BUREAU OF QUALITY ASSURANCE 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 QUALITY ASSURANCE PROGRAM REPORT FOR Milton Girls Juvenile Residential Facility Gulf Coast Youth Services (Contract Provider) 5570 E. Milton Road Milton, Florida Review Date(s): October 25-27, 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 18

2 Residential Performance Rating Profile Program Name: Milton Girls Juvenile Residential Facility QA Program Code: 1022 Provider Name: Gulf Coast Youth Services Contract Number: R2045 Location: Santa Rosa County / Circuit 1 Number of Beds: 60 Review Date(s): October 25-27, 2011 Lead Reviewer Code: Management Accountability 3. Mental Health and Substance Abuse Services (cont.) 1.01 Background Screening of Employees/Vol Suicide Prevention 1.02 Provision of an Abuse Free Environment 3.06 Mental Health Crisis Intervention 1.03 Incident Reporting 3.07 Emergency Services 1.04 Protective Action Response (PAR) 3.08 Specialized Treatment Services 1.05 Pre-Service/Certification Requirements % Indicators Rated Compliance: 100% 1.06 In-Service Training Requirements % Indicators Rated Limited Compliance: 0% 1.07 Logbook Maintenance % Indicators Rated Failed Compliance: 0% 1.08 Internal Alert System 1.09 Escapes 4. Health Services 1.10 Youth Records 4.01 Designated Health Authority 1.11 Community Partnerships 4.02 Healthcare Admission Screening 1.12 Facility Integration and Stability 4.03 Comprehensive Physical Assessment % Indicators Rated Compliance: 100% Sexually Transmitted Diseases % Indicators Rated Limited Compliance: 0% Sick Call % Indicators Rated Failed Compliance: 0% Medication Administration Medication Control 2. Intervention and Case Management 4.08 Infection Control 2.01 Classification 4.09 Chronic Illness Treatment 2.02 Assessment 4.10 Episodic and Emergency Care 2.03 Intervention and Treatment Team 4.11 Consent and Notification 2.04 Performance Plan 4.12 Prenatal/Neonatal Care 2.05 Performance Review and Reporting % Indicators Rated Compliance: 100% 2.06 Parent/Guardian Communication % Indicators Rated Limited Compliance: 0% 2.07 Transition Planning and Release % Indicators Rated Failed Compliance: 0% 2.08 Grievance Process 2.09 Gang Prevention and Intervention 5. Safety and Security 2.10 Staff Characteristics 5.01 Supervision of Youth 2.11 Delinquency Programming 5.02 Key Control 2.12 Gender-Specific Programming 5.03 Contraband and Searches 2.13 Vocational Programming 5.04 Transportation % Indicators Rated Compliance: 100% Tool Management % Indicators Rated Limited Compliance: 0% Disaster/Continuity of Operations Plan % Indicators Rated Failed Compliance: 0% Flammable, Poisonous, and Toxic Items Water Safety Non-Applicable 3. Mental Health and Substance Abuse Services 5.09 Behavior Management System 3.01 Designated Mental Health Authority 5.10 Behavior Management Unit Non-Applicable 3.02 MH and SA Admission Screening 5.11 Controlled Observation 3.03 MH and SA Assessment/Evaluation % Indicators Rated Compliance: 100% 3.04 Treatment Plan/Team/Service Delivery 4 % Indicators Rated Limited Compliance: 0% (continued above) 0 % Indicators Rated Failed Compliance: 0% 0 Compliance: Limited Compliance: Failed Compliance: Indicator Ratings Overall Rating Summary 100% 0% 0% * Percentages have been rounded to the nearest whole number. Percentages may not total 100% due to rounding. Office of Program Accountability Page 2 of 18

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 2 # Case Managers 2 # Clinical Staff 0 # Food Service Personnel 2 # Healthcare Staff Documents Reviewed 1 # Maintenance Personnel 1 # Program Supervisors 0 # 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 3 # Personnel Records 5 # Training Records/CORE 3 # Youth Records (Closed) 7 # Youth Records (Open) 0 # Other: 7 # Youth 7 # Direct Care Staff # Other: Observations During Review Admissions Confinement Facility and Grounds First Aid Kit(s) Group Meals Medical Clinic Medication Administration Posting of Abuse Hotline Program Activities Recreation Searches Security Video Tapes Sick Call Social Skill Modeling by Staff Staff Interactions with Youth Comments Staff Supervision of Youth Tool Inventory and Storage Toxic Item Inventory and Storage Transition/Exit Conferences Treatment Team Meetings Use of Mechanical Restraints Youth Movement and Counts Items not marked were either not applicable or not available for review. Office of Program Accountability Page 3 of 18

4 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; limited, unintentional, and/or non-systemic exceptions that do not result in reduced or substandard service delivery; or exceptions with corrective action already applied and demonstrated. Exceptions to the requirements of the indicator that result in the interruption of service delivery, and 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 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 Daniel May, Review Specialist, DJJ Bureau of Quality Assurance Sherri Swan, Clinical Director, Lutheran Services Florida - Currie House Linda Williams, Program Monitor, DJJ Residential Services, North Region Office of Program Accountability Page 4 of 18

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 Overview Milton Girls Residential Juvenile Facility is a sixty (60) bed, hardware secure intensive mental health program for female youth between the ages of thirteen (13) and eighteen (18). The youth that are admitted to this program must display moderate to severe functional impairment as a result of a mental health diagnoses. A licensed mental health professional serves as the program director, and this individual has fulfilled this role since the program s inception. An assistant program director also provides administrative support, and this individual s focus is primarily related to care, custody, and operational issues within the program. The program director participates on daily conference calls with other members of the provider s Management Team. Additionally, the Quality Assurance director compiles monthly trend analyses for the program, relating to incidents, use of force, escapes, abuse calls, etc. The provider also has a corporate Training Coordinator who is responsible for all staff and management training. 1.01: Background Screening of Employees/Volunteers Compliance A review of staff five-year re-screenings found that one (1) staff screening was completed six (6) months after the required timeframe. 1.02: Provision of an Abuse Free Environment Compliance 1.03: Incident Reporting Compliance 1.04: Protective Action Response (PAR) Compliance A review of seven (7) PAR reports found all of the required documentation. In addition the program has put emphasis on the reduction of PAR restraints used in the program; this was evident through a comprehensive training curriculum for verbal de-escalation interventions that staff have received. Office of Program Accountability Page 5 of 18

6 1.05: Pre-Service/Certification Requirements Compliance A review of two (2) newly hired employees found that in both cases the required 120 hour training requirement had been exceeded through instructor-led courses. The staff obtained 150 and 197 training hours respectfully. 1.06: In-Service Training Requirements Compliance A review of four (4) annual staff training files found all to have a minimum of eighty (80) hours of training (an overwhelming majority of which was instructor-led). Of the four (4) files reviewed, two (2) were supervisors, and in each case the required eight (8) hours of supervisory training was exceeded [eleven (11) and fourteen (14) hours respectfully]. 1.07: Logbook Maintenance Compliance 1.08: Internal Alert System Compliance There are various alert types throughout the facility. Located at each egress door is a list of escape or flight risk youth for easy identification. The kitchen area has a food allergy board with the corresponding youth s picture, in addition to a board in master control that identifies youth with medical and mental health alerts. 1.09: Escapes Compliance The program has an agreement with the adjacent Santa Rosa Correctional Institute to participate in escape drills as well as in actual escape events. There are five (5) escape kits located in the master control area for disbursement to staff in the event of an escape. These kits contain items such as flex cuffs, binoculars, flagging material, compass, flashlight, etc., to be used in the event of an actual escape. 1.10: Youth Records Compliance 1.11: Community Partnerships Compliance A review of documentation as well discussion with the program director found that the facility has re-established its on-site community advisory board. Since August 2011 there have been efforts to engage additional board members. Although documentation showed that there was a meeting held on September 8, 2011, there was no additional Office of Program Accountability Page 6 of 18

7 information that would suggest that these efforts were made over the span of the six (6) month prevailing practice window. 1.12: Facility Integration and Stability Compliance There are several outlets for staff to voice their opinions and concerns relative to their employment and treatment of the youth, which includes informal discussions with the Assistant Program Director prior to going on shift and monthly meetings with the administration. All of the floor staff, case managers and therapist stated that they have access to the program director and their concerns are heard and changes made when applicable. None of the staff felt they were being overlooked or dismissed by their supervisors. Staff are rewarded when they provide exceptional services by the awarding of a gift card that is redeemable at local businesses. Interviews with staff from all level of the program found a high rate of moral and belief that the services provided to the youth are meaningful and have a positive result to effect change in the youth s behavior. Staff also stated the belief that they are supported by their supervisor and administration. The availability for advancement as demonstrated recently by hiring of two (2) current staff to fill three (3) vacant positions. The one (1) position that was not filled in house was for a therapist. Case managers, floor staff and therapists are evaluated on an annual basis by their supervisors. There is a standard Gulf Coast Youth Services Inc. evaluation form and an additional competency form which outlines additional practices pertinent to the individual positions. Continued employment with the program hinges on a favorable rating on the annual evaluation. Standard 2: Intervention and Case Management Overview Milton Girls JRF currently had forty-five (45) youth in the program at the time of the on-site review. There were three (3) case managers assigned to the youth for assessment, performance planning and transitional services. The previous lead case manager had been with Milton Girls since it opened in 2001 and had recently left the program. The new lead case manager supervisor has also been with the program since it opened. The case files were well organized and documents there consistently placed throughout the file. The Program Director conducts three (3) orientation groups with the youth within thirty (30) days of admission or as soon as there are enough admitted youth to conduct a group session. The groups cover a variety of topics that address issues that the youth might experience during their first couple of weeks in the program such as; program rules, activities and expectations for release. The case managers and the youth s parents complete an initial interview that addresses demographic and any other issues that might affect the youth s treatment. There is an Orientation workbook that is also completed during the youth s first month in the program. Office of Program Accountability Page 7 of 18

8 All of the files reviewed contained a classification document to record statutory requirements of F.A.C. 63E-7.013(7) such as; age, maturity, suspected gang affiliation, and likelihood of sexual aggression toward another youth. A Risk Assessment is completed on all of the youth every two (2) weeks. Youth are not eligible for additional privileges if they don t meet the requirements of the Risk Assessment. Of the forty-five (45) youth in the program, thirteen (13) are Exceptional Student Education (ESE) students were given classes receive either a regular or special diploma while in the program or when they return to their community. 2.01: Classification Compliance 2.02: Assessment Compliance 2.03: Intervention and Treatment Team Compliance A review of the intervention and treatment teams meetings found that they were well attended by the program staff. Observation of treatment team for four (4) youth found all of the therapists; case managers, two floor staff, the nurse, and the psychiatrist were present. The psychiatrist took an active role during the treatment meetings in reviewing with the youth their experience with the medication that were prescribed as to side effects or if the medication is counter indicated for the youth Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition, Text Revised (DSM-IV-TR) diagnosis. All of the discussion was focused on the youth s progress in meeting the goals of the performance plan, and medication management. Transition plans and issues concerning release were discussed with the one (1) youth who was within thirty (30) days of completing the program. Included in the treatment team meetings was the involvement of the youth s parents by phone seeking their input their child s progress in treatment or any other concerns. The parents are also encouraged to give their child a personal message to facilitate progress in the program. 2.04: Performance Plan Compliance 2.05: Performance Review and Reporting Compliance Office of Program Accountability Page 8 of 18

9 2.06: Parent/Guardian Communication Compliance Parents are a major focus of the program s treatment efforts. It starts with the initial contact with the parents when the youth is admitted into the program and an extensive letter sent by the program director. Also completed during the first week of the youth s admission into the program is the Initial Parent Interview, which is completed on all of the youth as soon as the case manager can contact them after their admission. There was documentation in one (1) of the seven (7) youth files of a weekly contact with the parents by the case manager to address a communication problem between the youth and their family. As stated before, parents are contacted during the treatment team meetings to provide additional information and support for the youth. During visitation, a case manager and therapist are on site to address any issues the parents may have and provide additional family treatment. This is also the time for family therapy while both the youth and parents are present. The parents receive a questionnaire during Multi-Family day so they can give their feedback about the successfulness of the event and are their needs being met. 2.07: Transition Planning and Release Compliance There are transition objectives in the Performance Plan that are adjusted during the subsequent treatment team meetings to meet the needs of the youth. The youth s behavior is graphically tracked to assess their appropriateness for release by completing the behavioral requirements of their performance plan. There is a twelve (12) week transition group that meets weekly for ninety (90) minutes. The group topics address transition needs for a dually diagnosed youth. Group topics vary from; six (6) healthy habits for a successful transition, preventive health information, and managing your finances. The youth complete Choices: Transition workbook to address issues surrounding the return to their community. Youth being picked up at the program are allowed to take the workbook with them. Interview with a youth who was leaving the program during the review found a detailed plan to not recidivate, change her friends, and gain employment and return to school. The youth had referral to the Florida Division of Vocational Rehabilitation to set up access to services to return to school, employment and financial aid. All youth are referred to Vocational Rehabilitation for access to resources in their community and through the State of Florida. 2.08: Grievance Process Compliance Interviews with three (3) youth from different levels in the Behavior Management System found that they all knew the grievance procedures as described in Florida Statue F.A.C. 63E-7006(6). However, there were no grievances in the grievance file. The youth stated that all of their complaints are immediately addressed by either floor staff or their supervisor. This practice is much more effective than waiting several days for the issue to be reviewed by supervisory staff. If the issue has not been resolved they take it to either the Assistant Program Director or the youth can wait for the biweekly Community meeting. The Community meeting is attended by all of the youth where they are allowed Office of Program Accountability Page 9 of 18

10 to voice any complaints or recommendations they have about the program staff or program/treatment. Observation of a Community meeting found an enthusiastic participation of the youth, often standing up, yelling and clapping to voice their approval of the issue at hand. At first glance the meeting seemed out of control, but the youth were quickly quieted by the Assistant Program Director and the other staff at the meeting. At no time was it observed that the youth were treated unprofessionally. 2.09: Gang Prevention and Intervention Compliance A Sheriff representative from the Santa Rosa County Sheriff s Office comes to the program to talk with groups of youth about gang prevention and any other issue that have to do with youth gangs activity. The teachers report any suspected youth of gang involvement to the school board where the youth will returning. 2.10: Staff Characteristics Compliance 2.11: Delinquency Programming Compliance 2.12: Gender-Specific Programming Compliance A review of facility documentation revealed that youth participate in gender-based group sessions facilitated by mental health staff. Multiple curriculums are used, to include, VOICES, Girls Matters, Girls Circles, Life-skills Training, and several Trauma Workbooks. Staff receive annual Trauma Informed Care Training; this was supported through a review of staff training files. Positive female role models from the community are invited to the program as guest speakers. These individuals discuss topics of interest of the youth, proper skin care, makeup application, manicures and pedicures. Youth that have displayed appropriate behaviors/social skills are awarded with Tea time with the program director. 2.13: Vocational Programming Compliance Both the case managers and teachers provide vocational programing. Youth not returning to school are trained in the first stage for Medical Office procedures which they can complete when they return to their community. There is an established curriculum for the class. Another teacher has recently started a class for employability skills which included resume writing and filling out a job application. These resume writing and completion of an employment application are also provided by the youth s case manager. However they additionally refer the youth to Florida Division Vocational Office of Program Accountability Page 10 of 18

11 Rehabilitation to facilitate access academic and employment resources in their community. Youth determined to meet the requirements for being an Exceptional Student Education (ESE) student are referred to the One Stop Center in their community. Standard 3: Mental Health and Substance Abuse Services Overview Milton Girls Juvenile Residential Facility is designated as an Intensive Mental Health treatment services provider. The Program Director is a Licensed Clinical Social Worker (LCSW) and also functions as the program s Designated Mental Health Authority (DHMA). There are six (6) master s level therapists that provide individual, group and family therapy for the youth and their families. The facility offers group services seven (7) days per week. Each youth receives a new comprehensive mental health and substance abuse evaluation at admission, and each youth participates in the development of an individualized treatment plan. It was evident that treatment services are the foundation of all programming at the facility. The services are comprehensive, and intervention is provided frequently to each youth, and yet the program is doing itself an injustice by not documenting a number of these approaches. Emergency and suicide prevention services are available. Due to the openness and approachability of staff, most potential crises are resolved without a formal intervention being necessary. Treatment teams meet often to monitor treatment and functional status of each youth. The facility s psychiatrist is an active participant in the treatment team process. 3.01: Designated Mental Health Authority (DJJ Program) Compliance The program director who is a licensed Clinical Social Worker (LCSW) is the Designated Mental Health Authority (DMHA) and is on-site five (5) days per week and attends selected functions on the weekends. Supervision logs documented weekly clinical supervision by the DMHA that consisted of case staffing, current information that related to mental health/substance treatment and clinical training. The sessions were of between sixty (60) to ninety (90) minutes in length. The sessions including an agenda for each meeting, notes regarding cases staffed with each therapist and plans for future interventions. In addition to the formal weekly supervision meetings, the DMHA meets with the therapists on an as-needed basis throughout the work day. The DMHA is very involved with the youth in the program and works to promote positive self-esteem and personal growth starting wherever the girls happen to be. This includes a vast quantity of gender specific material. 3.02: Mental Health and Substance Abuse Admission Screening Compliance Office of Program Accountability Page 11 of 18

12 3.03: Mental Health/Substance Abuse Assessment/Evaluation Compliance A review of seven (7) youth files found all contained a new Bio-psychosocial Evaluation and Substance Abuse Screen/Evaluation. In addition, each file contained a Sexual Trauma Assessment, a Personal Safety Plan and a Recreation Therapy Assessment. The Bio-psychosocial and Substance Abuse Evaluations were written in narrative form and were used to create the youth s treatment plan. The findings and treatment recommendation sections contained extensive documentation of the youth s mental health and substance abuse needs and supported the development of the goals and objective in the Individualized Mental Health and Substance Abuse Treatment Plan. 3.04: Treatment Plan, Treatment Team, and Service Delivery Compliance Psychiatric interventions were noted and followed on treatment plans. Treatment notes documented progress or need for medications. In two cases there was minor confusion about medications; however, review of psychiatric notes provided clarity. Youth were very knowledgeable of their goals and objectives in their treatment plan and an interview with thee (3) youth who were able to articulate their goals and progress towards completing their treatment plan. All seven (7) files contained documentation of weekly individual comprehensive narrative notes that focused on treatment goals. There was documentation in all of the files of weekly updates summarizing the groups and any case management activities done on the youth s behalf. Family sessions conducted by the therapists were documented in all files deemed appropriate. In some cases family sessions were not conducted due to the family resources. Each therapist maintained separate group logs which containing more information on the group, if anything notable occurred beyond good and attentive participation. 3.05: Suicide Prevention Compliance The program maintains a detailed Suicide Prevention Plan that starts with extensive training, 10 hours beyond the required 20. Documentation and interviews with therapists support the practice of staffing each case of a youth on suicide precautions with the Program Director prior to decreasing levels of precautionary supervision. The observation checks were completed in 10 to 15 minute increments well within the 30 minute timeframe. Suicide assessments are completed on all youth admitted to the program. Youth identified at risk for suicide are immediately referred to a Mental Health Counselor for further evaluation. Documentation showed this to be completed consistently within the required 24 hour timeframe. 3.06: Mental Health Crisis Intervention Compliance Office of Program Accountability Page 12 of 18

13 3.07: Emergency Services Compliance 3.08: Specialized Treatment Services Compliance Standard 4: Health Services Overview Milton Girls Regional Juvenile Facility has three (3) nursing staff to provide healthcare services to the youth in the facility s care. There are two (2) full-time Licensed Practical Nurses (LPNs) and one (1) part-time Registered Nurse (RN). Further oversight is provided by the agency s Director of Nurses, who is also an RN. Nursing coverage is provided seven (7) days per week, and, based on the program s schedule; there is at least one nurse on-site from 7 AM until 7 PM each day. The Designated Health Authority (DHA) is a Florida-licensed Medical Doctor (MD). This individual is on-site once a week, and there was evidence in the files of the doctor providing required services, such as: completing health assessments and periodic evaluations, reviewing off-site care orders, monitoring medications prescribed for health concerns, and referring youth for testing (as necessary). Of the seven (7) files reviewed, each had a completed Facility Entry Physical Health Screening (FEPHS), Health Related History (HRH), and Comprehensive Physical Assessment (CPA). All reviewed youth met at least one of the criteria for a chronic condition, and, as such, each youth was receiving periodic evaluations as required. Youth were also clinically screened for Sexually Transmitted Diseases (STDs) and when indicated a referral was provided for further evaluation. Youth were referred to the obstetrician/gynecologist (OBGYN) for Human Immunodeficiency Virus (HIV) and STD testing. There was evidence that youth are tested and, when necessary, treated for STDs, however, there were noted delays in the program receiving the OBGYN s dictated records. There was documentation, through a calendar log, of when youth were transported to the OBGYN for testing services. Youth are oriented to the health services available at admission, and there was evidence that nursing staff complete weekly health care education with the youth. Topics include disease prevention, infection control, female health issues, reproductive health, etc. In addition to education services, sick call is conducted daily at 2:30 PM. Due to the population served by the facility, there are a number of youth on psychotropic medication. The facility has a clearly written medication administration protocol, and all medications are provided by licensed healthcare professionals. In an effort to minimize risk, only a limited amount of over-the-counter (OTC) medication is stored at the facility. There were current, accurate inventories for OTC medications. Also, there was evidence of routine shift-to- Office of Program Accountability Page 13 of 18

14 shift inventories for controlled medications. Finally, the facility had accurate inventories for sharps. The Medication Administration Record (MAR) book maintained by the facility includes a variety of helpful information about medications, such as lists of medications that cannot be crushed, medications that interact with particular foods, protocols to prevent cheeking, etc. The facility also makes significant efforts to minimize potential infectious exposures. The Director of Nurses is a member of the Association of Professional in Infection Control, and she has developed an exposure control manual that identifies over twenty potential workplace exposures. This manual provides guidelines for reporting exposure and actions to take when a potential exposure is encountered. The Director of Nurses also compiles data on exposures and infectious illnesses, and this data is used for agency-wide trend analyses. 4.01: Designated Health Authority Compliance 4.02: Healthcare Admission Screening Compliance A LPN conducted the Facility Entry Physical Health Screening (FEPHS) on the date of admission in all seven (7) files reviewed. The DHA was notified of all youth admitted into the program, though this notification is only required for youth identified with emergency needs or chronic conditions. 4.03: Comprehensive Physical Assessment Compliance 4.04: Sexually Transmitted Diseases Compliance 4.05: Sick Call Compliance 4.06: Medication Administration Compliance 4.07: Medication Control Compliance The facility has a pharmacist on-site monthly to review the medication storage and audit medications. This individual also collaborates with nurses to destroy controlled Office of Program Accountability Page 14 of 18

15 medications. There was documented evidence that the pharmacist conducts an in-depth review of the clinic area. The facility maintains controlled medications behind three locks (a locked box inside a locked medication cart inside a locked room of the clinic). 4.08: Infection Control Compliance There was clear evidence that the facility is committed to limiting infection and exposure and has a detailed, thorough infection control system. The procedures, exposure control plan, and training materials were developed by a medical professional who is a member of the Association of Professionals in Exposure Control (APIC). Further, there are protocols and educational materials in place that address a number of potential exposures/infectious diseases, and the identified diseases extend well beyond those identified in the Health Services Manual. The facility generates a monthly infection report that identifies the youth, location of the infection and type of infection, antibiotic treatment and its end date, along with whether or not a culture was required. This report is sent to the Director of Nurses who incorporates the results into the facility s risk management processes. 4.09: Chronic Illness Treatment Compliance The program maintains an Excel spreadsheet to monitor youth with chronic conditions. This document identifies youth in need of periodic evaluations and serves as a tool to address needed follow-up labs, tests, or other referrals needed. In addition to the medical doctor s development of a plan, utilizing the Subjective, Objective, Assessment, Plan ( SOAP ) note format, the facility monitors all youth with chronic conditions on the DJJ-recommended treatment plan, which provides an additional source of documentation for youth s response to treatment. 4.10: Episodic and Emergency Care Compliance 4.11: Consent and Notification Compliance The program sends out a Parental Notification to the parent or legal guardian upon the youth s admission to the program and after completing the Facility Health Entry Screening and admission process. This notification reviews the youth s history, medications and allergies. It gives the name of the nurse and phone number to call with any questions or clarification. The youth s parents are also sent a list of the Over-The-Counter medications used at the program and basic medical protocols for these medications. All consents or requests for information are sent to the parent or guardian with a selfaddressed stamp envelope. The program nurse also sends out a Parental Notification to the parent or guardian anytime the youth is seen by the DHA, physician or psychiatrist. This includes clinic visits when medications are not prescribed, treatment rendered such as laboratory Office of Program Accountability Page 15 of 18

16 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 Compliance The program nurses developed a notebook for an easy-to-use reference guide for when the youth leaves the program. This guide consists of an extensive amount of instructional and informative material for the youth concerning postnatal conditions, alternatives, and activities/services the mother and child. The program held a baby shower for the youth to provide for the essential needs postpartum. Additionally, the program purchased a car seat for the youth and will provide training on the appropriate use of the car seat. The OBGYN has been consulted throughout the youth s length of stay. No over-thecounter medications were provided to the youth without the approval of the local OBGYN. An informal interview with the youth indicated that she felt blessed to be at the program, as she has learned about motherhood, appropriate nutrition, and pre/post-natal expectations. The program provided the youth with a baby (a realistic doll) to develop her life skills. The youth had to coordinate care for the child, such as obtaining a babysitter while she was in class, etc. Standard 5: Safety and Security Overview Milton Girls Juvenile Residential Facility is a hardware secure residential facility located in Milton, Florida. There is video surveillance equipment available that covers much of the campus and dormitory areas. A designated staff member serves as the facility maintenance man, and this individual is responsible for the oversight of safety and security provided at the program, such as tool management and flammable, poisonous and toxic items. The program has video surveillance to record the daily activities performed by youth and staff at all times. However, during the on-site Quality Assurance review the facility was only able to produce fourteen (14) days of video recording, due to technical issues with a digital video recording (DVR) device. Staff communication is accomplished by two-way radios, logbooks and shift reports maintained by direct care staff. The programs behavior management system is based on the company s strategic model, called Adolescent Behavioral/ Development Incentive Program. It is a multistage point system with privileges available to the youth at each succeeding level. The program does utilize room restriction and controlled observation, however, does not maintain a behavior management unit. Routine safety/security practices include conducting perimeter checks on each shift, as well as daily shift exchange meetings to share information about issues from previous shifts. The program has established procedures for supervision of youth and accounting for youth whereabouts at all times. Office of Program Accountability Page 16 of 18

17 5.01: Supervision of Youth Compliance 5.02: Key Control Compliance 5.03: Contraband and Searches Compliance 5.04: Transportation Compliance 5.05: Tool Management Compliance A review of facility Class-A and B tools found a screwdriver located in the maintenance tool-bag that was not numerically identified or identified on the tool inventory sheet. 5.06: Disaster and Continuity of Operations Planning Compliance The Program Director s spouse is meteorologist with the United States Air Force, and this individual helped develop an extensive natural disaster plan as well as drills conducted by the staff. There is documentation of monthly Continuity of Operations Plan (COOP) drills on a variety of events listed in the COOP plan. The drills included analysis/critique, description and a checklist of timelines that outlines the course of action for the program. The program has access to a satellite phone to ensure that all of the provider's programs have a constant line of communication in the event of an emergency. Documentation of an agreement with a food service provider to provide a refrigerated trailer is in place to ensure that in the event of a major power outage or emergency, that the program has adequate food supplies. 5.07: Flammable, Poisonous, and Toxic Items Compliance All items had the required Materials Safety Data Sheets (MSDS) in place, as well as a color photo of the corresponding items to ensure accuracy. Office of Program Accountability Page 17 of 18

18 5.08: Water Safety Non-Applicable The program s policy, procedure, and practice confirm that the requirements for this indicator were not applicable for this program. 5.09: Behavior Management System Compliance A review of staff and youth surveys indicated a positive response to the BMS and the feeling that it was helping the youth to become successful while in the program. And to learn the behaviors necessary to become successful upon their return to their community. Dry erase boards are maintained in the dining area that indicates youth daily progress in the program. This practice allows for youth to track progress instantly. The program utilizes Disciplinary Referral (DR) Court that allows the youth to dispute, and or defend their actions/behavior [or other issues] to the Program and Assistant Program director in a court-like setting. Youth are permitted to call witness and state their case. 5.10: Behavior Management Unit Non-Applicable The program s policy, procedure, and practice confirm that the requirements for this indicator were not applicable for this program. 5.11: Controlled Observation Compliance A review of both controlled observation logs and video footage of controlled observation practices found inconsistencies in staff monitoring the youth and its subsequent documentation. Overall Rating Summary Compliance: 100% Limited Compliance: 0% Failed Compliance: 0% * Percentages have been rounded to the nearest whole number. Percentages may not total 100% due to rounding. Office of Program Accountability Page 18 of 18