Coke County Juvenile Justice Center Audit

A Report by the Texas Youth Commission

September 26th – October 2nd 2007

Dimitria D. Pope
Acting Executive Director

Sylvia Martinez
Project Manager

• The scope of the project with attendant objectives and strategies was identified by a cross functional group of TYC staff. It was the consensus of the group to select a project manager that did not have any ties to the operation of the facility or contract provider. To this end, Ms. Sylvia Martinez, Juvenile Corrections Regional Director was elected to serve as the Project Manager. Ms. Martinez’s responsibilities included the coordination and collection of data, management of audit staff to ensure the timely and efficient collection of information specific to their area of assignment, and compilation of information and presentation of a report of findings, inclusive of any recommendations.
• Wade Phillips, Deputy General Counsel and Ken Stewart, Contract Attorney reviewed the contract history, current contract provisions and provided appropriate legal advice to staff. Ms. Karol Davidson, Juvenile Law and Policy Attorney served to review the legal status of each of the youth assigned to the Coke County facility.
• TYC staff were sent to the Coke County Juvenile Justice facility to collect audit data. The collection of information was obtained through various methods that included: observation of facility operations and staff interactions with youth, youth interviews and forums, staff interviews, review of statistical data on youth housed at Coke County, review of youth’s master files, review of grievance data, review of facility work order requests, review of previous year’s quality assurance reports, analysis of staff/youth ratios, review of contracted staff’s training records, operational review of physical plant in accordance with TYC policies and standards and an assessment of quality of care for youth.
• Independent reports were completed by audit team members based on their respective areas of assignment. This report synthesizes the information collected by team members at the facility, but full reports that contain details not included in this document are available.

Audit Review

This section highlights the primary areas of review by TYC staff. Review areas were driven by the agency’s mission and therefore focus on performance accountability systems.  Specific areas examined are:

• Life Safety and Physical Plant;
• Operations and Security;
• Youth Rights and Community Involvement; and
• Treatment and Education

Life Safety: Physical Plant

• The facility life safety systems to include detectors, door locks, intercoms, exhaust fans, etc. are not tested routinely or adequately.
• Emergency drills have not been conducted in accordance to policy.
• The group release test of doors in a living area found that not all doors were capable of unlocking in an emergency situation.
• Upon request, staff could not open an emergency exit door in a living area.
• Detectors and sprinkler heads had been vandalized and sanitation issues to include lint, dust, toilet paper, clothes, etc. were interfering with detection. 
• The facility appeared to have smoke removal equipment in place; however, they did not operate upon the detection of smoke.   When smoke is introduced to the detectors, the exhaust system should have activated and began a process of removing smoke.
• Vents were in a severe state of neglect as many were dirty, covered and rusted, resulting in problems with the intake of fresh air and the removal of smoke.
• The Ansul Hood Fire Suppression System staff pull station located in the kitchen was blocked, as was the emergency exit.
• The fire extinguisher in the kitchen was outdated.
• The self-contained breathing apparatuses throughout the facility have not been maintained and are inoperable.
• Toxic and flammable materials/chemicals were found in the facility to include the common areas, the living areas, and the kitchen area.  Unidentified liquids were found in unlabeled containers. 
• Chemicals were found that were not addressed in the Material Safety Data Sheet book located in the area.
• Master locks and chains are utilized to secure doors instead of detention grade locking devices.  Of concern is the staff’s ability to remove occupants in an emergency situation.
• Safety glazing has been removed from the detention doors in a dormitory.  This creates not only a hazard for the youth and staff but may create air flow problems.

Life Safety: Medical

• There were no seriously medically ill youth at Coke County, and there has not been over the past year, according to the monthly facility Serious Medical Condition Report submitted by UTMB to TYC.
• There were 35 ER visits over the past year: majority are related to recreational injuries (basketball), there was a youth who purposely dislocated his own shoulder, several abscesses/cysts, two self-harms (cut, head banging), and one restraint injury (fractured jaw).
• According to the Access to Care Reports, there were numerous missed appointments in July 2007 but the monthly report shows generally that youth have been taken for nursing, doctor, and dental, and specialist appointments as schedules (MD had emergency leave in July 2007).
• There was one youth suicide in October 2006 (hanging).
• There was an alleged mistreatment over the past year related to health care in which a youth who is allergic to garlic was given pizza with garlic.

Sanitation

• The GEO Group does not ensure that the youth are provided with a clean and orderly living environment.
• The overall sanitation of the facility can only be rated as poor.  There is no evidence that housekeeping plans are being followed.
• Mops, brooms, mop buckets and cleaning supplies are not stored correctly.  They are often left unattended in common areas and cells.
• Water leaks are numerous throughout the facility, creating an unsanitary and unsafe environment for all youth and staff.
• The cleanliness of uniforms, undergarments, and bedding is not maintained at an acceptable level.
• Mattresses were located in the facility that did not have fire resistant covers,
• There was evidence of paint and chemicals being disposed of in the laundry room sink.

Generator

• According to the documentation provided by facility staff, the facility generator is not tested in accordance to policy. The testing that was conducted was infrequent and insufficient.
• The monthly load test of the generator is not conducted correctly.  The testing currently conducted by staff is done only by the transfer switch and the normal power is not being interrupted for the testing. 
• No life safety system to include smoke alarms or removal or security systems to include audible communication and door locking systems have been tested under emergency power; therefore, it is unknown whether the generator is able to support the facility during an emergency. 
• The generator is only re-fueled when the fuel level is at a quarter of its capacity which could create a situation where the facility can only operate under emergency power for a very limited time.  
• The generator panel located in the Central Control does not function; therefore, staff is unaware if the generator is operating or if there are issues with fuel, oil pressure, temperature, etc.
• A transfer test was conducted while members on site.  The test itself incapacitated several dormitory doors and cameras.  Staff which included the assigned Control Room Operator and the maintenance employee was unable to reset the systems.

Emergency Battery Powered Lighting

• Only one battery powered lighting fixture was operable.

Fire Alarm System

• Several smoke detectors throughout the facility to include detectors in the youth’s living areas were inoperable. 
• Upon detection of smoke, the system does not annunciate at continuously staffed locations.  They are dependant on the dorm staff to notify the control room staff of the emergency. If the officer is incapacitated and unable to request assistance the emergency may go unknown for an extended period of time.  In addition, there are not enough hand held radios or battery backup packs in the facility for each staff on shift.
• The alarm panel was not reset to “normal” function at the time of the inspection and the system had been placed in silenced mode; therefore, when the system was activated it did not annunciate and staff was unaware of the alarm. The fire annunciation had been silenced due to the numerous problems with the detectors; however, neither the Control Room Operator nor the Risk Manager at the facility were aware that the alarm system had been silenced nor that the system could be reset.

Maintenance

• The facility currently has 90 open maintenance work orders; however, several maintenance issues identified during the inspection process did not have an active work order in place.
• All intercoms have been removed from the living areas.  Devices used for communication between staff and youth are not in place.  Staff indicated that youth must beat on the door to request staff assistance.
• Remaining intercoms are either inoperable or produce a distorted, inaudible communication.  The Control Room Officers are responding to the call button to open doors rather than to identify a speaker or emergency.
• The door indicator lights on the control room panel did not properly identify whether a door is open or closed; therefore, staff is often assuming that a door is closed when it may be opened.
• Although documentation indicated that routine pest control is being conducted there are serious problems with insects throughout the facility and grounds.
• Graffiti is a problem although there are some attempts of covering it with paint.
• The lavatories in the youth living areas are often inoperable, leaving the youth without appropriate means of obtaining an acceptable level of hygiene and possible drinking water.  Temperature testing of water indicated a high of only 87 degrees.  Appropriate levels should be between 100 and 120 degrees.
• Not all showers are operable and can result in an inappropriate number of showers for the number of youth housed in the living area.
• Detention grade hardware (screws/nuts/etc) is replaced with non-detention grade hardware.
• Non slip surfaces at the shower areas do not appear to be provided to the youth.
• Plumbing chases were not secure at the time of the inspection.  Contraband and pests were found in these areas. 
• Light fixtures are damaged, burned, and often filthy.  It is unknown whether the current level of lighting can reach the appropriate 20 foot candles.
• Cells with maintenance issues are utilized for storage areas.
• The facility attempts to maintain the laundry workload with only one operable washer and one operable dryer.  The lint buildup in the dryer creates a fire hazard.
• Door closers are no longer operable and the hardware often remains partially attached to the door jam.  The door closers could be utilized as weapons or escape tools by the youth.
• Seating from part of the youth living areas has been removed by maintenance staff; therefore, youth must eat, study, etc on their bunks.

Tool Control

• Tools to include Class A tools were missing from the kitchen area and the maintenance shop.  Documentation indicated that all the tools identified as missing had been checked out and returned.

Entrance Security

• Although the metal detector alarm sounded when TYC staff entered, GEO staff did not perform a search.  Additionally, staff was not asked to sign out as they exited the facility for the day.  Too, TYC staff’s names were not recorded at the front desk upon entrance or exit.
• In addition to GEO’s policies, the reviewers have determined that  the GEO Group may have violated the following Commission policies in their operation of the Coke County Juvenile Justice Center:

• Warden Bement indicated that he was aware of many of the life safety issues identified by TYC staff.  He also indicated that corporate did not respond to many of his purchasing needs due to the lack of a long-term contract.
• GEO Risk Manager Amanda Meyers indicated that GEO staff had not worried about past TYC audits.
• GEO maintenance worker Roy Parks indicated that he had learned more about life safety equipment maintenance and checks in the two hours he had spent with TYC staff than he had in the nine months he has worked in the facility.
• The individual briefing the on-coming shift on the evening of September 27, 2007 stated that staff need not worry if TYC pulled out of its contract because GEO would be able to secure another contract.

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