BUREAU OF QUALITY ASSURANCE 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 ASSURANCE PROGRAM REPORT FOR Kissimmee Juvenile SOP Correctional Facility Sequel Youth and Family Services (Contract Provider) 2330 New Beginnings Road Kissimmee, Florida Review Date(s): November 15-17, 2011 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 F F W E N H O L D, B U R E A U C H I E F Office of Program Accountability Page 1 of 16

2 Residential Performance Rating Profile Program Name: Kissimmee Juvenile SOP Correctional Facility QA Program Code: 989 Provider Name: Sequel Youth and Family Services Location: Osceola County / Circuit 9 Number of Beds: 50 Review Date(s): November 15-17, 2011 Lead Reviewer Code: 91 Contract Number: R Management Accountability 3. Mental Health and Substance Abuse Services (cont.) 1.01 Background Screening of Employees/Vol Suicide Prevention 1.02 Provision of an Abuse Free Environment 3.06 Mental Health Crisis Intervention 1.03 Incident Reporting 3.07 Emergency Services 1.04 Protective Action Response (PAR) 3.08 Specialized Treatment Services 1.05 Pre-Service/Certification Requirements % Indicators Rated Compliance: 88% 1.06 In-Service Training Requirements % Indicators Rated Limited Compliance: 13% 1.07 Logbook Maintenance % Indicators Rated Failed Compliance: 0% 1.08 Internal Alert System Limited 1.09 Escapes 4. Health Services 1.10 Youth Records 4.01 Designated Health Authority 1.11 Community Partnerships 4.02 Healthcare Admission Screening 1.12 Facility Integration and Stability 4.03 Comprehensive Physical Assessment % Indicators Rated Compliance: 92% Sexually Transmitted Diseases % Indicators Rated Limited Compliance: 8% Sick Call % Indicators Rated Failed Compliance: 0% Medication Administration Medication Control 2. Intervention and Case Management 4.08 Infection Control 2.01 Classification 4.09 Chronic Illness Treatment 2.02 Assessment 4.10 Episodic and Emergency Care Limited 2.03 Intervention and Treatment Team Limited 4.11 Consent and Notification 2.04 Performance Plan Limited 4.12 Prenatal/Neonatal Care Non-Applicable 2.05 Performance Review and Reporting % Indicators Rated Compliance: 91% 2.06 Parent/Guardian Communication % Indicators Rated Limited Compliance: 9% 2.07 Transition Planning and Release % Indicators Rated Failed Compliance: 0% 2.08 Grievance Process 2.09 Gang Prevention and Intervention 5. Safety and Security 2.10 Staff Characteristics 5.01 Supervision of Youth 2.11 Delinquency Programming 5.02 Key Control 2.12 Gender-Specific Programming 5.03 Contraband and Searches 2.13 Vocational Programming 5.04 Transportation % Indicators Rated Compliance: 85% Tool Management % Indicators Rated Limited Compliance: 15% Disaster/Continuity of Operations Plan % Indicators Rated Failed Compliance: 0% Flammable, Poisonous, and Toxic Items Water Safety Non-Applicable 3. Mental Health and Substance Abuse Services 5.09 Behavior Management System 3.01 Designated Mental Health Authority 5.10 Behavior Management Unit Non-Applicable 3.02 MH and SA Admission Screening Limited 5.11 Controlled Observation 3.03 MH and SA Assessment/Evaluation % Indicators Rated Compliance: 100% 3.04 Treatment Plan/Team/Service Delivery 3 % Indicators Rated Limited Compliance: 0% (continued above) 1 % Indicators Rated Failed Compliance: 0% 0 Compliance: Limited Compliance: Failed Compliance: Indicator Ratings Overall Rating Summary 91% 9% 0% * Percentages have been rounded to the nearest whole number. Percentages may not total 100% due to rounding. Office of Program Accountability Page 2 of 16

3 Methodology This review was conducted in accordance with FDJJ-1720 (Quality Assurance Policy and Procedures), and focused on the areas of (1) Management Accountability, (2) Intervention and Case Management, (3) Mental Health and Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included in the Residential Standards (July 2011). Persons Interviewed Program Director DJJ Monitor DHA or designee DMHA or designee 5 # Case Managers 5 # Clinical Staff 1 # Food Service Personnel 1 # Healthcare Staff Documents Reviewed 1 # Maintenance Personnel 2 # 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 7 # Health Records 7 # MH/SA Records 9 # Personnel Records 7 # Training Records/CORE 3 # Youth Records (Closed) 7 # Youth Records (Open) # Other: 7 # Youth 7 # 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 16

4 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; limited, unintentional, and/or non-systemic exceptions that do not result in reduced or substandard service delivery; or exceptions with corrective action already applied and demonstrated. Exceptions to the requirements of the indicator that result in the interruption of service delivery, and 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 Assurance 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: Ashley Davies, Lead Reviewer, DJJ Bureau of Quality Assurance Donna Connors, Program Administrator, DJJ Bureau of Quality Assurance Pamela Graves, Review Specialist, DJJ Bureau of Quality Assurance Carldernett Davis, Program Monitor, DJJ Residential Services, Central Region Wendy Whittington, Clinical Manager, Frances Walker Halfway House Office of Program Accountability Page 4 of 16

5 Please note that this report refers to each indicator by number and title only. Please see the applicable standards for the full text of each indicator. The standards are available on the Bureau of Quality Assurance website, at Standard 1: Management Accountability Overview Kissimmee Juvenile Correctional Facility Sex Offender Program is a fifty-bed high-risk residential program for male youth. The program is operated by Sequel Youth and Family Services, through a contract with the Department of Juvenile Justice. This program has been in operation since 2001, and had been co-located with the Osceola Regional Juvenile Detention Center, which closed in July The program relocated to the side of the building previously occupied by the detention center. This allowed the program to have more recreational space for the youth, additional space for administrative offices and a fully operational kitchen. There is twelve foot fencing, topped with razor wire, surrounding the facility. The youth are placed in single occupancy, detention style rooms that contain a stainless steel sink and commode. There are three living units, two that can house sixteen youth each, and one that houses eighteen youth. Each of the three living units has an attached classroom, a common area with dining tables that are used for indoor recreation and meals, and a self-contained outdoor recreation area, which is also fenced. The design allows for minimal movement and interaction between youth from different living units. The master control unit is centered among the three living units, and each unit is easily viewed from master control. The program management is provided by an Executive Director, who is responsible for all aspects of program operation, and a Regional Manager. The management staff includes, a unit coordinator, a lead nurse, a business manager; a kitchen manager and a maintenance manager. At the time of the quality assurance review, the clinical manager position was vacant. The executive director, who is a Licensed Mental Health Counselor (LMHC), has been fulfilling the requirements for the clinical manager postion since March The program tracks all incident reports at the program level, as well as at the corporate level, and a trend analysis is completed monthly and reviewed with all staff. An individual training file is maintained for each employee, with certificates, sign-in sheets, and test results included in the files. Training is offered by program and corporate staff and through web-based training sites. The program has not had any escapes since opening in : Background Screening of Employees/Volunteers Compliance 1.02: Provision of an Abuse Free Environment Compliance Seven staff responded to the survey; one reported hearing a co-worker use profanity occasionally, and one staff reported occasionally observing a co-worker using threats, intimidation, or humiliation when interacting with the youth. Office of Program Accountability Page 5 of 16

6 Seven youth responded to the survey; one reported staff are not respectful when talking with him or other youth. Two youth reported they have heard staff use profanity when speaking with the youth. One youth reported hearing it once and the other youth reported hearing it occasionally. One youth reported not feeling safe in the program. Two of seven youth reported hearing staff threaten them or another youth. One youth reported hearing it once and the other youth reported hearing it occasionally. 1.03: Incident Reporting Compliance During the quality assurance review, the team came across one incident of a youth with a sexually transmitted disease (STD) that had not been reported to the Central Communications Center (CCC). The program nurse immediately called the CCC to report the incident. 1.04: Protective Action Response (PAR) Compliance Two of seven Protective Action Response (PAR) reports reviewed did not indicate whether the use of force was consistent with policy. One PAR report did not indicate whether a medical review was necessary. The program submitted the PAR summary report each month; there was one PAR report missing for June and one missing for July. 1.05: Pre-Service/Certification Requirements Compliance One of three staff training files reviewed for pre-service training requirements documented the staff received 114 of the required 120 hours of training during the first 180 days of employment. 1.06: In-Service Training Requirements Compliance 1.07: Logbook Maintenance Compliance 1.08: Internal Alert System Limited Compliance Two youth did not have a mental health alert entered into the Juvenile Justice Information System (JJIS) as required. A youth with medical issues that required his placement on the alert roster was admitted to the program on August 9, 2011; he was placed on the alert roster August 12, The program also did not complete their Medical Alert Report that was to be placed in the master control medical binder. Office of Program Accountability Page 6 of 16

7 One youth was placed on the program s medical alert log however his Medical Alert Report was not in the master control medical binder. 1.09: Escapes Compliance The program has had no escapes since the last quality assurance review. The program conducted and documented a mock escape drill. The program completed a risk assessment on each youth in the program. The program had an escape backpack, for use if an escape were to occur. The backpack contained flex cuffs, a poncho, bandages, maps and a flashlight. These items would assist the staff in case of an escape. This backpack would only be utilized if needed. 1.10: Youth Records Compliance 1.11: Community Partnerships Compliance The program recently implemented a Communtity Advisory Board, convening one meeting in the last six months. The board did not contain a member of the judiciary, a victim advocate or a parent of a youth previously in the juvenile justice system. The executive director advised he had drafted a letter to recruit these members, however the letter presented for review was for the meeting in October and did not address the need for particular members. 1.12: Facility Integration and Stability Compliance Standard 2: Intervention and Case Management Overview The program employs six counselors who are responsible for conducting case management duties and providing treatment services. Each counselor carries a caseload fewer than ten youth at one time. The youth s counselor completes the classification form, as well as all admission paperwork for the youth. At the time of the quality assurance review, the clinical director postion was vacant, therefore the executive director, who is a licensed clinician, was completing the clinical director duties. The executive director reviews all intake documents, completing a section of the classification form that provides a detailed review of the youth s case to assist in the classification process. The direct care staff complete an orientation with each youth. The youth s counselor is responsible for completing the needs assessment, developing the performance plans, leading the youth s treatment team meeting and creating the performance summaries. The youth s counselor is also responsible for all transition services Office of Program Accountability Page 7 of 16

8 including inviting pertinent parties to the transition and exit conferences, developing the exit plans and submitting the Pre-release Notifications (PRNs). During the quality assurance review, treatment team staffings were observed for several youth; all of the parties were in attendance interacted positively with the youth, providing praise and constructive feedback. The program has a gang liaison who is responsible for reporting any gang related information to the Florida Department of Law Enforcement (FDLE) and for updating the gang binder. The program s grievance process is explained to the youth at admission, and is included in the student handbook and is posted on the mods. The grievance process is effective, as the majority of the youth responding to the survey rated it good or very good. In addition to the grievance process, the program has request for service forms, to allow the youth to speak to particular staff on any issues. The program conducts several family days during the year, and the youth s families are strongly encouraged to be part of the youth s treatment. The program provides vocational instruction for the youth, by conducting a career assessment, and developing an Individual Academic Plan for the youth. The program also conducts a weekly job skills group for the youth ready to be transitioned. 2.01: Classification Compliance Seven files were reviewed; six of the classification forms did not include the youth s physical stature, as required. 2.02: Assessment Compliance 2.03: Intervention and Treatment Team Limited Compliance Seven files were reviewed; there was no documentation for any of the treatment team reviews that the youth s parent or guardian were involved, either in person or via telephone. In two of the seven files, the formal and informal treatment team review forms contained the exact wording, including mispellings and grammatical errors, for several months in a row. Four files contained Residential Positive Acheivement Change Tool (RPACT) reassessments; there was no documented discussion of the RPACT reassessments in any of the applicable files. 2.04: Performance Plan Limited Compliance Seven files were reviewed; the transition activities for the youth were discussed on one performance plan. The program s responsibilities to enable youth to accomplish goals were discussed on one performance plan. On five of the seven plans, the youth s treatment plan was not referenced or attached to the performance plan. Office of Program Accountability Page 8 of 16

9 For one youth, there was no documentation of the performance plan being sent to the applicable parties; another file did not contain the transmittal letter. Seven youth responded to the survey; a couple of the youth reported not being provided a copy of their performance plans. 2.05: Performance Review and Reporting Compliance Seven files were reviewed; four were applicable for ninety-day reviews. In one file, there was no documentation of a transmittal letter or summary being sent to the judge. The youth s initial adjustment to the program, level of motivation to change and significant positive and negative events were not included on one ninety-day summary. 2.06: Parent/Guardian Communication Compliance The program conducted weekly parent groups, an hour prior to visitation, on topics such as Why telling the Truth is Important, and advising parents on how to better interact with their son. In addition to providing written documentation that the youth had arrived at the program, the youth s parent or guardian received a copy of the student handbook and the program rules. The program conducted quarterly family days, and special visitation on the youth s birthday or other signficant event. 2.07: Transition Planning and Release Compliance Three files were reviewed for transition planning and release activitites. The transition plans and exit plans for all three youth did not contain target completion dates, nor the person responsible for completing the goal. The Pre-Release Notification (PRN) for one youth was sent eighty days prior to the youth s projected release date. 2.08: Grievance Process Compliance 2.09: Gang Prevention and Intervention Compliance The program maintained a gang binder that included the completed gang identification card of each youth, updated gang information and training information. The program conducted gang awareness training in January 2011 for all staff. 2.10: Staff Characteristics Compliance Office of Program Accountability Page 9 of 16

10 2.11: Delinquency Programming Compliance 2.12: Gender-Specific Programming Compliance 2.13: Vocational Programming Compliance The program has not offered instruction to the youth in resume writing or application completion in the past six months. Standard 3: Mental Health and Substance Abuse Services Overview The program s executive director, who is a Licensed Mental Health Counselor (LMHC) has served as the program s Designated Mental Health Authority since March The clinical team is comprised of six unlicensed Master's level counselors. The program also contracts with a Certified Addictions Professional (CAP), who is on-site three hours per week, to assist the LMHC in completing substance abuse evaluations and providing substance abuse services. The program has a contract with a psychiatrist who is on-site one day per week to provide psychiatric evaluations and medication monitoring. The counselors have offices immediately adjacent to the three living units, and provide groups in school classrooms or the multi-purpose room, which are also adjacent to the living unit. The LMHC provides weekly supervision for all the unlicensed counselors. Each counselor completes the Massachusetts Youth Screening Instrument- Second Version (MAYSI-2), comprehensive mental health evaluations and treatment plans for their respective youth. The youth are also assessed using the Juvenile Sexual Offender Assessment (JSOAP) and the Child and Adolescent Functional Assessment Scale (CFARS). The LMHC or the CAP completes the substance abuse evaluations. The program has a suicide prevention plan in place that includes the training of staff, referrals based on staff observations, the use of Department of Juvenile Justice approved forms and a policy of supervision. The program conducted six suicide drills in the last six months. The program also has a crisis intervention plan, as well as an emergency services plan, and policy. The emergency plan is outlined and placed on the staff name badges, for easy access. 3.01: Designated Mental Health Authority (DJJ Program) Compliance Office of Program Accountability Page 10 of 16

11 3.02: Mental Health and Substance Abuse Admission Screening Limited Compliance One of seven files reviewed documented the Massachusetts Youth Screening Instrument Second Version (MAYSI-2) was completed two days after the youth was admitted to the program. One of seven files reviewed documented the MAYSI-2 was completed on the day of admission however it was not entered into the Juvenile Justice Information System (JJIS) until weeks later. One of three applicable files documented hits in the area of suicide ideation on the MAYSI-2, requiring an Assessment of Suicide Risk (ASR) to be completed. The documentation reviewed revealed the ASR was completed prior to the completion of the MAYSI-2. Two of three applicable suicide risk alerts were not entered into JJIS. 3.03: Mental Health/Substance Abuse Assessment/Evaluation Compliance One of seven files reviewed documented the youth had hits in the area of traumatic experiences on the MAYSI-2, and this was not addressed in the youth s comprehensive evaluation. 3.04: Treatment Plan, Treatment Team, and Service Delivery Compliance One of seven files reviewed documented one diagnosis on the youth s psychiatric evaluation that was not addressed on the youth s treatment plan. Two of seven files reviewed documented the youth did not receive any restorative justice groups for two months, as required by the youth s treatment plan. One of seven files reviewed documented a change in the youth s DSM-IV diagnosis by the psychiatrist; this change was not addressed on the youth s treatment plan until two months later. 3.05: Suicide Prevention Compliance 3.06: Mental Health Crisis Intervention Compliance 3.07: Emergency Services Compliance Office of Program Accountability Page 11 of 16

12 3.08: Specialized Treatment Services Compliance Standard 4: Health Services Overview A Licensed Registered Nurse (RN) serves as the lead nurse for the program and oversees the day-to-day operations of the clinic; the program also employs two full-time Licensed Practical Nurses (LPNs). The program provides nursing staff on-site seven days a week, for a minimum of twelve hours per day. The nursing staff provides youth with an orientation to the program s medical services. The program has an agreement with a licensed Osteopathic Physician (DO) to act as their Designated Health Authority (DHA) and to complete physicals, periodic assessments and conduct sick call that is beyond the scope of the nursing staff. The program also has a contract with a Psychiatrist to provide psychiatric services on-site. The program has an agreement with a dentist, optometrist, a mobile x-ray unit, and with a pharmacy. HIV testing services are provided on-site by the RN, who has been certified to provide the testing and counseling services. The program has a class II pharmacy permit and has an agreement with a Consultant pharmacist. The program has an infection control plan in place, a monthly report is completed by the RN, and the staff and youth receive infection control training. The program maintains strict control over sharps and medications, by conducting daily or weekly inventories. There were documented issues with the program s use of the sick call log, episodic care log, consent and notification to parents and placing the side effects on the youth s initial Medication Administration Record (MAR). 4.01: Designated Health Authority Compliance 4.02: Healthcare Admission Screening Compliance A review of seven files revealed that the Facility Entry Physical Health Screening Form (FEPHS) was completed by the licensed nursing staff on all youth upon admission to the program. The youth are brought to the nursing office to begin the intake process. The program s nursing staff completed a New Student Admission Form on all youth that was faxed to the DHA and psychiatrist. The fax transmittal sheets were located the admission form in all of the youth s files. The nursing notes documented that the faxes were sent; if the youth had a medical issue, the nurse would speak to the DHA or psychiatrist. Office of Program Accountability Page 12 of 16

13 4.03: Comprehensive Physical Assessment Compliance 4.04: Sexually Transmitted Diseases Compliance The program s RN was certified as a Human Immunodeficiency (HIV) counselor, which allowed her to provide HIV testing and counseling. The test results were placed in a sealed envelope in the youth s medical file; there was documented pre and post-test counseling on the youth s Health Education record. A review of seven files revealed that all youth were screened upon admission for sexually transmitted diseases. Four of the youth consented to the HIV and STD testing. The DHA reviewed and signed all of the STD screening forms, and ordered the testing for applicable youth. 4.05: Sick Call Compliance Three files contained sick calls documented on the sick call index; the sick call forms were found in the files, however they were not consistently recorded on the sick call log. 4.06: Medication Administration Compliance The program s initial Medication Administration Record (MAR) for the youth contained the medications written by the nurses. The MARs did not include the side effects for the medications. 4.07: Medication Control Compliance 4.08: Infection Control Compliance 4.09: Chronic Illness Treatment Compliance 4.10: Episodic and Emergency Care Limited Compliance One youth had two separate incidents of episodic care; a review of his file found one incident was documented in the episodic care log. Office of Program Accountability Page 13 of 16

14 In three other youth s files, the nursing notes reflected that the youth had episodic events that were not documented on the episodic care log. 4.11: Consent and Notification Compliance One youth was taken off-site for medical care on two different occasions for an injury received. There was no documentation of written notification made to the youth s parent or guardian. For one of the incidents, there was documentation of a telephone call to his parent. One youth had been taken off-site for a dental cleaning and there was no written notification sent to his parent or guardian. 4.12: Prenatal/Neonatal Care Non-Applicable The program s policy, procedure, and practice confirm the requirements for this indicator were not applicable for this program, as this is a program for male youth. Standard 5: Safety and Security Overview The program has a maintenance manager that is responsible for key control, internal safety inspections, toxic chemical control, tool control, the replacement of keys and the physical plant repairs. The direct care staff are responsible for perimeter checks, youth supervision, counts and searches, and recording entries in the logbook. The program has an operational security camera system. The program has three shifts per day. The program supervisors conduct monthly meetings in order to communicate with the direct care staff, and all pertinent information regarding the program s safety and security issue are discussed at these meetings. The program does not utilize room restriction or have a behavior management unit. The program implemented a new behavior management system in August The new system is not based on levels, but based on the youth s treatment progress, behavior and education. The system is comprised of three focus areas and each focus area contains a comprehensive list of treatment assignments and expectations the youth must fulfill in order to move to the next area. The youth reported through the surveys an understanding of the behavior management system, and that it is fair. The program maintains strict control of the tools, keys, toxic and chemical items. The program s Continuity of Operations Plan (COOP) was approved by Residential Services. 5.01: Supervision of Youth Compliance The program had a substantiated incident of improper supervision on a Central Communications Center (CCC) report dated September 12, The incident of improper supervision occurred on July 22, Office of Program Accountability Page 14 of 16

15 5.02: Key Control Compliance There was no inventory of the maintenance manager s or and the program administrator s keys. There was no evidence of a key tracking system being completed by the program. 5.03: Contraband and Searches Compliance 5.04: Transportation Compliance 5.05: Tool Management Compliance All class A tools were inventoried daily, regardless of whether they had been used or not. All tools were identified by a code located on the tool. All class A tools, as well as any other tool located in the storage shed, had the same identifying code in the spot where the tool was located, for easy identification of missing tools or tools in use. All staff received training on tool management annually. All youth received training on tool management at admission and were also required to read and sign a tool management policy indicating their awareness and knowledge of all procedures. Risk assessments were completed on each youth at admission and also before any activity involving the use of tools. 5.06: Disaster and Continuity of Operations Planning Compliance 5.07: Flammable, Poisonous, and Toxic Items Compliance 5.08: Water Safety Non-Applicable The program s policy, procedure, and practice confirm the requirements for this indicator were not applicable for this program. Office of Program Accountability Page 15 of 16

16 5.09: Behavior Management System Compliance 5.10: Behavior Management Unit Non-Applicable The program s policy, procedure, and practice confirm the requirements for this indicator were not applicable for this program. 5.11: Controlled Observation Compliance The program had one report of controlled observation since the last quality assurance review. There was no written documentation from the program director or designee authorizing the removal of the youth from controlled observation. Overall Rating Summary Compliance: 91% Limited Compliance: 9% Failed Compliance: 0% * Percentages have been rounded to the nearest whole number. Percentages may not total 100% due to rounding. Office of Program Accountability Page 16 of 16