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 Okeechobee Juvenile Offender Correctional Center G4S Youth Services, LLC (Contract Provider) 5050 North East 168th Street Okeechobee, Florida Review Date(s): January 13-16, 2015 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES

2 PrevPage OkeechobeeJO CCMaxRisk Behavioral/MentalHealthProgram (Opened3/1/03) QuarterlyDataFY NextPage Program Name Provider Program Group Program Type Open/Closed OkeechobeeJO CCMax Risk G4SYouthServices,LLC Maximum Risk-Male Behavioral/MentalHealth (Opened3/1/03) Program Activity AvgLengthofStay(Days) Escapes* Excessive/UnnecessaryUseofForceIncidents* MajorDeficiencies/CriticalIssues* PARRate(per1,000filedbeddays)* PAR(ProgramType) PAR(Statewide) YouthArests 1st Quarter nd Quarter 3rd Quarter 4th Quarter Total (FYTD) PACTRisktoReofend HighRisk Moderate-HighRisk ModerateRisk LowRisk RPACT IncreaseProtective 1st Quarter 51% 35% 9% 5% 100% 2nd Quarter 3rd Quarter 4th Quarter Total (FYTD) 51% 35% 100% DecreaseRisk 100% 100% 9% 5% *Thisdatamaybereportedforco-locatedprograms PACTRisktoReofend FiscalYearToDate SPEP QualityImprovement Review PrimaryService ServiceDeliveryRating N/A N/A N/A HighRisk Moderate-HighRisk ModerateRisk LowRisk Foradditionalinformationaboutthisfacility,visithtp:/

3 PrevPage OkeechobeeJO CCMaxRisk Behavioral/MentalHealthProgram (Opened3/1/03) NextPage AnnualOutcomes (YearofCompletion) SeriousnessIndex (YearofCompletion) SeriousnessIndex FY FY FY Program TypeSeriousnessIndex Recidivism (YearofCompletion) 44% 27% 21% Program TypeRecidivism CompletionRate Program TypeCompletionRate 41% 73% 87% 31% 58% 73% 34% 100% 97% 0 FY FY FY Recidivism (YearofCompletion) StatewideCompletionRate 86% 90% 88% 40% TotalReleases Program Releases (YearofRelease) % 0% FY FY FY Program StatewideAvg(CompletionRate) Program TypeAvg 15 CompletionRates (YearofCompletion) % 5 50% 0 FY FY FY % FY FY FY Foradditionalinformationaboutthisfacility,visithtp:/

4 PrevPage OkeechobeeMaxRiskSexOfender SexOfenderProgram (Opened1/1/10) QuarterlyDataFY NextPage Program Name Provider Program Group Program Type Open/Closed OkeechobeeMaxRiskSex Ofender G4SYouthServices,LLC Maximum RiskSex Ofender-Male SexOfender (Opened1/1/10) Program Activity AvgLengthofStay(Days) Escapes* Excessive/UnnecessaryUseofForceIncidents* MajorDeficiencies/CriticalIssues* PARRate(per1,000filedbeddays)* PAR(ProgramType) PAR(Statewide) YouthArests 1st Quarter nd Quarter 3rd Quarter 4th Quarter Total (FYTD) PACTRisktoReofend HighRisk Moderate-HighRisk ModerateRisk LowRisk RPACT IncreaseProtective 1st Quarter 41% 12% 12% 35% 100% 2nd Quarter 3rd Quarter 4th Quarter Total (FYTD) 41% 12% 12% 35% 100% DecreaseRisk 67% 67% *Thisdatamaybereportedforco-locatedprograms PACTRisktoReofend FiscalYearToDate SPEP QualityImprovement Review PrimaryService ServiceDeliveryRating N/A N/A N/A HighRisk Moderate-HighRisk ModerateRisk LowRisk Foradditionalinformationaboutthisfacility,visithtp:/

5 PrevPage OkeechobeeMaxRiskSexO fender SexO fenderprogram (Opened1/1/10) NextPage AnnualOutcomes (YearofCompletion) SeriousnessIndex (YearofCompletion) SeriousnessIndex FY FY FY Program TypeSeriousnessIndex Recidivism (YearofCompletion) 0% 0% 22% Program TypeRecidivism CompletionRate Program TypeCompletionRate StatewideCompletionRate TotalReleases % 100% 100% 86% 31% 100% 73% 90% 24% 95% 72% 88% 0 30% 20% FY FY FY Recidivism (YearofCompletion) Program Releases (YearofRelease) % 0% FY FY FY Program StatewideAvg(CompletionRate) Program TypeAvg % CompletionRates (YearofCompletion) FY FY FY % 0% FY FY FY Foradditionalinformationaboutthisfacility,visithtp:/

6 PrevPage OkeechobeeSexOfenderFacility SexOfenderProgram (Opened2/28/03) QuarterlyDataFY NextPage Program Name Provider Program Group Program Type Open/Closed OkeechobeeSexOfender Facility G4SYouthServices,LLC HighRiskSexOfender-Male SexOfender (Opened2/28/03) Program Activity AvgLengthofStay(Days) Escapes* Excessive/UnnecessaryUseofForceIncidents* MajorDeficiencies/CriticalIssues* PARRate(per1,000filedbeddays)* PAR(ProgramType) PAR(Statewide) YouthArests 1st Quarter nd Quarter 3rd Quarter 4th Quarter Total (FYTD) PACTRisktoReofend HighRisk Moderate-HighRisk ModerateRisk LowRisk RPACT IncreaseProtective 1st Quarter 48% 26% 15% 11% 100% 2nd Quarter 3rd Quarter 4th Quarter Total (FYTD) 48% 26% 15% 11% 100% DecreaseRisk 67% 67% *Thisdatamaybereportedforco-locatedprograms PACTRisktoReofend FiscalYearToDate SPEP QualityImprovement Review PrimaryService ServiceDeliveryRating N/A N/A N/A HighRisk Moderate-HighRisk ModerateRisk LowRisk Foradditionalinformationaboutthisfacility,visithtp:/

7 PrevPage OkeechobeeSexO fenderfacility SexO fenderprogram (Opened2/28/03) NextPage AnnualOutcomes (YearofCompletion) SeriousnessIndex (YearofCompletion) SeriousnessIndex FY FY FY Program TypeSeriousnessIndex Recidivism (YearofCompletion) 17% 8% 0% 10 Program TypeRecidivism CompletionRate Program TypeCompletionRate 15% 100% 53% 43% 92% 84% 0% 100% 100% 0 FY FY FY Recidivism (YearofCompletion) StatewideCompletionRate 86% 90% 88% 40% TotalReleases % Program Releases (YearofRelease) 0% FY FY FY Program Program TypeAvg StatewideAvg(CompletionRate) % CompletionRates (YearofCompletion) 3 50% 0 FY FY FY % FY FY FY Foradditionalinformationaboutthisfacility,visithtp:/

8 PrevPage DEFINITIONSOFMEASURES NextPage AverageLengthofStay-ALOS(Days)Theaveragenumberofdaysthatayouthstaysinaparticularprogram.Thisiscalculatedbytotalingthedaysservedforalyouthwhocompleted from aprogram (inthetimeperiodspecified)anddividingthisnumberbythetotalnumberofyouthwhocompletedfrom theprogram. Source:JJIS,BureauofResearch&Planning. CompletionRate-Youthwhocompleteaprogram andreturntothecommunityareconsideredcompleters.whetherayouthisconsideredacompleterisbasedupon hisorherexitstatus.exitstatusisdeterminedbythefolowingfactors: Releasereason Therestrictivenesslevelofthenextcommitmentprogram,ifany Thetimebetweenthereleaseandnextcommitmentplacement ThenextplacementintheServiceHistorydata ThetimebetweenthereleaseandthenextServiceHistoryplacement Threeexitstatusesareconsideredprogram completions: Releasesfrom careandcustody(includingthosereleasedbecausetheyservedthemaximum term alowedbylaworreachedthemaximum ageofjurisdiction). Releasestopost-commitmentprobation. Releasestoconditionalrelease. Thecompletionrateisthepercentageofthoseyouthreleasedwhoareconsideredacompleter,asdefinedabove,ascomparedtothetotalofalyouthreleasedfrom aprogram. Source:JJIS,BureauofResearch&Planning. CriticalIssue-AnidentifiedCriticalIssueandorCriticalDeficiencyistheabsenceofacomponentessentialtoservicedeliveryortheverificationthatthedeliveryofanessentialservice hasbeencompromised.thedeficiencyissodireoracutethatitpresentsapotentialthreattothehealthorsafetyoftheyouthserved,ormayotherwisecompromiseprogram security. Criticalissuesrelatedtoescapesarenotcountedinthenumberreflectedinthisreportastheyarereportedseparately. Source:Regions(MonitoringandQIReviews) Escapes-Numberofindividualspereventwhoescapedfrom afacilityduringthereportingperiod. Source:CCC,OficeofResidentialServices. Excessive/UnnecessaryForceIncidents-ThenumberofincidentsreportedtotheCentralCommunicationCenter(CCC)duringthereportingquarterthatresultinasubstantiatedfinding(s)ofunnecessaryand/orexcessiveuseofforce.EachspecificCCCincidentwithsubstantiatedfindingsiscountedonce,regardlessofthenumberofstafwithsubstantiatedfindings involvedinanincident.sinceanincidentisonlycountedaftera substantiated findinghasbeenmade,thenumbersforaquartermaybeadjustedatsomepointinthefuturetoreflectupdatedfindings. Source:CCC,OficeofResidentialServices. Expectedrecidivism rate-toensurethatprogramsservingyouthwithdiferentdificultylevelsareheldtoreasonableandfairrecidivism standards,thedepartmentcalculatesanexpectedrecidivism rateforthegroupofyouthwhocompletedeachresidentialprogram duringthetimeperiodunderanalysis.programsthatserveyouthwithsignificantriskfactorsforreofendingwilhaveahigherexpectedrecidivism ratethanprogramsservingyouthwithlessriskfactors. Source:JJIS,BureauofResearch&Planning. MajorDeficiencies-Aprogram deficiencyand/orcontractualcomplianceissuethatresultsinaninteruptionineitherthedeliveryofservicesand/orthereceiptofpublicfundsforprogram servicesnotdelivered.amajordeficiencycanalsobebasedonrepeatedminordeficiencieswithnoindicationprogressisbeingmadetocorectthedeficiency.majordeficienciesaresignificantinnatureandtypicalyrequireoversightbymanagementtoensuretheissuesareaddressedsystemicaly.thedeterminationofanissue(s)beinga majordeficiency ismade throughthecontractmonitoringprocess.majordeficienciesrelatedtoescapesarenotcountedinthenumberreflectedinthisreportastheyarereportedseparately. Source:Regions(MonitoringandQIReviews) Foradditionalinformationaboutthisfacility,visithtp:/

9 PrevPage DEFINITIONSOFMEASURES(2) NextPage PACTRisktoReofend-ThePositiveAchievementChangeTool(PACT)isacomprehensiveassessmentthataddressesbothcriminogenicneedsandprotectivefactorsandidentifiesa youth srisktore-ofendaseitherlow,moderate,moderate-highorhigh.thismeasureisbasedontheyouthservedinthereportingquarter.source:jjis,bureauofresearch&planning. PAM Score-ThePAM (Program AccountabilityMeasure)scoreisstandardizedgradeincorporatingbothprogram recidivism costefectivenessandprogram costpercompletion.it presentsrecidivism andcostefectivenessresultsfortheprogramsthatcompletedatleast15youthduringtheone-yearperiodduringthetimeperiodunderanalysis.source:jjis,bureau ofresearch&planning. PARRate-PAR(ProtectiveActionResponse)istheDJJ-approvedphysicalinterventiontechnique,includingtheapplicationofmechanicalrestraints.TheuseofPAR,andstaftraining requirements,areoutlinedintheadministrativerules.theparrateisthenumberofparincidentsper1000filedbeddaysduringthereportingperiod.thestatewideaverageisbased onalcurentlyoperatingprogramsinthestateduringthereportingperiod.source:regions(reportedbyprograms);compiledbyoficeofresidentialservices. Program Group-Identifiesthegenderandcommitmentrisklevelserved.Source:JJIS. Program Type-Identifiesthetypes ofspecializedtreatmentservicesprovidedbyaprogram,suchasmentalhealth,substanceabuse,sexofender.source:jjis. QualityImprovement-Thesystem usedfortheassessmentofprogram complianceinareassuchasmanagement,operations,andservicedelivery.source:bureauofqualityimprovement. Recidivism -Forresidentialcommitmentprograms,thetwelve-monthrecidivism-trackingperiodbeginsthedaythatayouthcompletestheprogram (asdefinedabove),including both youthwhoarereleasedfrom thecareandcustodyofthedepartmentandyouthwhoarereceivingconditionalreleaseorpost-commitmentprobationservicesinanonresidentialseting. Recidivism isdefinedasaladjudications,adjudicationswithheld,andconvictionsforanynewviolationoflawwithintwelvemonthsofprogram completion.recidivism isreportedbythe yearofprogram completion.forexample,youthwhocompleteandexitaprogram infy aretrackedforrecidivism foroneyearfolowingthedaytheyexittheprogram.although theoneyeartrackingperiodmayrolintothefolowingfiscalyear(i.e.fy inthisinstance),therecidivism isreportedforthefiscalyeartheyouthexited(so,fy inthisexample).source:jjis,bureauofresearch&planning. Releases-Thetotalnumberofyouthreleasedfrom theprogram betweenjuly1andjune30ofthefiscalyearunderreview,asreportedinthejuvenilejusticeinformationsystem (JJIS). Source:JJIS,BureauofResearch&Planning. SeriousnessIndex-Aweightingmethodologyinwhichofensesareassignedapointvaluebasedonthedegreeofseriousness.Ahigherratingindicatesahigherlevelofseriousness. Theofenseseriousnessweightsareusedtocomputeanindexoftheseriousnessofpriorofensesforeachyouthreleasedduringthefiscalyear.Asummationofpointvaluescorespondingtoeachchargeforwhichtheyouthwasadjudicatedpriortotheprogram placementdateiscomputedaccordingtotheweightingschemebelow.foreachprogram,thesummationsforyouthwhocompletetheprogram aretotaledandthendividedbythenumberofindividualyouthreleasedfrom thatprogram tocomputeanaveragevaluefortheindexofofender seriousnessforeachprogram.source:jjis,bureauofresearch&planning. YouthArests-Forthepurposesofthisreport,thenumberreflectsthe youthsarestedforofensesoccuringwhileintheprogram,regardlessofwhetherornotthecaseisfiledwiththe court.arestinformationisgatheredfrom thecentralcommunicationscenter(ccc)databaseforalyouth,includingthose18yearsofageandolder.eachyoutharestedinanygiven incidentiscountedindividualy.ifayouthisarestedformorethanoneincidentduringthequarter,eacharestiscounted.source:ccc,oficeofresidentialservices. SPEP TheStandardizedProgram EvaluationProtocol(SPEP)evaluateshowcloselydelinquencyinterventions,asprovided,alignwiththefeaturesofthemostefectiveevaluatedprogramsinthefield.SPEPisanevaluationtoolthatidentifiesshortcomingsincurentjuvenileprograms,andprovidesguidelinesforimprovementinordertooptimizeinterventionefectivenessandpositiveoutcomesstatewide.TheSPEPevaluatesservicesinthefolowingcategories:ServiceType(e.g.,cognitivebehavioral;groupcounseling);ServiceQuantity/Dosage(Durationandintensityofcontacthours)andServiceQuality(e.g.,writenprotocols/manuals;training;fidelitymonitoring;corectiveaction).ThedatasheetscurentlyreportonlyonService Quality.TheServiceQuantityiscurentlybeingassessedasabaselineandwilbereflectedonthedatareportsnextyear. Foradditionalinformationaboutthisfacility,visithtp:/

10 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: Yvrose Sylvain, Office of Program Accountability, Lead Reviewer Odilanda Brito, Office of Program Accountability, Regional Monitor Heather Newman, Senior Juvenile Probation Officer, DJJ Probation, Circuit 15 Patrick Morse, Office of Program Accountability, South Regional Supervisor Pamela Rollins, Program Director, Broward Girls Academy, YSI

11 Program Name: Okeechobee Juvenile Offender Correctional Center QI Program Code: 1047 Provider Name: G4S Youth Services, LLC Contract Number: R2075 Location: Okeechobee County / Circuit 19 Number of Beds: 96 Review Date(s): January 13-16, 2015 Lead Reviewer Code: 125 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 and Performance Plan, (3) Mental Health and Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included in the Residential Standards. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee 1 # Case Managers 3 # Clinical Staff 1 # Food Service Personnel 2 # Healthcare Staff 1 # Maintenance Personnel 2 # Program Supervisors Documents Reviewed 5 # Staff 7 # Youth 3 # Other (listed by title): Director Case Manager, Compliance Manager, Master Control Operator 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 9 # Health Records 9 # MH/SA Records 9 # Personnel Records 9 # Training Records/CORE 5 # Youth Records (Closed) 9 # Youth Records (Open) # Other: 9 # Youth 9 # 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 59 (Revised September 2014)

12 Standard 1: Management Accountability Residential Rating Profile Indicator Ratings 1.01 Standard 1 - Management Accountability * Initial Background Screening 1.02 Five-Year Rescreening 1.03 * Provision of an Abuse-Free Environment 1.04 * Management Response to Allegations 1.05 * Incident Reporting (CCC) 1.06 Protective Action Response (PAR) 1.07 * Pre-Service/Certification Requirements 1.08 In-Service Training 1.09 Logbook Entries and Shift Report Review 1.10 * Internal Alerts System 1.11 * Alerts (JJIS) 1.12 Youth Records (Healthcare and Management) 1.13 Advisory Board 1.14 Program Planning 1.15 Staff Performance * 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 59 (Revised September 2014)

13 Standard 2: Assessment and Performance Plan Residential Rating Profile Indicator Ratings 2.01 Standard 2 - Assessment and Performance Plan Initial Contacts to Parent 2.02 Youth Orientation 2.03 Court Notifications 2.04 Classification Factors 2.05 Classification Procedures 2.06 Reassessment for Activities 2.07 R-PACT Assessment 2.08 Youth Needs Assessment Summary 2.09 R-PACT Reassessments 2.10 Parent/Guardian Involvement in Case Mgmt Members of Treatment Team 2.12 Performance Plan Development 2.13 Treatment Team Meetings (Formal Review) 2.14 Treatment Team Meetings (Informal Review) 2.15 * Performance Plan Goals 2.16 Performance Plan Transmittal 2.17 Performance Plan Revisions 2.18 Incorporation of Other Plans Into Performance Plan 2.19 Performance Summaries 2.20 Performance Summary Transmittal 2.21 Visitation and Communication 2.22 Written Consent of Youth Eighteen Years or Older 2.23 Written Consent for Substance Abuse Information 2.24 Transition Planning and Conference 2.25 Exit Portfolio 2.26 Exit Conference 2.27 Grievance Process Training 2.28 Grievance Process 2.29 Grievance Process Documentation 2.30 Gang Identification: Notification of Law Enforcement 2.31 Gang Identification: Intervention Activities 2.32 Life Skills Training Provided to Youth 2.33 Staff Training: Delinquency Interventions 2.34 Restorative Justice Awareness For Youth 2.35 Delinquency Intervention Services 2.36 Recreation and Leisure Activities 2.37 Youth Input 2.38 Gender-Specific Programming 2.39 Vocational Programming 2.40 Educational Access 2.41 Education Transition * 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 59 (Revised September 2014)

14 Standard 3: Mental Health and Substance Abuse Services Residential Rating Profile Indicator Ratings Standard 3 - Mental Health and Substance Abuse Services 3.01 Designated Mental Health Authority or Clinical Coordinator 3.02 * Licensed Mental Health and Substance Abuse Clinical Staff 3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff 3.04 Mental Health and Substance Abuse Admission Screening 3.05 Mental Health and Substance Abuse Assessment/Evaluation 3.06 Mental Health and Substance Abuse Treatment 3.07 * Treatment and Discharge Planning 3.08 * Specialized Treatment Services 3.09 * Psychiatric Services 3.10 * Suicide Prevention Plan 3.11 * Suicide Prevention Services 3.12 * Suicide Precaution Observation Logs 3.13 * Suicide Prevention Training 3.14 * Mental Health Crisis Intervention Services 3.15 * Crisis Assessments 3.16 * Emergency Mental Health and Substance Abuse Services 3.17 * Baker and Marchman Acts * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 6 of 59 (Revised September 2014)

15 Standard 4: Health Services Residential Rating Profile Indicator Ratings Standard 4 - Health Services 4.01 * Designated Health Authority/Designee 4.02 * Psychiatrist/Designee 4.03 Facility Operating Procedures 4.04 Authority for Evaluation and Treatment 4.05 Parental Notification 4.06 Notification - Clinical Psychotropic Progress Note 4.07 Immunizations 4.08 Healthcare Admission Screening Form 4.09 Medical Alerts 4.10 Youth Orientation to Healthcare Services 4.11 Designated Health Authority/Designee Admission Notification 4.12 Healthcare Admission Rescreening 4.13 Health Related History 4.14 Comprehensive Physical Assessment 4.15 Female-Specific Screening/Examination Non-Applicable 4.16 Tuberculosis Screening 4.17 Sexually Transmitted Infection Screening 4.18 HIV Testing 4.19 Sick Call Process - Requests/Complaints 4.20 Sick Call Process - Visits/Encounters 4.21 Restricted Housing 4.22 Episodic/First Aid Care 4.23 Emergency Care 4.24 Off-Site Care/Referrals 4.25 Chronic Illness/Periodic Evaluations 4.26 Medication Management - Verification 4.27 Medication Management - Orders/Prescriptions 4.28 Medication Management - Storage 4.29 Medication Management - Medication and Sharps Inventory 4.30 Medication Management - Controlled Medications 4.31 Medication Management - Medication Administration Record 4.32 Medication Management - Medication Administration By Licensed Staff 4.33 Medication Management - Medication Provided By Non-Licensed Staff 4.34 Medication Management - Psychotropic Medication Monitoring 4.35 Infection Control - Surveillance, Screening, and Management 4.36 Infection Control - Education 4.37 Infection Control - Exposure Control Plan 4.38 Prenatal Care - Physical Care of Pregnant Youth Non-Applicable 4.39 Prenatal Care - Nutrition and Education of Youth Non-Applicable 4.40 Neonatal Care - Infant Physical Care and Nutrition of Infants Non-Applicable 4.41 Neonatal Care - Supervision of Infants Non-Applicable 4.42 Neonatal Care - Education and Lactation Non-Applicable 4.43 Prenatal and Neonatal Staff Education Non-Applicable * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 7 of 59 (Revised September 2014)

16 Standard 5: Safety and Security Residential Rating Profile Indicator Ratings 5.01 Standard 5 - Safety and Security Youth Supervision 5.02 * Ten-Minute Checks 5.03 Census, Counts, and Tracking 5.04 Key Control 5.05 Contraband Procedure 5.06 Frisk and Strip Searches 5.07 Vehicles and Maintenance 5.08 Transportation of Youth 5.09 Tool Inventory and Management 5.10 Youth Tool Handling and Supervision 5.11 Outside Contractors 5.12 Fire, Safety, and Evacuation Drills 5.13 Mental Health and Medical Drills 5.14 Disaster and Continuity of Operations Planning 5.15 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials 5.16 Youth Handling and Supervision for Flammable, Poisonous, and Toxic Items and Materials 5.17 Disposal of All Flammable, Toxic, Caustic, and Poisonous Items 5.18 Elements of Water Safety Plan Non-Applicable 5.19 Staff Training: Water Safety Non-Applicable 5.20 * Swim Test Non-Applicable 5.21 Comprehensive Behavior Management System 5.22 Implementation and Consistency of Behavior Management System 5.23 Behavior Management System Infractions 5.24 Staff Training: Behavior Management System 5.25 Behavior Management System Monitoring 5.26 Controlled Observation 5.27 Search and Inspection of Controlled Observation Room 5.28 Controlled Observation Safety Checks 5.29 Controlled Observation Release Procedures * 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 8 of 59 (Revised September 2014)

17 Strengths and Innovative Approaches The program conducts management meetings Monday through Friday, which include all members of the management team. During the meetings, the management team address issues regarding the youth, as well as any safety, security and training issues, the daily activities within the facility, and any issues of which the management team needs to be aware. The program has a Home Builders Institute (HBI) and a culinary arts program, which offers classroom instruction in food safety that leads to an industry recognized certification as a ServSafe Food Protection Staff. Additionally, an advanced certification as a ServSafe Food Protection Manager certification is also available to youth. Both certifications are industry recognized. The program has monthly reviews and fidelity checks as part of their administrative review process. The corporate office conducts reviews and followups on any monitoring, and holds meetings at least monthly to address any issues. The corporate office produces trend analysis compiled from the reports submitted by the various programs; the reports include all of the programs operated by the provider and how each program is performing in the different areas. The program utilizes a sex offender treatment manual developed for the provider that is modular-based and allows the clinical therapists to tailor treatment to meet a youth s individualized needs. The modules provide youth with an extensive responsibility oriented model designed to foster the development of appropriate sexual behaviors, self-monitoring, impulse control, victim empathy, social competency, and offense prevention skills. Competency-based assessments at the end of each module allow for measurement of each youth s progress. The program conducts ten-minute checks every five minutes on all units. The master control operator calls the staff to advise when it is time to conduct the room check, which is routinely every five minutes. Office of Program Accountability Page 9 of 59 (Revised September 2014)

18 Standard 1: Management Accountability Overview The Department contracts with G4S Youth Services, LLC to operate Okeechobee Juvenile Offender Correctional Center (OJOCC). The program is located in Okeechobee, Florida. The ninety-six bed program serves male maximum-risk, high-risk, and maximum-risk sex offenders ages thirteen to twenty-one years of age with an average length of stay at a minimum of twelve to eighteen months. The program has two housing wings, each of which has three living units. The living units have single occupancy rooms. Each unit is equipped with an attached classroom and a common area with dining tables that are used for indoor recreation and meals. Each housing wing has a sub-control station, in addition to one master control station located in the main lobby of the facility. The management team consists of a facility administrator, an assistant facility administrator, unit managers, director of case management, director of clinical services, health services administrator, food service manager, regional compliance manager, and a human resource manager. At the time of the annual compliance review, the program had thirteen vacant positions; eight youth care workers, two case managers, one mental health therapist, and two teachers Initial Background Screening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. The background screening process is completed prior to hiring an employee or utilizing the services of a volunteer, mentor, or intern. An Annual Affidavit of Compliance with Level 2 Screening Standards is completed annually. The program has written policies and procedures requiring compliance with the Department s background screening requirements. The program hired seventeen new staff since the last annual compliance review. A review of initial background screenings for seventeen newly hired employees found that the program received a background screening check from the Department s Background Screening Unit (BSU) prior to each staff s hire date. In addition, the program conducted driver s license checks through the Department of Highway Safety and Motor Vehicles on all seventeen staff upon hire. A review of one volunteer and one intern background screening file found that an initial background screening was conducted on both prior to working in the program. The annual Affidavit of Compliance with Level 2 Screening Standards was submitted to the Department s BSU on January 2, 2015, meeting the annual requirement 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 program has written policies and procedures requiring compliance with the Department s five-year background re-screening requirements. The program s human resource manager tracks the five-year anniversary of hire dates, and processes the five-year re-screening for all staff. Reviewed documentation supported that there were ten applicable staff requiring five-year re-screenings. One of the ten re-screenings was submitted after the staff member s anniversary Office of Program Accountability Page 10 of 59 (Revised September 2014)

19 date and not ten days prior to the staff member s anniversary date. The Department s Background Screening (BSU) verification system validated that one applicable staff was not completed within the required time frame. There were no volunteers, mentors, or interns applicable for five-year re-screening Provision of an Abuse-Free Environment Compliance The program provides an environment in which youth, staff, and others feel safe, secure, and not threatened by any form of abuse or harassment. Posting of the Florida Abuse Hotline telephone number and the Central Communications Center for youth 18 years of age and older telephone number. All allegations of child abuse or suspected child abuse are immediately reported to the Florida Abuse Hotline. Youth and staff have unhindered access to report alleged abuse to the Florida Abuse Hotline pursuant to Section (1)(a), F.S. The environment is free of physical, psychological, and emotional abuse. A code of conduct for staff that clearly communicates expectations for ethical and professional behavior, including the expectation for staff to interact with youth in a manner that promotes their emotional and physical safety. The program has written policies and procedures in place for the provision of an abuse-free environment and a code of conduct. A review of nine staff personnel files documented that staff signed a code of conduct that prohibits any use of physical abuse, profanity, threats, or intimidation. Observations found throughout the facility the program has postings of the Florida Abuse Hotline number, as well as the Central Communications Center (CCC) number for youth ages eighteen and older. Nine case management records were reviewed; each contained documentation that the program provided each youth with a copy of the resident handbook upon admission, which included information on youth rights, grievance process, the Florida Abuse Hotline telephone number, as well as the telephone number to the CCC. There were no allegations of abuse reported to the Florida Abuse Hotline during the annual compliance review period. Nine youth responded to the survey; none of the youth reported ever being stopped from reporting abuse. All nine youth reported that staff are respectful when speaking to them. Two youth reported occasionally hearing staff using curse words when speaking to a youth and seven reported never. All nine youth reported feeling safe at the program. Five interviewed youth indicated that each youth felt safe in the program. Nine staff responded to the survey; all were able to explain the process of allowing a youth to call the Florida Abuse Hotline or the CCC. None of the nine staff reported ever seeing a co-worker deny a youth an abuse call. One staff reported on one occasion hearing staff using profanity when speaking to a youth and one reported occasionally. One staff reported occasionally observing a co-worker using threats or intimidation towards a youth. Five staff were interviewed; all reported that the youth have access to report abuse allegations. Office of Program Accountability Page 11 of 59 (Revised September 2014)

20 1.04 Management Response to Allegations Compliance Management shall be cognizant of youth and staff needs and provide direction to each on how to access the Florida Abuse Hotline. There is evidence that management takes immediate action to address incidents of physical, psychological, and emotional abuse. A review of nine staff training files, including pre-service and in-service training, was conducted. All nine reviewed files contained documentation of the receipt of training on child abuse reporting requirements. Staff interviews confirm that the program has provided direction on how to access the Florida Abuse Hotline. In the past six months there were three incidents reported by the program to the Central Communications Center (CCC). Reviewed documentation supported that management took immediate corrective action to address the staff conduct when staff violated proper procedures Incident Reporting (CCC) Compliance Whenever a reportable incident occurs, the program notifies the Department s Central Communications Center (CCC) within two hours of the incident, or within two hours of becoming aware of the incident. The program has written policies and procedures requiring compliance with the Department s Central Communications Center (CCC). The program s policy requires that prior to any incident being called to the CCC, the regional director is contacted. The program had five CCC reports in the past six months. All five incidents were reported within two hours, as required. A review of the master control logbook confirmed that the reported CCC incidents were documented in the logbook. During the annual compliance review, there were no internal incidents or grievances noted that should have been called to the CCC, which were not Protective Action Response (PAR) Compliance The program uses physical intervention techniques in accordance with Florida Administrative Code. Any time staff uses a physical intervention technique, such as countermoves, control techniques, takedowns, or application of mechanical restraints (other than for regular transports), a PAR Incident Report is completed and filed in accordance with the Florida Administrative Code. The program maintains policy and procedures related to Protective Action Response (PAR). The program had two PAR reports in the past six months. A review of the PAR reports indicated that the two reports were completed as required. The program s PAR training plan was approved by the Department s Office of Staff Development and Training on May 22, Pre-Service/Certification Requirements Compliance Contracted and State residential staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. The program maintains a pre-service training plan for all new staff. Reviewed documentation validated that the plan was reviewed and accepted by the Department s Office of Staff Development and Training. Four staff training files were reviewed for pre-service certification training. All four reviewed training files documented that each staff completed the certification Office of Program Accountability Page 12 of 59 (Revised September 2014)

21 process within 180 days of hire. The staff completed the required trainings related to Protective Action Response (PAR), first aid, cardiopulmonary resuscitation (CPR), and automated external defibrillator (AED). All completed training was documented in the Department's Learning Management System (SkillPro). All training was delivered by qualified trainers In-Service Training Compliance Residential staff complete twenty-four hours of in-service training, including mandatory topics specified in Florida Administrative Code, each calendar year, effective the year after preservice/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. The program maintains a written in-service training plan that was reviewed and accepted by the Department s Office of Staff Development and Training. The program had a current training calendar, which is updated as necessary. Five staff training files were reviewed for in-service training. All reviewed staff training files documented that each staff member exceeded the twenty-four annual requirement. All five staff had up-to-date certifications in Protective Action Response (PAR), first aid, automated external defibrillator (AED), and cardiopulmonary resuscitation (CPR). All five staff had professionalism and ethics and suicide prevention training. Two of the five staff members were applicable for supervisory training and the eight hours of supervisor training were completed. All of the program s nursing staff maintains current certification in CPR with AED. All completed training was documented in the Department's Learning Management System (SkillPro) Logbook Entries and Shift Report Review Compliance The program maintains a chronological record of events, incidents, and activities in a central logbook maintained at master control, living unit logbooks, or both, in accordance with Florida Administrative Code. The program ensures that direct care staff, including each supervisor, is briefed when coming on duty. The program maintains a master control logbook that contains a chronological record of events, incidents, and activities. The master control logbooks were reviewed from July 2014 to January All logbook entries were brief and legible, written in ink, included the date and time of the event, and any exceptional applicable entries had consistent color-coded highlighting. All logbook corrections were made as required, with a single line struck through the error, dated and initialed by the person correcting. The master control logbook was also reviewed for reporting incidents to the Central Communications Center (CCC). The program conducts shift briefings prior to each shift with significant issues identified on the shift report. All staff signed the shift briefing sign-in log to document their presence at the briefing Internal Alerts System Compliance The program shall maintain and use an internal alert system that is easily accessible to program staff and keeps them alerted about youth who are security or safety risks, and youth with healthrelated concerns, including food allergies and special diets. When risk factors or special needs are identified during or subsequent to the classification process, the program immediately enters this information into its internal alert system. The program ensures that only appropriate staff may recommend downgrading or discontinuing a youth s alert status. Office of Program Accountability Page 13 of 59 (Revised September 2014)

22 The program has an alert board in master control that identifies special alerts, such as youth with allergies, medical restrictions, mental health alert, and gang affiliations. The alert board has each youth s picture, arranged by dormitory, and the alert associated with the youth. Reviewed documentation also indicated that the alert report is reviewed daily during shift briefing by the program's supervisory staff. All internal alerts were downgraded or discontinued by the appropriate staff member. Nine staff responded to the survey; all nine staff reported being informed of youth alerts through the internal alert forms, the shift meetings, and the alert board Alerts (JJIS) Compliance When risk factors or special needs are identified during or subsequent to the classification process, the program immediately enters this information into the Juvenile Justice Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are downgraded or discontinued. The program enters an alert into the Department s Juvenile Justice Information System (JJIS) for youth that require an alert that may not have been previously entered prior to the youth s admission. The alerts entered into JJIS are verified through the medical staff, assistant facility administrator, and the designated mental health authority (DMHCA). Nine youth records were reviewed for case management, medical, mental health, and all alerts were accurately entered into JJIS Youth Records (Healthcare and Management) Compliance The program maintains an official case record, labeled confidential, for each youth, which consists of two separate files: An individual healthcare record An individual management record The review of the program s youth records and observations confirmed that the program maintains an individual youth healthcare record, mental health and substance abuse record, and an individual case management record for each youth in the program. Each reviewed record was marked as confidential, contained the required information, and were organized as required. Observations found that all the program records were secured. The case management records, mental health records are maintained in a locked closet in the mental health office, and the healthcare records are maintained in a locked room in the clinic Advisory Board Compliance The program has a community support group or advisory board that meets at least quarterly. The program director solicits active involvement of interested community partners. G4S Youth Services, LLC operates multiple Department of Juvenile Justice (DJJ) programs in Okeechobee County; the community advisory board for their various boys programs were combined into one advisory board. The community advisory board included representatives from local law enforcement, the business community, the judiciary, the school board, the Department of Children and Families, a local domestic violence shelter, and the faith-based community. The community advisory board does not have a representative of a parent/guardian whose child was previously involved in the juvenile justice system; however, there was Office of Program Accountability Page 14 of 59 (Revised September 2014)

23 documentation to support that the program made attempts to recruit parents/guardians. The meeting minutes were reviewed for the six months prior to the annual compliance review; there was documentation of the advisory board meeting quarterly Program Planning Compliance The program uses data to inform their planning process and to ensure provisions for staffing. The program conducts daily management, shift briefings, and monthly meetings for all staff to discuss relevant issues affecting the program s operation and to keep staff informed of corporate objectives. Areas discussed in each monthly meeting included security issues, training, community projects, safety drills, medical and mental health alerts, and upcoming events. Reviewed documentation supported that staff are given opportunities to provide input and feedback on the program s operations during monthly meetings. The program has a recognition program call G4S Way that entails three chips labeled to recognize positive culture, teamwork, and going above and beyond, which staff can provide to each other. In addition, the program offers special rewards such as a monthly special meal during monthly meeting, PNC Bank donates a two-hundred dollar gift card upon staff opening an account every ninety days. Every ninety days the local Sam s Club provides a fifty dollar Walmart gift card upon signing up for a membership. The program conducts a Biggest Loser weight contest annually and the prize ranges from one hundred to five hundred dollars and the program provides special reward for perfect attendance and employee of the month. The program conducts parent/guardian and youth surveys upon each youth s discharge from the program and parent/guardian surveys every ninety days during family day. The program also utilizes family day as an opportunity to speak with the parents/guardians and youth to obtain input into the treatment processes to discuss any relevant concern. Nine staff responded to the survey; eight staff reported no comments on the ability to provide feedback on facility operations and one reported very little. Four staff reported in the past year the working conditions at this program is fair, one reported poor, and four reported good. Nine staff reported staff meetings are conducted monthly Staff Performance Compliance The program ensures a system for evaluating staff, at least annually, based on established performance standards. The program conducts ninety-day performance evaluations for newly hired staff, and annual evaluations for all staff. Nine reviewed personnel files contained last year s annual evaluations and four files contained ninety-day performance evaluations. The performance evaluations were specific to the applicable staff s job description. All nine reviewed performance evaluations found that each staff s evaluation was based on the performance standards for that position. The staff annual performance evaluation process included the effective delivery of any specific evidence-based curricula that is being delivered by staff. The evaluations rate the staff s quality of work, modeling appropriate behavior, a positive reinforcement in a four-to-one ratio, and each evaluation included ratings on the staff s specific job responsibilities. Eight of nine surveyed staff reported receiving an annual evaluation and one reported receiving every six months. Office of Program Accountability Page 15 of 59 (Revised September 2014)

24 Standard 2: Assessment and Performance Plan Overview The program s case management director provides oversight for all case management services provided by the case managers in the program. The case managers complete risk classifications, the Residential Positive Achievement Change Tool (R-PACT), the Youth Needs Assessment Summary (YNAS), individual performance plans, progress reports, and provides transition planning with youth. The case managers are members of the treatment team and meet formally once per month and informally twice per month with each youth to discuss the youth s progress. The case managers are the primary liaison between the youth and their family, assigned juvenile probation officer (JPO), and committing judge. The program allows each youth to make weekly telephone calls, and to exchange letters with approved family members. In addition, the program has identified staff members to provide the primary service of Standardized Program Evaluation Protocol (SPEP), which include Impact of Crime (IOC), Young Men's Work, Thinking for a Change (T4C), and Voyage. Observations and interviews with the facilitators supported that all of the primary services were consistently delivered in the past six months. Fidelity monitoring of all the primary services are conducted; however, inconsistently for Young Men s Work. At the time of the annual compliance review, the program was conducting SPEP groups at least two times per week Initial Contacts to Parent Compliance The program notifies the youth s parent/guardian by telephone within twenty-four hours of the youth s admission, and by written notification within forty-eight hours of admission. The program has written policies and procedures regarding parental notification. Nine youth case management records were reviewed. All nine reviewed records documented that the program notified each youth s parent/guardian by telephone within twenty-four hours of admission. All nine case management records also indicated that the program notified each youth s parent/guardian in writing within forty-eight hours of admission. In addition, all of the written notification was mailed to the parent/guardian on the date of admission. The notification letter contained a map of the program, a copy of parent handbook, public transportation arrangement information, and directions from the youth s home to the program site Youth Orientation Compliance The program shall provide each youth an orientation to the program rules, procedures, schedules, and services that apply to youth, to begin within twenty-four hours of admission. The program has written policies and procedures related to youth orientation. Nine youth case management records were reviewed. All nine reviewed records documented that each youth was provided an orientation within twenty-four hours of admission. Orientation to the program included a review of services available, a daily schedule, procedures on visitations, access to the Florida Abuse Hotline, and the Central Communications Center (CCC). In addition, orientation addressed items considered to be contraband, performance planning process, dress code and hygiene practices, mail and telephone procedures, anticipated length of stay and expectation for release from the program, explanation of expectations and responsibilities of youth, and the written behavior management system provided in the resident handbook. Nine Office of Program Accountability Page 16 of 59 (Revised September 2014)