STATE OF FLORIDA DEPARTMENT OF JUVENILE JUSTICE BUREAU OF QUALITY ASSURANCE PROGRAM REPORT FOR Sarasota YMCA Shelter Sarasota Family YMCA Inc. (Contract Provider) 1106 Briggs Avenue Sarasota, Florida 34234-8140 Review Date(s): August 3-5, 2010 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES FRANK PETERMAN, JR., SECRETARY JEFF WENHOLD, BUREAU CHIEF Office of Program Accountability Page 1 of 9
CINS/FINS Performance Rating Profile Program Name: Sarasota YMCA Shelter QA Program Code: 320 Provider Name: Sarasota Family YMCA Inc. County/Circuit #: Sarasota/Circuit #12 Number of Beds/Slots: 8 Review Date(s): August 3-5, 2010 Lead Reviewer Code: 77 Program Performance by Indicator/Standard Contract Number: Network 1. Management Accountability 3. Shelter Care/Health Services 1.01 Background Screening of Employees/Vol. 8 Comme 3.01 Shelter Care Requirements 7 1.02 Provision of an Abuse Free Environment 7 Accepta 3.02 Healthcare Admission Screening 7 1.03 Incident Reporting 8 Comme 3.03 Suicide Prevention 5 1.04 Training Requirements 5 Minima 3.04 Medications 7 1.05 Interagency Agreements and Outreach 10 Excepti 3.05 Medical/Mental Health Alert Process 5 1.06 Disaster Planning 7 Accepta 3.06 Episodic/Emergency Care 7 Acceptable 75% 45 Minimal 63% 60 2. Intervention and Case Management 2.01 Screening and Intake 7 Acceptable 2.02 Psychosocial Assessment 8 2.03 Case/Service Plan 5 Minimal 2.04 Case Management and Service Delivery 7 Acceptable 2.05 Counseling Services 7 Acceptable 2.06 Adjudication/Petition Process 8 Acceptable 70% 42 Standard Program Max. Score Score Rating Failed Minimal Acceptable 0-59% 60-69% 70-79% 1. Management Accountability 45 60 75% X 2. Intervention and Case Management 42 60 70% X 3. Shelter Care/Health Services 38 60 63% X Overall Program Performance Minimal 69% 80-89% 90-100% Office of Program Accountability Page 2 of 9
Methodology This review was conducted in accordance with Florida Administrative Code 63L-2 (Quality Assurance, 6/10/10 Hearing Draft), and focused on the areas of (1) Management Accountability, (2) Intervention and Case Management, and (3) Shelter Care/Health Services, which are included in the Children/Families in Need of Services (CINS/FINS) Standards (July 2010). Persons Interviewed Program Director DJJ Monitor DHA or designee DMHA or designee 1 # Case Managers 1 # Clinical Staff # Food Service Personnel # Healthcare Staff # Maintenance Personnel 2 # Program Supervisors Documents Reviewed 5 # Other (listed by title): Executive Director, Human Resources Vice- President, Risk Management Director, Assistant Shelter Director, Education Specialist 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 7 # MH/SA Records # Personnel Records 8 # Training Records/CORE 8 # Youth Records (Closed) 2 # Youth Records (Open) 1 # Other: Disaster Preparedness Plan 3 # 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. In addition, the following items were observed or reviewed during the quality assurance review: medication storage, sharps inventory, hygiene, first aid supplies and bed checks. Office of Program Accountability Page 3 of 9
Performance Ratings Performance ratings were assigned to each indicator by the review team using the following definitions and numerical values defined by F.A.C. 63L-2.002(10)(a) (6/10/10 Hearing Draft): (10) (8) Acceptable (7) Minimal (5) Failed (0) The program consistently meets all requirements, and a majority of the time exceeds most of the requirements, using either an innovative approach or exceptional performance that is efficient, effective, and readily apparent. The program consistently meets all requirements without exception, or the program has not performed the activity being rated during the review period and exceeds procedural requirements and demonstrates the capacity to fulfill those requirements. The program consistently meets requirements, although a limited number of exceptions occur that are unrelated to the safety, security, or health of youth, or the program has not performed the activity being rated during the review period and meets all procedural requirements and demonstrates the capacity to fulfill those requirements. The program does not meet requirements, including at least one of the following: an exception that jeopardizes the safety, security, or health of youth; frequent exceptions unrelated to the safety, security, or health of youth; or ineffective completion of the items, documents, or actions necessary to meet requirements. The items, documentation, or actions necessary to accomplish requirements are missing or are done so poorly that they do not constitute compliance with requirements, or there are frequent exceptions that jeopardize the safety, security, or health of youth. Review Team The Bureau of Quality Assurance 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: Paul Czigan, Lead Reviewer, DJJ Bureau of Quality Assurance Pierre Bandoo, Shelter Director, Crosswinds Youth Services Ann Little, Review Specialist, DJJ Bureau of Quality Assurance Audrey Pat McGhee, DJJ Program Monitor Office of Program Accountability Page 4 of 9
Please note that this report refers to each indicator by number and title only. Please see the applicable standards for the full text of each indicator. The standards are available on the Bureau of Quality Assurance website, at http://www.djj.state.fl.us/qa/index.html. Standard 1: Management Accountability Failed Minimal Acceptable Overview Sarasota YMCA Shelter contracts with the Florida Network of Youth & Family Services to provide emergency shelter and non-residential services to at-risk youth. The residential shelter, which is located in Sarasota, Florida, is contracted to provide shelter beds, in addition to individual family and crisis counseling to families in Manatee, Sarasota and Desoto Counties. The non-residential program also provides individual, family and crisis counseling services. The Executive Director of Youth and Family Services is responsible for supervising the directors of the non-residential and residential services programs. The non-residential director is a Licensed Mental Health Counselor, and serves as the Clinical Director of residential and non-residential counselors. The program has a new Shelter Director and Assistant Director, both of whom were appointed to their positions a few months prior to the quality assurance review. The shelter has three shift leaders who assist in managing the facility. At the time of the quality assurance review, there were two vacancies at the program: one non-residential counselor, and one parttime administrative assistant. The non-residential staff, one of which is an adventure-based counselor, were the primary staff members responsible for conducting the community outreach and public awareness activities. 1.01: Background Screening of Employees/Volunteers (8) The program consistently met all requirements for this indicator without exception. 1.02: Provision of an Abuse Free Environment Acceptable (7) Surveys indicated, and staff interviews confirmed that program administration inconsistently addressed violations of the staff code of conduct. 1.03: Incident Reporting (8) The program consistently met all requirements for this indicator without exception. Office of Program Accountability Page 5 of 9
1.04: Training Requirements Minimal (5) Three applicable files were reviewed; two new-hire staff files documented minimal hours of training, and the staff do not appear to be on track to complete the required hours within the timeframe. New-hire staff inconsistently received training in CORE, CINS/FINS CORE, Suicide Prevention and Title IV-E Procedures. Two of five files reviewed documented the required in-service training hours and CPR certification. There was inconsistent documentation of training in Signs and Symptoms of Mental Health and Substance Abuse, and Universal Precautions. 1.05: Interagency Agreements and Outreach (10) The program had thirty-five current interagency agreements with agencies representing Law Enforcement, School Districts, Department of Juvenile Justice agencies, Mental Health and Crisis Centers, as well as Scouting, Civic and Religious agencies. Documentation reviewed indicated continual and on-going efforts to keep interagency agreements current, as well as increase the number of agencies involved. The program has designated two full-time staff to provide outreach activities. The program documented an average of more than thirty events per month during the school year, including events such as presentations to all sixth graders in Sarasota County, Anger Management and Parenting classes, large and small school assemblies, art therapy, Decision Making and Risk management skills and Safe Place events. 1.06: Disaster Planning Acceptable (7) A program administrator did not document the annual review of the Disaster Preparedness Plan. The evacuation site for use during disasters changed, however the plan was not amended to reflect this revision. The program inconsistently documented inventories of supplies required for the execution of the plan. Standard 2: Intervention and Case Management Failed Minimal Acceptable Overview The program provided several screening and assessment services for the youth who are admitted to the program. Most of the non-residential counselors maintained offices in the community, particularly within the schools. The Clinical Director provided clinical supervision directly in the counselor s offices, in an effort to avoid transporting case files for reviews. The Office of Program Accountability Page 6 of 9
shelter counselor and case manager maintain offices inside the shelter and provide services on campus. 2.01: Screening and Intake Acceptable (7) Eight of nine eligibility screenings were completed within the required timeframe. Three of nine files documented the youth and the youth s parent or guardian were informed of possible actions occurring with involvement with CINS/FINS services. 2.02: Psychosocial Assessment (8) The program consistently met all requirements for this indicator without exception. 2.03: Case/Service Plan Minimal (5) Two Service Plans were developed prior to the completion of the psychosocial assessment. One youth had a substance abuse need identified in the psychosocial assessment, however, this was not reflected on the youth s Service Plan. One Service Plan contained target dates that had expired, and there was no documentation regarding the revision or extension of the target dates. Numerous thirty-day reviews were documented as completed on an internal audit checklist; progress notes inconsistently documented the review, the content discussed or inclusion of required persons involved in the review, or the reasons the review was not completed according to requirements. Several thirty-day reviews were not conducted within the required timeframe. 2.04: Case Managment and Service Delivery Acceptable (7) Progress notes inconsistently documented the intervention or services being provided during the contact. 2.05: Counseling Services Acceptable (7) Progress notes inconsistently documented the intervention or services being provided during the contact. The clinical supervision notes in two files inconsistently documented staff involvement. 2.06: Adjudication/Petition Process (8) The program consistently met all requirements for this indicator without exception. Office of Program Accountability Page 7 of 9
Standard 3: Shelter Care/Health Services Failed Minimal Acceptable Overview The shelter is located on the campus and next to a full-service family YMCA that includes a gymnasium, aquatic center and youth activity areas. The Shift Leaders provide oversight of direct care workers to ensure that required activities are provided and documented. The youth placed at the shelter receive services including individual counseling, family counseling, life skills, anger management counseling, and crisis counseling. In addition, educational classes were coordinated with the local school district. All youth admitted to the program are screened using the CINS/FINS Intake Form and the Family Management Services Screening/Intake form. The process includes completing a Suicide Probability Scale (SPS) when a youth answers yes to any of the six questions pertaining to suicide risk on the CINS/FINS Intake form. A medical and mental health alert system is in place, and the shelter staff that administer medications have been trained in the dispensing of medications. All medications are stored in locked cabinets located in the staff office. The knife-for-life, wire cutters, and first aid supplies are also maintained in the staff office. The Clinical Director s office is located in a building adjacent to the Shelter. 3.01: Shelter Care Requirements Acceptable (7) The program s policies and procedures did not address the model or methods which would be used in behavioral interventions. The staff files inconsistently documented training in hands-on interventions or deescalation practices. 3.02: Healthcare Admission Screening Acceptable (7) The program utilizes the CINS/FINS Intake form to perform a preliminary physical health screening; not included on the screening form was the observation for the presence of scars, tattoos, or other skin marking. An additional form was located in the youth s file that documented physical characteristics of the youth, however, the form was not dated to indicate when it was completed. 3.03: Suicide Prevention Minimal (5) Of the five files reviewed, three youth answered yes to at least one of the six questions pertaining to suicide risk on the CINS/FINS Intake form, however the Suicide Probability Scale (SPS) was not completed immediately; one was completed in six hours and the other two were completed the following day. In one file reviewed, the youth did not answer yes to any of the six questions pertaining to suicide risk on the CINS/FINS Intake form, however it was documented on the Family Office of Program Accountability Page 8 of 9
Management Services Screening/Intake form, section IV Risk Screening, that the youth s parent stated the youth was actively suicidal. According to the form, emergency procedures should have been implemented, however there was no documentation regarding what, if any, action was taken by the program. Two additional files were provided for review in which the youth answered yes to at least one of the six questions pertaining to suicide risk on the CINS/FINS Intake form; the Suicide Probability Scale (SPS) was completed and the youth were subsequently referred for an assessment of suicide risk. In one file, there were conflicting dates indicating when the assessment was completed. In both files the assessment was completed by a master s level staff, but was not reviewed by the licensed professional. 3.04: Medications Acceptable (7) The medication administration records did not include the youth s DJJ ID number, signature, and information concerning precautions and/or side effects of medications. A review of medication administration records found some instances of overwriting, and a few instances in which the staff did not initial the record. 3.05: Medical/Mental Health Alert Process Minimal (5) The program s policy regarding alerts was not clear, and it appears that the practice does not consistently follow the policy. Of the four applicable files reviewed, two did not include the youth s mental health information on the alert form. There was no indication on the medical and mental health alert form that either youth had mental health or attempted suicide histories. However, the intake form of one youth listed a history of cutting and of being Baker Acted twice, and the other youth had been admitted to an Intensive Care Unit for a drug overdose. 3.06: Episodic/Emergency Care Acceptable (7) There was no documentation to support whether staff received training on the program s emergency medical procedures and the calling of 911. The file of a youth sent off-site to the emergency room did not contain documentation to support whether the hospital discharge instructions were followed by program staff. Overall Program Performance Minimal 69% Failed Minimal Acceptable Office of Program Accountability Page 9 of 9