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 Dade Juvenile Residental Facility TrueCore Behavioral Solutions, LLC (Contract Provider) South West 424 th Street] Florida City, Florida Review Date(s): May 15-18, 2018 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: Teves Bush, Office of Program Accountability, Lead Reviewer (Standard 1]) Jeffery Barrett, Office of Program Accountability, Technical Assistance Specialist (SPEP) Juli-Ann Knight, Sequel Youth Services, Assistant Clinical Director (Standard 3) Marie Lockwood, Office of Program Accountability, Regional Monitor (Interviews) Shawna Prope, Office of Program Accountability, Regional Monitor, (Standard 4) Maryann Sanders, Office of Program Accountability, Regional Deputy Supervisor, (Standard 2) Rubin Smith, Probation Circuit 17, Probation Officer Supervisor, (Standard 5)

3 Program Name: Dade Juvenile Residential Facility MQI Program Code: 1113 Provider Name: TrueCore Behavioral Solutions, LLC Contract Number: Location: Miami-Dade County / Circuit 11 Number of Beds: 32 Review Date(s): May 15-18, 2018 Lead Reviewer Code: 154 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 # Clinical Staff 1 # Food Service Personnel 2 # Healthcare Staff 1 # Maintenance Personnel 2 # Program Supervisors 7 # Staff 7 # Youth Documents Reviewed 4 # Other (listed by title): Business Manager, Lead Teacher, Regonal Compliance Manager, Maser Control operator 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 5 # Training Records/CORE 3 # Youth Records (Closed) 5 # Youth Records (Open) 3 # Other: Transition, JJIS, PMM, independent contracts 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. Office of Program Accountability Page 3 of 73 (Revised July 2017)

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 *Internal Alerts System 1.18 *Alerts (JJIS) 1.19 Education Acces 1.20 Youth Records (Healthcare and Management) 1.21 Youth Input Limited 1.22 Advisory Board 1.23 Program Planning 1.24 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 73 (Revised July 2017)

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 Limited 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 Limited 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 73 (Revised July 2017)

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 Limited 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 73 (Revised July 2017)

7 Standard 4: Health Services Residential Rating Profile Indicator Ratings Standard 4 - Health Services 4.01 * Designated Health Authority/Designee 4.02 Facility Operating Procedures 4.03 Authority for Evaluation and Treatment 4.04 Parental Notification 4.05 Notification - Clinical Psychotropic Progress Note 4.06 Immunizations 4.07 Healthcare Admission Screening Form 4.08 Medical Alerts 4.09 Youth Orientation to Healthcare Services 4.10 Designated Health Authority/Designee Admission Notification 4.11 Healthcare Admission Rescreening 4.12 Health Related History 4.13 Comprehensive Physical Assessment 4.14 Female-Specific Screening/Examination Non-Applicable 4.15 Tuberculosis Screening 4.16 Sexually Transmitted Infection Screening 4.17 HIV Testing 4.18 Sick Call Process - Requests/Complaints 4.19 Sick Call Process - Visits/Encounters 4.20 Restricted Housing Non-Applicable 4.21 Episodic/First Aid Care 4.22 Emergency Care 4.23 Off-Site Care/Referrals 4.24 Chronic Illness/Periodic Evaluations 4.25 Medication Management - Verification 4.26 Medication Management - Orders/Prescriptions 4.27 Medication Management - Storage 4.28 Medication Management - Medication and Sharps Inventory 4.29 Medication Management - Controlled Medications 4.30 Medication Management - Medication Administration Record 4.31 Medication Management - Medication Administration By Licensed Staff 4.32 Medication Management - Medication Provided By Non-Licensed Staff 4.33 Medication Management - Psychotropic Medication Monitoring 4.34 Infection Control - Surveillance, Screening, and Management 4.35 Infection Control - Education 4.36 Infection Control - Exposure Control Plan 4.37 Prenatal Care - Physical Care of Pregnant Youth Non-Applicable 4.38 Prenatal and Neonatal Care - Nutrition, Education of Youth, and Lactation Non-Applicable 4.39 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 73 (Revised July 2017)

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 Logbook Entries and Shift Report Review 5.05 Key Control 5.06 Contraband Procedure 5.07 Searches and Full Body Visual Searches 5.08 Vehicles and Maintenance Limited 5.09 Transportation of Youth 5.10 Tool Inventory and Management 5.11 Youth Tool Handling and Supervision 5.12 Outside Contractors 5.13 Fire, Safety, and Evacuation Drills 5.14 Disaster and Continuity of Operations Planning 5.15 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials 5.16 Youth Handling and Supervision for Flammable, Poisonous, and Toxic Items and Materials 5.17 Disposal of All Flammable, Toxic, Caustic, and Poisonous Items 5.18 Recreation and Leisure Activites 5.19 Elements of the Water Safety Plan Non-Applicable 5.20 Staff Training: Water Safety Non-Applicable 5.21 * Swim Test Non-Applicable 5.22 Visitation and Communication 5.23 Comprehensive Behavior Management System 5.24 Implementation and Consistency of Behavior Management System 5.25 Behavior Management System Infractions 5.26 Staff Training: Behavior Management System 5.27 Behavior Management System Monitoring 5.28 Search and Inspection of Controlled Observation Room Non-Applicable 5.29 Controlled Observation Non-Applicable 5.30 Controlled Observation Safety Checks Non-Applicable 5.31 Controlled Observation Release Procedures Non-Applicable * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 8 of 73 (Revised July 2017)

9 Strengths and Innovative Approaches Youth in the program participated in Exchange for Change (E4C). E4C is a Miami-based organization who initiates letter writing exchanges between youth in the program and academic institutions. The program is designed to foster empathy and create opportunities for social change, and provide youth with an opportunity to express themselves without the fear of being stigmatized. Youth in the program elect to stay after school once weekly for a writing class in which they expressed thoughts and feelings about the juvenile justice system in brief essays. The students exchange essays on the same topic written by students enrolled in the University of Miami Sociology Department s Juvenile Delinquency course. Youth in the program travelled periodically during the semester to the University of Miami Coral Gable (main) campus, where they participated in interviews conducted by the youth. Trips led by the recreational therapist are provided to the Good Hope Equestrian Training Center to help youth make positive changes in cognitive, physical, emotional and social domains. Youth volunteer and assist the horse trainers by preparing the horses and cleaning the stalls. The youth also can complete restorative justice projects by doing community service hours while at the training center. Office of Program Accountability Page 9 of 73 (Revised July 2017)

10 Standard 1: Management Accountability Overview Dade Juvenile Residential Facility (DJRF) is operated by TrueCore Behavioral Solutions, LLC under a contract with the Department of Juvenile Justice (DJJ). DJRF is a thirty-two bed, nonsecure residential program located in Florida City, Florida. The program is contracted to provide specialized comprehensive treatment services to youth for major disorders, including dual diagnosis and/or major disorder treatment. Management accountability consists of the regional director (RD), who is acting in the capacity of the facility administrator (FA due to the FA position currently being vacant, assistant facility administrator (AFA), human resource personnel, physical plant manager, staff development specialist, unit managers, shift supervisors, health services manager (HSM), director of clinical services (DCS), director of case management (DCM), the designated health authority (DHA), psychiatrist, training coordinator, and a certified behavioral analyst (CBA). The program had some difficulty in the past with comprising an advisory board. The program has reach out by way of letter and telephone to recruit new members from the local community. The program provides for highly structured interventions fostering peer interaction, personal growth for youth, social skills development, and responsibility through a therapeutic model. The campus is co-located to include Dade Youth Academy (DYA) and is comprised of three separate youth living dormitories named Alpha, Bravo, and Charlie, which the Alpha dorm is allocated for DYA youth, Bravo and Charlie for DJRF youth. During the tour of the facility, all three dormitories had new windows, doors, lighting installed and recently received interior painting. Observation of the DJRF dormitories found books stored in a room on the floor, food trays in youth rooms, youth beds not made, graffiti on the walls, toilets backed-up, feces in the toilets, sinks loose and leaking, and exposed light canisters in the shower ceiling. There is a free-standing education building, a dining hall/kitchen, an administration building, and a multiple purpose building where offices for case managers, therapist and the clinic are stationed. Observation of the school building found the bathroom floors were dirty and toilet paper in the toilets. The program hired a new physical plant manager and has created a maintenance list to ensure on-going and new maintenance issues are addressed timely. Educational services are provided by Miami-Dade County School District Initial Background Screening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. The background screening process is completed prior to hiring an employee or utilizing the services of a volunteer, mentor, or intern. An Annual Affidavit of Compliance with Level 2 Screening Standards is completed annually. The program has a written policy and procedures in place which follows the established statutory requirements for background screening along with the submission of the Annual Affidavit of Compliance with Level 2 Screening Standards. The program had twenty-seven new employees hired since the last annual compliance review. Review of background screenings for each new employee verified they received an initial background screening prior to employment. There were six new volunteers since the last annual compliance review. Review of background screenings for new volunteers verified each received an initial background screening prior to starting. The Annual Affidavit of Compliance with Leve 2 Screening Standards was approved by the Departments Background Screening Unit on January 23, 2018, meeting the annual requirement. Teachers working at the program are employed by the Miami-Dade County School Office of Program Accountability Page 10 of 73 (Revised July 2017)

11 District and received background screenings provided by the Department of Education. The last annual screening was received on January 18, 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 policy and procedures to rescreen employees every five years from the date of hire. During the annual compliance review, there were no staff eligible for five-year rescreening Provision of an Abuse-Free Environment Compliance The program provides an environment in which youth, staff, and others feel safe, secure, and not threatened by any form of abuse or harassment. Posting of the Florida Abuse Hotline telephone number and the Central Communications Center for youth 18 years of age and older telephone number. All allegations of child abuse or suspected child abuse are immediately reported to the Florida Abuse Hotline. Youth and staff have unhindered access to report alleged abuse to the Florida Abuse Hotline pursuant to Section (1)(a), F.S. The environment is free of physical, psychological, and emotional abuse. A code of conduct for staff who clearly communicates expectations for ethical and professional behavior, including the expectation for staff to interact with youth in a manner promoting their emotional and physical safety. The program has a policy and procedures addressing an abuse free environment to ensure youth, staff, and others feel safe, secure, and not threatened by any form of abuse or harassment. The facility operating procedures for abuse and neglect reporting, along with ethics and values are provided to staff during the hiring orientation process. Staff provide a signed document for the code of ethics to indicate they have been provided the policy. Random review of staff training records verified all staff have been trained on the program s code of ethics. The Florida Abuse Hotline and the Department s Central Communications Center (CCC) telephone numbers were observed posted throughout the program. At the time of the review, there was one pending Prison Rape Elimination Act (PREA) investigation, no open Department of Children s and Families incidents, police incidents, and/or Office of the Inspector General (OIG) investigations pending. The program s policy requires allegations of child abuse or suspected child abuse to be immediately reported, also the youth handbook indicated, Youth will be given the opportunity to place a call within a reasonable time frame. You need to be patient. An informal interview with two youth stated they have never had to report abuse and feel they could if the need arises. Five staff were interviewed and indicated if a youth need to make an abuse call, the call is made from the program cellular telephone or supervisors office. The staff places the call and obtain operators information before handing the cellular telephone over to the Office of Program Accountability Page 11 of 73 (Revised July 2017)

12 youth. Five staff were interviewed and stated they have never observed a co-worker telling a youth he could not make an abuse call. When staff was asked if they ever heard a co-worker using profanity when speaking to a youth, two stated yes and three stated no. Five youth were interviewed and each stated they feel safe in the program and staff are respectful when talking to them. Five youth were interviewed and stated they never had to make an abuse call and occasionally heard staff using curse words when speaking to them to gain control. Interview with the program director stated physical abuse, threats, and/or profanity toward the youth are all considered critical violations of the standard of conduct. Critical violations are subject to progressive discipline to include termination 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 policy and procedures for incident reporting. A review of five internal incident reports called in to either the Florida Abuse Hotline and/or the Department s Central Communication Center (CCC) for the past six months found all forms contained information of the immediate action taken by staff to address the concerns. All forms were reviewed and signed by either the facility administrator (FA) or designee with the date and time of day, along with the youth signature explaining the youth s issues, and whether the call was accepted by either the Florida Abuse Hotline or the CCC. Interview with the facility administrator indicated staff receive training on contacting the Florida Abuse Hotline during new hire training and the youth receive the information during the admission process. The contact numbers were observed posted in various places around the program. Abuse calls are reported out during the daily morning meeting and entered into the morning management meeting database for tracking 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 policy and procedures for reporting Central Communications Center (CCC) reports within the two-hour time frame. The program had a total of thirty-five CCC reports for the past six-months, which one of the thirty-five was reported during the annual compliance review week. A review of six CCC reports verified each were reported within the two-hour time frame. A review of the facility logbooks indicated five of the six reviewed CCC reports were documented. One CCC report was not documented in the logbook. A review of the program internal incident reports found there were no incidents which met the requirements for being reported to the CCC and were not reported. Office of Program Accountability Page 12 of 73 (Revised July 2017)

13 1.06 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 policy and procedures related to Protective Action Response (PAR). There were twenty-eight PAR incidents documented in the programs hardbound notebook for the past six months. A random review of five PAR incidents found all were completed by staff trained to perform physical intervention techniques. Each PAR report was completed by staff involved, nature of the intervention, date, time, supervisory review and signature, facility administrator (FA) or designee. There was additional documentation attached to the Department s required forms, which captured additional information provided by staff and youth. None of the reviewed PAR reports indicated mechanical restraints were used nor youth needing medical attention after the use of PAR. The program s PAR rate during the annual compliance review period is 3.96, which is above the statewide residential PAR rate of An interview with the facility administrator indicated PAR incidents are reviewed by the FA for appropriateness and then discussed by the management team during the daily morning meeting 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. The program has an annual training plan for pre-service training approved by the Department s Office of Staff Development and Training on August 2, The plan outlines the Department required training hours, training objectives, course names, and descriptions for any instructorled training. The training plan also outlines training opportunities for identified special positions such as management, case managers, mental health, and direct care staff. Medical staff are not Protective Action Response (PAR) certified, along with kitchen staff and administrative assistant/office staff. All supervisors, facility administrator (FA), and assistant facility administrator (AFA) are PAR certified and are qualified to supervise youth in special circumstances. The program s policy indicates all new hire training includes a minimum of 120 hours of training for direct care staff, which can be computer-based and/or instructor-led topics, and shall be completed within the first thirty-days of employment. A review of five staff preservice training records verified the program s documented practice of new hires completing all required pre-service training requirements within the first thirty-days of employment, inclusive of suicide prevention, emergency procedures, child abuse reporting, professionalism, ethics and standards of conduct, along with cardiopulmonary resuscitation (CPR), and first aid. Office of Program Accountability Page 13 of 73 (Revised July 2017)

14 1.08 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. The program has an annual training plan inclusive of all required Departmental trainings and include the provider s required internal trainings. The plan was approved by the Department s Office of Staff Development and Training on August 2, A review of five staff in-service training records indicated no discrepancies. All staff had supporting documentation to verify their cardiopulmonary resuscitation (CPR), automated external defibrillator (AED), and first aid trainings were up-to-date. All staff completed training in suicide prevention, ethics, Protective Action Response (PAR), communications skills, and professionalism. Three staff were identified to be in supervisory positions and review of the training records indicated each completed the required eight hours of management training. All trainings were found to be entered in the Department s Learning Management System (SkillPro) database Grievance Process Training Compliance Program staff shall be trained on the program s youth grievance process and procedures. The program maintains a pre-service training plan for all newly hired staff to follow and complete. A review of five staff pre-service training records verified each staff received grievance process training during the first week of pre-service training 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 has a written policy and procedures addressing the grievance procedure. The program has a three-phase protocol of attempting to talk through the problem informally with the youth known as the Speak Out process. In step two of the process, youth who are not satisfied with the initial response, may file a written grievance. If the youth is not satisfied with the response from step two, they may appeal to the facility administrator and/or designee if necessary in the third phase. Grievance forms are available to youth in the living area of each dormitory. The grievance forms are placed on the wall in a file holder which is accessible to all youth in the living area. The grievance box is locked and forms are accessible to youth and staff. Five youth, five staff, and the facility administrator were interviewed and understood the process for filing a grievance. Office of Program Accountability Page 14 of 73 (Revised July 2017)

15 1.11 Grievance Process Documentation Compliance Completed grievances shall be maintained by the program for a minimum of twelve months. A review of five completed grievances found all forms indicated the youth s name, description of the issue, date, and how the youth would like to have the concern resolved, but did not identify the nature of the grievances. Four of the reviewed grievances were noted to have been resolved at phase two and one was found to have progressed to phase three with the facility administrator. Two of the five grievance forms did not indicate if the youth agreed or disagreed with the findings or actions identified by the grievance officer or designee. Five youth were interviewed and stated if needed, they can receive assistance when completing a grievance form Life Skills Training Provided to Youth Compliance The program shall provide interventions or instruction focusing on developing life and social skill competencies in youth. Although the activity schedule indicated groups are taking place, the schedule does not indicate groups to be specific to life skills training. However, in an interview with the staff in charge of the life skills training it was explained groups are conducted between the targeted primary mental health groups depending on the number of youth eligible to participate in the independent living skills groups and seminars. A review of five youth performance plans revealed all five youth were targeted to receive life skills training to include Skill Streaming, Living in Balance, and Thinking for Change (T4C). The sign-in sheets provided by the program validated groups were being conducted on a regular basis, and the staff facilitating the groups are properly trained to deliver the curriculum Staff Training: Delinquency Interventions Compliance Staff whose regularly assigned job duties include implementation of a specific delinquency intervention model, strategy, or curriculum receive training in its effective implementation. A review of five mental health staff training and personnel records verified staff providing interventions were master-level clinicians, and received training to provide interventions to youth either in a group, individual, and/or family setting. Other staff such as case managers and the transition specialist have completed motivational interviewing, the balanced approach to restorative justice, trauma-informed care, effective verbal and non-verbal communication, along with delivering constructive criticism and human trafficking. According to the facility administrator, youth are matched with a therapist based upon the individual need of the youth 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 provides a curriculum which assists the youth to accept responsibility for the harm their criminal actions have caused. Youth are exposed to victim s statements by way of video tape to learn of the impact of being a victim of crime. Youth participate in on-site work details Office of Program Accountability Page 15 of 73 (Revised July 2017)

16 and volunteer in the community to heal some of the harm they caused. The staff providing the service have been trained in the curriculum. The program utilizes the Impact of Crime (IOC) curriculum. Interview with the facility administrator indicated youth participate in IOC groups and are allowed to participate in community service projects such as the equestrian program and working in the local soup kitchen 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 provides delinquency intervention services to youth and their contract specifically outlines, Thinking for a Change (T4C) and the Impact of Crime (IOC) as the delinquency intervention programing which helps youthful offenders understand the harm they have created to victims. These interventions are delivered by either a licensed therapist and/or a master slevel facilitator working under the direction of a licensed mental health counselor (LMHC). A review of the program s daily activity schedule indicated there are no specified days and time established for youth participation in the interventions. A review of the program s contacts and group sign-in sheets validates the groups are consistently taking place. A review of five youth case management records indicated a goal was identified on each youth s performance plan and enrolled in either an evidence-based practice or promising practice during the review period. The staff providing the practice was trained in the intervention and it was being delivered as designed. Interview with the facility administrator indicated the primary services identified for the program are individual therapy, T4C, and IOC Gender-Specific Programming Compliance The program provides delinquency intervention and gender-specific treatment services. The program is providing delinquency intervention and gender-specific treatment services for each youth in the program which target health, hygiene, physical environment, life, and social skills training. The program utilizes the Young Men s Work curriculum and each group is facilitated by trained staff. The curriculum addresses gender-specific issues and is being delivered as designed. Interview with the facility administrator indicated treatment planning is based on the individualized needs of the youth and gender responsive programming which creates a therapeutic environment 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 to address youth with health-related concerns, mental health, safety, and security risks. The program maintains an on-going alert system to ensure information concerning a youth s special conditions, suicide risks, safety, and/or security risks are effectively communicated to staff in a manner which preserves the youth s privacy. Office of Program Accountability Page 16 of 73 (Revised July 2017)

17 Alerts are identified at the time of admission, either through an interview with the youth and/or supporting documentation within the admission packets. Alerts are then entered into the Department s Juvenile Justice Information System (JJIS), along with being added to the program s internal alert system. Internal alerts record is posted on an alert board in master control, and distributed to program managers for safety and security risks, mental health/clinical staff for suicide risks and other mental health alerts, along with medical for health conditions and medications, and the food service staff for dietary and allergies. An alert board is also maintained in the kitchen area to inform staff of youth who have food allergies. A random review of five youth identified on the internal alert system verified information entered into JJIS was accurate to include youth with limited strenuous activity, suspected gang affiliation, allergies, asthma, diet, single room only, medical, psychotropic medications, and suicide risks. When mental health/substance abuse youth identified to be at risk, the youth is placed on precautionary observation (PO) and the alert is entered both in JJIS and their internal alert system within two hours. The clinical director (CD) and all therapist can enter alerts. When the youth is removed and/or stepped down from PO, the CD and all therapists can update the alert system. For medical alerts and food allergies, medical staff enter the alerts in JJIS and initiates the internal alert. Interview with the facility administrator indicated a communication board is utilized as the internal alert system. The board is updated as needed by medical, mental health, and case management. Nursing, case management, and clinical staff are responsible for entering, updating, and closing out alerts in JJIS. Five staff were interviewed and stated they are notified of alerts by way of the alert board and posting of the alerts inside the staff office 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. The program has a written policy and procedures to address youth with health-related concerns, mental health, safety, and security risks. A review of the Department s Juvenile Justice Information System (JJIS) database compared with the program s internal alert report found consistent information for both reports. Mental health, healthcare, and case management records reflected youth with applicable alerts for medications, risk of suicide, medications, diet, allergies, and gang members were identified and added to the database. An interview with the facility administrator indicated the nursing, case management, and clinical staff are responsible for entering, updating, and closing out alerts in JJIS 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 educational component of the program s design is operated by the Miami-Dade County Public Schools (MDCPS), which operates on a year-round basis. The program provided a weekly schedule of the times classes are scheduled. Interview with the lead teacher indicated the scheduling of class times totaled three hundred minutes a week, Monday through Friday. Exceptions to youth completing the required number of hours daily and weekly are weatherrelated and/or youth behavior incidents. A review of three logbooks from three separate months indicated school attendance was not consistent for the week of December 4-8, The Office of Program Accountability Page 17 of 73 (Revised July 2017)

18 logbook has entries which reflect youth arriving to the education building past the schedule start time and there are lapses in logbook entries to reflect when the youth returned to the education building at the conclusion of their scheduled lunch time. Interview with the lead teacher verified the late start to school for reasons including youth behavior and weather conditions, but indicated within the past four months school attendance has improved. A review of the facility logbooks verified adhering to the school schedule. The daily schedule is structured so it is not possible to make up the missed daily minutes by extending the classes on the day youth begin class past the scheduled start time as mental health and other group activities begin immediately after school 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 written policy and procedures for record management. The individual healthcare, mental health, and case management records were all observed to have been marked confidential. The separate youth records were secured in the respective offices inaccessible to youth. Each binder identified the youth s name and Department of Juvenile Justice (DJJ) identification (ID) number. The case management record was labeled with all the required youth information such as name, date of birth, committing offense, legal information, county of residence and the assigned juvenile probation officer (JPO). In addition, the separate sections of the records were broken into demographic and chronological information, treatment team activities, correspondence, and a miscellaneous section Youth Input Limited Compliance The program has a formal process to promote constructive input by youth. The program has a youth advisory board in place which allows youth to express their needs and themselves. An interview with the facility administrator (FA) stated youth attend a community meeting which is ran by members of the youth advisory board. The youth are able to voice concerns regarding the program as well as make suggestions for things they would like to see within their community. Youth are also able to utilize the Let s Talk suggestion form to provide constructive input into the program. The program conducts advisory board meeting once a month. Review of student counsel binder indicated for the past six months, meeting minutes and sign in sheets were maintained only for the months of April and May Random review of Let s Talk forms indicated youth utilize the forms, but it is unclear if the youth comments are addressed in the youth advisory board meetings. The program conducts a community meeting during lunch with the youth and staff which is documented in the program s logbook, but there is no information on what may have been discussed in the meetings. Four of five interviewed youth stated the program has a process allowing youth to provide input into the program, and one of five youth stated he has not been a part of the advisory board and he is not sure if the program has a meeting which allows him to give his input. Office of Program Accountability Page 18 of 73 (Revised July 2017)

19 1.22 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 had some difficulty in the past soliciting members of the community to participate on their advisory board. Meetings are to be held quarterly and each board member is invited by way of letter informing them of the date and time of the meeting. The program has solicited a total of six new individuals from law enforcement, community partners, the school board, and the faith community. The letter also requests for the member to RSVP to ensure their attendance. Review of the updated advisory board members and the corresponding attendance letters verified this practice. A random call of two new members verified they have been contacted regarding the next meeting which is scheduled for June 29, The last documented advisory board meeting was held on February 8, Review of the documentation found an agenda was created, but no sign-in sheets to indicate who was in attendance Program Planning Compliance The program uses data to inform their planning process and to ensure provisions for staffing. The program has a written policy and procedures in place pertaining to employment recognition. The program conducts daily management meetings Monday through Friday, daily shift briefings, and monthly meetings for all staff to discuss issues affecting the program s operation and to keep staff informed of important corporate information. Reviewed documentation supported staff are given opportunities to provide input and feedback on the program s operations during monthly meetings. Areas discussed in each monthly meeting included Department updates, human resources information, training updates, mental health updates, and case management updates. The program has a recognition program called the TrueCore Way, which entails three chips labeled to recognize positive culture, teamwork, and going above and beyond, which staff can provide to each other. The program also recognizes one staff each month as the employee of the month. The program conducts parent/guardian and youth surveys upon each youth s admission and discharge from the program and some parent/guardian surveys are conducted through telephone calls to parents/guardians. An interview with the facility administrator (FA) stated surveys are sent to the parent/guardian upon the youth s admission to the program, as well as upon discharge. Staff and youth are also surveyed quarterly and the information is reviewed with staff at all-staff meetings. Five staff were interviewed and stated meetings are held monthly and example of topics discussed include, but not limited to scheduling, things to improve on, training, policy and procedures, Central Communications Center (CCC), and youth complaints. A random review of staff meeting minutes and agendas verified this practice. Five staff were interviewed on how effective they believe communication is amongst the staff at the program. Two staff stated good, two staff stated fair, and one staff stated poor Staff Performance Compliance The program ensures a system for evaluating staff, at least annually, based on established performance standards. The program has an employee performance evaluation policy and procedures to ensure unique processes continually and proactively assess and measure job functions or duties and performance standards. Evaluations are conducted semi-annually and annually to provide staff Office of Program Accountability Page 19 of 73 (Revised July 2017)

20 feedback regarding their performance and give staff an opportunity to make comments. New performance goals are also added to assist the staff with exceeding expectations. Review of seven different performance evaluations along with the corresponding position description indicated each identified specific comment based on each individual job duties. Interview with the facility administrator indicated annual evaluations are completed to provide feedback to the staff regarding their performance over the past year to include implementation of the positive performance system and overall job specific duties. Five staff were interviewed on how often they receive formal evaluations of their performance based on their performance standards. Two staff stated every six months, two stated yearly, and one stated never, but is assuming one is coming up. Office of Program Accountability Page 20 of 73 (Revised July 2017)