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 Charles Britt Academy Youth Services International, Inc. (Contract Provider) th Avenue South Saint Petersburg, Florida Review Date(s): April 14-17, 2015 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES

2 PrevPage CharlesBritAcademy IntegratedSubstanceAbuseProgram (Opened7/1/13) QuarterlyDataFY NextPage Program Name Provider Program Group Program Type Open/Closed CharlesBritAcademy YouthServices International,Inc. Non-Secure-Male IntegratedSubstanceAbuse (Opened7/1/13) Program Activity AvgLengthofStay(Days) Escapes* Excessive/UnnecessaryUseofForceIncidents* MajorDeficiencies/CriticalIssues* PARRate(per1,000filedbeddays)* PAR(ProgramType) PAR(Statewide) YouthArests 1st Quarter nd Quarter rd Quarter 4th Quarter Total (FYTD) PACTRisktoReofend HighRisk Moderate-HighRisk ModerateRisk LowRisk RPACT IncreaseProtective 1st Quarter 71% 23% 2% 4% 95% 2nd Quarter 62% 23% 10% 100% 3rd Quarter 4th Quarter Total (FYTD) 66% 23% 97% Avg.DecreaseRisk 79% 100% 89% 5% 4% 7% *Thisdatamaybereportedforco-locatedprograms PACTRisktoReofend FiscalYearToDate SPEP QualityImprovement Review PrimaryService ServiceDeliveryRating N/A N/A N/A HighRisk Moderate-HighRisk ModerateRisk LowRisk Foradditionalinformationaboutthisfacility,visithtp:/

3 PrevPage DEFINITIONSOFMEASURES NextPage AverageLengthofStay-ALOS(Days)Theaveragenumberofdaysthatayouthstaysinaparticularprogram.Thisiscalculatedbytotalingthedaysservedforalyouthwhocompleted from aprogram (inthetimeperiodspecified)anddividingthisnumberbythetotalnumberofyouthwhocompletedfrom theprogram. Source:JJIS,BureauofResearch&Planning. CompletionRate-Youthwhocompleteaprogram andreturntothecommunityareconsideredcompleters.whetherayouthisconsideredacompleterisbasedupon hisorherexitstatus.exitstatusisdeterminedbythefolowingfactors: Releasereason Therestrictivenesslevelofthenextcommitmentprogram,ifany Thetimebetweenthereleaseandnextcommitmentplacement ThenextplacementintheServiceHistorydata ThetimebetweenthereleaseandthenextServiceHistoryplacement Threeexitstatusesareconsideredprogram completions: Releasesfrom careandcustody(includingthosereleasedbecausetheyservedthemaximum term alowedbylaworreachedthemaximum ageofjurisdiction). Releasestopost-commitmentprobation. Releasestoconditionalrelease. Thecompletionrateisthepercentageofthoseyouthreleasedwhoareconsideredacompleter,asdefinedabove,ascomparedtothetotalofalyouthreleasedfrom aprogram. Source:JJIS,BureauofResearch&Planning. CriticalIssue-AnidentifiedCriticalIssueandorCriticalDeficiencyistheabsenceofacomponentessentialtoservicedeliveryortheverificationthatthedeliveryofanessentialservice hasbeencompromised.thedeficiencyissodireoracutethatitpresentsapotentialthreattothehealthorsafetyoftheyouthserved,ormayotherwisecompromiseprogram security. Criticalissuesrelatedtoescapesarenotcountedinthenumberreflectedinthisreportastheyarereportedseparately. Source:Regions(MonitoringandQIReviews) Escapes-Numberofindividualspereventwhoescapedfrom afacilityduringthereportingperiod. Source:CCC,OficeofResidentialServices. Excessive/UnnecessaryForceIncidents-ThenumberofincidentsreportedtotheCentralCommunicationCenter(CCC)duringthereportingquarterthatresultinasubstantiatedfinding(s)ofunnecessaryand/orexcessiveuseofforce.EachspecificCCCincidentwithsubstantiatedfindingsiscountedonce,regardlessofthenumberofstafwithsubstantiatedfindings involvedinanincident.sinceanincidentisonlycountedaftera substantiated findinghasbeenmade,thenumbersforaquartermaybeadjustedatsomepointinthefuturetoreflectupdatedfindings. Source:CCC,OficeofResidentialServices. Expectedrecidivism rate-toensurethatprogramsservingyouthwithdiferentdificultylevelsareheldtoreasonableandfairrecidivism standards,thedepartmentcalculatesanexpectedrecidivism rateforthegroupofyouthwhocompletedeachresidentialprogram duringthetimeperiodunderanalysis.programsthatserveyouthwithsignificantriskfactorsforreofendingwilhaveahigherexpectedrecidivism ratethanprogramsservingyouthwithlessriskfactors. Source:JJIS,BureauofResearch&Planning. MajorDeficiencies-Aprogram deficiencyand/orcontractualcomplianceissuethatresultsinaninteruptionineitherthedeliveryofservicesand/orthereceiptofpublicfundsforprogram servicesnotdelivered.amajordeficiencycanalsobebasedonrepeatedminordeficiencieswithnoindicationprogressisbeingmadetocorectthedeficiency.majordeficienciesaresignificantinnatureandtypicalyrequireoversightbymanagementtoensuretheissuesareaddressedsystemicaly.thedeterminationofanissue(s)beinga majordeficiency ismade throughthecontractmonitoringprocess.majordeficienciesrelatedtoescapesarenotcountedinthenumberreflectedinthisreportastheyarereportedseparately. Source:Regions(MonitoringandQIReviews) Foradditionalinformationaboutthisfacility,visithtp:/

4 PrevPage DEFINITIONSOFMEASURES(2) NextPage PACTRisktoReofend-ThePositiveAchievementChangeTool(PACT)isacomprehensiveassessmentthataddressesbothcriminogenicneedsandprotectivefactorsandidentifiesa youth srisktore-ofendaseitherlow,moderate,moderate-highorhigh.thismeasureisbasedontheyouthservedinthereportingquarter.source:jjis,bureauofresearch&planning. PAM Score-ThePAM (Program AccountabilityMeasure)scoreisstandardizedgradeincorporatingbothprogram recidivism costefectivenessandprogram costpercompletion.it presentsrecidivism andcostefectivenessresultsfortheprogramsthatcompletedatleast15youthduringtheone-yearperiodduringthetimeperiodunderanalysis.source:jjis,bureau ofresearch&planning. PARRate-PAR(ProtectiveActionResponse)istheDJJ-approvedphysicalinterventiontechnique,includingtheapplicationofmechanicalrestraints.TheuseofPAR,andstaftraining requirements,areoutlinedintheadministrativerules.theparrateisthenumberofparincidentsper1000filedbeddaysduringthereportingperiod.thestatewideaverageisbased onalcurentlyoperatingprogramsinthestateduringthereportingperiod.source:regions(reportedbyprograms);compiledbyoficeofresidentialservices. Program Group-Identifiesthegenderandcommitmentrisklevelserved.Source:JJIS. Program Type-Identifiesthetypes ofspecializedtreatmentservicesprovidedbyaprogram,suchasmentalhealth,substanceabuse,sexofender.source:jjis. QualityImprovement-Thesystem usedfortheassessmentofprogram complianceinareassuchasmanagement,operations,andservicedelivery.source:bureauofqualityimprovement. Recidivism -Forresidentialcommitmentprograms,thetwelve-monthrecidivism-trackingperiodbeginsthedaythatayouthcompletestheprogram (asdefinedabove),including both youthwhoarereleasedfrom thecareandcustodyofthedepartmentandyouthwhoarereceivingconditionalreleaseorpost-commitmentprobationservicesinanonresidentialseting. Recidivism isdefinedasaladjudications,adjudicationswithheld,andconvictionsforanynewviolationoflawwithintwelvemonthsofprogram completion.recidivism isreportedbythe yearofprogram completion.forexample,youthwhocompleteandexitaprogram infy aretrackedforrecidivism foroneyearfolowingthedaytheyexittheprogram.although theoneyeartrackingperiodmayrolintothefolowingfiscalyear(i.e.fy inthisinstance),therecidivism isreportedforthefiscalyeartheyouthexited(so,fy inthisexample).source:jjis,bureauofresearch&planning. Releases-Thetotalnumberofyouthreleasedfrom theprogram betweenjuly1andjune30ofthefiscalyearunderreview,asreportedinthejuvenilejusticeinformationsystem (JJIS). Source:JJIS,BureauofResearch&Planning. SeriousnessIndex-Aweightingmethodologyinwhichofensesareassignedapointvaluebasedonthedegreeofseriousness.Ahigherratingindicatesahigherlevelofseriousness. Theofenseseriousnessweightsareusedtocomputeanindexoftheseriousnessofpriorofensesforeachyouthreleasedduringthefiscalyear.Asummationofpointvaluescorespondingtoeachchargeforwhichtheyouthwasadjudicatedpriortotheprogram placementdateiscomputedaccordingtotheweightingschemebelow.foreachprogram,thesummationsforyouthwhocompletetheprogram aretotaledandthendividedbythenumberofindividualyouthreleasedfrom thatprogram tocomputeanaveragevaluefortheindexofofender seriousnessforeachprogram.source:jjis,bureauofresearch&planning. YouthArests-Forthepurposesofthisreport,thenumberreflectsthe youthsarestedforofensesoccuringwhileintheprogram,regardlessofwhetherornotthecaseisfiledwiththe court.arestinformationisgatheredfrom thecentralcommunicationscenter(ccc)databaseforalyouth,includingthose18yearsofageandolder.eachyoutharestedinanygiven incidentiscountedindividualy.ifayouthisarestedformorethanoneincidentduringthequarter,eacharestiscounted.source:ccc,oficeofresidentialservices. SPEP TheStandardizedProgram EvaluationProtocol(SPEP)evaluateshowcloselydelinquencyinterventions,asprovided,alignwiththefeaturesofthemostefectiveevaluatedprogramsinthefield.SPEPisanevaluationtoolthatidentifiesshortcomingsincurentjuvenileprograms,andprovidesguidelinesforimprovementinordertooptimizeinterventionefectivenessandpositiveoutcomesstatewide.TheSPEPevaluatesservicesinthefolowingcategories:ServiceType(e.g.,cognitivebehavioral;groupcounseling);ServiceQuantity/Dosage(Durationandintensityofcontacthours)andServiceQuality(e.g.,writenprotocols/manuals;training;fidelitymonitoring;corectiveaction).ThedatasheetscurentlyreportonlyonService Quality.TheServiceQuantityiscurentlybeingassessedasabaselineandwilbereflectedonthedatareportsnextyear. Foradditionalinformationaboutthisfacility,visithtp:/

5 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: Scott Luciano, Office of Program Accountability, Lead Reviewer Felicia Goldstein, Office of Program Accountability, Regional Monitor Bridget Letthand, Pinellas Regional Juvenile Detention Center, Detention Officer Supervisor Stephanie Lobzun, Office of Program Accountability, Regional Monitor Kent Rinehart, Office of Program Accountability, Regional Supervisor, Central Region Jared White, Senior Juvenile Probation Officer, DJJ Probation Circuit 6

6 Program Name: Charles Britt Academy QI Program Code: 1279 Provider Name: Youth Services International, Inc. Contract Number: Location: Pinellas County / Circuit 6 Number of Beds: 28 Review Date(s): April 14-17, 2015 Lead Reviewer Code: 119 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 2 # Case Managers 3 # Clinical Staff 1 # Food Service Personnel 2 # Healthcare Staff 1 # Maintenance Personnel 3 # Program Supervisors Documents Reviewed 5 # Staff 5 # Youth # Other (listed by title): 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 5 # Health Records 5 # MH/SA Records 12 # Personnel Records 12 # Training Records/CORE 3 # Youth Records (Closed) 5 # Youth Records (Open) # Other: 5 # Youth 5 # 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 60 (Revised September 2014)

7 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 Non-Applicable 1.05 * Incident Reporting (CCC) 1.06 Protective Action Response (PAR) 1.07 * Pre-Service/Certification Requirements 1.08 In-Service Training 1.09 Logbook Entries and Shift Report Review 1.10 * Internal Alerts System Limited 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 60 (Revised September 2014)

8 Standard 2: Assessment and Performance Plan Residential Rating Profile Indicator Ratings 2.01 Standard 2 - Assessment and Performance Plan Initial Contacts to Parent 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 Mgmt Members of Treatment Team 2.12 Performance Plan Development 2.13 Treatment Team Meetings (Formal Review) 2.14 Treatment Team Meetings (Informal Review) 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 Limited 2.21 Visitation and Communication 2.22 Written Consent of Youth Eighteen Years or Older 2.23 Written Consent for Substance Abuse Information 2.24 Transition Planning and Conference 2.25 Exit Portfolio 2.26 Exit Conference 2.27 Grievance Process Training 2.28 Grievance Process 2.29 Grievance Process Documentation 2.30 Gang Identification: Notification of Law Enforcement Limited 2.31 Gang Identification: Intervention Activities Limited 2.32 Life Skills Training Provided to Youth 2.33 Staff Training: Delinquency Interventions 2.34 Restorative Justice Awareness For Youth 2.35 Delinquency Intervention Services 2.36 Recreation and Leisure Activities 2.37 Youth Input 2.38 Gender-Specific Programming 2.39 Vocational Programming 2.40 Educational Access 2.41 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 60 (Revised September 2014)

9 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 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 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 6 of 60 (Revised September 2014)

10 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 60 (Revised September 2014)

11 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 60 (Revised September 2014)

12 Strengths and Innovative Approaches Charles Britt Academy conducts a food handler s certification class. This class provides youth information concerning food safety, sanitation, proper storage, and appropriate temperatures. Upon the completion of the class and passing of the food handlers certification test, each youth is given a Safe Serve Certificate. The program conducts a silk screening program. Youth participating in this program experience the basic method of creating income producing possibilities with little financial startup cost. Youth are introduced to techniques that can be applied to jobs such as printing, street curb house number printing, sand blasting, air brushing, or painting designs on interior walls. This creative process is an excellent tool for building confidence and self-esteem in youth. When a youth is able to create a t-shirt from a basic concept to a finished product, they feel a great sense of accomplishment. Youth gain confidence & knowledge with each t-shirt made. Community meetings are conducted on a weekly basis and include youth, staff, and management team members addressing community issues, concerns, and promotes healthy communication and problem resolution among staff and youth. The program has a youth advisory board that promotes effective and on-going communication to address youth needs and concerns. The program utilizes evidence-based programs and practices such as Thinking for a Change (T4C), Impact of Crime (IOC), Aggression Replacement Training (ART), and Cannabis Youth Treatment (CYT) to promote positive, self-motivating change in each youth through individual, group, and family counseling sessions. The program conducts quarterly family day events to promote family reunification, family togetherness, and family involvement in treatment. The program holds a PAR review committee meeting after every PAR incidents. The meeting includes all parties involved in the incident, as well as the management team. The events, actions, and any preventive strategies are discussed to reduce or eliminate the future use of PAR techniques. The program provides substance abuse overlay services (SAOS) to all youth in the program by qualified substance abuse professionals. Office of Program Accountability Page 9 of 60 (Revised September 2014)

13 Standard 1: Management Accountability Overview Charles Britt Academy is a twenty-eight bed program that serves as a non-secure residential program for males fourteen to eighteen in age. The program is located in Saint Petersburg, Florida. The program is operated by Youth Services International, Inc. The program operates through a contract with the Department of Juvenile Justice. The program serves youth who have been assessed and identified with a need for comprehensive substance abuse overlay services (SAOS). The length of stay in the program is based on the youth s progress and success in meeting performance and treatment plan goals. The youth participate in a variety of delinquency intervention groups such as Thinking for a Change (T4C), Aggression Replacement Training (ART), Impact of Crime (IOC), Cannabis Youth Treatment (CYT), Men s Trauma Recovery Empowerment Model (M-TREM), and Boys Council. The program utilizes Living in Balance (LIB) as their substance abuse treatment approach. The management team consists of a facility administrator, assistant facility administrator, and a director of clinical services. The program had no staff vacancies at the time of the annual compliance review 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. There were five new staff and four new volunteers who were applicable for initial background screening. All staff and volunteers received an initial background screening prior to their date of hire. The program submitted their Annual Affidavit of Compliance with Level 2 Screening Standards for staff to the Department s Background Screening Unit prior to the required time frame, 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 written procedures for conducting a new background screening for all staff, volunteers, and interns every five years. There were no staff eligible for rescreening since their contract began on July 1, Office of Program Accountability Page 10 of 60 (Revised September 2014)

14 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 that clearly communicates expectations for ethical and professional behavior, including the expectation for staff to interact with youth in a manner that promotes their emotional and physical safety. The program has a policy and procedure for the provisions of an abuse-free environment and unhindered access to report alleged abuse. The program has a code of conduct for staff, which clearly communicates expectations for ethical and professional behavior. The program had postings for the Florida Abuse Hotline and the Central Communications Center (CCC) telephone numbers throughout the facility and dormitory areas. All staff and youth surveys indicated youth have unimpeded access to call the Florida Abuse Hotline. Five youth surveyed and five interviewed youth indicated they have never been stopped from reporting abuse. All of the youth surveyed and interviewed stated they felt safe in the program. All staff and youth surveys and interviews also indicated the program is free from profanity and physical, psychological, and emotional abuse Management Response to Allegations Non-Applicable 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 that management takes immediate action to address incidents of physical, psychological, and emotional abuse. The program had no incidents of physical, psychological, or emotional abuse in the facility during this review period; therefore, this indictor rates as non-applicable 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 has a written policy and procedure for reporting incidents to the Department s Central Communications Center (CCC) within two hours of the incident. The program provides training for all staff on the requirements of incident reporting. All staff and volunteers of the program are required to adhere to the Department s incident reporting guidelines that are Office of Program Accountability Page 11 of 60 (Revised September 2014)

15 indicated in the program s facility operating procedure (FOP). The facility administrator or designee is responsible for contacting the CCC within two hours of the incident or within two hours of learning of the incident. There were two medical incidents reported to the CCC during the six months prior to the review, and all were reported within the required two-hour time frame Protective Action Response (PAR) Compliance 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. The program uses physical intervention techniques in accordance with Florida Administrative Code. A Protection Action Response (PAR) incident report is completed by staff if at any time staff uses a physical intervention technique. The program had five PAR reports for review. In the five reports, there were a total of eleven staff statements. One of the eleven staff statements was missing a staff signature. Two of the five reports indicated a medical review was necessary, however, the assistant program administrator indicated during the review that this box was checked in error and none of the five reports required a medical review. Two of the five reports did not indicate if a medical review was necessary, however, there was no indication a medical review would have been necessary. All five reports were reviewed by a PAR certified instructor/supervisor staff. A post PAR interview was conducted in all reports within thirty minutes of the incident. All five reports were reviewed and signed by the program director within forty-eight hours. Documentation supports monthly reports are sent to the regional residential director within two weeks of the end of each month. The PAR reports are maintained in a central file. The program s PAR plan was approved by the Department in April of 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. The Department s Learning Management System (SkillPro) and five staff training files were reviewed for pre-service training. All files indicated staff received the required training in cardiopulmonary resuscitation (CPR), automated external defibrillator (AED), First Aid, Protection Action Response (PAR), professionalism and ethics, suicide prevention, emergency procedures, child abuse reporting, behavior management system (BMS), grievance process, specialized services, and safe use of tools, as required. Documentation supported all instructors were qualified to deliver the training provided. The programs pre-service training plan for the fiscal year 2014 was approved by the Department s Office of Staff Development and Training. Three staff were applicable for providing substance abuse treatment overlay services (SAOS). All three staff received specialized training and this training is documented in SkillPro and in their respective training files. Office of Program Accountability Page 12 of 60 (Revised September 2014)

16 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. Five staff training files, along with the Department s Learning Management System (SkillPro), were reviewed for documentation of annual in-service training. Each training file indicated staff exceeded the twenty-four hours annual training requirements. An additional four training files were reviewed that were applicable for facility supervisors. All training files indicated supervisors completed the required eight hours of management training. All staff training files contained current certifications in First Aid, cardiopulmonary resuscitation (CPR), automated external defibrillator (AED), suicide prevention training, professionalism and ethics training, as well as documentation of the eight hours of Protection Action Response (PAR) refresher training. Eight staff training files were reviewed for staff whose regularly assigned job duties include implementation of an evidence based model, strategy, or curriculum for receiving training in its effective implementation. All eight staff training files contain evidence of receiving this training. The facility in-service training plan for the fiscal year 2014 was approved by the Department s Office of Staff Development and Training 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 that direct care staff, including each supervisor, is briefed when coming on duty. The program documents facility events, incidents, and activities in the facility logbook. The program s central logbook is maintained on the living unit. Each logbook is bound with numbered pages, however, the hard cover had fallen off all of the logbooks reviewed for the last six months. There were very few exceptions noted where staff did not strike through errors with one line and initial. Each incoming staff reviewed entries made during the previous two shifts, and then indicated their review by documenting their name, date, time, and a signature. The assistant program director reviews the logbooks on a monthly basis and discusses her findings and recommendations with supervisors at their monthly meetings. All Central Communications Center (CCC) and Protection Action Response (PAR) incidents were documented in the logbook chronologically as applicable. Office of Program Accountability Page 13 of 60 (Revised September 2014)

17 1.10 Internal Alerts System Limited Compliance The program shall maintain and use an internal alert system that is 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 that only appropriate staff may recommend downgrading or discontinuing a youth s alert status. The program had a policy and procedure that was not specific regarding responsibilities for placing youth on or removing youth from alerts. The program uses an alert board with corresponding colored pins to identify alerts. This board was not current to the information maintained in the Juvenile Justice Information System (JJIS) alerts or in the youth s file. Medical alerts are also maintained in an alert binder that was available if staff chose to review the binder. Throughout the week, colored pins did not correctly identify all gang or medical alerts. The internal alert system for identifying youth with a risk to escape was also inconsistent. Three youth had an open alert in JJIS, however, all three of the youth had an internal risk screening that incorrectly documented the alert in JJIS. Prior to the end of this review, the program director provided a revised policy and procedure, and proof that all applicable staff had been trained on this revision 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. A review of five medical records, five mental health records, and five case management records revealed that all applicable alerts were entered into and/or closed out in the Department s Juvenile Justice Information System (JJIS). Two youth were placed on precautionary observation for being a suicide risk and the all alerts were entered in and closed out by the proper mental health staff. Medical alerts were entered in and closed out properly by medical staff in all five reviewed medical records 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 maintains an individual case management record, individual healthcare record (IHCR), and an individual mental health and substance record for each youth. All records are marked Confidential and maintained in a locked cabinet when not in use. The individual case management records were organized and had separate sections for legal information, demographic and chronological information, correspondence, case management and treatment team activities, and miscellaneous information. Office of Program Accountability Page 14 of 60 (Revised September 2014)

18 1.13 Advisory Board Compliance The program has a community support group or advisory board that meets at least quarterly. The program director solicits active involvement of interested community partners. The program has a community advisory board that meets quarterly as evident by prior meeting minutes. The program has an advisory board that includes representatives from the business community, law enforcement, school district, the faith community, and someone who has been the victim of a crime. Currently, there is not a member from the judiciary community or a parent/guardian of a youth with prior DJJ involvement, however, the program was able to show their documented efforts to recruit these members. A review of the advisory board minutes from the last six months revealed that the board did not meet quarterly. A board meeting did not occur in the last quarter of Program Planning Compliance The program uses data to inform their planning process and to ensure provisions for staffing. The program has an established policy for effective communication outlining procedures to ensure that information is disseminated to all staff effectively. The policy outlines that the program will conduct monthly staff meetings with all program staff, monthly supervisory meetings, and weekly meetings with the management team. All meetings give staff an opportunity to give input into the program s operation. Additionally, the program s management staff has an open door policy, and staff can speak with them about ideas at any time. All five survey s confirmed this practice. Results from program youth surveys, as well as reports published annually by the Department, are shared at monthly staff meetings. The program has a resident council, which is a group of high level youth elected to a group that represents the overall youth community and shares ideas with management on a regular basis. In addition, all youth have the opportunity to give input through the use of a Speak Out form. A review of minutes and agendas for all staff, supervisory, and management meetings found that this practice was consistent with the program s policy and procedure. All five staff surveys indicate the working conditions over the last year have been good or very good. The program has had very little turnover in the last year, but the management team plans team building outings and events for staff at least once a quarter in an effort to keep morale high. Five staff were interviewed, and all of them mentioned they were very satisfied with their job and the staff they work with Staff Performance Compliance The program ensures a system for evaluating staff, at least annually, based on established performance standards. The program evaluates new staff after a ninety-day period and on an annual basis. There were eight staff files reviewed for staff evaluations, and all contained a ninety-day or annual evaluation. Position descriptions for each staff member is specific to their required qualifications, job functions or duties, and performance standards. Annual evaluations address the staff s implementation of the program behavior management system (BMS), understanding youth s stages of change, use of rewards at a four to one ratio, demonstrating consistent use of rewards, or consequences and delivery of interventions services for applicable staff. Office of Program Accountability Page 15 of 60 (Revised September 2014)

19 Standard 2: Assessment and Performance Plan Overview The program has two case managers and a transition specialist who are responsible for providing case management services to all youth. The case managers are responsible for notifications and contacts with the parents/guardians, juvenile probation officers (JPO), and the judiciary. The case managers complete risk classifications, the Residential Positive Achievement Change Tool (R-PACT), the Youth Needs Assessment Summary (YNAS), performance plans, progress reports, and transition planning. The program provides Type B, Level 2 vocational programming. Youth are provided with a variety of vocational programming to include CHOICES, Florida Ready to Work, First Aid and CPR, and food handler permit. Youth are taught how to prepare for interviews, and how to complete job applications and résumés. The program assembles an exit portfolio with vocational certificates earned in the program, educational records, transcripts, résumés, and completed job applications to assist youth when released back into the community. The program delivers delinquency intervention through evidence-based and promising practice curriculum Initial Contacts to Parent 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. Charles Britt Academy has a policy in place to contact the parent/guardian within twenty-four hours of a youth s admission via telephone. The policy indicates if the parent/guardian is not reached, the staff will continue to attempt to make contact for twenty-four hours, and if within that time frame no contact is made, the staff will notify the juvenile probation officer (JPO) for assistance in contacting the parent/guardian. The policy also indicates a personal letter is prepared by the facility administrator to be mailed to the parent/guardian within forty-eight hours of the youth s admission. Five records were reviewed and all five records contained documentation in the chronological notes that the parent/guardian was notified of the youth s arrival to the facility within twenty-four hours. All five reviewed records contained a letter signed by the case manager and facility administrator dated the day the youth arrived notifying the parent/guardian of the youth s placement at the Charles Britt Academy. The letter contained information regarding the youth being acclimated to the rules and regulations of the facility including visiting and phone schedules, grievance procedure, and information regarding performance planning and treatment team reviews encouraging the parent/guardian participation. All five records contained an additional letter to the parent/guardian signed by the facility administrator informing them of sick call procedures and insurance information requested by the program. A separate letter was mailed to the JPO, and there was a form indicating the commitment manger was notified via telephone of the youth s admission on the day of arrival. All five records contained documentation of parent/guardian information mailed to them by the program. Office of Program Accountability Page 16 of 60 (Revised September 2014)

20 2.02 Youth Orientation Compliance The program shall provide each youth an orientation to the program rules, procedures, schedules, and services that apply to youth, to begin within twenty-four hours of admission. Five reviewed case management records contained documentation that each youth was provided an orientation to the program within twenty-four hours of their arrival. Every youth record contained an orientation checklist signed by the youth acknowledging receipt of a resident handbook and certification that all topics had been explained to the youth. The resident handbook provides detailed information regarding program components, guidelines, schedule, and services that apply to the youth. Some of the key areas discussed with each youth were access to medical and mental health services, identification of key staff members, the behavior management system (BMS), program rules and regulations, contraband, performance planning, dress code, grievance process, and emergency situations. Each youth was also provided the necessary contact information for the Florida Abuse Hotline and Central Communications Center (CCC). All records contained a signature page acknowledging the youth received a copy of the resident handbook. All five records contained an Orientation Test that was administered to each youth within ten days of admission. The test included questions regarding what was acceptable behavior for the program, thinking patterns, levels of intervention, grievance, intensive support supervision (ISS), and roles of staff. The test also includes questions regarding delinquency services provided by Charles Britt Academy, as well as youth rights and responsibilities. All five records contained separate forms regarding grievance procedure, treatment team meeting members, rewards and consequences, and auxiliary aids and services. All of the forms were signed and dated by the youth and staff as the grievance form did not contain a date. All five surveyed youth indicated orientation began within twenty-four hours of their admission and included program rules, procedures, schedule, and services to be provided during their stay Court Notification Compliance The program notifies the youth s committing court(s) by written notification within five working days of admission. The program has a policy in place indicating they notify the committing judge within five working days of the youth s admission to the facility. The five reviewed records contained letters addressed to the committing court notifying the youth was admitted to the facility, and all letters were dated the day of the youth s admission. Review of the records showed Charles Britt Academy was incorrectly identified on the letters as a moderate risk program. The issue was addressed while the review team was on site to change the language to identify the program as a non-secure commitment program Classification Factors Compliance The program utilizes a classification system, in accordance with Florida Administrative Code, that promotes safety and security, as well as effective delivery of treatment services. Charles Britt Academy has a policy in place addressing classification factors of each youth to identify alerts, monitoring of youth, victimization, determine sleeping assignment, maturity, violence, special needs, gang affiliation, and criminal behavior. The case manager will review the commitment packet and other collateral information prior to admission in order to determine classification, however, the procedure indicates the classification form is completed during the Office of Program Accountability Page 17 of 60 (Revised September 2014)