ndependent ) mbudsman Office of Independent Ombudsman’s Review and Observations of the Lyle B. Medlock Treatment Center: A Facility of the Dallas County Juvenile Department. September 20, 2017 At the request of a member of the Dallas County Juvenile Board, the Office of Independent Ombudsman (O10) conducted an investigation into the daily operations of the Lyle B. Medlock Treatment Center, a Dallas County Juvenile Department facility that houses post adjudicated residents. The basis for the request and subsequent review by the O10 resulted from allegations of sexual misconduct between residents. The incidents occurred when residents were sleeping in the facility's Multi-Purpose Room (MPR) that was being utilized as an alternative housing arca. ‘The MPR also serves as the cafeteria and visitation area. The following is a summary of that review, observations, and conclusions. The Lyle B. Medlock Treatment Center is located in the southem portion of Dallas County, Dallas, TX. The facility has a capacity of 96 residents in 8 separate dorms, although dorms 7 and 8 have been closed for an extended period. The current budgeted capacity is 84. Each dorm is an copen-bay multiple occupancy housing unit (MOHU) with 6 bunk beds, thus allowing for 12 residents per dorm. There are 4 individual time out rooms and | medical observation room in the facility. Texas Administrative Code (TAC) Chapter 343.100 defines these rooms as Specialized Housing and describes them as “Any room or celll used for disciplinary seclusion, safety-based seclusion, protective isolation, assessment isolation, or medical isolation.”” On April 18, 2017, a resident at the Medlock Center disclosed allegations of resident-on-resident inappropriate sexual behaviors during a therapy session and admitted to participating in sexual misconduct on multiple occasions while residents were sleeping in the MPR. On April 19, 2017, Medlock Center management submitted an incident report to the Texas Juvenile Justice Department's (TIJD) Administrative Investigations Division (AID) reporting the alleged incident(s) of inappropriate sexual behavior. The incident(s) was classified as a Serious Incident/Not Investigated by AID. During the Dallas County Juvenile Board meeting on May 22, 2017, the use of the MPR to sleep residents due to staff shortages at Medlock was discussed. The allegations of resident-on-resident sexual misconduct were also discussed during this same meeting. On June 1, 2017, AID reopened its investigation into the incident, classifying it as Negligent Supervision. On July 6, 2017, the O10 received a formal request from a member of the Dallas County Juvenile Boatd to investigate the incident(s) and the day-to-day operations that led to the incident(s). Prior to June 23, 2017, the facility housed two treatment programs: the Successful Thinking and Responsible Sexuality (STARS) program and the EPIC (RTC) program. Dorms 1, 2, and 3 housed the STARS residents. The remaining dorms housed the EPIC residents.Not including education staff, the facility has 74 designated staff positions with 48 of those positions being Juvenile Supervision Officers (JSOs). TAC, Chapter 343.630 states that for MOHUs, “the juvenile supervision officer-to-resident ratio shall not be less than (1) one juvenile supervision officer to every 12 residents during program hours; and (2) one juvenile supervision officer to every 24 residents during non-program hours. Based on the configuration of dorms at Medlock, this would require a minimum of at least six SOs during program and non-program hours for the six open-bay dorms. Review and Observation At the request of the O10, the Dallas County Juvenile Department provided a large volume of documentation from June 2016 to May 2017 which included, but was not limited to: © Organizational chart Daily population reports Daily available direct care staff ‘The average number of staff vacancies by position Human Resources policy and procedures for the JSO hiring process Starting pay for ISO over the last few years The dates the multipurpose room was used Documentation of each use List of similar rooms that could be used for overflow housing Memos, emails, or other documents discussing the request for the use of the MPR Description of the conditions of the alternative housing spaces and what type of bedding was used ‘* Memos, emails, or other documentation regarding the practice of using the MPR or similar rooms as a remedy for insufficient staffing Documentation of communications which illustrates the issue/concern of staffing ‘* The process used to determine who would be housed in the MPR Copies of all grievances related to supervision, housing, and voluntary/involuntary sleep outs * Incident reports and incident logs © Shift logs Copies of Juvenile Board Meeting Minutes A total of 21 staff and 15 residents were interviewed, including some of the residents involved in the sexual incidents. Interviews were conducted with: © Department administration at the Henry Wade Center (Director, Deputy Director, and Deputy Director of Institutional Services) © Facility administration at Medlock (Current and Previous Superintendent, Program Director (Assistant Superintendent) ‘© Resident Manager © Shift supervisors Floor workers * ISOs © ResidentsBased on the extensive documentation reviewed by the OIO, interviews with employees and residents, and observations during a walkthrough, several concerns were identified regarding, operations of the Medlock facility that potentially provided an opportunity for the sexual incidents to occur. This report will address the following concerns: © Staffing + Communication/Reporting Supervision * Documentation Staffing Department administration and facility administration articulated that juvenile facilities in Dallas County have suffered from staffing shortages for several years, Shift supervisors reported that staffing has been an issue since 2015. The interviews revealed two major factors that contributed to the shortage. The first being the continual tumover that department administration stated falls within the national average based on annual rates for 2014-2016; and second, the length of time involved in the hiring and training processes. The length of time from application to notification of job offer was not calculated, but based upon the time frames presented by the Human Resources Department (HR) and responses during interviews, it could be as long as 2 months. Based on interviews, some of the delay is due to applicants not providing requested information ina timely manner and delays in background checks. A review for the last 12 months indicated an average of 70 days from the time an employee is notified of acceptance until he or she can begin supervising residents. The result of this lengthy process often leads to potential employees accepting other job offers. ‘Two additional issues that have significant impact on the staffing shortage are the number of staff out on Family and Medical Leave Act (FMLA) and staff call-ins (staff calling in to say they are not going to be at work). ISOs and facility shift level supervisors repeatedly said that long shifts, not being able to take time off, and lack of overtime pay led to stress and were contributing factors to the use of FMLA and call-ins, Often staff ate held over for an additional half shift (4 hours) or called in early for a half shift before their regular shift for days and weeks. During documentation review, it was noted by the OIO that on one shift, not one JSO reported for his assigned shift. Half of the shift was covered by hold overs, and the other half by JSOs called in early. On average, 3.5 positions out of 9 on the 10:00pm to 6:00am shift were filled by staff hold overs and staff called in early, including supervisor positions. On several occasions, staff from the Youth Village, a facility operated by the department that is adjacent to the Medlock facility, were called in to work vacant positions at Medlock. Documentation indicated that the Youth Village was also suffering critical staffing issues. Employees are required to collect 240 hours in compensatory time (comp time) before they become eligible for overtime pay. Comp time can only be used to take time off and is not converted to pay, unlike overtime. Staff reported that accumulating comp time was worthless because they could not use it due to being short staffed. During the course of interviews, the facility management and department administration purportedly were unaware of the amount of comp time being accumulated by JSOs to cover the staffing shortage. Facility management stated comp time was not something that needed to be brought to their attention because there was no financial cost, thus there was no reporting to them or to department administration 3Based on information obtained from interviews, review of HR policy, and documentation review, it appears that in early November, all Dallas County facilities were notified they would not be able to use part time employees, due to reaching the budgeted salary cap. The O10 was informed that part time staff were used in a variety of positions, including supervision of residents. The reviewed policy and information received during interviews indicate that each part time employee is limited to working 900 hours per year; once that cap is met, they are unable to work until the following year. The loss of part time employees, employee turnover, employees out on FMLA, and call-ins created a critical staffing shortage. Once the new year began, many of the part time staff did not return, which continued to contribute to the staffing shortage. Staffing shortages had two effects on the facility, first, in June 2016, the facility merged the swing shift staff (a 4th shift) in to the day and evening shift, none of the swing shift staff were sent to the midnight shift. This move improved staffing on the day and evening shift. Second the shortage prompted the use of the MPR and time out rooms as alternative housing solutions on the ‘midnight shift. Interviews indicated that when it became evident that shifts would not meet the required ratio, the resident manager devised the idea of having the youth from dorms 1 and 2 (STARS dorms) sleep in the MPR. Interviews indicated no other options to alleviate the staff shortage were discussed or considered. Staff interviews suggested the MPR was used an average of 15-20 nights a month from November 2016 through April 2017. Department administration acknowledged they were aware of staffing shortages at Medlock and other facilities, but did not realize the shortage was critical. In reviewing OIO reports, it was found the O10 had reported staff shortages and the combining of dorms at Medlock, and at Youth Village as early as January of 2017. The OIO reports from January and March discuss youth sleeping in the MPR due to staffing shortages. The March report states that the Facility Administrator said the staffing shortage had improved and the MPR was only being used a couple of times a week, when in fact the MPR was used 31 nights in March. It must be noted that once the sexual misconduct incident came to light, the use of the MPR was immediately stopped, although staffing levels had not changed. Number of Nights the Multi-Purpose Room (MPR) was utilized [Month ¥of LN MPR Month [#of LIN MPR Utilized | Utilized Tune 2016 Onights documented | December 2016 19 nights documented July 2016 Onights documented | January 2017 24 nights documented ‘August 2016 nights documented | February 2017 20 nights documented ‘September 2016 Onights documented [March 2017 31 nights documented October 2016 nights documented | April 2017 19 nights documented November 2016 nights documented _— ‘Communieation/Reporting According to documentation dated November 17, 2016, to address the shortage, the Resident Manager issued an email authorizing the shift supervisors to use the MPR on Sundays and Mondays, allowing 24 residents to be housed in the MPR for the purpose of sleeping. Two staff were to be present at all times and any additional usage must be approved by the residential manager. The residents brought their mattresses to the MPR and slept on the floor. The ResidentManager did not consider this an unusual measure because the MPR had been used on other ‘occasions. This practice is a violation of TAC, Chapter 343.654(b) which states “residents assigned toa MOHU must have a bed above floor level.” Subsection 343.100(2) defines a bed as “including a frame or platform that may be a permanent or portable fixture.” This practice was noted as deficient in the June 2017 Monitoring and Inspection audit conducted by TJJD. In addition, TJJD also found Medlock deficient in 343.660(b) which states “each MOHU in facilities that were constructed and operating on or after March I, 1996, must contain one operable toilet above floor level for every six beds in the housing unit”. This means the MPR did not meet this requirement and once use of the MPR was stopped, the facility was compliant. The first use of the MPR to house youth was documented on Sunday, November 20, 2016. This followed the approval email sent by the Resident Manager on November 17". There were no other written approvals provided that discussed the use of the MPR to house youth from November 2016 through April 2017. It was also evident that the use of the MPR as alternative housing expanded over the months. The Resident Manager said that in the beginning, staff would call to get authorization for the extra days, but over time, it became the norm. The MPR was used every day of the week, not just Sunday and Monday as stipulated in the November 17, 2017 email. ‘Throughout the interviews, with all levels of staff, it was apparent that the use of the MPR for staff shortages was common knowledge and practice at the shift level, but the extent of use was not as well known to the facility administration or hardly known by the department administration. When facility administration was questioned about their knowledge of housing youth in the MPR, they informed the OIO that this is not something they would expect to know, as the use of the MPR is not considered serious. They acknowledged they were aware of the November 17, 2016 email, because they were made aware of the use of the MPR at that time but ‘were unaware of the extensive and frequent use of the MPR past that date, They said that they expected to be informed of major incidents, but did not consider the staffing shortage and housing adjustments to be a major incident. The Resident Manager stated he discussed the staff shortage and use of the MPR on a weekly basis with the facility management. When department administration was questioned about the staffing shortages, they acknowledged they were not aware of the seriousness of the staffing shortage and were not aware of the practice to use the MPR to cover staffing shortages. Throughout the interviews, department administration denied knowledge of the ongoing practice and stated they were surprised to learn that the practice had grown from two times a week to virtually every day by March and April. A late request for documentation of unannounced rounds, a requirement for PREA certification, found that facility administrators conducted unannounced rounds and documented on multiple occasions that the MPR was being used to sleep dorms I and 2 The Deputy Director of Institutional Services did not know that the residents were sleeping on the floor of the MPR until after the incident(s) of inappropriate sexual behavior was reported in April. Through his interview, it was learned that he then went back and read an earlier OIO report from January 2017, and leamed that youth had been sleeping in the MPR for an extended time. His interview, as well as other department administrator's interviews, revealed that they were not aware of the email that was distributed in November until it surfaced in the O10’s request for documentation for this report. They also reported they were first made aware of the sexual misconduct allegation when one of the Psychologists reported the incidents to the Deputy Director of Institutional Services and the Deputy Chief. According to department administration,the initial report received from the facility superintendent did not fully detail the extent of the misconduct. It was not until the Board Meeting on May 22, 2017, that department administration learned that the incidents involved oral sex. Department administration reported that the Facility Administrator continued to downplay the extent of the misconduct during subsequent conversations with them. The Facility Administrator stated in her interview that she believed the only reason the youth reported the incident was because they knew they were going to be polygraphed. She also stated that this was not alarming behavior by these youth. All of the department administration readily admitted they should have known what was taking place at the facility. At the same time the MPR was being used to house youth, the facility was also using the four time out rooms and the medical isolation cell to hold an additional 5 youth. The residents commonly called the use of the time out cells “sleep-outs” and reported they were voluntary. Residents reported they volunteered for the “sleep-outs” because it would lead to an extra food tray and privacy. The purpose of using the time out rooms was to move 5 of the 29 STARS. residents so the MPR would only contain 24 residents, keeping them in the 1:24 ratio. Average Number of Voluntary Sleep Outs in Time Out Rooms Month ‘Average per Night | Month Average Per Night June 2016 _[3.2 youth December 2016 3.6 youth, July 2016 [3.8 youth January 2017 3.8 youth ‘August 2016 [2.0 youth February 2017 3.4 youth September 2016 2.0 youth ‘March 2017 4.1 youth October 2016 3.5 youth April 2017 43 youth ‘November 2016 [4.0 youth’ Supervision Interviews, shift logs, dorm logs, and incident reports showed inconsistencies with how supervision was conducted in the MPR. Some staff reported walking around the residents while others reported sitting at a desk. The November 17, 2016 email indicated there would be two staff at all times, but did not indicate what level of staff would be required; thus, often the supervision consisted of the shift supervisor sitting in an office and one JSO providing direct supervision. Residents reported and shift logs indicated they would be moved into the MPR from their dorms as early as 6:00pm: JSO staff reported they did not move youth into the MPR u 8:00pm or 8:30pm. Residents and JSOs confirmed that prior to 10:00pm there were two ISOs in the MPR, and after 10:00pm there was usually only one JSO to supervise. An observation of the MPR by the O10 found that the supervisor sitting in his or her office would not be able to see all the residents who were sleeping. During interviews, residents expressed that they were also aware the supervisor or person sitting in the office was not able to see all the residents. When the supervisor provided the JSO a break, the residents reportedly took advantage of the lack of sight and performed sexual acts on each other. One resident reported that an incident occurred when the staff and supervisor were in the supervisor's office watching football. The same resident reported that at least one other incident occurred when staff were all in the supervisor’s office. Another resident reported an incident occurred when the staff on duty sat at the end of a table and allowed the residents to lie on the floor behind her where she couldn’t see them. Residents also reported that there were no staff in the MPR for periods of time and alleged that staff were on their cell phones or reading while supposedly supervising residents. Youth said they wouldsneak under the kitchen serving line to get snacks from the kitchen. During the walkthrough, the O10 noted the space under the serving line would have provided enough space for this to occur. Others reported that some staff left the bathroom door unsecured so residents could use the restroom during the night. There were allegations by residents and staff that on multiple ‘occasions there were more than 24 residents who slept in the MPR. JSOs and residents also reported the “blocks” (game tables) on the dorms were utilized to make a 13" bunk so an additional youth could sleep on the dorm. The O10 was unable to confirm any of these reports through the documentation provided and there are no cameras in the MPR to review video. Documentation After extensive document review and follow up interviews, the O10 determined that the mechanisms for reporting were deficient. The dorm logs completed by JSOs who supervise a dorm or the residents in the MPR contain information such as the time, a one to three word description of activity (i.e. sleeping, showering, visitors, periodic head counts, movement), and the initials of the person documenting the activities. Documentation did not consistently indicate who was assigned to the dorm, the number of residents assigned, any changes in staff, significant issues, or follow-up for any concerns. The lack of consistency made it impossible to determine how many youth were actually moved to the MPR on the days that it was utilized, JSOs reported that shift supervisors are supposed to sign the log book every hour when they make their rounds. However, a review of the logs indicated supervisors were either not signing the logs or were not making rounds each hour during the overnight shift. The shift assignment sheet contained more information and included who was assigned to what location, the names of supervisors and managers, the number of residents, medication notations, miscellaneous information, and maintenance issues. When facility administrators were questioned about the shift reports, they indicated they scanned them for information, but did not review them in detail. The O10 was informed there was an On Duty Supervisor Daily Log that would contain more information regarding the details of the shift. The OIO requested these logs for the time frame uring which the MPR was used. The Deputy Director of Institutional Services provided logs from June and July 2016 and stated no other logs were saved for the period requested. There are four different methods to document activities and details of shift happenings, but all would need to be reviewed to get an accurate depiction of what happened during a shift on any given dorm. In reviewing incident reports (IRs), it was found that each instance a time out room was used for a sleep-out, an IR was generated. The only information reflected in the IR is whether the resident volunteered to steep in the cell. The IR was to be signed by the shift supervisor. The IR also provided space for notification to the Resident Manager and a space for the facility administrator's review. The Resident Manager had signed the IRs indicating he knew the youth had volunteered to sleep out. Not one IR could be found that contained a facility administrator's signature. Additionally, no IRs could be located documenting the use of the MPR even though it was being used for the same purpose. An explanation for why an IR was required for the time ut room and not the MPR was not requested.Concluding Observations There were several factors that led to the sexual incidents that took place in the MPR at the Medlock Center. 1. Lack of acknowledgement that staff shortages on the 10:00pm-6:00am shift was critical 2. Minimizing the significance of the staff shortage, which required the MPR to be used for the purpose of sleeping or ...to be used for a sleeping area for residents, 3. Insufficient knowledge of each instance the MPR was used to sleep residents 4, Accepting the use of the MPR and the staff shortage as status quo 5. Lack of oversight, knowledge, and apparent disinterest of the 10:00 pm ~ 6:00 am shift details 6. Lack of appropriate mechanisms to report information (i.c. -staffing hold overs, staffing strength, day-to-day staffing levels, etc.) regarding facility operations to those beyond the shift supervisor and local facility administrators 7. Lack of accountability/expectations for facility administrators to be aware of staffing, call ins, shift operations, and part time staff availability 8. Absence ofa video surveillance system in the MPR 9. Lack of concem regarding safety, security, and welfare issues surrounding the placement of 24 residents in an open setting (MPR) with only 1 direct care staff providing supervision 10. Lack of department administrator oversight Changes Since May 2017, some changes have been put in place, which include the facility administrators meeting weekly with the department administration, increasing the frequency of unannounced rounds by department administration, and filling many vacant positions. Steps have also been taken to shorten the process of hiring new staff, even though this new process was not articulated to the OIO. There is a new shift report that is being used, which contains much more information. This shift report was being used at another facility and has now been adopted by Medlock Debbie Unruh Chief Ombudsman Office of the Independent Ombudsman for TJD. 11209 Metric Blvd. Bldg. H Austin, TX 78758 512-490-7993 512-431-4051