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 Tampa Residential Facility G4S Youth Services, LLC (Contract Provider) 9508 East Columbus Drive Tampa, Florida Review Date(s): March 14-17, 2017 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES

2 Rating Definitions Ratings were assigned to each indicator by the review team using the following definitions: Compliance Limited Compliance Failed Compliance No exceptions to the requirements of the indicator; or limited, unintentional, and/or non-systemic exceptions that do not result in reduced or substandard service delivery; or systemic exceptions with corrective action already applied and demonstrated. Systemic exceptions to the requirements of the indicator; exceptions to the requirements of the indicator that result in the interruption of service delivery; and/or typically require oversight by management to address the issues systemically. The absence of a component(s) essential to the requirements of the indicator that typically requires immediate follow-up and response to remediate the issue and ensure service delivery. Review Team The Bureau of Monitoring and Quality Improvement wishes to thank the following review team members for their participation in this review, and for promoting continuous improvement and accountability in juvenile justice programs and services in Florida: Scott Luciano, Office of Program Accountability, Lead Reviewer (Standard 1) Felicia Goldstein, Office of Program Accountability, Regional Monitor (Standard 3) Vernon Pryer, Office of Program Accountability, Regional Monitor (Standard 2) Ramona Salazar, Office of Program Accountability, Regional Monitor (Standard 2) Canitha Taylor, Office of Program Accountability, Regional Monitor (Standard 4) April Walker, Central Region Detention Services, Government Operations Consultant II (Standard 5)

3 Program Name: Tampa Residential Facility QI Program Code: 1281 Provider Name: G4S Youth Services, LLC Contract Number: Location: Hillsborough County / Circuit 13 Number of Beds: 60 Review Date(s): March 14-17, 2017 Lead Reviewer Code: 119 Methodology This review was conducted in accordance with FDJJ-2000 (Contract Management and Program Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1) Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included in the Residential Standards. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee 1 # Case Managers 1 # Clinical Staff 1 # Food Service Personnel 2 # Healthcare Staff 1 # Maintenance Personnel 7 # Program Supervisors Documents Reviewed 7 # Staff 7 # Youth 1 # Other (listed by title): Lead Teacher 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 14 # Personnel Records 14 # Training Records/CORE 5 # 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. Additional observations included master control operations, location of first aid kits and suicide response kits, and delinquency intervention group sessions. Office of Program Accountability Page 3 of 68 (Revised July 2016)

4 Standard 1: Management Accountability Residential Rating Profile Indicator Ratings 1.01 Standard 1 - Management Accountability * Initial Background Screening 1.02 Five-Year Rescreening 1.03 * Provision of an Abuse-Free Environment 1.04 * Management Response to Allegations 1.05 * Incident Reporting (CCC) 1.06 Protective Action Response (PAR) and Physical Intervention Rate 1.07 * Pre-Service/Certification Requirements 1.08 In-Service Training 1.09 Grievance Process Training 1.10 Grievance Process 1.11 Grievance Process Documentation 1.12 Life Skills Training Provided to Youth 1.13 Staff Training: Delinquency Interventions 1.14 Restorative Justice Awareness for Youth 1.15 Delinquency Intervention Services 1.16 Gender-Specific Programming 1.17 Logbook Entries and Shift Report Review 1.18 * Internal Alerts System 1.19 * Alerts (JJIS) 1.20 Education Acces 1.21 Youth Records (Healthcare and Management) 1.22 Youth Input 1.23 Advisory Board 1.24 Program Planning 1.25 Staff Performance * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 4 of 68 (Revised July 2016)

5 Standard 2: Assessment and Performance Plan Residential Rating Profile Indicator Ratings Standard 2 - Assessment and Performance Plan 2.01 Initial Contacts to Parent/Gaurdian 2.02 Court Notification 2.03 Youth Orientation 2.04 Written Consent of Youth Eighteen or Older 2.05 Classification Factors 2.06 Classification Procedures 2.07 Reassessment for Activities 2.08 Gang Identification: Notification of Law Enforcement 2.09 Gang Identification: Prevention and Intervention Activities 2.10 R-PACT Assessment 2.11 Youth Needs Assessment Summary 2.12 R-PACT Reassessments 2.13 Parent/Guardian Involvement in Case Management Services 2.14 Members of Treatment Team 2.15 Performance Plan Development 2.16 *Performance Plan Goals 2.17 Performance Plan Transmittal 2.18 Incorporation of Other Plans Into Performance Plan 2.19 Treatment Team Meetings (Formal Reviews) 2.20 Treatment Team Meetings (Informal Reviews) 2.21 Performance Plan Revisions 2.22 Performance Summaries 2.23 Performance Plan Summary Transmittal 2.24 Career Education 2.25 Education Transition Plan 2.26 Transition Planning and Conference 2.27 Exit Portfolio 2.28 Exit Conference * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 5 of 68 (Revised July 2016)

6 Standard 3: Mental Health and Substance Abuse Services Residential Rating Profile Indicator Ratings Standard 3 - Mental Health and Substance Abuse Services 3.01 Designated Mental Health Clinician Authority or Clinical Coordinator 3.02 * Licensed Mental Health and Substance Abuse Clinical Staff 3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff 3.04 Mental Health and Substance Abuse Admission Screening 3.05 Mental Health and Substance Abuse Assessment/Evaluation 3.06 Mental Health and Substance Abuse Treatment 3.07 * Treatment and Discharge Planning 3.08 * Specialized Treatment Services 3.09 * Psychiatric Services 3.10 * Suicide Prevention Plan 3.11 * Suicide Prevention Services 3.12 * Suicide Precaution Observation Logs 3.13 * Suicide Prevention Training 3.14 * Mental Health Crisis Intervention Services 3.15 * Crisis Assessments 3.16 * Emergency Mental Health and Substance Abuse Services 3.17 * Baker and Marchman Acts Non-Applicable * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 6 of 68 (Revised July 2016)

7 Standard 4: Health Services Residential Rating Profile Indicator Ratings Standard 4 - Health Services 4.01 * Designated Health Authority/Designee 4.02 * Psychiatrist/Designee 4.03 Facility Operating Procedures 4.04 Authority for Evaluation and Treatment 4.05 Parental Notification 4.06 Notification - Clinical Psychotropic Progress Note 4.07 Immunizations 4.08 Healthcare Admission Screening Form 4.09 Medical Alerts 4.10 Youth Orientation to Healthcare Services 4.11 Designated Health Authority/Designee Admission Notification 4.12 Healthcare Admission Rescreening 4.13 Health Related History 4.14 Comprehensive Physical Assessment 4.15 Female-Specific Screening/Examination Non-Applicable 4.16 Tuberculosis Screening 4.17 Sexually Transmitted Infection Screening 4.18 HIV Testing 4.19 Sick Call Process - Requests/Complaints 4.20 Sick Call Process - Visits/Encounters 4.21 Restricted Housing Non-Applicable 4.22 Episodic/First Aid Care 4.23 Emergency Care 4.24 Off-Site Care/Referrals 4.25 Chronic Illness/Periodic Evaluations 4.26 Medication Management - Verification 4.27 Medication Management - Orders/Prescriptions 4.28 Medication Management - Storage 4.29 Medication Management - Medication and Sharps Inventory 4.30 Medication Management - Controlled Medications 4.31 Medication Management - Medication Administration Record 4.32 Medication Management - Medication Administration By Licensed Staff 4.33 Medication Management - Medication Provided By Non-Licensed Staff Non-Applicable 4.34 Medication Management - Psychotropic Medication Monitoring 4.35 Infection Control - Surveillance, Screening, and Management 4.36 Infection Control - Education 4.37 Infection Control - Exposure Control Plan 4.38 Prenatal Care - Physical Care of Pregnant Youth Non-Applicable 4.39 Prenatal and Neonatal Care - Nutrition, Education of Youth, and Lactation Non-Applicable 4.40 Prenatal and Neonatal Staff Education Non-Applicable * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 7 of 68 (Revised July 2016)

8 Standard 5: Safety and Security Residential Rating Profile Indicator Ratings Standard 5 - Safety and Security 5.01 Youth Supervision 5.02 * Ten-Minute Checks 5.03 Census, Counts, and Tracking 5.04 Key Control 5.05 Contraband Procedure 5.06 Frisk and Strip Searches 5.07 Vehicles and Maintenance 5.08 Transportation of Youth 5.09 Tool Inventory and Management 5.10 Youth Tool Handling and Supervision 5.11 Outside Contractors 5.12 Fire, Safety, and Evacuation Drills 5.13 Disaster and Continuity of Operations Planning 5.14 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials 5.15 Youth Handling and Supervision for Flammable, Poisonous, and Toxic Items and Materials 5.16 Disposal of All Flammable, Toxic, Caustic, and Poisonous Items 5.17 Recreation and Leisure Activites 5.18 Elements of the Water Safety Plan Non-Applicable 5.19 Staff Training: Water Safety Non-Applicable 5.20 * Swim Test Non-Applicable 5.21 Visitation and Communication 5.22 Comprehensive Behavior Management System 5.23 Implementation and Consistency of Behavior Management System 5.24 Behavior Management System Infractions 5.25 Staff Training: Behavior Management System 5.26 Behavior Management System Monitoring 5.27 Search and Inspection of Controlled Observation Room Non-Applicable 5.28 Controlled Observation Non-Applicable 5.29 Controlled Observation Safety Checks Non-Applicable 5.30 Controlled Observation Release Procedures Non-Applicable * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 8 of 68 (Revised July 2016)

9 Strengths and Innovative Approaches The program encourages teamwork and healthy competition. There are weekly intramural football and basketball games. There are also festival type functions and games for youth and staff to take part in to build an esprit de corps between youth and staff. These events are used to create an environment which is recognized by a large majority of the community as something they take pride in and participate in while in their home community. The program offers a different daily incentive to youth who make a positive day. A positive day is achieved when youth follow facility rules, complete all assignments assigned by either program staff for educational staff, and are respectful to all staff and other youth. These incentives promote a feeling of pride, fellowship, and common loyalty shared by the members of a particular group. Tampa Residential facility has teamed with Jesus for Juveniles (JFJ) ministries to provide a mentor program called, the Steadfast Mentors. Background screened volunteers are matched with youth who have the same interests or hobbies. Mentors have been a great asset to the youth by providing reading material, hygiene products a youth may not have access to, and sometimes tickets for various outings. Youth benefit from the mentoring program as it has assisted in the family reunification process. Mentors have traveled to the youth s home county or city and brought the youth s family to a visitation or family day event. The program provides youth an opportunity to learn the principles and technologies involved in farming, hydroponics, and small animal care. The objective is to provide an interactive learning experience where participants are taught the advances in the growth of agriculture and the sciences, its application to career opportunities as well as the home, and the provision of a model for healthy cultural change. The vegetables that are raised in the gardens are either consumed by the youth within the program or are donated to a community food bank. Staff are encouraged to take part in the program s morale committee where staff coordinate special functions to celebrate special occasions like Black History Month, President s Day, Staff Appreciation Day, and youth high s school graduations. Office of Program Accountability Page 9 of 68 (Revised July 2016)

10 Standard 1: Management Accountability Overview The Department contracts with G4S Youth Services, LLC to operate the Tampa Residential Facility (TRF). The program serves youth who have been assessed and identified with a need for substance abuse treatment and comprehensive mental health services. The program is a sixty-bed, high-risk, secure residential program for adolescent male youth, ages fourteen to eighteen, located in Tampa, Florida. The anticipated length of stay for each youth is nine to twelve months. The youth participate in a variety of delinquency intervention and treatment groups. The groups consist of Thinking for a Change (T4C), Impact of Crime (IOC), Council for Boys and Young Men, Pathways to Self-Discovery and Change, and Life-Skills Training. The management team includes the facility administrator, assistant facility administrator for operations, assistant facility administrator for security, director of case management, health service administrator, the school principal, director of clinical services, dietary manager, and human resources manager. The on-site management of the program is the responsibility of the facility administrator. The facility administrator receives support and oversight, including training and compliance, from the provider s corporate team. On-site medical services are provided by a Florida licensed physician and health services are provided by Florida licensed nurses twentyfour hours a day, seven days a week. Positions vacant at the time of the annual compliance review included two licensed therapists and one case manager. Sixty youth were assigned to the program in the Department s Juvenile Justice Information System (JJIS) on the first day of the annual compliance review. All youth receive three hundred minutes a day in high-school education. The provider operates the school under contract with the Hillsborough County School Board. The 1,500 minutes of weekly educational instruction is provided by six certified teachers, which includes a lead teacher, two support exceptional student education (ESE) facilitators, two assistant teachers, one guidance counselor, one assistant principal, and one secretary. All staff providing educational services are certified by the Hillsborough County School Board. The school board also provides vocational education as part of the school day 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 policies and procedures for conducting a new background screening for all staff, volunteers, and interns prior to their hire date. The program completes a driver s license check and local law enforcement check on all staff, prior to offering them employment. A review of forty-one staff, four corporate staff, three contracted staff, and nine volunteers was conducted and confirmed background screening, driver s license, and local law enforcement checks were completed prior to their hire or start date. All program staff and volunteers received an eligible background screening from the Department s Background Screening Unit (BSU) or the Clearinghouse, prior to hire or volunteering. The Annual Affidavit of Compliance with Level 2 Screening Standards for all staff was submitted to the Department on January 6, Office of Program Accountability Page 10 of 68 (Revised July 2016)

11 1.02 Five-Year Rescreening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. Employees and volunteers are rescreened every five years from the initial date of employment. The program has a written policy and procedures in place regarding a five-year rescreening for all staff, volunteers, and interns. The rescreening date is calculated from the staff s original date of hire or by the original screening date for volunteers and interns. Six staff files were applicable for rescreening since the last annual compliance review. Each reviewed file contained the staff s background rescreening results and each staff was found to be eligible Provision of an Abuse-Free Environment Compliance The program provides an environment in which youth, staff, and others feel safe, secure, and not threatened by any form of abuse or harassment. Posting of the Florida Abuse Hotline telephone number and the Central Communications Center for youth 18 years of age and older telephone number. All allegations of child abuse or suspected child abuse are immediately reported to the Florida Abuse Hotline. Youth and staff have unhindered access to report alleged abuse to the Florida Abuse Hotline pursuant to Section (1)(a), F.S. The environment is free of physical, psychological, and emotional abuse. A code of conduct for staff who clearly communicates expectations for ethical and professional behavior, including the expectation for staff to interact with youth in a manner promoting their emotional and physical safety. The program has a policy and procedure for the provisions of an abuse-free environment and unhindered access to report alleged abuse. All staff sign a code of conduct during the orientation process. A review of seven staff personnel files documented the code of conduct had been signed by each of the staff. The code of conduct details the expectations for ethical and professional behavior, including the expectation for staff to interact with youth in a manner promoting their emotional and physical safety. The program s policy for youth to report abuse requires the youth to notify a staff member, the staff member then contacts a supervisor, and the supervisor escorts the youth to a phone to call the Florida Abuse Hotline. The program has abuse-reporting phone numbers posted throughout the facility. The program had two incidents of alleged abuse, reported to the Florida Abuse Hotline or the Central Communications Center (CCC), since the last annual compliance review. Both incidents were unsubstantiated. Seven youth and seven staff surveyed confirmed the youth have unhindered access to the Florida Abuse Hotline and CCC. Five staff and five youth were interviewed, of which all youth reported feeling safe at the program and have never been denied a telephone call to the Florida Abuse Hotline or CCC. Each surveyed youth reported the staff were respectful when talking to the youth. All staff and youth feedback from surveys and interviews supported the program is free from profanity, and physical, psychological, and Office of Program Accountability Page 11 of 68 (Revised July 2016)

12 emotional abuse. All staff surveyed were able to describe the program s practice for allowing youth to call the Florida Abuse Hotline and the CCC to report allegations of abuse. None of the staff reported hearing co-workers use profanity when speaking to the youth or refusing to let a youth call to report allegations of abuse Management Response to Allegations Compliance Management shall be cognizant of youth and staff needs and provide direction to each on how to access the Florida Abuse Hotline. There is evidence management takes immediate action to address incidents of physical, psychological, and emotional abuse. A review of the program s Central Communications Center (CCC) reports, internal incident reports, and grievance records for the past six months confirmed the program had two reportable CCC incidents and one of these two incidents required an additional call to the Florida Abuse Hotline. Both incidents were categorized as complaints against staff. Both incidents were unsubstantiated and closed, requiring no further action against staff by management; however, a review of the documentation provided by the program showed evidence in which management took immediate action to address these incidents. In each incident, staff were removed from direct contact with the youth, pending the outcome of the investigation 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 policy and procedure for reporting incidents to the Department s Central Communications Center (CCC) within two-hours of the incident. The program provides training for all staff regarding the requirements of incident reporting. All staff and volunteers of the program are required to adhere to the Department s incident reporting guidelines, which are also included in the program s facility operating procedure (FOP). The facility administrator or designee is responsible for contacting the CCC within two-hours of a reportable incident, or within two-hours of learning of the incident. A review of CCC reports for the past six months confirmed ten applicable incidents were reported to the CCC within the required two-hour time frame of the caller gaining knowledge of the incident. The reviewed documentation supports each incident was documented in the program s logbook. The annual compliance review team determined there were no additional incidents which should have been reported to the CCC after reviewing internal incidents and grievances. Office of Program Accountability Page 12 of 68 (Revised July 2016)

13 1.06 Protective Action Response (PAR) and Physical Compliance Intervention Rate The program uses physical intervention techniques in accordance with Florida Administrative Code. Any time staff uses a physical intervention technique, such as countermoves, control techniques, takedowns, or application of mechanical restraints (other than for regular transports), a PAR Incident Report is completed and filed in accordance with the Florida Administrative Code. The program uses physical intervention techniques in accordance with the Florida Administrative Code. The program has a Department approved Protective Action Response (PAR) training plan signed by the facility administrator and the Department s residential services director. A review of the PAR logbook for this annual compliance review period found the program had seven PAR incidents within the last six months. The reports were all contained within a central file and completed in accordance with Departmental policy. Each report was completed by the end of the involved staff member s workday. The reports included documentation of reviews by the supervisor on duty, the PAR certified supervisor, and written statements by each staff. Each PAR report indicated a post-par interview was conducted with the youth, within thirty-minutes of the incident. Each report had a documented review, completed by the program director or designee, within seventy-two-hours of the incident. Monthly reports are documented and sent to the regional residential program monitor by the tenth of each month. It is the program s protocol to assess each youth for the need of medical services after each PAR. The program s 2016 PAR plan was approved by the Department s Office of Staff Development and Training on September 21, The program provides a monthly PAR report to the Departments residential services staff by the fifth of each month 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. Seven staff training files were reviewed for documentation of pre-service training. The program s training plan and documentation verified each of the seven staff completed a minimum of 120- hours of pre-service training, within 180-days of their hire date. Each reviewed staff training file contained documentation of the completed essential skills training, prior to contact with youth. All seven staff received training in the youth grievance process, infection control, site-specific exposure control plan, safe use of tools, and the behavior management system. All instructors were qualified to facilitate the training. The program s training plan includes a detailed jobspecific component specifically tailored to the program. The training provided meets the requirements of the Department. All trainings were documented in the Department s Learning Management System (SkillPro) and the G4S youth program s pre-service training checklist. The pre-service training plan for the program also includes instructional and competency testing. The program s 2016 pre-service training plan was submitted and approved by the Department s Office of Staff Development and Training on February 24, Office of Program Accountability Page 13 of 68 (Revised July 2016)

14 1.08 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. Seven staff training files were reviewed for annual in-service training requirements. All training files contained documentation of staff exceeding the minimum twenty-four-hours of annual training. Each staff had current first aid, cardiopulmonary resuscitation (CPR), and automated external defibrillator (AED) certifications documented in their training files. All staff also had documentation for eight-hours of in-service training, including Protective Action Response (PAR) update, professional ethics, and suicide prevention. A review of six supervisory personnel files documented each supervisor received more than the required annual eight-hours of supervisory training. All trainings were documented in the Department s Learning Management System (SkillPro) and G4S in-service training checklist. The 2016 in-service training plan for the program was approved by the Department s Office of Staff Development and Training on February 10, Grievance Process Training Compliance Program staff shall be trained on the program s youth grievance process and procedures. The program has a policy and procedures outlining the provisions of the program s grievance process. The policy requires all staff to be trained in the grievance process. A review of seven pre-service staff training files indicated all staff were trained in the program s grievance process during their initial training. An additional seven in-service training files were reviewed, and all staff received annual training in the program s grievance process. Seven staff surveyed and five interviewed staff validated staff are trained on the program s grievance process upon new-hire training and during staff annual in-service training Grievance Process Compliance The program adheres to their grievance process and shall ensure it is explained to youth during orientation and grievance forms are available throughout the facility. The program has a written policy which ensures all youth are orientated on the facility s grievance process, specifying the process for youth to grieve actions of the program and/or staff, including violation or denial of basic rights. The policy outlines the process for an informal, formal, and appeal phase of the grievance procedure, including time frame requirements of each phase. The seven reviewed youth case management records contained documentation of signed forms, in which the youth had been advised of the grievance procedure at the time of intake. The grievance process was also addressed in the admissions letter mailed to the parent/guardian. There were grievance forms located in each of the living areas. The facility also has an informal process allowing youth to address concerns. This process requires a youth to complete a Let s Talk form, which is addressed to the staff with whom they would like to speak. Seven youth were surveyed in regards to the grievance process and each confirmed Office of Program Accountability Page 14 of 68 (Revised July 2016)

15 they were able to seek assistance when completing a grievance form. During a facility tour, grievance and Let s Talk forms were observed in a wall mounted letter sorter, in the dining hall, next to the locked grievance box. Interviews were conducted with five youth and five staff, and all were able to articulate the program s grievance process Grievance Process Documentation Compliance Completed grievances shall be maintained by the program for a minimum of twelve months. The program has a policy and procedures in place detailing the process for maintaining grievances. The program s policy states all completed grievances are to be placed in a centralized grievance binder and logged on a grievance log. The policy further states the program is to maintain the grievances in the centralized binder for at least one year, and are not to be placed in the youth s individual case management record. A review of the program s grievance binder indicated there had not been any grievances filed in the six months, prior to the annual compliance review; however, the program did have three Let s Talk forms filled out by youth. These were reviewed for compliance with the program s informal grievance process. All three informal grievances were handled and resolved in the informal phase of the program s process, and none were elevated to the appeal phase. All informal grievances were handled within seventy-two-hours, as outlined in the program s policy Life Skills Training Provided to Youth Compliance The program shall provide interventions or instruction focusing on developing life and social skill competencies in youth. The program provides a wide variety of interventions focusing on the development of life and social skills for the youth. The program s clinical and direct care staff conduct groups on various topics including Life Skills Training, The Council for Boys and Young Men, Thinking for a Change, Impact of Crime, and Pathways to Self-Discovery and Change. The program s life and social skill interventions address how to avoid high-risk situations, communication, interpersonal relationships and interactions, non-violent conflict resolution, anger management, critical thinking, and problem solving. There were group sign-in sheets documenting the completion of group interventions. The program has a transitional service manager who works with each youth during the transitional phase of the program to develop life skills, such as budgeting, housing, and transportation. A review of seven staff training files indicated designated staff were certified to teach one or more of the program s life skill interventions. A review of seven youth case management records revealed all youth were currently involved, or previously involved, in a life skills group. The program s activity schedule was observed. When scheduled, the program adheres to offering life skills training to youth as confirmed by group sign-in sheets. Five youth were interviewed to determine their participations in groups, all confirmed they actively participate in life skill groups. Office of Program Accountability Page 15 of 68 (Revised July 2016)

16 1.13 Staff Training: Delinquency Interventions Compliance Staff whose regularly assigned job duties include implementation of a specific delinquency intervention model, strategy, or curriculum receive training in its effective implementation. The program facilitates Thinking for a Change (T4C), Impact of Crime (IOC), and Life Skills Training (LST) curriculum. Since the last annual compliance review, the program had three different staff facilitate the LST curriculum, and the program provided documentation all facilitators were certified to teach the curriculum. Since the last annual compliance review, the program had four different staff facilitate the T4C and IOC curriculum and the program provided documentation all four facilitators were certified to facilitate either T4C, IOC, or both. The program schedule indicated delinquency interventions are facilitated each weekday. An interview was conducted with the facility administrator (FA) to discuss how the program determines which staff should be considered to facilitate a delinquency intervention. The FA advised the program takes into consideration a staff member s educational background, previous group facilitation, and prior training, such as motivational interviewing, before considering them for a facilitator role. The FA also ensures staff have great communication skills, listening skills, and work well with the population of the program, before sending them to a delinquency intervention facilitator training Restorative Justice Awareness for Youth Compliance The program shall provide activities or instruction intended to increase youth awareness of, and empathy for, crime victims and survivors, and increase personal accountability for youths criminal actions and harm to others. The program uses the Impact of Crime (IOC) curriculum to teach and reinforce the idea of restorative justice awareness to the youth in the program. IOC is facilitated two days a week, until all twenty-four sessions have been taught to each group. A review of three staff training files verified each staff was certified to facilitate IOC groups. The program employs a restorative justice counselor to provide the youth with activities to increase the youth s awareness of, and empathy for, crime victims, survivors, and increase the youth s personal accountability for their actions against others. The program schedule indicated restorative justice awareness to the youth are facilitated on Mondays and Wednesdays. A review of seven youth case management records indicated all seven youth had at least one goal increasing the youth s accountability for their criminal actions and harm to others. The youth are assigned to participate in IOC, complete letters of apology, and community service work hours as part of their case plan, to help them increase their knowledge of restorative justice. There were group sign-in sheets documenting the completion of group interventions. The IOC primary service was being co-facilitated by two qualified and trained staff. The group was being held every Monday and Wednesday from 11:20 a.m. to 12:20 p.m. and was observed by a regional monitor. The regional monitor received a copy of the lesson plan being presented to the group prior to the class being observed. The monitor observed the co-facilitators using their own words to convey the meaning of the topic under discussion and did not read the lesson verbatim from the manual. The facilitators took turns presenting the information to the group and were easy to follow. Both facilitators engaged the youth and had various youth read and answer the exercises. Office of Program Accountability Page 16 of 68 (Revised July 2016)

17 1.15 Delinquency Intervention Services Compliance The program shall implement a delinquency intervention model or strategy that is an evidencebased practice, promising practice, or a practice with demonstrated effectiveness, for each youth. The program has a policy and procedures outlining the implementation of delinquency intervention models or strategies, including evidence-based practices, promising practices, or practices with demonstrated effectiveness to address the prioritized needs identified for each youth. The program utilizes Thinking for a Change and Impact of Crime as their delinquency interventions. Each youth s need for a delinquency intervention is identified when they are admitted to the program by the completion of the Daniel Memorial Assessment and the Residential Positive Achievement Change Tool (R-PACT). Delinquency interventions are provided to the youth either on Mondays, Tuesdays, Wednesdays, or Thursdays. A review of seven youth case management records indicated each youth had been participating in delinquency interventions services, as evidenced by their treatment plans and sign-in sheets for the specified groups. A review of the programs daily activity schedule determined the program was providing structured programming at least 60% of the youth s wake hours Gender-Specific Programming Compliance The program provides delinquency intervention and gender-specific treatment services. The program delivers The Council for Boys and Young Men curriculum to all youth, on a weekly basis. This curriculum includes twenty-six sessions, which are delivered by trained therapists. Gender-specific treatment focus areas address sexual abuse, trauma, substance abuse, crimespecific topics, as well as relational and emotional topics. The Council is a strengths-based group approach to promote healthy masculinity development for boys and young men from ages nine to eighteen. It focuses on boys' natural strengths and broadens their understanding about being male in today's world. It challenges myths about how to be a "real boy" or " real man." The Council engages boys in activities, dialogue, and self-expression to question stereotypical concepts. By promoting valuable relationships with peers and adult facilitators, The Council increases boys' emotional, social, and cultural literacy. A review of seven youth case management records found each of the seven youth received The Council for Boys and Young Men curriculum on a weekly basis Logbook Entries and Shift Report Review Compliance The program maintains a chronological record of events, incidents, and activities in a central log-book maintained at master control, living unit logbooks, or both, in accordance with Florida Administrative Code. The program ensures direct care staff, including each supervisor, are briefed when coming on duty. The program maintains a chronological record of events, incidents, and program activities in the master control logbook and a facility shift report logbook. The master control logbook is located in master control and is maintained by the master control technician. The facility shift logbook is maintained by the shift supervisor and is kept with the supervisor throughout their shift. Six months of logbooks were reviewed for their content. The logbooks were bound and one logbook out of the eight reviewed had a loose page stapled to the back of the logbook cover. All of the pages of the logbook were accounted for with no blank pages. There was no evidence of correction fluid found in any of the logbooks. All entries were in ink and there were no eraser Office of Program Accountability Page 17 of 68 (Revised July 2016)

18 marks. Errors were documented as with a single line through the error, along with the initials of the person making the entry. The date and time of the entry was placed in the left margin for each event. The entries were brief descriptions of events and included the names of the involved youth and staff. The required scheduled and unscheduled counts were documented. Perimeter checks were documented in the logbooks. Transportations away from the facility, including the names of the youth, staff, and the destination were also documented in the logbooks. The facility shift logbook contained documentation the supervisor verbally briefed incoming staff about the contents of the shift logbook, and all incoming staff signed and dated the facility shift logbook, indicating they were briefed on the contents. Log entries regarding medical, special needs, mental health alerts, and other issues impacting the facility s safety and security were highlighted within each logbook. Each entry in the master control and facility shift logbook, starting from approximately December 13, 2016, documented the name and signature of the person who made the entry. The program realized they were not completing the entries with a printed name and signature in early December 2016 and corrected their practice Internal Alerts System Compliance The program shall maintain and use an internal alert system easily accessible to program staff and keeps them alerted about youth who are security or safety risks, and youth with healthrelated concerns, including food allergies and special diets. When risk factors or special needs are identified during or subsequent to the classification process, the program immediately enters this information into its internal alert system. The program ensures only appropriate staff may recommend downgrading or discontinuing a youth s alert status. The program has a policy and procedures in place to address how internal alerts are determined and made accessible to program staff. The program maintains an alert form, which is located in the staff area where shift briefings are held. The alert form is reviewed for alerts by staff prior to, during, and after shift briefing. The alert form includes youth information regarding medical conditions, medical grade, allergies, dietary restrictions, recreation restrictions, security alerts, mental health status and supervision, gang affiliations, and program level. The alert form information is updated daily by the clinical staff, medical staff, and case management staff. Program management reviews all alerts during the daily management meeting and the internal alert form is updated, as necessary. Additionally, copies of the youth alerts are located in the kitchen area and medical clinic for those staff to have quick and easy access to youth alerts. There were seven youth case management records, seven individual healthcare records, and seven mental health records reviewed for compliance with the program s internal alert system. All records reviewed were required to have one or several internal alerts placed on the alert board, which all alerts were found to be documented on the internal alert board. Seven staff were surveyed, and all seven staff advised they were informed of the youth alerts by reviewing the logbooks, at shift briefings, and the alert board. All of those seven staff further indicated they are informed of youth alerts by alert forms located in the facility. Five interviewed staff reported they are informed of youth s alerts through the alert board. Office of Program Accountability Page 18 of 68 (Revised July 2016)

19 1.19 Alerts (JJIS) Compliance When risk factors or special needs are identified during or subsequent to the classification process, the program immediately enters this information into the Juvenile Justice Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are downgraded or discontinued. A review of seven youth mental health and substance abuse, healthcare, and case management records documented all youth who were identified with an alert, were entered into the Department s Juvenile Justice Information System (JJIS). All youth with alerts relating to medications, special diets, allergies, gang association, suicide risk, and mental health were entered JJIS in a timely manner. When necessary, the alerts were downgraded or discontinued by an appropriate staff member. An interview with the facility administrator, licensed mental health clinical authority, health services administrator, and case manager supervisor confirmed this practice Educational Access Compliance The facility shall integrate educational instruction (career and technical education, as well as academic instruction) into their daily schedule in such a way ensuring the integrity of required instructional time. The program and G4S Youth Services, LLC have a cooperative agreement with the Hillsborough County School Board to provide educational services to the youth who are committed to the Tampa Residential Facility. The educational program delivers academic instruction 250 days a year and delivers 300 minutes of instruction daily, five days a week. The program operates a summer session and has two holiday periods for Thanksgiving and Christmas and four weeks off for summer break. The youth are able to work towards earning a General Educational Development (GED) or a high school diploma. A review of three closed youth case management records revealed youth receive course credit for completion of work documented on transcripts. The program schedule includes science, creative writing, language arts, history, math, reading, social studies, and use of the computer lab to reinforce academic skills. The program also shares an assistant principle with three other residential programs colocated on the compound grounds. A review of the facility logbooks and activity schedules found classes are taking place, as scheduled by the program 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. The program maintains three separate binders for each youth as it pertains to case management, mental health, and individual healthcare records. During the annual compliance review, there were twenty-one different binders used by the program and all binders were marked confidential. Each binder contained the youth s name, Department of Juvenile Justice identification number, date of birth, county of residence, and committing offense. Each of the youth s individualized records were divided into sections labeled legal information, demographic and chronological information, correspondence, case management, treatment team activities, and miscellaneous. Each binder was marked Confidential and secured in locked filing cabinets Office of Program Accountability Page 19 of 68 (Revised July 2016)

20 in either the medical clinic, case management office, or therapist office. All filing cabinets were also marked Confidential Youth Input Compliance The program has a formal process to promote constructive input by youth. The program has an informal process which allows youth to address their concerns. The process requires youth to complete a Let s Talk form addressed to the staff with whom they would like to speak. The program also maintains a youth advisory board who meet with facility administration to share feedback about the program, ideas for improvement, and plan future activities. Documentation indicated the youth advisory board meets approximately twice a month. The youth advisory board consists of six representatives from the living units and each representative has to fill out an application to be on the advisory board. The program holds morning opening circle, an afternoon community meeting, and evening closing circle. The afternoon community meeting addresses minor community issues and promotes communication between the youth and staff. The morning opening and evening closing circles allow youth additional opportunities to communicate with staff currently supervising them and share their feelings. The youth are surveyed quarterly regarding any concerns, as well as programming input. The program s management team reviews the youth surveys, implements appropriate ideas, and corrects concerns put forth by the youth. A review of the seven youth surveys and five youth interviews indicated all youth felt the program had a process which allows them to provide input regarding what happens at the program Advisory Board Compliance The program has a community support group or advisory board meeting at least quarterly. The program director solicits active involvement of interested community partners. The program has a community advisory board which includes representatives from law enforcement, the judiciary, community partners, business community, school board, faith community, victim advocate s office, and has recently recruited a parent/guardian of a former youth involved with the Department. Documentation indicated the advisory board met quarterly, with all members being invited and reminded of the meetings. The facility administrator (FA) indicated the advisory board is very influential and involved with youth in order to enhance program services. The program held advisory board meetings on August 18, 2016, October 27, 2016, and January 26, An interview was conducted with a faith-based member of the advisory board who verified meetings are held quarterly and are a great way to keep the members informed about what is occurring in the program, as well as any updates to the program s policies and procedures. The board member further advised each member is able to voice concerns about the program and give feedback to facility administration with regards to improving the program Program Planning Compliance The program uses data to inform their planning process and to ensure provisions for staffing. The program has a policy and procedures regarding program planning. The program conducts a daily management meeting to discuss issues regarding the youth, as well as programmatic issues regarding pending background screenings, trending data, potential risks, work orders, and general announcements. The program also conducts monthly supervisory staff meetings, Office of Program Accountability Page 20 of 68 (Revised July 2016)