BUREAU OF QUALITY IMPROVEMENT PROGRAM REPORT FOR

Transcription

1 STATE OF FLORIDA DEPARTMENT OF JUVENILE JUSTICE BUREAU OF QUALITY IMPROVEMENT PROGRAM REPORT FOR Duval Halfway House Department of Juvenile Justice (State-Operated) 7500 Ricker Road Jacksonville, Florida Review Date(s): September 18-20, 2012 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES WANSLEY WALTERS, SECRETARY JENNIFER RECHICHI, BUREAU CHIEF

2 Prev Page Quarterly Data FY Next Page Program Name Provider Program Group Program Type Duval Halfway House Department of Juvenile Justice Moderate Risk-Male Behavioral / Mental Health This program provides mental health overlay services including individual and group counseling, career building and vocational exploration. The average length of stay is 4 to 6 months. Avg Length of Stay (Days) Escapes* Excessive/Unnecessary Use of Force Incidents* Major Deficiencies/Critical Issues* PACT Risk to Reoffend High Risk Moderate-High Risk Moderate Risk Low Risk PAR Rate (per 1,000 filled bed days)* PAR (ProgramType) PAR (Statewide) Program Measures Duval Halfway House 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Total (FYTD) % 30% 13% 22% 30% 17% 22% 30% Youth Arrests * This data may be reported for co-located programs For additional information about this facility, visit % 17% 24% 26% PACT Risk to Reoffend Fiscal Year To Date Annual Measures Quality Improvement (QI) For a copy of the most recent QI Report visit: PAM Report N/A High Risk Moderate-High Risk Moderate Risk Low Risk Recidivism FY % For the most recent CAR and PAM Reports, visit

3 Prev Page Duval Halfway House Behavioral / Mental Health Program Annual Data (July 1, June 30, 2010) Next Page FY Seriousness Index Program Type Seriousness Index Recidivism (Year of Completion) 51% Program Type Recidivism 45% Recidivism Expected v Actual (Difference) Program Type Recidivism Expected v Actual (Difference) Completion Rate 93% Program Type Completion Rate 89% Statewide Completion Rate 86% Total Releases 57 Seriousness Index (Year of Release) Recidivism (Year of Completion) Recidivism Rate Expected vs Actual (Difference) 20 40% Data Pending 10 20% 0% 0 FY % FY FY Legend Program Program Type Avg Statewide Avg (Completion Rate) Completion Rates Program Releases % 60% 40 40% 20 20% 0% FY FY For additional information about this facility, visit

4 Prev Page Quarterly Data FY Next Page Program Name Provider Program Group Program Type Duval Halfway House Low Risk Department of Juvenile Justice Low Risk-Male Behavioral / Mental Health This program provides mental health overlay services including individual and group counseling, career building and vocational exploration. The average length of stay is 2 to 4 months. Avg Length of Stay (Days) Escapes* Excessive/Unnecessary Use of Force Incidents* Major Deficiencies/Critical Issues* PACT Risk to Reoffend High Risk Moderate-High Risk Moderate Risk Low Risk PAR Rate (per 1,000 filled bed days)* PAR (ProgramType) PAR (Statewide) Program Measures Duval Halfway House Low Risk 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Total (FYTD) % 33% 33% 42% 25% 25% 8% 0% Youth Arrests * This data may be reported for co-located programs For additional information about this facility, visit % 38% 25% 4% PACT Risk to Reoffend Fiscal Year To Date Annual Measures Quality Improvement (QI) For a copy of the most recent QI Report visit: PAM Report N/A High Risk Moderate-High Risk Moderate Risk Low Risk Recidivism FY For the most recent CAR and PAM Reports, visit

5 Prev Page Duval Halfway House Low Risk Behavioral / Mental Health Program Annual Data (July 1, June 30, 2010) Next Page Seriousness Index Program Type Seriousness Index Recidivism (Year of Completion) Program Type Recidivism Recidivism Expected v Actual (Difference) Program Type Recidivism Expected v Actual (Difference) Completion Rate Program Type Completion Rate Statewide Completion Rate Total Releases Seriousness Index (Year of Release) Recidivism (Year of Completion) FY Recidivism Rate Expected vs Actual (Difference) Data Pending 0 0% 0% FY FY FY Legend Program Program Type Avg Statewide Avg (Completion Rate) Completion Rates Program Releases 0% 0 FY FY For additional information about this facility, visit

6 Prev Page DEFINITIONS OF MEASURES Next Page Average Length of Stay - ALOS (Days) The average number of days that a youth stays in a particular program. This is calculated by totaling the days served for all youth who completed from a program (in the time period specified) and dividing this number by the total number of youth who completed from the program. Source: JJIS, Bureau of Research & Planning. Completion Rate - Youth who complete a program and return to the community are considered completers. Whether a youth is considered a completer is based upon his or her exit status. Exit status is determined by the following factors: Release reason The restrictiveness level of the next commitment program, if any The time between the release and next commitment placement The next placement in the Service History data The time between the release and the next Service History placement Three exit statuses are considered program completions: Releases from care and custody (including those released because they served the maximum term allowed by law or reached the maximum age of jurisdiction). Releases to post-commitment probation. Releases to conditional release. The completion rate is the percentage of those youth released who are considered a completer, as defined above, as compared to the total of all youth released from a program. Source: JJIS, Bureau of Research & Planning. Critical Issue - An identified Critical Issue and or Critical Deficiency is the absence of a component essential to service delivery or the verification that the delivery of an essential service has been compromised. The deficiency is so dire or acute that it presents a potential threat to the health or safety of the youth served, or may otherwise compromise program security. Critical issues related to escapes are not counted in the number reflected in this report as they are reported separately. Source: Regions (Monitoring and QI Reviews) Escapes - Number of individuals per event who escaped from a facility during the reporting period. Source: CCC, Office of Residential Services. Excessive/Unnecessary Force Incidents - The number of incidents reported to the Central Communication Center (CCC) during the reporting quarter that result in a substantiated finding(s) of unnecessary and/or excessive use of force. Each specific CCC incident with substantiated findings is counted once, regardless of the number of staff with substantiated findings involved in an incident. Since an incident is only counted after a substantiated finding has been made, the numbers for a quarter may be adjusted at some point in the future to reflect updated findings. Source: CCC, Office of Residential Services. Expected recidivism rate - To ensure that programs serving youth with different difficulty levels are held to reasonable and fair recidivism standards, the Department calculates an expected recidivism rate for the group of youth who completed each residential program during the time period under analysis. Programs that serve youth with significant risk factors for reoffending will have a higher expected recidivism rate than programs serving youth with less risk factors. Source: JJIS, Bureau of Research & Planning. Major Deficiencies - A program deficiency and/or contractual compliance issue that results in an interruption in either the delivery of services and/or the receipt of public funds for program services not delivered. A major deficiency can also be based on repeated minor deficiencies with no indication progress is being made to correct the deficiency. Major deficiencies are significant in nature and typically require oversight by management to ensure the issues are addressed systemically. The determination of an issue(s) being a major deficiency is made through the contract monitoring process. Major deficiencies related to escapes are not counted in the number reflected in this report as they are reported separately... For additional information about this facility, visit

7 Prev Page DEFINITIONS OF MEASURES (2) Next Page PACT Risk to Reoffend - The Positive Achievement Change Tool (PACT) is a comprehensive assessment that addresses both criminogenic needs and protective factors and identifies a youth s risk to re-offend as either low, moderate, moderate-high or high. This measure is based on the youth served in the reporting quarter. Source: JJIS, Bureau of Research & Planning. PAM Score - The PAM (Program Accountability Measure) score is standardized grade incorporating both program recidivism cost effectiveness and program cost per completion. It presents recidivism and cost effectiveness results for the programs that completed at least 15 youth during the one-year period during the time period under analysis. Source: JJIS, Bureau of Research & Planning. PAR Rate - PAR (Protective Action Response) is the DJJ-approved physical intervention technique, including the application of mechanical restraints. The use of PAR, and staff training requirements, are outlined in the administrative rules. The PAR rate is the number of PAR incidents per 1000 filled bed days during the reporting period. The statewide average is based on all currently operating programs in the state during the reporting period. Source: Regions (Reported by Programs); Compiled by Office of Residential Services. Program Group - Identifies the gender and commitment risk level served. Source: JJIS. Program Type - Identifies the types of specialized treatment services provided by a program, such as mental health, substance abuse, sex offender. Source: JJIS. Quality Improvement - The system used for the assessment of program compliance in areas such as management, operations, and service delivery.source: Bureau of Quality Improvement. Recidivism - For residential commitment programs, the twelve-month recidivism-tracking period begins the day that a youth completes the program (as defined above), including both youth who are released from the care and custody of the Department and youth who are receiving conditional release or post-commitment probation services in a nonresidential setting. Recidivism is defined as all adjudications, adjudications withheld, and convictions for any new violation of law within twelve months of program completion. Recidivism is reported by the year of program completion. For example, youth who complete and exit a program in FY are tracked for recidivism for one year following the day they exit the program. Although the one year tracking period may roll into the following fiscal year (i.e. FY in this instance), the recidivism is reported for the fiscal year the youth exited (so, FY in this example). Source: JJIS, Bureau of Research & Planning. Releases - The total number of youth released from the program between July 1 and June 30 of the fiscal year under review, as reported in the Juvenile Justice Information System (JJIS). Source: JJIS, Bureau of Research & Planning. Seriousness Index - A weighting methodology in which offenses are assigned a point value based on the degree of seriousness. A higher rating indicates a higher level of seriousness. The offense seriousness weights are used to compute an index of the seriousness of prior offenses for each youth released during the fiscal year. A summation of point values corresponding to each charge for which the youth was adjudicated prior to the program placement date is computed according to the weighting scheme below. For each program, the summations for youth who complete the program are totaled and then divided by the number of individual youth released from that program to compute an average value for the index of offender seriousness for each program.source: JJIS, Bureau of Research & Planning. Youth Arrests - For the purposes of this report, the number reflects the youths arrested for offenses occurring while in the program, regardless of whether or not the case is filed with the court. Arrest information is gathered from the Central Communications Center (CCC) database for all youth, including those 18 years of age and older. Each youth arrested in any given incident is counted individually. If a youth is arrested for more than one incident during the quarter, each arrest is counted. Source: CCC, Office of.. For additional information about this facility, visit

8 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 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: Janet Hampton, Lead Reviewer, DJJ Bureau of Quality Improvement Keith Banks, Recreational Therapist, Hastings Comprehensive Mental Health Treatment Facility, G4S Susan Edgell, Administrative Secretary, DJJ Bureau of Quality Improvement Angela Mills, Review Specialist, DJJ Bureau of Quality Improvement Mike Marino, Program Administrator, DJJ Bureau of Quality Improvement Caroline Sanchez, Program Monitor, DJJ Residential Services, North Region

9 Program Name: Duval Halfway House QI Program Code: 190 Provider Name: State-Operated Contract Number: NA Location: Duval County / Circuit 4 Number of Beds: 20 Review Date(s): September 18-20, 2012 Lead Reviewer Code: 9 Methodology This review was conducted in accordance with FDJJ-1720 (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 (August 2012). Persons Interviewed Program Director DJJ Monitor DHA or designee DMHA or designee 1 # Case Managers 1 # Clinical Staff # Food Service Personnel 1 # Healthcare Staff Documents Reviewed 1 # Maintenance Personnel # Program Supervisors # Other (listed by title): Accreditation Reports Affidavit of Good Moral Character CCC Reports Confinement Reports Continuity of Operation Plan Contract Monitoring Reports Contract Scope of Services Egress Plans Escape Notification/Logs Exposure Control Plan Fire Drill Log Fire Inspection Report Fire Prevention Plan Grievance Process/Records Key Control Log Logbooks Medical and Mental Health Alerts PAR Reports Precautionary Observation Logs Program Schedules Sick Call Logs Supplemental Contracts Table of Organization Telephone Logs Surveys Vehicle Inspection Reports Visitation Logs Youth Handbook 5 # Health Records 5 # MH/SA Records 6 # Personnel Records 5 # Training Records/CORE 5 # Youth Records (Closed) 5 # Youth Records (Open) # Other: 5 # Youth 5 # Direct Care Staff # Other: Observations During Review Admissions Confinement Facility and Grounds First Aid Kit(s) Group Meals Medical Clinic Medication Administration Posting of Abuse Hotline Program Activities Recreation Searches Security Video Tapes Sick Call Social Skill Modeling by Staff Staff Interactions with Youth Comments Staff Supervision of Youth Tool Inventory and Storage Toxic Item Inventory and Storage Transition/Exit Conferences Treatment Team Meetings Use of Mechanical Restraints Youth Movement and Counts Items not marked were either not applicable or not available for review. Additional files were reviewed for specific indicators when the initial sample did not include information needed for those specific indicators. Office of Program Accountability Page 3 of 50 (Revised September 2012)

10 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) Limited 1.07 * Pre-Service/Certification Requirements 1.08 In-Service Training Failed 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). The following limited and/or failed indicators require immediate corrective action Protective Action Response (PAR) 1.08 In-Service Training Office of Program Accountability Page 4 of 50 (Revised September 2012)

11 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 Conference 2.26 Grievance Process Training 2.27 Grievance Process 2.28 Grievance Process Documentation 2.29 Gang Identification: Notification of Law Enforcement 2.30 Gang Identification: Intervention Activities 2.31 Life Skills Training Provided to Youth Limited 2.32 Staff Training: Delinquency Interventions 2.33 Restorative Justice Awareness For Youth Limited 2.34 Delinquency Intervention Services Failed 2.35 Recreation and Leisure Activities 2.36 Youth Input 2.37 Gender-Specific Programming 2.38 Vocational Programming 2.39 Educational Access 2.40 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). The following limited and/or failed indicators require immediate corrective action Life Skills Training Provided to Youth 2.33 Restorative Justice Awareness For Youth 2.34 Delinquency Intervention Services Office of Program Accountability Page 5 of 50 (Revised September 2012)

12 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 50 (Revised September 2012)

13 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 Suicide Risk Screening Instrument Non-Applicable 4.11 Youth Orientation to Healthcare Services 4.12 Designated Health Authority/Designee Admission Notification 4.13 Healthcare Admission Rescreening 4.14 Health Related History 4.15 Comprehensive Physical Assessment 4.16 Gender-Specific Screening/Examination Non-Applicable 4.17 Tuberculosis Screening 4.18 Sexually Transmitted Infection Screening 4.19 HIV Testing 4.20 Sick Call Process - Requests/Complaints 4.21 Sick Call Process - Visits/Encounters 4.22 Restricted Housing 4.23 Episodic/First Aid Care 4.24 Emergency Care Limited 4.25 Off-Site Care/Referrals 4.26 Chronic Illness/Periodic Evaluations 4.27 Medication Management - Verification 4.28 Medication Management - Orders/Prescriptions 4.29 Medication Management - Storage 4.30 Medication Management - Medication and Sharps Inventory 4.31 Medication Management - Controlled Medications 4.32 Medication Management - Medication Administration Record 4.33 Medication Management - Medication Administration By Licensed Staff 4.34 Medication Management - Medication Provided By Non-Licensed Staff 4.35 Medication Management - Psychotropic Medication Monitoring 4.36 Infection Control - Surveillance, Screening, and Management 4.37 Infection Control - Education 4.38 Infection Control - Exposure Control Plan Limited 4.39 Prenatal Care - Physical Care of Pregnant Youth Non-Applicable 4.40 Prenatal Care - Nutrition and Education of Youth Non-Applicable 4.41 Neonatal Care - Infant Physical Care and Nutrition of Infants Non-Applicable 4.42 Neonatal Care - Supervision of Infants Non-Applicable 4.43 Neonatal Care - Education and Lactation Non-Applicable 4.44 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). The following limited and/or failed indicators require immediate corrective action Emergency Care 4.38 Infection Control - Exposure Control Plan Office of Program Accountability Page 7 of 50 (Revised September 2012)

14 Standard 5: Safety and Security Residential Rating Profile Indicator Ratings 5.01 Standard 5 - Safety and Security Youth Supervision Limited 5.02 * Ten-Minute Checks 5.03 Census, Counts, and Tracking 5.04 Key Control Limited 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 Limited 5.10 Youth Tool Handling and Supervision Limited 5.11 Outside Contractors Failed 5.12 Fire, Safety, and Evacuation Drills 5.13 Mental Health and Medical Drills 5.14 Disaster and Continuity of Operations Planning Limited 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 Limited 5.22 Implementation and Consistency of Behavior Management System Limited 5.23 Behavior Management System Infractions 5.24 Staff Training: Behavior Management System Limited 5.25 Behavior Management System Monitoring Failed 5.26 Controlled Observation Non-Applicable 5.27 Search and Inspection of Controlled Observation Room Non-Applicable 5.28 Controlled Observation Safety Checks Non-Applicable 5.29 Controlled Observation Release Procedures 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). The following limited and/or failed indicators require immediate corrective action Youth Supervision 5.04 Key Control 5.09 Tool Inventory and Management 5.10 Youth Tool Handling and Supervision 5.11 Outside Contractors 5.21 Comprehensive Behavior Management System 5.14 Disaster and Continuity of Operations Planning 5.22 Implementation and Consistency of Behavior Management 5.24 Staff Training: Behavior Management System 5.25 Behavior Management System Monitoring Office of Program Accountability Page 8 of 50 (Revised September 2012)

15 Strengths and Innovative Approaches The program has an active community advisory board. The community advisory board has met on a quarterly basis during the past six months. The members have been instrumental in planning activities and seeking educational scholarships for youth. The program received a $35,000 Perkins Grant to deliver CORE Constructions certification training to selected youth through Duval County Public Schools. The program adopted a local family during the past year. At Thanksgiving, Christmas, and Easter the program donates food baskets and gifts to the mother and her five adopted children. Two vehicles were donated to the program. Staff made arrangements for the vehicles to be repaired and donated to two victims of crime. Office of Program Accountability Page 9 of 50 (Revised September 2012)

16 Standard 1: Management Accountability Overview Duval Halfway House is a low- and moderate-risk residential program for males aged fourteen to eighteen. Seven beds are allotted for low-risk youth. Thirteen beds are dedicated to moderate-risk youth. The average length of stay for low-risk youth is two to four months. Moderate-risk youth have an average length of stay of four to six months. There have been no changes in key management positions during the past year. The management team consists of the superintendent, assistant superintendent, registered nurse (RN), maintenance officer, designated mental health authority (DMHA), and food service manager. At the time of the Quality Improvement review, the program had one direct care staff vacancy. The DMHA and RN are primarily responsible for entering alerts in the Juvenile Justice Information System (JJIS) 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. Four staff were hired during the past year. Each staff received a background screening clearance prior to date of hire. The Annual Affidavit of Compliance with Level 2 Screening Standards was submitted to the Department s Background Screening Unit in December 2012, 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. Two staff required a five-year rescreening from the Department. Both staff were screened according to Departmental policy. Driver s license checks were conducted on five staff. Each staff had a valid driver s license. Driver s license checks are done on a monthly basis 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 abuse reporting phone numbers throughout the facility. All allegations of child abuse or suspected child abuse are immediately reported to the Florida Abuse Hotline. Office of Program Accountability Page 10 of 50 (Revised September 2012)

17 Youth and staff have unhindered access to report alleged abuse to the Florida Abuse Hotline pursuant to Section (1)(a), F.S. Youth eighteen years of age or older report to the Central Communications Center. 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 Florida Abuse Hotline telephone number was posted throughout the facility. There were two allegations of unnecessary force and/or abuse during the past six months. In one case, the superintendent reported the allegation to the Florida Abuse Hotline. One parent/guardian called the Central Communications Center (CCC) and made an abuse allegation against an unnamed Duval Halfway House staff. The mother was advised to call the Florida Abuse Hotline. Five youth completed surveys. Each youth said he had never been denied a telephone call to the Florida Abuse Hotline. Four youth said staff talk to them respectfully. Five staff completed surveys as well. None of the staff had observed a coworker denying youth telephone calls to the Florida Abuse Hotline. Each staff stated that if a youth asks to make an abuse allegation, he is allowed to make the telephone call to report the suspected abuse 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. There were two allegations of unnecessary force and/or abuse during the past six months. One allegation was under investigation at the time of the Quality Improvement review. In the second case, a mother called the Central Communications Center (CCC) and made an abuse allegation to the CCC staff. The CCC staff instructed the mother to call the Florida Abuse Hotline. There was no indication the mother reported her allegations to the Florida Abuse Hotline. The program did not have a written Code of Conduct for staff 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. Nine incidents were reported to the Central Communications Center (CCC) during the past six months. Each incident was reported to the CCC within two hours of the incident, or within two hours of staff becoming aware of the incident Protective Action Response (PAR) Limited 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 Office of Program Accountability Page 11 of 50 (Revised September 2012)

18 Administrative Code. Six Protective Action Response (PAR) reports were completed during the past six months. Five reports were written on an outdated form, which was from The current form was developed in The 2003 form did not have a section for the post-par interview between the superintendent/designee and youth. Two reports did not contain statements from all staff involved in the incidents. In one case, it appeared that youth assisted in a restraint. One staff was alone in the dormitory and radioed for another staff s assistance. One report s description of the incident was vague 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. One training file was applicable for pre-service training requirements. The staff completed preservice training within two months of hire. The Department s Office of Staff Development and Training had not received a list of pre-service training topics from the program In-Service Training Failed Compliance Contracted and State residential staff completes twenty-four hours of in-service training, including mandatory topics specified in Florida Administrative Code, each calendar year, effective the year after pre-service/certification training is completed. Supervisory staff completes eight hours of training (as part of the twenty-four hours of annual inservice training) in the areas specified in Florida Administrative Code. Four training files were reviewed for in-service training requirements. Four staff had lapsed automated external defibrillator (AED) and cardiopulmonary resuscitation (CPR) certification in None of the staff had taken a course on professionalism and ethics. Protective Action Response (PAR) update training was conducted in 2011, but not entered in the Department s Learning Management System (CORE). Two staff did not receive twenty-four hours of training in the 2011 calendar year. Two supervisory staff did not receive training in management topics in The program did not send a list of in-service training topics to the Department s Office of Staff Development and Training 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. Logbooks are maintained on each living unit. A facility logbook is also maintained by supervisory staff. Logbook entries were not always legible. It was difficult to determine the staff recording the entries. One PAR incident was not recorded in the logbooks. One security alert and one gang alert were not recorded in the logbooks. Office of Program Accountability Page 12 of 50 (Revised September 2012)

19 Shift reports were completed at the beginning and end of each shift. The shift reports documented youth counts, perimeter checks, staff assignments, activities, and significant events 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. The registered nurse (RN) maintains a list of youth with chronic medical conditions, allergies, and prescribed medications, which is maintained in notebooks located in each dormitory s subcontrol office. Suicide risk alerts are recorded in the logbooks by the treatment staff. Security, escape, and gang alerts are written on a board in the supervisor s office. One youth had a suspected gang alert listed in the Juvenile Justice Information System (JJIS); this information was not captured on the alert board in the supervisor s office 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. Ten youth records were reviewed in the Juvenile Justice Information System (JJIS). All alerts were entered in JJIS, as required by Departmental policy. The alerts were entered by the registered nurse (RN) and the designated mental health authority (DMHA). The alerts were entered for suicide risk, medications, security concerns, and chronic medical conditions 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 program maintains three files for each youth. Case management records are maintained by the two social services counselors. The case management records have tabs with each youth s name, date of birth, Department of Juvenile Justice identification number, county of residence, and committing offense. The case management records are divided into five sections. Healthcare records are maintained by the nursing staff and kept in the clinic. Mental health and substance abuse documentation is maintained by the treatment staff in a working record 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. Office of Program Accountability Page 13 of 50 (Revised September 2012)

20 The program has an advisory board. Fifteen individuals are listed on the membership roster. A victim services representative is a member of the advisory board. The advisory board did not have a representative from the judiciary or a parent/guardian of a former resident. Local businesses and churches are also represented on the advisory board. Meeting minutes and agendas were reviewed. The advisory board met twice during the past six months. Topics of discussion included youth activities, education scholarships, mentoring, and tutoring services Program Planning Compliance The program uses data to inform their planning process and to ensure provisions for staffing. The program had low staff turnover during the past year. There was one direct care staff vacancy at the time of the Quality Improvement review. One direct care staff was hired during the past year. Youth complete satisfaction surveys when they initially enter the program, as well as approximately thirty days after admission. Most of the responses were favorable. Parents/guardians complete satisfaction survey after their child is released from the program. Facility-wide meetings were held three times during the past six months. Management team meetings were conducted five times during the same time period. Supervisory meetings were conducted on a monthly basis. Five staff completed surveys. Four staff said they were briefed on the youth and parent/guardian satisfaction survey results, as well as the Department s Comprehensive Accountability Report (CAR) Staff Performance Compliance The program ensures a system for evaluating staff, at least annually, based on established performance standards. Five personnel files were reviewed for annual performance evaluations. Four staff received annual performance evaluations in May One new staff had a quarterly performance evaluation. The annual performance evaluation was not due for the new staff. Standard 2: Assessment and Performance Plan Overview Two social services counselors are employed at Duval Halfway House. One social services counselor is a certified Residential Positive Achievement Change Tool (R-PACT) instructor and the other has received R-PACT training. The social services counselors had a reduction in their caseloads due to a reduction in the number of beds. Each social services counselor has a caseload of ten youth. The social services counselors are responsible for administering the R- PACT assessments and reassessments along with the Youth Needs Assessment Summary Office of Program Accountability Page 14 of 50 (Revised September 2012)

21 (YNAS), developing performance plans, completing performance summaries, and coordinating transition activities. Direct care staff are responsible for facilitating groups in life skills, ARISE, Thinking for a Change (T4C), and Impact of Crime 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. Five case management records were reviewed for initial contact with parents/guardians. All five records reflected initial contact being made with parents/guardians within twenty-four hours of each youth s admission to the program. The records also documented written notification to each parent/guardian within forty-eight hours of admission. One notification letter was dated on the youth s admission date; however, the body of the letter referenced another date 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. Five case management records were reviewed for documentation of orientation. The five records reviewed were reflective of a thorough orientation to the program. Each file contained an orientation checklist, which outlined all required areas of discussion. Orientation checklists were signed and dated by each youth Court Notification Compliance The program notifies the youth s committing court(s) by written notification within five working days of admission. Five case management records were reviewed for notification to the committing court of each youth s admission. All records documented notification to the committing court(s) within five days of admission; however, one notification letter had a date prior to the youth s date of admission. Cross references showed the courts were notified within five days of admission Classification Factors Compliance The program utilizes a classification system, in accordance with Florida Administrative Code, that promotes safety and security, as well as effective delivery of treatment services. Five case management records were reviewed for admission classification forms. Four admission classification forms were completed in accordance with Florida Administrative Code. All identified areas were addressed in full. One admission classification form was incomplete. The staff did not address any special needs on the admission classification form, including mental health, physical disabilities, and developmental issues Classification Procedures Compliance Initial classification should be used for the purposes of assigning each newly admitted youth to a living unit, sleeping room, and youth group or staff advisor. Office of Program Accountability Page 15 of 50 (Revised September 2012)

22 Five case management records were reviewed for each youth s assignment to a living unit. In each case, the admission classification form documented each youth s assignment to a living unit and a group. Additionally, each youth was assigned to a staff mentor. The admission classification forms were completed and reviewed by mental health and healthcare staff. All alerts were entered into JJIS immediately Reassessment for Activities Compliance Youth are reassessed and reclassified, if warranted, prior to considering an increase in privileges or freedom of movement, participation in work projects, or other activities that involve tools or instruments that may be used as potential weapons or means of escape, or participation in any off-campus activity. The program uses multiple processes to determine reassessments. The program completes a class A and class B tool assessment upon each youth s admission and a progress review staffing/risk classification form. The formal treatment team review form addresses risk as well. The recreation therapist also completes a separate risk assessment prior to off-site activities R-PACT Assessment Compliance The program shall ensure that an initial assessment of each youth is conducted within thirty days of admission. The program shall maintain all documentation of the initial assessment process in JJIS. Two staff administer the Residential Positive Achievement Change Tool (R-PACT). Both staff are trained to administer the R-PACT. Each reviewed R-PACT was completed within the thirtyday time frame. The R-PACTs are maintained in JJIS Youth Needs Assessment Summary (YNAS) Compliance The program shall ensure that a Youth Needs Assessment Summary (YNAS) of each youth is conducted within thirty days of admission. The program shall maintain all documentation of the YNAS. The Youth Needs Assessment Summary (YNAS) was completed at the same time as the R- PACT in each record reviewed. The YNASs are maintained in JJIS as well R-PACT Reassessments Compliance The program shall ensure that a reassessment of each youth is conducted within ninety days. The program shall ensure that any other updates or reassessments are completed when deemed necessary by the intervention and treatment team to effectively manage the youth s case. The program shall maintain all reassessment documentation in the youth s official youth case record. Five case management records were reviewed for R-PACT reassessments. Four R-PACT reassessments were completed within ninety days of the initial assessment. One youth was assigned to the low-risk component. Two R-PACT reassessments were completed within two months of his admission to the program. Risk assessments were completed as required and/or needed and all assessments were maintained in each youth s case management record. Office of Program Accountability Page 16 of 50 (Revised September 2012)

23 2.10 Parent/Guardian Involvement in Case Management Services Compliance The program shall, to the extent possible and reasonable, encourage and facilitate involvement of the youth s parent/guardian in the case management process. Five case management records were reviewed for documentation of parent/guardian participation in the treatment process. Each record documented parent/guardian involvement in the assessment process, the development of the performance plan, and progress reviews. Three of the five youth were in the transition phase. The three records documented each parent/guardian was a part of the transition process Members of Treatment Team Compliance The team includes, at a minimum, the youth, representatives from the program s administration and residential living unit, and others responsible for providing or overseeing the provision of intervention and treatment services. All required members participate in and/or provide input into treatment team meetings with the exception of the program s administration. Treatment team members include the youth, social services counselors, mental health staff, healthcare staff, and education representatives. The program s policy does require a member from administration participate in treatment team meetings Performance Plan Development Compliance The intervention and treatment team, including the youth, shall meet and develop the performance plan, based on the findings of the initial assessment of the youth, within thirty days of admission. All five initial performance plans were developed within thirty days of each youth s admission and after the initial assessment. All required treatment team members participated in the development of the performance plan with the exception of an administrative representative Treatment Team Members (Formal Review) Compliance A residential commitment program shall ensure that the intervention and treatment team meets every thirty days to review each youth s performance, to include R-PACT reassessment results, progress on individualized performance plan goals, positive and negative behavior, including behavior that resulted in physical interventions. If the youth has a treatment plan, review their treatment progress. Five case management records were reviewed for documentation of formal reviews of the performance plan. In each case, there was documentation of formal reviews every thirty days. The reviews documented each youth s name, the date of the review, participants, and comments from treatment team members. Each youth s progress was discussed as well. Performance plan revisions were not consistently documented on the formal review forms Treatment Team Meetings (Informal Reviews) Compliance A residential commitment program shall ensure that the intervention and treatment team reviews each youth s performance, including R-PACT reassessment results, progress on individualized performance plan goals, positive and negative behavior, including behavior that Office of Program Accountability Page 17 of 50 (Revised September 2012)