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 Paxen Community Connections - Manatee Paxen Learning Corporation (Contract Provider) th Street West Palmetto, Florida Review Date(s): July 12-13, 2017 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: Paul Sheffer, Office of Program of Accountability, Lead Reviewer (Standard 1 and Standard 4) Stephanie Lobzun, Office of Program Accountability, Regional Monitor (Standard 3) Amanda Lopresti, Probation, Senior Juvenile Probation Officer (Standard 2)

3 Program Name: Paxen Community Connections - Manatee MQI Program Code: 1260 Provider Name: Paxen Learning Corporation Contract Number: P2120 Location: Manatee County / Circuit 12 Number of Beds: 22 Review Date(s): July 12-13, 2017 Lead Reviewer Code: 118 Methodology This review was conducted in accordance with FDJJ-2000 (Contract Management and Program Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1) Management Accountability, (2) Assessment and Intervention Services, (3) Mental Health and Substance Abuse Services, and (4) Medical Services, which are included in the Day Treatment Standards. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee 1 # Case Managers # Clinical Staff # Food Service Personnel # Healthcare Staff # Maintenance Personnel 1 # Program Supervisors 3 # Staff 3 # Youth Documents Reviewed 2 # Other (listed by title): Assistant Director of Day Treatment Services, Regional Program Manager-West Region 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 3 # Health Records 3 # MH/SA Records 3 # Personnel Records 3 # Training Records/CORE 3 # Youth Records (Closed) 3 # Youth Records (Open) # Other: 3 # Youth 3 # Direct Care Staff # Other: Observations During Review Admissions Confinement Facility and Grounds First Aid Kit(s) Group Meals Medical Clinic Medication Administration Posting of Abuse Hotline Program Activities Recreation Searches Security Video Tapes Sick Call Social Skill Modeling by Staff Staff Interactions with Youth Comments Staff Supervision of Youth Tool Inventory and Storage Toxic Item Inventory and Storage Transition/Exit Conferences Treatment Team Meetings Use of Mechanical Restraints Youth Movement and Counts Items not marked were either not applicable or not available for review.

4 Standard 1: Management Accountability Day Treatment Rating Profile Indicator Ratings Standard 1 - Management Accountability 1.01 Initial Background Screening* 1.02 Five-Year Rescreening 1.03 Protective Action Response (PAR) Non-Applicable 1.04 Pre-Service/Certification Training 1.05 In-Service Training 1.06 Cleanliness and Sanatation 1.07 Fire Prevention and Evacuation Procedures 1.08 Water Activities Non-Applicable 1.09 Food Services 1.10 Transportation 1.11 Administration 1.12 Incident Reporting (CCC)* Non-Applicable 1.13 Abuse-Free Enviorment* 1.14 Behavior Management System 1.15 Youth Record * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 4 of 31 (Revised July 2016)

5 Standard 2: Assessment and Intervention Services Day Treatment Rating Profile Indicator Ratings 2.01 Standard 2 - Assessment Services Admission and Orientation 2.02 Medical, Mental Health, and Suicide Risk Alerts in JJIS 2.03 Positive Achievement Change Tool (PACT) Full Assessment 2.04 Transitional Planning/Reintegration* Non-Applicable 2.05 Youth-Empowered Success (YES) Plan Development 2.06 Youth Requreiment/PACT Goal Elements 2.07 YES Plan Implementation/Supervision 2.08 Ninety-Day YES Plan Updates 2.09 Ninety-Day Supervisory Reviews 2.10 PACT Reassessment 2.11 Progress Reports 2.12 Education Transition Plan Non-Applicable 2.13 Termination Release 2.14 Career Education 2.15 Educational Access 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 5 of 31 (Revised July 2016)

6 Standard 3: Mental Health and Substance Abuse Services Day Treatment Rating Profile Indicator Ratings Standard 3 - Intervention Services 3.01 Designated Mental Health Clinician Authority or Clinical Coordinator 3.02 Licensed Mental Health and Substance Abuse Clinical Staff* 3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff 3.04 Mental Health and Substance Abuse Admission Screening* 3.05 Mental Health and Substance Abuse Assessment/Evaluation 3.06 Mental Health and Substance Abuse Treatment 3.07 Treatment and Discharge Planning 3.08 Mental Health Crisis Intervention Services* 3.09 Crisis Assessments* 3.10 Emergency Mental Health and Substance Abuse Services* 3.11 Baker and Marchman Acts* Non-Applicable 3.12 Suicide Prevention Services* 3.13 Suicide Precaution Observation Logs* 3.14 Suicide Prevention Plan* 3.15 Suicide Prevention Training* * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 6 of 31 (Revised July 2016)

7 Standard 4: Medical Services Day Treatment Rating Profile Indicator Ratings Standard 4 - Medical, Mental Health, and Substance Abuse Services 4.01 Medical Screening* 4.02 Medication Management - Verification of Medications 4.03 Medication Management - Delivery of Medications 4.04 Medication Management - Medication Storage 4.05 Episodic/Emergency Services * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 7 of 31 (Revised July 2016)

8 Strengths and Innovative Approaches The program strives to continually enhance their community engagement services in order to fully connect their youth to the community in which they live. Several guest speakers have met with the youth from local organizations such as Safe Place and Rape Crisis Center (SPARCC), Mothers Against Drunk Driving (MADD), Cons Helping Cons, and the driver safety course, Buckle Up for BSwag and Bubba (B.U.B.B.A), to reinforce social skills and the consequences of poor decision making. Through developing relationships with local community partners, such as Keep Manatee Beautiful and the Humane Society, the program has the ability to provide youth with the opportunity to volunteer community service hours and feel as though they are making a difference in their community. Youth in the program continued to benefit from the partnership with Jobs for Florida s Graduates during the first half of Selected youth were assigned to a job placement specialist who provides additional assistance with employability and educational and vocational placement. Additionally, all youth in the program are provided enhanced community engagement opportunities. Jobs for Florida s Graduates works to strengthen youths core competencies, as it relates to employment. The program has been able to engage their youth in the Junior Chef Program at Keiser University. In this monthly class, youth have the opportunity to not only learn more about the Culinary Arts program, as well as other majors offered by Keiser, but they also have the benefit of learning advanced cooking techniques. This program allows them to inspire their youth to focus on their future education and career goals through this partnership. Office of Program Accountability Page 8 of 31 (Revised July 2016)

9 Standard 1: Management Accountability Overview Paxen Community Connections Manatee is operated by Paxen Learning Corporation. through a contract with the Department. The program serves youth from Manatee and Sarasota Counties, and serves youth ages fourteen through nineteen referred by the Department. The program has twenty-two allocated slots; however, only nine youth were in the program at the time of the annual compliance review. The youth placed in the program had all been on probation. The program can also accept youth who have been committed to minimum risk commitment programs, or those who are on either conditional release or post-commitment probation supervision, since they do not have other local providers for these placements. Youth referred to the program receive a combination of evidence-based services, case management, community supervision, community service work projects, and life skills training. Youth identified through the screening process who require mental health or substance abuse treatment services are referred to the clinical coordinator for on-site assessment and counseling and/or treatment. The program also provides transportation services to and from the program, snacks, and an evening meal for each youth. The staffing is comprised of one program coordinator, one case manager, and one program support specialist. There were no vacant positions at the time of the annual compliance review. The program coordinator has the overall responsibility and accountability for day-to-day program operations, ensuring youth and staff safety, and ensuring program services are provided in a safe and conducive learning environment. The program employs a licensed clinical social worker (LCSW) who conduct assessments, counseling, and treatment for applicable youth. The program maintains an individual training and personnel file for each staff 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. One staff member was hired since the last annual compliance review. The program has had no volunteers or interns assisting with the program during this review period. The new staff received an initial background screening prior to their date of hire. The Annual Affidavit of Compliance with Level 2 Screening Standards was submitted to the Department s Background Screening Unit on January 10, 2017, meeting the annual requirement Five-Year Rescreening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. Employees and volunteers are rescreened every five years from the initial date of employment. The program did not have any staff applicable for a five-year background rescreening during this annual compliance review period. The program has a written policy and procedures which establishes the completion of five-year rescreenings, when applicable. Office of Program Accountability Page 9 of 31 (Revised July 2016)

10 1.03 Protective Action Response (PAR) Non-Applicable 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. There have been no Protective Action Response (PAR) incidents during the annual compliance review period; therefore, this indicator rates as non-applicable Pre-Service/Certification Training Compliance Contracted non-residential staff are trained in accordance with Florida Administrative Code. Contracted non-residential staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. Contracted non-residential staff who have not completed essential skills training, as defined by Florida Administrative Code, do not have any direct contact with youth. Contracted non-residential staff who have not completed pre-service/certification training do not have direct, unsupervised contact with youth. The program hired one staff during this annual compliance review period. A review of their training file and the Department s Learning Management System (SkillPro) revealed the staff completed their training plan within 180-days of hire. The program has a pre-service training plan, which was most recently approved by the Department s Office of Staff Development and Training (SD&T) on February 10, The program maintains an individual training and personnel file for each staff. The program provides instructor-led training by corporate and program staff, Department trainers, and e-learning through SkillPro. The program was able to enter their instructor-led courses into SkillPro and register the new staff; however, the system would not allow them to reflect these courses as complete within the system. They have contacted SD&T and are working with them to have this issue resolved In-Service Training Compliance Contracted non-residential staff completes in-service training in accordance with Florida Administrative Code. Contracted non-residential staff must complete twenty-four hours of annual in-service training, beginning the calendar year after the staff has completed pre-service training. Supervisory staff shall complete eight hours of training in the areas listed below, as part of the twenty-four hours of annual in-service training. Two staff training files were reviewed for in-service training requirements. Both staff exceeded the required twenty-four hours of in-service training. Each of the reviewed staff received training in Protective Action Response (PAR), cardiopulmonary resuscitation (CPR), first aid, suicide training, and professionalism and ethics. The program coordinator s file was also reviewed for supervisory training. A review of the training file reflected they had completed the required eight hours of supervisory training, which included courses on management, leadership, and communication skills. The program has an in-service training plan, which was most recently Office of Program Accountability Page 10 of 31 (Revised July 2016)

11 approved by the Department s Office of Staff Development and Training (SD&T) on February 10, The program maintains an individual training and personnel file for each staff. The program provides instructor-led training by corporate and program staff, Department trainers, and e-learning through the Department s Learning Management System (SkillPro) Cleanliness and Sanitation Compliance The program provides a safe and appropriate treatment environment including maintenance and sanitation of the facility. The program has a written policy and procedures which define how they will provide a safe and appropriate treatment environment through maintenance and cleanliness of the facility. A tour of the program and observations made during the annual compliance review found the building to be clean, neat, and well maintained. No graffiti was observed in the program, and all furnishings were in good repair. A review of program records reflected they completed a Weekly Safety, Sanitation, and Maintenance Inspection Checklist every week for the past six months. No current concerns were noted which would have required corrective action by the program. The program has separate bathroom facilities for males and females, with working toilets and sinks. There is adequate space for individual and group counseling Fire Prevention and Evacuation Procedures Compliance The program provides a safe and appropriate treatment environment including fire prevention and evacuation procedures. The program has a written policy and procedures which define their fire alarm, fire extinguisher, and fire evacuation procedures. This policy designates the program coordinator as the disaster coordinator for the facility and they are responsible for all aspects of their Fire Safety Plan. The program had postings which indicated smoking is not allowed in any area of the facility. The program maintains a fire drill and safety logbook, which contains annual fire safety inspections and fire drill documentation. A review of documentation in this log reflected fire drills were conducted monthly. The drill documentation indicated the number of youth present, and how long it took staff and youth to exit the premises. The program logbook was reviewed and reflected each of the fire drills were documented and highlighted. Fire protection equipment is strategically located within the facility. There are three fire extinguishers, each of which was inspected in July Evacuation routes were posted in each room of the facility. The most recent annual fire safety inspection was conducted by the Fire Marshal, on February 1, The fire inspection identified minor deficiencies. A re-inspection conducted on February 21, 2017, found the program had corrected all of the identified concerns. The review of staff training files found each staff had been trained on the site-specific Fire Safety Plan, fire evacuation procedures, and the use of a fire extinguisher. All three surveyed youth indicated they had been trained what to do in case of a fire Water Activities Non-Applicable The program provides a safe and appropriate treatment environment including procedures for water activities. The program does not participate in any water-related activities; therefore, this indicator rates as non-applicable. Office of Program Accountability Page 11 of 31 (Revised July 2016)

12 1.09 Food Services Compliance The program provides a safe and appropriate treatment environment including food service. The program has a written policy and procedures which define how they provide food services to the youth. The program has a kitchen which was observed to be clean and well maintained. They maintain a stock of certain menu items and snacks in this area. Youth allergies were also found posted in this area for staff reference. Program policy requires youth with a special diet for either religious, health, or other needs to be provided appropriate meal substitutions. All three surveyed staff and all three surveyed youth indicated the program offers the same menu to both staff and youth. The program menu was approved by a licensed dietitian, on December 16, 2013, and was found posted in the common area of the program. None of the youth indicated food is withheld as a form of discipline Transportation Compliance The program provides a safe and appropriate treatment environment including transportation. The program has a written policy and procedures which define their transportation rules. The program provides daily transportation for all youth to and from the program. Transportation is provided using a seven-passenger Dodge Grand Caravan and a fifteen-passenger Ford F350 van. Records indicate all three staff have a valid driver s license and each has been trained in the program policy. Each of the vans were found to have current vehicle registration and insurance coverage. The annual vehicle inspection for the Dodge was conducted on July 8, 2017, and an annual vehicle inspection for the Ford was conducted on July 10, Reviewed records reflected program staff had been conducting monthly inspections on each vehicle. They also maintain a transportation log which documented all trips taken with each van. All three surveyed staff and all three surveyed youth indicated everyone wears a seatbelt during transports. An observation was conducted during the annual compliance review when youth arrived at the program, and all youth and the staff member were wearing a seatbelt. The program does not deny youth within their catchment area services based on a lack of transportation Administration Compliance The program provides a safe and appropriate treatment environment including administrative and operational oversight. The program has a program coordinator who is responsible for maintaining information regarding the program and completing required reports for the Department. A review of monthly reports was conducted. The program maintains statistical information on admissions, releases, transfers, abuse reports, episodic emergencies, incidents, and average length of stay. This information is documented and submitted on a monthly basis to the Department. A review of the Department s Juvenile Justice Information System (JJIS) indicated the youth roster matched the JJIS program youth census report. The program maintains a daily facility log, which is used to document significant program activities, events, and incidents. A review of the log for the past six months found bi-weekly reviews were completed by the program coordinator to ensure proper documentation of program activities. Entries impacting the safety and security of the program, such as emergency Office of Program Accountability Page 12 of 31 (Revised July 2016)

13 drills and youth on suicide precautions, were found to be highlighted. The entries were brief, and were all written in ink. All mistakes in the logbook were struck through with a single line, void or error was written by the mistake, and initialed by staff. All log entries contained the following information: the date, time of incident, name of the youth, program staff involved, brief statement of the incident, and signature of the person making the entry Incident Reporting (CCC) Non-Applicable The program provides a safe and appropriate treatment environment including transportation. Whenever a reportable incident occurs, the program notifies the Department s Central Communications Center (CCC) within two hours of the incident, or within two hours of becoming aware of the incident. The program did not have any incidents requiring a report to the Central Communications Center (CCC) during this annual compliance review period; therefore, this indicator rates as non-applicable Abuse-Free Environment Compliance Any knowledge or suspicion of abuse, abandonment or neglect is reported to the Florida Abuse Hotline. The program has a written policy and procedures in place to ensure youth are in a safe environment where there is no abuse or harassment. Staff have a code of conduct they adhere to and are provided the code of conduct as part of their orientation. All staff and youth have unimpeded access to report abuse or harassment, without the fear of threat or repercussion. There was no evidence in any of the youth case management records, medical, or mental health records where any youth alleged any abuse. The Florida Abuse Hotline and Central Communications Center (CCC) numbers were found posted throughout the program. All three surveyed youth indicated they felt safe in the program and none of them reported ever feeling a need to make a report to the abuse hotline. None of the youth reported having heard a staff member use profanity or make any threats or use intimidation towards themselves or any other youth. All three surveyed youth also reported the staff have never asked to meet with them on a social basis outside the program. Each of the interviewed staff reported they would give youth access to a phone in a private area, if they wanted to make a report to the Florida Abuse Hotline. Program policy indicates youth shall have unimpeded access to place a call to the Florida Abuse Hotline. None of the three surveyed staff indicated they had ever seen a coworker deny youth a call to the Florida Abuse Hotline. Each of the staff also reported they had never heard another staff member use profanity, or make any threats or use intimidation, towards any youth. Office of Program Accountability Page 13 of 31 (Revised July 2016)

14 1.14 Behavior Management System Compliance The program utilizes a behavior management system providing privileges and consequences to encourage youth to fulfill programmatic expectations. Consequences are fair and directly correlate with the behavior problem. The use of facility restriction does not exceed seven consecutive days. Disciplinary procedures are carried out promptly. Youth are not allowed to have control over or discipline other youth. Time-out is used in accordance with Florida Administrative Code. All behavior problems, time-outs, in-facility suspensions, and privilege suspensions are documented in the facility log and case file in accordance with Florida Administrative Code. The program has a policy and procedures outlining the programs behavior management system (BMS). The mission statement for the provider and the Department is posted in various areas of the program including the lobby and the program learning areas. There is also a description of the program s design, objectives, and the daily activity schedule posted in the lobby. The program uses an effective response system (ERS) with a focus on positive reinforcement within the BMS. The BMS is designed to reinforce pro-social behaviors and develop and enhance each youth s personal decision making by increasing their level of personal accountability. The youth and parent/guardian are provided with a copy of the youth and parent/guardian orientation handbook during the youth s initial intake, which provides detailed information about the program rules, expectations, and BMS. The program rules and expectations are posted in the primary activity room, as well as the common areas the youth frequent. Using principles of a token economy, the BMS uses skill cards, credit points, and opportunities to earn verbal praise, certificates, or snack items in the program s bid store and the ability to participate in special activities and outings. There was evidence in treatment team documentation, case notes, and on individual skill cards indicating how the BMS works and how the program provides privileges and consequences. Documentation reflected disciplinary procedures are carried out promptly, and the consequences are fair and directly associated with the displayed negative behavior. Three youth records were reviewed. Each record contained the weekly skill cards initialed by the program staff. The skill cards provide information such as how each youth demonstrates skills appropriately with others, as well as how tracking each youth s progress on their own skill for the week. The policy, youth handbook, and the staff How to Guide provides staff direction on how to handle negative consequences for minor misconduct. Consequences may include verbal redirection, removal from a program activity, counseling, and privilege suspension. Major offenses could warrant meetings with the juvenile probation officer (JPO), calls to law enforcement, and possible termination from the program. Any youth involved in critical infractions including program disruption and serious negative consequences, such as activity restriction, are to be documented in the facility logbook. The program does not use any form of time out. All three surveyed youth indicated they have never been placed in time out. All surveyed youth also reported they are never allowed to enforce or decide discipline or have control over other youth. Office of Program Accountability Page 14 of 31 (Revised July 2016)

15 1.15 Youth Records (Healthcare and Management) Compliance The program maintains an official case record, labeled Confidential, for each youth, which consists of two separate files: An individual healthcare record An individual management record. The program maintains official case records for individual case management and individual healthcare. Each record is labeled Confidential and provides identifiable youth information such as name, date of birth, date of admission, and the Department of Juvenile Justice identification number. The case management records are organized in accordance to the Department and Florida Statute requirements. All records are kept in a secure locked cabinet, behind a secured locked office, to maintain confidentiality. Standard 2: Assessment and Intervention Services Overview The program provides day treatment services to youth ages fourteen through nineteen who have been referred by the Department of Juvenile Justice (DJJ). Program staff are responsible for communicating with the juvenile probation officer (JPO), youth, parent/guardian, and court. Program staff conduct an intake orientation, which includes providing the youth with a youth handbook, as well as signed copies of the admission forms. Program staff are also responsible for administering the Positive Achievement Change Tool (PACT) and the Youth Empowerment Success (YES) Plan. The YES Plan includes specific target dates, action steps, and intervention plans for successful completion of the goals. Program staff also provide academic assistance, life skills instruction, and career education Admission and Orientation Compliance Facility orientation shall be conducted within twenty-four hours of a youth s admission to the facility. Case notes should document the date and time of the orientation and the youth received orientation documents. The program has a written policy and procedures which establish how they will conduct their admission process, to include orientation, for each youth. Three youth case management records were reviewed for documentation of the orientation process. There was case note documentation of the intake meeting in the Department s Juvenile Justice Information System (JJIS) for each of the reviewed records. All three records documented completion of orientation within twenty-four hours, the date and time of orientation, the orientation process, a tour of the facility, and an introduction to the staff on the date of the youth s admission into the program. Each of the reviewed records contained documentation reflecting each youth received a copy of the youth handbook. There was documentation in each of the three records which included details regarding program services and the behavior management system utilized by the program. The program uses an orientation checklist where the youth and staff initial once each topic is discussed. The youth, parent/guardian, and staff sign and date the checklist once completed. Each of the three reviewed records included a completed orientation checklist indicating a discussion of all required topics took place during the intake process. The topics included the program s expectation and rules, contraband items and consequences, daily Office of Program Accountability Page 15 of 31 (Revised July 2016)

16 schedules, medical and mental health services, evacuation and emergency procedures, the performance planning process, average length of stay, and dress code. Youth s accessibility to the program s telephone to report abuse is also discussed in the handbook Medical Alerts, Mental Health Alerts, and Suicide Risk Compliance Alerts in JJIS The program shall alert staff of medical, mental health, and suicide risk issues that may affect the security and safety of the youth in the program. The program has a written policy and procedures in place identifying the documentation of medical, mental health, and suicide risk alerts. Three youth records were reviewed to determine compliance. One youth record indicated there was not a need for any type of alerts. One of the three records required a medical alert, which was appropriately documented in the Department s Juvenile Justice Information System (JJIS). Two of the three records reviewed required suicide risk alerts to be entered into JJIS. All alerts were entered correctly and in a timely manner and were updated appropriately. They were closed on the program alert log and in JJIS without exception. The program alert log is available for staff review at all times. It is specifically reviewed whenever the program has a new admit, and at every staff meeting. All three surveyed staff reported the alert system and process for sharing of information is very good Positive Achievement Change Tool (PACT) Full Compliance Assessment The PACT Full Assessment is completed by program staff for all youth, regardless of risk to reoffend, within seven calendar days of admission. The program has a written policy and procedures in place which define how staff are to complete Positive Achievement Change Tool (PACT) Full Assessments. Three case management records were reviewed for the completion of the PACT Full Assessments. Each of the PACT Full Assessments were completed within seven calendar days of the youth s admission into the program and documented in the Department s Juvenile Justice Information System (JJIS) Transition Planning/Reintegration Non-Applicable Program staff actively participates in the transitional planning process for youth who are being released from a residential program on conditional release (CR) or post-commitment probation (PCP). For conditional release and post-commitment probation youth, the YES Plan must address recommendations from the residential program during transition. The program does not receive referrals for youth while they are in their residential program; therefore, this indicator rates as non-applicable. Office of Program Accountability Page 16 of 31 (Revised July 2016)

17 2.05 Youth-Empowered Success (YES) Plan Development Compliance The YES Plan (Form DJJ/PACTFRM 4) is cooperatively developed for youth on Probation, Conditional Release, and Post-Commitment Probation. Youth and parent/guardian signatures do not indicate cooperative development of the YES Plan. The program has a written policy and procedures outlining how the development of each youth s Youth Empowered Success (YES) Plan. Each of the three reviewed records had a Positive Achievement Change Tool (PACT) assessment, completed prior to the development of the initial Youth Empowered Success (YES) Plan. The reviewed case note documentation reflected the youth and a parent/guardian participated in the development of the plan and were completed within fourteen days of the youth s admission into the program. All three records contained documentation in the case notes of collaboration between the youth, parent/guardian, juvenile probation officer (JPO), and case manager during the development of the YES Plan. There was a signed acknowledgment form in each of the records indicating the youth and parent/guardian were informed of the importance of compliance with the YES Plan. All three records contained documentation the youth and parent/guardian received a copy of the approved YES Plan. All three surveyed youth indicated they participated in the development of their YES Plans. Each youth also confirmed, during an interview, they were provided with a copy of the plan, as well Youth Requirement/PACT Goal Elements Compliance The YES Plan provides appropriate and individualized target dates for the completion of each youth requirement and PACT goal. All youth requirement and PACT goal action steps include the intervention plan elements (i.e., who, what, and how often). The program has a written policy and procedures outlining the development of each youth s Youth Empowered Success (YES) Plan. Three youth case management records were reviewed for appropriate and individualized target dates, and for the completion of all youth requirements and Positive Achievement Change Tool (PACT) Change Goal elements. All three records documented court-ordered sanctions in the Department s Juvenile Justice Information System (JJIS) Youth Requirements module. Each record reviewed had youth requirements which contained at least one specific action step for the youth, parent/guardian, and case manager. The action steps clearly defined who is responsible, what action is to be taken, and how often the action should be taken. All three YES Plans contained a Change Goal addressing one of the youth s top three criminogenic needs, as identified by the PACT. Each of the surveyed youth were able to explain the current goals they were focusing on YES Plan Implementation/Supervision Compliance Youth on supervision (i.e., probation, conditional release, or post-commitment probation) are supervised in a manner ensuring compliance with the court order and completion of YES Plan (youth requirements and PACT goals). Case notes demonstrate compliance (or attempted compliance) with youth, parent/guardian, and staff action steps contained in the YES Plan. The program has a written policy and procedures stating staff are to document case activities including contact with the youth, parent/guardian, juvenile probation officer, and other collateral sources. Three youth records were reviewed for Youth Empowered Success (YES) Plan implementation and supervision. The Department s Juvenile Justice Information System (JJIS) case notebook module for all three reviewed records reflected compliance with the YES Plan Office of Program Accountability Page 17 of 31 (Revised July 2016)

18 action steps for the youth, parent/guardian, staff, and collateral contacts. The program staff documented case activities including face-to-face interactions with the youth, parent/guardian, and collateral sources in the JJIS case notes. JJIS case notes reflected the program staff maintained contact with all necessary individuals to ensure the youth s compliance with their YES Plan. The reviewed case notes allowed for the reader to gauge the youth s compliance with supervision, parent/guardian cooperation, and the participation of others in the youth s success Ninety-Day YES Plan Updates Compliance Staff adjust the YES Plan to reflect any new needs and progress made during the course of supervision. Staff must make necessary updates to youth requirements and PACT goals and save a new YES Plan in the Juvenile Justice Information System (JJIS) prior to ninety-day supervisory reviews. When updates are made to the YES Plan reasonably requiring the input of the youth and parent/guardian, this discussion is clearly documented in the case notes. Use of the case notations or a similar form the youth and/or parent/guardian initials to indicate the YES Plan was reviewed does not signify compliance. The case notes clearly document any communication regarding the YES Plan. The program has a written policy and procedures which outlines how the program will complete ninety-day Youth Empowered Success (YES) Plan updates. All three reviewed records required ninety-day YES Plan updates. Documentation supported the case manager updated each youth requirement prior to the supervisory review of the YES Plan. All three reviewed records clearly documented the input of the youth and parent/guardian in case notes when changes were made Ninety-Day Supervisory Reviews Compliance Cases under supervision (i.e., probation, conditional release, post-commitment probation) are reviewed by the supervisor at least once every ninety calendar days. The supervisor ensures staff review any instructions given during the review, and ensures they were followed during the subsequent review. The program has a written policy and procedures requiring supervisory staff to complete ninetyday supervisory reviews. Three case records were reviewed, and all were applicable for ninetyday supervisory reviews. Each record contained a ninety-day review within the required timeframe and also provided guidance and instructions for the case manager to follow for each case. All three records reviewed had updated Change Goals and youth requirements in the Department s Juvenile Justice Information System prior to the supervisory review PACT Reassessment Compliance Staff complete PACT Reassessments for youth on probation, conditional release, and postcommitment probation, as well as minimum-risk non-residential commitment youth. Regardless of risk to reoffend, the PACT Full Assessment is completed every ninety days. The program has a written policy and procedures which require the completion of a Positive Achievement Change Tool (PACT) Reassessment every ninety-days, regardless of the youth s risk to reoffend. Three case records were reviewed, and all were applicable for ninety-day PACT Reassessments. All three records reviewed contained a PACT Reassessment completed every Office of Program Accountability Page 18 of 31 (Revised July 2016)

19 ninety days. Each of the three closed records reviewed had a PACT Assessment which was completed within fourteen days of release, as required Progress Reports Compliance Progress reports are completed detailing the youth s progress with the youth requirements and PACT goals outlined in the YES Plan. The program has a written policy and procedures outlining how progress reports are to be prepared and distributed. Three youth records were reviewed for the completion of progress reports. It is the program s policy to complete a progress report every thirty days, which exceeds the ninety-day requirement. All progress reports contained a specific section for the youth to provide comments about how they felt they were progressing in the program. Each progress reports reviewed contained information regarding the youth s overall performance in the program, and were signed by the youth, case manager, and program coordinator. All three progress reports reviewed contained a cover letter indicating the original report was sent to the court, with copies being forwarded to the juvenile probation officer, youth, and parent/guardian. These progress reports are also uploaded into the Department s Juvenile Justice Information System (JJIS) for reference Education Transition Plan Non-Applicable Staff and youth complete an Education Transition Plan prior to release including provisions for continuation of education and/or employment. The program does not provide educational services to youth; therefore, this indicator rates as non-applicable Termination/Release Compliance The program shall recommend termination to the Department for youth on probation, conditional release, or post-commitment probation, as well as minimum-risk commitment youth, upon successful completion of court-ordered sanctions and substantial compliance with restitution and/or court fees. For youth on probation, conditional release, or post-commitment probation, the program works with the JPO/CM to facilitate the release of the youth upon completion of the program. For youth on minimum-risk commitment or conditional release, staff completes the Pre-Release Notification and Acknowledgement (PRN) (DJJ/BCS Form 19) and follows the required procedure. The program has a written policy and procedures outlining how they will request discharge for program youth. Three closed case management records were reviewed for termination and/or program release documentation. All three records were applicable for local law enforcement warrant checks being completed, prior to the submission of the termination. The paperwork was then forwarded to the juvenile probation officer to send to the court. Each of the records displayed the correct discharge date in the Department s Juvenile Justice Information System (JJIS). Only one record reviewed was due to loss of jurisdiction and the court was notified fifteen days prior to the loss of jurisdiction. In all three records reviewed, each youth was released in JJIS within five days of the program receiving notification of the youth s discharge and/or Office of Program Accountability Page 19 of 31 (Revised July 2016)

20 termination. All three closed records contained documentation indicating the youth and parent/guardian were notified in writing the youth was no longer required to attend the program. All three letters further indicated the youth was no longer under the Department s supervision Career Education Compliance Staff shall develop and implement a career education competency development program. The program provides Type-2 programing, providing skill-building activities, and life skills training exercises designed to foster the development of skills necessary for youth to successfully seek and maintain employment. The provider uses the Career Pathways curriculum with the primary focuses on developing each youth s vocational competency, by teaching them a variety of social skills and values needed in day-to-day employment. Two case management records were reviewed for the implementation of career education, and each record contained an approved Youth Empowered Success (YES) Plan. An additional closed record was reviewed due to one of the original records being non-applicable because of youth s age. Each YES Plan contained an education goal, and none of the youth were eligible for an employability goal as it was not one of their top three identified criminogenic needs on the Positive Achievement Change Tool (PACT) assessment. All three records reviewed contained a completed Casey Life Skills assessment tool to include skill topics on daily living, self-care, communication and relationships, housing and money management, work/study life, career and education planning, and looking forward. The program provides the youth with career/vocational material promoting practical skills of completing job applications, creating resumes, and rehearsing for job interviews. All three records contained a career inventory and a life skills assessment, providing staff with guidance on each youth s individualized career education goals and their specific interests, aptitudes, and abilities Educational Access Non-Applicable The program shall integrate educational instruction (career and technical education, as well as academic instruction) into their daily schedule in such a way ensuring the integrity of required instructional time. The program does not provide educational services to youth; therefore, the indicator rates as non-applicable. Standard 3: Mental Health and Substance Abuse Services Overview The program contracts with a licensed clinical social worker to act as the program s clinical coordinator. The clinical coordinator is on-site two days a week, and is available for consultation by telephone twenty-four hours a day, seven days a week. The program does not employ any non-licensed mental health counselors. The clinical coordinator oversees the mental health and substance abuse services at the program. The mental health counselor provides individualized mental health and substance abuse services to the youth, as well as group substance abuse services. The clinical coordinator determines which youth require mental health and substance abuse services based on the results of the intake screening assessments, Massachusetts Youth Screening Instrument Second Version (MAYSI-2), and by reviewing the latest Positive Achievement Change Tool (PACT) Mental Health and Substance Abuse form. Office of Program Accountability Page 20 of 31 (Revised July 2016)

21 3.01 Designated Mental Health Clinician Authority or Clinical Compliance Coordinator Each program director is responsible for the administrative oversight and management of mental health and substance abuse services in the program. Programs with an operating capacity of 100 or more youth, or those providing specialized treatment services, must have a single licensed mental health professional designated as the Designated Mental Health Clinician Authority (DMHCA) who is responsible for coordinating and verifying implementation of necessary and appropriate mental health and substance abuse services in the program. Programs with an operating capacity of fewer than 100 youth or those not providing specialized treatment services, may have either a DMHCA or a Clinical Coordinator. The program has a policy and procedures in place outlining the role and responsibilities of the program s designated clinical coordinator. The program employs a licensed clinical social worker (LCSW) to provide administrative oversight and management of the mental health and substance abuse services in the program. The clinical coordinator has a clear and active license in the State of Florida. The clinical coordinator is required to be on-site weekly; however, the clinical coordinator is on-site every Tuesday and Thursday. A review of all sign-in logs indicated the clinical coordinators has been on-site every week to provide services to the youth Licensed Mental Health and Substance Abuse Clinical Compliance Staff The program director is responsible for ensuring mental health and substance abuse services are provided by individuals with appropriate qualifications. Clinical supervisors must ensure clinical staff working under their supervision are performing services they are qualified to provide based on education, training, and experience. The program has a policy and procedures establishing the protocol for the qualifications, credentials, licenses, and experience for the program s licensed mental health staff. The program has one licensed clinical social worker, who serves as the programs designated clinical coordinator. The clinical coordinator has a clear and active license in the State of Florida. The program uses other licensed mental health counselors from nearby PAXEN programs to provide back-up services to the youth in the program, when the clinical coordinator is unavailable or on vacation Non-Licensed Mental Health and Substance Abuse Compliance Clinical Staff The program director is responsible for ensuring mental health and substance abuse services are provided by individuals with appropriate qualifications. Clinical supervisors must ensure clinical staff working under their supervision are performing services they are qualified to provide, based on education, training, and experience. The program has a policy and procedures in place indicating they only use licensed mental health staff to provide mental health and substance abuse services to the youth. The program s policy further acknowledges the requirements for the delivery of mental health and substance abuse treatment services by non-licensed clinicians set for in Florida Administrative Rule 63N-1. A review of three youth mental health and substance abuse records revealed all mental health and substance abuse services were provided by the program s licensed clinical coordinator. Office of Program Accountability Page 21 of 31 (Revised July 2016)