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 St. Johns Youth Academy Sequel TSI of Florida, LLC (Contract Provider) 4500 Avenue D St. Augustine, Florida Review Date(s): April 26-29, 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: Mike Marino, Office of Program Accountability, Lead Reviewer (Standard 1) Tangela Brown, G4S Youth Services, Assistant Facility Administrator (Standard 5) Kevin Greaney, Office of Program Accountability, Regional Monitor (Standard 4) Bruce Morton, Office of Program Accountability, Regional Monitor (Standard 3) Gwen Nelson, Office of Program Accountability, Regional Monitor (Standard 2,) Jennifer Schad, Office of Program Accountability, Regional Monitor (Standard 2,)

3 Program Name: St. Johns Youth Academy MQI Program Code: 1266 Provider Name: Sequel TSI of Florida, LLC Contract Number: Location: St. Johns County / Circuit 7 Number of Beds: 70 Review Date(s): April 26-29, 2016 Lead Reviewer Code: 37 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 1 # Case Managers 1 # Clinical Staff # Food Service Personnel 1 # Healthcare Staff 1 # Maintenance Personnel 1 # Program Supervisors Documents Reviewed 5 # Staff 5 # Youth 1 # Other (listed by title): Lead Teacher 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 9 # Personnel Records 9 # Training Records/CORE 5 # Youth Records (Closed) 9 # Youth Records (Open) 1 # Other: Shift reports, Advisory Board minutes 9 # Youth 9 # Direct Care Staff # Other: Observations During Review Admissions Confinement Facility and Grounds First Aid Kit(s) Group Meals Medical Clinic Medication Administration Posting of Abuse Hotline Program Activities Recreation Searches Security Video Tapes Sick Call Social Skill Modeling by Staff Staff Interactions with Youth Comments Staff Supervision of Youth Tool Inventory and Storage Toxic Item Inventory and Storage Transition/Exit Conferences Treatment Team Meetings Use of Mechanical Restraints Youth Movement and Counts Items not marked were either not applicable or not available for review. Office of Program Accountability Page 3 of 61 (Revised July 2015)

4 PrevPage St.JohnsYouthAcademy IntegratedSubstanceAbuseProgram (Closed9/15/14) QuarterlyDataFY NextPage Program Name Provider Program Group Program Type Open/Closed St.JohnsYouthAcademy YouthServices International,Inc. Non-SecureSubstance Abuse-Male IntegratedSubstanceAbuse (Closed9/15/14) 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 48% 30% 19% 4% 90% 2nd Quarter 3rd Quarter 4th Quarter Total (FYTD) 48% 30% 19% 90% DecreaseRisk 50% 50% 4% *Thisdatamaybereportedforco-locatedprograms PACTRisktoReofend FiscalYearToDate SPEP QualityImprovement Review PrimaryService ServiceDeliveryRating N/A N/A N/A HighRisk Moderate-HighRisk ModerateRisk LowRisk Foradditionalinformationaboutthisfacility,visithtp:/

5 PrevPage St.JohnsYouthAcademy IntegratedSubstanceAbuseProgram (Closed9/15/14) NextPage AnnualOutcomes (YearofCompletion) SeriousnessIndex (YearofCompletion) SeriousnessIndex FY FY Program TypeSeriousnessIndex Recidivism (YearofCompletion) Program TypeRecidivism 36% 40% 39% 44% 0 FY FY CompletionRate Program TypeCompletionRate StatewideCompletionRate 100% 92% 90% 100% 93% 88% 40% Recidivism (YearofCompletion) TotalReleases % 0% Program Releases (YearofRelease) 51 Program Program TypeAvg FY CompletionRates (YearofCompletion) FY StatewideAvg(CompletionRate) % 20 50% 0 0% FY FY FY Foradditionalinformationaboutthisfacility,visithtp:/ FY

6 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:/

7 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:/

8 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 1.05 * Incident Reporting (CCC) 1.06 Protective Action Response (PAR) and Physical Intervention Rate Limited 1.07 * Pre-Service/Certification Requirements Limited 1.08 In-Service Training Limited 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). Office of Program Accountability Page 4 of 61 (Revised July 2015)

9 Standard 2: Assessment and Performance Plan Residential Rating Profile Indicator Ratings 2.01 Standard 2 - Assessment and Performance Plan Initial Contacts to Parent/Gaurdian 2.02 Youth Orientation 2.03 Court Notifications 2.04 Classification Factors 2.05 Classification Procedures 2.06 Reassessment for Activities 2.07 R-PACT Assessment 2.08 Youth Needs Assessment Summary 2.09 R-PACT Reassessments 2.10 Parent/Guardian Involvement in Case Management Services 2.11 Members of Treatment Team Limited 2.12 Performance Plan Development 2.13 Treatment Team Meetings (Formal Reviews) 2.14 Treatment Team Meetings (Informal Reviews) 2.15 * Performance Plan Goals Limited 2.16 Performance Plan Transmittal 2.17 Performance Plan Revisions Limited 2.18 Incorporation of Other Plans Into Performance Plan Failed 2.19 Performance Summaries Limited 2.20 Performance Summary Transmittal 2.21 Visitation and Communication 2.22 Written Consent of Youth Eighteen Years or Older 2.23 Transition Planning and Conference 2.24 Exit Portfolio 2.25 Exit Conference 2.26 Grievance Process Training Limited 2.27 Grievance Process 2.28 Grievance Process Documentation 2.29 Gang Identification: Notification of Law Enforcement 2.30 Gang Identification: Intervention Activities 2.31 Life Skills Training Provided to Youth 2.32 Staff Training: Delinquency Interventions 2.33 Restorative Justice Awareness For Youth 2.34 Delinquency Intervention Services 2.35 Recreation and Leisure Activities 2.36 Youth Input 2.37 Gender-Specific Programming 2.38 Career Education 2.39 Educational Access 2.40 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). Office of Program Accountability Page 5 of 61 (Revised July 2015)

10 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 Clinician Authority or Clinical Coordinator Failed 3.02 * Licensed Mental Health and Substance Abuse Clinical Staff 3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Limited 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 Limited 3.12 * Suicide Precaution Observation Logs Limited 3.13 * Suicide Prevention Training Limited 3.14 * Mental Health Crisis Intervention Services 3.15 * Crisis Assessments 3.16 * Emergency Mental Health and Substance Abuse Services 3.17 * Baker and Marchman Acts Non-Applicable * 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 61 (Revised July 2015)

11 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 4.21 Restricted Housing 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). Office of Program Accountability Page 7 of 61 (Revised July 2015)

12 Standard 5: Safety and Security Residential Rating Profile Indicator Ratings 5.01 Standard 5 - Safety and Security Youth Supervision 5.02 * Ten-Minute Checks 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 5.08 Transportation of Youth 5.09 Tool Inventory and Management Limited 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 Limited 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). Office of Program Accountability Page 8 of 61 (Revised July 2015)

13 Standard 1: Management Accountability Overview St. Johns Youth Academy is a secure, seventy bed residential facility for high-risk male youth, between the ages of fourteen and eighteen. The program is located in St. Augustine, Florida. All seventy beds are designated for mental health overlay services (MHOS). The average length of stay is nine to twelve months. The program is operated as Sequel TSI of Florida, LLC, through a contract with the Department of Juvenile Justice. Sequel took over operations of the program from another provider on July 1, The management team consists of the facility administrator (FA), assistant facility administrator (AFA) for administration, AFA for operations, program manager, clinical director, director of case management, director of nursing, kitchen manager, and business office manager. The program contracts for psychiatric services and a Designated Health Authority (DHA). All management positions were filled at the time of the review, although there has been turnover in management positions since Sequel took over the program in July. Specifically, the clinical director was hired in October 2015, the FA was hired in December 2015, and the director of nursing was hired in March Staff vacancies at the time of the review included five youth care workers (YCW), one therapist, one registered nurse, one case manager, and the human resources coordinator 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 written policy and procedures requiring compliance with the Department s background screening requirements. A review of forty newly hired staff found an initial background screening was completed on each staff, prior to their date of hire. Background screens were completed on contracted staff as well. An Annual Affidavit of Compliance with Level 2 Screening Standards was completed by the program and submitted to the Department s Background Screening Unit on January 8, The St. Johns County School District completed and submitted an Annual Affidavit of Compliance with Level 2 Screening Standards for contracted education staff on January 5, 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 written policy and procedures addressing background rescreening of staff and volunteers every five years. There were no eligible staff whom required a five-year rescreening. Office of Program Accountability Page 9 of 61 (Revised July 2015)

14 1.03 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 who clearly communicates expectations for ethical and professional behavior, including the expectation for staff to interact with youth in a manner promoting their emotional and physical safety. The program has an established code of conduct, which prohibits all forms of abuse (physical, verbal, neglect) and inappropriate language. The code of conduct outlines professional and ethical expectations and requires staff be courteous, respectful, truthful, maintains confidentiality, and adhere to the dress code. The code of conduct specifically identifies unacceptable conduct. All staff acknowledge the code of conduct by signature upon hire and are expected to adhere to the code of conduct. The Florida Abuse Hotline and Central Communications Center (CCC) phone numbers are posted throughout the facility. The program has not had any substantiated incidents of abuse. Nine youth were surveyed. All nine youth indicated they had never been denied access to report abuse to the Florida Abuse Hotline or CCC. All surveyed youth reported they feel safe at the program. Seven of the nine youth stated staff are respectful when speaking with youth; two youth indicated they have heard staff use profanity occasionally. Nine staff were surveyed and all were able to describe the process for a youth calling the Florida Abuse Hotline or CCC to report abuse, which is to notify the supervisor, who will take the youth to a private area and facilitate the call. All nine staff indicated they had never seen, nor heard staff threaten or intimidate a youth or tell a youth he could not report abuse. Seven staff reported they have never heard staff use profanity while talking with youth, one staff indicated he heard staff use profanity once and one said occasionally, though it was not directed at youth Management Response to Allegations Compliance Management shall be cognizant of youth and staff needs and provide direction to each on how to access the Florida Abuse Hotline. There is evidence management takes immediate action to address incidents of physical, psychological, and emotional abuse. There have been two allegations of abuse reported to the Florida Abuse Hotline or CCC. One report made by a youth regarding medical care in January 2016 was closed as unsubstantiated, as the youth recanted the allegation once the investigation began. An allegation made by a Office of Program Accountability Page 10 of 61 (Revised July 2015)

15 former youth on April 1, 2016, which alleged staff gave candy to other youth to fight youth in the program, is still pending. Although, the initial interviews and investigation completed by residential services did not find any information to support the youth s allegation. In addition, all nine youth surveyed during this review reported youth are not allowed to punish other youth. The program conducted internal investigations of each incident and cooperated with outside investigations in each instance. A review of nine personnel files indicated management responds to violations to the code of conduct. There were seven staff who had documentation of coaching notes and/or discipline in the personnel files reviewed for violations of the code of conduct including tardiness to inappropriate supervision 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. Central Communication Center (CCC) reports for the past six months were reviewed, which included seventeen incidents reported by the program. All seventeen incidents were reported to the CCC within two hours of knowledge of the incident as required Protective Action Response (PAR) and Physical Intervention Limited Compliance Rate The program uses physical intervention techniques in accordance with Florida Administrative Code. Any time staff uses a physical intervention technique, such as countermoves, control techniques, takedowns, or application of mechanical restraints (other than for regular transports), a PAR Incident Report is completed and filed in accordance with the Florida Administrative Code. The program has a written policy and procedures addressing the use of Protective Action Response (PAR). The policy and procedures do not identify a designee for administration to complete the post-par interview when PAR incidents occur during non-traditional working hours. The program s PAR rate during the annual compliance review period was.76, which is below the statewide Residential PAR rate of Six PAR reports were reviewed and found five of the six reports were completed by the end of the shift. One PAR report had conflicting dates for the incident occurrence and report completion. Two reports did not include statements from all staff involved in the PAR restraint, with each of these two reports missing statements from two of the four staff involved. All reports were reviewed by administration within seventy-two hours; however, one final review was completed prior to all statements being completed. While all PAR reports were reviewed by an administrator, the Post-PAR interview section of the report, which is to be completed by an administrator or designee, within thirty minutes of the incident, was not documented in the reports reviewed. All youth are seen by medical following a PAR restraint, which was documented in each report. There were no instances of youth being injured as a result of a PAR restraint, during the review period. Office of Program Accountability Page 11 of 61 (Revised July 2015)

16 1.07 Pre-Service/Certification Requirements Limited Compliance Contracted and State residential staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. A review of training files and the Department s Learning Management System (SkillPro) was completed for six newly hired staff. Training files documented all staff were certified in first aid, cardiopulmonary resuscitation (CPR) with automated external defibrillator (AED), and Protective Action Response (PAR), prior to having contact with youth. All six staff completed training in emergency procedures, incident/child abuse reporting, and the behavior management system. Suicide prevention training was documented for four of the six staff. Training records in the Department s Learning Management System (SkillPro) were not up to date for any of the six staff and did not reflect all training completed. The program updated their training plan in January The plan includes pre-service training requirements and was submitted to the Department s Office of Staff Development and Training In-Service Training Limited 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. Training files and the Department s Learning Management System (SkillPro) were reviewed for three staff in subsequent years of employment. Each staff held current first aid, cardiopulmonary resuscitation (CPR) with automated external defibrillator (AED) certifications and a PAR update. Two of the three staff did not have documentation of twenty-four hours of annual training, with one staff having twenty-one hours and one staff having twenty-two hours. Two supervisors reviewed did not have eight hours of supervisory or management related training. Training records in the Department s Learning Management System (SkillPro) were not up to date for any of the three staff reviewed for in-service training, with the last entries being for training completed in March The program updated their training plan in January The plan includes in-service training requirements and was submitted to the Department s Office of Staff Development and Training 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 direct care staff, including each supervisor, is briefed when coming on duty. Logbooks and shift reports from the last six months were reviewed. The program maintains logbooks in each master control, when both are staffed. If staffing only allows one master control unit to be staffed, the south master control unit is staffed and the logbook in this unit is maintained for the entire facility. Logbooks were bound and had numbered pages. Each reviewed logbook contained a chronological record of events at the facility, including head counts, youth transports, admissions and releases, medical issues, when youth were removed Office of Program Accountability Page 12 of 61 (Revised July 2015)

17 from the general population, and significant incidents. Perimeter checks, which were reflected on shift reports, were not consistently documented in logbooks. Each logbook entry was neatly written in black ink and included a brief description of the event. Errors were struck out with a single line and initialed by the staff making the error. Significant entries related to security were highlighted in yellow. Significant entries related to youth medical needs were highlighted in blue. The program utilizes shift reports to brief oncoming staff of the previous shifts events. All staff acknowledge their review of the previous shift report by signature Internal Alerts System Compliance The program shall maintain and use an internal alert system 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 only appropriate staff may recommend downgrading or discontinuing a youth s alert status. The internal alert system consists of an alert form or list, alert boards, and food related alerts maintained in the kitchen. The alerts are easily accessible to program staff and keep staff informed of youth with security or safety risks and youth with health related concerns, including food allergies and special diets. Nine staff were surveyed and all responded they are informed of youth alerts during shift briefings. Four staff surveyed also reported getting alerts from an alert board and six responded they learn by other means, such as from the nurse or other staff. Seven of the nine staff indicated communication of alerts is good and two indicated very good. Fourteen youth who had alerts were reviewed and nine had all of their alerts identified on the internal alert board, internal alert form, and/or the kitchen alerts board. The remaining five youth had one of their alerts not identified in each alert list or board, though the alert was identified and available to staff through one of the internal alert processes. The program ensures only appropriate staff may recommend downgrading or discontinuing a youth s alert status 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. Juvenile Justice Information System (JJIS) alerts were compared to internal alerts for fourteen youth. The JJIS alerts and internal alerts matched for eight youth. For the remaining six youth, alerts identified in JJIS did not match those in the internal alert system, which included three food allergy alerts, a gang association alert, a medical alert, and a no strenuous activity alert. The no strenuous activity alert had been open in JJIS since March 16, In addition, seven youth in the program had open suicide alerts in JJIS should have been closed. Office of Program Accountability Page 13 of 61 (Revised July 2015)

18 1.12 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 Case management, mental health, and medical records for nine youth were reviewed. Each record reviewed was marked as confidential. The front cover and spine of each record included the youth s name, date of birth, date of admission, Department of Juvenile Justice Identification number, and county of residence. The case management, medical, and mental health records were divided in the appropriate sections by tabs, making documents easy to locate. Case management records are maintained in locked file cabinets in case manager offices. Medical records are maintained in a locked file cabinet behind a locked door in the clinic. Mental health records are maintained in a locked cabinet within an office in the mental health area Advisory Board Compliance The program has a community support group or advisory board, meeting at least quarterly. The program director solicits active involvement of interested community partners. The program has developed an advisory board, which includes members from the business community, faith community, education, and community partners. The program attempted to recruit representatives from law enforcement and the judiciary, though neither are currently represented on the board. The program asks parents/guardians of youth completing the program to participate on the board, though none have joined the board. The advisory board had their first meeting in January 2016 and had a second quarterly meeting in April Topics discussed during the advisory board meetings included activities for youth, obtaining resources and training for youth, and recruiting other members for the board Program Planning Compliance The program uses data to inform their planning process and to ensure provisions for staffing. The program has a youth advisory board, which meets monthly. The youth advisory board includes a pod leader from each living unit, or pod, who represents all youth from their pod during the youth advisory board meetings. The program recently completed youth and parents/guardians surveys. The youth surveys addressed facility conditions, living environment, and services provided. The parent/guardian surveys addressed program communication and solicited parent/guardian input and opinions. Information from the youth and parent/guardian surveys has been considered by administration, as evidenced by actions taken by administration. For example, many youth made comments regarding the food and administration has met with nutrition staff to address the comments made in the surveys. The program conducts monthly retention group meetings to address staff retention. Staff meetings are held on a regular basis, with executive staff meetings held weekly on Mondays, shift supervisor meetings and shift meetings are conducted twice per month. Nine staff were surveyed. All surveyed staff reported they could provide input related to program operations during staff meetings, directly to their supervisor, or administration. When asked how working conditions have been at the facility since Sequel took over operations in July 2015, one staff Office of Program Accountability Page 14 of 61 (Revised July 2015)

19 answered fair, seven answered good, and one staff answered very good. In addition, eight of nine staff commented working conditions are getting better Staff Performance Compliance The program ensures a system for evaluating staff, at least annually, based on established performance standards. The provider s policy states all employees shall receive formal competency evaluations at the completion of their ninety-day probation period and annually thereafter. Nine personnel files were reviewed. Seven of the nine personnel files documented a performance evaluation completed within ninety days or shortly after the completion of the ninety-day probationary period. Two of the evaluations were completed nine months after hire. The evaluations address standard work expectation requirements, such as professionalism and quality of work, as well as job specific criteria for supervisory, case management, clinical, and management staff. None of the staff were applicable for an annual performance review, as the provider (Sequel) took over operations of the program, less than a year ago. Office of Program Accountability Page 15 of 61 (Revised July 2015)

20 Standard 2: Assessment and Performance Plan Overview Case management staff includes six case managers, a transitional case manager, and a director of case management. The case management staff are responsible for all admission notifications, orientation, Residential Positive Achievement Tool (R-PACT) Assessments and Reassessments, performance and transitional planning, performance summaries, and providing liaison services between the program, youth, parents/guardians, courts, and juvenile probation officers (JPO). Youth orientation begins upon admission and each youth receives a resident handbook. Performance plan reviews occur biweekly, with formal reviews monthly. Case management staff make every effort to include parent/guardian and JPOs in formal treatment reviews, transition conferences, and exit conferences. The program provides three primary services, which are Thinking for a Change (T4C), Impact of Crime (IOC), and Talks My Father Never Had With Me. All of the primary services are provided through groups, facilitated by trained staff. T4C is an evidence-based service, IOC is a practice with demonstrated effectiveness, and Talks My Father Never Had With Me is a gender-specific curriculum. Education services at the program are provided by G4S Youth Services, LLC, through a contract with the St. Johns County School District. This contract also includes education services at another juvenile justice residential facility in the St. Johns County Initial Contacts to Parent/Guardian Compliance The program notifies the youth s parent/guardian by telephone within twenty-four hours of the youth s admission, and by written notification within forty-eight hours of admission. The program has a written policy and procedures in place for initial contacts to the parent/guardian upon a youth s admission into the program. Nine youth case management records were reviewed. Eight youth records had documentation of a telephone call to the parent/guardian upon the youth s admission into the program. One youth record did not have documentation a call to the parent/guardian was made. Eight youth records had documentation of a letter being mailed to the parent/guardian within forty-eight hours of the youth s admission into the program. One youth record did not have a copy of the letter, but had copies of documents signed and returned from the parent, indicating the letter was sent. One of the nine letters did not have signatures of any program staff Youth Orientation Compliance The program shall provide each youth an orientation to the program rules, procedures, schedules, and services applicable to youth, to begin within twenty-four hours of admission. The program has a written policy and procedures in place for youth orientation. The program provides each youth an orientation within twenty-four hours of admission into the program. Nine youth case management records were reviewed. Each youth record documented the youth received orientation on the day of his admission to the program. Orientation includes services available, expectations and responsibilities of youth, access to medical services, contraband, dress code, hygiene, access to the Florida Abuse Hotline, emergency procedures, length of Office of Program Accountability Page 16 of 61 (Revised July 2015)

21 stay, and performance plan goals. Nine youth were surveyed and each stated orientation was conducted at admission Court Notification Compliance The program notifies the youth s committing court(s) by written notification within five working days of admission. The program has a written policy and procedures in place to notify the committing court of the youth s admission into the program. Nine youth case management records were reviewed. In each youth record, there was documentation of the committing court being notified of the youth s admission into the program within five working days of admission. One letter did not include the signature of the facility administrator or designee when mailed Classification Factors Compliance The program utilizes a classification system, in accordance with Florida Administrative Code, promoting safety and security, as well as effective delivery of treatment services. The program has a written policy and procedures in place to classify each youth admitted into the program. Youth have a classification form completed at intake and again fourteen days after admission into the program. Nine youth case management records were reviewed. One youth record did not have a classification form. Eight youth records had documentation of an initial classification form, which was completed on the day the youth was admitted into the program. At a minimum, initial classification factors included physical characteristics, age, maturity level, identified special needs, history of violence gang affiliation, criminal behavior, and sexual aggression or vulnerability to victimization. In five youth records, alert documentation was not aligned with additional information on the classification form or in the Juvenile Justice Information System (JJIS) Classification Procedures Compliance Initial classification should be used for the purposes of assigning each newly admitted youth to a living unit, sleeping room, and youth group or staff advisor. The program has a written policy and procedures in place to classify each youth admitted into the program. Nine youth case management records were reviewed for classification procedures. One youth record did not have a classification form. Eight youth records had documentation of youth being assigned a room based on the classification factors of physical characteristics, background information, current offense, demonstrated and history of behavior, and security alerts. Each of the eight youth records had a classification form completed at intake and fourteen days after admission Reassessment for Activities Compliance Youth are reassessed and reclassified, if warranted, prior to considering an increase in privileges or freedom of movement, participation in work projects, or other activities involving tools or instruments that may be used as potential weapons or means of escape, or participation in any off-campus activity. Youth in the program are not eligible for off-campus activities or home visits due to the restrictiveness level of the program (high risk). A review of nine youth case management Office of Program Accountability Page 17 of 61 (Revised July 2015)