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 AMIkids Southwest Florida AMIkids, Inc. (Contract Provider) 1190 Main Street Fort Myers Beach, Florida Review Date(s): May 24-26, 2016 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: Yvrose Sylvain, Office of Program of Accountability, Lead Reviewer (Standard 1) Doris Baquero, Senior Juvenile Probation Officer, DJJ Probation, Circuit 11 (Standard 2) Lut Clarcq, Office of Program Accountability, Regional Monitor (Standards 1, 3, 4) Sharon Coplin, Office of Program Accountability, Regional Monitor (Standards 2, 4) Michelle Johnson, Senior Juvenile Probation Officer, DJJ Probation, Circuit 11 (Standard1, 3)

3 Program Name: AMIkids Southwest Florida MQI Program Code: 1252 Provider Name: AMIkids, Inc. Contract Number: P2119/21 Location: Fort Myers Beach County / Circuit 20 Number of Beds: 34 Review Date(s): May 24-26, 2016 Lead Reviewer Code: 125 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 Executive director DJJ Monitor DHA or designee DMHCA or designee 1 # Case Managers 1 # Clinical Staff # Food Service Personnel 1 # Healthcare Staff Documents Reviewed # Maintenance Personnel # Program Supervisors 1 # Other (listed by title): Business Manager 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 3 # Personnel Records 8 # Training Records/CORE 3 # Youth Records (Closed) 7 # Youth Records (Open) # Other: 7 # Youth 7 # Direct Care Staff # Other: Observations During Review Admissions Confinement Facility and Grounds First Aid Kit(s) Group Meals Medical Clinic Medication Administration Posting of Abuse Hotline Program Activities Recreation Searches Security Video Tapes Sick Call Social Skill Modeling by Staff Staff Interactions with Youth Comments Staff Supervision of Youth Tool Inventory and Storage Toxic Item Inventory and Storage Transition/Exit Conferences Treatment Team Meetings Use of Mechanical Restraints Youth Movement and Counts Items not marked were either not applicable or not available for review. Office of Program Accountability Page 3 of 31 (Revised July 2015)

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) Limited 1.04 Pre-Service/Certification Training 1.05 In-Service Training Limited 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 Limited 1.11 Water Activities 1.12 Food Services 1.13 Transportation Limited 1.14 Administration 1.15 Ninety-Day Supervisory Reviews 1.16 *Incident Reporting (CCC) 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 July 2015)

5 Standard 2: Assessment Services Day Treatment Rating Profile Indicator Ratings 2.01 Standard 2 - Assessment Services 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 July 2015)

6 Standard 3: Intervention Services Day Treatment Rating Profile Indicator Ratings Standard 3 - Intervention Services 3.01 Career Education 3.02 Educational Access 3.03 Youth-Empowered Success (YES) Plan Development 3.04 Youth Requirements/PACT Goal Elements 3.05 * Transitional Planning/Reintegration Non-Applicable 3.06 YES Plan Implementation/Supervision 3.07 Behavior Management System 3.08 Ninety-Day YES Plan Updates 3.09 Educational Transition 3.10 Termination/Release * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 6 of 31 (Revised July 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 Clinician 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 Limited 4.13 * Mental Health Crisis Intervention Services 4.14 * Crisis Assessment 4.15 * Emergency MH and SA Services 4.16 * Baker and Marchman Acts Non-Applicable * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 7 of 31 (Revised July 2015)

8 Strengths and Innovative Approaches The director of education also indicated the program received a grant for Career Shines beginning January Standard 1: Management Accountability Office of Program Accountability Page 8 of 31 (Revised July 2015)

9 Overview AMIkids Southwest Florida is a non-residential day treatment program operated by AMIkids, Inc. under contract with the Department of Juvenile Justice (DJJ). The program is contracted for thirty-four slots and serves males and females residing in Circuit 20, Lee County. The program duration ranges between three and six months, depending upon the individual youth s progress in the program. A tour of the facility found the program is clean and maintained in good condition, supporting positive interactions between youth and staff. The program maintains an agreement with the Lee County School Board for the provision of meals to the youth in the program and participates in the National School Lunch and Breakfast program. Each youth in the program receives breakfast, lunch, and a snack five days per week. At the time of the annual compliance review, the program staff included the executive director, one business manager, one behavioral interventionist, one director of education, three certified teachers, one mental health professional, three local care counselors, one job recruiter, two bus drivers, and one vocational construction instructor. There was one vacant regional care coordinator position 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 a policy and procedures requiring compliance with the Department s background screening requirements. The program had eight staff members and two volunteers who were applicable for an initial background screening. A review of the initial background screenings found the program received a background screening check from the Department s Background Screening Unit (BSU) prior to each staff s start date and/or on the same data as their start date. The Annual Affidavit of Compliance with Level 2 Screening Standards was completed and submitted to the BSU on January 5, 2016, meeting the annual requirement 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 had one staff who was applicable for a five-year background rescreening. The staff member s re-screening was completed and submitted to the Department s Background Screening Unit, prior to the anniversary date. There were no volunteers applicable for the rescreening Protective Action Response (PAR) Limited Compliance The program uses physical intervention techniques in accordance with Florida Administrative Office of Program Accountability Page 9 of 31 (Revised July 2015)

10 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 had one Protective Action Response (PAR) report in the past year. According to the executive director, on May 6, 2016 a PAR took place during an outing at a park involving two staff and one youth. However, the program was not aware of the incident until May 24, 2016, through a Report It Tool. A review of the PAR report indicated each staff involved completed a report statement. The PAR report verified the staff did not complete their statements prior to the end of their shift. The PAR report was not reviewed and processed within the required timeframe of seventy-two hours by all required parties. The PAR report included a post-par interview to determine if the youth had any physical complaints or visible injuries. The program initiated a preliminary investigation and put corrective action in place. The program s corrective action indicated all staff will complete PAR refresher and reporting training, and staff will take copy of a PAR report with them on all future outings. There was documentation to support a monthly summary of PAR reports was submitted to the program s corporate headquarters as required. The program s Protective Action Response (PAR) plan was approved by the Department s Office of Staff Development and Training on January 8, 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 who have not completed essential skills training, as defined by Florida Administrative Code, do not have any direct contact with youth. Contracted non-residential staff who have not completed pre-service/certification training do not have direct, unsupervised contact with youth. Pre-service training is provided in a combination of instructor-led and web-based courses. An individual training file is maintained for each staff, containing certificates, sign-in sheets, and test results. Four training files for newly hired staff were reviewed. Each staff completed more than the required 120 hours within 180 days of hire, including cardiopulmonary resuscitation (CPR) with automated external defibrillator (AED), first aid, child abuse reporting requirements, Protective Action Response (PAR), and professionalism and ethics. All completed training was not documented in the Department's Learning Management System (SkillPro) as required due to issues with the system but they are currently working on getting the information updated. The pre-service training plan was approved by the Department s Office of Staff Development and Training on January 5, In-Service Training Limited Compliance Office of Program Accountability Page 10 of 31 (Revised July 2015)

11 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. Four staff training files were reviewed for in-service training. All reviewed staff training files documented each staff member exceeded the twenty-four hours of annual in-service training requirements. All staff had current certifications in Protective Action Response (PAR), first aid, automated external defibrillator (AED), cardiopulmonary resuscitation (CPR), and professionalism and ethics. None of the four staff completed the six hours suicide prevention training. One applicable staff completed the eight hours of management/supervisory training. The program had a training calendar, which is updated as necessary. All training was delivered by qualified trainers; however, all completed training was not documented in the Department's Learning Management System (SkillPro) as required due to issues with the system but they are currently working on getting the information updated Medical Alerts, Mental Health Alerts, and Suicide Risk Compliance Alerts 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 enters an alert into the Department s Juvenile Justice Information System (JJIS) for youth requiring an alert, which may not have been previously entered prior to the youth s admission. The alerts entered into JJIS are verified through the executive director and mental health staff. The program maintains an alert binder for staff to review. Seven youth records were reviewed and all alerts were accurately entered into JJIS Episodic/Emergency Services Compliance The program shall have a comprehensive process for the provision of Episodic Care, First Aid, and Emergency Care. The program shall be capable of facilitating an appropriate response to an emergency situation. The program has a written policy and procedures regarding episodic and emergency care services. Reviewed episodic logs and logbooks revealed there was one youth requiring off-site emergency care with response from the emergency medical services (EMS) for transport to the hospital. An incident report was completed, which included the time the youth was referred for medical treatment and documentation of parent/guardian notification. No documentation was maintained in reference to determining the youth s condition on a daily basis or with follow-up upon the youth s return to the program. Episodic monthly logs were reviewed documenting episodic treatment was provided. The program maintains emergency equipment such as first aid kits, knife-for-life, and wire cutters, as validated by a tour of the facility and inspection of two of the three program buses; one bus was out of commission for repairs. The program utilizes Zee Medical, Incorporation to monitor and stock the program s first aid kits. The program does not have an automated external defibrillator (AED) on-site, which is not required per contract. The program conducted quarterly emergency drills involving a cardiopulmonary resuscitation Office of Program Accountability Page 11 of 31 (Revised July 2015)

12 (CPR) and emergency first aid demonstration. The emergency drill conducted on September 18, 2015 did not include CPR demonstration Medication Management Medication Storage Compliance All medications (prescriptions, over-the-counter, topical, etc.) shall be stored in separate, secure (locked) areas and are inaccessible to youth and ensures proper inventory control. The program has a written policy and procedures regarding medication management storage. An interview with the director of operations (DO) and an observation during the facility tour, found the program had a locked cabinet located in the director of operations office. The top drawer of the cabinet contained a locked box for controlled substances and the bottom drawer contained two locked boxes; one for topical and one for over-the-counter (OTC) medications. Keys to the locked cabinet are maintained in a locked safe box, which is opened via a digital numerical combination. This locked area is inaccessible to youth. The program also has a refrigerator for the use of medication, located in the conference room. At the time of the annual compliance review, there was no medication requiring refrigeration and there were two youth requiring medication to be administered on site Cleanliness and Sanitation Compliance The program provides a safe and appropriate treatment environment including maintenance and sanitation of the facility. The program maintains a facility maintenance log. A review of the log found the log contained a maintenance plan and documentation confirming the program staff conducted a weekly facility housekeeping and security checklist. The program has a large group area used as the cafeteria, counseling sessions, promotions, and other celebratory events with the youth and staff. The program was observed to be clean and well maintained during the annual compliance review week. There were no visible signs of graffiti on the walls, doors, or windows throughout the program. The program has adequate space for planning activities Fire Prevention and Evacuation Procedures Limited Compliance The program provides a safe and appropriate treatment environment including fire prevention and evacuation procedures. The program received a fire inspection by the Fort Myers Beach Fire Rescue on June 30, 2015 with satisfactory results. The program received their last fire extinguisher inspection on May 28, The fire alarm system was last inspected on May 28, Documentation confirmed fire protection equipment is checked weekly. Reviewed documentation supported monthly fire drills were unannounced. A review of the monthly fire drills for the past six months did not include all staff. Although, several staff names were written on the monthly fire drill documentation and reflected non-applicable as a role in participation during the fire drills. Reviewed training documentation for four staff found the program staff did not received annual training on proper operation of the fire protection equipment. Three of the four staff did not complete operation of the fire alarm system training. Youth surveys indicated the youth are aware of what to do in case of a fire. Office of Program Accountability Page 12 of 31 (Revised July 2015)

13 1.11 Water Activities Compliance The program provides a safe and appropriate treatment environment including procedures for water activities. The program has a policy and procedures related to water activities requiring youth swim testing and diver certification. Each youth received a swim evaluation prior to participating in waterrelated activities. One program staff is a certified lifeguard through the American Red Cross. Four of seven surveyed youth stated they participated in water activities and the program reported youth participated in a swim evaluation during this review period for the upcoming water activity. Reviewed documentation indicated the program notified each youth s parent/guardian of the swim test in case of serious illness, injury, or death prior to participation in a swim test and/or any water-related activities Food Services Compliance The program provides a safe and appropriate treatment environment including food service. The program has a policy and procedures related to food services. They have an agreement with the Lee County School Board for the provision of food to the youth in the program. The program participates in the National School Lunch and Breakfast program. All youth in the program receive breakfast, lunch, and a snack daily. A tour of the program found the large indoor dining area was observed clean and well maintained. The program provides special diets for applicable youth. The last food inspection of the program s food service was completed on July 15, 2015, by the Department of Health, with satisfactory results Transportation Limited Compliance The program provides a safe and appropriate treatment environment including transportation. The program has three buses and one van, which provides daily transportation for youth to and from the program. Observation of the morning transport in the van revealed the youth and bus driver were wearing seatbelts during transport. Vehicle maintenance checklists, daily pre-trip inspection logs, current/valid driver s licenses for bus driver s, and current insurance documentation were reviewed. Two of the buses and the van were inspected during the annual compliance review and appeared to be in satisfactory condition. One bus was not on-site and/or used due to maintenance repair. Each contained a knife-for-life, first aid kit, and a fully charged fire extinguisher. During vehicle observations, one bus door was not locked when not in use, keys were left inside the bus at switch ignition, and a cellular telephone was next to the driver s seat. A review of the vehicles maintenance invoices revealed all vehicles were serviced as required however, the annual inspection was completed on one of the vehicles. All seven surveyed youth and staff reported wear their seatbelts while the vehicle is in operation Administration Compliance The program provides a safe and appropriate treatment environment including administrative and operational oversight. According to the executive director, the program submits the required statistical information to the program s corporate headquarters on a monthly basis. The statistical information provided includes admissions, releases, transfers, average length of stay, and Protective Action Office of Program Accountability Page 13 of 31 (Revised July 2015)

14 Response (PAR) incidents. The program maintains a daily logbook, which records significant activities, incidents, and events. The logbook entries also show the safety and security of the program issues, which were highlighted. The logbook entries are legible, brief, written in ink with the date, time, and name of the person making the entry. There was consistent documentation in the logbook verifying the executive director reviewed the entries and signed the logbook on a bi-weekly basis. Documentation indicated errors were consistently corrected in accordance with Florida Administrative Code 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 staff review any instructions given during the review, and ensures they were followed during the subsequent review. Seven youth case management files were reviewed for the completion of the ninety-day supervisory reviews and six were applicable. All applicable records found ninety-day supervisory reviews completed as required. All six files documented the supervisor reviewed and ensured the local care counselor updated youth requirements and the Positive Achievement Change Tool (PACT) goals in the Department s Juvenile Justice Information System (JJIS) prior to supervisor review Incident Reporting (CCC) Compliance Whenever a reportable incident occurs, the program notifies the Department s Central Communications Center (CCC) within two hours of the incident, or within two hours of becoming aware of the incident. The program had four Central Communications Center (CCC) reportable incidents involving complaints against staff, youth behavior, and medical/program disruptions. All incidents were reported to the Department s Central Communications Center (CCC) within two hours, as required. In reviewing the program s internal incident, there were no incidents, which should have been reported to the CCC and were not reported Abuse-Free Environment Compliance Any knowledge or suspicion of abuse, abandonment, or neglect is reported to the Florida Abuse Hotline. Observations made during a tour of the program found signs posted throughout the facility listing the telephone numbers for the Florida Abuse Hotline and Central Communication Center (CCC). A student handbook is provided to each youth upon admission, which includes the youth s rights, the program s grievance process, and the telephone numbers for the Florida Abuse Hotline and CCC. Staff receive an employee handbook with the expectations of team members, code of conduct, and a new hire packet including documentation regarding inappropriate behavior on social media and reporting it when relating to staff and/or youth involved with the program. There was one abuse allegation reported to the CCC during the annual compliance review period and it is still pending investigation. Seven surveyed youth reported never being stopped from reporting abuse to the Florida Abuse Hotline if they want to make a call the staff take them to make the call.. Seven youth reported staff are respectful when speaking with them. All seven youth reported feeling safe at the program. None of the Office of Program Accountability Page 14 of 31 (Revised July 2015)

15 seven staff reported ever seeing a co-worker deny a youth an abuse call, and using profanity when speaking to a youth. Standard 2: Assessment Services Overview Youth admitted to AMIkids Southwest Florida receive intake, orientation, screening, assessment, individualized service planning, individualized treatment planning, and assignment to evidence-based and promising practice interventions based on the identified individual needs. Screening is designed to identify youth in need of further assessment due to risk factors in aggression, suicide, trauma, mental health, and substance abuse. During the admission process, the program s local care counselors are responsible for completion of the assessment services provided to each youth, including completion of a medical screening, and a Positive Achievement Change Tool (PACT) 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 the youth received orientation documents. Seven youth case management files were reviewed and each contained a day treatment program orientation acknowledgement form signed by the youth, parent/guardian, and local care counselor. Each reviewed youth file and case notes indicated the date and time of the orientation. All seven youth files found orientation was completed within twenty-four hours of admission. The youth received orientation documentation, which included the program rules, student handbook, and contact information. The handbook included all of the required guidelines. The program orientation included the student dress code, expectations, goals, procedures, rewards and incentives, behavior management system, educational services, abuse reporting, mental health and substance abuse orientation, and other services, which apply to each youth. Youth are introduced to program staff and receive a tour of 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 requiring 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 procedures outlining a process indicating all youth are medically screened upon entry into the program. Seven youth individual healthcare records were reviewed and each had an enrollment information form indicating the youth was screened at admission to determine if the youth has a condition requiring medical care while in the program. In addition, an interview with the program s mental health professional found further Office of Program Accountability Page 15 of 31 (Revised July 2015)

16 screenings were completed when deemed appropriate. All medical, mental health, and substance abuse information was documented in the youth s individual healthcare record Medication Management Verification of Medications Compliance The program shall determine a youth s medication regimen upon admission to the program. The program obtains information regarding allergy and health issues at the time of each youth s admission. A review of seven youth healthcare records found two youth were applicable for verification of medications. A review of both youth healthcare records found an interview about current medication regimen were completed. Also, both youth s parent/guardian were interviewed about current medication regimen. Documentation found medications of both youth were from a licensed pharmacy with their specific label intact on the original medication bottles. In addition to verify the medication, the program utilizes the Medication Distribution Log to document each youth and their medications. Youth s parent/guardian is required to sign, verifying they have provided the medications after verification of the quantity and description of each medication is documented. Reviewed documentation in both youth records validated the program practice 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 requiring 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.) A review of seven youth individual healthcare records found each record contains documentation of the youth s medical, mental health, and substance abuse information. Each of the seven youth received a mental health and substance abuse (MH/SA) screening on the day of admission in accordance to the Department s Rule 63N-1. In four of seven youth healthcare records reviewed, a Massachusetts Youth Screening Instrument-Second Version (MAYSI-2) screening was found. All seven reviewed records had a Positive Achievement Change Tool (PACT) Mental Health and Substance Abuse Screening Report and Referral for MH/SA Assessment Form filed in each of the healthcare record. Five applicable youth received an Assessment of Suicide Risk (ASR), and all seven youth received a comprehensive assessment. All screenings were completed within twenty-four hours of admission. When an ASR was completed, the non-licensed staff completing the screening contacts the program s executive director and the designated mental health clinician authority (DMHCA), who is a licensed clinical social worker (LCSW) and a certified additions professional (CAP), to discuss the findings and recommendations for immediate interventions for the youth. A suicide risk alert is entered into the Department s Juvenile Justice Information System (JJIS) for every youth receiving a suicide hit on the MH/SA Referral Screening form, and the intake screening for suicide risk form. Youth placed on precautionary observation as a result of either having a history of suicide, Baker Acts, or other mental health issues were placed on constant supervision until further assessment was Office of Program Accountability Page 16 of 31 (Revised July 2015)

17 completed. The non-licensed staff developed an initial individualized MH/SA plan for each of the seven youth reviewed, which included the signatures of the youth, the mental health clinician, and other treatment team members participating in the development of the plan. The licensed mental health/substance abuse professional signature and date was obtained within ten days of the plan being completed Positive Achievement Change Tool (PACT) Full Compliance Assessment The PACT Full Assessment is completed by program staff for all youth, regardless of risk to reoffend, within seven calendar days of admission. A review of seven youth case management files found each had a Positive Achievement Change Tool (PACT) Full Assessment completed by the program. All PACT Full Assessments were completed within seven calendar days of each youth admission 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. A review of seven youth case management files found five youth who had been at the program longer than ninety days and were eligible for a reassessment. All applicable youth had a Positive Assessment Change Tool (PACT) Re-Assessment completed in a timely manner. None of the seven reviewed youth records were eligible for an exit PACT. A review of three closed youth files supported exit PACTs were completed as required Progress Reports Compliance Progress reports are completed detailing the youth s progress with the youth requirements and PACT goals outlined in the YES Plan. A review of seven youth case management files found five were applicable. All five youth progress report were completed within ninety days. All five reviewed files indicated the youth had an opportunity to review the report and make comments. All progress reports were signed and dated by the youth and staff who prepared the report. All progress reports were reviewed and signed by the executive director or designee. Documentation in all five files indicated the reports had been sent to the assigned juvenile probation officer (JPO), judge, and parent/guardian. Office of Program Accountability Page 17 of 31 (Revised July 2015)

18 Standard 3: Intervention Services Overview The program s local care counselors and teachers are responsible for the provision of intervention services for each youth enrolled in the program. The program provides each youth with education, behavior modification, opportunities for vocational enhancement, life skills, and community service. The program offers evidence-based interventions to include Aggression Replacement Therapy (ART), Cannabis Youth Treatment (CYT), Boys Council, Skill Streaming, spiritual group, narcotics anonymous group, and enrichment group. The services provided are guided through the implementation of the Youth-Empowered Success (YES) Plan and the utilization of the AMIkids Personal Growth Model as a delinquency intervention strategy for the services provided. Seven youth records were reviewed and found documentation confirmed program staff also coordinate with the Department, other agencies and members of the community for the provision of the intervention services for each youth. Reviewed documentation revealed the program conducts interventions prior to each youth s admission, during the youth s attendance and prior to transitioning each youth back into the community. These interventions included assessing needs, developing a plan to meet the needs, managing behavior, and releasing youth with a transition plan to meet future goals Career Education Programming Compliance Staff shall develop and implement a career education competency development program. The program provides Level 2 career education for each youth. Upon admission into the program, each youth is assessed with their learning styles in order to explore their skills, personal abilities, and career interests. Each youth is also evaluated with the Supplementary Tests of Achievement in Reading (STAR) assessment for mathematics and reading skills. The program utilized student diagnostic report and Kuder career interest assessment to determine reading scores and top career pathways. Youth have an opportunity to practice job interview role play, conduct internet searches for employment, and complete sample applications. The program has designated staff assisting each youth with employment searches online. Seven case management files were reviewed and found each reviewed case management file contained documentation essential to obtaining employment, creating a résumé, and completing employment applications Educational Access Compliance The program 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. An interview with the director of education and a review of the school schedule confirmed the program operates on a year-round basis. The program s educational component exceeds the number of required days of instruction. The program s scheduled activities do not interfere with educational instruction activities. The director of education also indicated the program received a grant for Career Shines beginning January Office of Program Accountability Page 18 of 31 (Revised July 2015)

19 3.03 Youth-Empowered Success (YES) Plan Development Compliance The YES Plan (Form DJJ/PACTFRM 4) is cooperatively developed for youth on Probation, Conditional Release, and Post-Commitment Probation. Youth and parent/guardian signatures do not indicate cooperative development of the YES Plan. Case notes clearly reflect that the youth and/or parent/guardian was involved, or refused to be involved, in the development of the YES Plan. All parties sign the YES Plan within fourteen calendar days of youth s admission to the facility. A review of seven youth case management files found the local care counselors completed a Positive Achievement Change Tool (PACT) prior to the development of the initial Youth- Empowered Success (YES) Plan. Five of the seven reviewed files revealed the local care counselors completed the initial YES Plan within fourteen calendar days of the youth s admission into the program and obtained signatures from the youth, parent/guardian, program staff, and executive director. One of the seven initial YES Plans was completed one day late and one was not signed by the youth s parent/guardian. Each of the reviewed files found the case notes clearly reflected the participation of each youth and the parent/guardian in the development of the action steps and target dates for completion of all sanctions and goals of the plan. All seven YES Plans were based on prioritized needs and addressed the completion of court-ordered sanctions. All seven surveyed youth confirmed they participated in the development of the YES Plan and received a copy of the plan Youth Requirement/PACT Goal Elements Compliance The YES Plan provides appropriate and individualized target dates for the completion of each youth requirement and PACT goal. All youth requirement and PACT goal action steps include the intervention plan elements (i.e., who, what, and how often). A review of seven youth case management files validated all of the Youth-Empowered Success (YES) Plans contained appropriate and individualized target dates for the completion of each youth requirement, including court-ordered sanctions. All seven youth files documented at least one of the youth s top three criminogenic needs and was incorporated into a Positive Achievement Change Tool (PACT) goal with action steps for the youth, parent/guardian and local care counselor. The action steps clearly defined who is responsible, what action should be taken, and how often. The PACT goal was created in the Department s Juvenile Justice Information System (JJIS) Transitional Planning/Reintegration Non-Applicable Program staff actively participates in the transitional planning process for youth who are being released from a residential program on conditional release (CR) or post-commitment probation (PCP). For conditional release and post-commitment probation youth, the YES Plan must address recommendations from the residential program during transition. The program did not have any youth referred in the past six months prior to release from a residential commitment program; therefore, this indicator rates as non-applicable. Office of Program Accountability Page 19 of 31 (Revised July 2015)

20 3.06 YES Plan Implementation/Supervision Compliance Youth on supervision (i.e., probation, conditional release, or post-commitment probation) are supervised in a manner ensuring compliance with the court order and completion of YES Plan (youth requirements and PACT goals). Case notes demonstrate compliance (or attempted compliance) with youth, parent/guardian, and staff action steps contained in the YES Plan. A review of seven youth case management files found case notes demonstrating compliance or attempted compliance with the youth, parent/guardian, and staff, action steps and sanctions contained in the Youth-Empowered Success (YES) Plan. Documentation reflected case note activities, including face-to-face interactions and telephone contact with the youth, parent/guardian, and providers, as well as review of written or verbal reports from collateral sources such as educational institutions, the assigned juvenile probation officer (JPO), employers, and counselors. The program staff made referrals to appropriate community providers when needed to ensure each youth s compliance with the YES Plan s measurable goals and sanctions Behavior Management System Compliance The program utilizes a behavior management system providing privileges and consequences to encourage youth to fulfill programmatic expectations. Consequences are fair and directly correlate with the behavior problem. The use of facility restriction does not exceed seven consecutive days. Disciplinary procedures are carried out promptly. Youth are not allowed to have control over or discipline other youth. Time-out is used in accordance with Florida Administrative Code. All behavior problems, time-outs, in-facility suspensions, and privilege suspensions are documented in the facility log and case file in accordance with Florida Administrative Code. The program maintains a policy and procedures regarding the behavior management system. The program utilizes a behavior management system, which has three primary components to include a point card system, a token economy, and a rank system. The system provides behavioral expectations for youth, immediate reinforcement for target behaviors, and access to privileges. The program has a gift window store where youth are eligible to earn rewards based on their earned tokens. These rewards range from snacks to different hygiene items. All seven surveyed youth indicated no youth or group of youth can discipline or have control over other youth. All seven surveyed youth reported when a youth is in time out they are never denied regular meals, healthcare, religious needs, legal assistance, or staff assistance. The program has a daily activity schedule, which was observed posted in the large room, and substantially follows a structured outdoor/indoor recreational and leisure activities teaching values and encouraging sportsmanship. Office of Program Accountability Page 20 of 31 (Revised July 2015)

21 3.08 Ninety-Day YES Plan Updates Compliance Staff adjust the YES Plan to reflect any new needs and progress made during the course of supervision. Staff must make necessary updates to youth requirements and PACT goals and save a new YES Plan in the Juvenile Justice Information System (JJIS) prior to ninety-day supervisory reviews. When updates are made to the YES Plan reasonably requiring the input of the youth and parent/guardian, this discussion is clearly documented in the case notes. Use of the case notations or a similar form the youth and/or parent/guardian initials to indicate the YES Plan was reviewed does not signify compliance. The case notes clearly document any communication regarding the YES Plan. A review of seven youth case management files found five were applicable for ninety-day Youth-Empowered Success (YES) Plan updates. All applicable reviewed files indicated staff made modifications to the YES Plans to reflect any new needs and progress made during the course of supervision. Each reviewed file indicated necessary updates of the YES Plan requirements and Positive Achievement Change Tool (PACT) goals were completed and a new YES Plan was generated in the Department s Juvenile Justice Information System (JJIS) prior to the supervisory review. Reviewed documentation confirmed input and involvement from the youth and parent/guardian was made to the YES Plan. The development of the YES Plan for each youth was clearly documented in the case notes and the case notes confirmed involvement of the treatment team members in the plan updates Education Transition Compliance Staff and youth complete an education transition plan prior to release including provisions for continuation of education and/or employment. Three closed case management files were reviewed and each contained documentation of an education transition plan, which was developed with the youth and signed by all required parties. Each educational transition plan was completed and signed prior to the youth s release and included provisions for the continuation of each youth s education, treatment, and employment when applicable. Each of the three youth case management files contained a sample job application and resume s summarizing education, work experience, and career training. The program works with the youth and family to assist with obtaining a valid form of identification for each youth. The program collaborates with the Lee County School Board and other community providers to refer applicable youth to local Career Source Centers for employment assistance. Office of Program Accountability Page 21 of 31 (Revised July 2015)