BUREAU OF MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR

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1 S T A T E O F F L O R I D A D E P A R T M E N T O F J U V E N I L E J U S T I C E BUREAU OF MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR Dade Juvenile Residential Facility G4S Youth Services. LLC (Contract Provider) South West 424 th Street Florida City, Florida Review Date(s): September 22-25, 2015 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES

2 Rating Definitions Ratings were assigned to each indicator by the review team using the following definitions: Compliance Limited Compliance Failed Compliance No exceptions to the requirements of the indicator; or limited, unintentional, and/or non-systemic exceptions that do not result in reduced or substandard service delivery; or systemic exceptions with corrective action already applied and demonstrated. Systemic exceptions to the requirements of the indicator; exceptions to the requirements of the indicator that result in the interruption of service delivery; and/or typically require oversight by management to address the issues systemically. The absence of a component(s) essential to the requirements of the indicator that typically requires immediate follow-up and response to remediate the issue and ensure service delivery. Review Team The Bureau of Monitoring and Quality Improvement wishes to thank the following review team members for their participation in this review, and for promoting continuous improvement and accountability in juvenile justice programs and services in Florida: Tom Mahoney, Office of Program Accountability, Lead Reviewer (Standard 1) Enrique Garcia, Executive Director, AMIkids Miami-Dade North, Circuit 11 (Standard 5) Gabriel Medina, Office of Program Accountability, Regional Monitor (Standard 3) Patrick Morse, Office of Program Accountability, Regional Supervisor (Standard 4) Patrice Starks, Office of Program Accountability, Deputy Regional Supervisor (SPEP/Standard 2) Nancy Romero, Juvenile Probation Officer Supervisor, Circuit 11 (Standard 2)

3 Program Name: Dade Juvenile Residential Facility MQI Program Code: 1113 Provider Name: G4S Youth Services, LLC Contract Number: Location: Miami-Dade County / Circuit 11 Number of Beds: 56 Review Date(s): September 22-25, 2015 Lead Reviewer Code: 107 Methodology This review was conducted in accordance with FDJJ-2000 (Contract Management and Program Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1) Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included in the Residential Standards. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee 3 # Case Managers 3 # Clinical Staff 1 # Food Service Personnel 3 # Healthcare Staff 2 # Maintenance Personnel 5 # Program Supervisors 5 # Staff 5 # Youth Documents Reviewed 5 # Other (listed by title): Regional FA, Regional Business Mgr., Regional QI Officer, Regional DMHCA, Lead Teacher Accreditation Reports Affidavit of Good Moral Character CCC Reports Confinement Reports Continuity of Operation Plan Contract Monitoring Reports Contract Scope of Services Egress Plans Escape Notification/Logs Exposure Control Plan Fire Drill Log Fire Inspection Report Fire Prevention Plan Grievance Process/Records Key Control Log Logbooks Medical and Mental Health Alerts PAR Reports Precautionary Observation Logs Program Schedules Sick Call Logs Supplemental Contracts Table of Organization Telephone Logs Surveys Vehicle Inspection Reports Visitation Logs Youth Handbook 7 # Health Records 7 # MH/SA Records 7 # Personnel Records 7 # Training Records/CORE 3 # Youth Records (Closed) 21 # Youth Records (Open) # Other: 7 # Youth 7 # Direct Care Staff # Other: Observations During Review Admissions Confinement Facility and Grounds First Aid Kit(s) Group Meals Medical Clinic Medication Administration Posting of Abuse Hotline Program Activities Recreation Searches Security Video Tapes Sick Call Social Skill Modeling by Staff Staff Interactions with Youth Comments Staff Supervision of Youth Tool Inventory and Storage Toxic Item Inventory and Storage Transition/Exit Conferences Treatment Team Meetings Use of Mechanical Restraints Youth Movement and Counts Items not marked were either not applicable or not available for review. Office of Program Accountability Page 3 of 58 (Revised July 2015)

4 Standard 1: Management Accountability Residential Rating Profile Indicator Ratings 1.01 Standard 1 - Management Accountability * Initial Background Screening 1.02 Five-Year Rescreening 1.03 * Provision of an Abuse-Free Environment 1.04 * Management Response to Allegations 1.05 * Incident Reporting (CCC) 1.06 Protective Action Response (PAR) and Physical Intervention Rate 1.07 * Pre-Service/Certification Requirements 1.08 In-Service Training 1.09 Logbook Entries and Shift Report Review 1.10 * Internal Alerts System 1.11 * Alerts (JJIS) 1.12 Youth Records (Healthcare and Management) 1.13 Advisory Board 1.14 Program Planning 1.15 Staff Performance * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 4 of 58 (Revised July 2015)

5 Standard 2: Assessment and Performance Plan Residential Rating Profile Indicator Ratings Standard 2 - Assessment and Performance Plan 2.01 Initial Contacts to Parent/Gaurdian 2.02 Youth Orientation 2.03 Court Notifications 2.04 Classification Factors 2.05 Classification Procedures 2.06 Reassessment for Activities 2.07 R-PACT Assessment 2.08 Youth Needs Assessment Summary 2.09 R-PACT Reassessments 2.10 Parent/Guardian Involvement in Case Management Services 2.11 Members of Treatment Team 2.12 Performance Plan Development 2.13 Treatment Team Meetings (Formal Reviews) 2.14 Treatment Team Meetings (Informal Reviews) 2.15 * Performance Plan Goals 2.16 Performance Plan Transmittal 2.17 Performance Plan Revisions 2.18 Incorporation of Other Plans Into Performance Plan 2.19 Performance Summaries 2.20 Performance Summary Transmittal 2.21 Visitation and Communication 2.22 Written Consent of Youth Eighteen Years or Older 2.23 Transition Planning and Conference 2.24 Exit Portfolio 2.25 Exit Conference 2.26 Grievance Process Training 2.27 Grievance Process 2.28 Grievance Process Documentation 2.29 Gang Identification: Notification of Law Enforcement 2.30 Gang Identification: Intervention Activities 2.31 Life Skills Training Provided to Youth 2.32 Staff Training: Delinquency Interventions 2.33 Restorative Justice Awareness For Youth 2.34 Delinquency Intervention Services 2.35 Recreation and Leisure Activities 2.36 Youth Input 2.37 Gender-Specific Programming 2.38 Career Education 2.39 Educational Access 2.40 Education Transition * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 5 of 58 (Revised July 2015)

6 Standard 3: Mental Health and Substance Abuse Services Residential Rating Profile Indicator Ratings Standard 3 - Mental Health and Substance Abuse Services 3.01 Designated Mental Health Clinician Authority or Clinical Coordinator 3.02 * Licensed Mental Health and Substance Abuse Clinical Staff 3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff 3.04 Mental Health and Substance Abuse Admission Screening 3.05 Mental Health and Substance Abuse Assessment/Evaluation 3.06 Mental Health and Substance Abuse Treatment 3.07 * Treatment and Discharge Planning 3.08 * Specialized Treatment Services 3.09 * Psychiatric Services 3.10 * Suicide Prevention Plan 3.11 * Suicide Prevention Services 3.12 * Suicide Precaution Observation Logs 3.13 * Suicide Prevention Training 3.14 * Mental Health Crisis Intervention Services 3.15 * Crisis Assessments 3.16 * Emergency Mental Health and Substance Abuse Services 3.17 * Baker and Marchman Acts * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 6 of 58 (Revised July 2015)

7 Standard 4: Health Services Residential Rating Profile Indicator Ratings Standard 4 - Health Services 4.01 * Designated Health Authority/Designee 4.02 * Psychiatrist/Designee 4.03 Facility Operating Procedures 4.04 Authority for Evaluation and Treatment 4.05 Parental Notification 4.06 Notification - Clinical Psychotropic Progress Note 4.07 Immunizations 4.08 Healthcare Admission Screening Form 4.09 Medical Alerts 4.10 Youth Orientation to Healthcare Services 4.11 Designated Health Authority/Designee Admission Notification 4.12 Healthcare Admission Rescreening 4.13 Health Related History 4.14 Comprehensive Physical Assessment 4.15 Female-Specific Screening/Examination Non-Applicable 4.16 Tuberculosis Screening 4.17 Sexually Transmitted Infection Screening 4.18 HIV Testing 4.19 Sick Call Process - Requests/Complaints 4.20 Sick Call Process - Visits/Encounters 4.21 Restricted Housing Non-Applicable 4.22 Episodic/First Aid Care 4.23 Emergency Care 4.24 Off-Site Care/Referrals 4.25 Chronic Illness/Periodic Evaluations 4.26 Medication Management - Verification 4.27 Medication Management - Orders/Prescriptions 4.28 Medication Management - Storage 4.29 Medication Management - Medication and Sharps Inventory 4.30 Medication Management - Controlled Medications 4.31 Medication Management - Medication Administration Record 4.32 Medication Management - Medication Administration By Licensed Staff 4.33 Medication Management - Medication Provided By Non-Licensed Staff 4.34 Medication Management - Psychotropic Medication Monitoring 4.35 Infection Control - Surveillance, Screening, and Management 4.36 Infection Control - Education 4.37 Infection Control - Exposure Control Plan 4.38 Prenatal Care - Physical Care of Pregnant Youth Non-Applicable 4.39 Prenatal Care - Nutrition and Education of Youth Non-Applicable 4.40 Neonatal Care - Infant Physical Care and Nutrition of Infants Non-Applicable 4.41 Neonatal Care - Supervision of Infants Non-Applicable 4.42 Neonatal Care - Education and Lactation Non-Applicable 4.43 Prenatal and Neonatal Staff Education Non-Applicable * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 7 of 58 (Revised July 2015)

8 Standard 5: Safety and Security Residential Rating Profile Indicator Ratings 5.01 Standard 5 - Safety and Security Youth Supervision 5.02 * Ten-Minute Checks 5.03 Census, Counts, and Tracking 5.04 Key Control 5.05 Contraband Procedure 5.06 Frisk and Strip Searches 5.07 Vehicles and Maintenance 5.08 Transportation of Youth 5.09 Tool Inventory and Management 5.10 Youth Tool Handling and Supervision 5.11 Outside Contractors 5.12 Fire, Safety, and Evacuation Drills 5.13 Mental Health and Medical Drills 5.14 Disaster and Continuity of Operations Planning 5.15 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials 5.16 Youth Handling and Supervision for Flammable, Poisonous, and Toxic Items and Materials 5.17 Disposal of All Flammable, Toxic, Caustic, and Poisonous Items 5.18 Elements of Water Safety Plan Non-Applicable 5.19 Staff Training: Water Safety Non-Applicable 5.20 * Swim Test Non-Applicable 5.21 Comprehensive Behavior Management System 5.22 Implementation and Consistency of Behavior Management System 5.23 Behavior Management System Infractions 5.24 Staff Training: Behavior Management System 5.25 Behavior Management System Monitoring 5.26 Controlled Observation Non-Applicable 5.27 Search and Inspection of Controlled Observation Room Non-Applicable 5.28 Controlled Observation Safety Checks Non-Applicable 5.29 Controlled Observation Release Procedures Non-Applicable * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 8 of 58 (Revised July 2015)

9 Strengths and Innovative Approaches The program has Career Service of South Florida mobile van on campus once per month to provide CareerSource and Workforce Alliance services for all youth. Twenty youth in the program have been certified in cardiopulmonary resuscitation (CPR) and first aid. The program conducts drug screening and driver s license checks prior to hiring any staff, regardless of position. The program conducts monthly driver s license checks on all employees and discusses the findings in daily management meetings. All youth classified as a gang member have their picture and gang affiliation listed on the alert board located in the shift reporting room for staff reference. The program conducts quarterly family day events to promote family reunification and involvement in the treatment process. At each visitation, there is a therapist and/or case manager available on-site to speak with parents/guardians. All youth receive a new annual Comprehensive Physical Assessment (CPA), regardless of assigned medical grade. The program utilizes a color-coded key identification system, which ensures easy sight identification of designated location of keys within the control cabinets. Red key rings for restricted keys, and green key rings for active keys. Red key rings are maintained in a locked box in the master control booth. A photograph identification system provides for easy reference guide for key permissions. Staff pictures are assigned key numbers and the program maintains a written master key inventory, which is color-coded for identification. All maintenance and kitchen tools are identified on a shadow board, along with a picture and corresponding inventory number for easy visual reference. Class-A tools are stored outside the facility and are inaccessible to youth and accessible only to authorized staff members. All Class-A tools are clearly marked with red tape on the handle and all Class- B tools are marked with black tape on the handle for easy identification. Office of Program Accountability Page 9 of 58 (Revised July 2015)

10 Standard 1: Management Accountability Overview Dade Juvenile Residential Facility (DJRF) is a fifty-six-bed, non-secure residential program located in Florida City, Florida, on approximately ten acres of state-owned land. The program provides comprehensive services for major disorders, which are the most intensive level of mental health treatment within the Department of Juvenile Justice (DJJ) continuum of specialized treatment programs. The program provides services including dual diagnosis and/or major disorders treatment to fifty-six male youth ages thirteen to eighteen. The program is operated by G4S Youth Services, LLC under contract with the DJJ. The program s management team is comprised of a facility administrator, assistant facility administrator, office manager, director of nursing, director of clinical services, and physical plant manager. The program has a full-time staff development coordinator to ensure staff training. The program provides for a highly structured therapeutic community fostering peer interaction, personal growth, social development, and responsibility through a therapeutic community model. The program has an active twenty-eight member community advisory board Initial Background Screening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. The background screening process is completed prior to hiring an employee or utilizing the services of a volunteer, mentor, or intern. An Annual Affidavit of Compliance with Level 2 Screening Standards is completed annually. A review of program staff, contracted staff, and volunteers/interns found the program had twenty applicable staff for initial background screenings. All twenty staff and interns received an eligible background screening rating prior to hire. Seven staff received eligible with charges clearance. In addition to the background screenings, the program conducts drug screenings, driver s license checks, and local law enforcement checks on each employee prior to hire. The human resources department also conducts monthly driver s license checks on each employee and the findings are discussed in the daily management meetings. An annual tracking system is maintained in master control. The Annual Affidavit of Compliance with Level 2 Screening Standards was completed and submitted to the Department s Background Screening Unit on January 22, 2015, meeting the annual requirement Five-Year Rescreening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. Employees and volunteers are rescreened every five years from the initial date of employment. The program has a policy and procedure for five-year rescreening. The program maintains a background screening tracking system to monitor five-year rescreen due dates, so they are completed, and submitted timely. The program did not have any staff applicable for a five-year background rescreening during the annual compliance review period. Office of Program Accountability Page 10 of 58 (Revised July 2015)

11 1.03 Provision of an Abuse-Free Environment Compliance The program provides an environment in which youth, staff, and others feel safe, secure, and not threatened by any form of abuse or harassment. Posting of the Florida Abuse Hotline telephone number and the Central Communications Center for youth 18 years of age and older telephone number. All allegations of child abuse or suspected child abuse are immediately reported to the Florida Abuse Hotline. Youth and staff have unhindered access to report alleged abuse to the Florida Abuse Hotline pursuant to Section (1) (a), F.S. The environment is free of physical, psychological, and emotional abuse. A code of conduct for staff who clearly communicates expectations for ethical and professional behavior, including the expectation for staff to interact with youth in a manner promoting their emotional and physical safety. The Florida Abuse Hotline and the Central Communications Center (CCC) telephone numbers were observed posted throughout the facility. The program had one CCC report related to a subsequent call made to the Florida Abuse Hotline within the last six months, with no substantiated findings. A review of seven staff personnel and training files indicated all staff were trained on the program s code of conduct and on ethics, in pre-service, and in annual refresher trainings. Seven youth surveys indicated none of the seven youth had been stopped from calling the Florida Abuse Hotline. All youth responded staff are respectful to youth. All seven youth reported feeling safe at the program. All seven surveyed staff denied knowing of a co-worker refusing a youth a call to the Florida Abuse Hotline. All seven staff presented a process of how youth and staff can call the Florida Abuse Hotline or the CCC, which involved contacting a supervisor who would then handle placing the call if the youth wanted a call Management Response to Allegations Compliance Management shall be cognizant of youth and staff needs and provide direction to each on how to access the Florida Abuse Hotline. There is evidence management takes immediate action to address incidents of physical, psychological, and emotional abuse. In the past six months, one anonymous incident was reported to the Florida Abuse Hotline. There was clear documentation management took immediate action to address the issue until completion of an internal investigation. The abuse investigator interviewed all fifty-one youth in the program and concluded the allegations were unfounded. Office of Program Accountability Page 11 of 58 (Revised July 2015)

12 1.05 Incident Reporting (CCC) Compliance Whenever a reportable incident occurs, the program notifies the Department s Central Communications Center (CCC) within two hours of the incident, or within two hours of becoming aware of the incident. The program had eight Central Communications Center (CCC) reports in the past six months. All incidents involving youth injury or staff injury and contraband were documented in the facility logbook; all others were included on daily shift reports. There were no Department of Children and Families Phoenix referrals applicable during this annual compliance review period Protective Action Response (PAR) and Physical Compliance Intervention Rate The program uses physical intervention techniques in accordance with Florida Administrative Code. Any time staff uses a physical intervention technique, such as countermoves, control techniques, takedowns, or application of mechanical restraints (other than for regular transports), a PAR Incident Report is completed and filed in accordance with the Florida Administrative Code. Reviewed documentation indicated there were twenty-three Protective Action Response (PAR) reports in the last six months. All twenty-three reports were completed by the end of the staff members workday, along with written statements from all staff involved. No mechanical restraints were used. No involved youth alleged abuse where the Florida Abuse Hotline needed to be called. In all cases, the PAR report was processed, by all required parties, within seventytwo hours, excluding weekends and holidays. Each reviewed report was reviewed by a supervisor and PAR Instructor, or PAR certified supervisor. A PAR medical review and Post- PAR interview was conducted, even when not required. All PAR reports were reviewed and processed by the facility administrator after all other reviews and signatures. The PAR report and attachments were observed placed in a central file within forty-eight hours of being signed by the facility administrator. A monthly summary of PAR reports is submitted to the Department. All reports submitted accurately reflected all youth involved in a PAR incident for the last six months. The program s PAR plan was submitted to, and approved by, the Department on January 30, Pre-Service/Certification Requirements Compliance Contracted and State residential staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. Three staff training files were reviewed for pre-service training indicating all staff were certified within 180 days of date of hire. All staff exceeded 120 training hours. All staff were trained in first aid and cardiopulmonary resuscitation (CPR), automated external defibrillator (AED), suicide prevention, and Protective Action Response (PAR). Each staff received training on professionalism and ethics, code of conduct, emergency procedures, youth grievance procedures, behavior management system, and child abuse reporting. All pre-service training was documented in the Department s Learning Management System (SkillPro). All training was delivered by qualified trainers. All reviewed files were organized and properly labeled. The program had an approved pre-service training plan for 2014 and Office of Program Accountability Page 12 of 58 (Revised July 2015)

13 1.08 In-Service Training Compliance Residential staff complete twenty-four hours of in-service training, including mandatory topics specified in Florida Administrative Code, each calendar year, effective the year after preservice/certification training is completed. Supervisory staff completes eight hours of training (as part of the twenty-four hours of annual inservice training) in the areas specified in Florida Administrative Code. Four staff training files were reviewed for in-service training with all files indicating each staff received more than twenty-four required training hours. All four staff had training in Protective Action Response (PAR) refresher, cardiopulmonary resuscitation (CPR), first aid, automated external defibrillator (AED), professionalism and ethics, and suicide prevention. Two supervisory staff training files were reviewed and found each staff received the required eight hours of supervisory training. All in-service and instructor-led training was documented in the Department s Learning Management System (SkillPro) and all instructors were qualified to deliver the training provided. The program s annual training plan was submitted to, and approved by, the Department s Office of Staff Development and Training in December 2014 and January The program has an in-service calendar. The program s staff development manager maintains a training calendar and posts it for all staff. The calendar is updated as necessary, and trainings are held monthly or sooner. The staff development manager sends each department head a notification of staff requiring training one month prior to any scheduled training so the staff can make arrangements to attend Logbook Entries and Shift Report Review Compliance The program maintains a chronological record of events, incidents, and activities in a central logbook maintained at master control, living unit logbooks, or both, in accordance with Florida Administrative Code. The program ensures direct care staff, including each supervisor, is briefed when coming on duty. A review of the facility master control daily logbooks for the past six months found logbooks were bound with preprinted numbered pages and an information template. All entries in the logbooks were made in ink. Errors were struck through with a single line and by the person correcting the error. Entries included the date and time of the event, name of staff and youth involved, and a brief description of the event. The name and signature of the staff making the entry was documented in the logbook. All program initiated Central Communications Center (CCC) reports were documented and highlighted. Entries were highlighted to reflect safety, security, mental health, and medical issues related to youth. Perimeter checks, transports away from the facility, including the names of staff, youth, and destination were included in the logbook. Admissions and releases, including the name, date, and time, were included in the logbook. The program utilizes a shift report, three times daily, to summarize the events, incidents, and activities documented in the master control daily logbook. Office of Program Accountability Page 13 of 58 (Revised July 2015)

14 1.10 Internal Alerts System Compliance The program shall maintain and use an internal alert system easily accessible to program staff and keeps them alerted about youth who are security or safety risks, and youth with healthrelated concerns, including food allergies and special diets. When risk factors or special needs are identified during or subsequent to the classification process, the program immediately enters this information into its internal alert system. The program ensures only appropriate staff may recommend downgrading or discontinuing a youth s alert status. The program utilizes an internal alert system, which includes displays of the current alerts for all applicable youth. The program uses alert boards and binders, which include a photograph of the youth and identifying information for each housing unit. Review of alert boards in all three dormitories, food service, and operations matched the documentation in the Department s Juvenile Justice Information System (JJIS) and/or printed alert list. Review of eight youth healthcare records, mental health and substance abuse records, and case management records indicated assigned staff ensure listing the appropriate medical grade, health-related concerns, food allergies medication allergies, security risks, applicable gang involvement, and mental health status Alerts (JJIS) Compliance When risk factors or special needs are identified during or subsequent to the classification process, the program immediately enters this information into the Juvenile Justice Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are downgraded or discontinued. The program has written policy and procedure on how alerts are identified, documented, updated, and communicated to staff. Alerts for eight youth who were randomly selected for review presented an alert entered into the Department s Juvenile Justice Information System (JJIS). A review of healthcare, mental health and substance abuse, and case management records indicated all youth with applicable alerts of mental health, suicide risk, medication, special diet, allergies, and gang membership, or gang affiliation were entered into JJIS Youth Records (Healthcare and Management) Compliance The program maintains an official case record, labeled Confidential, for each youth, which consists of two separate files: An individual healthcare record An individual management record The program has a system in place to maintain an individual healthcare record, an individual mental health and substance abuse record, and an individual case management record for each youth in the facility. Review of seven healthcare records and mental health and substance abuse records indicated each reviewed record was marked as confidential, labeled with the youth s name, and the Department of Juvenile Justice (DJJ) identification number (ID). Each youth s case management record was marked as confidential and labeled with the youth s name, DJJID number, date of birth, county of residence, and committing offense. All records were observed organized and each reviewed youth case management record contained the required sections to include legal information, demographic and chronological information, correspondence, case management, treatment team activities, and a miscellaneous section. Office of Program Accountability Page 14 of 58 (Revised July 2015)

15 Records are secured within locked offices on shelves or in cabinets. Upon discharge from the program, the staff gathers the healthcare records, mental health and substance abuse records, and case management records, makes a copy of necessary documents for the provider records, then sends the combined records to the assigned juvenile probation officer (JPO) Advisory Board Compliance The program has a community support group or advisory board, meeting at least quarterly. The program director solicits active involvement of interested community partners. The program has an active community advisory board consisting of twenty-eight members. The board meets quarterly at the facility. The advisory board includes representatives from law enforcement, community partners, business community, school board, victim advocate, parent/guardian, youth, and the faith community. The program held three advisory board meetings this calendar year. Documentation of these meetings consisted of agendas, sign-in sheets, and copies of letters sent out to individuals inviting them to attend and become members. The advisory board has assisted the program with involvement in community service initiatives to include the feeding of the homeless and needy, Everglades Preservation Assistance, and partnerships with non-profit organizations to include the Homestead Soup Kitchen Program Planning Compliance The program uses data to inform their planning process and to ensure provisions for staffing. The program has documentation indicating the conducting of parent/guardian and youth surveys. Program Accountability Measures (PAM), and Comprehensive Accountability Report (CAR) are included in the program planning process. To minimize staff turnover, the program provides various types of staff enhancements and incentives. The facility administrator conducts daily management meetings, weekly department head meetings, and monthly meetings with all staff. The facility administrator also conducts meetings with the designated health authority (DHA), dietary staff, psychiatrist, and Miami-Dade County school board administrators on a monthly basis. The clinical director conducts weekly staff meetings with the therapists and the case managers. Unit managers have monthly meetings with their assigned staff. The program utilizes information in the management team meetings and monthly staff meetings for trends and resolutions to any issues which may arise Staff Performance Compliance The program ensures a system for evaluating staff, at least annually, based on established performance standards. The program has a policy and procedure for evaluating all staff annually. Review of staff personnel files documented the program consistently conducts annual performance evaluations for all staff and a new hire evaluation for the initial ninety days of employment. The immediate supervisor completes the evaluation and the facility administrator reviews and signs all evaluations. Review of position descriptions for case manager, youth care worker I and II, mental health therapist, and shift supervisor all indicated specific job functions and duties, and performance standards matched the reviewed evaluations. For all direct care staff positions, the evaluations included behavior management system, four-to-one positive reinforcers, Office of Program Accountability Page 15 of 58 (Revised July 2015)

16 consistence in giving rewards and consequences, and level of understanding of the stages of change. Standard 2: Assessment and Performance Plan Overview The program has a director of case management services, three case managers, and a transition service manager responsible for the provision of case management and transition services to all youth in the program. The case management staff coordinates with the Department, other agencies, and members of the community for the provision of services provided to each youth. The staff complete individual assessments identifying the needs of the youth and maintains progress reports shared with the judiciary, parents/guardians, assigned juvenile probation officer (JPO), and other applicable individuals. Case management staff conduct monthly reviews for each youth to verify the progress made on their performance plan goals and objectives. Case management staff actively participate in the multidisciplinary treatment team s formal and informal meetings to evaluate the progress of each youth in the program Initial Contacts to Parent/Guardian Compliance The program notifies the youth s parent/guardian by telephone within twenty-four hours of the youth s admission, and by written notification within forty-eight hours of admission. Seven case management records were reviewed. All seven records documented notification of the parent/guardian, by telephone, on the day of each youth s admission to the program. The telephone notification was documented in the initial entry of the chronological record and on an intake checklist in each record. The program documented the completion of written notification in each record. The written notification was mailed to the parent/guardian on the date of admission Youth Orientation Compliance The program shall provide each youth an orientation to the program rules, procedures, schedules, and services applicable to youth, to begin within twenty-four hours of admission. The program has written policies and procedures requiring the provision of an orientation to the youth. Seven case management records were reviewed; orientation was documented in each record on the day each youth was admitted to the program. An orientation checklist was completed in each record, which documented a review of each required element including the daily schedule, how to access services, the behavior management system, how to access the Florida Abuse Hotline and Central Communications Center (CCC), contraband, and other requirements. Upon admission, each youth received a resident handbook, which addressed all requirements. All seven records contained documentation each youth acknowledged, by signature, completion of the orientation process and receipt of the resident handbook. Office of Program Accountability Page 16 of 58 (Revised July 2015)

17 2.03 Court Notification Compliance The program notifies the youth s committing court(s) by written notification within five working days of admission. The program has written policies and procedures requiring the notification of the committing court of the youth s admission. The seven reviewed case management records had written notification of the committing court completed and mailed on the day of admission. The written notification included a description of the program and the services provided Classification Factors Compliance The program utilizes a classification system, in accordance with Florida Administrative Code, promoting safety and security, as well as effective delivery of treatment services. The program has written policies and procedures outlining the initial classification process. The program completes an admission classification form addressing the youth s physical characteristics, maturity level, history of violence, gang affiliation, suicide risk, and sexual aggression, or vulnerability to victimization. In addition, a security threat questionnaire, an admission security and treatment alert form, and escape risk assessment are completed on the youth. Seven case management records were reviewed; each record contained an admission classification completed on the day of each youth s admission to the program. Two records contained information relating to gang affiliation on the initial classification form and security threat questionnaire. The two youth were identified as gang members and alerts were entered in the Department s Juvenile Justice Information System (JJIS) Classification Procedures Compliance Initial classification should be used for the purposes of assigning each newly admitted youth to a living unit, sleeping room, and youth group or staff advisor. The program has a procedure, which begins when the youth is assessed upon admission into the program. The program uses the information gathered from the classification forms to determine the youth s placement on a living unit. The case managers and therapists are assigned to a specific living unit; the strengths and characteristics of the case managers and therapists are considered when placing a youth on their living unit. Seven case management records were reviewed; assignment to a living unit and room was documented on the admission classification form in each record. The assignment to a case manager and therapist was documented during the classification process in each record. Special needs were addressed for each of the seven reviewed case management records and alerts were entered in the Department s Juvenile Justice Information System (JJIS). Six of the seven reviewed records reflected youth had alerts in program s internal alert system and in JJIS. There were four youth with medical alerts and two with gang alerts. Office of Program Accountability Page 17 of 58 (Revised July 2015)

18 2.06 Reassessment for Activities Compliance Youth are reassessed and reclassified, if warranted, prior to considering an increase in privileges or freedom of movement, participation in work projects, or other activities involving tools or instruments that may be used as potential weapons or means of escape, or participation in any off-campus activity. Youth are reassessed and reclassified, if warranted, prior to considering an increase in privileges and consideration for work activity details. The program has written policies and procedures requiring the completion of risk assessments once a month. The reassessments are to be completed during formal treatment team meetings. Seven case management records were reviewed, which showed risk reassessments were completed during formal treatment teams. Work details and the culinary arts program contained risk reassessments completed and approved by the treatment team R-PACT Assessment Compliance The program shall ensure an initial assessment of each youth is conducted within thirty days of admission. The program shall maintain all documentation of the initial assessment process in JJIS. Seven case management records were reviewed. A Residential Positive Achievement Change Tool (R-PACT) was completed within thirty days of admission, and contained in each record. Each R-PACT was completed and maintained in the Department s Juvenile Justice Information System (JJIS) for all seven youth. Each of the seven records contained a copy of the R-PACT Youth Needs Assessment Summary (YNAS) Compliance The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is conducted within thirty days of admission. The program shall maintain all documentation of the YNAS. The program has written policy and procedures requiring the completion of a Youth Needs Assessment Summary (YNAS). Seven case management records were reviewed. A YNAS was completed within thirty days of each youth s admission into the program. Each YNAS was completed and maintained in the Department s Juvenile Justice Information System (JJIS) and a copy was maintained in each reviewed youth s case management record R-PACT Reassessments Compliance The program shall ensure a reassessment of each youth is conducted within ninety days. The program shall ensure any other updates or reassessments are completed when deemed necessary by the intervention and treatment team to effectively manage the youth s case. The program shall maintain all reassessment documentation in the youth s official youth case record. Seven case management records were reviewed. All seven were applicable for a Residential Positive Achievement Change Tool (R-PACT) Reassessment. The R-PACT Reassessment was completed within ninety days of the completion of the initial R-PACT in all seven reviewed applicable records. The R-PACT reassessments were maintained in the Department s Juvenile Justice Information System (JJIS) and in each of the seven applicable reviewed case management records. Office of Program Accountability Page 18 of 58 (Revised July 2015)

19 2.10 Parent/Guardian Involvement in Case Management Compliance Services The program shall, to the extent possible and reasonable, encourage and facilitate involvement of the youth s parent/guardian in the case management process. Seven case management records were reviewed. Each of the seven applicable records documented parent/guardian involvement or attempts to have them involved in the development of the needs assessment, performance plan, Residential Positive Achievement Change Tool (R- PACT), and in treatment team reviews. They are notified via letter and telephone. The treatment team documentation showed for parents/guardians who were not present to participate in the treatment team or had not called by telephone, staff attempted to contact the parent/guardian by telephone during treatment team meetings. Seven reviewed records reflected the program encouraged parents/guardians input on youth s services and they were regularly contacted and provided with the opportunity to participate in their child s treatment. Observation of a treatment team meeting was conducted during the annual compliance review week and found the parent/guardian provided written input. There was documentation a letter was sent in advance to the parent/guardian encouraging participation Members of Treatment Team Compliance The team includes, at a minimum, the youth, representatives from the program s administration and residential living unit, and others responsible for providing or overseeing the provision of intervention and treatment services. A review of the seven case management records reflected each youth is assigned to a multidisciplinary team. The team includes, at a minimum, the youth, and representatives from the program s administration and residential living unit, and others responsible for providing or overseeing the provision of intervention and treatment services. Other treatment team members consists of the primary therapist, case manager or case administrator, education representative, registered nurse (RN), living unit representative, clinical director, facility administrator or designee, parent/guardian, and the youth. Treatment team assignment was documented on the day of admission for each youth in the seven reviewed case management records. Treatment team documentation showed good participation by all treatment team members, as all members either attended treatment team meetings, or provided written progress reports for treatment team meetings. Observation of a treatment team meeting conducted during the annual compliance review week revealed the youth, mental health and substance abuse department, facility administrator, parent/guardian, case manager, direct care manager, juvenile probation officer (JPO), education, and nursing staff attended the meeting. The parent/guardian participated by advanced written documentation and the JPO participated via telephone Performance Plan Development Compliance The intervention and treatment team, including the youth, shall meet and develop the performance plan, based on the findings of the initial assessment of the youth, within thirty days of admission. Seven case management records were reviewed. Initial performance plans were developed within thirty days of admission, and after the initial needs assessment was completed. Documentation showed all required parties of the multidisciplinary treatment team were involved in the development of the performance plans, as needs assessment summaries documented input from all program departments, each youth, and parents/guardians, as applicable. Each Office of Program Accountability Page 19 of 58 (Revised July 2015)

20 performance plan was signed by representatives from case management, direct care, clinical treatment, education, nursing, and administration, as well as each youth Treatment Team Meetings (Formal Reviews) Compliance A residential commitment program shall ensure the intervention and treatment team meets every thirty days to review each youth s performance, to include R-PACT reassessment results, progress on individualized performance plan goals, positive and negative behavior, including behavior resulting in physical interventions. If the youth has a treatment plan, review their treatment progress. Seven case management records were reviewed. There was documentation to support formal treatment team meetings were conducted at least every thirty days. Each parent/guardian receives written correspondence encouraging their participation in the performance plan and on the Youth Needs Assessment Summary. Copies of letters were located in each of the seven records reviewed. Each record contained documentation of at least one formal treatment team meeting. The documentation for each formal treatment team meeting included the youth s name, date of review, attendee s participation, in person or by telephone, comments by treatment team members and others, youth s progress in the program, positive and negative behaviors, and whether the youth had been involved in any physical altercations. Each youth completed a written summary of the progress they felt they had made in the program. Reviews of Residential Positive Achievement Change Tool (R-PACT) Reassessment results and performance plan revisions were noted by checking off boxes on the treatment team review forms. The treatment team documentation appropriately reflected reviews of R-PACT reassessment results and performance plan reviews in the seven reviewed records Treatment Team Meetings (Informal Reviews) Compliance A residential commitment program shall ensure the intervention and treatment team reviews each youth s performance, including R-PACT reassessment results, progress on individualized performance plan goals, positive and negative behavior, including behavior resulting in physical interventions. If the youth has a treatment plan, review their treatment progress. The program conducts informal treatment team reviews at least every thirty days, with input provided by all program areas. Seven case management records were reviewed. Each record had documentation of at least one informal treatment team meeting. The documentation of informal treatment team reviews included the youth s name, date of review, attendee s participation in person or by telephone, comments by treatment team members and others, youth s progress in the program, positive and negative behaviors, and whether the youth was involved in any physical altercations. Each treatment team member constantly provided written input regarding each youth s progress Performance Plan Goals Compliance For each goal, the performance plan shall specify its target date for completion, the youth s responsibilities to accomplish the goal, and the program s responsibilities to enable the youth to complete the goal. A review of seven performance plans found each plan contained individualized goals based on each youth s prioritized needs. The youth s top three criminogenic needs identified in the Residential Positive Achievement Change Tool (R-PACT) were addressed in all seven Office of Program Accountability Page 20 of 58 (Revised July 2015)