BUREAU OF QUALITY ASSURANCE PROGRAM REPORT FOR

Transcription

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 QUALITY ASSURANCE PROGRAM REPORT FOR West Florida Wilderness Institute AMIkids, Inc. (Contract Provider) 1912 Old Mt. Zion Road Ponce De Leon, Florida Review Date(s): August 30-September 1, 2011 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES W A N S L E Y W A L T E R S, S E C R E T A R Y J E F F W E N H O L D, B U R E A U C H I E F Office of Program Accountability Page 1 of 17

2 Residential Performance Rating Profile Program Name: West Florida Wilderness Institute QA Program Code: 23 Provider Name: AMIkids, Inc. Contract Number: R2012 Location: Holmes County / Circuit 14 Number of Beds: 40 Review Date(s): August 30-September 1, 2011 Lead Reviewer Code: 112 Program Performance by Indicator/Standard 1. Management Accountability 3. Mental Health and Substance Abuse Services (cont.) 1.01 Background Screening of Employees/Vol. 7 Accepta3.05 Suicide Prevention Provision of an Abuse Free Environment 7 Accepta3.06 Mental Health Crisis Intervention Incident Reporting 7 Accepta3.07 Emergency Services Protective Action Response (PAR) 8 Commen3.08 Specialized Treatment Services Pre-Service/Certification Requirements 8 Commendable Commendable 84% 1.06 In-Service Training Requirements 10 Exceptional 1.07 Logbook Maintenance 7 Accepta 4. Health Services 1.08 Internal Alert System 5 Minima 4.01 Designated Health Authority Escapes 5 Minima 4.02 Healthcare Admission Screening Youth Records 7 Accepta4.03 Comprehensive Physical Assessment Community Partnerships 10 Exceptio4.04 Sexually Transmitted Diseases Facility Integration and Stability 8 Commen4.05 Sick Call 8 Acceptable 74% Medication Administration Medication Control 7 2. Intervention and Case Management 4.08 Infection Control Classification 7 Accepta4.09 Chronic Illness Treatment Assessment 7 Accepta4.10 Episodic and Emergency Care Intervention and Treatment Team 7 Accepta4.11 Consent and Notification Performance Plan 5 Minima 4.12 Prenatal/Neonatal Care NA 2.05 Performance Review and Reporting 7 Acceptable Acceptable 78% 2.06 Parent/Guardian Communication 8 Commendable 2.07 Transition Planning and Release 5 Minima 5. Safety and Security 2.08 Grievance Process 7 Accepta5.01 Supervision of Youth Gang Prevention and Intervention 5 Minima 5.02 Key Control Staff Characteristics 8 Commen5.03 Contraband and Searches Delinquency Programming 8 Commen5.04 Transportation Gender-Specific Programming 8 Commen5.05 Tool Management Vocational Programming 10 Exceptio5.06 Disaster/Continuity of Operations Planning 8 Acceptable 71% Flammable, Poisonous, and Toxic Items Water Safety 7 3. Mental Health and Substance Abuse Services 5.09 Behavior Management System Designated Mental Health Authority 10 Exceptio5.10 Behavior Management Unit NA 3.02 MH and SA Admission Screening 8 Commen5.11 Controlled Observation NA 3.03 MH and SA Assessment/Evaluation 10 Exceptional Minimal 68% 3.04 Treatment Plan/Team and Service Delivery 7 Acceptable Standard Program Score Max. Score Rating Failed 0-59% Minimal 60-69% Acceptable 70-79% Commendable 80-89% 1. Management Accountability % X 2. Intervention and Case Management % X 3. Mental Health and Substance Abuse Services % X 4. Health Services % X 5. Safety and Security % X Exceptional % Overall Program Performance Acceptable 75% Office of Program Accountability Page 2 of 17

3 Methodology This review was conducted in accordance with FDJJ-1720 (Quality Assurance Policy and Procedures), and focused on the areas of (1) Management Accountability, (2) Intervention and Case Management, (3) Mental Health and Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included in the Residential Standards (July 2011). Persons Interviewed Program Director DJJ Monitor DHA or designee DMHA or designee 1 # Case Managers 2 # Clinical Staff 1 # Food Service Personnel 1 # Healthcare Staff Documents Reviewed 1 # Maintenance Personnel 1 # 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 7 # Health Records 7 # MH/SA Records 7 # Personnel Records 7 # Training Records/CORE 3 # Youth Records (Closed) 7 # Youth Records (Open) # Other: 7 # 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 17

4 Performance Ratings Performance ratings were assigned to each indicator by the review team using the following definitions and numerical values defined by FDJJ-1720: Exceptional (10) Commendable (8) Acceptable (7) Minimal (5) Failed (0) The program consistently meets all requirements, and a majority of the time exceeds most of the requirements, using either an innovative approach or exceptional performance that is efficient, effective, and readily apparent. The program consistently meets all requirements without exception, or the program has not performed the activity being rated during the review period and exceeds procedural requirements and demonstrates the capacity to fulfill those requirements. The program consistently meets requirements, although a limited number of exceptions occur that are unrelated to the safety, security, or health of youth, or the program has not performed the activity being rated during the review period and meets all procedural requirements and demonstrates the capacity to fulfill those requirements. The program does not meet requirements, including at least one of the following: an exception that jeopardizes the safety, security, or health of youth; frequent exceptions unrelated to the safety, security, or health of youth; or ineffective completion of the items, documents, or actions necessary to meet requirements. The items, documentation, or actions necessary to accomplish requirements are missing or are done so poorly that they do not constitute compliance with requirements, or there are frequent exceptions that jeopardize the safety, security, or health of youth. Review Team The Bureau of Quality Assurance 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: William Hardy, Lead Reviewer, DJJ Bureau of Quality Assurance Bruce Morton, Review Specialist, DJJ Bureau of Quality Assurance Bobbie Frenton, Program Director, White Foundation Contracted Supervision - Circuit 14 Mary Gaiser, Review Specialist, DJJ Bureau of Quality Assurance Lori Jernigan, Program Monitor, DJJ Residential Services, North Region Mike Murphy, Senior Juvenile Probation Officer, DJJ Probation, Circuit 1 Diane Ruane, Technical Assistance Specialist, DJJ Programming and Technical Assistance Office of Program Accountability Page 4 of 17

5 Please note that this report refers to each indicator by number and title only. Please see the applicable standards for the full text of each indicator. The standards are available on the Bureau of Quality Assurance website, at Standard 1: Management Accountability Failed Minimal Acceptable Commendable Exceptional Overview West Florida Wilderness Institute is a member of the AMIkids, a non-profit organization that provides rehabilitative services for juvenile offenders. West Florida Wilderness Institute operates under contract with the (DJJ) and the Holmes County school board. This forty (40) bed facility is located in a wilderness setting in rural Holmes County. The length of program commitment is performance based and the average length of stay is between six (6) and nine (9) months. West Florida Wilderness Institute is a non-hardware secure program that does not have video surveillance equipment. There has been an escape by a youth from the program since the last Quality Assurance review. The program, through an internal investigation determined that improper supervision contributed to the escape. There were other noted concerns regarding inappropriate supervision practices. These issues will be discussed in more detail in the appropriate corresponding indicators. The Executive Director and Director of Operations are the management staff. The program provides specialized services in the form of Behavioral Health Overlay Services (BHOS). West Florida Wilderness Institute continues to demonstrate strong community involvement, through a number of service projects, and there is an emphasis on experiential learning. 1.01: Background Screening of Employees/Volunteers Acceptable (7) A review of employee background screenings found that two (2) employees five (5) year re-screenings were not completed within the required timeframes. 1.02: Provision of an Abuse Free Environment Acceptable (7) Staff and youth surveys were conducted for this indicator. Six (6) of the seven (7) youth surveyed indicated that staff use profanity when speaking to them or other youth in the program. Five (5) of five (5) staff surveyed indicated that they have observed other staff using profanity when speaking to youth. Office of Program Accountability Page 5 of 17

6 1.03: Incident Reporting Acceptable (7) A review of six (6) facility incident reports revealed that two (2) incidents were not reported to the Central Communication Center (CCC) within the two (2) hour requirement. 1.04: Protective Action Response (PAR) Commendable (8) 1.05: Pre-Service/Certification Requirements Commendable (8) 1.06: In-Service Training Requirements Exceptional (10) A review of six (6) in-service staff training records found that all staff exceeded the twenty-four (24) hour annual training requirement. This was achieved with an average of more than ten (10) additional hours for each staff reviewed. 1.07: Logbook Maintenance Acceptable (7) A review of facility logbooks found an inconsistent practice of each log entry containing the printed name of the person making the entry, as required. 1.08: Internal Alert System Minimal (5) The facility has an alert system in place, however there was no evidence to indicate that this system identified youth in the program that are documented gang members, have gang affiliation, or have been charged with a sex offense. Therefore, there was no way to ensure that this security information was being relayed to direct-care staff. 1.09: Escapes Minimal (5) The program experienced one (1) escape incident one (1) week prior to the on-site Quality Assurance review. 1.10: Youth Records Acceptable (7) One (1) of seven (7) individual case management records did not contain the youth s home county on the binder, as required. Office of Program Accountability Page 6 of 17

7 1.11: Community Partnerships Exceptional (10) Through discussion with the Program Director and review of documentation, community involvement includes meetings with the Kiwanis Club, Ministerial Association and the CASE Coalition. Documentation showed that these meetings are held bi-monthly, rather than quarterly. This program has an Advisory Board which contains community involvement with members of law enforcement, school board or district, business and faith community, as well as a victim advocate. The only community involvement not included on the advisory board was judicial; however, documentation shows active solicitation of this party. 1.12: Facility Integration and Stability Commendable (8) Standard 2: Intervention and Case Management Failed Minimal Acceptable Commendable Exceptional Overview West Florida Wilderness Institute has one Case Manager to provide delinquency intervention services to the youth in the program's care. The Case Manager is primarily responsible for classification and screening, coordination of services and legal sanctions, and acting as a liaison between the program and youth's guardians. In addition, the Case Manager is the designated treatment team leader for formal intervention and treatment team meetings and informal reviews. The Case Manager is responsible for developing, preparing and completing RPACT assessments, Youth Needs Assessment Summaries, Performance Plans, Performance Summaries and tracking youth progress. The Case Manager is also responsible for identifying and working with each youth on transition needs to ensure a successful reintegration into the youth's home community. 2.01: Classification Acceptable (7) A review of facility classification documentation found an inconsistent practice of identifying all pertinent information. An example found in one of the youth records revealed that the youth was admitted to the program and was classified as a sex offender on the program s classification checklist. However, the Alerts Present section of the Admission Risk Classification Findings was marked None. The youth was placed in the program on a petition for violation of probation on a case that involved sexual offenses on which he was adjudicated delinquent. The program uses the WFWI Off-Campus Day Activity Trip Plan form to document that youth are assessed before they leave the program to participate in off-campus activities. Office of Program Accountability Page 7 of 17

8 However, four (4) of twenty-one (21) trip plans reviewed had a risk assessment column that was blank, and others were difficult to determine the actual risk assigned. 2.02: Assessment Acceptable (7) Three (3) of the seven (7) youth files reviewed required reassessments. All three (3) reassessments were completed every ninety (90) day as required. However, there was no documentation that the reassessment results were addressed, presented to the treatment team, or used to update performance plans. 2.03: Intervention and Treatment Team Acceptable (7) A review of documentation found no indication that a direct care staff was a member of the treatment team as required by 63E (4)(b). 2.04: Performance Plan Minimal (5) Seven (7) of the performance plans reviewed neither referenced nor incorporated the youths mental health treatment plans and one (1) did not include the needs of a youth classified by the program as a sex offender. Three youth files that contained reassessments did not contain documentation that the performance plans were updated based upon the new results. Performance plan goals and interventions did not reference or incorporate academic plans. Two (2) performance plans for two (2) different 14-year old youths were not signed by education staff. One performance plan for a youth was not signed by medical; the Juvenile Justice Information System (JJIS) Current Special Alerts showed this youth was placed on psychotropic medication. Only two (2) of five (5) youth records in the transition phase of the program showed transition activities. 2.05: Performance Review and Reporting Acceptable (7) There was no documentation that the intervention and treatment team provided an opportunity for youth to demonstrate skills acquired in the program. Two (2) of seven (7) surveyed youth indicated that they were not provided an opportunity during intervention and treatment team meetings, to demonstrate skills they have learned in the program. A review of one (1) youth record found written progress noted for the youth s work on one of his goals, however this goal was not found on this youth s performance plan. There wasn t any information noted in one (1) youth s record to determine progress or lack of progress on any goals after a formal treatment team meeting was held. There was no documentation indicating that youth are given an opportunity to add comments. None of the performance summaries reviewed included any youth comments. Office of Program Accountability Page 8 of 17

9 2.06: Parent/Guardian Communication Commendable (8) 2.07: Transition Planning and Release Minimal (5) A review of three (3) closed youth records revealed that two (2) of three (3) exit conferences were held less than fourteen (14) days prior to release. Two (2) of three (3) closed youth records reviewed contained documentation that the Pre-Release Notification and Acknowledgment form and performance summary were sent less than forty-five (45) days to the youth s JPO. Only two (2) of five (5) applicable youth records showed transition activities. 2.08: Grievance Process Acceptable (7) A review of youth grievances found there was no information to describe how the grievance was resolved, other than the youth s signature next to a box, checked resolved. 2.09: Gang Prevention and Intervention Minimal (5) A review of facility practices found no clearly defined gang prevention and intervention strategy in place during the time of review. There was no system in place to inform staff of youth that were admitted to the program and were documented gang members or have suspected gang affiliations. 2.10: Staff Characteristics Commendable (8) 2.11: Delinquency Programming Commendable (8) 2.12: Gender-Specific Programming Commendable (8) 2.13: Vocational Programming Exceptional (10) Program staff collaborates with the educational component to assist the youth in acquiring necessary academic and vocational skills. Youth are provided with an employment aptitude skill assessment that directs the direction of vocational and Office of Program Accountability Page 9 of 17

10 educational services. The program participated in the Florida Ready to Work program which uses three levels, Gold, Silver, and Bronze, to compare the youth s skills with the skills needed for employment with the top thirty 30% percent of all jobs provided nationally through the WorkKeys system. All of the eligible youth from the sample were provided with work related experience. The youth s discharge folder contained all of the academic test results and transcripts, vocational training that was completed, a typed resume and any certificates the youth had earned. Completing practice job applications are completed in class but not made a part of the vocational folder. The One Stop employment center is located in the towns of Bonifay and Chipley are within fifteen miles of the program and is made available to all of the youth. The program uses the Choices Interest Profiler to assess vocational/career interest. All of the youth complete the SafeStaff entry level food handler training program before leaving the program. They have recently started a Fiber Optic training program which is also for all of the youth to complete for possible employment upon release. A certificate as an Open Water Diver is also available to the youth. For youth returning to gain their General Equivalency Diploma (GED) are provided with additional funding to complete the courses. Standard 3: Mental Health and Substance Abuse Services Failed Minimal Acceptable Commendable Exceptional Overview There are three (3) master s level therapists that provide individual, group and family therapy for the youth and their families. In addition, there is a Licensed Mental Health Counselor (LMHC) who is the Designated Mental Health Authority (DMHA). When the program is at full capacity each of the therapists would have a caseload of twelve (12) to fourteen (14) youth. The DMHA also carries a small case load, which are the more difficult or complicated cases. Clinical services are limited to evidence-based curriculum such as Aggression Replacement Training (ART) and Cannabis Youth Treatment (CYT). The program receives Behavioral Health Overlay Services (BHOS) per diem for all forty of the youth. The focus of mental health and substance abuse treatment is directed from AMIkids corporate offices. 3.01: Designated Mental Health Authority (DJJ Program) Exceptional (10) There is an LMHC who is on site forty (40) hours per week. The LMHC conducts group, individual and family therapy. She also responds to any mental health or substance abuse emergency. A review of the weekly clinical supervision notes found they are held in a group format and review all of the clinical services for the week as well as case review, training and any recommendation that the DMHA might have. Office of Program Accountability Page 10 of 17

11 3.02: Mental Health and Substance Abuse Admission Screening Commendable (8) 3.03: Mental Health and Substance Abuse Assessment/Evaluation Exceptional (10) A review of documentation revealed that bio-psychosocial assessments were updated in January The new form focused on a narrative response to each topic rather than check boxes, providing more detailed information. An extensive narrative review of the previous assessments and documents from the commitment packet was documented on the first page of the assessment. This provided a comprehensive base to build the rest of the information on the assessment and on the master treatment plan. There was an extensive description of clinical issues in the sections for clinical findings and treatment recommendations. The findings in each category from the MAYSI-2 screening were reviewed and documented in the assessment. 3.04: Treatment Plan, Treatment Team, and Service Delivery Acceptable (7) The treatment plan reviews in one (1) of seven (7) youth mental health records had numerous deficiencies in the documentation of completed objectives and the date of the reviews. In four (4) of seven (7) treatment plan reviews the date of the completed objective was after the date on the review indicating that the objective would be completed in the future. The transition goal in one (1) of the treatment plans showed an objective for the development of a substance abuse relapse prevention plan although there was no indication of a substance abuse problem in the bio-psychosocial assessment. 3.05: Suicide Prevention Acceptable (7) A review of seven (7) youth mental health records found one (1) applicable youth who was assessed to be at risk for suicide. The time checks while the youth was on close supervision indicated for a one (1) hour time block the facility was conducting ten (10) minute checks rather than the required five (5) minute checks. In addition, there was some missing documentation to determine if all supervision checks were conducted during the entire timeframe this youth was on close supervision. 3.06: Mental Health Crisis Intervention Commendable (8) Office of Program Accountability Page 11 of 17

12 3.07: Emergency Services Acceptable (7) The DMHA completed an Assessment of Suicide Risk (ASR) upon a youth s return to the facility from a Baker Act. The youth in question was not suicidal; therefore, requiring a crisis assessment to be conducted. The ASR that was completed did not cover all key elements required by the Office of Health Services mental health manual when conducting a crisis assessment. 3.08: Specialized Treatment Services Error! Not a valid link. (10) In addition to the weekly clinical supervision provided by the Designated Mental Health Authority, supervision is also provided by the BHOS Director who has a Doctor of Philosophy degree (PhD) during weekly conference calls with the mental health department. Documentation showed that the status of all mental health services are discussed, along with admissions and discharges from the program. The BHOS Director also addresses any clinical issues brought forth by the team and offers suggestions with regard to documentation, treatment services, etc. Random chart audits are conducted by the DMHA who is on site 5 days per week. The BHOS Director also conducts random chart reviews when she is on site bi-monthly. Random chart audits consisted of a review of Bio-Psychosocial Assessments, Individualized Treatment Plans, and BHOS certifications. The BHOS audit conducted one month prior to the on-site QA review resulted in a score of 97% with a minor deficiency. Standard 4: Health Services Failed Minimal Acceptable Commendable Exceptional Overview West Florida Wilderness Institute has contracted with a Florida licensed Medical Doctor (MD) to act as the Designated Health Authority (DHA). This individual is on-site once a week, and there was evidence in the medical records of the DHA providing numerous medical services. These services where evident in the completion of health assessments and periodic evaluations, reviewing off-site care orders, monitoring medications prescribed for health concerns, and referring youth for testing (as necessary). There is one (1) Licensed Practical Nurse (LPN) providing medical services on-site forty (40) hours per week. Duties of the LPN include, but are not limited to; conducting sick call, Facility Entry Physical Health Screening, and Health Related History (HRH) forms for all new admissions. In addition, the LPN is responsible for documenting all medical services being provided for a maximum daily population of forty (40) youth. Office of Program Accountability Page 12 of 17

13 The program keeps a limited supply of over-the Counter (OTC) medications on site, and there is a running balance with weekly inventories conducted by the LPN. All prescription medications are stored in a locked medical cart which is stored in the locked medical clinic. The clinic was very well organized and well stocked. The clinic provided a private location to ensure privacy for the youth receiving services. 4.01: Designated Health Authority Commendable (8) 4.02: Healthcare Admission Screening Commendable (8) 4.03: Comprehensive Physical Assessment Acceptable (7) A review of seven (7) youth comprehensive physical assessments (CPA) found one (1) in which the youth refused the genital exanimation and there was no youth signature verifying that refusal. 4.04: Sexually Transmitted Diseases Acceptable (7) All seven (7) youth medical records reviewed contained a sexually transmitted diseases (STD) form completed during the admission process. Documentation showed two (2) of those seven (7) youth either requested testing or the youth reported that they engaged in unprotected sex. However, testing for those two (2) youth was not conducted in a timely manner. 4.05: Sick Call Commendable (8) 4.06: Medication Administration Acceptable (7) Two (2) of seven (7) youth healthcare records found issues with medication administration documentation on the Medication Administration Record (MAR). The documentation did not show that the medication was provided for these two (2) youth when they were on an off-site field trip or community services project. 4.07: Medication Control Acceptable (7) A review of medication count sheets found issues in documentation. Further review of documentation determined that the medication counts were physically correct, but the documentation of the counts did not always match. Office of Program Accountability Page 13 of 17

14 4.08: Infection Control Commendable (8) 4.09: Chronic Illness Treatment Commendable (8) 4.10: Episodic and Emergency Care Commendable (8) 4.11: Consent and Notification Exceptional (10) All consents or requests for information are sent to the parent or guardian with a selfaddressed stamp envelope. In addition, the nurse contacts each parent to discuss medical conditions and provide information regarding the youth s medical treatment plan. The program nurse also sends out a Parental Notification to the parent or guardian when medications are not prescribed, treatment rendered such as laboratory review, routine follow-up or youth s request to be seen by the DHA but doesn t require any new or change in medical treatment 4.12: Prenatal/Neonatal Care Non-Applicable (NA) The program is contracted for males only, and therefore this indicator is not applicable. Standard 5: Safety and Security Failed Minimal Acceptable Commendable Exceptional Overview West Florida Wilderness Institute is a staff secure program. The program has no perimeter fences or visual monitoring system. The program consists of one (1) main building and several other buildings including classrooms, mental health staff offices, a ropes course, and food service. The main building consists of four (4) administrative offices, nurse s station and two (2) dorms. All staff members are PAR certified and have been trained in the use of chemicals and toxic chemicals. The Director of Operations is designated as the key control officer and manager of the tools. Office of Program Accountability Page 14 of 17

15 The program provided written policy and procedures relating to staff supervision of the youth, key control, transportation, chemical and tool control processes and inventories. Observation of supervision practices were conducted during the entire Quality Assurance review and deficiencies were identified, as well as issue with supervision in relationship to a youth escaping from the facility. These issues will be addressed in the corresponding indicator. 5.01: Supervision of Youth Minimal (5) A review of the documentation provided by the program found there to be an inconsistent practice of staff documenting ten minute checks of youth while sleeping. Program staff would mark number of youth observed rather than documenting each youth individually. Observations made by the review team revealed children of program staff interacting with residents of the program. During this observation a staff members two (2) young sons were interacting and engaging in physical horseplay with at least two (2) residents in the front entrance to the facility unsupervised by any direct-care staff member. The facility had an escape incident, and an investigation is pending in relationship to supervision practices. 5.02: Key Control Minimal (5) The program has a process in place to account for all facility keys, however the process is not followed consistently, as staff often do not sign-out the facility key or indicate the facility key # they are signing out. The staff frequently indicates POV in the Key# column on the Key Log. There is an inconsistent practice of staff signing keys back in on the Key Log, as required by the program policy. During the on-site review on September 31, 2011, nine (9) sets of facility keys were in use by staff, but only one (1) set of keys was signed out. Observations of facility staff revealed that keys are passed from staff to staff, which is not consistent with policy. 5.03: Contraband and Searches Minimal (5) Three (3) of the facility Central Communication Center (CCC) Reports indicated that contraband (tobacco products) was found in youth s possession. Documentation provided by the program indicated that the program has conducted only two (2) documented searches of youth in the last six month. A review of documentation found no indication the facility has a system in place to prevent the integration of contraband into the facility. An interview with the Program Director of Operations confirms the practice of the program to only conduct searches when items are stolen or missing. 5.04: Transportation Commendable (8) Office of Program Accountability Page 15 of 17

16 5.05: Tool Management Commendable (8) 5.06: Disaster and Continuity of Operations Planning Commendable (8) 5.07: Flammable, Poisonous, and Toxic Items Commendable (8) 5.08: Water Safety Acceptable (7) A review water activity forms found an inconsistent practice of completing the form in its entirety. The documentation did not include names and certification, dates of certification of additional staff supervising youth on a trip. Also, these staff did not consistently sign the trip plan so the ratio of staff-to-youth was unable to be determined on several occasions. Further review found that the type of swimming area, water condition, and position of lifeguards were not consistently indicated. 5.09: Behavior Management System Acceptable (7) A review of six (6) staff training files found that none were trained on the facilities behavior management system. 5.10: Behavior Management Unit Non-Applicable (NA) During the on-site review there was no evidence that the program operated a behavior management unit. In addition, the program s policy and procedures indicate that they do not operate a behavior management unit. 5.11: Controlled Observation Non-Applicable (NA) Interviews with seven (7) randomly selected youth and staff indicated that the program does not use controlled observation. Additionally the program s policy and procedures confirms that controlled observation is not used at the program. Office of Program Accountability Page 16 of 17

17 Overall Program Performance Acceptable 75% Failed Minimal Acceptable Commendable Exceptional Office of Program Accountability Page 17 of 17