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 Paxen Community Connections- Brevard Paxen Learning Corporation (Contract Provider) 285 N. Lakeview Blvd. Cocoa, Florida Review Date(s): April 21-23, 2015 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: Donna Connors, Office of Program Accountability, Lead Reviewer Abby Anderson, Juvenile Probation Officer Supervisor, Circuit 9 David Bassler, Office of Program Accountability, Regional Monitor Bonita Williams, Office of Program Accountability, Regional Monitor

3 Program Name: Paxen Community Connections-Brevard QI Program Code: 1264 Provider Name: Paxen Learning Corporation LLC Contract Number: P2120 Location: Brevard County / Circuit 18 Number of Beds: 20 Review Date(s): April 21-23, 2015 Lead Reviewer Code: 097 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 Services, (3) Intervention Services, and (4) Medical, Mental Health, and Substance Abuse Services, which are included in the Day Treatment Standards. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee 1 # Case Managers # Clinical Staff # Food Service Personnel # Healthcare Staff Documents Reviewed # Maintenance Personnel # Program Supervisors Regional Program Manager # 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 5 # MH/SA Records 5 # Personnel Records 5 # Training Records/CORE 3 # Youth Records (Closed) 5 # Youth Records (Open) # Other: 5 # Youth 4 # 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 31 (Revised September 2014)

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) 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) Non-Applicable 1.17 * 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 4 of 31 (Revised September 2014)

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 * 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 31 (Revised January 2015)

6 Standard 3: Intervention Services Day Treatment Rating Profile Indicator Ratings Standard 3 - Intervention Services 3.01 Vocational Programming 3.02 Educational Access Non-Applicable 3.03 Youth-Empowered Success (YES) Plan Development 3.04 Youth Requirements/PACT Goal Elements Limited 3.05 * Transitional Planning/Reintegration Non-Applicable 3.06 YES Plan Implementation/Supervision Limited 3.07 Effective Response System Limited 3.08 Behavior Management System 3.09 Ninety-Day YES Plan Updates 3.10 Educational Transition Non-Applicable 3.11 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 31 (Revised January 2015)

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 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 * 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 31 (Revised January 2015)

8 Strengths and Innovative Approaches The staff accompanied the youth on a tour of the career and technical programs at a local college. The youth were able to learn about career choices such as welding, automotive, heating and air-conditioning, and cosmetology. The youth participated in a home restoration project at Nana s House, a shelter for children who have been abused and/or neglected. Using independent living skills, the youth prepared a meal; the youth followed a recipe, and learned how to add ingredients to make the meal healthy, and to make enough to eat for several meals. The youth went on an outing to a local police department to learn how to de-escalate situations, and to promote personal safety. The program s coordinator and director of treatment attended a training regarding the principles of trauma-informed care and positive youth development. Office of Program Accountability Page 8 of 31 (Revised January 2015)

9 Standard 1: Management Accountability Overview Through a contract with the Department of Juvenile Justice, Paxen Learning Corporation operates a day treatment program in Brevard County, Florida. The program is designed to serve youth placed on probation, or who are under the legal status of minimum-risk commitment. The program recently moved into a new building, and relocated from Melbourne, Florida to Cocoa, Florida. The program staff consists of one program coordinator, one case manager, and two program support specialists. At the time of the annual compliance review, there was one program support specialist position vacant. The program contracts with a licensed mental health counselor (LMHC) to provide services for applicable youth. The program receives support and oversight from their regional program manager, as well as the state director and the director of treatment. An individual training file is maintained for each staff; the training files contain certificates, sign-in sheets, and individual training plans. The program provides instructor-led staff training by program staff, Department of Juvenile Justice trainers, and on-line through the Department s Learning Management System (SkillPro). The program serves male and female youth, who are between the ages of fourteen and nineteen. The program has twenty slots, however, there were twelve youth in the program at the time of the annual compliance review. The program receives referrals from the Department of Juvenile Justice Juvenile Probation Office, Circuit 18. During their time in the program, youth are provided services in evidence-based interventions, case management, community supervision, and life skills training. Any youth identified through the screening process as requiring mental health or substance abuse treatment services are referred to the LMHC to receive an on-site assessment and any needed treatment 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 written policies and procedures regarding background screening of staff. Prior to hire, all staff are required to have a background screen conducted through the Department of Juvenile Justice Background Screening Unit (BSU). The program s human resource functions are completed by the provider s corporate staff located in Palm Harbor, Florida. In addition to completing a background check through BSU, record checks are conducted on all staff through a national database. Prior to hire, each staff s driving record and criminal history are checked; each staff is also checked against a sex offender database. The staff s driver s licenses are checked monthly to ensure license is valid. The program hired two staff since the last review. There was documentation to support the program received a favorable clearance from the Department s BSU prior to hire for both staff. The personnel files also contained documentation of a record check through the national database. The program s Annual Affidavit of Compliance with Level 2 Screening Standards was received by the BSU on January 14, 2015, meeting the annual requirement. Office of Program Accountability Page 9 of 31 (Revised January 2015)

10 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 written policies and procedures requiring compliance with the Department s five-year rescreening requirements. All of the program s human resource functions are completed by staff located in Palm Harbor, Florida. Each program operated by the provider maintains a tracker for five-year rescreens. The tracker contains the name of each staff, the date of hire, the date the five-year rescreen is due, and the date the rescreening was completed. The program has been operational since 2012; therefore, there were no staff requiring a five-year rescreen at the time of the annual compliance review Protective Action Response (PAR) Compliance The program uses physical intervention techniques in accordance with Florida Administrative Code. Any time staff uses a physical intervention technique, such as countermoves, control techniques, takedowns, or application of mechanical restraints (other than for regular transports), a PAR Incident Report is completed and filed in accordance with the Florida Administrative Code. The program has written policies and procedures regarding the use of physical intervention techniques. The policy requires the completion of a Protective Action Response (PAR) report following each use of a physical intervention. There was one documented use of a physical intervention in the past year; the completed PAR report was reviewed. The report was completed before the staff left the program on the day of the incident. A post PAR interview was conducted with the youth and the regional program manager. There was no documentation to support the youth received any injuries or required any medical treatment. The PAR report was reviewed as required by the program coordinator, a PAR certified supervisory staff, and the program s regional program manager. The PAR report was reviewed by all required staff within the specified time frames; the PAR report was reviewed by the regional program manager prior to the review by the PAR certified supervisory staff. The program submits a monthly report to the Department of Juvenile Justice; the report for February 2015 included documentation of the PAR incident 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 has written policies and procedures regarding pre-service training. The program has a written pre-service training plan; the training plan was submitted and approved by the Department s Office of Staff Development and Training on February 3, The program Office of Program Accountability Page 10 of 31 (Revised January 2015)

11 provides training in a combination of web-based training and instructor-led training. The program hired three staff since the last review. The two training files were reviewed for the receipt of pre-service training requirements. One staff completed all of the essential job skills training within the first thirty days of employment, documenting eighty-three and one half hours of training. This staff transitioned to a position with another program operated by the provider; therefore, was not required to complete the DJJ training. One staff has been working since November 2014; his training file documented 142 hours of pre-service training. All of the required training topics had been covered, and the staff was certified in cardiopulmonary resuscitation (CPR), First Aid, and Protective Action Response (PAR). One staff was hired three weeks prior to the annual compliance review. This staff s training file documented eighty-eight and one half hours of pre-service training, with time remaining in the staff s first 180 days of employment to complete the remainder of the required training. The staff had completed the essential job skills 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 has written policies and procedures regarding the provision of in-service training. The program has a written in-service training plan that was submitted and approved by the Department s Office of Staff Development and Training on February 3, The program also develops an annual training calendar, which was updated as needed. Two training files were reviewed for in-service training requirements. The training files documented between thirty-eight and forty-three hours of in-service training in There was documentation in both reviewed files that the staff received all required training topics; both staff had received eight hours of PAR training updates. Both staff had current First Aid and CPR certification. Both files were for supervisors. One file documented five hours of supervisory training in 2014; there was documented training in management, leadership, and employee relations, however, the remaining two hours were listed on SkillPro as Paxen Supervisory Training. The second supervisory file documented four hours Paxen Supervisory 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 written policies and procedures regarding medical and mental health alert process. The program utilizes a form entitled Mental Health/Medical Alert Notification including the applicable youth s name, the date the alert started, a description of the alert, and the staff completing the alert form. The form includes a section for the alert to be revised if necessary. Each staff is required to sign the form to indicate their review of the information; the form also contains reminders to staff to enter alerts into the Juvenile Justice Information System (JJIS). Five youth requiring placement on the program s alert system were reviewed; each youth was identified with at least one condition. The Mental Health/Medical Alert Notification form was Office of Program Accountability Page 11 of 31 (Revised January 2015)

12 completed on the date of admission to the program for all five youth. The alert notification forms were signed by all staff, to acknowledge their review of the alerts. Each youth s medical and/or mental health condition was noted on JJIS, with one exception. One youth was placed on precautionary observation due to his history. Later that same day, an Assessment of Suicide Risk was completed on the youth, placing him on standard supervision. There was no documentation in JJIS of the youth being placed on and removed from precautionary observation. Three staff responded to the survey; the staff reported being informed of the youth s alerts through reading the youth s information, and through the JJIS alerts 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 written policies and procedures for providing emergency medical care to youth. The program stores a knife-for-life, wire cutters, needle-nose pliers, a spill kit, and a first aid kit in a locked drawer of the case manager s desk. There is a first aid kit placed in a backpack that is taken with each transport. The policy requires a regular inventory of the first aid kits, not to exceed one month. As part of the weekly safety sanitation and maintenance inspection, the regional program manager checks the seals on the first aid kits are intact. On a monthly basis, a safety committee checklist is completed by the regional program manager; this checklist documents the first aid kits are fully stocked. In an informal interview with the regional program manager, he reported the contents of the first aid kits are not checked monthly. The contents of three first aid kits were reviewed during the annual compliance review. Each kit contained all of the items required by the program s policy; none of the items were expired, nor were any items exposed to extreme temperatures as the first aid kits for the vehicles are kept inside the facility until a transport. There is not an automated external defibrillator on site. The program conducted medical drills utilizing first aid and/or CPR techniques; the drills were conducted on a quarterly basis. The program s drill documentation form includes the date of the drill, the start and ending time of the drill, the name of the person conducting the drill, the names of staff involved in the drill, drill scenario, the staff s response, a critique of the drill, and whether a follow-up drill was needed. There was one incident requiring on-site first aid since the last review; the program utilized the DJJ Episodic Care Log, as required. There has not been any incident where a youth had to be transported off-site for emergency medical care 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 written policies and procedures regarding medication storage. There were no youth taking prescribed medication during the day at the time of the annual compliance review. There were two youth who were each prescribed an inhaler due to asthma. There was documentation in both youth s healthcare records that their parent/guardian refused to provide the youth s inhaler to the program, instructing the program to contact the parent/guardian if the youth started having difficulty breathing. The program reported in the event either youth had a need for their inhaler, would be called. The program does not keep any over-the-counter (OTC) medications or any medical equipment classified as sharps on site. The program has a locked box, placed in a locked drawer of the case manager s desk to be used for the placement Office of Program Accountability Page 12 of 31 (Revised January 2015)

13 of medication. There is also a locked refrigerator dedicated to store any medications that would require refrigeration. The weekly safety, sanitation, and maintenance inspection included a check that the medication box was locked Cleanliness and Sanitation Compliance The program provides a safe and appropriate treatment environment that includes maintenance and sanitation of the facility. The program has written policies and procedures regarding cleanliness and sanitation. The program moved into the current building within the past six months. There is a conference room, a large meeting area, a kitchen, and offices for staff. There are areas to facilitate groups and to have meetings that require privacy. There are two restrooms, one designated for females and one designated for males. The facility was clean inside and outside with no graffiti noted on the walls, doors, or windows during the annual compliance review. The program s regional program manager completes a weekly safety, sanitation, and maintenance inspection checklist. There is a two-page checklist that includes checks on whether specific areas were clean or needed repairs. The items to be checked and noted included whether the locks were functional, walkways were clear, any cracks in plaster, the placement of hand sanitizer, whether the refrigerator, toilets, and sinks were clean, and the trash cans emptied. The checklist also documents whether any corrective action was taken for each item. There was documentation to support the checklist was completed weekly 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 policies and procedures regarding fire safety. The program has a Continuity of Operations Plan (COOP) to be utilized in case of an emergency. The policy requires the program to conduct monthly fire drills, documenting them on the program s fire safety log. A review of fire drill documentation and the fire safety log confirmed the program completed one fire drill per month for the past six months. During pre-service training, staff receive training on fire safety and fire prevention. The training files of four staff were reviewed, and each file contained documentation of fire safety and emergency training. The policy requires youth receive training on fire safety and fire prevention during orientation to the program. Five case management files were reviewed. There was documentation in each file that the youth received training on the proper way to use a fire extinguisher and on evacuation procedures. The Fire Marshall completed an inspection on September 2, 2014, and there were no violations noted. There are three fire extinguishers placed in various locations in the building. All three fire extinguishers were observed during the annual compliance review. The tag on each documented a company inspected the fire extinguishers in July The regional program manager completes a weekly safety, sanitation, and maintenance inspection checklist; one of the checked items is to document that fire extinguishers were checked weekly. Five youth responded to the survey, and four youth reported knowing what to do in the event of a fire. In a follow-up interview, the youth reiterated not knowing what to do in the event of a fire, and denied participating in a fire drill or receiving information during orientation on fire safety. The youth s file documented signed receipt of the fire safety information. Office of Program Accountability Page 13 of 31 (Revised January 2015)

14 1.11 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 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 has written policies and procedures regarding the provision of meals to the youth. The program provides an evening snack/meal for the youth daily. The program has a menu approved by a registered dietician. According to the menu, the youth receive a sandwich, pizza or pasta daily. In addition, the menu includes fresh fruit and side dishes. The menu includes alternatives to be used for youth requiring alternative food due to food allergies or religious beliefs. The menu is a two-week meal cycle, which is rotated by the third and fourth weeks of each month. The building is not equipped with appliances on which to prepare food. The staff order food from local fast food restaurants that correspond with the daily menu. As part of the program s skill training, youth are taken to restaurants to learn how to order from a menu, and the proper behavior in a restaurant setting. The youth eat meals in a large conference room that has long tables and chairs. There are drinks, condiments, fresh fruit, and vegetables kept in a refrigerator located in another room. Both areas were noted to be clean. During the annual compliance review, the youth were taken off site for a meal on day one and day two; it was noted the meal served corresponded with the meal on the menu. Five youth responded to the survey, and four youth reported the staff eat the same meals as the youth. Three youth reported the program provides alternative food if a youth is allergic to an item on the menu. Three staff responded to the survey, and all three staff reported youth and staff eat meals from the same menu Transportation Compliance The program provides a safe and appropriate treatment environment that includes transportation. The program has written policies and procedures regarding transportation. The program provides transportation for the youth to and from the facility daily, and transports the youth to program-related activities. The program completes a check of staff driver s license at hire through a national data base. The program utilizes a tracker to document driver s licenses are checked monthly for all staff. There was documentation all four applicable staff had a valid driver s license. The program requires all staff complete training in fleet safety during their preservice training. There are two vans used to transport youth. A twelve passenger van, and a seven passenger van. Both vans appeared to be in good operational condition. There was a fire extinguisher, a window punch, and a seat belt cutter located in each van. A transport for each vehicle was observed during the annual compliance review. The staff conducted a check of the outside of the vehicle for any dents and chipped windows; a backpack containing the first aid kit was brought from the office and placed in the van. The current vehicle insurance and registration Office of Program Accountability Page 14 of 31 (Revised January 2015)

15 were located in a binder kept inside each van at all times. Five youth responded to the survey, and all youth reported staff and youth always wear their seat belts during transports Administration Compliance The program provides a safe and appropriate treatment environment that includes administrative and operational oversight. The program has written policies and procedures regarding administrative responsibilities. The list of youth admitted to the program matched the list of youth listed in the Juvenile Justice Information System (JJIS). The program coordinator is ultimately responsible for the day-to-day operation of the program. Each month, the program coordinator completes a monthly statistical report. The report includes information on intakes, transfers, successful and unsuccessful releases, absconders, abuse cases reported, medical and mental health emergencies, and incidents reported to the Central Communications Center (CCC). The report is submitted to the corporate office where it is placed in a report on all programs operated by the provider. There was documentation to support the information had been forwarded to the appropriate parties monthly. The monthly reports do not include information regarding personnel actions. The program maintains a logbook, to document daily events, activities, and incidents. The logbooks for October 2014 through April 2015 were reviewed. The logbook entries were made in ink and were legible. There were no noted usages of correction fluid. The logbook errors were either struck through, but did not consistently include the initials of the staff making the entry. The entries regarding safety and security were consistently highlighted. The regional program manager conducted biweekly reviews of the logbook as required 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 program has written policies and procedures regarding supervisory reviews. Five case management files were reviewed, and three files were applicable for the supervisor reviewing the files at least once every ninety calendar days. There was documentation to support a supervisory review, as required for each file. In each reviewed file, the case manager documented his review of the supervisory review. The case manager took action according to the supervisory reviews Incident Reporting (CCC) Non-Applicable 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. There have not been any reports to the Central Communications Center (CCC) during this review frame; therefore, this indicator rates as non-applicable. Office of Program Accountability Page 15 of 31 (Revised January 2015)

16 1.17 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. The program has written policies and procedures regarding the treatment of youth. The program has a code of conduct requiring staff to provide a safe and supportive environment for youth. The code of conduct is included in the employee handbook. Staff are required to sign acknowledging receipt of the employee handbook and the code of conduct. There are postings of the telephone numbers for the Florida Abuse Hotline and the Central Communications Center (CCC) located in various locations in the facility. An orientation to the program is completed upon the youth s admission to the program. The orientation includes the youth and parent/guardian. During the orientation, the program provides information on the requirements for reporting abuse to the Florida Abuse Hotline, as well as the CCC. The personnel files of four staff were reviewed, and there was documentation in all reviewed files to support staff received the program s code of conduct. Five case management files were reviewed, and each file contained an orientation checklist. Each youth and their parent/guardian signed to acknowledge youth s rights regarding abuse, which also included the telephone number of the Florida Abuse Hotline and the CCC. There were no documented calls to the CCC or the Florida Abuse Hotline of allegations of abuse during the annual compliance review period. Three staff responded to the survey, and all three reported never observing a co-worker deny a youth a call to the Florida Abuse Hotline. All staff also reported never observing a co-worker use profanity when speaking to youth. Five youth responded to the survey, and all five youth reported feeling safe at the program. Four youth reported never being denied a call to the Florida Abuse Hotline, and one youth reported being denied a call. In a follow-up interview, the youth reported a couple of weeks prior to the annual compliance review, he was denied a milkshake when on an outing. When he wanted to report this to the Florida Abuse Hotline, the youth advised that program staff told him this was not considered abuse or neglect. The youth was asked by the review team whether he wanted to call the Florida Abuse Hotline; he stated he felt his rights had been violated, so he completed and submitted a grievance regarding the milkshake. All five youth reported staff are respectful when speaking to the youth; none of the youth reported ever hearing staff use profanity. Standard 2: Assessment Services Overview The program provides day treatment services to youth who have been referred by the Department of Juvenile Justice or the court. There are slots for twenty youth. At the time of the annual compliance review, the program was providing services for twelve youth. The program s case manager is responsible for completing the intake and orientation process for all youth entering the program. The case manager is also responsible for completing the initial Positive Achievement Change Tool (PACT) Full Assessment, the Massachusetts Youth Screening Achievement Instrument - Second Version (MAYSI-2), and the Facility Entry Physical Health Screening (FEPHS) form on all youth on admission day. If a youth is identified with medical Office of Program Accountability Page 16 of 31 (Revised January 2015)

17 issues, the program immediately places the youth on the program s alert log and enters a Juvenile Justice Information System (JJIS) alert. The program has a contract with a licensed mental health counselor (LMHC) to provide mental health and substance abuse assessments and conduct individual counseling to applicable youth Admission and Orientation Compliance Facility orientation shall be conducted within twenty-four hours of a youth s admission to the facility. Case notes should document the date and time of the orientation and that the youth received orientation documents. The program has a written policy and procedure that explains the admission and orientation process for youth who are referred and accepted into the program. The program requires the youth and parent/guardian attend the orientation. The orientation and admission process includes a review of the program s handbook/brochure, introduction to the staff, a tour of the facility, program expectation/rules, contraband items and consequences, daily schedules, medical and mental health services, evacuation and emergency procedures, review of the performance plan process, and average anticipated length of stay to successfully complete the program and facility. The youth handbook provided contains additional information such as a description of the behavior management system (BMS). The program uses a checklist for the staff, parent/guardian, and youth to initial. This is to acknowledge the orientation process was explained, and they agree to abide by the guidelines. The staff who conducts the orientation documents the orientation process in the case notes. The documentation includes the date and time of the orientation, and that the youth received the orientation documents. Five case management files were reviewed. In each file, the orientation was completed with the youth and parent/guardian within twenty-four hours of admission. In all files, there was a receipt to document the youth received the handbook. All five files included information regarding bullying to ensure the safety of youth while they are attending the program 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) or Medication receipt/transfer disposition (Form HS053), 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. The program has a written policy and procedure for screening youth for health-related conditions at the time of admission. The program completes an individual healthcare plan for all youth, which contains medical and mental health conditions, as well as any special provisions or restrictions. Five case management files were reviewed; each youth was screened at admission to determine whether there were any medical conditions that would require medical care while in the program. Each reviewed file contained a Facility Entry Physical Health Screening (FEPHS) and an individual healthcare plan that had been completed during orientation. In all five files, staff either made or documented attempts to contact the youth s parent/guardian about concerns or questions regarding the youth s medical conditions. The attempts and/or contacts with parent/guardian were documented in chronological notes, as well as in the applicable youth s healthcare record. All medical, mental health, and substance abuse information is documented in the youth s healthcare record. In addition, the information is documented on Office of Program Accountability Page 17 of 31 (Revised January 2015)

18 each youth s problem list; updates are made as needed on each youth s individual healthcare plan 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 and procedure regarding the verification of medication. At the time of the annual compliance review, the program reported there were no youth who required medication while on site. Upon each youth s admission into the program, the staff speaks with the parent/guardian regarding any medications. There was documentation that two youth were prescribed medication that is taken prior to their arrival at the program. There were two youth prescribed an inhaler to be used when breathing difficulties occur. There was documentation in both youth s files that their parent/guardian would not provide an inhaler to the program, however, they would bring the inhaler to the program if necessary 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 of the Massachusetts Youth Screening Instrument (MAYSI-2). The program ensures further assessment of the youth, or immediate intervention/treatment, as indicated by the mental health/substance abuse screening or through collateral information or behavior observation which indicates the need for further mental health/substance abuse assessment. (For the entire indicator statement, please reference the Monitoring and Quality Improvement FY Day Treatment indicators.) The program has a written policy and procedure regarding mental health/substance abuse screening. Five case management records were reviewed. The screening of the youth for medical, mental health, and substance abuse was completed upon youth s admission/orientation into the program. All five reviewed records contained a completed Massachusetts Youth Screening Instrument- Second Version (MAYSI-2), and a Positive Achievement Change Tool (PACT) mental health/substance abuse report. As a result of the screenings, a referral was made to address areas of concern for each of the five youth. The youth were referred for an Assessment Suicide Risk (ASR) and/or a comprehensive assessment. Four of the five youth were applicable for a suicide risk alert to be entered into the Juvenile Justice Information System (JJIS). In the four applicable records, the program director or designee notified and discussed the youth with the licensed mental health counselor. There was documentation in the chronological section and on the youth s individual health care plan, including recommendations for interventions. The ASR was completed for all five youth within twenty-four hours of admission. In four of the records, the youth were placed on precautionary observation until the youth could be seen for further assessment. A comprehensive mental health/substance abuse (MH/SA) evaluation was completed for four applicable youth, and all four required a treatment plan as a result of the evaluation. One plan Office of Program Accountability Page 18 of 31 (Revised January 2015)

19 was not due at the time of the annual compliance review. Each reviewed MH/SA plan had been signed and dated by the youth and the person completing the plan. The licensed mental health counselor (LMHC) signed each plan within ten days of the completion of the plan. Three of the four plans were signed by the treatment team member; one plan was not signed by a member of the treatment team. The program completed a referral to an outside agencies that could provide additional services needed by the youth 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. The program has written policies and procedures on the completion of the Positive Achievement Change Tool (PACT). Five case management files were reviewed and each contained a PACT. All of the reviewed PACTs were completed by the program within seven days of the youth s admission into the program. Each youth also completed a Casey Life Skills questionnaire to provide additional information. The Casey Life Skills questionnaire helps to determine the youth s independence level 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. The program has policies and procedures regarding the completion of Positive Achievement Change Tool (PACT) Reassessments. Five case management files were reviewed, and three files were applicable for a PACT Reassessment. Each applicable file contained a PACT Reassessment that had been completed within ninety days of the original PACT. The program clearly documented that updates to YES Plans were discussed with each youth and parent/guardian. The discussions were either by telephone or during the youth s monthly treatment team meetings. Two youth had not been in the program long enough for a PACT Reassessment to be completed. Three closed files were presented for review, and each closed file contained a PACT Reassessment. In two of the three closed files, the PACT Final Assessment was completed before the youth was released from the program; the PACT documented the youth s progress in the program to address court sanctions and criminogenic needs. In one closed file, the PACT Final Assessment was completed five days after the youth s discharge date Progress Reports Compliance Progress reports are prepared and distributed in accordance with Florida Administrative Code. 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. The program has a written policy and procedure for completing progress reports for youth in the program. Five case management files were reviewed, and four were applicable. The program completed progress reports between thirty and thirty-seven days of the youth s admission to the program. All of the progress reports were signed and dated by the youth, staff, and program Office of Program Accountability Page 19 of 31 (Revised January 2015)

20 director or designee. The progress reports were sent to each youth s juvenile probation officer (JPO), and there was a cover letter that included a description of youth s progress in the program for all applicable youth. The progress reports documented the youth s overall progress, as well as progress in evidence-based interventions, attendance, and legal sanctions. In all reviewed files, there were no documentation to determine whether the youth was given the opportunity to make comments, as the section of the report was left blank on all reviewed plans. Standard 3: Intervention Services Overview The program has one case manager who is responsible for conducting all case management duties. The case management functions included for each youth are completing a Positive Achievement Change Tool (PACT) Full Assessment and required PACT Reassessments, developing the Youth-Empowered Success (YES) Plan, leading the treatment team, developing progress reports, and conducting group sessions using evidenced-based interventions. All activities are to be documented in the Department s Juvenile Justice Information System (JJIS) case notebook module Vocational Programming Compliance Staff shall develop and implement a vocational competency development program. The program has written policies and procedures regarding the provision of vocational programming to the youth. The policy requires vocational preparation training provided to youth with employment listed as a goal from the Positive Achievement Change Tool (PACT). The program offers vocational programming at Type A/Level 1, which is described as services that teach personal accountability skills and behaviors that are appropriate for youth in all age groups and ability levels and that lead to work habits that help maintain employment and living standards. Five case management files were reviewed, and none of the youth had a PACT goal of employability requiring vocational preparation training. Though not required, two of the files contained sample job applications, two with sample résumés, and one youth earned a Safe Staff Food Handler certificate. Additionally, the program log documented that the youth are provided opportunities to participate in outings to the Department of Highway Safety and Motor Vehicles and a career center. Two of the files also documented employment verification. There was documentation that all the youth participated in groups that teach personal accountability skills and behaviors that are appropriate for youth in all age groups and ability levels, and that lead to work habits that help maintain employment and living standards. This was documented in Thinking for a Change (T4C), Independent Living, Job Search, and Effective Employee group attendance sheets. Additionally, the youth participated in outings such as grocery shopping and visiting a restaurant to observe customer service that directly correlated to group topics documented in the group activity log. Office of Program Accountability Page 20 of 31 (Revised January 2015)