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 Highlands Youth Academy G4S Youth Services, LLC (Contract Provider) 242 South Boulevard Avon Park, Florida Review Date(s): December 2-5, 2014 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES

2 PrevPage HighlandsYouthAcademy Behavioral/MentalHealthProgram (Opened5/1/14) QuarterlyDataFY NextPage Program Name Provider Program Group Program Type Open/Closed HighlandsYouthAcademy G4SYouthServices,LLC Non-Secure-Male Behavioral/MentalHealth (Opened5/1/14) Program Activity AvgLengthofStay(Days) Escapes* Excessive/UnnecessaryUseofForceIncidents* MajorDeficiencies/CriticalIssues* PARRate(per1,000filedbeddays)* PAR(ProgramType) PAR(Statewide) YouthArests 1st Quarter nd Quarter 3rd Quarter 4th Quarter Total (FYTD) PACTRisktoReofend HighRisk Moderate-HighRisk ModerateRisk LowRisk RPACT IncreaseProtective 1st Quarter 46% 37% 9% 8% 74% 2nd Quarter 3rd Quarter 4th Quarter Total (FYTD) 46% 37% 74% DecreaseRisk 70% 70% 9% 8% *Thisdatamaybereportedforco-locatedprograms PACTRisktoReofend FiscalYearToDate SPEP QualityImprovement Review PrimaryService ServiceDeliveryRating N/A N/A N/A HighRisk Moderate-HighRisk ModerateRisk LowRisk Foradditionalinformationaboutthisfacility,visithtp:/

3 PrevPage HighlandsYouthAcademy Behavioral/MentalHealthProgram (Opened5/1/14) NextPage SeriousnessIndex AnnualOutcomes (YearofCompletion) FY SeriousnessIndex (YearofCompletion) Program TypeSeriousnessIndex 0 Recidivism (YearofCompletion) Program TypeRecidivism CompletionRate Program TypeCompletionRate FY Recidivism (YearofCompletion) StatewideCompletionRate TotalReleases 0% Program Releases (YearofRelease) Program Program TypeAvg FY StatewideAvg(CompletionRate) 0 CompletionRates (YearofCompletion) 0% FY Foradditionalinformationaboutthisfacility,visithtp:/ FY

4 PrevPage DEFINITIONSOFMEASURES NextPage AverageLengthofStay-ALOS(Days)Theaveragenumberofdaysthatayouthstaysinaparticularprogram.Thisiscalculatedbytotalingthedaysservedforalyouthwhocompleted from aprogram (inthetimeperiodspecified)anddividingthisnumberbythetotalnumberofyouthwhocompletedfrom theprogram. Source:JJIS,BureauofResearch&Planning. CompletionRate-Youthwhocompleteaprogram andreturntothecommunityareconsideredcompleters.whetherayouthisconsideredacompleterisbasedupon hisorherexitstatus.exitstatusisdeterminedbythefolowingfactors: Releasereason Therestrictivenesslevelofthenextcommitmentprogram,ifany Thetimebetweenthereleaseandnextcommitmentplacement ThenextplacementintheServiceHistorydata ThetimebetweenthereleaseandthenextServiceHistoryplacement Threeexitstatusesareconsideredprogram completions: Releasesfrom careandcustody(includingthosereleasedbecausetheyservedthemaximum term alowedbylaworreachedthemaximum ageofjurisdiction). Releasestopost-commitmentprobation. Releasestoconditionalrelease. Thecompletionrateisthepercentageofthoseyouthreleasedwhoareconsideredacompleter,asdefinedabove,ascomparedtothetotalofalyouthreleasedfrom aprogram. Source:JJIS,BureauofResearch&Planning. CriticalIssue-AnidentifiedCriticalIssueandorCriticalDeficiencyistheabsenceofacomponentessentialtoservicedeliveryortheverificationthatthedeliveryofanessentialservice hasbeencompromised.thedeficiencyissodireoracutethatitpresentsapotentialthreattothehealthorsafetyoftheyouthserved,ormayotherwisecompromiseprogram security. Criticalissuesrelatedtoescapesarenotcountedinthenumberreflectedinthisreportastheyarereportedseparately. Source:Regions(MonitoringandQIReviews) Escapes-Numberofindividualspereventwhoescapedfrom afacilityduringthereportingperiod. Source:CCC,OficeofResidentialServices. Excessive/UnnecessaryForceIncidents-ThenumberofincidentsreportedtotheCentralCommunicationCenter(CCC)duringthereportingquarterthatresultinasubstantiatedfinding(s)ofunnecessaryand/orexcessiveuseofforce.EachspecificCCCincidentwithsubstantiatedfindingsiscountedonce,regardlessofthenumberofstafwithsubstantiatedfindings involvedinanincident.sinceanincidentisonlycountedaftera substantiated findinghasbeenmade,thenumbersforaquartermaybeadjustedatsomepointinthefuturetoreflectupdatedfindings. Source:CCC,OficeofResidentialServices. Expectedrecidivism rate-toensurethatprogramsservingyouthwithdiferentdificultylevelsareheldtoreasonableandfairrecidivism standards,thedepartmentcalculatesanexpectedrecidivism rateforthegroupofyouthwhocompletedeachresidentialprogram duringthetimeperiodunderanalysis.programsthatserveyouthwithsignificantriskfactorsforreofendingwilhaveahigherexpectedrecidivism ratethanprogramsservingyouthwithlessriskfactors. Source:JJIS,BureauofResearch&Planning. MajorDeficiencies-Aprogram deficiencyand/orcontractualcomplianceissuethatresultsinaninteruptionineitherthedeliveryofservicesand/orthereceiptofpublicfundsforprogram servicesnotdelivered.amajordeficiencycanalsobebasedonrepeatedminordeficiencieswithnoindicationprogressisbeingmadetocorectthedeficiency.majordeficienciesaresignificantinnatureandtypicalyrequireoversightbymanagementtoensuretheissuesareaddressedsystemicaly.thedeterminationofanissue(s)beinga majordeficiency ismade throughthecontractmonitoringprocess.majordeficienciesrelatedtoescapesarenotcountedinthenumberreflectedinthisreportastheyarereportedseparately. Source:Regions(MonitoringandQIReviews) Foradditionalinformationaboutthisfacility,visithtp:/

5 PrevPage DEFINITIONSOFMEASURES(2) NextPage PACTRisktoReofend-ThePositiveAchievementChangeTool(PACT)isacomprehensiveassessmentthataddressesbothcriminogenicneedsandprotectivefactorsandidentifiesa youth srisktore-ofendaseitherlow,moderate,moderate-highorhigh.thismeasureisbasedontheyouthservedinthereportingquarter.source:jjis,bureauofresearch&planning. PAM Score-ThePAM (Program AccountabilityMeasure)scoreisstandardizedgradeincorporatingbothprogram recidivism costefectivenessandprogram costpercompletion.it presentsrecidivism andcostefectivenessresultsfortheprogramsthatcompletedatleast15youthduringtheone-yearperiodduringthetimeperiodunderanalysis.source:jjis,bureau ofresearch&planning. PARRate-PAR(ProtectiveActionResponse)istheDJJ-approvedphysicalinterventiontechnique,includingtheapplicationofmechanicalrestraints.TheuseofPAR,andstaftraining requirements,areoutlinedintheadministrativerules.theparrateisthenumberofparincidentsper1000filedbeddaysduringthereportingperiod.thestatewideaverageisbased onalcurentlyoperatingprogramsinthestateduringthereportingperiod.source:regions(reportedbyprograms);compiledbyoficeofresidentialservices. Program Group-Identifiesthegenderandcommitmentrisklevelserved.Source:JJIS. Program Type-Identifiesthetypes ofspecializedtreatmentservicesprovidedbyaprogram,suchasmentalhealth,substanceabuse,sexofender.source:jjis. QualityImprovement-Thesystem usedfortheassessmentofprogram complianceinareassuchasmanagement,operations,andservicedelivery.source:bureauofqualityimprovement. Recidivism -Forresidentialcommitmentprograms,thetwelve-monthrecidivism-trackingperiodbeginsthedaythatayouthcompletestheprogram (asdefinedabove),including both youthwhoarereleasedfrom thecareandcustodyofthedepartmentandyouthwhoarereceivingconditionalreleaseorpost-commitmentprobationservicesinanonresidentialseting. Recidivism isdefinedasaladjudications,adjudicationswithheld,andconvictionsforanynewviolationoflawwithintwelvemonthsofprogram completion.recidivism isreportedbythe yearofprogram completion.forexample,youthwhocompleteandexitaprogram infy aretrackedforrecidivism foroneyearfolowingthedaytheyexittheprogram.although theoneyeartrackingperiodmayrolintothefolowingfiscalyear(i.e.fy inthisinstance),therecidivism isreportedforthefiscalyeartheyouthexited(so,fy inthisexample).source:jjis,bureauofresearch&planning. Releases-Thetotalnumberofyouthreleasedfrom theprogram betweenjuly1andjune30ofthefiscalyearunderreview,asreportedinthejuvenilejusticeinformationsystem (JJIS). Source:JJIS,BureauofResearch&Planning. SeriousnessIndex-Aweightingmethodologyinwhichofensesareassignedapointvaluebasedonthedegreeofseriousness.Ahigherratingindicatesahigherlevelofseriousness. Theofenseseriousnessweightsareusedtocomputeanindexoftheseriousnessofpriorofensesforeachyouthreleasedduringthefiscalyear.Asummationofpointvaluescorespondingtoeachchargeforwhichtheyouthwasadjudicatedpriortotheprogram placementdateiscomputedaccordingtotheweightingschemebelow.foreachprogram,thesummationsforyouthwhocompletetheprogram aretotaledandthendividedbythenumberofindividualyouthreleasedfrom thatprogram tocomputeanaveragevaluefortheindexofofender seriousnessforeachprogram.source:jjis,bureauofresearch&planning. YouthArests-Forthepurposesofthisreport,thenumberreflectsthe youthsarestedforofensesoccuringwhileintheprogram,regardlessofwhetherornotthecaseisfiledwiththe court.arestinformationisgatheredfrom thecentralcommunicationscenter(ccc)databaseforalyouth,includingthose18yearsofageandolder.eachyoutharestedinanygiven incidentiscountedindividualy.ifayouthisarestedformorethanoneincidentduringthequarter,eacharestiscounted.source:ccc,oficeofresidentialservices. SPEP TheStandardizedProgram EvaluationProtocol(SPEP)evaluateshowcloselydelinquencyinterventions,asprovided,alignwiththefeaturesofthemostefectiveevaluatedprogramsinthefield.SPEPisanevaluationtoolthatidentifiesshortcomingsincurentjuvenileprograms,andprovidesguidelinesforimprovementinordertooptimizeinterventionefectivenessandpositiveoutcomesstatewide.TheSPEPevaluatesservicesinthefolowingcategories:ServiceType(e.g.,cognitivebehavioral;groupcounseling);ServiceQuantity/Dosage(Durationandintensityofcontacthours)andServiceQuality(e.g.,writenprotocols/manuals;training;fidelitymonitoring;corectiveaction).ThedatasheetscurentlyreportonlyonService Quality.TheServiceQuantityiscurentlybeingassessedasabaselineandwilbereflectedonthedatareportsnextyear. Foradditionalinformationaboutthisfacility,visithtp:/

6 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: Paul Czigan, Office of Program Accountability, Lead Reviewer Elma Adame, Office of Program Accountability, Regional Monitor Dave Bassler, Office of Program Accountability, Regional Monitor Julia Hillery, Supervisor, Orange Regional Juvenile Detention Center Melissa Johnson, Office of Program Accountability, Deputy Supervisor Ann Little, Office of Program Accountability, Regional Monitor Stephanie Lobzun, Office of Program Accountability, Regional Monitor Scott Luciano, Office of Program Accountability, Regional Monitor

7 Program Name: Highlands Youth Academy QI Program Code: 1291 Provider Name: G4S Youth Services, LLC Contract Number: Location: Polk County / Circuit 10 Number of Beds: 80 Review Date(s): December 2-5, 2014 Lead Reviewer Code: 77 Methodology This review was conducted in accordance with FDJJ-2000 (Contract Management and Program Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1) Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included in the Residential Standards. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee 2 # Case Managers 2 # Clinical Staff 1 # Food Service Personnel 2 # Healthcare Staff 2 # Maintenance Personnel 2 # Program Supervisors 5 # Staff 5 # Youth 16 # Other (listed by title): psychiatrist, regional compliance manager, compliance manager, regional health servcies administrator, training coordinator, regional clincal director, assistant facility adminstrator for operations, Documents Reviewed principal, director of case management, vocational program manager, gang coordinator, security chief, advanced registered nurse practitioner, program director, Home Builders Institute program manager, and human resources manager. Accreditation Reports Affidavit of Good Moral Character CCC Reports Confinement Reports Continuity of Operation Plan Contract Monitoring Reports Contract Scope of Services Egress Plans Escape Notification/Logs Exposure Control Plan Fire Drill Log Fire Inspection Report Fire Prevention Plan Grievance Process/Records Key Control Log Logbooks Medical and Mental Health Alerts PAR Reports Precautionary Observation Logs Program Schedules Sick Call Logs Supplemental Contracts Table of Organization Telephone Logs Surveys Vehicle Inspection Reports Visitation Logs Youth Handbook 9 # Health Records 9 # MH/SA Records 13 # Personnel Records 17 # Training Records/CORE 5 # Youth Records (Closed) 9 # Youth Records (Open) 3 # Other: CORE records, SkillPro records, and shift briefings. 9 # Youth 9 # Direct Care Staff 0 # 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 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 Office of Program Accountability Page 3 of 62 (Revised September 2014)

8 Comments Items not marked were either not applicable or not available for review. Additional observations included master control operations, first aid kits, suicide response kit, vocational classes, and school classroom decorum. Office of Program Accountability Page 4 of 62 (Revised September 2014)

9 Standard 1: Management Accountability Residential Rating Profile Indicator Ratings 1.01 Standard 1 - Management Accountability * Initial Background Screening 1.02 Five-Year Rescreening 1.03 * Provision of an Abuse-Free Environment 1.04 * Management Response to Allegations Non-Applicable 1.05 * Incident Reporting (CCC) 1.06 Protective Action Response (PAR) 1.07 * Pre-Service/Certification Requirements 1.08 In-Service Training 1.09 Logbook Entries and Shift Report Review 1.10 * Internal Alerts System 1.11 * Alerts (JJIS) Limited 1.12 Youth Records (Healthcare and Management) 1.13 Advisory Board 1.14 Program Planning 1.15 Staff Performance * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). The following limited and/or failed indicators require immediate corrective action Alerts (JJIS) Office of Program Accountability Page 5 of 62 (Revised September 2014)

10 Standard 2: Assessment and Performance Plan Residential Rating Profile Indicator Ratings 2.01 Standard 2 - Assessment and Performance Plan Initial Contacts to Parent 2.02 Youth Orientation 2.03 Court Notifications 2.04 Classification Factors 2.05 Classification Procedures 2.06 Reassessment for Activities Limited 2.07 R-PACT Assessment 2.08 Youth Needs Assessment Summary 2.09 R-PACT Reassessments 2.10 Parent/Guardian Involvement in Case Mgmt Members of Treatment Team 2.12 Performance Plan Development 2.13 Treatment Team Meetings (Formal Review) Limited 2.14 Treatment Team Meetings (Informal Review) 2.15 * Performance Plan Goals 2.16 Performance Plan Transmittal 2.17 Performance Plan Revisions 2.18 Incorporation of Other Plans Into Performance Plan 2.19 Performance Summaries 2.20 Performance Summary Transmittal 2.21 Visitation and Communication 2.22 Written Consent of Youth Eighteen Years or Older 2.23 Written Consent for Substance Abuse Information 2.24 Transition Planning and Conference 2.25 Exit Portfolio Limited 2.26 Exit Conference 2.27 Grievance Process Training 2.28 Grievance Process 2.29 Grievance Process Documentation 2.30 Gang Identification: Notification of Law Enforcement 2.31 Gang Identification: Intervention Activities 2.32 Life Skills Training Provided to Youth 2.33 Staff Training: Delinquency Interventions 2.34 Restorative Justice Awareness For Youth 2.35 Delinquency Intervention Services 2.36 Recreation and Leisure Activities 2.37 Youth Input 2.38 Gender-Specific Programming 2.39 Vocational Programming 2.40 Educational Access 2.41 Education Transition * 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). The following limited and/or failed indicators require immediate corrective action Reassessment for Activities 2.13 Treatment Team Meetings (Formal Review) 2.25 Exit Portfolio Office of Program Accountability Page 6 of 62 (Revised September 2014)

11 Standard 3: Mental Health and Substance Abuse Services Residential Rating Profile Indicator Ratings Standard 3 - Mental Health and Substance Abuse Services 3.01 Designated Mental Health Authority or Clinical Coordinator 3.02 * Licensed Mental Health and Substance Abuse Clinical Staff 3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff 3.04 Mental Health and Substance Abuse Admission Screening 3.05 Mental Health and Substance Abuse Assessment/Evaluation 3.06 Mental Health and Substance Abuse Treatment 3.07 * Treatment and Discharge Planning 3.08 * Specialized Treatment Services 3.09 * Psychiatric Services 3.10 * Suicide Prevention Plan 3.11 * Suicide Prevention Services 3.12 * Suicide Precaution Observation Logs 3.13 * Suicide Prevention Training 3.14 * Mental Health Crisis Intervention Services 3.15 * Crisis Assessments 3.16 * Emergency Mental Health and Substance Abuse Services 3.17 * Baker and Marchman Acts Non-Applicable * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 7 of 62 (Revised September 2014)

12 Standard 4: Health Services Residential Rating Profile Indicator Ratings Standard 4 - Health Services 4.01 * Designated Health Authority/Designee 4.02 * Psychiatrist/Designee 4.03 Facility Operating Procedures 4.04 Authority for Evaluation and Treatment 4.05 Parental Notification 4.06 Notification - Clinical Psychotropic Progress Note 4.07 Immunizations 4.08 Healthcare Admission Screening Form 4.09 Medical Alerts 4.10 Youth Orientation to Healthcare Services 4.11 Designated Health Authority/Designee Admission Notification 4.12 Healthcare Admission Rescreening 4.13 Health Related History 4.14 Comprehensive Physical Assessment 4.15 Female-Specific Screening/Examination Non-Applicable 4.16 Tuberculosis Screening 4.17 Sexually Transmitted Infection Screening 4.18 HIV Testing 4.19 Sick Call Process - Requests/Complaints 4.20 Sick Call Process - Visits/Encounters Limited 4.21 Restricted Housing Non-Applicable 4.22 Episodic/First Aid Care 4.23 Emergency Care 4.24 Off-Site Care/Referrals 4.25 Chronic Illness/Periodic Evaluations 4.26 Medication Management - Verification 4.27 Medication Management - Orders/Prescriptions 4.28 Medication Management - Storage 4.29 Medication Management - Medication and Sharps Inventory 4.30 Medication Management - Controlled Medications 4.31 Medication Management - Medication Administration Record 4.32 Medication Management - Medication Administration By Licensed Staff 4.33 Medication Management - Medication Provided By Non-Licensed Staff 4.34 Medication Management - Psychotropic Medication Monitoring 4.35 Infection Control - Surveillance, Screening, and Management 4.36 Infection Control - Education 4.37 Infection Control - Exposure Control Plan 4.38 Prenatal Care - Physical Care of Pregnant Youth Non-Applicable 4.39 Prenatal Care - Nutrition and Education of Youth Non-Applicable 4.40 Neonatal Care - Infant Physical Care and Nutrition of Infants Non-Applicable 4.41 Neonatal Care - Supervision of Infants Non-Applicable 4.42 Neonatal Care - Education and Lactation Non-Applicable 4.43 Prenatal and Neonatal Staff Education Non-Applicable * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). The following limited and/or failed indicators require immediate corrective action Sick Call Process - Visits/Encounters Office of Program Accountability Page 8 of 62 (Revised September 2014)

13 Standard 5: Safety and Security Residential Rating Profile Indicator Ratings 5.01 Standard 5 - Safety and Security Youth Supervision 5.02 * Ten-Minute Checks Limited 5.03 Census, Counts, and Tracking 5.04 Key Control 5.05 Contraband Procedure 5.06 Frisk and Strip Searches 5.07 Vehicles and Maintenance Limited 5.08 Transportation of Youth 5.09 Tool Inventory and Management 5.10 Youth Tool Handling and Supervision 5.11 Outside Contractors 5.12 Fire, Safety, and Evacuation Drills 5.13 Mental Health and Medical 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 Elements of Water Safety Plan Non-Applicable 5.19 Staff Training: Water Safety Non-Applicable 5.20 * Swim Test Non-Applicable 5.21 Comprehensive Behavior Management System 5.22 Implementation and Consistency of Behavior Management System 5.23 Behavior Management System Infractions 5.24 Staff Training: Behavior Management System 5.25 Behavior Management System Monitoring 5.26 Controlled Observation Non-Applicable 5.27 Search and Inspection of Controlled Observation Room Non-Applicable 5.28 Controlled Observation Safety Checks Non-Applicable 5.29 Controlled Observation Release Procedures Non-Applicable * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). The following limited and/or failed indicators require immediate corrective action Ten-Minute Checks* 5.07 Vehicles and Maintenance Office of Program Accountability Page 9 of 62 (Revised September 2014)

14 Strengths and Innovative Approaches The program offers additional voluntary vocational classes after normal school hours and during leisure time for all youth that qualify. Following each incident in which a Protective Action Response (PAR) is initiated resulting in a takedown, the program administration brings together all the parties involved in the incident and processes what happened, what could have been done differently, and how do we move on from here. The process has become an integral part of the program and is consistently documented with each PAR report. Office of Program Accountability Page 10 of 62 (Revised September 2014)

15 Standard 1: Management Accountability Overview The Department of Juvenile Justice contracts with G4S Youth Services, LLC to operate Highlands Youth Academy (HYA), a secure/non-secure residential program for male youth. The program is located in Polk County, Florida, on thirty-seven acres at the site of the MacDill Auxiliary Air Field/Avon Park Bombing Range. The on-site management of the program is the responsibility of the facility administrator. The management team includes the school principal, director of clinical services, assistant facility administrator for operations, assistant facility administrator for security, program director, vocational services director, business manager, director of case management, director of nursing, dietary manager, health services administrator, human resources manager, and facility plant manager. The responsibilities for various aspects of programming and maintenance are divided among the management team. The facility administrator receives support and oversight from the provider s corporate team including training and compliance. The program has several other permanent structures including school, administration office, dining facility, and various vocational buildings. The program occupies buildings formerly used by the military for family housing. The program provides services to eighty youth who are provided mental health overlay services. Seventy-eight youth were assigned to the program on the Juvenile Justice Information System (JJIS) on the first day of the annual compliance review. In addition, the program has twenty-five slots for vocational overlay services. There is an additional contract with Home Builders Institute (HBI) to provide vocational education to forty youth at a time and eighty youth within the contract year. HBI employs several vocational instructors who are located on-site in addition to the manager. The provider operates the school under contract with the Polk County School Board. The school board also provides vocational education as part of the school day. All staff providing educational services are certified by the Polk County School Board. At the time of the annual compliance review, the program had several vacant positions including forty direct care staff, one shift supervisor, one therapist, and one case manager. A review of the program s provision of the value added elements of the contract, documented they were consistently performed or significantly planned by a licensed psychologist/behavior analyst providing services, cardiopulmonary resuscitation (CPR) training for youth, transition portfolio (with some exceptions), uniform change (polo shirts and khaki trousers), choice of hairstyle (clearly evident although there was no policy description of this), monthly parent support group, with poor participation from the families (therapists advertise and show up, but no parents have shown up), and parenting wisely curriculum was available for use. There was no evidence of the planning for program policy draft or practical implementation of annual staff tuition assistance, college tuition assistance for applicable youth graduates, program pet, reduced rate one night hotel assistance, and transportation to and from the hotel for families. There was evidence of family bus ticket assistance for visitation availability in one case 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. Office of Program Accountability Page 11 of 62 (Revised September 2014)

16 The program hired fifty-eight new staff since the last review. All fifty-eight new hire staff received an eligible background screening from the Department s Background Screening Unit (BSU) prior to hire. The program consistently completes a driver s license check and local law enforcement check of all staff prior to offering them employment. A review of staff files confirmed background screening, driver s license, and local law enforcement checks were being conducted. The Annual Affidavit of Compliance with Level 2 Screening Standards for all staff was submitted to the Department on January 10, The Annual Affidavit was received by the BSU on January 14, The Annual Affidavit for Home Builders Institute was received by the BSU on January 13, 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. Sixteen staff were eligible for a five-year rescreening. All sixteen staff received an eligible rescreening from the BSU within the required time frame prior to the five-year anniversary. Administrative staff maintains a tracker for staff hire dates in five-year increments and monthly reviews. Staff submits rescreening requests two months prior to the hire anniversary dates. A review of staff files revealed the background screening results were in each file Provision of an Abuse-Free Environment Compliance The program provides an environment in which youth, staff, and others feel safe, secure, and not threatened by any form of abuse or harassment. Posting of the Florida Abuse Hotline telephone number and the Central Communications Center for youth 18 years of age and older telephone number. All allegations of child abuse or suspected child abuse are immediately reported to the Florida Abuse Hotline. Youth and staff have unhindered access to report alleged abuse to the Florida Abuse Hotline pursuant to Section (1)(a), F.S. The environment is free of physical, psychological, and emotional abuse. A code of conduct for staff that clearly communicates expectations for ethical and professional behavior, including the expectation for staff to interact with youth in a manner that promotes their emotional and physical safety. The program has a corporate ethics code which is discussed with all new staff during orientation. Staff sign the corporate ethics code upon employment. A review of all new staff files found a copy of the signed code. During the team tour of the facility, the team observed postings of the Florida Abuse Hotline and the Central Communications Center phone numbers on bulletin boards in all living quarters, education buildings, and administrative areas. Also posted on bulletin boards was a student rights statement. Each youth was informed of the right and Office of Program Accountability Page 12 of 62 (Revised September 2014)

17 procedures for reporting abuse during orientation. This orientation was documented in each youth file. Nine youth were surveyed for staff and youth interactions. All nine youth indicated they had never been stopped from reporting abuse. Six of the nine youth indicated staff were respectful when conversing with them. Follow-up interviews with two youth indicated sometimes staff have a bad day. One youth on follow-up interviews indicated one female staff annoys the youth by speaking loudly and being real bossy. Nine staff were surveyed regarding staff and youth communication and relations. All nine staff explained the process of reporting abuse that included unimpeded access to report for staff and youth. Four of nine surveyed staff reported never having heard staff use profanity when speaking with youth. Three staff reported hearing it once and on occasion. One staff reported hearing staff use profanity often. Five of nine staff surveyed reported they never observed a coworker using threats, intimidation, or humiliation when interacting with the youth. Three staff reported they observed this once and one staff reported observing this occasionally Management Response to Allegations Non-Applicable 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 that management takes immediate action to address incidents of physical, psychological, and emotional abuse. The program had no incidents of physical, psychological, or emotional abuse in the facility during this review period; therefore, this indicator rates as non-applicable Incident Reporting (CCC) Compliance Whenever a reportable incident occurs, the program notifies the Department s Central Communications Center (CCC) within two hours of the incident, or within two hours of becoming aware of the incident. The program has written policies and procedures for reporting incidents to the Department s Central Communications Center (CCC). All staff are trained in reporting incidents during orientation and during in-service along with child abuse report training. Two administrators are primarily responsible for making the call to the CCC. There were twelve applicable reports made to the CCC during the review period. All twelve of them were reported by the two staff indicated by the program. All twelve files documented the incidents within the required two-hour time frame. All of the calls were documented in the master control logbook. The program management team meets daily with the facility administrator and discusses each incident from the day and night before and ensures reporting is done in a timely manner. The program maintains a scorecard with all incidents and CCC calls documented. The scorecard and incidents are reviewed by the facility administrator and compliance personnel daily and reported to corporate personnel. Office of Program Accountability Page 13 of 62 (Revised September 2014)

18 1.06 Protective Action Response (PAR) Compliance The program uses physical intervention techniques in accordance with Florida Administrative Code. Any time staff uses a physical intervention technique, such as countermoves, control techniques, takedowns, or application of mechanical restraints (other than for regular transports), a PAR Incident Report is completed and filed in accordance with the Florida Administrative Code. The program has written policies and procedures for physical interventions and reporting. The program uses a Protective Action Response (PAR) training plan that is the same for all G4S programs and was signed by the residential regional director on August 21, 2012 and the Department on September 20, All staff are trained in PAR during orientation on filling out the PAR report following a physical intervention. A review of ten PAR reports revealed all were completed before the end of the shift and included statements by all staff involved. Each report included a supervisory review, post PAR evaluation, and facility administrator review within the time frame. The monthly PAR report was in the file for each respective month. There were numerous reports documenting controlled techniques. One PAR report in August documented a takedown that was not included in the monthly report. However, upon review of the narrative the staff documented a fall down technique with ground control executed following the fall. A supervisor processes with the staff and youth involved about what happened, what was done right and wrong, and how could the event have been prevented following each PAR incident. The documentation of this conversation was attached to each PAR report. All PAR incidents are reviewed by the entire management team at the daily management meeting. The meeting includes PAR trainers and PAR trained supervisors Pre-Service/Certification Requirements Compliance Contracted and State residential staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. All four new staff training files documented each staff received the required elements for preservice training. Documentation reviewed in staff training files revealed numerous subjects were included together, so it was difficult to ascertain the number of hours of individualized courses. In addition, although two new staff under the new contract provisions received 129 hours of preservice training in the first thirty days of hire, the pre-service training was not documented in SkillPro. A review of each individual training file revealed the staff had completed the required hours of training. Not all training delivered was found documented in SkillPro such as job shadowing. Other required courses such as suicide prevention, exposure control, infection control, the intended and safe use of tools, or mental health overlay services were documented under more generalized headings. There were a couple of inadvertent exceptions found in the training files reviewed, including a missing PAR instructor signature on the performance evaluation of one staff, and the wrong date on another training document. Sign-in sheets confirmed the wrong date was a mistake. The program provided documentation to support that instructors were qualified to present most training including PAR, CPR, and first aid. Several modules in suicide prevention were presented by two licensed therapists. However, two other non-licensed staff also presented Office of Program Accountability Page 14 of 62 (Revised September 2014)

19 suicide prevention modules. Neither of these staff were part of the mental health therapy staff. One of the staff was trained in the Department s suicide prevention trainer module. There was no evidence presented that other staff had training in presenting the suicide prevention module. The program also provided documentation that all the trainings required was addressed in the contract. A review of staff training files indicated the added subjects were included in various pre-service modules under generalized titles In-Service Training Compliance Residential staff complete twenty-four hours of in-service training, including mandatory topics specified in Florida Administrative Code, each calendar year, effective the year after preservice/certification training is completed. Supervisory staff completes eight hours of training(as part of the twenty-four hours of annual inservice training) in the areas specified in Florida Administrative Code. All five reviewed in-service training files documented staff received most required elements, including CPR, first aid, PAR update, suicide prevention, and professionalism and ethics. Two of the five staff required supervisory training. These supervisors received eight and sixteen hours respectively in supervisory training. However, the subject of the training was documented as Agenda. The program did not provide the review team with the list of subjects supervisory staff received in training. There was no documentation one staff had received the required annual PAR update since The staff was removed from contact with youth during the review week pending completion of the PAR update. The program maintains an in-service training calendar and documented applicable updates. The program sent their in-service training plan to the Department for approval Logbook Entries and Shift Report Review Compliance The program maintains a chronological record of events, incidents, and activities in a central logbook maintained at master control, living unit logbooks, or both, in accordance with Florida Administrative Code. The program ensures that direct care staff, including each supervisor, is briefed when coming on duty. The program has written policies and procedures for documenting in the logbook and shift reports regarding events, incidents, and activities. The program maintains a logbook in master control in which assigned staff document population counts, movements, visitors, incidents, and activities. The shift supervisor prepares a shift report that includes all the Department requirements including admissions, discharges, alerts, PAR incidents, CCC calls, and similar incidents. The master control logbook was the only logbook being used on the campus during the review week. A review of logbooks revealed they consistently documented population counts at the beginning and end of each shift, periodic and emergency counts, youth admissions and discharges, significant incidents, and visitors to the campus. The shift reports document youth counts of beginning and ending total facility count, unit counts, and particular zone counts during the day including five zones; the store, dining hall, case management, mental health, HBI groups, and other areas, as well as counts of youth off campus/on transport. The actual time each population count is taken throughout the shift is documented on the shift report. Shift reports also document all equipment, transports, staff assignments, perimeter checks, schedule Office of Program Accountability Page 15 of 62 (Revised September 2014)

20 changes if any, refusal of medications, and comments. Shift reports included the off-going and on-coming supervisor s and the security director s signatures. Logbook reviews revealed documentation of supervisory reviews of the books on a daily basis and administrative reviews weekly Internal Alerts System Compliance The program shall maintain and use an internal alert system that is easily accessible to program staff and keeps them alerted about youth who are security or safety risks, and youth with healthrelated concerns, including food allergies and special diets. When risk factors or special needs are identified during or subsequent to the classification process, the program immediately enters this information into its internal alert system. The program ensures that only appropriate staff may recommend downgrading or discontinuing a youth s alert status. The program has a written policy and procedure addressing the use of the internal alert system to address specific medical, mental health, and case management issues. The program had an alert board located in the same area as master control. The alert board addressed youth that were on mental health, medical, and safety/security alerts. The board was observed to be updated throughout the review week. The medical department maintained an alert roster and a medical alert log. The alert roster identified youth with allergies, food, or dietary alerts. The medical alert log identified youth with chronic conditions, physical restrictions, and medical grades. There was a gang roster maintained in a confidential cabinet also located in the same area as master control. Morning meeting minutes supported staff were informed of youth internal alerts during that time as well. Nine case management records were reviewed; all applicable alerts were placed on the internal alert system as required. Nine mental health and substance abuse records were reviewed; all applicable alerts were placed on the internal alert system as required. Nine healthcare records were reviewed; all applicable alerts were placed on the internal alert system as required Alerts (JJIS) Limited Compliance When risk factors or special needs are identified during or subsequent to the classification process, the program immediately enters this information into the Juvenile Justice Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are downgraded or discontinued. The Juvenile Justice Information System (JJIS) youth alert report was compared with the nine healthcare records, nine mental health and substance abuse records, nine case management records that were reviewed, and the programs internal alert records. There were twenty exceptions where either information on the JJIS alert report was not captured on the program s medical alert log or the information on the program s medical alert log was not captured on the JJIS alert report. There were no alert issues with mental health or case management records. JJIS gang alerts were entered for all applicable youth. Mental health and suicide alerts were entered for all applicable youth Youth Records (Healthcare and Management) Compliance The program maintains an official case record, labeled confidential, for each youth, which consists of two separate files: Office of Program Accountability Page 16 of 62 (Revised September 2014)

21 An individual healthcare record An individual management record The tabs included all required elements including name, DJJ identification number, date of birth, county of residence, and committing judge and were divided into the required sections on all nine youth records. All case management records were stored separately from the healthcare record and the mental health and substance abuse record. The medical records were stored in a secure room in the clinic and inaccessible to youth. The mental health and substance abuse records were stored in a separate building in a secure space and inaccessible to youth. Each binder in all three disciplines was labeled according to the requirement and marked confidential on the tab and the front cover Advisory Board Compliance The program has a community support group or advisory board that meets at least quarterly. The program director solicits active involvement of interested community partners. Since the last review, the program documented minutes of meetings on January 16, April 17, June 26, and October 16 of The meeting scheduled for July 2014 was rescheduled earlier, because numerous board members were unavailable. This reschedule of the July meeting meant the October 16 meeting was outside the ninety-day requirement. Those disciplines represented on the board included law enforcement, interested community partners, business community, school board, faith community, and parent/guardian of a child previously in juvenile justice system. The board member that represented a youth previously in the juvenile justice system was the grandparent of a youth in custody by the Department, who although not the official guardian, was the primary caregiver. The program has solicited participation in the advisory board from the base commander, the captain of the emergency squad, and the warden of the adult prison since the program is situated on the military base. The facility administrator participates in the base commanders advisory council as well. Meetings were attended by most members each quarter. There was no participation in the board meetings from the judiciary; however, the program sent invitations to a judge for each meeting. One of the board members was the victim of a robbery and represented the victim community on the board. One of the members was instrumental in assisting recruitment of new staff from the veteran s community to fill vacancies Program Planning Compliance The program uses data to inform their planning process and to ensure provisions for staffing. The program has written policies and procedures for providing information from administration to staff and receiving input from staff, as well as staff recognition guidelines, benefits and rewards. The contract requires the program to offer annual tuition reimbursement for direct care workers to pursue a bachelor s or master s degree. The program has instituted a system of token recognition in which staff can be recognized for their positive contribution to youth, the culture of the campus, or going above and beyond expectations. Staff that receive a token turn it in to human resources and the staff s name is included in the box for drawings at the monthly staff meetings. Staff receiving the tokens are recognized in the campus newsletter, and receive Office of Program Accountability Page 17 of 62 (Revised September 2014)

22 points that can be banked and redeemed for tangible prizes of jewelry, electronic equipment, or a cruise. The program conducts a daily management meeting in which staff discuss issues, events, and incidents on campus and provide input to the management team for program planning. The program conducts two monthly staff meetings on the same day so information is shared with both shifts and all staff are given the opportunity for feedback at the monthly meetings. Reviews of monthly team minutes revealed consistent participation by all staff for meetings held at 6:00 a.m. and 6:00 p.m. The agenda/minutes included training, and discussion of hot-button issues. The results of the PREA audit and the results of the substance abuse audit were discussed during one monthly meeting. There is a procedure in the staff handbook for input from staff related to suggestions. The review of all staff minutes did not reveal any discussion of results of the youth/parent or staff surveys with all the team members. In addition, the review did not find documentation of those suggestions from the surveyed participants, independent staff interviews, or suggestion box that resulted in changes to the program. The program also holds a weekly town hall meeting with all youth and the facility administrator in which awards are handed out and issues discussed. Minutes of the town hall meetings revealed the first meeting in the review period was on July 15, 2014 and no meetings were held again until October 15, The minutes documented weekly meetings of the last six weeks. A review of the minutes did not reveal any suggestions from youth that were acted on by the program Staff Performance Compliance The program ensures a system for evaluating staff, at least annually, based on established performance standards. The program has a policy in place to provide annual performance evaluations based on performance standards. Reviews of five staff files selected for training purposes revealed evaluations were completed on all eligible staff annually. All five staff evaluations included performance related to involvement with the behavior management system, four-to-one ratio of positive reinforces, and an understanding the stages of change. The team reviewed four additional direct care staff files for those identified as included in the direct care ratio. One of the four additional files evaluation included the worker s performance related to involvement with the behavior management system, four-to-one ratio of positive reinforces, and an understanding the stages of change. The other three did not include this level of evaluation. Performance evaluations were consistently completed annually for all sixteen staff files reviewed. Minutes of the all staff meetings consistently documented the program publicly recognizes exceptional staff performance. The program has a designated parking spot for the staff of the year. That staff s picture is displayed prominently at the program. The pictures of staff receiving token recognition are published in the monthly newsletter. Office of Program Accountability Page 18 of 62 (Revised September 2014)