Independent Ombudsman for the Texas Juvenile Justice System Gainesville State School Site Visit Report OIO-SV-17-036 October 4-6 13, 2016 Observer: -?wan and Allen wallace Purpose: utine ure Fa i' ite i Report: This report is designed to identify problems and seek remedies that help secure the rights and ensure the safety of youth housed at the facility. The issues identi?ed in this report are based entirely on the Ombudsman?s observations, interviews with staff and youth, and collected data. Unless otherwise noted, the issues identified in this report do not constitute formal legal ?ndings. Last Review Date: 09/20-21/2016 Facility Budgeted Capacity: 186 Facility Population: 262 Number of Youth Interviewed: 128 Summary: FACILITY, PROGRAMS, PROCESSES or ADMINISTRA TIVE FUNCTIONS: On October 4-6, 2016 four Ombudsmen conducted a site visit for the purpose of interviewing youth. A follow?up visit was conducted on October 13, 2016. The visits included a walk-through of some dorms, security, the Re-Direct Program unit, and education. The facility was 76 over the current budgeted population. There were 11 youth in the security unit including 2 on Medical Observation (MD), 1 on RDP status and 8 on security program. Review of security files revealed various files continue to re?ect non-compliance; speci?cally, Incident Reports not being completed properly; and room/cell check forms indicated the room checks were not random, and were completed at exact 15 intervals. One security extension [past 24 hours) had appropriate documentation and justifications, while 2 others were not documented in accordance with policy. The youth on MO acknowledged receiving services as required by agency policy. There were 9 youth assigned to the RDP unit. The reviewed indicated the random safety/welfare checks had improved and - Individual Youth Performance Rating Logs for youth had been signed by the ICO VI or designee. The youth phone had been installed in the RDP group room. Youth indicated their Large Muscle Exercise was completed in the group room, 30 minutes at a time. The LME always consisted of calisthenics and they did not have access to outdoors activities. They also stated there was "little to no recreation time" table games, etc). Youth also indicated they did not receive visits from the Chaplain. Not all youth residing on the RDP hall were actually placed in the RDP program for behavior management reasons. Two youth were on campus transition, 3 on RDP program, 2 on MD for medical issues, 1 refusing to leave security program, and 1 for safety reasons. The youth refusing to leave security had been doing so for several weeks. One youth residing on the RDP hall for safety reasons had been assaulted 4 times since the last 10 site visit after he had reported his case manager had made inappropriate comments to him in front of others regarding his committing offense. The 2 youth on M0 were placed on the RDP unit for "closer observation" due to diabetic issues and physical restrictions due to neck injuries. One youth on RDP status was being housed in security after he had ?ed from the RDP unit. INTERVIEWS: One hundred twenty-eight youth were interviewed during the site visit. Due to the number of youth interviewed during this site visit various complaints were received that resulted in numerous referrals to the agency Incident Reporting Center numerous OIO Inquiry/Referral reports and 4 010 individual cases. One youth interviewed had recently been knocked unconscious when he was hit in the head by a staff with a radio. He reported he occasionally still felt dizzy but had followed up with nursing staff. One youth who had sustained a neck injury was concerned because he was no longer involved in physical therapy. The it] submitted an Ombudsman?s Medical Review Request to the TIID medical department. That review indicated the youth should be in physical therapy and it was being scheduled. Various youth reported they felt security staff were doing "dirty restraints? by being overly aggressive, twisting their wrist, and lifting/pulling their arms in the air behind their backs when in handcuffs. Two youth also complained that they had been 0C pepper sprayed and security staff took the longest route around campus to security, thus delaying their decontamination. Youth also reported "staff? called "hits? [assaults] on other youth. Youth on dorm 5/6 continue to complain they spend "most of the time? in their rooms and were placed on telephone restriction for misbehaviors not related to abuse or misuse of the telephone. Several youth complained that security cells were not properly cleaned or sanitized and bodily ?uids were present on walls, beds, etc. They also complained that security sleeping mattresses were never cleaned, and their clothing was not washed while in security. They indicated new security rules established deny them the ability to talk through their doors or vents in security, and that "flipping your cuffs" [moving handcuffs from behind their back to in front of them) is considered a major rule violation of tampering with safety equipment. Both of these may result in extended stays in security. The TIID General Counsel?s Of?ce (GCO) was consulted for clari?cation of these rules meeting agency policies. In both situations the GCO supported the practice. Numerous youth reported feeling uncomfortable with the new strip search procedure in the security unit and the inconsistent application of the procedure. They also indicated they had not been advised of the changes until it began to occur sometime in July. The GCO was consulted for clarification on the strip search procedure itself and the youth?s basic right to be informed Gainesville State School, October 4-6 13, 2016 Page 2 of 13 01/16 Right to be Informed - Youth have the right to be informed of all rights, policies, procedures, and rules a?ecting them while in the custody of . TJJD. The response to the request for clarification stated: "Youth have no right to be informed of a procedural change in advance of the change. There is simply not time to inform all youth in advance of every procedural change in case it might at some point later impact thatyouth. Staffinformed individualyouth ofthe changes to procedure when it was about to impact the individuals, and that is sufficient. The clarification of this Basic Right appears to be inconsistent with historic interpretation and implementation of the Right. MON UMMARY: The chart below is based on data collected by TIID re?ective of participant incidents which have taken place at the facility. Nov?15 Dec-15 Jan?16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 16-Jul 16?Aug 16?Sep 16-0ct Restraints 133 176 179 185 106 161 149 148 112 145 135 105 Assaults YGang related Staff Assault Part. Major DistFlee App 260? .. . I 180 160 140 120 100 Assaults 80 . 4 . '55; _?Gang related 60 ?Staff Assault 40 .- 7 :Part. Major Dist. 20 Flee App 0 . Nov-15 Dec?15 Jan-16 Feb~16 Mar?16 Apr-16 May?16 Jun-16 Jul-16 Aug-16 Sep?16 Oct-16 Gainesville State School, October 4?6 13, 2016 Page 3 of 13 IO-003 01/16 Issues from previous site visits remain on the report until the Ombudsman has con?rmed that the response presented by Tij has been completed and implemented. Date Identi?ed Issue TIID Response Follow Up 10/13/16 Youth assigned to dorm 5 6 reported they were placed on ?phone restriction? for behavioral issues not related to the abuse or misuse of the youth phones. They stated restrictions were as long as 7 days in length. This complaint has been voiced previously to the 010. This appears to be in violation ofthe Basic Right for Access to Telephone. What action will be implemented to ensure the youth has access to telephones as stated in their Basic Rights GAP.380.9301 I 11/22/16 ~The Dorm Supervisor stated that she had not placed any students on phone restrictions nor had their C-Tell suspended. As a follow up measure, she met with the VI and the case manager to ensure that youth are not restricted from phone use when placed on a loss of privileges that does not pertain to misuse of the telephone. Staff met with the youth on the dorm to ensure they know that they have access to the blue phones as long as they are not being combative and it is safe to open their door. They are not restricted from phone use when placed on a loss of privileges unless it pertains to misuse of the telephone. This was documented on a TRN-955. 10/13/16 Youth in security stated they had been advised they were not allowed to use the youth (blue) phones any longer, including making contact with IRC or 010 They were required to use paper grievances. Youth also stated their LME was completed in their rooms, and they had no access to LME out of their room or the outdoor exercise area. These practices do not appear meet the TIID security standards What plan 11/22/16 - The Manager I of operations has been making daily visits to the security unit, and reviewed the security documentation to monitor youth activities. Youth are taken out to the recreation yard for large muscle exercise. Youth also have access to the blue phones as long as they are not being combative and it is safe to open their door. Gainesville State School, October 4?6 81 13, 2016 Page 4 of 13 IO-OO3 01/16 will be implemented to ensure youth are afforded access to all program services as outlined in TJJD policy? 10/13/16 Youth stated the security search process changed in July when they were referred to security, the same month the new policy and procedures went into effect (INS.91.81 Process for Strip Searches. Youth were informed of the new search procedure when they were referred and had arrived in security, indicating they were not informed in advance of the procedural change. Based upon youth contentions and observations, rarely were 2 staff members present during the strip search in security. They described a very inconsistent application of the policy/procedures since July, indicating some staff followed the new search process, others required additional elements described, and some using the 01d method of search. Do the requirements of the strip search policy/procedures apply to all referrals to the security unit, and if so what plan will be implemented to ensure 2 staff members are present as required by the policy? 1 1/22/16 - All youth entering into the security unit will be searched per INS.75.03 (D). Security staff will place youth arriving at the unit in a room and search the youth in accordance with GAP.97.9. As a precautionary measure it is assumed that all youth entering the security unit may possibly be in custody of contraband or items that they can potentially harm themselves with. A strip search is conducted to remove any such contraband to ensure the safety of the youth and the staff. The MGRI will ensure that outside security stays and searches the youth on the hall with the hall staff and if it is an emergency and the outside security staff has to leave. the male caseworker can be pulled in as the second staff. 11/28/16 - The GCO response to a request for clarification included the following excerpts: "Strip searches must be based on a reasonable belief that the youth has custody or control of contraband. However, reasonable belief is not required when a youth returns from contact with the general public or from outside the facility or from visitation. On its face this provision does not authorize strip search of all referrals to the security unit. "The response does not appear to match with the TJJD operational response of ?All youth entering into the security unit will be searched per INS.75.03 D. (policy 75.(b) 3 Security sta?? will place youth arriving at the unit in a room and search the youth in accordance with GAP.97.9 (380.9709). As a precautionary measure it is assumed that all youth entering the security unit may possibly be in custody of contraband or items that they can potentially harm themselves with. 9/21/16 Two youth were con?ned in the security unit on Institutional Detention (IDP) status. One youth assigned to the 10/14/16 -Training will be conducted with representatives of the Ron Jackson State School. They are subiect area 10/13/16 - This issue will remain open. It is the 10?s understanding the training mentioned in the Gainesville State School, October 4-6 81 13, 2016 Page 5 of 13 [0?003 01/16 Cottrell Halfway House was pending a Level I revocation hearing, and the second was assigned to Gainesville ?pending a court hearing.? Neither youth had been afforded the appropriate due process Level IV Detention Review Hearing. The youth from Cottrell House had not been afforded the opportunity to confer with his Attorney regarding the Level IV hearing and the Gainesville youth had no Level IV hearings since his admission on 08.18.2016. Both situations are in direct violation of agency policy and standards. What action will be implemented to ensure Level IV due process detention reviews are completed in accordance with TIID policy and how will this process be monitored? experts. The following staff will be required to attend the training: Director of Security, Security Case Managers and the ICU 8; VI of the Security unit. This training is being set up for the end of October. Additionally, the Manager I of Operations will meet twice per week with the Dorm Supervisor for Security to review admissions, releases and extensions to ensure ongoing compliance with policy for two months, at least until December 15, 2016. At that time, we will re-evaluate whether twice weekly meetings need to continue or whether routine reviews per policy are adequate. agency response will be conducted the week of 10/17-21. Follow up will be conducted by the 10 after that date. 9/21/16 Room Cell checks were found to be in non-compliance with agency standards/procedures in the Re-Direct Program (RDP), Security unit, and on the dorms specifically Unit 17-18. Checks were documented at exact 15 minutes intervals and not random or the Room Checks indicated the youth had exited their rooms, when in fact they were asleep in their beds, and no follow up checks had been documented. This issue has been identified previously by the 010 in narrative reports as well as in Requests for Plan of Action. 010 is aware of the changes to the agency Institutional procedures regarding this issue, but on the local level what new plan will be implemented to ensure staff receive training on this critical issue and what 10/14/16 The new Manager of Operations held a meeting to address the procedures and protocols in relation to 15 minute checks. A signed copy of the was completed and the Manager 1, Directory of Security, and the ICC VI V?s will be conducting Spot checks. 10/ 13/ 16 This issue will remain open. It is the 10?s understanding that further training will be provided during the week of 10/17-21. Follow up will be conducted by the 10 after that date. Gainesville State School, October 4-6 13, 2016 Page 6 of 13 lO-003 01/16 steps will be implemented to monitor this matter? 9/21/16 Youth WIS referred to security on 09.12.2016 at approximately 7:40p. The Incident report (CCF-225) does not document that the youth was admitted to security by a case manager, the time of the arrival of the 225, or any extensions being granted for a late arrival of the 225. The youth was released from security at approximately 11:00 am. on 09.13.2016. The Room/Cell checks indicate the majority of room checks were conducted at exact 15 intervals with no randomness as required by THD procedures, and had no identifying date. Upon further review the Security Unit: Daily Arrivals Releases indicated the youth was admitted by a case manager at 9:40p. 2 hours after his arrival. These due?process issues have been identi?ed in previous 010 site visits and Plans of Action were implemented, but it appears to be a re?occurring problem. What new plan will be implemented to ensure the youths due process rights and the safety/welfare of the youth are protected? 10 14 16 - Training will be conducted with representatives of the Ron jackson State School. They are subject area experts. The following staff will be required to attend the training: Director of Security, Security Case Managers and the ICO 8: VI ofthe Security unit. This training is being set up for the end of October. Additionally, the Manager I of Operations will meet twice per week with the Dorm Supervisor for Security to review admissions, releases and extensions to ensure ongoing compliance with policy for two months, at least until December 15, 2016. At that time, we will re-evaluate whether twice weekly meetings need to continue or whether routine reviews per policy are adequate. 10/13/16 This issue will remain open. It is the 10?s understanding the training mentioned in the agency response will be conducted the week of 10/17-21. Follow up will be conducted by the 10 after that date. 8/17/16 Three youth were admitted to the Security Program (SP) for major rule violations. Level II disciplinary hearings were scheduled but the date was past the 5-day agency policy. Each youth had received a Level extension hearing in SP, with the justification of ?pending a level 11 hearing.? Security staff had documented that the youth had been "compliant" on the Security Unit: 09/15/2016 -This issue was addressed with the 010 on 9-9-16. At that time we discussed the reasons why a youth can be extended and the additional information that is required to keep the youth in security for an extended period of time. We discussed the Policies and Procedures and also the spirit of the policy and procedures as it relates to due process. 9/21/16 - Although, the Corrective Action Plan completed by the facility stated all training would be completed by 8/30/16, further issues regarding security due process issues and Room/Cell Checks were once again identi?ed during this site visit. This issue will remain open, and further review and monitoring will Gainesville State School, October 4-6 13, 2016 Page 7 of 13 01/16 Individual Youth Record, and there was no documentation indicating the youth would likely interfere with a pending or ongoing investigation or a requested or scheduled due process hearing. For an extension on SP -GAP.380.9740 requires one or more of the following criteria be met: An extension may be authorized if the following criteria are met, as established through a Level hearing conducted in accordance with {$380.95 5 7 of this title: based on current behavior, one or more of the admission criteria listed in subsection of this section continue to be present; or (ii) there is documented evidence that theyouth is not complying with the Security Program rules of conduct. It does not appear this criteria was met to continue the extension on SP. One of the youth involved also stated he had appealed level hearings, and was not given the opportunity to speak on his behalf when the Administrative Duty Officer reviewed his appeal, but was simply told ?You are staying.? What plan will be implemented to ensure the due process rights of youth during the SP extension process is maintained; they are also afforded the opportunity to speak on their behalf during an appeal; and staff appropriately document reasons for requesting an extension that meet the agency policy criteria. A due process review is scheduled in the ICU VI meeting being held on 9-14- 16 and additional meetings occurred with the case managers assigned to the security unit on 9?13-16 and 9-14-16. conducted by the 010. 10/13/16 One security extension was found to have appropriate documentation Justification for the extension. This issue will remain open. It is the 10's understanding that further training will be provided during the week of 10/17-2 1. Follow up will be conducted by the 10 after that date. 8/17/16 The Re?Direct Program (RDP) recently moved from the Security Unit to dorm 16. During the site visit it was noted a Blue Phone [youth telephone) was not 09/15/2016 - The youth on unit 16 have access to the Blue Phone daily. The youth are not able to roam the building to make calls on any dorm or within the 9/21/2016 The response received from TJID did not seem to address the issue raised. Gainesville State School, October 4?6 13, 2016 Page 8 of 13 01/16 located on that hallway. The Blue phones are located in a common area shared with youth not confined in the RDP program. RDP youth do not currently have access to the phones until youth on dorm 15 go to school in the afternoon. This appears to limit the youth's access to the phone for hotline calls to the Incident Reporting Center and/ or 010. What plan will be implemented to ensure access to the phones as outlined in security unit. No changes will be made at this time for the youth assigned to unit 16. 8/17/2016. The primary issue was limited access to youth phones to make contact with hotline numbers Incident Reporting Center (IRC) and/ the 010. Nothing was said about youth being allowed to "roam the building." During the exit conference on 9/21/2016 facility management stated that a work order had been submitted to change the location of a youth phone to the RDP hallway. Please clarify the response provided to the 010 on 9/15/2016 and verify that a youth phone is actually being re-located so youth in the RDP have access to the phone for calls, specifically hotline calls. 10/14/16 - Blues phone were placed in the group room and were operational as of 10?7?16. 10/13/16 - On this date the 10 confirmed a blue phone had been placed in the RDP group room. This issue will be closed. 8/3/16 On July 8, 2016, between 9:00p-9:30p, three youth age 15.3;.age 17.8; and . age were released from the security unit, and placed in a security van for transport to their dorms. During the transport a security referral and assistance call was received and the security staff responded, leaving the 3 identified youth unsupervised in the security van. During the absence of the security staff evidently words were exchanged 09/02/16 - A corrective action has been initiated and completed at Gainesville to include refresher training for Security, Case Manager, ICO Vl?s and Dorm Supervisors. A Compliance Officer led training related to PREA. Issues related to due process were covered by the Superintendent. Both trainings will be ongoing and will be placed as standing agenda items on the agenda for the Operation Meetings. 9/21/16 - Due to the seriousness of this incident the 010 will keep this issue open until completion of the OIG and AID investigations. 10/13/16 - Due to the seriousness of this incident the 010 will keep this issue open until completion of the and AID investigations. 11/03/16 - The 010 identified a need to follow up on this incident Gainesville State School, October 4?6 13, 2016 Page 9 of 13 01/16 between the 3 youth, resulting in the younger youth?s shorts and boxers being removed from his body. Upon the security staff returning to the van it was determined something had occurred and all 3 were returned to security. ICO VI and ADO were noti?ed and youth were questioned and statements were written. Clothing was secured according to statements. . wrote "they started pulling my clothes off and sexually touching me. Grooming my thigh, penis, leg, buttocks." Youth were placed in rooms in security where they remained all night. None were admitted to security that evening. On the morning ofluly 9, 2016, the security case manager determined the youth had not been admitted and could not find incident reports. The 010 was advised the incident reports had been locked in ICU Vl?s office. Nine hours after the fact . and .were admitted to security for their participation in the incident. The 010 was able to determine the incident was reported to the IRC at approximately 11:30p but a Report of Serious Incident evidently was not written and/or forwarded per institutional procedures. It was further determined that the incident was sent to the OIG for investigation and assigned Youth I had advised the 010 that he went to the hospital for an exam. Follow up with Nurse Manager (NM) indicated they had no record in the EMR system ofthe incident being reported to medical staff at Gainesville or Mart, and no record of off campus medical transport being Specifics to the case: - The OIG Officer has completed his investigation and he finds the victim not credible at this time. It does not appear any charges are forth coming. - Level II Hearings were held and appealed by the youth and Central Office legal staff upheld the hearings. - Retaliation forms have been initiated on involved youth. - Safety Plans have been placed in effect on youth. - A L8051 has been submitted on ICO staff that left the youth unattended in the van. regarding the submission of a 051 as stated in the THD response. On 11.03.16 3 request was submitted to TIID requesting a copy of the and/or the separate IRC that was assigned. Please provide the information requested. 1 1/18/16 - Although this incident was called in, it was not assigned as an AID. The ODS on duty failed to submit a LS-051 and is no longer employed with the agency. A new has been submitted on the incident by the Dorm Supervisor. Gainesville State School, October 4?6 13, 2016 Page 10 of 13 IO-OO3 01/16 authorized for. on July 8 or 9, 2106. During the interview on August 3, 2016, with the 010, .stated that this was the first she had heard of the incident. Both . and. were released from security on July 11, 2016. .and-both had Level 11 Hearings conducted on July 18, 2016, and the written record indicates they were at the exact same time, 10:00 am. Other than the Staff Representative, Advocate, and Hearing Manager the written record does not indicate any other persons being present in the hearing(s). The Correctional Care System does not contain an Incident Report indicating that-had been the victim of this incident; nor does CCS contain a chrono record indicating.?s guardian(s) were notified of the incident. Due to the apparent lack of notifications, the appropriate PREA protocols were not implemented (notifications to medical staff, SANE exam, guardian notification, Retaliation Monitoring, etc). Several issues appear evident in this incident including: a) absence of supervision of youth in a security van, b) lack of appropriate notifications regarding apparent PREA Violations, c] youth rights due process violations by admission to security 9 hours after the fact and d] questions regarding the Level II Hearings conducted. After further review of these issues What steps and action plan will be implemented to correct and ensure these types of youth safety and youth rights issues do not occur again? Gainesville State School, October 4?6 13, 2016 Page 11 of 13 01/16 8/3/16 On July 14, 2016,fwas referred to Security at 9:30p. A 30 minute extension for the Incident Report [225] was granted at 9:46p. Another youth, . was referred to security at 11:06p and an extension was granted on the 225 at 11:35p. At 11:31p, a third youth, -was referred to security. All 3 youth were placed in rooms on the B- hallway. The Security Unit: Arrivals and Releases indicate the arrival times coincide with the above times. The 210 and corresponding 2255 show-was released 10:30a [should be pm] and.was released at 12:00a. .was released at 12:303, according to the 210, but an incident report was not found. The 210 and 225 further shows that ODS. was the releasing authority. The Security Control Center Log documents the arrival of each youth by name, but does not indicate their departure. Although at 5:35a on July 15, 2016, the log shows "3 youth from Hall taken back to dorms.? it also indicates that ODS only entered the Security Unit 1 time during the late night shift, arriving at 3:103 and departing at 3:40a. BL. and Room/Cell Checks form document safety/welfare checks were conducted at exact 15 intervals all night long concluding at 4:30a, indicating the youth were not released from the unit as the 210 indicates. It appears the youth were not actually seen and counseled with by ODS, which is standard practice and procedure. What plan ofaction will be implemented to ensure the due process rights of youth are not violated in the future and that 09/02/16 - A corrective action plan has been initiated at Gainesville to include refresher training for Security, Case Manager, ICO VIs and Dorm Supervisors in regards to due process. In addition, a HR 200 has been initiated on the staff failed to follow established practices of the Gainesville ODS. NOTE: A copy of the Corrective Action Plan referenced is attached. 9/2 1/16 - Although, the Corrective Action Plan completed by the facility stated all training would be completed by 8/30/16, further issues regarding security due process issues and Room/Cell Checks were once again identi?ed during this site visit. This issue will remain open, and further review and monitoring will be conducted by the 010. 10/13/16 - This issue will be considered closed. No similar incident has been identi?ed in the current site visit, although room/ cell checks continue to be a concern. That portion of the issue is covered in a more recent issue dated 9/21/16. Gainesville State School, October 4?6 13, 2016 Page 12 of 13 IO-003 01/16 safety/welfare checks are conducted in accordance with agency policy of random checks not exceeding 15 minutes? 8/3/16 On July 22, 2016, ?s referred to Security arriving at 10:40p. Records indicate the youth was not seen by the ODS and it appears an incident report was not received from the referring dorm staff. The youth was released via a phone call from ODS at 12:07a. The Room/Cell Check form documents safety/welfare checks were completed at exact 15 minutes from 10:40p until 12:07a. What plan of action will be implemented to ensure the due process rights of youth are not violated in the future; and that safety/welfare checks are conducted in accordance with agency policy of . random checks not exceeding 15 minutes? 09/02/16 An HR 200 has been initiated on the staff that failed to follow established practices ofthe Gainesville ODS. NOTE: A copy of the Corrective Action Plan referenced is attached. 9/21/16 - Although, the Corrective Action Plan completed by the facility stated all training would be completed by 8/30/16, further issues regarding security due process issues and Room /Cell Checks were once again identi?ed during this site visit. This issue will remain open, and further review and monitoring will conducted by the 010. 10/13/16 This issue will be considered closed. No similar incident has been identi?ed in the current site visit, although room/cell checks continue to be a concern. That portion of the issue is covered in a more recent issue dated 9/21/16. I certify that this report represents a true and accurate assessment of all issues identified. mitted by: Allen'E Wallace Senior Deputy Ombudsman Gainesville State School, October 4?6 13, 2016 Date Page 13 of 13 01/16