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 Alachua Regional Juvenile Detention Center Department of Juvenile Justice (State-Operated) 3440 NE 39th Avenue Gainesville, Florida Review Date(s): August 5-8, 2014 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES

2 Rating Definitions Ratings were assigned to each indicator by the review team using the following definitions: Compliance Limited Compliance Failed Compliance No exceptions to the requirements of the indicator; or limited, unintentional, and/or non-systemic exceptions that do not result in reduced or substandard service delivery; or systemic exceptions with corrective action already applied and demonstrated. Systemic exceptions to the requirements of the indicator; exceptions to the requirements of the indicator that result in the interruption of service delivery; and/or typically require oversight by management to address the issues systemically. The absence of a component(s) essential to the requirements of the indicator that typically requires immediate follow-up and response to remediate the issue and ensure service delivery. Review Team The Bureau of Monitoring and Quality Improvement wishes to thank the following review team members for their participation in this review, and for promoting continuous improvement and accountability in juvenile justice programs and services in Florida: Mike Marino, Lead Reviewer, DJJ Bureau of Monitoring and Quality Improvement Kevin Greaney, Review Specialist, DJJ Bureau of Quality Improvement Elise Kasten, Juvenile Justice Detention Officer Supervisor, Volusia Regional Juvenile Detention Center Angela Mills, Review Specialist, DJJ Bureau of Quality Improvement Theresa Susino, Juvenile Justice Detention Officer Supervisor, Marion Regional Juvenile Detention Center

3 Program Name: Alachua Regional Juvenile Detention Center QI Program Code: 089 Provider Name: Department of Juvenile Justice Contract Number: NA Location: Alachua County / Circuit 8 Number of Beds: 48 Review Date(s): August 5-8, 2014 Lead Reviewer Code: 37 Methodology This review was conducted in accordance with FDJJ-1720 (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 DMHA or designee # Case Managers 1 # Clinical Staff # Food Service Personnel 1 # Healthcare Staff Documents Reviewed 1 # Maintenance Personnel # 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 5 # Health Records 5 # MH/SA Records 5 # Personnel Records 8 # Training Records/CORE 5 # Youth Records (Closed) 5 # Youth Records (Open) 22 # Other: Background screening records as applicable for staff, contracted staff, and volunteers 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 45 (Revised July 2014)

4 Standard 1: Management Accountability Detention Rating Profile Indicator Ratings 1.01 Standard 1 - Management Accountability * Initial Background Screening 1.02 Five-Year Rescreens 1.03 Staff Code of Conduct 1.04 * Incident Reporting (CCC) 1.05 Protective Action Response (PAR) Limited 1.06 * Pre-Service/Certification Requirements 1.07 In-Service Training 1.08 Logbook Maintenance 1.09 Logbook Reviews Limited 1.10 * Entering Alerts (JJIS) 1.11 Sharing of Alert Information * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). The following limited and/or failed indicators require immediate corrective action Protective Action Response (PAR) 1.09 Logbook Reviews Detention Quality Improvement Report Office of Program Accountability Page 4 of 45 (Revised August 2013)

5 Standard 2: Youth Management Detention Rating Profile Indicator Ratings 2.01 Standard 2 - Youth Management Admission 2.02 Orientation 2.03 Classification 2.04 Classification of Gang Members 2.05 Notification of Law Enforcement 2.06 Admission of Youth Personal Property 2.07 Storage of Youth Personal Property 2.08 Release 2.09 Release of Youth Personal Property 2.10 Release of Medication, Aftercare Instructions 2.11 Review of Youth in Secure Detention 2.12 Review of Youth on Home Detention 2.13 Daily Activity Schedule 2.14 Adherence to Daily Schedule 2.15 Educational Access 2.16 Vocational Programming 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 45 (Revised July 2014)

6 Standard 3: Mental Health and Substance Abuse Services Detention Rating Profile Indicator Ratings Standard 3 - Mental Health and Substance Abuse Treatment 3.01 Designated Mental Health Authority (DMHA) 3.02 * Licensed Mental Health and Substance Abuse Clinical Staff 3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff 3.04 Mental Health and Substance Abuse Admission Screening 3.05 Mental Health and Substance Abuse Assessment/Evaluation 3.06 Mental Health and Substance Abuse 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 Limited 3.12 * Suicide Prevention Training 3.13 * Mental Health Crisis Intervention Services 3.14 * Crisis Assessments 3.15 * Emergency Care Plan 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). The following limited and/or failed indicators require immediate corrective action Suicide Precaution Observation Logs* Office of Program Accountability Page 6 of 45 (Revised July 2014)

7 Standard 4: Health Services Detention Rating Profile Indicator Ratings Standard 4 - Healthcare Services 4.01 * Designated Health Authority/Designee 4.02 * Psychiatrist/Designee 4.03 Facility Operating Procedures 4.04 Authority for Evaluation and Treatment 4.05 Parental Notification Limited 4.06 Notification - Clinical Psychotropic Progress Note 4.07 Immunizations 4.08 Healthcare Admission Screening Form 4.09 Medical Alerts Limited 4.10 Suicide Risk Screening Instrument Non-Applicable 4.11 Youth Orientation to Healthcare Services 4.12 Designated Health Authority/Designee Admission Notification 4.13 Healthcare Admission Rescreening 4.14 Health Related History 4.15 Comprehensive Physical Assessment 4.16 Female-Specific Screening/Examination 4.17 Tuberculosis Screening 4.18 Sexually Transmitted Infection Screening 4.19 HIV Testing 4.20 Sick Call Process - Requests/Complaints 4.21 Sick Call Process - Visits/Encounters 4.22 Restricted Housing 4.23 Episodic/First Aid Care 4.24 Emergency Care 4.25 Off-Site Care/Referrals 4.26 Chronic Illness/Periodic Evaluations 4.27 Medication Management - Verification 4.28 Medication Management - Orders/Prescriptions 4.29 Medication Management - Storage 4.30 Medication Management - Medication and Sharps Inventory 4.31 Medication Management - Controlled Medications 4.32 Medication Management - Medication Administration Record 4.33 Medication Management - Medication Administration By Licensed Staff 4.34 Medication Management - Medications Provided By Non-Licensed Staff 4.35 Medication Management - Psychotropic Medication Monitoring 4.36 Infection Control - Surveillance, Screening, and Management 4.37 Infection Control - Education 4.38 Infection Control - Exposure Control Plan 4.39 Prenatal Care - Physical Care of Pregnant Youth 4.40 Prenatal Care - Nutrition and Education of Youth 4.41 Prenatal Staff Education * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). The following limited and/or failed indicators require immediate corrective action Parental Notification 4.09 Medical Alerts Office of Program Accountability Page 7 of 45 (Revised July 2014)

8 Standard 5: Safety and Security Detention Rating Profile Indicator Ratings 5.01 Standard 5 - Safety and Security * Active Supervision of Youth 5.02 * Ten-Minute Checks 5.03 Census Counts and Tracking 5.04 Key Control 5.05 Vehicles and Maintenance 5.06 Tool Inventory and Management 5.07 Kitchen Tools 5.08 * Youth Access & Use of Tools, Cleaning Items 5.09 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items 5.10 * Access to all Flammable, Toxic, Caustic, and Poisonous Items 5.11 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items 5.12 Confinement Under Twenty-Four Hours 5.13 Confinement Over Twenty-Four Hours Limited 5.14 Continuity of Operations Planning (COOP) Drills 5.15 Escape Drills 5.16 Fire Drills * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). The following limited and/or failed indicators require immediate corrective action Confinement Over Twenty-Four Hours Office of Program Accountability Page 8 of 45 (Revised July 2014)

9 Strengths and Innovative Approaches The Alachua Regional Juvenile Detention Center staff employ trauma informed care practices throughout their interactions with the youth in the center. In addition to annual training on trauma informed care for all staff, the center has started doing trauma informed care training sessions in supervisory meetings to emphasize a holistic approach throughout all interactions at the center, to include those between staff and supervisors as well as youth and staff. This top-down approach to applying trauma informed care allows staff to experience the benefits of trauma informed care, which helps to fortify their belief in the practices they are asked to employ with the youth. The center has softened the facility in many areas by using carpets, bean bags, and artwork to reduce the institutional feel. The youth have been actively involved in painting the facility and have created multiple murals with staff guidance. The center updated the behavior management system to make the levels within the system more attainable and achievable without having any drastic negative impacts for misbehavior, which allows youth to refocus and get back on track. The center conducts visitation four times a week, providing a greater opportunity for youth to be able to connect with their families. One of these visitation opportunities is a special reward incentive within the behavior management system. In collaboration with Shands Hospital and the University of Florida Art in Medicine program, the center has had artwork done within the facility as well as had college students volunteer their time to work with youth through many different avenues of art, such as dance, painting, and acting. Office of Program Accountability Page 9 of 45 (Revised July 2014)

10 Standard 1: Management Accountability Overview The Alachua Regional Juvenile Detention Center is a forty-eight bed, secure facility located in Gainesville, Florida. The center houses male and female youth pending adjudication, disposition, or placement in a commitment facility. There were twenty-five youth in the facility the day before the review. The center serves Alachua, Baker, Bradford, Columbia, Dixie, Gilchrist, Hamilton, Lafayette, Levy, Putnam, Suwannee, and Union counties. The center provides education, behavior management, healthcare, mental health and substance abuse services, security, safety, and transportation. The management team consists of the superintendent, two assistant superintendents, and seven juvenile justice detention officer supervisors (JJDOS). Center staffing includes forty juvenile justice detention officers (JJDO), five other personnel services (OPS) JJDOs, four food service staff, one maintenance mechanic, and one administrative secretary. The maintenance mechanic and four JJDO positions were vacant and there were seven newly hired JJDOs attending certification training at the academy at the time of the review. Contracted provider staff provide medical and mental health and substance abuse treatment services. Education services are provided by North American Family Institute through a contract with the Alachua County School District. The center enters all shift reports, confinement reports, grievances, and Protective Action Response (PAR) reports into the Facility Management System (FMS). Youth alerts are discussed at each shift briefing 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. Eleven staff and seven contracted provider staff were applicable for an initial background screening. The eleven staff and seven contracted personnel were background screened prior to hire. An initial background screening was completed for one volunteer who is scheduled to begin providing services at the center in the near future. The Annual Affidavit of Compliance with Level 2 Screening Standards for the center was submitted to the Background Screening Unit (BSU) on January 9, The Annual Affidavit of Compliance with Level 2 Screening Standards for the education program, North American Family Institute was submitted to the Background Screening Unit (BSU) on January 15, 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. Three staff required a five-year background rescreening. Two of the three staff were rescreened within the required time frame. For the remaining staff, the center submitted a request for the rescreening more than ten days in advance of the anniversary of hire date, but used the wrong Office of Program Accountability Page 10 of 45 (Revised July 2014)

11 form. The BSU requested the information be placed on the correct form after the anniversary of hire date. The rescreening request was resubmitted on the correct form and the rescreening was completed Staff Code of Conduct Compliance Program staff adheres to a code of conduct that prohibits 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 center s code of conduct is included in the policy and procedure. The code of conduct clearly outlines expectations for attendance, overall professionalism, and interactions with youth and the public. Personnel files for five staff were reviewed. Each staff acknowledged the code of conduct by signing the Receipt for the Department Employee Handbook and Oath of Loyalty form. The personnel files showed that management holds staff accountable for violations of the code of conduct. Disciplinary actions taken were thoroughly documented and appropriate. Five staff were surveyed. All five staff were familiar with child abuse reporting procedures. None of the staff reported ever seeing a co-worker telling a youth that they could not report abuse to the Florida Abuse Hotline of Central Communications Center (CCC). None of the staff reported ever seeing a co-worker using threats, intimidation or humiliation when interacting with youth. One staff reported hearing a co-worker use profanity in front of youth. Five youth were surveyed. All five youth reported they have never been stopped from reporting abuse to the Florida Abuse Hotline. All five youth reported staff are respectful when addressing youth and all five youth reported they feel safe at the facility. Four youth stated they have heard staff use profanity. Each of the four youth stated the profanity was not directed at youth, but was rather an utterance or part of conversation. One youth reported staff immediately apologized after accidently using profanity 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. Nineteen Central Communications Center (CCC) reports were reviewed for the past six months. Documentation showed all but one incident was called in to the CCC within two hours as Office of Program Accountability Page 11 of 45 (Revised July 2014)

12 required. One incident was classified as a failure to report, as it was reported approximately eight hours after the center became aware of the incident Protective Action Response (PAR) Limited 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. Ten Protective Action Response (PAR) reports were reviewed. All ten reports included statements from all staff involved, though five reports included statements that were completed or modified a day or more after the PAR incident occurred. Two reports had two staff statements which were completed or modified the day after the PAR incident. Three reports had one staff statement that was completed or modified over a month after the PAR incident. Six reports had all input and reviews completed within seventy-two hours. Four reports were not processed within seventy-two hours. One report did not document a superintendent or PAR instructor review, one report had one staff statement and the PAR instructor review after the seventy-hour period, and two reports had one staff statement completed after the seventy-hour period. Supervisor reviews were documented in each report, but were completed prior to staff statements being completed in seven cases. The supervisor reviews did document review of the incident by video or through direct involvement. One report did not document a post-par interview and one had the post-par interview documented two days after the incident. A PAR medical review was not documented in one applicable case due to the nurse being new and not having JJIS access. The superintendent/designee review was documented within seventy-two hours in nine reports, but was not completed after all other input in five reports. Five youth were surveyed. Three youth reported they had not witnessed any restraints at the facility. The remaining two youth reported staff try to talk to youth prior to using physical interventions. Five staff were surveyed. All five staff stated they try to talk with youth prior to using physical interventions 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. One staff was applicable for completion of juvenile detention officer certification during the review period. The staff completed the certification and all other required training within 180 days of hire. Training records for two staff attending the academy were reviewed. Each staff completed all phase I training requirements prior to going to the academy In-Service Training Compliance All detention staff completes twenty-four hours of in-service training, including mandatory topics specified in Florida Administrative Code, each calendar year, effective the year after preservice/certification training. Supervisory staff completes eight hours of training (as part of the twenty-four hours of in-service training) in the areas specified in Florida Administrative Code. Office of Program Accountability Page 12 of 45 (Revised July 2014)

13 Five staff were reviewed for in-service training in 2013, three of which were supervisors. All five staff had well over twenty-four hours of annual training, with hours ranging from sixty-six to 176. The three supervisory staff completed well over eight hours of training on management-related topics, with hours ranging from nineteen to sixty-three. All five staff held current cardiopulmonary resuscitation (CPR), first aid, and automated external defibrillator (AED) certifications. All five staff completed a PAR update in 2013, though two did not complete their PAR update within a year of their previous PAR update. One staff did not have CPR or first aid training in One staff did not have training in professionalism and ethics Logbook Maintenance Compliance The program maintains a chronological record of events, incidents, and activities in logbooks maintained at master control and in each living area in accordance with Florida Administrative Code. Each logbook is a bound book with numbered pages. If electronic logbook software is used by the facility, it is password-protected and configured to prevent entries from being deleted or altered after they are saved. At a minimum, each logbook entry includes the date and time of the event, the names of staff and youth involved, a brief description of the event, the initials of the person making the entry, and the date and time of the entry. Logbook entries are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are obliterated or removed; errors are struck through with a single line and initialed by the person correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts, or other issues that may impact facility safety and security shall be highlighted. Master control and module logbooks were reviewed. Logbooks were bound with numbered pages. All facility events were recorded. Facility activities could be followed in the logbooks. Dates were recorded at the top of each page and/or the beginning of each shift. Times were listed with each entry. Staff recorded their initials following each entry. All counts, new admissions, releases, alerts (medical, mental health, and security), and other significant information was documented in red ink. Corrections of errors were not consistently documented with a single line through the error and the staff initials. There were write overs rather than corrections, though no entries were obliterated Logbook Reviews Limited Compliance The superintendent or designee reviews all logbooks on a weekly basis. The supervisor(s) reviews the facility logbook maintained at master control when he/she accepts responsibility for the facility. The Juvenile Justice Detention Officer (JJDO) Supervisor(s) reviews logbooks maintained in each living area daily. The JJDO(s) reviews the logbook maintained in his/her assigned living area when he/she accepts responsibility for the living area at shift change. A review of module logbooks found supervisors and JJDOs assigned to the mods reviewed the previous shifts with minor exceptions. Module logbooks were reviewed by assistant Office of Program Accountability Page 13 of 45 (Revised July 2014)

14 superintendents on a weekly basis with one exception. A review of master control logbooks found that the superintendent/designee reviews were not regularly documented on a weekly basis. Further, the supervisor reviews of the master control logbook at the beginning of each shift were sporadic Entering Alerts (JJIS) Compliance Superintendents shall ensure that Critical and Special Alerts are reviewed and responded to appropriately. Upon completion of the Admission Wizard, the officer shall ensure that the all Critical and Special Alerts are listed in JJIS. The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure that it correctly reflects the status of youth. If the electronic system is inoperable, for any reason, the JJDO Supervisor shall ensure that 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. Alerts were entered and updated in the Juvenile Justice Information System (JJIS) for medical, mental health, gang affiliation, dietary, and security alerts. Alerts noted in youth files and JJIS were congruent with minor exceptions. Qualified staff made alert entries and updates in JJIS. There were inconsistencies with medical alerts in JJIS for three youth, which were corrected during the review. There was one suicide alert left open following a youth s release. The alert was still active upon the youth s recent admission and was closed following the completion of an Assessment of Suicide Risk (ASR) 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. Alerts are discussed at each shift meeting. An alert list is printed for each meeting and distributed to different program areas, including the kitchen, when updates are made. Each youth s alert status was noted in the master control and module logbook upon admission. Alert status updates were noted in the logbooks as well. Office of Program Accountability Page 14 of 45 (Revised July 2014)

15 Standard 2: Assessment and Performance Plan Overview JJDOs complete admission processes and paperwork, which includes orientation and classification. JJDOSs review all admission and classification paperwork. All personal property of youth is inventoried and stored. Valuables are inventoried, placed in a drop safe, and then transferred to a safe in administration for safe keeping. There is limited access to the safe and the safe is under video surveillance. The schedule includes education, recreation, visitation, and other structured activities. All direct care staff are responsible for the implementation of the behavior management system. Youth progress or status in the behavior management system is regularly reviewed Admission Compliance All youth are admitted to the program in accordance with Florida Administrative Code through a process that, at a minimum, addresses 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. Five files were reviewed for the admission process and review of admission information. All five files documented review of paperwork from law enforcement and screening staff. All five files documented youth were frisk and stripped searched by an officer of the same gender as the youth. Each youth was given the opportunity to make a phone call and each youth was offered something to eat. Admission paperwork with three exceptions was accurately completed and signed appropriately by youth, staff, and others designated to do so, such as supervisors and mental health staff. Three files were missing the vulnerability to victimization form 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; Office of Program Accountability Page 15 of 45 (Revised July 2014)

16 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. Five of five files reviewed documented all required elements of orientation were provided to youth upon admission. Youth signed orientation documents to acknowledge the information covered. Each youth receives an orientation brochure covering youth rights and center rules. The center reviews the brochure on each module every Monday as well. Four of five youth surveyed said staff reviewed the center s rules and expectations at admission Classification Compliance All youth admitted to the detention center shall be classified to provide the highest level of safety and security. Considerations shall include, at a minimum: 1. Physical characteristics (e.g. sex, height and weight); 2. Age and level of aggressiveness; 3. Special needs (mental illness, developmental disabilities, and physical disabilities); 4. History of violent behavior; 5. Gang affiliation; 6. Criminal behavior; 7. History of sexual offenses; 8. Vulnerability to victimization; and 9. Suicide risk identified or suspected. Youth shall be assigned to a room based on their classification and are reclassified if changes in behavior or status are observed. Youth with a history of committing sexual offenses or a victim of a sexual offense are not to be placed in a room with any other youth. Youth with a history of violent behavior shall be assigned to rooms where it is least likely that they will be able to jeopardize safety and security. Five files were reviewed. Classification documentation reflected physical characteristics, age, level of aggression, special needs, history of violent behavior, gang affiliation, medical needs, and suicide risk were addressed and considered for the classification of youth and room assignment. Three files did not have a Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) form. One youth scored fifteen points on the VSAB, which indicated the youth to be vulnerable to victimization due to scoring twelve points or higher. The classification for this youth indicated standard supervision and that he could share a room. While the classification indicated this youth could share a room, documentation showed he was placed in a single room during his stay at the center Classification of Gang Members Compliance All newly admitted youth are screened to determine if he or she is a criminal street gang member or is affiliated with any criminal street gang. Each facility shall identify a staff person to serve as a gang representative who shall review Office of Program Accountability Page 16 of 45 (Revised July 2014)

17 identified youth for suspected gang involvement or gang activity. All five youth files reviewed had a completed Gang Identification Form signed by the youth and staff reflecting no gang affiliation reported. The center has a tracking form reflecting youth documented as gang members and their gang affiliation. An assistance superintendent serves as the center s gang liaison Notification of Law Enforcement Compliance A referral on a youth for suspected gang involvement shall be shared with local law enforcement and educational providers or local school districts providing educational services at the facility, as well as with the youth s Juvenile Probation Officer (JPO) and, if identified, their post residential services counselor. Facility staff shall share pertinent gang-related information, as appropriate, with the Florida Department of Law Enforcement, local law enforcement, Department of Corrections, school districts, the judiciary, and social service agencies, as well as with a youth s JPO. Written policy and procedure outlines notification of law enforcement for youth suspected of gang involvement. None of the files reviewed required notification for gang affiliation. The assistant superintendent who serves as the gang liaison maintains a gang tracking form and shares information with gang representatives from local law enforcement, educational providers, local school districts, and juvenile probation officers. The tracking form showed notifications were made when youth were identified to be affiliated with a gang Admission of Youth Personal Property Compliance The program takes possession of each youth s personal property during admission. In the presence of each youth, staff inventories all personal property in the youth s possession and records each surrendered item on the Property Receipt Form. Five files were reviewed. Personal property was appropriately inventoried in each case. Each personal property form and valuables inventory form, as applicable, were signed by youth and the staff completing the inventory. Each youth signed a property acknowledgement form, acknowledging property left at the center would be disposed of or donated. There were no reports of lost or stolen property at the center in this review period. All five youth surveyed said they signed a property form to indicate the form accurately listed their property Storage of Youth Personal Property Compliance The program safeguards each youth s personal property until it can be returned to the youth and/or legal guardian. Policy and procedure is in place to ensure youth s personal property is safeguarded. Youth s personal property is stored in a secure area and the youth s valuables are secured in lock box in a secure area under video surveillance Release Compliance When releasing youth from detention, the releasing officer shall verify the court s authorization to release the youth. Care must be taken to ensure all case file information is reviewed to Office of Program Accountability Page 17 of 45 (Revised July 2014)

18 prevent the negligent release of a youth. All releases from the program are court-ordered, with the exception of deaths, escapes, and expirations of detention time period. In the absence of a written order, documentation of a verbal order in open court may be used for release. The on-duty JJDO Supervisor reviews all paperwork prior to release. The JJDO Supervisor is responsible for ensuring that there are no holds, court orders, or other legal reasons not to release the youth. Questions concerning release are presented and addressed by the Superintendent, or designee, prior to release. The releasing officer shall verify the identification of the youth. Three closed files were reviewed for youth released from the center. Each file documented that release paperwork was reviewed by a JJDOS, which included an Alachua County Sheriff s Office warrants check sheet, the court order, electronic monitoring contract (as applicable), and parent/guardian identification Release of Youth Personal Property Compliance Upon the youth s release from detention and retrieval of personal property, the releasing officer, the youth, and the youth s legal guardian shall review and sign the Property Receipt Form and account for all of the youth s personal property. Three closed files reviewed documented that the youth and parents/guardians signed for personal property and valuables upon release. Documentation in the property logbook reflects that property was last purged on June 6, 2014 to headquarters to be forwarded to the bureau of unclaimed property, as per policy. The Facility Management System (FMS) reflected there were no youth with property left at detention center for over thirty days at the time of the review Release of Medication, Aftercare Instructions Compliance The program ensures that there are provisions in place to ensure that prescribed medication, along with medical instructions. accompanies detained youth upon release. Three closed files were reviewed for youth released with medication. Each file contained acknowledgement receipts complete with required signatures, dates, and medication instructions provided by a facility nurse Review of Youth in Secure Detention Compliance Detention reviews are conducted by the program on a weekly basis to ensure proper management of youth placed in secure detention and appropriate sharing of information. The superintendent appoints an appropriate staff person to coordinate detention reviews. Documentation showed reviews of all youth in secure detention are conducted at the facility on a weekly basis. The documentation and observation of a detention review meeting showed representatives from probation attend in person or by phone. The status of each youth in secure detention is addressed during the detention reviews. Office of Program Accountability Page 18 of 45 (Revised July 2014)

19 2.12 Review of Youth on Home Detention Compliance Detention reviews are conducted by the program on a weekly basis to ensure proper management of youth placed in home detention and appropriate sharing of information. The superintendent appoints an appropriate staff person to coordinate detention reviews. Documentation showed reviews of all youth on home detention are conducted at the facility on a weekly basis at the same time youth in secure detention are reviewed. The documentation and observation of a detention review meeting showed representatives from probation attend in person or by phone. The status of each youth on home detention is addressed during the detention reviews Daily Activity Schedule Compliance Youth are provided the opportunity to participate in constructive activities that will benefit the youth and the program. The Superintendent or Designee develops a daily activity schedule, which is posted in each living area and outlines the days and times for each youth activity. Daily activity schedules are posted on the walls of each module, as observed during the facility tour. At no time during the review period were scheduled visitations cancelled or postponed. Youth on Level III of the behavior management system are eligible for additional visitation on Tuesdays from 7:30 p.m. through 8:30 p.m. Gender-specific groups were conducted for male and female youth on multiple occasions Adherence to Daily Schedule Compliance Facility staff shall adhere to the daily activity schedules. Documentation of all activities shall be made in all applicable logs. The on-duty supervisor must approve any significant changes in the activity schedule and shall document the reason for the change(s) in the shift report. Any cancellation of visitation shall be approved by the superintendent. A review of logbooks and comparison to the daily scheduled found that the daily schedule is followed. Observations during the review also found that the daily schedule is followed. Schedule adjustments are made as needed for nurse calls, court, weather conditions, staff, or unexpected events. All five youth and all five staff surveyed said the daily schedule is followed Educational Access Compliance The facility shall integrate educational instruction (career and technical education, as well as academic instruction) into their daily schedule in such a way that ensures the integrity of required instructional time. The Alachua County School District contracts with North American Family Institute to provide education services at the center. Educational instruction is incorporated into the daily activity schedule. The schedule provides for the required amount of instruction time. Youth enrolled in the educational program receive school credit(s). A review of logbooks and review team observations found minimal interference with the educational program. All five youth surveyed said they attend school five days a week. Office of Program Accountability Page 19 of 45 (Revised July 2014)

20 2.16 Vocational Programming Compliance Staff shall develop and implement a vocational competency development program. The education program at the center provides Level 1 vocational programming. Youth receive instruction in life skills and basic vocational skills. Instruction provided is based on age and educational abilities of the youth Behavior Management System Compliance The program provides a system of rewards, privileges, and consequences to encourage youth to fulfill the program s expectations. Each facility shall implement and maintain a behavior management system to meet the needs of the youth and the facility. The system shall be approved by the regional director and shall include rewards for positive behavior and consequences for inappropriate behavior. The behavioral norms and expectations for youth shall be posted in all living areas and shall clearly specify appropriate and inappropriate behaviors. The center recently updated the behavior management system to include another level and more incentives for positive behavior. The behavior management system, center rules, and expectations were posted in the living areas. Point sheets reviewed reflected documentation of positive and negative behavior and related consequences, to include confinement. Five youth were surveyed. Four youth rated the behavior management system as good and the other rated it as fair. Youth who had received consequences said they felt the consequences were fair. Five staff were surveyed. Four staff stated the behavior management system is effective. All five staff said youth are given the opportunity to explain their behavior prior to consequences being applied and that consequences are explained to the youth. All five staff said they receive feedback from the supervisor on their implementation of the behavior management system Unauthorized Use of Punishment Compliance The center s behavior management system restricts certain types of penalties on youth who demonstrate negative behaviors. Group punishment shall not be used as a part of the facility s behavior management plan. However, corrective action taken with a group of youth is appropriate when the behavior of a group jeopardizes safety or security, and this should not be confused with group punishment. Corporal punishment shall not be used in detention facilities. All allegations of corporal punishment of any youth by facility staff shall be reported to the Florida Abuse Hotline, pursuant to Chapter 39, F.S., and the Central Communications Center. The use of drugs to control the behavior of youth is prohibited. This does not preclude the proper administration of medication as prescribed by a licensed physician. There was no indication in incident reports or other documentation reviewed of unauthorized use of punishment during the review period. Five youth and five staff were surveyed. None of Office of Program Accountability Page 20 of 45 (Revised July 2014)

21 the youth or staff surveyed reported any type of unauthorized punishment being utilized at the center Grievances Compliance The grievance procedures establish each youth s right to grieve and ensure that all youth are treated fairly, respectfully, without discrimination, and that their rights are protected. The process includes: 1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with the youth using effective communication skills; 2. Formal phase, wherein the youth submits a written grievance that results in a response from a JJDO Supervisor by the end of the shift (if possible), or otherwise within twentyfour hours; and 3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the superintendent or designee. Three grievances were reviewed. Each grievance documented responses at all levels within the required time frames. Youth acknowledged resolution of grievances by signature. Five youth were surveyed, of which two reported they had filed a grievance. One of the youth filing a grievance rated the grievance process as good and the other rated the process as fair Trauma-Informed Care Compliance The facility is incorporating trauma-informed practice into current operations to deliver services and to provide care to youth in custody that acknowledge the role that violence and victimization play in the lives of most of the youth entering the facility. Trauma-informed practice has many characteristics, which include the following: A recognition of the high prevalence of trauma Assessment for traumatic histories and symptoms Recognition of culture and practices that may be re-traumatizing Collaboration of caregivers Training of staff to improve trauma knowledge and sensitivity Increased staff understanding of the function of behavior (rage, self-injury, etc.) as an expression of trauma Use of objective and neutral language (avoids labeling of youth) Five of five training files reviewed for in-service training documented annual training for staff in trauma informed care. All five staff surveyed reported they have received training in trauma informed care. The center s administration emphasizes the use of trauma informed care practices with youth and among staff. The center has softened the facility in many areas by using carpets, bean bags, and artwork to reduce the institutional feel. Youth have been allowed to paint many murals as well, especially in the living areas. Office of Program Accountability Page 21 of 45 (Revised July 2014)

22 Standard 3: Mental Health and Substance Abuse Services Overview The center has a contract with a licensed mental health counselor (LMHC), who serves as the designated mental health authority (DMHA). The DMHA is responsible for oversight of mental health and substance abuse treatment services. The DMHA is at the center forty hours per week and is on-call twenty-four hours per day, seven days per week. Another LMHC provides services twenty hours per week. One unlicensed staff provides twenty hours of service per week. The mental health staff are responsible for the completion of Suicide Risk Screening Instruments (SRSI), Crisis Assessments, Assessments of Suicide Risk (ASR), and Follow up Assessments of Suicide Risk, initial treatment plans, individual treatment plans, and reviewing Precautionary Observations (PO) log sheets. The mental health staff complete Substance Abuse Mental Health-2 (SAMH-2) assessments, when applicable. The DMHA is the coordinator of mini-treatment team meetings, which are held each Wednesday. The center has a contract for psychiatric services. The psychiatrist is on site one day per week for two hours Designated Mental Health Authority (DMHA) Compliance A Designated Mental Health Authority (DMHA) is required in each detention center. The DMHA is responsible and accountable for ensuring appropriate coordination and implementation of mental health and substance abuse services in the facility and shall promote consistent and effective services and allow the facility superintendent and staff a specific source of expertise and referral. The designated mental health authority (DMHA) is a licensed mental health counselor (LMHC). The DMHA is on site forty hours per week. The DMHA s license was reviewed and found to be clear and active. The contract with the DMHA included Department requirements. The DMHA was interviewed. The interview confirmed the DMHA is responsible for oversight of mental health and substance abuse treatment services Licensed Mental Health and Substance Abuse Clinical Staff Compliance The facility superintendent is responsible for ensuring that mental health and substance abuse services are provided by individuals with appropriate qualifications. Clinical supervisors must assure that clinical staff working under their supervision are performing services that they are qualified to provide based on education, training, and experience. The DMHA and a part-time LMHC provide services at the center. The licenses for both are clear and active. All services provided by the licensed staff were within the scope of their licensure Non-Licensed Mental Health and Substance Abuse Clinical Compliance Staff The facility superintendent is responsible for ensuring that mental health and substance abuse services are provided by individuals with appropriate qualifications. Clinical supervisors must assure that clinical staff working under their supervision are performing services that they are qualified to provide based on education, training, and experience. One treatment staff is unlicensed. Clinical supervision was conducted with the unlicensed staff on a weekly basis. Clinical supervision was provided by the DMHA. Each supervision session Office of Program Accountability Page 22 of 45 (Revised July 2014)