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 JDAP Circuit 12 Bay Area Youth Services (Contract Provider) th Street, Building H Sarasota, Florida Review Date(s): April 17-18, 2017 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 which 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 which 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 which 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: Melissa Johnson, Office of Program Accountability, Lead Reviewer (Standard 1) Tamara Mahl-Adkins, Office of Program Accountability, Regional Monitor, (Standard 2) Charnisha Palmore, DJJ Juvenile Probation Officer, Circuit 13 (Standard 2)

3 Program Name: JDAP Circuit 12 MQI Program Code: 1276 Provider Name: Bay Area Youth Services Contract Number: P2072 Location: Sarasota, Manatee, Desoto County / Circuit 12 Number of Beds: 60 Review Date(s): April 17-18, 2017 Lead Reviewer Code: 137 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 and (2) Assessment Services, which are included in the Juvenile Diversion Alternative Programs Standards. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee 2 # Case Managers # Clinical Staff # Food Service Personnel # Healthcare Staff Documents Reviewed # Maintenance Personnel # Program Supervisors # 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 0 # Health Records 0 # MH/SA Records 4 # Personnel Records 4 # Training Records/CORE 7 # Youth Records (Closed) 7 # Youth Records (Open) # Other: 0 # Youth 0 # Direct Care Staff 0 # 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 13 (Revised July 2016)

4 Standard 1: Management Accountability JDAP Rating Profile Indicator Ratings 1.01 Standard 1 - Management Accountability * Initial Background Screening 1.02 Five-Year Rescreening 1.03 Protective Action Response (PAR) Non-Applicable 1.04 Pre-Service/Certification Training 1.05 In-Service Training 1.06 * Incident Reporting (CCC) Non-Applicable 1.07 * Abuse-Free Environment * 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 13 (Revised July 2016)

5 Standard 2: Assessment Services JDAP Rating Profile Indicator Ratings 2.01 Standard 2 - Assessment Services Youth Eligibility 2.02 Case Assignment, Initial Contact, and Positive Achievement Change Tool (PACT) Full Assessment 2.03 Individual Service Plan 2.04 *Referrals for Mental Health and Substance Abuse Assessment and Treatment Services 2.05 Individual Service Plan Implementation/Supervision 2.06 PACT Final Assessment 2.07 Release * 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 13 (Revised July 2016)

6 Strengths and Innovative Approaches During the holiday season and spring break, staff and youth of the program worked in conjunction with juvenile probation officers to complete community service hours at various work sites. The community service activities were aimed to teach the youth how to contribute to the community in positives ways. PGT Industries serves as a sponsor for the program by offering the youth an opportunity to participate in the Suncoast Work Force. Youth develop employment skills and are assisted in finding employment. Office of Program Accountability Page 6 of 13 (Revised July 2016)

7 Standard 1: Management Accountability Overview Bay Area Youth Services (BAYS), Inc. is contracted to operate the Juvenile Diversion Alternative Program (JDAP) in Circuit 12. The program serves Sarasota, Manatee, and Desoto counties. The program is contracted to serve sixty youth who are seventeen years of age and under. Only youth who are referred by the Department and approved by the State Attorney s Office are admitted to the program. Admission criteria includes youth with misdemeanor offenses and first-time felony offenders. The average length of stay in the program is two to four months. The program can work with youth beyond the contracted length of stay, only after requesting and receiving approval from the chief probation officer of Circuit 12, or their designee. The program staff is comprised of one circuit supervisor, three full-time case managers, and one administrative assistant. The program was fully staffed at the time of the annual compliance review. The program employs consulting clinicians who assist the supervisor and case managers with cases needing additional time and detailed attention 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. The program has a policy and procedures addressing the initial background screening processes. The program hired two new staff during this annual compliance review period. One of these staff transferred from JDAP Circuit 13 after returning from a brief absence. Both staff were screened appropriately prior to hire. The annual Affidavit of Compliance with Level 2 Screening Standards was submitted to the Department s Background Screening Unit on January 17, 2017, 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 procedures which define how five-year background re-screening will be conducted. The program had no staff applicable for a five-year re-screening during this annual compliance review period. Office of Program Accountability Page 7 of 13 (Revised July 2016)

8 1.03 Protective Action Response (PAR) Non-Applicable 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. There have been no Protective Action Response (PAR) incidents during this annual compliance review period; therefore, this indicator rates as non-applicable Pre-Service/Certification Training Compliance Contracted non-residential staff are trained in accordance with Florida Administrative Code. Contracted non-residential staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. Contracted non-residential staff who have not completed essential skills training, as defined by Florida Administrative Code, do not have any direct contact with youth. Contracted non-residential staff who have not completed pre-service/certification training do not have direct, unsupervised contact with youth. One new staff member was hired during this annual compliance review period. This staff member completed the essential skills, prior to youth contact, and was able to complete more than the required 120-hours of training within 180-days of hire. Another staff member, who transferred from the JDAP Circuit 13 location, had a brief separation from BAYS prior to their transfer. Upon return from the separation, which was well under a year, staff completed Protective Action Response (PAR) training, and was updated on program policies and procedures In-Service Training Compliance Contracted non-residential staff completes in-service training in accordance with Florida Administrative Code. Contracted non-residential staff must complete twenty-four hours of annual in-service training, beginning the calendar year after the staff has completed pre-service training. Supervisory staff shall complete eight hours of training in the areas listed below, as part of the twenty-four hours of annual in-service training. There were three staff applicable for in-service training during the 2016 calendar year. All three staff exceeded the twenty-four hours of required training and all required training topics were completed. The program supervisor completed nine hours of supervisory training. All trainings were documented in SkillPro, the Department s Learning Management System. The program has an individual training plan for each different type of job description. All training plans were submitted to, and were approved by, the Department s Office of Staff Development and Training in January Office of Program Accountability Page 8 of 13 (Revised July 2016)

9 1.06 Incident Reporting (CCC) Non-Applicable 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. There were no incidents reported to the Central Communications Center (CCC) during this annual compliance review period; therefore, this indicator rates as non-applicable Abuse-Free Environment Compliance Any person who knows, or has reasonable cause to suspect, a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or other person responsible for the child's welfare, as defined by Florida Statute, or a child is in need of supervision and care and has no parent, legal custodian, or responsible adult relative immediately known and available to provide supervision and care, reports such knowledge or suspicion to the Florida Abuse Hotline. The program has a policy promoting an abuse-free environment and requires reporting of any suspected child abuse, neglect, or exploitation. Each employee signs an acknowledgement for the receipt of the employee handbook containing the code of conduct which promotes a safe and supportive environment for the protection of the staff, youth, and public. All seven open reviewed youth records contained a case note indicating the youth and parent/guardian were provided telephone numbers for the Florida Abuse Hotline and Central Communications Center (CCC) during the intake process. The review of all open and closed youth records did not reveal any situation indicating abuse on the part of program staff. Both the CCC and Florida Abuse Hotline telephone numbers were posted inside the program offices. Standard 2: Assessment Services Overview The program provides services to youth residing in Sarasota, Manatee, and Desoto counties, which make up Circuit 12. The targeted age group is youth seventeen years of age and under, and the program serves both males and females. Only youth who are referred by the Department and approved by the State Attorney s Office are admitted to the program. Admission criteria includes youth with misdemeanor offenses and first-time felony offenders. The program s average length of stay in the program is two to four months. The program can work with youth beyond the contracted length of stay only after requesting and receiving approval from the chief probation officer of Circuit 12, or their designee. Th program s three case managers are responsible for completion of the Positive Achievement Change Tool (PACT), development of the Individual Service Plan (ISP), and documenting case activities in the Department s Juvenile Justice Information System (JJIS) case note module. Youth are referred to community providers for any identified mental health or substance abuse needs. Successful completion of the program occurs when the youth completes their requirements specified in the ISP. Youth who do not complete their service plan requirements are unsuccessfully discharged from the program, after a pre-closure meeting has been conducted with the youth and family. Office of Program Accountability Page 9 of 13 (Revised July 2016)

10 2.01 Youth Eligibility Compliance Youth admitted to the program meet the admission criteria defined by the provider s contract: The program shall serve male and female youth aged 17 and under. Admission/Eligibility criteria should include, but not limited to any misdemeanor offender and first-time felony offenders. Seven open youth records were reviewed and all youth met the admission criteria for admission to the program. The program made special exceptions for two youth who had charges higher than a third-degree felony offense Case Assignment, Initial Contact, and Positive Compliance Achievement Change Tool (PACT) Full Assessment The program shall ensure each youth is assigned a case manager and shall conduct a PACT Full Assessment on all youth within ten (10) calendar days of the date the provider receives the youth s complete referral packet. The program received a complete referral packet for all seven youth records reviewed. The circuit supervisor assigned the youth to a program case manager, within twenty-four hours of receiving the referral. Case managers completed the intake with the youth and parent/guardian within ten days of the youth s admission. The intake included signing the program participation agreement and negotiating the youth s Individualized Service Plan (ISP). All seven records contained a full Positive Achievement Change Tool (PACT) assessment, which was completed within ten days of the youth s admission date. The PACT assessments were completed in the Juvenile Justice Information System (JJIS) within the ten-day requirement Individual Service Plan Compliance The results of the initial PACT Full Assessment will outline the risks and needs of the child and will assist in case planning. The PACT Risk Report must be viewed to determine if any of the dynamic domains have moderate-high or high risk scores. For youth with no moderate-high or high risk domain scores, case planning should be focused on a sixty-day schedule for program completion. For youth with any moderate-high or high risk domain scores, case planning should be focused on a 90 to 120-day schedule for program completion addressing the specific identified needs. The program has 21 calendar days from program admission to develop the individualized service plan. The results of each youth s Positive Achievement Change Tool (PACT) risk report were documented in all seven Individual Service Plans (ISPs). Two of the ISPs were applicable for dynamic domains identified as moderate-high and high. These plans were focused on a ninety to 120 day schedule for completion. Three of the five ISPs with low and moderate dynamic domains focused on a sixty-day schedule for completion of goals. All of the ISPs were developed within twenty-one calendar days from the youth s admission to the program. The youth s goals on the ISPs were individualized. The plans addressed the clear action steps of who, what, when, and how often. Office of Program Accountability Page 10 of 13 (Revised July 2015)

11 2.04 Referrals for Mental Health and Substance Abuse Compliance Assessment and Treatment Services The provider shall provide services based on individual youth and family needs. If needs are identified requiring a referral for services outside the program, staff ensure all referrals are made to address criminogenic needs and mental health and substance abuse service needs identified by the PACT. Staff develops a follow-up and monitoring plan for all outside referrals made as a result of program participation. Provide is defined as arranging/referring/brokering or actually providing the service directly to the youth and family. All seven youth records reviewed showed documentation youth were receiving either mental health or substance abuse services from local community providers. Two of the youth were referred by the program and five of the youth were admitted to the program with services already established. The case managers maintained monthly contact with the community providers to ensure services were being received by the youth and their family. Case managers documented negative reports for the local community providers regarding the youth s progress in the program and followed-up with the youth and family Individual Service Plan Implementation/Supervision Compliance Youth are supervised in a manner ensuring completion of the Individual Service Plan. Staff documents all case activities, including face-to-face interaction and telephone contact with the youth, parent(s)/guardian(s), and providers, and review of written or verbal reports from collateral sources, such as educational institutions, employers, counselors, electronic databases, etc. Case notes demonstrate compliance (or attempted compliance) with youth, parent/guardian, and staff action steps contained in the Individual Service Plan. All seven youth records reviewed contained an Individualized Service Plan (ISP). Case notes for all seven youth addressed ISP goals; however, case management responsibilities are not consistently documented in the case notes. Two ISPs contained goals for the case manager to conduct at least one random drug screen during the 120-day period. There was no indication the sanction was addressed with the youth or the sanction was completed, as the action step required. The sanctions on the ISPs indicated the case manager would check with the school at least once a month. There was no school contact for the youth who were preparing to take the General Education Diploma (GED) test. One youth missed the deadline date to complete the letter of apology. The missed deadline was not addressed with the youth by the case manager. One youth s ISP contained a sanction of court fees and no contract with the co-defendant. There was no documentation to support the case manager addressed these sanctions with the youth, as required by the ISP. There was a total of seventy-one individual service plan (ISP) goals in the seven records reviewed. Out of those seventy-one goals, eleven goals were not addressed as documented in each ISP narrative PACT Final Assessment Compliance A PACT Full Assessment shall be completed prior to the request for case closure. The PACT assessment shall document pre- and post-testing. No R-PACT reassessments during the program participation are required. All five closed youth records reviewed contained a completed final Positive Achievement Change Tool (PACT) assessment, which was completed prior to the request for case closure. The final PACT demonstrated a growth with the youth s protective factors. Interviews with the Office of Program Accountability Page 11 of 13 (Revised July 2016)

12 case managers demonstrated their knowledge of this practice and the importance of the youth s increase in protective factors prior to discharge from the program Release Compliance The program releases youth upon completion of the program, or otherwise as indicated by the provider s contract. All five closed youth records showed each of the youth were successfully discharged from the program. One youth exceeded four months and the circuit supervisor received an approved extension from the chief probation officer. Four of the five youth s release dates in the Department s Juvenile Justice Information System (JJIS) were correct. The program was not able to close the fifth youth in JJIS, due to technical issues, and they had reached out to the Department s Data Integrity Officer (DIO) for assistance. The closure summaries for all five youth documented the completion of the Individualized Service Plan (ISP) goals. Office of Program Accountability Page 12 of 13 (Revised July 2016)

13 Program Name: JDAP Circuit 12 MQI Program Code: 1276 Provider Name: Bay Area Youth Services Contract Number: P2072 Location: Sarasota, Manatee, Desoto County / Circuit 12 Number of Beds: 60 Review Date(s): April 17-18, 2017 Lead Reviewer Code: 137 Overall Rating Summary All indicators have been rated and no corrective action is needed at this time. Office of Program Accountability Page 13 of 13 (Revised July 2016)