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 Hastings Comprehensive Mental Health Treatment Facility G4S Youth Services, LLC (Contract Provider) 765 E. St. Johns Avenue Hastings, Florida Review Date(s): October 25-28, 2016 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES

2 Rating Definitions Ratings were assigned to each indicator by the review team using the following definitions: Compliance Limited Compliance Failed Compliance No exceptions to the requirements of the indicator; or limited, unintentional, and/or non-systemic exceptions that do not result in reduced or substandard service delivery; or systemic exceptions with corrective action already applied and demonstrated. Systemic exceptions to the requirements of the indicator; exceptions to the requirements of the indicator that result in the interruption of service delivery; and/or typically require oversight by management to address the issues systemically. The absence of a component(s) essential to the requirements of the indicator that typically requires immediate follow-up and response to remediate the issue and ensure service delivery. Review Team The Bureau of Monitoring and Quality Improvement wishes to thank the following review team members for their participation in this review, and for promoting continuous improvement and accountability in juvenile justice programs and services in Florida: Mike Marino, Office of Program Accountability, Lead Reviewer (Standard 1 and SPEP) Kevin Greaney, Office of Program Accountability, Regional Monitor (Standard 4) Lisa Lamb, DJJ Residential Services, Northeast Region, General Services Liaison (Standard 5) Angela Mills, DJJ Probation, Circuit 4, Senior Juvenile Probation Officer (Standard 2) Gwen Nelson, Office of Program Accountability, Regional Monitor (Standard 1 and SPEP) Jennifer Schad, Office of Program Accountability, Regional Monitor (Standard 3) Amy Tyson, Office of Program Accountability, Regional Monitor (Surveys & Interviews)

3 Program Name:Hastings Comprehensive Mental Health Treatment MQI Program Code: 897 Provider Name: G4S Youth Services, LLC Contract Number: R2104 Location: St. Johns County / Circuit 7 Number of Beds: 64 Review Date(s): October 25-28, 2016 Lead Reviewer Code: 37 Methodology This review was conducted in accordance with FDJJ-2000 (Contract Management and Program Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1) Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included in the Residential Standards. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee # Case Managers 1 # Clinical Staff # Food Service Personnel 1 # Healthcare Staff 1 # Maintenance Personnel # Program Supervisors Documents Reviewed 5 # Staff 5 # Youth # 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 7 # Health Records 7 # MH/SA Records # Personnel Records 12 # Training Records/CORE 5 # Youth Records (Closed) 7 # Youth Records (Open) # Other: 7 # Youth 7 # Direct Care Staff # Other: Observations During Review Admissions Confinement Facility and Grounds First Aid Kit(s) Group Meals Medical Clinic Medication Administration Posting of Abuse Hotline Program Activities Recreation Searches Security Video Tapes Sick Call Social Skill Modeling by Staff Staff Interactions with Youth Comments Staff Supervision of Youth Tool Inventory and Storage Toxic Item Inventory and Storage Transition/Exit Conferences Treatment Team Meetings Use of Mechanical Restraints Youth Movement and Counts Items not marked were either not applicable or not available for review. Office of Program Accountability Page 3 of 61 (Revised July 2016)

4 Standard 1: Management Accountability Residential Rating Profile Indicator Ratings 1.01 Standard 1 - Management Accountability * Initial Background Screening 1.02 Five-Year Rescreening 1.03 * Provision of an Abuse-Free Environment 1.04 * Management Response to Allegations 1.05 * Incident Reporting (CCC) 1.06 Protective Action Response (PAR) and Physical Intervention Rate 1.07 * Pre-Service/Certification Requirements 1.08 In-Service Training 1.09 Grievance Process Training 1.10 Grievance Process 1.11 Grievance Process Documentation 1.12 Life Skills Training Provided to Youth 1.13 Staff Training: Delinquency Interventions 1.14 Restorative Justice Awareness for Youth 1.15 Delinquency Intervention Services 1.16 Gender-Specific Programming 1.17 Logbook Entries and Shift Report Review 1.18 * Internal Alerts System 1.19 * Alerts (JJIS) 1.20 Education Acces 1.21 Youth Records (Healthcare and Management) 1.22 Youth Input 1.23 Advisory Board 1.24 Program Planning 1.25 Staff Performance * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 4 of 61 (Revised July 2016)

5 Standard 2: Assessment and Performance Plan Residential Rating Profile Indicator Ratings Standard 2 - Assessment and Performance Plan 2.01 Initial Contacts to Parent/Gaurdian 2.02 Court Notification 2.03 Youth Orientation 2.04 Written Consent of Youth Eighteen or Older 2.05 Classification Factors 2.06 Classification Procedures 2.07 Reassessment for Activities 2.08 Gang Identification: Notification of Law Enforcement 2.09 Gang Identification: Prevention and Intervention Activities 2.10 R-PACT Assessment 2.11 Youth Needs Assessment Summary 2.12 R-PACT Reassessments 2.13 Parent/Guardian Involvement in Case Management Services 2.14 Members of Treatment Team 2.15 Performance Plan Development 2.16 *Performance Plan Goals 2.17 Performance Plan Transmittal 2.18 Incorporation of Other Plans Into Performance Plan 2.19 Treatment Team Meetings (Formal Reviews) 2.20 Treatment Team Meetings (Informal Reviews) 2.21 Performance Plan Revisions 2.22 Performance Summaries 2.23 Performance Plan Summary Transmittal 2.24 Career Education 2.25 Education Transition Plan 2.26 Transition Planning and Conference 2.27 Exit Portfolio 2.28 Exit Conference * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 5 of 61 (Revised July 2016)

6 Standard 3: Mental Health and Substance Abuse Services Residential Rating Profile Indicator Ratings Standard 3 - Mental Health and Substance Abuse Services 3.01 Designated Mental Health Clinician Authority or Clinical Coordinator 3.02 * Licensed Mental Health and Substance Abuse Clinical Staff 3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff 3.04 Mental Health and Substance Abuse Admission Screening 3.05 Mental Health and Substance Abuse Assessment/Evaluation 3.06 Mental Health and Substance Abuse Treatment 3.07 * Treatment and Discharge Planning 3.08 * Specialized Treatment Services 3.09 * Psychiatric Services 3.10 * Suicide Prevention Plan 3.11 * Suicide Prevention Services 3.12 * Suicide Precaution Observation Logs 3.13 * Suicide Prevention Training 3.14 * Mental Health Crisis Intervention Services 3.15 * Crisis Assessments 3.16 * Emergency Mental Health and Substance Abuse Services 3.17 * Baker and Marchman Acts * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 6 of 61 (Revised July 2016)

7 Standard 4: Health Services Residential Rating Profile Indicator Ratings Standard 4 - Health Services 4.01 * Designated Health Authority/Designee 4.02 * Psychiatrist/Designee 4.03 Facility Operating Procedures 4.04 Authority for Evaluation and Treatment 4.05 Parental Notification 4.06 Notification - Clinical Psychotropic Progress Note 4.07 Immunizations 4.08 Healthcare Admission Screening Form 4.09 Medical Alerts 4.10 Youth Orientation to Healthcare Services 4.11 Designated Health Authority/Designee Admission Notification 4.12 Healthcare Admission Rescreening 4.13 Health Related History 4.14 Comprehensive Physical Assessment 4.15 Female-Specific Screening/Examination Non-Applicable 4.16 Tuberculosis Screening 4.17 Sexually Transmitted Infection Screening 4.18 HIV Testing 4.19 Sick Call Process - Requests/Complaints 4.20 Sick Call Process - Visits/Encounters 4.21 Restricted Housing 4.22 Episodic/First Aid Care 4.23 Emergency Care 4.24 Off-Site Care/Referrals 4.25 Chronic Illness/Periodic Evaluations 4.26 Medication Management - Verification 4.27 Medication Management - Orders/Prescriptions 4.28 Medication Management - Storage 4.29 Medication Management - Medication and Sharps Inventory 4.30 Medication Management - Controlled Medications 4.31 Medication Management - Medication Administration Record 4.32 Medication Management - Medication Administration By Licensed Staff 4.33 Medication Management - Medication Provided By Non-Licensed Staff Non-Applicable 4.34 Medication Management - Psychotropic Medication Monitoring 4.35 Infection Control - Surveillance, Screening, and Management 4.36 Infection Control - Education 4.37 Infection Control - Exposure Control Plan 4.38 Prenatal Care - Physical Care of Pregnant Youth Non-Applicable 4.39 Prenatal and Neonatal Care - Nutrition, Education of Youth, and Lactation Non-Applicable 4.40 Prenatal and Neonatal Staff Education Non-Applicable * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 7 of 61 (Revised July 2016)

8 Standard 5: Safety and Security Residential Rating Profile Indicator Ratings Standard 5 - Safety and Security 5.01 Youth Supervision 5.02 * Ten-Minute Checks 5.03 Census, Counts, and Tracking 5.04 Key Control 5.05 Contraband Procedure 5.06 Frisk and Strip Searches 5.07 Vehicles and Maintenance 5.08 Transportation of Youth 5.09 Tool Inventory and Management 5.10 Youth Tool Handling and Supervision 5.11 Outside Contractors 5.12 Fire, Safety, and Evacuation Drills 5.13 Disaster and Continuity of Operations Planning 5.14 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials 5.15 Youth Handling and Supervision for Flammable, Poisonous, and Toxic Items and Materials 5.16 Disposal of All Flammable, Toxic, Caustic, and Poisonous Items 5.17 Recreation and Leisure Activites 5.18 Elements of the Water Safety Plan Non-Applicable 5.19 Staff Training: Water Safety Non-Applicable 5.20 * Swim Test Non-Applicable 5.21 Visitation and Communication 5.22 Comprehensive Behavior Management System 5.23 Implementation and Consistency of Behavior Management System 5.24 Behavior Management System Infractions 5.25 Staff Training: Behavior Management System 5.26 Behavior Management System Monitoring 5.27 Search and Inspection of Controlled Observation Room 5.28 Controlled Observation Limited 5.29 Controlled Observation Safety Checks 5.30 Controlled Observation Release Procedures * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 8 of 61 (Revised July 2016)

9 Strengths and Innovative Approaches The program continues to encourage family involvement for each youth. Families are invited to participate in quarterly family days, during which the program provides food and fun activities. Staff are available during family days to answer any questions families may have about their youth s treatment and progress in the program. Parents/guardians are informed of the treatment team scheduled and are called at the time of each meeting so they can participate. Case management staff facilitate weekly phone calls for youth to their family and visitation is provided weekly as well. The program is accredited by the Commission on Accreditation and Rehabilitation Facilities (CARF). Office of Program Accountability Page 9 of 61 (Revised July 2016)

10 Standard 1: Management Accountability Overview Hastings Comprehensive Mental Health Treatment Facility is located in Hastings, Florida, colocated at the same site as Gulf Academy. Both programs are operated by G4S Youth Services, LLC, through a single contract with the Department of Juvenile Justice. By contract, both programs are non-secure residential programs for male youth between the ages of twelve and nineteen. Hastings Comprehensive Mental Health Treatment Facility includes sixty-four beds. Thirty-four beds are designated for youth needing comprehensive mental health treatment services and thirty beds are designated for youth needing substance abuse overlay services (SAOS). The specialized treatment services are included in the per diem and are not billed separately. There is one management team for Gulf Academy and Hastings Comprehensive Mental Health Treatment Facility. Staff often serve at each program. The management team consists of a facility administrator (FA), three assistant facility administrators (AFA), a clinical director, two assistant clinical directors, a health services administrator, a business manager, a human resources manager, a training coordinator, and a physical plant manager. The FA was on extended leave at the time of the annual compliance review and the senior regional director for G4S has been serving as the FA for the site. The management team meets each weekday morning to discuss scheduling issues, transportation needs, and any other operational concerns. The program contracts for psychiatric services and a designated health authority (DHA). At the time of the review, staff vacancies included an assistant facility administrator for Gulf Academy, one case manager for Hastings Comprehensive Mental Health Treatment Facility, two nurses (one for each side), two therapists (one for each side), and ten youth care workers (five for each side) Initial Background Screening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. The background screening process is completed prior to hiring an employee or utilizing the services of a volunteer, mentor, or intern. An Annual Affidavit of Compliance with Level 2 Screening Standards is completed annually. The program has a written policy and procedures requiring compliance with the Department s Background Screening Unit (BSU) requirements. Background screening is completed for all staff, contractors, volunteers, and interns prior to date of hire or providing services. There were twenty-nine staff, two volunteers, and one contracted staff applicable for an initial background screening. A review of the Department s BSU database and personnel files confirmed a background screening was completed in all cases, prior to the date of hire or providing services. Annual Affidavits of Compliance with Level 2 Screening Standards for the program and the education component of the program were submitted to the Department s BSU on January 5, Office of Program Accountability Page 10 of 61 (Revised July 2016)

11 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 has a written policy and procedures requiring compliance with the Department s five-year background rescreening requirements. Eight program staff and two corporate staff who visit the program regularly required a five-year rescreen during the review period. A background rescreen was completed on each staff prior to and within one year of their anniversary of hire date Provision of an Abuse-Free Environment Compliance The program provides an environment in which youth, staff, and others feel safe, secure, and not threatened by any form of abuse or harassment. Posting of the Florida Abuse Hotline telephone number and the Central Communications Center for youth 18 years of age and older telephone number. All allegations of child abuse or suspected child abuse are immediately reported to the Florida Abuse Hotline. Youth and staff have unhindered access to report alleged abuse to the Florida Abuse Hotline pursuant to Section (1)(a), F.S. The environment is free of physical, psychological, and emotional abuse. A code of conduct for staff who clearly communicates expectations for ethical and professional behavior, including the expectation for staff to interact with youth in a manner promoting their emotional and physical safety. The program s code of conduct prohibits abuse of any kind. The code of conduct outlines staff behavioral expectations and company policy related to personnel. All staff are trained on the code of conduct and acknowledge receipt of the code of conduct by signature upon hire. In addition, when updates are made to the code of conduct, all staff are required to acknowledge the updated version by signature, which was confirmed in a review of five personnel files. Child abuse reporting procedures state youth cannot be denied the opportunity to report abuse. Child abuse reporting procedures are posted in each living area, as are phone numbers for the Florida Abuse Hotline and the Department s Central Communication Center (CCC). All seven surveyed staff and five interviewed staff were familiar with abuse reporting requirements, with all stating youth have the right to call. The procedure for reporting abuse is for the supervisor to be contacted when a youth makes the request and the supervisor facilitates the call. All surveyed and interviewed staff said they had never seen a co-worker deny a youth the right to report abuse, they had never heard a staff use profanity when speaking with youth, and never seen a co-worker use threats, humiliation, or intimidation when interacting with youth. The program had one substantiated incident for excessive use of force, which was immediately investigated by the program and the staff was terminated. Observations during the annual compliance review found staff and youth interactions were appropriate and staff were respectful when addressing youth. Office of Program Accountability Page 11 of 61 (Revised July 2016)

12 Seven youth were surveyed and five youth were interviewed. Eleven of the twelve youth reported they felt safe at the program; one youth said he felt safe sometimes due to other youth, though he said staff do what they can to keep him safe. Six youth said staff were respectful when speaking with youth and the remaining six youth reported some staff were not always respectful. Three youth reported they have heard staff use profanity often and two said staff use profanity occasionally. Nine youth said they had never heard staff threaten youth; three youth said they had heard staff threaten youth. Eleven of twelve youth reported they have never been denied a call to report suspected abuse. The remaining youth said his call to the Florida Abuse Hotline regarding medical care was delayed, but he was able to make his call later (the youth s allegation and delay in receiving the call were being investigated at the time of the annual compliance review) Management Response to Allegations Compliance Management shall be cognizant of youth and staff needs and provide direction to each on how to access the Florida Abuse Hotline. There is evidence management takes immediate action to address incidents of physical, psychological, and emotional abuse. The program has a written personnel policy and a code of conduct. All staff are trained on and are expected to adhere to the personnel policy and code of conduct. The program had one incident of a staff using excessive force during the review period and the staff member was terminated. Five personnel files were reviewed for management response to violations of the personnel policy and the code of conduct. The personnel files showed the program has responded to staff violations though counseling, oral and written reprimands, and termination Incident Reporting (CCC) Compliance Whenever a reportable incident occurs, the program notifies the Department s Central Communications Center (CCC) within two hours of the incident, or within two hours of becoming aware of the incident. The program has a written policy and procedures regarding their response to incidents, which meets the requirements of the Florida Administrative Code. Seven incidents reported to the Department s Central Communication Center (CCC) within the past six months were reviewed. Each incident was reported to the CCC within two hours of the incident or within two hours of staff becoming aware of each incident. Each incident and call to the CCC was documented in the logbook Protective Action Response (PAR) and Physical Compliance Intervention Rate The program uses physical intervention techniques in accordance with Florida Administrative Code. Any time staff uses a physical intervention technique, such as countermoves, control techniques, takedowns, or application of mechanical restraints (other than for regular transports), a PAR Incident Report is completed and filed in accordance with the Florida Administrative Code. The program has a written policy and procedures regarding the use of physical intervention techniques. The policy meets the requirements of the Florida Administrative Code. Five Protective Action Response (PAR) reports were reviewed. Each PAR report was completed by Office of Program Accountability Page 12 of 61 (Revised July 2016)

13 the end of the staff s workday, including statements from all involved, was reviewed by a supervisor and a PAR instructor, and was reviewed by the facility administrator or designee. Four of the five reports documented a post-par interview with each youth within thirty minutes. The post-par interview in the remaining report was documented five hours after the incident. According to an interview with the acting facility administrator, all PAR incidents are reviewed on video and discussed during management meetings. The program submits a monthly summary of PAR incidents to residential services, northeast region, as required. The PAR plan was approved by the Department on February 10, The program s PAR rate during the fiscal year was 1.13, which is below the statewide Residential PAR rate of Pre-Service/Certification Requirements Compliance Contracted and State residential staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. Five training files for newly hired staff were reviewed for pre-service training. Documentation in the Department s Learning Managements System (SkillPro) confirmed each staff completed required certifications, to include Cardiopulmonary Resuscitation (CPR), first aid, use of an Automated External Defibrillator (AED), and PAR prior to having contact with youth. Documentation of orientation training for each staff included suicide prevention, child abuse reporting, emergency procedures, and ethics. The pre-service training plan was submitted to the Department s Office of Staff Development and Training and was approved on February 24, In-Service Training Compliance Residential staff complete twenty-four hours of in-service training, including mandatory topics specified in Florida Administrative Code, each calendar year, effective the year after preservice/certification training is completed. Supervisory staff completes eight hours of training (as part of the twenty-four hours of annual inservice training) in the areas specified in Florida Administrative Code. Seven staff training files were reviewed for in-service training. Documentation in the Department s Learning Management System (SkillPro) showed each staff had received at least twenty-four hours of training in calendar year Each staff received protective action response (PAR) refresher training and had current certifications in Cardiopulmonary Resuscitation (CPR), first aid, and use of an Automated External Defibrillator (AED). Each staff received training on professionalism and ethics and completed at least six hours of suicide prevention training. Training files for five supervisors documented each received at least eight hours of training in supervisory topics. The in-service training plan was submitted to the Department s Office of Staff Development and Training and was approved on February 10, In addition, the in-service training plan for management staff was submitted to the Department s Office of Staff Development and Training and was approved on February 24, Office of Program Accountability Page 13 of 61 (Revised July 2016)

14 1.09 Grievance Process Training Compliance Program staff shall be trained on the program s youth grievance process and procedures. Training on the grievance process is included in the pre-service and in-service training plans. Reviewed training files found all staff completed training on the grievance process upon hire and annually thereafter. Surveyed and interviewed staff were able to explain the grievance process Grievance Process Compliance The program adheres to their grievance process and shall ensure it is explained to youth during orientation and grievance forms are available throughout the facility. The program s grievance process includes informal, formal, and appeal phases. The program is to respond to youth grievances within seventy-two hours. The program also uses Speak Outs, which allow the youth to request to speak with staff, request assistance with issues not prompting a grievance, and to acknowledge staff in a positive manner. Youth are informed of the grievance and the speak out processes during orientation. Grievance and speak out forms are available in the dining room and youth can request the forms from staff. Locked boxes are located in the dining room for youth to submit grievances and speak outs. The boxes are checked daily and the grievance and speak out forms submitted are addressed by management. Youth typically complete Speak Outs when they have concerns. Seven youth were surveyed and asked to rate the grievance process. One youth rated the grievance process as very good, two rated it as fair, two rated it as poor, one rated it as very poor, and one youth said he had never filed a grievance. The youth rating the process as poor or very poor stated the program did not respond or did not seriously consider the grievance. (Note: it appeared the youth may have been considering speak outs, as only five grievances were filed during the annual compliance review period.) All seven youth acknowledged they could ask for assistance in completing a grievance form Grievance Process Documentation Compliance Completed grievances shall be maintained by the program for a minimum of twelve months. Four grievances were filed during the annual compliance review period. Responses from administration were documented within seventy-two hours on each grievance. Documentation showed each grievance was resolved. The program maintains a binder for all grievances, which confirmed grievances are maintained for at least twelve months Life Skills Training Provided to Youth Compliance The program shall provide interventions or instruction focusing on developing life and social skill competencies in youth. The program uses the Life Skills 225 curriculum by Sandra McTavish for life skills training for youth, which, addresses topics such as drug and alcohol use, sex, relationships, stress, foodrelated issues, and self-esteem. The curriculum is designed for grades six through twelve. Staff Office of Program Accountability Page 14 of 61 (Revised July 2016)

15 providing groups based on the curriculum have been trained to do so. Youth interviews and group documentation reflected youth attend life skills groups. Youth reported they practice life skills learned through role plays in group and in daily interactions with staff and other youth Staff Training: Delinquency Interventions Compliance Staff who s regularly assigned job duties include implementation of a specific delinquency intervention model, strategy, or curriculum receive training in its effective implementation. A review of nine personnel staff files who provide delinquency intervention groups verified all staff are trained in the delinquency intervention(s) they provide. A review of treatment staff credentials found all treatment staff are qualified to provide individual counseling, which the program provides as a delinquency intervention Restorative Justice Awareness for Youth Compliance The program shall provide activities or instruction intended to increase youth awareness of, and empathy for, crime victims and survivors, and increase personal accountability for youths criminal actions and harm to others. The program utilizes the evidenced-based Impact of Crime (IOC) curriculum to provide the youth restorative justice awareness. Youth participate in group activities to increase their awareness of and empathy for victims and survivors and to also increase personal accountability for criminal actions and harm to others. The program maintains a binder with sign-in sheets to verify youth participated in group sessions every Wednesday and Thursday evenings. The reviewer also observed youth participating in groups. This was verified through observations of the review team. All staff facilitating IOC groups have the required training and qualifications to facilitate the groups. The daily activity schedule reflected IOC groups. The program integrates restorative justice awareness in their Life Skills/Living in Balance groups, as well as in their gender-specific groups (Young Men s Work curriculum), and Thinking for a Change (T4C) course Delinquency Intervention Services Compliance The program shall implement a delinquency intervention model or strategy that is an evidencebased practice, promising practice, or a practice with demonstrated effectiveness, for each youth. The program s evidenced-based delinquency intervention services are Impact of Crime (IOC), Thinking for a Change (T4C), and Young Men s Work. Groups were observed by the annual compliance review monitor. The interventions are listed on the daily activity schedule. The program maintains a binder with sign-in sheets. The sign-in sheets document the facilitator, date, time, and the names of the youth participating in each group. A review of seven youth individualized performance plans reflected youth are assigned to the specific groups based upon their needs identified in the Residential Positive Achievement Change Tool (R-PACT) assessments. A review of nine staff personnel files who facilitate intervention groups verified all staff are trained in the delinquency intervention(s) they provide and the interventions are a part of the staff s annual performance evaluations. The program s activity schedule shows the program is providing structured and planned programming for at least sixty percent of the youth s awake hours. Office of Program Accountability Page 15 of 61 (Revised July 2016)

16 1.16 Gender-Specific Programming Compliance The program provides delinquency intervention and gender-specific treatment services. The program utilizes the Young Men s Work curriculum for gender-specific programming. The curriculum addresses the need for young men to work together to solve problems without resorting to violence. The model focuses on real life experience and emotions. Topics include power and violence, bullies, relationships with women and men, race and culture, drugs, and family. The curriculum includes a manual for facilitators and a workbook for youth. The curriculum has twenty-six sessions with each session having a detailed plan page describing the objective, agenda, session outline, lesson, and check out. The program has a binder with sign-in sheets which reflects the names of youth attending the groups, the name of the facilitator, lesson for the day, and the date/time of the groups. The groups are held on Wednesdays for one hour. The gender-specific programming groups are facilitated by the program therapists. A review of the seven therapist s personnel and training files showed all are trained in the intervention and are evaluated annually on their delivery of the curriculum on their performance evaluation Logbook Entries and Shift Report Review Compliance The program maintains a chronological record of events, incidents, and activities in a central log-book maintained at master control, living unit logbooks, or both, in accordance with Florida Administrative Code. The program ensures direct care staff, including each supervisor, are briefed when coming on duty. The program maintains a chronological record of events, incidents, and activities in a central logbook maintained at master control in accordance with Florida Administrative Code. Six months of logbooks were reviewed. All of the logbooks were bound with no loose pages. All of the pages of the logbooks were accounted for with no blank pages. There was no evidence of correction fluid found in any of the reviewed logbooks. All entries were in ink and there were no eraser marks. Errors were corrected with a single line through the error and were initialed by the person making the entry. The date and time of the entry is placed in the left margin for each event. The entries were brief descriptions of events and included the names of youth and staff involved. Scheduled and unscheduled counts were documented as required. Perimeter checks were documented in the logbooks. The shift supervisors made entries indicating they had read the entries from the previous two shifts. Log entries regarding medical, special needs, mental health alerts, and other issues which may impact facility safety and security were highlighted in accordance with a color code in the logbooks. Shift reports were signed by off-going and oncoming shift supervisors, then counter-signed by the chief of security. Shift reports include incidents, alerts, significant events, and behavior issue. Office of Program Accountability Page 16 of 61 (Revised July 2016)

17 1.18 Internal Alerts System Compliance The program shall maintain and use an internal alert system easily accessible to program staff and keeps them alerted about youth who are security or safety risks, and youth with healthrelated concerns, including food allergies and special diets. When risk factors or special needs are identified during or subsequent to the classification process, the program immediately enters this information into its internal alert system. The program ensures only appropriate staff may recommend downgrading or discontinuing a youth s alert status. The program has a written policy and procedures for internal alerts. The policy outlines the process of identifying, documenting, and updating alert information and how the information is communicated to other staff. The program has alert boards listing medical, mental health, and security alerts. The alert boards are located in areas of the facility accessible to staff, keeping staff alerted to security or safety risks and youth with health related concerns, including food allergies and special diets. When risk factors or special needs are identified during or subsequent to the classification process, the assigned staff immediately enters this information into its internal alert system. Additionally, alerts are shared during shift briefings. Seven staff were surveyed and all were familiar with the alert process, stating alerts are communicated through alert boards, on alert forms, and shift briefings. Two staff rated the communication of alerts as very good, four rated it as good, and one rated it as poor Alerts (JJIS) Compliance When risk factors or special needs are identified during or subsequent to the classification process, the program immediately enters this information into the Juvenile Justice Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are downgraded or discontinued. A review of seven youth records and the Department s Juvenile Justice Information System (JJIS) reflected the youth alerts were consistent with the program s internal alerts. When risk factors or special needs are identified during or subsequent to the classification process, the program immediately enters this information into JJIS. Only authorized staff have the authority to enter, adjust, downgrade, or discontinue alerts Educational Access Compliance The facility shall integrate educational instruction (career and technical education, as well as academic instruction) into their daily schedule in such a way ensuring the integrity of required instructional time. The program offers academic instruction, as well as, Type 2 and Type 3 vocational education. Youth can earn certification for vocational skills while enrolled at the program. The program also offers the Home Builders Institute (HBI) curriculum, which allows youth to learn construction skills, including how to use tools. Youth may be certified with SafeServ, which teaches basic culinary safety and cleanliness. Youth learn how to develop résumés, fill out job applications as part of their educational curriculum, and learn interviewing skills as part of their life skills class. Youth attend classes for 350 minutes five days a week and the school year runs year-round. A review of the logbook showed movement to and from classes at assigned times. The education staff acknowledged school information is shared with each youth s juvenile probation officer, parent/guardian, and community members during community re-entry team meetings. Office of Program Accountability Page 17 of 61 (Revised July 2016)

18 1.21 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 in place for developing youth records. Separate case management, mental health, and medical records are maintained for each youth. Seven youth records were reviewed. All records are maintained in locked offices. Each record reviewed was marked as confidential. Six of the seven records were appropriately labelled with the youth s name, date of birth, date of admission, Department of Juvenile Justice identification number (DJJID), offense, and county of residence. One record was labelled with the required information with the exception of the youth s county of residence and offense. The case management, medical, and mental health records were divided in the appropriate sections. The records contained all the required demographic, legal, assessment, correspondence, case management, and miscellaneous information Youth Input Compliance The program has a formal process to promote constructive input by youth. The program provides suggestion boxes throughout the facility for the youth to provide input regarding the facility s operations. The student council meets monthly under the supervision of the program advocate. The council gives the youth the opportunity to have verbal contact with the program s administration regarding program operation issues. The program also utilizes speak out forms, which gives the youth a chance to address both positive and negative issues with staff. Four of seven surveyed youth acknowledged the program has systems in place to solicit input from youth the other three youth answered no Advisory Board Compliance The program has a community support group or advisory board meeting at least quarterly. The program director solicits active involvement of interested community partners. The program has a community advisory board. The board consists of community partners including representatives from law enforcement, the judiciary, the school board, the business community, and faith community. The board also has a victim advocate and parent/guardian of a child previously involved in the juvenile justice system. The program maintains in a binder agendas and sign-in sheets for all advisory board meetings. The advisory board meets quarterly. The advisory board meeting dates for this year were January 21, 2016, April 21, 2016, July 21, 2016, and September 22, The next advisory board meeting is scheduled for November 17, Topics addressed during the advisory board meetings included status updates for the program, special activities for youth, such as holiday activities or community service activities, and program needs. Office of Program Accountability Page 18 of 61 (Revised July 2016)

19 1.24 Program Planning Compliance The program uses data to inform their planning process and to ensure provisions for staffing. The program has a policy regarding program planning. The program has systems in place to ensure a clear line of communication between staff and management. The program conducts nine types of meetings (regional, management, case management, community advisory board, youth advisory board, Motivation Positive Change Committee (MPCC), shift managers, food service, and all-campus). Meetings are held daily, monthly, bi-monthly, and quarterly. All meetings have minutes, sign-in sheets, and agendas. There are suggestion boxes for youth, staff, and families to place positive programmatic suggestions for management. The program conducts parent/guardian surveys upon admission and at discharge of each youth. Youth surveys are completed monthly and quarterly by the regional compliance manager. Five parent/guardian surveys completed by the program were reviewed. The parent/guardian responses were positive regarding the services provided for their youth while in the program. Five youth surveys completed by the program were reviewed. None of the youth reported being impeded from contacting the Florida Abuse Hotline, being denied the opportunity to file a grievance, or hearing threats from staff. The youth surveys completed by the program indicated youth felt safe in the program. Seven staff were surveyed by the annual compliance review team. All staff said they have staff meetings at least monthly. All seven staff said they could provide input for facility operations by bringing issues up at staff meetings and/or approaching their supervisor or administration. Four of the staff reported they are briefed with information from youth and parent/guardian surveys and reviews of the program Staff Performance Compliance The program ensures a system for evaluating staff, at least annually, based on established performance standards. Nine personnel files were reviewed. Personnel files included job descriptions for all positions, evaluations, education records/degrees, and a copy of the code of conduct. Annual performance evaluations were completed in all files reviewed. The program completes annual evaluations in the month October for all employees. New employees are evaluated upon their first ninety days of employment. Annual performance evaluations are based on established performance standards. The evaluation process includes best practice elements. Evaluations are adapted for the multiple types of employees at the program. Facilitators are evaluated for their skill at facilitating a delinquency intervention. All seven surveyed staff said they receive performance evaluations based on established performance standards at least annually. Office of Program Accountability Page 19 of 61 (Revised July 2016)

20 Standard 2: Assessment and Performance Plan Overview At the time of the annual compliance review, there was one case manager vacancy at Hastings Comprehensive Mental Health Treatment Facility. Case managers are designated as treatment team leaders. Case managers are responsible for completing the Residential Positive Achievement Change Tool (R-PACT) within thirty days of admission for each youth and every ninety days thereafter. Case managers are responsible for completing the Youth Needs Assessment Summary (YNAS), developing the performance plans, completing performance summaries, coordinating formal and informal treatment team meetings, and transition planning. Case managers also facilitate prevention groups, visitation, weekly telephone calls, and supportive counseling for youth and their parents/guardians. The case managers have a system to track the due dates of all required case management functions. All case managers maintain chronological notes for each youth on their caseload. The St. Johns County School district contracts with G4S to provide educational services for the Department of Juvenile Justice (DJJ) residential programs in the district (Hastings and St. Johns Academy). This contract is separate from the DJJ contract. The program has services provided by Home Builders Institute (HBI). HBI provides youth with various vocational service certifications Initial Contacts to Parent/Guardian Compliance The program notifies the youth s parent/guardian by telephone within twenty-four hours of the youth s admission, and by written notification within forty-eight hours of admission. The program has a policy and procedures to notify a youth s parent/guardian by telephone and also by written notification on each youth s date of admission. Seven youth case management records were reviewed. Six of seven records documented the parents/guardians were called within twenty-four hours of arrival at the program. The other youth was eighteen and had consented to their parent/guardian to be contacted within twenty-four hours of arrival at the program. All Seven records documented a letter was sent to the parents/guardians on the date of admission Court Notification Compliance The program notifies the youth s committing court(s) by written notification within five working days of admission. The program has a policy and procedures to notify the youth s committing court by written notification on the youth s day of admission. Seven youth case management records were reviewed. Each record documented a letter notifying the committing court of the youth s admission to the program was sent to the court on the date of admission Youth Orientation Compliance The program shall provide each youth an orientation to the program rules, procedures, schedules, and services applicable to youth, to begin within twenty-four hours of admission. The program has a policy and procedures to provide each youth an orientation to the program on the day of their admission. The program utilizes an orientation checklist to explain and Office of Program Accountability Page 20 of 61 (Revised July 2016)

21 discuss program rules, schedules, and services available. Seven youth case management records were reviewed. Each record contained an orientation checklist completed on the youth s admission date. One checklist had one box on the form not checked and another checklist had thirty-three out of thirty-seven boxes checked. Seven youth completed a survey. Five of seven youth indicated they participated in orientation within twenty-four hours of admission and two youth said they did not. There was not an opportunity to observe an orientation during the week of the annual compliance review Written Consent of Youth Eighteen Years or Older Compliance The program obtains written consent of any youth eighteen years of age or older, unless the youth is incapacitated and has a court-appointed guardian, before providing or discussing with the parent/guardian any information related to the youth s physical or mental health screening, assessment, or treatment. The program has a policy and procedures to have all youth eighteen years of age or older sign consent forms on the day of admission or on the day of their eighteenth birthday. Three records for youth who are eighteen-years-old were reviewed. One youth turned eighteen-years-old while in the program and he signed a consent on his birthday. The two remaining youth were eighteen-years-old at the time of admission and signed consents on their admission date Classification Factors Compliance The program utilizes a classification system, in accordance with Florida Administrative Code, promoting safety and security, as well as effective delivery of treatment services. The program has a policy and procedures to assign a youth to a living and/or sleeping room on the day of admission. The program reviews classification factors such as physical characteristics, age and maturity, special needs, history of violence, gang affiliation, criminal behavior, sexual aggression or vulnerability, and identified or suspected risk. Seven youth case management records were reviewed. Each record contained a classification form completed on the youth s admission date. The program director interview indicated the program uses the Victimization and Sexually Aggressive Behavior (VSAB) screening as part of the classification process in addition to conducting a thorough review of all available information Classification Procedures Compliance Initial classification should be used for the purposes of assigning each newly admitted youth to a living unit, sleeping room, and youth group or staff advisor. The program has a policy and procedures to conduct a classification review meeting for each newly admitted youth on the day of admission for the purpose of assigning youth to a living unit, sleeping room, and youth group or staff advisor. Seven youth case management records were reviewed. All classification forms indicated the dorm and bedroom assignment. Six of seven forms documented the justification for the room assignment. The justification section was blank on one classification form. Office of Program Accountability Page 21 of 61 (Revised July 2016)