BUREAU OF MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR

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1 S T A T E O F F L O R I D A D E P A R T M E N T O F J U V E N I L E J U S T I C E BUREAU OF MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR Probation & Community Intervention Circuit 18 Department of Juvenile Justice (State-Operated) 3880 S. Washington Avenue, suite 156 Titusville, Florida Review Date(s): April 28-30, 2015 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES

2 Rating Definitions Ratings were assigned to each indicator by the review team using the following definitions: Compliance Limited Compliance Failed Compliance No exceptions to the requirements of the indicator; or limited, unintentional, and/or non-systemic exceptions that do not result in reduced or substandard service delivery; or systemic exceptions with corrective action already applied and demonstrated. Systemic exceptions to the requirements of the indicator; exceptions to the requirements of the indicator that result in the interruption of service delivery; and/or typically require oversight by management to address the issues systemically. The absence of a component(s) essential to the requirements of the indicator that typically requires immediate follow-up and response to remediate the issue and ensure service delivery. Review Team The Bureau of Monitoring and Quality Improvement wishes to thank the following review team members for their participation in this review, and for promoting continuous improvement and accountability in juvenile justice programs and services in Florida: Ann Little, Office of Program Accountability, Lead Reviewer Linda Beckelheimer, Juvenile Probation Officer Supervisor, DJJ Probation, Circuit 9 Paul Czigan, Office of Program Accountability, Regional Monitor James Garner, Juvenile Probation Officer Supervisor, DJJ Probation, Circuit 13 Tamara Mahl-Adkins, Senior Juvenile Probation Officer, DJJ Probation, Circuit 9 Lienyvette Patella, Juvenile Probation Officer Supervisor, DJJ Probation, Circuit 10 Wanda Walker, Executive Director, AMIkids Orlando

3 Program Name: Probation & Community Intervention Circuit 18 QI Program Code: 1193 Provider Name: Department of Juvenile Justice Contract Number: N/A Location: Brevard County / Circuit 18 Number of Beds: N/A Review Date(s): April 28-30, 2015 Lead Reviewer Code: 84 Methodology This review was conducted in accordance with FDJJ-2000 (Contract Management and Program Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1) Management Accountability, (2) Assessment Services, and (3) Intervention Services, which are included in the Probation and Community Intervention Standards. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee # Case Managers # Clinical Staff # Food Service Personnel # Healthcare Staff Documents Reviewed # Maintenance Personnel 2 # Program Supervisors 1 # Other (listed by title): Deputy Chief Probation Officer 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 # Health Records # MH/SA Records 12 # Personnel Records 10 # Training Records/CORE 10 # Youth Records (Closed) 57 # Youth Records (Open) 2 # Other: Volunteer Background Screenings # Youth # 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 19 (Revised September 2014)

4 Standard 1: Management Accountability Probation and Community Intervention Rating Profile Indicator Ratings 1.01 Standard 1 - Management Accountability * Initial Background Screening 1.02 Five-Year Rescreening 1.03 Protective Action Response (PAR) Non-Applicable 1.04 Pre-Service/Certification Training 1.05 In-Service Training 1.06 Supervisory Document Reviews 1.07 Ninety-Day Supervisory Reviews 1.08 * Incident Reporting (CCC) 1.09 * Abuse-Free Environment * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 4 of 19 (Revised September 2014)

5 Standard 2: Assessment Services Probation and Community Intervention Rating Profile Indicator Ratings 2.01 Standard 2 - Assessment Services Positive Achievement Change Tool (PACT) Pre-Screen 2.02 PACT Full Assessment 2.03 PACT Reassessment 2.04 Mental Health/Substance Abuse Screening 2.05 * Comprehensive Assessment 2.06 State Attorney Recommendation (SAR) 2.07 Pre-Disposition Report (PDR) * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 5 of 19 (Revised September 2014)

6 Standard 3: Intervention Services Probation and Community Intervention Rating Profile Indicator Ratings Standard 3 - Intervention Services 3.01 Youth-Empowered Success (YES) Plan Development 3.02 Youth Requirement/PACT Goal Elements 3.03 * Transitional Planning/Reintegration Limited 3.04 * Referrals for Mental Health and Substance Abuse Assessment and Treatment Services 3.05 YES Plan Implementation/Supervision 3.06 Effective Response System 3.07 Ninety-Day YES Plan Updates 3.08 Termination of Supervision * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 6 of 19 (Revised September 2014)

7 Strengths and Innovative Approaches Circuit 18 has an interagency agreement in place to address issues that cross lines with other state agencies and child serving agencies. Participants includes the Department of Juvenile Justice, the Department of Children and Families, the Department of Health, Agency for Persons with Disabilities, Children s Medical Services, Agency for Health Care Administration, Brevard Family Partnership, and Community Based Care of Central Florida. Circuit 18 was selected to implement the Georgetown University Crossover Youth Practice Model. The in-person consultation with Georgetown University concluded in January 2015 with ongoing consultation available via conference call. Full implementation is expected by the summer of Circuit 18 was selected as a pilot site for the Effective Practices in Community Supervision (EPICS), through the University of Cincinnati Corrections Institute. Circuit staff completed the EPICS training in March 2015 and ongoing skill development is continuing through October Circuit 18 has a faith-based partnership with Youth Promise Team Florida (YPTF). The YPTF is part of the faith community network and volunteer chaplaincy services, and provides mentoring and other support services in Brevard and Seminole counties. Brevard County has a re-entry board that serves to assist youth returning to the community from residential commitment. The re-entry board meets every other month. Participants include the Brevard Public Schools transition coordinator, the Brevard Public Schools guidance counselor for foster care youth, CareerSource Brevard, the chief probation officer and/or deputy chief probation officer, juvenile probation officer supervisors (JPOS), and representatives from the faith-based community. Office of Program Accountability Page 7 of 19 (Revised September 2014)

8 Standard 1: Management Accountability Overview Probation and Community Intervention - Circuit 18 serves Brevard and Seminole counties. The circuit consists of seven units, four located in Brevard and three in Seminole. The circuit s allocated positions are a chief probation officer, a deputy chief probation officer, seven juvenile probation officer supervisors (JPOS), eight senior juvenile probation officers (JPO), thirty-nine JPOs, one OPS JPOs, one OPS community youth leader, two secretary specialist positions, and one administrative assistant. At the time of the annual compliance review, the circuit had one vacant JPO position. On April 30, 2015 the chief probation officer retired; and effective May 1, 2015 the deputy chief probation officer was promoted to fill this position. JPOS also retired on April 30, The circuit maintains an individual training file and individual personnel file for each employee. Training is received through a combination of web-based training and instructor led training and is documented in the Department s Learning Management System (Skill Pro) Initial Background Screening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. The background screening process is completed prior to hiring an employee or utilizing the services of a volunteer, mentor, or intern. An Annual Affidavit of Compliance with Level 2 Screening Standards is completed annually. The circuit had six new staff applicable for background screening. All six staff were screened by the Department s Background Screening Unit (BSU) and received an eligible rating prior to his or her date of hire. The circuit also had two volunteers that started working in January 2015; both documented an eligible screening from the background screening unit prior to starting. The Annual Affidavit of Compliance with Level 2 Screening Standards was received by the BSU on January 8, 2015 and is in compliance with the Department s requirement of January 31 st Five-Year Rescreening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. Employees and volunteers are rescreened every five years from the initial date of employment. The circuit had six staff applicable for a five-year rescreening. Five of six staff documented completion of the five-year rescreen as required. The last staff s date of hire was March 25, 2005; however, the request for rescreen was not received by the Background Screening Unit until April 7, 2015; and the rescreen was completed on April 10, The circuit advised the staff has been out on extended medical leave since December 2014, and obtaining signatures on the required documents took an inordinate amount of time. Office of Program Accountability Page 8 of 19 (Revised September 2014)

9 1.03 Protective Action Response (PAR) Non-Applicable The program uses physical intervention techniques in accordance with Florida Administrative Code. Any time staff uses a physical intervention technique, such as countermoves, control techniques, takedowns, or application of mechanical restraints (other than for regular transports), a PAR Incident Report is completed and filed in accordance with the Florida Administrative Code. There have been no Protective Action Response (PAR) incidents during this review period; therefore, this indicator rates as non-applicable Pre-Service/Certification Training Compliance Contracted and state non-residential staff are trained in accordance with Florida Administrative Code. Contracted and state non-residential staff satisfy pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. Three training files were reviewed for completion of the required pre-service/certification training. All three new staff completed phase one and phase two training within the required time frame In-Service Training Compliance Contracted and state non-residential staff completes in-service training in accordance with Florida Administrative Code. Contracted and state non-residential staff completes twenty-four hours of in-service training, including mandatory topics specified in Florida Administrative Code, each calendar year, effective the year after pre-service/certification training is completed. Supervisory staff completes eight hours of training (as part of the twenty-four hours of annual inservice training) in the areas specified in Florida Administrative Code. Seven training files were reviewed for completion of required in-service training. All seven staff exceeded the minimum required twenty-four hours of training in 2014; a combination of webbased training and instructor led training. Each staff documented training in suicide prevention, professionalism and ethics, and current First Aid and cardiopulmonary resuscitation (CPR) certification. Six staff completed eight hours of Protective Action Response (PAR) updates as required. One staff was unable to complete eight hours of PAR refresher training in 2014 due to a medical waiver. The staff did complete PAR training in January 2015 once released by a medical doctor. Two staff were also applicable for supervisory training; documenting four and ten hours respectively of supervisory related training. The Central Region Probation 2014 In-Service Training Plan was approved by the Office of Staff Development and Training on October 1, The circuit did not have an annual training calendar available for review. Office of Program Accountability Page 9 of 19 (Revised September 2014)

10 1.06 Supervisory Document Reviews Compliance Supervisor or designee reviews and signs all reports to the court, such as Detention Risk Assessment Instrument (DRAI), the State Attorney Recommendation (SAR), Pre-Disposition Report (PDR), and Progress Reports, within the timeframes required. Fifty-seven open files and ten closed files were reviewed for supervisory signature on all required documents. Thirty-two files required a supervisory review of the State Attorney Recommendation (SAR); thirty-one were initialed by the supervisor prior to the SAR being sent to the court. In one file, the SAR was not initialed by the supervisor. The supervisor signed the Pre-Disposition Report (PDR) prior to sending it to the court in all fourteen applicable files reviewed. Twenty-nine files required a supervisory review of the Detention Risk Assessment Instrument (DRAI); twenty-eight were signed by the supervisor and one was not. In each of the ten closed files reviewed, the supervisor signed the progress report prior to the termination request being submitted to court. Five files also required the supervisor to sign the Pre-Release Notification (PRN) submitted with the progress report; four were signed as required. One PRN was submitted to court without a supervisory signature 1.07 Ninety-Day Supervisory Reviews Compliance Cases under supervision (probation, conditional release, post-commitment probation) are reviewed by the supervisor at least once every ninety calendar days. The supervisor ensures that staff review any instructions given during the review, and ensures that they were followed during the subsequent review. Fifty-seven open files were reviewed for the juvenile probation officer supervisor (JPOS) review of the Youth-Empowered Success (YES) Plan and ninety-day case reviews. In each of the fiftyseven files, the JPOS documented a review of the YES Plan in the Juvenile Justice Information System (JJIS) case notebook module. Thirty-five files required at least one supervisory review during the first ninety-day period of supervision, and twenty were completed within the required time frame and fifteen were completed late. In four of the fifteen files, the review was only one day late, one review was two days late, one review was three days late, one review was four days late, one review was eight days late, one review was fifteen days late, one review was sixteen days late, one review was twenty-two days late, one review was thirty-five days late, one review was forty-four days late, one review was forty-nine days late, and in the last file the review was seventy-two days late. Nine files required a supervisory review for the second ninety-day period of supervision. Seven were completed within the required time frame and two were late; twelve and sixteen days respectively Incident Reporting (CCC) Compliance Whenever a reportable incident occurs, the program notifies the Department s Central Communications Center (CCC) within two hours of the incident, or within two hours of becoming aware of the incident. The Department s Central Communications Center (CCC) database documented twenty incidents reported during the last six months. All incidents were called in to the CCC within the required time frame. Office of Program Accountability Page 10 of 19 (Revised September 2014)

11 1.09 Abuse-Free Environment Compliance Any person who knows, or has reasonable cause to suspect, that a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or other person responsible for the child's welfare, as defined by Florida Statute, or that a child is in need of supervision and care and has no parent, legal custodian, or responsible adult relative immediately known and available to provide supervision and care, reports such knowledge or suspicion to the Florida Abuse Hotline. Circuit staff are expected to abide by the Department s Code of Ethics and Personal Responsibility; and upon hire, new staff sign a statement of personal responsibility. A tour of the Titusville offices found the Central Communications Center (CCC) and Florida Abuse Hotline phone numbers were prominently displayed in each office. The circuit advised only the Florida Abuse Hotline number was posted in the Melbourne and Sanford offices; however, by the end of the annual compliance review, the CCC number was also posted in those offices. Upon request, the circuit was able to provide a couple of examples of instances in which a juvenile probation officer (JPO) called the Florida Abuse Hotline, on the behalf of a youth, to report suspected abuse and/or neglect. Standard 2: Assessment Services Overview The circuit serves two counties and consists of seven units; four located in Brevard County and three in Seminole County. The units handle intake, probation, and aftercare supervision; however, screening services are contracted to outside providers. Juveniles taken into custody and presented for detention screening in Brevard are handled by the screening unit housed at the Brevard Regional Juvenile Detention Center. Brevard screening services are provided by the Juvenile Services Program (JSP). Brevard County also has a county funded Juvenile Assessment Center (JAC) for youth that are not detainable. The JAC is operated by Crosswinds Youth Services. Youth that are not being detained are either transported to Crosswinds or given a notice to report within twenty-four hours to Crosswinds for assessment and referral. Seminole County has a JAC located in Sanford. The Seminole JAC is managed by the Seminole County Sheriff s Office (SCSO), and the SCSO staff are responsible for detention screening. The Seminole Truancy Alternatives for Youth Center (STAY) is also located at the Seminole JAC. The design is for all youth being charged with a delinquent act, which including those referred for a civil citation to be assessed after being transported by law enforcement to the JAC. If a youth receives a new law violation and is not presented for detention screening, the Department s juvenile probation officers are responsible for conducting the initial conference with the youth and parent/guardian. The juvenile probation officers and/or detention screeners are responsible for completion of the Positive Achievement Change Tool (PACT), PACT Mental Health and Substance Abuse Screening Report and Referral Form, State Attorney Recommendations (SAR), and Pre- Disposition Reports (PDR). The circuit has an interagency agreement with the Office of the State Attorney of the 18th Judicial Circuit, which has determined that the Department shall only submit a recommendation to the state attorney in a limited number of specific instances. Diversion services are offered through the Office of the State Attorney in Brevard County and through the county government in Seminole County. These services include arbitration, teen Office of Program Accountability Page 11 of 19 (Revised September 2014)

12 court, civil citations, and pre-disposition sentencing agreements. The Juvenile Diversion Alternative Program (JDAP) is also offered in Brevard County 2.01 Positive Achievement Change Tool (PACT) Pre-Screen Compliance Staff complete the PACT Pre-Screen whenever a youth is referred to the Department for a new law charge (taken into custody or at-large) or taken into custody and screened for a non-law violation of supervision. Thirty-five files were applicable for completion of the Positive Achievement Change Tool (PACT) pre-screen due to the youth receiving a new law violation, and prior to completion of the State Attorney Recommendations (SAR) and/or Pre-Disposition Report (PDR). The PACT pre-screen was completed as required in all thirty-five files PACT Full Assessment Compliance Staff complete the PACT Full Assessment for youth designated Moderate-High or High-risk to reoffend by the Pre-Screen PACT, if being referred for Redirections, or if residential commitment is anticipated. Of the thirty-five files in which the Positive Achievement Change Tool (PACT) Pre-Screen was completed, six youth were identified as moderate-high or high-risk. In all six instances the PACT Full Assessment was completed as required PACT Reassessment Compliance Staff complete PACT Reassessments for youth on probation, conditional release, and postcommitment probation. A total of fifty-seven files were reviewed. Of the fifty-seven files reviewed, there were forty-eight separate instances in which a Positive Achievement Change Tool (PACT) Reassessments was required. Twenty-six of thirty-one required instances, there was no more than 180 days between PACT Reassessments. Three reassessments were not completed and two were late; two days and forty-one days respectively. Seventeen separate instances required a PACT Reassessment due to a new law violation; sixteen were completed Mental Health/Substance Abuse Screening Compliance Whenever a youth is referred to the Department for a new law charge (taken into custody or atlarge) or taken into custody and screened for a non-law violation of supervision, staff shall complete the PACT Mental Health and Substance Abuse Screening Report and Referral Form (Form DJJ/PACTFRM 1). Twenty-three files were reviewed for completion of the Positive Achievement Change Tool (PACT Mental Health and Substance Abuse Screening Report and Referral form. The form was completed in each applicable file. Fifteen of the twenty-three instances indicated a need for further assessment. Six youth were released to a parent/guardian, and five documented the parent/guardian was provided the results of the PACT. Nine youth were released to the custody of the local juvenile detention center and the PACT results were forwarded to the detention center. Office of Program Accountability Page 12 of 19 (Revised September 2014)

13 2.05 Comprehensive Assessment Compliance Youth shall be referred for a comprehensive assessment (e.g., TASC/SAMH) if the PACT Mental Health and Substance Abuse Screening Report and Referral Form indicates a need for further assessment. In all, fifteen applicable instances in which the Mental Health and Substance Abuse Screening Report and Referral form indicated a need for further assessment, the juvenile probation officer (JPO) referred the youth for a comprehensive assessment. The results of the comprehensive assessment were received in four of the fifteen instances. Referrals for services based on recommendations made in comprehensive assessments were made in three of the four instances. The circuit reported a reduction of services in the months of December 2014 and January 2015, as there was a transition in services from one provider to another for the provision of comprehensive assessments State Attorney Recommendation (SAR) Compliance Staff shall complete the State Attorney Recommendation (SAR) (Form DJJ/PACTFRM 3) to document the Department s recommendation of judicial or non-judicial handling of the case, unless waived pursuant to an Interagency Agreement with the local State Attorney s Office (SAO), or the SAO makes a filing decision prior to the twenty-day deadline for non-detained youth. Twenty-five files were applicable for completion of the State Attorney Recommendation (SAR). In twenty-four of the twenty-five instances the SAR was completed after the Positive Achievement Change Tool (PACT) Pre-Screen. In twenty-three of the twenty-five SARs, issues identified by the PACT Pre-Screen were discussed in the narrative section of the SAR. Twentythree SARs were submitted within the required time frame; two files had no documentation to support when the SAR was submitted to court. In five of the fourteen applicable SARs, which the youth scored low risk on the PACT Pre- Screen, the youth was considered for non-judicial action or diversion. Nine of the SARs in which the youth scored low-risk on the PACT Pre-Screen and non-judicial handling or diversion was not recommended. The justification was explained in the narrative section of the SAR for six. In the remaining three instances, the narrative section did not justify the recommendation for judicial handling Pre-Disposition Report (PDR) Compliance Staff shall prepare the Pre-Disposition Report (PDR) (Form DJJ/PACTFRM 5) when ordered by the court, detailing the Department s recommendation for disposition and interventions to address needs in the most appropriate, least-restrictive environment that reasonably ensures public safety. Fourteen files were applicable for completion of the Pre-Dispositional Report (PDR). Five youth scored either moderate-high or high-risk on the Positive Achievement Change Tool (PACT) Pre- Screen and a PACT Full Assessment was completed prior to completing the PDR in three files. In the remaining nine files, the youth scored either low or moderate-risk on the PACT Pre- Screen and a PACT Full Assessment was not required prior to completing the PDR. The recommendations in the PDR reflected treatment needs identified by the PACT and/or other sources in all eight applicable PDRs. Thirteen of the fourteen PDRs were submitted to the court Office of Program Accountability Page 13 of 19 (Revised September 2014)

14 at least forty-eight hours prior to the disposition hearing. In the last file, there was no documentation to support when the PDR was submitted to court. Standard 3: Intervention Services Overview The circuit is comprised of seven units; three units located in Sanford, two units located in Melbourne, and two units located in Titusville. Cases are assigned according to geographical zip code and some juvenile probation officers (JPOs) carry specialized caseloads. The JPOs are responsible for completion of the Positive Achievement Change Tool (PACT), Youth- Empowered Success (YES) Plans, and documenting case activities in the Juvenile Justice Information System (JJIS) case notebook module. Youth identified in need of mental health and/or substance abuse treatment are referred to an appropriate provider within the community. The circuit is in the midst of implementing the Georgetown University Crossover Youth Practice Model. The in-person consultation with Georgetown University concluded in January 2015 with ongoing consultation available via conference call. Full implementation is expected by the summer of The circuit was also chosen as a pilot site for the Effective Practices in Community Supervision (EPICS), through the University of Cincinnati Corrections Institute. Circuit staff completed the EPICS training in March 2015 and ongoing skill development is continuing through October The Department of Juvenile Justice has written agreements in place with different service providers within the circuit. The juvenile probation officers refer youth to the service providers to address the needs of the youth when deemed appropriate. These services include transition services for conditional release and post commitment probation youth, either through Project Bridge or the Seminole County Sheriff s Office, Paxen Community Connection that is a day treatment program serving youth in Brevard County, the Department s Redirection program, project Sheriff s Work Ethics and Training (SWEAT), the Consequence Alternative Sanction Unit (CASU); and drug court 3.01 Youth-Empowered Success (YES) Plan Development Compliance Staff complete the YES Plan (Form DJJ/PACTFRM 4) for youth on Probation, Conditional Release, and Post-Commitment Probation. Fifty-seven files were reviewed for development of the Youth-Empowered Success (YES) Plan; each file contained an initial plan. Forty-nine files documented a new Positive Achievement Change Tool (PACT) completed after placement on probation or release from a residential program and prior to the development of the YES Plan. Forty-seven files documented youth and parent/guardian participation in the development of the plan. One file documented the parent/guardian unwillingness to participate in the plan development, and nine files did not have clear documentation of the youth and parent/guardian participation in the development of the plan. Fifty-five YES Plans were signed by the youth within thirty days as required. One plan was signed one day late, and on one plan the youth s signature was not dated. Fifty-one YES Plans were signed by the parent/guardian within thirty days as required, two plans were not signed, one plan was signed one day late, and on two plans the parent/guardian signature was not Office of Program Accountability Page 14 of 19 (Revised September 2014)

15 dated. The last file did not require a parent/guardian signature as the youth was eighteen years of age and the parent/guardian was not involved. Forty-nine YES Plans were signed by the juvenile probation officer (JPO) as required, one plan was three days late, and seven plans did not document the juvenile probations officer s actual signature, rather only the electronically printed name of the individual who created the plan in the Juvenile Justice Information System (JJIS). Fifty-six YES Plans were signed/approved by the supervisor within thirty days, and one plan was six days late. Of the fifty-seven files reviewed, only twenty-six documented in the case notes the youth and parent/guardian were provided a copy of the approved YES Plan. Five files documented a copy of the YES Plan was provided prior to the plan being approved. Twenty-six files had no documentation in the case notes to support a copy of the YES Plan was provided Youth Requirements/PACT Goal Elements Compliance For youth designated Moderate-High or High-risk to reoffend by the PACT, the YES Plan includes at least one Change Goal. The YES Plan provides appropriate and individualized target dates for the completion of each Youth Requirement and Goal. All Youth Requirement and Goal action steps include the intervention plan elements (i.e., who, what, and how often). The Youth Requirements and Change Goals for all fifty-seven Youth-Empowered Success (YES) Plans were reviewed. A total of 451 Youth Requirements and/or Change Goals were included in the initial YES Plans, of which 450 contained the intervention plan elements of who and what for the youth and parent/guardian, 445 contained the intervention plan elements of who, what, and how often for the juvenile probation officer (JPO), and 450 contained an appropriate target date for completion. Of the fifty-seven YES Plans reviewed, sixteen were classified as either moderate-high or high risk and required at least one Change Goal. Fifteen plans included a Change Goal on the initial YES Plan and one did not. The Change Goal addressed one of the youth s top three criminogenic needs in twelve of the plans reviewed. Eight youth were classified as high risk to reoffend requiring an evidence based intervention targeting one of the youth s top three criminogenic needs. Three YES Plans included an evidence-based intervention that targeted one of the youth s top three criminogenic needs. In the five remaining files, two documented barriers to the youth s participation in the case notes and three did not Transitional Planning/Reintegration Limited Compliance Juvenile Probation Officers actively participate in the transitional planning process for youth who are being released from a residential program on Conditional Release (CR), Post-Commitment Probation (PCP), or Direct Discharge. For conditional release and post-commitment probation youth, the YES Plan must address recommendations from the residential program made during transition and any other criminogenic need(s). Ten applicable files were reviewed for transitional planning. Four out of the ten files documented consistent participation by the juvenile probation officer (JPO) in treatment team meetings while the youth was in residential commitment. In the six files in which the JPO did not participate in the treatment team meetings, the JPO did not consistently document follow-up with the program and youth within seventy-two hours of the meetings. Nine files were applicable for monthly contact with the youth's parent/guardian while the youth was in residential commitment, and one youth was eighteen years of age and parent/guardian contacts were not required. None of the nine applicable files documented the required monthly parent/guardian contacts. Office of Program Accountability Page 15 of 19 (Revised September 2014)

16 The JPO document his or her participation in the transition conference in nine of ten files. Nine files contained a copy of the youth s transition plan and/or information concerning the youth s aftercare services were clearly documented in the case notes. Seven files documented the JPOs participation in the exit conference, but two did not. In the last file, the youth was released by the judge during a review hearing, and did not have an exit conference. In all ten files the JPO documented receipt of the Pre-Release Notification (PRN) and submission to court within three days, as required. All ten files documented treatment recommendations from the residential program; nine included the recommendations on the initial Youth-Empowered Success (YES) Plan. In the last file, the residential program recommended mental health and substance abuse counseling; however, the YES Plan only included the mental health counseling. Referrals for treatment services were not always documented prior to the youth s release; however, follow-up with the treatment providers was documented within thirty days of the YES Plan approval in nine of the ten files Referrals for Mental Health and Sub-stance Abuse Compliance Assessment and Treatment Services Staff shall ensure that all referrals for services are made as indicated by the court order or as negotiated to address criminogenic needs identified by the PACT (for youth that are Moderate- High or High risk to reoffend), and that youth identified as in need of further assessment on the PACT Mental Health and Sub-stance Abuse Report and Referral Form are referred for and receive a Comprehensive Assessment. Referrals for mental health and substance abuse treatment services are based upon Comprehensive Assessment findings and recommendations and the youth s YES Plan. Staff shall develop a follow-up and monitoring plan for all referrals for treatment made as a result of the Comprehensive Assessment and YES Plan. If referred for services, staff follows up with the service provider within thirty days to ensure that the youth and parent/guardian have taken the appropriate steps to initiate services. Staff receives, reviews, and documents written and verbal progress reports from the provider. Staff shall act upon negative reports, such as missed appointments or lack of participation, and document the response in the case notes. On September 19, 2014 a supplemental monitoring was conducted regarding issues identified during the annual compliance review from April 8-10, As a result of the initial monitoring, a follow-up monitoring was conducted on January 23, Subsequently, the circuit was placed on a corrective action plan. As part of the corrective action plan, each unit developed a spreadsheet to assist the supervisors in tracking case dispositions, Youth-Empowered Success (YES) Plan negotiations, supervisory approval of YES Plans, ten day referral requirements, and the thirty day follow-up requirements. At the time of the annual compliance review, the circuit had implemented the corrective action plan, and the review served as a second verification monitoring. A total of fifty-three files were reviewed for mental health and substance abuse treatment referrals during the annual compliance review. However, in a majority of the files, the YES Plan approval and referral process occurred prior to the implementation of the corrective action plan. Nineteen files documented a YES Plan that was approved by the juvenile probation officer supervisor (JPOS) subsequent to the January verification monitoring, and were used to complete the second verification. Seventeen documented a referral for services within ten days of the YES Plan approval. Two files had no documentation to support a referral was made. Out of the seventeen applicable files, sixteen documented follow-up by the juvenile probation officer (JPO) within thirty days as required, and one documented follow-up by the JPO; however, it was Office of Program Accountability Page 16 of 19 (Revised September 2014)

17 not within the thirty-day requirement. The JPO either received written and/or verbal progress reports from the provider or documented attempts to solicit information from the provider in all eleven applicable files. In each of the five applicable files, the JPO documented follow-up on progress reports when required YES Plan Implementation/Supervision Compliance Youth on supervision (Probation, Conditional Release, or Post-Commitment Probation) are supervised in a manner that ensures compliance with the court order and the completion of the YES Plan (Youth Requirements and PACT Goals). Case notes demonstrate compliance (or attempted compliance) with youth, parent/guardian, and staff action steps contained in the YES Plan. Fifty-seven files were reviewed for implementation of the Youth-Empowered Success (YES) Plan. A total of 364 action steps were required within the first ninety-day supervision period; documentation supported the juvenile probation officer (JPO) compliance with 347 action steps. A total of eighty-five action steps were required within a second ninety-day period of supervision; documentation supported compliance with seventy-eight action steps. The case notes supported the documentation of case activities that included face-to-face interactions, telephone contacts, and review of written or verbal reports from collateral sources Effective Response System Compliance Staff responds to noncompliance in a manner that is consistent with the program s progressive response system. Thirty-one files documented instances of non-compliance by the youth requiring the JPO to respond. The juvenile probation officer (JPO) responded according to the circuit s graduated sanctions matrix in twenty-eight out of the thirty-one instances; three either had no documented response by the JPO or did not follow the matrix Ninety-Day YES Plan Updates Compliance Staff adjust the YES Plan to reflect any new needs and progress made during the course of supervision. Staff must make necessary updates to Youth Requirements and PACT Goals and save a new YES Plan in the Juvenile Justice Information System (JJIS) prior to ninety-day supervisory reviews. When updates are made to the YES Plan that reasonably require the input of the youth and parent/guardian, this discussion is clearly documented in the case notes. The case notes clearly document any communication regarding the YES Plan. Thirty-five of the fifty-seven files reviewed were applicable for a ninety-day update to the Youth- Empowered Success (YES) Plan. Twenty-seven files documented a new YES Plan saved in the Juvenile Justice Information System (JJIS) prior to the supervisory review and/or at least within ninety days of the initial YES Plan. In the remaining eight files, the plan was not generated in the Juvenile Justice Identification (JJIS) within the ninety-day requirement; seven days, eight days, thirteen days, fourteen days, thirty-five days, forty-four days, forty-nine days, and seventy-two days late respectively. Twenty-two of twenty-three applicable files reflected the youth requirements were updated in JJIS prior to the plan being updated. Sixteen of the nineteen applicable files had the target dates updated. All twelve applicable files had the Change Goal updated in JJIS. Additionally, all six applicable files changes to the YES Plan that reasonably required the input of the youth and parent/guardian were documented in the case notes. Office of Program Accountability Page 17 of 19 (Revised September 2014)

18 Nine files were applicable for a second ninety-day review of the YES Plan. Eight files documented a new YES Plan saved in the JJIS prior to the supervisory review and/or at least within ninety days of the previous YES Plan; one plan was four days late. Youth requirements and Change Goals were updated as required. The target dates were updated in seven of the eight applicable files. Additionally in the two applicable files, changes to the YES Plan that reasonably required the input of the youth and parent/guardian were documented in the case notes Termination of Supervision Compliance The JPO requests termination for youth on Probation, Conditional Release, or Post- Commitment Probation upon successful completion of court-ordered sanctions and substantial compliance with restitution and/or court fees. Termination must also be requested if the Department is losing jurisdiction because the youth has reached the maximum age provided in statute or based on the maximum period of supervision applicable to the charge. Ten applicable files were reviewed for termination of supervision. Each of the ten files documented a completed progress report; six requesting early termination of supervision and the other four notifying the court of the Department s loss of jurisdiction. Two youth scored moderate-high or high risk on the Positive Achievement Change Tool (PACT) at the time the progress report was submitted; only one included the comparative risk and/or comparative protective factors report information with the progress report. Ten files of the five youth were on conditional release status at the time termination was requested and the pre-release notification (PRN) was submitted with the progress report as required. In the six applicable files where the juvenile probation officer (JPO) requested early termination of supervision, a check to verify if there were outstanding warrants on the youth prior to submitting the request for termination was documented in five files. The termination request was submitted prior to the warrants check being completed in the last file. In four files the Department lost jurisdiction, and one documented the progress report was submitted to court at least fifteen working days prior to the loss of jurisdiction as required. In the other three files, the progress report was submitted fourteen days, thirteen days, and five days prior to the loss of jurisdiction. Seven out of the ten files contained a copy of the letter mailed to the youth and parent/guardian advising of the termination of supervision. Two files documented in the case notes a letter was mailed to the family; however, a copy of the letter was not maintained in the file. One file had no documentation in the case notes to support the family was notified of the termination, and no copy of the letter was maintained in the file. In the five applicable files, there was no documentation to support the youth and parent/guardian were advised the court retained jurisdiction for purposes of paying restitution and/or fees. The JPO documented in the case notes the Juvenile Justice Information System (JJIS) was updated to reflect case closure within five days as required in six files. In the remaining four files, the case notes did not indicate when the JJIS was update. However, the JJIS did reflect all four cases were closed at the time of the annual compliance review. Office of Program Accountability Page 18 of 19 (Revised September 2014)

19 Program Name: Probation & Community Intervention Circuit 18 QI Program Code: 1193 Provider Name: Department of Juvenile Justice Contract Number: N/A Location: Brevard County / Circuit 18 Number of Beds: N/A Review Date(s): April 28-30, 2015 Lead Reviewer Code: 84 Overall Rating Summary The following limited and/or failed indicators require immediate corrective action Transitional Planning/Reintegration* Office of Program Accountability Page 19 of 19 (Revised September 2014)