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 PACE Center for Youth PACE Center for Girls, Inc. (Contract Provider ) One West Adams Street, Suite 301 Jacksonville, Florida Review Date(s): FY PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES

2 Program Name: PACE Center for Youth Contract Number: Provider Name: PACE Center for Girls, Inc. Number of Slots: 1037 Location: Duval County (Headquarters) / Circuit 4 Review Teams The Bureau of Monitoring and Quality Improvement wishes to thank the following review team members for their participation in these reviews, and for promoting continuous improvement and accountability in juvenile justice programs and services in Florida: David Bassler, Office of Program Accountability, Regional Monitor Odilanda Brito, Office of Program Accountability, Regional Monitor Marge Connelly, PACE Polk, Social Services Manager Paula Friedrich, Office of Program Accountability, Regional Monitor Glenn Garvey, Office of Program Accountability, Regional Monitor Brienne Gilbo, PACE Pasco, Program Director Danyelle Green, PACE Manatee, Social Services Manager Melissa Johnson, Office of Program Accountability, Regional Monitor Dr. Lynne Kiehne, PACE Headquarters, Regional Director Davia Lerebours, PACE Hillsborough, Program Director Stephanie Lobzun, Office of Program Accountability, Regional Monitor Brienne Long, PACE Pasco, Program Director Scott Luciano, Office of Program Accountability, Regional Monitor Michael Marino, Office of Program Accountability, Regional Monitor Gabriel Medina, Office of Program Accountability, Regional Monitor Janie K. Smalley, PACE Headquarters, Program Project Manager Alexa Vilenski, PACE Lee, Social Services Manager Kimberly Vollmer, PACE Marion, Program Director Adrian Williams, Office of Program Accountability, Contract Manager Leight Williams, PACE Headquarters, Associate Director-Program Support

3 Methodology PACE Center for Girls, Inc. conducts quality reviews of each center annually. The quality reviews assess compliance with various Department requirements, PACE policies and procedures, and education requirements. A report is completed following each review and is submitted to the Department s contract monitor. The quality reviews reflect each program s level of compliance in the following six sections: Section 1: Leadership, Management, Accountability, and Fiscal Responsibility; Section 2: Social Services; Section 3: Academic Services; Section 4: Health Services; Section 5: Program Safety, Sanitation, and Emergency Procedures; and Section 6: Training and Staff Development. PACE Center documents a summary of these reviews in the Department s Program Management and Monitoring (PMM) system. The monitoring summary identifies areas of compliance and areas of deficiencies. The reports also include a plan of action to address any areas of non-compliance and identify recommendations for improvement. Progress on each center s plan of action is updated by the individual center or PACE headquarters and is reported to the Department s contract manager on a quarterly basis. Quality reviews were conducted in all nineteen PACE Centers during fiscal year Professionals from PACE headquarters and/or PACE Centers, who have been trained in the quality review process, conduct the quality reviews. Regional monitoring staff from the Bureau of Monitoring and Quality Improvement serve as peers and assisted in all nineteen PACE Center quality assurance reviews (QAR) during fiscal year During each quality review, members of the review team reviewed program policies and procedures and documentation of services provided. Review team members also observed program practices and conducted interviews with staff and youth. For this report, thirteen quality review reports completed by PACE were reviewed. Additionally, monitoring summaries completed by regional monitors within the Bureau of Monitoring and Quality Improvement and administrative monitoring summaries completed by the Department s contract mangers were reviewed. The 2015 was also reviewed.

4 Strengths and Innovative Approaches Most PACE Centers utilize daily alerts to all center staff to apprise staff of issues and the emotional status of youth arriving at each center. alerts are also printed and included in a daily communication binder maintained in the center, which is available for staff review. PACE Lee has initiated a new process through a partnership with a registered nurse from the local Salvation Army to serve as a consultant for medical supervision who will educate the program staff on each youth's specific medical needs. PACE Lee utilizes a serenity pass which is a physical pass provided by the case manager to any youth having a difficult day. The youth provides the serenity pass to her teacher upon returning to class as a nonverbal way of communicating to educational staff the youth s fragile emotional status without having to rehash and explain the issue. Interviewed youth consistently reported staff were very supportive and each center s environment is very positive. Through community networking and engagement, PACE Palm Beach expanded PACEWorks, a workforce development program providing internships, school-to-work readiness workshops, and partnerships with local universities to continue postsecondary education. Office of Program Accountability Page 4 of 20 (Revised July 2016)

5 Leadership, Management, Accountability, and Fiscal Responsibility Overview The Department contracts with PACE Center for Girls, Inc. to provide prevention services for youth ages eleven to seventeen at risk for juvenile delinquency. PACE Center for Girls contracts with the Department to provide community-based, gender-specific prevention and intervention services in a non-traditional educational setting at various PACE Centers throughout the state. Through the PACE program, youth are to be diverted from initial contact with the Department or diverted from further Department involvement. Services provided are to include gender-specific life management curriculum, counseling, case management, community and service learning, transition planning, and referral services. Management at each center is responsible for maintaining an abuse-free environment for female youth. PACE staff and volunteers must adhere to a code of conduct prohibiting using physical abuse, profanity, threats, or intimidation. Youth are to be given unimpeded access to report suspected abuse to the Florida Abuse Hotline or the Department s Central Communications Center (CCC). Management at each center must ensure reportable incidents are appropriately reported to the CCC within two hours, in accordance with Department reporting requirements. Each PACE Center receives funding from their local school district to provide education services to the youth served. Additional funding is obtained by PACE through grants and private donations. The contract with the Department includes nineteen PACE Centers statewide. The Department s practice included verification of 100% of youth in attendance by a comparison of each center s youth attendance records to the monthly contract census report. Findings Management staff at each PACE Center include an executive director, a social services manager, and an academic manager. Staffing at each center varies; however, generally includes educational staff, social service counselors, administrative support, and resource development staff. Background Screening of Employees and Volunteers: Reviewed practice found PACE s process for hiring employees ensures all staff members are background screened through the LiveScan Background Screening process, in accordance with the Department s Background Screening policy. PACE s human resources department oversees all background screening procedures to ensure adherence to the required process. After interviewing prospective job applicants, selected candidates are background screened. Only those receiving eligible results are notified and offered employment. Upon acceptance of the employment offer, each candidate is hired. Volunteers are determined to be active if they have signed into the center at any time during the prior six months. The program maintains a documentation binder relating to volunteer background screening and maintains a separate sign-in log for volunteers. Additionally, PACE s human resources department ensures a five-year rescreening is conducted on each employee and volunteer every five years from their date of employment. Background screening results are stored in the employees electronic personnel files, which are accessible to the employee, their Office of Program Accountability Page 5 of 20 (Revised July 2016)

6 managers, and administrators in human resources. Each year the Annual Affidavit of Compliance with Level 2 Screening Standards is submitted to the Department of Juvenile Justice. During the annual reviews the employee s and volunteer s background screenings were verified through the Department s Background Screening Unit. Situational Risk Management and Incident Reporting: Managers address incidents of physical or psychological abuse and incidents of verbal intimidation and excessive use of force by staff towards youth. Most centers were found to be compliant with requirements to notify the Department s Central Communication Center (CCC) within two hours of an occurrence, or gaining knowledge of a reportable incident. The Florida Abuse Hotline telephone number was observed posted and accessible to youth in each center and there is a process in place, which is followed, for the reporting of abuse to the Florida Abuse Hotline. Documented incidents were reported to the Florida Abuse Hotline in compliance with PACE and the State of Florida requirements. Reviewed documentation confirmed staff were aware of their status as mandatory reporters and the associated requirements. There were identified staff in each center whom youth could easily access if they were in need of support, which was verified via youth interviews. Incident report logs and documented actions taken to address emergencies, abuse, and other incidents were reviewed. Safety Committee Meetings were conducted and interviews with the executive directors revealed safety topics were discussed on two levels, with managers initially discussing incidents followed by the information being shared with staff through daily communications and/or monthly meetings. Safety committees met quarterly to discuss wellness topics and documentation was stored in training binders. The on-site reviews revealed seven separate incidents occurred at five different PACE Centers, which were not reported to the Department s Central Communication Center (CCC); therefore, the incidents were called into the CCC during each respective review and the reports were accepted. Documentation at one center included observation of the executive director not acknowledging her review of all the incident reports by her signature on each incident report, which was rectified during the on-site review. In addition, one center did not report four CCC incidents and another did not report one CCC incident within the required two-hour time frame. At one center following their annual compliance review, several steps were initiated to ensure vehicle-related incidents were reported to the CCC, as required. First, the executive director informed the staff of the reporting requirements. Second, the executive director responded to the Department s request for information. Third, as vehicle-related incidents have occurred, staff reported them according to policies and procedures. Volunteers and Interns: Each program s policies and procedures address volunteers and interns regarding job descriptions, which are outlined in writing and maintained on file at each center. Completion of orientation and training programs for new hires specific to the duties of interns was documented in volunteer and intern files. Volunteers and interns were also required to complete the Prison Rape Elimination Act (PREA) training. At one center, reviewed documentation did not include acknowledgment by two volunteers of their duties and responsibilities; however, both volunteers were contacted during the review and acknowledged their duties. One center had not trained any existing volunteers on PREA; however, the training was planned for later in the calendar year. The center acknowledged the deficiency and indicated PREA training will be included as part of all forthcoming volunteer orientation training, which each volunteer is required to complete prior to volunteering within the center. The Department of Juvenile Justice conducted follow-up monitoring and the identified deficiencies were corrected and documented in the Department s Program Management and Monitoring system. At another center, one volunteer in the Reach Program received the required training. Office of Program Accountability Page 6 of 20 (Revised July 2016)

7 The numerous volunteers managed under Resource Development were continuing to work toward completing the required training. One center needed to develop job descriptions for the volunteers. A volunteer handbook had been created and types of volunteer opportunities have been identified; however, the job descriptions have yet to be developed. Provision of an Abuse Free Environment: Quality reviews found management and staff at each center adhere to a staff code of conduct and maintain an abuse free environment. Instructions for reporting suspected abuse to the Florida Abuse Hotline or the Department s Central Communications Center (CCC) were observed posted throughout each center and reviewed with each youth during the orientation process. Interviewed youth at each center reported feeling safe at PACE and were largely complimentary of the staff. The youth reported they felt staff were helpful and they could approach staff if they had problems. Observations of interactions between the youth and staff found staff were professional and courteous when interacting with youth. Records Retention: All youth records not maintained in the PACE Center for Girls, Inc. Efforts to Outcomes (ETO) system are required to be securely locked in areas limited to staff who have legitimate need to access the youth records. Reviewed youth records in each center found the records were marked as Confidential and securely stored inaccessible to youth with the exception of one center. At the time of one PACE Center s annual review a deficiency was noted in the program securing confidential information. Observations found youth records stored in lockable filing cabinets in an office area open to youth, staff, and visitors were left unlocked and the office door was left open when unoccupied by program staff. Invoice Verification: Invoice verification conducted during the annual review visits compared youth attendance records with submitted monthly contract census reports found there were no discrepancies noted during this auditing process. Administrative monitoring conducted in April 2016 found PACE has been doing a very good job of updating and submitting property inventories as required quarterly. However, several items of equipment were destroyed prior to submitting them for inventory and without obtaining Department permission. Additionally, although the provider submitted copies of pamphlets inclusive of the Department s logo and sponsorship language, the PACE website, Facebook webpage, and Twitter webpage did not include the required statement or Department logo. Additionally, although the PACE 2014 annual report evidenced compliance with the logo requirement, the 2015 annual report failed to include the required sponsorship statement and the Department s logo. Lastly, the provider maintains written travel policies; however, the documentation provided was not sufficient to determine if the provider is in compliance with section , Florida Statutes (F.S.). The travel form submitted by the provider is similar; however, it is not the required form outlined in Florida Statute. Office of Program Accountability Page 7 of 20 (Revised July 2016)

8 Social Services Overview Each PACE Center is required to provide gender-specific life management skills training and instruction addressing the needs of adolescent girls, addressing trauma, and fostering positive gender-identity development. Each center is required to provide information or instruction related to career exploration, career planning, and development of school-to-work employability skills. During each ninety-day enrollment period, youth are to be provided the opportunity to participate in community and service learning. PACE Centers are required by contract to provide transition services for a period of six months following discharge. Each center actually provides transition services for at least a year after a youth is discharged. At least one staff at each center is responsible for overseeing transition services. Transition planning begins upon enrollment. During the orientation process, each youth completes the Florida Choices assessment, which identifies possible career interests. Each center provides information or instruction related to career exploration, career planning, and development of school-to-work employability. Youth complete work or career related projects, which include researching information related to career interests and job shadowing for career readiness. Further, staff ensure transition back into the school system and/or assist youth with applying for post-secondary education. Care plans include goals to prepare youth for transition from the program with goals addressing continuing education and/or vocational or career interests. Observations at each center found staff responsible for transition were familiar with community, vocational, and educational resources in their area and appropriately referred youth to services. Care review meetings are held at least one time per week and in many centers, twice per week, to ensure each youth is addressed. Staff provide each youth positive and supportive comments. Daily communication meetings are held after youth dismissal each day. Additionally, a binder is maintained with the meeting information for review by any staff unable to attend the meeting. Findings Admission and Orientation / Assessment and Evaluation: All youth admitted to a PACE Center program are screened prior to admission to determine eligibility and appropriateness for the program. Youth and their parents/guardians are informed of program expectations. Each youth must indicate she understands the expectations and chooses to participate. Upon enrollment, a Physical Ongoing Needs Assessment (PONA) is completed within twenty-four hours. The Department s Prevention Assessment Tool (PAT) and a comprehensive Ongoing Needs Assessment are completed within thirty days of admission. The Ongoing Needs Assessment addresses six development domains, which include relationships, physical, emotional, intellectual, sexual, and spiritual. The PONA and Ongoing Needs Assessment are updated every six months, or sooner if needed. Care review meetings are held weekly during a youth s first thirty days in PACE, and then at least every thirty days thereafter. The care review meetings are primarily used to address youth progress, but are also used to identify new needs or update previously identified needs. A review of youth files at one center revealed all enrollment documents were not signed by the parent/guardian upon enrollment and file reviews Office of Program Accountability Page 8 of 20 (Revised July 2016)

9 of four youth enrolled in the day program at the center revealed assessments were not conducted and administered upon enrollment. One center did not consistently complete the PONA in full. Case Management / Individualized Care Plan: Each youth admitted to a PACE Center is to receive an initial assessment and screening to determine eligibility for services and identify needs. Following the assessment and screening and within thirty days of admission, an individualized care plan is to be developed for each youth. Care plans are to include counseling and case management services, monthly parent/guardian contacts, goal setting and problem solving to attain goals, individual, group and/or family crisis counseling in accordance with needs, and psycho-educational groups to increase protective factors and mitigate risk factors in accordance with needs. Individualized care plans are to be reviewed monthly and re-evaluated every six months. During the annual reviews, four of nineteen centers were found to be deficient and inconsistently documenting services specific to individualized academic plans (Individual Progress Monitoring Plans), care review planning, individualized goal development, timely completion of ongoing needs assessment, and monthly parent/guardian contacts. At one center eight of eleven reviewed files for ongoing needs assessments were found to have been completed late; however, the program had a plan in place for improvement. A review at another center found there was no documented practice of reviewing goals and objectives monthly. Five centers were noted to be deficient with inconsistent documentation of services such as care review meetings, youth participation in volunteer activities, academic advising sessions, Spirited Girls classes, monthly parent/guardian contacts, individualized academic plans, transition contacts, and follow-up services. One center had turnover in the Spirited Girls position, which affected the Spirited Girls attendance from being documented daily. The center hired and trained a new Spirited Girls teacher on uploading the attendance daily into the Efforts to Outcomes (ETO) system. Additionally, the instructor is utilizing the Spirited Girls attendance report to monitor input on a weekly basis. One center required all staff to be retrained on documenting all services provided to the youth daily into the ETO system and sign off acknowledgement of this practice. Reviewed documentation supported care review meetings took place at least once per week. Care review meetings were observed in all programs and included information sharing from all staffing perspectives for each youth reviewed. Discussion was professional and provided a positive perspective. Smoke-Free Environment: Each program maintained written policies and procedures addressing a smoke-free workplace, which applies to all employees, youth, volunteers, interns, and visitors. Smoking is prohibited throughout the work place to include the center s vehicles and all PACE sponsored events, activities, and field trips. Signs were observed posted inside each program building declaring it a tobacco-free campus. Observations validated no staff or youth were observed smoking on the program grounds or surrounding areas. Master Program Schedule: Each PACE Center maintains master daily program schedules, which were observed posted throughout each center and accessible to everyone. Adherence to Dress Code: Each program maintained written policies and procedures addressing dress code, which includes detailed descriptions of appropriate clothing for the youth and prohibited clothing items. Youth are required to wear PACE shirts, which are provided by each program. Observations included the youth consistently dressed neatly, in appropriate PACE shirts and slacks, in adherence to the dress code. Transportation / Bus Pass Process: One reviewed center, located in a more urban area, maintained written policies and procedures addressing transportation and bus passes to ensure Office of Program Accountability Page 9 of 20 (Revised July 2016)

10 the youth have a means to attend the program. During the intake process, this center determined if each youth was in need of transportation assistance. Youth holding a valid State of Florida driver s license and written parent/guardian permission were allowed to drive to the program. Safety: Sight and Sound Supervision: Observations evidenced the youth are provided sight and sound supervision at all times while on-site. Staff supervision schedules were posted and outlined all activities and times of the program s day to ensure youth were supervised at all times. Interviewed youth at one center stated one of the things they liked best about PACE is the staff members always being available to them and the ease with which they could speak to their counselors. Behavior Management: Each center maintains written policies and procedures to address the behavior management, point level, and reward systems. Each program utilized redirection and de-escalation techniques as part of their behavior management system. The youth earn points for positive behavior, attendance, participation, and progress starting at the orientation stage for at least one month before progressing towards level one. The behavior management system consists of four levels: self, friends, family, and career/future. To progress to the next level, each youth must complete an application which is considered at a care review meeting. The policies also addressed possible consequences should a youth not maintain her level assignments. Youth interviews confirmed they are aware of the behavior management system and how it works. The program s anti-bullying, anti-discrimination, and harassment/sexual harassment policies were consistently prominently posted in rooms throughout the PACE Centers. De-escalation and Redirection: Each PACE Center maintained written policies and procedures to address the redirection and de-escalation techniques methods staff are to use to help youth achieve pro-social behaviors, and what methods could be used if redirection and/or deescalation prove unsuccessful. The policies also addressed prohibited disciplinary actions including the use of corporal punishment, allowing youth to discipline other youth, denying any basic rights, physical exercise as punishment, verbal abuse, isolation, and access to parents/guardians or legal services. The use of locked time-out rooms and the use of mechanical restraints is also prohibited. There were no instances observed during any of the on-site reviews which would have required a staff to use de-escalation and redirection techniques. Daily Staff Communication Each center maintained written policies and procedures on daily staff communication addressing, at a minimum, critical information concerning staffing, significant youth issues, events, and schedule changes. Centers use daily communication notebooks, which all staff are required to review and are maintained for at least three years. Review of the daily communication notebook verified required information was included and any information not part of the master schedule was included in the daily communication information. Some centers documented staff meetings each morning for approximately ten minutes to ensure daily communications are occurring and minutes are kept for these meetings. Staff interviews confirmed daily review of daily communication information. Office of Program Accountability Page 10 of 20 (Revised July 2016)

11 Academic Services Overview Each center provides academic services, which are funded through local school districts. Each center provides middle school and high school classes for youth. The educational topics addressed for academic services during quality reviews include reading curriculum and instruction, exceptional student education (ESE) and related services, educational personnel qualifications, teachers certifications, and staff-to-student ratio. Staff from PACE headquarters or peer reviewers from other PACE programs review the academic services section during quality reviews. Teachers are made aware of a youth s ESE needs as they get a copy of each youth individualized education plan (IEP) and receive communications from the academic manager regarding the IEP needs. The academic manager also communicates with the local ESE representative from the school district, at least one time per month, to review each youth and ensure she is doing well. The ESE representative from the local school district is ultimately responsible for reviewing, updating, and maintaining the IEP records. In the absence of the academic manager, the executive director is the liaison between the center and the local school district. Some school districts have contracts with local agencies for speech and language services. Meals are served to the youth during the school day, with the meals being delivered by local schools or companies. Findings Reading Curriculum and Instruction: The reading coach utilizes a variety of curricula approved by the state and adopted by the local school district. Center s purchase reading curricula materials from their local school districts. Observations found some centers utilized Achieve 3000 for grades six through twelve, Edge curriculum for high school youth, Rewards, Impact and Read 180 for middle school youth, and the 100 Book Challenge curriculum. Reading enrichment activities are held throughout the day with literacy across curriculum as reading is infused within other subjects. Youth with intensive reading also received supplemental vocabulary and/or English classes. Intake counselors administer Common Core State Standards Initiative. The designated discipline instructors administer the Standardized Testing and Reporting (STAR) assessments used to screen students for their reading and math achievement levels. However, at one center, three of four reviewed common assessments revealed the assessments were not being conducted within ten days, as required. Some of the reviewed assessments at the center were completed one month after the youth s admission to the program, due to challenges in accessing the program s computer lab, which was also used for other Department of Education (DOE) and school district testing. All classes have leisure reading materials and youth are offered time for individual reading time. There are also reading materials placed around the centers to encourage reading. Centers are encouraged to dedicate time for each youth to read during the day. The acronym Drop Everything and Read (DEAR) is utilized and encouraged in each center. Youth are provided the flexibility to read something of interest to them or teachers may assign a group reading activity. Youth have access to the library with daily reading opportunities provided in classes. At one center, youth participate in the Breakfast & Books Club where each youth and a mentor select a book to read individually throughout the course of each month and followed by group dialogue and activities pertaining to the book. Some centers have poetry groups to encourage youth to read and develop their poetry writing skills. Office of Program Accountability Page 11 of 20 (Revised July 2016)

12 Exceptional Student Education (ESE) and Related Services: As part of student planning, each youth receives an individual academic plan (IAP) within fifteen school days, which is to be updated every nine weeks. Academic advisors are to review the obtained information and notify providers. Academic managers are to review each youth s individualized education plan (IEP) accommodations with the youth to ensure the youth are aware of their options and rights. The academic manager meets with both the academic and social service team to review IEP accommodations and assess measures, which can be done to contribute improved progress whether academic or emotional guidance. Each IEP is confidential and securely stored. Seven reviewed files at one center found only one included a timely completed IAP as six were either late or incomplete. Additionally, three of four reviewed files at this same center were missing IAP assessments, which was required by PACE policies and procedures. The review at another center documented failure to complete all IAP s within fifteen days of admission; however, this deficiency was closed prior to the completion of this report. One center indicated due to academic staff turnover there have been inconsistencies in maintaining compliance with biweekly advising sessions. Youth received advising during their first period reading class; however, youth who were late often missed their advising times. To correct this problem the academic advisors use their planning periods during the week to meet with the youth who have been tardy or absent during scheduled advising session in reading class. Academic staff are required to update all IAP s to include vocational goals. At one center all academic staff were retrained on how to create vocational goals in the IAP and are utilizing the custom report from the youth s Ongoing Needs Assessment, completed within her first thirty days. The social service staff are providing the academic staff with important information from their career interest inventory to develop vocational goals. At enrollment the social service manager scans the career interests inventory to the academic advisor to provide additional data for developing the initial vocational goals. Educational Personnel Qualifications: Qualifications of educational personnel and teacher certifications were reviewed through the Department of Education s website for teaching certification credentials. There were no deficiencies noted during any of the nineteen reviews. Staff to Student Ratio: The required staff to student ratio is one to fourteen in classrooms and one to twelve in common areas. All centers were found to be in compliance with the required ratios. Office of Program Accountability Page 12 of 20 (Revised July 2016)

13 Health Services Overview All youth at each center receive a health-related assessment to identify serious medical/dental needs. The information is confirmed and shared with the parents/guardians either in person, by telephone, or letter depending on the identified need. Referrals are made on an as needed basis. Each center has provisions to verify, securely store, inventory, distribute, and dispose of medication. A medication form is to be completed for each medication a youth takes. The parent/guardian must bring medication to the center in its original container or packaging, identify the medication regimen, and sign the medication form. Medication forms were completed at all centers. Quality reviews found medications were stored securely and only staff trained in mediation procedures had access to medications. Stored medications were separated by type, and youth did not have access to medication storage areas. PACE policies and procedures hold each youth responsible for requesting distribution of their own medication, as needed or prescribed. The medication form, which is signed by the parent/guardian, also states youth are responsible for requesting their medication, as needed or prescribed. However, the policies also state staff may remind the youth, as needed, to ensure the youth s medication regimen is followed and is uninterrupted if the youth forgets to ask for her medication. PACE policies require inventories be taken upon receipt of medication(s) and be maintained on a perpetual basis, each time a medication is given to a youth. The perpetual inventory is to be documented on the medication distribution form. Findings Healthcare Admission Screening / Physical Domain Ongoing Needs Assessment: All youth are screened for health-related conditions during the completion of the physical domain portion of the Ongoing Needs Assessment (ONA) Form. Documentation was maintained in each center s Efforts to Outcomes (ETO) system. Verification of Authenticity of Medication Upon Admission: The centers maintained written policies and procedures to address the verification of authenticity of medication, which prevents each from dispensing any medication not delivered in the original container. The container must include the youth name, pharmacy name/number, medication name, and physician name/number. Parents/guardians are responsible for providing each youth s medication along with a printed description and fact sheet from the pharmacy. Receiving staff are required to complete the Authenticity Prescription Medication form and place a copy in the youth file, as well as a note documented in the Efforts to Outcomes (ETO) system. Medication of Storage, Access, Inventories, and Disposal: Medication disposal procedures were in place at each center. The procedures follow guidelines established by the Office of National Drug Control Policy. There were no issues with first aid and emergency care at any of the centers reviewed. Most staff at each center were certified in first aid and cardiopulmonary Office of Program Accountability Page 13 of 20 (Revised July 2016)

14 resuscitation (CPR). First aid kits were available to staff at each center and contained items necessary to provide aid, and contents had been reviewed by health care professionals. Medications stored on-site were maintained using perpetual inventories; however, two centers failed to inventory medications on a weekly/daily basis, as required by program policy, one of which could not document maintenance of a perpetual inventory for the sharps stored on-site. Medication logs at another center did not reflect medication for two youth being given as prescribed or any explanation as to why dosages were missed. One center stored ear drops with the oral medications; however, corrected the storage by separating the ear drops and overthe-counter medications during the review. Medication Observation: Each center maintained written policies and procedures specifying only staff trained in the PACE medication policy and identified in writing are to dispense medication. The centers maintained a written list of all staff authorized to dispense medication. At one center, reviewed medication logs found the program was not utilizing the current PACE medication log. Additionally, the logs reflected each dosage of medication given; however, the logs did not reflect uninterrupted medication regimens for two youth who were on prescription medication. One center utilized the lead nurse from the county school board to provide training on various health topics to include diabetes and asthma inhalers, and reviewed the diabetes management plans. The lead nurse has agreed to come to the center on a quarterly basis to cover various health topics or review changes in diabetes management plans. Another center utilized a nurse from the local Salvation Army as a consultant for medical supervision providing education to program staff on each youth s specific medical need. At one center, a youth was prescribed an Epi-Pen Auto-Injector and it was stored in the non-oral medication lockbox. Training for medication administration was documented for each staff who had access to the medication. Student Immunization Records: The centers maintained policies and procedures to address immunization record verification. Review documentation indicated school records were transferred to the program and/or the parent/guardian was responsible for provision of immunization records to the program. However, one reviewed youth record at a center did not contain immunization information. Attempts to obtain information was documented. Reviewed practices found the centers could utilize the local health department as a resource to refer the youth for the required immunizations. Some centers utilized the Florida Shot on-line database to obtain immunization records. Medical and Mental Health Alert Process: The program maintained written policies and procedures to address medical and mental health alerts. Alerts were maintained in the electronic Efforts to Outcomes (ETO) system. However, a review of youth records at one center revealed medication side effects were not consistently documented in the center s medical alert system. The alerts at another center did not consistently reflect medications youth were taking and the side effects were not identified for medications listed; although, medication information forms which included side effect information were available with the medication logs. Numerous alerts at a third center were missing medication side effects. A fourth center maintained medical alerts within ETO system, which included information to describe a youth s allergies and information pertaining to a youth s prescribed Epi-Pen Auto-Injector; however, the information was found to include notation of the youth being allergic and not specific as to what allergen the youth was sensitive. Emergency Medical and Dental Care: The centers each have policies and procedures in place to address emergency medical and dental care. Each center is responsible for setting up agreements with local dentists and orthodontists for both emergency and maintenance issues. Office of Program Accountability Page 14 of 20 (Revised July 2016)

15 Reviewed practice found most centers utilized the local health department for maintenance and emergencies. Parents/guardians must identify a provider of services on the medical release form. The emergency plan for one center did not include dental care and or locations for dental services. All interviewed staff reported being able to contact 911 directly for emergency care. Office of Program Accountability Page 15 of 20 (Revised July 2016)

16 Program Safety, Sanitation, and Emergency Procedures Overview Safety, sanitation, emergency procedures at each center address center cleanliness, maintenance, supervision of youth, security of and access to toxic materials, emergency plans, vehicle safety, key control, fire prevention, and first aid. Each center was found to be clean and well maintained. Regular housekeeping and maintenance was evident at each facility. Emergency and fire prevention procedures were in place at each center. Issues were noted at four centers for the storage of and access to flammable, poisonous, and toxic materials. Findings Center Cleanliness and Maintenance / Safety, Maintenance, and Housekeeping: Each center maintains policies and procedures to address center cleanliness and maintenance. There was evidence at each center of staff and youth participating in maintaining the center's grounds and furnishings. Documentation confirmed staff conducted monthly checks for safety, maintenance, and housekeeping with the exception of one center. The last documented review checklist was completed in July The latest health inspection for each center was conducted within the past year from the annual compliance review. Safety, Maintenance, and Housekeeping: Each reviewed center appeared to be clean and in good standards. Youth help with the lunch clean up and in other areas, as needed. During the facility tour observations found the classrooms, cafeteria, and outside recreational areas clean and free of debris. Flammable, Poisonous, and Toxic Chemicals: The centers each have policies and procedures in place to address flammable, poisonous, and toxic materials. An inventory of all flammable, poisonous, and toxic materials used in the center is required to be maintained. Flammable, toxic, and poisonous items are required to be stored in a restricted area away from youth when not in use. One center did not have copies of Safety Data Sheets (SDS) on hand for those cleaning supplies they maintained; however, they did print out SDS for each maintained cleaning supply item while the review team was on-site. Chemicals stored on-site at a second center were not secured properly nor inventoried accurately as chemicals were discovered in unlocked cabinets in common areas and classrooms and inventories were missing the total count of items and SDS sheets. Since the review the items were donated to a local Goodwill Industries Center. The third center was noted as they did not maintain an inventory of the cleaning items on-site with the explanation provided of staff not believing it was necessary based upon the cleaning items being green and the items in the janitors closet belonging to a contracted janitorial service. However, it was noted the green cleaning items included the warning Keep Out of Reach of Children on the label. Emergency Preparedness Plan: Each center maintained policies and procedures addressing emergency preparedness plans specific to each site. Emergency procedures were specified in the events of hurricanes, tornados, fire, flood, youth riots, hostage situations, shootings, chemical spills, and bomb threats. One center was missing the bomb threat plan; however, did add it, as required. Procedures were inclusive of notification to appropriate persons, including Office of Program Accountability Page 16 of 20 (Revised July 2016)

17 PACE headquarters, local authorities, and the Department s Central Communication Center (CCC). Appropriate checklists included staff emergency rosters, emergency telephone numbers, disaster supply checklist forms, and first aid supply checklist forms. Documentation evidenced staff and youth participated in quarterly emergency and/or medical drills. One center was missing an annual medical drill. There was also evidence staff reviewed emergency procedures during their new hire orientation and reviewed emergency procedures with youth during each youth s orientation review. The emergency preparedness plan for one center failed to delegate specific emergency response roles and procedures for staff members in the event of a youth riot, shooting, or chemical spill. Additionally, the center s plan did not designate a specific evacuation location, nor did it include disaster supply or first aid supply checklist forms, or a staff emergency roster checklist. This center conducted quarterly emergency drills with the staff and youth; however, none of the drills simulated an episodic event which called for the administration of cardiopulmonary resuscitation (CPR) or other major emergency procedures such as over-dose, choking, bleeding, allergic reaction, or burns. Another center failed to conduct quarterly emergency preparedness drills with at least one inclusive of a medical emergency scenario. One center s automated external defibrillator s (AED) pads were expired and were replaced by the executive director. Another center s plan addressed hostage and shooting situation evacuation to go to one identified location and another location for chemical spills. It was not specified what destinations or locations are to be utilized in evacuation cases for fire, bomb threat, or flooding emergencies. There were no specific evacuation locations specified for youth and staff in the situation of a riot and the plan did not specify any plan or description of transportation in the event of an evacuation. The plan did not designate the procedures for securing the disaster supply kit and first aid kits. Vehicle Safety and Security: The centers each maintained written policies and procedures to address vehicle safety and security. Keys to PACE vehicles were secured in a locked location in each center. Fire extinguishers and first aid kits were located in the program vehicles. Some centers documented additional safety measures taken to provide staff with a spring-loaded window punch to use in the case of an emergency. Documentation for one center indicated an annual vehicle inspection had been completed on only one of their two vehicles since the last annual compliance review. A second center maintained fire extinguishers in their program vehicles; however, the extinguishers were not inspected nor did they possess expiration stickers. Another center found the pin had come out of the fire extinguisher in one vehicle, though there was no noticeable discharge. Key Control: Each center issues keys to staff which are to be maintained on their person at all times. Keys not issued are to be secured in the business manager s office. A key log is to be maintained by each center to track keys issued to staff and should reflect when keys are issued and when keys are returned with staff acknowledging keys received with their signature. Random checks were conducted of staff to ensure they were in possession of their assigned keys and no discrepancies were identified. The review at one center found there was no inventory of exactly how many keys of each different key was made. The center did maintain a record of keys issued to staff; however, there was no periodic accounting of all keys, both those issued and those secured. Fire Prevention: Each center had written policies and procedures in place to address fire prevention. Fire evacuation routes and egress plans were posted throughout each center. Fire drills were generally conducted monthly and during times when the majority of youth are present; however, two centers failed to conduct fire drills each month, missing five and two months respectively. Each center maintained a fire evacuation plan approved by the Fire Marshal or designee. An annual inspection of all fire prevention equipment and supplies by the Office of Program Accountability Page 17 of 20 (Revised July 2016)

18 Fire Marshal/designee or a qualified vendor was conducted at eighteen of the nineteen centers. A second center failed to document a quarterly emergency drill during the second quarter of 2015; however, this minor deficiency was administratively closed by the program operation area on February 3, 2016, as they determined the deficiency did not impact the performance of the contract expectations. On-site First Aid and Emergency Care: The centers maintained policies and procedures to address on-site first aid and emergency care. Each center had a written first aid and emergency care plan to ensure the safety of youth, staff, and visitors in case of a medical emergency. Documentation of each event was included in the Efforts to Outcomes (ETO) system under the youth s profile. Staff employed six months or longer were all certified in first aid and cardiopulmonary resuscitation (CPR). One center did not include a list specifying which staff were CPR and first aid certified. First Aid Kits: Each center maintained written policies and procedures to address first aid kits. Observation confirmed there is at least one emergency kit accessible to staff at each center. Supplies in the first aid kit(s) were reviewed and approved by a licensed physician, health care administrator, registered nurse, or certified company at all but one of the nineteen centers. This center also inspected one out of five of their first aid kits on a monthly basis. Office of Program Accountability Page 18 of 20 (Revised July 2016)