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 - Hillsborough Paxen Learning Corporation (Contract Provider) 3014 North Highway 301 Tampa, Florida Review Date(s): April 18-24, 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: Toni Del Regno, Office of Program of Accountability, Lead Reviewer (Standard 1) Felicia Goldstein, Office of Program of Accountability, Regional Monitor (Standard 3) Dennis McKinney, DJJ Probation Services, Probation Supervisor (Standard 2) Canitha Taylor, Office of Program of Accountability, Regional Monitor (Standard 4)

3 Program Name: Paxen Hillsborough MQI Program Code: 1257 Provider Name: Paxen Learning Corporation Contract Number: P2120 Location: Hillsborough County / Circuit 13 Number of Beds: 25 Review Date(s): April 18-20, 2017 Lead Reviewer Code: 147 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 1 # Clinical Staff # Food Service Personnel # Healthcare Staff # Maintenance Personnel 2 # Program Supervisors Documents Reviewed 3 # Staff 5 # Youth 1 # Other (listed by title): Accreditation Reports Affidavit of Good Moral Character CCC Reports Confinement Reports Continuity of Operation Plan Contract Monitoring Reports Contract Scope of Services Egress Plans Escape Notification/Logs Exposure Control Plan Fire Drill Log Fire Inspection Report Fire Prevention Plan Grievance Process/Records Key Control Log Logbooks Medical and Mental Health Alerts PAR Reports Precautionary Observation Logs Program Schedules Sick Call Logs Supplemental Contracts Table of Organization Telephone Logs Surveys Vehicle Inspection Reports Visitation Logs Youth Handbook # Health Records 5 # MH/SA Records 4 # Personnel Records 4 # Training Records/CORE 5 # Youth Records (Closed) 5 # Youth Records (Open) # Other: 5 # 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) 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 Ninety-Day Supervisory Reviews 1.13 Incident Reporting (CCC)* 1.14 Abuse-Free Enviorment* 1.15 Behavior Management System 1.16 Youth Record * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 4 of 40 (Revised July 2016)

5 Standard 2: Assessment and Intervention Services Day Treatment Rating Profile Indicator Ratings Standard 2 - Assessment Services 2.01 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 PACT Reassessment 2.10 Progress Reports 2.11 Education Transition Plan Non-Applicable 2.12 Termination Release 2.13 Career Education 2.14 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 40 (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 40 (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 40 (Revised July 2016)

8 Strengths and Innovative Approaches Paxen Community Connections in Hillsborough County has arranged for all eligible youth who have completed the requirements for a high school diploma to attend the annual graduation ceremony held at the Florida State Fairgrounds in May Paxen Community Connections in Hillsborough County has arranged for its youth to tour two local college campuses (Hillsborough Community College, Ybor campus and Brewster Technical College) and to learn about education opportunities offered by each college. Paxen Community Connections in Hillsborough County staff and youth recently visited the McDill Airforce Base for their Military/S.T.E.M Day where students were able to interact with local service men and women to learn about the many careers opportunities offered by the United States Air Force. Paxen students have also toured the and will tour the University of South Florida campus this summer. Paxen Community Connections in Hillsborough County has arranged for its male youth to participate in local job fairs and to be fitted for business suits gifted to them free of charge when they participate in a Dress for Success Day through a local partnership with Jobs for Florida s Graduates. Paxen Community Connections in Hillsborough County youth benefit from local partnerships with Metro Wellness, who provide the youth with sex education and free and confidential testing for all types of sexually transmitted disease. Paxen Community Connections in Hillsborough County has formed a partnership with The Spring of Tampa Bay, a local domestic violence shelter, which offers the youth educational material and group sessions regarding the characteristics of healthy relationships. Paxen Community Connections in Hillsborough County has formed a partnership with Suncoast Credit Union, a local financial institution which offers the youth educational material and group sessions regarding money management and financial literacy. Office of Program Accountability Page 8 of 40 (Revised July 2016)

9 Standard 1: Management Accountability Overview Paxen Community Connections Hillsborough is a day treatment program serving male and female youth referred by the Department of Juvenile Justice, Circuit 13 Probation Office, who are either on probation, post-commitment probation, conditional release, or minimum risk commitment. A key focus of this program is the provision of an on-site General Educational Development (GED) preparation program, as well as, opportunities to develop job readiness and vocational skills through participation in the employment preparation curriculum. Therefore, only youth between the ages of sixteen through nineteen years of age are eligible to attend the program. The program operates five days a week, Monday through Friday, with the exception of various holidays. In addition to the on-site GED preparation and employment readiness services, the program also provides the youth with involvement in the evidence-based delinquency intervention Thinking for a Change (T4C), a cognitive restructuring curriculum as well as, twice weekly group lessons on victim impact. The youth are also provided case management services including the development and supervision of a Youth Empowered Success (YES) Plan and opportunities to engage in community service projects to meet probation requirements. Life Skills training is also afforded to each youth through their involvement in various activities giving meaning and understanding to the decision making process. Furthermore, any youth identified through the screening process requiring mental health or substance abuse treatment services are referred to the licensed clinician for an on-site assessment of treatment needs. The clinician then provides appropriate mental health and substance abuse counseling services to the youth or makes a referral for specialized services. The program offers daily transportation to and from the program, snacks, and a balanced meal for all youth. Paxen Community Connections - Hillsborough is contracted to serve twenty-six youth. At the time of the annual compliance review, there were sixteen youth enrolled in and attending the program. According to the current organization chart, program staff include: a program coordinator, one case manager, and two program support specialists. There is also a licensed mental health counselor position providing clinical services to the program, at least once weekly, split between three Paxen sites in neighboring counties. There were no reported vacant positions, however, it is significant to note at the time of the annual compliance review, the program coordinator was on maternity leave and a staff person from another Paxen program was substituting to assume the responsibilities of the position. Additional staff support for each of the provider s programs is provided by the Paxen Learning Corporation management staff. All program staff are provided instructor-led staff training conducted by certified trainers, Paxen staff, and Department of Juvenile Justice staff, as well as, on-line training through the Department s Learning Management System (SkillPro). Office of Program Accountability Page 9 of 40 (Revised July 2016)

10 1.01 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 in place for conducting background screening for all staff prior to hiring or using their services, as well as, timely submission of the Annual Affidavit of Compliance with Level 2 Screening Standards. Notably, the services of interns, mentors or volunteers are not utilized. The program hired two new staff since the last annual compliance review, specifically, the case manager and a program support specialist. Confirmation of the completion of each background screening was conducted through access with the Department s Background Screening Unit system, which presented a face sheet documenting the dates of submission and completion of the screening, as well as, the results of the screening. This information was compared to the program s reported dates of hire for each staff. The case manager had a background screening completed weeks prior to the date of hire. The program specialist, however, had a start date on the Friday before the following Monday when the screening was submitted and four business days prior to the completion of the background screening; however, during those four days, the individual was in training. He did not have direct contact with youth at the program until after the background screening was completed. Both new staff received an eligible rating on their background screening. The program completed and submitted their Annual Affidavit of Compliance with Level 2 Screening Standards for staff to the Department s Background Screening Unit on January 12, 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 requiring a five-year background rescreening for all staff, who have any access to program youth, every five years. The program does not utilize volunteers, mentors, or interns. The policy stipulates a five-year background rescreen will be conducted prior to the staff member s fifth anniversary of the date of hire and every five years thereafter. During the annual compliance review period, with each of the staff hired within the past two years, a review of the employee roster, background screening, and personnel records confirm there are no staff eligible for a five-year rescreen Protective Action Response (PAR) Compliance The program uses physical intervention techniques in accordance with Florida Administrative Code. Any time staff uses a physical intervention technique, such as countermoves, control techniques, takedowns, or application of mechanical restraints (other than for regular transports), a PAR Incident Report is completed and filed in accordance with the Florida Administrative Code. The program has a written policy and procedures regarding the use of Protective Action Response (PAR) techniques in accordance with the Florida Administrative Code. A review of the PAR plan indicated all procedures used by the program are authorized by the Department. Office of Program Accountability Page 10 of 40 (Revised July 2016)

11 A review of staff training records documents all staff have completed the forty hours of basic PAR training, as well as, a specialized training on the completion of PAR Reports. Additionally, the eight-hour PAR Update refresher training has been completed by two of the staff who have been employed longer than a year. Since the last annual compliance review, the program has used physical interventions on one occasion. There has been no use of mechanical restraints to address the behavior of any youth. A review of the required PAR report regarding the single incident verified the report was completed by both staff who were engaged in the PAR on the same date the incident occurred. The report was also reviewed by the PAR certified instructor and the Director of Day Treatment Services on the date of the incident. The reviewed PAR report listed five witnesses to the PAR incident. Four of the five witnesses provided statements after the incident occurred which were attached to the PAR report. However, there is a missing witness statement from the program case manager. Two of the statements did not address the actual PAR incident, instead describing the demeanor of the youth involved. Also, two of the witness statements failed to document the date of observation and/or completion of their statement. However, the program was able to produce an sent the day of the incident with all four completed witness statements attached, confirming the statements were written on the date of the incident Pre-Service/Certification Training Compliance Contracted non-residential staff are trained in accordance with Florida Administrative Code. Contracted non-residential staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. Contracted non-residential staff who have not completed essential skills training, as defined by Florida Administrative Code, do not have any direct contact with youth. Contracted non-residential staff who have not completed pre-service/certification training do not have direct, unsupervised contact with youth. The program has a written pre-service orientation training plan, which stipulates training of new staff in accordance with the Florida Administrative Code and with the Department of Juvenile Justice Office of Staff Development and Training requirements. The program provided documentation to confirm all instructor-led trainings were conducted by qualified trainers including First Aid/CPR, Thinking for a Change and Protective Action Response. Since the last annual compliance review conducted in May 2016, the program has hired two new staff. A review of documentation in both staff training files indicates each of the new staff completed the essential skills training (specific hours of training in professionalism and ethics, suicide prevention, cardiopulmonary resuscitation and first aid, as well as, emergency procedures, and training regarding the Protective Action Response) before the required ninety-day time frame. None of the reviewed documentation indicated these staff had any direct contact with youth until they had successfully completed the essential skills curriculum. The two staff completed the required 120 hours of training within the first 180 days as required, consistent with the then current training plan approved February 11, However, there were specific trainings stipulated on the Department approved pre-service training plan which were not completed by staff during the first 180 days of employment. One staff did not complete training plan required hours of training in diversity, changing youth behavior and youth supervision, until after her first 180 days of employment. Additionally, two of three staff failed to complete a course related to gang awareness as stipulated on the training plans. Both staff completed this training during the week of the annual compliance review. The program was able, however, able to provide documentation these topics had been addressed during the staff s involvement in forty hours of Office of Program Accountability Page 11 of 40 (Revised July 2016)

12 on the job training soon after hire. Only one of the two staff applicable for training on medication management, the program coordinator, had completed training by a qualified trainer. The program offered a valid reason for the missed training due to a change in staff and trainers, and has a plan place to obtain training for this staff member and to ensure if the program admits any youth who require medication during program hours, management will ensure there is a staff member on site to provide the service. Finally, a review of documentation regarding instructorled training sessions, supported the program s compliance with the Department requirement all staff trainings are to be recorded on the SkillPro training record, however, a few instructor-led trainings were observed to have not yet been documented on SkillPro 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 preservice training. Supervisory staff shall complete eight hours of training in the areas listed below, as part of the twenty-four hours of annual in-service training. The program has a written policy stipulating twenty-four hours of in-service training is required to be completed, each calendar year in accordance with the Florida Administrative Code. The twenty-four hours include at least sixteen hours of course work on the Department s Learning Management System (SkillPro) and instructor-led trainings. These courses must specifically include professionalism and ethics, suicide prevention, as well as cardiopulmonary resuscitation (CPR), and first aid, if certification is expiring during the calendar year. Eight hours of refresher training utilizing the Protective Action Response (PAR) is another requirement. Additionally, the program has developed and maintained an annual training calendar for all staff employed longer than one year to follow to ensure all trainings are completed by the end of the calendar year. Only one of the program s four staff was applicable for in-service training. This staff is the program coordinator. A review of the staff s training plan, approved by the Department February 11, 2016, indicated the staff had completed more than sixty hours of training, exceeding the required twenty-four hours of training. Additional hours of training documented in the training record and/or on SkillPro included trainings regarding the positive motivation system, security awareness, sexual harassment, human trafficking, mental health and substance abuse services, the Prison Rape Elimination Act (PREA), and universal precautions. Additionally, a review of training documentation of this individual who functions as in a supervisory role, verified completion of supervisory training in the areas of management, human resources, personal accountability, and communication exceeding the required eight hours for the calendar year Cleanliness and Sanitation Compliance The program provides a safe and appropriate treatment environment including maintenance and sanitation of the facility. The program has a policy and procedures in place to address cleanliness and maintenance of the facility. A tour of the facility was completed during the annual compliance review and observations of the facility were made throughout the three days of the review. The facility was observed to be consistently neat and orderly. There are staff offices and adequate rooms for youth to meet in groups and for private counseling. The furnishings were in good repair and Office of Program Accountability Page 12 of 40 (Revised July 2016)

13 appropriate to the purposes of the program. Separate bathroom facilities were inspected and observed to be operable, sanitary, well-stocked with supplies, and free of mold/mildew. Also observed the walls around the program to be colorfully decorated with informational and/or inspirational posters, photographs of the youth engaged in various activities and youth artwork. The program has developed and implemented a perpetual maintenance and housekeeping plan. An integral part of this plan is the consistent completion of a weekly safety, sanitation, and maintenance inspection checklist. The checklist, requires inspection of the facility for cleanliness and safety to include the exterior grounds, and several aspects of the interior, including the refrigerator and the bathroom surfaces. The checklists also document needed maintenance and/or repairs and when the repairs or maintenance was completed. Each week s safety, sanitation, and maintenance inspection checklist is stored in a binder maintained in the program coordinator s office. This binder was reviewed to verify the consistency of checklist completion over the past six months. Checklists were present for each week the past six months without exception 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 regarding fire prevention ensuring there is a comprehensive safety regimen, which includes the prohibition of smoking by staff or youth in the facility, staff and youth training regarding fire safety, as well as, routine fire drills practicing evacuation of the building. The program maintains a fire drill and safety logbook, which contains annual fire safety inspections, documentation of all fire drills and documentation of any specialized fire safety training. The program policy addresses fire prevention through routine inspection and scheduled maintenance of fire protection equipment in the facility. Located in an office complex, the facility is not equipped with an alarm system, however, a sprinkler system will operate if smoke and or excessive heat are detected. Evacuation/Egress diagrams, which also specify how to access emergency medical care/transportation are posted throughout the facility for easy reference. Training regarding safe evacuation of the building is reinforced for both youth and staff during monthly drills. No smoking signs are prominently posted in the facility and observations by the review team substantiated the enforcement of this rule. Subsequent to a monitoring visit in March, 2017 the program requested a smoke detector for the snack area which is equipped with a refrigerator and microwave. A new smoke alarm had been installed when the team was present for the annual compliance review in April, There are two fire extinguishers in the facility to use in case of emergency. One is in entrance area of the facility and the other is located in snack area of the building. Additionally, during inspection of the transport vans, it was noted each vehicle was equipped with a small fire extinguisher for use in case of emergency. The tags on the fire extinguishers documented all devices are charged and valid to December, Fire safety equipment is checked weekly when the weekly safety, sanitation, and maintenance inspection checklist is completed. A review of the fire drill and safety logbook indicated the last fire inspection of the facility occurred on July 6, No findings or violations were noted at by the inspector from the Hillsborough County Fire and Rescue Department. Documentation in the program s fire safety log supports the program s completion of one fire drill per month for the past six months prior to the annual compliance review. Fire drills are also consistently documented in the dated facility log book, though the entries often fail to document the exact times the drills took place. A review of staff training records documented all four staff received training on fire safety and fire prevention as part of their pre-service training. While only two of five surveyed youth reported they had been trained about what to do in case of fire at the facility, a review of five Office of Program Accountability Page 13 of 40 (Revised July 2016)

14 youth management records revealed each youth signs a form confirming they have been informed of fire safety principles, the proper way to use a fire extinguisher, and program evacuation procedure in case of fire during the orientation process. Additionally, reviewed training logs documented all staff and all youth present in the program on April 4, 2017 participated in a training regarding how to use a fire extinguisher 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, the indicator rates as non-applicable Food Services Compliance The program provides a safe and appropriate treatment environment including food service. The program has a written policy and procedures regarding food services, which includes a daily snack upon arrival to the program and a light meal just prior to the youth returning home. The review team noticed upon entry to the program each morning containers of dry cereal accompanied by a bowl of fresh fruit were set up on a table for the morning snack. Milk was added to the table for use once the youth arrived to the program. The evening meal is specified on the program menu which operates on a two-week cycle rotated for the third and fourth weeks of each month. The program menu has been approved by a licensed dietician. The menu lists daily meals consisting of pizza, pasta, or a sandwich, a side dish usually a vegetable, and fresh fruit. The youth are also provided water or milk to drink. Each day, the staff order food from local fast food restaurants which corresponds with the daily menu. All completed surveys confirmed one single menu is provided for youth and staff and program staff accommodate youth with special dietary needs due to religious beliefs and food allergies by providing appropriate substitutions. Additionally, food items, particularly sweets, such as candy, baked goods, and soft drinks are provided to the youth on a regular basis serving as the primary reinforcement in the program s behavior management system. The youth use earned points to purchase these items in the bid store. The facility has a small kitchen area equipped with cabinets where they store paper products and bulk non-perishable food items. There is a refrigerator/freezer containing milk, juice, water, condiments, and a variety of fresh fruit and vegetables. There is also a microwave. The kitchen area was observed to be clean and food appeared to be handled in a sanitary manner. During the program tour reviewer observed there is a list of youth and their food allergies affixed to the refrigerator to ensure the youth are not accidentally provided with a food which would cause allergy symptoms. There was also a list of dietician approved substitution for menu items if special accommodations are needed attached to the refrigerator door Transportation Compliance The program provides a safe and appropriate treatment environment including transportation. The program has a written policy and procedures addressing transportation of youth and vehicle maintenance to ensure the program provides safe transportation to and from the program, school, and community-based events. The program currently uses two vehicles to provide daily Office of Program Accountability Page 14 of 40 (Revised July 2016)

15 transportation for youth to and from the facility. Presently, one of the vehicles is maintained by the program and the other van is rented on a weekly basis until a new van which is currently on order is available. Both vehicles are fifteen passenger vans. Observation during the review week confirmed each of the vehicles was locked and secure when not in use. Inspection of the vans during the review determined each van was clean, equipped with a fire extinguisher, and had working seat belts for every passenger. Survey results of five youth and three staff unanimously assert seat belt use is enforced on every program transport. Additionally, each time there is a transport the staff takes travel bag, which includes a first aid kit and a window punch in case of emergency. There was documentation the program s vehicle had undergone weekly vehicle inspections by the program staff to check for safety issues and overall working condition. Additional documentation was reviewed to verify the vehicle owned by the program had undergone routine servicing and a maintenance check by a licensed mechanic three times within the past six months. The program also provided a current vehicle registration and proof of current insurance for this van. The reviewed program approved driver list indicated each of the staff is an authorized driver able to transport the youth. The program provided documentation indicating each driver has a valid driver s license and the status of the licenses are checked monthly Administration Compliance The program provides a safe and appropriate treatment environment including administrative and operational oversight. The program has a written policy and procedures to ensure administrative and operational oversight of program services and effective communication of pertinent information to the Department of Juvenile Justice is provided in a timely and comprehensive manner. A review of the reports for the months of February and March substantiates the program submits a monthly statistical report to the Department detailing significant incidents and population information. The report includes admissions, releases, transfers, abuse reports, medical/mental health emergencies, incidents, absconders, volunteer hours, and data regarding the number of youth completing the program at the contracted length of stay. The program s current youth roster was observed to match the census report in the Juvenile Justice Information System (JJIS) on the first and final dates of the review. The program maintains a daily facility logbook, to record significant facility activities, events, and, as appropriate any unusual incidents occurring in the program on a given day. Two facility logbooks documenting information from August 2016 through April 2017 were examined during the annual compliance review. The majority of reviewed entries included dates and times of events and significant incidents, the names of staff and youth involved in the events, alerts regarding youth, and other informational advisories needing to be conveyed to staff. Each page was dated on top and there was a page for each day the program provided services. All of the entries included the signature of the person making the entry, and in the past three months, included the name of the person responsible for the entry written as well. All of the logbook entries were observed to be written in ink and legible. While there were only a few errors noted, all observed errors were struck through with one line with void written by the error. There was documentation indicating the program coordinator often exceeded the requirement regarding biweekly reviews of the logbooks and she repeatedly commented on the need for appropriate documentation. Upon arrival to the program each day, the staff are required to review the logbook and sign the book to confirm their review. The program consistently highlighted any entries regarding safety and security issues. It was observed, however, several of the logbook entries each day, did not include the time of the entry or of the incident described in the entry. Office of Program Accountability Page 15 of 40 (Revised July 2016)

16 Rather, the staff would use Note to address the information. Often, these notes would convey time sensitive information such as the time a fire drill was initiated and/or completed or when a youth was placed on precautions and when the youth was stepped down to standard supervision. Sometimes the Notes were written in the body of the daily logbooks so a time of occurrence could be estimated, but other times, the notation was documented as the last entry of the day, making it difficult to discern when the event/incident occurred. The timing of the event/incident not documented in the log book was able to be found documented elsewhere and the time of occurrence rather easily determined. Program management staff indicated all Paxen staff will undergo a re-training as to log book documentation in the near future Ninety-Day Supervisory Reviews Compliance Cases under supervision (i.e., probation, conditional release, post-commitment probation) are reviewed by the supervisor at least once every ninety calendar days. The supervisor ensures staff review any instructions given during the review, and ensures they were followed during the subsequent review. The program has a policy and procedures requiring a supervisory review be conducted regarding each youth s progress in the program at least once ever ninety days. A review of five open records indicated four youth were applicable for one ninety-day supervisory review. The remaining youth was admitted eighty-eight days prior to the first date of the annual compliance review. However, it was observed all five reviewed records included documentation of a supervisory review. Four of five of the supervisory reviews were conducted on or before the ninetieth day. One review, however, was observed to be one day late. Prior to the completion to the supervisory reviews, according to reviewed documentation, the youth s case manager had completed a Positive Achievement Change Tool (PACT) reassessment of the youth s risks and needs. Each supervisory review was completed by the Central Region Program Manager and each supervisory note addressed the youth s progress in program and offered the recommendation case manager to sustain the documentation and monitoring of the case. Additionally, in one record, the supervisory review referenced the PACT and Youth Empowered Success (YES) Plan having been updated. There was documentation in the four of the five case notes confirming the case manager had acknowledged the supervisory review Incident Reporting (CCC) Compliance The program provides a safe and appropriate treatment environment including transportation. Whenever a reportable incident occurs, the program notifies the Department s Central Communications Center (CCC) within two hours of the incident, or within two hours of becoming aware of the incident. The program has a written policy and documented procedures regarding the reporting incidents to the Department s Central Communication Center (CCC). In the past six months, the program experienced one reportable CCC incident. The incident was a minor car crash involving the program vehicle. A review of the CCC daily report indicated the report was made within the required two-hour time frame. A review of internal incident reports, the program log book and the youth grievance log did not document any additional incidents or events which should have been reported to the CCC. Office of Program Accountability Page 16 of 40 (Revised July 2016)

17 1.14 Abuse-Free Environment Compliance Any knowledge or suspicion of abuse, abandonment or neglect is reported to the Florida Abuse Hotline. The program has a policy and procedures in place to ensure the provision of safe environment for the youth under their supervision, free of any form of abuse or maltreatment. Additionally, reviewed documentation indicates the program seeks to inform the youth under their care of the program s responsibility and availability to assist them in reporting any abuse they have or are experiencing whether it involves program staff, family members or others in the community. To ensure the on-site environment is free from abuse, bullying, intimidation and/or prejudice, the Paxen Learning Corporation employee handbook and standard operating procedures outline a staff code of conduct prohibiting any kind of abusive and/or disrespectful behavior towards youth. The corporate Code of Conduct was reviewed and found to address any kind of unprofessional behavior with and/or involving the youth in the program. Each new staff signs a copy of the employee Code of Conduct and a copy is maintained in the staff s personnel record. During this review period, there have been no allegations of staff misconduct in the program milieu or involving program youth. A review of documentation or the verbal reports of management did not indicate any staff has been disciplined due to violations of the Code of Conduct. Furthermore, five of five surveyed youth indicated they feel safe in the program. The program requires staff and youth to have unimpeded access to report abuse to the appropriate agency, dependent on the youth s age, via the Florida Abuse Hotline or the Department s Central Communication Center (CCC). If a youth requests the opportunity to use the telephone to report abuse, program policy mandates staff escort the youth to a private office and allow the youth to call the appropriate reporting number. Notably, five youth case management records were reviewed and each documented intake procedures during which the program provided to the youth and parent/guardian an educational packet of information defining the different kinds of abuse, characteristics of abusers, signs of abuse, and how to report abuse. Instructions and telephone numbers for abuse hotline numbers for every state in the country is attached to the report. A review of intake documentation indicates each of the five youth and the parent/guardian acknowledged receipt of this information. All five surveyed staff reported never hearing another staff tell a youth they could not call the Florida Abuse Hotline or CCC. All five surveyed youth reported they have not been stopped from reporting abuse to the Florida Abuse Hotline since they have been in the program. There were no documented calls to the CCC to report allegations of abuse within the program or incidents during which staff reported abuse or neglect on behalf of the youth during the annual compliance review period. Neither was there any incidence in the reviewed documentation of staff failing to report abuse. Five of five surveyed youth indicated they are treated respectfully by program staff and they have never heard the staff use threats or curse words when speaking to them or other youth. Office of Program Accountability Page 17 of 40 (Revised July 2016)

18 1.15 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 written policy and procedures outlining the Behavioral Management System (BMS). Paxen has implemented the BMS to foster youth accountability for their behaviors and compliance with the expectations, rules, and requirements of the program, as well as, the Department of Juvenile Justice (DJJ), and state and federal laws. The program displays its mission statement and the correlating DJJ mission statement asserting the reduction of juvenile crime in the lobby of the facility. The BMS is informed by the What Works principles adopted by DJJ and focuses on the provision of a safe, structured environment where youth are treated respectfully and fairly with opportunities to access positive reinforcement and recognition for prosocial change as they learn to recognize their behaviors yield consequences for themselves and others. A review of the intake documentation including the Youth and Parent Handbook provided by the program at admission, indicates the program seeks to educate the youth and parent/guardian about the program activity schedule and goals, as well as, the BMS from the onset of contact with the program staff. The Handbook articulates the consequences imposed by the program for, both, positive and negative behaviors. The program rules and expectations are also posted on the walls in the main room where youth congregate. The program utilizes an Effective Response System (ERS) and a contingency-based behavior management system (BMS) to teach and reinforce positive, prosocial, and productive behaviors, and to promote personal accountability for the choices the youth make regarding negative behaviors. Using the principles of a token economy, the behavior management system uses skill cards, credit points, and opportunities to earn verbal praise, certificates, or other reinforcers such as snack items in the program s bid store and the ability to participate in special activities and outings. Negative consequences for minor misconduct includes verbal redirection, removal from the program activity so points and reinforcers cannot be earned, counseling, and privilege suspension. Major offenses could warrant meetings with the juvenile probation officer, calls to law enforcement, and possible termination from the program. Five youth records including Juvenile Justice Information System (JJIS) case notes, and the program log book were reviewed for BMS documentation. All records contained the weekly skill cards initialed by the program staff, which documents the youth behavior and points earned during the various activities for each day during the week. Consequences for noncompliance are also documented on the youth s skill card and the youth s case notes. Documentation indicated disciplinary procedures are carried out promptly, and the consequences are fair and directly associated with the negative behavior. The case notes in all reviewed records contained documentation of staff responses to non-compliance with program rules utilizing the program s ERS in association with the youth s individualized YES Plan youth requirements and Positive Achievement Change Tool (PACT) goals. Accordingly, when negative behavior is displayed, there is documentation of staff meetings with the youth, the juvenile probation officer, the mental health therapist, and the parent/guardian focused on improving the youth s behavior. If the behavior infraction is critical in nature, the youth is removed from the general population to obtain counseling or discuss the potential consequences of their behavior and, at times, sent Office of Program Accountability Page 18 of 40 (Revised July 2016)

19 home to avoid program disruption. All critical infractions and serious negative consequences, such as activity restriction, are documented in the facility logbook. The program does not use any form of facility restriction or time out. Neither is any youth or group of youth permitted to discipline or exert control over other youth according to all five youth and all three staff surveyed during the annual compliance review. Consistently, all five surveyed youth indicated they have never been placed in time out. All surveyed youth indicated they have never experienced prohibited restrictions of loss of regular meals, health care, religious needs, contact with parents/guardians, legal assistance, or staff assistance as a consequence for negative behavior or resistance to program expectations or rules Youth Records (Healthcare and Management) Compliance The program maintains an official case record, labeled Confidential, for each youth, which consists of two separate files: An individual healthcare record An individual management record. The program has a policy and procedures for maintaining youth case records. During the annual compliance review, it was observed all documentation regarding program youth is stored in a locked record cabinet in a locked office where only authorized staff have key access. The record cabinet housing the youth records was observed to have confidential labels affixed to it. The review of youth records confirmed program compliance with the requirement of the maintenance of two separate youth records for each youth on the program roster, specifically, an individual health care record, and an individual management record. Each of these records is maintained in a three ring binder. Additionally, the program maintains a separate clinical record folder where all mental health and substance abuse documentation is contained. All records were marked as confidential. Each individual management record is maintained in a binder with five tabbed sections, as required, designating separate sections for legal information, demographic and chronological information, correspondence, case management/treatment team activities, and a miscellaneous information. Office of Program Accountability Page 19 of 40 (Revised July 2016)