BUREAU OF MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR

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1 S T A T E O F F L O R I D A D E P A R T M E N T O F J U V E N I L E J U S T I C E BUREAU OF MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR Dade Youth Academy G4S Youth Services, LLC (Contract Provider) South West 424 th Street Florida City, Florida Review Date(s): May 2-5, 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 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: Sharon Coplin, Office of Program Accountability, Lead Reviewer (Standard 1) Nicos Antonakos, Office of Program Accountability, Technical Assistance Specialist (SPEP, Surveys and Interviews) Teves Bush, Office of Program Accountability, Regional Monitor (Standard 5) Stacey Dunkel, DJJ Probation, Circuit 17, Juvenile Probation Officer Supervisor (Standard 2) Paula Friedrich, Office of Program Accountability, Regional Monitor (Standard 4) Tonya Gittens, Office of Program Accountability, Regional Monitor (Standard 2) Maryann Sanders, Office of Program Accountability, South Deputy Regional Monitoring Supervisor, (Standard 3)

3 Program Name: Dade Youth Academy QI Program Code: 1418 Provider Name: G4S Youth Services, LLC Contract Number: Location: Miami-Dade County / Circuit 11 Number of Beds: 24 Review Date(s): May 2-5, 2017 Lead Reviewer Code: 123 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 1 # Case Managers 1 # Clinical Staff # Food Service Personnel 2 # Healthcare Staff # Maintenance Personnel # Program Supervisors 3 # Staff 5 # Youth 12 # Other (listed by title): Regional Compliance Manager, Human Documents Reviewed Resource Personnel, Recreation Therapist, Assistant Facility Administrator, Career Education Teacher, G4S Trainers, and Youth Care Workers Accreditation Reports Affidavit of Good Moral Character CCC Reports Confinement Reports Continuity of Operation Plan Contract Monitoring Reports Contract Scope of Services Egress Plans Escape Notification/Logs Exposure Control Plan Fire Drill Log Fire Inspection Report Fire Prevention Plan Grievance Process/Records Key Control Log Logbooks Medical and Mental Health Alerts PAR Reports Precautionary Observation Logs Program Schedules Sick Call Logs Supplemental Contracts Table of Organization Telephone Logs Surveys Vehicle Inspection Reports Visitation Logs Youth Handbook 7 # Health Records 5 # MH/SA Records 28 # Personnel Records 21 # Training Records/CORE 11 # Youth Records (Closed) 9 # Youth Records (Open) # Other: 5 # Youth 3 # 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 68 (Revised July 2016)

4 Standard 1: Management Accountability Residential Rating Profile Indicator Ratings 1.01 Standard 1 - Management Accountability * Initial Background Screening 1.02 Five-Year Rescreening Limited 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). Residential Quality Improvement Report Office of Program Accountability Page 4 of 68

5 Standard 2: Assessment and Performance Plan Residential Rating Profile Indicator Ratings Standard 2 - Assessment and Performance Plan 2.01 Initial Contacts to Parent/Gaurdian 2.02 Court Notification 2.03 Youth Orientation 2.04 Written Consent of Youth Eighteen or Older Non-Applicable 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 68 (Revised July 2016)

6 Standard 3: Mental Health and Substance Abuse Services Residential Rating Profile Indicator Ratings Standard 3 - Mental Health and Substance Abuse Services 3.01 Designated Mental Health Clinician Authority or Clinical Coordinator 3.02 * Licensed Mental Health and Substance Abuse Clinical Staff 3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff 3.04 Mental Health and Substance Abuse Admission Screening 3.05 Mental Health and Substance Abuse Assessment/Evaluation 3.06 Mental Health and Substance Abuse Treatment 3.07 * Treatment and Discharge Planning 3.08 * Specialized Treatment Services 3.09 * Psychiatric Services 3.10 * Suicide Prevention Plan 3.11 * Suicide Prevention Services 3.12 * Suicide Precaution Observation Logs 3.13 * Suicide Prevention Training 3.14 * Mental Health Crisis Intervention Services 3.15 * Crisis Assessments 3.16 * Emergency Mental Health and Substance Abuse Services 3.17 * Baker and Marchman Acts 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 68 (Revised July 2016)

7 Standard 4: Health Services Residential Rating Profile Indicator Ratings Standard 4 - Health Services 4.01 * Designated Health Authority/Designee 4.02 * Psychiatrist/Designee 4.03 Facility Operating Procedures 4.04 Authority for Evaluation and Treatment 4.05 Parental Notification 4.06 Notification - Clinical Psychotropic Progress Note 4.07 Immunizations 4.08 Healthcare Admission Screening Form 4.09 Medical Alerts 4.10 Youth Orientation to Healthcare Services 4.11 Designated Health Authority/Designee Admission Notification 4.12 Healthcare Admission Rescreening 4.13 Health Related History 4.14 Comprehensive Physical Assessment 4.15 Female-Specific Screening/Examination Non-Applicable 4.16 Tuberculosis Screening 4.17 Sexually Transmitted Infection Screening 4.18 HIV Testing 4.19 Sick Call Process - Requests/Complaints 4.20 Sick Call Process - Visits/Encounters 4.21 Restricted Housing Non-Applicable 4.22 Episodic/First Aid Care 4.23 Emergency Care 4.24 Off-Site Care/Referrals 4.25 Chronic Illness/Periodic Evaluations 4.26 Medication Management - Verification 4.27 Medication Management - Orders/Prescriptions 4.28 Medication Management - Storage 4.29 Medication Management - Medication and Sharps Inventory 4.30 Medication Management - Controlled Medications 4.31 Medication Management - Medication Administration Record 4.32 Medication Management - Medication Administration By Licensed Staff 4.33 Medication Management - Medication Provided By Non-Licensed Staff 4.34 Medication Management - Psychotropic Medication Monitoring 4.35 Infection Control - Surveillance, Screening, and Management 4.36 Infection Control - Education 4.37 Infection Control - Exposure Control Plan 4.38 Prenatal Care - Physical Care of Pregnant Youth Non-Applicable 4.39 Prenatal 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 68 (Revised July 2016)

8 Standard 5: Safety and Security Residential Rating Profile Indicator Ratings Standard 5 - Safety and Security 5.01 Youth Supervision Limited 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 Non-Applicable 5.28 Controlled Observation Non-Applicable 5.29 Controlled Observation Safety Checks Non-Applicable 5.30 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 68 (Revised July 2016)

9 Strengths and Innovative Approaches Each week, the faith-based network sponsors five youth from the program to attend a Microsoft Outlook training located in Dadeland Mall. On a quarterly basis, the program holds a Family Day where families are provided the opportunity to add drawings to the program s recreation area murals. Twice a week, the local group, Motivational Edge, comes to the program and meets with youth in order to conduct lyrical expressions and audio recordings. Farm Share is a restorative justice project where youth in the program participate monthly in sorting donated food. Bridge to Home is another restorative justice project in which youth are able to participate by serving food to families and cleaning up afterwards. Gifted Love is a community-based organization who works with the youth on-site and in the community on restorative justice projects. I Am Affiliated and Brotherhood Initiative provides mentoring services for youth in the program. All youth enrolled in Dade Youth Academy are eligible to participate in and receive a SafeServ food handling class and certification. The program creates a monthly newsletter which features program events and celebrates the accomplishments of both the staff and program. The program reported 100% of youth who participated in the General Educational Diploma (GED) program received their GED diploma. Office of Program Accountability Page 9 of 68 (Revised July 2016)

10 Standard 1: Management Accountability Overview Dade Youth Academy is a twenty-four bed program for males ages thirteen to eighteen and is co-located on the grounds of Dade Juvenile Residential Facility. The program is a non-secure residential commitment program operated by G4S Youth Services, LLC, which is a contracted provider with the Department. The provider is contracted to provide innovations in delinquency programming for male youth including mental health overlay services, evidence-based delinquency interventions, and mental health and substance abuse treatment services. The contractual agreement between G4S and the Department, executing Dade Youth Academy, was effective June 1, 2016, and the program was in full execution effective July The program has one dormitory/living area (Alpha Dorm) for the twenty-four bed program. The dorm is an open-bay living area with a sub-control office. A complete walk-through of Dade Youth Academy on May 5, 2017, with the facility administrator (FA), assistant facility administrator (AFA), and physical plant manager included the nurse station, Alpha dorm, school, and cafeteria. During the observation, it was noted in the nurse station a broken floor tile behind the examination table. Observation of Alpha dorm noted vinyl baseboards loose, a missing tile on the bathroom wall, rust and mold in the showers and on the shower curtains. The physical plant manager indicated he has begun to use a new product to clean and remove mold from the showers. The program has replaced the urinals in the Alpha dorm. An observation of the school classrooms found broken tiles in the restroom and broken drywall in the library behind a bookshelf. Graffiti was also observed in the dorm areas and classroom, but was removed while the annual compliance review team was on-site. There are some physical plant projects which have been earmarked by the Department and were approved for completion. These projects include replacing doors, windows, all light fixtures, and heating, ventilating, and air-conditioning (HVAC) diffusers in the dorm and hardening the fire alarm system with vandal-restraint strobes, exit signs, and pull stations. Contractors have been on-site to take measurements, but had not begun any work at time of the annual compliance review. The management accountability consists of the FA, AFA, human resource personnel, physical plant manager, staff development specialist, a unit manager, four shift supervisors, health services manager (HSM), director of clinical services (DCS), director of case management (DCM), the designated health authority (DHA), psychiatrist, training coordinator, and a certified behavioral analyst (CBA). The anticipated average length of stay in the non-secure residential program is between six to twelve months, depending upon each youth s successful completion of the individualized treatment plan goals. Education services are provided by Miami-Dade County School District 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 written policy and procedures requiring compliance with the Department s background screening requirements. Background screenings are mandatory for all employees, with access to youth, to ensure eligibility of established statutory requirements of good moral character. Therefore, the Department has established stringent screening requirements for all Department personnel, contracted providers, mentors, interns, and volunteers utilizing Level 2 Office of Program Accountability Page 10 of 68 (Revised July 2016)

11 Screening Standards, as required by Florida Statutes Neither the Department nor contracted provider shall hire any applicant without a rating of eligible on the background screening. An applicant with an ineligible rating must receive an approved exemption from disqualification by the Department. A review of the background screenings for each of the forty newly hired staff, since the last annual compliance review, found each new staff had received a background screening prior to hire and the rating for each staff was eligible through the Department s Office of the Inspector General Background Screening Unit (BSU). The Affidavit of Compliance with Level 2 Background Screening Standards was submitted to the BSU on January 17, 2017, meeting the annual requirement Five-Year Rescreening Limited 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 maintains a written policy and procedures for the five-year rescreening process, which outlines a tracking system to monitor staff due dates. A rescreening is completed every five years calculated from the original agency hire date. Five-year rescreens shall not be completed more than twelve months prior to the staff s five-year anniversary date. Rescreening forms must be submitted to the Department s Office of the Inspector General Background Screening Unit (BSU) within ten days prior to the five-year anniversary date. A review of the program s staff roster with original hire dates revealed fifteen staff were applicable for a fiveyear rescreening. Three of the fifteen re-screenings are due in June 2017, and one of the fifteen I,s due May 21, The remaining eleven five-year rescreenings were due between June 2016 and March A review of the eleven staff personnel files found six of the rescreenings had been submitted for clearance, within the required time frame and received an eligible rating from the Department s BSU. The remaining five rescreenings were submitted less than ten business days prior to the staff s anniversary date. One of five re-screenings was submitted less than the ten-day requirement; however, the clearance was completed on the staff s five- year anniversary date. One of the five re-screenings was submitted and completed three months after the staff s five-year anniversary date, the remaining three five-year rescreenings were submitted twelve days, five days and four days respectively after the staff s anniversary date 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. Office of Program Accountability Page 11 of 68 (Revised July 2016)

12 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 shall provide an environment in which youth, staff, and others feel safe, secure and not threatened by any form of abuse or harassment. Five youth were surveyed and each reported feeling safe in the program. During a tour of the program, postings of the Florida Abuse Hotline telephone number and the Central Communications Center for youth eighteen years of age and older were observed on the walls in the living area and other locations throughout the program. Youth and staff having unhindered access to report alleged abuse to the Florida Abuse Hotline pursuant to Florida Statues Section (1) (a) was validated by five youth who unanimously responded no to the survey question, have you ever been stopped from reporting abuse to the Florida Abuse Hotline since you have been at this program? The program provides each youth with a resident handbook, which outlines the procedures in which youth are able to report abuse to outside authorities, without interference or retaliation of any kind. Youth are to request an abuse call and the staff must notify the shift supervisor and/or administrative duty officer (ADO) in a timely manner. Youth will then be given the opportunity to place an abuse call within a reasonable time frame and are asked to complete an abuse call form to track the matter if the call is accepted. Youth are asked to be patient when requesting an abuse call and to be truthful when making the call and completing the abuse call form. Three staff reported being able to report abuse as deemed necessary, as defined in the program s policy and procedures for abuse reporting. The environment is free of physical, psychological, and emotional abuse. Five youth each reported staff are respectful when speaking to them and other youth. However, in the same survey three youth responded never hearing staff using curse words or threatening them or other youth, and two youth responded occasionally hearing staff threaten and use curse words when speaking directly to youth. Three staff were surveyed and denied ever hearing another staff threaten, curse or stop a youth from making and abuse call. A review of the program s thirteen Central Communications Center (CCC) reportable incidents for the past nine months (inception of the program) found no substantiated allegations of abuse. Staff are required to adhere to a code of conduct, which is discussed during new hire orientation and included in the employee handbook 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 has developed a written policy and procedures regarding incident reporting, which was signed by the facility administrator (FA) and the corporate administrator on August 22, Attached to the written policy on incident reporting is a policy on ethics and values. According to the FA, all staff are trained during their pre-service phase of employment on contacting the Florida Abuse Hotline and the Department s Central Communications Center (CCC). The program had two internal incidents of physical, psychological, or emotional abuse in the past nine months and immediate action was taken by management. One staff violated facility operating procedure 10-3-Contraband Control and Searches and was terminated from employment with the provider. The second incident involved staff violating G4S Standard of Conduct- Major #: 1- staff will be in regular attendance and are expected to work as scheduled. Management provided the second staff with a warning for previous violations of standard code of conduct and eventually terminated the staff for subsequent violations. Office of Program Accountability Page 12 of 68 (Revised July 2016)

13 1.05 Incident Reporting (CCC) Compliance Whenever a reportable incident occurs, the program notifies the Department s Central Communications Center (CCC) within two hours of the incident, or within two hours of becoming aware of the incident. The program has a written policy and procedures to address the process of incident reporting. 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. A review of the program s incident report binder included all internal incident reports. The internal incident notebook maintained by the provider contained all internal incidents. Documentation reviewed for the thirteen reportable CCC reports indicated the program notified the CCC within the required two-hour time frame. An interview with the facility administrator confirmed this practice 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. The program maintains a policy and procedures related to Protective Action Response (PAR). The program s approved PAR was signed by all pertinent parties from the program and the Department s Office of Staff Development and Training on February 10, All staff are familiar with Florida Administrative Rule 63H-1, as every staff with direct supervision and care of youth are required to complete forty hours of PAR training, within the first 180-days of hire, for pre-service training with an eight-hour refresher course annual requirement for in-service training. The program had a total of thirty-four PAR reports for the past six months. The facility administrator (FA) reports the increase in PAR numbers from last year resulting from the administration over reporting incidents. The issue of increased PARs was identified, handled, and resolved by management. The program s PAR rate is 6.24 which is above statewide average of A review of five written PAR reports found reports were completed for each of the PAR incidents selected from the monthly PAR reports submitted to the Department. Youth who were involved with a straight arm to takedown technique each received a medical review. A PAR report, dated April 2, 2017, indicated a straight arm to takedown had involved two staff; however, only one had completed a written statement completed. Another PAR report, dated December 11, 2016, revealed an altercation between two youth where a code blue had been called and ground control technique was used on one youth and an escort technique was used on the other youth. Only the staff using ground control wrote a statement. Each PAR incident was reviewed by a PAR-certified instructor. Each reviewed PAR indicated they were also reviewed by the FA within 72 hours and a post-par interview was conducted with each applicable youth. According to residential program operations, the monthly PAR reports are submitted timely and compiled into a report sent to Department headquarters. The interviewed FA indicated PAR reports are reviewed by shift managers and the assistant facility administrator. PARS are reviewed through video when possible. PAR reports are entered into a data base and maintained in a binder. Office of Program Accountability Page 13 of 68 (Revised July 2016)

14 1.07 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 program policy and procedures titled, Staff Development and Training, ensures all newly hired staff are sufficiently prepared to meet the needs of the facility and youth in the program s care. The policy further addresses compliance with training requirements, in accordance to Training Rule 63H-2, Protective Action Response (PAR) Rule 63H-1, Florida Administrative Code (F.A.C.), facility licensure, contract, accreditation, and certification. The policy defines direct care staff as persons having direct contact with youth for the purpose of providing care, supervision, custody, or control. These staff are identified as youth care workers (YCWs), shift managers, therapists, and case managers. The program s policy indicates all pre-service training includes a minimum of 120-hours of training for direct care staff, which can be computer-based and/or instructor-led topics, and shall be completed within the first thirty-days of employment. The program s pre-service training plan was submitted to the Department s Office of Staff Development and Training (SD&T) and signed on February 24, 2016, and also included three weeks of required training, totaling forty hours each week. The new training plan for 2017 was submitted and signed by SD&T on January 30, A review of five staff pre-service training files found documentation of the program s documented practice requiring new hire staff to complete all required pre-service training requirements within the first thirty-days of employment 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. The program s in-service training plan was submitted to the Department s Office of Staff Development and Training on January 30, In-service training includes three days of instructor-led training topics, meeting the mandatory training requirements for twenty-four hours of annual training, as well as the required Department Learning Management (SkillPro) trainings. Supervisory staff are also required to complete an additional eight hours of management training. A review of five staff training files (two supervisory staff and three direct care staff) validated the program s practice of ensuring all staff complete the required mandatory trainings which are documented in the Department s Learning Management System (Skill Pro). All staff have met the requirement for annual training in accordance with the approved in-service training plan Grievance Process Training Compliance Program staff shall be trained on the program s youth grievance process and procedures. The program maintains a pre-service training plan for all newly hired staff to follow and complete. All program staff are trained during orientation, and annually thereafter, on the program s youth grievance process and procedures. According to the 2016 annual pre-service Office of Program Accountability Page 14 of 68 (Revised July 2016)

15 training calendar, the training occurs during week two, designated in the Department s Learning Management System (SkillPro) as G4S New Hire Orientation Week 2. The in-service training calendar indicates the training occurs during the third day of in-service training designated as G4S Annual In-service Day 3 in the Department s Learning Management System (SkillPro). The program s grievance process training was validated by a review of five staff pre-service training files and five staff in-service training files 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 written procedures specifying the process for youth to grieve the actions of program staff and/or the conditions or circumstances in the program related to the violation or denial of basic rights. The procedures establish each youth s right to grieve and ensures each youth is treated fairly, respectfully, without discrimination, and their rights are protected. All youth are oriented to the grievance process during the admission orientation. The program s policy indicates there is no time frame for youth to file a grievance and there is nothing which prohibits the youth from filing a grievance without first using the informal compliant and resolution steps. The grievance process shall include an external level of control and staff shall encourage informal resolution of complaints on the lowest level possible and encourage twoway communication between staff and youth. However, all youth have access to formal grievance procedures allowing each youth the opportunity to grieve actions, errors, and omissions which violate their rights. The grievance forms are placed on the wall in a file holder which is accessible to all youth in the living/dorm area. The grievance box, which is locked on the opposite wall of the grievance forms, is accessible to youth and staff to drop grievance forms in the box. Staff were surveyed and all three indicated an understanding of the grievance process. Five youth were surveyed and asked to rate the grievance process, of which two youth rated the process as fair, one youth rated the process as good, one rated it as poor, and one youth indicated never using the grievance process Grievance Process Documentation Compliance Completed grievances shall be maintained by the program for a minimum of twelve months. The program has developed a written policy and procedures addressing the grievance process, inclusive of the retention of the grievance forms. The program maintained the written grievances from July 2016, the month of the program s effective date, to the present date. The program had forty-five grievances filed from December 2016 through March A review of five grievance forms found youth participation, supervisory oversight, and a final outcome. A survey of five youth indicated four youth answered they are able to request assistance when filling out a grievance form. The remaining youth reported he never filed a grievance. Office of Program Accountability Page 15 of 68 (Revised July 2016)

16 1.12 Life Skills Training Provided to Youth Compliance The program shall provide interventions or instruction focusing on developing life and social skill competencies in youth. A review of the program s life skills curricula found Living In Balance, 100 Interactive Activities for Mental Health and Substance Abuse Recovery, A Journey through Emotional, Social, Cognitive, and Self-Development Program (designed to be used with sixth through eighth grade youth), Young Men s Work, Don t Let Your Emotions Run Your Life for Teens, Skill Streaming The Adolescent (third edition), and The Teen Relationship Workbook, each meeting the definition and guidelines for life skills and focused and addressing the identified topics according to Florida Administrative Rule 63E (2)(d) (2a) and contractual requirements. A review of the program s daily schedule documented daily groups were conducted. A review of the group and recreation schedule documented the exact day of the week, time, and length of each group for the identified life skills intervention the Alpha living unit. A review of the sign-in sheets for three different interventions found the twenty-four youth in Dade Youth Academy were participating in a life skills intervention group 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. Education and work experience are considered by the facility administrator when determining which staff would be most appropriate for the delivery of delinquency intervention services. A review of seven files for staff with responsibilities for delivery of delinquency intervention models, such as life skills groups, Teen Relationships, Thinking for a Change (T4C), and Impact of Crime (IOC) found staff were trained for delivery of T4C, IOC, and the therapist conducting therapeutic sessions had the required education and work experience. In an interview with the facility administrator (FA), he stated youth are reviewed prior to admission and accepted based upon their history and diagnosis. There is then a classification meeting before youth arrive where the treatment team discusses the youth s placement and how best to serve their needs. Youth are assigned to a specific dormitory with a therapist and case manager who will focus on the youth s unique individual needs. The FA further added placement of youth in a dormitory where positive rapport is already established can only benefit the youth s acceptance into a new living environment 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 activities or instruction intended to increase youth awareness of, and empathy for, crime victims and survivors, as well as increase personal accountability for a youth s criminal actions and harm to others. The program provides activities which involve restorative justice and accountability. Documentation of youth risk assessments, transition services manager input, case management chronological notes, and community service hours completed by youth were provided as examples of restorative justice activities for youth. Bridge to Home is a restorative justice project in which youth participate by serving food to families and Office of Program Accountability Page 16 of 68 (Revised July 2016)

17 cleaning up afterwards. Gifted Love is a community-based organization which works with the youth on-site and in the community on restorative justice projects. I Am Affiliated and Brotherhood Initiative are mentoring services for youth in the program which also addresses restorative justice. All staff receive restorative justice training during G4S orientation training and the annual in-service training. A review of the program s daily activity schedule found restorative justice activities were listed and the program was also able to provide a list of innovative activities conducted in the community with the youth. The facility administrator confirmed the types of restorative justice awareness activities for the program are community outings, Farm Share, murals, Hands of Love community feeding and nursing home visits with youth creating valentine s cards for the residents 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. A review of the contract requirements revealed the provider shall provide a program utilizing evidence-based or promising interventions, modalities, and practices designed to reduce the influence of specific risk factors related to reoffending behavior, based upon each youth s assessment. A review of the program s pre-service training plan documented all newly hired staff are trained on the program s treatment model of evidence-based services during orientation training. The program s written description addresses the delinquency intervention strategies utilized which are documented evidence-based practices and promising practices. Thinking for A Change (T4C), Impact of Crime (IOC), and Teen Relationships are the strategies implemented by the program for each youth. The sign-in sheets for the primary services Teen Relationships, T4C, and IOC documents the groups are being delivered as designed. A review of the program s activity daily schedule validates the program provides structured, planned programming or activities sixty-three percent of youth s awake hours. Five youth performance plans were reviewed and each youth s plan included a delinquency intervention service, based on the youth s needs. The facility administrator reports the program s delinquency intervention model is the evidence-based model T4C Gender-Specific Programming Compliance The program provides delinquency intervention and gender-specific treatment services. The program provides delinquency intervention and gender-specific treatment services which address the needs of the targeted group. Health and hygiene, physical environment, life and social skills training, recreation and leisure activities are included in the program s genderspecific programming. Youth participate in gender-specific groups such as Young Men s Work, Teen Relationships, presented from a male perspective, conducted twice a week, for one hour each session. The program s recreational schedule includes sports and exercise geared for male participants only and is scheduled Monday through Friday, for an hour each day 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. Office of Program Accountability Page 17 of 68 (Revised July 2016)

18 The program policy and procedures regarding logbooks indicates the program shall maintain and properly document a logbook system to record routine and emergency situations involving youth and all other critical aspects of the program. Additionally, the logbook system serves as a communication network for staff members from shift-to-shift and serves as a data and information source for administrative and supervisory reviews. Dade Youth Academy utilizes a single logbook maintained by master control and shift report reviews. Shift supervisors facilitate a verbal shift report at the beginning of each shift to ensure the direct care staff and next shift supervisor is briefed on events, incidents, and activities, which have been documented in master control s logbook prior to the start of the next shift. Incoming staff must sign and date shift reports for the previous shift indicating the information was reviewed or verbally briefed with staff. A review of the program logbooks for November and December 2016, and March 2017 found the entries to be legible, included the date and time of each event, the youth involved, and staff name making the entry in the logbook. There were no instances of strikethroughs or errors found in the reviewed logbooks. The logbooks included each of the thirteen documented calls/reports to the Central Communication Center (CCC). The logbooks reviewed were in compliance with program policy and Florida Administrative Code 63E A review of the program logbook for December 2016 found discrepancies, for example, on December 6, 2016 at 8:10 a.m., youth leaving the dorm (Alpha) to school and on December 8, 2016 at 7:40 a.m., youth leaving the dorm to school did not clearly document in the logbook whether the youth returned to school after lunch or when school ended. During an interview with the facility administrator, it was reported on a day without incidents, the school hours/routine for preparation and escorting youth to school from the living area is 7:20 a.m. and school ends 2:00 p.m. for youth. However, the actual time for youth arrival to school could vary day-to-day due to weather conditions and issues/circumstances involving youth behaviors, and other unforeseen matters occurring causing an adjustment to the printed schedule Internal Alerts System Compliance The program shall maintain and use an internal alert system easily accessible to program staff and keeps them alerted about youth who are security or safety risks, and youth with healthrelated concerns, including food allergies and special diets. When risk factors or special needs are identified during or subsequent to the classification process, the program immediately enters this information into its internal alert system. The program ensures only appropriate staff may recommend downgrading or discontinuing a youth s alert status. The program has developed a written policy and procedures to address youth with healthrelated concerns, mental health, safety, and security risks. The program s internal alert system is easily assessable to program staff, keeping them updated regarding youth who have been identified as security or safety risks, as wells as to youth with health-related concerns, including food allergies and special diets. Any direct care, supervisory, or clinical staff may place a youth on alert status if he meets the criteria for inclusion in the program s internal alert system. The program s procedures indicate these same staff are able to enter alerts in the Department s Juvenile Justice Information System (JJIS), and downgrading or discontinuing alerts in JJIS. Information documented on the program internal alert system was consistent with the alerts entered into JJIS for the five youth selected for review. The program s procedures indicate the medical staff are responsible for ensuring accuracy of the alerts and maintaining the required updates and downgrades to alerts. Office of Program Accountability Page 18 of 68 (Revised July 2016)

19 1.19 Alerts (JJIS) Compliance When risk factors or special needs are identified during or subsequent to the classification process, the program immediately enters this information into the Juvenile Justice Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are downgraded or discontinued. The program has developed a written policy and procedures to address youth with healthrelated concerns, mental health, safety, and security risks. When risk factors or special needs are identified during or subsequent to the admission classification process, the program immediately enters this information into the Department s Juvenile Justice Information System (JJIS). Upon recommendations from appropriate staff, JJIS alerts are downgraded or discontinued. The healthcare staff are responsible for verifying medical alerts and maintaining the program s internal alert system. A review of five youth face sheets in JJIS found medical alerts, history of chronic conditions and psychotropic medications, food allergies, and gang alerts were also included on the program s internal alert system 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. Students are required to participate in educational and career-related programs for 250-days of instruction, distributed over twelve months, for a minimum of twenty-five hours of instruction weekly. A review of the program s daily schedule documents educational instruction hours as 7:20 a.m. until 11:00 a.m., lunch is provided from 11:00 a.m. until 11:20 a.m., special treatment teams are held daily from 11:20 a.m. until 12:30 p.m., and youth return to school 12:30 p.m. until 2:00 p.m. The school schedule documents school hours from 7:40 a.m. until 2:10 p.m. The school calendar documents youth are receiving 240-days of instructional time and teachers work days are 251. Teachers will receive a total of eleven planning days from August 2016 to June The school provides Saturday school days to make up for teacher planning days. A review of the program logbook for December 2016 found discrepancies; for example, on December 6, 2016 at 8:10 a.m. youth leaving the dorm (Alpha) to school and on December 8, 2016 at 7:40 a.m., youth leaving the dorm to school did not clearly document in the logbook whether the youth returned to school after lunch, or when school ended. An interview with the facility administrator, revealed on days without incidents, the school hours/routine for preparation and escorting youth to school from the living area is 7:20 a.m. and school ends 2:00 p.m. for youth. However, the actual time for youth arrival to school could vary day-to-day due to weather conditions and issues/circumstances involving youth behaviors, and other unforeseen matters occurring, causing an adjustment to the printed schedule. The lead teacher was able to provide documentation of the school schedule. The school day includes six periods, with first period beginning at 7:40 a.m. and sixth period ending 2:10 p.m. Each class period is fifty minutes long with, a thirty-minute lunch period from 12:00 p.m. until 12:30 p.m. Courses are math, English, science, and history. Office of Program Accountability Page 19 of 68 (Revised July 2016)