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 Hillsborough West Regional Juvenile Detention Center Re-Review Department of Juvenile Justice (State-Operated) 3948 West Martin Luther King Jr. Blvd Tampa, Florida Review Date(s): August 29-31, 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: Satisfactory 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: Paul Sheffer, Office of Program Accountability, Lead Reviewer (Standard 1) Glenn Garvey, Office of Program Accountability, Regional Monitor (Standard 1 and 5) Melissa Johnson, Office of Program Accountability, Central Regional Monitoring Supervisor (Standard 5) Stephanie Lobzun, Office of Program Accountability, Regional Monitor (Standard 5) Dawn Perkins, Manatee RJDC, Juvenile Justice Detention Officer II (Standard 5)

3 BUREAU OF MONITORING AND QUALITY IMPROVEMENT RE-REVIEW ADDENDUM Program Name: Hillsborough Regional Juvenile Detention Center MQI Program Code: 294 Provider Name: State Operated Contract Number: N/A Location: Hillsborough County / Circuit 13 Number of Beds: 93 Review Date(s): August 29-31, 2017 Lead Reviewer Code: 118 Standard 1: Management Accountability Detention Rating Profile Indicator Ratings Original Review Re-Review Standard 1 - Management Accountability 1.01 * Initial Background Screening Satisfactory Satisfactory 1.02 Five-Year Rescreening Limited Satisfactory 1.03 Staff Code of Conduct Limited Satisfactory 1.04 * Incident Reporting Satisfactory Satisfactory 1.05 Protective Action Response (PAR) Limited Limited 1.06 * Pre-Service/Certification Requirements Satisfactory Satisfactory 1.07 In-Service Training Limited Satisfactory 1.08 *Entering Alerts(JJIS) Satisfactory Satisfactory 1.09 Sharing of Alert Information Satisfactory Satisfactory * 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 Satisfactory 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 3 of 30 (Revised July 2016)

4 Standard 5: Safety and Security Detention Rating Profile Indicator Ratings Original Review Re-Review Standard 5 - Safety and Security 5.01 * Active Supervision of Youth Satisfactory Satisfactory 5.02 * Ten-Minute Checks Failed Failed 5.03 Census Counts and Tracking Failed Satisfactory 5.04 Logbook Maintenance Limited Satisfactory 5.05 Logbook Reviews Limited Failed 5.06 Key Control Failed Failed 5.07 Vehicles and Maintenance Failed Failed 5.08 Tool Inventory and Management Failed Satisfactory 5.09 Kitchen Tools Satisfactory Satisfactory 5.10 * Youth Access & Use of Tools, Cleaning Items Satisfactory Satisfactory 5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items Failed Limited 5.12 * Access to all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory Satisfactory 5.13 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory Satisfactory 5.14 Confinement Under Twenty-Four Hours Failed Failed 5.15 Confinement Over Twenty-Four Hours Failed Failed 5.16 Continuity of Operations Planning (COOP) Drills Limited Satisfactory 5.17 Escape Drills Satisfactory Satisfactory 5.18 Fire Drills Limited Limited * 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 Satisfactory 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). Summary Office of Program Accountability Page 4 of 30 (Revised July 2016)

5 During the original annual compliance review, the center failed Standard 1 Management Accountability and Standard 5 Safety and Security. These standards were re-reviewed in accordance with FDJJ-2000 (Contract Management and Program Monitoring and Quality Improvement Policy and Procedures). Florida Statute Section (5)(f) reads, Evaluate each program operated by the Department or a provider under a contract with the Department annually and establish minimum standards for each program component. If a provider fails to meet the established minimum standards, such failure shall cause the Department to cancel the provider s contract, unless the provider achieves compliance with minimum standards within six months or unless there are documented extenuating circumstances. In addition, the Department may not contract with the same provider for the canceled service for a period of twelve months. If a Department-operated program fails to meet the established minimum standards, the Department must take necessary and sufficient steps to ensure and document program changes to achieve compliance with the established minimum standards. If the Department-operated program fails to achieve compliance with the established minimum standards within six months, and if there are no documented extenuating circumstances, the Department must notify the Executive Office of the Governor and the Legislature of the corrective action taken. Appropriate corrective action may include, but is not limited to: 1. Contracting out for the services provided in the program; 2. Initiating appropriate disciplinary action against all employees whose conduct or performance is deemed to have materially contributed to the program s failure to meet established minimum standards; 3. Redesigning the program; or 4. Realigning the program. Office of Program Accountability Page 5 of 30 (Revised July 2016)

6 Standard 1: Management Accountability Hillsborough West Regional Juvenile Detention Center is located in Tampa, Florida, and is a ninety-three bed, hardware-secure facility, operated by the Department. The center serves male and female youth from Hillsborough County. The center provides a safe environment for youth detained with pending adjudication, disposition, or pending placement in a residential commitment facility. There were fifty-five youth in the center during the annual compliance review. Medical services for youth are provided through a contract with Maxim Healthcare Services, Inc., and all mental health services are provided through a contract with Camelot Community Care, Inc. Education services are provided to youth by the Department of Education, through the Hillsborough County Public School District. The center had vacancies for the following positions during the annual compliance review: three juvenile justice detention officer (JJDO) I staff, twelve JJDO II staff, three JJDO supervisors, one food service worker, and one maintenance mechanic staff. The center also reported having three staff on light-duty and three out due to workman s compensation claims. A tour of the center, by the annual compliance review team, found the following concerns: mold was seen in the shower areas of the living modules, some of the plumbing was not working appropriately, and there was graffiti in some of the youth s rooms. The regional maintenance staff responded, along with maintenance mechanics from two other local detention centers, to immediately begin correcting some of the concerns Initial Background Screening During the annual compliance re-review, background screenings were reviewed for thirteen applicable program staff, who were hired during the previous six-month period. Each was found to have received a background screening, with a rating of eligible or eligible with charges, prior to their date of hire. There were also ten new volunteers who began supporting youth in the center, during this annual compliance review period, and each of them had a background screening completed appropriately. Each was screened prior to contact with youth at the center and each had an eligible rating. The Annual Affidavit of Compliance with Level Two Screening Standards was completed and submitted to the Department s Background Screening Unit (BSU) on January 6, 2017, and the Annual Affidavit of Compliance with Level Two Screening Standards for School Board Teachers was completed and submitted to the BSU on January 5, 2017, thus meeting the annual requirement. This was confirmed through a review of documentation, and an interview with the administrative assistant. The program originally received a Satisfactory Compliance rating for this indicator, during the FY annual compliance review, which was conducted February 21-24, The center has a written policy and procedures addressing the background procedures for all employees, contracted staff, and volunteers/interns. The center has a total of sixty-five staff, fourteen contracted staff, and fifty-two volunteers and interns. Since the center s last annual compliance review, a total of twenty new Department employees have been hired, four contracted staff, and twenty-five volunteers. Contracted medical and mental health/substance abuse staff received a background screening through the Department s BSU, prior to the provider assigning the staff to work at this center, not prior to provider date of hire. Each staff s personnel file contained a final background screening form which had been completed prior to the date of hire, with the exception of one. One volunteer had a screening result of closed/ineligible due to documentation not provided to the BSU. This volunteer had been on-site less than three hours since her start date. The center will ensure an eligible screening is completed prior to her return to the facility. The center had no applicable Office of Program Accountability Page 6 of 30 (Revised July 2016)

7 new hires in need of exemption by the Inspector General. The Annual Affidavit of Compliance with Level 2 Screening Standards was sent to the Department s BSU, by the center, on January 9, 2017, meeting the annual requirement, and by the Hillsborough County School district on January 10, 2017, also meeting the annual requirement. During the re-review, the program received a Satisfactory Compliance rating for this indicator Five-Year Rescreening There were two staff eligible for a five-year rescreening during the annual compliance re-review period. Each of these staff had their five-year rescreening conducted at least three months prior to the anniversary date of hire. No volunteers required a five-year rescreening during this annual compliance review period. The administrative assistant has a tracking log for each staff and volunteer, which shows their date of hire/start and the due dates for when their five-year rescreening s are required. The program originally received a Limited Compliance rating for this indicator during the FY annual compliance review, which was conducted February 21-24, The center has a written policy and procedures addressing the background procedures for all employees, contracted staff, and volunteers/interns. The center had two contracted staff and five volunteers/interns applicable for a five year rescreen. Both applicable contracted staff and four of the five volunteers all had a background screen completed prior to the anniversary date of hire. One of the five volunteers completed their rescreening over four months late. The screening was due June 3, 2016, but was not completed until October 26, The center provided no reason for the delay. The volunteer was at the center, on a routine basis, from June until October 2016, a minimum of eight times. The center indicated they will ensure an eligible rescreen is completed, prior to the volunteer s return to the center. During the re-review, the program received a Satisfactory Compliance rating for this indicator Staff Code of Conduct A review of ten personnel files was conducted during the annual compliance re-review. Three of these files were for staff who violated the code of conduct and received disciplinary action. Two of the staff used excessive force on a youth during Protective Act Response. Each was dismissed as a result of the investigations for each incident. The third staff was disciplined for failing to call the Central Communications Center (CCC) in a timely manner. A review of all ten personnel files found each staff signed the receipt of the Department s employee handbook and oath of loyalty, acknowledging the code of conduct staff must adhere to while working for the Department. Seven youth were interviewed. Six indicated they have never wanted to call the Florida Abuse Hotline. One youth indicated he had not been provided a meal, and was forced to wait a few hours to make the call. He indicated the call was not accepted by the Florida Abuse Hotline, since the center had rectified his concern prior to the call. Each of the seven interviewed staff shared youth would be provided a call to the Florida Abuse Hotline, when requested. Those working the floor indicated they may need to have a supervisor respond since they cannot leave the floor and break the ration of youth to staff. All reported these calls would be made as soon as possible, depending on staffing and safety concerns. Each of the seven interviewed youth reported staff are respectful when speaking with them. Two youth indicated they have never heard staff curse, two indicated they have heard a staff member curse once, one stated they have heard staff curse occasionally, and two said they have heard staff curse often. When questioned further, they relayed this was never used in a derogatory way, and was more out of frustration, or just a slip in conversation. Seven staff also responded to the interview. Four reported never hearing a co-worker use profanity, one stated they have heard Office of Program Accountability Page 7 of 30 (Revised July 2016)

8 this once, one said occasionally, and one said they have heard co-workers curse often. This was reported to be used out of frustration or just part of conversation. The one who reported it was often stated some staff have left, and this has improved. Six of the seven interviewed youth reported never having heard staff threaten a youth. The other youth said staff will get angry, but this does not mean to harm a youth; they are just frustrated sometimes. Six of the seven staff reported never having heard another staff use threats or intimidation towards a youth. The other staff member did could not think of a specific instance, but said there should always be more than one staff available in any given situation. This will allow someone to tap them out if things get heated. Six of the seven youth reported feeling safe in the center. The other youth has anxiety concerns, and shared the other youth are unpredictable and he is afraid of their actions. He does feel staff are there to protect him, and would do so, if there was an incident near him. An interview was conducted with the superintendent, who indicated the center will call the Florida Abuse Hotline, CCC, and parent/guardian of youth if an incident occurs. They will begin an internal investigation immediately, and will remove staff immediately. Based on any findings, staff may be disciplined. The review of the two applicable staff files and CCC documentation confirmed this practice. The program originally received a Limited Compliance rating for this indicator during the FY annual compliance review, which was conducted February 21-24, The center has a written policy and procedures regarding the staff code of conduct. The center utilizes the Department s employee handbook, which contains a code of conduct to be signed by each new staff, upon hire. Seven applicable staff personnel files were reviewed and each contained the acknowledgement, receipt, and review of the Department s code of conduct. None of the reviewed seven files had any disciplinary action. The center had no substantiated abuse allegations during this annual compliance review period. Additional documentation was provided regarding two staff who were given the employee of the month award, one was honored in January 2017 and the other in November One of the two staff was also named the Central Region employee of the month for detention. A total of seven staff were surveyed. Four reported they have heard other coworkers use profanity occasionally, one said they heard it once, and two said never. All surveyed staff indicated they have never heard staff threaten, intimidate, or humiliate youth. Four of seven staff surveys indicated the working conditions this past year have been fair. One staff reported the conditions were poor and two said good. All seven surveyed staff indicated they have never seen a youth be denied access to the Florida Abuse Hotline. A total of seven youth were surveyed. Four of the seven youth indicated staff are not respectful when speaking to them, nor other youth, and three youth reported staff are respectful. Four youth indicated they have heard staff use profanity when speaking with them or other youth occasionally, one youth said often, one youth said once, and one youth said never. The same seven youth were asked if they have heard staff threaten them or other youth. One youth indicated often, two stated occasionally, two said once, and two youth stated never. All surveyed youth were asked follow-up questions to clarify, and only one indicated one specific staff had threatened them with physical harm. This allegation was immediately reported to detention center management and the Florida Abuse Hotline. Five of the seven surveyed youth stated staff routinely intimidate them or threaten them by using confinement as a consequence for not following directives or detention center rules. A review of several confinement reports supported the youth allegations. During the annual compliance review week, staff were heard using profanity in front of reviewers on more than one occasion. During the re-review, the program received a Satisfactory Compliance rating for this indicator. Office of Program Accountability Page 8 of 30 (Revised July 2016)

9 1.04 Incident Reporting (CCC) The center had fifty-five incidents reported to the Department s Central Communications Center (CCC) during the six months prior to the annual compliance re-review. The center maintains a policy and procedures for incident reporting. A sample of six CCC reports were reviewed to establish the center s compliance with reporting procedures. Five of the six reports were called in to the CCC within the two-hour reporting timeframe. The other incident, regarding a missing set of keys, was called in twenty-four minutes late. The center was in the process of conducting a search for the missing keys during this time. The superintendent was interviewed to determine the process for calls being made to the CCC. He explained staff will notify the supervisor on shift whenever a reportable incident occurs. They will then call the superintendent to make them aware of what has occurred. Guidance will be given, including whether or not an investigation or search needs to be conducted. The center s practice is for the superintendent/designee to report the incident after needed information has been gathered, and prior to the two-hour reporting requirement. The superintendent also indicated he will report any updates, as applicable, to the CCC. The program originally received a Satisfactory Compliance rating for this indicator during the FY annual compliance review, which was conducted February 21-24, The detention center has a written policy and procedures regarding incident reporting. A review of nine incidents reported to the Central Communications Center (CCC) revealed each of the incidents had been reported within the required two-hour time frame. Two of the nine reports were not applicable due to the call coming from another center/program. According to policy, the center documents all CCC reports in the master control logbook, as well as in a separate CCC logbook. A review of the master control logbooks showed five of the seven applicable CCC calls had not been documented. Only two of the seven were not documented in the CCC logbook. A review of incidents in the last six months revealed fifty-three calls to the CCC. All logbook entries, which are CCC reportable, were reported to the CCC, as required. During the re-review, the program received a Satisfactory Compliance rating for this indicator Protective Action Response (PAR) The center had ninety-two Protective Action Response (PAR) reports since the last verification visit on June 27, During the annual compliance re-review, a review was conducted on nine PAR reports which occurred since the last verification visit. Eight of the nine reports included statements from each involved staff. The other report was missing a statement from a staff who assisted with ground control. All entered statements were found to be completed by the end of staff member s workday. One of the reports resulted in an injury to an involved staff. A review of Central Communications Center reports found this was reported, as required. None of the reviewed reports documented the use of mechanical restraints or any allegations of abuse by the involved youth. Each of the reports were reviewed, by the supervisor on shift and a PAR-certified supervisor, to determine if the use of force was consistent with the policy. One of the supervisor reviews and three of the PAR-certified supervisor reviews were conducted outside the seventy-two hour review/processing requirement. Each of the reports reflected a post-par interview was done with each youth within thirty minutes of each incident. None of the youth reported any injuries; therefore, none required a post-par medical review. All nine were found to have been reviewed by the superintendent or designee; however, four of them were after the seventy-two hour timeframe. These were one day, thirteen days, six days, and five days late, respectively. Two additional reports were reviewed, prior to other required supervisor reviews. was sent to staff who had not completed the required reviews, and these were subsequently completely. All PAR reports are maintained electronically in the Department s Office of Program Accountability Page 9 of 30 (Revised July 2016)

10 Juvenile Justice Information System (JJIS). The superintendent submits a summary of all PAR reports to the Department each month. Six of the seven surveyed staff indicated staff try to speak with youth, prior to using physical restraints. The other staff member stated some staff are struggling. He reported trying to influence some of the newer staff to show more understanding and try other avenues with youth. OBCAP Verification The program received a minor deficiency on February 24, 2017, during the annual compliance review. First verification was conducted on April 3, 2017, and found administrative reviews were not being conducted within the seventy-two hour timeframe. A second verification was conducted on May 9, Two of the reviewed reports had an administrative review, indicating the closed-circuit television (CCTV) review would be completed at a later date. There was no way to know if this was conducted to verify if the PAR was done appropriately. Another report had an administrative review conducted on April 27, 2017, reflecting other reviews still needed to be completed. These reviews had not been completed at this time. Another PAR report was reviewed due to documentation found during a logbook review. This PAR report had no review completed by supervisory staff, and no documentation to reflect a post-par interview was done. Based on the reviewed documentation, this was elevated to a major deficiency. The first verification was conducted on June 27, The action step for this was, All PAR reports will be reviewed by the superintendent or designee within seventy-hours of incident, excluding weekends and holidays. A review of the Department s Facility Management System (FMS) found the center had twenty-one PAR incidents during this time period, and five were selected for review. This review found one report missing a statement by an involved staff member, two did not have a review by the supervisor on shift, three did not have a post-par interview documented, and three did not have a review by the administrator/designee. The missing administrative reviews were conducted while the monitors were on-site. Based on the noted exceptions, this was set for a second verification. The center was granted an extension for second verification on the major deficiency, to allow them more time to work on these concerns. The second verification was conducted during the annual compliance re-review. Based on the findings, this will be set for a third verification. The program originally received a Limited Compliance rating for this indicator during the FY annual compliance review, which was conducted February 21-24, The center has a written policy and procedures regarding Protective Action Response (PAR). According to the Department s Juvenile Justice Information System (JJIS), the center had 253 incidents involving the use of PAR from August 2016 to February Fifteen reports, ranging from October 2016 to February 2017, were still incomplete at the time of the annual compliance review. Ten of these fifteen were missing the signature of a post-par reviewer, PAR instructor, supervisor, and/or administrator. An administrator signed off on five of the fifteen incomplete reports, even though the report was not complete. A review of ten randomly selected PAR reports indicated each of the reports had been completed, as required. One of these ten reports indicated staff attempted an unapproved control technique, prior to a second approved move. The staff member involved in the aforementioned PAR incident received additional PAR training. One additional report was missing one of two explanation sheet statements required from the involved staff. In this same report, the lead staff also reviewed the report as the PAR instructor/par certified supervisory staff, which is not in compliance with Florida Administrative Rule 63H-1. There was no documentation to suggest mechanical restraints were used in any of the reviewed reports. PAR summaries are completed by the center, on a monthly basis, and submitted to the Department. Seven surveyed youth indicated staff try to talk with youth before the use of physical interventions. Six of the seven youth stated they feel safe at this center, and one said they did not. After further clarification, this one youth indicated they are afraid of other Office of Program Accountability Page 10 of 30 (Revised July 2016)

11 youth assaulting them as they have before. Seven staff were surveyed, and all reported staff try to speak with youth before the use of PAR. During the re-review, the program received a Limited Compliance rating for this indicator Pre-Service/Certification Requirements During the annual compliance re-review, a review of seven staff training files was completed. These were the only staff hired by the center during this six-month period. Two of the seven reviewed staff completed the requirements for pre-service certification within 180-days of hire. Another staff completed Phase Two of training, which included the Academy; however, they have not been able to pass the exam. They are still within their initial 180-days, and will have at least one more attempt. Each of the seven staff completed the required essential skills training, prior to contact with any youth. These essential skill topics are first aid, cardiopulmonary resuscitation (CPR), automated external defibrillator (AED), mental health and substance abuse services, suicide prevention, safety, security, and supervision, and the center s facility operating procedures. Each of the seven staff completed forty-hours of Protective Action Response (PAR) training within ninety-days of hire. Three of the staff are currently attending Phase Two of training, and the other staff will attend the Academy starting October 23, Each completed training was delivered by a qualified trainer and all were documented in the Department's Learning Management System (SkillPro). The program originally received a Satisfactory Compliance rating for this indicator during the FY annual compliance review, which was conducted February 21-24, The center has a written policy and procedures regarding the training of all new staff. S even staff training files were reviewed and each file reflected staff had completed the certification process, within 180-days of hire. All staff completed the required training and certification related to cardiopulmonary resuscitation (CPR), first aid, automated external defibrillator (AED), and Protective Action Response (PAR). Each file also indicated staff had received training in suicide prevention, mental health and substance abuse services, safety and security measures, detainee behavior, and detention facility operations. Each completed training was documented in the Department s Learning Management System (SkillPro). Seven staff were surveyed and all agreed they had been adequately trained for their job. During the re-review, the program received a Satisfactory Compliance rating for this indicator In-Service Training A review of seven staff training files was conducted during the annual compliance re-review. The review included only those trainings which had been conducted during the current calendar year, since the calendar year of 2016 was reviewed during the annual compliance review. The center has been without a field training coordinator (FTC) since May The training files found staff have been completing required training topics. Five of the seven staff were found to have completed over thirteen hours of training. One other staff member had completed nine and half hours, and the other had not completed any hours this calendar year. The center is utilizing the FTC from Pinellas Regional Juvenile Detention Center to have the remainder of their mandatory trainings and refreshers conducted, prior to the end of this year. They were able to provide a copy of the Detention Center Statewide Annual Training Plan, which was approved by the Assistant Secretary for Detention Services. Office of Program Accountability Page 11 of 30 (Revised July 2016)

12 The program originally received a Limited Compliance rating for this indicator during the FY annual compliance review, which was conducted February 21-24, The center has a written policy and procedures regarding annual training for all staff. The center has an annual inservice training calendar, which is updated, as needed. The detention center provides in-service training to staff through a combination of the Department s Learning Management System (Skill Pro) and instructor-led classes. Seven staff training files were reviewed, and all exceeded the twenty-four training hours required. All staff completed training on Protective Action Response (PAR) update, first aid, automated external defibrillator (AED), and cardiopulmonary resuscitation (CPR). All staff received professionalism, ethics, and suicide prevention training. One of the seven staff was missing training in infection control and an additional staff had not completed training in fire prevention. Four supervisor training files were reviewed, and two of the four had the required eight hours of supervisory training in the areas of management, leadership, personal accountability, employee relations, communication skills, and fiscal. Both of these staff had over forty hours of training after completing the leadership academy. Of the remaining two supervisors, the only training topic documented in their training files and in SkillPro was for medication administration for supervisors, which was for an hour and a half. Seven surveyed staff stated they have been adequately trained for their job. In-service training was also found documented in SkillPro. During the re-review, the program received a Satisfactory Compliance rating for this indicator Entering Alerts (JJIS) The detention center has written facility operating procedures to address how alerts are entered in to the Department s Juvenile Justice Information System (JJIS). The policy addresses the JJIS alert report shall be reviewed daily by the supervisors and administrators and addresses medical and mental health review alerts to ensure each alert is correctly tracked and managed. A review of JJIS open alerts for the center and five randomly selected youth found alerts were being entered and closed by the appropriate staff. The program originally received a Satisfactory Compliance rating for this indicator during the FY annual compliance review, which was conducted February 21-24, The detention center has a written policy and procedures regarding the placement of applicable youth on alert status in the Department s Juvenile Justice Information System (JJIS). Seven youth healthcare and mental health/substance abuse records were reviewed, including seven detention youth files, and each was found to have one or more alert entered into JJIS. Each alert had been entered by the center, based on the youth s risk factor or identified need. Supervisors and management staff are responsible for updating and downgrading JJIS security alerts. All medical and mental health alerts were entered or updated by the appropriate Department representative. During the re-review, the program received a Satisfactory Compliance rating for this indicator Sharing of Alert Information The detention center has written facility operating procedures to address how alerts are to be reviewed daily by supervisors and administration, and changes are reviewed with staff at shift briefing. Attendance and observation of two shift briefings confirmed alerts and any changes made were reviewed with staff, during the briefing. The out-going shift supervisor briefed the oncoming shift on any pertinent information from their shift. A review of six random days of shift briefing reports also found the alerts were discussed during daily shift briefings. Seven staff Office of Program Accountability Page 12 of 30 (Revised July 2016)

13 were interviewed, and they indicated alert information is shared through the logbook at shift briefings, on alert forms, and through the Department s Juvenile Justice Information System (JJIS). The dining hall receives an alert print out three times a day, before breakfast, lunch, and dinner, which lists each youth and any food allergy they may have at the time. The program originally received a Satisfactory Compliance rating for this indicator during the FY annual compliance review, which was conducted February 21-24, The center has a written policy and procedures in regards to sharing alert information with staff. Prior to each shift briefing, the juvenile justice detention officer supervisors (JJDOS) prints all alerts, which had been entered into the Department s Juvenile Justice Information System (JJIS) and reviews them with all staff coming on shift. If any changes in alerts occur during a shift, staff are made aware at shift briefing. The alerts in JJIS are updated if there are any changes with the information. The alert system reflected updates by medical, mental health, or other staff in regards to critical alerts. All JJDOS are responsible for ensuring the detailed alert list is read during each shift briefing and during the shift, when necessary. When a JJDOS receives a change to the alert list, they will notify the staff affected by the changes and add the information to the next shift briefing. The daily alert reports included healthcare, mental health and substance abuse, safety and security, and other applicable youth alerts. A review of the center s documentation and seven youth healthcare and mental health and substance abuse records found all applicable alerts were documented in JJIS, as required. Observations of one shift briefing validated this practice. Six surveyed staff reported they receive youth-specific alert information from logbooks, five reported alert forms, four reported JJIS. Two indicated other methods which were not specified, and one indicated an alert board. Additionally, informal interviews with two juvenile justice detention officers (JJDO) verified the practice of alert review at briefing and throughout the shift, if necessary. During the re-review, the program received a Satisfactory Compliance rating for this indicator. Office of Program Accountability Page 13 of 30 (Revised July 2016)

14 Standard 5: Safety and Security The Hillsborough West Regional Juvenile Detention Center is a ninety-three bed, hardware secure facility, equipped to supervise detained youth in a safe, secure, and humane environment. The center s population was under capacity at the time of the annual compliance re-review with fifty-five youth. There are four living modules, three designated for male youth and one for female youth. One of the male modules has had plumbing concerns; therefore, only half of the module can be used at the current time. They are utilizing the useable half of this module for youth confinements. All areas of the facility are monitored through video surveillance. All juvenile justice detention officers (JJDO) are responsible to provide supervision of the youth in a safe, secure, and humane environment. The center s superintendent is responsible for overseeing the overall safety and security at the center. The center is required to maintain an inventory and control of keys, tools, and all flammable, poisonous, and toxic items. Staff use two-way radios to communicate routine and emergency information. The master control logbook documents all youth movements, admissions, releases, and all pertinent information. Living module logbooks are used to document information pertaining to each separate living area. All vital information is passed on during shift briefings, is documented in the center s logbooks, and is maintained in the Department s Juvenile Justice Information System (JJIS) through the facility management system (FMS). The center has no maintenance staff to conduct regular preventative maintenance. They have been having the regional maintenance supervisors and maintenance mechanics from other centers assist with any emergencies or needed repairs. The center uses an electronic computer system, which is a hand-held wand to document ten-minute checks when youth are in their rooms during sleeping hours. The center uses paper Visual Observation Reports (VOR) for all other instances, in which a youth is in their room Active Supervision of Youth The center has a policy and procedures regarding supervision of youth. Observations during the annual compliance re-review confirmed staff were actively supervising youth. Observations also confirmed consistent communication between staff and master control using a two-way radio to complete head counts and to receive authorization for all movement within the center. A review of the center s logbooks for the last six months established headcounts are conducted on a consistent basis, during the beginning and ending of each shift, randomly during each shift, prior to youth movement, and during sleeping hours. Informal interviews with six different staff confirmed these counts are done consistently. The program maintains a grease board in master control to account for the population of youth in the center. It has the total number of youth, and is also broken down to reflect the current population on each living module. Observations during the review confirmed this is maintained appropriately, and changes are made when they occur. Six of the seven interviewed staff indicated they felt there have been enough staff to provide for the safety and security of youth and staff during the past year, and the other stated there have been enough, if people would just do their job. Each of the interviewed staff indicated all movement will be stopped, and an immediate recount will be done, if the count conducted my master control does not match. The program originally received a Satisfactory Compliance rating for this indicator during the FY annual compliance review, which was conducted February 21-24, The center has a policy and procedures in place to address the supervision of youth. Observations were made throughout the week of this annual compliance review, during which none of the youth were seen unattended or away from the sight of a juvenile justice detention officer (JJDO). Observations of youth during school activities, meals, and line movement found staff provided active supervision at all times. Prior to youth movement, staff must radio master control with a request to move youth from one location to another and wait for master control s approval. No Office of Program Accountability Page 14 of 30 (Revised July 2016)

15 movement occurs until cleared by master control. A review of master control logbooks for the last six months validated this practice. Additionally, there is a grease board in master control, which keeps a constant count of youth in and out of the center. Two staff were informally interviewed, and both were able to articulate the methods by which they reconcile counts. Seven staff were surveyed, of which five stated they think there has been enough staff to provide for the safety and security of the youth and staff. Two staff did not think there was enough staff. In November 2016, several youth were involved in an altercation. A review of one of the involved youth s confinement report shows staff responded to the code only after they were told by master control their help was mandatory. At the time, this staff person was alone on the Charlie module, with one youth on precautionary observation, and one youth on level three of the behavior management system, who had earned a late bed time. After request for assistance was given by master control, the Charlie module staff person put the level three youth in their sleeping room, brought the precautionary observation youth to the interview room next to master control, and then left the living module. Both rooms were secured and master control had sight and sound of youth in interview room across from master control. During the re-review, the program received a Satisfactory Compliance rating for this indicator Ten-Minute Checks The center has a written policy and procedures to ensure the safety and security of youth placed in a room, whether for sleeping or other reasons. Detention staff are required to conduct visual observation checks every ten-minutes when the youth are placed in their rooms to ensure the safety of each youth. The center uses an electronic wand system and staff must physically observe the youth before verifying the check. This wand system is used during sleeping hours. The center uses paper Visual Observation Reports (VOR) during showers, during completion of hygiene in the mornings, and at shift change in the afternoon. Electronic wand reports were reviewed for the nights of May 9, 2017, June 5, 2017, July 19, 2017, July 25, 2017, August 11, 2017, and August 15, The majority of checks were completed as required; however, numerous discrepancies were seen in which staff began rounds of checks one or two minutes late. A review was conducted on VORs for six different dates. The discrepancies are as follows: May 24, 2017 eleven VORs were reviewed, and one had a missing ten-minute check; June 5, 2017 twenty-one VORs were reviewed, and ten had at least one missing ten-minute check; July 20, 2017 eight VORs were reviewed, and five had at least one missing check; July 25, 2017 ten VORs reviewed, and nine of them had at least one missing ten minute check; July 26, 2017 eleven VORs were reviewed, and nine of them had at least one missing ten minute check; August 12, 2017 seven VORs were reviewed, and all seven had at least one missed ten-minute check. None of the sixty-eight reviewed VORs had any staff signatures or initials at the bottom of the form. The forms were not being filled out consistently, with many missing dates and rooms number for youth. During the annual compliance re-review, a review team member was able to review three days of video footage. The visual observations confirmed the following during the reviewed periods: July 25, 2017 eight ten-minute check rounds were not conducted; July 26, 2017 two ten-minute check rounds were not conducted; August 12, 2017 eight ten-minute check rounds were conducted. The center did not provide any documentation to reflect the wand checks or VORs were reviewed for any discrepancies. Observation of youth living modules and rooms confirmed there were no obstructions over the windows and areas where direct line of sight is needed. All seven interviewed staff indicated room checks should be completed every ten minutes when a youth is placed in their room for sleeping or nonpunishment reasons. Office of Program Accountability Page 15 of 30 (Revised July 2016)

16 The program originally received a Failed Compliance rating for this indicator during the FY annual compliance review, which was conducted February 21-24, The center has a policy and procedures regarding the supervision of youth while in sleeping rooms. The center uses an electronic wand system to record the time of each check. This system was updated in December of A review of the electronic system for six separate dates/incidences revealed several exceptions in ten-minute checks. The electronic wand report for September 11, 2016 showed one living unit had a total of 139 missed checks. On October 10, 2016, there were sixty missed checks. Wand reports for four other dates in three different living units revealed some of the checks were being completed anywhere from one to twenty-four minutes late. One room had fifteen of forty-nine checks completed late, another room had four of forty-eight checks completed late. The electronic wand reports for two separate living modules on two days in February 2017 were reviewed, and the reports showed several late ten-minute checks. Late checks ranged from one-minute to twenty-four minutes, with most late checks averaging around five minutes. A review of closed circuit television (CCTV) confirmed the late checks listed in the reviewed wand reports. Seven staff were surveyed regarding how often room checks are conducted when a youth is placed in their room for sleeping or non-punishment, and all indicated checks are conducted every ten minutes. During the re-review, the program received a Failed Compliance rating for this indicator Census, Counts, and Tracking The detention center has policy and procedures in place for conducing census verification, youth head counts, and tracking youth. A review of four master control logbooks and six living module logbooks confirmed the facility is conducting youth head counts at the beginning, middle, and end of each shift. In addition, the master control logbook confirmed at least one random facility head count is conducted during each shift. A review of the master control logbooks further confirms the program is conducting facility head counts after the completion of mock emergency drills. During the re-review, the annual compliance review team observed counts being conducted at various times throughout the day. The counts were reported to the master control operator by the juvenile justice detention officers (JJDO) supervising the youth. The JJDOs were also observed requesting permission to move youth throughout the building and the movements were recorded in the master control (MC) logbook and living modules logbooks. Seven staff interviews were conducted during the re-review and all staff indicated emergency counts are conducted when a youth is believed to be missing, when visibility of youth is hindered, and after a major disturbance. The program originally received a Failed Compliance rating for this indicator during the FY annual compliance review, which was conducted February 21-24, The center has a policy and procedures for census, counts, and tracking of youth. A review of center logbooks, from September 2016 to February 2017, showed the MC officer documents youth census counts at the beginning and end of each shift with minor exceptions. Minor exceptions were noted where MC was not documenting a youth census count at the end of the shift. Reviewed logbooks show documented counts prior to and following routine group movement and any time there was a population change. The reviewed logbooks did not show random counts of youth at least once a shift. An informal interview with a MC staff was conducted and the staff admitted they have not been conducting random counts, but believes some MC staff do. Additionally, counts were not consistently being documented following any emergencies to include evacuation due to emergency drills. Seven staff were surveyed regarding when emergency counts are conducted, and all indicated the counts are conducted after a youth is believed to be missing, when visibility is hindered, and after a disturbance. Office of Program Accountability Page 16 of 30 (Revised July 2016)