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 Melbourne Center for Personal Growth Re-Review AMIkids, Inc. (Contract Provider) 1000 Inspiration Lane Melbourne, Florida Re-Review Date(s): February 13-16, 2018 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: Satisfactory Compliance Limited Compliance Failed Compliance No exceptions to the requirements of the indicator; or limited, unintentional, and/or non-systemic exceptions 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 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 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: Kamille Payne, Office of Program Accountability, Lead Reviewer (Standard 1) Teresa Andersen, Office of Program Accountability, Deputy Regional Monitoring Supervisor (Standard 5) Paul Czigan, Office of Program Accountability, Regional Monitor (Interviews) Tamara Mahl-Adkins, Office of Program Accountability, Regional Monitor (Standards 2) Donna Stanton, TrueCore Behavioral Solutions, Health Services Administrator (Standard 4) Bonita Williams, Office of Program Accountability, Regional Monitor (Standard 3)

3 Program Name: Melbourne Center for Personal Growth QI Program Code: 1270 Provider Name: AMIkids, Inc. Contract Number: R2119 Location: Melbourne County / Circuit 18 Number of Beds: 32 Original Review Date(s): July 18-21, 2017 Lead Reviewer Code: 155 Original Report Posted: December 8, 2017 Failed: STANDARD-LEVEL OVERALL Re-Review Date(s): February 13-16, 2018 Residential Quality Improvement Report Office of Program Accountability Page 3 of 117 (Revised January, 2012)

4 Standard 1: Management Accountability Residential Rating Profile Indicator Ratings Standard 1 - Management Accountability Re-Review Original Review 1.01 * Initial Background Screening 1.02 Five-Year Rescreening Satisfactory Limited 1.03 * Provision of an Abuse-Free Environment 1.04 * Management Response to Allegations 1.05 * Incident Reporting (CCC) Satisfactory Limited 1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory Limited 1.07 * Pre-Service/Certification Requirements Satisfactory Failed 1.08 In-Service Training Satisfactory Failed 1.09 Grievance Process Training 1.10 Grievance Process 1.11 Grievance Process Documentation 1.12 Life Skills Training Provided to Youth 1.13 Staff Training: Delinquency Interventions 1.14 Restorative Justice Awareness for Youth 1.15 Delinquency Intervention Services 1.16 Gender-Specific Programming 1.17 *Internal Alerts System Satisfactory Limited 1.18 *Alerts (JJIS) Satisfactory Limited 1.19 Education Acces 1.20 Youth Records (Healthcare and Management) Satisfactory Limited 1.21 Youth Input 1.22 Advisory Board 1.23 Program Planning 1.24 Staff Performance * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Satisfactory 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 117 (Revised July 2017)

5 Standard 2: Assessment and Performance Plan Residential Rating Profile Indicator Ratings Standard 2 - Assessment and Performance Plan Re-Review Original Review 2.01 Initial Contacts to Parent/Gaurdian 2.02 Court Notification 2.03 Youth Orientation 2.04 Written Consent of Youth Eighteen or Older 2.05 Classification Factors 2.06 Classification Procedures 2.07 Reassessment for Activities 2.08 Gang Identification: Notification of Law Enforcement 2.09 Gang Identification: Prevention and Intervention Activities 2.10 R-PACT Assessment 2.11 Youth Needs Assessment Summary 2.12 R-PACT Reassessments 2.13 Parent/Guardian Involvement in Case Management Services 2.14 Members of Treatment Team Satisfactory Limited 2.15 Performance Plan Development 2.16 *Performance Plan Goals 2.17 Performance Plan Transmittal 2.18 Incorporation of Other Plans Into Performance Plan 2.19 Treatment Team Meetings (Formal Reviews) 2.20 Treatment Team Meetings (Informal Reviews) 2.21 Performance Plan Revisions 2.22 Performance Summaries 2.23 Performance Plan Summary Transmittal Satisfactory Limited 2.24 Career Education 2.25 Education Transition Plan 2.26 Transition Planning and Conference 2.27 Exit Portfolio Satisfactory Limited 2.28 Exit Conference * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Satisfactory 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 117 (Revised July 2017)

6 Standard 3: Mental Health and Substance Abuse Services Residential Rating Profile Indicator Ratings Standard 3 - Mental Health and Substance Abuse Services Re-Review Original Review 3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory Failed 3.02 * Licensed Mental Health and Substance Abuse Clinical Staff 3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff 3.04 Mental Health and Substance Abuse Admission Screening 3.05 Mental Health and Substance Abuse Assessment/Evaluation 3.06 Mental Health and Substance Abuse Treatment Limited Satisfactory 3.07 * Treatment and Discharge Planning 3.08 * Specialized Treatment Services 3.09 * Psychiatric Services 3.10 * Suicide Prevention Plan 3.11 * Suicide Prevention Services 3.12 * Suicide Precaution Observation Logs 3.13 * Suicide Prevention Training Satisfactory Limited 3.14 * Mental Health Crisis Intervention Services 3.15 * Crisis Assessments 3.16 * Emergency Mental Health and Substance Abuse Services 3.17 * Baker and Marchman Acts Non-Applicable Failed * 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 Satisfactory 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 117 (Revised July 2017)

7 Standard 4: Health Services Residential Rating Profile Indicator Ratings Standard 4 - Health Services Re-Review Original Review 4.01 * Designated Health Authority/Designee 4.02 Facility Operating Procedures 4.03 Authority for Evaluation and Treatment 4.04 Parental Notification Satisfactory Failed 4.05 Notification - Clinical Psychotropic Progress Note 4.06 Immunizations 4.07 Healthcare Admission Screening Form 4.08 Medical Alerts 4.09 Youth Orientation to Healthcare Services 4.10 Designated Health Authority/Designee Admission Notification 4.11 Healthcare Admission Rescreening 4.12 Health Related History 4.13 Comprehensive Physical Assessment 4.14 Female-Specific Screening/Examination Non-Applicable Non-Applicable 4.15 Tuberculosis Screening 4.16 Sexually Transmitted Infection Screening 4.17 HIV Testing Satisfactory Limited 4.18 Sick Call Process - Requests/Complaints 4.19 Sick Call Process - Visits/Encounters 4.20 Restricted Housing Non-Applicable Non-Applicable 4.21 Episodic/First Aid Care 4.22 Emergency Care 4.23 Off-Site Care/Referrals 4.24 Chronic Illness/Periodic Evaluations 4.25 Medication Management - Verification 4.26 Medication Management - Orders/Prescriptions 4.27 Medication Management - Storage 4.28 Medication Management - Medication and Sharps Inventory 4.29 Medication Management - Controlled Medications Satisfactory Limited 4.30 Medication Management - Medication Administration Record 4.31 Medication Management - Medication Administration By Licensed Staff 4.32 Medication Management - Medication Provided By Non-Licensed Staff 4.33 Medication Management - Psychotropic Medication Monitoring 4.34 Infection Control - Surveillance, Screening, and Management 4.35 Infection Control - Education 4.36 Infection Control - Exposure Control Plan 4.37 Prenatal Care - Physical Care of Pregnant Youth Non-Applicable Non-Applicable 4.38 Prenatal and Neonatal Care - Nutrition, Education of Youth, and Lactation Non-Applicable Non-Applicable 4.39 Prenatal and Neonatal Staff Education Non-Applicable 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 Satisfactory 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 117 (Revised July 2017)

8 Standard 5: Safety and Security Residential Rating Profile Indicator Ratings Standard 5 - Safety and Security Re-Review Original Review 5.01 Youth Supervision 5.02 * Ten-Minute Checks Limited Satisfactory 5.03 Census, Counts, and Tracking 5.04 Logbook Entries and Shift Report Review 5.05 Key Control Satisfactory Limited 5.06 Contraband Procedure Satisfactory Limited 5.07 Searches and Full Body Visual Searches 5.08 Vehicles and Maintenance 5.09 Transportation of Youth 5.10 Tool Inventory and Management 5.11 Youth Tool Handling and Supervision 5.12 Outside Contractors Limited Satisfactory 5.13 Fire, Safety, and Evacuation Drills 5.14 Disaster and Continuity of Operations Planning 5.15 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials 5.16 Youth Handling and Supervision for Flammable, Poisonous, and Toxic Items and Materials 5.17 Disposal of All Flammable, Toxic, Caustic, and Poisonous Items 5.18 Recreation and Leisure Activites 5.19 Elements of the Water Safety Plan 5.20 Staff Training: Water Safety 5.21 * Swim Test 5.22 Visitation and Communication 5.23 Comprehensive Behavior Management System 5.24 Implementation and Consistency of Behavior Management System 5.25 Behavior Management System Infractions 5.26 Staff Training: Behavior Management System 5.27 Behavior Management System Monitoring 5.28 Search and Inspection of Controlled Observation Room Non-Applicable Non-Applicable 5.29 Controlled Observation Non-Applicable Non-Applicable 5.30 Controlled Observation Safety Checks Non-Applicable Non-Applicable 5.31 Controlled Observation Release Procedures Non-Applicable 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 Satisfactory Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 8 of 117 (Revised July 2017)

9 Summary During the original annual compliance review, the program received an overall rating of failed. All standard(s) were re-reviewed in accordance with FDJJ-2000 (Contract Management and Program Monitoring and Quality Improvement Policy and Procedures) (5)(f) Evaluate each program operated by the department or a provider under a contract with the department annually and establish minimum standards for each program component. If a provider fails to meet the established minimum standards, such failure shall cause the department to cancel the provider s contract, unless the provider achieves compliance with minimum standards within six months or unless there are documented extenuating circumstances. In addition, the department may not contract with the same provider for the canceled service for a period of twelve months. If a department-operated program fails to meet the established minimum standards, the department must take necessary and sufficient steps to ensure and document program changes to achieve compliance with the established minimum standards. If the department-operated program fails to achieve compliance with the established minimum standards within 6 months and if there are no documented extenuating circumstances, the department must notify the Executive Office of the Governor and the Legislature of the corrective action taken. Appropriate corrective action may include, but is not limited to: 1. Contracting out for the services provided in the program; 2. Initiating appropriate disciplinary action against all employees whose conduct or performance is deemed to have materially contributed to the program s failure to meet established minimum standards; 3. Redesigning the program; or 4. Realigning the program. Office of Program Accountability Page 9 of 117 (Revised July 2017)

10 Standard 1: Management Accountability Overview The Department contracts with AMIkids, Inc. to operate Melbourne Center for Personal Growth. The program is a thirty-two bed, non-secure program, serving male youth between the ages of thirteen and eighteen. The youth receive substance abuse treatment, social and life skills, vocational training, and on-site educational classes. The program staff consists of the executive director, director of operations, director of case management, director of education, four shift managers, administrative assistant, case manager, food service manager, food service worker, business manager, three teachers, one vocational instructor, substitute teacher, career coordinator, registered nurse, part-time nurse, and twenty-two direct care workers. The program has seven volunteer mentors and two bible study volunteers. The program training is conducted by staff or through the Department s Learning Management System (SkillPro). The program contracts with Circles of Care to provide mental health counseling and to facilitate evidence-based, gender-specific and life skills groups. The program contracts with Brevard Health Alliance to provide medical services to the youth. During the annual compliance review, the program had no staff vacancies. The program s education department provides general education development (GED) preparation, credit recovery, vocational certifications, as well as middle and high school curriculum. Treatment services include Seven Challenges, Aggression Replacement Training (ART), Boys Council for Boys and Young Men, Impact of Crime (IOC), Substance Abuse Skill Training, and individual and family counseling Initial Background Screening Satisfactory 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 a written policy and procedures regarding the screening of all newly hired staff through the Department s Background Screening Unit (BSU). Ten staff and one contracted-staff were hired during the annual compliance re-review period. The initial background screening was pulled for each of the staff in the Clearinghouse background screening system. A completed and eligible background screening was located for all eleven of the staff which were completed prior to the employee start date. All teachers are AMIkids employees and are subject to the Clearinghouse background screening process. Background screenings for all teachers were provided. The Annual Affidavit of Compliance with Level 2 Screening Standards was completed and sent to the BSU on December 8, 2017 for the calendar year FY annual compliance review conducted July 18-21, The program also conducts a driver s license check through the Department of Highway Safety and Motor Vehicles. A review of nineteen applicable personnel files documented a background screening was conducted on all staff prior to their hire date. Of the nineteen staff, ten were employees, three were contracted staff, and six were mentors. All staff files reviewed documented each staff was eligible for hire. Of the nineteen, one staff had a break in service, in which the program conducted a background screening prior to the staff s new date of hire. Another staff was hired from another provider and Office of Program Accountability Page 10 of 117 (Revised July 2017)

11 a background screening was conducted prior to the staff s date of hire. The program completed the Annual Affidavit of Compliance with Level 2 Screening Standards and sent it to the Department s Background Screening Unit on January 1, 2017, prior to the required date of January 31, The teachers are employees of the program; therefore, require background screening conducted by the program. Of the nineteen staff who were applicable for background screening, two were educational staff. All other educational staff had previously been screened by the program prior to their hire date Five-Year Rescreening Satisfactory 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. This indicator was reviewed from August 21, 2017 to February 13, 2018 due to the verification for this indicator occurring August 21, The program has a written policy and procedures in place regarding a re-screening of all staff every five years of employment, in compliance with the Department s Background Screening Unit (BSU) requirements. One staff was due for a fiveyear rescreen during the annual compliance re-review period on September 4, The rescreen was submitted to the BSU and was completed on June 26, In addition, two staff were currently eligible for their rescreens. One staff is due for a rescreen February 27, 2018, which was submitted to the BSU and completed November 22, The other staff is due for a rescreen on February 25, 2018 and the rescreen submitted to the BSU and completed November 17, Minor Verification- The verification for five-year rescreening occurred on August 21, One staff was due for a rescreen on January 9, A request for the rescreen was submitted on August 17, The program continues to utilize the list of staff with the staff s date of hire and five-year rescreen date on the list. The program originally received a Limited Compliance rating for this indicator during the FY annual compliance review conducted July 18-21, The program has a written policy and procedures in place regarding five-year rescreening, which states a rescreening is completed every five years, calculated from the agency hire date. Two staff were eligible for a five-year rescreening. Of the two staff who were eligible for a five-year rescreening, one was due for the re-screen on February 4, 2017 and was completed on January 23, The second staff eligible for a five-year rescreen was due on February 27, 2017; however, the rescreen was not completed until May 10, 2017, seventy-two days late. Thus, the program s revised policy and procedures state the business manager will implement a tracking system to ensure timeliness of the rescreens. This revision was completed May Office of Program Accountability Page 11 of 117 (Revised July 2017)

12 1.03 Provision of an Abuse-Free Environment Satisfactory Compliance The program provides an environment in which youth, staff, and others feel safe, secure, and not threatened by any form of abuse or harassment. Posting of the Florida Abuse Hotline telephone number and the Central Communications Center for youth 18 years of age and older telephone number. All allegations of child abuse or suspected child abuse are immediately reported to the Florida Abuse Hotline. Youth and staff have unhindered access to report alleged abuse to the Florida Abuse Hotline pursuant to Section (1)(a), F.S. The environment is free of physical, psychological, and emotional abuse. A code of conduct for staff who clearly communicates expectations for ethical and professional behavior, including the expectation for staff to interact with youth in a manner promoting their emotional and physical safety. The program has a written policy and procedures which states youth have unhindered access to contact the Florida Abuse Hotline, which must be accommodated as soon as reasonably possible and may not be screened by any staff member. Five youth were interviewed and each reported they had never been stopped from calling the Florida Abuse Hotline. The program has a code of conduct by which staff are required to follow. Signed employee codes of conduct were provided for all seven pre-service and seven in-service staff records reviewed during the annual compliance re-review. The executive director reported staff are subject to disciplinary action up to and including termination if the code of conduct is violated. Five youth and five staff were interviewed. All five staff reported they had never been subject to or seen youth or staff be threatened or intimidated by staff and have never heard staff use profanity. All five youth reported they had never been threatened or intimidated; however, three youth reported staff sometimes or often use profanity. One youth reported a specific staff who frequently uses profanity, one youth said staff use profanity when they think youth aren t listening, and the other youth reported staff will use profanity towards the youth. The program provided a corrective action to the specific staff alleged to be using profanity and issued a memo to all staff reminding them of the requirement to not use profanity in the code of conduct. FY annual compliance review conducted July 18-21, The program has a written policy and procedures in place regarding the provision of an abuse-free environment. The program has the Florida Abuse Hotline and Central Communications Center (CCC) phone number posted throughout the facility. Both, the Florida Abuse Hotline and CCC phone numbers and instructions are listed in the youth handbook. The notification instructions are as follows: the youth will request to make a call to the Florida Abuse Hotline, the youth will be permitted to call the hotline immediately, or within no more than one hour if staff need to accommodate the staff to youth ratio; the youth will be then be taken to a private room to make the call; the shift supervisor will notify the program manager or executive director of the call; the director of operations or designee will meet with the youth to discuss the problem the youth is currently having and an internal investigation will begin immediately. Of the seven youth case management records reviewed, all seven documented each youth signed acknowledging they received the youth handbook. The code of conduct is in the staff s handbook under Office of Program Accountability Page 12 of 117 (Revised July 2017)

13 Expectations of Team Members. The staff sign a Team Member Handbook Acknowledgement Statement acknowledging they have received the handbook. Staff also sign a Youth/Staff Boundary Safety Guideline, which outlines the boundaries staff are required to follow when working with youth. Seven staff and seven youth were interviewed by the review team. Of the staff and youth who were interviewed, all stated they know how to report abuse, are free to call, and have unhindered access to do so. The staff and youth stated they feel safe in the program and state the youth s basic needs are met. Staff are trained, as part of their required pre-service and in-service training, in Child Abuse: Recognition, Reporting and Prevention. There were no substantiated incidents of abuse during this annual compliance review period. An interview was conducted with the program director regarding the program s process for ensuring the staff follow the code of conduct, who state the code of conduct is included in the handbook and gave the guidelines the staff must follow. The program director further stated staff disciplinary action, up to termination will take place, if the allegation is substantiated. Seven staff were surveyed and all reported they understood the process for allowing youth to call the Florida Abuse Hotline and the CCC. Of the seven staff surveyed, none indicated youth were ever denied access to call the Florida Abuse Hotline or the CCC. Of the seven staff surveyed, all seven indicated staff do not use profanity when speaking to the youth, threats, intimidation, or humiliation when interacting with the youth. Of the seven, one staff indicated there are times when the staff are harsh with the youth and it is not what they say, rather how they say it. Seven youth were surveyed and indicated they feel safe in the program and have never been denied being able to contact the Florida Abuse Hotline or the CCC. Of the seven youth surveyed, six indicated the staff are respectful when talking with the youth; one indicated the staff can be sarcastic and push the youth s buttons, but also indicated some staff are respectful. Of the seven youth surveyed, four indicated the staff never use profanity and three youth indicated the staff occasionally use profanity. Of the three who indicated staff use profanity, two youth indicated staff have cursed in front of them, but never at them; the third youth indicated the staff have called youth names Management Response to Allegations Satisfactory Compliance Management shall be cognizant of youth and staff needs and provide direction to each on how to access the Florida Abuse Hotline. There is evidence management takes immediate action to address incidents of physical, psychological, and emotional abuse. During the annual compliance re-review period, the program had no allegations of abuse called into the Florida Abuse Hotline; however, the program has a policy and procedures in place regarding the management response to any allegations of abuse. The program did have one complaint against staff incident reported to the Central Communications Center (CCC) on December 6, The report alleged Protective Action Responses (PAR) were not being documented and other complaints against the administration. The program had a documented response on the same day of the call, including interviews and other investigation into the allegation. The program also documented a disciplinary memorandum for the director of operations for not immediately notifying the program director of a PAR due to a family emergency. Youth and staff are aware of how to contact the Florida Abuse Hotline and CCC through the youth handbook and the employee code of conduct. Further, staff receive training during pre-service and in-service on the abuse call procedures. During the program tour, the annual compliance review team observed multiple postings throughout the program for the number of both the CCC and the Florida Abuse Hotline. Office of Program Accountability Page 13 of 117 (Revised July 2017)

14 FY annual compliance review conducted July 18-21, The program has a written policy and procedures in place regarding management response to allegations. The program staff are to notify the program administration immediately upon learning of an abuse allegation. It further states, depending on the nature of the incident, a call will be made to the Florida Abuse Hotline and the Central Communications Center (CCC), and an internal investigation will be conducted by program administration. The program had three incidents involving an internal investigation. The incidents were documented on the program s internal Incident Report Form for immediate documentation. All three incidents were also documented, by director of operations, in the form of a formal memo. The memo provided a summary of the incident, an interview of all staff involved, youth statements, conclusion, and actions taken. Of the three incidents, two of the three staff involved were placed on administrative leave pending the internal investigation. Of the three incidents, all were called into the CCC. An internal investigation was conducted and documented; where each of the incidents were found to be unsubstantiated by the CCC. The program director stated in his interview, staff and youth are knowledgeable about the reporting process and signs are posted throughout the facility with the phone numbers to the Florida Abuse Hotline and the CCC. The program director further stated staff and youth are provided with a handbook documenting the process of reporting abuse and any results of incidents are incorporated into the management meetings Incident Reporting (CCC) Satisfactory 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. This indicator was reviewed from November 1, 2017 through February 13, 2018 due to the verification for this indicator occurring on November 1, The program has a policy and procedures in place regarding compliance with reporting guidelines for the Central Communications Center (CCC). The program has had five incidents reported to the CCC during the annual compliance re-review period. Four of the CCC reports were reviewed and all were reported to the CCC within the required two-hour time frame. Two of the four CCC incidents were documented in the logbook. One call was not documented in the logbook and the fourth incident was not called in by the program and was therefore not required to be documented in the logbook. The program does not maintain internal incidents; however, through a review of the grievances and other program documentation, the annual compliance review team did not find any incidents which were not appropriately reported to the CCC. OBCAP verification- The verification for the outcome based corrective action plan (OBCAP) for incident reporting occurred on November 1, The program identified two action steps for the OBCAP. The team verified completion of the action steps, as demonstrated by the completion of training on incident reporting for all management staff on August 30, This training was documented in the program training log and in the Department s Learning Management System (SkillPro) for each member of the management team. Office of Program Accountability Page 14 of 117 (Revised July 2017)

15 The program originally received a Limited Compliance rating for this indicator during the FY annual compliance review conducted July 18-21, The program has a written policy and procedures in place regarding incident reporting. The policy states incidents will be reported to the Central Communications Center (CCC) and the reports are to be maintained in the executive director s CCC reports binder. It further states program staff will notify the parent and includes a list of scenarios when the parents should be contacted. A review of five CCC reports documented the staff called the CCC within the required two-hour time period three of the five times. Of the two calls not placed to the CCC in the required timeframe, one was forty-one hours late and the other was two hours and fifteen minutes late. The program became aware of the first incident on April 25, 2017 at 8:30pm and made the report to the CCC on April 27, 2017 at 1:30pm. The program became aware of the second incident on May 11, 2017 at 4:30pm and made the report to the CCC on May 11, 2017 at 6:45pm. Upon review of the case management, mental health, and medical records, there were no incidents which occurred and were not reported to the CCC. Of the five CCC reports reviewed, two were not documented in the program s logbook Protective Action Response (PAR) and Physical Satisfactory Compliance Intervention Rate The program uses physical intervention techniques in accordance with Florida Administrative Code. Any time staff uses a physical intervention technique, such as countermoves, control techniques, takedowns, or application of mechanical restraints (other than for regular transports), a PAR Incident Report is completed and filed in accordance with the Florida Administrative Code. The program had five Protective Action Response (PAR) incidents, which occurred during the annual compliance re-review period and all were reviewed. All of the of PAR reports were completed by the end of the work day from all staff involved, were reviewed by the supervisor, PAR-certified instructor, and program director or designee, and the youth was counseled with a post-par interview within thirty minutes of the incident. One of the PAR reports had a wrong date printed for the post-par interview which was prior to the PAR date. The program provided a corrected report while the annual compliance review team was on-site. The program provided a PAR report each month, by the fifteenth of the month, to the Department. In November, it was discovered a PAR incident was not reported in a timely manner, so a revised PAR report was created. This revised report was physically handed to Program Operations and a report on the incident was ed to Program Operations, but an official revised report was not submitted to the Department. The revised report was sent while the annual compliance review team was onsite. The program s PAR rate during the annual compliance re-review period was.37, which is below the statewide residential PAR rate of FY annual compliance review conducted July 18-21, The program has a written policy and procedures in place regarding Protective Action Response (PAR) and Physical Intervention Rate, which states staff will receive training and instruction on the physical restraint policy. The staff must sign, upon hire, a Statement of Understanding which states the youth must see the nurse after a PAR restraint, regardless if the youth received any injuries. There were two PARs incidents over the last six months. Of the two PAR reports reviewed, both were completed by the end of the staff member s shift and reviewed within seventy-two hours by all required parties, to include a PAR instructor, the shift supervisor, and the executive director. Of Office of Program Accountability Page 15 of 117 (Revised July 2017)

16 the two PAR reports reviewed, both documented the youth was interviewed by the executive director or the designee within thirty minutes of the incident. The program director reviewed both applicable reports and the reports were placed in the program s PAR binder after being signed by the executive director. Of the two applicable PAR reports reviewed, neither documented mechanical restraints were used, injuries to staff or youth, or the youth alleged abuse. Of the two PARs reviewed, one documented both staff involved provided statements in regards to the incident; the second PAR reviewed only documented one of three staff involved provided a statement regarding the incident. The last six months of monthly summaries of all PARs were reviewed. The summaries documented the two PARs and each were submitted to the Department within the required timeframe. The program has not had an increase in PARs since the last annual compliance review. The last annual compliance report documented eleven PARs in the six-month review period. An interview was conducted with the program director who stated the PAR incidents are reviewed with the respective shift supervisors and reviewed during the management meetings. The PAR training plan was reviewed and it documented the Department s Office of Staff Development and Training approved the plan on January 24, The program s PAR rate during the annual compliance review period was.039, which is below the statewide Residential PAR rate of Pre-Service/Certification Requirements Satisfactory Compliance Contracted and State residential staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. This indicator was reviewed from November 1, 2017 through February 13, 2018 due to the verification for this indicator occurring on November 1, The program has a written policy and procedures in place regarding the completion of pre-service training which complies with the Department requirements, as well as training required in the program contract and the program training plan. The program submitted their pre-service training plan to the Department s Office of Staff Development and Training on January 2, 2017 and the updated training plan for 2018 was submitted January 1, 2018 and signed by Staff Development January 9, During the annual compliance re-review, seven staff records were reviewed for pre-service requirements. One staff completed their 180-day training period and was documented as having completed the requirements on October 30, The other six staff are still in their 180-day training period; however, five of the staff have completed their Department-required training. The seventh staff was hired in January and has completed all requirements to work with youth, but has not completed the rest of the pre-service training. All seven staff records reviewed had documentation of Protective Action Response (PAR) certifications, first aid/cardio pulmonary resuscitation (CPR)/automated external defibrillator (AED) certifications, professionalism and ethics training, suicide prevention training, and child abuse reporting training prior to working with the youth. One staff did not complete the training for Health Insurance Portability and Accountability Act (HIPAA), which was required in the program s training plan. All of the trainings were entered into the Department s Learning Management System (SkillPro) and were taught by certified instructors. OBCAP verification- The verification for the outcome based corrective action plan (OBCAP) for preservice/certification requirements occurred on November 1, The annual compliance review team verified completion of the action steps, as demonstrated by the creation of a pre- Office of Program Accountability Page 16 of 117 (Revised July 2017)

17 service/certification checklist, utilization of the checklist, and documentation of training in the Department s Learning Management System (SkillPro). The program provided documentation for three staff who had completed their pre-service training after the annual compliance review. All staff had a pre-service/certification checklist completed in their record and all training was documented in SkillPro. The program originally received a Limited Compliance rating for this indicator during the FY annual compliance review conducted July 18-21, The program has a written policy and procedures in place regarding pre-service training which states staff will complete 120- hours of pre-service/certification requirements within 180-days of hiring. The program s preservice New Hire Training Requirements Plan was approved by the Department s Office of Staff Development and Training on March 15, A review of seven staff training files, which were applicable for pre-service training, documented five of the seven staff completed the required training within 180-days of hire. Of the two staff who completed their required training late, one staff completed the Protective Action Response (PAR) training on July 19, 2016 which should have been completed by June 22, 2016, twenty-seven days late. The second staff who did not complete the required training within the required timeframe, completed the suicide prevention training on June 26, 2016, which should have been completed on June 7, 2016, nineteen days late. All seven completed, at a minimum, the required 120-hours of pre-service training. All seven received the required training topics to include cardiopulmonary resuscitation (CPR), firstaid, automated external defibrillator (AED), PAR, suicide prevention, professionalism, ethics, emergency procedures, and child abuse reporting. There was documentation showing each of the instructors were qualified to provide the training on topics of first aid and CPR. During a review of seven staff files, it was determined the staff had completed hours of preservice training. Of those training hours, only 663 were recorded in the Department s Learning Management System (SkillPro). The program was unable to provide documentation the staff applicable for pre-service training, had completed the training listed in their approved preservice training plan. The staff applicable for pre-service training, completed thirty-four of the fifty-two trainings listed on the program s approved pre-service training plan In-Service Training Satisfactory Compliance Residential staff complete twenty-four hours of in-service training, including mandatory topics specified in Florida Administrative Code, each calendar year, effective the year after preservice/certification training is completed. Supervisory staff completes eight hours of training (as part of the twenty-four hours of annual inservice training) in the areas specified in Florida Administrative Code. This indicator was reviewed from November 1, 2017 through February 13, 2018 due to the verification for this indicator occurring on November 1, The program has a written policy and procedures in place regarding the completion of in-service training, which complies with Department requirements, as well as training required in the program contract and the program training plan. The program submitted their training plan for 2017 on January 2, 2017 and it was signed by the Department s Office Staff Development and Training on January 8, The program also has a master training plan calendar for During the annual compliance rereview, seven staff records were reviewed for 2017 in-service training. All seven staff completed more than the required twenty-four hours of annual training. Six of the seven staff had documented first aid/cardio pulmonary resuscitation (CPR)/automated external defibrillator Office of Program Accountability Page 17 of 117 (Revised July 2017)

18 (AED) certifications, Protective Action Response (PAR) certifications, professional and ethics training, and suicide prevention training. One staff did not complete the required Suicide Prevention training in the Department s Learning Management System (SkillPro). Additionally, all seven staff completed trainings required by the program contract or training plan in Life and Stress Management, Behavior Modification, Universal Precautions, Emergency Procedures, 4 R s of Suicide, Prison Rape Elimination Act (PREA), Homicidal Risk Factors, Suicide Prevention, Substance Abuse Overlay Services, Trauma Informed Care, and Emergency Procedures for DJJ. Six of the seven staff completed Gang Awareness, DJJ Safety, and Child Abuse Reporting. Five of the seven staff completed Infection Control and Exposure Control training. The three supervisory staff records reviewed completed all required Department and contract required trainings. These staff completed beyond the required eight hours of supervisory training. All courses were taught by certified instructors and all training was entered into SkillPro. The program contract requires the program staff to complete a list of trainings. The program previously completed an Outcome Based Corrective Action Plan on this indicator which was closed in November Due to this timeframe, the annual compliance review team was not able to examine completion of these trainings; however, the program provided documentation all of the trainings were listed on the program s in-service training plan and training calendar. Further, the program provided documentation five of these trainings have already occurred with staff in Documentation was provided for the CPR/First Aid/AED and PAR certifications for all staff included in the direct care ratio, including nursing and kitchen staff. Both nurses had active CPR/First Aid/AED certifications. The program also has two staff with lifeguard certifications which were provided to the review team. Documentation of training was also provided for all staff who facilitate life skills and delinquency intervention groups. OBCAP verification- The verification for in-service training occurred on November 1, The annual compliance review team verified completion of the four action steps, as demonstrated by the revision and approval of the annual training calendar, documentation of all annual trainings in the Department s Learning Management System (SkillPro), and the oversight of the executive director. The program provided SkillPro information for all staff which matched the revised and approved training calendar for all training completed in August, September, and October. The program training log was verified by the executive director as evidenced by the signatures and dates on the training signature sheets. The program originally received a Failed Compliance rating for this indicator during the FY annual compliance review conducted July 18-21, The program has a written policy and procedures in place regarding in-service training which states the staff shall complete twentyfour hours of in-service training, including the mandatory topics specified in Florida Administrative Code, each calendar year, effective the year after pre-service training is complete. The program s in-service training plan was approved by the Department s Office of Staff Development and Training on January 7, Of the seven staff training files reviewed, six received the required training which includes cardiopulmonary resuscitation (CPR), first-aid, automated external defibrillator (AED), Protective Action Response (PAR), suicide prevention, professionalism, and ethics. Of the seven staff, one staff member completed all of the required training with the exception of training in professionalism. Of the required trainings received by applicable staff, the CPR, first-aid, and AED trainings were not documented in the Department s Office of Program Accountability Page 18 of 117 (Revised July 2017)

19 Learning Management (SkillPro). Of the seven staff, all exceeded the required amount of training hours, ranging from thirty-two hours to fifty-one hours. The program does not meet the contract requirements for in-service training. The following training is listed in the provider s contract and was not documented as being completed in the staff training files reviewed, nor is it on their approved training plan: Post-Traumatic Stress Disorder, Risk Factors and Triggers Relating to Homicidal Risk and Homicidal Prevention, Effective Pro-Social Modeling and Bonding Techniques for Mentors, Role Models and Advisors, Staff Development Pace: Goal Setting and Staff Evaluations, and Casey Life Skills. Of the seven staff training files reviewed, three were supervisors. The three supervisor training files reviewed documented two of the supervisors completed supervisory training topics on June 15, 2016 for four hours and another supervisory training on October 19, 2016 for three hours. The third supervisor completed three of the eight required hours of supervisory training on October 19, Of the three supervisors, none of them completed the required eight hours of supervisory training. A review of certifications documented the two nursing staff received the required trainings for CPR, firstaid, and AED Grievance Process Training Satisfactory Compliance Program staff shall be trained on the program s youth grievance process and procedures. The program has a written policy and procedures in place requiring all staff to be trained during pre-service and annually thereafter on the grievance process. Documentation of all seven preservice and seven in-service staff reviewed was provided for completed grievance training during the annual compliance re-review. FY annual compliance review conducted July 18-21, The program has a written policy and procedures regarding grievance process training which states all new staff will be trained on the grievance process as a component of orientation and pre-service training. Upon a review of seven pre-service training files, all seven staff received training on the grievance process and procedures. In addition, the youth were trained on the grievance process on April 19, 2017, in addition to receiving the process in their student handbook upon admission Grievance Process Satisfactory Compliance The program adheres to their grievance process and shall ensure it is explained to youth during orientation and grievance forms are available throughout the facility. The program has a written policy and procedures in place outlining the grievance process including an informal, formal, and appeal phase. The program director was interviewed during the annual compliance re-review regarding grievances and discussed the grievances process from informal to formal phases, where they are reviewed by the director of operations, and then the appeal phase where they are reviewed by the director of operations and executive director. Five staff were interviewed and all knew the grievance process. Five youth were interviewed and all reported knowing the grievance process, but they have never needed to file a grievance. Office of Program Accountability Page 19 of 117 (Revised July 2017)