I ndependent
Ombudsman

for the Texas Juvenile Justice Department

PHOENIX PROGRAM
SPECIAL REPORT
A special site visit was conducted September 18 and 20, 2013, at the Phoenix Program
in response to concerns raised while viewing a video of TJJD staff fighting with youth.
The OIG was dispatched on Sept 18th following an IRC report of these incidents and
made the determination the activities were “horseplay”. The IO continued its
investigation and found several issues of concern.
Agency Response:
On September 17, 2013 a Case Manager assigned to the Phoenix Program reported
concerns to Mart Assistant Superintendent about the actions of several second-shift
staff on the Phoenix Program and recommended that he review video on the unit. The
Assistant Superintendent notified the Superintendent and both located instances of
video reflecting staff engaged in inappropriate physical contact with youth on the unit.
This information was phoned into the IRC per policy and notification was submitted to
Executive staff, the Office of Inspector General (OIG) and the Office of Independent
Ombudsman (IO). Review of video revealed additional incidents of concern regarding
inappropriate physical contact between staff and youth. OIG officers were on site within
two hours of the initial report. The IO responded the following day. On September 18,
2013, the TJJD Administrative Investigations Division received notice from OIG
regarding the allegations. AID opened multiple investigations and was on-site the same
day the notice from the OIG was received.
The activities viewed on the video occurred on two separate days, one in August and
one in September. The video from August took place in the day area of dorm A. There
were three staff and multiple youth visible on camera. One male staff would take youth
one by one and pick them up slam them to the floor and lay on them, pinning them to
the floor. The youth could be seen flailing his legs and arms. The staff would complete
the “pinning” and then move on to another youth repeating the act. At no time did the
other staff attempt to stop the act; they only watched. During the course of 15 minutes
there were 6 youth who were slammed to the floor and pinned by the staff for an
extended period of time. It was reported to the IO that two weeks prior to the IRC report
the staff involved in the wrestling had been reprimanded by his supervisor for the
behavior, but it appears to have continued.

11209 Metric Blvd, Bldg H∙ Austin, Texas 78758
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Human Resources Code, Sec. 261.002. " The office of independent ombudsman is a state agency established for the purpose of investigating, evaluating, and securing the
rights of the children committed to the department, including a child released under supervision before final discharge."

The second video, from September, shows two incidents where staff can be viewed
entering a youth’s room, closing the door behind them and then exiting a period of time
after. Video from inside one of the youth’s rooms shows the staff grabbing the youth
and slamming him to the floor where the staff pins the youth and makes repeated
punches to the youth’s ribs. After a period of time the staff and youth get up. The staff
exits the room and the youth can be seen holding his ribs. The camera inside the
second youth’s room could not be viewed due to the youth putting tissue over the
camera. Before the staff entered that room he was seen giving the youth tissue. The
youth in this incident was interviewed by the IO at which time the youth reported that the
staff entered his room with the intent of engaging the youth in a fist fight. There was no
“horseplay” involved in this situation. The staff member and the youth reportedly
exchanged multiple punches and both parties suffered injuries to their faces before the
supervising JCO entered the room and broke up the fight. The youth suffered a bloody
nose and a black eye, and the staff member suffered a cut over his left eye.
Youth and staff interviews conducted during the site visit indicate the practice of
wrestling with youth on the Phoenix dorm was common on the second shift. Youth
commented that they like the behavior and this is just the staff “being friendly with
them.” The youth stated that the practice was for the staff and youth to trade punches in
the ribs until one or the other gave up. Some youth claimed they did not want to
participate but felt they would be made fun of if they refused.
The practice could be tracked back to at least May of 2013 with an incident involving a
youth who complained to the IO that the staff had become angry with him after
exchanging punches to the ribs, and the situation escalated from recreational to a fist
fight inside the youth’s room. The youth claims that the staff filed a 225 (youth incident
report) on the youth after the fight in an attempt to get the youth in trouble. The youth
reported the case was dismissed. The IO obtained a copy of the 225 which indicates the
youth threatened the JCO and told him that he wanted to “catch a cell” to beat him.
According to the 225, the youth did not receive a Level III or Level II hearing for the
incident. “Catch a cell” is a term used to indicate a fight in a youth’s room per the youth.
Staff identified as participating in the inappropriate physical contact were immediately
removed from direct care positions and not allowed contact with youth effective
September 18, 2013.
Agency Response:
The agency has taken the immediate actions in response to the above incidents:
The following personnel actions were taken as a result of the AID investigations:
The Dorm Supervisor over the Phoenix Unit was suspended without pay pending
termination.
The JCO VI was suspended, placed on disciplinary probation and reassigned.
The two JCOs involved in inappropriate conduct with youth were suspended
without pay and terminated.

Three JCO who failed to report the incident were placed on disciplinary probation
and reassigned.
Clear lines of responsibility have been established and formal oversight of the Phoenix
Program has been placed under the Assistant Superintendent.
Approximately 40 Phoenix staff were trained on the following policies:
PRS .02.09 Conditions of Employment: Staff Youth Relationship
GAP .07.03 Internal Reporting: Incident Reporting
GAP.380.9723 Security and Control: Use of Force
A DVR monitoring schedule was implemented on 9/25/13 to ensure routine monitoring
of the Phoenix Unit. The Mart Superintendent, Assistant Superintendent and Phoenix
Dorm Supervisor are also responsible for DVR monitoring.
A comprehensive corrective action plan has been developed and is being implemented
(attached).
The TJJD OIG concluded its criminal investigation into the allegations on 9/30/13 and
presented the facts in the case to the Special Prosecutions Unit Chief Juvenile
Prosecutor and SPU Executive Director on 10/15/13. The SPU presented the case to a
McLennan County Grand Jury on 10/23/13 and the grand jury “no billed” the charges.
In the course of researching how this behavior could happen, the IO began to look into
the Phoenix program. The Phoenix program was developed and implemented by the
TJJD Director of Facility Operations and the Director of Rehabilitation Services, both
administrative staff out of Central Office. It was originally created as a result of
extremely aggressive and assaultive youth operating in the Giddings facility. According
to the Phoenix Program manual for operations released at the onset of the program,
July 25, 2012, Phoenix was designed to be a more structured self-contained behavior
treatment program for the most assaultive youth at TJJD. The staff for the program
were to be seasoned staff who had experience dealing with assaultive youth and who
had demonstrated proficiency at working with this particular culture. These staff were to
receive additional hours of training for dealing with assaultive behavior and the specific
program to be administered in Phoenix.
Agency Response:
The Phoenix Program does operate as a self-contained behavior treatment program
and houses many of the most aggressive and assaultive youth assigned to the agency.
The program was developed by the agency primarily under the leadership of the former
Director of Facility Operations and Director of Rehabilitation Services but in concert with
treatment, education and correctional staff at the Mart Unit as well as from Central
Office.

Staff design included seasoned staff with experience dealing with assaultive youth but
in light of staffing configurations and personnel-related issues there will occasionally be
staff assigned to the Phoenix Unit who may be newer to the agency. Regardless of
tenure, all Phoenix staff are trained in motivational interviewing, skill building, and nonsuicidal self-injury, among others.
The day to day operations of the program were overseen by the TJJD’s Director of
Facility Operations, who had an office outside the Mart facility, from the program’s start
date in July of 2012 until the time of his retirement in November of 2012. The
Superintendent of the Mart facility at that time reportedly did not play an active role in
the operations of the Phoenix program during the time the Director of Facility
Operations was on site. Unfortunately, the Superintendent’s lack of participation in
Phoenix left him little knowledge of the operations of the program once the Director of
Facility Operations retired. The Facility Superintendent reportedly put faith in the
Phoenix Dorm Supervisor to operate the program. The Superintendent resigned his
position around May of 2013. An interim Superintendent was appointed that same
month, being made permanent in July of 2013. Interviews with staff at Mart indicate that
the current Superintendent is a more frequent presence on the Phoenix dorm, but no
Phoenix specific training was provided regarding the design and operation of the
program. On the Job Training (OJT) records for the Mart Superintendent were provided
to the IO as part of this inquiry. The curriculum for superintendent OJT does not contain
any training related to the Phoenix program other than the process to refer a youth to
the program, and this portion of the OJT has not been completed with the current
Superintendent.
Agency Response:
TJJD agrees that changes in leadership over the program had created a lack of focus
and requires corrective action. Prior to the current administration there was no written
plan for OJT training for any position other than Juvenile Correctional Officers. The
Director of Secure Operations developed a comprehensive OJT plan for
Superintendents and Assistant Superintendents.
As a result of this incident, the Director of Secure Operations along with the Director of
Integrated State Operated Programs have set training dates at Phoenix to review the
original program design, policy and other relevant training with program staff. The first
training is scheduled for November 2013.
The JCO VI in the Phoenix Program was described in interviews as being an effective
supervisor. However, concerns were expressed that he was never scheduled to work
any shifts other than first shift and was rarely in the Phoenix Unit to provide direction
past 2 or 3 o’clock in the afternoon. This is concerning as the most vulnerable times for
situations to occur in these types of settings are after normal business hours. The
person the Superintendent most heavily relied on for his expertise was the Dorm
Supervisor in charge of the day to day operations of the Phoenix program. The Dorm
Supervisor was described as being “very non-confrontational” with his staff and not
good at holding people accountable for their actions. Examples were provided of
Phoenix staff meetings where staff members would engage in “cursing matches”

towards one another and situations where staff members were threatening one another
with no intervention from the Dorm Supervisor. Additionally, staff described instances of
Phoenix staff meetings being scheduled and the Dorm Supervisor not showing up for
the meeting.
Agency Response:
The Senior Director of State Programs and Facilities has directed the Phoenix Dorm
Supervisor to work the 2-to-10 p.m. shift on an intermittent basis along with the normal
day shift schedule. Additionally, the JCO V shift supervisor or JCO VI will be present on
every evening shift.
TJJD leadership was aware of performance issues with the Dorm Supervisor and,
beginning in May 2013, began progressive discipline to improve his performance.
When this incident occurred, the Dorm Supervisor was suspended without pay pending
termination.
A review of records and interviews with agency staff indicates that staff from Central
Office and the Mart facility worked in collaboration to provide a five to six day training
block in June of 2012 to the staff specially selected to work in the Phoenix program.
This training was specific to the program and covered teambuilding, tactical response
and post orders, reviews of the Anger Control Cycle, Mental Health 101, and teaching
Social Skills. Phoenix staff also received training in communication and de-escalation
skills, Phoenix specific paperwork, conducting Check-in Groups and processing thinking
reports. The Phoenix supervisory staff also received Motivational Interviewing training
and additional skills trainings prior to the program beginning operations. Agendas
provided to the IO show follow up training on Motivational Interviewing, a 2 nd round of
program training, and an on-site coaching were scheduled in one day sessions in July
and August of 2012. An additional training agenda was provided for a 3 day block
training that was held for new Phoenix staff in October of 2012. This training also
appears to have been a collaborative effort as the training was delivered by personnel
from Central Office and the Mart facility. This appears to be the last documented formal
training for Phoenix staff even though there are very few of the original staff still
assigned to the program. It appears that any significant new hire training or on-going
skills development training has not continued. This is concerning as many of the current
JCO staff are new hires with limited experience in corrections let alone experience
dealing with assaultive youth. TJJD management has acknowledged the lack of training
provided to the staff working in this specialized program. A September 30, 2013, email
was circulated by the Director of Secure Facility Operations to the Mart facility
administration acknowledging the training deficiencies and requesting that an 8 hour
block training be scheduled for the Phoenix staff.
Agency Response:
Training records of the 37 staff assigned to the Phoenix Program were reviewed in
response to this report. Four of the 37 staff had less than one year’s experience in their
position. The most tenured staff had 17 years’ experience with 25 of the staff (73

percent) having more than three years’ experience.
assigned to Phoenix is 5.7 years.

The average tenure of staff

The following training was conducted with Phoenix staff in 2013:
January 9, 2013 – The Director of State Integrated State Operated Programs met
with Phoenix staff to review findings of Internal Audit dated December 2012,
review policy, case management standards and audit findings. Additionally, the
CCF-410 on youth behavior to be specific to Phoenix was revised.
March 2013 – All Phoenix staff received training on the administration of OC
spray.
July 29, 2013 – Director of State Integrated State Operated Programs met with
Phoenix staff at Mart to review new case management standards to be effective
8/1/13.
Several action plans were put together detailing strategies and action steps for the
development of curriculum for the initial required block of staff training for the Phoenix
Program. According to the project description the training would be designed to equip
staff affiliated with the Phoenix Program with the tools, methodologies and techniques to
successfully perform their job duties. The most recent action plan obtained by the IO is
a detailed 49 step plan that was started in July of 2012 and was projected to be
completed in February of 2013 with the result being a 24 hour, or 3 day curriculum that
the TJJD Training Academy would have available to be delivered as needed to new
staff working in the Phoenix Program. Work on this project appears to have stopped in
October or November of 2012. In October of 2012 the Juvenile Justice Training
Academy reassigned several members of their department, including the staff working
on the Phoenix Program training curriculum, to work on curriculum development for the
Comprehensive Approach to Promote Sexual Safety in Youth (CAPPSY) program,
which was obtained through a TJJD grant. The grant funding had definitive timelines in
place so this program development was given priority status. The Juvenile Justice
Training Academy staff did not return to work on the Phoenix Program training
curriculum until July or August of 2013. The staff person in the TJJD Training Academy
assigned to work on the Phoenix Program curriculum left the agency in September of
2013. An interview with the TJJD Training Academy manager revealed that the current
status of the curriculum is the equivalent of approximately 2 hours of training.
Agency Response:
TJJD agrees that various personnel changes have affected staff training efforts at the
Phoenix Unit. The agency has instructed the training department to bring the modules
to completion and implement the training on a routine schedule in the immediate future.
The Phoenix Program Manual describes the program oversight and evaluation
measures in detail. One of the oversight and evaluation methods described in the

manual is a periodic assessment of the program implementation by the Director of
Facility Operations. To the IO’s knowledge this has not been done. The manual also
states that the division responsible for quality and risk management will conduct an
annual formal review of the program. The Monitoring and Inspections Department
conducted a comprehensive review of the Phoenix Program April 15-17, 2013 and
identified a number of deficiencies relating to policy (CMS.03.75) which outlines
programming for the youth in this program. TJJD disputed a majority of these finding
even though they contradict policy and offered limited action plans for correcting
undisputed claims that do not address the actual problem. The manual also describes a
series of outcome measures to evaluate the overall success of the Phoenix Program.
Interviews conducted by the IO revealed that the process to gather this data has not
begun.
Agency Response:
Since December 1, 2012, the Director of State Operations has been on site at the
Phoenix Program on the following dates:
January 28, 2013 – Mart/Phoenix monitoring visit
February 12, 2013 –Mart/Phoenix monitoring visit
March 25, 2013 – Mart/Phoenix monitoring visit
May 14, 2013 – Mart/Phoenix monitoring visit
May 30, 2013 – Phoenix visit with Mart Superintendent, just after being assigned
as Interim Superintendent
June 6, 2013 – meeting on site with Mart Superintendent and Phoenix staff
regarding findings and planned response to Comprehensive Audit of Phoenix by
the Internal Audit Department
June 10 – 11, 2013 – Onsite at Mart with Director of Integrated State Operated
Programs for Redirect training. Monitored Phoenix while on site.
July 8, 2013 – Mart Site Visit and Phoenix review
July 29, 2013 – Mart site visit and Phoenix review
September 10, 2013 – Mart/Phoenix Site visit, disciplinary letters issued
September 23-25, 2013 – Mart/Phoenix site visit, corrective action planning
Additional action in FY 13 prior to this incident:
January 24, 2013 – Letter of concern and Performance Improvement Plan issued
from Director of State Operations to former Mart Superintendent outlining
expectations for improved facility operations which included issues on the
Phoenix Unit.
January 30, 2013 – Former Superintendent met with Dorm Supervisor and JCO
VI on Phoenix to review and train policy on Use of OC spray at the direction of
Director of State Operations.
Senior Director of State Programs and Facilities visited Mart and the Phoenix unit on the
following dates:

December 20 -21, 2012
January 9 -11, 2013
May 9 -10, 2013
July 12, 2013
August 5, 2013
September 26-27, 2013
TJJD agrees there were discrepancies as identified in the Monitoring and Inspection
report. Once the report was finalized, corrective action was taken. A follow-up review
was conducted by the Monitoring and Inspection Division in May 2013 this review
reflected positively on the Phoenix Program showing improvements in documentation
on the unit.
A review of Correctional Care System records indicates that the youth in the Phoenix
Program may not be provided the level of services required by policy or outlined in the
program manual. A sample of records for youth in the Phoenix Program on October 7,
2013 was selected for review through CCS. The youth selected had all been at Phoenix
for at least 60 days. Policy (CMS.03.75) dictates that the Phoenix case manager make
daily contact with each youth in the program and this contact should be summarized at
least weekly on an automated chronological record, the CCF-520. The Phoenix case
manager is also required to provide at least 30 minutes of individual counseling per
week and conduct a daily Skills Development Group. CMS.03.75 calls for the Phoenix
case manager to conduct the skills development groups in accordance with the daily
schedule while the TJJD Phoenix Program Manual states that the youth attend groups
facilitated by case managers five days per week. The following deficiencies were not in
accordance with Case Management Standards:
The CCF 119 Group Log Summary shows that from July 1, 2013 through
September 30, 2013 a total of 16 case manager led groups have been entered
into the system. For a 3 month period this equals just over 1 group per week.
Policy calls for groups to be conducted by the case managers 5 days per week.
Youth #1224311 has no chronological entries in the Correctional Care System
since August 2, 2013.
Youth #1213404 has no chronological entries from August 2, 2013-September 3,
2013 or from September 9-30, 2013.
Youth #1223290 has no case manager chronological entries since August 15,
2013.
Youth #1205675 has had 2 case manager chronological entries from August 2,
2013 to date.
This review indicates that either there has been a significant decrease in the frequency
of services provided to the youth in the Phoenix Program compared to what is written in
TJJD policy or multiple examples of services not being documented.

The TJJD Internal Audit Department issued a report detailing an audit of the Phoenix
Program in November of 2012. This report includes several findings that are worth
noting as they appear to be part of a trend:
Individual counseling to the youth was not consistently provided.
Skill development and behavior groups were not consistently supported.

Agency Response:
Based on earlier reports that identified ongoing issues, the agency has made and
continues to make changes to the case management system at the Phoenix Program.
Responsibility for the Phoenix case management system has been reassigned to the
Director of Integrated State Operated Programs and Services. Additionally, the
Performance and Accountability Specialist for Case Management from the State
Programs and Facilities Division will conduct bi-monthly reviews of case management
records at Phoenix to evaluate compliance with case management standards. The
Behavioral Treatment Specialist from the State Programs and Facilities Division will
conduct bi-monthly reviews of the Phoenix program to evaluate the behavior
management program fidelity to the program design. Both staff will provide technical
assistance, training, coaching and mentoring when appropriate.
The Internal Audit report goes on to state that oversight reviews could ensure better
compliance with Phoenix programming. One of the official recommendations in the
report states the following:
To assure compliance with the Phoenix Program, the Facility Superintendent
should ensure oversight outlined in CMS 03.75 be completed to identify concerns
and that proper actions are taken to address them.
TJJD management concurred with this finding and responded that their plan of action
was implemented as of October 30, 2012. The plan of action detailed that the Facility
Superintendent met with his management team to review CMS 03.75 to clarify roles,
responsibilities and expectations. Documentation of service provision of program
components-including behavior and skills group, individual counseling, mental status
evaluations, program visits-was emphasized with the responsible staff.
A review of the last seven IO reports of the Mart facility was conducted to specifically
identify trends in the Phoenix portion of the report. In three of the seven reports,
unstructured time for the youth was identified as a concern by the reporting
Ombudsman. Structure was one of the many elements specified in the original design to
provide continuous activity to maintain control of the culture and to educate youth on
ways to control their behavior.
Conclusion:
The Phoenix program has detoured from its original design as a structured selfcontained behavior treatment program. It is now a separate housing unit for difficult

youth, providing little or no specialized programming. Many of the personnel specially
selected for their knowledge, experience and training have been replaced with newly
hired staff lacking training, knowledge and experience. Program oversight is minimal.
Outcome measures, mentioned in the Phoenix Program Manual, have not been
completed. If they had been, the data would be inaccurate due to a lack of program
implementation. TJJD’s failure to maintain and supervise this program has resulted in
behaviors like the ones that instigated this review. It is noted that TJJD has been
responsive and has begun addressing many of the issues identified by the IO during the
course of this investigation.
Agency Response:
TJJD agrees that the quality of programming and delivery of all services in the Phoenix
Program merit close attention. A corrective action plan has been put into place and
increased monitoring will occur. Documentation reflects that corrective action was
taking place prior to the incident that resulted in this special report.
Since its inception, 43 youth have completed the Phoenix Program with average stays
of 104 days. Fourteen of the 43 youth have had no assaults following program
completion, and 34 of the 43 have seen a significant reduction in the number of
incidents following completion.
Eleven (11) youth assigned to the Phoenix program in FY 13 have completed their GED
while they were assigned to the Phoenix unit with one scoring a perfect score on the
Math Section.
Additionally, in the past year, the agency has improved outcomes specifically in the area
of workers compensation related to youth aggression, something the Phoenix unit was
designed (at least in part) to help address. The agency has experienced in FY 13 the
lowest workman’s compensation rates in its history and has reduced overall workman’s
compensation claims by up to 30% overall. The most recent report reflects again a
continuing downward trend in injuries due to youth aggression. Costs and rates have
decreased by 28% and 30% respectively, while the entire employee population has
reduced by only 2% in the same time frame.

Recommendations:
It is the opinion of the IO that TJJD should follow through and completely implement the
Phoenix Program as described in July 2012. Staff must be properly trained from the
beginning and receive regular periodic training while working in the Phoenix Program.
It is recommended that outcome measures be defined and regularly checked.
Issues and recommendations by oversight entities such as the IO, Internal Audits, and
Monitoring and Inspections should be reviewed with action plans submitted for
improvement.

TJJD should outline an internal process to monitor the program and ensure it is
progressing as planned.
Agency Response
The agency agrees with the IO’s recommendations and has already taken steps to
ensure staff is properly trained and a comprehensive training is being developed for all
new Phoenix staff.
The agency has been developing a method of performance tracking for each state
facility. The Phoenix Program will have its own section in this performance report.
The agency will continue to respond, as appropriate, to all IO, Internal audit and
monitoring reports with corrective action plans. The Monitoring and Inspections Division
will conduct both announced and unannounced on-site monitoring to ensure program
compliance and progress.