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 Hillsborough Girls Academy G4S Youth Services, LLC (Contract Provider) 9506 East Columbus Drive Tampa, Florida Review Date(s): November 4-7, 2014 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES

2 PrevPage HilsboroughGirlsAcademy Behavioral/MentalHealthProgram (Opened8/1/11) QuarterlyDataFY NextPage Program Name Provider Program Group Program Type Open/Close HilsboroughGirlsAcademy G4SYouthServices, LLC HighRisk-Female Behavioral/MentalHealth (Opened8/1/11) AvgLengthofStay(Days) Escapes* Excessive/UnnecessaryUseofForceIncidents* MajorDeficiencies/CriticalIssues* PACTRisktoReofend HighRisk Moderate-HighRisk ModerateRisk LowRisk PARRate(per1,000filedbeddays)* PAR(ProgramType) PAR(Statewide) 1stQuarter 2ndQuarter 3rdQuarter 4thQuarter Total(FYTD) YouthArests 1 1 *Thisdatamaybereportedforco-locatedprograms Program Measures HilsboroughGirlsAcademy % 20% 7% 13% Foradditionalinformationaboutthisfacility,visithtp:/ % 31% 8% 8% % 23% 15% 15% % 18% 9% 18% % 23% 10% 14% PACTRisktoReofend FiscalYearToDate AnnualMeasures QualityImprovement(QI) ForacopyofthemostrecentQIReportvisit: htp:/ HighRisk Moderate-HighRisk ModerateRisk LowRisk FY ForthemostrecentCARandPAM Reports,visithtp:/

3 PrevPage HilsboroughGirlsAcademy Behavioral/MentalHealthProgram (Opened8/1/11) AnnualData(July1,2010-June30,2012) NextPage SeriousnessIndex Program TypeSeriousnessIndex Recidivism (YearofCompletion) Program TypeRecidivism Recidivism ExpectedvActual(Diference) Program TypeRecidivism ExpectedvActual(Diference) CompletionRate Program TypeCompletionRate StatewideCompletionRate TotalReleases SeriousnessIndex (YearofRelease) FY Recidivism (YearofCompletion) FY Recidivism Rate ExpectedvsActual(Diference) 0 0% 0% DataPending FY FY FY FY FY FY Legend Program Program TypeAvg StatewideAvg(CompletionRate) CompletionRates Program Releases 0% 0 FY FY FY FY Foradditionalinformationaboutthisfacility,visithtp:/

4 PrevPage HilsboroughGirlsAcademyMaxRisk Behavioral/MentalHealthProgram (Opened8/1/11) QuarterlyDataFY NextPage Program Name Provider Program Group Program Type Open/Close HilsboroughGirlsAcademy MaxRisk G4SYouthServices, LLC Maximum RiskMental Health-Female Behavioral/MentalHealth (Opened8/1/11) AvgLengthofStay(Days) Escapes* Excessive/UnnecessaryUseofForceIncidents* MajorDeficiencies/CriticalIssues* PACTRisktoReofend HighRisk Moderate-HighRisk ModerateRisk LowRisk PARRate(per1,000filedbeddays)* PAR(ProgramType) PAR(Statewide) 1stQuarter 2ndQuarter 3rdQuarter 4thQuarter Total(FYTD) YouthArests 1 1 *Thisdatamaybereportedforco-locatedprograms Program Measures HilsboroughGirlsAcademyMaxRisk 1 25% 25% 25% 25% Foradditionalinformationaboutthisfacility,visithtp:/ 1 40% 20% 20% 20% % 0% 33% 33% % 0% 25% 50% % 11% 26% 32% PACTRisktoReofend FiscalYearToDate AnnualMeasures QualityImprovement(QI) ForacopyofthemostrecentQIReportvisit: htp:/ HighRisk Moderate-HighRisk ModerateRisk LowRisk FY ForthemostrecentCARandPAM Reports,visithtp:/

5 PrevPage HilsboroughGirlsAcademyMaxRisk Behavioral/MentalHealthProgram (Opened8/1/11) AnnualData(July1,2010-June30,2012) NextPage SeriousnessIndex Program TypeSeriousnessIndex Recidivism (YearofCompletion) Program TypeRecidivism Recidivism ExpectedvActual(Diference) Program TypeRecidivism ExpectedvActual(Diference) CompletionRate Program TypeCompletionRate StatewideCompletionRate TotalReleases SeriousnessIndex (YearofRelease) FY Recidivism (YearofCompletion) FY Recidivism Rate ExpectedvsActual(Diference) 0 0% 0% DataPending FY FY FY FY FY FY Legend Program Program TypeAvg StatewideAvg(CompletionRate) CompletionRates Program Releases 0% 0 FY FY FY FY Foradditionalinformationaboutthisfacility,visithtp:/

6 PrevPage DEFINITIONSOFMEASURES NextPage AverageLengthofStay-ALOS(Days)Theaveragenumberofdaysthatayouthstaysinaparticularprogram.Thisiscalculatedby totalingthedaysservedforalyouthwhocompletedfrom aprogram (inthetimeperiodspecified)anddividingthisnumberbythetotal numberofyouthwhocompletedfrom theprogram. Source:JJIS,BureauofResearch&Planning. CompletionRate-Youthwhocompleteaprogram andreturntothecommunityareconsideredcompleters.whetherayouthisconsideredacompleterisbasedupon hisorherexitstatus.exitstatusisdeterminedbythefolowingfactors: Releasereason Therestrictivenesslevelofthenextcommitmentprogram,ifany Thetimebetweenthereleaseandnextcommitmentplacement ThenextplacementintheServiceHistorydata ThetimebetweenthereleaseandthenextServiceHistoryplacement Threeexitstatusesareconsideredprogram completions: Releasesfrom careandcustody(includingthosereleasedbecausetheyservedthemaximum term alowedbylaworreachedthe maximum ageofjurisdiction). Releasestopost-commitmentprobation. Releasestoconditionalrelease. Thecompletionrateisthepercentageofthoseyouthreleasedwhoareconsideredacompleter,asdefinedabove,ascomparedtothe totalofalyouthreleasedfrom aprogram. Source:JJIS,BureauofResearch&Planning. CriticalIssue-AnidentifiedCriticalIssueandorCriticalDeficiencyistheabsenceofacomponentessentialtoservicedeliveryorthe verificationthatthedeliveryofanessentialservicehasbeencompromised.thedeficiencyissodireoracutethatitpresentsapotentialthreattothehealthorsafetyoftheyouthserved,ormayotherwisecompromiseprogram security.criticalissuesrelatedtoescapes arenotcountedinthenumberreflectedinthisreportastheyarereportedseparately. Source:Regions(MonitoringandQIReviews) Escapes-Numberofindividualspereventwhoescapedfrom afacilityduringthereportingperiod. Source:CCC,OficeofResidentialServices. Excessive/UnnecessaryForceIncidents-ThenumberofincidentsreportedtotheCentralCommunicationCenter(CCC)duringthe reportingquarterthatresultinasubstantiatedfinding(s)ofunnecessaryand/orexcessiveuseofforce.eachspecificcccincidentwith substantiatedfindingsiscountedonce,regardlessofthenumberofstafwithsubstantiatedfindingsinvolvedinanincident.sincean incidentisonlycountedaftera substantiated findinghasbeenmade,thenumbersforaquartermaybeadjustedatsomepointinthe futuretoreflectupdatedfindings. Source:CCC,OficeofResidentialServices. Expectedrecidivism rate-toensurethatprogramsservingyouthwithdiferentdificultylevelsareheldtoreasonableandfairrecidivism standards,thedepartmentcalculatesanexpectedrecidivism rateforthegroupofyouthwhocompletedeachresidentialprogram duringthetimeperiodunderanalysis.programsthatserveyouthwithsignificantriskfactorsforreofendingwilhaveahigherexpected recidivism ratethanprogramsservingyouthwithlessriskfactors. Source:JJIS,BureauofResearch&Planning. MajorDeficiencies-Aprogram deficiencyand/orcontractualcomplianceissuethatresultsinaninteruptionineitherthedeliveryof servicesand/orthereceiptofpublicfundsforprogram servicesnotdelivered.amajordeficiencycanalsobebasedonrepeatedminor deficiencieswithnoindicationprogressisbeingmadetocorectthedeficiency.majordeficienciesaresignificantinnatureandtypicaly requireoversightbymanagementtoensuretheissuesareaddressedsystemicaly.thedeterminationofanissue(s)beinga majordeficiency ismadethroughthecontractmonitoringprocess.majordeficienciesrelatedtoescapesarenotcountedinthenumberreflectedinthisreportastheyarereportedseparately. Source:Regions(MonitoringandQIReviews) Foradditionalinformationaboutthisfacility,visithtp:/

7 PrevPage DEFINITIONSOFMEASURES(2) NextPage PACTRisktoReofend-ThePositiveAchievementChangeTool(PACT)isacomprehensiveassessmentthataddressesbothcriminogenicneedsandprotectivefactorsandidentifiesayouth srisktore-ofendaseitherlow,moderate,moderate-highorhigh.this measureisbasedontheyouthservedinthereportingquarter. Source:JJIS,BureauofResearch&Planning. PAM Score-ThePAM (Program AccountabilityMeasure)scoreisstandardizedgradeincorporatingbothprogram recidivism costeffectivenessandprogram costpercompletion.itpresentsrecidivism andcostefectivenessresultsfortheprogramsthatcompletedat least15youthduringtheone-yearperiodduringthetimeperiodunderanalysis. Source:JJIS,BureauofResearch&Planning. PARRate-PAR(ProtectiveActionResponse)istheDJJ-approvedphysicalinterventiontechnique,includingtheapplicationofmechanicalrestraints.TheuseofPAR,andstaftrainingrequirements,areoutlinedintheadministrativerules.ThePARrateisthenumberofPARincidentsper1000filedbeddaysduringthereportingperiod.Thestatewideaverageisbasedonalcurentlyoperating programsinthestateduringthereportingperiod. Source:Regions(ReportedbyPrograms);CompiledbyOficeofResidentialServices. Program Group-Identifiesthegenderandcommitmentrisklevelserved.Source:JJIS. Program Type-Identifiesthetypes ofspecializedtreatmentservicesprovidedbyaprogram,suchasmentalhealth,substanceabuse, sexofender.source:jjis. QualityImprovement-Thesystem usedfortheassessmentofprogram complianceinareassuchasmanagement,operations,and servicedelivery.source:bureauofqualityimprovement. Recidivism -Forresidentialcommitmentprograms,thetwelve-monthrecidivism-trackingperiodbeginsthedaythatayouthcompletes theprogram (asdefinedabove),including bothyouthwhoarereleasedfrom thecareandcustodyofthedepartmentandyouthwho arereceivingconditionalreleaseorpost-commitmentprobationservicesinanonresidentialseting.recidivism isdefinedasaladjudications,adjudicationswithheld,andconvictionsforanynewviolationoflawwithintwelvemonthsofprogram completion.recidivism is reportedbytheyearofprogram completion.forexample,youthwhocompleteandexitaprogram infy aretrackedforrecidivism foroneyearfolowingthedaytheyexittheprogram.althoughtheoneyeartrackingperiodmayrolintothefolowingfiscalyear (i.e.fy inthisinstance),therecidivism isreportedforthefiscalyeartheyouthexited(so,fy inthisexample). Source:JJIS,BureauofResearch&Planning. Releases-Thetotalnumberofyouthreleasedfrom theprogram betweenjuly1andjune30ofthefiscalyearunderreview,asreportedinthejuvenilejusticeinformationsystem (JJIS).Source:JJIS,BureauofResearch&Planning. SeriousnessIndex-Aweightingmethodologyinwhichofensesareassignedapointvaluebasedonthedegreeofseriousness.A higherratingindicatesahigherlevelofseriousness.theofenseseriousnessweightsareusedtocomputeanindexoftheseriousness ofpriorofensesforeachyouthreleasedduringthefiscalyear.asummationofpointvaluescorespondingtoeachchargeforwhichthe youthwasadjudicatedpriortotheprogram placementdateiscomputedaccordingtotheweightingschemebelow.foreachprogram, thesummationsforyouthwhocompletetheprogram aretotaledandthendividedbythenumberofindividualyouthreleasedfrom that program tocomputeanaveragevaluefortheindexofofenderseriousnessforeachprogram.source:jjis,bureauofresearch& Planning. YouthArests-Forthepurposesofthisreport,thenumberreflectsthe youthsarestedforofensesoccuringwhileintheprogram, regardlessofwhetherornotthecaseisfiledwiththecourt.arestinformationisgatheredfrom thecentralcommunicationscenter (CCC)databaseforalyouth,includingthose18yearsofageandolder.Eachyoutharestedinanygivenincidentiscountedindividualy.Ifayouthisarestedformorethanoneincidentduringthequarter,eacharestiscounted.Source:CCC,OficeofResidential Services. Foradditionalinformationaboutthisfacility,visithtp:/

8 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: Ramona Salazar, Office of Program Accountability, Lead Reviewer Elma Adame, Office of Program Accountability, Regional Monitor Ryan Egg, Juvenile Probation Officer Supervisor, Probation and Community Intervention C13 Melissa Johnson, Office of Program Accountability, Regional Monitor Bridget Letthand, Juvenile Detention Officer Scott Luciano, Office of Program Accountability, Regional Monitor

9 Program Name: Hillsborough Girls Academy QI Program Code: 1224 Provider Name: G4S Youth Services, LLC Contract Number: R2111 Location: Hillsborough County / Circuit 13 Number of Beds: 18 Review Date(s): November 4-7, 2014 Lead Reviewer Code: 136 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 DMHA or designee 1 # Case Managers 1 # Clinical Staff # Food Service Personnel 1 # Healthcare Staff # Maintenance Personnel 2 # Program Supervisors Documents Reviewed 5 # Staff 5 # Youth 1 # Other (listed by title): Board Member Accreditation Reports Affidavit of Good Moral Character CCC Reports Confinement Reports Continuity of Operation Plan Contract Monitoring Reports Contract Scope of Services Egress Plans Escape Notification/Logs Exposure Control Plan Fire Drill Log Fire Inspection Report Fire Prevention Plan Grievance Process/Records Key Control Log Logbooks Medical and Mental Health Alerts PAR Reports Precautionary Observation Logs Program Schedules Sick Call Logs Supplemental Contracts Table of Organization Telephone Logs Surveys Vehicle Inspection Reports Visitation Logs Youth Handbook 5 # Health Records 5 # MH/SA Records 6 # Personnel Records 14 # 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 53 (Revised September 2014)

10 Standard 1: Management Accountability Residential Rating Profile Indicator Ratings 1.01 Standard 1 - Management Accountability * Initial Background Screening 1.02 Five-Year Rescreening 1.03 * Provision of an Abuse-Free Environment 1.04 * Management Response to Allegations Non-Applicable 1.05 * Incident Reporting (CCC) 1.06 Protective Action Response (PAR) 1.07 * Pre-Service/Certification Requirements 1.08 In-Service Training 1.09 Logbook Entries and Shift Report Review 1.10 * Internal Alerts System 1.11 * Alerts (JJIS) 1.12 Youth Records (Healthcare and Management) 1.13 Advisory Board 1.14 Program Planning 1.15 Staff Performance * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 4 of 53 (Revised September 2014)

11 Standard 2: Assessment and Performance Plan Residential Rating Profile Indicator Ratings 2.01 Standard 2 - Assessment and Performance Plan Initial Contacts to Parent 2.02 Youth Orientation 2.03 Court Notifications 2.04 Classification Factors 2.05 Classification Procedures 2.06 Reassessment for Activities 2.07 R-PACT Assessment 2.08 Youth Needs Assessment Summary 2.09 R-PACT Reassessments 2.10 Parent/Guardian Involvement in Case Mgmt Members of Treatment Team 2.12 Performance Plan Development 2.13 Treatment Team Meetings (Formal Review) 2.14 Treatment Team Meetings (Informal Review) 2.15 * Performance Plan Goals 2.16 Performance Plan Transmittal 2.17 Performance Plan Revisions 2.18 Incorporation of Other Plans Into Performance Plan 2.19 Performance Summaries 2.20 Performance Summary Transmittal 2.21 Visitation and Communication 2.22 Written Consent of Youth Eighteen Years or Older 2.23 Written Consent for Substance Abuse Information 2.24 Transition Planning and Conference 2.25 Exit Portfolio Limited 2.26 Exit Conference 2.27 Grievance Process Training 2.28 Grievance Process 2.29 Grievance Process Documentation 2.30 Gang Identification: Notification of Law Enforcement 2.31 Gang Identification: Intervention Activities 2.32 Life Skills Training Provided to Youth 2.33 Staff Training: Delinquency Interventions 2.34 Restorative Justice Awareness For Youth 2.35 Delinquency Intervention Services 2.36 Recreation and Leisure Activities 2.37 Youth Input 2.38 Gender-Specific Programming 2.39 Vocational Programming 2.40 Educational Access 2.41 Education Transition * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). The following limited and/or failed indicators require immediate corrective action Exit Portfolio Office of Program Accountability Page 5 of 53 (Revised September 2014)

12 Standard 3: Mental Health and Substance Abuse Services Residential Rating Profile Indicator Ratings Standard 3 - Mental Health and Substance Abuse Services 3.01 Designated Mental Health Authority or Clinical Coordinator 3.02 * Licensed Mental Health and Substance Abuse Clinical Staff 3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff 3.04 Mental Health and Substance Abuse Admission Screening 3.05 Mental Health and Substance Abuse Assessment/Evaluation 3.06 Mental Health and Substance Abuse Treatment 3.07 * Treatment and Discharge Planning 3.08 * Specialized Treatment Services 3.09 * Psychiatric Services 3.10 * Suicide Prevention Plan 3.11 * Suicide Prevention Services 3.12 * Suicide Precaution Observation Logs 3.13 * Suicide Prevention Training 3.14 * Mental Health Crisis Intervention Services 3.15 * Crisis Assessments 3.16 * Emergency Mental Health and Substance Abuse Services 3.17 * Baker and Marchman Acts * 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 53 (Revised September 2014)

13 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 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 4.39 Prenatal Care - Nutrition and Education of Youth 4.40 Neonatal Care - Infant Physical Care and Nutrition of Infants Non-Applicable 4.41 Neonatal Care - Supervision of Infants Non-Applicable 4.42 Neonatal Care - Education and Lactation Non-Applicable 4.43 Prenatal and Neonatal Staff Education * 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 53 (Revised September 2014)

14 Standard 5: Safety and Security Residential Rating Profile Indicator Ratings 5.01 Standard 5 - Safety and Security Youth Supervision 5.02 * Ten-Minute Checks 5.03 Census, Counts, and Tracking 5.04 Key Control 5.05 Contraband Procedure 5.06 Frisk and Strip Searches 5.07 Vehicles and Maintenance 5.08 Transportation of Youth 5.09 Tool Inventory and Management 5.10 Youth Tool Handling and Supervision 5.11 Outside Contractors 5.12 Fire, Safety, and Evacuation Drills 5.13 Mental Health and Medical Drills 5.14 Disaster and Continuity of Operations Planning 5.15 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials 5.16 Youth Handling and Supervision for Flammable, Poisonous, and Toxic Items and Materials 5.17 Disposal of All Flammable, Toxic, Caustic, and Poisonous Items 5.18 Elements of Water Safety Plan Non-Applicable 5.19 Staff Training: Water Safety Non-Applicable 5.20 * Swim Test Non-Applicable 5.21 Comprehensive Behavior Management System 5.22 Implementation and Consistency of Behavior Management System 5.23 Behavior Management System Infractions 5.24 Staff Training: Behavior Management System 5.25 Behavior Management System Monitoring 5.26 Controlled Observation Non-Applicable 5.27 Search and Inspection of Controlled Observation Room Non-Applicable 5.28 Controlled Observation Safety Checks Non-Applicable 5.29 Controlled Observation Release Procedures Non-Applicable * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 8 of 53 (Revised September 2014)

15 Strengths and Innovative Approaches The program utilizes the Girls 4 Success model that is part of the G4S Youth Services, LLC where the gender-responsive program environment and gender-specific values are utilized with each female youth through all programmatic services. The genderresponsive culture enhances the normalization living environment specific to girls programming. The program conducts quarterly family day events to promote family reunification activities and celebration of holiday events for continued family reunification. This promotes ongoing communication, and continued and active involvement in all treatment areas. All staff receives gender-responsive training as part of the Girls 4 Success model. The program uses the VOICES curriculum, which addresses the unique needs of adolescent girls and young women. Implementation and delivery of this evidence-based curriculum is facilitated by the master s level therapeutic staff and is monitored by the clinical director. The program model encourages girls to seek and celebrate their true selves by providing a safe space, encouragement, structure, and the support they need to embrace their journey of self-discovery. The program conducts a PAR review committee meeting following each use of physical intervention known as Protective Action Response (PAR). Specialized treatment team meetings are held with the youth to discuss the situation and events that led to the PAR intervention. New coping skills or preventative strategy recommendations are made, and the team discusses ways things could have been handled differently while maintain youth accountability for their actions. The program uses SKYPE to communicate with family members to include infants and children of the youth in the program. The program has an environment described as normalization by the Department. This is evident as the living units, multipurpose rooms, and serenity rooms are decorated similar to youth dorm-style living quarters. Youth wear active-wear as day-to-day uniforms. Office of Program Accountability Page 9 of 53 (Revised September 2014)

16 Standard 1: Management Accountability Overview Hillsborough Girls Academy is located in Tampa, Florida and is operated by G4S Youth Services, LLC through a contract with the Department of Juvenile Justice. The program is designed to serve adjudicated girls committed as high and maximum-risk by the courts between the ages of thirteen to twenty-one years old. The program provides gender-responsive programming through their therapeutic milieu of mental health overlay services (MHOS) and substance abuse services along with cognitive and skill-based interventions, which have been identified to work with this population. The program staff is comprised of a facility administrator, an assistant facility administrator, a director of clinical services, two master s level therapists, a licensed practical nurse (LPN)/health services coordinator, a case manager, four shift supervisors, two master-control technicians, and twelve youth care workers. Staff vacancies at the time of the review were a full-time clinical director, full-time master control operator, six fulltime youth care workers, and a part-time licensed practical nurse (LPN) 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. Initial background screening for all new staff is in accordance with the Department s and program s policies and procedures. There were six new staff hired since the last annual compliance review. Background screenings were conducted and verified through the Department s screening unit and they were completed prior to the date of hire. A roster of program volunteers was provided from JFJ Ministries. All volunteer screenings are handled through the ministry s administrative office and verified through the Department s Background Screening Unit. The Annual Affidavit of Compliance was submitted to the Department s Background Screening Unit on January 2, Five-Year Rescreening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. Employees and volunteers are rescreened every five years from the initial date of employment. The program has a five-year screening process that is in accordance with the Department s rescreening process. There was one eligible staff for a five-year rescreening, which was completed and submitted to Background Screening Unit within ten days of the employee s fiveyear anniversary date. Office of Program Accountability Page 10 of 53 (Revised September 2014)

17 1.03 Provision of an Abuse-Free Environment Compliance The program provides an environment in which youth, staff, and others feel safe, secure, and not threatened by any form of abuse or harassment. Posting of the Florida Abuse Hotline telephone number and the Central Communications Center for youth 18 years of age and older telephone number. All allegations of child abuse or suspected child abuse are immediately reported to the Florida Abuse Hotline. Youth and staff have unhindered access to report alleged abuse to the Florida Abuse Hotline pursuant to Section (1)(a), F.S. The environment is free of physical, psychological, and emotional abuse. A code of conduct for staff that clearly communicates expectations for ethical and professional behavior, including the expectation for staff to interact with youth in a manner that promotes their emotional and physical safety. There is an employee manual, policy, and procedure in place that promotes an abuse-free and safe environment for all youth and staff. All youth and staff surveys indicate that they feel safe in the program and there is no offensive language directed at the youth at any time. The policy includes a staff code of conduct that is provided during staff pre-service orientation and annual in-service training. There is unimpeded access for reporting abuse which was confirmed by the youth and staff survey results. The abuse reporting hotline number is posted through the facility Management Response to Allegations Non-Applicable Management shall be cognizant of youth and staff needs and provide direction to each on how to access the Florida Abuse Hotline. There is evidence that management takes immediate action to address incidents of physical, psychological, and emotional abuse. The program had no incidents of physical, psychological, or emotional abuse in the facility during this review period; therefore, this indicator rates as non-applicable Incident Reporting (CCC) Compliance Whenever a reportable incident occurs, the program notifies the Department s Central Communications Center (CCC) within two hours of the incident, or within two hours of becoming aware of the incident. The program had three incidents called into the Department s Central Communications Center (CCC) over the past six months. All three reports were called into the CCC within the two-hour time frame of the incident or learning of the incident. The three incidents consisted of a staff arrest, complaint against staff, and for an alarm system malfunction. All staff received training as part of pre-service or in-serving training requirements on incident reporting. Office of Program Accountability Page 11 of 53 (Revised September 2014)

18 1.06 Protective Action Response (PAR) Compliance The program uses physical intervention techniques in accordance with Florida Administrative Code. Any time staff uses a physical intervention technique, such as countermoves, control techniques, takedowns, or application of mechanical restraints (other than for regular transports), a PAR Incident Report is completed and filed in accordance with the Florida Administrative Code. There is a policy and procedure in place to address the use of PAR in accordance with Florida Administrative Code. The provider has an approved PAR plan by the Department, which outlines the approved PAR intervention and techniques to be used. A review of PAR reports were completed by all required parties and were kept in a report binder. All reports were completed and documented as reviewed by a PAR certified instructor, supervisory staff, and the facility administration within seventy-two hours. There were no abuse or CCC notifications required and a PAR medical review was conducted when needed. The program does not utilize mechanical restraints 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 s training plan was submitted and approved by the Department. There was a total of fourteen staff training files reviewed for pre-service/certification training as defined within 180 days from the date of hire. The G4S Youth Services, LLC has a management development academy (MDA), which has specialized supervisor and management training. Training requirements include obtaining required certifications such a cardiopulmonary resuscitation (CPR), first aid and automated external defibrillator (AED) for direct care and licensed nursing staff. Staff that provide direct care supervision of youth are required to complete the forty-hour PAR certification course at pre-service and eight hours annual in-service training. All completed courses and training information are input into the Department s Learning Management System (SkillPro). All required trainings are also completed for all five reviewed pre-service training files. Staff responsible for the implementation of evidence based intervention, life and/or social skills, are also required to complete specific training to assist youth in the demonstration and use of those interventions and skills 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. There are twenty-four hours of in-service training required on an annual basis for staff. The G4S in-service training plan outlines the areas in training needed to include a PAR refresher update of eight hours. A total of fourteen files were reviewed for in-service training which included four shift supervisors that completed the additional eight hours of supervisory training. All fourteen files exceeded the number of hours needed on an annual basis. Courses and/or certifications for first aid, CPR and AED were reviewed, and all staff had current and active certifications. Office of Program Accountability Page 12 of 53 (Revised September 2014)

19 1.09 Logbook Entries and Shift Report Review Compliance The program maintains a chronological record of events, incidents, and activities in a central logbook maintained at master control, living unit logbooks, or both, in accordance with Florida Administrative Code. The program ensures that direct care staff, including each supervisor, is briefed when coming on duty. A facility and master control logbook is maintained and documents daily events with the date, time, and a brief description of the entry and staff initials. The logbook also provides valuable information and significant events such as youth on or off-site and the alert status of youth. The logbooks provide a variety of information available for review by all staff. Information includes the number of youth on each living unit, movement and counts, staff assigned and working on each shift of perimeter checks conducted, shift briefings, and community meetings. The master control logbook has generalized notes to include movement, counts, staff, and/or visitor s movement on and off-site. There were minor edits made that had not been initialed by the writer found during the logbook review, however, the edits did not impact or compromise safety and/or security of youth or any critical situation. All emergency situations or incidents with the use of physical restraints were well documented. Any youth requiring transportation, security checks, one-to-one or enhanced supervision, and access by law enforcement, Department of Children and Families or parent/guardian are noted and highlighted Internal Alerts System Compliance The program shall maintain and use an internal alert system that is easily accessible to program staff and keeps them alerted about youth who are security or safety risks, and youth with healthrelated concerns, including food allergies and special diets. When risk factors or special needs are identified during or subsequent to the classification process, the program immediately enters this information into its internal alert system. The program ensures that only appropriate staff may recommend downgrading or discontinuing a youth s alert status. There is an internal alert communication system that is consistently updated and kept current with the youth s medical, mental health, and dietary alerts. The alert system is inclusive of a program alert board, alert logs, s, and/or text notification to staff regarding any immediate changes. These alerts are kept current and are updated as needed and input into the Juvenile Justice Information System (JJIS). Assigned staff are responsible for updating the opening or closing alerts entered into the system. Youth alerts were also found documented and highlighted in the facility logbook, such as diet restrictions, medical, mental health, and/or security issues or concerns 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 JJIS alert entry is maintained and updated as appropriate by staff. The date and staff names are updated in the system as the alert is updated once verified by staff completing the entry. All current alerts noted in the medical and mental health files reviewed were consistent with the alert board. Office of Program Accountability Page 13 of 53 (Revised September 2014)

20 1.12 Youth Records (Healthcare and Management) Compliance The program maintains an official case record, labeled confidential, for each youth, which consists of two separate files: An individual healthcare record An individual management record There are health, mental health, and case management records for each youth. All records are stored in a secured file cabinet and behind locked doors. All records contain pertinent youth information to include name, date of admission, home circuit, committing offense, and has confidential stamped on the each record cover. Records also contain legal, demographic information, correspondence, and case or chronological entries/notes. All records were found to be organized and documents were filed in chronological order for each section Advisory Board Compliance The program has a community support group or advisory board that meets at least quarterly. The program director solicits active involvement of interested community partners. The program has an active community advisory board that is co-chaired with Lake Academy. There are agendas, meeting minutes, and pictures for each quarterly meeting. There is evidence to support that the facility administrator routinely sends letters and invitations to community partners, local law enforcement, child protection specialists, judiciary representatives, and victim services staff, as well as school board representatives and local business partners. The program has documentation to support it has solicited participation from a parent/guardian whose youth was previously involved in the juvenile justice system at the program A phone call was made to an advisory board member to verify their attendance and participation with the advisory board. An interview with the program director confirms solicitation of members in order to maintain an active advisory board and the board members are actively involved in providing support through gifts, involvement, special meals, and community and faith based events for youth and their families Program Planning Compliance The program uses data to inform their planning process and to ensure provisions for staffing. The facility administrator conducts monthly mandatory general staff meetings where communication is shared. There are surveys provided to youth, staff, and parent/guardian where they are all asked to provide input and feedback about program service enhancements, changes, and/or recommendations. Survey results are also shared during these meeting and recommendations are taken under careful consideration by administration and implementation of these recommendations are thoughtfully carried out. There is a plan in place to address staff turnover, which includes incentives for maintaining current staff. Staff incentives and rewards allow for management to recognize staff by providing lunches, celebrations with special meals, and recognition of a staff for employee of the month. All five interviewed staff indicated working conditions were positive. Administrative staff communicates information from the Department's Comprehensive Accountability Report (CAR) and Quality Improvement reports with the staff. Office of Program Accountability Page 14 of 53 (Revised September 2014)

21 1.15 Staff Performance Compliance The program ensures a system for evaluating staff, at least annually, based on established performance standards. Staff are evaluated at their first ninety days and then on an annual basis for performance as it relates to their assigned job functions and/or duties. Performance standards are provided in job descriptions that are used to develop performance measures. Performance evaluations include staff delivery of the behavior management system, positive reinforcement, consistency of the implantation of rewards, punishments, and/or incentives. Staff providing specialized services, such as evidence based intervention curricula, are also evaluated on their performance for the delivery and implementation of such interventions. Standard 2: Assessment and Performance Plan Overview All youth in the program have one case manager responsible for providing case management services. The case manager also serves as the treatment team leader who coordinates meetings with all treatment team members. It is also the responsibility of the case manager to encourage cooperation from the parent/guardian whose participation is critical for the transition of each youth back into the community. At admission the case manager completes the risk classifications, Residential Positive Achievement Change Tool (R-PACT), needs assessment summary, performance plans, transition planning, and progress reports Initial Contacts to Parent Compliance The program notifies the youth s parent/guardian by telephone within twenty-four hours of the youth s admission, and by written notification within forty-eight hours of admission. All five case records reviewed document contact with the parent/guardian within twenty-four hours of admission via telephone and in writing. A written notification was documented in chronological notes with a copy of the letter placed in the case record, exceeding the forty-eight hour time frame required for written notification Youth Orientation Compliance The program shall provide each youth an orientation to the program rules, procedures, schedules, and services that apply to youth, to begin within twenty-four hours of admission. The youth s admission orientation begins within the first twenty-four hours of admission into the program and is documented using an orientation checklist, admission classification, and intake chronological. These forms are either signed or initialed by each youth to indicate that they have been provided information about the program including mental health services, expectations, the grievance procedure, medical services, and the daily schedule that was posted throughout the program for easy access. All surveyed youth indicated that an orientation was conducted within twenty-four hours of admission into the program. Office of Program Accountability Page 15 of 53 (Revised September 2014)

22 2.03 Court Notification Compliance The program notifies the youth s committing court(s) by written notification within five working days of admission. Court notification is to be completed and sent within five working days from the date of admission into the program. All five reviewed records contained documentation that notification exceeded the required five-day time frame by providing the committing judge written notification on the same day of admission. This notification was copied to the assigned juvenile probation officer (JPO) Classification Factors Compliance The program utilizes a classification system, in accordance with Florida Administrative Code, that promotes safety and security, as well as effective delivery of treatment services. All five reviewed records contained a comprehensive admission classification form. The initial classification forms for each youth provided information on factors including physical characteristics, maturity level, and history of violence, gang affiliation, and criminal behavior. The factors addressed by the admission classification form promote safety, security, and an opportunity for delivery of treatment services Classification Procedures Compliance Initial classification should be used for the purposes of assigning each newly admitted youth to a living unit, sleeping room, and youth group or staff advisor. All five reviewed records demonstrated that the initial classification form was utilized in determining an appropriate assignment for each youth to a living unit. Each reviewed record provided justification and documentation on the reason for placement in the assigned living unit. JJIS records also indicated that risk factors were entered into the alert system when identified by staff during the classification process Reassessment for Activities Compliance Youth are reassessed and reclassified, if warranted, prior to considering an increase in privileges or freedom of movement, participation in work projects, or other activities that involve tools or instruments that may be used as potential weapons or means of escape, or participation in any off-campus activity. The reassessment of the youth s needs and risk factors was conducted for the purpose of youth s placement into another dorm/sleeping unit. There was no risk assessment completed for the purpose of increasing a youth s privilege or freedom of movement in the records reviewed. The youth do not participate in work projects that include the use of tools or instruments that may be used as potential weapons or means of escape or off-site campus activities at this time. Office of Program Accountability Page 16 of 53 (Revised September 2014)

23 2.07 R-PACT Assessment Compliance The program shall ensure that an initial assessment of each youth is conducted within thirty days of admission. The program shall maintain all documentation of the initial assessment process in JJIS. All five reviewed records provided documentation that an initial Residential Positive Achievement Change Tool (R-PACT) was completed within the required thirty days of admission into the program. Each reviewed record exceeded the thirty-day time frame and was maintained in JJIS Youth Needs Assessment Summary (YNAS) Compliance The program shall ensure that a Youth Needs Assessment Summary (YNAS) of each youth is conducted within thirty days of admission. The program shall maintain all documentation of the YNAS. The Youth Needs Assessment Summary (YNAS) is completed and maintained in JJIS. All reviewed records documented completion of the summaries within the required time frame of thirty days from admission. The YNAS was maintained in the case records by the program R-PACT Reassessments Compliance The program shall ensure that a reassessment of each youth is conducted within ninety days. The program shall ensure that any other updates or reassessments are completed when deemed necessary by the intervention and treatment team to effectively manage the youth s case. The program shall maintain all reassessment documentation in the youth s official youth case record. The R-PACT reassessments are required to be completed by the program every ninety days after completion of the initial R-PACT. Four of the five reviewed records required reassessments to be completed. All four were completed within the required ninety-day time frame and maintained in each youth s case record Parent/Guardian Involvement in Case Management Services Compliance The program shall, to the extent possible and reasonable, encourage and facilitate involvement of the youth s parent/guardian in the case management process. All five reviewed records provided documentation that the program case manager attempted to encourage and facilitate involvement with the parent/guardian in the case management process. This was documented through chronological notes and copies of letters mailed to the parent/guardian contained in the case records. The letters provided different information to the parent/guardian that would allow them to participate in the treatment process. Letters included notification of admission to the program, as well as significant dates for formal and informal treatment team meetings. The letters contained in each reviewed record provided each parent/guardian with dates of each treatment team, encouragement of their participation, and the need for their input in the process. Office of Program Accountability Page 17 of 53 (Revised September 2014)