Case 2:11-cv-02484-HGB-JCW Document 1 Filed 10/04/11 Page 1 of 6

IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF LOUISIANA

UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

)

)

v.

)

)

TERREBONNE PARISH and

)

MICHEL CLAUDET,

)

President of Terrebonne Parish Consolidated

)

Government, in his official capacity only,

)

)

Defendants.

)

)

----------------------------)

COMPLAINT

CNIL ACTION NO: COMPLAINT

PLAINTIFF, THE UNITED STATES OF AMERICA ("Plaintiff'), by its undersigned

attorneys, hereby alleges upon information and belief:

1. The Attorney General files this Complaint on behalf of the United States, pursuant to the

pattern or practice provision of the Violent Crime Control and Law Enforcement Act of

1994,42 U.S.C. § 14141, to enjoin the named Defendants from depriving youths confined in

the Terrebonne Parish Juvenile Detention Center ("TPJDC") in Houma, Louisiana of rights,

privileges, or immunities secured or protected by the Constitution and laws ofthe United

States.

JURISDICTION AND VENUE

2. This Court has jurisdiction over this action pursuant to 28 U.S.C. §§ 1331 and 1345.

3. The United States is authorized to initiate this action pursuant to 42 U.S.C. § 14141.

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4. Venue is proper in this district pursuant to 28 U.S.C. § 1391, as a substantial portion of the acts and omissions giving rise to this action occurred in the Eastern District of Louisiana. PARTIES
5. Plaintiff is the United States of America. 6. Defendant, Terrebonne Parish Consolidated Government ("Parish") owns and operates
TPIDC. Accordingly, the Parish is responsible for the conditions and operation ofTPJDC. 7. Defendant Michel Claudet, is the President of the Parish and responsible for operation of
TPIDC. Defendant Claudet is sued in his official capacity as President of the Parish. FACTUAL ALLEGATIONS
8. The Parish is legally responsible for the operation ofTPIDC and for the health and safety of the youths confined at TPJDC.
9. The Parish is a governmental authority with responsibility for the administration of juvenile justice or incarceration ofjuveniles within the meaning of 42 U.S.C. § 14141.
10. The Parish is obligated to operate TPJDC in a manner that does not infringe upon the federal rights, as protected by the Fourteenth Amendment to the Constitution of the United States and by other federal law, of individuals confined at TPJDC.
11. At all relevant times, the Parish has acted or failed to act, as alleged herein, nnder color of state law.
12. The Parish has engaged in a pattern or practice of failing to ensure that youth at TPIDC are adequately protected from harm and from undue risk of harm as outlined in further detail below.
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13. The Parish has failed to protect its youth from harm by staff by failing to adequately supervise staff and failing to hold staff accountable for misconduct related to confinement checks, suicide precautions and youth supervision. For example, TPJDC staff have left housing units and youth unsupervised and, in one instance, an unsupervised youth attempted suicide by strangulation.
14. The Parish has failed to protect its youth from harm by staff by failing to provide adequate ratios of direct care staff to youth to ensure the safety of the youth at TPJDC. For example, TPIDC erroneously count "general vicinity" staff in the direct and continuous supervision staff ratios.
15. The Parish has failed to protect its youth from harm by failing to implement adequate systems for reporting allegations of child abuse. For example, TPJDC regularly conducts administrative investigations of allegations of physical abuse without reporting such allegations to an independent law enforcement or child welfare agency.
16. The Parish has failed to protect its youth from harm by failing to provide appropriate training on the prevention of custodial sexual misconduct. For example, TPJDC has failed to develop and train staff on the prevention, detection, and reporting of sexual misconduct by staff.
17. The Parish has failed to protect its youth from harm by staff by failing to provide and implement adequate use of force policies and procedures. Accordingly, TPJDC staff have used wmecessary or poorly executed force. For example, youth have been urmecessarily subjected to physical, mechanical, isolation room, and chemical restraints when proper behavior management techniques and sound verbal de-escalation skills would have been
3

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appropriate and more effective. 18. The Parish has failed to protect its youth from harm by failing to adequately protect youth from
self-harm. Specifically, TPJDC was deficient in the following areas regarding suicide prevention: supervision of youth on suicide precautions; training of staff; intake screening; communication; assessment; and housing. 19. The Parish has failed to protect its youth from harm by other youth by failing to develop and implement an adequate objective housing classification system and procedure. For example, TPJDC's classification system was based on subjective procedures, unsupported by procedures and tools to assess youths' risk, silent on the process for making subsequent unit and bed assignments, and lacked enhancements to supervision and programming to mitigate the risks posed by highly aggressive youth. 20. The Parish has failed to protect its youth from harm by failing to adequately report incidents and collect key data. A full, complete, and accurate record of incidents at TPJDC wilL assist administrators to identifY and adjust various conditions that create the opportunity for incidents to occur, to monitor staff responses, to identify training needs, and develop prevention strategies that could prevent or reduce the amount of incidents from occurring. Moreover, TPJDC has failed to implement an adequate quality assurance program to ensure that remedial measures are appropriately implemented and sustainable.
VIOLATIONS OF 42 U.S.C. § 14141 21. The allegations of Paragraphs 1 through 20 are hereby re-alleged and incorporated by
reference.
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22. The acts and omissions alleged in Paragraphs 12 through 20 constitute a pattern or practice of conduct that violates the federal rights, as protected by the Fourteenth Amendment to the Constitution of the United States and by other federal law, of youths confined at TPJDC. PRAYER FOR RELIEF
23. The Attorney General is authorized, pursuant to 42 U.S.C. § 14141, to seek equitable and declaratory relief. WHEREFORE, the United States ofAmerica prays that the Court:
24. Declare that the acts, omissions, and practices of the Defendant Parish set forth in Paragraphs 12 through 20 above constitute a pattern or practice of conduct that deprives TPJDC's youths of rights, privileges, or immunities secured or protected by the Constitution or laws ofthe United States, and that those acts, omissions, and practices violate the Constitution and laws of the United States;
25. Permanently enjoining Defendants, their officers, agents, employees, subordinates, successors in office, and all those acting in concert or participation with them from continuing the acts, omissions, and practices set forth in Paragraphs 12 through 20 above, and requiring Defendants to take such actions as will ensure that lawful conditions of confinement are afforded to youths at TPJDC; and
5

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26. Granting such other and further equitable relief as the Court may deem just and proper.

Dated: October 4, 2011

Respectfully submitted,

FOR THE UNITED STATES:

THOMAS E. PEREZ Assistant Attorney General Civil Rights Division
ROY AUSTIN Deputy Assistant Attorney General Civil Rights Division

J
pecial Litigation Section
J~-

enior Tri ! Att Y U.S. Department of Jus ice Civil Rights Division Special Litigation Section 950 Pennsylvania Ave, NW Washington, D.C. 20530 (202) 305-1457 (202) 514-6903 FAX jeyon.jung@usdoj.gov
6

 
 Case 2:11-cv-02484-HGB-JCW Document 3 Filed 10/05/11 Page 1 of 6

IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF LOUISIANA

UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

)

)

v.

)

)

TERREBONNE PARISH,

)

LOUISIANA

)

)

)

)

Defendant.

)

)

---------------------------)

Civil Action No.2: Il-cv-02484-HGB-JCW AMENDED COMPLAINT

AMENDED COMPLAINT

PLAINTIFF, THE UNITED STATES OF AMERICA ("Plaintiff'), by its undersigned

attorneys, hereby alleges upon information and belief:

1. The Attorney General files this Complaint on behalf of tbe United States, pursuant to the

pattern or practice provision of the Violent Crime Control and Law Enforcement Act of

1994,42 U.S.C. § 14141, to enjoin the named Defendant from depriving youths confined in

the Terrebonne Parish Juvenile Detention Center ("TPJDC") in Houma, Louisiana of rights,

privileges, or immunities secured or protected by the Constitution and laws of the United

States.

JURISDICTION AND VENUE

2. This Court has jurisdiction over this action pursuant to 28 U.S.C. §§ 1331 and 1345.

3. The United States is authorized to initiate this action pursuant to 42 U.S.C. § 14141.

4. Venue is proper in this district pursuant to 28 U.S.C. § 1391, as a substantial portion ofthe

acts and omissions giving rise to this action occurred in the Eastern District of Louisiana.

Case 2:11-cv-02484-HGB-JCW Document 3 Filed 10/05/11 Page 2 of 6
PARTIES
5. Plaintiff is the United States of America. 6. Defendant, Terrebonne Parish ("Parish") owns and operates TPJDC. Accordingly, the
Parish is responsible for the conditions and operation ofTPJDC.
FACTUAL ALLEGATIONS
7. The Parish is legally responsible for the operation of TPJDC and for the health and safety of the youths confined at TPJDC.
8. The Parish is a governmental authority with responsibility for the administration ofjuvenile justice or incarceration ofjuveniles within the meaning of 42 U.S.C. § 14141.
9. The Parish is obligated to operate TPJDC in a manner that does not infringe upon the federal rights, as protected by the Fourteenth Amendment to the Constitution of the United States and by other federal law, of individuals confined at TPJDC.
10. At all relevant times, the Parish has acted or failed to act, as alleged herein, under color of state law.
11. The Parish has engaged in a pattern or practice of failing to ensure that youth at TPJDC are adequately protected from harm and from undue risk of harm as outlined in further detail below.
12. The Parish has failed to protect its youth from harm by staff by failing to adequately supervise staff and failing to hold staff accountable for misconduct related to confinement checks, suicide precautions and youth supervision. For example, TPJDC staff have left housing units and youth unsupervised and, in one instance, an unsupervised youth attempted suicide by strangulation.
2

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13. The Parish has failed to protect its youth from harm by staff by failing to provide adequate ratios of direct care staff to youth to ensure the safety ofthe youth at TPJDC. For example, TPJDC erroneously count "general vicinity" staff in the direct and continuous supervision staff ratios.
14. The Parish has failed to protect its youth from harm by failing to implement adequate systems for reporting allegations of child abuse. For example, TPJDC regularly conducts administrative investigations of allegations of physical abuse without reporting such allegations to an independent law enforcement or child welfare agency.
15. The Parish has failed to protect its youth from harm by failing to provide appropriate training on the prevention of custodial sexual misconduct. For example, TPJDC has failed to develop and train staff on the prevention, detection, and reporting of sexual misconduct by staff.
16. The Parish has failed to protect its youth from harm by staffby failing to provide and implement adequate use offorce policies and procedures. Accordingly, TPJDC staff have used unnecessary or poorly executed force. For example, youth have been unnecessarily subjected to physical, mechanical, isolation room, and chemical restraints when proper behavior management techniques and sound verbal de-escalation skills would have been appropriate and more effective.
17. The Parish has failed to protect its youth from harm by failing to adequately protect youth from self-harm. Specifically, TPJDC was deficient in the following areas regarding suicide prevention: supervision of youth on suicide precautions; training of staff; intake screening; communication; assessment; and housing.
3

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18. The Parish has failed to protect its youth from harm by other youth by failing to develop and implement an adequate objective housing classification system and procedure. For example, TPJDC's classification system was based on subjective procedures, unsupported by procedures and tools to assess youths' risk, silent on the process for making subsequent unit and bed assigmnents, and lacked enhancements to supervision and programming to mitigate the risks posed by highly aggressive youth.
19. The Parish has failed to protect its youth from harm by failing to adequately report incidents and collect key data. A full, complete, and accurate record of incidents at TPJDC will assist administrators to identify and adjust various conditions that create the opportunity for incidents to occur, to monitor staff responses, to identity training needs, and develop prevention strategies that could prevent or reduce the amount of incidents from occurring. Moreover, TPJDC has failed to implement an adequate quality assurance program to ensure that remedial measures are appropriately implemented and sustainable. VIOLATIONS OF 42 U.S.C. § 14141
20. The allegations of Paragraphs I through 19 are hereby re-alleged and incorporated by reference.
21. The acts and omissions alleged in Paragraphs 12 through 19 constitute a pattern or practice of conduct that violates the federal rights, as protected by the Fourteenth Amendment to the Constitution of the United States and by other federal law, of youths confined at TPJDC. PRAYER FOR RELIEF
22. The Attorney General is authorized, pursuant to 42 U.S.C. § 14141, to seek equitable and declaratory relief.
4

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WHEREFORE, the United States of America prays that the Court:

23. Declare that the acts, omissions, and practices of the Defendant Parish set forth in Paragraphs

12 through 19 above constitute a pattern or practice of conduct that deprives TPJDC's youths

of rights, privileges, or immunities secured or protected by the Constitution or laws of the

United States, and that those acts, omissions, and practices violate the Constitution and laws of

the United States;

24. Permanently enjoining Defendant, its officers, agents, employees, subordinates, successors in

office, and all those acting in concert or participation with them from continuing the acts,

omissions, and practices set forth in Paragraphs 12 through 19 above, and requiring Defendant

to take such actions as will ensure that lawful conditions of confinement are afforded to youths

at TPJDC; and

25. Granting such other and further equitable relief as the Court may deem just and proper.

Dated: October 5,2011

Respectfully submitted,

FOR THE UNITED STATES:

THOMAS E. PEREZ Assistant Attorney General Civil Rights Division
ROY AUSTIN Deputy Assistant Attorney General Civil R' hts

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Case 2:11-cv-02484-HGB-JCW Document 3 Filed 10/05/11 Page 6 of 6
Deputy Chief Special Litigation Section
or Trial ttomey U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Ave, NW Washington, D.C. 20530 (202) 305-1457 (202) 514-6903 FAX jeyon.jung@usdoj.gov
6

 
 Case 2:11-cv-02484-HGB-JCW Document 6-1 Filed 10/19/11 Page 1 of 29

UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF LOUISIANA

____________________________________

)

UNITED STATES OF AMERICA, )

)

Plaintiff,

)

)

v.

)

) Civil Action No. 2:11-cv-02484-HGB-JCW

TERREBONNE PARISH,

)

LOUISIANA

)

)

)

)

Defendant.

)

____________________________________)

REVISED SETTLEMENT AGREEMENT AND ORDER

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I. INTRODUCTION

1. On November 19, 2009, the United States, through the Department of Justice, (“the United States”) notified the Parish of Terrebonne, Louisiana (“Parish”) of its intention to investigate the conditions of confinement at the Terrebonne Parish Juvenile Detention Center Facility (“Facility”), pursuant to the Violent Crime Control and Law Enforcement Act of 1994, 42 U.S.C. § 14141 (“Section 14141”).

2. On March 22-25, 2010, the United States conducted an on-site inspection of the Facility with experts in juvenile protection from harm and secure detention. The United States has reviewed relevant Facility policies and procedures, reports, logs, video recordings, and other relevant documents and data, and interviewed Facility staff and detainees.

3.

On January 18, 2011, the United States issued an investigative findings

letter which concluded that certain conditions at the Facility violated the

constitutional rights of juveniles detained or committed to the Facility (“Findings

Letter”). The Findings Letter is Attached.

4. This Revised Settlement Agreement and Order (“Agreement”) is entered into between the United States and the Parish (collectively, “Parties”) to address conditions of confinement at the Facility. Consistent with the Court’s October 18, 2011, Order, this Agreement is filed in the United States District Court, Eastern District of Louisiana (Dkt. No. 5), and along with the Amended Complaint (Dkt. No. 3), which supersedes the initial Complaint (Dkt. No.1) in toto, shall resolve the United States’ claims, to date, that the Parish is in violation of Section 14141 in its operation and management of the Facility.

5. The Court has jurisdiction over this action pursuant to 28 U.S.C. § 1331, 28 U.S.C. § 1345, and 42 U.S.C. § 14141. Venue is proper in this District pursuant to 28 U.S.C. § 1391(b).

6. The Parties stipulate that this Agreement complies in all respects with the provisions of the Prison Litigation Reform Act, 18 U.S.C. § 3626(a) (“PLRA”).

7. The Parties stipulate and agree that all of the prospective relief in this Agreement is narrowly drawn and extends no further than is necessary to correct the violations of the federal rights as described in the attached Findings Letter and incorporated into this Agreement. The Parties further stipulate and agree that the provisions of this Agreement are the least intrusive means necessary to correct the violations of the federal rights.

8. This Agreement shall constitute the entire integrated agreement of the Parties. Except for the United States’ January 18, 2011, Findings Letter, no prior contemporaneous communications, oral or written, or prior drafts shall be relevant

Case 2:11-cv-02484-HGB-JCW Document 6-1 Filed 10/19/11 Page 3 of 29
or admissible for purposes of determining the meaning of any provisions herein in this litigation or in any other proceeding.
9. To the extent possible and with adequate procedures and supports, the United States welcomes and encourages community placement for eligible youth as an alternative to detention in the Facility. The Parish should implement appropriate procedures to determine those youth within the Facility who are eligible to be placed in the community and place such individuals within the community with adequate community supports and services.
II. DEFINITIONS
As used in this Agreement, the following definitions apply:
10. “Facility” shall mean the Terrebonne Parish Juvenile Detention Center in Houma, Louisiana, or any facility that is used to replace or supplement that Facility.
11. “Parish” shall mean the Parish of Terrebonne in Louisiana, including the executive branch of the Parish government.
12. “United States” shall mean the United States Department of Justice, Civil Rights Division, which represents the United States in this matter.
13. “Effective Date” shall mean the date the Court enters this Agreement as its Order.
14. “Facility Director” shall be primarily and ultimately responsible for the Facility Director duties, responsibilities, or notification requirements outlined herein. However, for the instances when the Facility Director is unable to perform these duties and responsibilities or receive notification in accordance with this Agreement (i.e. leave, emergency, etc.), the Facility Director may identify a designee in writing and such writing shall include the effective and termination dates of such designee status.
15. “Substantial Compliance” shall mean that the majority of the substantive requirements of a provision or the Agreement have been met for both quantitative (i.e., 90% performance measure) and qualitative (i.e., consistent with the larger purpose of the Agreement) measures.
16. “Noncompliance” during a period of declared emergency or acts of God (such as, but not limited to: hurricane, earthquake, tsunami, flood), that makes compliance impossible or impractical will not constitute failure to maintain substantial compliance. Parties to this Agreement shall not consider any period of

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time for which compliance was not possible or impractical due to an act of God in any calculations used in determining substantial compliance. At the same time, temporary compliance during a period of otherwise sustained noncompliance will not constitute substantial compliance.
17. “Youth” shall mean any person who is residing at a Facility.
18. “Direct care staff” shall mean employees whose primary responsibility is the direct and continuous supervision of youth.
19. “Include” or “including” shall mean “including, but not limited to”.
20. “Qualified medical professional” means a medical care provider who is licensed and sufficiently trained to provide medical services. This includes physicians, physician assistants, registered nurses, and licensed practical nurses.
21. “Qualified mental health professional” means a mental health care provider who is licensed and sufficiently trained to provide mental health services. This includes social workers, counselors, psychologists, and psychiatrists.
22. “Chemical Agent” means an active chemical substance, such as capsicum spray mace or tear gas, that is used to immobilize a person, overcome resistance to physical control, or to deter or stop activities that may cause personal harm to the individual or others.
23. “Restraint” shall mean any method that restricts, limits, or directs an individual’s freedom of movement, including mechanical restraints (e.g., handcuffs, belly chains, leg shackles) and physical restraints (e.g., manual holds). The term “restraint” does not include verbal directives, room confinement or use of handcuffs or shackles for and during transport.
24. “Train” shall mean to instruct an individual or individuals in the skills addressed, including ongoing assessment of mastery of instructional material. Training shall be competency based and shall incorporate testing and instructional methods that establish minimal standards for defining staff competency.
25. “Use of force” shall mean any physical contact initiated by a staff person that intentionally restricts the movement of a youth, including a physical restraint.
III. SUBSTANTIVE REMEDIAL MEASURES
A. Protection from Harm

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To provide youth in the Facility with reasonably safe living conditions, the Facility shall:
1. Incident Reporting 26. Policy. Within 30 days of the United States’ approval in accordance with Paragraph 78 below, the Facility shall implement a stand-alone incident reporting policy outlining the specific incidents that require a separate and complete incident report. Such incident categories shall include the following types of incidents:
a) use of force; b) youth-on-staff violence; c) youth-on-youth violence; d) allegations of child abuse or neglect, including allegations of
inappropriate relationships between youth and staff and other allegations of staff misconduct; and e) suicidal behavior, including gestures or attempts. 27. Incident Report Content. This policy shall require an incident report to be written by one of the staff present during the incident. The narrative shall include: a) the number, names, and specific locations of youth and staff present at the time of the incident; b) the relevant facts preceding and subsequent to the incident; c) descriptive facts related to the incident (e.g., what youth did and said, the nature of the physical altercation); d) the type of force and/or restraint used (i.e., escort, handcuffs, taken to the ground, etc.); e) injuries sustained by youth and staff and the type, time, and location of medical response or attention provided; and f) whether isolation was required to address imminent threats to safety or security following the incident. 28. Witness Statements. In addition to the staff member writing the incident report as required above, all other staff who were present during, or who responded

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to the event, shall complete a staff witness statement. All youth involved in, or who were present during the event shall complete a youth witness statement. Witness statements shall be completed independently and as soon as possible after the incident.
29. Incident Report Packet. The incident report and all staff and youth witness statements shall comprise the Incident Report Packet.
30. Supervisory Review. Before the end of each shift, a shift supervisor should review all Incident Report Packets generated during his or her shift to ensure that each report meets all of the requirements of the incident report policies and content requirements, and that required witness statements have been completed. Accordingly, the Incident Report Packet shall be completed for the shift supervisor’s review before the end of the shift during which the incident occurred. When available and if not already provided, the shift supervisor should review independent data to corroborate the information reported in the incident reports. These data include video tape recordings; unit logs; security logs; safety checks of youth in isolation; medical records; and information coming from interviews with the youth and staff involved. Once all data have been reviewed, the shift supervisor should critique the staff’s handling of the event to determine whether different decisions or choices could have prevented the incident from occurring, including whether force or restraint was necessary and properly applied and the least restrictive technique possible was used. The supervisor’s review and critique should be provided, in writing, on the incident report.
31. Mandatory Reporting. In addition to an incident report, all serious incidents (i.e., lacerations, broken bones, black eyes, etc.) requiring medical attention within or outside of the Facility shall be reported to the Facility Director immediately and no later than the end of the shift during which the incident occurred. All staff, including administrative, medical, and direct care staff or contractors shall have an obligation to report serious incidents and suspicion of abuse to the Facility Director immediately upon discovery.
32. Performance Measure. The Facility shall review the incident reports and provide feedback to staff as frequently as needed to ensure that at least 90% of the incidents meet the requirements of this subsection. Such review and the monthly compliance rate shall be documented.
33. Quality Assurance. On at least a monthly basis, the Facility shall aggregate and analyze the data on the types of incidents occurring at the Facility. Monthly statistics should be assembled to assess changes over time. Each monthly report shall include:
a) relevant aggregate data (i.e., number of incidents under each

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category);
b) trends and/or patterns that appear to contribute to the incident’s occurrence (e.g., time, location, staff involved, youth involved);
c) specific interventions that have been or will be implemented in response to the underlying conditions that may have contributed to the incident’s occurrence;
d) status reports on the effectiveness of interventions undertaken in response to trends identified in previous months; and
e) staff cited or disciplined for violating the Incident Reporting policies.
2. Use of Force
34. Use of Force Curriculum. Within 30 days of the United States’ approval in accordance with Paragraph 78 below, the Facility shall implement a wellresearched, age-appropriate curriculum for the use of physical force and mechanical restraints, which shall include:
a) verbal and non-verbal de-escalation techniques;
b) a continuum of physical restraint techniques that are safe and limit the risk of positional asphyxiation; and
c) guidance for staff on using safe alternatives if the authorized techniques are impractical given the circumstances.
35. Policy. Within 30 days of the United States’ approval in accordance with Paragraph 78 below, the Facility shall implement a use of force curriculum and policy that includes:
a) identification of the situations in which physical force is authorized (i.e., only in situations where the youth’s behavior threatens imminent harm to youth or staff);
b) staff to use one of the authorized physical restraint techniques or a safe alternative, if an authorized technique is not practical;
c) staff to temper the use of force as the youth begins to comply with staff instructions;

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d) an Incident Report Packet be completed for all uses of force;
e) all youth involved in a physical restraint be assessed by qualified medical professional immediately following the incident; and
f) shift supervisors review and critique all uses of force before the end of the shift on which they occurred.
36. Eliminate Unsafe Practices. The Facility shall develop and implement a systematic plan to eliminate the following practices within 60 days of the Effective Date: restraint chairs and chemical agents. During the 60 day period during which the practices are being eliminated, the Facility shall ensure that an Incident Report Packet and supervisory review shall be completed for any use of these practices. In addition, use of these practices shall be limited to situations when less severe interventions are unsuccessful or unavailable, is necessary to prevent imminent physical harm to youth or others, and authorized by a supervisor. Until these practices are fully eliminated, a supervisor shall promptly review all uses of these techniques to ensure compliance with this provision. Defendants do not and will not begin using the following practices: pain compliance techniques, four- or fivepoint restraints, and fixed restraints.
3. Isolation
37. Restricting Use of Isolation. Within 30 days of the United States’ approval in accordance with Paragraph 78 below, the Facility shall implement an adequate continuum of disciplinary sanctions, including appropriate use of isolation; due process protections, including a due process hearing when isolation is in excess of 24 hours; and limitation of the use of isolation to situations in which a youth poses an imminent threat to self or others and when less severe disciplinary measures have proven ineffective. All uses of isolation shall require written justification and authorization by a shift supervisor.
38. Facility Director Notification of Isolation. The Facility or Assistant Director shall be notified of all periods of isolation as follows:
a) for all periods of isolation beyond two hours, the Facility Director shall be notified within 30 minutes of the isolation extending beyond two hours;
b) for all periods of isolation wherein youth are placed in isolation for a cumulative period of two hours or more within a 24 hour period, the Facility Director shall be notified within 30 minutes of the cumulative isolation extending beyond two hours in a 24 hour period; and

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c) for all periods of isolation wherein youth are placed in isolation three or more times within a week, regardless of the length of time for each isolation period, the Facility Director shall be notified within the first 30 minutes that the youth is placed in isolation for the third time in a week.
39. Facility Director Notification Content. Such foregoing notification to the Facility Director shall include the circumstances and facts related to the youth’s ongoing imminent threat to self or others and the less severe disciplinary measures that have been attempted and proven ineffective. The Facility shall prohibit periods of disciplinary isolation longer than 24 hours, except in extraordinary circumstances and with the express authorization of the Facility Director.
40. Services and Supervision of Youth in Isolation. Youth in isolation shall continue to receive meals, showers, and educational and recreational services. An isolated youth’s safety and welfare shall be visually verified and documented by Facility staff at frequent and random intervals, no fewer than four times per hour. In addition, youth in isolation shall be counseled by a qualified mental health professional and visited by a shift supervisor on a daily basis, as long as he or she is in isolation. The requirements of this provision shall be documented in writing.
41. Performance Measure. The Facility shall review isolation documents and provide feedback to staff as frequently as needed to ensure that 90% of isolation episodes in a given month meet the requirements of this subsection. Such review and the monthly accuracy rate shall be documented.
42. Quality Assurance. On a monthly basis, the Facility shall aggregate and analyze the data on the use of isolation. Monthly statistics should be assembled to assess changes over time. Each monthly report shall include:
a) the number of incidents of isolation, the duration, and the reason for isolation;
b) trends and/or patterns regarding the use of isolation (e.g., frequency of particular youth and/or staff involved in incidents of isolation; frequency of particular reasons given for isolation; frequency of the use of isolation during certain times of day or days of the week);
c) specific actions that have been or will be undertaken in response to the underlying conditions that may have contributed to the problematic patterns or trends; and
d) status reports on the effectiveness of interventions undertaken in response to identified trends from previous months.

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4. Self-Harm 43. Policy. Within 30 days of the United States’ approval in accordance with Paragraph 78 below, the Facility shall implement a comprehensive suicide prevention policy which includes:
a) intake screening for risk of self-harm; b) procedures for initiating and terminating precautions; c) communication between direct care and mental health staff regarding
youth on precautions; d) assessments of the risk of self-harm by qualified mental health
professionals; e) housing and supervision requirements including minimal intervals of
supervision and documentation; f) interdisciplinary reviews of all serious suicide attempts or completed
suicides; and g) multiple levels of precautions, each with increasing levels of protection. 44. Intake Screening. Within 30 days of the United States’ approval in accordance with Paragraph 78 below, the Facility shall implement a revised intake screening questionnaire that includes questions whether the youth: a) currently feels like hurting himself or herself; b) has engaged in self-injurious behavior in the past (in a facility or
otherwise); c) has ever been hospitalized for suicidal behavior; d) has experienced any recent, significant trauma; and e) has any family or friends who have committed suicide. 45. Intake Screening Training. All intake staff shall be trained within seven days after the intake screening questionnaire has been drafted and approved. All incoming youth shall be screened and only trained staff shall be authorized to administer the screening tool.

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46. Isolation of Youth on Suicide Precautions. The suicide prevention policy shall prohibit youth on suicide precautions from being isolated unless specifically authorized by a qualified mental health professional. Any such isolation and its justification shall be thoroughly documented in the accompanying incident report.
47. Assessment of Youth on Suicide Precautions. A qualified mental health professional shall regularly, but no less than daily, reassess youth on suicide precautions to determine whether the level of precaution or supervision should be raised or lowered. These reassessments shall be documented and recorded in the youth’s medical chart. Only a qualified mental health professional may promote, demote, or terminate a youth’s suicide precaution level or status.
48. Supervision of Youth on Suicide Precautions. The Facility shall ensure that direct care staff supervise youth on suicide precautions at the intervals required by policy, and that staff document their visual verification of the youth’s welfare accurately and completely. A supervisor shall conduct and document a review of all documents related to this provision before the end of the shift during which it occurred to ensure compliance with policy and this Agreement.
49. Communication. The Facility shall require direct care staff to immediately notify a qualified mental health professional any time a youth is placed on suicide precautions and mental health care staff shall conduct a face-to-face evaluation of the youth immediately but no later than one hour after he or she is placed on suicide precautions. If a qualified mental health professional is unable to conduct a face-to-face evaluation of the youth within an hour of being placed on suicide precautions, the youth shall be placed on direct one-to-one supervision pending the face-to-face evaluation, which shall occur no later than 24 hours of placement. Direct care staff shall provide mental health care staff with all relevant information related to placing a youth on suicide precautions. The Facility shall ensure that all mental health care staff within the Facility have access to critical information for youth on suicide precautions (e.g., progress notes from all treating clinicians). Following each daily assessment, mental health care staff shall provide direct care staff with pertinent and relevant information regarding a youth on suicide precautions to the extent that it affects the direct care staff’s duties and responsibilities for supervising youth on suicide precautions. All staff, including administrative, medical, and direct care staff or contractors, have an obligation to report all incidents of self-harm to the Facility Director immediately upon discovery.
50. Mortality and Morbidity Review. The Facility shall ensure that all relevant facts and circumstances surrounding serious suicide attempts and completed suicides are reviewed by a multidisciplinary team. This team shall identify any areas in which staff performance could be improved or facility procedures that need to be adjusted to improve the ability to protect youth from

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self-harm. All reviews shall be documented and shall include the team’s findings, concerns, recommendations and remedial actions.
51. Performance Measure. The Facility shall review documents and provide feedback to staff related to suicide precautions as frequently as needed to ensure that at least 90% of the self-harm incidents meet the requirements of this subsection in a given month. Such review and the monthly accuracy rate shall be documented.
52. Quality Assurance. On a monthly basis, the Facility shall aggregate and analyze the data regarding self-harm. Monthly statistics should be assembled to assess changes over time. Each monthly report shall include:
a) self-harm data: number of incidents related to self-harming behavior, suicide gestures, attempts or completed suicides; and the structures, objects, or instruments used to execute the self-harm;
b) trends and/or patterns regarding the self-harm data (i.e., the location and shift during which the majority of self-harm occurred; circumstances surrounding the discovery of the self-harm; youth frequently engaged in self-harm);
c) specific interventions that have been or will be implemented in response to the underlying conditions that may have contributed to the problematic patterns or trends; and
d) status reports on the effectiveness of interventions undertaken in response to identified trends from previous months.
5. Staffing
53. Ratio. The Facility shall ensure that direct care staff-to-youth ratios are maintained at a minimum of 1:8 at all times during waking hours and 1:16 at all times during sleeping hours.
54. Staff Accountability. The Facility shall ensure that staff are in the same room as the youth, awake, and alert at all times. On a weekly basis, a Facility supervisor shall conduct and document random reviews of shift schedules, videotapes, unit logs, etc. to verify compliance with this provision. In addition, the Facility shall conduct routine and unpredictable audits of video recordings and surprise in-person visits to the Facility during the overnight shift and on weekends to determine whether staff may be violating any policies, procedures, or rules related to supervising youth. These audits shall be reviewed against staff documentation regarding shifts, checks, incident reports, and logs. The audit, its

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findings, and corrective action, if any, shall be documented.
55. Performance Evaluations and Discipline. Accurate and timely compliance with the requirements of the any of the policies and provisions enumerated herein shall be a specifically enumerated performance requirement to the job descriptions, duties, and responsibilities of all relevant staff and supervisors. Failure to meet this performance requirement may result in counseling, reprimand, training, and/or sanction, including termination.
56. Performance Measure. The Facility shall review shift schedules and other supplementary data and provide feedback to staff to ensure a 90% compliance rate in a given month for the requirements of this subsection. Such review and the monthly accuracy rate shall be documented.
57. Quality Assurance. On a monthly basis, the Facility shall aggregate and analyze the data regarding staffing. Monthly statistics should be assembled to assess changes over time. Each monthly report shall include:
a) the number of shifts not in ratio in a given month;
b) trends and/or patterns regarding the shift ratio data (i.e., incidents where failure to follow staffing ratio requirements appears to have contributed to the problem; whether particular shifts frequently fail to satisfy staffing ratios; use of sick call and leave);
c) specific interventions that have been or will be implemented in response to the underlying conditions that may have contributed to the problematic patterns or trends; and
d) status reports on the effectiveness of interventions undertaken in response to identified trends from previous months.
6. Abuse
58. Policy. Within 30 days of the United States’ approval in accordance with Paragraph 78 below, the Facility shall implement a policy related to physical and sexual abuse or neglect of youth by staff. The policy shall define and prohibit physical and sexual abuse of youths by staff and or by other youths. This policy shall also include that:
a) allegations of abuse shall be reported to the appropriate external law enforcement agency immediately and no later than the end of shift when the allegation was made;

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b) staff failing to report allegations of abuse to his or her supervisor or the appropriate law enforcement agency in a timely manner shall be disciplined or terminated;
c) staff retaliating against another staff or youth for reporting an allegation of abuse shall be disciplined or terminated;
d) staff and other youth shall be prohibited from entering a youth’s room during sleeping hours without specific and documented justification for such entry;
e) staff shall be prohibited from taking youth to a room or area outside of camera view during sleeping hours without prior written authorization; and
f) procedures for conducting an internal investigation.
59. Reporting Avenues. In addition, the policy shall require that youth are given access to multiple avenues for reporting allegations of abuse (i.e., youth witness statements on incident reports; grievances; Facility Director; social worker or case manager; legal representatives; parents or guardians; medical staff; etc.). The Facility shall also make a formal arrangement with a local social service agency for regular visits to meet with and interview youth regarding their experiences at the Facility. In the alternative, the Facility may provide youth in the Facility with unencumbered access to a crisis hotline. Instructions for accessing these avenues shall be incorporated into the youth’s orientation handbook and posted prominently in each Facility pod, the visitation area, medical area, and other places where youth routinely congregate.
60. Internal Investigation. The Facility, through an individual no lower than an Assistant Director, shall conduct an administrative investigation of all allegations to ensure compliance with all Facility policies and procedures. This administrative investigation, its findings, and post-finding action should be thoroughly documented in a formal report.
61. Chronology of Allegations. The Facility shall maintain a chronology of all events pertaining to each allegation which includes the following data and information:
a) reporter;
b) alleged victim;
c) alleged perpetrator;

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d) date, time and manner in which the allegation was communicated to the reporter;
e) date, time and manner in which the allegation was reported to an external law enforcement agency;
f) forensic medical evaluation; g) response from the external law enforcement agency; h) steps taken to prevent any further abuse or retaliation pending the
completion of any internal or external investigation; i) finding of the investigation; and j) corrective actions or disciplinary measures taken against the staff
involved. 62. Performance Measure. The Facility Director is responsible for ensuring that all allegations of abuse are handled in a manner consistent with policy and procedures and meet the requirements of this subsection. 63. Quality Assurance. On a monthly basis, the Facility shall aggregate and analyze the data regarding reporting abuse. Monthly statistics should be assembled to assess changes over time. Each monthly report shall include:
a) the number of reports of physical and sexual abuse or neglect, including the avenues utilized to make such reports;
b) trends and/or patterns regarding the abuse or neglect reports (i.e., specific staff, shifts, or locations);
c) specific interventions that have been or will be implemented in response to the underlying conditions that may have contributed to the problematic patterns or trends; and
d) status reports on the effectiveness of interventions undertaken in response to identified trends from previous months.
7. Classification 64. Policy. Within 30 days of the United States’ approval in accordance with Paragraph 78 below, the Facility shall implement policies and procedures for a

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housing classification system that includes objective initial classification and reclassification instruments, to determine each youth’s risk of engaging in serious institutional misconduct (e.g., assaultive behavior). The scored risk factors should include a youth’s prior institutional misconduct. The policy shall specify the procedures for initial and re-classification, housing assignments, and supervision procedures flowing from the assessment of risk. The policy should include timelines for classification and the events or incidents that trigger reclassification. Because of the limited housing units available, the Facility may consider enhanced supervision plans and other measures to ensure that youth located in the same housing unit are sufficiently supervised and that staff are informed accordingly.
65. Housing and Supervision. All youth should be initially classified in accordance with this provision within 24 hours of entry to the Facility and should not be placed in a regular housing unit until properly classified. High -risk youth shall be supervised more intensively than low-risk youth, and shall be housed separately.
66. Performance Measure. The Facility shall review all classifications as frequently as needed and provide feedback to staff to ensure that at least 90% of the intakes are classified within 24 hours of arrival to the Facility; that at least 90% of the youth are placed in housing units consistent with their risk level; and that at least 90% of the youth eligible to be reclassified are reclassified within appropriate timeframes and re-housed accordingly. Such review and the monthly accuracy rate shall be documented.
67. Quality Assurance. On a monthly basis, the Facility shall aggregate and analyze the data on classification. Monthly statistics should be assembled to assess changes over time. Each monthly report shall include:
a) the number of initial classification and reclassifications, high-risk and low-risk youth, and other subsequent housing assignments;
b) trends and/or patterns regarding the classification data (i.e., frequency of reclassifications; overrides; and assaults);
c) specific interventions that have been or will be implemented in response to the underlying conditions that may have contributed to the problematic patterns or trends; and
d) status reports on the effectiveness of interventions undertaken in response to identified trends from previous months.
B. Training

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68. For all direct care staff and supervisors, mental health and medical personnel and education staff, the Facility shall provide the following training modules:
a) Incident reporting: a minimum of four hours of competency-based training on the Incident Reporting Policy and the specific requirements for timely, accurate, and complete reporting for each of incident category and two hours of annual refresher training;
b) Use of force: a minimum of eight hours of competency-based training for all staff on the approved use of force curriculum (including the use of verbal de-escalation, physical and mechanical restraints) and two hours of annual refresher training. Both training sessions must include a component in which staff’s ability to properly and safely implement each physical restraint technique is assessed by a qualified trainer;
c) Suicide prevention: a minimum of eight hours of competency-based training for all staff on suicide prevention, including the environmental risk factors for suicide, individually predisposing factors, high‐risk periods for incarcerated youth, warning signs and symptoms, known sources of stress to potentially suicidal youth, the specific risks posed, coping mechanisms or activities that may help to mitigate the risk of harm, the Facility’s suicide prevention procedures, liability issues, a discussion of recent suicide attempts at the Facility, and the use of a rescue tool, and four hours of annual refresher training on these same topics. All staff shall be certified in CPR and first aid; and
d) Child abuse reporting: a minimum of two hours of competency-based training for all staff on the identification and prevention of custodial misconduct, including physical and sexual abuse, including appropriate reporting and non-retaliation requirements, and one hour of annual refresher training.
C. Document Maintenance, Data Collection, and Reporting
69. Document Maintenance. Any and all of the reports, audits, and/or documentation required by the provisions in this Agreement shall be maintained and secured by the Facility. The United States and/or Monitor may review such reports at any time. Upon request, copies of such reports should be forwarded to the United States and/or the Monitor within three business days by electronic mail, facsimile, or overnight mail.

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70. Monthly Reporting. The Facility Director shall prepare a monthly report that contains the following information and provide it to the United States and the Monitor within 10 business days of the end of each month:
a) Monthly statistics, trends, and corrective actions regarding each Performance Measure and Quality Assurance provision required under this Agreement.
b) Updates on all open investigations pertaining to allegations of physical or sexual abuse;
c) Summary of the status of training including the proportion of staff who have been trained on each topic, including the names and titles of individuals trained, the date on which training was completed, and the remaining number and percentage of staff to be trained and the dates by which they should be trained; and
d) Details related to the serious incidents reported to the Facility Director including the facts and circumstances leading to the report, the date the incident was reported, and the actions, if any, taken by the Facility Director in response to the report.
IV. IMPLEMENTATION AND MONITORING
71. For purposes of substantial compliance with this Agreement, the Parish shall fully implement all of the provisions of this Agreement within twelve (12) months of the Effective Date. For purposes of substantial compliance with the specific provisions of the Agreement, the Parish shall comply with Paragraph 78 of this Agreement and the requirements set forth within each provision accordingly. If the Parish cannot fully implement the reforms required by this Agreement or a specific provision within the allotted time, the Parish shall notify the United States in writing.
72. Within two (2) weeks of the Effective Date, the Parish shall communicate the provisions set forth in this Agreement to officials, employees, agents, and independent contractors who are involved in providing care to the youth confined at the Facility.
73. The Parish shall require that youth admitted prior to the Effective Date and residing at any of the Facility are afforded all of the same protections and services provided by this Agreement to youth admitted on or subsequent to the Effective Date.

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74. Monitor Selection. Compliance with this Agreement shall be assessed by a Monitor jointly selected by the Parties (“Monitor”). The Monitor shall be an expert in the area of juvenile protection from harm. The Parties shall agree upon a Monitor within thirty (30) days of the Effective Date. If the Parties are unable to agree upon a Monitor, then each Party shall submit two names, along with resumes or curricula vitae and cost proposals, to the Court, within 120 days of the Effective Date and the Court shall appoint the Monitor from among the names submitted.
75. Monitor.
a) The Parish shall bear all reasonable fees and costs of the Monitor.
b) The Monitor shall be permitted to initiate and receive ex parte communications with all Parties.
c) Except as required or authorized by the terms of this Agreement or the Parties acting together, the Monitor shall not make any oral or written public statements – including statements to the press, conference presentations, lectures, or articles – with regard to: the status of the Parish’s compliance or noncompliance with this Agreement; any act or omission of the Parish or its agents, representatives or employees; or the terms of his or her employment as the Monitor.
d) Except as required or authorized by the terms of this Agreement or the Parties acting together, the Monitor shall not testify in any other litigation or proceeding with regard to the status of the Parish’s compliance or noncompliance with this Agreement; any act or omission of the Parish or its agents, representatives or employees; or the terms of his or her employment as the Monitor, unless otherwise lawfully compelled to do so. The Monitor may testify in this litigation concerning the Parish’s compliance or noncompliance with this Agreement.
e) Unless such conflict is waived by both Parties, the Monitor shall not accept employment or provide consulting services that would present a conflict of interest with his or her responsibilities under this Agreement, including being retained (on a paid or unpaid basis) by any current or future litigant or claimant or such litigant’s or claimant’s attorney, in connection with a claim or suit against the Parish or its departments, officers, agents or employees concerning matters relevant to this Agreement.

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f) Neither Party, nor any employee or agent of either Party, shall have any supervisory authority over the Monitor’s activities, reports, findings, or recommendations.
g) The Monitor may be terminated if both Parties agree and upon good cause shown. Good cause shall include any violation of Parish or federal law which reasonably calls into question the Monitor’s fitness to continue serving as the Monitor. In the event the Parties do not agree upon the need for termination, the Parties agree to work in good faith to resolve their differences.
76. Monitor’s Access to Facility and Records. In order to assess the Parish’s implementation of each substantive provision of this Agreement, the Monitor will conduct regular compliance reviews to ensure that the Parish has implemented and continues to implement all measures required by this Agreement. Such access shall continue until this Agreement is terminated.
a) The first compliance review will be conducted within ninety (90) days of the Monitor Selection or Effective Date, whichever is later. Thereafter, routine compliance reviews will be conducted by the Monitor every 180 days until this Agreement is terminated. Such routine compliance reviews will assess the Parish’s compliance with each of the substantive remedial measures set forth in Section III.
b) The United States may determine that an additional compliance review or reviews is necessary due to emergent issues at the Facility (including the death of a youth or receipt of credible allegations of sexual abuse by staff or youth) or recurring problems with substantive provision(s) of the Agreement. If the United States believes that such additional compliance reviews are necessary, the Facility shall provide access to the Monitor and/or the United States within 48 hours of the request.
c) At each compliance review, the Monitor shall have the responsibility and authority to independently observe, assess, review, and report on the Parish’s implementation and compliance with the provisions of this Agreement. In order to accurately assess conditions at the Facility, the Monitor shall: conduct on-site inspections; observe programs and activities; interview pertinent administrators, professional staff, direct care staff, and contractors; individually interview a sample of youth; review a sampling of videotapes from housing units; and conduct detailed reviews of youth records and other pertinent documents and reports. The Monitor shall spend a sufficient amount of time at the Facility in order to accurately assess day-to-day operations and

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conditions. The Monitor shall be responsible for independently verifying representations from the Parish regarding progress toward compliance.
d) Within sixty (60) days after each compliance review, the Monitor shall file with the Court a final consolidated report which describes the steps taken by the Parish to implement this Agreement, evaluates the extent to which the Parish has complied with each substantive provision of the Agreement, cites the evidence upon which such evaluation is based, and provides recommendations. Each report shall be provided to the Parties in draft form for comment within twenty-eight (28) days after each compliance review, and the Parties shall have twenty (20) days after receipt of the draft report to comment on the report before it is finalized by the Monitor. Neither Party, however, shall have authority over the Monitor’s reports, findings, or recommendations.
e) For the purpose of ascertaining compliance with this Agreement, the Monitor shall have reasonable access to: the buildings and grounds of the Facility; Facility documents and records; Facility officials, employees, agents, and independent contractors; Parish officials, employees, agents, and independent contractors; and youth residing at the Facility, including the right to meet with youth privately. Prior to each compliance visit, the Facility shall provide the Monitor with the names and contact information of youth who have been released from the Facility within the previous reporting period. The Monitor shall have the right to conduct unannounced visits to the Facility; however, the Monitor shall generally coordinate the timing of on-site Facility visits and requests for documents so as to minimize disruption to Facility operations and Parish employee work functions.
77. Settlement Agreement Coordinator. The Parish shall appoint a settlement agreement coordinator to oversee compliance with this Agreement. The settlement agreement coordinator shall:
a) Be responsible for coordinating all document and information requests from the Monitor and the United States;
b) Coordinate all on-site visits, including document and information requests prior to each on-site visit by the Monitor and/or the United States;
c) Catalog all incident reports, documents, and other source data used to compile the monthly reports outlined herein to ensure that they can be produced upon request by the Monitor and/or the United States; and

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d) Supervise and ensure that all of the document maintenance, data collection, and reporting requirements under this Agreement are met on a timely basis.
78. Document Development and Revision. The Parish shall timely revise and/or develop policies and procedures, forms, screening tools, blank log forms, and other documents as necessary to ensure that they are consistent with, incorporate, address, and implement all provisions of this Agreement. To the extent that a provision within this Agreement requires the development and/or implementation of a policy or procedure, such provision shall not be effective until the Facility and the United States have complied with the terms of this provision.
The Parish shall provide all such documents to the United States for its review within thirty (30) days of the Effective Date. Within forty-five (45) days of its receipt of the policies, procedures and other written documents, the United States shall provide either written approval of each document, or written concerns or objections it has to the documents that include proposed revisions. Such approval shall not be unreasonably withheld. In the event that the United States asserts that policies, procedures, or other written documents are not in compliance with the terms of this Agreement, the Parties will confer on the matter for up to thirty (30) days. If, after conferring for thirty (30) days, the parties are unable to reach an agreement, the Parties shall submit a Motion(s) to the Court outlining the disagreement and seeking the Court’s resolution of the disagreement.
If, after the policies, procedures, and practices affected by this Agreement are implemented, any of the Parties determines that a policy, procedure, or practice, as implemented, fails to effectuate the terms of this Agreement, the Parish shall consult with the United States and revise the policy, procedure, or practice to effectuate the terms of this Agreement.
79. Request for Technical Assistance. The United States, at its discretion, and the Monitor agree to provide technical assistance to the Parish for policy/procedure development.
80. United States’ Access to Facility and Records. The United States shall have full and complete access to: the buildings and grounds of the Facility; Facility documents and records; Parish documents and records; Facility officials, employees, agents, and independent contractors; Parish officials, employees, agents, and independent contractors; and youth residing at the Facility, including the right to meet with youth and staff privately. The United States shall have the right to conduct unannounced visits to the Facility; however, the United States shall generally coordinate the timing of its on-site Facility visits and requests for documents so as to minimize disruption to Facility operations and Parish

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employees’ work functions. Such access shall continue until this Agreement is terminated.
81. Response to Questions. Within thirty (30) days of the receipt of written questions from the United States regarding the Parish’s compliance with this Agreement, the Parish shall provide the United States with written answers and access to any requested documents regarding the Parish’s compliance with the requirements of this Agreement.
82. Monitor’s Response to Questions. Within thirty (30) days of the receipt of written questions from the United States or the Parish regarding a Monitor’s activities in assessing compliance with this Agreement and/or the Parish’s compliance with this Agreement, the Monitor shall provide the United States with written answers.
83. Notification to the United States of Incidents. The Parish shall notify the United States no later than one business day after the Parish becomes aware of the following categories of incidents: youth death; youth injury resulting in transport of the youth to the emergency room or requiring hospitalization; group disturbance; use of the restraint practices and techniques being eliminated in accordance with the provisions above; and allegations of physical or sexual abuse or misconduct by staff.
a) The Parish shall timely forward to the United States copies of all incident report packets and final reports of investigations related to such incidents, as well as any autopsies, medical records, mortality reviews, and death summaries.
b) For the purposes of this provision, the requirement to notify the United States is met when the Parish contacts at least one of the Special Litigation Section trial attorneys assigned to this matter and receives written confirmation of such contact.
V. ENFORCEMENT AND TERMINATION
84. Notice Prior to Judicial Action. With the exception of conditions or practices that pose an immediate and serious threat to the life, health, or safety of youth, if the United States believes that the Parish has failed to substantially comply with any obligation under this Agreement, the United States shall give written notice of the failure to the Parish prior to seeking judicial enforcement of the Agreement.
a) With the exception of an immediate or serious threat to life, health, or safety of youth residing at the Facility, the Parish shall have thirty

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(30) days from the date of such written notice to cure the failure and provide the United States with sufficient proof of its cure if the failure can be cured within thirty (30) days. If the failure cannot be cured within thirty (30) days, the Parish shall promptly submit a plan to cure the failure, but, in any event, the failure shall be cured no later than forty-five (45) days from receipt of the written notice.
b) If either the Parish or the United States believes or if the Parties agree that modification of this Agreement is required to cure the failure, the Party or Parties shall move the Court to modify the Agreement.
c) If the Parties agree to a plan to cure an alleged violation and the United States believes that the violation has still not been cured, the United States shall provide at least fifteen (15) days notice before filing any motion with the Court.
d) In the event a disagreement occurs, the United States and the Parish commit to work in good faith to resolve disputes; provided, however, nothing in this subparagraph shall impede resolution of a matter deemed by the United States to present an immediate and serious threat to the life, health, or safety of youth.
e) Parish reserves the right to seek judicial review, upon motion to the Court, in the event the United States makes a determination that the Parish has failed to substantially comply with any obligation under this Agreement.
85. Termination. This Agreement shall terminate in accordance with the following conditions:
a) This Agreement will terminate in its entirety when the United States certifies that the Parish is in substantial compliance with all provisions of this Agreement for twelve (12) consecutive months.
b) The Parties, in conjunction with the Monitor, may place certain provisions in “inactive” monitoring if the Parties, including the Monitor, agree that a particular provision has been in substantial compliance for twelve (12) consecutive months. However, based on good cause, the United States may place a previously inactive provision into an active monitoring status by notifying the Parish, in writing, at any time that this Agreement is in effect.
c) The Parish may, at any time during the term of this Agreement, request that the United States certify that the Parish has maintained

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substantial compliance with all provisions of this Agreement for twelve (12) consecutive months. If the United States so certifies, the parties shall jointly move the Court to dismiss this action.
c) The United States shall notify the Parish by the fifty-eighth (58) month after the Effective Date if it has determined that the Parish will not be in substantial compliance with this Agreement, or portions thereof, in month sixty (60) of this Agreement. If the United States provides such notification, the United States shall move the Court for a status conference to discuss the Parish’s noncompliance with this Agreement.
d) Noncompliance with mere technicalities or temporary failure to comply with a period of otherwise sustained compliance will not constitute failure to maintain substantial compliance. At the same time, intermittent or temporary compliance during a period of sustained noncompliance shall not constitute substantial compliance.
VI. GENERAL PROVISIONS
86. Successors. This Agreement shall be binding on all successors, assignees, employees, agents, contractors, and all others working for or on behalf of the Parish.
87. Non-retaliation. The Parish agrees that it shall not retaliate against any person because that person has provided any information or assistance to the United States or the Monitor, has filed or will file a complaint, or has participated in any other manner in an investigation or proceeding relating to this Agreement. The Parish agrees that it shall timely and thoroughly investigate any allegations of retaliation in violation of this Agreement and take corrective actions identified through such investigations.
88. Notice. Notice under this Agreement shall be provided by electronic mail and overnight delivery and shall be provided to counsel for the Parish of Terrebonne and counsel for the United States.
89. Defense of Agreement. The Parties agree to defend the provisions of this Agreement. The Parties shall notify each other of any court challenges to this Agreement. In the event any provision of this Agreement is challenged in any local or state court, removal to a federal court shall be sought.
90. No Waiver for Failure to Enforce. Failure by either Party to enforce this entire Agreement or any provision thereof with respect to any deadline or other provision herein shall not be construed as a waiver of its right to enforce deadlines or provisions of this Agreement.

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Case 2:11-cv-02484-HGB-JCW Document 6-1 Filed 10/19/11 Page 29 of 29 SO ORDERED THIS ____ DAY OF _____________________, 2011
________________________________ Judge Helen G. Berrigan U.S. DISTRICT JUDGE

 
 Case 2:11-cv-02484-HGB-JCW Document 7 Filed 10/31/11 Page 1 of 2

UNITED STATES DISTRICT COURT EASTERN DISTRICT OF LOUISIANA

UNITED STATES OF AMERICA

CIVIL ACTION

VERSUS

NO. 11‐2484

TERREBONNE PARISH, ET AL

SECTION ʺCʺ (2)

ORDER

IT IS ORDERED that unopposed motion for entry of revised settlement

agreement filed by the plaintiff is GRANTED. Rec. Doc. 6. The revised settlement

agreement shall be entered into the record. Based on the stipulation of the parties, the

Court finds that the prospective relief in the revised agreement is narrowly drawn,

extends no further than necessary to correct the violation of the federal right, and is the

least intrusive means necessary to correct the violation of the federal right for purposes

of 18 U.S.C. § 3626. The Court will retain jurisdiction to enforce the revised settlement

agreement.

IT IS FURTHER ORDERED that the first unopposed motion for entry of

settlement agreement is DISMISSED as moot. Rec. Doc. 4.

Case 2:11-cv-02484-HGB-JCW Document 7 Filed 10/31/11 Page 2 of 2 IT IS FURTHER ORDERED that this matter is ADMINISTRATIVELY CLOSED. New Orleans, Louisiana, this 31st day of October, 2011.
____________________________________ HELEN G. BERRIGAN UNITED STATES DISTRICT COURT
2

 
 U.S. Department of Justice Civil Rights Division
Assistant Attorney General 950 Pennsylvania Ave, NW - RFK Washington, DC 20530

January

18, 2011

BY FIRST CLASS MAIL
The Honorable Michel Claudet President, Terrebonne Parish 8026 Main Street, Suite 700 Houma, LA 70360
Re: Terrebonne Parish Juvenile Detention Center, Houma, Louisiana
Dear Mr. Claudet:
I write to report the findings of the Civil Rights Division’s investigation of conditions at the Terrebonne Parish Juvenile Detention Center (“Terrebonne” or "the Facility"). On November 19, 2009, we notified Parish officials of our intent to conduct an investigation of Terrebonne pursuant to the Violent Crime Control and Law Enforcement Act of 1994, 42 U.S.C. § 14141 (“Section 14141”). Section 14141 gives the Department of Justice authority to seek a remedy for a pattern or practice of conduct that violates the constitutional or federal statutory rights of youth in juvenile justice institutions.
Summary of Findings
The youth confined to Terrebonne are subjected to conditions that place them at serious risk of avoidable harm in violation of their rights protected by the Constitution of the United States. During our investigation, we received a significant number of credible reports of sexual and physical misconduct by staff members on youth within their custody. The allegations exposed wide-spread and systemic abuses and revealed a lack of accountability and controls that would have prevented harm to the young people confined there.
Allegations of sexual misconduct have led to criminal charges against seven staff members. Our findings are not limited to the conduct charged in the criminal cases, but include numerous additional accounts. These incidents are compounded by a lack of systems in place to identify and correct misconduct.
In addition to sexual misconduct, there is a pervasive atmosphere of excessive force and violence. We found:

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 Physical restraints, including handcuffing and a restraint chair, are routinely used when verbal or non-physical methods would have been adequate;
 The inappropriate and dangerous use of chemical agents;  Excessive use of isolation as punishment or for control;  Suicidal behavior six times the national average and an inadequate suicide prevention
program; and  High levels of fighting and assaults between youth.
These conditions are the result of, and allowed to continue to exist because generally accepted juvenile justice standards are not followed. We found that staff did not receive minimally adequate training, and that existing policies and procedures are inadequate to ensure: that minimally necessary force is used to control youth; that chemicals are used safely; or that youth are protected from sexual or physical abuse. In addition, we found that the facility lacks adequate staff and that the staffing pattern places youth at risk of harm because of fatigue, reduced accountability, overreliance on seclusion, and inadequate supervision.
Significantly, we found limited mechanisms to provide accountability. During our inspections we uncovered staff members who lied about performing room checks. This information would not have been discovered but for our efforts. In addition, we found that child abuse allegations are not reported to state officials as required by law; the facility fails to collect data that would permit managers to identify and address problems; there is inadequate supervision of line staff; and no meaningful quality assurance program exists.
The failure to meet generally accepted juvenile justice standards in the face of severe problems in the facility violates the Fourteenth Amendment’s mandate that youth in state custody be protected from harm. In this letter we provide additional recommendations that are minimally necessary to bring the facility into compliance with the Constitution.
Investigation
On March 22-25, 2010, we conducted on-site inspections at Terrebonne with expert consultants in juvenile justice administration and protection from harm. We interviewed Facility management personnel, direct care and administrative staff, and youth. Before, during, and after our visits, we reviewed an extensive number of documents, including policies and procedures, incident reports, investigative reports, grievances from youth, staff personnel files, unit logs, orientation materials, staff training materials, and school records. In keeping with our pledge of transparency and to provide technical assistance where appropriate, we conveyed our preliminary findings to Terrebonne and Terrebonne Parish officials at the close of our on-site visits. We followed up with a letter to the Parish on April 22, 2010 outlining some of our most pressing concerns.1

1

In our letter, we expressed serious concern that overnight rooms checks were not being

consistently performed, and that staff routinely appeared to be falsifying room check

documentation. In addition, we expressed concern that overnight shift staff were not being

adequately supervised and were not being held accountable for complying with Terrebonne

policies and procedures.

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We commend the staff at Terrebonne for their helpful and professional conduct throughout the course of the investigation. We received full cooperation with our investigation and appreciate the Parish’s receptiveness to our consultants’ on-site recommendations. Also, we appreciate comments made by Ralph Mitchell, the Director of the Terrebonne Parish Department of Public Safety, indicating that he had become aware of some of the problems we identified, and had begun formulating remedies to address some of our most serious concerns.
In addition, we appreciate the thorough cooperation provided by Facility Director Jason Hutchinson. Director Hutchinson brings a number of strengths to the role of facility superintendent -- he is a bright, caring, dedicated, and committed person who has brought about several innovations in education and programming that affirm his commitment to the best interest of detained youth. He is appropriately educated, holding a bachelor’s degree in psychology and a master’s degree in special education. Director Hutchinson has experience working with troubled youth in the public schools and educational programming for adults in jail. The Director was highly receptive to our observations and has reported to us that he has implemented a number of remedial measures in response to our April 22, 2010 letter. In particular, on May 20, 2010 we were advised by counsel for the Parish that the Director has taken steps to ensure that overnight room checks are performed in a timely manner, and that overnight shift staff are now subject to periodic surprise visits by external law enforcement personnel.
We now write to advise you of the findings of our investigation, the facts supporting them, and the minimum remedial steps that are necessary to address the deficiencies we have identified. As described more fully below, we conclude that certain conditions at Terrebonne violate the constitutional rights of the youth.
I. BACKGROUND
Terrebonne is a secure juvenile detention facility opened on September 1, 1998 and located in Houma, Louisiana. The Facility’s mission is to “provide short-term care in the secured custody of juveniles who are accused, adjudicated pending court action, awaiting transfer to another facility, and who cannot be served in an open setting.”2 Terrebonne also served as one of three regional placement centers in Louisiana for adjudicated female youth pursuant to a per diem contract between Terrebonne Parish and the State. In May 2009, however, the State removed its contracted population from the Facility, and only the detention and pending placement populations remain.
One of the published goals of Terrebonne is to house “the juveniles in a safe and humane environment, maintaining the level of security necessary to prevent escape and assure that the juveniles live free of fear from assault or intimidation by staff or other juveniles.” Terrebonne has a capacity to hold 60 juveniles, including 40 males and 20 females. On February 1, 2010, the Facility housed a total population of 40 youth, and during the period of review, remained below

2

http://www.tpcg.org/view.php?f=juvenile_detention.

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operational capacity. Between its 1998 opening and July 31, 2007 (the most recent period for which published figures are available), the Facility has processed over 7,000 youth.3
II. LEGAL STANDARDS
Section 14141 authorizes the Department of Justice to seek a remedy for a pattern or practice of conduct that violates the constitutional or federal statutory rights of youth in juvenile justice institutions. 42 U.S.C. § 14141. Youth detained at Terrebonne are protected by the Fourteenth Amendment and have a substantive due process right to reasonably safe conditions of confinement and freedom from unreasonable bodily restraints. Youngberg v. Romeo, 457 U.S. 307, 316 (1982) (“If it is cruel and unusual punishment to hold convicted criminals in unsafe conditions, it must be unconstitutional to confine the involuntarily detained - who may not be punished at all - in unsafe conditions.”). The Fourteenth Amendment, rather than the Eighth Amendment applies because the youth are held for detention or rehabilitation, not punishment. 4 The purpose of the Louisiana youth delinquency statute is to "accord due process to each child who is accused of having committed a delinquent act... and to secure for him care as nearly as possible equivalent to that which the parents should have given him."5
To determine whether the Fourteenth Amendment was violated, a balancing test must be applied: “It is necessary to balance ‘the liberty of the individual’ and ‘the demands of an organized society.’” Youngberg at 320 citing Poe v. Ullman, 367 U.S. 497, 542 (1961) (Harlan, J., dissenting). The Youngberg Court went on to hold that “If there is to be any uniformity in protecting these interests, this balancing cannot be left to the unguided discretion of a judge or jury.” Id. at 321. Instead, the Court held that there was a constitutional violation if the detaining official substantially departed from generally accepted professional standards, and that departure endangers youth in their care. See id. at 314.
As a general matter, the Supreme Court has held that corrections officials must take reasonable steps to guarantee detainees' safety and provide "humane conditions" of confinement. Farmer v. Brennan, 511 U.S. 825, 832 (1994); Scott v. Moore, 85 F.3d 230, 235 (5th Cir. 1996) (holding that a municipality assumed a constitutional obligation to provide pre-trial detainees with minimal levels of safety and security); Hare v. City of Corinth, 74 F.3d 633, 639 (5th Cir.) (en banc) (recognizing a duty to provide detainees with basic human needs including protection from harm). In addition, an official's failure to maintain adequate policies, procedures, and

3

Id.

4

In Ingraham v. Wright, the Supreme Court rejected application of the Eighth Amendment

deliberative indifference standard in a non-criminal context. 430 U.S. 651, 669 n.37 (1977)

(“Eighth Amendment scrutiny is appropriate only after the State has complied with the

constitutional guarantees traditionally associated with criminal prosecutions.”). In addition, the

Court held that the Due Process Clause of the Fourteenth Amendment was the proper

constitutional gauge to determine the rights of adults detained by a state, but not yet convicted of

any crime. Bell v. Wolfish, 441 U.S. 520 (1979). See also, Scott v. Moore, 85 F.3d 230, 235

(5th Cir. 1996). At a minimum, youth should be accorded the same constitutional protections.

5

La. Child. Code Ann. art. 801 (2010).

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practices for the prevention of suicides may violate a detainee's due process rights. Silva v. Donley County, 32 F.3d 566, 1994 WL 442404, *5-7 (5th Cir. 1994) (unpublished) (holding sheriff's failure to establish suicide detection and prevention training for jail personnel, condoning de facto policy of sporadic cell checks, and absence of a policy for observing "at-risk" detainees may rise to deliberate indifference to known risk of suicide in detention settings).
Additionally, juvenile detainees have a constitutional right to be free from sexual assault and forced sexual contact by correctional staff. See, e.g., Spencer v. Doe, 139 F.3d 107, 112 (2d Cir. 1998) (noting that juvenile detainee had the right to be protected from sexual molestation under the Fourteenth Amendment); Ware v. Jackson County, 150 F.3d 873, 884-85 (8th Cir. 1998) (sexual assault of adult inmate may violate Eighth Amendment); Barney v. Pulsipher, 143 F.3d 1299, 1310 (10th Cir. 1998) (forced oral sex and sexual assault of adult prisoners are "sufficiently serious to constitute a violation under the Eighth Amendment"). Sexual assaults by staff, including rape, coerced sodomy, or touching of female prisoners' breasts and genitalia, are simply not part of the penalty that juvenile detainees pay for their offenses against society. See Farmer v. Brennan, at 834.
Confined youth have a constitutional right of freedom from unreasonable bodily restraints. Youngberg v. Romeo, at 320. The routine improper use of an isolation unit in a state facility can constitute cruel and unusual punishment. Morgan v. Sproat, 432 F. Supp 1130 (S.D. Miss. 1977). In Morgan, youth were placed on the highly restrictive unit for a variety of disciplinary offenses, including some as minor as "being disrespectful to staff members, stealing, and behaving inadequately...". Id. at 1129. The average length of confinement on the unit was 11 days. After considering extensive expert testimony in other cases, the court severely restricted the conditions under which the facility could place youth in such a unit:
The defendants will therefore be enjoined from using the isolation unit as an isolation unit, except under the following limited conditions which are necessary to insure that placement therein will not do any emotional or psychological harm to the students: students may not be placed in the isolation unit except where there is substantial evidence that they constitute an immediate threat to the physical well-being of themselves or others; confinement may not exceed 24 hours and must be approved within one hour of the confinement by the Superintendent, one of the Assistant Superintendents, the Chief Counselor or a staff psychologist; students in the isolation unit must be visited at least once every three hours during the day by the Chief Counselor, the students' own counselor or a licensed psychologist; the cells in the isolation unit must be provided with transparent windows, lights, mattresses, blankets, sheets, pillows, small tables for reading, chairs, soap and towels; unless a contrary program is indicated in an individual case by a licensed psychologist, students placed in the isolation unit must be permitted to sleep a reasonable time during the day, to have reading materials, to send and receive mail, and to have visitors; the students must receive daily at least an hour's physical exercise outside of the isolation unit or in the gym; and they must be allowed to eat their meals outside of their cells. Id. at 1140.
Finally, conditions of confinement claims may be based not only upon existing physical harm to youth, but also on conditions that threaten to cause future harm. Helling v. McKinney,

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509 U.S. 25 (1993) (stating "it would be odd to deny relief to detainees who plainly proved an unsafe, life-threatening condition in their facility on the ground that nothing yet had happened to them."). In Helling, the court recognized various circuit courts holding that "a detainee need not wait until he is actually assaulted before obtaining relief" and that the Constitution "protects against sufficiently imminent dangers..." Id., at 33-35 (internal citations omitted). See also, Herman v. Holiday, 238 F.3d 660 (5th Cir. 2001) (recognizing Helling standard); Hoeing v. Collins, 95 F.3d 53 (5th Cir. 1996) (unpublished); Gates v. Collier, 501 F.2d 1291, 1308-10 (5th Cir. 1974) (holding that failure to provide adequate systems to protect inmates against future harm including physical assaults and abuse constituted cruel and unusual punishment).
III. FINDINGS
We find that Terrebonne fails to adequately protect youth in its care from harm and serious threat of harm by staff, other youth and from self-harm.
A. The Facility fails to adequately protect youth from harm by detention staff.
In 2009, direct care staff members (including two supervisors) were indicted or charged with a total of 21 counts of custodial sexual misconduct or related crimes involving female youth under their supervision. These crimes include molestation, indecent behavior, criminal malfeasance, and obstruction of justice. While the charged staff members have not yet been adjudicated in a criminal court,6 Parish and Facility officials have not disputed the substance of the charges, and have taken some corrective action to prevent a recurrence of the conduct alleged. The charged staff members have all been removed or have resigned from their posts. A summary of the most serious charges follow.
On June 24, 2009, a Louisiana grand jury returned an eight-count indictment against Supervisor 17, a male Terrebonne correctional supervisor in charge of the night shift, alleging that Supervisor 1 engaged in unlawful lewd behavior and sexual conduct with four detained female youth, ages 15 or 16, between April 29, 2008 and April 28, 2009.
Three weeks later, on July 13, 2009, the grand jury returned a four-count indictment against Staff 1, a male Terrebonne correctional officer, alleging that Staff 1 engaged in unlawful lewd behavior and sexual conduct with two detained female youth, ages 15 and 16.

6

Four of the accused staff are scheduled for trial in February 2011, with the remaining

staff trial dates to occur sometime afterwards.

7

Because individuals who have been charged but not yet adjudicated in a criminal court

are presumed innocent, we are not using the names of the accused staff.

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In addition to the grand jury indictments against Supervisor 1 and Staff 1, the Terrebonne Parish District Attorney brought charges directly (bypassing the grand jury system) against four additional Terrebonne staff related to custodial sexual misconduct at the Facility.8
* * *
Whether or not each of the charged staff are ultimately adjudicated guilty in a criminal court, we examined whether there are adequate systems and structures in place at Terrebonne to minimize the risk of future harm to youth. Helling, 509 U.S. at 33-35. We find, among other things, that youth are not adequately protected from harm by staff. Specifically, we find that staff are not adequately supervised; that use of force policies, procedures, and practices are inadequate; that there are inadequate numbers of direct care staff to ensure the safety of youth; that there are inadequate systems for reporting allegations of child abuse; and that the Facility fails to provide appropriate training on the prevention of custodial sexual misconduct. In each of these areas, we find that Terrebonne substantially departs from generally accepted professional standards in juvenile detention in a manner that endangers youth, and thus violates the youths' constitutional rights to reasonably safe conditions of confinement and freedom from unreasonable bodily restraint. Youngberg, 457 U.S. at 324.9
1. Staff Accountability
Since February 2009, a total of 15 incidents of staff misconduct were investigated at the facility level. The 15 incidents were all investigated and staff were held accountable for their failure to follow required procedures. Staff received letters from the Director that discussed the procedures violated and why they were important to the effort to protect youth from harm and suggested appropriate ways of handling the situation, should it arise again in the future.
While these examples represent efforts on the part of Facility administrators and supervisors to enforce some Facility procedures and hold staff accountable for their failures to follow certain Facility procedures, during the week of our visit, we became aware of several other instances in which staff routinely violate policy and procedure and yet were not held

8

These charges alleged, among other things, that Staff 2 engaged in unlawful custodial

sexual misconduct with a female youth, age 14-15, over a ten month period ending in March

2009; and that Supervisor 2 engaged in unlawful custodial sexual misconduct with a female

youth, age 15-16, over a six month period ending in March 2009. Both Staff 2 and Supervisor 2

are male.

9

Even applying the more lenient adult corrections deliberate indifference standard, we find

that Parish officials disregarded known substantial risks of serious harm to youth at the Facility,

and thus acted with deliberate indifference to those risks in violation of youths' constitutional

rights. See Helling, 509 U.S. at 33-35. For example, at least as early as June 2009, officials

were aware of serious criminal allegations regarding custodial sexual misconduct at the Facility,

but had not taken necessary remedial steps to eliminate this known danger. Similarly, at least as

early as October 2009, officials were aware of the high rate of suicidal behavior at the Facility,

but had not taken necessary remedial steps to ameliorate this known risk.

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accountable for their behavior. While certain supervisors may have been aware of the staffs' failures in these areas, no formal investigation or documentation regarding employee discipline was provided. As discussed throughout this letter, this lack of staff accountability has led to a blatant disregard for the performance of job functions essential to keeping youth reasonably safe in a juvenile detention facility. Youngberg, 457 U.S. at 324. See also, Gates, 501 F.2d at 130810 (holding failure to adequately supervise inmates unconstitutional). These situations included:



Failing to make 15‐minute confinement checks (violates Policy #17.2 "Minor Violations

and Their Resolutions," "During room restriction staff contact will be made every 15

minutes"). Several examples were noted during our videotape verification of Room

Confinement Check Sheets.

 Failing to notify the Facility’s social worker of all youth placed on suicide precautions (violates Policy #8.5 "Mental Health Care Program," "Suicide watch... shall be on a continuous basis until evaluation can be performed by a clinician"). We discovered two situations in March 2010 where two youths were placed on suicide precautions and the social worker was not notified.



Failing to stay on post on the 3rd shift or otherwise leaving a housing unit unsupervised

(violates Policy #15.4 “Shift Assignments” “To ensure proper supervision... juvenile

caseworker positions should be located in or immediately adjacent to juvenile living

areas”). Several youth and staff reported to us that direct care staff members on the 3rd

shift congregate in the common area during the youths' sleeping hours, leaving the

housing units unattended. Further, an incident report from March 11, 2010 revealed that

a staff member assigned to monitor a housing unit left the dorm, and one of the youth

attempted suicide by strangulation. Staff members were alerted to the situation by one of

the other youth housed on the unit.

 During interviews, several staff indicated a blatant disregard for policy. One second shift employee believed it was unnecessary to conduct routine room checks of youth during the night. Another staff admitted to sleeping during the night shift. One second shift supervisor indicated that when staff appear to be sleeping, the supervisor is merely "telling them to walk around in order to wake them up" without instituting any disciplinary action.

Each of these situations represents staff misconduct and failure to follow policy and procedure that could result in serious harm to youth (by youth, by staff, or self‐inflicted). While the Director had taken action against staff members who violated the Use of Force policy and other types of misconduct, the other issues appeared not to have been addressed in any substantive manner. Each of the issues — 15‐minute confinement checks, suicide precautions, and youth supervision — should be part of routine oversight by the Facility’s supervisors. This does not appear to be occurring with either the regularity or the keen eye required to ascertain whether staff are following policy consistently.

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2. Use of Force and Isolation
The duty to protect youth from harm includes efforts to prevent youth from harming each other (i.e., fighting) and also efforts to ensure that, when staff must intervene physically, they do so using means that do not unnecessarily subject youth to pain or injury. Youngberg, 457 U.S. at 324. Attaining either of these objectives requires a facility to have detailed policies and procedures guiding the use of force that are in line with contemporary standards.
In many cases, youth‐on‐youth violence and other out‐of‐control behavior can be prevented with proper behavior management techniques and sound verbal de‐escalation skills. Failing this, staff has a duty to reduce the harm that can occur by intervening with tempered, well‐timed, well‐executed physical restraint. Conditions of confinement at the Facility are unconstitutional because youth are being harmed or are at risk of harm, Terrebonne's policies and procedures substantially depart from generally accepted standards of care, and actual practices suggest that staff do not regularly follow these inadequate policies. Youngberg, 457 U.S. at 324.
a. Policy and Training
The Facility’s Policy #15.3 “Use of Force” emphasizes using non‐physical means to control the situation and, failing that, using only the minimum amount of force necessary to gain control. While this is a solid beginning, the policy lacks several key elements.
Terrebonne's policy does not provide specific training requirements for the use of force, stating only that “staff will be trained in approved methods.” Currently there are no approved methods, indicating that the policy itself is largely aspirational. All staff reported that they had never been trained on specific restraint techniques and were forced to rely on their own judgment or training received in other settings (e.g., military or adult correctional facilities). Not only does this make enforcing Terrebonne's policy difficult, as there are no sanctioned techniques and therefore no techniques that are specifically prohibited, it also leaves staff with very few tools for safely and effectively responding to youth’s aggression or out-of-control behavior. As a result, youth have been injured and the risk to both youth and staff safety is significant.
Further, knowledge about the safe use of chemical agents (oleo capsicum or "OC") was minimal among staff. Some staff were able to recount only basic facts about the use of OC (e.g., to deploy the spray in very short bursts; how to hold the canister), while others could not recall any specific information from the OC training they received. In addition, none of the staff interviewed were well‐versed in proper OC decontamination procedures.
b. Improper and Unnecessary Use of Physical Restraint
Conditions of confinement at Terrebonne are unconstitutional because staff members use force that is either unnecessary or poorly executed. Generally accepted professional standards in a juvenile detention facility require that only appropriate levels of force are used, and only when a youth’s behavior poses an imminent risk of harm to himself or others, or only when necessary to restore essential institutional security. See Youngberg, 457 U.S. at 324; Hudson v. McMillian, 503 U.S. at 6-9 (1992); Gomez v. Chandler, 163 F.3d 921 (5th Cir. 1999). Examples of the inappropriate or unnecessary use of force at Terrebonne include the following:

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 On March 5, 2010, a youth went into the bathroom on the housing unit without permission. The youth complied with the staff’s directive to come out of the bathroom, but balked at the staff’s insistence that he be placed in isolation for this minor rule violation. When staff responded to the call for assistance to transport the youth to the isolation unit, the youth then became aggressive, resulting in a physical restraint, a botched mechanical restraint (staff could not remove the handcuffs), the use of OC spray, and two staff injuries. Given that the youth complied with the initial directive to leave the bathroom and (at that point) posed no threat to other youth or staff, the entire restraint and ensuing injuries could have been avoided.

 On March 4, 2010, a youth reportedly cursed at staff and then went to his bunk. Staff reported that he “took him out of bed” to transport him to the isolation unit for this minor rule violation. Video footage of this incident showed a single male staff person lifting a youth (who was simply lying on his bed, not threatening staff or other youth) off his bed and struggling with him as he carried him off the housing unit. Neither the written incident report nor the video footage suggested any reason why this youth’s behavior could not have been handled on the unit, without physical intervention. The restraint was both unnecessary and very poorly executed. The staff member involved received a verbal warning for his involvement in this incident.



On March 7, 2010, a youth approached another youth in the housing unit and began to

punch him in the head and body. Two staff members pulled the two youth apart from

behind. One staff member pulled one of the youth to another area of the unit, but did not

secure him in any way (e.g., using an escort technique or other method to control the

youth’s movement until he was calm). That youth broke away, ran across the dorm and

jumped over a table, and began to assault the other youth again. The staff members’

physical intervention was so poorly executed that it provided an opportunity for another

assault to occur.

c. Unnecessary Use of Chemical Agents and Restraint Chair

In determining whether a physical intervention may be unconstitutional, it is "proper to evaluate the need for application of force, the relationship between that need and the amount of force used, the threat 'reasonably perceived by the responsible officials,' and 'any efforts made to temper the severity of a forceful response.'" Hudson v. McMillian, 503 U.S. 1, 6-9 (1992). Conditions of confinement at Terrebonne violate youths' constitutional rights because the use of severe interventions at the Facility, such as chemical agents and restraint devices, are often not needed, when no threatening behavior is apparent, and before reasonable efforts to temper the precipitating behavior have been attempted.

Terrebonne policy permits the use of both OC spray and the restraint chair only in extraordinary circumstances. After these items are deployed, generally accepted professional standards dictate that nursing staff must assess the youth to determine whether any injuries or complications arise as a result of their use. Nonetheless, we identified a number of examples where staff used these types of force on youth who were not particularly threatening, and sometimes even compliant, or where nursing staff were not consulted after their use, both

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violations of youths' constitutional rights. Hudson v. McMillian, 503 U.S. 1; Youngberg, 457 U.S. at 324. Examples include:
 On March 14, 2010, a female youth was booked into the Facility. The youth indicated that she did not want to take a shower but was very calm during this refusal, walking slowly with her arms wrapped around her torso. Staff tried to persuade her for a couple minutes, and then wheeled the restraint chair over to her. The youth became very distressed as the staff forced her into the chair; crying and thrashing her head about as the staff strapped her in. She remained in the restraint chair for 20 minutes. Although the Director of the Facility initially stated that this was a “good example of the use of the restraint chair,” when questioned during the viewing of the videotape, he agreed that the youth did not pose a threat to herself or anyone else at the time. The videotape clearly shows that the restraint chair caused distress and was completely unnecessary in the circumstance in which it was used.
 On September 1, 2009, a male youth is seen on videotape hitting his head on a table one time. Staff walked over to him and engaged the youth in a short discussion. The youth got up from the table and walked to the unit door, on his own and without any threatening gestures or body language. As the restraint chair was brought toward him (it is unclear in the documentation why staff felt the restraint chair was necessary), the youth’s behavior escalated and he began to resist staff’s efforts to put him in the chair. The chair itself was off camera, and the restraint chair documentation indicates only that the youth was still in the chair at the first 15‐minute check. The exact time of release is not noted. This is another example of a fully compliant youth who was placed in a mechanical restraint device that caused the youth significant distress. If used at all, the restraint chair should be reserved only for out‐of‐control youth who pose an immediate danger to themselves or others.
 On January 9, 2010, an incident report describes a youth refusing to comply with a directive to proceed to the isolation unit. The youth was seated at a table at the time. Staff did not attempt physical restraint nor did staff call for assistance. Given the youth’s history of threatening staff verbally, the staff “thought the safest way for everyone would be to pepper spray the youth.” The first burst of spray hit the youth on the side of the face and the youth “retreated,” only to be hit with a second burst of spray on the neck. After being sprayed twice, the youth then became assaultive toward staff. Not only was OC spray used as a “first” rather than a “last resort,” but it was used on a youth who was merely non‐compliant and not physically threatening or aggressive toward staff. This youth did not receive medical attention following the use of OC spray as “no medical personnel were present.” Staff was given a written warning and additional training for this incident, although the failure to provide prompt medical attention was not addressed.
 On February 2, 2010, a youth who assaulted another youth and became physically assaultive toward staff was sprayed with OC spray. The Chemical Agent Form indicates “No medical attention was needed.” Failure to provide medical attention after such exposure to OC is a blatant departure from generally accepted professional standards.

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These examples illustrate that Terrebonne's policy and practices around these issues are inadequate in terms of their ability to assure that staff use these tools only when necessary, or that youth receive medical attention following their use. Rather than protecting youth from harm, staff may in fact cause harm with their uncontrolled, poor execution and lack of medical attention following the incident.
d. Use of Excessive or Unnecessary Isolation
Terrebonne violates youths' constitutional rights by subjecting them to harmful and unnecessary restraint in isolation rooms. In addition, the amount of youth isolation at Terrebonne is excessive and disproportionate to the underlying disciplinary offense committed by the youth. Isolation in juvenile facilities should only be used when the youth poses an imminent danger to staff or other youth, or when less severe interventions have failed.10 Morgan v. Sproat, 432 F. Supp. at 1132. Youth at Terrebonne are denied many of these basic protections.
Youth at the Facility are isolated at rates significantly higher than nationally reported field averages. Specifically, the number of room confinements and the average number of hours spent in isolation are approximately twice the Performance-based Standards ("PbS")11 national field average ("NFA"), and the maximum time youth spend in confinement is approximately four times the PbS NFA.12
10 Examples of less severe interventions may include, among other things, a loss of certain privileges, a reduction in behavior management levels, or a restriction from participating in an optional activity. 11 Performance-based Standards for Youth Correction and Detention Facilities is a selfimprovement and accountability system used in 31 states and the District of Columbia to better the quality of life for youths in custody. PbS gives agencies the tools to collect data, analyze the results to design improvements, implement change, and measure effectiveness with subsequent data collections from within the facility and against other participating facilities. See http://www.pbstandards.org. 12 We note that, while the PbS national field average is neither a representative nor a random sample, it is the best available database for external comparisons related to the occurrence of critical behaviors.

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Table 1. Estimated TPJDC Rates of Specifi c Incidents for October 2009 as Compared with PbS Field Averages from the October 2009 National Data Collection period

Incident Category
Suicidal Behavior Battery and Fighting Pepper Spray Isolations Avg. Isolation Hours – Max. Avg. Isolation Hours – Med.

Total Number
9 6 3 76 3240 1620

Terrebonne Rate
0.627 0.418 0.209 5.299 42.63 21.32

PbS National Field
Average 0.119 0.350 0.105 2.84 11.44 11.44

While isolation in certain circumstances may clearly be warranted, use of isolation at the Facility is sometimes unnecessary. The following examples reflect the common practice at Terrebonne:



On February 27, 2010, a female youth received an incident report for writing

notes to male residents and for becoming rude and argumentative when presented

with the infraction. According to the Facility records, she received 35 hours of

isolation or room confinement for behaviors that could have been handled with a

time out or some type of program restriction.



On February 27, 2010, another youth received 31 hours of isolation for refusal to

stop talking during sleeping hours in the boys' dorm. Again, this is an example

where isolation is used although no lesser interventions had been attempted and

no security threat was present.

Use of isolation for mere rule enforcement is unnecessary and inappropriate. In addition, the duration of such sanctions is far in excess of acceptable practice for such minor violations, and violates youths' constitutional rights.

3. Staffing

Some of the above described problems appear to have resulted from inadequate staffing. For example, this serious deficiency in staffing places youth at risk of harm because of staff fatigue, reduced accountability, overreliance on seclusion, and inadequate youth supervision. Terrebonne claims to maintain a 1:8 staffing ratio during waking hours.13 However, we found

13 Generally accepted professional standards in a juvenile detention center require a direct supervision ratio of a minimum of 1:8 during waking hours, and a minimum of 1:16 during sleeping hours. More staff-rich ratios may be required depending on the unique features and characteristics of the facility and youth.

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that, typically, the direct supervision ratios are much lower and fall far below generally accepted professional standards. This deficiency contributes to violations of youths' constitutional rights to reasonably safe conditions of confinement. Youngberg, 457 U.S. at 324.
Terrebonne uses an unusual staff schedule. Four discreet teams of staff exist, and each team works a designated 12-hour shift on designated days, a 4-3 rotation with some built-in overtime. In other words, there are two different teams that cover the first shift (6:00 a.m. – 6:00 p.m.) and two different teams that cover the second shift (6:00 p.m. – 6:00 a.m.). Within each team, there is a shift supervisor and an assistant shift supervisor in addition to a standard rotation of post assignments, even though there are no official post designations. Staff rotate through various unofficial posts at three-hour intervals, which results in only one staff member assigned to the direct and continuous supervision of a living unit for a three-hour period of time while the additional staff perform other support duties in the "general vicinity." These "general vicinity" staff do not provide direct and continuous supervision but are available on short notice to supply back-up and support to the single staff member assigned to direct and continuous supervision. These "general vicinity" staff are counted into the staffing ratio by the Facility. This process represents a miscalculation of the ratio and a misrepresentation of the level of supervision.
4. Child Abuse Reporting
Generally accepted professional standards and Louisiana State Law require any caretaker who knows or suspects that an incident of alleged child abuse14 has occurred must immediately initiate or cause to be initiated a report to the local law enforcement or social services agency.15 This is so, whether or not the responsible individual believes the allegations to be credible. In other words, self-screening of abuse allegations undermines the important safeguard principles the standards are designed to maintain.
Because Terrebonne's Child Abuse Reporting policy provides the Director with latitude in determining the veracity of allegations prior to reporting to law enforcement and child welfare, youths' constitutional rights are violated. See Youngberg, 457 U.S. at 324. The policy states that the Director “shall promptly determine the facts surrounding the incident.” In a small number of cases, this latitude has resulted in the Director’s review and investigation of incidents of mistreatment alleged via the grievance system, when these allegations should also have been reported to law enforcement and child welfare. Failing to report allegations of abuse to an appropriate external agency is contrary to accepted professional standards (see PREA IN‐2) and
14 Under Louisiana law, "child abuse" includes, among other things, "[t]he infliction, attempted infliction, or, as a result of inadequate supervision, the allowance of the infliction or attempted infliction of physical or mental injury upon a child... which seriously endanger the physical, mental, or emotional health and safety of a child...". La. Child. Code Ann. art. 603(1) (2010).
15 See La. Child. Code Ann. art. 610 (2010). In addition, proposed Prison Rape Elimination Commission Standards for the Prevention, Detection, Response, and Monitoring of Sexual Abuse in Juvenile Facilities ("PREA") require that "investigations of abuse are prompt, thorough, objective and conducted by individuals who have specialized training in abuse involving young victims." PREA IN-2 (emphasis added).

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is also a violation of State law. Allegations that were not reported to law enforcement are summarized below:

 On December 28, 2009, a youth alleged that staff “slung him across the dorm... slammed him into the wall... dragged him by his handcuffs and threw him into the door.” The Director conducted an administrative investigation concluding that the staff had not violated Facility policies.

 On March 8, 2010, a youth alleged that he witnessed one staff choking another youth and another staff dragging a third youth to the isolation unit. While the reporting youth withdrew his compliant, the Director continued to administratively investigate the incident, finding the allegations to be unsubstantiated.



During our interviews, a youth told us about an incident that occurred the day before in

which he was reportedly “choked” by staff during a restraint. The youth had visible

scratches on his neck. When we brought this incident to the attention of the Director, he

indicated that he was already aware of it and had sent the accused staff home pending the

outcome of an administrative investigation.

The Facility Director should have reported each of these occurrences to the law enforcement and child welfare agencies so that they could make an independent determination about whether the facts in each case warranted an investigation. The three investigatory bodies serve different purposes: 1) law enforcement determines whether a criminal violation occurred; 2) child welfare determines whether abuse or neglect occurred according to child welfare standards; and 3) the Facility determines whether policies and procedures were violated. Each of these entities must be informed of all allegations of abuse to ensure that all three inquiries are pursued. The Facility Director should never screen out an allegation or otherwise determine that it should not be reported to law enforcement and child welfare, no matter the findings of the administrative investigation. This is because law enforcement and social services agencies have specialized training in investigations of this type, where many internal facility investigators do not. Failure to make the reports improperly removes the oversight of external agencies from their shared duty to protect youth from harm.

5. Training on Prevention of Sexual Misconduct

While training on certain subjects at Terrebonne is adequate, one serious omission is staff training regarding custodial sexual misconduct. In the year since the discovery of allegations of serious and pervasive sexual misconduct at the Facility, Terrebonne has failed to develop a curriculum and mandate that all staff receive training in the prevention of this insidious danger. Given the apparent history of problems at the Facility, this omission is a substantial departure from generally accepted professional standards and in violation of the law. Youngberg, 457 U.S. at 324.
B. The Facility fails to adequately protect youth from self harm.

In addition to failing to protect youth from harm by staff, Terrebonne fails to adequately protect youth from self harm, and therefore violates youths' constitutional rights. Youngberg,

- 16 -
457 U.S. 307; Silva, 32 F.3d 566. Generally, youth in juvenile justice systems are at increased risk of suicide, but available statistics for the Facility reveal that youth confined at Terrebonne may be even more prone to engage in self harming behavior. For example, in October 2009, the rate of suicidal behavior at the Facility was more than five times the National Field Average. See Table 1.
Shockingly, we found that room checks for youth being held in isolation were routinely missed, and that staff often falsified the documentation of required room checks. Because youth held in isolation are known to be at heightened risk of suicide, this practice subjects youth at the Facility to serious risk of harm in violation of youths' constitutional rights. Helling, 509 U.S. at 25; Silva, 32 F.3d at 566. See also, Lewis v. Parish of Terrebonne, 894 F.2d 142 (5th Cir. 1990) (stating "one need not find a 'goose case' to imbue a warden at a jail with a constitutional duty to protect a prisoner prone to suicide from self destruction."). Also, we identified significant deficiencies in each of the core components of an adequate suicide prevention program. Taken together, these deficiencies place youth at serious risk of future harm. In each of these areas, we find that Terrebonne substantially departs from generally accepted professional standards in juvenile detention, and thus violate the youths' constitutional right to reasonably safe conditions of confinement. See Youngberg, 457 U.S. at 324. Each of the core components and the Facility's deficiencies in each area are described below.
1. Supervision
We reviewed the incident reports and observation forms for 17 youth placed on suicide precautions between September 2009 and March 2010. The observation forms, called “Confinement Check Forms,” nearly always indicate that staff checked the safety and welfare of youth at exact 15‐minute intervals. Not only is this level of precision impossible to achieve, it is counter to the best interest of the youth. The generally accepted practice is for youth on close observation to be checked at random (unpredictable) intervals, not to exceed 15 minutes. Further, we attempted to verify the data presented on the observation forms using videotaped footage of the overnight shifts on the isolation unit. In February 2010, large proportions of safety and welfare checks were determined to have been fraudulently recorded (i.e., the staff indicated a check was conducted on the observation form, but the videotaped footage revealed they did not actually do so). The following examples are illustrative of this extremely dangerous failure:
 A male detainee received a 48-hour confinement from February 21 through February 22, 2010. On the evening of February 21, the time under review ran from 2215 hours through 0530 hours or 7 hours and 15 minutes. This equates to 30 room checks. The log contains 30 entries by the staff, including the staff member’s initials and the numerical behavior identifier, indicating that 30 room checks were made. However, the video shows only 11 room checks were actually performed.
 On the following evening the same detainee was confined from 2200 hours through 05:30 hours or 7.5 hours. This equates to 31 room checks. The log shows 26 entries by the staff members, including the staff member’s initials and the numerical behavior identifier, thereby acknowledging that five room checks were missed. But the video shows only 19 room checks. Additionally, the 48-hour confinement extended over a

- 17 -
Monday and Tuesday, but there is no documentation that the detainee received any schooling or recreation.
 A detainee received a 32-hour room confinement beginning on February 27, 2010. For the evening of February 27, the time under review was from 2200 hours to 0530 hours or 7.5 hours. This equates to 31 room checks. Thirty-one room checks were entered on the form, including the staff member’s initials and the numerical behavior identifier; but the video shows that only eight were made.
 On the following evening the same detainee was under review from 2200 hours through 0545 hours or 7 hours and 45 minutes. This equates to 32 room checks. Thirty-two room checks appear on the log, including the staff member’s initials and the numerical behavior identifier; but the video shows again that only eight room checks were made.
 A female detainee received a 35-hour room confinement beginning on February 27, 2010. On the evening of February 27, the time under review ran from 2200 hours through 0600 hours this equates to 33 room checks. Thirty-three room checks are indicated on the log, including the staff member’s initials and the numerical behavior identifier; but the video shows that only four room checks were made.
This pattern of overnight supervision creates a severe risk of harm to youth in the facility. The dangerousness of this situation cannot be overemphasized. Anytime a youth is locked in a room alone, the risk of self‐harm increases. The combination of a youth assessed at higher risk of self‐harm, isolation, and staff negligence in performing safety checks is a serious risk to youth safety.16
Additionally, Terrebonne has a single level of suicide precautions — "close observation" where youth are to be monitored at 15 minute intervals. Youth who are actively suicidal, either threatening or engaging in suicidal behavior, are routinely transported to the local emergency room for an evaluation and possible admission to a psychiatric hospital. Both documentation and reports from staff indicated that these high‐risk youth are indeed transferred to the hospital for evaluation. However, generally accepted professional standards require that, pending transfer, these youth should be placed under constant observation by a dedicated staff member with no other responsibilities at the time (i.e., one-on-one supervision). This does not occur at Terrebonne, in violation of youths' constitutional rights to reasonably safe conditions. Youngberg, 457 U.S. at 324. Instead, youth awaiting transfer are only monitored at the 15‐minute intervals prescribed for youth at much lower‐risk of self‐harm. This is an extremely dangerous practice given the youth’s demonstrated active suicidal behavior.
16 As indicated previously, Parish Counsel forwarded us a list of measures the Facility has purportedly taken to ensure that, among other things, room checks are being performed as required by policy. A number of these reported measures should assist the Facility in monitoring staff in performing these duties, including plans to purchase an electronic tour guard system, and the periodic verification of overnight room checks with Facility digital video reviews. While these proactive measures are commendable, we are not in a position to confirm the adequacy of implementation of this corrective action.

2. Training

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Adequate suicide prevention training standards require initial training for new staff that includes the instruction in environmental risk factors for suicide, individually predisposing factors, high‐risk periods for incarcerated youth, warning signs and symptoms, the facility’s suicide prevention procedures, liability issues, and a discussion of recent suicide attempts at the facility. In addition, the program should include a two‐hour annual refresher training with a review of risk factors, warning signs and symptoms, and policy changes. All staff should also be trained in the use of emergency equipment (e.g., the rescue tool).
In late 2009, the Facility developed a training curriculum for suicide prevention. The curriculum content appears adequate. However, rather than the prescribed eight-hour training, the training session was only five hours of actual instruction time. Of the 52 direct care staff at the Facility, documentation indicated that 83% participated in the training. Several staff reported that training in this area was not considered to be mandatory and that staff who did not attend were not held accountable. Make‐up sessions for those staff who did not attend had not been scheduled, nor had provisions been made for teachers and other non‐direct care staff to attend the training. While most of the staff believed the Facility owned a rescue tool, none of the staff knew where it was or had been trained in how to use it. These inadequacies in the training for direct care and other Facility staff (e.g., teachers) is particularly concerning because most of a youth’s self‐harm behavior will happen in their presence, rather than in the presence of mental health staff who may have greater expertise in this area.
3. Intake Screening

Terrebonne's intake screening questionnaire asks only if the youth currently feels like hurting himself or herself. This single question is inadequate to the task of identifying youth at elevated risk of self‐harm and is not aligned with contemporary standards. The screening should also include questions about past suicidal behavior, prior mental health treatment, recent significant losses, family/friend’s history of suicide, and whether the youth demonstrated any risk of suicide during his or her previous stays at the Facility. Further, at Terrebonne, intake staff sometimes waits for the Facility’s social worker to become available so that she can perform the screening, which is contrary to the standard endorsing immediate screening upon admission. Finally, the intake screening should be conducted by an individual who is trained to ask these questions competently. We learned that the Facility had just recently begun training intake staff on appropriate youth screening.

4.

Communication

The strength of a facility’s suicide prevention program rests on the quality of communication between direct care staff and mental health staff (who must be engaged in treatment to mitigate the youth’s risk of self‐harm). Communication between the direct care staff and mental health staff at Terrebonne is fragmented, at best. While a list of youth on suicide precautions is created each day, it is not broadly distributed and some of the direct care staff interviewed indicated that they were often unaware of which youth were on precautions. Further, we learned that twice during March 2010, youth were placed on suicide precautions by direct care staff and the social worker was not notified. We were informed that the direct care

- 19 -
staffs' experience with the previous social worker, who was unresponsive to most staff requests, led them to rely on the direct care supervisors for most decisions regarding mental health. Reportedly, this has been a difficult cycle to interrupt. Finally, there is no mechanism for the mental health staff to communicate with direct care staff regarding the source of potentially suicidal youth’s stress, the specific risks posed, or coping mechanisms or activities that may help to mitigate the youth’s risk of harm. Given that youth spend most of their time with direct care staff at the Facility, effective communication is vital if there is to be a coherent strategy for supporting youth during a time of crisis. Overall, the mechanisms for communication between direct care and mental health care staff at the Facility do not conform to contemporary standards of care.
5. Assessment
A youth’s risk of self‐harm is not static — it will increase and decrease depending on a range of influences (e.g., contact with family, outcomes in court, environmental stressors, treatment by mental health care staff, interaction with peers and direct care staff, etc.). Accordingly, the youth’s need for precautions needs to be assessed frequently so that the level of supervision can be adjusted as necessary. Rather than using a structured assessment process on a daily basis, the social worker did not have a set schedule for follow‐up with youth on suicide precautions. This was confirmed in our review of the mental health care files of five youth who had been on suicide precautions in early 2010. While detailed progress notes were kept on all contacts with youth, these contacts were not at the frequency (i.e., daily) prescribed by contemporary standards.
In large part, the lack of a clear and consistent procedure for on‐going assessment of suicide risk can be attributed to the fragmentation of the mental health service delivery system at the Facility. The Facility's lead social worker, another part‐time social worker, a counselor, and a variety of community‐based counselors all provide mental health care services to Terrebonne youth. While the number of available counselors is encouraging, the fact that they do not communicate regularly, share information on clients, or have access to each other’s progress notes means that the service delivery system is disjointed and a strong potential exists for a youth’s mental health needs to fall through the cracks.
6. Housing
In early January 2010, the Facility began to maintain youth on suicide precautions in the general population, reassigning their bunks to ensure the best camera angle possible. But, youth on suicide precautions at the Facility are sometimes placed in isolation on the Delta dorm, in the individual cells on the housing units, or in the cells adjacent to the medical unit. While these assignments may be convenient for the staff who are responsible for supervising the youth, isolating youth at risk of self‐harm can increase their sense of alienation and detachment from programming, and thus may actually increase their risk of self‐harm rather than reduce it. When legitimate security concerns permit, facilities should house youth on suicide precautions in the general population, where their access to programming is more certain and they are able to maximize their interactions with staff and peers, which is likely to reduce the risk of self‐harm. Several staff explained that the decision to house youth at risk of self‐harm in the isolation unit was because of the availability of video surveillance. While video surveillance can be a good

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supplement to staff supervision (but should never replace it), the extent to which staff actually monitor the video feed is questionable whether the youth is in the dorm or an isolation cell. Several of the isolation rooms are literally covered in graffiti made with writing implements or etched into the paint with sharp objects. In addition to the obvious concern about youth’s access to sharp objects, the time required to complete the graffiti suggests that staff may not be monitoring the youth’s behavior in the isolation rooms with any regularity.
More regularly housing youth on suicide precautions in the general population will be difficult to execute properly given the Facility’s current staffing pattern. A single staff person is often responsible for supervising up to 20 youth on a housing unit. Without an improved ratio of staff to youth, maintaining youth at risk of self‐harm on the housing units is impractical, if not dangerous.
7. Lethality Reviews
Following a serious suicide attempt17 or a completed suicide, generally accepted professional standards require facilities to convene a multidisciplinary team to review the circumstances surrounding the incident to identify the conditions that gave rise to it. The discussion should include a review of the circumstances, facility procedures relevant to the incident, training issues, mental health services received by the youth, and recommendations for changes to Facility policy and procedure that could reduce the likelihood of a similar incident in the future. It is particularly concerning that, at Terrebonne, no such review process exists.
* * *
Overall, Terrebonne's suicide prevention practices are far outside of contemporary standards for adequately protecting youth from self‐harm. The fragmentation between and among direct care and mental health care staff, the failure to maintain close supervision of youth with demonstrated risks of self harm, the failure to conduct required room checks for youth at heightened risk of self harm (i.e., isolated youth), and the lack of any process to review the circumstances surrounding incidents of self‐harm, despite their recent uptick, creates a very dangerous situation for the Facility, its staff, and the youth in its care, in violation of youths' constitutional rights. Youngberg, 457 U.S. at 307; Silva, 32 F.3d at 566.
C. The Facility fails to provide an appropriate housing classification system.
There are significant occurrences of youth violence at Terrebonne. For example, the most recent comparative statistics indicate that youth-on-youth assaults are approximately 20% higher than the National Field Average. See Table 1. Terrebonne lacks certain fundamental safeguards to adequately protect youth from harm by other youth. This violates youths' constitution rights to reasonably safe conditions of confinement. Youngberg, 457 U.S. 307. See also, Farmer v. Brennan, 511 U.S. at 825. Specifically, one key strategy for protecting youth from harm is to identify those at highest risk of causing harm to other youth and supervising
17 We identified two incidents in February 2010 where youth engaged in serious suicide attempts and/or were considered to be at such heightened risk of suicide that protective hospitalization was required.

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them intensively to mitigate this risk. Accurately identifying high‐risk youth requires an objective process that is consistently implemented at admission. Once identified, high‐risk youth must be supervised more closely and supported with other behavior management techniques to either limit their access to potential victims or to help them to develop the skills they need to control their aggression. Adequate standards of care require a structured classification process to guide housing and programming decisions. Terrebonne's lack of an adequate housing classification system substantially departs from generally accepted professional standards in juvenile detention, and thus violates the youths' constitutional right to reasonably safe conditions of confinement. Youngberg, 457 U.S. 307
Terrebonne's policy requires each youth to be “classified according to age, sex, delinquent orientation, level of risk and program needs” and that youth with special needs must receive “special consideration.” However, the policy provides no procedures, tools or instruments toward this end. Once the youth is classified, the policy offers no guidance as to what a classification to a certain category would mean in terms of the youths’ housing or supervision. Again, this policy appears to be aspirational but has no bearing on the actual practices at the Facility. The Facility Director and various supervisors indicated that they currently make efforts to place more aggressive male youth in a housing unit separate from less aggressive males, but these determinations were entirely subjective and based on either recollections from a youths’ previous admissions or his behavior during the current incarceration. Bed assignments are made at the discretion of unit supervisors. Aside from grouping more aggressive youth together, no additional staffing or programming enhancements were in place to address the heightened risk.
While both the policy and the current effort to segregate more violent youth from less violent youth indicate the Facility is aware of the need for strategic housing decisions, the procedures for classifying youth are well outside contemporary standards of care. As noted above, the Facility’s policy implies a structured classification process, but it is entirely subjective, unsupported by procedures and tools to assess youths’ risk, silent on the process for making subsequent unit and bed assignments, and lacks enhancements to supervision and programming to mitigate the risks posed by highly aggressive youth. As a result, the classification process at the Facility is ineffective to the task of protecting youth from harm.
D. The Facility fails to adequately report incidents and collect key data.
The purpose of a facility incident reporting process is to have a full and complete record of what occurs in the facility so that administrators can identify the various conditions that create the opportunity for incidents to occur, can monitor staff responses, can identify training needs, and can develop prevention strategies that could make each type of incident less likely to occur in the future. The overall process for incident reporting at Terrebonne is far below generally accepted practices creating risks of undetected or unidentified harm, in violation of youths' constitutional rights. See Youngberg, 457 U.S. at 307; Helling, 509 U.S. at 25. An adequate incident reporting and data collection system should be implemented at Terrebonne to ensure that remedial measures are appropriately implemented and sustainable.
Terrebonne does not have a stand‐alone incident reporting policy; rather, procedures for reporting incidents are embedded within a much broader policy. While the section of the policy

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pertaining to incident reporting includes a comprehensive list of the types of incidents that must be reported, it provides no guidance on the required content of the reports or any procedures for administrative review.
If incident reports are to be useful in the effort of preventing institutional misconduct and protecting youth from harm, they must also provide a complete account of the event. Only when these details are known can the underlying causes of youths’ misbehavior be addressed. Further, improving the quality of staff responses to misconduct requires an understanding of the precise way in which staff handled the incident. We reviewed approximately 150 incident reports generated at the Facility in early 2010. Key omissions across these reports include: 1) the number of youth and staff present at the time of the incident, and the location of individuals present; 2) activity that occurred just prior to the incident; 3) a thorough description of the incident; 4) specificity as to how staff responded and intervened; and 5) witness statements from all staff and youth present.
Perhaps as a result of these inadequacies in the content of the incident reports, aggregate data on the types of incidents occurring at the Facility are difficult to reconcile with the incident reports themselves. Incidents may be variously marked as “horseplay,” “pushing,” “battery,” or “fighting” but the distinctions in the written narratives are unclear. Terrebonne's leadership discussed the difficulty experienced in responding to our document request because many of the incident reports were either mislabeled or did not clearly specify the type of incident that occurred.
E. The Facility fails to provide adequate quality assurance systems.
Terrebonne does not currently have any structured process for quality assurance. In fact, Facility leadership indicated that the assimilation of documents in preparation for our visit marked the first time that Facility staff had begun to look at the patterns that exist across the various documents needed to illustrate the Facility’s practices. While individual incidents and situations are reviewed by the Facility’s management team on a daily basis, the historical lack of oversight of the program, its various components and how they intersect and, at times, interfere with each other have contributed to an environment that does not adequately protect youth from harm from other youth, staff, or themselves. An adequate quality assurance program should be implemented at Terrebonne to ensure that remedial measures are appropriately implemented and sustainable.
* * *
The Parish should expeditiously implement the following remedial measures to correct the constitutional deprivations outlined above. The remedial measures below are consistent with generally accepted juvenile corrections standards.

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IV. REMEDIAL MEASURES
A. Protection from Harm by Staff
1. Adopt a zero-tolerance policy for abuse of youths by staff and other youths, including sexual abuse.
2. Review all incident reports at least three times per week to determine whether staff may be violating policies, procedures, and rules, and document the review.
3. Review all youth grievances at least three times per week to determine whether staff may be violating policies, procedures, and rules, and document the review.
4. Conduct routine and unpredictable audits of video recordings and surprise in-person visits to the Facility during the overnight shift and on weekends to determine whether staff may be violating policies, procedures and rules.
5. Promptly investigate any incident where staff are suspected of possible violations of policies, procedures, or rules.
6. Impose and document appropriate counseling, reprimands, training, or sanctions on staff found to have violated policies, procedures, or rules.
7. Develop and implement an age-appropriate use of force curriculum (including, among other things, de-escalation techniques and an appropriate continuum of interventions short of physical force).
8. Provide a minimum of eight hours of competency-based training for all staff on the approved use of force curriculum (including use of physical force, physical restraints, mechanical restraints, any fixed-restraints, and any chemical agents), provide new employee training, and provide two hours of annual refresher training.
9. Prohibit the use of fixed-restraints and chemical agents, except in extraordinary circumstances (e.g., when less severe interventions are unsuccessful or unavailable).
10. Adopt an adequate continuum of disciplinary sanctions, restricting the use of isolation to situations where a youth poses an imminent threat to themselves or others, or when less severe disciplinary measures have proven ineffective.
11. Prohibit the use of disciplinary isolation longer than 72 hours, except in extraordinary circumstances and with the express authorization of the Facility Director. Thorough documented justification shall be maintained for any use of isolation longer than 72 hours.

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12. Ensure that direct care staffing ratios are maintained at a minimum of 1:8 during waking hours and 1:16 during sleeping hours, and that staff are in the same room as the youth, awake, and alert.
13. Ensure that all youth allegations or staff reports of child abuse are referred to the appropriate external agency immediately, and no later than the end of the employee's shift.
14. Provide a minimum of two hours of competency-based training for all staff on the identification and prevention of custodial sexual misconduct or other sexual misconduct, and provide new employee and annual refresher training.
B. Protection for Self-Harm
1. Provide a minimum of eight hours of competency-based suicide prevention training for all staff which includes: the environmental risk factors; individually predisposing factors; high‐risk periods; warning signs and symptoms, the Facility’s suicide prevention procedures; liability issues; a discussion of recent suicide attempts at the Facility; the use of a rescue tool. This should be part of new employee training, and there shall be four hours of annual refresher training. Staff shall be certified in CPR and first aid.
2. Revise the intake screening questionnaire to include, among other things, whether the youth feels like hurting himself or herself, any past suicidal behavior (in a facility or otherwise), any prior mental health care treatment, any recent significant losses, family or friends' history of suicide.
3. Require direct care staff to immediately notify mental health care staff any time a youth is placed on suicide precautions.
4. Notify all direct care staff on a daily basis of all youth on suicide watch precautions.
5. Provide a mechanism where mental health care staff provide critical information about youth on suicide precautions to direct care staff regarding known sources of stress to potentially suicidal youth, the specific risks posed, or coping mechanisms or activities that may help to mitigate the risk of harm.

- 25 -
6. Ensure that youth on suicide precautions are re-assessed at least three times per week by the mental health care staff to determine whether the level of supervision should be raised or lowered.
7. Ensure that all mental health care staff within the Facility have access to critical information for youth on suicide precaution (e.g., progress notes from all treating clinicians).
8. Prohibit the routine use of isolation rooms for youth on suicide precautions. Ensure that isolation rooms are only used when legitimate security concerns exist and are documented.
9. Ensure that youth who have been identified with a high risk of suicide (e.g., selected for transfer to a hospital) receive one-on-one supervision by a direct care staff with no other duties until the youth is transferred out of the Facility.
10. Ensure that the safety and welfare of all youth in isolation is verified by staff at unpredictable intervals not to exceed 15 minutes, and that each check is accurately documented.
11. Ensure that all serious suicide attempts are reviewed by a multidisciplinary team to review all relevant facts and circumstances surrounding the incident, and implement any appropriate remedial action.
C. Housing Classification
1. Adopt and implement an adequate objective housing classification instrument and system that determines a youths’ risk of engaging in serious institutional misconduct (e.g., assaultive behavior). The scored factors should include, among other things, a youth's prior institutional misconduct. Administrative overrides of risk classification should not exceed 20%.
2. Ensure that youth are classified to an appropriate housing unit and bed within 24 hours of intake, and that high-risk youth are housed separately from low-risk youth.
3. Ensure that youth who commit serious institutional misconduct after their initial classification are reassessed within 72 hours.
D. Incident Reporting and Data Collection
Ensure that incident reports contain all material information including, at a minimum, a) the number of youth and staff present at the time of the incident, and the location of individuals present; b) activity that occurred just prior to the incident; c) a thorough description of the incident; d) specificity as to how staff

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responded and intervened; and e) witness statements from all staff and youth present.

E. Quality Assurance

Develop and implement an effective quality assurance program to ensure that policies, procedures, and practices at the Facility are being followed, and whether policies require improvement or updating. The program should: a) create standards that reflect current facility policies; b) establish a process for auditing facility practices that includes document review, interviews with youth and staff, and observation of operational procedures and programs; c) draft a written report on the level of compliance with each quality assurance standard; and d) create corrective action plans to address the deficits noted by the quality assurance audits.

* * *

Please note that this letter is a public document. It will be posted on the Civil Rights Division’s website. While we will provide a copy of this letter to any individual or entity upon request, as a matter of courtesy, we will not post the letter on the Civil Rights Division’s website until five calendar days from the date of this letter.

Thank you for your cooperation and assistance with this investigation. We hope that these recommendations will be received in the spirit of assisting in our mutual goal of ensuring the safety and security of youth in the Terrebonne Parish Juvenile Detention Center. We look forward to working with you to negotiate a resolution of the deficiencies described in this letter.

If you have any questions regarding this letter, please call Jonathan M. Smith, Chief of the Civil Rights Division’s Special Litigation Section at (202) 514-6255.

Sincerely,

s/ Thomas E. Perez

Thomas E. Perez Assistant Attorney General

cc: Courtney Alcock, Esquire Counsel for Terrebonne Parish

Mr. Jason Hutchinson

Facility

Director

Terrebonne Parish Juvenile Detention Center

Jim Letten, Esquire United States Attorney for the Eastern District of Louisiana

 
 Case: 2:11-cv-02484 As of: 11/20/2014 11:25 AM CST 1 of 2
U. S. District Court Eastern District of Louisiana (New Orleans) CIVIL DOCKET FOR CASE #: 2:11−cv−02484−HGB−JCW

CLOSED

United States of America v. Terrebonne Parish et al Assigned to: Judge Helen G. Berrigan Referred to: Magistrate Judge Joseph C. Wilkinson, Jr Cause: 28:1331 Federal Question: Other Civil Rights
Plaintiff

Date Filed: 10/04/2011 Date Terminated: 10/31/2011 Jury Demand: None Nature of Suit: 440 Civil Rights: Other Jurisdiction: U.S. Government Plaintiff

United States of America

represented by Je Yon Jung U. S. Department of Justice (Civil Rights Division) 601 D Street NW Washington, DC 20004 202−305−1457 Fax: 202−514−6903 Email: jeyon.jung@usdoj.gov TERMINATED: 04/17/2014 LEAD ATTORNEY ATTORNEY TO BE NOTICED

Joshua C Delaney U. S. Department of Justice (Civil Rights Division) 601 D Street NW Washington, DC 20004 202−616−2446 Email: joshua.delaney@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

V. Defendant Terrebonne Parish
Defendant Michel Claudet President of Terrebonne Parish Consolidated Government, in his official capacity only

represented by Courtney Elizabeth Alcock Law Office of Courtney E. Alcock 620 School St. Suite A Houma, LA 70360 985−655−6104 Email: calcock@alcocklaw.net LEAD ATTORNEY ATTORNEY TO BE NOTICED

Date Filed 10/04/2011
10/05/2011

# Docket Text
1 COMPLAINT against All Defendants (Filed on behalf of USA − Filing Fee not required) filed by United States of America. (Attachments: # 1 Civil Cover Sheet)(Jung, Je) Modified on 10/6/2011 (plh, ). (Entered: 10/04/2011)
2 Initial Case Assignment to Judge Helen G. Berrigan and Magistrate Judge Joseph C. Wilkinson, Jr. (jmd, ) (Entered: 10/05/2011)

Case: 2:11-cv-02484 As of: 11/20/2014 11:25 AM CST 2 of 2

10/05/2011 10/05/2011 10/18/2011 10/19/2011 10/31/2011
04/16/2014
04/17/2014
11/19/2014 11/19/2014

3 First AMENDED COMPLAINT against Terrebonne Parish filed by United States of America.(Jung, Je) Modified text on 10/6/2011 (plh, ). (Entered: 10/05/2011)
4 EXPARTE/CONSENT MOTION for Settlement Agreement Entry by United States of America. (Attachments: # 1 Proposed Order Settlement Agreement)(Jung, Je) Modified text on 10/6/2011 (plh, ). (Entered: 10/05/2011)
5 ORDERED that by October 24, 2011, counsel for the plaintiff shall amend 4 MOTION for Settlement Agreement Entry as set forth in document. Signed by Judge Helen G. Berrigan on 10/18/11.(mm, ) (Entered: 10/18/2011)
6 EXPARTE Amended MOTION for Settlement Agreement Entry by United States of America. (Attachments: # 1 Proposed Order, # 2 Exhibit)(Jung, Je) Modified on 10/20/2011 (plh, ). (Entered: 10/19/2011)
7 ORDER granting 6 Motion for Entry of Revised Settlement; FURTHER ORDERED dismissing as moot 4 Motion for Settlement; FURTHER ORDERED that this matter is ADMINISTRATIVELY CLOSED. Signed by Judge Helen G. Berrigan on 10/31/2011. (mm, ) (Entered: 10/31/2011)
8 EXPARTE/CONSENT MOTION to Substitute Attorney. Attorney Joshua C. Delaney to be substituted in place of Je Yon Jung by United States of America. (Attachments: # 1 Proposed Order)Attorney Joshua C Delaney added to party United States of America(pty:pla).(Delaney, Joshua) (Entered: 04/16/2014)
9 ORDER granting 8 Motion to Substitute Attorney. Attorney Joshua C. Delaney enrolled as counsel for the United States of America. Attorney Je Yon Jung terminated. Signed by Judge Helen G. Berrigan on 4/16/2014. (kac) (Entered: 04/17/2014)
10 EXPARTE/CONSENT Joint MOTION to Dismiss Case by United States of America, Terrebonne Parish. (Attachments: # 1 Proposed Order of Final Dismissal)(Delaney, Joshua) Modified on 11/19/2014 (plh). (Entered: 11/19/2014)
11 ORDER granting 10 Motion to Dismiss Case − ORDER OF FINAL DISMISSAL dismissing case with prejudice. Signed by Judge Helen G. Berrigan on 11/19/2014. (kac) (Entered: 11/19/2014)