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 Redirection Service - Circuit 10 The Chrysalis Center, Inc. (Contract Provider) 6800 N. Dale Mabry Hwy.,, SUITE 164 Tampa, Florida Review Date(s): October 7-8, 2015 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES

2 Rating Definitions Ratings were assigned to each indicator by the review team using the following definitions: Compliance Limited Compliance Failed Compliance No exceptions to the requirements of the indicator; or limited, unintentional, and/or non-systemic exceptions that do not result in reduced or substandard service delivery; or systemic exceptions with corrective action already applied and demonstrated. Systemic exceptions to the requirements of the indicator; exceptions to the requirements of the indicator that result in the interruption of service delivery; and/or typically require oversight by management to address the issues systemically. The absence of a component(s) essential to the requirements of the indicator that typically requires immediate follow-up and response to remediate the issue and ensure service delivery. Review Team The Bureau of Monitoring and Quality Improvement wishes to thank the following review team members for their participation in this review, and for promoting continuous improvement and accountability in juvenile justice programs and services in Florida: Scott Luciano, Office of Program Accountability, Lead Reviewer (Standard 1 & 4) Phillipa Robertson, Juvenile Probation Officer Supervisor, Circuit 13, (Standard 2 & 3) Paul Sheffer, Office of Program Accountability, Regional Monitor, (Standard 2 & 3)

3 Program Name: Redirection Service - Circuit 10 MQI Program Code: 1339 Provider Name: Chrysalis Health Contract Number: Location: Polk County / Circuit 10 Number of Beds: 23 Review Date(s): October 7-8, 2015 Lead Reviewer Code: 119 Methodology This review was conducted in accordance with FDJJ-2000 (Contract Management and Program Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1) Management Accountability, (2) Assessment Services, and (3) Intervention Services, which are included in the Probation and Community Intervention Standards. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee # Case Managers # Clinical Staff # Food Service Personnel # Healthcare Staff Documents Reviewed # Maintenance Personnel # 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 8 # MH/SA Records 4 # Personnel Records 4 # Training Records/CORE 3 # Youth Records (Closed) 5 # Youth Records (Open) # Other: # Youth # Direct Care Staff # Other: Observations During Review Admissions Confinement Facility and Grounds First Aid Kit(s) Group Meals Medical Clinic Medication Administration Posting of Abuse Hotline Program Activities Recreation Searches Security Video Tapes Sick Call Social Skill Modeling by Staff Staff Interactions with Youth Comments Staff Supervision of Youth Tool Inventory and Storage Toxic Item Inventory and Storage Transition/Exit Conferences Treatment Team Meetings Use of Mechanical Restraints Youth Movement and Counts Items not marked were either not applicable or not available for review. Office of Program Accountability Page 3 of 19 (Effective July 2015)

4 Standard 1: Management and Accountability Redirection Services Rating Profile Indicator Ratings Standard 1 - Management Accountability 1.01 Initial Background Screening* 1.02 Five-Year Rescreening 1.03 Pre-Service and/or In-Service Training Non-Applicable 1.04 Incident Reporting (CCC)* 1.05 Administration 1.06 JJIS and Data Requirements Non-Applicable 1.07 Mental Health Services Staffing Requirements/Qualifications 1.08 Substance Abuse Services Staffing Requirements/Qualifications * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 4 of 19 (Effective July 2015)

5 Standard 2: Assessment Services Redirection Services Rating Profile Indicator Ratings 2.01 Standard 2 - Assessment Services Referral Process 2.02 Admission and Services Provision Processes 2.03 Intake Conference and Orientation 2.04 Clinical Assessments 2.05 Clinical Assessment Qualifications* 2.06 Abuce Reporting (DCF)* * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 5 of 19 (Effective July 2015)

6 Standard 3: Intervention Services Redirection Services Rating Profile Indicator Ratings Standard 3 - Intervention Services 3.01 Individualized Plan of Care 3.02 Practitioner Qualifications 3.03 Individualized Plan of Care Development and Approval Process 3.04 Redirection Therapy Services 3.05 Mental Health and/or Substance Abuse Treatment Planning 3.06 Mental Health and/or Substance Abuse Sevices 3.07 Release/Discharge * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 6 of 19 (Effective July 2015)

7 Standard 4: Fidelity Monitoring Redirection Services Rating Profile Indicator Ratings Standard 4 - Fidelity Monitoring 4.01 Treatment Manual/Protocol 4.02 Facilitator Training 4.03 Internal Fidelity Monitoring* 4.04 Corrective Action Based on Fidelity Monitoring 4.05 Evaluation of Facilitator Skill in Delivering the Intervention * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 7 of 19 (Effective July 2015)

8 Strengths and Innovative Approaches Chrysalis Health provides quality services to over 20,000 children, adolescents, adults, and families each year. Chrysalis Health provides behavior health and support services to children, adolescents, and adults throughout Florida, who are experiencing an array of needs including emotional, social, cognitive, behavioral, and psychiatric in nature. Chrysalis also provides a wide range of redirection services, such as cognitive behavior therapy, multisystemic therapy, therapeutic support, and functional family therapy. Redirection Services facilitate a positive change in youth behavior and emotional functioning, bringing out positive changes in criminal thinking, and provides the youth with the tools necessary to avoid recidivism or future criminal involvement and is designed to address family issues and needs with the goal of improving family functionality. Office of Program Accountability Page 8 of 19 (Effective July 2015)

9 Standard 1: Management Accountability Overview The Chrysalis Center and the Department of Juvenile Justice (DJJ) initiated Redirection Services in Probation Circuit 10, via a contract on January 31, The program is designed to provide evidence-based practices, promising practices, and/or alternative family centered therapy to probationary youth, conditional release youth, post commitment youth, and their families. In Probation Circuit 10, the Chrysalis Center utilizes cognitive behavior therapy (CBT) and functional family therapy (FFT) as the treatment modality. The program is designed to serve youth on probation, conditional release, or post-commitment probation with CBT or FFT services. Services are in-home, individual, and family therapy with an average length of stay from twelve to sixteen weeks. The contract allows for twenty-three youth in Circuit 10 to receive redirection services at the same time. The program s organizational chart consists of a regional director, two program directors, and two therapists. All four staff for the Redirection Service program in Circuit 10 were hired since Initial Background Screening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. The background screening process is completed prior to hiring an employee or utilizing the services of a volunteer, mentor, or intern. An Annual Affidavit of Compliance with Level 2 Screening Standards is completed annually. The program has a written policy and procedure in place for conducting initial background screening for all perspective staff prior to them providing services to youth in the program. A review of four applicable staff files indicated all four staff members received a Level 2 background screening prior to providing services to youth in the program. The Annual Affidavit of Compliance with Level 2 Screening Standards was submitted to the Department s Background Screening Unit (BSU) on January 27, The program also conducts additional screenings on new hires including clearance from the Department of Children and Families, a local county law enforcement check, a driving history check, Florida Sexual Offender Registry search, and the National Sexual Offender Registry search. There were no interns utilized by the program during this review cycle. The program does not utilize volunteers Five-Year Rescreening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. Employees and volunteers are rescreened every five years from the initial date of employment. The program has a written policy and procedure for conducting background rescreenings for all staff, volunteers, and interns every five years. There were no staff eligible for the five-year rescreening during this annual compliance review cycle. Office of Program Accountability Page 9 of 19 (Effective July 2015)

10 1.03 Pre-Service and/or In-Service Training Compliance All Redirection Service staff successfully complete training requirements as set forth below. The following training shall be completed prior to the delivery of direct services to Department youth and/or as in-service training to Redirection Service staff: Juvenile Justice Information System (JJIS) - Pre-Service Information Safety Awareness - Pre and In-Service Motivational Interviewing (MI) - Pre-Service Prison Rape Elimination Act (PREA) - Pre and In-Service Critical Incident Reporting Requirements - Pre-Service Trauma Informed Care - Pre-Service Adolescent Behavior - Pre-Service The program has a written policy and procedure for pre-service and in-service training. The Department s Learning Management System, SkillPro, and four staff training files were reviewed for pre-service training. All four training files confirmed staff received all required trainings listed within their contract with the Department. The program did not have any staff who required inservice training Incident Reporting (CCC) Non-Applicable 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. There have not been any reports to the Central Communications center (CCC) during this review period; therefore, this indicator rates as non-applicable Administration Compliance The Redirection Service program provides a safe and appropriate treatment environment including administrative and operational oversight. The program maintains various statistical data reports and submits the information to the Department of Juvenile Justice (DJJ) on a monthly basis. The statistical information maintained and submitted on a monthly basis includes data on admissions, releases, abuse reports, personnel actions, reportable Central Communications Center (CCC) incidents, youth progress reports, service summary reports, and discharge reports. The program submits quarterly fidelity monitoring reports to the Department. The youth listed on the program s roster matched the Department s census report. Office of Program Accountability Page 10 of 19 (Effective July 2015)

11 1.06 JJIS and Data Requirements Compliance The Redirection Service provider and subcontracted service providers shall utilize the Department s Juvenile Justice Information System (JJIS) for data entry and shall monitor accuracy at all times. The program utilizes the Department s Juvenile Justice Information System (JJIS) for data entry. The program specifically utilizes the youth placement facility module in JJIS to accept or reject referrals within forty-eight hours of receiving them from the Department. A review of five open files indicated the program accepted or rejected the referrals in JJIS within the required fortyeight hour time frame. A review of the JJIS evidence-based services report indicated the provider entered all five reviewed open files into JJIS as receiving evidence-based services. A review of three closed files indicated all of the youth were released from JJIS within the required twenty-four hour time frame Mental Health Services Staffing Requirements and Qualifications Compliance All Redirection Service staff providing mental health services must be fully licensed and have completed the prerequisite training to provide such services according to Florida law. The program has two licensed mental health counselors (LMHC) on staff. Each LMHC serves as a program director, one for CBT services, and the other for FFT services. Each LMHC holds a clear and active license in the state of Florida. The program also has two non-licensed mental health staff who provide cognitive behavior therapy (CBT) and functional family therapy (FFT) services to youth and their families. The non-licensed mental health staff hold a master s degree from an accredited university in the field of counseling, social work, psychology, or a related human services field. The non-licensed mental health staff both receive direct supervision weekly from their respective program director, who is a licensed mental health counselor Substance Abuse Services Staffing Requirements and Compliance Qualifications All Redirection Service staff providing substance abuse services must be fully licensed or have completed the prerequisite training as required by Florida law. The program currently holds a Chapter 397 license to provide substance abuse services to youth and their families. The program has two licensed mental health counselors and two nonlicensed mental health counselors. The non-licensed staff have the appropriate educational degrees and training to provide substance abuse services. Each program director for his or her respective discipline has provided each non-licensed mental health counselor with direct supervision on a weekly basis. Office of Program Accountability Page 11 of 19 (Effective July 2015)

12 Standard 2: Assessment Services Overview The program utilizes two non-licensed mental health counselors to provide initial assessment services to youth in the program and their families. One of the two licensed mental health counselors completes a clinical assessment, known as the behavioral health status examination, once each youth enters the Redirection Service program Referral Process Compliance The Redirection Service provider shall review each referred youth s referral via and JJIS to assess the youth s service needs and shall accept or reject all DJJ youth referred for Redirection Services within forty-eight (48) hours of referral from the Department (excluding weekend and holiday hours). Five reviewed case management records contained documentation indicating each referral was accepted, via the Department s Juvenile Justice Information System (JJIS) resource booking system, within forty-eight hours of the Department submitting the referral to the provider. Documentation confirms immediate contact was made by the program to the juvenile probation officer (JPO) to review the referral in all five records within the required time frame Admission and Services Provision Processes Compliance Each referred youth shall be admitted for an intervention service that meets his/her assessed needs and upon admittance, service implementation (initial face-to-face contact with the youth) by the provider/practitioner shall occur and services shall commence within five (5) working days of assignment/placement for services. Five reviewed case management records indicated the provider conducted an initial face-to-face interview with the youth. All five records indicated the provider commenced services within five working days of the youth being placed into the program. All five records contained documentation indicating the assigned juvenile probation officer (JPO) was notified when cognitive behavior therapy and functional family therapy services began. All five records contained documentation the parent/guardian agreed to participate in the cognitive behavior therapy (CBT) or functional family therapy (FFT) services Intake Conference and Orientation Compliance Upon acceptance and intake of the youth for services, the Redirection Service provider/practitioner shall ensure all youth and his/her parents receive an orientation within twenty-four (24) hours of the youth s initial face to face contact by the provider/practitioner. Five reviewed case management records indicated the youth and parent/guardian received an orientation to cognitive behavior therapy (CBT) or functional family therapy (FFT) services within twenty-four hours of the initial face-to-face meeting with the provider. All five records contained a consent for services signed and dated by both the youth and parent/guardian. Each signed consent form reflected the therapist discussed with the youth and family what service goals were going to be provided, expectations, hours and location of services, identified key staff for contact, and provided emergency contact information. A program description was given to youth Office of Program Accountability Page 12 of 19 (Effective July 2015)

13 and families which contained additional information to include client rights, emergency and first aid procedures, emergency contact information, incident-reporting procedures, and the grievance process Clinical Assessments Compliance Each youth must receive a Clinical Assessment of his or her emotional and behavioral functioning through structured clinical interview of the youth and parent, guardian, or caregiver and administration of appropriate standardized assessment instruments, such as symptom checklists and behavioral rating scales, when clinically indicated. Five reviewed case management records documented each youth received a clinical assessment. All five records indicated youth and parents/guardians were interviewed by an assessor to complete the assessment. The clinical assessments utilized a standardized assessment instrument and reflected the identifying information, reason for the assessment, relevant background information, history of physical abuse, sexual abuse, neglect, witnessing violence and other forms of trauma, behavior functioning, current life situations and sources of stress, examination of youth s mental health needs, strengths and preferences, current functioning and symptoms, diagnoses, and treatment recommendation. All five clinical assessments documented what clinical records and other collateral information was utilized to develop the client s individual treatment team Clinical Assessment Qualifications Compliance Clinical Assessments must be conducted by a licensed mental health professional. Five reviewed case management records contained clinical assessments completed by a licensed mental health counselor. A review of the medical quality assurance services website confirmed the licensed mental health counselors licenses were clear and active in the State of Florida Abuse Reporting (DCF) Compliance Any person who knows, or has reasonable cause to suspect, 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 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. The program has a written policy and procedure for abuse reporting. The program had postings for the Florida Abuse Hotline throughout the office. The program adheres to a code of conduct forbidding staff from using physical abuse, profanity, threats, or intimidation. Four personnel records were reviewed for code of conduct information. All records contained evidence the program had each staff member review and sign their abuse, neglect, and mandatory reporting policy statement at the time of hire. These records included a signed receipt for acknowledging review of an employee manual, employment harassment policy, abuse and neglect policy, and a corporal and degrading punishment policy. There were no complaints against staff and no abuse allegations made during this review period. Office of Program Accountability Page 13 of 19 (Effective July 2015)

14 Standard 3: Intervention Services Overview The program maintains an active Chapter 397 license. The program has two licensed clinical professionals who complete the assessments upon the youth s admission into the program. The program has two non-licensed mental health professionals who develop master treatment plans with the youth and family. Mental health and substance abuse services are provided to the youth and families in accordance with the individualized treatment plan. Services include weekly individual sessions with the youth, along with weekly family therapy sessions Individualized Plan of Care Compliance Based on the independent assessment, the Provider shall develop an Individualized Plan of Care (IPC) which is developed with a person-centered process in consultation with the youth, and others at the option of the youth such as the youth s family, guardian, and treating and consulting health care and support professionals. The person-centered planning process must identify the individual s physical and mental health support needs, strengths and preferences, and desired outcomes. A review of five youth case management records contained individualized treatment plans. A non-licensed mental health professional in consultation with the youth, parent/guardian, and treatment care professionals completed all treatment plans. The treatment plans identified the youth s physical and mental health support needs, strengths, preferences, and desired outcomes. Documentation in progress notes supported the youth and parent/guardian were provided opportunities to participate in the planning and development of the individualized goals and objectives of the treatment plan Practitioner Qualifications Compliance Treatment plans shall be developed and therapies provided by one of the following qualified practitioners: Physician; Psychiatrist; Psychiatric physician assistant; Psychiatric advanced registered nurse practitioner; Licensed Practitioner of the healing arts (LPHA); Master s level practitioner; or Bachelor s level practitioner. The program has two licensed clinical professionals who complete assessments upon a youth s admission into the program. The program has two non-licensed mental health professionals who develop master treatment plans with the youth and parent/guardian. The non-licensed clinicians provide mental health and substance abuse services to the youth and parent/guardian. A review of personnel files supported both non-licensed clinicians have a master s level degree, and at least, two years of direct experience working with emotionally disturbed children with criminogenic factors. A review of the direct supervision logs support the non-licensed clinicians received weekly supervision by a licensed mental health professional. Office of Program Accountability Page 14 of 19 (Effective July 2015)

15 3.03 Individualized Plan of Care Development and Approval Compliance Process Person-centered youth treatment plans shall be developed and approved by a multidisciplinary team (MDT). The MDT should include the recipient, the recipient s parents, caregivers or guardians, the recipient s Redirection Service therapist, the Redirection Service staff supervisor, a representative from the Department of Juvenile Justice, as well as representation from any other community supports applicable. A review of five case management records contained individualized plans of care, also known as an Individualized Treatment Plan approved by the multidisciplinary team (MDT). The members of the MDT prior to September 1, 2015 included the youth, parent/guardian, therapist, Redirection Service staff supervisor, and a representative from the Department of Juvenile Justice. Effective on September 1, 2015, the program s amended contract no longer requires a representative from the Department of Juvenile Justice be a part of the MDT. In July 2015, one youth s juvenile probation officer (JPO) did not sign the individualized treatment plan, and there was no evidence a treatment plan was ever reviewed by the MDT. In August 2015, one youth s JPO did not sign the individualized treatment plan and the MDT completed the monthly review of the individual treatment plan late. In July 2015, one youth record contained no documentation to support Redirection Service staff attempted to obtain invite the JPO to the MDT so the JPO could participate in the creation or modification of the youths individualized treatment plan and provide a signature on the document. This plan showed no evidence of the JPOs signature. After September 1, 2015, all individualized treatment plans contained all other required MDT members signatures. All youth records were applicable for monthly MDT reviews of the youth s individualized treatment plan. All five records contained monthly reviews of the youth s treatment plan, and all required MDT signatures were on all of the reviewed documents Redirection Therapy Services Compliance The provider shall provide the following for Redirection Service youth: Individual therapy services Family therapy services Group therapy services A combination of therapy services, aside from Redirection Service 24 hour crisis therapeutic support services, must be provided at least two times weekly. Five reviewed case management records contained progress notes supporting individual therapy sessions and family sessions were occurring with youth and families on a weekly basis. A review of the program s contract confirmed the staff are responsible for the delivery of individual, family, crisis intervention, and supportive therapy. All youth were receiving individual and family therapy. None of the youth required crisis intervention services. Office of Program Accountability Page 15 of 19 (Effective July 2015)

16 3.05 Mental Health and/or Substance Abuse Treatment Compliance Planning If the services to be provided are mental health and/or substance abuse treatment (individual, group or family counseling or other therapy service) the subcontracted service provider shall ensure subcontractors develop an individualized treatment plan for each youth receiving mental health and/or substance abuse services. All five youth records contained an individualized treatment plan, which was approved by the multidisciplinary treatment team (MDT). All five treatment plans contained the signatures of the youth, parent/guardian, the therapist, Redirection Service staff supervisor, and other treatment team members. Documentation in all the records supported the parent/guardian was included in the development of the individualized goals and objectives. A non-licensed professional developed all five treatment plans. All five treatment plans were reviewed and signed by a licensed professional on the same day the non-licensed professional signed the plan. All five youth had their treatment plans developed within the first fourteen days of admission and prior to the initiation of treatment. All five youth had individualized treatment plans based on their clinical assessments. All treatment goals and objectives were written in achievable and measurable terms. The goals and objectives were related to each client s diagnosis. All of the five youth had mental health and substance abuse goals and objectives on their individualized treatment plans. There were no youth taking psychotropic medication as documented in the biopsychosocial. The program does not monitor psychotropic medication; therefore, it is not included on the youth s individualized treatment plan Mental Health and/or Substance Abuse Treatment Compliance Services The provider shall ensure youth have access to necessary and appropriate mental health and substance abuse services (on or off-site) performed by qualified mental health and substance abuse professionals or service provider(s). All five youth records contained a behavioral health status examination completed by a licensed professional on the date of the youth s admission into the program. The behavioral health status examination document established the youth s diagnosis. All five youth records contained a biopsychosocial completed by a non-licensed professional. The biopsychosocial was reviewed and signed by a licensed professional on the same day it was signed by the non-licensed professional. Information from the biopsychosocial was used to develop treatment plan goals and objectives. A review of the progress notes in all five youth records supported treatment services provided to all youth included individual therapy sessions and family sessions on a weekly basis. The program also provides therapeutic support counseling, crisis intervention services, and suicide prevention services as necessary. None of the five youth required suicide prevention or crisis intervention services Release/Discharge Compliance Prior to release or discharge of a youth from services (prior to completion of the intervention) the Redirection Service provider must coordinate discharge planning with the youth s JPO. Three closed youth records were reviewed for release and discharge documentation. Two youth records documentation supported discharge planning was coordinated with the youth s juvenile probation officer (JPO) prior to discharge. One youth was not applicable for discharge planning because the youth was terminated prior to successful completion of the program. An additional Office of Program Accountability Page 16 of 19 (Effective July 2015)

17 youth record was reviewed for this indicator. This applicable youth record contained no evidence of documentation to support the JPO was invited to the multidisciplinary treatment team (MDT) to discuss discharge; however, there was documentation to support the program did follow-up with the JPO one day after the youth was released from the program to advise them of the youth s release. All three applicable youth s discharge summaries were uploaded into JJIS. There was documentation to support the assigned JPO was notified for all three records when the discharge summary had been uploaded into JJIS via or telephone. In all three cases, the JJIS case notes were updated to reflect service activities. Standard 4: Fidelity Monitoring Overview The program monitors the implementation of cognitive behavior therapy (CBT) and functional family therapy (FFT) for consistency of treatment, quality, and delivery of the services on a weekly basis. These services are evidence-based interventions. Program directors are responsible for observing their staff in individual and family therapy sessions. The delivery of the primary service is discussed in weekly clinical supervision with staff. Staff are evaluated on the delivery of the primary service during their probationary period and on an annual basis thereafter Treatment Manual/Protocol Compliance There is a specific written manual or protocol for the treatment service(s). The facilitators of that service(s) adhere to the written manual or protocol. The program utilizes the evidence-based cognitive behavior therapy (CBT) and functional family therapy (FFT) curriculums for all youth participating in Redirection Service. The program maintains a detailed manual and protocol explaining how to deliver CBT and FFT services. The CBT and FFT manuals thoroughly outline exactly what a facilitator must accomplish when delivering the service Facilitator Training Compliance All facilitators of the service(s) must have received formal training specific to the intervention or model/protocol by a qualified trainer in each specific service(s). The program has two staff members responsible for the delivery of cognitive behavior therapy (CBT) and functional family therapy (FFT) services to the youth and two program directors who supervise this delivery. A review of the four staff members training files indicated two received training in CBT and two received training in FFT services. A review of documentation provided by the program indicated the CBT and FFT trainers were certified to train other staff in the CBT and FFT curriculum. Office of Program Accountability Page 17 of 19 (Effective July 2015)

18 4.03 Internal Fidelity Monitoring Compliance The Redirection Service program has an internal process to monitor the delivery of the evidence-based practice, promising practice or alternative family centered therapy to examine how closely actual implementation matches the model protocol. The program has an internal process for monitoring the delivery of cognitive behavior therapy (CBT) and functional family therapy (FFT) services, which is outlined in the programs CBT and FFT protocol. The respective program directors, who are both qualified to deliver each service, reviews each case weekly with the therapists, and rates their sessions using the cognitive therapy rating scale (CTRS). The CTRS form is designed to measure the therapist competency and highlight a therapist s specific strengths and weaknesses during a therapy session. The CTRS further gives supervisors direct feedback regarding their knowledge of the CBT and FFT models, effective use of these models, and the youth s progress. The program is exceeding the contractual requirements for fidelity monitoring by conducting fidelity monitoring weekly instead of monthly Corrective Action Based on Fidelity Monitoring Compliance The Redirection Service program has a process by which corrective action is applied and demonstrated based on the fidelity monitoring of the delivery of the evidence-based practice, promising practice or alternative family centered therapy. The program has a process where corrective action is applied and demonstrated by basing it on the fidelity monitoring of cognitive behavior therapy (CBT) and functional family therapy (FFT). A review of documentation indicated corrective action was not required during this review period Evaluation of Facilitator Skill in Delivering the Compliance Intervention Performance evaluations of the facilitators of the specific intervention/service include the evaluation of skill in delivering the interventions/services. The program utilizes ninety-day probationary performance reviews, as well as annual performance reviews. Performance evaluations were reviewed for the two staff members who were delivering cognitive behavior therapy (CBT) and functional family therapy (FFT) services to youth during the review period. Both staff members received a ninety-day performance evaluation addressing the staff s skills and abilities in delivering CBT and FFT services. Both staff members also received an annual performance evaluation encompassing their skills and abilities in delivering CBT and FFT services. The CBT and FFT directors both receive evaluations completed by the Redirection Service regional director. Probation and Community Intervention Quality Improvement Report Office of Program Accountability Page 18 of 19 (Effective July 1, 2015)

19 Program Name: Redirection Service - Circuit 10 MQI Program Code: 1339 Provider Name: Chrysalis Health Contract Number: Location: Polk County / Circuit 10 Number of Beds: 23 Review Date(s): October 7-8, 2015 Lead Reviewer Code: 119 Overall Rating Summary All indicators have been rated and no corrective action is needed at this time. Office of Program Accountability Page 19 of 19 (Effective July 2015)