BUREAU OF 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 QUALITY IMPROVEMENT PROGRAM REPORT FOR Probation and Community Intervention - Circuit 3 Department of Juvenile Justice (State-Operated) 690 East Duval Street Lake City, Florida Review Date(s): May 7-9, 2013 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES W A N S L E Y W A L T E R S, S E C R E T A R Y J E N N I F E R R E C H I C H I, B U R E A U C H I E F

2 Rating Definitions Ratings were assigned to each indicator by the review team using the following definitions: Compliance Limited Compliance Failed Compliance No exceptions to the requirements of the indicator; or limited, unintentional, and/or non-systemic exceptions that do not result in reduced or substandard service delivery; or systemic exceptions with corrective action already applied and demonstrated. Systemic exceptions to the requirements of the indicator; exceptions to the requirements of the indicator that result in the interruption of service delivery; and/or typically require oversight by management to address the issues systemically. The absence of a component(s) essential to the requirements of the indicator that typically requires immediate follow-up and response to remediate the issue and ensure service delivery. Review Team The Bureau of 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: Kevin L Greaney, Lead Reviewer, DJJ Bureau of Quality Improvement Brenda Frazier, Juvenile Probation Officer Supervisor, DJJ Probation, Circuit 5 Mike Marino, Program Administrator, DJJ Bureau of Quality Improvement

3 Program Name: Probation and Community Intervention - Circuit 3 QI Program Code: 1178 Provider Name: Department of Juvenile Justice Contract Number: NA Location: Columbia County County / Circuit 3 Number of Beds: NA Review Date(s): May 7-9, 2013 Lead Reviewer Code: 116 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 Services, and (3) Intervention Services, which are included in the Probation and Community Intervention Standards (August 2012). Persons Interviewed Program Director DJJ Monitor DHA or designee DMHA or designee # Case Managers # Clinical Staff # Food Service Personnel # Healthcare Staff Documents Reviewed # 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 # Health Records # MH/SA Records 7 # Personnel Records 7 # Training Records/CORE 6 # Youth Records (Closed) 21 # Youth Records (Open) 1 # Other: Progressive response plan # Youth # Direct Care Staff # Other: Observations During Review Admissions Confinement Facility and Grounds First Aid Kit(s) Group Meals Medical Clinic Medication Administration Posting of Abuse Hotline Program Activities Recreation Searches Security Video Tapes Sick Call Social Skill Modeling by Staff Staff Interactions with Youth Comments Staff Supervision of Youth Tool Inventory and Storage Toxic Item Inventory and Storage Transition/Exit Conferences Treatment Team Meetings Use of Mechanical Restraints Youth Movement and Counts Items not marked were either not applicable or not available for review. Office of Program Accountability Page 3 of 16 (Revised September 2012)

4 Standard 1: Management Accountability Probation and Community Intervention Rating Profile Indicator Ratings 1.01 Standard 1 - Management Accountability * Initial Background Screening 1.02 Five-Year Rescreening 1.03 Protective Action Response (PAR) Non-Applicable 1.04 Pre-Service/Certification Training 1.05 In-Service Training 1.06 Supervisory Document Reviews 1.07 Ninety-Day Supervisory Reviews 1.08 * Incident Reporting (CCC) * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 4 of 16 (Revised September 2012)

5 Standard 2: Assessment Services Probation and Community Intervention Rating Profile Indicator Ratings 2.01 Standard 2 - Assessment Services Positive Achievement Change Tool (PACT) Pre-Screen 2.02 PACT Full Assessment 2.03 PACT Reassessment 2.04 Mental Health/Substance Abuse Screening 2.05 * Comprehensive Assessment 2.06 State Attorney Recommendation (SAR) 2.07 Pre-Disposition Report (PDR) 2.08 * Abuse-Free Environment * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 5 of 16 (Revised September 2012)

6 Standard 3: Intervention Services Probation and Community Intervention Rating Profile Indicator Ratings Standard 3 - Intervention Services 3.01 Youth-Empowered Success (YES) Plan Development 3.02 Youth Requirement/PACT Goal Elements 3.03 * Transitional Planning/Reintegration 3.04 * Mental Health and Substance Abuse Services 3.05 YES Plan Implementation/Supervision 3.06 Progressive Response System 3.07 Ninety-Day YES Plan Updates 3.08 Termination of Supervision Limited * 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 Termination of Supervision Office of Program Accountability Page 6 of 16 (Revised September 2012)

7 Strengths and Innovative Approaches Circuit juvenile probation officers (JPO) have frequent contact with service providers in the circuit. Case notes showed counseling services were often provided at circuit offices, which allowed JPOs to have face-to-face contacts with youth, families, and service providers at the time of their appointments. Reviewed files showed JPOs made appropriate referrals and followed up on the referrals whenever youth were found to be in need of services. Progress reports and other updates were provided to the JPOs by the service providers in all applicable files reviewed. Office of Program Accountability Page 7 of 16 (Revised September 2012)

8 Standard 1: Management Accountability Overview Probation and Community Intervention - Circuit 3 serves seven counties. There are two units in the circuit. One unit serves Columbia, Suwannee, and Hamilton counties. The other unit serves Dixie, Lafayette, Madison, and Taylor counties. Circuit management includes a chief probation officer, an assistant chief probation officer, and two juvenile probation officer supervisors (JPOS). Civil citation operates in Columbia, Madison, and Hamilton counties. The remaining counties are expected to become involved with civil citation during the coming year. Conditional release services are provided through a contract with a temporary agency, which provides a juvenile probation officer (JPO) to supervise youth Initial Background Screening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. The background screening process is completed prior to hiring an employee or utilizing the services of a volunteer, mentor, or intern. An Annual Affidavit of Compliance with Level 2 Screening Standards is completed annually. The circuit had two new hires and one volunteer who required pre-employment background screening since the last Quality Improvement review. These three files were reviewed and showed the background screenings were completed prior to the date of hire. The Annual Affidavit of Compliance with Level 2 Screening Standards was completed and sent to the Department s Background Screening Unit (BSU) by January 31, 2013, 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. Three staff required a five-year background rescreening since last review. Those files were reviewed and showed all three received a background rescreening as required Protective Action Response (PAR) Non-Applicable The program uses physical intervention techniques in accordance with Florida Administrative Code. Any time staff uses a physical intervention technique, such as countermoves, control techniques, takedowns, or application of mechanical restraints (other than for regular transports), a PAR Incident Report is completed and filed in accordance with the Florida Administrative Code. There have been no PAR incidents since the last review; therefore, this indicator rates as nonapplicable Pre-Service/Certification Training Compliance Office of Program Accountability Page 8 of 16 (Revised September 2012)

9 Contracted and state non-residential staff are trained in accordance with Florida Administrative Code. Contracted and state non-residential staff satisfy pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. One staff was applicable for pre-service certification within 180 days of hire. The Department s Learning Management System (CORE) certification screen indicated the staff completed certification in accordance with Florida Administrative Code In-Service Training Compliance Contracted and state non-residential staff completes in-service training in accordance with Florida Administrative Code. Contracted and state non-residential staff completes twenty-four hours of in-service training, including mandatory topics specified in Florida Administrative Code, each calendar year, effective the year after pre-service/certification training is completed. Supervisory staff completes eight hours of training (as part of the twenty-four hours of annual inservice training) in the areas specified in Florida Administrative Code. Five training files were reviewed for completion of annual in-service training. All five staff completed over the required twenty-four hours of annual training. All direct care staff reviewed had current certifications in first aid, cardiopulmonary resuscitation (CPR), and Protective Action Response (PAR). Two of the five files were for supervisory staff. Both supervisory staff completed greater than eight hours of annual training in supervisory-related topics Supervisory Document Reviews Compliance Supervisor or designee reviews and signs all reports to the court, such as Detention Risk Assessment Instrument (DRAI), the State Attorney Recommendation (SAR), Pre-Disposition Report (PDR), and Progress Reports, within the timeframes required. Twenty-one files were reviewed for a supervisor s review and signature on required documents. Thirteen of twenty-one YES Plans were signed by a supervisor; all twenty-one had a documented supervisor review of the YES plan in the case notes within thirty days. All Pre- Disposition Reports (PDR) and other reports to the court were reviewed and signed by a supervisor Ninety-Day Supervisory Reviews Compliance Cases under supervision (probation, conditional release, post-commitment probation) are reviewed by the supervisor at least once every ninety calendar days. The supervisor ensures that staff review any instructions given during the review, and ensures that they were followed during the subsequent review. File reviews showed supervisors reviewed YES Plans every ninety days in nineteen out of twenty-four occasions. Supervisor reviews were documented within ninety days of the signing of the initial YES Plan in thirteen of sixteen applicable files. Subsequent supervisory reviews were documented ninety days following the initial review in six of eight applicable cases. All supervisory reviews were documented in the case notes Incident Reporting (CCC) Compliance Office of Program Accountability Page 9 of 16 (Revised September 2012)

10 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) since the last Quality Improvement review. On one occasion, a self-reported incident on April 26, 2013, indicated the reporter gained knowledge of the incident on April 25 at 10:00 a.m.; the incident was not classified as a failure to report by the CCC. All other incidents were reported within two hours of the circuit gaining knowledge of the incident. Standard 2: Assessment Services Overview Juvenile probation officers (JPO) complete Positive Achievement Change Tool (PACT) Pre- Screens when youth are referred to the Department. The PACT Pre-Screen determines each youth s risk to reoffend. There are four scores, low, moderate, moderate-high, and high-risk to reoffend. If the score is moderate-high or high, a PACT Full Assessment is completed by a JPO. A PACT Mental Health/Substance Abuse Screening Report and Referral Form is also completed at intake by a JPO. If a youth has a hit on the screening, the JPOs refer the youth for a comprehensive assessment. The circuit has an agreement with the State Attorney s Office indicating State Attorney Recommendations (SAR) are necessary only when requested by the state attorney. Pre-Disposition Reports (PDR) are completed by the JPOs when ordered by the courts. Circuit 3 has multiple counseling services available for youth depending on needs. Counseling services for youth and families requiring specialized services include evidencebased services Positive Achievement Change Tool (PACT) Pre-Screen Compliance Staff complete the PACT Pre-Screen whenever a youth is referred to the Department for a new law charge (taken into custody or at-large) or taken into custody and screened for a non-law violation of supervision. Twenty-one files were reviewed. All files revealed that staff completed a PACT Pre-Screen when a youth was referred to the Department PACT Full Assessment Compliance Staff complete the PACT Full Assessment for youth designated Moderate-High or High-risk to reoffend by the Pre-Screen PACT, or if residential commitment is anticipated. Six files were applicable for a PACT Full Assessment based on each youth being identified as moderate-high or high-risk to reoffend by the PACT Pre-Screen. A PACT Full Assessment was completed in each case PACT Reassessment Compliance Staff complete PACT Reassessments for youth on probation, conditional release, and postcommitment probation. Office of Program Accountability Page 10 of 16 (Revised September 2012)

11 Fifteen files reviewed were eligible for PACT Reassessments for youth on probation. Ten of fifteen reassessments were completed within the required time frame. PACT Reassessments were completed in the remaining cases, which included four low-risk youth and one moderatehigh-risk youth, though were conducted late Mental Health/Substance Abuse Screening Compliance Whenever a youth is referred to the Department for a new law charge (taken into custody or atlarge) or taken into custody and screened for a non-law violation of supervision, staff shall complete the PACT Mental Health and Substance Abuse Screening Report and Referral Form (Form DJJ/PACTFRM 1). File reviews showed a PACT Mental Health and Substance Abuse Screening Form was completed when required, with two exceptions. For detained youth, the PACT Mental Health/Substance Abuse Report and Referral Form was uploaded on JJIS for the detention staff to review. Youth were already receiving services for needs identified or parents/guardians were informed of the results of the PACT Mental Health and Substance Abuse Screening Form when needs were identified Comprehensive Assessment Compliance Youth shall be referred for a comprehensive assessment (e.g., TASC/SAMH) if the PACT Mental Health and Substance Abuse Screening Report and Referral Form indicates a need for further assessment. File reviews showed youth were referred for a comprehensive assessment whenever the need for further assessment was identified on the PACT Mental Health and Substance Abuse Screening Form State Attorney Recommendation (SAR) Compliance Staff shall complete the State Attorney Recommendation (SAR) (Form DJJ/PACTFRM 3) to document the Department s recommendation of judicial or non-judicial handling of the case, unless waived pursuant to an Interagency Agreement with the local State Attorney s Office (SAO), or the SAO makes a filing decision prior to the twenty-day deadline for non-detained youth. The circuit has a waiver from the State Attorney s Office, signed by current state attorney, dated April 17, This waiver is valid for five years unless modified. The waiver indicates State Attorney Recommendations (SAR) do not have to be completed unless requested by the state attorney. There were no SARs requested by the state attorney during the review period Pre-Disposition Report (PDR) Compliance Staff shall prepare the Pre-Disposition Report (PDR) (Form DJJ/PACTFRM 5) when ordered by the court, detailing the Department s recommendation for disposition and interventions to address needs in the most appropriate, least-restrictive environment that reasonably ensures public safety. Pre-Disposition Reports (PDR) are completed when ordered by the court. In two of two applicable files, PACT Full Assessments were completed before the completion of the PDRs. Office of Program Accountability Page 11 of 16 (Revised September 2012)

12 The PDRs reflected all required information, to include the treatment needs of youth. Each PDR was submitted to the court at least forty-eight hours prior to disposition Abuse-Free Environment Compliance Any person who knows, or has reasonable cause to suspect, that a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or other person responsible for the child's welfare, as defined by Florida Statute, or that a child is in need of supervision and care and has no parent, legal custodian, or responsible adult relative immediately known and available to provide supervision and care, reports such knowledge or suspicion to the Florida Abuse Hotline. Files, case notes, and other reviewed documentation indicated no youth made allegations of abuse of any kind. There were no CCC reports of allegations against staff for abuse since the last Quality Improvement review. All staff are aware of the code of conduct for state employees. Standard 3: Intervention Services Overview Juvenile probation officers are responsible for the development of the Youth-Empowered Success (YES) Plan within thirty days of a youth being placed on probation, post-commitment probation, or conditional release supervision. A PACT goal is to be included in YES Plans for youth determined to be moderate-high or high-risk to reoffend; the PACT goal should address one of the youth s top three criminogenic needs. YES Plans are to be updated by the JPOs every ninety days. Youth, parents/guardians, and JPOs all have responsibilities towards the completion of the YES Plan goals. Circuit staff maintain positive relationships with service providers in the communities they serve. Files and case notes showed various services are frequently provided at circuit offices, which allows JPOs to have contact with service providers and ensure youth are attending appointments Youth-Empowered Success (YES) Plan Development Compliance Staff complete the YES Plan (Form DJJ/PACTFRM 4) for youth on Probation, Conditional Release, and Post-Commitment Probation. Twenty-one files were reviewed for staff completion of the YES Plan. All of the twenty-one files showed that initial YES Plans were developed within thirty calendar days. There was documentation in nineteen files of youth and parent/guardian participation in the development of the YES Plan. All parties signed thirteen of the twenty-one YES Plans within thirty days of disposition; eight were not actually signed by the supervisor, although the supervisor had approved each YES Plan according to case notes. A PACT Pre-Screen or Full Assessment was completed prior to the development of the initial YES Plan in all cases. One file had the YES Plan based on a PACT that was three months old. One youth was reinstated on probation for a new law charge and violation of probation, but a new plan was not negotiated or signed by all parties Youth Requirements/PACT Goal Elements Compliance Office of Program Accountability Page 12 of 16 (Revised September 2012)

13 For youth designated Moderate-High or High-risk to reoffend by the PACT, the YES Plan includes at least one PACT Goal. The YES Plan provides appropriate and individualized target dates for the completion of each Youth Requirement and PACT Goal. All Youth Requirement and PACT Goal action steps include the intervention plan elements (i.e., who, what, and how often). Of twenty-one youth files reviewed, six files were applicable for youth designated as moderatehigh or high-risk to reoffend by the PACT. Each applicable YES Plan included at least one PACT goal. There was an evidence-based intervention for one of the two high-risk youth reviewed. For conditional release (CR) and post-commitment probation (PCP) youth, the initial YES Plan addressed recommendations made by the residential program. There were 109 PACT goals in the initial YES Plans; eighty-one contained the intervention plan elements of who, what, and how often. Ninety-one goals included appropriate target dates. One of the YES Plans did not contain all the court-ordered sanctions. One youth had blanks within goals dealing with the payment of fees. In one case, the target date was for ninety days but the statement stated sixty days. For another youth, the projected date was one year after the due date in the goal statement. One youth s goal had a projected end date of one day for seeking employment Transitional Planning/Reintegration Compliance Program staff actively participate in the transitional planning process for youth who are being released from a residential program on Conditional Release (CR) or Post-Commitment Probation (PCP). For conditional release and post-commitment probation youth, the YES Plan must address recommendations from the residential program made during transition. Six files were applicable for transition planning for CR or PCP youth. Program staff actively made contact with youth, their parents/guardians, and residential program staff in all cases while youth were in a residential commitment program, which was documented in the case notes. The notes reflected JPOs addressed any issues and considered transition needs during each youth s placement in their residential commitment program. On one occasion, a JPO had a face-to-face contact with a youth during a home visit while that youth was in transition. JPOs participated in transition conferences in all but one case. Increased contacts were noted in each case just prior to each youth s release, though documentation of participation in exit conferences was not noted in three files; it was not clear if the residential program actually conducted the exit conferences in those cases Mental Health/Substance Abuse Services Compliance Staff shall ensure that all referrals for services are made as indicated by the court order or as negotiated to address criminogenic needs identified by the PACT (for youth that are Moderate- High or High-risk to reoffend). Staff shall develop a follow-up and monitoring plan for all referrals made as a result of the YES Plan. Referrals for services are made pursuant to the YES Plan. If referred for services, staff follows up with the service provider within thirty days to ensure that the youth and parent/guardian have taken the appropriate steps to initiate services. Staff receives, reviews, and documents written and verbal progress reports from the provider. Staff shall act upon negative reports, such as missed appointments or lack of participation, and document the response in the case notes. Sixteen files were applicable for mental health and/or substance abuse services, which were reflected in each YES Plan. Appropriate referrals were documented as indicated in the YES Plans in fifteen cases and the JPO followed up with the service provider within thirty days in Office of Program Accountability Page 13 of 16 (Revised September 2012)

14 those fifteen cases. Continued follow-up, to include face-to-face and telephone contacts with service providers, was noted in many cases. Written and verbal progress reports were received from service providers in all cases. In four of five applicable instances, JPOs appropriately followed up on negative reports. One youth received a negative report on January 14, 2013, but there was no documented contact with the youth until March 12, YES Plan Implementation/Supervision Compliance Youth on supervision (Probation, Conditional Release, or Post-Commitment Probation) are supervised in a manner that ensures compliance with the court order and the completion of the YES Plan (Youth Requirements and PACT Goals). Case notes demonstrate compliance (or attempted compliance) with youth, parent/guardian, and staff action steps contained in the YES Plan. File and case note reviews showed seventy-eight of eighty-seven actions steps were completed as outlined in the YES Plans during the first ninety-days of supervision. Thirty-five of the thirtysix action steps were completed as outlined in the YES Plans during the second ninety days of supervision Progressive Response System Compliance Staff responds to noncompliance in a manner that is consistent with the program s progressive response system. The circuit has developed a written progressive response plan. There were ten files applicable for non-compliance with the YES Plan. For nine files, a progressive response was documented and steps were implemented in accordance with the plan. One youth received a new charge on November 26, 2012, but there were no youth contacts documented until January 23, 2013; this youth was later placed in a residential program Ninety-Day YES Plan Updates Compliance Staff adjust the YES Plan to reflect any new needs and progress made during the course of supervision. Staff must make necessary updates to Youth Requirements and PACT Goals and save a new YES Plan in the Juvenile Justice Information System (JJIS) prior to ninety-day supervisory reviews. When updates are made to the YES Plan that reasonably require the input of the youth and parent/guardian, this discussion is clearly documented in the case notes. The case notes clearly document any communication regarding the YES Plan. Sixteen files were applicable for ninety-day YES Plan updates. Youth requirements and PACT goals were updated prior to the first ninety-day supervisory review, with three exceptions. YES Plans were saved in JJIS within ninety days of signing of the initial YES Plan, with three exceptions. The updates and new YES Plans were late for the three exceptions noted. PACT Reassessments were completed for moderate-high and high-risk youth prior to the first ninetyday YES Plan update in four of five applicable cases. Subsequent ninety-day YES Plan updates were applicable in nine instances. PACT Reassessments were completed prior to the ninety-day update in seven cases. New YES Plans were saved in JJIS and updates to youth requirements and PACT goals were reflected within ninety days in four cases; the remaining were either late or the same plans and goals were Office of Program Accountability Page 14 of 16 (Revised September 2012)

15 resaved. Four updated YES Plans required input of the youth and parent/guardian; three of these updated plans were signed by each youth and parent/guardian Termination of Supervision Limited Compliance The program requests termination for youth on Probation, Conditional Release, or Post- Commitment Probation upon successful completion of court-ordered sanctions and substantial compliance with restitution and/or court fees. Termination must also be requested if the Department is losing jurisdiction because the youth has reached the maximum age provided in statute or based on the maximum period of supervision applicable to the charge. Six closed files were reviewed for termination of supervision, with one of those being a high-risk youth. All six had the Progress Report completed. The high-risk youth had a Comparative Risk Factor Scores report and Comparative Protective Factor Scores report printed from the JJIS PACT module. In all cases, JJIS was updated within five days of receipt of the court termination order. Only one of six files had documentation of the JPO requesting information from law enforcement to determine if a youth had any outstanding warrants or charges pending. Three youth were terminated because of loss of jurisdiction; the court was not notified fifteen working days before the date of loss of jurisdiction. None of the six files had documentation of written notification sent to the parent/guardian informing them that their child was no longer under supervision. Office of Program Accountability Page 15 of 16 (Revised September 2012)

16 Program Name: Probation and Community Intervention - Circuit 3 QI Program Code: 1178 Provider Name: Department of Juvenile Justice Contract Number: NA Location: Columbia County / Circuit 3 Number of Beds: NA Review Date(s): May 8-9, 2013 Lead Reviewer Code: 116 Overall Rating Summary The following limited and/or failed indicators require immediate corrective action Termination of Supervision Office of Program Accountability Page 16 of 16 (Revised September 2012)