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 Miami-Dade South AMIkids, Inc. (Contract Provider ) 1820 Arthur Lamb Jr. Road Miami, Florida Review Date(s): October 4-5, 18-19, 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: Keith Bennis, Office of Program of Accountability, Lead Reviewer (Standard 1) Myhosi Ashton, Office of Program Accountability, Technical Assistance Specialist (SPEP/Surveys) Odilanda Brito, Office of Program Accountability, Regional Monitor (Standard 1, Standard 4) Sharon Coplin, Office of Program Accountability, Regional Monitor (Standard 3) Shandria Striggles, Program Operation Specialist, Probation South Region (Standard 2)

3 Program Name: AMIkids Miami-Dade South MQI Program Code: 1250 Provider Name: AMIkids, Inc. Contract Number: P2121/19 Location: Miami-Dade County / Circuit 11 Number of Beds: 50 Review Date(s): October 4, 5, 18, 19, 2016 Lead Reviewer Code: 142 Methodology This review was conducted in accordance with FDJJ-2000 (Contract Management and Program Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1) Management Accountability, (2) Assessment and Intervention Services, (3) Mental Health and Substance Abuse Services, and (4) Medical Services, which are included in the Day Treatment Standards. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee 3 # Case Managers 1 # Clinical Staff # Food Service Personnel # Healthcare Staff 1 # Maintenance Personnel 2 # Program Supervisors Documents Reviewed 9 # Staff 7 # Youth # Other (listed by title): Accreditation Reports Affidavit of Good Moral Character CCC Reports Confinement Reports Continuity of Operation Plan Contract Monitoring Reports Contract Scope of Services Egress Plans Escape Notification/Logs Exposure Control Plan Fire Drill Log Fire Inspection Report Fire Prevention Plan Grievance Process/Records Key Control Log Logbooks Medical and Mental Health Alerts PAR Reports Precautionary Observation Logs Program Schedules Sick Call Logs Supplemental Contracts Table of Organization Telephone Logs Surveys Vehicle Inspection Reports Visitation Logs Youth Handbook 7 # Health Records 7 # MH/SA Records 7 # Personnel Records 7 # Training Records/CORE 3 # Youth Records (Closed) 7 # Youth Records (Open) # Other: 7 # Youth 7 # Direct Care Staff # Other: Observations During Review Admissions Confinement Facility and Grounds First Aid Kit(s) Group Meals Medical Clinic Medication Administration Posting of Abuse Hotline Program Activities Recreation Searches Security Video Tapes Sick Call Social Skill Modeling by Staff Staff Interactions with Youth Comments Staff Supervision of Youth Tool Inventory and Storage Toxic Item Inventory and Storage Transition/Exit Conferences Treatment Team Meetings Use of Mechanical Restraints Youth Movement and Counts Items not marked were either not applicable or not available for review.

4 Standard 1: Management Accountability Day Treatment Rating Profile Indicator Ratings Standard 1 - Management Accountability 1.01 Initial Background Screening* 1.02 Five-Year Rescreening 1.03 Protective Action Response (PAR) 1.04 Pre-Service/Certification Training 1.05 In-Service Training 1.06 Cleanliness and Sanatation 1.07 Fire Prevention and Evacuation Procedures 1.08 Water Activities 1.09 Food Services 1.10 Transportation 1.11 Administration Limited 1.12 Ninety-Day Supervisory Reviews 1.13 Incident Reporting (CCC)* 1.14 Abuse-Free Enviorment* 1.15 Behavior Management System 1.16 Youth Record * 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 37 (Revised July 2016)

5 Standard 2: Assessment and Intervention Services Day Treatment Rating Profile Indicator Ratings 2.01 Standard 2 - Assessment Services Admission and Orientation 2.02 Medical, Mental Health, and Suicide Risk Alerts in JJIS 2.03 Positive Achievement Change Tool (PACT) Full Assessment 2.04 Transitional Planning/Reintegration* 2.05 Youth-Empowered Success (YES) Plan Development 2.06 Youth Requreiment/PACT Goal Elements 2.07 YES Plan Implementation/Supervision 2.08 Ninety-Day YES Plan Updates 2.09 PACT Reassessment 2.10 Progress Reports 2.11 Education Transition Plan 2.12 Termination Release 2.13 Career Education 2.14 Educational Access * 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 37 (Revised July 2016)

6 Standard 3: Mental Health and Substance Abuse Services Day Treatment Rating Profile Indicator Ratings Standard 3 - Intervention Services 3.01 Designated Mental Health Clinician Authority or Clinical Coordinator 3.02 Licensed Mental Health and Substance Abuse Clinical Staff* 3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff 3.04 Mental Health and Substance Abuse Admission Screening* 3.05 Mental Health and Substance Abuse Assessment/Evaluation 3.06 Mental Health and Substance Abuse Treatment 3.07 Treatment and Discharge Planning 3.08 Mental Health Crisis Intervention Services* 3.09 Crisis Assessments* 3.10 Emergency Mental Health and Substance Abuse Services* 3.11 Baker and Marchman Acts* 3.12 Suicide Prevention Services* 3.13 Suicide Precaution Observation Logs* 3.14 Suicide Prevention Plan* 3.15 Suicide Prevention Training* * 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 37 (Revised July 2016)

7 Standard 4: Medical Services Day Treatment Rating Profile Indicator Ratings Standard 4 - Medical, Mental Health, and Substance Abuse Services 4.01 Medical Screening* 4.02 Medication Management - Verification of Medications 4.03 Medication Management - Delivery of Medications 4.04 Medication Management - Medication Storage 4.05 Episodic/Emergency Services * 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 37 (Revised July 2016)

8 Strengths and Innovative Approaches AMIkids Miami-Dade South participated in their third cycle of Connection Coalition s (CoCo) yoga classes, formerly known as Yoga Gangsters. CoCo provides volunteer yogis to teach the youth tools geared to help calm the nervous system and allow better decision making through yoga, mindfulness, and meditation. AMIkids Miami-Dade South held a school-wide art contest. Students competed in various art categories, including charcoal pencil sketches, paintings, and clay sculptures. All the student work was displayed for a week for all staff, youth, and visitors to observe. First, second, and third place winners in each category received prizes such as gift cards and MP3 players. Project KnuckleHead is a non-profit organization with programs across the country. They use education, mentoring, music, art, and other forms of self-expression as tools to inspire their most vulnerable youth. They serve youth involved in the juvenile justice system and schools in low-income communities. Through a partnership with Project Knucklehead, AMIkids Miami-Dade South has started setting up a recording studio with various instruments, microphones, and Disc Jockey equipment for youth to practice their self-expression. The program s director of operations facilitated a schoolwide Vision Board project. Staff and students collected magazines, newspapers, and art materials in order for each youth to make their own vision board. A vision board is a tool used to help clarify, concentrate, and maintain focus on specific life goals. To make a vision board, youth choose and display images which may represent whatever they want to be, do, or have in their lives. Youth participated in a field trip to the Wynwood Yard, which is a vegan food truck. The chef s conducted a cooking demonstration where they taught the students how to make a vegan meal. In addition, youth took a tour of their organic fruit, vegetable, and herb garden. Office of Program Accountability Page 8 of 37 (Revised July 2016)

9 Standard 1: Management Accountability Overview AMIkids Miami-Dade South is a non-residential, day treatment program operated by AMIkids, Inc., under contracts P2119 and P2121 with the Department of Juvenile Justice (DJJ). The program is located in Virginia Key, Miami, Florida, in a facility owned by AMIkids, Inc., located on land owned by Miami-Dade County. The program has a capacity to provide services for up to fifty youth. The program s staff is comprised of an executive director, a director of administration, a director of education, local care counselors, a community safety specialist, career coordinator, vocational instructor, behavior interventionist, teachers, and a mental health counselor. According to the executive director, the program had one vacancy during this review which was for a math teacher position. The program utilizes a restorative approach for rehabilitating the youth by holding each youth accountable for their actions helping them develop competency in education and vital life skills, personal responsibility, and assisting them in restoration efforts. Depending upon the individual youth s progress in the program, the program s length of stay ranges between three and five months. A tour of the facility reflected the program is maintained in a clean and orderly condition supporting positive interactions between staff and youth. Services provided to the youth are designed to address criminogenic risk factors according to each youth s identified risk and needs. The program has a contract with Exquisite Catering by Robert to cater all food to the youth and staff at the program. The program participates in the National School Lunch and Breakfast program and provides daily breakfast, lunch, and one snack to each youth and staff. The program holds comprehensive staff meetings at least twice a week with representatives from each program area. The program does not have licensed medical staff on-site. Miami-Dade County Public Schools provides oversight, academic assistance, and support to the program s educational component, as well as, school bus transportation for applicable youth. The program maintains a master training plan and also has an internal alert system which is reviewed and updated daily. Each youth receives instructions in various aquatic skills, such as scuba diving, boating, seamanship, marine mechanics, marine sciences, biodiversity, and maintenance. Each youth is also provided the opportunity to earn a scuba diving certification, construction certification, and food handling certification while enrolled at the program. Seven surveyed youth indicated they feel safe in the program 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 a policy and procedures which addresses initial background screening. Reviewed documentation of personnel files for seven staff, two contracted staff, and three volunteers/interns who were hired since the last annual compliance review, reflected each received an eligible background screening rating prior to being hired or having interaction with you. In addition to background screening, each potential new hire is screened through the Florida Department of Law Enforcement for a sexual offender/predator check. The Annual Affidavit of Compliance with Level 2 Screening Standards was completed and submitted to the Department s Background Screening Unit on December 15, 2015, meeting the annual Office of Program Accountability Page 9 of 37 (Revised July 2016)

10 requirement. The program did not have any applicable staff who were currently working in the program who were rated ineligible for employment by the Department's Inspector General Five-Year Rescreening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. Employees and volunteers are rescreened every five years from the initial date of employment. The program has a policy and procedures which address the completion of five-year background rescreening. A review of the only two applicable personnel files requiring a five-year background rescreening found each rescreening was processed within the required time frame. The program s executive director utilizes Microsoft Outlook as an internal tracking and reminder system to ensure applicable five-year background rescreening is completed prior to a staff member s anniversary date. The program also conducts driver s license checks twice annually, for all staff Protective Action Response (PAR) Compliance The program uses physical intervention techniques in accordance with Florida Administrative Code. Any time staff uses a physical intervention technique, such as countermoves, control techniques, takedowns, or application of mechanical restraints (other than for regular transports), a PAR Incident Report is completed and filed in accordance with the Florida Administrative Code. The program has a policy and procedures in place for the use of Protective Action Response (PAR) moves, when applicable. An interview with the program s executive director (ED), as well as, a review of documentation from seven staff training files validated each staff is trained, upon hire, in the appropriate use of PAR and each staff must complete PAR refresher training annually, thereafter. The program had a total of one applicable instance where PAR was used since the last annual compliance review. The reviewed PAR report reflected the techniques used were Department approved and were appropriate in use. Staff who were either a witness to, or participated in, the particular incident completed the required employee statements by the end of the staff member s workday. The applicable PAR report was reviewed and processed within seventy-two hours by all required parties. The report was reviewed by the ED / PAR Instructor within the required time frame, to determine if use of force was consistent with the program s policy. The post-par interview with the youth was conducted by the ED within thirty minutes after the incident and included the youth s input, to determine if they had any physical complaints or visible injuries present. The reviewed PAR report did not indicate the youth was in need of a PAR medical review. The program maintains a centralized binder which contains all PAR reports and any applicable attachments. Reviewed documentation also found the program maintained the monthly trend analysis of the number of PARs utilized. Office of Program Accountability Page 10 of 37 (Revised July 2016)

11 1.04 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. The program has a policy and procedures in place for pre-service/certification training. Three staff training files applicable for pre-service certification training were reviewed. Each staff member completed the required training and exceeded the minimum of 120 hours completed within 180 days of being hired. Each of the three staff members completed the required training prior to having any contact with youth. The program submitted a master training schedule to the Department s Office of Staff Development and Training, on January 4, 2016, which outlines various scheduled training topics. All pre-service trainings were entered in the Department s Learning Management System (SkillPro). The program also utilizes an internal web-based learning system called Moodle to document and track various pre-service and in-service staff trainings, which includes Department required trainings, as well as specific AMIkids required trainings In-Service Training Compliance Contracted non-residential staff completes in-service training in accordance with Florida Administrative Code. Contracted non-residential staff must complete twenty-four hours of annual in-service training, beginning the calendar year after the staff has completed pre-service training. Supervisory staff shall complete eight hours of training in the areas listed below, as part of the twenty-four hours of annual in-service training. The program has a policy and procedures in place for in-service training. Seven staff training files were reviewed for in-service training requirements. Reviewed documentation validated each staff exceeded the twenty-four-hour annual requirement. Three of the seven files reviewed were supervisory staff training files and each reflected the staff exceeded the eight-hour requirement of leadership training. All reviewed staff training files documented staff receiving all mandatory required trainings. All in-service trainings were entered in the Department s Learning Management System (SkillPro). The program also utilizes an internal web-based learning system called Moodle to document and track various pre-service and in-service staff trainings, which includes Department required trainings, as well as, specific AMIkids required trainings. The program submitted an in-service training plan to the Department s Office of Staff Development and Training, on January 4, Office of Program Accountability Page 11 of 37 (Revised July 2016)

12 1.06 Cleanliness and Sanitation Compliance The program provides a safe and appropriate treatment environment including maintenance and sanitation of the facility. The program maintains a policy and procedures consistent with the Department s guidelines ensuring the program provides a safe and appropriate treatment environment, including maintenance and sanitation. A complete facility tour was conducted by the review team on the first day of the review. All areas were observed to be clean and neat. Observations of the building and grounds made during the annual compliance review reflected the facility was free of graffiti on any walls, doors, or windows and was well maintained overall. The program has sufficient space designated for educational classrooms, group meetings, and individual, family, or group counseling. Program staff follow a maintenance and housekeeping plan which requires staff to conduct daily inspections of the facility in various areas. These inspections were documented, in writing, on a site-specific inspection form. The facility has two separate restrooms for the youth; one for males and one for females. Each restroom was equipped with at least one operable toilet stall. Each restroom was observed on the facility tour and both were fully operational and equipped with a washbasin. Each washbasin had hot and cold running water, as well as antibacterial soap available for use. The program was last inspected by the Miami-Dade Water and Sewer Department, on August 22, 2016, and no issues were reported. Though the program does not operate during evening hours, the facility was observed to be equipped with outdoor lighting Fire Prevention and Evacuation Procedures Compliance The program provides a safe and appropriate treatment environment including fire prevention and evacuation procedures. The program has a policy and procedures outlining comprehensive fire prevention and evacuation procedures during an emergency situation. There is no smoking permitted in the facility or on program grounds. Applicable staff may take their personal vehicles, during their break, to any off-site area designated as a smoking area. Reviewed documentation of staff training files, as well as youth case management files, confirmed each staff and youth receive training on fire safety. Reviewed documentation supported emergency fire drills were conducted on a monthly basis, under varied conditions. These drills were documented on program-specific mock drill forms and documented all required elements. Program staff also maintain a fire safety log which contains annual fire inspections, any applicable deficiencies found by fire officials, a record of corrections, and the results of periodic fire safety inspections and equipment checks. The facility is equipped with an automatic fire detection system which was last inspected and tested through Haig Service Corporation, on January 19, At the time of the inspection, a few issues were found and were corrected by the inspecting agency. The program has a total of ten fire extinguishers; eight are located throughout the facility and one is located in each of the program s two functional transport vehicles. A review of the program s egress plan and observations made during the facility tour, reflected the program has fire protection equipment available at strategic locations throughout the facility and each were inspected at least quarterly. The program maintains one blood borne pathogen kit and two knife-for-life kits within the facility. The program has a total of seven first aid kits; four of which are maintained on-site, inside the facility two are used for each of the program s two transport vehicles, and one is used for the program s boat. Six of seven surveyed youth each confirmed they have been instructed on what to do in case of a fire. The one youth who said he was not instructed was interviewed again by the review team. The youth reported he has been enrolled at the program since August of 2016 Office of Program Accountability Page 12 of 37 (Revised July 2016)

13 and did not recall participating in a fire drill. The youth confirmed again he could not remember if he has been instructed on what to do in case of a fire, or not. Reviewed documentation of fire drills and attendance records reflected the program conducted a mock fire drill on September 19, 2016, in which the youth was present for and participated in. Additionally, fire procedures are outlined in the program s student handbook, which is provided to the youth and parent/guardian upon orientation to the program Water Activities Compliance The program provides a safe and appropriate treatment environment including procedures for water activities. The program has a policy and procedures addressing water activities. The program s policy calls for a maximum certified lifeguard-to-youth ratio of one to seven for all aquatic activities. Reviewed documentation supported all youth receive a student swim evaluation, identifying their current swimming level, prior to participating in any swimming activities. If a youth chooses not to swim, they will not be evaluated with the swim test and will not participate in any water activities. This is documented on the program s swim test form and is kept in a centralized binder. The program currently has one staff member who is a certified lifeguard. A review of youth case management files confirmed the completion of youth swim tests. The program has a policy in place, which provides for the prompt notification of a youth s parent/guardian in cases of serious illness, injury, or death. An interview with the program s executive director confirmed the program has not had any illnesses, injuries, or death stemming from water activities since the last annual compliance review. Five of seven surveyed youth confirmed they have participated in water activities and received a swimming evaluation prior to gaining approval to swim. Two of the seven surveyed youth indicated they do not participate in water activities Food Services Compliance The program provides a safe and appropriate treatment environment including food service. The program has a policy and procedures in place to ensure a safe and appropriate treatment environment, including food services, is provided to each youth. The program provides daily breakfast, lunch, and snacks to each youth, as well as to program staff. The program maintains a contract with Exquisite Catering by Robert, Inc. for all meals. The contract with Exquisite Catering was last renewed on July 1, 2016, and ends on June 30, The vendor is certified with the Florida Department of Agriculture and Consumer Services Division of Food, Nutrition, and Wellness as a vended school meal service for the National School Lunch and School Breakfast Program. Observations made during the review reflected the indoor dining area was clean and well-maintained. There were fourteen youth identified with special dietary restrictions/allergies at the time of this annual compliance review. An interview with the program s executive director (ED) confirmed the program makes accommodations to those youth, who are identified with special dietary restrictions or to accommodate religious beliefs, when applicable. Furthermore, the ED confirmed the program does not withhold food as a disciplinary measure. The program s food services were last inspected by the State of Florida s Department of Health on September 26, 2016, and yielded no violations. Seven surveyed youth and seven surveyed staff confirmed the program offers a single menu for both program staff and youth. Office of Program Accountability Page 13 of 37 (Revised July 2016)

14 1.10 Transportation Compliance The program provides a safe and appropriate treatment environment including transportation. The program has a policy and procedures in place which address transportation. The program has two, twelve passenger vans and one, five passenger sedan. The vans are utilized to transport youth for off-campus activities, if necessary. The sedan at the program is not operational, nor is it used for transport at this time. Observations made reflected each van was equipped with a fire extinguisher, knife-for-life, first aid kit, and window punch. An inspection of randomly selected personal and program vehicles were also conducted during the annual compliance review and all vehicles were found to be securely locked. The program s policy reflects if an employee has qualifying moving or speeding violations, the employee is unable to drive any program vehicle or transport any youth. A review of current vehicle insurance and registrations validated each vehicle is properly insured. Reviewed documentation also supported each vehicle was up-to-date on their annual inspections and maintenance. Reviewed documentation reflected the program maintains daily, weekly, and monthly logs and inspections for each vehicle. Supporting documentation, as well as an interview with the program s executive director (ED), indicated the program conducts driver s license checks every six months on all employees. The ED confirmed the program presently has eighteen staff who have a clear driver s license and are able to transport youth, if necessary. The ED also confirmed youth are never denied services, nor are they penalized, due to a lack of transportation Administration Limited Compliance The program provides a safe and appropriate treatment environment including administrative and operational oversight. The program has a policy and procedures in place to ensure a safe and appropriate treatment environment, including administrative and operational oversight. The program s executive director (ED) maintains statistical information including admission data, transfers, releases, absconds, emergencies, abuse reports, incidents, and length of stay. Reviewed documentation also confirmed the program s ED generates a population and incident data report and submits it to the Department, on a monthly basis. A review of the program s youth census, in comparison with the census report in the Department s Juvenile Justice Information System (JJIS), confirmed the youth listed on the facility roster matched the census report in JJIS. A facility tour was conducted by the review team on the first day of the annual compliance review. Observations made while on the facility tour, as well as observations made throughout the annual compliance review week, indicated the program provides a safe and appropriate treatment environment for the youth they serve. A review of Central Communications Center (CCC) reports from the last six months showed the program had nine incidents called into the CCC. A review of the program s logbook compared to the CCC reports confirmed each incident was documented in the program s logbook. Other randomly selected/reviewed entries indicated staff document significant program activities, events, and incidents each day. Log entries were brief, written in ink, contained the date and time of incident, name of youth and program staff involved, and name of the person making the entry with the date, time of entry, and signature. If program staff wrote an error, there was evidence of staff striking through the error with a single line, with Void written by the error, and the corrections were initialed by program staff. Entries which impacted the safety and security of the program were highlighted to ensure special attention. A review of logbooks maintained since the last annual compliance review reflected the program s ED was not consistent with reviewing the program s logbooks, on a bi-weekly basis. Office of Program Accountability Page 14 of 37 (Revised July 2016)

15 The requirement is for the program director to review the log on a bi-weekly basis, taking action where appropriate. There was no documentation of the logbook being reviewed, at all, for the months of February and March of The ED reviewed the logbooks timely for the months of April, May, September, and October of 2016; however, for the months of June, July, and August of 2016, the logbooks were reviewed beyond the bi-weekly requirement 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. The program has a policy and procedures in place outlining ninety-day supervisory reviews. Seven youth case management files were reviewed for the completion of ninety-day supervisory reviews. Reviewed documentation reflected each of the seven youth case management files contained a supervisory review, which was conducted at least once every ninety calendar days, as required. In each of the seven reviewed case management files, the supervisory review confirmed each youth received appropriate interventions and supervision and their risk and needs assessments, as well as their case plans, were updated appropriately, prior to supervisory review. Reviewed documentation in each of the reviewed youth case management files reflected both the Youth-Empowered Success (YES) Plan and the Positive Achievement Change Tool (PACT) were updated prior to each supervisory review Incident Reporting (CCC) Compliance The program provides a safe and appropriate treatment environment including transportation. Whenever a reportable incident occurs, the program notifies the Department s Central Communications Center (CCC) within two hours of the incident, or within two hours of becoming aware of the incident. The program has a policy and procedures regarding incident reporting to the Central Communications Center (CCC). The program had nine incidents called into the CCC within the last six months. Reviewed documentation reflected each was in compliance with the Department s CCC reporting procedures and were reported by the program, within the required time frame. The program maintains a centralized binder containing all CCC related reports. In addition, the program maintains an internal incident report binder, as well as a grievance binder. A review of randomly selected internal incident and grievance reports found there were no additional incidents needing to be reported to the CCC Abuse-Free Environment Compliance Any knowledge or suspicion of abuse, abandonment or neglect is reported to the Florida Abuse Hotline. The program has a policy and procedures which establishes a process to report any suspected abuse or neglect to the Florida Abuse Hotline. This policy reflects any program staff, volunteer, or intern who knows or has reasonable cause to suspect a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or other person responsible for the child s welfare must report this suspicion to the Florida Abuse Hotline. Additionally, the policy also reflects if a child is suspected to be in need of supervision and care and has no parent, legal Office of Program Accountability Page 15 of 37 (Revised July 2016)

16 custodian, or responsible adult relative immediately known and available to provide supervision and care, staff must report such knowledge of suspicion to the Florida Abuse Hotline. Observations made by the review team, throughout the annual compliance review, validated the program provides an environment in which youth, staff, and others feel safe, secure, and not threatened by any form of abuse or harassment. The program s abuse reporting procedures are included in the youth handbook, which each youth receives a copy of upon admission. Each staff, upon being hired, acknowledges and signs a code of conduct, located within AMIkids s Team Handbook, which forbids staff from using physical abuse, profanity, threats, or intimidation towards youth. The telephone numbers to the Florida Abuse Hotline and the Central Communications Center (CCC) for youth eighteen years or older were observed posted throughout the facility. There have been no allegations of abuse against staff since the last annual compliance review. According to the program s executive director (ED), if a youth would like to report abuse, they are to notify staff and staff allow them to make the call. The staff are to immediately report this to their supervisor and the ED. Seven surveyed youth confirmed they have never been stopped from reporting abuse to the Florida Abuse Hotline, have never observed a staff member threaten a youth, and felt safe in the program. Seven surveyed youth confirmed staff are respectful when talking with the youth. Three youth stated they have never heard staff use curse words when speaking with youth; two youth said they heard staff curse once when speaking with the youth; and one youth said he occasionally hears staff curse when speaking with the youth. Seven surveyed staff confirmed they have never seen a co-worker telling a youth they could not call the Florida Abuse Hotline, nor have they ever observed a coworker using threats, intimidation, or humiliation when interacting with the youth 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 has a policy and procedures outlining the behavior management system (BMS), which is titled as the AMIkids Personal Growth Model, by AMIkids, Inc. The BMS was designed specifically for AMIkids employees to deliver consistent services, with fidelity, across all positions and provides privileges and consequences to encourage youth to fulfill programmatic expectations. Upon admission, each youth receives a student handbook explaining the rules of the program, the point card system, the rank system, tokens, and consequences. Observations made by the review team, during the facility tour, confirmed the program s BMS was posted throughout the facility. The BMS is a three layered behavior system which includes rank, a point system, and token economy. There are five ranks making up the BMS. Examples of the ranks, in order, are: Recruit, Ensign, Lieutenant, Commander, and Captain. In order for a youth to advance from one rank and phase to the next, they are required to achieve a certain number of points for a targeted number of days and must demonstrate appropriate social and academic skills. An increase in rank allows for a youth to receive an increase in privileges, such as additional snacks, hygiene items, and/or opportunities for off-campus activities. Observations found the program has a bid store, where youth are eligible to earn rewards based on their earned tokens. The program also incorporates Youth-Empowered Success (YES) Plan goals into rank goals, which youth must achieve in order to earn rank. The program s BMS also Office of Program Accountability Page 16 of 37 (Revised July 2016)

17 includes fair consequences directly correlating with the behavior problem, so the youth understand the consequences of their negative behavior. The program follows a daily activity schedule, which provides structure and routine for youth. The program s activity schedule includes structured indoor/outdoor recreational and leisure activities teaching values and encouraging sportsmanship. Reviewed documentation confirmed the program has documents containing the Department s mission to reduce juvenile crime, a description of the program s design, and the program s educational goals and objectives. An interview with the program s executive director (ED), as well as a review of their BMS policy, confirmed the program does not use time-out or facility restriction as disciplinary procedures; however, they may use privilege suspension due to negative behaviors, which may include denial of participation in recreational activities and other activities outside the facility. Privilege suspension never includes the loss of regular meals, healthcare services, contact with parent/guardian, or legal assistance. Staff are to immediately address a youth of any rule violations. Seven surveyed youth verified the program does not use time-out and the youth are never allowed to discipline or have control over other youth. Each of the seven surveyed youth reported if privilege suspension occurs, staff do not deny youth meals, health care, religious needs, parental contacts, or legal assistance. Furthermore, each youth confirmed the staff explain to the youth the reason for the suspension and youth are able to explain their behavior leading to the suspension Youth Records (Healthcare and Management) Compliance The program maintains an official case record, labeled Confidential, for each youth, which consists of two separate files: An individual healthcare record An individual management record. The program has a policy and procedures for maintaining an official case record for each youth. The program maintains an individual management file and individual healthcare record for each youth enrolled at the program. Seven individual case management files, as well as seven individual healthcare records, confirmed each were labeled as Confidential and were maintained separately, as required. The case files and healthcare records were each kept organized having separate tabs dividing the information dispersed into specific sections. Observations made during the facility tour confirmed all official youth case files and healthcare records are secured in a locked file cabinet, clearly identified as Confidential, which are stored within locked offices. Office of Program Accountability Page 17 of 37 (Revised July 2016)

18 Standard 2: Assessment and Intervention Services Overview Each youth receives a physical copy of the youth orientation handbook upon admission. The handbook contains the program s rules, guidelines, and expectations. Each youth is screened and assessed by staff during the admission process. Screening is designed to identify youth in need of further assessment due to risk factors in suicide, aggression, trauma, mental health, and substance abuse. Youth admitted to the program receive intake, orientation, screening, assessment, individualized service planning, individualized treatment planning, and an assignment to delinquency and promising practice interventions, based on each youth s individualized needs. The program has two local care counselors who are responsible for providing case management services and overseeing the completion of the admission and orientation of each youth. Case management staff are responsible for completing each youth s Positive Achievement Change Tool Screening Report, Referral for Mental Health and Substance Abuse Assessment, and a Mental Health/Substance Abuse Referral Summary form. The program does not have a licensed medical staff on-site. The program employs a licensed clinical social worker who serves as the designated mental health clinician authority, a clinical coordinator who is a licensed registered mental health counselor intern, and three bachelor s level interns. The program continues to utilize the Biotrak electronic monitoring system which records each youth s attendance, on a daily basis, by using the youth s thumb print and photograph. This system is explained to the youth during the admission process. The Biotrak system notifies the youth s assigned juvenile probation officer, by , when the youth is absent from the program and also creates attendance and lunch reports for each youth Admission and Orientation Compliance Facility orientation shall be conducted within twenty-four hours of a youth s admission to the facility. Case notes should document the date and time of the orientation and the youth received orientation documents. The program has a policy and procedures in place addressing admissions and orientation. A review of seven youth files found each youth received an orientation for substance abuse treatment and an outline of services. Orientation includes the student dress code, daily activity schedule, expectations, goals, procedures, emergency medical/mental health services, evacuation procedures, behavior management system, contraband, educational services, abuse reporting, mental health and substance abuse orientation, anticipated length of stay, and other applicable services such as their vocational programs. In addition, each youth receives an AMIkids Miami-Dade South tour of the program, and a student handbook. The student handbook explains the program s goals and available services, the case planning process, telephone guidelines, the search policy, youth rights and grievances, the Florida Abuse Hotline telephone number, Advocacy Center for Persons with Disabilities telephone number, and facility rules governing youth conduct and consequences for major rules violations. Office of Program Accountability Page 18 of 37 (Revised July 2016)

19 2.02 Medical Alerts, Mental Health Alerts, and Suicide Risk Compliance Alerts in JJIS The program shall alert staff of medical, mental health, and suicide risk issues that may affect the security and safety of the youth in the program. The program has a policy and procedures outlining the program s alert system which addresses medical, mental health, and suicide alerts. The program s alert system addressed medical, mental health, and suicide alerts. Three of the seven youth files were applicable and presented documentation of a medical alert. Each applicable alert was entered timely in the program alert system. Reviewed documentation indicated the executive director and the therapist placed the applicable alerts in the Department s Juvenile Justice Information System. Seven surveyed staff confirmed they are informed of any applicable youth medical alerts in various ways, which include staff being advised during staff meetings, through reviewing the daily log list of alerts, by reviewing the medical and mental health logbooks, or being advised by administration or the clinical director verbally and/or through updates 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. The program has a policy and procedures outlining Positive Achievement Change Tool (PACT) Full Assessments. A review of seven youth case management files found a Positive Achievement Change Tool (PACT) Full Assessment completed by program staff within seven calendar days of each youth s admission. A review of PACT documentation indicated program staff utilized information and observations received from the parents/guardians, other program staff, law enforcement, and other informed parties who have knowledge of the youth s behavior and background history during the completion of the assessment Transition Planning/Reintegration Compliance 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 has a policy and procedures addressing transition planning and reintegration. A review of three applicable youth case management files reflected each file had documentation in the case notes validating program staff contacted each youth and parent/guardian while the youth was still in the residential program and during the youth s last sixty days at the residential program. A review of three applicable files contained documentation confirming program staff participated in the exit conference. Case planning for the youth s transition to the community began at the commitment conference. A review of each applicable youth's Youth-Empowered Success (YES) Plan validated treatment and intervention recommendations identified during the exit and/or discharge summary from the sending program were included on the YES Plan. Office of Program Accountability Page 19 of 37 (Revised July 2016)

20 2.05 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. The program has a policy and procedures outlining the development of Youth-Empowered Success (YES) Plans. A review of seven youth case management files found the local care counselors completed a Positive Achievement Change Tool (PACT) assessment prior to the development of their initial YES Plan. In the seven reviewed files, 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 YES Plan. Each reviewed plan was performance-based, contained measurable and positive objectives, and described outcomes. Reviewed documentation also confirmed the youth and parent/guardian were provided a copy of the YES Plan, upon their review and signature, and the youth and parent/guardian were informed of the importance of complying with the sanctions and goals as outlined. Seven surveyed youth indicated they participated in the development of their YES Plan and also confirmed they received a copy of their YES 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). The program has a policy and procedures outlining youth requirements and Positive Achievement Change Tool (PACT) goal elements. A review of seven youth case management files found each youth requirement and Positive Achievement Change Tool (PACT) goal contained at least one specific action step for the youth, parents/guardians, and juvenile probation officer (JPO). The plans also contained at least one of the youth s top three criminogenic need goals and the applicable court-ordered sanctions. Action steps on each plan had reasonable projected completion dates and also clearly defined who was responsible, what action should be taken, and how often the action should be taken 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. The program has a policy and procedures which address the implementation and supervision of Youth-Empowered Success (YES) Plans. A review of seven youth case management files found each youth was supervised by program staff in a manner ensuring compliance with courtordered sanctions and the Youth-Empowered Success (YES) Plan. A review of the youth case management files also validated there was appropriate documentation of case activities. Staff document all case activities, including any face-to-face or telephone interactions with the youth, parent/guardian, and providers. 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. Case notes confirmed program staff maintain regular quality contacts with the youth and family. Office of Program Accountability Page 20 of 37 (Revised July 2016)