of a PAR technique, the center s practice is to generate a PAR incident report. There were seventy-eight recorded PAR incidents at Pasco Regional Juvenile Detention Center during the six months prior to the annual compliance review. The review team did not find any other incidents when PAR physical intervention techniques were used during their review of the center logbooks, incident reports, or grievance forms. A random sampling of eight PAR incident reports were reviewed for compliance with Florida Administrative Code 63H-1. These reports were selected at random and printed from the center s Facility Management System (FMS), located on the Juvenile Justice Information System (JJIS). Overall, the reviewed reports were observed to be complete and timely with a few exceptions noted. None of the exceptions appeared to represent systemic issues or required immediate staff oversight. Six of the eight reviewed PAR reports contained narratives completed by all involved staff members on the same day the incident occurred. One PAR report included a narrative completed by a staff member one day late and another PAR report was completed two days after the incident. All eight PAR reports included narratives from all staff involved in the incidents, however one report was missing two narratives from two different staff who had witnessed the incident. None of the eight PAR reports included the use of mechanical restraints. None of the reports included allegations of abuse, which needed to be reported to the Florida Abuse Hotline. All eight PAR reports were reviewed by a certified PAR instructor and/or a supervisory staff member. Six of the eight reviewed reports documented a post-par interview conducted by the superintendent or designee within the required thirty-minute timeframe of the incident. The remaining two reports documented the post-par interview as occurring late, one by five minutes, and the other, by an hour and four minutes. Two of the five reports were applicable for a post-par medical review. One post-par medical review described a youth transport to an emergency room youth after the PAR incident due to observed injuries. The medical review indicated the youth received medical attention and clearance from the hospital. The medical documentation from the hospital was subsequently uploaded into the youth s electronic medical record in JJIS. The second post-par medical review was not available to the review team because the youth s individual health care record, which contained the document, had been sent with the youth upon his transfer from the center to a residential commitment program. All eight reviewed PAR reports were signed by the superintendent or designee within seventy-two hours of the incident Office of Program Accountability Page 13 of 75 (Revised July 2016)

14 and the superintendent wrote comments on each of the reports. A review of eight PAR reports verified the center s practice of maintaining all PAR reports in the Department s electronic database. The detention center receives weekly tableau reports regarding all PAR incidents occurring in the center from their regional office. and The center s administration staff reviews all reports upon receipt. Five interviewed staff reported they have observed the center s practice of implementing verbal de-escalation techniques prior to physical restraints Pre-Service/Certification Requirements Compliance Detention staff are trained in accordance with Florida Administrative Code. Detention staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. The center has a written policy and procedures in place to ensure all staff complete two phases of training including training in the workplace for on-the-job experiences and training at the Department of Juvenile Justice Academy as required by Florida Administrative Code. The center s policy requires all detention officers to obtain their certification within the first 180 days of being hired. Phase One training content includes the completion of essential skills required before the new staff is authorized to be in the presence of a youth, as well as, other training topics provided on the Department s web-based Learning Management System(SkillPro) and through attendance in a standardized course of more experiential, instructor-led seminars. The Department s Learning Management System (SkillPro) in comparison with five staff training records were reviewed for pre-service training. All reviewed records indicated staff had received the required essential skills training in certifications in cardiopulmonary resuscitation (CPR), automated external defibrillator (AED), first aid, and Protective Action Response (PAR) within the first ninety days. Each of the five reviewed records indicated the staff had also completed essential skills trainings related to mental health and substance abuse, suicide recognition, prevention and intervention, safety, security, and youth supervision, as well as, the Department of Juvenile Justice Detention Facility Operations and Procedures prior to the staff being in direct contact with any youth. Each staff member had documentation in their records and in SkillPro indicating the successful completion of the phase one curriculum. Many of the reviewed forms documenting instructor-led trainings lacked the signatures of the training coordinator and the dates of completion of the trainings. All reviewed records contained documentation of the staff graduating from the Academy and obtaining certification within 180 days of hire. A review of five staff training records substantiated all completed training, including instructor-led sessions, were documented in the Department s Learning Management System (SkillPro) In-Service Training Compliance All detention staff completes twenty-four hours of in-service training, including mandatory topics specified in Florida Administrative Code, each calendar year, effective the year after preservice/certification training. Supervisory staff completes eight hours of training (as part of the twenty-four hours of in-service training) in the areas specified in Florida Administrative Code. The center has a written policy and procedures in place regarding in- service training. The center maintains an annual training calendar to ensure every staff is trained in all mandatory topics as specified in Florida Administrative Code and the Department s approved Detention Training Plan. A statewide annual training calendar has been developed for all detention staff by Detention Services. Training opportunities are provided on the Department s Web-Based Office of Program Accountability Page 14 of 75 (Revised July 2016)

15 Learning Management System (SkillPro), as well as, through attendance and participation in more experiential, instructor-led seminars/courses. The annual training plan (2017) and training calendars for 2017 and 2018 were reviewed. The calendars showed documentation of annual trainings for juvenile justice detention officers (JJDO), more than the required twenty-four hours of in-service training specified in the Florida Administrative Code. Five randomly selected detention officer staff training records were reviewed for completion of mandatory in-service training. The reviewed records reflected the training of two shift supervisors, two JJDO II s and one JJDO I. It was observed each of the five reviewed staff had exceeded the required number of training hours in 2017 with totals ranging from forty-nine to ninety-six completed hours. Almost all training was consistently documented in SkillPro, verifying all five reviewed staff met the requirement of twenty-four hours of training in the mandatory topics specified in the Florida Administrative Code. Instructor led trainings were recorded in SkillPro with a hard copy maintained in their training records, along with signed rosters from these trainings. Two of the five reviewed staff training records reflected supervisor positions. These records also documented in excess of the required eight hours of training in supervisory skills including leadership, management, employee relations and communication skills as required for supervisory staff with one staff having completed fifty-one of these hours and the other staff having completed fourteen. During the annual compliance review, five staff were interviewed. Each interviewee confirmed they felt they were adequately trained to for their job Entering Alerts (JJIS) Compliance Superintendents shall ensure Critical and Special Alerts are reviewed and responded to appropriately. Upon completion of the Admission Wizard, the officer shall ensure all Critical and Special Alerts are listed in JJIS. The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it correctly reflects the status of youth. If the electronic system is inoperable, for any reason, the JJDO Supervisor shall ensure the last hard copy of the alerts shall have a written notification or update of the recent admissions or changes to existing alerts on the alert sheet and distribute to all staff within the facility immediately. Medical and mental health staff shall review alerts to ensure each alert is correctly tracked and managed. The responses and updates by medical, mental health and other staff should be documented in JJIS alerts as they pertain to that critical alert. The center has a written policy and procedures for entering youth alerts into the Juvenile Justice Information System (JJIS). The policy stipulates upon completion of the Admission Wizard, the intake officer shall ensure all critical and special alerts are posted in JJIS. Medical and mental health staff also add alerts and alert updates into the JJIS System when appropriate. Additional alerts are later added by detention staff, if issues become known to staff or if a youth s behavior warrants. During the annual compliance review, the team reviewed medical records, mental health and substance abuse records, and case management records of five youth. Each of the five reviewed youth records had alerts documented in JJIS by the center staff either from the current or previous admissions to the Center. Observed alerts included mental health concerns Office of Program Accountability Page 15 of 75 (Revised July 2016)

16 including precautionary observation status and the prescription of psychotropic medications, chronic disease (asthma) or health impairment due to injury, allergies, special diet, vision impairment, Prison Rape Elimination Act (PREA), vulnerability and PREA sexual aggression, as well as foster care status. Reviewed documentation validated the administrators and supervisors review and update the alert report daily to ensure the accuracy of the information regarding the youth s status in the alerts. Administrative staff then ensure the critical and special alerts are dispersed to appropriate staff and effectively addressed. The review of JJIS alerts for each youth also indicated alerts related to medical issues and suicide precautions were consistently updated by medical or mental health staff, to ensure each alert is well tracked and successfully managed throughout the youth s detention stay. The JJIS reports also noted alerts are closed in a timely manner when qualified staff indicate the alert has expired or is no longer applicable Sharing of Alert Information Compliance JJDOS s shall inform staff of alerts during shift briefing. When a JJDOS receives changes to the alert list, he or she shall notify the staff affected by changes and add the information to the shift briefing for the oncoming shift upon receipt of the information. The center has a written policy and procedures focused on ensuring alert information related to youth in their care and custody is documented, consistently updated, and shared with all staff responsible for the supervision of youth. All youth alerts are documented in the Juvenile Justice Information System (JJIS) either upon admission, or immediate after it is evident an alert needs to be posted based on consultation with a parent, an observed behavior, or other indicators. Subsequently, daily alert reports listing the alerts for all youth in the facility are printed near the end of each shift then discussed and distributed to all detention officer staff at each shift briefing. An observation of a shift briefing during the week of the annual compliance review, as well as, a review of the shift briefing document confirmed all JJIS alerts regarding each detained youth are discussed/addressed with staff to ensure their awareness of all alerts and any changes to the alerts pertaining to each youth and copies of the alert report to review as needed throughout the shift are provided to all staff as well. A sampling of five days of shift reports (three shifts each day for five non-consecutive days totaling fifteen shift reports) from the previous three months was reviewed to verify alerts were addressed with staff during the shift change. Any time a new or updated critical alert is posted in JJIS by medical and mental health staff, the staff who posted the alert immediately notifies the shift supervisor who then communicates the information to the staff and ensures the alert is documented in the logbooks detention officers are required to review daily. A tour of the kitchen verified updated alerts related to food allergies is provided to dietary staff. Educational, medical, and mental health providers also indicated they are provided updated alert information regarding each youth daily. Five of five interviewed staff reported they are informed of alerts (security, safety, medical, and mental health) during daily shift debriefings, logbook reviews, center provided JJIS alert forms and for critical alerts, a specialized alert board located in master control. None of the interviewed staff indicated they are not informed of youth alert information. Office of Program Accountability Page 16 of 75 (Revised July 2016)

17 Standard 2: Assessment and Performance Plan Overview The Pasco Regional Juvenile Detention Center ensures all youth detained at the center experience a uniform intake process regardless of the number of times the youth has been detained in the past and/or the time of admission. The center s trained juvenile justice detention officers (JJDO s) process the youth into the center. During the intake process each youth is searched, their personal property is collected, inventoried, and secured in a locker or drop safe depending on the type of property. Then a standardized interview takes place comprised of the gathering of information regarding the youth s medical and mental health history and current status, which also includes screening for suicidal ideations. All information obtained during the intake interview is entered into the Juvenile Justice Information System (JJIS) detention intake wizard. The center reviews the Positive Achievement Change Tool (PACT), the Massachusetts Youth Screening Instrument, Second Version (MAYSI-2), the Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB), the Department-approved suicide risk screening instrument and the youth s prior criminal history and, if applicable, gang affiliation, to determine the appropriate living unit and room assignment for each youth. During the admission process the JJDO conducts a comprehensive orientation to the facility. The youth are also informed of their rights and the center s grievance process is discussed so youth are aware what steps to take if they believe their rights have been violated while in the center. Each youth also receives an orientation brochure which reiterates the orientation information for their reference, as needed. Education services are provided by Pasco County School Board employees and youth are able to earn credits towards attendance and graduation for their involvement in school activities while in the center. The center s JJDO s also conduct standardized release procedures for each youth upon discharge to ensure the safety of the youth and the community. All release data is entered in the JJIS detention release wizard and each youth s property is returned to them. Each youth under the age of eighteen is released to a parent or legal guardian whose identification is verified prior to granting access to the youth. Office of Program Accountability Page 17 of 75 (Revised July 2016)

18 2.01 Admission Compliance All youth are admitted to the program in accordance with Florida Administrative Code through a process, at a minimum, addressing the following: 1. Review of required paperwork from law enforcement and screening staff. 2. Review of inactive files shall be conducted, if available, to obtain useful information. 3. All youth shall be electronically searched, frisk searched, and stripped searched by an officer of the same sex as the youth. 4. All youth shall be allowed to place a telephone call at the facility s expense to his/her parent/guardian and the call shall be documented on all applicable forms, or document refusal to make a telephone call. 5. If the admission process is completed two hours or more before the serving of the next scheduled meal, youth shall be offered something to eat. 6. All youth shall be screened to identify medical, mental health, and substance abuse needs. Any youth identified as at risk of suicide shall be placed on Precautionary Observation until evaluated by the licensed mental health provider. The center implements a state-wide detention policy and procedures regarding the admission process and the initial screening of youth. The center juvenile justice detention officers (JJDO s) conduct the admission process with each youth upon arrival to the center. All intakes occur in a designated intake area of the center, separate from where youth are housed. A review of five youth case management records for admission documentation, indicated a copy of an arrest affidavit/custody order, a Detention Risk Assessment Instrument (DRAI), and a Suicide Risk Screening Instrument (SRSI) were contained in the record. There was also documentation the JJDO conducting the youth s admission reviewed these documents during the intake process. A review of five youth intake records indicated the admission wizard tool was completed on each youth. Documentation of three separate searches including a frisk-search, an electronic search, and full body search conducted by an officer of the same gender as the youth being detained was present in each of the five reviewed records. Though the requirement is for the youth to be offered a meal at intake under specific conditions, it is the center s practice to provide all youth a meal at intake. Reviewed documentation supported all five youth were offered a meal at the time of their admission, and all youth accepted the meal. All five youth intake records indicated each youth was screened for medical, mental health, and substance abuse needs. All five records indicated the youth received a telephone call to their legal guardian during the admission process. Each of the five records also contained a Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) screening. All five reviewed intake records indicated the youth arrived at the center on precautionary observation and remained on these precautions at least until they were evaluated by the licensed mental health professional at the center or a trained, non-licensed mental health professional under the supervision of a licensed mental health professional. The reviewer observed the admission of a youth into the center. An intake officer of the same gender as the youth was observed conducting a frisk search and an electronic search. The officer then accompanied the youth to a shower area, affording the youth more privacy, for a full body search. The youth was also provided a shower and clean detention issued clothing. During the intake interview, the detention officers were observed being positive towards the youth and helping the youth adjust to the center s environment. The detention officers were witnessed reviewing the admission paperwork, including the VSAB screening, Massachusetts Youth Office of Program Accountability Page 18 of 75 (Revised July 2016)

19 Screening Instrument - Second Version (MAYSI-2) and conducting the Suicide Risk Screening Instrument. The detention officer then reviewed the youth s mental health, medical and substance abuse history with the youth. The detention officer contacted the youth s assigned juvenile probation officer and reviewed the youth s mental health and suicide history with them, as well. The youth was offered a telephone call and spoke with their legal guardian. The detention officer also spoke with the guardian to confirm the youth s mental health, medical and substance abuse history. The youth was given a lunch tray because it was lunch time when they were admitted to the center Orientation Compliance Program orientation process shall occur within twenty-four hours of a youth being admitted into detention and documented according to Facility Operating Procedures. During the orientation process, youth must be advised, both verbally and in writing, at a minimum, the following: 1. Facility rules and regulations; 2. Grievance procedures; 3. Visitation; 4. Telephone calls; 5. Available medical, mental health and substance abuse services and how to access them; 6. How to access the Florida Abuse Hotline; 7. Expectations for behavior and related consequences; 8. Possible new law violations for destruction of property; and 9. Youth rights. The center maintains written policy and procedures regarding the orientation of newly admitted youth. The center s juvenile justice detention officers (JJDO s) complete a standardized orientation to the center and its operations with each youth during the admission meeting. The orientation process is an interactive discussion between the youth and the JJDO which is documented on orientation checklist and orientation review forms. The JJDO reviews center rules, regulations and behavioral expectations with the youth, as well as, related consequences, including possible new law violations. The orientation also includes information regarding family contact including visitation and telephone calls, abuse reporting, Florida Abuse Hotline numbers, Central Communication Center (CCC) number, the Prison Rape Elimination Act (PREA), youth rights while in the custody of the Department, the grievance process and how to access the array of services the center provides including educational services, mental health and/or substance abuse intervention, medical services, and the provision of recreational and religious opportunities. As each key topic is discussed, the youth initials the topic on the checklist and upon completion of the orientation, the youth signs and dates the orientation forms. The youth is then provided an orientation brochure for future reference, which reviews all orientation information. A review of five youth intake records contained an acknowledgement form signed by each youth confirming understanding of the orientation information, all documented within twenty-four-hours of admission. A review of the orientation brochure provided to each youth found a summary of the essential orientation information. Five randomly selected youth were interviewed regarding their experiences at the center. Each of the five youth acknowledged they were provided a thorough orientation consistent with the Department s required detention policies and procedures and Florida Administrative Code (F.A.C.) requirements during their admission. An orientation to the detention center was observed during the week of the annual compliance review. The JJDO informed the youth regarding all topics on the orientation checklist form and as topics were discussed and Office of Program Accountability Page 19 of 75 (Revised July 2016)