BUREAU OF QUALITY IMPROVEMENT PROGRAM REPORT FOR

Transcription

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 QUALITY IMPROVEMENT PROGRAM REPORT FOR Paxen - Hillsborough Paxen Learning Corporation (Contract Provider) 1905 North Florida Avenue Tampa, Florida Review Date(s): April 15-16, 2014 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES W A N S L E Y W A L T E R S, S E C R E T A R Y J E N N I F E R R E C H I C H I, B U R E A U C H I EF

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 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: Glenn Garvey, Lead Reviewer, DJJ Bureau of Quality Improvement Gerald Felty, Senior Juvenile Probation Officer, DJJ Probation, Circuit 12 Mack McLeod, Program Monitor, DJJ Residential Services, Central Region Paul Sheffer, Review Specialist, DJJ Bureau of Quality Improvement

3 Program Name: Paxen - Hillsborough QI Program Code: 1257 Provider Name: Paxen Learning Corporation Contract Number: P2120 Location: Hillsborough County / Circuit 13 Number of Beds: 25 Review Date(s): April 15-16, 2014 Lead Reviewer Code: 121 Methodology This review was conducted in accordance with FDJJ-1720 (Quality Improvement Policy and Procedures), and focused on the areas of (1) Management Accountability, (2) Assessment Services, (3) Intervention Services, and (4) Medical, Mental Health, and Substance Abuse Services, which are included in the Day Treatment Standards (August 2012). Persons Interviewed Program Director DJJ Monitor DHA or designee DMHA or designee 1 # Case Managers # Clinical Staff # Food Service Personnel # Healthcare Staff Documents Reviewed # Maintenance Personnel # Program Supervisors # Other (listed by title): Accreditation Reports Affidavit of Good Moral Character CCC Reports Confinement Reports Continuity of Operation Plan Contract Monitoring Reports Contract Scope of Services Egress Plans Escape Notification/Logs Exposure Control Plan Fire Drill Log Fire Inspection Report Fire Prevention Plan Grievance Process/Records Key Control Log Logbooks Medical and Mental Health Alerts PAR Reports Precautionary Observation Logs Program Schedules Sick Call Logs Supplemental Contracts Table of Organization Telephone Logs Surveys Vehicle Inspection Reports Visitation Logs Youth Handbook 5 # Health Records 9 # MH/SA Records 3 # Personnel Records 3 # Training Records/CORE 6 # Youth Records (Closed) 5 # Youth Records (Open) # Other: 5 # Youth 1 # Direct Care Staff 2 # Other: Case Manager and Program Coordinator (stand-in) 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 26 (Revised August 2013)

4 Standard 1: Management Accountability Day Treatment Rating Profile Indicator Ratings Standard 1 - Management Accountability 1.01 * Initial Background Screening 1.02 Five-Year Rescreening 1.03 Protective Action Response (PAR) Non-Applicable 1.04 Pre-Service/Certification Training 1.05 In-Service Training 1.06 Medical Alerts, Mental Health Alerts and Suicide Risk Alerts in JJIS 1.07 Episodic/Emergency Care 1.08 Medication Management - Medication Storage 1.09 Cleanliness and Sanitation 1.10 Fire Prevention and Evacuation Procedures 1.11 Water Activities Non-Applicable 1.12 Food Services 1.13 Transportation 1.14 Administration 1.15 Ninety-Day Supervisory Reviews 1.16 * Incident Reporting (CCC) * 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 26 (Revised August 2013)

5 Standard 2: Assessment Services Day Treatment Rating Profile Indicator Ratings Standard 2 - Assessment Services 2.01 Admission and Orientation 2.02 * Medical Screening 2.03 Medication Management - Verification of Medications 2.04 * Mental Health/Substance Abuse Screening 2.05 Positive Achievement Change Tool (PACT) Full Assessment 2.06 PACT Reassessment 2.07 Progress Reports 2.08 *Abuse-Free Environment * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 5 of 26 (Revised August 2013)

6 Standard 3: Intervention Services Day Treatment Rating Profile Indicator Ratings Standard 3 - Intervention Services 3.01 Vocational Programming 3.02 Youth-Empowered Success (YES) Plan Development 3.03 Youth Requirements/PACT Goal Elements 3.04 * Transitional Planning/Reintegration Non-Applicable 3.05 YES Plan Implementation/Supervision 3.06 Effective Response System 3.07 Behavior Management System 3.08 Ninety-Day YES Plan Updates 3.09 Educational Transition Non-Applicable 3.10 Termination/Release * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 6 of 26 (Revised August 2013)

7 Standard 4: Medical, Mental Health, and Substance Abuse Services Day Treatment Rating Profile Indicator Ratings Standard 4 - Medical, Mental Health, and Substance Abuse Services 4.01 Medication Management - Delivery of Medications Limited 4.02 Designated Mental Health Authority or Clinical Coordinator 4.03 * Licensed MH/SA Clinical Staff 4.04 Non-Licensed MH/SA Clinical Staff 4.05 MH and SA Admission Screening 4.06 MH and SA Assessment/Evaluation 4.07 MH and SA Treatment 4.08 Treatment and Discharge Planning 4.09 * Suicide Prevention Plan 4.10 * Suicide Prevention Services 4.11 * Suicide Precaution Observation Logs 4.12 * Suicide Prevention Training 4.13 * Mental Health Crisis Intervention Services 4.14 * Crisis Assessment 4.15 * Emergency MH and SA Services 4.16 * 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). The following limited and/or failed indicators require immediate corrective action Medication Management - Delivery of Medications Office of Program Accountability Page 7 of 26 (Revised August 2013)

8 Strengths and Innovative Approaches The program s mission is to provide fundamental life, education, and workforce skills that together form the building blocks for better lives through working in partnerships with the Department of Juvenile Justice, Hillsborough County School Board, community agencies, and organizations. Youth admitted to Paxen Community Connections Hillsborough have the opportunity to enroll in a GED program that is affiliated with Hillsborough County School District. Paxen s location is a satellite campus for Chamberlain GED services which is reserved exclusively for Paxen referred youth. The teacher is a certified instructor and has several years both professionally and volunteering with teaching at risk youth. Paxen has been able to reenroll each youth in educational services and empower each youth to further their educational plans/goals. The program utilizes a restorative justice approach in rehabilitating each youth who attend the program. This entails holding each youth accountable for their actions, helping them develop confidence and competency in vital life skills and educational areas, and leading them to acceptance and personal responsibility. Youth admitted to the program receive a combination of evidence-based services, gender-responsive delinquency interventions, case management, community supervision, community service work projects, and life skill training. Evidence-based and promising-practices delinquency interventions are delivered in a group setting and include Thinking for a Change (T4C), a cognitive restructuring curriculum, Impact of Crime, a curriculum focused on restorative justice, and Girl s Circle and the Council for Boys and Young Men curricula, which address gender-responsive issue. Office of Program Accountability Page 8 of 26 (Revised August 2013)

9 Standard 1: Management Accountability Overview The program provides day treatment services through a contract with Paxen Learning Corporation and the Department of Juvenile Justice initiated in July 2012, with a contract amendment that was effective August 1, The program provides twenty-five day treatment slots and is designed to serve youth ages fourteen to nineteen on probation and minimum-risk commitment. The program s organizational chart consists of a regional program manager, program coordinator, case manager, and two program support specialist. The program currently has the program coordinator and one program support specialist position vacant since March The program has identified staff to fill both vacancies and is awaiting the results of their background screening to offer them employment. The company has temporarily placed a program coordinator from a sister program at the facility to assist with the daily operations until the new program coordinator has been hired and has received the required training. Transportation services are provided by the program. Currently, the program provides food for youth using local fast food establishments while following the approved program menu 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 hired one staff member since the last Quality Improvement review and that staff member received an initial background screening prior to their date of hire and prior to providing services. The Annual Affidavit of Compliance with Level 2 Screening Standards was submitted to the Department s Background Screening Unit on January 6, 2014, meeting the annual requirement. The program has no volunteers Five-Year Rescreening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. Employees and volunteers are rescreened every five years from the initial date of employment. The program has written procedures for conducting a new background screening for all staff, volunteers, and interns every five years. There was no staff eligible for the five-year background rescreening during the Quality Improvement review period Protective Action Response (PAR) Non-Applicable The program uses physical intervention techniques in accordance with Florida Administrative Code. Any time staff uses a physical intervention technique, such as countermoves, control techniques, takedowns, or application of mechanical restraints (other than for regular transports), a PAR Incident Report is completed and filed in accordance with the Florida Administrative Code. Office of Program Accountability Page 9 of 26 (Revised August 2013)

10 There have been no Protective Action Response (PAR) incidents during this review period; therefore, this indicator rates as non-applicable Pre-Service/Certification Training Compliance Contracted non-residential staff are trained in accordance with Florida Administrative Code. Contracted non-residential staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. Contracted non-residential staff that have not completed essential skills training, as defined by Florida Administrative Code, do not have any direct contact with youth. Contracted non-residential staff that have not completed pre-service/certification training do not have direct, unsupervised contact with youth. The program had one staff member that was applicable for pre-service training. The staff completed all essential skills training that included PAR, CPR, first aid, suicide prevention, emergency procedures, professionalism and ethics prior to direct contact with youth. The staff received 163 hours of pre-service training requirements of web-based and/or instructor-led training at the time of the review. The written list for pre-service training topics was submitted and approved by the Department s Office of Staff Development and Training In-Service Training Compliance Contracted non-residential staff completes in-service training in accordance with Florida Administrative Code. Contracted non-residential staff must complete twenty-four hours of annual in-service training, beginning the calendar year after the staff has completed pre-service training. Supervisory staff shall complete eight hours of training in the areas listed below, as part of the twenty-four hours of annual in-service training. The program had one staff member who was applicable for annual in-service training. The staff completed all essential skills training that included PAR, CPR, first aid, suicide prevention, professionalism and ethics along with other subjects for a total of twenty-nine hours. There currently is not a supervisor for the program however; the previous supervisor that departed in March 2014, completed 8.5 hours of the required management related subjects in addition to the other annual required training in excess of the required twenty-four hours. The program s annual training plan was approved by the Department s Office of Staff Development and Training Medical Alerts, Mental Health Alerts, and Suicide Risk Alerts Compliance in JJIS The program shall alert staff of medical issues that may affect the security and safety of the youth in the program. The program has a written policy in place for a medical alert system. Two of the five youth files reviewed were applicable for a medical alert and those alerts were entered into the Department s Juvenile Justice Information System (JJIS) as required as well as documented in the facility log book and alert log book. There was a new intake on April 9, 2014 that required a suicide alert to be entered into JJIS; however it was not entered in JJIS or the facility log book. Office of Program Accountability Page 10 of 26 (Revised August 2013)

11 Staff surveys indicate they are informed of any alerts on youth via face to face communication, the facility log book, and the alert log book Episodic/Emergency Services Compliance The program shall have a comprehensive process for the provision of Episodic Care, First Aid, and Emergency Care. The program shall be capable of facilitating an appropriate response to an emergency situation. The program has a written policy for the provision of episodic, first aid, and emergency care. The program has three first aid kits and a suicide response kit which consisted of a knife for life, needle nose pliers and wire cutters. The first aid kits were located in areas easily accessible to staff and the suicide response kit was located in the program coordinator s office. The program does not have an automated external defibrillator (AED). The program conducts quarterly emergency drills that required the demonstration of the use of CPR and a basic critique of each drill scenario. There were four instances where staff had to apply first aid on-site this review period which consisted of the youth being given bandages for small paper cuts or abrasions and follow-up care was not necessary Medication Management Medication Storage Compliance All medications (prescriptions, over-the-counter, topical, etc.) shall be stored in separate, secure (locked) areas that are inaccessible to youth and ensures proper inventory control. The program has a written policy for the storage and maintenance of all medications. Medications are to be stored in a locked box inside a locked cabinet located in program coordinator s office. The area is clean and free of moisture and extreme temperatures. The program had no medication on-site during the week of the Quality Improvement review; however the policy does require liquid and oral medications to be stored separately as well as topical medications to be stored separately from oral medications. The program utilizes a small lockable refrigerator in a locked room for any medication that requires refrigeration. A small locked box is located in the locked filing cabinet for the storage of all controlled medications Cleanliness and Sanitation Compliance The program provides a safe and appropriate treatment environment that includes maintenance and sanitation of the facility. The program was found to be clean and well-maintained during the Quality Improvement review. All indoor areas were clean and free of any graffiti on any walls, doors, or windows. The program conducts weekly sanitation and safety inspections of all internal areas. The program has a maintenance and housekeeping plan to ensure the facility remains in good condition. Separate restroom facilities are provided for males and females. The program has adequate space for private counseling, group meetings, and classrooms Fire Prevention and Evacuation Procedures Compliance The program provides a safe and appropriate treatment environment that includes fire prevention and evacuation procedures. The program has written procedures that include fire prevention and evacuation during an emergency situation. Each youth is oriented to the fire drill procedures during the admission Office of Program Accountability Page 11 of 26 (Revised August 2013)

12 process. Fire extinguishers are placed throughout the facility and are checked by staff on a weekly basis as evidenced by review of the documentation from the weekly sanitation and safety inspections conducted. Review of each staff training file and youth case management file had documentation of training in the operation and use of a fire extinguisher. There are no pull alarms on the floor of the building the program occupies. Monthly fire drills and inspections are documented in a fire safety log; however the program did not conduct a fire drill for the month of November The program was inspected by their local fire department fire marshal on June 25, 2013, with no violations noted. The use of tobacco products is prohibited on company property Water Activities Non-Applicable The program provides a safe and appropriate treatment environment that includes procedures for water activities. The program does not participate in any water-related activities; therefore, this indicator rates as non-applicable Food Services Compliance The program provides a safe and appropriate treatment environment that includes food service. The program uses local fast food establishments for meal purposes. The program uses a two week cycle menu that was approved by a licensed dietitian that they follow when selecting meals for the youth at the program. Special dietary meals are available for youth when health reasons or religious beliefs require an alternative menu. The program has a list of youth with their food allergies posted in the food service area. The food service area was observed to be clean and well maintained. A single menu is offered for facility staff and youth, which was verified through youth surveys. The program does not withhold food as a form of discipline Transportation Compliance The program provides a safe and appropriate treatment environment that includes transportation. The program utilizes two passenger vans to provide daily transportation for youth to and from the program. All vehicles were found to be in sound mechanical condition and had current proof of insurance and registration. The vehicles were secured when not in use by program staff. Documentation included numerous inspections performed on the vehicles at the time of service. Youth surveys validated that the use of seat belts is required any time they ride in facility vehicles. The program conducts driver s license checks on a monthly basis for all staff and all staff had a valid Florida driver s license Administration Compliance The program provides a safe and appropriate treatment environment that includes administrative and operational oversight. The program maintains statistical information on admissions, releases, transfers, absconders, abuse reports, medical/mental health emergencies, volunteer hours, incidents, and average length of stay. This information as well as information on personnel actions and Protective Office of Program Accountability Page 12 of 26 (Revised August 2013)

13 Action Response (PAR) data is also submitted to the Department on a daily/monthly basis. The program maintains a daily facility log utilized to record significant facility activities, incidents, and events. Entries impacting the safety and security of the facility are highlighted for easy identification by staff. All entries were a brief statement of the information, legible and contained minimum error. The facility utilizes the logbook as an ongoing record of documentation. The logbook was reviewed by the program coordinator daily. There was not an entry for a new intake on April 9, 2014, indicating there were placed on suicide alert, however all previous incidents of suicide alert was found to be documented in the log book Ninety-Day Supervisory Reviews Compliance Cases under supervision (i.e., probation, conditional release, post-commitment probation) are reviewed by the supervisor at least once every ninety calendar days. The supervisor ensures that staff review any instructions given during the review, and ensures that they were followed during the subsequent review. The regional program manager documented supervisory reviews every ninety days in the five applicable reviewed files. The reviews included a summary of the youth s performance and instructions for the case manager. All reviews listed the supervisor's name and indicated it was a supervisory review. There were two supervisory reviews that the case manager did not document that they reviewed the supervisor review and instructions Incident Reporting (CCC) Compliance Whenever a reportable incident occurs, the program notifies the Department s Central Communications Center (CCC) within two hours of the incident, or within two hours of becoming aware of the incident. The program has a written policy and procedure for reporting incidents to the Department's Central Communications Center (CCC) within two hours of the incident. There was one reportable incident within the last six-month period which was reported within the two hour time frame. The incident involved contraband in the facility. Standard 2: Assessment Services Overview The program utilizes the program coordinator, the case manager, and two program support specialist to provide services to youth in the program. These staff are responsible for notifications and contacts with the parents/guardians and juvenile probation officers. The case manager completes risk classifications, Community Positive Achievement Change Tool (C- PACT), Youth-Empowered Success (YES) Plan, progress reports, and release planning Admission and Orientation Compliance Face-to-face contacts are conducted with youth within three working days of any probation disposition or release from a residential program, if the youth is on conditional release (CR) or post-commitment probation (PCP). Applicability of the face-to-face contact requirement depends on whether the youth has been admitted to the program at the time of disposition or release. All Office of Program Accountability Page 13 of 26 (Revised August 2013)

14 youth participate in a program orientation process, which includes the elements required by Florida Administrative Code, within twenty-four hours of admission. Five case management files were reviewed for admission and orientation. All five files contained documentation to support orientation was completed on each youth s admission date. The orientation process involved a parent/guardian, as evidenced by all five files containing parent/guardian signatures on various orientation forms including student rights, family involvement, attendance policy, search, contraband, dress code, bullying policy, emergency procedures, and grievance policy. The program provides a handbook to each youth that contains an orientation checklist that includes the program rules, procedures, schedules, and services that apply to youth. All of the reviewed files contained youth signatures indicating receipt of a student handbook. All required topics were addressed on the orientation checklist. Four of the five youth selected for file reviews were classified as being on probation status, (Probation Day Treatment) and the remaining youth was classified as Committed Non- Residential Medical Screening Compliance Youth are screened for health-related conditions at the time of admission to determine if the youth has any conditions that require medical attention. The screening includes a review of the most recent Health Discharge Summary (Form HS 012), if applicable, and documented contact with the parent/guardian if there are any questions or concerns regarding the youth s medical condition. Screening may be performed by non-licensed staff during the admission process. All medical, mental health, and substance abuse information is documented in the youth s Individual Health Care Record. Five case management files were reviewed for medical screening. Each file contained a Facility Entry Physical Health Screening form completed by a non-licensed staff. All reviewed files indicate the medical screening occurred on the day the youth was admitted to the program. None of the health screening forms indicated any medical concerns or issues therefore a need to contact the parent/guardian was non-applicable for those youth. Medical, mental health and substance abuse information were filed in each youth s individual healthcare record. Health Discharge Summaries were not applicable in each case Medication Management Verification of Medications Compliance The program shall determine a youth s medication regimen upon admission to the program. The program has a written policy that clearly conveys the procedures of medication management and verification of medication. None of the youth selected for file reviews were taking medication. There were no youth currently attending the program that were taking medications at the program; therefore the need to discuss the youth s medication regimen with his or her parent was not applicable Mental Health/Substance Abuse Screening Compliance Youth are screened for mental health/substance abuse issues at the time of admission to determine if the youth has any conditions that require further assessment and/or immediate attention. The screening includes a review of available information and completion of the Positive Achievement Change Tool (PACT) and the PACT Mental Health and Substance Abuse Report and Referral Form when further assessment is indicated by the PACT, or administration Office of Program Accountability Page 14 of 26 (Revised August 2013)

15 of the Massachusetts Youth Screening Instrument (MAYSI-2). The program ensures further assessment of the youth, or immediate intervention, as indicated by the mental health/substance abuse screening. (For the entire indicator statement, please reference the Quality Improvement FY Day Treatment indicators.) Five case management files were reviewed for mental health and substance abuse screenings. The program is using the Massachusetts Youth Screening Instrument - Second Version (MAYSI-2) as its mental health and substance abuse screening assessment. Each reviewed file contained a MAYSI-2 instrument. All five MAYSI-2 screenings were administered on the youth s date of admission. All five screenings were completed on the Juvenile Justice Information System (JJIS). Based on the results of the five MAYSI-2 assessments, one of five assessments indicated a need to refer the youth for an assessment of suicide risk. The file contained the referral summary form that had been submitted to the licensed clinical staff, (licensed mental health counselor) immediately after the assessment had been completed. Based on the signature of the licensed staff, date and time, the youth was assessed for suicide risk within two hours of the referral, exceeding the twenty-four hour requirement. A review of the completed precautionary observation form indicated the youth was placed on precautionary observation and his behavior evaluated as required. The precautionary observation form had been properly completed in its entirety to include identification of the safe housing area and all required signatures and dates. The suicide risk alert was entered into JJIS. With regard to the five files reviewed, the staff conducting all of the MAYSI-2 screenings had completed the MAYSI-2 course on the Department s Learning Management System (CORE) Positive Achievement Change Tool (PACT) Full Assessment Compliance The PACT Full Assessment is completed by program staff for all youth, regardless of risk to reoffend, within seven calendar days of admission. Five case management files were reviewed for completion of the Positive Achievement Change Tool (PACT) Full Assessments. All five reviewed files indicated the PACT Full Assessment had been completed within seven days of the youth s admission to the program. Each youth scored as low, moderate-high, or high risk to re-offend PACT Reassessment Compliance Staff complete PACT Reassessments for youth on probation, conditional release, and postcommitment probation, as well as minimum-risk non-residential commitment youth. Regardless of risk to reoffend, the PACT Full Assessment is completed every ninety days. Five active case management files were reviewed for completion of the PACT Reassessments. Based on admission dates for all youth reviewed, all five files contained a ninety-day PACT Reassessment, as required. A review of four closed files where the youth had successfully completed the program indicated the Exit PACT had been completed on three of the four youth within 14 days of the youth being released from the program. One file contained an exit PACT that had been completed two months in advance of the youth s discharge date Progress Reports Compliance Progress reports are prepared and distributed in accordance with Florida Administrative Code. Office of Program Accountability Page 15 of 26 (Revised August 2013)

16 The report details the youth s progress and status of youth requirements and PACT goals contained in the YES Plan. The youth is given an opportunity to review the report and provide comments. The report is signed and dated by the youth and the staff that prepared the report. The report is reviewed and signed by the program director or designee. Five applicable case management files were reviewed for completion of ninety-day progress reports. All five files indicated the program completes progress reports every month, exceeding the ninety day requirement. All reports provide a specific location that affords the youth an opportunity to review and add comments to the report prior to being sent. Progress reports include information about the youth s overall progress, the evidenced based interventions used for that youth and legal issues. All progress reports were signed and dated by the staff that prepared the report, program coordinator and youth when present. All progress reports were reviewed and signed by the program director or designee prior to being sent. All five files documented the progress reports were sent to all required parties. All five files contained a cover letter that was attached with each progress report. Approximately one-half of the cover letters summarized the youth s current progress as required. Interviews with staff indicated cover letters had been modified to ensure the letter described a brief description of the youth s overall performance to include any extraordinary information about the youth. Based on review of all of the cover letters, the most current letters sent were the revised letters that included the required information Abuse-Free Environment Compliance Any person who knows, or has reasonable cause to suspect, that a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or other person responsible for the child's welfare, as defined by Florida Statute, or that a child is in need of supervision and care and has no parent, legal custodian, or responsible adult relative immediately known and available to provide supervision and care, reports such knowledge or suspicion to the Florida Abuse Hotline. Five case management files were reviewed for abuse reporting. Abuse reporting procedures were discussed during orientation with each youth and documented in each case management file. The Florida Abuse Hotline and DJJ Central Communications Center (CCC) telephone numbers were posted throughout the program. Five youth completed a survey; each youth indicated they had never been denied access to call the Florida Abuse Hotline. Furthermore, all five youth indicated they felt safe during their time in the program, staff treated them with respect and none of the youth had ever heard staff threaten them or any other youth. A review of the program s internal incident reports and CCC reports during the last six months indicated no allegations of abuse. Three staff was surveyed; each staff provided written comments describing how youth may contact the abuse hotline if requested by the youth. Furthermore, each of the three staff indicated they had never seen another staff deny any youth the opportunity to call the abuse hotline, have never seen any staff use profanity when speaking with a youth and have never seen another co-worker use any threats or intimidation when speaking with a youth. Office of Program Accountability Page 16 of 26 (Revised August 2013)

17 Standard 3: Intervention Services Overview The program s program coordinator and case manager provide intervention services to the youth in the program. The services are guided through the implementation of a Youth- Empowered Success (YES) Plan. The program provides academic assistance Florida opportunities through General Educational Development (GED) test preparation, life skills instruction, introduction to vocational enhancement, and community service for youth in the program Vocational Programming Compliance Staff shall develop and implement a vocational competency development program. The program provides Type A/Level 1 vocational programming that teaches personal accountability skills and behaviors that are appropriate for youth in all age groups and ability levels that lead to work habits that help maintain employment and living standards. The program facilitates this through LifeSkills Training (LST) groups. A review of five youth case management files indicates that two files reflected competency development training in the areas of LifeSkills, effective employee, and communications. The documentation indicated that the youth and parent/guardian were aware of the vocational/educational plan for the youth. The three remaining files did not contain documentation of competency development training as those youth had attendance issues Youth-Empowered Success (YES) Plan Development Compliance The YES Plan (Form DJJ/PACTFRM 4) is cooperatively developed for youth on Probation, Conditional Release, and Post-Commitment Probation. Youth and parent/guardian signatures do not indicate cooperative development of the YES Plan. Case notes clearly reflect that the youth and/or parent/guardian was involved, or refused to be involved, in the development of the YES Plan. All parties sign the YES Plan within fourteen calendar days of youth s admission to the facility. Five youth case management files were reviewed for completing a Positive Achievement Change Tool (PACT) prior to the development of the initial Youth Empowered Success (YES) Plan. The case notes in all five files reflected that the PACT was completed prior to the development of the initial YES Plan. All YES Plans were completed within fourteen days of the youth s admission. All five files clearly reflected that the youth and parent/guardian were involved in the development of action steps and target dates for the completion of all sanctions and goals in the YES Plan as well as the importance of complying with the sanctions and goals of the plan. All five files contained evidence of case notes reflecting that the youth and parent/guardian were provided a copy of the initial YES Plan. Youth surveys confirmed they were involved in the development and received a copy of the YES Plan Youth Requirement/PACT Goal Elements Compliance The YES Plan provides appropriate and individualized target dates for the completion of each youth requirement and PACT goal. All youth requirement and PACT goal action steps include the intervention plan elements (i.e., who, what, and how often). Office of Program Accountability Page 17 of 26 (Revised August 2013)

18 Five youth case management files were reviewed for youth requirements and PACT goal elements. All five files had court-ordered sanctions documented in the youth requirements module in JJIS. All five files contained at least one specific action step for the youth, parent/guardian, and JPO/case manager that clearly defined who was responsible, what action should be taken, and how often the action should be taken. All five files contained a PACT goal that addressed at least one of the youth s top three criminogenic needs. All five files contained at least one specific action step for the youth, parent/guardian, and JPO/case manager that clearly defined who was responsible, what action should be taken, and how often the action should be taken Transitional Planning/Reintegration Non-Applicable Program staff actively participates in the transitional planning process for youth who are being released from a residential program on conditional release (CR) or post-commitment probation (PCP). For conditional release and post-commitment probation youth, the YES Plan must address recommendations from the residential program during transition. This review focused on probation and minimum-risk youth; therefore, the indicator rates as nonapplicable YES Plan Implementation/Supervision Compliance Youth on supervision (i.e., probation, conditional release, or post-commitment probation) are supervised in a manner that ensures compliance with the court order and completion of YES Plan (youth requirements and PACT goals). Case notes demonstrate compliance (or attempted compliance) with youth, parent/guardian, and staff action steps contained in the YES Plan. Five youth case management files were reviewed for the YES Plan implementation and supervision. The case notes in all five files demonstrated compliance or attempted compliance with the youth, parent/guardian, and staff action steps contained in the YES Plan. All five files stipulated measurable goals each youth must achieve. All five files documented ongoing revisions to the YES Plan as goals were accomplished by the youth Effective Response System Compliance Staff responds to noncompliance in a manner that is consistent with the program s progressive response system. Five youth case management files were reviewed for staff responses to noncompliance. All five files reviewed indicated that the staff responded to noncompliance in a manner that is consistent with the program s progressive response system. The noncompliance was mainly for unexcused absences Behavior Management System Compliance The program utilizes a behavior management system that provides privileges and consequences to encourage youth to fulfill programmatic expectations. Consequences are fair and directly correlate with the behavior problem. The use of facility restriction does not exceed seven consecutive days. Disciplinary procedures are carried out promptly. Youth are not allowed to have control over or discipline other youth. Time-out is used in accordance with Florida Administrative Code. All behavior problems, time-outs, in-facility suspensions, and Office of Program Accountability Page 18 of 26 (Revised August 2013)

19 privilege suspensions are documented in the facility log and case file in accordance with Florida Administrative Code. The program utilizes a behavior management system that provides privileges and consequences to encourage youth to fulfill programmatic expectations. Consequences are fair and directly correlate with the behavior problem. The program does not use facility restriction or time-out, which was confirmed by the youth surveys. Disciplinary procedures are carried out promptly, and youth are not allowed to have control over or discipline other youth. The program identifies with the Department of Juvenile Justice mission statement, which is posted throughout the facility along with the program rules. The daily schedule includes structured indoor recreational and leisure activities that teach values and encourage sportsmanship Ninety-Day YES Plan Updates Compliance Staff adjust the YES Plan to reflect any new needs and progress made during the course of supervision. Staff must make necessary updates to youth requirements and PACT goals and save a new YES Plan in the Juvenile Justice Information System (JJIS) prior to ninety-day supervisory reviews. When updates are made to the YES Plan that reasonably require the input of the youth and parent/guardian, this discussion is clearly documented in the case notes. Use of the case notations or a similar form that the youth and/or parent/guardian initials to indicate that the YES Plan was reviewed does not signify compliance. The case notes clearly document any communication regarding the YES Plan. Five youth case management files were reviewed for ninety-day YES Plan updates. All five files reflected that the staff made necessary updates to the youth requirements and PACT goals and generated a new YES Plan in JJIS prior to the supervisory reviews. Four applicable files required youth and parent/guardian input when updates to the YES Plan were made and case note entries reflected the discussion between all parties. Four of five applicable youth files showed case note documentation to support that the youth and parent/guardian were notified of the YES Plan status after the supervisory case review within fourteen calendar days Education Transition Non-Applicable Staff and youth complete an education transition plan prior to release that includes provisions for continuation of education and/or employment. The program does not provide educational services to the youth; therefore, this indicator rates as non-applicable Termination/Release Compliance The program shall recommend termination to the Department for youth on probation, conditional release, or post-commitment probation, as well as minimum-risk commitment youth, upon successful completion of court-ordered sanctions and substantial compliance with restitution and/or court fees. For youth on probation, conditional release, or post-commitment probation, the program works with the Juvenile Probation Officer (JPO) to facilitate the release of the youth upon completion of the program. For youth on minimum-risk commitment, staff completes the Pre-Release Notification and Office of Program Accountability Page 19 of 26 (Revised August 2013)

20 Acknowledgement (PRN) (DJJ/BCS Form 19) and follows the required procedure. Six closed youth case management files were reviewed for termination/release. There were no youth that the program recommended for termination, therefore the requirement that the JPO and case manager (CM) check with local law enforcement to determine if there are any outstanding warrants or charges was not applicable. All six files contained documentation that the program worked with the JPO to facilitate the release of the youth upon completion of the program. All six files showed that youth were on probation status, and therefore, not-applicable for completing a Pre-Release Notification (PRN). None of the files reviewed involved the loss of jurisdiction or the requirement to close the case and update JJIS; therefore, all six were nonapplicable. The program did not request termination from the court and did not receive the court s termination order; therefore the JPO was responsible for updating JJIS within five working days of receipt of the court s termination order and notifying the youth and parent/guardian in writing that the youth was no longer under supervision. Standard 4: Medical, Mental Health, and Substance Abuse Services Overview The program has a part-time contracted licensed mental health counselor (LMHC) on site twice per week to provide mental health and substance abuse services. They are primarily responsible for preparing and/or reviewing clinical documentation, which includes the Substance Abuse and Mental Health (SAMH-2) assessments, initial treatment plans, individualized treatment plans, and Assessments of Suicide Risk (ASR). The LMHC also serves as the clinical coordinator for the program. The program offers mental health and substance abuse services to those youth that have an identified treatment need in one of these areas Medication Management Delivery of Medications Limited Compliance The program shall have a process in place to assist youth with self-administration of oral medications. The program has a policy in place to address medication distribution. They also have a binder set up for this to be monitored, when necessary, with the appropriate medication distribution logs ready for use. The program had one youth with an as needed asthma inhaler during this review period, but the youth never had the need to utilize it while he was in attendance. Evidence was found indicating that staff members were trained to assist youth with the selfadministration of medication; however, this training was not delivered by a registered nurse. There were no procedures to validate their competency or any monitoring processes in place for the unlicensed staff Designated Mental Health Authority or Clinical Coordinator Compliance Each program director is responsible for the administrative oversight and management of mental health and substance abuse services in the program. Each day treatment program must designate either a Designated Mental Health Authority or a Clinical Coordinator to be responsible for coordinating and verifying implementation of necessary and appropriate mental health and substance abuse services in the program. Office of Program Accountability Page 20 of 26 (Revised August 2013)

21 The program has a licensed mental health counselor (LMHC) that serves as the clinical coordinator. The program provided the LMHC s current and active license. The LMHC was on site twice weekly to provide services at the program, as evidenced by a review of sign-in logs. The program also has a LMHC from one of their other sites who provides coverage in the absence of the clinical coordinator Licensed Mental Health and Substance Abuse Clinical Staff Compliance The program director is responsible for ensuring that mental health and substance abuse services are provided by individuals with appropriate qualifications. Clinical supervisors must assure that clinical staff working under their supervision are performing services that they are qualified to provide based on education, training, and experience. The clinical coordinator is a LMHC and is the only licensed staff member working at the program. The LMHC provides all of the mental health and substance abuse services at the program. The program was able to verify the LMHC s qualifications by providing a copy of the current and active license Non-Licensed Mental Health and Substance Abuse Clinical Compliance Staff The program director is responsible for ensuring that mental health and substance abuse services are provided by individuals with appropriate qualifications. Clinical supervisors must assure that clinical staff working under their supervision are performing services that they are qualified to provide based on education, training, and experience. The program does not currently have any non-licensed mental health or substance abuse staff members. Their current suicide prevention plan and mental health crisis intervention plan each require that if a non-licensed mental health staff person conducts an Assessment of Suicide Risk (ASR) or a Crisis Assessment instrument, a licensed staff member must then review, sign, and date the assessment Mental Health and Substance Abuse Admission Screening Compliance The mental health and substance needs of youth are identified through a comprehensive screening process that ensures referrals are made when youth have identified mental health and/or substance abuse needs or are identified as a possible suicide risk. Five youth records were reviewed for completion of the Massachusetts Youth Screening Instrument - Second Version (MAYSI-2). All five reviewed records documented that each youth had this screening completed at their intake by a trained staff member. All five reviewed records had hits on the MAYSI-2, which would require further assessment. The request for a comprehensive mental health and substance abuse evaluation was made in each record. One of the five reviewed records was applicable for suicide risk screening. Four additional applicable records were provided for review. They were each placed on precautionary observation and were seen by the LMHC for the completion of an ASR within twenty-four hours. One of the reviewed records did not have the required suicide risk alert entered in the JJIS Mental Health and Substance Abuse Assessment/Evaluation Compliance The day treatment program director or designee must develop procedures whereby youth who Office of Program Accountability Page 21 of 26 (Revised August 2013)