BUREAU OF MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR

Transcription

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 Department of Juvenile Justice (State-Operated ) 3948 West Martin Luther King Jr. Blvd. Tampa, Florida Review Date(s): February 23-26, 2016 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: Felicia S. Goldstein, Office of Program Accountability, Lead Reviewer ([Standard 1]) Toni DelRegno, Office of Program Accountability, Regional Monitor (Standard 3) Scott Luciano, Office of Program Accountability, Regional Monitor (Standard 4) Vernon B. Pryer Jr., Office of Program Accountability, Regional Monitor (Standard 2) Canitha Taylor, Pasco Juvenile Detention Center, Juvenile Justice Detention Officer Supervisor (Standard 5)

3 Program Name: Hillsborough West 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): February Lead Reviewer Code: 121 Methodology This review was conducted in accordance with FDJJ-2000 (Contract Management and Program Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1) Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention Standards. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee 0 # Case Managers 1 # Clinical Staff 0 # Food Service Personnel 1 # Healthcare Staff Documents Reviewed 0 # Maintenance Personnel 0 # Program Supervisors 1 # Other (listed by title): Intake Officer, 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 9 # Health Records 10 # MH/SA Records 7 # Personnel Records 7 # Training Records/CORE 5 # Youth Records (Closed) 7 # Youth Records (Open) # Other: 7 # Youth 7 # Direct Care Staff # Other: Observations During Review Admissions Confinement Facility and Grounds First Aid Kit(s) Group Meals Medical Clinic Medication Administration Posting of Abuse Hotline Program Activities Recreation Searches Security Video Tapes Sick Call Social Skill Modeling by Staff Staff Interactions with Youth Comments Staff Supervision of Youth Tool Inventory and Storage Toxic Item Inventory and Storage Transition/Exit Conferences Treatment Team Meetings Use of Mechanical Restraints Youth Movement and Counts Items not marked were either not applicable or not available for review. Office of Program Accountability Page 3 of 57 (Revised July 2015)

4 Standard 1: Management Accountability Detention Rating Profile Indicator Ratings Standard 1 - Management Accountability 1.01 * Initial Background Screening 1.02 Five-Year Rescreenings 1.03 Staff Code of Conduct 1.04 * Incident Reporting (CCC) 1.05 Protective Action Response (PAR) 1.06 * Pre-Service/Certification Requirements 1.07 In-Service Training 1.08 Logbook Maintenance Limited 1.09 Logbook Reviews 1.10 * Entering Alerts (JJIS) 1.11 Sharing of Alert Information * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 4 of 57 (Revised July 2015)

5 Standard 2: Youth Management Detention Rating Profile Indicator Ratings Standard 2 - Youth Management 2.01 Admission 2.02 Orientation 2.03 Classification 2.04 Classification of Gang Members 2.05 Notification of Law Enforcement Limited 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 Career Education 2.17 Behavior Management System 2.18 * Unauthorized Use of Punishment 2.19 Grievances 2.20 Trauma-Informed Care * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 5 of 57 (Revised July 2015)

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 Clinician Authority (DMHCA) 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 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). Office of Program Accountability Page 6 of 57 (Revised July 2015)

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 4.06 Notification - Clinical Psychotropic Progress Note 4.07 Immunizations 4.08 Healthcare Admission Screening Form 4.09 Medical Alerts 4.10 Suicide Risk Screening Instrument 4.11 Youth Orientation to Healthcare Services 4.12 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 Conditions/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 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 Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 7 of 57 (Revised July 2015)

8 Standard 5: Safety and Security Detention Rating Profile Indicator Ratings Standard 5 - Safety and Security 5.01 * Active Supervision of Youth 5.02 * Ten-Minute Checks 5.03 Census Counts and Tracking 5.04 Key Control 5.05 Vehicles and Maintenance 5.06 Tool Inventory and Management 5.07 Kitchen Tools 5.08 * Youth Access & Use of Tools, Cleaning Items 5.09 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items 5.10 * Access to all Flammable, Toxic, Caustic, and Poisonous Items 5.11 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items 5.12 Confinement Under Twenty-Four Hours 5.13 Confinement Over Twenty-Four Hours 5.14 Continuity of Operations Planning (COOP) Drills 5.15 Escape Drills 5.16 Fire Drills 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 Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 8 of 57 (Revised July 2015)

9 Strengths and Innovative Approaches Hillsborough West Regional Juvenile Detention Center has partnered with the local campus of Argosy University to have master s level mental health clinicians provide weekly life skills classes and complete comprehensive mental health evaluations on youth being considered for residential commitment. Hillsborough West Regional Juvenile Detention Center has implemented a Youth Mail via Program, which allows parents/guardians to send to their youth through a facility address. Office of Program Accountability Page 9 of 57 (Revised July 2015)

10 Standard 1: Management Accountability Overview Hillsborough West Regional Juvenile Detention Center is located in Tampa, Florida. The center is a state-operated facility, with a capacity of ninety-three beds, of which, sixty five were occupied. The management team consists of a superintendent, two assistant superintendents, and nine juvenile justice detention officer supervisors (JJDOS). There were four staff vacancies at the time of the annual compliance review along with fifteen new recruits, two staff starting this week, and five staff out on extended leave. Services for the youth include education, mental health, substance abuse, and healthcare. The medical services are provided through a contract with Maxim Healthcare Services and mental health services are provided through a contract with Camelot Community Care, Inc. Education services are provided by the Department of Education through the Hillsborough County Public School District Initial Background Screening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. The background screening process is completed prior to hiring an employee or utilizing the services of a volunteer, mentor, or intern. An Annual Affidavit of Compliance with Level 2 Screening Standards is completed annually. Thirty-one new staff members have been hired since the last annual compliance review. All new staff members were screened by the Department s Background Screening Unit (BSU) before their date of hire. The Annual Affidavit of Compliance with Level 2 Screening Standards was submitted to the Department s BSU on January 28, The Annual Affidavit of Compliance with Level 2 Screening Standard for school board teachers was sent to the BSU on January 29, The Annual Affidavit of Compliance with Level 2 Screening Standard for Camelot Community Care was sent to the BSU on January 13, The Annual Affidavit of Compliance with Level 2 Screening Standard for Maxim Healthcare Services was sent to the BSU on January 25, There were no volunteers requiring a background screening during this annual compliance review period 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. Nine center staff members and one Camelot Community Care employee were eligible for a fiveyear background screening. All center staff had a rescreening completed within one year prior to their anniversary date. The Camelot Community Care employee was hired on September 1, 2010, and screened prior to working at the center on October 19, 2010; however, the five-year screening was not completed until November 20, No Maxim Healthcare Services staff or center volunteers were eligible for a rescreening during this annual compliance review period. Office of Program Accountability Page 10 of 57 (Revised July 2015)

11 1.03 Staff Code of Conduct Compliance Program staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats, harassment, intimidation, horseplay, or personal relationships with youth. Officers shall maintain the confidentiality afforded to all youth, and shall not release any information to the general public or the news media about any youth in detention or who has been in the custody of the department. Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use profanity in the performance of their job. Officers shall not engage in or allow horseplay, either verbal or physical with and/or between any youth. Officers shall not engage in personal relationships nor discuss personal information related to themselves or other officers with any youth. Management takes immediate action to investigate or address all allegations or violations of the code of conduct. The center uses the Department of Juvenile Justice (DJJ) employee handbook and code of conduct. The personnel files of seven staff were reviewed and each contained a signed receipts of Department employee handbook, oath of loyalty, and the Department s internet policy. Three of the seven reviewed staff files contained documentation of disciplinary action, of which two received verbal counseling and one received a written notice of counseling. Two staff received commendations in 2015, one staff was recognized for outstanding service, and one was selected as the overall state DJJ employee of the month and featured in the DJJ newsletter. Two Central Communications Center (CCC) reports showed substantiated allegations of staff improper conduct; however, the staff resigned during the investigation process in both cases. A total of seven youth were surveyed, and four of seven youth indicated some staff are not respectful when talking to them and other youth. Five of seven youth stated they have heard staff curse occasionally or often. Three youth said they have heard staff threaten them or other youth often or occasionally. When questioned further the youth indicated staff threaten to put them in confinement for their behavior or threaten to take their level or level privileges away. Seven staff were surveyed and all reported they have never heard staff threaten or intimidate other youth. Two of seven staff indicated they have heard staff use profanity in the presence of youth Incident Reporting (CCC) Compliance Whenever a reportable incident occurs, the program notifies the Department s Central Communications Center (CCC) within two hours of the incident, or within two hours of becoming aware of the incident. The center has a written policy and procedure regarding their response to incidents. A review of sixty-one closed incidents involving calls to the Central Communications Center (CCC) was conducted for the last six months. Reports were made regarding program disruptions, youth behavior incidents, medical incidents, and complaints against staff. All of the incidents were called into the CCC within two hours of the incident or within two hours of becoming aware of the incident. Not all CCC reports are being documented consistently into the center logbook; Office of Program Accountability Page 11 of 57 (Revised July 2015)

12 however, they were being documented in the shift briefing reports, which are stored in the Juvenile Justice Information System (JJIS) Protective Action Response (PAR) Compliance The program uses physical intervention techniques in accordance with Florida Administrative Code. Any time staff uses a physical intervention technique, such as countermoves, control techniques, takedowns, or application of mechanical restraints (other than for regular transports), a PAR Incident Report is completed and filed in accordance with the Florida Administrative Code. There have been approximately one hundred Protective Action Response (PAR) reports completed within the last six months. A review of eleven randomly selected PAR reports indicated each of the reports was completed as required. All reports included statements from each staff involved and were completed by the end of the staff member s workday. All eleven reports were completed within seventy-two hours by required parties. None of the reports documented an injury and ten of the reports documented a Post-PAR interview with the youth conducted within thirty minutes of the incident. One PAR report did not indicate an interview was conducted for a Post-PAR interview. There was no documentation to suggest mechanical restraints were used in any of the reviewed reports. Seven youth were surveyed and five indicated staff tried to talk with youth before the use of physical interventions; two youth indicated staff do not always try to talk with the youth before using physical intervention Pre-Service/Certification Requirements Compliance Detention staff are trained in accordance with Florida Administrative Code. Detention staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. Seven staff training files were reviewed, of which, four were applicable to this indicator. Reviewed training files reflected each staff completed the certification process within 180 days of hire. All seven 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 indicated staff 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 seven agreed they are adequately trained for their job In-Service Training Compliance All detention staff completes twenty-four hours of in-service training, including mandatory topics specified in Florida Administrative Code, each calendar year, effective the year after preservice/certification training. Supervisory staff completes eight hours of training (as part of the twenty-four hours of in-service training) in the areas specified in Florida Administrative Code. The center provides in-service training to staff in a combination with instructor-led courses and courses in the Department s Learning Management System (SkillPro). The center has an annual training plan to identify which trainings will be provided each month. Seven staff training Office of Program Accountability Page 12 of 57 (Revised July 2015)

13 files were reviewed and three were applicable to this indicator. All of the files documented receiving between thirty-seven and eighty-six hours of in-service training, exceeding the annual requirement of twenty-four hours. Each reviewed file contained documentation of Protective Action Response (PAR) updates, as well as current cardiopulmonary resuscitation (CPR) and first aid certification. Two of the three reviewed training files were applicable for supervisory training. Both supervisors had more than the required eight hours of supervisory training documented in SkillPro; however, only one file clearly indicated the required topics of management, leadership, personal accountability, employee relations, communication skills, and fiscal responsibility were provided within the supervisory training. Seven staff were surveyed and all seven agreed they are adequately trained for their job Logbook Maintenance Limited Compliance The program maintains a chronological record of events, incidents, and activities in logbooks maintained at master control and in each living area in accordance with Florida Administrative Code. Each logbook is a bound book with numbered pages. If electronic logbook software is used by the facility, it is password-protected and configured to prevent entries from being deleted or altered after they are saved. At a minimum, each logbook entry includes the date and time of the event, the names of staff and youth involved, a brief description of the event, the initials of the person making the entry, and the date and time of the entry. Logbook entries are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are obliterated or removed; errors are struck through with a single line and initialed by the person correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts, or other issues impacting facility safety and security shall be highlighted. The center maintains a master control logbook in addition to a logbook for each living unit. A sample of logbooks for the last six months was reviewed and each logbook contained a record of events, activities, and most incidents. Each book is bound with numbered pages. All entries are made in black or blue ink with no erasures or correction fluids used in the logbooks. Each 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. Most errors were struck through with a single line and initialed by the person correcting the error. Minor amounts of entries related to facility safety and security events were not consistently highlighted and some were highlighted in a variety of colors. Entries were not always documented properly for youth going in and out of confinement rooms. Some entries showed a youth entering D Cell but not the time of their release. Since the center uses more than one confinement room, it was difficult to determine the placement of the youth while in confinement. Office of Program Accountability Page 13 of 57 (Revised July 2015)

14 1.09 Logbook Reviews Compliance The superintendent or designee reviews all logbooks on a weekly basis. The supervisor(s) reviews the facility logbook maintained at master control when he/she accepts responsibility for the facility. The Juvenile Justice Detention Officer (JJDO) Supervisor(s) reviews logbooks maintained in each living area daily. The JJDO(s) reviews the logbook maintained in his/her assigned living area when he/she accepts responsibility for the living area at shift change. A reviewed sample of master control and living unit logbooks for the past six months documented the superintendent and/or designee reviewed the logbooks at a minimum on a weekly basis. There was also evidence the juvenile justice detention officer supervisor (JJDOS) and juvenile detention officers (JDOs) were reviewing the logbooks for each shift change and accepting responsibility for their assigned living area with one exception; supervisors did not always clearly indicate in their entry they were assuming responsibility the shift Entering Alerts (JJIS) Compliance Superintendents shall ensure Critical and Special Alerts are reviewed and responded to appropriately. Upon completion of the Admission Wizard, the officer shall ensure all Critical and Special Alerts are listed in JJIS. The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it correctly reflects the status of youth. If the electronic system is inoperable, for any reason, the JJDO Supervisor shall ensure the last hard copy of the alerts shall have a written notification or update of the recent admissions or changes to existing alerts on the alert sheet and distribute to all staff within the facility immediately. Medical and mental health staff shall review alerts to ensure each alert is correctly tracked and managed. The responses and updates by medical, mental health and other staff should be documented in JJIS alerts as they pertain to that critical alert. The reviewed documentation of the Juvenile Justice Information System (JJIS) Critical and Special Alert Report verified the center has a procedure to ensure all appropriate alerts are entered into the Juvenile Justice Information System (JJIS). Seven youth records were reviewed and all appropriate alerts were entered and closed into JJIS, as required. The center s procedure is to discuss the alert status of all youth at each shift briefing. Observations during this annual compliance review and a review of twelve shift briefings over the last six months, validate this practice. A review of seven youth healthcare, mental health, and youth case management records were reviewed and all necessary alerts were entered and/or closed in Office of Program Accountability Page 14 of 57 (Revised July 2015)

15 JJIS, as required. Alerts related to suicide precautions consistently included notifications of the applicable youth step down process Sharing of Alert Information Compliance JJDOS s shall inform staff of alerts during shift briefing. When a JJDOS receives changes to the alert list, he or she shall notify the staff affected by changes and add the information to the shift briefing for the oncoming shift upon receipt of the information. A review of twelve shift-briefing reports from the last six months indicated juvenile justice detention officer supervisors (JJDOS) were consistently sharing current, closed, and new alerts with staff during each shift briefing. Changes to a youth s alert status was entered by the appropriate party into Juvenile Justice Information System (JJIS) and in the living unit logbook. During the annual compliance review, a shift change briefing/meeting was observed; all youth with open alerts or recent changes to their alert in JJIS were discussed, in detail, with staff. Six of seven staff surveys verified information pertaining to youth alerts is shared routinely at shift briefings in addition to center staff meetings and the logbook. Office of Program Accountability Page 15 of 57 (Revised July 2015)

16 Standard 2: Assessment and Performance Plan Overview The intake juvenile justice detention officer (JJDO) is responsible for completing all admissions of youth to the detention center. This includes securing personal property, conducting orientation, providing an intake meal, ensuring a parent/guardian is contacted, and collecting all pertinent information. Upon entering the detention center, each youth receives orientation, which includes reading a brochure and watching a video. The orientation brochure is done both verbally and in writing. All youth are screened and classified, utilizing the Juvenile Justice Information System (JJIS) Detention Admission Wizard form, according to their level of risk, to ensure each youth is properly placed in a living unit. Youth are screened for any significant mental health, medical, and security alerts including gang affiliation upon admission. All alerts are entered into the Facility Management System (FMS) and JJIS along with making needed referrals. The center has four modules for housing with one for females and the other three for males. Educational services and vocational programming are provided to each youth by the Hillsborough County School District Admission Compliance All youth are admitted to the program in accordance with Florida Administrative Code through a process, at a minimum, addressing the following: 1. Review of required paperwork from law enforcement and screening staff. 2. Review of inactive files shall be conducted, if available, to obtain useful information. 3. All youth shall be electronically searched, frisk searched, and stripped searched by an officer of the same sex as the youth. 4. All youth shall be allowed to place a telephone call at the facility s expense to his/her parent/guardian and the call shall be documented on all applicable forms, or document refusal to make a telephone call. 5. If the admission process is completed two hours or more before the serving of the next scheduled meal, youth shall be offered something to eat. 6. All youth shall be screened to identify medical, mental health, and substance abuse needs. Any youth identified as at risk of suicide shall be placed on Precautionary Observation until evaluated by the licensed mental health provider. The center has written operating procedures in place regarding the process of admitting youth to the center. The intake/admission screener ensures the Detention Risk Assessment Instrument (DRAI), Suicide Risk Screening Instrument (SRSI), Positive Achievement Change Tool (PACT), and expanded face sheet are provided for each admission. Seven files were reviewed and each contained all the required elements of this indicator. All seven reviewed youth files contained documentation a telephone call was offered to the youth, and the orientation process was completed for each youth within twenty-four hours of admission. All youth were screened for medical, mental health, and substance abuse needs. Two of the seven reviewed files documented youth were placed on precautionary observation until evaluated by the mental health professional. A review team member observed the admission process of three youth. A same sex juvenile justice detention officer (JJDO) performed an electronic and frisk search of each youth. The intake JJDO offered each youth a telephone call and something to Office of Program Accountability Page 16 of 57 (Revised July 2015)

17 eat. All admissions were documented in the Juvenile Justice Information System (JJIS) Detention Admission Wizard Orientation Compliance Program orientation process shall occur within twenty-four hours of a youth being admitted into detention and documented according to Facility Operating Procedures. During the orientation process, youth must be advised, both verbally and in writing, at a minimum, the following: 1. Facility rules and regulations; 2. Grievance procedures; 3. Visitation; 4. Telephone calls; 5. Available medical, mental health and substance abuse services and how to access them; 6. How to access the Florida Abuse Hotline; 7. Expectations for behavior and related consequences; 8. Possible new law violations for destruction of property; and 9. Youth rights. The center has a policy and procedure in place outlining the orientation process. All youth receive an orientation at the center within twenty-four hours of admission. Both the juvenile justice detention officer (JJDO) conducting the orientation and the youth sign an orientation acknowledgement form on the day of the youth s admission. Seven files were reviewed and all seven contained a signed orientation acknowledgement form. Each youth is shown an orientation video and provided an orientation brochure which includes the identification of key staff, facility schedule, visitation and communication times, school information, youth rights, clothing, and hygiene, access to medical and mental health treatment, center rules, and the center s behavior level system. A copy of the brochure, indicating possible consequences, was observed posted on all living units and classrooms. All seven youth responded to the survey and reported they received an orientation upon arrival. Office of Program Accountability Page 17 of 57 (Revised July 2015)

18 2.03 Classification Compliance All youth admitted to the detention center shall be classified to provide the highest level of safety and security. Considerations shall include, at a minimum: 1. Physical characteristics (e.g. sex, height and weight); 2. Age and level of aggressiveness; 3. Special needs (mental illness, developmental disabilities, and physical disabilities); 4. History of violent behavior; 5. Gang affiliation; 6. Criminal behavior; 7. History of sexual offenses; 8. Vulnerability to victimization; and 9. Suicide risk identified or suspected. Youth shall be assigned to a room based on their classification and are reclassified if changes in behavior or status are observed. Youth with a history of committing sexual offenses or a victim of a sexual offense are not to be placed in a room with any other youth. Youth with a history of violent behavior shall be assigned to rooms where it is least likely they will be able to jeopardize safety and security. In an effort to provide the highest level of safety and security, the center maintains a written policy for the classification of youth. Youth are interviewed and classified based upon a classification matrix. Youth are assigned to a room based on their classification and are reclassified if changes in behavior or status are observed. The center uses the Screening for Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) to classify youth. Seven youth records were reviewed for classification. Each reviewed youth record contained a (VSAB). Two of the seven reviewed case management records contained documentation the youth were identified as gang members and one required a single room. Youth who are classified as gang members, single room only, or escape risks are identified at the facility and housed accordingly throughout the facility Classification of Gang Members Compliance All newly admitted youth are screened to determine if he or she is a criminal street gang member or is affiliated with any criminal street gang. Each facility shall identify a staff person to serve as a gang representative who shall review identified youth for suspected gang involvement or gang activity. The center maintains a written policy for the classification for youth who have been identified as gang members. The center has one staff identified as the gang liaison. The center maintains a binder, placed in a centralized area, to document information on all youth classified with gang affiliation or membership. The binder contained pictures, demographics, and the gang name for each applicable youth. Two of the seven reviewed files indicated the youth were identified as documented gang members on their respective Juvenile Justice Information System (JJIS) face sheets. At the time of this review, each applicable youth had an alert entered into JJIS. All gang alerts are documented on the shift briefing report and distributed throughout the center to all staff. Youth suspected to have gang affiliation are discussed with the local sheriff s office, by , to determine the youth s alleged involvement in gang activity. An informal interview with one of the center s gang liaisons found the center was scheduled to participate in the monthly Office of Program Accountability Page 18 of 57 (Revised July 2015)

19 local multi-agency gang task force meetings, but was unable to attend due to a conflict in schedules Notification of Law Enforcement Limited 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. The center has a written policy and procedure to ensure the sharing of information regarding youth suspected gang involvement with local law enforcement, the youth s juvenile probation officer (JPO), and other applicable parties. A review of seven files showed two youth were documented gang members and the remaining five files did not indicate gang involvement. A juvenile justice detention officer (JJDO) is designated as the gang liaison; however, this officer was on vacation at the time of this annual compliance review. The center is currently training another JJDO, as a back-up gang liaison. This JJDO was interviewed informally and reported the center s practice of notifying local law enforcement of documented and or suspected gang members. Gang notification is conducting by contact with the Tampa Police Department and the Hillsborough County s Sheriff Office, by , to provide updates of the center s gang issues. The review of documentation from the center to the local law enforcement verified the practice is consistent with notifying them of suspected gang involvement of youth at the time of admission; however, no information is sent routinely on gang activity occurring at the facility. Additionally, there was no documentation found where Department of Corrections, school districts, the judiciary, and social service agencies, or the youth s JPO were notified, as required by the Florida Administrative Rule 63G Admission of Youth Personal Property Compliance The program takes possession of each youth s personal property during admission. In the presence of each youth, staff inventories all personal property in the youth s possession and records each surrendered item on the Property Receipt Form. The center has a written policy and procedure to describe the methods of identification, care, control, disposition, and accountability of youth property. All personal property, other than valuables, is stored in an individual secure room in the intake area. All valuable items are inventoried and placed in a sealed, tamper-proof bag; the youth and the juvenile justice detention officer (JJDO) receiving the property sign the bag. The sealed bag is placed in a drop safe, located in the intake area, under video surveillance with the property documented in the property logbook. All seven reviewed files contained the property receipt form. All of the youth s clothing appeared to be in a brown paper bag, which corresponded with the property sheet in the active file. All seven reviewed youth files indicated they had property in the safe with a safe bag receipt stapled to their file. All seven reviewed files indicated the intake staff and youth signed the property receipt. A review of the safe contents verified each youth who had property in the safe, had items listed on the youth s property receipt. All seven surveyed youth verified this practice. Office of Program Accountability Page 19 of 57 (Revised July 2015)

20 2.07 Storage of Youth Personal Property Compliance The program safeguards each youth s personal property until it can be returned to the youth and/or legal guardian. The center has a written policy and procedure regarding the storage of youth s personal property to safeguard personal property until it can be returned to the youth or parent/guardian. All personal property not claimed within thirty days of a youth s release is considered abandoned property. The seven reviewed files contained a letter signed by the youth acknowledging their understanding of the facility s process for unclaimed property. Both areas where youth property is stored are maintained under constant video surveillance. The property log is reviewed regularly by center administration. A review of the Central Communications Center (CCC) reports for the last six months documented there were no incidents regarding youth property. Seven youth files reviewed had property stored in the safe Release Compliance When releasing youth from detention, the releasing officer shall verify the court s authorization to release the youth. Care must be taken to ensure all case file information is reviewed to prevent the negligent release of a youth. All releases from the program are court-ordered, with the exception of deaths, escapes, and expirations of detention time period. In the absence of a written order, documentation of a verbal order in open court may be used for release. The on-duty JJDO Supervisor reviews all paperwork prior to release. The JJDO Supervisor is responsible for ensuring there are no holds, court orders, or other legal reasons not to release the youth. Questions concerning release are presented and addressed by the Superintendent, or designee, prior to release. The releasing officer shall verify the identification of the youth. The center maintains a written policy and procedure for the release of youth from secure detention to ensure youth are not released inappropriately. Seven closed files were reviewed, and the files indicated the juvenile justice detention officer supervisor (JJDOS) reviewed all seven of the files prior to the youth s release. There was a review of each youth s Juvenile Justice Information System (JJIS) face sheet, as well as the court authorization to release the youth. The identification (I.D.) of the parent/guardian was copied and maintained in each file. A review of Central Communications Center (CCC) reports for the last six months indicated there were no unauthorized releases. During this annual compliance review, an observation of the release process was observed and the JJDOS reviewed all paperwork prior to the youth s release to a residential facility and provided the youth, and transporting staff, with all necessary paperwork. Office of Program Accountability Page 20 of 57 (Revised July 2015)

21 2.09 Release of Youth Personal Property Compliance Upon the youth s release from detention and retrieval of personal property, the releasing officer, the youth, and the youth s parent or legal guardian shall review and sign the Property Receipt Form and account for all of the youth s personal property. The center has a written policy and procedure for releasing property to youth. The policy includes property of youth being released to commitment programs, unclaimed property, and damaged or missing personal property. Each of the seven closed files contained a detention release wizard supporting the return of the youth s property. Three of the seven youth were transferred to jail or a commitment facility. The four remaining youth were released to their parent/guardian, at which time, a property receipt form was signed and dated by the youth and the parent/guardian at the time of release. The process for unclaimed property requires a letter to be sent out to the parent/guardian explaining they have thirty days to pick up the unclaimed property. The youth property will be itemized and then the letter and the face sheet are stapled to the unclaimed property. The unclaimed property will go to family services, and the unclaimed money goes to detention headquarters, in Tallahassee, in the form of a money order Release of Medication, Aftercare Instructions Compliance The program ensures there are provisions in place to ensure prescribed medication, along with medical instructions, accompanies detained youth upon release. The center has a written policy and procedure for the release of youth, which includes steps to ensure all prescribed medication and medical instructions accompanies the youth upon release. Seven closed files were reviewed and none were applicable for this indicator. Three additional closed files were reviewed for validation of release of medication verification. A review of each additional file found the center uses the Office of Health Services Medication Receipt, Transfer, and Disposition form to document all release of medication information. The Detention Release Wizard indicated all medication was given to the parent/guardian, or other appropriate person, by the facility staff Review of Youth in Secure Detention Compliance Detention reviews are conducted by the program on a weekly basis to ensure proper management of youth placed in secure detention and appropriate sharing of information. The superintendent appoints an appropriate staff person to coordinate detention reviews. The center has a written policy and procedure for the review of youth placed in secure detention. The center conducts detention reviews weekly for youth from Hillsborough County to ensure proper management of the youth placed in secure detention and all appropriate sharing of information is passed on to all participating parties. Each youth s case is monitored to ensure all information is shared regarding court dates, physical or behavioral issues, and any paperwork needed from the Department of Juvenile Justice. An audit was observed during the annual compliance review and all required parties were present from mental health, medical, education, the juvenile probation officer (JPO) supervisors, the assistant chief probation officer, the detention center the superintendent, and the commitment manager. There was documentation to support a detention review was consistently conducted each week for the past six months and all required documentation was present for each week. Office of Program Accountability Page 21 of 57 (Revised July 2015)

22 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. The center has a written policy and procedure for the review of youth placed on home detention in Hillsborough County. All youth placed on home detention are reviewed by the center on weekly conference calls. Each youth s case is monitored to ensure all information is shared regarding court dates, or behavioral issues, and any paperwork needed from the Department of Juvenile Justice. A home detention review was conducted with a youth, by the facility, in the superintendent s office. A member of the review team observed a detention review meeting and attendees consisted of mental health, medical, education, juvenile probation officer supervisor (JPOS), the assistant chief probation officer, the detention center superintendent, and the commitment manager. There was documentation to support a home detention review was consistently conducted each week for the past six months and all required documentation was present for each week Daily Activity Schedule Compliance Youth are provided the opportunity to participate in constructive activities that will benefit the youth and the program. The Superintendent or Designee develops a daily activity schedule, which is posted in each living area and outlines the days and times for each youth activity. The center has a daily activity schedule for weekdays, weekends, and holidays. The schedule is posted, in all living units, as well as the cafeteria and classrooms, for all youth to view. The schedule includes times for meals, hygiene, visitation, school, and recreation. The center has a procedure to ensure the daily schedule is followed stating the cancellation of activities is allowed for weather, safety, or security reasons. The cancellation of activities is to be documented in the master control logbook. Five of seven surveyed youth responded the facility has a written daily schedule. Two youth reported they did not see a schedule posted; however, they were aware of the facility schedule, and all seven youth reported following the schedule 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. The facility has a daily schedule. Review of several logbook entries from the last six months contained verification of compliance with daily activities being conducted, as the schedule dictates. Formal interviews with the assistant principal and the superintendent indicated a scheduled is modified when there is a disturbance or special activity and the reviewed documentation indicates the facility follows their policy for schedule deviation. Seven surveyed staff and seven surveyed youth indicated the facility follows a daily schedule. Office of Program Accountability Page 22 of 57 (Revised July 2015)

23 2.15 Educational Access Compliance The facility shall integrate educational instruction (career and technical education, as well as academic instruction) into their daily schedule in such a way ensuring the integrity of required instructional time. The center provides daily education for all youth. Educational services are provided by the Hillsborough County School District. The youth attend school seven hours per day, which is equivalent to 300 minutes. The center s education program operates 240 days and in accordance with school guidelines. The education department has six teachers and one assistant. Two of the six teachers are Exceptional Student Education (ESE) certified. The center s practice was validated by a lead teacher who was interviewed during the annual compliance review. All seven youth surveyed verified youth attend school and receive education in a variety of subjects Career Education Compliance Staff shall develop and implement a career education competency development program. The education program provides Type A/Level 1 programming for the youth. The education program uses the ONET system, which is a credit recovery program for youth who are behind in school credits and not at the appropriate grade level. The teachers provide the youth with an introduction to various careers, including General Education Development (GED) and adult basic education (TABE) testing 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 facility uses a behavior management system (BMS) which provides rewards and consequences. Every living module has the BMS guidelines posted. The BMS consists of three levels. At the time of admission, youth start on a level two and can work their way to a level three, allowing youth to earn additional privileges such as phone calls or canteen, which has a variety of snacks. The youth s level can drop due to negative behavior. Staff carry a level card for each youth, which documents positive and negative behaviors. If a negative behavior is exhibited, a recommendation for a consequence is made. Before a suggested consequence can be imposed, supervisors must approve it. Four of seven surveyed youth rated the behavior management system as fair or poor Three of the seven surveyed youth reported never receiving consequences they felt were fair. Six of seven surveyed staff stated the BMS is effective. All seven surveyed youth indicated they have never seen a youth placed in mechanical restraints for behavior reasons; however, five youth did say they have been sent to their room for punishment, and four of the five indicated their door was shut and locked. Follow-up interviews with the youth indicated youth were placed in their rooms to take a time out and calm down or Office of Program Accountability Page 23 of 57 (Revised July 2015)

24 separate the youth from another youth because the two youth were agitating each other. Two youth indicated they were in their rooms five to ten minutes until they were calm. The other youth did not know how long they remained in their rooms Unauthorized Use of Punishment Compliance The center s behavior management system restricts certain types of penalties on youth who demonstrate negative behaviors. Group punishment shall not be used as a part of the facility s behavior management plan. However, corrective action taken with a group of youth is appropriate when the behavior of a group jeopardizes safety or security, and this should not be confused with group punishment. Corporal punishment shall not be used in detention facilities. All allegations of corporal punishment of any youth by facility staff shall be reported to the Florida Abuse Hotline, pursuant to Chapter 39, F.S., and the Central Communications Center. The use of drugs to control the behavior of youth is prohibited. This does not preclude the proper administration of medication as prescribed by a licensed physician. The center s behavior management system (BMS) restricts certain types of penalties for youth who demonstrate negative behavior. The BMS also prohibits the use of group punishment, and no youth is allowed to punish another youth. The use of drugs, to control a youth s behavior, is prohibited. All seven surveyed youth reported youth are not allowed to punish youth and consequences for inappropriate behavior did not include the loss of meals, snacks, sleep, or school. Seven surveyed staff indicated they have never witnessed intimidation, humiliation, or unauthorized use of punishment Grievances Compliance The grievance procedures establish each youth s right to grieve and ensure all youth are treated fairly, respectfully, without discrimination, and their rights are protected. The process includes: 1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with the youth using effective communication skills; 2. Formal phase, wherein the youth submits a written grievance resulting in a response from a JJDO Supervisor by the end of the shift (if possible), or otherwise within twentyfour hours; and 3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the superintendent or designee. The center has a policy and procedure allowing youth the opportunity to file a grievance when they feel their rights have been violated, or if they have been treated unfairly. If a youth cannot resolve their grievance with a juvenile justice detention officer (JJDO), the grievance form will be forwarded to juvenile justice detention officer supervisor (JJDOS). The JJDOS is allotted two hours to respond to the youth s grievance. A review of five grievances indicated all five were reviewed by a JJDOS within two hours of being filed by the youth. All five original grievances contained staff and youth signatures. All seven youth responded to the survey, with two reporting the process to be fair or good, and five youth reporting the have never filed a grievance. The facility has the grievances filed, by month, in a folder and they correspond with the Facility Management System (FMS) in the Juvenile Justice Information System (JJIS). Office of Program Accountability Page 24 of 57 (Revised July 2015)

25 2.20 Trauma-Informed Care Compliance The facility is incorporating trauma-informed practice into current operations to deliver services and to provide care to youth in custody, acknowledging the role that violence and victimization play in the lives of most of the youth entering the facility. Trauma-informed practice has many characteristics, which include the following: A recognition of the high prevalence of trauma Assessment for traumatic histories and symptoms Recognition of culture and practices that may be re-traumatizing Collaboration of caregivers Training of staff to improve trauma knowledge and sensitivity Increased staff understanding of the function of behavior (rage, self-injury, etc.) as an expression of trauma Use of objective and neutral language (avoids labeling of youth) The center has incorporated trauma-informed care practices. The center is in the process of creating a soft room on each living module. Seven staff training files were reviewed and all seven have received trauma-informed care training, which included training on how to recognize the high prevalence of trauma in youth with traumatic histories. The center has softened the facility in several areas by painting the facility blue to reduce the institutional feel. Office of Program Accountability Page 25 of 57 (Revised July 2015)

26 Standard 3: Mental Health and Substance Abuse Services Overview Comprehensive mental health and substance abuse services at Hillsborough West Regional Juvenile Detention Center are provided through a contract between the Department of Juvenile Justice and Camelot Community Care, Inc. The contract provides for mental health coverage seven days per week, twenty-four hours per day. Coverage includes one licensed clinician who serves as the center s designated mental health clinician authority (DMHCA) and one full-time, non-licensed, and master s level clinician who works under the supervision of the DMHCA. An additional contract between the Department of Juvenile Justice and Camelot Community Care, Inc. provides for three hours per week of psychiatric services by a licensed, board certified psychiatrist. The mental health and substance abuse staff at Hillsborough West Regional Detention Center have access to the Juvenile Justice Information System (JJIS), as well as the center s Office of Health Services (OHS) web forms, which enables them to create and update alert information within the JJIS and in the center s logbooks facilitating communication of the alert information to staff Designated Mental Health Clinician Authority (DMHCA) Compliance A Designated Mental Health Clinician Authority (DMHCA) is required in each detention center. The DMHCA 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 center has a licensed clinical social worker (LCSW) who serves as their designated mental health clinician authority (DMHCA) and is employed by Camelot Community Care, Inc. The DMHCA is on-site a minimum of forty hours per week, Monday through Friday, and is on-call twenty-four hours per day, seven days per week, for emergency consultation. The DMHCA is responsible and accountable for the appropriate coordination and implementation of mental health and substance abuse services in the center. A reviewed position description further indicated the DMHCA oversees all clinical and administrative operations of the center to ensure clinical integrity, quality, contract compliance, utilization, budget/fiscal efficiency, and adherence to the standards of the Department of Juvenile Justice (DJJ). The DHMCA s license is active and clear Licensed Mental Health and Substance Abuse Clinical Compliance Staff The facility superintendent is responsible for ensuring mental health and substance abuse services are provided by individuals with appropriate qualifications. Clinical supervisors must ensure clinical staff working under their supervision are performing services they are qualified to provide based on education, training, and experience. In addition to the designated mental health clinician authority (DMHCA), one other licensed clinician provided services to the youth at the center during this annual compliance review period. This individual, a licensed mental health counselor (LMHC), works on an as-needed basis, to ensure full coverage and also serves as a back-up to the DMHCA or the non-licensed Office of Program Accountability Page 26 of 57 (Revised July 2015)

27 position. The LMHC license is active and clear. Two medical doctors serve as a primary and a back-up psychiatrist for the center. The licenses for both medical doctors are active and clear Non-Licensed Mental Health and Substance Abuse Compliance Clinical Staff The facility superintendent is responsible for ensuring mental health and substance abuse services are provided by individuals with appropriate qualifications. Clinical supervisors must ensure clinical staff working under their supervision are performing services they are qualified to provide based on education, training, and experience. One non-licensed clinician provides clinical services to the youth under the direct supervision of the designated mental health clinician authority (DMHCA). This individual has a master s degree in rehabilitation counseling and is a registered mental health counselor intern with the State of Florida. Having worked at the center for almost ten years, it was evident she was experienced in providing services to the youth and there was documentation showing the non-licensed clinician had received the necessary training to perform all assigned duties including twenty hours of training and supervised experience to conduct Assessments of Suicide Risk (ASR). A review of the clinical supervision logs for the past six months confirmed the DMHCA provided weekly onsite supervision to the staff providing services to the youth. The reviewed documentation indicated the hour-long supervisory sessions included discussion of the cases the non-licensed staff encountered over the previous week, specific issues regarding the provision of services, training for the staff on a variety of topics, as well as a detailed summary of directions, instructions, and recommendations from the DMHCA for the staff. There was also documentation reflecting a review of work samples, but not as consistently every week. However, all reviewed documentation of the non-licensed clinician s work, including progress notes and assessments, was signed off by the licensed DMHCA soon after completion of the work substantiating the DMHCA s review took place Mental Health and Substance Abuse Admission Compliance Screening The mental health and substance needs of youth are identified through a comprehensive screening process ensuring referrals are made when youth have identified mental health and/or substance abuse needs or are identified as a possible suicide risk. Detention center superintendent has established procedures for a thorough review of preliminary screening conducted by the Office of Probation and Community Intervention. The center has a policy and procedure in place providing a comprehensive screening process to ensure the identification of the mental health and substance abuse needs of each youth admitted to the center. The screening procedures are continued through the detention admission initiated at the juvenile assessment center (JAC). Typically, youth who are determined to be at risk for suicide are placed on precautionary observations at the JAC. Upon arrival to the center, the intake staff conducts a thorough review of the preliminary screening form, the Positive Achievement Change Tool (PACT) Mental Health and Substance Abuse Report and Referral Form, which are completed by the Office of Probation and Community Intervention at the JAC. Each of the seven reviewed mental health records validated the staff reviewed the referral form. However, one record was found to include a PACT Mental Health and Substance Abuse Report and Referral Form from a previous admission on January 18, 2016, instead of the form developed on February 19, 2016, the date of the current admission. All seven reviewed mental health and substance abuse records included the Suicide Risk Office of Program Accountability Page 27 of 57 (Revised July 2015)

28 Screening Instrument (SRSI) completed on the Juvenile Justice Information System (JJIS). This form is started at the JAC, then reviewed and continued by the detention staff, to include either a representative from mental health or nursing. Each of the six youth whose PACT Mental Health and Substance Abuse Report and Referral Form indicated the need of an Assessment of Suicide Risk (ASR) or further mental health and/or substance abuse evaluation were referred to mental health clinical staff using the Department form. This form requires documentation of a consultation with the designated mental health clinician authority (DMHCA) or licensed mental health professional; however, none of the six reviewed applicable records documented this consultation. Discussion with the DMHCA revealed the required consultation had not been occurring in practice; however, further discussion indicated the mental health clinician completed each of the applicable SRSI forms upon the youth s admission to the facility and became aware of the needed referral during the youth s intake process. Youth in need of an evaluation and ASR were then evaluated by a mental health clinician within hours of intake, were not stepped down from precautionary observations until the DMHCA consultation, and approval of the change in level of supervision. There was no negative impact to the delivery of services related to the past omission on the referral form. It should be noted, upon notification of the need for documentation of consultation with the DMHCA on the referral form, the DMHCA immediately implemented new procedures and informed intake staff of the change so consultations will now take place and future referral forms will include the required documentation Mental Health and Substance Abuse Evaluation Compliance The Probation and JAC intake/detention screening process ensures youth identified through preliminary screening as having mental health and substance abuse issues or problems receive in-depth mental health and/or substance abuse assessment shortly after intake to the juvenile justice system. The center has a written policy and specific procedures addressing the completion of comprehensive mental health and substance abuse evaluations for youth who need them. A youth s need is determined by results of the preliminary screening and/or the youth s behavior after admission to the center. The policy requires a new comprehensive evaluation be completed by detention clinical staff when a current evaluation is not received from the youth s juvenile probation officer (JPO) by the thirtieth day of the youth s admission to the detention center.the JPO is to request an assessment and have it completed by a private provider within fourteen days. None of the original samples of seven reviewed mental health and substance abuse records contained a comprehensive assessment, nor had any of the youth in the reviewed sample been in detention more than thirty days. Each of the three reviewed records of youth who had been in detention fourteen days or more, did contain documentation indicating the designated mental health clinician authority (DMHCA) had requested the status of the assessment from the JPO, on or about the fourteenth day. Three additional records were reviewed for youth whose admission to the center was longer than thirty days and required the completion of a comprehensive evaluation. One record contained a comprehensive evaluation completed by a community provider and two contained comprehensive assessments completed by the DMHCA. Each of these comprehensive assessments was completed within the thirty-one day timeframe and each reviewed assessment contained all of the required elements identified in the Department s Mental Health and Substance Abuse Rule. Office of Program Accountability Page 28 of 57 (Revised July 2015)

29 3.06 Mental Health and Substance Abuse Treatment Compliance Mental health and substance abuse treatment planning in departmental facilities focuses on providing mental health and/or substance abuse interventions which will reduce or alleviate the youth's symptoms of mental disorder or substance abuse impairment and enable youth to function adequately in the juvenile justice setting. Each youth determined to need mental health treatment, including treatment with psychotropic medication, or substance abuse treatment while in a detention center, must be assigned to a mini-treatment team. Seven youth mental health and substance abuse records were reviewed for documentation regarding the implementation of mental health and/or substance abuse treatment services. Four of the seven reviewed records related to a youth determined to be in need of mental health treatment services. There was documentation each of these four youth were assigned to a minitreatment team and had attended/participated in at least one mini-treatment team meeting, within seven days of their arrival to the center. Every applicable treatment record contained a valid Authority for Evaluation and Treatment (AET), and three records contained a signed Substance Abuse Consent and Release form MHSA 013. Mental health treatment progress notes on the designated form MHSA 018 indicated each youth was provided individual mental health counseling services according to the treatment plan. Group or family therapy sessions were not the indicated treatment on any of the plans. Each of the four youth were receiving mental health treatment services and three of the four were receiving psychiatric services. None of the youth in the originally reviewed sample required substance abuse treatment services Treatment and Discharge Planning Compliance The superintendent and DMHCA or mental health and substance abuse clinical staff are responsible for ensuring the development and review of an initial and/or individualized mental health/substance abuse treatment plan for each youth receiving mental health and/or substance abuse treatment in the facility. All youth who receive mental health and/or substance abuse treatment while in a detention facility shall have a discharge summary completed documenting the focus and course of the youth's treatment and recommendations for mental health and/or substance abuse services upon youth's release from the facility. The review team was unable to attend a treatment team meeting during this annual compliance review, due to the meeting being rescheduled in order to accommodate the psychiatrist s schedule. Seven youth mental health and substance abuse records reviewed for initial treatment plans and five were applicable. All five applicable records contained an initial treatment plan, which was developed within seven days of admission. Each of the plans was documented on the designated form MHSA 015 and each required element of the plan was detailed by the designated mental health clinician authority (DMHCA) to ensure the plan was understood by all parties in the mini-treatment team. Three of these plans were applicable for psychiatric treatment, and each of these plans specified the provided services and the frequency of monitoring by the psychiatrist. Each of the five initial treatment plans were signed by the youth, the DMHCA, the psychiatrist, if applicable, and at least one other mini-treatment team member. The parent/guardian consistently attended the initial treatment team meeting by telephone, or an effort was made to contact them. In addition to the original sample of seven Office of Program Accountability Page 29 of 57 (Revised July 2015)

30 youth mental health records, three closed mental health and substance abuse records were reviewed for treatment plans and discharge summaries. It was observed, each of these records contained an initial treatment plan, completed by the DHMCA, signed by all appropriate parties, and developed within the required timeframe. Also observed, two of these three additional records contained individualized treatment plans, which were completed within thirty days of admission, and each subsequent to the receipt or completion of the comprehensive assessment. Both individualized treatment plans included all of the required elements of the plan including details of psychiatric services accessed by the youth. Both individual treatment plans were signed by mini-treatment team members, with the exception of the parents/guardians who were able to attend each treatment team meeting by telephone only. Progress notes describing the treatment, youth s response to treatment, and treatment goal gains were observed in both records. One record also contained a thirty-day treatment individual plan review, which updated the youth s progress on the plan. Four records were applicable for discharge summaries. Each had a discharge summary form MH/SA 011, which was completed on the same day of the initial treatment plan to ensure the youth signature is obtained before release. Documentation was provided indicating the youth, parent/legal guardian, and the juvenile probation officer received a copy of the discharge plan Psychiatric Services Compliance Psychiatric services include psychiatric evaluation, psychiatric consultation, medication management, and medical supportive counseling provided to youth with a diagnosed DSM-IV- TR or DSM-5 mental disorder and substantial functional limitations. Two contracted medical doctors serve as the primary and back-up psychiatrist providing services to the youth in the center. The primary psychiatrist, who is board certified in child and adolescent psychiatry, is on-site three hours per week and is on-call twenty-four hours per day, seven days per week, for emergency consultation. The back-up psychiatrist, who is board certified in psychiatry and neurology, is available when needed for coverage. The review of the center sign-in logbook, from August 1, 2015 through February 24, 2016, verified a psychiatrist was on-site each week during this timeframe. Four reviewed mental health records documented youth participation in psychiatric treatment and two reviewed closed records were of youth who had received psychiatric services. Of the total reviewed records, five of the youth entered the center having been previously prescribed psychotropic medications. In each of the six records, documentation verified all youth had undergone a diagnostic evaluation by the psychiatrist within seven days of admission, consistently exceeding the fourteen-day requirement. Each of the initial evaluations was documented on the Department s Clinical Psychotropic Progress Note (CPPN) which included all three pages. The evaluations included all required elements with two exceptions. One psychiatrist consistently neglected to document the reason for referral on the CPPN, and both psychiatrists were inconsistent in documenting the diagnosis/target symptoms section on page three of the CPPN. All psychiatric evaluations occur within the context of a treatment team meeting, with the youth and treatment team staff present. The youth is never seen on a one-to-one ratio with the psychiatrist according to the documentation in the records and interview with the DMHCA. Attempted or successful contact with parent/guardian, to afford them the opportunity to participate in treatment team meetings with the psychiatrist, was documented on each psychiatric evaluation. Both the initial and subsequent evaluations are completed on the CPPN form. Review of the CPPN forms for youth who were in the center beyond thirty days, revealed there is little differentiation between the initial evaluation and the required thirty-day in-depth evaluation in either information gathered or documentation. When medications were prescribed by the psychiatrist, all required documentation was completed including contact with the parent/ guardian to access their authorization. The reviewed Office of Program Accountability Page 30 of 57 (Revised July 2015)

31 documentation showed the DMHCA arranged for the youth to be evaluated by the psychiatrist at thirty-day intervals Suicide Prevention Plan Compliance The program follows a suicide prevention plan to safely assess and protect youth with elevated risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida Administrative Code. The center has a written suicide prevention plan designed to screen all admitted youth for suicide risk and to protect those who are assessed to be at elevated-risk for self-harm/suicide. The screening process at admission identifies youth at risk for suicide and refers these youth for clinical assessment of risk. The center s suicide prevention plan includes all of the required elements in the indicator, including the identification and assessment of youth at risk of suicide, staff training, and suicide precautions, levels of supervision, referral process, communication, notification/alerts, documentation, and immediate staff response to situations when a youth may be in danger. The plan also included the need to conduct a review of serious suicide attempts or incidents of self-injurious behavior, per Department s Juvenile Justice (DJJ) Rule 63-N The plan is reviewed annually and was last signed on August 10, 2015, by the superintendent and the DMHCA Suicide Prevention Services Compliance Suicide Precautions are the methods utilized for supervising, observing, monitoring, and housing youth identified through screenings as having suicide risk factors or identified through assessment as a potential suicide risk. Any youth exhibiting suicide risk behaviors must be placed on Suicide Precautions (Precautionary Observation or Secure Observation), and a minimum of constant supervision. All youths identified as having suicide risk factors by screening, information obtained regarding the youth, or staff observations must be placed on Suicide Precautions and receive an assessment of suicide risk. The center has a plan in place to supervise, monitor, and house youth identified to be at risk for suicide. None of the five youth in the original sample to be reviewed were placed on precautionary observation subsequent to their admission to the center. Four additional records were reviewed for instances of the center addressing high-risk suicide behaviors of the youth. Two of the four reviewed records documented the use of precautionary observations, and the other of the four records documented the use of secure observations. In each instance, the center s policy and procedures were followed and all required documentation for detention and contracted staff was completed fully. Each youth placed on precautionary observation had an alert entered into the Juvenile Justice Information System (JJIS) and an entry into the master control logbook, when placed on precautions and when the youth was stepped down to standard supervision. While on precautions, the youth s activities did not limit them to their individual room and each log identified the safe housing areas for the center. Every youth was maintained on precautionary observation until they received a Follow-Up ASR, by a qualified clinician, indicating they could be returned to standard supervision. All records reflected the observation logs were completed in their entirety, the precautionary observation was authorized as required, and the mental health staff provided supportive services. Office of Program Accountability Page 31 of 57 (Revised July 2015)

32 Records reviewed regarding youth placed on secure observation indicated the shift supervisor, who was the superintendent designee, and the designated mental health clinician authority (DMHCA) authorized the placement for each youth. Each applicable youth received an Assessment of Suicide Risk (ASR) and supportive counseling, within eight hours of placement. Supervision of each youth was documented on a Suicide Precaution Observation Log. Each of the reviewed logs indicated the youth had been searched prior to placement, and the room was inspected prior to the youth s placement. The reviewed documentation also confirmed a health status checklist was completed prior to their placement in secure observation. There was also documentation to support the center entered a required alert in the Department s Juvenile Justice Information System (JJIS). Every youth was maintained on secure observation until they received a Follow-Up ASR, by a qualified clinician, indicating they could be stepped down to constant supervision. Entries were also reviewed in the master control logbook regarding placement and step down related to secure observations for two youth. The review of one entry documented the youth was stepped down from secure observations to close observations at 4:30 p.m., when he was actually stepped down the same evening at 7:00 p.m Suicide Precaution Observation Logs Compliance Youth placed on suicide precautions must be maintained on one-to-one or constant supervision. The staff member assigned to observe the youth must provide the appropriate level of supervision and record observations of the youth's behavior at intervals of no more than thirty minutes. There were seven instances requiring the youth be placed on precautionary observation, and the Suicide Precaution Observation Log was maintained for the duration the youth remained on suicide precautions. The review of the Suicide Precaution Observation Logs found the staff were documenting the youth s behavior at thirty-minute intervals. None of the logs documented an instance where staff observed any warning signs, which required notifications to the superintendent/designee and mental health clinical staff. Each shift supervisor was reviewing and signing the log, as was the mental health clinical staff, with two exceptions noted on the same log where the shift supervisor documented the wrong date of January 21, 2016, rather than the correct date of February 21, It was also observed the officers unnecessarily checked the housing box on the log when the youth was placed on secure observations Suicide Prevention Training Compliance All staff who work with youth must be trained to recognize verbal and behavioral cues indicating suicide risk, suicide prevention, and implementation of suicide precautions. There were five staff training records reviewed for suicide prevention training. Each of the staff met or exceeded the required six hours of suicide prevention training. Additionally, the last three quarters of 2015 were reviewed for mock suicide drills. The center provided numerous mock suicide drills throughout the year, exceeding the requirement in Rule 63N (c). The review of the mock suicide drills found they occurred once on each shift, for the last three quarters of 2015, and the majority of the staff attended at least one drill per quarter. All staff including the food service, fiscal, personnel, and maintenance workers participated in at least one suicide mock drill in Office of Program Accountability Page 32 of 57 (Revised July 2015)

33 3.13 Mental Health Crisis Intervention Services Compliance Every program must respond to youth in crisis in the least restrictive means possible to protect the safety of the youth and others while maintaining control and safety of the facility. The program must be able to differentiate a youth who has an acute emotional problem or serious psychological distress from one who requires emergency services. A youth in crisis does not pose an imminent threat of harm to himself/herself or others, which would require suicide precautions or emergency treatment. The center has a written integrated mental health crisis intervention and emergency mental health and substance abuse services plan last revised and signed by the superintendent of the facility and the designated mental health clinician authority (DMHCA) on July 1, The plan includes all of the required elements including a notification and alert system, the means of referral, youth self-referral, communication, supervision, and documentation. The plan also includes a multidisciplinary of administrative, direct care, mental health, and medical staff review process related to any serious, self-inflicted injury or suicide attempt, as required in Department of Juvenile Justice (DJJ) Rule 63-N Crisis Assessments Compliance A crisis assessment is a detailed evaluation of a youth demonstrating acute psychological distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a licensed mental health professional, or under the direct supervision of a li-censed mental health professional, to determine the severity of youth s symptoms, and level of risk to self or others. When staff observations indicate a youth s acute psychological distress is extreme/severe and does not respond to ordinary intervention, the superintendent or designee must be notified of the crisis situation and need for crisis assessment. A Crisis Assessment is to be utilized only when the youth s crisis (psychological distress) is not associated with suicide risk factors or suicide risk behaviors. If the youth s behavior or statements indicate possible suicide risk, the youth must receive an Assessment of Suicide Risk instead of a Crisis Assessment. The center has a policy and procedure in place to address needed crisis assessments. The center only had one instance where a youth required a crisis assessment during this review period. The crisis assessment was completed using Department of Juvenile Justice (DJJ) form MHSA 023 and was completed by the designated mental health clinician authority (DMHCA). The reason for the assessment, mental status examination, the degree of danger, initial clinical impressions, supervision recommendation, treatment recommendations, notification to parent/guardian, and alerts were addressed in the reviewed crisis assessment. The crisis assessment was part of a death notification and supportive counseling was provided to help the youth cope with, and express, his emotions. No change in the youth s level of supervision was deemed appropriate and no alert was required or entered into Juvenile Justice Information System (JJIS), due to the youth s controlled emotional response, denial of suicide ideation, and willingness to contract for safety. The DMHCA did document the circumstances and assessment on the log for the shift supervisor to share during shift change to ensure direct care staff were aware of the incident. An entry was also made in the mental health record chronological log for the non-licensed clinical staff to review, prior to meeting with the youth again later in the afternoon to check on his mental status. Office of Program Accountability Page 33 of 57 (Revised July 2015)

34 3.15 Emergency Care Plan Compliance Youth determined to be an imminent danger to themselves or others due to mental health and substance abuse emergencies occurring in facility require emergency care provided in accordance with the facility's emergency care plan. The Crisis Intervention Plan and Emergency Care Plan may be combined into an integrated Crisis Intervention and Emergency Services Plan which contains all the elements specified in the Rule 63N-1, Florida Administrative Code. The center has a written mental health crisis intervention and emergency mental health and substance abuse services plan last revised and signed by the superintendent of the facility and the designated mental health clinician authority (DMHCA) on July 1, The plan includes all of the required elements including immediate staff response, notifications, communication, supervision, authorization to transport for emergency mental health or substance abuse services, transport for emergency mental health evaluation treatment under Florida Statutes Chapter 394 Baker Act, transport for emergency substance abuse assessment and treatment under Florida Statutes Chapter 397 Marchman Act, documentation, and training. The plan further includes a multidisciplinary team (involving administrative, direct care, mental health, and medical personnel) review process related to any serious self-inflicted injury or suicide attempt, as required in Department s Juvenile Justice (DJJ) Rule 63-N Baker and Marchman Acts Compliance Individuals who are believed to be an imminent danger to themselves or others because of mental illness or substance abuse impairment require emergency mental health or substance abuse services. The center was able to provide documentation for two youth who had been Baker Acted from the center during this annual compliance review period. Neither of the youth was still at the center, so only records preserved for the annual compliance review were available. A review of documentation revealed each youth was supervised on precautionary observation and evaluated by a licensed clinician, or a non-licensed clinician operating under the direct supervision of a licensed clinician, prior to a Baker Act. Each youth was monitored on one-toone supervision until the youth was transported for evaluation. The Hillsborough County Sheriff s Office then transported each youth to Gracepoint, a local crisis center. Upon return to the center, each youth was immediately placed on constant supervision, and a qualified clinician completed an Assessment of Suicide Risk (ASR) to determine the level of precaution to ensure the safety of the youth. Both youth were transferred to other detention centers while still on suicide precautions. A review of the documentation found the program followed all procedures set forth in their plan. The center entered an alert in Juvenile Justice Information System (JJIS) when the youth returned from the crisis center. The program completed no Marchman Acts during this annual compliance review period. The center also conducted the semi-annual mock drill training on emergency response procedures, as required by rule 63N Office of Program Accountability Page 34 of 57 (Revised July 2015)

35 Standard 4: Health Services Overview The healthcare services are provided to the youth through an agreement between the Department of Juvenile Justice and Maxim Healthcare Services. The center has a designated health authority (DHA) who is a licensed medical physician. The DHA has a designee who is an advanced registered nurse practitioner (ARNP). The center also has a second ARNP, who serves as the Maxim Healthcare Services regional nurse manager. The DHA is on-site weekly, for two hours, and is on-call twenty-four hours per day, seven days per week. The ARNP is onsite twenty hours per week. There are no registered nurse (RN) positions at this center. There are three full-time licensed practical nurse (LPN) positions. The LPNs work staggered schedules providing coverage seven days per week. The contract provides for one full-time medical records clerk, working forty hours per week. Sick call is conducted by medical personnel daily. Tuberculin skin tests (TST) are administered on-site by nursing staff; however, youth needing vaccinations are referred to the Hillsborough County Health Department (HCHD). Human Immunodeficiency Virus (HIV) services are provided through an agreement with Youth Education Services (YES) Designated Health Authority/Designee Compliance The Designated Health Authority (DHA) is clinically responsible for the medical care of all youth at the facility. The center maintains an agreement with Maxim Healthcare Services for the provision of a licensed physician, who serves as the designated health authority (DHA). The DHA is responsible for providing oversight and supervision of all health and medical services, including general supervision of all medical personnel. The DHA is responsible for the overall clinical direction and the development of policies and protocols for the medical services provided in the center. The DHA is scheduled to be on-site approximately two hours per week and is on-call twenty-four hours per day, seven days per week. The medical provider has identified a physician to serve as acting DHA in the event the current DHA is on approved leave. There was documentation to support the licensed physician has been cleared through the Department s Background Screening Unit to serve as back-up physician when the DHA. The contract further provides for an advanced registered nurse practitioner (ARNP) who is scheduled to be on-site approximately twenty hours per week. There was documentation to support the DHA was on-site weekly during the past six months, and the ARNP was on-site twenty hours per week. The center does maintain a current copy of the collaborative practice protocols, filed with the Department of Health, between the DHA and the ARNP. There was documentation to support routine sick call was performed by the DHA or the ARNP at times when they were at the center. The DHA and/or ARNP provide follow-up medical care when the youth are referred by nursing staff. Office of Program Accountability Page 35 of 57 (Revised July 2015)

36 4.02 Psychiatrist/Designee Compliance The Psychiatrist is responsible for the provision of psychiatric services, the management of psychiatric conditions, and the prescribing of psychotropic medications. The center maintains an agreement with Camelot Community Care for the provision of psychiatric services by a licensed board certified psychiatrist. The psychiatrist is on-site approximately three hours each week to evaluate and monitor youth. The psychiatrist is available for emergency consultation twenty-four hours per day, seven days per week. The center has identified a physician to serve as the acting psychiatrist, in the event the current psychiatrist is on approved leave. There was documentation to support the psychiatrist was onsite weekly for the previous six months Facility Operating Procedures Compliance There shall be Facility Operating Procedures (FOP) for all health-related procedures and protocols utilized at the facility. The center has written operating procedures for health-related procedures, as well as protocols for the staff to follow. The facility health services operating procedures and protocols were updated and approved by the center s current designated health authority (DHA) on December 14, 2015, and by the center s superintendent on December 9, The facility operating procedures contain the requirements outlined in the Department s Health Services Rule. The psychiatrist developed and reviewed the facility operating procedure, which related to the administration of psychotropic medications, on December 22, The center maintains current nursing protocols approved by the DHA. The nursing protocols were reviewed and approved by the DHA on January 11, There was documentation to support all nursing staff reviewed the facility operating procedures and nursing protocols. There was additional documentation to support all newly employed healthcare personnel received a comprehensive orientation to the center s healthcare policies and procedures Authority for Evaluation and Treatment Compliance Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET) or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in the custody of the Department. The center has written policies and procedures regarding an Authority for Treatment and Evaluation (AET) form. Seven healthcare records were reviewed for this indicator. Four records contained a valid original AET and two records contained copies of the AET. All of the copies were stamped with the word copy. These documents were found in each youth s reviewed healthcare record. All signatures were witnessed and signed by either a juvenile justice detention officer (JJDO) or another representative. One youth did not have a current and valid AET. This youth had a parent/guardian report to the center to fill out an AET while the annual compliance review team was on-site. Office of Program Accountability Page 36 of 57 (Revised July 2015)

37 4.05 Parental Notification Compliance The center shall inform the parent/guardian of significant changes in the youth s condition and obtain consent when new medications and treatments are prescribed. The center has written policies and procedures regarding parental notification. Seven healthcare records were reviewed for this indicator. None of the youth had conditions such as hospitalizations, surgeries, or had the same sick call complaint three times within two weeks. Four healthcare records were applicable for parental notifications for youth who required changes to their existing medication or due to a change in their chronic condition. Each record documented a telephone call was placed to the youth s parent/guardian to discuss the change in healthcare status. An additional staff member witnessed the conversations on a consistent basis. All five records contained documentation of the center providing written information to the youth s parent/guardian regarding the change in healthcare status Notification Clinical Psychotropic Progress Note Compliance The Department s requirement to inform the parent or guardian and obtain consent for the prescription of new psychotropic medications, discontinuances or psychotropic medication adjustments. The center has written policies and procedures regarding the provision of parental notification. A review of three applicable youth healthcare records found each youth was prescribed psychotropic medication. All three examples documented the psychiatrist conducted telephone contact with the parent/guardian, and a nursing staff witnessed the telephone call. The Clinical Psychiatric Progress Note (CPPN) was used to document additions or changes to psychotropic medications. Each record documented page three of the CPPN was sent to the parent/guardian with the Acknowledgement of Receipt of CPPN or Practitioner Form Immunizations Compliance Each youth s immunization history and status shall be verified to meet state and Department requirements, and subsequently provide necessary immunizations/vaccinations (with parent/guardian consent). The center has written policies and procedures regarding immunizations. Each medical staff has access to the Florida Shots Immunization Records website to retrieve the youth s immunization record. The center s process is to review the youth s immunization record prior to the youth receiving the Health Related History. The review of seven youth healthcare records documented each record contained a current and valid immunization record. There were no youth in the center requiring any immunizations Healthcare Admission Screening Form (Medical and Mental Health Screening Form) (screening entered into Compliance JJIS/FMS) Youth are screened upon admission for healthcare concerns that may need a referral for further assessment by healthcare staff. The center maintains a policy and procedure, which requires all youth receive a healthcare admission screening upon admission. A review of seven youth healthcare records validated all contained the Department s Detention Medical and Mental Health Admission Screening form for Office of Program Accountability Page 37 of 57 (Revised July 2015)

38 the most recent admission. Each form was completed by a juvenile justice detention officer (JJDO). The reviewed documentation supported the Department s Detention Medical and Mental Health Admission Screening forms were reviewed by nursing staff within twenty-four hours of each youth s admission to the center Medical Alerts Compliance The Department s requirement to alert staff of medical issues that may affect the security and safety of the youth in the facility. The center maintains a written policy and procedure regarding medical alerts. The center utilizes the Department s Juvenile Justice Information System (JJIS) and the Facility Management System (FMS) to document medical alerts. Seven youth healthcare records reviewed found six youth were applicable for placement on the center s medical alert system for having a chronic medical condition, food or medication allergy, taking medications with significant side effects, or having dietary restrictions. A review of open medical alerts documented all six youth were placed in the alert system. A review of the center s alert roster found each youth was listed with the appropriate alert. The center utilizes an internal alert system in addition to placing youth on the FMS alert. All youth who have allergies, a chronic condition, or have a medical issue are placed on the pass on report for discussion during the shift change meeting. A shift change meeting was observed during the annual compliance review. All youth placed on the report were discussed in detail Suicide Risk Screening Instrument Compliance A Suicide Risk Screening Instrument shall be completed within twenty-four hours of admission and filed in the Individual Health Care Record. The center maintains a written policy and procedure regarding the completion of a suicide riskscreening unit. There was a current Suicide Risk Screening Instrument (SRSI) in each of the seven reviewed records. Each SRSI was completed within twenty-four hours of the youth s admission to the center. Each reviewed SRSI contained documentation of a review, by nursing staff and/or mental health staff, within twenty-four hours Youth Orientation to Healthcare Services Compliance All youth are to be oriented to the general process of healthcare delivery services at the facility. The center maintains a written policy and procedure regarding the provision of healthcare orientation to the youth. The center has created a youth orientation to the medical services form containing all required health education. The form is forwarded, by intake staff, to healthcare services, within twenty-four hours of the youth s admission to the center. The orientation includes the sick call process, what constitutes an emergency, and how medications are administered. It also includes the youth are to notify staff immediately if they are having side effects from medications, allergies and/or medical alert issues, how the youth are to notify staff of any chest pain, extreme shortness of breath, and faintness while exercising. The healthcare orientation discusses with youth the right to refuse care, what to do in the case of a sexual assault or attempted sexual assault, outlines the non-disciplinary role of the healthcare providers, and situations in which the healthcare staff shall notify facility administration. Seven healthcare records were reviewed for this indicator. Each orientation contained all of the Office of Program Accountability Page 38 of 57 (Revised July 2015)

39 required elements, per the Health Services Rule. The center showed evidence of completing all of these orientations within twenty-four hours of the youth s admission into the center Designated Health Authority/Designee Admission Compliance Notification The DHA or designee is notified when youth ad-mitted require emergency care or routine notification in accordance with Department requirements. Seven youth healthcare records were reviewed for this indicator, and six were applicable for designated health authority (DHA) notification. There was documentation the DHA was notified regarding each youth admitted to the center with a known or suspected chronic medical condition, significant illness, or injury in all applicable records. This notification was documented on each initial intake nursing progress note and in the DHA notification log. One healthcare record did not require notification of the DHA upon admission, since the youth had no reportable chronic conditions or medical issues Healthcare Admission Rescreening Compliance A Healthcare Admission Rescreening is to be completed each time the physical custody of the youth changes and they are subsequently returned or readmitted to the facility. The center maintains a written policy and procedure regarding healthcare admission rescreening. None of the seven reviewed youth healthcare records was applicable for the youth leaving the center and being readmitted back into the center. The center was able to provide two examples for review. The applicable records documented the center completed a healthcare admission rescreening upon the youth s return to the center, when there was a change in physical custody Health-Related History Compliance The standard Department Health-Related History (HRH) form shall be completed for all youth admitted into the physical custody of a DJJ facility. The center maintains a written policy and procedure regarding the completion and maintenance of the Department s Health-Related History (HRH) form. Seven healthcare records were reviewed for this indicator. Six HRH forms were completed within the required timeframe. All six reviewed records confirmed the HRH forms were all current; however, they were updated within seven days of the youth s admission. All forms had been completed by a licensed practical nurse (LPN) and completed prior to the completion of the Comprehensive Physical Assessment. The reviewed documentation supports all six HRH forms were reviewed by the advanced registered nurse practitioner (ARNP) or the designated health authority (DHA). One youth did not have a current and valid AET. This youth had a parent/guardian report to the center to fill out an AET while the annual compliance review team was on-site. Once an AET was obtained, the center completed an HRH on the youth Office of Program Accountability Page 39 of 57 (Revised July 2015)

40 4.15 Comprehensive Physical Assessment Compliance The Comprehensive Physical Assessment (CPA) form shall be completed for all youth admitted in-to the physical custody of a DJJ facility. A review of seven youth healthcare records found six contained a current Comprehensive Physical Assessment (CPA). Each reviewed CPA contained all required elements of the Department s Health Services Administrative Rule. All CPAs were completed within the required timeframe of the youth s admission to the center. One of the seven youth records did not have a current and valid AET. This youth s parent/guardian reported to the center to fill out an AET while the annual compliance review team was on-site during the review. Once an AET was obtained, the center completed a CPA prior to the annual compliance review team s departure. When applicable, alerts were updated in the center s alert system and in Juvenile Justice Information System (JJIS) Female-Specific Screening/Examination Compliance The Department requires all adolescent girls receive gender-appropriate screenings, examinations, and tests to address their unique needs. The center maintains a written policy and procedure regarding the completion of gender-specific screening. Two youth healthcare records were applicable for gender-specific screening of the seven reviewed healthcare records. The center provided an additional two examples for this indicator. Two youth healthcare records contained documentation to support the youth provided verbal consent to receive testing while the other two youth refused gynecological testing. The review of four youth healthcare records documented each youth received a qualitative urine pregnancy test. Two youth were pregnant and were referred to a contracted off-site provider for an obstetrics and gynecological examination Tuberculosis Screening Compliance All youth are required to be screened for Tuberculosis (TB), and accurate documentation of results shall be maintained by each facility. A review of seven youth healthcare records found each documented at least one verified tuberculin skin test (TST) in the last twelve months. This information was documented on each youth s Comprehensive Physical Assessment and the Infectious and Communicable Disease form. All reviewed healthcare records contained documentation of an initial Tier I tuberculosis (TB) screening as part of the initial intake screening. The nursing staff utilized the TB syringe inventory sheet and the TB log to keep track of youth, documenting the youth name, date and time administered, quantity of TB syringes on hand, balance, and the name of the nurse administering the screening Sexually Transmitted Infection Screening Compliance The facility shall ensure all youth are evaluated and treated (if necessary) for sexually transmitted infections (STIs). The center maintains a written policy and procedure regarding the completion of Sexually Transmitted Infection (STI) Screening Forms. Six reviewed healthcare records contained documentation to support the youth had been screened for sexually transmitted infections by nursing staff. Two youth were referred to the designated health authority (DHA) for further Office of Program Accountability Page 40 of 57 (Revised July 2015)

41 evaluation. The two applicable records contained documentation to support the DHA or advanced registered nurse practitioner (ARNP) ordered STI testing. The test results from the Department of Health were filed within the youth s individual healthcare record. Three youth were offered testing; however, they refused this service. One youth record documented testing was not clinically indicated, so testing did not occur. One youth did not have a current and valid AET. This youth had a parent/guardian report to the center to fill out an AET while the annual compliance review team was on-site. Once an AET was obtained, the center completed a STI Screening Form while the annual compliance review team was on-site. Testing was not required according to documentation found within the youth s individual health care record (IHCR) HIV Testing Compliance The facility shall routinely offer counseling, testing, and referrals for medical treatment to all youth at risk for HIV infection. All youth admitted into the center are offered the opportunity to consent to receiving Human Immunodeficiency Virus (HIV) testing and counseling provided through an agreement with Youth Education Services (YES). A juvenile justice detention officer has the youth sign a form created by the center indicating whether the youth consented or refused the exam. A review of seven healthcare records documented five youth signed a form indicating refusal of HIV testing. Two youth signed the Department s consent form and testing has not been completed yet by the service provider. The service provider is on-site, at a minimum of once per month, to provide pre/post-test counseling, as well as to conduct the testing. During the annual compliance review, the center did not have any HIV results in the healthcare records to review. The center has a procedure in place to ensure the service provider documented the pre/post-test counseling in the youth s healthcare record or in the progress notes. The center s procedure ensures test results are sealed in an envelope provided by the examiner, labeled as confidential, and placed in the youth s healthcare record for disposition Sick Call Process Requests/Complaints Compliance All youth in the facility shall be able to make Sick Call requests and have their complaints treated appropriately through the Sick Call system. The center maintains written nursing protocols and non-healthcare protocols for the provision of sick call. Sick call is provided seven days per week, from 8:30 a.m. to 10:30 a.m. The center's nurse reported sick call could be conducted at any time during the day, in the event there is a need for it. Sick call is conducted by licensed healthcare professionals, pursuant to the scope of practice authorized by the designated health authority (DHA). The policy requires youth to receive an orientation to the center s sick call process during admission. The youth complete a Sick Call Request form and provide the request to a juvenile justice detention officer (JJDO). The medical complaint is placed into the center s Facility Management System (FMS) by the JJDO alerting the nursing staff of a Sick Call Request form. There was documentation to support sick call was conducted by either the licensed practical nurses (LPN), advanced registered nurse practitioner (ARNP), and/or the DHA when each were on-site. The DHA and/or ARNP provided follow-up medical care for applicable youth. The juvenile justice detention officer supervisors (JJDOS) review all Sick Call Request forms within four hours of their submission when no licensed nursing staff are on-site. The JJDOS will speak to the youth to determine the nature of the complaint and assess whether the youth s discomfort can be alleviated utilizing a process approved by the DHA. In the event the complaint requires further treatment, the JJDOS is required to contact a healthcare professional for consultation. Office of Program Accountability Page 41 of 57 (Revised July 2015)

42 Seven youth healthcare records were reviewed and there was documentation to support five youth who submitted a Sick Call Request form were seen by nursing staff in a timely manner. The sick call documentation was filed in each youth s healthcare record, in the Sick Call Index, and Sick Call Referral Log, or Facility Management System (FMS). Youth and staff interviews and surveys confirmed all officers receive training on the center s emergency response plan to respond to any emergency a youth may verbalize and immediately the officer informs supervisory staff of the situation. All sick calls completed by a LPN were verified, by the ARNP or DHA, the next day Sick Call Process Visits/Encounters Compliance The facility shall respond appropriately, in a timely manner, and document all Sick Call encounters as required by the Department. Seven youth healthcare records were reviewed, in which five youth submitted Sick Call Request forms. There was documentation to support all youth who submitted a Sick Call Request form were seen by nursing staff in a timely manner. The sick call documentation was filed in each applicable youth s healthcare record. The five sick calls were completed by a licensed practical nurse (LPN). In all five applicable instances, the advanced registered nurse practitioner (ARNP) or the designated health authority (DHA) reviewed the Sick Call Request form within twenty-four hours. The Sick Call Referral Log is electronically maintained in the center s Facility Management System (FMS). The Sick Call Index form is updated at every encounter and is maintained within the youth s individual healthcare record. Sick call progress notes consistently included the subjective, objective, assessment, and plan (SOAP) format. Staff and youth interviews and surveys confirm youth are given the opportunity to submit a Sick Call Request form and are seen within twenty-four hours of submission Restricted Housing Compliance All youth in Restricted Housing/Confinement shall have timely access to medical care, as required by the Department. The center has a policy and procedure in place to address youth placed in restricted housing. Youth can be placed in restricted housing for various amounts of time to over twenty-four hours. None of the seven medical files indicated the youth were placed in restricted housing. The facility was able to provide two additional examples where youth were in restricted housing less than twenty-four hours but required medication. These two examples confirm health services staff make a daily visit to the youth in restricted housing to ask about any health related complaints Episodic/First Aid Care Compliance The facility shall have a comprehensive process for the provision of Episodic Care and First Aid. The center has written procedures for the provision of episodic care and first aid, which include the documentation requirements for episodic care performed by non-healthcare staff. The designated health authority (DHA) is available on-call, twenty-four hours per day, seven days per week. The center maintains an Episodic Care Log to document the provision of episodic care and first aid treatment. Seven youth healthcare records were reviewed, of which two were applicable for the provision of episodic care. The center provided five additional examples of youth requiring episodic care for review. The licensed healthcare staff documented all episodic Office of Program Accountability Page 42 of 57 (Revised July 2015)

43 care in the Episodic Care Log. Healthcare staff saw all seven applicable youth. Each applicable youth s healthcare record contained appropriate documentation of the episodic care events. There are twelve first aid kits located throughout the facility and kits are made available for each of the vehicles. One first aid kit was reviewed and inventoried in master control. This reviewed kit contained all items required by the DHA, with none expiring. There was documentation to support the kits are monitored monthly for content and the need for replenishment of expired items. The kits are resealed and dated upon completion of each monthly review. The center maintains a suicide response kit in medical, master control, and one in each of the four modular living units. Each kit contained the required contents such as a knife-for-like, a wire cutter, and needle-nose pliers Emergency Care Compliance The facility shall have established processes and procedures for either directly providing Emergency Care or facilitating an appropriate response to an emergency situation. The center has written procedures for the provision of emergency care. Reviewed staff training documentation found all healthcare and non-healthcare staff members received the required cardiopulmonary resuscitation (CPR) training. Emergency drills were held on each shift, on a monthly basis, consistently exceeding the Department s quarterly expectation. Several of the reviewed drills contained a demonstration of CPR. The center has one automated external defibrillators (AED) located in the medical clinic and another in the administration. There was documentation to support monthly inspections of the AEDs. The center maintains a list of emergency telephone numbers, which is accessible to the staff. The training records contained documentation to support all supervisory staff received training by a registered nurse (RN) on the use of an Epi Pen Auto-Injector. Staff who were interviewed and surveyed confirm they have the ability to call Off-Site Care/Referrals Compliance The facility shall provide for timely referrals and coordination of medical services to an off-site healthcare provider (emergent and non-emergent), and document such services, as required by the Department. The center has written procedures for the provision of off-site medical care. Seven healthcare records were reviewed, of which two youth had been taken off-site for medical treatment. The center provided two additional examples of youth who had been taken off-site for review. There was a Summary of Off-Site Care Consultation Report form in each applicable healthcare record. Each summary had been signed by the designated health authority (DHA) to document a review of the treatment. None of the youth required a follow-up visit Chronic Conditions/Periodic Evaluations Compliance The facility shall ensure youth who have chronic conditions receive regularly scheduled evaluations and necessary follow-up. The center has written procedures for the provision of treatment for youth identified as having a chronic medical condition. The center maintains a roster to document youth with chronic conditions requiring a periodic evaluation. During the intake process, youth are screened for any medical condition requiring periodic evaluations or follow-up care. There are procedures in place for youth who are detained longer than one month to receive periodic evaluations. The Office of Program Accountability Page 43 of 57 (Revised July 2015)

44 center has a practice of seeing youth who have been in the center more than thirty days regardless of chronic conditions. A review of seven youth healthcare records confirmed five youth were identified as having a chronic medical condition, such as asthma or allergies, and/or were taking prescribed medications. All required periodic evaluations were conducted by the designated health authority (DHA). The Problem List was updated in all applicable youth Medication Management Verification Compliance A youth s medication regimen shall be ascertained upon admission to the facility. The center has written procedures regarding medication verification. The nursing staff verify the medications for youth entering the center. The nursing staff verifies the medications through a review of each youth s information, and follows up with a telephone call to the youth s parent/guardian and/or the prescribing pharmacy. Seven reviewed healthcare records documented three youth entered the center taking medications. The center provided an additional three examples for review. Each applicable record contained documentation of the medication regimen verified upon the youth's admission into the center. The medication receipt, transfer, and disposition form had been completed and signed by a nurse. The verification was documented in the nursing chronological notes in each youth s healthcare record. There was documentation to support the nurse received an order from the designated health authority (DHA) or the psychiatrist to continue the medication for each youth Medication Management Orders/Prescriptions Compliance All medications shall have a current, valid order and are given pursuant to a current prescription or Practitioner Order. The center has written procedures regarding medication management. A nurse verifies the youth s medication upon admission to the center, and an order is received from the designated health authority (DHA) to continue the youth's medication. Youth who are admitted with psychotropic medications are continued on the medication until the completion of the initial psychiatric evaluation. Seven reviewed youth healthcare records documented three youth entered the center taking medications. The center provided an additional three examples of youth who were on prescription medication upon their admission. All six applicable records contained current, valid orders for prescription medication. The initial Medication Administration Record matched the youth's medication list for all youth who entered the program taking medication. The reviewed documentation supported the youth were continued on their medication once the nursing staff verified the prescription and notified the designated health authority (DHA) or psychiatrist. The DHA or psychiatrist provided an order for the nursing staff to continue their medication in all six applicable Individual Health Care Record (IHCR) Medication Management Storage Compliance All medications (e.g., prescriptions, over-the-counter, topical) are stored in separate, secure (locked) areas inaccessible to youth. The center has written procedures regarding medication storage. All prescription medications and current over-the-counter (OTC) medications are stored in a locked medical cart. There is a locked cabinet, in the medical department, where replenished OTC medications are stored at all times. The medications are accessible to supervisory staff with approved access to the clinic. The various forms of medications, such as topical and injectable, are separated from routine Office of Program Accountability Page 44 of 57 (Revised July 2015)

45 medication. The clinic has a dedicated refrigerator to store medications requiring refrigeration. The center has an agreement with a pharmacy allowing the return of any expired or discontinued medication for disposal. The center maintains procedures for the disposal of all medications, including controlled substances, which are disposed of by the registered consultant pharmacist Medication Management Medication and Sharps Compliance Inventory All medications and sharps shall be inventoried, as per Department requirements. The center has written procedures regarding medication and sharp inventories. The center maintains an inventory for all medications and medical equipment classified as sharps. These inventories were conducted consistently for the past six months, as outlined in the Department s Health Services Rule. All medications, syringes, and sharps are securely maintained in the clinic. The center conducted perpetual and weekly inventories of all over-the-counter (OTC) medications. All sharps were counted weekly. The inventories were found conducted as required by the Department s Health Services Rule. A review of three youth medications three sharps and three over the counter (OTC) were all accounted for., Inventories were consistently conducted as often as outlined in the Florida Administrative Code Medication Management Controlled Medications Compliance All controlled substances shall be inventoried, stored, and documented, as per Board of Pharmacy and Department requirements. The center has written procedures regarding controlled medication. The center procures all medications from Diamond Pharmacy, which is located in Pennsylvania. A local Publix pharmacy in Tampa, Florida, is used in cases of emergency, as the back-up pharmacy. The center maintains all controlled substances in the medication cart, which is behind a double-lock system. The center s practice is to conduct shift-to-shift inventories for controlled substances. At the time of the annual compliance review, there was only one youth taking controlled medication. There were perpetual and shift-to-shift counts maintained on one applicable youth s Controlled Medication Inventory Record, on file for the past six months. An inventory was conducted on one youth applicable controlled substance and this inventory was found to be correct. No discrepancies were noted on medication counts since the last annual compliance review Medication Management Medication Administration Compliance Record The standard Department Medication Administration Record (MAR) shall be maintained at the facility for each youth who has a current, valid medication order. The center utilizes the standard Department of Juvenile Justice Medication Administration Record (MAR) to document the administration of medication. The healthcare records of seven youth were reviewed for this indicator. All of the reviewed MARs contained the name of the youth, Department of Juvenile Justice Identification (DJJID) number, date of birth, allergies, medical precautions, assigned medical grade, and medical alerts. The MARs for the current month are maintained in a binder, and there is a photograph of the youth with the current MAR for identification purposes. Each reviewed MAR documented all youth received the ordered medication. Any refusals were documented on the MAR and the Department of Juvenile Justice Office of Program Accountability Page 45 of 57 (Revised July 2015)

46 (DJJ) refusal form. Each MAR documented a start and stop date of the medication. If a doctor discontinued a youth s medication, the applicable medication entry on the MAR was highlighted in yellow. There were no noted lapses in medication administration Medication Management Medication Administration by Compliance Licensed Staff Medication Administration shall occur as scheduled in a comprehensive, accurate, and organized manner in the facility, only by a licensed nurse. The center has written procedures regarding medication administration. The center's practice is to have nursing staff provide medication administration. The exception is if ordered medication is to be administered when nursing staff is not on-site. The medications are provided to the youth in the clinic. During the annual compliance review, medication administration by licensed healthcare staff was observed for two youth. The youth were brought into the clinic and the youth approached the medication cart. The youth confirmed his name, medication, and whether he had any other medical issues. The nurse asked about any allergies or side effects from the medication. The nurse reviewed the youth's medication administration record (MAR), which contained a photograph of the youth, to ensure the right medication was being provided to the right youth. The medication was placed in a small cup, and given to the youth, with a cup of water. The nurse gave the youth the medication, had the youth open his mouth, and then cough to ensure medication was swallowed by the youth. Both the youth and the nurse initial the MAR confirming the dose was given to the youth. An observation of medication pass during the annual compliance review found nursing staff are verifying the five rights of medication administration Medication Management Medication Provided by Non- Compliance Licensed Staff Trained, non-healthcare staff may assist youth with self-administration of oral prescription medications or over-the-counter (OTC) medications, only when licensed nurses are not available on site. The nurse shall delegate the delivery, supervision, and oversight of youth during self-administration of medications. The center has written procedures regarding medication administration by non-licensed staff. Nurses generally administer the medication; the exception being when medication is ordered to be administered when nursing staff are not on-site. The center has a trained juvenile justice detention officer supervisor (JJDOS) to assist youth with self-administration of medication. There was documentation to support medication administration by JJDOS is rare. There are limited types of over the counter (OTC) medications stored in the medication cart. There was documentation to support a licensed nurse provided the required training to the center s supervisory staff. Documentation and interviews with staff and youth verified medication administration by a juvenile justice detention officer supervisor is very rare, only occurring in the late evenings and on weekends Medication Management Psychotropic Medication Compliance Monitoring The facility shall have a comprehensive process in place for the monitoring of psychotropic medications, to ensure youths safety and as required by the Department. The center has written procedures regarding psychotropic medication monitoring. The center's practice is to make a psychiatric referral on the day of admission for applicable youth. Seven Office of Program Accountability Page 46 of 57 (Revised July 2015)

47 reviewed healthcare records documented three youth entered the program taking psychotropic medications upon admission. All youth had a valid Authority for Evaluation and Treatment (AET) upon admission. The initial diagnostic psychiatric interviews were conducted within fourteen days of admission for all applicable youth. None of the three applicable youth were in the center long enough to require a medication monitoring; however, documentation confirms youth applicable for monthly medication management saw the psychiatrist, on an as needed basis, for psychotropic medication management. When indicated, the health services staff has a procedure in place to document the monitoring for tardive dyskinesia on a monthly basis Infection Control Surveillance, Screening, and Compliance Management The facility shall have implemented Infection Control procedures including prevention, containment, treatment, and reporting requirements related to infectious diseases, as per OSHA federal regulations and the Centers for Disease Control and Prevention (CDC) guidelines. The center maintains an infection control plan. The plan contained all the required elements as outlined in the Department s Health Services Administrative Rule. The infection control plan addresses common childhood diseases, self-limiting episodic contagious illnesses, and viral or bacterial infectious diseases. The plan also addresses tuberculosis, hepatitis A, B, and C, human immunodeficiency virus (HIV), infectious diseases caused by blood borne pathogens, other outbreaks or epidemics caused by any other infectious agent, outbreaks of pediculosis and/or scabies, methicillin-resistant staphylococcus aureus (MRSA), and other emerging antibiotic-resistant micro-organisms, foodborne illnesses, bioterrorism agents, and chemical exposures in the workplace. There were no reportable incidents where the local county health department, Centers for Disease Control and Prevention (CDC), and/or Central Communications Center (CCC) should have been notified of an infectious disease. There is personal protective equipment available to staff. Staff training files validated staff received training in 2015 on the plan Infection Control Education Compliance The facility's comprehensive Infection Control education plan shall include pre-service and inservice training for all staff, and youth infection control education, as per Centers for Disease Control and Prevention (CDC) guidelines. The center provides infection control education to all youth and staff. Youth and staff receive training of hand washing techniques, prevention, transmission of communicable diseases, and universal precautions. There was clear documentation in each of the seven reviewed youth healthcare records to support the youth received training on infection control within seven days of their admission to the center. A review of training files for new staff documented the receipt of infection control training at the time of hire. A review of training documentation provided by the advanced registered nurse practitioner (ARNP) reflected all staff are provided this training on an annual basis, during in-service training. Office of Program Accountability Page 47 of 57 (Revised July 2015)

48 4.38 Infection Control Exposure Control Plan Compliance The facility's exposure control plan shall meet the requirements of OSHA standards (29 CFR 1910), with maintenance and documentation of the plan, as per the requirements of the Department. The center maintains an exposure control plan. The plan was reviewed and signed on December 1, 2015, by the superintendent and by the designated health authority (DHA) on December 7, The plan includes risk assessment and methods of compliance. The plan meets the Occupational Safety and Health Administration (OSHA) requirements outlining the process for the prevention, treatment, containment, and reporting of infectious diseases. The center has not had any incidents involving a contagious disease requiring the quarantined or hospitalization of at least ten percent of the total population of youth or staff during this annual compliance review period Prenatal Care Physical Care of Pregnant Youth Compliance The facility shall provide prenatal care at recommended intervals. High-risk pregnant youth will be provided additional testing and services, as recommended. The center has a written plan to care for pregnant youth. The plan includes procedures for the youth s medical issues, nutrition, medication, and education. Seven healthcare records were reviewed, of which, none were applicable for this indicator. The program provided two additional examples of pregnant youth who were admitted to the center during this annual compliance review period and both records confirmed the youth received the prescribed prenatal care from both the on-site and off-site providers Prenatal Care Nutrition and Education of Youth Compliance The facility shall provide nutritious foods in sufficient quantities meeting the standards of the minimum daily allowances for pregnant youth. Each pregnant adolescent shall receive prenatal, postpartum, and parenting education including topics directly related to healthcare issues and medical risk for pregnant adolescents. The center provides health education to pregnant youth. The training topics include nutrition, contraception, basic baby care, child/infant development, and parenting skills. Nursing staff documented all required training topics, as outlined in the Department s Health Services Rule and the Florida Administrative Code. The review of documentation supported when a pregnant youth is admitted into the center there is weekly monitoring of the youth s height and weight, along with the provision of nutritional supplements are provided to the applicable youth Prenatal Staff Education Limited Compliance All non-healthcare staff involved in the supervision or treatment of pregnant youth shall receive appropriate education. A review of seven staff training records reveal three staff were trained in monitoring, observation, and emergency care for pregnant youth. One of the four untrained staff was hired after the conducted training. The last training was conducted on May 8,, 2015, by the advanced registered nurse practitioner (ARNP). Office of Program Accountability Page 48 of 57 (Revised July 2015)

49 Standard 5: Safety and Security Overview The Hillsborough West Regional Juvenile Detention Center is a hardware secure center with a capacity of ninety-three beds. The center s population was under capacity at the time of the annual compliance review, with sixty-five youth. There are four living modules, three designated for male youth and one for female youth. 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 maintains an inventory and strict 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. All vital information is communicated by , passed on during shift briefings, and documented in the logbooks, and the Juvenile Justice Information System (JJIS). The maintenance staff are responsible for preventative and routine maintenance of all center systems. The center uses an electronic Brooklyn Computer System (BCS), which is a wand to document ten-minute checks when youth are in their rooms and behind a closed door Active Supervision of Youth Compliance Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor the movement of youth in their direct care from one location to another. Youth are in sight of at least one Juvenile Justice Detention Officer (JJDO) at all times (with the exception of sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all times. At no time shall another youth be allowed to exercise control over or provide discipline or care of any type to another youth. When a youth leaves the group or program area of the facility for any reason, all staff assigned to supervise the youth are informed. Master control authorizes all movement of youth prior to the actual movement, and no movement occurs until cleared by master control. Staff moves youth from one area of the facility to another in accordance with Florida Administrative Code. The center has a written policy and procedure, which addresses supervision of youth. No youth was left unattended or unsupervised during the annual compliance review. It was also noted, at least one juvenile justice detention officer (JJDO) was actively supervising youth at all times during daily activities and escorting youth during movement from one part of the center to the other. The staff contacted master control prior to the movement of youth. No movement took place until cleared by master control. The review of unit logbooks confirmed youth counts were consistently documented by the staff. The master control logbook also maintained a continuous tracking of the youth s location. Five of seven staff surveyed felt there is not enough staff at the center to provide for the safety and security of the youth and staff. Office of Program Accountability Page 49 of 57 (Revised July 2015)

50 5.02 Ten-Minute Checks Compliance Staff shall visually observe youth on standard supervision at least every ten minutes while they are in their sleeping quarters, either during sleep time or at other times, such as during an illness or room restriction. Staff conducts observations in a manner ensuring the safety and security of each youth and documents real-time observation manually or electronically. Documentation must include the actual time of each visual observation and initials of the staff conducting the check; pre-printed times are not acceptable. There shall be no obstructions (e.g., clothing, memos, pictures) over windows and areas where direct line of sight is needed. If an officer, in the course of completing visual observation, is unable to see the youth or any part of the youth s body, the officer shall, with the assistance of another officer, open the door to verify the youth s presence. The center has written policies and procedures regarding ten-minute checks. The examples of ten-minute checks were reviewed by closed circuit television (CCTV). Checks were conducted for the four modules housing youth. Completed visual ten-minute checks are documented through the Brooklyn Computer System (BCS). A review of the last six months of visual observation reports and CCTV on various nights concluded there was no incident where the time between rounds exceeded the required ten minutes. All seven surveyed staff verified the practice of completing checks at a minimum of every ten minutes Census, Counts, and Tracking Compliance Officers must know the exact number and location of all youth under their supervision at all times. Census counts of youth shall be taken, called into Master Control, and documented, at a minimum: At the beginning and end of each shift. Following any emergency to include power outages, evacuation due to emergency drills, and any code called outside the secure walls. In the event a code is called in any location outside the main walls of a facility, it is critical all youth counts are reconciled prior to the movement of any group of youth. Prior to and following routine group movement. Any time a population change occurs. Randomly, at least once on each shift. Staff should not include youth in the count who are not physically present with the staff person at the time of the count (e.g., court, clinic, confinement). The center maintains census counts and tracking with written counts in the master control and living module logbooks. Counts are conducted at the beginning, middle, and end of each shift and are documented in the master control logbook. Routine group movements are documented in the living module and master control logbooks. All population changes of youth being admitted or released are documented in all appropriate logbooks. Seven staff surveys indicated they are familiar with census tracking and conducting emergency counts. All staff indicated emergency counts would be conducted if a youth is believed to be missing. Six staff indicated Office of Program Accountability Page 50 of 57 (Revised July 2015)

51 counts would be conducted after a major disturbance or when visibility of the youth is hindered. One staff also included counts would be conducted during a code red Key Control Compliance Each facility is responsible for maintaining inventory and control of all facility keys. All keys shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys. Emergency key rings shall be maintained separately from other facility keys, in master control, in a secure location designated by the Superintendent. These keys shall be notched or otherwise identifiable by touch. The key(s) on these rings shall provide egress through facility exterior doors providing access to evacuation areas. A key inventory shall be maintained by the Superintendent or designee at all times. (For the entire indicator statement, please reference the Monitoring and Quality Improvement FY Detention indicators.) The center has a written policy and procedure to address key control. Observations and interviews with staff indicated they are familiar with the key control process. The facility utilizes the key-per-key system and keys are secured in a locked box in master control. All key rings are tamper resistant. Emergency keys are secured and maintained separately from other facility keys. The center has a list of keys including key ring number and number of keys on each ring. The center has a set of grandmaster keys which are restricted and maintained separately from the other center keys. All reviewed documentation included the date and time of the returned key. During this annual compliance review period, the center had one incident related to missing keys. All reviewed documentation verified the center s policy was followed and the appropriate corrective action was taken during, and before, closing the incident Vehicles and Maintenance Compliance The program ensures any vehicle used by the program to transport youth is properly maintained, and maintains documentation on the use and maintenance of each vehicle. Youth and staff are not permitted to use tobacco products. Program vehicles are locked when not in use. The center has a written policy and procedure regarding vehicles and vehicle maintenance. An inspection of the center s transport vehicles was conducted during the annual compliance review. All of the vehicles were locked when not in use and contained operable seat belts, a seat belt cutter, a window punch, a fire extinguisher, and a sealed first aid kit. During the annual compliance review, a transport of nine youth was observed. The staff searched the vehicle prior to departing the center. All the vehicles were in operable condition and had received the appropriate inspections. Office of Program Accountability Page 51 of 57 (Revised July 2015)

52 5.06 Tool Inventory and Management Compliance The program ensures all tools and equipment related to maintenance are properly maintained, stored, and inventoried. The center has a written policy and procedure addressing tool inventory and management. The interviewed maintenance staff was familiar with the procedure for lost/damaged tools. Only maintenance and authorized staff are allowed to sign-out tools for use. All tools are etched with a code identifying them as Department of Juvenile Justice (DJJ) property, stored on a shadow board, and in a locked area inaccessible to youth. The maintenance staff conducts a continuous inventory of all tools on a monthly basis. A review of the monthly inventories for the past six months confirmed all tools were accounted for and there were no tools needing to be replaced due being damaged or lost. The maintenance staff makes sure all service vendors are escorted to the area of the center where the work is to be conducted and remains with them until the work has been finished for the day Kitchen Tools Compliance Kitchen knives and other hazardous kitchen sharps are stored in a locked cabinet, drawer, or toolbox containing an inventory list. All storage areas, including cabinets and drawers, are secured when not in use. Kitchen staff conducts an itemized inventory of all equipment, including kitchen knives and other hazardous kitchen implements, upon reporting for duty. All equipment is accounted for prior to the departure of the kitchen staff. Any discrepancy must be reported to the Superintendent or designee. The center has a written policy and procedure addressing the maintenance and storage of kitchen tools. The center maintains a detailed inventory of all kitchen equipment to include knives. No youth are allowed access to the kitchen at any time. A review of the inventory found all kitchen tools were present and accounted for. A daily count is conducted by the juvenile justice detention officer (JJDO) supervisor twice per day. All kitchen sharps are secured when not in use, in a locked box, and behind a locked door. Prior to leaving the center for the day, the staff are required to report any discrepancies to the superintendent. There were no incidents noted of any kitchen tools, which were unaccounted for or missing during this annual compliance review period Youth Access & Use of Tools, Cleaning Items Compliance Youth are forbidden to use or access any tools, including kitchen or medical equipment. Youth may use cleaning items such as mops, brooms, buckets, and other common household items under direct supervision. The center has a written policy and procedure addressing the youth s access to tools. Youth are not permitted access to any tools except brooms and mops. A review of the closed circuit television (CCTV) during clean up in the living areas confirmed the youth use mops and scrub brushes. The juvenile justice detention officer (JJDO) handles the cleaning solution and monitors youth during the cleaning process. Staff are in constant supervision of the youth at all Office of Program Accountability Page 52 of 57 (Revised July 2015)

53 times. Seven staff responded to the survey and all reported the youth are only permitted to use mops and scrub brushes. Seven youth responded to the survey and all reported they only use mops and scrub brushes and never handle chemicals Inventory of all Flammable, Toxic, Caustic, and Compliance Poisonous Items The Superintendent is responsible for the implementation of a safety plan addressing proper use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured when not in use. The use of hazardous material shall be consistent with the manufacturers instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and poisonous items shall have the Material Safety Data Sheets (MSDS) on hand in the facility. Toxic or caustic materials shall not be allowed to enter into the facility unless an MSDS is on file in an MSDS logbook and posted near items. A master copy of the MSDS logbook shall be maintained in an accessible binder for all personnel to review at all times. No hazardous chemicals should be mixed, as this could result in an explosion or emission of toxic gas. The center has a written policy and procedure addressing the proper use, storage, and disposal of chemicals including flammable, toxic, caustic, and poisonous items. The review of the storage area for the center s flammable, toxic, caustic, and poisonous items found the items were stored in a secured area not accessible to the youth. The review of stored items also found there were no hazardous chemicals preventing the possibility of an explosion or emission of any toxic gas. The center indicated an internal review identified deficiencies with their chemical inventory process. A corrective action plan was put in place in December 2015 and the review team was provided with the chemical inventory for the last two months for this time frame for review. The center corrected their deficiency and a review of the inventory and documentation for the last two months support this correction Access to all Flammable, Toxic, Caustic, and Poisonous Compliance Items Flammable, toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any other person s bio hazardous material, bodily fluids, or human waste. The center has a written policy and procedure addressing the access to all flammable, toxic, caustic, and poisonous items. These items are kept in a secured storage area not accessible to youth. The review of surveillance video did not show youth handling any cleaning chemicals. Seven youth responded to the survey and reported never handling any cleaning agents. Youth indicated staff spray the chemicals when youth are cleaning. Six of seven surveyed staff reported youth are not allowed to clean with substances which are toxic, flammable, or poisonous. Office of Program Accountability Page 53 of 57 (Revised July 2015)

54 5.11 Disposal of all Flammable, Toxic, Caustic, and Poisonous Compliance Items The Maintenance Mechanic or other trained staff who have the safety equipment for diluting, handling, and disposing of hazardous waste and/or solid waste shall be responsible for disposing of hazardous items and toxic materials in accordance with Occupational Safety and Health Administration (OSHA) Standard 29 CFR (amended ). The center has a written policy and procedure addressing the disposal of all flammable, toxic, caustic, and poisonous items. The center did not have any instances of any chemical spills during this annual compliance review period. There were no flammable, toxic, caustic, and poisonous items requiring disposal. The maintenance mechanic or other trained staff who have the safety equipment shall be responsible for disposing of hazardous items and toxic materials in accordance with Occupational Safety and Health Administration (OSHA) standards in one of the following methods; compaction, evaporation, flushed, incineration, or bio-hazardous waste contractor. Hazardous liquid waste shall be disposed of in accordance with the safety data sheet Confinement Under Twenty-Four Hours Compliance Staff shall use behavioral confinement as an immediate, short term response strategy during volatile situations in which a youth s sudden or unforeseen onset of behavior imminently and substantially threatens the physical safety of others or self. The center has a written policy and procedure addressing confinement of youth under twentyfour hours. A review of ten confinement reports for youth placed in confinement under twentyfour hours found documentation was entered into the Facility Management System (FMS), within one hour of each youth being placed in confinement. Each form documented the room was searched prior to placement and each entry was done in real time. There was documentation to support the juvenile justice detention officer (JJDO) supervisor conducted a review within two hours, spoke with the youth every three hours, and reviewed all confinement reports within forty-eight hours of the end of the confinement. Office of Program Accountability Page 54 of 57 (Revised July 2015)

55 5.13 Confinement Over Twenty-Four Hours Compliance Confinement beyond twenty-four hours must be approved by the Superintendent or designee. The Superintendent shall approve confinements extended beyond twenty-four hours and every twenty-four hours afterwards. Reasons for extended confinement must be clearly documented on the confinement report. The JJDOS(s) shall continue to evaluate and document the youth s status every three hours. Current youth behavior and/or conversation with the youth shall be documented on the confinement report as evidence for the need to continue or terminate confinement. The length of confinement shall not exceed three days unless the release of the youth into the general population would jeopardize the safety and security of the facility as documented by the Superintendent. No youth shall be held in confinement beyond three days without a confinement hearing conducted by an employee of the Department who holds a management or supervisory position. The center has a written policy and procedure addressing confinement of youth over twenty-four hours. The center had only two confinements during this annual compliance review period lasting over twenty-four hours, and there was only one three-hour supervisory review done two hours late Continuity of Operations Planning (COOP) Drills Compliance COOP drills shall be conducted and documented, at minimum, twice a year, with one drill being completed prior to the hurricane season, which begins June 1st. The center had an approved Continuity of Operations Plan (COOP) in place and available for review. The staff conducted three emergency drills in the past year and one of those drills was conducted in May 2015, at the start of hurricane season. The center documented drills in the master control logbook and on the appropriate emergency drill form Escape Drills Compliance The center shall develop, implement, and maintain an escape prevention plan incorporating the Department s established policies and procedure regarding escapes. The facility shall conduct and document quarterly mock escape drills. The center has a written policy addressing their escape prevention plan. A review of escape drill documentation for the last two quarters in 2015 showed the center conducted an escape drill for the past two quarters; however, the facility did not have the fourth quarter drill documented on the applicable drill form with a list of staff who participated. The only documentation provided by the center to verify a drill took place was a master control logbook entry. Seven staff were surveyed and six recalled their participation in an escape drill sometime in the last six months. Office of Program Accountability Page 55 of 57 (Revised July 2015)

56 5.16 Fire Drills Limited Compliance Management has implemented a disaster preparedness plan and fire prevention plan. Monthly fire drills (with procedures being approved by local fire officials) are documented and conducted under varied conditions and on each shift. The center has a written fire prevention policy and procedures to address fire prevention. A review of the provided documentation revealed all drills were being conducted on a monthly basis; however, for the month of August 2015, on third shift, there was no documentation provided to identify a monthly drill was conducted. Drills for the months of October 2015 on third shift, November 2015 on first shift, and December 2015 for all shifts was only documented in master control logbook. Fire drills are required to be conducted monthly on all three shifts and these drills must contain an attendance record, be critiqued, and reviewed by supervisory staff. A review of the facility operating procedures states fire drills will be documented on the emergency drill from. Office of Program Accountability Page 56 of 57 (Revised July 2015)

57 Program Name: Hillsborough West 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): February 23-26, 2016 Lead Reviewer Code: 146 Overall Rating Summary The following limited and/or failed indicators require immediate corrective action. Limited Ratings 1.08 Logbook Maintenance 2.05 Notification of Law Enforcement 4.41 Prenatal Staff Education 5.16 Fire Drills Failed Ratings Office of Program Accountability Page 57 of 57 (Revised July 2015)