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 Rainwater Center for Girls Crosswinds Youth Services, Inc. (Contract Provider) 1407 Dixon Blvd. Cocoa, Florida Review Date(s): August 16-17, 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 CINS/FINS Quality Assurance Report Office of Program Accountability Page 1 of 12

2 Day Treatment Performance Rating Profile Program Name: Rainwater Center for Girls QA Program Code: 613 Provider Name: Crosswinds Youth Services, Inc. Contract Number: P2010 Location: Brevard County / Circuit 18 Number of Slots: 21 Review Date(s): August 16-17, 2011 Lead Reviewer Code: 84 Program Performance by Indicator/Standard 1. Management Accountability 3. Health, Mental Health, and Substance Abuse 1.01 Background Screening of Employees/Vol. 7 Accepta 3.01 Healthcare Admission Screening Provision of an Abuse Free Environment 7 Accepta 3.02 Mental Health/SA/Suicide Risk Screening Incident Reporting 8 Comme 3.03 Mental Health/SA Treatment Planning Protective Action Response (PAR) NA Non-Ap 3.04 Suicide Prevention Pre-Service/Certification Requirements 8 Comme 3.05 Emergency Mental Health/SA Services In-Service Training Requirements 7 Accepta 3.06 Medications Supervisory Reviews 8 Comme 3.07 Medical/Mental Health Alert Process Safety and Administration 8 Comme 3.08 Episodic/Emergency Care 7 Acceptable 76% 53 Minimal 60% Intervention and Case Management 2.01 Admission and Orientation 8 Commendable 2.02 Positive Achievement Change Tool (PACT) 7 Acceptable 2.03 YES Plan Development 8 Commendable 2.04 YES Plan Implementation 7 Acceptable 2.05 PACT Reassessments/YES Plan Updates 8 Commendable 2.06 Behavior Management System 7 Acceptable Acceptable 71% 2.07 Progress Reports 8 Commendable 2.08 Termination/Release 10 Exceptional Acceptable 79% 63 Standard Program Max. Score Score Rating Failed Minimal Acceptable 0-59% 60-69% 70-79% 1. Management Accountability % X 2. Intervention and Case Management % X 3. Health, Mental Health, and Substance Abuse % X Overall Program Performance Acceptable 71% Commendable 80-89% Exceptional % Office of Program Accountability Page 2 of 12

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, and (3) Health, Mental Health, and Substance Abuse, which are included in the Day Treatment Standards (July 2011). Persons Interviewed Program Director DJJ Monitor DHA or designee DMHA or designee 0 # Case Managers 1 # Clinical Staff 0 # Food Service Personnel 0 # Healthcare Staff Documents Reviewed 0 # Maintenance Personnel 0 # Program Supervisors 1 # Other (listed by title): Teacher 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 6 # Health Records 7 # MH/SA Records 4 # Personnel Records 5 # Training Records/CORE 3 # Youth Records (Closed) 5 # Youth Records (Open) 0 # Other: 5 # Youth 5 # Direct Care Staff # Other: Observations During Review Admissions Confinement Facility and Grounds First Aid Kit(s) Group Meals Medical Clinic Medication Administration Posting of Abuse Hotline Program Activities Recreation Searches Security Video Tapes Sick Call Social Skill Modeling by Staff Staff Interactions with Youth Comments Staff Supervision of Youth Tool Inventory and Storage Toxic Item Inventory and Storage Transition/Exit Conferences Treatment Team Meetings Use of Mechanical Restraints Youth Movement and Counts Items not marked were either not applicable or not available for review. Office of Program Accountability Page 3 of 12

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: Ann Little, Lead Reviewer, DJJ Bureau of Quality Assurance Daniel Seavey, Assistant Bureau Chief, DJJ Bureau of Quality Assurance Pamela Graves. Review Specialist, DJJ Bureau of Quality Assurance Carldernett Davis, Program Monitor, DJJ Residential Services, Central Region Office of Program Accountability Page 4 of 12

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 The Department of Juvenile Justice contracts with Crosswinds Youth Services, Inc. to operate Rainwater Center for Girls, a gender-specific Day Treatment program. The program can provide services for up to twenty-one girls between the ages of thirteen and eighteen, that have been referred by Probation and Community Intervention-Circuit 18. Girls who are not yet thirteen years of age may be admitted on a case-by-case basis. The program serves youth living in Brevard County who have been placed on Probation or Post-Commitment Probation with the Department, as well as youth served under Minimum-Risk Commitment. The program may also serve youth placed on Intensive Delinquency Diversion Services (IDDS) or Intake status, with the approval of the Chief Probation Officer. Seven girls were enrolled at the program at the time of the Quality Assurance review. The program staff consists of a Program Director, one full-time counselor, one part-time/asneeded counselor, a teacher, and three youth care workers; the program s counselors also serve as case managers. An individual training file is maintained for each employee that includes certificates, test results and sign-in sheets. Staff training and development is coordinated by the program s administrative office. Training is offered in-house by agency staff, and on the CORE Learning Management System (LMS) and other web-based training sites. Training is documented in the CORE LMS. Crosswinds Youth Services, Inc. has been accredited through the Council on Accreditation; this accreditation is active through May 31, The program operates two van routes to transport youth to and from the program, on any school related field trips, and for community service projects. The class schedule begins at 8:00 A.M. and ends at 5:05 P.M., Monday through Friday. Breakfast is provided to the girls shortly after arrival at the program; the youth are served lunch, which is usually picked up from a local Brevard County school. On days the program is in session and the local schools are closed, the girls eat lunch at the Robert E. Lehton Children s Shelter, which is operated by Crosswinds Youth Services, and is located on the same campus. 1.01: Background Screening of Employees/Volunteers Acceptable (7) Rainwater Center for Girls did not submit a program-specific Annual Affidavit of Compliance with Level 2 Screening Standards; one affidavit was submitted for all programs operated by Crosswinds Youth Services. Office of Program Accountability Page 5 of 12

6 1.02: Provision of an Abuse Free Environment Acceptable (7) Five staff responded to the survey; one reported hearing a co-worker use profanity when speaking to youth. Five youth responded to the survey; one youth reported not all staff are respectful when talking with youth, and two youth reported hearing staff use profanity when speaking with youth. 1.03: Incident Reporting Commendable (8) 1.04: Protective Action Response (PAR) Non-Applicable (NA) The program has not used physical interventions during the scope of the Quality Assurance review. 1.05: Pre-Service/Certification Requirements Commendable (8) 1.06: In-Service Training Requirements Acceptable (7) The program did not develop an annual in-service training calendar. 1.07: Supervisory Reviews Commendable (8) 1.08: Safety and Administration Commendable (8) Office of Program Accountability Page 6 of 12

7 Standard 2: Intervention and Case Management Failed Minimal Acceptable Commendable Exceptional Overview The Program Director and case managers are responsible for all case management functions and for maintaining the case files. Case management services include completing the Positive Achievement Change Tool (PACT), developing and updating the initial Youth-Empowered Success (YES) Plan, facilitating and monitoring the completion of court-ordered sanctions and providing delinquency intervention services to address criminogenic needs. The program's behavior management system consists of four levels, in addition to an orientation level. The level system consists of a series of steps that have expectations and privileges assigned to each of the levels; the privileges and criteria increase as the youth advances through system. Treatment team approval is required for level advancement. The program maintains extensive partnerships with businesses and educational institutions throughout the community to promote vocational development for the youth. The youth have participated in field trips to the Keiser University Center for Culinary Arts, Brevard Community College, Wuesthoff Hospital, Wesche Jewelers, Incredible Pets, Rockledge Gardens, Space Coast Health Institute, and Schlenker Automotive. The program provides opportunities for community involvement, such as having the youth participate in the Memory Bear program through VITAS Innovative Hospice Care, in which the youth sew teddy bears that are distributed to family members or friends of individuals who have passed away while in hospice care. 2.01: Admission and Orientation Commendable (8) 2.02: Positive Achievement Change Tool (PACT) Acceptable (7) In one of five files reviewed for this indicator, the program did not complete the Positive Achievement Change Tool (PACT) Full Assessment within seven calendar days of the youth s admission to the program. The program used the PACT Full Assessment previously completed by the DJJ Juvenile Probation Officer (JPO), and did not complete their own PACT Full Assessment until two months after the youth s admission to the program. 2.03: Youth-Empowered Success (YES) Plan Development Commendable (8) Office of Program Accountability Page 7 of 12

8 2.04: YES Plan Implementation Acceptable (7) In each of the five files reviewed for this indicator, there were a few instances where the case manager did not complete his/her action step as outlined in the Youth-Empowered Success (YES) Plan, to include activities such as conducting curfew checks, verifying stay-away orders, and facilitating the completion of essays and letters of apology. In two of the five files reviewed for this indicator, the program did not respond to documented noncompliance, such as excessive unexcused absences and testing positive for alcohol use. In the other three files, the program did respond in some manner to documented noncompliance. However, the program does not have a written progressive response/graduated sanctions plan. 2.05: PACT Reassessments and YES Plan Updates Commendable (8) 2.06: Behavior Management System Acceptable (7) Behavioral issues are documented using the program s Opportunity Behavior Report form. The program s written behavior management system does not outline specific consequences for specific behavioral issues. Consequences were determined on a case-by-case basis by the Program Director, and were sometimes inconsistent. 2.07: Progress Reports Commendable (8) 2.08: Termination/Release Exceptional (10) In each of the three closed files reviewed for this indicator, the program completed an extensive release process, which included a final treatment team meeting involving the youth, the youth s parent or guardian, and DJJ JPO; a final progress report; an educational exit transition plan completed by the youth, parent, Program Director, case manager, teacher, and DJJ JPO; and a Mental Health/Substance Abuse Treatment Discharge Summary form completed by the program s mental health staff. A graduation ceremony is held for each youth upon successful completion of the program. The youth receives a certificate of graduation, and staff and other youth gather to celebrate the youth s successful completion of the program. Office of Program Accountability Page 8 of 12

9 Standard 3: Health, Mental Health, and Substance Abuse Failed Minimal Acceptable Commendable Exceptional Overview All youth are screened on the date of admission using the Facility Entry Physical Health Screening form. This screening is completed either by the Program Director or one of the counselors. The program has a color-coded alert system, comprised of five colors. A colored dot is placed on the youth s file and on the alert board located in the locked file room. The program also has a mental health/medical alert sheet that is updated as needed. The Program Director and two counselors are trained in medication administration; the locked medication box and locked refrigerator are located in the file room. The knife-for-life and wire cutters are maintained in a file cabinet in the Program Director s office. The program has one full-time Master s level counselor and one part-time/as needed Master s level counselor providing on-site mental health services. The counselors work under the supervision of a licensed mental health professional at the program s corporate office. Discussions with the Program Director revealed that program staff were unaware of the PACT Mental Health and Substance Abuse Report and Referral Form. There were significant deficiencies observed in the suicide risk screening process, as well as in the program s provision of emergency mental health services. A bio-psychosocial evaluation is completed within thirty days of admission and is used to develop an individualized treatment plan. Youth identified as in need of substance abuse treatment are referred to an appropriate provider within the community. 3.01: Healthcare Admission Screening Acceptable (7) Of the five files reviewed, one youth was identified with asthma and this was not recorded on the youth s Problem List. Of the five files reviewed, four youth admitted to the program with chronic conditions did not have an individual health care plan developed. 3.02: Mental Health/Substance Abuse/Suicide Risk Screening Failed (0) The program did not complete either the Massachusetts Youth Screening Instrument- Version 2 (MAYSI-2) or the Positive Achievement Change Tool (PACT) Mental Health and Substance Abuse Report and Referral Form during the youth's admission, to screen for mental health, substance abuse, and suicide risk issues, therefore, no youth received an appropriate mental health/substance abuse screening upon admission to the program. The program developed their own Initial Risk Assessment, which included five questions; if the youth answered yes to any of the questions, an Assessment of Suicide Risk (ASR) was to be completed. Office of Program Accountability Page 9 of 12

10 Of the five files reviewed, three youth answered yes to at least one of the five questions on the Initial Risk Assessment. Two youth were released prior to the administration of an Assessment of Suicide Risk (ASR), and documentation did not support notification to the youth s parent or guardian of the possible suicide risk and need for further assessment. One youth had an ASR completed two days later, and suicide precautions were not implemented. The second youth had an ASR completed the next day by non-licensed mental health clinical staff that did not have the required training. In each of the three identified instances, the referral for assessment of suicide had not been documented on the mental health/substance abuse referral summary, and there were no documented discussions with the licensed mental health professional, including recommendations for immediate interventions. In each of the three instances, the suicide risk alert was not entered into the Juvenile Justice Information System (JJIS) as required. 3.03: Mental Health/Substance Abuse Treatment Planning Acceptable (7) Five files were reviewed; an initial treatment plan and individual treatment plan were completed within the required timeframes. However, three initial treatment plans did not document pharmacological interventions, and none of the applicable individual treatment plans included pharmacological interventions. There were a few objectives identified on the treatment plans in which the target dates were not specific, rather they were identified as on-going. The treatment plan review forms consistently indicated there were no revisions to the treatment plan, however revised target dates were documented on all five plans. The treatment plan review forms did not specifically address the youth s progress on her treatment goals. Of the two non-licensed clinical staff, one staff did not have weekly face-to-face supervision documented for approximately five weeks. 3.04: Suicide Prevention Acceptable (7) Two applicable incidents were reviewed for this indicator. Both youth were deemed a potential suicide risk after the initial Assessment of Suicide Risk (ASR) was completed, and both youth were continued on precautionary observation, with documentation maintained. However, upon removal from precautionary observation, neither youth was transitioned to close supervision, instead were transitioned directly to standard supervision. The suicide precautions observation logs did not identify safe housing areas for the youth. The documented review of the suicide precautions observation logs by the mental health staff was not always timely; the documentation revealed the reviews were conducted from a couple of days to a week later. Office of Program Accountability Page 10 of 12

11 3.05: Emergency Mental Health/Substance Abuse Services Minimal (5) A review of the one applicable incident revealed there was no documentation to support when the Program Director had been notified of the incident; the LMHC did complete the Assessment of Suicide Risk (ASR) and Baker Act paperwork. An alert was not entered into JJIS as required, and the program s logbook did not reflect the youth s alert status. A follow-up ASR was completed upon the youth s return to the program and the youth was continued on precautionary observation, however the program s logbook did not reflect the youth s alert status. A second follow-up ASR was completed and the youth was subsequently removed from precautionary observation; the youth was not transitioned to close supervision, instead was transitioned directly to standard supervision. The suicide precautions observation logs did not identify safe housing areas; additionally multiple days of precautionary observation were recorded on a single observation log. A critique of the event was not completed by the program. The program did not conduct semi-annual training on emergency response procedures with mock training in emergency response to a suicide attempt or incident of serious self-injury. 3.06: Medications Commendable (8) 3.07: Medical/Mental Health Alert Process Acceptable (7) Suicide Risk alerts are not entered into JJIS as required. The program s internal mental health/medical alert roster did not reflect an increase in the youth s risk status when placed on precautionary observation. 3.08: Episodic/Emergency Care Acceptable (7) A review of staff training files revealed that none of the program staff have been trained on the use of the knife-for-life. The first aid kits located in the two program vehicles contained heat sensitive items, which identified the range of temperature at which the items should be stored. During the quality assurance review in August, the temperature was well above the recommended storage temperature. In one instance in which a youth was transported to the hospital, the event was not recorded on the Episodic Care Log and was not documented in the youth s medical file. Office of Program Accountability Page 11 of 12

12 Overall Program Performance Acceptable 71% Failed Minimal Acceptable Commendable Exceptional Office of Program Accountability Page 12 of 12