BUREAU OF MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR

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1 S T A T E O F F L O R I D A D E P A R T M E N T O F J U V E N I L E J U S T I C E BUREAU OF MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR AMIkids Miami-Dade North AMIkids, Inc. (Contract Provider) 2701 North East 151 st Street North Miami Beach, Florida Review Date(s): October 27-29, 2015 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: Sharon Coplin, Office of Program Accountability, Lead Reviewer (Standard 1) Sherwood Handford, Monroe Sheriff s Office, Circuit 16 (Standard 2 & 3) Keyla Osorno, Office of Program Accountability, Contract Manager (Standard 3) Yvrose Sylvain, Office of Program Accountability, Regional Monitor, (Standards 1, 2, & 4)

3 Program Name: AMIkids Miami-Dade North MQI Program Code: 1249 Provider Name: AMIkids, Inc. Contract Number: P2121 Location: Miami-Dade County / Circuit 11 Number of Beds: 48 Review Date(s): October 27-29, 2015 Lead Reviewer Code: 123 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 Services, (3) Intervention Services, and (4) Medical, Mental Health, and Substance Abuse Services, which are included in the Day Treatment Standards. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee 2 # Case Managers 1 # Clinical Staff # Food Service Personnel # Healthcare Staff Documents Reviewed # Maintenance Personnel # Program Supervisors # 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 8 # Health Records 8 # MH/SA Records 12 # Personnel Records 7 # Training Records/CORE 5 # Youth Records (Closed) 10 # Youth Records (Open) # Other: JJIS, Water Activity Safety Plan, Lifeguard Certification 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 30 (Revised July 2015)

4 Standard 1: Management Accountability Day Treatment Rating Profile Indicator Ratings Standard 1 - Management Accountability 1.01 * Initial Background Screening 1.02 Five-Year Rescreening 1.03 Protective Action Response (PAR) 1.04 Pre-Service/Certification Training 1.05 In-Service Training 1.06 Medical Alerts, Mental Health Alerts and Suicide Risk Alerts in JJIS 1.07 Episodic/Emergency Care 1.08 Medication Management - Medication Storage 1.09 Cleanliness and Sanitation 1.10 Fire Prevention and Evacuation Procedures 1.11 Water Activities 1.12 Food Services 1.13 Transportation 1.14 Administration 1.15 Ninety-Day Supervisory Reviews 1.16 *Incident Reporting (CCC) 1.17 * Abuse-Free Environment * 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 30 (Revised July 2015)

5 Standard 2: Assessment Services Day Treatment Rating Profile Indicator Ratings Standard 2 - Assessment Services 2.01 Admission and Orientation 2.02 * Medical Screening 2.03 Medication Management - Verification of Medications 2.04 * Mental Health/Substance Abuse Screening 2.05 Positive Achievement Change Tool (PACT) Full Assessment 2.06 PACT Reassessment 2.07 Progress Reports * 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 30 (Revised July 2015)

6 Standard 3: Intervention Services Day Treatment Rating Profile Indicator Ratings Standard 3 - Intervention Services 3.01 Career Education 3.02 Educational Access 3.03 Youth-Empowered Success (YES) Plan Development 3.04 Youth Requirements/PACT Goal Elements 3.05 * Transitional Planning/Reintegration 3.06 YES Plan Implementation/Supervision 3.07 Behavior Management System 3.08 Ninety-Day YES Plan Updates 3.09 Educational Transition 3.10 Termination/Release * 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 30 (Revised July 2015)

7 Standard 4: Medical, Mental Health, and Substance Abuse Services Day Treatment Rating Profile Indicator Ratings Standard 4 - Medical, Mental Health, and Substance Abuse Services 4.01 Medication Management - Delivery of Medications 4.02 Designated Mental Health Clinician Authority or Clinical Coordinator 4.03 * Licensed MH/SA Clinical Staff 4.04 Non-Licensed MH/SA Clinical Staff 4.05 MH and SA Admission Screening 4.06 MH and SA Assessment/Evaluation 4.07 MH and SA Treatment 4.08 Treatment and Discharge Planning 4.09 * Suicide Prevention Plan 4.10 * Suicide Prevention Services 4.11 * Suicide Precaution Observation Logs 4.12 * Suicide Prevention Training 4.13 * Mental Health Crisis Intervention Services 4.14 * Crisis Assessment 4.15 * Emergency MH and SA Services 4.16 * 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 7 of 30 (Revised July 2015)

8 Strengths and Innovative Approaches The program received the 2015 Highest Utilization rate for Day Treatment Programs, and the Fundraising Leadership. The program received a Department of Labor five million dollar grant to provide vocational services in construction through the National Center for Construction and Educational Research (NCCER). The program youth and the construction instructor built a construction workshop and classroom on the grounds of AMIkids Miami-Dade North, where all construction projects and activities will occur. The program has a career coordinator who creates community partnerships to provide youth with job opportunities. The career coordinator follows-up with the youth while employed as well as for six months after completion of the day treatment program. The program has AdvanceED accreditation allowing youth the opportunity to receive a diploma and transcript, which holds the same accreditation as any certified public or private high school. The program participates in monthly community service projects organized by the Department of Juvenile Justice. In October the program youth participated in the Nantahala North Carolina White Water Rafting competition and received three distinct awards. The program has an electronic monitoring system, Bio-trak, which records each youth s attendance and absences by using the youth s thumbprint and photograph. The system sends notifications via to the assigned juvenile probation officer (JPO) recording pertinent information regarding the youth s participation in the program. Youth are provided an opportunity to join the program s scuba team, where youth receive swim lessons, learn to use scuba diving gear, and participate in scuba training. The youth on the scuba team have a potential opportunity for earning a scuba certification. Office of Program Accountability Page 8 of 30 (Revised July 2015)

9 Standard 1: Management Accountability Overview AMIkids Miami-Dade North serves troubled youth, ages thirteen through eighteen, in Miami- Dade County through a unique and effective educational and rehabilitation day treatment program. The program utilizes a restorative approach in rehabilitating the youth by holding them accountable for their actions, helping them develop confidence and competency in vital life skills and educational areas, leading them to acceptance of personal responsibility, and assisting them in restoration efforts. The program s mission is to reduce juvenile delinquency working in partnership with the Department of Juvenile Justice, Miami-Dade County Public School Board, United Way, Fisher Island Philanthropic Fund, community agencies and organizations. The program is located on the grounds of the Florida International University in North Miami Beach, Florida. At the time of the annual compliance review, the program staff included the executive director, director of administration, director of education, three active teachers, two pending vacant teacher positions, a career coordinator, a construction instructor, two scuba instructors, one lifeguard, a licensed mental health counselor/designated mental health clinician authority, a behavior interventionist, a safety specialist, a primary local care counselor who serves as the director of case management, three local care counselors, and a part-time administrative assistant. The programs enrollment at the time of the review was sixty-three youth who were either placed on probation day treatment, commitment, or conditional release. The program does not service post-commitment probation youth. The program s length of stay ranges between three and five months, depending upon the individual youth s progress in the program 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 had a total of fourteen new staff and interns requiring an initial background screening prior to being hired. Thirteen of the new staff and interns were actually screened through the Department s Background Screening Unit (BSU), receiving an eligible rating prior to being hired. The fourteenth employee was performing an internship with the program and left at the end of the internship, was later hired as a part-time employee, resulting in a break in service. This was reported to the Department s Central Communications Center (CCC). During the annual compliance review it was discovered the administrative assistant was rehired on October 19, 2015 prior to receiving a background screening. The review team reported the staff was initially hired as an intern on October 29, 2014 and the internship with the program ended on May 18, The review team also reported an employee within the Background Screening Unit (BSU) informed the program s business manager a background screening was not required for rehiring of the staff; however, a supervisor within BSU advised there was some miscommunication concerning this matter. The Annual Affidavit of Compliance with Level 2 Screening Standards was submitted to the BSU on December 18, 2014, meeting the annual requirement. Office of Program Accountability Page 9 of 30 (Revised July 2015)

10 1.02 Five-Year Rescreening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. Employees and volunteers are rescreened every five years from the initial date of employment. A review of staff personnel files found no staff applicable for the five-year background rescreening requirement. The program has a written policy and procedure in place to appropriately conduct five-year background screening adhering to Department guidelines. The program conducts semi-annual driver s license checks of all staff Protective Action Response (PAR) Compliance The program uses physical intervention techniques in accordance with Florida Administrative Code. Any time staff uses a physical intervention technique, such as countermoves, control techniques, takedowns, or application of mechanical restraints (other than for regular transports), a PAR Incident Report is completed and filed in accordance with the Florida Administrative Code. The program submitted a Protective Action Response (PAR) training plan, signed by the program s executive director, AMIkids vice president, and the regional director. The PAR plan was ed to the Department s Office of Staff Development and Training on January 21, A review of the program s PAR reports and incident report binder revealed a total of five PAR reports being completed within the last six months; one in April, May, July, August, and October. The PAR reports were all reviewed by supervisory staff. The post-par interview section does not require a time to be entered, therefore, it was difficult to determine if the post- PAR interview took place within thirty minutes of the incident. However, each of the five reports had a signature by the executive director or designee indicating the post-par interview was conducted. There were no applicable post-par interview forms or referral forms documenting a referral for medical review. Each of the five PAR reports documented in writing no injuries recorded. According to two of the written PAR reports, the box was checked indicating the youth required a medical review, but there was no documentation regarding a referral or follow-up by medical. The executive director indicated the forms were erroneously marked, as neither of the two youth identified received an injury. Two of the five reports completed were missing page four of the written PAR report, which would have included additional information if applicable. The PAR report written on October 21, 2015 indicated the youth was interviewed within the thirty-minute time frame; however, the signature date was the next day. Statements were obtained by all persons involved in the PAR incidents and the written PAR reports were completed on the same day the incident occurred. The techniques documented on the PAR report are techniques included on the program s submitted PAR plan to the Department s Office of Staff Development and Training. Office of Program Accountability Page 10 of 30 (Revised July 2015)

11 1.04 Pre-Service/Certification Training Compliance Contracted non-residential staff are trained in accordance with Florida Administrative Code. Contracted non-residential staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. Contracted non-residential staff who have not completed essential skills training, as defined by Florida Administrative Code, do not have any direct contact with youth. Contracted non-residential staff who have not completed pre-service/certification training do not have direct, unsupervised contact with youth. A review of four staff training files documented completion dates for the required pre-service training hours within the first six months of employment. The program submitted one master training plan for pre-service and in-service training courses via to the Department s Office of Staff Development and Training on January 13, The training plan included the course names and the months in which the training is scheduled. The training plan did not include a description of the training course, objectives, whether or not the course is located in the Department s Learning Management System (SkillPro), whether the course is instructor-led, and the number of credible training hours. However, the Office of Staff Development and Training did not return the plan indicating a correction was needed. The required pre-service trainings were found in SkillPro and the instructor-led courses were completed by a certified instructor in cardiopulmonary resuscitation (CPR) and first aid. The certifications in CPR/first aid for the reviewed staff indicated an expiration date of two years from the date of training. The program maintains an individual training file for each staff member In-Service Training Compliance Contracted non-residential staff completes in-service training in accordance with Florida Administrative Code. Contracted non-residential staff must complete twenty-four hours of annual in-service training, beginning the calendar year after the staff has completed pre-service training. Supervisory staff shall complete eight hours of training in the areas listed below, as part of the twenty-four hours of annual in-service training. A review of three staff training files, supervisory and direct care staff, documented staff are completing the mandatory training topics and exceeding the required training hours for the annual in-service training. The program submitted one master training plan for pre-service and in-service training courses via to the Department s Office of Staff Development and Training on January 13, The training plan included the course names, and the months in which the training is scheduled. The training plan did not include a description of the training course, objectives, whether or not the course is located in the Department s Learning Management System (SkillPro), whether the course is instructor led, and it does not include the number of credible training hours. However, the Office of Staff Development and Training did not return the plan indicating a correction was needed. Office of Program Accountability Page 11 of 30 (Revised July 2015)

12 1.06 Medical Alerts, Mental Health Alerts, and Suicide Risk Compliance Alerts in JJIS The program shall alert staff of medical issues that may affect the security and safety of the youth in the program. The program has policies and procedures in place where the licensed mental health counselor (LMHC), who serves as the designated mental health clinician authority (DMHCA), notifies all staff of youth medical issues, which may affect the security and safety of the youth in the program. The DMHCA also alerts staff of a youth s possible suicide risk or mental health disorder. The notifications are made via to all pertinent staff with a need-to-know about youth alerts, and the program s internal alert form is updated daily and provided to all staff during the morning meeting. The staff must review the alert information for each youth and sign the alert sign-in sheet acknowledging receipt and review of the youth alerts. A review of the program s internal youth alert list found twenty-nine youth names with an alert. Ten of the twenty-nine youth alerts were reviewed; the information was entered into the Department s Juvenile Justice Information System (JJIS) by the DMHCA. A survey of seven staff found staff are informed of the youth s medical alerts daily through s and the program s alert sheet. The staff further indicated the notification process is very effective Episodic/Emergency Services Compliance The program shall have a comprehensive process for the provision of Episodic Care, First Aid, and Emergency Care. The program shall be capable of facilitating an appropriate response to an emergency situation. The program has a comprehensive process for the provision of episodic care, first aid, and emergency care. These events are recorded within the facility logbook. A random review of three facility logbooks found no documentation of any off-site emergency care, or other episodic care/emergency services. The executive director and designated mental health clinician authority stated there have been no episodic/emergency services provided to any of the youth during the review period. The program provided copies of documentation for mandatory mock drills relating to episodic/emergency situations involving all staff. The mock drills were recorded on a monthly basis in the back of the facility logbooks. The program has a total of nine fire extinguishers located in various areas throughout the facility, as well as first aid kits. The program has two knife-for-life and wire cutter kits, which are located in the front office, and another one inside of a backpack equipped for placement in the facility van when transporting youth Medication Management Medication Storage Compliance All medications (prescriptions, over-the-counter, topical, etc.) shall be stored in separate, secure (locked) areas and are inaccessible to youth and ensures proper inventory control. The program has a written policy and procedure in place regarding medication management and medication storage. There were no youth receiving prescribed or over-the-counter medications at the program. Youth taking prescribed medications receive the medication at home. The program is aware of the youth s medications and have listed the youth on the program s internal alert list with possible side effects. The program has a written procedure in place for storing medications should a youth require administration of medication on site. There is a double locked medication cabinet and double locked refrigerator inside of the designated Office of Program Accountability Page 12 of 30 (Revised July 2015)

13 mental health clinician authority office. The program has a trained non-licensed staff to assist with administering medications when applicable Cleanliness and Sanitation Compliance The program provides a safe and appropriate treatment environment including maintenance and sanitation of the facility. The director of operations conducts a daily security check of the facility, inside and outside. The teachers also conduct a daily check for cleanliness of the classrooms. During the review week the facility was observed to be neat and well maintained. There were no visible signs of graffiti on the walls, doors, or windows throughout the facility. The youth and staff share in keeping the facility clean. Staff have a schedule of kitchen and bathroom duties to be completed by days of the week. There are separate bathroom facilities for males, females, staff, and youth. The program has a large group area used as the cafeteria, counseling sessions, promotions, and other celebratory events with the youth and staff. Youth are selected for program work detail based on their point cards and their levels on the behavior modification plan Fire Prevention and Evacuation Procedures Compliance The program provides a safe and appropriate treatment environment including fire prevention and evacuation procedures. The program provides a safe and appropriate treatment environment including fire prevention and evacuation procedures as outlined in the program s egress plan and the continuity of operations plan (COOP). A survey of seven youth documented the program provides routine instructions on the evacuation plan in case of an emergency, fire, or other disastrous event. Youth are aware of the exits and the plan, as the egress plan is posted in various locations in the program. The program receives annual fire inspections of the fire extinguishers and other fire/emergency equipment from the Miami-Dade Fire Rescue Department Water Activities Compliance The program provides a safe and appropriate treatment environment including procedures for water activities. The program provides opportunities for youth to participate in water activities, such as scuba diving, and the program has an established water safety plan. One of the two scuba diving instructors is also the certified lifeguard for the program. Seven youth were surveyed with five reporting they do participate in the program s water activities, and each of the five youth have taken the required swim test. The program has a provision in place for notifying the youth s parent/guardian in cases of serious illness, injury, or death Food Services Compliance The program provides a safe and appropriate treatment environment including food service. The program provides a safe and appropriate treatment environment including food service. The food service dining area was observed to be clean. Seven youth were surveyed and seven stated the program provides the staff and youth the same menu and food is never withheld from a youth as a form of punishment. Six youth indicated being aware of the program providing a Office of Program Accountability Page 13 of 30 (Revised July 2015)

14 special diet for youth with health/medical issues or religious beliefs. A survey of seven staff verified the program provides the same menu for youth and staff. The program provides breakfast, lunch, and snacks for the staff and youth through Exquisite Catering by Robert catering service Transportation Compliance The program provides a safe and appropriate treatment environment including transportation. The program has one van for transporting youth. Observations of the program van found it was locked when not in use. Based upon the contract with the Miami-Dade school district, youth are picked up and dropped off to the program via the Miami-Dade North District School Transportation Department. Youth are transported in the van for off-campus activities, when needed. Seven surveyed youth reported youth and staff wear their seatbelts when the van is in operation. Seven surveyed staff reported when using the program s vehicle to transport youth, both the youth and the staff members are mandated to wear seat belts when the vehicle is in operation. The program conducts random driver s license checks of staff to ensure staff have a valid license to operate the program vehicle. The review team observed youth and staff as they entered the van to be transported off campus for an added incentive during the review period Administration Compliance The program provides a safe and appropriate treatment environment including administrative and operational oversight. The current youth roster submitted to the Department by the program prior to the review date did not match the youth names in the Department s Juvenile Justice Information System (JJIS). Some youth were school based youth, some were new intakes and some were released and returned to the program and the youth roster had not been updated. The program s executive director provided an accurate list of youth enrollment via the bio-tracking system on the first day of the review. The executive director indicated the program submits to the Department on a monthly basis, the trend analysis reporting on program vacancies, grievances, law enforcement responses to the program, Protective Action Response (PAR) usage, and youth length of stay in the program. The reports were reviewed for April 2015 through September The program also keeps an internal record of the Department s Central Communication Center (CCC) reports, incident reports, and PAR reports for the month. The program has only one shift and there is one facility logbook maintained monthly for staff to record significant facility activities, events, and incidents. The executive director reviews the logbooks as required and initials the review. The logbook entries are legible, brief, written in ink with the date, time, and name of the person making the entry Ninety-Day Supervisory Reviews Compliance Cases under supervision (i.e., probation, conditional release, post-commitment probation) are reviewed by the supervisor at least once every ninety calendar days. The supervisor ensures staff review any instructions given during the review, and ensures they were followed during the subsequent review. A review of four applicable youth records indicated the director of case management reviews case notes at least once every ninety-days. All four youth records confirmed the director of case management ensures the local care counselors update the youth requirements and the Positive Office of Program Accountability Page 14 of 30 (Revised July 2015)

15 Achievement Change Tool (PACT) goals in the Department s Juvenile Justice Information System (JJIS). Evidence was also found in the youth records indicating appropriate referrals for services were made as identified from the PACT and youth needs assessments. The local care counselors documented follow-up and recommendations when necessary 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 had a total of ten Central Communications Center (CCC) reportable incidents involving absconder incidents, youth behavior, and one medical/program disruption incident. All incidents were in compliance with the CCC reporting guidelines. In reviewing the program s internal incident binder, there were no documented incidents which should have been reported to the CCC and a report was not made Abuse-Free Environment Compliance Any knowledge or suspicion of abuse, abandonment, or neglect is reported to the Florida Abuse Hotline. The program provides unimpeded access for youth to self-report alleged/suspected abuse and youth eighteen and older are allowed to contact the Department s Central Communications Center (CCC). The telephone numbers for the CCC and Florida Abuse Hotline were posted throughout the program easily accessible to the youth. Seven youth were surveyed and each reported never being stopped from making an abuse call and each of the youth reported feeling safe in the program. Seven surveyed staff members revealed the executive director has zero tolerance for any form of abuse, intimidation, humiliation or harassment of youth by staff in the program. Staff receive an employee handbook with the expectations of team members, code of conduct, as well as a new hire packet including documentation regarding inappropriate behavior on social media and reporting it when relating to staff and/or youth involved with the program. Office of Program Accountability Page 15 of 30 (Revised July 2015)

16 Standard 2: Assessment Services Overview Youth admitted to AMIkids Miami-Dade North receive intake, orientation, screening, assessment, individualized service planning, individualized treatment planning, and assignment to evidence-based and promising practice interventions based on the identified individual needs. Screening is designed to identify youth in need of further assessment due to risk factors in aggression, suicide, trauma, mental health and substance abuse. Assessments are not a onetime event, but an ongoing process, as treatment progress is reviewed monthly by the multidisciplinary treatment team. During the admission process, the program s local care counselors are responsible for completion of the assessment services, provided to each youth, including completion of a medical screening, a Positive Achievement Change Tool (PACT), and referrals for mental health and substance abuse services if applicable Admission and Orientation Compliance Facility orientation shall be conducted within twenty-four hours of a youth s admission to the facility. Case notes should document the date and time of the orientation and the youth received orientation documents. Seven youth case management records were reviewed and each contained a day treatment program orientation acknowledgement form signed by the youth, parent/guardian, and local care counselor. Each reviewed youth file and case notes indicated the date and time of the orientation. The youth received orientation documents which included the program rules, student handbook, and contact information. The handbook included all of the required guidelines. In addition, the program orientation acknowledgment forms revealed the youth and parent/guardian signatures verifying completion of the orientation process. The review found each youth were added to the program s census in the Department s Juvenile Justice Information System (JJIS). Face sheets were used to determine when the youth was added to the program s census Medical Screening Compliance Youth are screened for health-related conditions at the time of admission to determine if the youth has any conditions requiring medical attention. The screening includes a review of the most recent Health Discharge Summary (Form HS 012) or Medication receipt/transfer disposition (Form HS053), if applicable, and documented contact with the parent/guardian if there are any questions or concerns regarding the youth s medical condition. Screening may be performed by non-licensed staff during the admission process. All medical, mental health, and substance abuse information is documented in the youth s Individual Health Care Record. Seven youth healthcare records were reviewed and each had an enrollment information form indicating the youth was questioned about allergies and health issues at intake. In addition, an interview with the designated mental health clinician authority (DMHCA) found further screenings were completed when deemed appropriate. All medical, mental health, and substance abuse information was documented in the youth s Individual Health Care Record. Office of Program Accountability Page 16 of 30 (Revised July 2015)

17 2.03 Medication Management Verification of Medications Compliance The program shall determine a youth s medication regimen upon admission to the program. The program obtains information regarding allergy and health issues at time of orientation. A review of seven youth mental health records found an interview with the designated mental health clinician authority (DMHCA) for mental health screening is done on the day of orientation. The medical questionnaire utilized by the DMHCA asks for medication information to be included in the youth s medical alerts. An interview with the executive director revealed youth who attend the program generally keep and take medications at home. There were no youth required to receive their medications during the operation hours of the program. However, there are written policies and procedures addressing medication management should a youth need to take medications while on site at the program. The executive director was able to describe and demonstrate the established procedure Mental Health/Substance Abuse Screening Compliance Youth are screened for mental health/substance abuse issues at the time of admission to determine if the youth has any conditions requiring further assessment and/or immediate attention. The screening includes a review of available information and completion of the Positive Achievement Change Tool (PACT) and the PACT Mental Health and Substance Abuse Report and Referral Form when further assessment is indicated by the PACT, or administration of the Massachusetts Youth Screening Instrument (MAYSI-2). The program ensures further assessment of the youth, or immediate intervention/treatment, as indicated by the mental health/substance abuse screening or through collateral information or behavior observation which indicates the need for further mental health/substance abuse assessment. (For the entire indicator statement, please reference the Monitoring and Quality Improvement FY Day Treatment indicators.) Reviewed documentation for seven youth mental health records confirmed the program screened each youth for mental health and substance abuse issues at the time of admission. Upon each youth s admission, the program s staff completed a Positive Achievement Change Tool (PACT), a mental health/substance abuse screening assessment and referral when applicable, and a Massachusetts Youth Screening Instrument - Second Version (MAYSI-2). Four of the seven reviewed records had an elevated risk of suicide due to the results of the intake screening for suicide risk, PACT results, MAYSI-2 results, and/or current history. In all four youth records, the designated mental health clinician authority (DMHCA) completed an Assessment of Suicide Risk (ASR) within twenty-four hours. Reviewed documentation supported each of the four youth were placed on Precautionary Observation (PO) and were stepped-down to standard supervision, as required. All seven youth individual mental health treatment plans were reviewed, signed, and dated by the DMHCA within ten days of completion. All seven youth individual substance abuse treatment plans included all of the applicable components and signatures Positive Achievement Change Tool (PACT) Full Compliance Assessment The PACT Full Assessment is completed by program staff for all youth, regardless of risk to reoffend, within seven calendar days of admission. A review of seven youth case management records found each had a Positive Achievement Change Tool (PACT) Full Assessment completed. Although five of the seven were completed Office of Program Accountability Page 17 of 30 (Revised July 2015)

18 within the seven-calendar day requirement, two were not. One PACT was completed sixteen calendar days after admission (nine days late), and one PACT was completed ten calendar days after admission (three days late). The program s written policies and procedures indicate the PACT is to be completed within seven calendar days of admission PACT Reassessment Compliance Staff complete PACT Reassessments for youth on probation, conditional release, and postcommitment probation, as well as minimum-risk non-residential commitment youth. Regardless of risk to reoffend, the PACT Full Assessment is completed every ninety days. A review of seven youth case management records found five youth who had been at the program more than ninety days and were eligible for a reassessment. All five had a Positive Assessment Change Tool (PACT) Re-Assessment completed in a timely manner. Neither of the seven reviewed youth records were eligible for an exit PACT Progress Reports Compliance Progress reports are completed detailing the youth s progress with the youth requirements and PACT goals outlined in the YES Plan. A review of seven youth case management records found five had representation of youth who had been at the program more than ninety days and were eligible for completion of a progress report. Each of the five records had a detailed progress report signed by the youth and the program staff preparing the report. Documentation in each of the five records indicated the youth were given an opportunity to review the report and make comments. Further documentation was found indicating the reports had been sent to the assigned juvenile probation officer (JPO), judge, and parent/guardian. A cover letter, which summarizes the youth s performance, was also sent to the JPO and a copy was placed in the file. Office of Program Accountability Page 18 of 30 (Revised July 2015)

19 Standard 3: Intervention Services Overview The program offers evidence-based interventions to include Aggression Replacement Therapy (ART), Cannabis Youth Treatment (CYT), Boys Circle and Girls Council, Arise Skill Streaming, vocational preparation, and individual and family counseling. The local care counselors and certified teachers are responsible for the provision of intervention services for each youth enrolled in the program. The program provides each youth with education, behavior modification, opportunities for vocational enhancement, life skills, and community service projects. The program s delinquency intervention strategy for servicing youth includes the results of the Positive Achievement Change Tool (PACT), the goals and requirements on the Youth-Empowered Success (YES) plan, and utilization of the AMIkids personal growth model targeting gender-specific risk factors identified for individual youth. The program has a food handling training program where youth have opportunity to earn a ServeSafe culinary certification, and a National Center for Construction Education and Research (NCCER) standardized craft training program where youth learn how to use tools, practice tool safety, and complete construction projects. There are two certified scuba instructors on-site who work with the youth to provide opportunity to receive a professional association of diving instructors (PADI) scuba license through the program s marine component. Reviewed documentation found the program conducts interventions upon each youth s admission, during the youth s attendance, and prior to transitioning each youth back into the community Career Education Programming Compliance Staff shall develop and implement a career education competency development program. The program provides Type 2 career education competency development programming. The director of education and the career coordinator explained the program is teaching personal accountability skills and behaviors appropriate for youth in all age groups and ability levels leading to work habits, which help maintain employment and living standards, as well as an orientation to a broad scope of career choices, based upon personal abilities, aptitudes and interest. The youth has opportunities to explore and gain knowledge of occupation options and the level of effort required to achieve employment in certain professions. The program implemented vocational training and job placement in January 2015, and works diligently to engage workforce agencies. A review of three youth case management records revealed each youth had a sample of completed employment applications, a resume summarizing education, work experience, and/or career training Educational Access Compliance The program shall integrate educational instruction (career and technical education, as well as academic instruction) into their daily schedule in such a way ensuring the integrity of required instructional time. An interview with the director of education and a review of the program s school schedule confirmed youth are required to participate in educational and career-related programs meeting the annual requirements for instructional minutes per day distributed over twelve months. The career training and educational program supports the academic courses, and the youth receive course credit for completion of the education and training experience. A review of the facility Office of Program Accountability Page 19 of 30 (Revised July 2015)

20 logbooks and observations of the program reveals minimal interference of educational instruction Youth-Empowered Success (YES) Plan Development Compliance The YES Plan (Form DJJ/PACTFRM 4) is cooperatively developed for youth on Probation, Conditional Release, and Post-Commitment Probation. Youth and parent/guardian signatures do not indicate cooperative development of the YES Plan. Case notes clearly reflect that the youth and/or parent/guardian was involved, or refused to be involved, in the development of the YES Plan. All parties sign the YES Plan within fourteen calendar days of youth s admission to the facility. A review of seven youth case management records found a Positive Achievement Change Tool (PACT) was completed prior to the development of the initial Youth-Empowered Success (YES) plan. Each of the seven YES plans were developed within fourteen days of the youth s admission, and was signed by all pertinent parties. Five of the seven youth records case notes documented the youth and parent/guardian were involved in the development of the YES plan, and a copy of the YES plan was provided to the youth and parent/guardian. Two of the seven youth records reviewed had a late entry note documenting the youth and parent/guardian involvement, and a copy of the YES plan was provided to the youth and parent/guardian. Seven youth surveys confirmed the youth participation in the development of the YES plans, and each youth receiving a copy of the YES plan Youth Requirement/PACT Goal Elements Compliance The YES Plan provides appropriate and individualized target dates for the completion of each youth requirement and PACT goal. All youth requirement and PACT goal action steps include the intervention plan elements (i.e., who, what, and how often). A review of seven youth case management records found the Youth-Empowered Success (YES) plan includes court ordered sanctions and youth requirements containing at least one specific action step for the youth, parent/guardian, and the local care counselor. The action steps defined each person s responsibility, the actions needed, and how often the actions should occur. In all seven youth records reviewed at least one of the youth s top three criminogenic needs was incorporated into a Positive Achievement Change Tool (PACT) goal with action steps for the youth, parent/guardian, and local care counselor clearly defining who is responsible, what action should be taken, and how often. The PACT goal was created in the Department s Juvenile Justice Information System (JJIS) Transitional Planning/Reintegration Compliance Program staff actively participates in the transitional planning process for youth who are being released from a residential program on conditional release (CR) or post-commitment probation (PCP). For conditional release and post-commitment probation youth, the YES Plan must address recommendations from the residential program during transition. A review of eight youth case management records found three of the eight records were applicable for transition planning and reintegration. The chronological notes documented interaction between the day treatment staff, youth, parent/guardian, and residential program. Two of three youth were within the fifty mile radius; however, in one record, the assigned local care counselor had a face-to-face with the youth. In the second reviewed record the local care Office of Program Accountability Page 20 of 30 (Revised July 2015)

21 counselor contacted the youth by telephone due to the program being notified late of the youth referral to the day treatment program. Further review found in one of the three youth case notes documented program staff participation in the sixty-day transition staffing, and in another record documentation in case notes found program staff participated in the fourteen-day staffing, and recommendations were included in the exit plan form. Documentation was not included in the chronological case notes indicating whether or not staff participated in the exit conference or if information was received after the exit conference was conducted. There was one applicable reviewed record requiring the recommendations from the residential program during transition being incorporated into the Youth-Empowered Success (YES) plan and it was completed as required YES Plan Implementation/Supervision Compliance Youth on supervision (i.e., probation, conditional release, or post-commitment probation) are supervised in a manner ensuring compliance with the court order and completion of YES Plan (youth requirements and PACT goals). Case notes demonstrate compliance (or attempted compliance) with youth, parent/guardian, and staff action steps contained in the YES Plan. A review of seven youth case management records found case notes demonstrating compliance or attempted to comply with the youth, parent/guardian, staff, action steps, and sanctions contained in the Youth-Empowered Success (YES) plan. Case notes documented all case activities with regard to face-to-face contacts, telephone contacts, and local care counselor s interactions with youth, parent/guardian, and providers. One of seven reviewed youth records documented the youth was referred for services and the local care counselor reviewed the written and verbal reports from the collateral sources Behavior Management System Compliance The program utilizes a behavior management system providing privileges and consequences to encourage youth to fulfill programmatic expectations. Consequences are fair and directly correlate with the behavior problem. The use of facility restriction does not exceed seven consecutive days. Disciplinary procedures are carried out promptly. Youth are not allowed to have control over or discipline other youth. Time-out is used in accordance with Florida Administrative Code. All behavior problems, time-outs, in-facility suspensions, and privilege suspensions are documented in the facility log and case file in accordance with Florida Administrative Code. The program utilizes a behavior management system providing privileges and consequences to encourage youth to fulfill programmatic expectations. During a facility tour it was noticed the program s behavior modification plan was posted in various locations in the facility. The plan utilizes a point card system, which is updated at least weekly. The point card gains the youth extra incentives. Although points are earned for merit, a youth may not earn points for rule violations. A review of seven youth point cards found the most common rule violations were absenteeism and tardiness. The behavior management plan requires at least weekly reviews, which means the resulting status of the youth does not exceed seven consecutive days. The program follows a daily activity schedule to provide structure and routine for the youth. The programs mission statement includes the Department s mission to reduce juvenile crime, and a description of the program s design, educational goals, and objectives. A survey of seven youth verified the program does not use time-out, and youth are never allowed to discipline or have control over other youth. The seven surveyed youth unanimously reported during privilege suspensions never being denied meals, health care, religious needs, parental contacts, or legal Office of Program Accountability Page 21 of 30 (Revised July 2015)