BUREAU OF MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR

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1 S T A T E O F F L O R I D A D E P A R T M E N T O F J U V E N I L E J U S T I C E BUREAU OF MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR AMIkids Southwest Florida AMIkids, Inc. (Contract Provider) 1190 Main Street Fort Myers Beach, Florida Review Date(s): June 6-8, 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: Shawna Prope, Office of Program of Accountability, Lead Reviewer (Standard 1]) Shakela Minns, Office of Program of Accountability, Regional Monitor (Standard 2) Patrick Morse, Office of Program of Accountability, Regional Supervisor, (Standard 3 and Standard 4) Nicos Antonakos, Office of Program Accountability, Technical Assistance Specialist (SPEP) (Standard 1.05, 1.10)

3 Program Name: AMIkids Southwest Florida MQI Program Code: 1252 Provider Name: AMIkids, Inc. Contract Number: P2121/19 Location: Lee County / Circuit 20 Number of Beds: 34 Review Date(s): June 6-8, 2017 Lead Reviewer Code: 158 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 # Case Managers # Clinical Staff # Food Service Personnel # Healthcare Staff # Maintenance Personnel # Program Supervisors Documents Reviewed 5 # Staff 5 # Youth 1 # Other (listed by title): Lead educator, director of operations, Acting exective director 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 5 # Health Records 5 # MH/SA Records 5 # Personnel Records 7 # Training Records/CORE 3 # Youth Records (Closed) 5 # Youth Records (Open) # Other: 5 # Youth 5 # Direct Care Staff # Other: Observations During Review Admissions Confinement Facility and Grounds First Aid Kit(s) Group Meals Medical Clinic Medication Administration Posting of Abuse Hotline Program Activities Recreation Searches Security Video Tapes Sick Call Social Skill Modeling by Staff Staff Interactions with Youth Comments Staff Supervision of Youth Tool Inventory and Storage Toxic Item Inventory and Storage Transition/Exit Conferences Treatment Team Meetings Use of Mechanical Restraints Youth Movement and Counts Items not marked were either not applicable or not available for review.

4 Standard 1: Management Accountability Day Treatment Rating Profile Indicator Ratings Standard 1 - Management Accountability 1.01 Initial Background Screening* 1.02 Five-Year Rescreening 1.03 Protective Action Response (PAR) 1.04 Pre-Service/Certification Training 1.05 In-Service Training 1.06 Cleanliness and Sanatation 1.07 Fire Prevention and Evacuation Procedures 1.08 Water Activities 1.09 Food Services 1.10 Transportation 1.11 Administration 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 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 Limited 2.03 Positive Achievement Change Tool (PACT) Full Assessment 2.04 Transitional Planning/Reintegration* 2.05 Youth-Empowered Success (YES) Plan Development 2.06 Youth Requreiment/PACT Goal Elements 2.07 YES Plan Implementation/Supervision 2.08 Ninety-Day YES Plan Updates 2.09 PACT Reassessment 2.10 Progress Reports 2.11 Education Transition Plan 2.12 Termination Release 2.13 Career Education 2.14 Educational Access * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 5 of 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 Limited 3.06 Mental Health and Substance Abuse Treatment Limited 3.07 Treatment and Discharge Planning Failed 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 recently had a sail boat donated by a board member. During the annual compliance review, the program had construction underway to have a means of safely storing the boat. A pool table was donated to the program for the youth to use as part of the activities when it is raining and they are not able to have outside activities. Several youth were with two staff members in South Carolina participating in the AMIkids Olympics youth competition during the annual compliance review. While at the Olympics, the youth competed in activities such as swimming, boating, running, and other activities against other youth who are attending different AMIkids programs throughout the country. One of the two staff is certified life guard through the American Red Cross. Youth are chosen to attend the Olympics event based on progress in the program. Office of Program Accountability Page 8 of 31 (Revised July 2016)

9 Standard 1: Management Accountability Overview AMIkids Southwest Florida is a non-residential day treatment program operated by AMIkids, Inc. under contract with the Department of Juvenile Justice (DJJ). The program is contracted for thirty-four slots and serves males and females residing in Circuit 20, Lee County. The program s length of stay ranges between three and six months, depending upon the individual youth s progress in the program. A tour of the facility found the program is clean and maintained in good condition, supporting positive interactions between youth and staff. Each youth in the program receives breakfast, lunch, and a snack five days each week. At the time of the annual compliance review, the program staff included the acting executive director, operations director, mental health coordinator, director of education, certified teacher, mental health therapist, three local care counselors, two bus drivers, and one vocational construction instructor. There was one full-time teacher position vacancy and one executive director position vacancy at the time of the annual compliance review Initial Background Screening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. The background screening process is completed prior to hiring an employee or utilizing the services of a volunteer, mentor, or intern. An Annual Affidavit of Compliance with Level 2 Screening Standards is completed annually. The program has a policy and procedures which addresses initial background screening. A review of employee files indicated the program has nine employees and seven volunteers who were eligible for initial back ground screening since the last annual compliance review. A review of the Background Screening Unit (BSU) indicated all nine employees had screenings prior to employment or working with youth. An internal audit was completed by the program in February 2017, and at that time it was found five volunteers did not have background screening completed prior to working with youth. The program ceased all contact with youth and a call was made to the Department s Central Communications Center (CCC) by the executive director. The program created an outcome-based corrective action plan, which included the volunteers not working with youth until background screens were completed, and to have quality improvement standards regarding background screening shared with team members. An interview with the director of compliance indicated the five volunteers had started the week prior, and no incidents were made during the four and a half hours the volunteers were in contact with the youth. One of the five initial volunteers returned after the background screening was cleared through the Department's BSU. In addition, the two new volunteers did not have contact with youth prior to a cleared background screening through the Department. The executive director completed and submitted the Annual Affidavit of Compliance with Level 2 Screening Standards to the BSU on January 5, 2017, meeting the annual requirement. Office of Program Accountability Page 9 of 31 (Revised July 2016)

10 1.02 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 had one staff who was applicable for a five-year background screening since the last annual compliance review. The staff member s screening was completed and submitted to the Department s Background Screening Unit (BSU) at least ten days prior to the anniversary date 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 maintains a policy and procedures for Protective Action Response (PAR). A review of the program s documentation indicated one PAR report was completed after a countermove was used with one youth who was in an altercation with another youth. The report was reviewed by a PAR certified instructor. The report was completed within the required time frame of the incident. The youth involved in the PAR denied medical attention; the parent/guardian was notified of the incident. The PAR report was not reviewed within the seventy-two-hour time frame. Once it was noticed during the internal audit, an outcome-based corrective action plan was developed to ensure all incidents are reviewed and completed within the required time frames and contains appropriate signatures of all parties involved 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 instructor-led and web-based pre-service training courses for employees. The program submitted a master training schedule to the Department s Office of Staff Development and Training (SD&T), on January 18, 2017, which outlines various scheduled training topics. An individual training file is maintained for each staff. The file contains certificates, sign-in sheets, and test results. A review of five training files was conducted. All staff finished the required training needed prior to having contact with youth. One of five staff completed the required training and exceeded the minimum of 120 hours completed within 180 days of being hired. The other four staff were still within their 180 days of hire. All pre-service trainings were entered in the Department s Learning Management System (SkillPro). The program also utilizes an internal web-based learning system called Moodle to document and track various pre-service and in- Office of Program Accountability Page 10 of 31 (Revised July 2016)

11 service staff trainings, which includes Department required trainings, as well as specific AMIkids required trainings In-Service Training Compliance Contracted non-residential staff completes in-service training in accordance with Florida Administrative Code. Contracted non-residential staff must complete twenty-four hours of annual in-service training, beginning the calendar year after the staff has completed pre-service training. Supervisory staff shall complete eight hours of training in the areas listed below, as part of the twenty-four hours of annual in-service training. The program has a policy and procedures in place for in-service training. A review of five staff files found staff were applicable for in-service training. All staff received the required training in accordance with Florida Administrative Code. Each reviewed staff training file indicated each staff was trained in the operation of the fire alarm system, and the proper operation and use of available fire protection equipment. One of the five reviewed staff files indicated the staff was trained on medication administration. None of the five reviewed staff files were applicable for lifeguard certification. The applicable reviewed staff files indicated the staff received six hours of suicide training, and all staff participated in mock training in response to a suicide attempt or self-inflicted injury. During this annual compliance review, there were no applicable supervisors working at the program longer than twelve months Cleanliness and Sanitation Compliance The program provides a safe and appropriate treatment environment including maintenance and sanitation of the facility. The program maintains a facility maintenance log. A review of the log found the log contained a maintenance plan and documentation confirming the program staff conducted a weekly facility housekeeping and security checklist. The program has a large group area used as a cafeteria, where they conduct counseling sessions, and celebrate events with the youth and staff. The program was observed to be clean and well maintained during the annual compliance review. There were no visible signs of graffiti on the walls, doors, or windows throughout the program Fire Prevention and Evacuation Procedures Compliance The program provides a safe and appropriate treatment environment including fire prevention and evacuation procedures. The program has a policy and procedures for fire prevention and evacuation procedures. A review of the logbooks indicates the program is conducting fire safety drills as required. Five youth and five staff were surveyed pertaining to fire prevention and safety. All surveyed staff and youth indicated they are aware of what to do in case of a fire, and indicated they participate in fire safety drills. Fire protection equipment is available strategically throughout the program. Fire inspections was completed by Fort Myers Beach Fire Control District on May 8, 2017, with six deficiencies noted on the inspection. The Fort Myers Beach Fire Control District returned to the program on May 30, 2017 and all deficiencies were corrected resulting in a satisfactory final inspection report. Office of Program Accountability Page 11 of 31 (Revised July 2016)

12 1.08 Water Activities Compliance The program provides a safe and appropriate treatment environment including procedures for water activities. The program has a policy and procedures related to water related activities. The policy requires youth to have a swim test and diver certification prior to participating in water activities, to ensure youth are properly trained in water safety. The program has a teacher who is a certified lifeguard through the American Red Cross. Reviewed documentation indicated the program notified each youth s parent/guardian of the swim test in case of serious illness, injury, or death prior to participation in a swim test and/or any other water-related activities. Five youth were surveyed, four of the five youth stated they participated in water related activities and received a swim evaluation prior to the participation in the activities Food Services Compliance The program provides a safe and appropriate treatment environment including food service. The program provides a safe and appropriate treatment environment including food services. Five youth indicated being aware of the program providing a special diet for youth with health/medical issues or religious beliefs. A survey of five staff verified the staff provide their own meals. The program provides breakfast, lunch, and snacks for the youth through the Fresh Florida Kids Transportation Compliance The program provides a safe and appropriate treatment environment including transportation. The program provides a safe and appropriate treatment environment to include transportation. The program utilizes two school buses and a van for transportation. All three vehicles had current insurance and registration. The two school buses were in safe and sound condition. Both buses were equipped with seat belts. Five staff and five youth surveys indicated the youth and staff utilize seat belts during transportation. Both school buses had fire extinguishers, first aid kit, and a body fluid clean up kit. Emergency doors and windows were operational. The van was not available to be examined during this annual compliance review due to the van being in the repair shop getting a new transmission installed. The buses do not have locks on the doors. The program does not penalize or deny service to the youth based on lack of transportation. Five youth were surveyed, and all stated they wear seat belts when being transported on the bus. Office of Program Accountability Page 12 of 31 (Revised July 2016)

13 1.11 Administration Compliance The program provides a safe and appropriate treatment environment including administrative and operational oversight. According to the executive director, the program submits the required statistical information to the program s corporate headquarters on a monthly basis. The statistical information provided includes admissions, releases, transfers, average length of stay, and Protective Action Response incidents. The program maintains a daily logbook, which records significant activities, incidents, and events. The logbook entries also show the safety and security issues were highlighted. The logbooks did not indicate when a youth was given a timeout or removed from a classroom for behavioral issues. The logbook entries are legible, brief, written in ink with the date, time, and name of the person making the entry. There was inconsistent documentation in the logbook concerning counts of youth arriving in the morning and leaving the program at the end of the day. The executive director reviewed the entries and signed the logbook on a biweekly basis 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. Seven youth case management files were reviewed and found three youth were applicable for completion of the ninety-day supervisory review. All three youth case management files indicated supervisory reviews were completed within the required time frame, and Positive Achievement Change Tool (PACT) goals were updated prior to the 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 had three Central Communications Center (CCC) reportable incidents involving complaints against staff and medical/program disruptions during this annual compliance review period. Two of the three incidents were reported within the two-hour time frame. A review of the incident report logbook indicated a search of a school bus was conducted on April 26, 2017 and contraband was found hidden in a seat. Staff did call the youth s parent/guardian who stated the youth was taking medication. Since the medication was not in a prescription bottle, a call to the CCC should have been made. The program called in the incident during the annual compliance review; the call was not accepted by the CCC because the youth was not a Department of Juvenile Justice youth, but a school district youth. The program did place the incident in the logbook. Further review of the logbook found on May 25, 2017 a report was called to CCC concerning a youth was committed to the program by the court had absconded on April 26, The program did not meet the two-hour time frame to report this incident as it was a month late. Office of Program Accountability Page 13 of 31 (Revised July 2016)

14 1.14 Abuse-Free Environment Compliance Any knowledge or suspicion of abuse, abandonment or neglect is reported to the Florida Abuse Hotline. Observations made during a tour of the program found signs posted throughout the facility listing the telephone numbers for the Florida Abuse Hotline and the Central Communication Center (CCC). A student handbook is provided to each youth upon admission, which includes the youth s rights, the program s grievance process, and the telephone numbers for the Florida Abuse Hotline and CCC. Staff receive an employee handbook with the expectations of the team members, code of conduct, and new hire packet including documentation regarding inappropriate behavior on social media and reporting it when relating to staff and/or youth involved in the program. Five surveyed youth reported never being stopped from reporting abuse to the Florida Abuse Hotline. Youth stated if they wanted to make a call, the staff will take them to make the call. Five youth reported staff are respectful when speaking with them. All five youth reported feeling safe in the program. Five staff were surveyed and denied ever seeing a co-worker deny a youth an abuse call. The five interviewed staff stated they have never seen staff use profanity when speaking with youth Behavior Management System Compliance The program utilizes a behavior management system providing privileges and consequences to encourage youth to fulfill programmatic expectations. Consequences are fair and directly correlate with the behavior problem. The use of facility restriction does not exceed seven consecutive days. Disciplinary procedures are carried out promptly. Youth are not allowed to have control over or discipline other youth. Time-out is used in accordance with Florida Administrative Code. All behavior problems, time-outs, in-facility suspensions, and privilege suspensions are documented in the facility log and case file in accordance with Florida Administrative Code. The program maintains a policy and procedures regarding the behavior management system. The program utilizes a behavior management system, which has three primary components to include a point card system, a token economy, and a rank system. The system provides behavioral expectations for youth, immediate reinforcement for target behaviors, and access to privileges. The tokens can be used to purchase items such as hygiene products, snacks, or gifts for family members. Five youth were surveyed and stated they are given timeout for disruption of class or bad behaviors. Staff interviewed stated youth are removed for cursing or bad behavior and are encouraged to speak with a therapist. Youth stated they are never denied meals, snacks, or healthcare while in time out 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. A review of six youth case management records indicated the program maintains separate records for case management and healthcare for youth in the program. The individual case management records and medical/mental health records are organized with separate sections Office of Program Accountability Page 14 of 31 (Revised July 2016)

15 for legal, demographic, correspondence, treatment activities, and miscellaneous. The individual healthcare records contain the youth s medical, mental health, and substance abuse related information. Each youth record was marked confidential and were secured in a filing cabinet in a locked room when not in use. The program complies with the records and confidential information provisions pursuant to F.S Standard 2: Assessment and Intervention Services Overview Youth admitted into AMIkids Southwest Florida receives an initial screening, intake, orientation, individualized treatment planning, individualized service planning, assessments, and are assigned to evidence-based and promising practice interventions based on their identified individual needs. During the intake process, each youth is provided a handbook outlining the program s expectations for each youth. The program has local care counselors (LCC) responsible for completing the Positive Achievement Change Tool (PACT), Youth-Empowered Success (YES) Plan, progress reports, and monitoring completion of the YES Plan 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. Five youth case management records were reviewed. Each record included an orientation acknowledgment form signed by the youth, parent/guardian, and case manager. Each record documented orientation was completed within twenty-four hours of the youth s admission. A review of the case notes validated orientation was conducted. The orientation addressed all required information, including program goals and available services, case planning process, telephone guidelines, search policy, youth rights and grievances, Florida Abuse Hotline telephone number, Advocacy Center for Persons with Disabilities telephone number, facility rules governing youth conduct/consequences, introduction to program staff, and a tour of the facility. In addition, the orientation addressed expectations while in the program, rules, behavior management system, daily activity schedule, medical/mental health services, emergency safety, evacuation procedures for the facility, contraband, performance planning process, anticipated length of stay, and dress code. Each case management record reflected the youth received orientation. The admission date for each youth was accurately reflected in the Department s Juvenile Justice System (JJIS) Medical Alerts, Mental Health Alerts, and Suicide Risk Alerts Limited Compliance 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 for identifying and documenting medical, mental health, and suicide risk issues. According to the program s policy, a medical alert shall be entered into the Department s Juvenile Justice System (JJIS) and program alert system when a youth is identified as a medical risk during screening, staff observations, or evaluation. l. Office of Program Accountability Page 15 of 31 (Revised July 2016)

16 Five youth mental health records were reviewed and found medical, mental health, and suicide risk alerts were entered into the JJIS when applicable. However, a review of the program s internal alerts list revealed the program had not updated the internal alert system since May 19, During the annual compliance review, the program updated the internal alert system on June 6, A review of the program s internal alert list confirmed staff signed the internal alert list acknowledging being made aware of all alerts. Five staff surveys revealed staff are informed of youth s medical alerts during daily briefings and by checking the Department s JJIS 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. A review of five youth case management records validated a Positive Achievement Change Tool Assessment (PACT)Full Assessment was completed by the program. Each reviewed PACT was completed within seven days of the youth s admission into the program Transition Planning/Reintegration Compliance Program staff actively participates in the transitional planning process for youth who are being released from a residential program on conditional release (CR) or post-commitment probation (PCP). For conditional release and post-commitment probation youth, the YES Plan must address recommendations from the residential program during transition. The program has a written policy and procedures outlining transitional planning for youth who are being released from a residential program on conditional release (CR) or post-commitment probation (PCP). A review of one applicable youth case management record found documentation of communication with the youth and parent/guardian. Reviewed documentation validated intervention recommendations were identified on the Youth-Empowered Success (YES) Plan development. The reviewed record was not applicable regarding face-to-face contact during transition conference due to the program being beyond a fifty-mile radius. According to Florida Administrative Code 63T (2)(a), the juvenile probation office (JPO) must participate in intervention and treatment team meetings unless written authorization is obtained in advance from their supervisor. If the JPO does not participate in person, telephonically, or if available, through web-based video phone, they shall follow-up with the program and youth within seventy-two hours of the meeting to confirm progress, and identify which actions need to be initiated in the youth s home community by the JPO. A review of the case notes showed documentation of the case manager requesting to be a part of the transitional conference/exit. Documentation indicated phone requests were made on June 21, 2016, August 10, 2016, and September 1, 2016, to participate in the transitional planning prior to the youth being released on conditional release. However, the case manager was not given a date to attend the transitional planning process 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 the Youth-Empowered Success (YES) Plan development. Five youth case management records were reviewed. Each reflected Office of Program Accountability Page 16 of 31 (Revised July 2016)

17 the Positive Achievement Change Tool Assessment (PACT) Full Assessment was developed prior to the initial YES Plan. Reviewed case notes confirmed the YES Plan was developed with the youth, parent/guardian, and case manager within fourteen days of admission into the program. Each case management record documented a copy of the initial YES Plan was mailed for review and signature to the youth and parent/guardian. A review of the case notes indicated the youth and parent/guardian was informed of the importance of complying with the sanctions and goals of the plan, and participated in the development of the plan However, the YES Plans did not reflect when the signatures were obtained by all parties. Five youth were surveyed and indicated they participated in the development of their YES Plan and were provided with a copy 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). Five youth case management records were reviewed. Each record included a Youth- Empowered Success (YES) Plan with individualized target dates for completion and a Positive Achievement Change Tool (PACT) goal. A review of the Department s Juvenile Justice Information System (JJIS) reflected court-ordered sanctions for each youth in the Youth Requirements module. Each youth s YES Plan included the intervention elements (who, what, and how often). All five youth case management records had at least one of the top three criminogenic needs addressed by creating a PACT Change Goal. Each goal contained at least one action step for the youth, parent/guardian, and case manager. Five youth were interviewed and were able to explain goals included in the YES Plan 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. Five youth case management records were reviewed. Each record indicated the program documented contacts with the youth and parent/guardian in an attempt to ensure compliance with the action steps and sanctions outlined in the Youth-Empowered Success (YES) Plan. Reviewed documentation showed case note activities, including face-to-face interactions, and telephone contact with the youth, parent/guardian, and providers. Additionally, a review of written or verbal reports from collateral sources were documented. Office of Program Accountability Page 17 of 31 (Revised July 2016)

18 2.08 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. Five youth case management records were reviewed. Three of five case management records were applicable for ninety-day Youth-Empowered Success (YES) Plan updates. Two youth case management records were not applicable due to the youth being enrolled less than ninety days. Three applicable reviewed case management records indicated staff made modifications to the YES Plans to reflect new needs, when applicable, and progress made during the course of supervision. Three reviewed case management records indicated necessary updates of the YES Plan requirements and Positive Achievement Change Tool (PACT) goals were completed. Each applicable record had a new YES Plan generated in the Department s Juvenile Justice Information System (JJIS) prior to the supervisory review. Three case management records confirmed input and involvement from the youth and parent/guardian to develop the YES Plan. A review of the case notes confirmed the YES Plan was developed and negotiated with each youth, parent/guardian, and case manager 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 outlining the Positive Assessment Change Tool (PACT) Reassessment for each youth on probation, conditional release, and postcommitment probation, as well as minimum-risk non-residential commitment youth. According to the program s policy, a final PACT assessment will be completed at program completion to document the youth s progress in meeting criminogenic needs, as well as court-ordered sanctions. Additionally, any PACT completed within fourteen days of release shall be considered as the exit PACT. A review of five youth case management records found four of five youth who had been at the program longer than ninety days had a Positive Assessment Change Tool (PACT) Re-Assessment completed in a timely manner. One youth case management record found the PACT Re-assessment is still within the ninety-day window. Five reviewed youth case management records were not eligible for an exit PACT. A review of three closed youth management records showed a Positive Assessment Change Tool (PACT) Re- Assessment was completed in a timely manner. Three closed youth case management records did not have supporting documentation of a PACT Final Assessment being done to address the youth s progress in meeting criminogenic needs as well as court ordered sanctions. Three of the closed case management records did not include documentation of an exit PACT being conducted within fourteen days of the youth s release from the program. Office of Program Accountability Page 18 of 31 (Revised July 2016)

19 2.10 Progress Reports Compliance Progress reports are completed detailing the youth s progress with the youth requirements and PACT goals outlined in the YES Plan. A review of five youth case management records found three were applicable for progress reports. Three youth progress reports were completed within ninety days. Two youth case management records are still within the ninety-day window. A cover letter was included with each progress report. Reviewed documentation confirmed youth were given the opportunity to review their progress report(s) and add comments. All progress reports were signed and dated by the youth and staff who prepared the report. All progress reports were reviewed and signed by the executive director or designee. A review of three case management records included signed progress reports, which were never mailed to the courts or juvenile probation officer (JPO). A review of case notes reflected the case manager enters all progress report information into the Department s Juvenile Justice Information System (JJIS) by entering a case note Education Transition Plan Compliance Staff and youth complete an Education Transition Plan prior to release including provisions for continuation of education and/or employment. The program has a written policy and procedures outlining the education transition plan. Three closed case management files was reviewed, and each contained documentation of an education transition plan, which was developed with the youth and signed by all required parties. One reviewed educational transition plan did not have the youth s parent/guardian signature. Each educational transition plan was completed and signed prior to the youth s release and included provisions for the continuation of each youth s education, treatment, and employment when applicable. Each plan addressed services and interventions based on the youth s assessed educational needs and post-release education plan, services to be provided during the youth s stay and services to be implemented upon release, including, but not limited to, continuing education in secondary school, post-secondary education, or career opportunities, recommended educational placement for the youth s post-release from a juvenile justice program, and specific monitoring responsibilities by individuals who are responsible for reintegration and coordination of the provision of support services. Three youth case management files included a sample job résumé, sample job application, and career training. Reviewed documentation confirmed the program assists the youth with obtaining a valid form of identification for each youth. The program collaborates directly with community stakeholders for employment assistance. Office of Program Accountability Page 19 of 31 (Revised July 2016)

20 2.12 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 the termination and release process for youth who are on probation, conditional release (CR), and post-commitment probation (PCP). Three closed case management files were reviewed and confirmed the program works together with the juvenile probation officer (JPO) and notifies the JPO of completed sanctions to assist with completing the termination request. The assigned JPO is responsible for completing the termination request, checking with law enforcement for outstanding warrants, closing youth in the Department s Juvenile Justice Information System (JJIS), and notifying the parent/guardian of a youth s termination. The Department s Juvenile Justice Information System (JJIS) was updated by program staff and/or the JPO within the applicable timeframe upon receipt of the youth s termination Career Education Compliance Staff shall develop and implement a career education competency development program. The program has a written policy and procedures outlining career education. The program provides Type 2 career education for each youth. Each youth is also evaluated with the Supplementary Tests of Achievement in Reading (STAR) assessment for mathematics and reading skills. Four case management files were reviewed, and included documentation related to obtaining employment, creating a résumé, and completing employment applications. Upon admission into the program, each youth is assessed according to their learning styles in order to explore their skills, personal abilities, and career interests Educational Access Compliance 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. According to an interview with the executive director of education, and review of the program schedule, the program provides 300 minutes of instruction daily, and 1,500 minutes of instruction weekly. The program s career training and educational programs support the academic courses, giving the youth an opportunity to earn course credit for completion of the education and training experience. The program s scheduled activities do not interfere with the educational instruction activities. Logbooks reviewed and observations made during the review found there is minimal interference with educational instruction. Reviewed documentation Office of Program Accountability Page 20 of 31 (Revised July 2016)

21 confirmed the skills developed in the career training and education programs are supported by academic courses offered in the program. Standard 3: Mental Health and Substance Abuse Services Overview The program has a full-time licensed clinical social worker (LCSW) serving as the designated mental health clinician authority (DMHCA). The DMHCA is responsible for the coordination and implementation of mental health and substance abuse services in the program. The DMHCA supervises one full-time non-licensed master s-level clinician. Youth who demonstrate behaviors or symptoms indicative of a mental disorder or substance abuse during the screening process or upon a youth s admission into the program are referred for a comprehensive mental health and substance abuse evaluation and/or updated evaluation. The program is licensed through the Department of Children and Families in accordance with Chapter 397, Florida Statutes, to provide substance abuse services for children and adolescents in outpatient treatment. The program maintains a comprehensive plan for mental health and substance abuse services, suicide prevention, crisis intervention, and emergency care 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 full-time licensed clinical social worker (LCSW) serving as the designated mental health clinician authority (DMHCA). The DMHCA s current license is clear and active in the State of Florida with an expiration date of March 31, The program s DMHCA was hired on May 1, Prior to this date, the program s previous DMHCA resigned on March 2, During the period of March 2, 2017 through May 1, 2017, the program utilized clinical staff from the AMIKids Tampa program 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 one full-time licensed clinical social worker (LCSW) responsible for the coordination and implementation of mental health and substance abuse services in the Office of Program Accountability Page 21 of 31 (Revised July 2016)