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 Jacksonville Youth Academy G4S Youth Services, LLC (Contract Provider) 4501 Lannie Road Jacksonville, Florida Review Date(s): January 24-27, 2017 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES

2 JacksonvileYouthAcademy IntegratedSubstanceAbuseProgram (Opened7/2/14) QuarterlyDataFY Program Name Provider Program Group Program Type Open/Closed JacksonvileYouthAcademy G4SYouthServices,LLC Non-Secure-Male IntegratedSubstanceAbuse (Opened7/2/14) Program Activity AvgLengthofStay(Days) Escapes* Excessive/UnnecessaryUseofForceIncidents* MajorDeficiencies* PARRate(per1,000filedbeddays)* PAR(Statewide) 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Total (FYTD) YouthArests *Thisdatamaybereportedforco-locatedprograms PACTRisktoReofend HighRisk Moderate-HighRisk ModerateRisk LowRisk RPACT IncreaseProtective 1st Quarter 50% 31% 14% 6% 100% 2nd Quarter 62% 24% 10% 100% 3rd Quarter 63% 22% 13% 100% 4th Quarter 57% 34% 88% Total (FYTD) 58% 28% 11% 97% DecreaseRisk 100% 100% 100% 63% 91% 3% 3% 9% 0% 3% SPEP SPEPReview PrimaryService ServiceDelivery Quality AmountofService -Weeks AmountofService- Hours Program Basic Score Program Optimization Score Program Optimization Percentage CannabisYouthTreatment High 0% 0% 80-80% February2015 ImpactofCrime High 0% 20% 67 - LifeSkilsTraining High 0% 0% 58-79% 68% YoungMen'sWork Medium 40% 0% 64-67% Foradditionalinformationaboutthisfacility,visithtp:/

3 JacksonvileYouthAcademy IntegratedSubstanceAbuseProgram (Opened7/2/14) AnnualOutcomes (YearofCompletion) SeriousnessIndex (YearofCompletion) Recidivism (YearofCompletion) Program Releases (YearofRelease) CompletionRates (YearofCompletion) Foradditionalinformationaboutthisfacility,visithtp:/

4 DEFINITIONSOFMEASURES AverageLengthofStay-ALOS(Days)Theaveragenumberofdaysthatayouthstaysinaparticularprogram.Thisiscalculatedbytotalingthedaysservedforalyouthwhocompleted from aprogram (inthetimeperiodspecified)anddividingthisnumberbythetotalnumberofyouthwhocompletedfrom theprogram. Source:JJIS,BureauofResearch&Planning. CompletionRate-Youthwhocompleteaprogram andreturntothecommunityareconsideredcompleters.whetherayouthisconsideredacompleterisbasedupon hisorherexit status.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)duringthereportingquarterthatresultinasubstantiated finding(s)ofunnecessaryand/orexcessiveuseofforce.eachspecificcccincidentwithsubstantiatedfindingsiscountedonce,regardlessofthenumberofstafwithsubstantiated findingsinvolvedinanincident.sinceanincidentisonlycountedaftera substantiated findinghasbeenmade,thenumbersforaquartermaybeadjustedatsomepointinthefutureto reflectupdatedfindings. Source:CCC,OficeofResidentialServices. Expectedrecidivism rate-toensurethatprogramsservingyouthwithdiferentdificultylevelsareheldtoreasonableandfairrecidivism standards,thedepartmentcalculatesan expectedrecidivism rateforthegroupofyouthwhocompletedeachresidentialprogram duringthetimeperiodunderanalysis.programsthatserveyouthwithsignificantriskfactorsfor reofendingwilhaveahigherexpectedrecidivism ratethanprogramsservingyouthwithlessriskfactors. Source:JJIS,BureauofResearch&Planning. MajorDeficiencies-Aprogram deficiencyand/orcontractualcomplianceissuethatresultsinaninteruptionineitherthedeliveryofservicesand/orthereceiptofpublicfundsforprogram servicesnotdelivered.amajordeficiencycanalsobebasedonrepeatedminordeficiencieswithnoindicationprogressisbeingmadetocorectthedeficiency.majordeficienciesare significantinnatureandtypicalyrequireoversightbymanagementtoensuretheissuesareaddressedsystemicaly.thedeterminationofanissue(s)beinga majordeficiency ismade throughthecontractmonitoringprocess.majordeficienciesrelatedtoescapesarenotcountedinthenumberreflectedinthisreportastheyarereportedseparately. Source:Regions(MonitoringandQIReviews) Foradditionalinformationaboutthisfacility,visithtp:/

5 DEFINITIONSOFMEASURES(2) 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:bureauofquality Improvement. 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 inthis example).source:jjis,bureauofresearch&planning. Releases-Thetotalnumberofyouthreleasedfrom theprogram betweenjuly1andjune30ofthefiscalyearunderreview,asreportedinthejuvenilejusticeinformationsystem (JJIS). Source:JJIS,BureauofResearch&Planning. SeriousnessIndex-Aweightingmethodologyinwhichofensesareassignedapointvaluebasedonthedegreeofseriousness.Ahigherratingindicatesahigherlevelofseriousness. Theofenseseriousnessweightsareusedtocomputeanindexoftheseriousnessofpriorofensesforeachyouthreleasedduringthefiscalyear.Asummationofpointvalues corespondingtoeachchargeforwhichtheyouthwasadjudicatedpriortotheprogram placementdateiscomputedaccordingtotheweightingschemebelow.foreachprogram,the summationsforyouthwhocompletetheprogram aretotaledandthendividedbythenumberofindividualyouthreleasedfrom thatprogram tocomputeanaveragevaluefortheindexof ofenderseriousnessforeachprogram.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,alignwiththefeaturesofthemostefectiveevaluated programsinthefield.spepisanevaluationtoolthatidentifiesshortcomingsincurentjuvenileprograms,andprovidesguidelinesforimprovementinordertooptimizeintervention efectivenessandpositiveoutcomesstatewide.thespepevaluatesservicesinthefolowingcategories:servicetype(e.g.,cognitivebehavioral;groupcounseling);service Quantity/Dosage(Durationandintensityofcontacthours)andServiceQuality(e.g.,writenprotocols/manuals;training;fidelitymonitoring;corectiveaction).Thedatasheetscurently reportonlyonservicequality.theservicequantityiscurentlybeingassessedasabaselineandwilbereflectedonthedatareportsnextyear. Foradditionalinformationaboutthisfacility,visithtp:/

6 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: Kevin L Greaney, Office of Program Accountability, Lead Reviewer (Standard 1) Mike Marino, Office of Program Accountability, Regional Monitor, (SPEP) Patrick McKinstry, Office of Program Accountability, Regional Monitor, (Standard 3) Gwen Nelson, Office of Program Accountability, Regional Monitor, (SPEP & Surveys) Michael Philpot, Assistant Superintendent, Duval Detention (Standard 5) Jennifer Schad, Office of Program Accountability, Regional Monitor, (Standard 4) Marla Vose, Lead Case Manager, Marion Youth Academy (Standard 2)

7 Program Name: Jacksonville Youth Academy MQI Program Code: 1293 Provider Name: G4S Youth Services, LLC Contract Number: Location: Duval County / Circuit 4 Number of Beds: 24 Review Date(s): January 24-27, 2017 Lead Reviewer Code: 116 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 2 # Clinical Staff # Food Service Personnel 3 # Healthcare Staff 1 # Maintenance Personnel 2 # 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 8 # Health Records 5 # MH/SA Records 10 # Personnel Records 10 # Training Records/CORE 5 # 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 61 (Revised July 2016)

8 Standard 1: Management Accountability Residential Rating Profile Indicator Ratings Standard 1 - Management Accountability 1.01 * 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 Grievance Process Training 1.10 Grievance Process 1.11 Grievance Process Documentation 1.12 Life Skills Training Provided to Youth 1.13 Staff Training: Delinquency Interventions 1.14 Restorative Justice Awareness for Youth 1.15 Delinquency Intervention Services 1.16 Gender-Specific Programming 1.17 Logbook Entries and Shift Report Review 1.18 * Internal Alerts System 1.19 * Alerts (JJIS) 1.20 Education Acces 1.21 Youth Records (Healthcare and Management) 1.22 Youth Input 1.23 Advisory Board 1.24 Program Planning 1.25 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 61 (Revised July 2016)

9 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 Court Notification 2.03 Youth Orientation 2.04 Written Consent of Youth Eighteen or Older 2.05 Classification Factors 2.06 Classification Procedures 2.07 Reassessment for Activities 2.08 Gang Identification: Notification of Law Enforcement 2.09 Gang Identification: Prevention and Intervention Activities 2.10 R-PACT Assessment 2.11 Youth Needs Assessment Summary 2.12 R-PACT Reassessments 2.13 Parent/Guardian Involvement in Case Management Services 2.14 Members of Treatment Team 2.15 Performance Plan Development 2.16 *Performance Plan Goals 2.17 Performance Plan Transmittal 2.18 Incorporation of Other Plans Into Performance Plan 2.19 Treatment Team Meetings (Formal Reviews) 2.20 Treatment Team Meetings (Informal Reviews) 2.21 Performance Plan Revisions 2.22 Performance Summaries 2.23 Performance Plan Summary Transmittal 2.24 Career Education 2.25 Education Transition Plan 2.26 Transition Planning and Conference 2.27 Exit Portfolio 2.28 Exit Conference * 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 61 (Revised July 2016)

10 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 61 (Revised July 2016)

11 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 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 and Neonatal Care - Nutrition, Education of Youth, and Lactation Non-Applicable 4.40 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 61 (Revised July 2016)

12 Standard 5: Safety and Security Residential Rating Profile Indicator Ratings Standard 5 - Safety and Security 5.01 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 Disaster and Continuity of Operations Planning 5.14 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials 5.15 Youth Handling and Supervision for Flammable, Poisonous, and Toxic Items and Materials 5.16 Disposal of All Flammable, Toxic, Caustic, and Poisonous Items 5.17 Recreation and Leisure Activites 5.18 Elements of the Water Safety Plan Non-Applicable 5.19 Staff Training: Water Safety Non-Applicable 5.20 * Swim Test Non-Applicable 5.21 Visitation and Communication 5.22 Comprehensive Behavior Management System 5.23 Implementation and Consistency of Behavior Management System 5.24 Behavior Management System Infractions 5.25 Staff Training: Behavior Management System 5.26 Behavior Management System Monitoring 5.27 Search and Inspection of Controlled Observation Room 5.28 Controlled Observation 5.29 Controlled Observation Safety Checks 5.30 Controlled Observation Release Procedures * 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 61 (Revised July 2016)

13 Standard 1: Management Accountability Overview Jacksonville Youth Academy (JYA) is located at 4501 Lannie Road, Jacksonville, Florida. G4S Youth Services is the provider under contract number This contract is to provide a twenty-four bed residential program for non-secure boys, fourteen to eighteen years old with innovations in delinquency programing to include Substance Abuse Overlay Services (SAOS). Commitment is typically three to nine months and is dependent upon the youth s progress with treatment and performance plan goals. All clothing and hygiene items are provided by the program. The youth rooms are checked daily for cleanliness and good order. Three youth took the review team on a tour of the facility. The three youth took pride when presenting each individual area within the facility and were knowledgeable about their surroundings. The back of each dorm door is a chalkboard for the youth to utilize for art. The program is staffed with qualified employees for clinical and medical services, support services, and direct care. Staff members at all levels are full participants in an interdisciplinary treatment team approach to address individualized needs, offer guidance and assistance in goal completion, and monitor youth progress towards successful transition of the youth to his family and the community. Jacksonville Youth Academy utilizes evidence based and promising curricula of Impact of Crime, Cannabis Youth Treatment, Life Skills Training, Living in Balance, Young Men s Work, Teen Relationships, and Anger Management for Substance Abuse. Jacksonville Youth Academy academic program offers English, Math, Science, Social Studies, and one elective course. The elective course is typically used to provide additional reading assistance to needy students or vocational training. Education and vocational services are provided through the Duval County Public Schools. Youth participate in a variety of recreational activities, along with off-site activities to include good behavior incentive trips and volunteer work with Habitat for Humanity 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 fourteen new staff hired since the last annual compliance review. All fourteen staff were background screened prior to their date of hire. A review of the thirteen new volunteer files indicated all were background screened prior to contact with youth. The Annual Affidavit of Compliance with Level 2 Screening was completed for both the program staff and education staff and submitted to the Background Screening Unit (BSU) prior to January 31, 2016, meeting the annual requirement. The forms have already been sent out for this fiscal year prior to January 31, Office of Program Accountability Page 9 of 61 (Revised July 2016)

14 1.02 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 s policy and procedures addressed the requirement to complete a background rescreening on staff every five years after their initial hire date. Two facility staff members and one corporate staff required a five-year background rescreening. Two of the three were screened prior to their five-year anniversary and the third screening was four days late 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 program has a code of ethics which clearly prohibits abuse and promotes respect. All staff receive training on the Standards of Conduct and Code of Ethics during the first week of their new employee orientation and pre-service training. Training is detailed and concise. The code of ethics and the standards of conduct are also included in the employee handbook. The program provides an environment in which youth, staff, and others feel safe, secure, and not threatened by any form of abuse or harassment. The Florida Abuse Hotline and the Department s Central Communication Center s (CCC) phone numbers are posted throughout the facility. Management is cognizant of youth and staff needs and provide direction to each on how to access the Florida Abuse Hotline. Staff is trained during their pre-service training and annually in-service training. Youth are educated during their orientation to the program. The youth can request help through any staff members if he want to call the abuse hotline. That staff member will take him to their supervisor. That supervisor will take the youth up to the administration area and notify the assistant facility administrator or facility administrator who will call the abuse hotline and hand the phone to the youth. Five youth were surveyed and each of them reported never being stopped from calling the Florida Abuse Hotline, staff are respectful when talking to them, and all of the youth indicated they feel safe at the program. Each of the five surveyed youth also reported they have never heard staff using curse words when speaking to them and other youth at the program and never heard staff threaten them or any other youth. All of the five staff surveyed reported they have never seen a co-worker stop a youth from making a call to the Office of Program Accountability Page 10 of 61 (Revised July 2016)

15 Florida Abuse Hotline. Five surveyed staff indicated they never heard a co-worker use profanity, threats, intimidation, or humiliation when talking with youth. The program addressed professionalism and appropriate youth interactions during both operational and supervisory staff meetings and posting signs throughout the program prohibiting the use of profanity. Since the last annual compliance review, one staff member was identified as violating the program s policy and subsequently resigned. If they had not resigned the member would be placed on administrative leave during the investigation and the result of that investigation will determine the next step 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. The program s policy is to take action immediately to address incidents of alleged abuse. No one is to prevent a youth or staff from reporting abuse and staff and youth are to have unhindered access to report abuse or suspected abuse. There was one allegation of physical, psychological, or emotional abuse involving staff since the last annual compliance review. The staff, as per policy, was immediately removed from direct contact with the youth population until the investigation was complete. The staff member resigned the following day for another reason 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. On four separate occasions, incidents were reported into the Departments Central Communication Center (CCC). Each of the four CCC calls were reviewed. Each incident was called into the CCC within the required two-hour time frame. Whenever a reportable incident occurs, the program s policy is to notify the CCC within two hours of the incident or becoming aware of the incident. There were no indications of any reportable incidents not being called into the CCC. There was no increase in the number of CCC calls made in 2016 as compared to 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. There were a total of eight Protective Action Response (PAR) incidents in the past six months. Five of the PAR incidents were reviewed. Each of the five PARs had a report completed by staff prior to the end of the shift. The reports included a written statement from each of the staff engaged in the PAR incident and each of the five PAR reports was reviewed by the supervisor on duty at the time of the incident. Each of the reports were further reviewed by a PAR Office of Program Accountability Page 11 of 61 (Revised July 2016)

16 instructor, or PAR certified supervisory staff person within the required time frame. A post-par interview was conducted for each incident. A review by medical staff indicated no medical review required on each report. The techniques applied were found to be in accordance with the PAR administrative rule. The facility administrator s review and signature were within the program s seventy-two-hour time frame. The program monitor confirmed monthly PAR summary reports are sent to the regional residential director s office by the tenth of each month. The program s PAR plan was approved by the Department on February 10, Average PAR rate for the program was 1.37 for the second quarter which is within one standard deviation below the Statewide PAR rate of The facility administrator was interviewed and described the methods used in case of a PAR incident. All use of force incidents is to be communicated to supervisory and administrative staff immediately. All PAR incidents are monitored daily in the morning management meeting. The facility keeps an internal monitoring process to address all trends in regard to PAR 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. Five staff training files were reviewed and two were applicable for needing pre-service training. The G4S pre-service training plan includes a four-week training session, for a total of 120 hours, prior to the staff member being in the presence of youth. One and up to two additional weeks, if possible, are completed with on-the-job shadowing. Both staff received training in Protective Action Response (PAR), suicide prevention, and child abuse reporting plus certification in cardiopulmonary resuscitation (CPR), first aid, and automated external defibrillator (AED) prior to having contact with youth. G4S submitted the pre-service training plan for all their programs to the Department s Office of Staff Development and Training, which was approved February 24, 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 were reviewed with three being applicable for in-service training requirement during the 2016 calendar year. All three staff exceeded the required twenty-four hours of in-service training. One staff had forty-eight hours, another had fifty-three hours, and the third had fifty-two hours. All three staff completed an eight-hour Protective Action Response (PAR) refresher training and each received training and or certification in cardiopulmonary resuscitation (CPR) and first aid. Each staff completed at least six hours of suicide prevention training, as well as professionalism and ethics training. Two supervisor training files were reviewed and revealed each met, or exceeded, the eight-hour supervisory training requirement. Both of those supervisors had seventeen hours. The program submitted the in-service training plan to the Department s Office of Staff Development and Training, which was approved February 10, Office of Program Accountability Page 12 of 61 (Revised July 2016)

17 1.09 Grievance Process Training Compliance Program staff shall be trained on the program s youth grievance process and procedures. Training on the grievance policy is part of the pre-service training plan. A review of five staff training files found all staff were trained on the grievance process during pre-service training. Staff also receive annual refresher training on the grievance process Grievance Process Compliance The program adheres to their grievance process and shall ensure it is explained to youth during orientation and grievance forms are available throughout the facility. The program has an informal Let s Talk process to address youth minor concerns in an informal manner. These forms allow youth to request to speak to any staff member or staff position regarding their concern. The program s grievance procedure, as confirmed by the Facility Administrator during an interview, includes an informal, formal, and appeal phase. The informal phase allows the youth to address concerns with the staff and encourages communication between the youth and staff. Staff should respond to the informal phase within seventy-two hours. A youth may submit a formal grievance in which the grievance officer will review the grievance within seventy-two hours and render a solution. If the youth is not in agreement to the resolution, the youth may choose to appeal the resolution. All appealed grievances are reviewed by the facility administrator as expeditiously as possible. During observations, it was noted the Let s Talk and grievance forms are available in the youth s dorm and easily accessible. Youth interviews confirmed youth understand and use the grievance process. Five youth were surveyed concerning the program s grievance process and one responded the process is very good, one said it was good, one said it was fair, and two youth reported they have never filed a grievance. Each of the five surveyed youth responded they can request assistance when filing a grievance. Five staff were surveyed on whether the youth could get help filling out his grievance form and from whom. All five responded that the youth could get help from direct care staff, supervisory staff, and the case managers. Four reported that they could get help from administrative staff and one responded other. Five staff members were interviewed and each could explain the process for the youth to file a grievance Grievance Process Documentation Compliance Completed grievances shall be maintained by the program for a minimum of twelve months. The program has a policy and procedure concerning informal grievance, formal grievances, and their appeal process. Let s Talk forms are used as an informal grievance and usually concern a need or want to talk with a certain staff member or staff position. The Let s Talk forms document the youth s topic to be discussed, requested solution, staff feedback, and youth and staff signatures. The program has and maintains all Let s Talk forms for at least a year. The formal grievance form is used for other more serious matters. A review of the last twelve months revealed there were six formal grievances. Grievances were related to education, discipline, mental health, and disruption of a phone call. All six forms were addressed and resolved during the formal phase, within the seventy-two-hour time frame in accordance with policy. Five youth were surveyed concerning the program s grievance process and one responded the process is Office of Program Accountability Page 13 of 61 (Revised July 2016)

18 very good, one said it was good, one said it was fair, and two youth reported they have never filed a grievance Life Skills Training Provided to Youth Compliance The program shall provide interventions or instruction focusing on developing life and social skill competencies in youth. The program provides the evidenced-based Life Skills Training (LST). This group is provided to all youth. The program has three staff trained in LST. Documentation confirmed the program provided two LST groups per week, from February to April 2016, June to August 2016, and just started a new group in December. There were gaps in service delivery waiting for enough youth to start another group. Five youth were surveyed and each replied they provided time to demonstrate their new skills Staff Training: Delinquency Interventions Compliance Staff whose regularly assigned job duties include implementation of a specific delinquency intervention model, strategy, or curriculum receive training in its effective implementation. Jacksonville Youth Academy is contracted to deliver Impact of Crime (IOC), LifeSkills Training (LST), Cannabis Youth Treatment (CYT), and Young Men s Work (YMW). A number of staff have been trained and currently are facilitating and being evaluated for theses curriculums. Two staff members provide IOC and LST. Additionally, there are three staff actively providing CYT and YMW. The program has more facilitators who have already been trained but are not currently facilitating a session. There are five additional staff who have received training to facilitate IOC and four more staff members which are trained to facilitate LST. According to the Facility Administrator, staff are selected based on their education and work experience Restorative Justice Awareness for Youth Compliance The program shall provide activities or instruction intended to increase youth awareness of, and empathy for, crime victims and survivors, and increase personal accountability for youths criminal actions and harm to others. The program provides Impact of Crime (IOC) groups as their restorative justice awareness program. The program schedules IOC twice a week, Tuesday and Thursday at 6:00 p.m. to 7:00 p.m. This schedule was confirmed during the interview of the Facility Administrator. A review of documentation supports IOC groups are conducted as scheduled two times a week. Documentation confirms when one IOC group is completed, another one starts. There was a gap from one IOC completed in March and the next one did not start until May. All youth receive the IOC curriculum during their admission. The training files for staff who facilitate IOC groups indicated staff have been trained in the curriculum. The program provided documentation of several community service projects in which the program had participated. These projects include helping Potter House Christian Academy remake their entire playground, planting flowers, and doing other gardening chores; baseball buddies, a project where the youth assisted individuals with special needs to play softball; every other Friday help feed the homeless at the Salvation Army; assist with the displays, carry new items to the floor, and sometimes helping repair furniture at the Habitat for Humanity ReStore; speak at local churches; and spoke at the Fourth Annual Save Our Sons Summit which was hosted by a local pastor. Office of Program Accountability Page 14 of 61 (Revised July 2016)

19 1.15 Delinquency Intervention Services Compliance The program shall implement a delinquency intervention model or strategy that is an evidencebased practice, promising practice, or a practice with demonstrated effectiveness, for each youth. The facility administrator was interviewed and confirmed the program provides Life Skills Training (LST) and Cannabis Youth Treatment (CYT) as evidence-based practices facilitated by trained staff. It also provides the Impact of Crime (IOC) curriculum, which has been identified as a practice with demonstrated effectiveness. The program provides both LST and IOC groups two times per week each. CYT group is provided once per week. Five youth case management records were reviewed for delinquency intervention services in the performance summaries. All five youth performance summaries stated the youth will attend and participate in a list of particular delinquency intervention groups. The master log and the attendance rosters documents when groups were given Gender-Specific Programming Compliance The program provides delinquency intervention and gender-specific treatment services. The Facility Administrator was interviewed and stated the program utilizes the Young Men s Work (YMW) curriculum as the gender specific intervention provided to the youth. YMW is conducted once a week. Attendance rosters for the YMW topics along with the master log documents the therapy groups receive the training as scheduled. YMW include taking care of myself, act like a man, creating and maintaining good relationships, creating family, and getting by in life. The program also provides an opportunity for the youth to obtain personal hygiene products every other week through the canteen incentive program. Five youth case management records were reviewed for YMW groups and did not find YMW mentioned in either the performance plan or performance summaries. Gender specific groups are not identified as an intervention on the performance plan or the performance summaries Logbook Entries and Shift Report Review Compliance The program maintains a chronological record of events, incidents, and activities in a central log-book maintained at master control, living unit logbooks, or both, in accordance with Florida Administrative Code. The program ensures direct care staff, including each supervisor, are briefed when coming on duty. The program maintains a chronological record of events, incidents, and activities in a central logbook maintained at master control, in accordance with Florida Administrative Code. The last six months of logbooks for the program were reviewed. The logbooks were bound with no missing pages. There was no evidence of correction fluid being used and no eraser marks. Errors were corrected using a single line through the error and the initials of the person making the correction. The date was located at the top of each page and there was a time listed for each entry. If the entry was a late entry, it was identified and included, the time of the actual event and all entries were signed. The entries were brief descriptions of events and included the names of youth and staff involved. Formal and informal counts were documented, as required. The program s policy is to record a count every hour. Internal and external perimeter checks were documented in the logbooks. A shift report is part of each day s log. The shift supervisors made entries indicating they have reviewed the entries from the previous two shifts. Shift reports Office of Program Accountability Page 15 of 61 (Revised July 2016)

20 were signed by all the staff going off, and coming on duty. Administrative, mental health, medical, drills, and contraband issues are logged and highlighted according to a color code 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. As confirmed by the Facility Administrator s (FA) interview, the program maintains an internal alert system which includes utilization of an alert board and addresses medical, mental health, gang activity, sport restrictions, violent behavior, escape, and security alerts. The program also maintains a separate internal medical alert which includes medical alerts, dental alerts, diet, allergies, and sport restrictions. The program has designated staff in each department to enter alerts into the Department s Juvenile Justice Information System (JJIS). The FA reported alerts are reviewed daily at the management meetings. Only the licensed mental health and medical staff can recommend down grading or discontinuing a youth on alert status. The program s internal alerts, both the alert board and medical alerts, were consistent with those alerts listed in JJIS 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. When risk factors and or special needs are identified during or subsequent to the classification, the program enters this information into the Department of Juvenile Justice Information System (JJIS). All alerts entered into the JJIS match with the program s internal alert system. Alerts no longer active are closed as necessary. Only authorized staff in each department have access and permissions to enter and make adjustments to alerts in JJIS. The facility administrator reported that alerts are reviewed daily at the management meetings Educational Access Compliance The facility shall integrate educational instruction (career and technical education, as well as academic instruction) into their daily schedule in such a way ensuring the integrity of required instructional time. The program s activity schedule was reviewed and the head teacher was interviewed verifying school is conducted from 7:30 a.m. to 2:05 p.m., five days a week, and meets the 300 minutes of education daily requirement and the twenty-five-hour weekly requirement. The youth are able to obtain certifications in First Aid, cardiovascular pulmonary resuscitation (CPR), Microsoft Word, Occupational Safety and Health Administration (OSHA), and food handling. The students are taking a career class to focus on career choices. The master control log is annotated when school begins and ends including lunch breaks. An entry is also made when a student is removed from class for any purpose. Office of Program Accountability Page 16 of 61 (Revised July 2016)