BUREAU OF QUALITY ASSURANCE PROGRAM REPORT FOR

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 ASSURANCE PROGRAM REPORT FOR Pasco Girls Academy G4S Youth Services, LLC (Contract Provider) 2953 Wilson Road Land O' Lakes, Florida 34639 Review Date(s): January 3-5, 2011 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 F F W E N H O L D, B U R E A U C H I E F Office of Program Accountability Page 1 of 18

Residential Performance Rating Profile Program Name: Pasco Girls Academy QA Program Code: 1203 Provider Name: G4S Youth Services, LLC Contract Number: R2092 County/Circuit #: Pasco/6 Number of Beds: 24 Review Date(s): January 3-5, 2011 Lead Reviewer Code: 111 Program Performance by Indicator/Standard 1. Management Accountability 4. Health Services 1.01 Background Screening of Employees/Vol. 8 Comme 4.01 Designated Health Authority 10 1.02 Provision of an Abuse Free Environment 7 Accept 4.02 Healthcare Admission Screening 10 1.03 Incident Reporting 10 Exceptio4.03 Comprehensive Physical Assessment 10 1.04 Protective Action Response (PAR) 10 Exceptio4.04 Sexually Transmitted Diseases 10 1.05 Pre-Service/Certification Requirements 10 Exceptio4.05 Sick Call 7 1.06 In-Service Training Requirements 10 Exceptio4.06 Medication Administration 7 1.07 Logbook Maintenance 7 Accept 4.07 Medication Control 7 1.08 Internal Alert System 10 Exceptio4.08 Infection Control 10 1.09 Escapes 10 Exceptio4.09 Chronic Illness Treatment 8 Exceptional 91% 82 4.10 Episodic and Emergency Care 10 90 4.11 Consent and Notification 7 2. Intervention and Case Management 4.12 Prenatal/Neonatal Care 8 2.01 Classification 10 Exceptional Commendable 87% 2.02 Assessment 8 Commendable 2.03 Intervention and Treatment Team 10 Exceptio 5. Safety and Security 2.04 Performance Plan 8 Comme 5.01 Supervision of Youth 7 2.05 Performance Review and Reporting 8 Comme 5.02 Key Control 10 2.06 Parent/Guardian Communication 10 Exceptio5.03 Contraband and Searches 10 2.07 Transition Planning and Release 8 Comme 5.04 Transportation 8 2.08 Grievance Process 10 Exceptio5.05 Tool Management 10 2.09 Gang Prevention and Intervention 8 Comme 5.06 Disaster/Continuity of Operations Planning 7 Commendable 89% 80 5.07 Flammable, Poisonous, and Toxic Items 7 90 5.08 Water Safety NA 3. Mental Health and Substance Abuse Services 5.09 Behavior Management System 10 3.01 Designated Mental Health Authority 8 Comme 5.10 Behavior Management Unit NA 3.02 MH and SA Admission Screening 10 Exceptio5.11 Controlled Observation NA 3.03 MH and SA Assessment/Evaluation 8 Commendable Commendable 86% 3.04 Treatment Plan/Team and Service Delivery 7 Acceptable 3.05 Suicide Prevention 10 Exceptional 3.06 Mental Health Crisis Intervention 7 Acceptable 3.07 Emergency Services 8 Commendable 3.08 Specialized Treatment Services 10 Exceptional Commendable 85% 68 Standard Program Max. Score Score Rating Failed Minimal Acceptable Commendable Exceptional 0-59% 60-69% 70-79% 80-89% 90-100% 1. Management Accountability 82 90 91% X 2. Intervention and Case Management 80 90 89% X 3. Mental Health and Substance Abuse Services 68 80 85% X 4. Health Services 104 120 87% X 5. Safety and Security 69 80 86% X Overall Program Performance COMMENDABLE 88% Office of Program Accountability Page 2 of 18

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, (3) Mental Health and Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included in the Residential Standards (July 2010). Persons Interviewed Program Director DJJ Monitor DHA or designee DMHA or designee 1 # Case Managers 2 # Clinical Staff N/A # Food Service Personnel 2 # Healthcare Staff Documents Reviewed 1 # Maintenance Personnel 1 # 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 8 # MH/SA Records 19 # Personnel Records 9 # Training Records/CORE 3 # Youth Records (Closed) 5 # Youth Records (Open) # Other: 5 # Youth 6 # 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. The program did not utilize room restrictions or controlled observation. The program has not had any escapes since operations began. The Designated Health Authority was not on-site during the review period. There were no admissions, discharges, transition and/or exit conferences available for observation while the team was on site. Office of Program Accountability Page 3 of 18

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): Exceptional (10) Commendable (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: Kirstie Naoom, Lead Reviewer, DJJ, Bureau of Quality Assurance Michelle Miles, Review Specialist, DJJ, Bureau of Quality Assurance Ramona Salazar, Program Monitor, DJJ, Central Region Residential Charles Reese, Assistant Superintendent, Falkenburg Academy Office of Program Accountability Page 4 of 18

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 Commendable Exceptional Overview Pasco Girls Academy is a twenty -four bed low and moderate risk staff secure facility for female youth between the ages of thirteen and eighteen. The facility became operational in March 2010. The program provides Mental Health Overlay Services (MHOS) as well as cognitive behavioral treatment to all youth. Pasco Girls Academy provides a gender responsive approach and specific treatment areas address sexual abuse, substance abuse, domestic violence, trauma, and crime specific topics. Educational services are provided on-site by the Pasco County School Board. The management team consisted of the Facility Administrator, Assistant Facility Administrator, Director of Clinical Services, Medical Services Coordinator/Licensed Practical Nurse, Case Manager and Support Services Staff. The Department of Juvenile Justice contracts with G4S Youth Services to operate Pasco Girls Academy. At the time of the review the program had twenty-two residents. There were no staff vacancies. 1.01: Background Screening of Employees/Volunteers Commendable (8) 1.02: Provision of an Abuse Free Environment Acceptable (7) One of six staff surveyed indicated she had occasionally observed co-workers using profanity in the presence of youth. One of five youth surveyed indicated she had observed a staff using profanity in front of her and other youth. 1.03: Incident Reporting Exceptional (10) The program management team reviews all CCC reporting events during both daily and monthly management meetings. The program completes critical incident analysis each month which includes formal reviews and evaluations of each critical incident. The analysis provides an incident summary with identified primal casual factors, identified trends, actions for improvement, results of performance improvement plans, education and training needs, prevention efforts as well as internal and external reporting requirements. Internal risk management systems provide monthly evaluation of all incident reporting. The Quality Assurance Manager evaluates events, program action, reporting, and Office of Program Accountability Page 5 of 18

documentation and provides rating of program response and adherence to contractual and regulatory requirements for the reporting of incidents. Critical incident reporting data is tracked, monitored and analyzed on a monthly basis through Key Performance Indicator (KPI) reporting. Information is evaluated at program, regional and corporate levels in an effort to effectively manage risk and provide performance improvement planning and initiatives. 1.04: Protective Action Response (PAR) Exceptional (10) The program had received accolades from the Department of Juvenile Justice Regional office for maintaining low numbers of PAR use within the facility since the program opened. The program has consistently ranked as a top performer in Statewide PAR Data Report Summary. The facility had only two PAR incidents since the program opened. PAR review committee meetings follow each use of PAR which includes youth, staff involved and management team members. During these meetings the events, actions, alternatives and preventative strategies to the use of PAR are explored. Use of PAR is reviewed by management team members daily during the Morning Management Meeting. 1.05: Pre-Service/Certification Requirements Exceptional (10) All five staff training files indicated a minimum of one hundred and twenty-nine completed pre-service training hours. Each staff received eight hours of gender responsive training during pre-service training. Training for direct care staff is fully completed within the first thirty days of hire. New employees are provided an extensive job specific training plan which includes both instructional and competency testing components. Each new employee is paired with a seasoned mentoring staff to reinforce instructional led training and to guide onsite expectations. All staff members at Pasco Girls Academy are PAR certified and AED trained. Monthly audits and fidelity checks of training files and LMS entries are completed by the Quality Assurance Manager and the Staff Development and Training Manager as a part of the internal risk management process. 1.06: In-Service Training Requirements Exceptional (10) All five staff training files reviewed indicated a minimum of thirty hours of in-service annual training. All supervisory hours provided at the facility are conducted as a supplement to the thirty hours of annual in-service training. Supervisors receive a minimum of thirty-eight hours. All annual trainings are completed well in advance of calendar year guidelines outlined in Rule. Monthly reviews and audits of in-service training are conducted by the Quality Assurance Manager and Staff Development and Training Manager as part of the internal risk management system. Office of Program Accountability Page 6 of 18

1.07: Logbook Maintenance Acceptable (7) The logbooks reviewed indicated staff did not always draw a single line through the error or initialed the errors. 1.08: Internal Alert System Exceptional (10) The program uses a communication system with informational alert boards that include: key alert information, easy photo identification boards for alert, classification and suicide precautions. The facility has a specialized medical alert log which provides detailed medical alert information for staff. The program utilized a Restrictions Checklist that accompanied youth on Suicide Precautions as a specialized easy identification of special needs. All alerts are reviewed both in shift to shift debriefings and in the Daily Management Meetings. Youth on Alerts are placed in specific/color coded uniforms for easy identification: light blue-new intake/orientation; green-security alert; pink-suicide precautions. The alert system, notifications and precautions are all reviewed monthly within the risk management system by the assigned internal Quality Assurance Manager. All youth files (individual management, mental health/substance abuse, and medical) have color coded stickers/dots that signify any applicable alert status. 1.09: Escapes Exceptional (10) The program has had no escapes since it opened March 2010. The program uses color coded alerts to inform staff of key classification issues and includes: orange as an escape risk alert. Color coded classification codes are posted in the shift reporting room with key alert communication information on designated informational boards as a method to reinforce special classification needs and to promote staff awareness. Formal counts are conducted on an hourly basis, along with random counts. An escape assessment is completed on all youth upon admission as part of the intake process, and as needed thereafter. Monthly Safety Committee Meetings are conducted as a forum to identify and discuss related safety and security issues that may pose a risk. Safety and security issues are reviewed and discussed in monthly general staff meetings to assist with keeping staff alert and vigilant. The youth is security alert status is reviewed daily as part of daily management meeting. Weekly safety inspections are completed by designated staff and include inspection of key control, mechanical restraints, and security alarms. Weekly walkthroughs are completed by the Facility Administrator to monitor and assess physical structure and grounds for any related safety and security risks. Facility drills are conducted monthly that consist of a simulated potential escape/security risk event. Office of Program Accountability Page 7 of 18

Standard 2: Intervention and Case Management Failed Minimal Acceptable Commendable Exceptional Overview The program has one case manager assigned to twenty-four youth. The case manager is responsible for processing the youth into the program. She is the designated treatment team leader and responsible for the youth s formal orientation to the program. In collaboration with the treatment team, the case manager completes the Residential Positive Assessment Change Tool Instrument (R-PACT), Needs Assessment Summary, Performance Plan, Performance Summaries and Transitional Planning for all youth. 2.01: Classification Exceptional (10) All five files reviewed indicated a formal admission classification meeting was conducted for all new admissions and included participation by the youth, nurse, therapist, case manager, assistant facility administrator and/or program designee. The program uses color coded alerts to inform staff of key classification issues (i.e., Red=Gang, Orange=Escape, Green = Allergies, Yellow=Vulnerable to Victimization, Blue=Chronic Illnesses). Color coded classification codes are posted in the shift reporting room with key alert communication information on designated informational boards as a method to reinforce special classification needs and to promote staff awareness. Color coded classification symbols are located on the outside of each youth s file (i.e., Individual Management, Mental Health/Substance Abuse, Medical) for quick and easy reference. 2.02: Assessment Commendable (8) 2.03: Intervention and Treatment Team Exceptional (10) The treatment team meets with the psychiatrist on a bi-weekly basis to discuss medication management and to provide treatment updates in all areas of programming. Formal notifications for treatment team meetings are sent out each month to parent/guardians. All treatment team members are consistently in attendance at all meetings and provide written input. Each formal and informal review contains a section that allows youth to self report abuse and the ability to grieve personal safety issues which include alleged threats, intimidation, or feelings related to safety. Office of Program Accountability Page 8 of 18

Treatment Team fidelity checks are completed each month by the internal quality assurance staff and are scored based upon observational findings each month on the score card. Monthly parent surveys reflected positive feedback regarding case manager soliciting parental involvement in monthly treatment team meetings, as well as indications that they feel they are a valued member of their child s treatment team. Monthly youth surveys reflected youth were knowledgable of their performance/treatment plan goals, as well as their belief that their treatment team understands their problems, needs and goals. 2.04: Performance Plan Commendable (8) 2.05: Performance Review and Reporting Commendable (8) 2.06: Parent/Guardian Communication Exceptional (10) The treatment team observation confirmed that communication to the youth s parent/guardian is consistent, often and open. The files reviewed contained numerous documented contacts to the parent/guardian to include: Letter to parent regarding admission, treatment team dates, performance summary and updates, staff change notification/letter, youth and parent input forms, notification letter of family day events, and chronological entries. Following admission, the youth s parent/guardian is mailed the Parent Handbook, Program Activity Schedule and a letter outlining program location, and point of contact. The facility also utilizes risk management reporting processes to review parent survey results which are discussed during management team meetings. 2.07: Transition Planning and Release Commendable (8) 2.08: Grievance Process Exceptional (10) Eight applicable grievances were reviewed, all were completed and addressed within one day and were directly handled by the Facility Administrator. All grievances were resolved and youth provided confirmation through documented feedback on the grievance form. All grievances were also reviewed as part of the risk management process each week in community meetings with youth and staff. In addition, all youth can communicate concerns through the Chatty Cathy process. These were also reviewed and there was much dialogue and resolve documented by Office of Program Accountability Page 9 of 18

both youth and staff. This process allows the youth to communicate concerns and/or issues and they may request to speak to a particular staff to get answers. The program provides an open communication forum to all youth. 2.09: Gang Prevention and Intervention Commendable (8) Standard 3: Mental Health and Substance Abuse Services Failed Minimal Acceptable Commendable Exceptional Overview The program s Treatment Director is a Licensed Mental Health Counselor (LMHC) and is identified as the program s Designated Mental Health Authority. She has been on staff since the program became operational in March 2010. The Treatment Director provides supervision for two unlicensed master s level mental health therapists and all delinquency staff that provide evidenced based interventions and services. The Treatment Director, unlicensed therapists, and case manager insure treatment services are provided to all youth. The program has a contract with a Psychiatrist who provides services on-site bi-weekly. The program provides Mental Health Overlay Services to all youth in the program. Services are implemented in accordance with the specialty services guidelines that are provided contractually through the Department of Juvenile Justice. The program has a Chapter 397 license to provide Substance Abuse Outpatient Treatment Services. 3.01: Designated Mental Health Authority (DJJ Program) Commendable (8) 3.02: Mental Health and Substance Abuse Admission Screening Exceptional (10) All youth are administered the VSAB (Screening for Vulnerability to Victimization and Sexually Aggressive Behavior) upon admission. The screening instrument is used to assess and determine the level of sexual aggressiveness and vulnerability to victimization of each youth. All youth are administered an Alcohol and Other Drug Abuse screening to determine their need for substance abuse treatment. A licensed professional completes a detailed face to face screening of all youth on the day of admission that details a thorough records review, mental status exam, brief clinical interview, initial diagnostic impressions, and identification of service needs. Office of Program Accountability Page 10 of 18

3.03: Mental Health and Substance Abuse Assessment/Evaluation Commendable (8) 3.04: Treatment Plan, Treatment Team, and Service Delivery Acceptable (7) Two of three applicable youth files reviewed for pharmacological interventions did not include the youth s prescribed psychotropic medication as an intervention on the youth s treatment plan. One of five applicable youth files reviewed for Individualized Mental Health/ Substance Abuse Treatment Plans and Treatment Plan Reviews indicated a change in diagnosis on the treatment plan addendum, however there was no documented justification for the change in the youth s diagnosis. 3.05: Suicide Prevention Exceptional (10) The program uses a sight identification system for youth on suicide precautions (pink uniform). A Restrictions Checklist is used for each use of suicide precautions which provides staff with detailed individualized instructions for the youth on precautions. The facility uses color coded forms as easy sight identification of levels of supervisions and/or precautions. The facility utilizes a Non-Clinical Staff Reference Guide for Suicidal/Self-Harm Behaviors that is located in master control and in the shift reporting room for easy staff reference. The Risk Management system evaluates suicide precautions on a monthly basis within the Score Card system. Documentation reviews are completed as well as fidelity checks of observation practices and staff responses. The program had an alert communication board located in the shift reporting area for easy reference and identification that is reviewed daily and updated as indicated, in addition to documenting the youth s alert status in the log book. The Clinical Director facilitates simulated suicide prevention drills with all facility staff. The Clinical Director conducts formal staff training during General Staff Meetings as needed and informal training/consultation to all staff as applicable. 3.06: Mental Health Crisis Intervention Acceptable (7) The program had a Crisis Intervention Plan. The program had not implemented crisis intervention procedure for any youth since the program began operations. Therefore, there was no practice available for review. 3.07: Emergency Services Commendable (8) The program had a mental health and substance abuse emergency plan. The program had not implemented Baker Act or Marchman Act procedure for any youth since the opening in March 2010. There was no practice available for review. The program Office of Program Accountability Page 11 of 18

conducted semi-annual drills that exceed procedural requirements and demonstrated the capacity to fulfill the requirements. 3.08: Specialized Treatment Services Exceptional (10) Pasco Girls Academy provides gender specific treatment services that include the following minimum components: Use of Sanctuary Model which is a full system approach focused on helping effected children recover from the damaging effects of interpersonal trauma. Use of Girls Matter curriculum that creates a normative and gender specific environment. The Clinical Director is a Licensed Mental Health Counselor, who is also a Train the Trainer for Girls Matter. Motivational Interviewing approaches are used to promote healthy mood and behavior regulation. A licensed professional completes a detailed face to face assessment for all youth on the day of admission that details a thorough records review, mental status exam, brief clinical interview, initial diagnostic impressions, and identification of service needs. Each youth has a Children s Functional Assessment Rating Scale (CFARS) s assessment completed upon admission and every 6 months thereafter by the licensed professional that assesses the youth s level of functioning in areas such as school, in home behavior, substance abuse, medical, etc, and assists with developing individualized treatment services. All youth receive a psychiatric evaluation following admission. In addition, youth are seen every ninety days for continued follow-up by the psychiatrist regardless of medication needs. The youth and their families are provided therapeutic services in appropriate settings which include individual, group, and family therapy sessions on a weekly basis. The THINKING FOR A CHANGE group curriculum is utilized. Specialty treatment services are reviewed on a monthly basis as part of the internal risk management systems. Standard 4: Health Services Failed Minimal Acceptable Commendable Exceptional Overview The program has a contract with a medical doctor that serves as the Designated Health Authority (DHA). The DHA is on site every Thursday for at least two hours. There is a full time Licensed Practical Nurse (LPN) on site Monday through Friday between the hours of 7:00AM and 3:30PM. The program has a Registered Nurse (RN) on-site for eight hours every Friday. Both the RN and full time LPN have on-call availability. The program has two PRN nurses that are LPNs and utilized as needed. All youth are seen by the DHA within seven days of the youth s admission and a new comprehensive physical assessment is completed regardless if the prior comprehensive physical assessment is still current. Office of Program Accountability Page 12 of 18

4.01: Designated Health Authority Exceptional (10) The program has a contract with a Medical Doctor who serves as the Designated Health Authority (DHA). The program also has a contract with a medical consultant that is also a Medical Doctor. The medical consultant provided support and oversight to the DHA, Director of Health Services and the psychiatrist through face-to-face consultations, telephone calls and participation on the monthly conference calls and site visits. The DHA examined all youth admitted to the program for completion of a new Comprehensive Physical Assessment to ensure the health status of each youth. The program utilizes an Advance Registered Nurse Practitioner (ARNP) for on-site emergency services and vacation coverage when needed. 4.02: Healthcare Admission Screening Exceptional (10) All Facility Entry screening forms were completed by nursing staff. The Designated Health Authority was notified of all admissions regardless of the youth s medical status. The youth s medical history was discussed with the DHA and any medical requirements were immediately implemented. The Designated Health Authority saw all youth within seven days regardless of the youths medical condition. Documentation included a phone call to parents/guardians to confirm medical information and allergies during the admission screening. The nurse completed a detailed admission progress note identifying all pertinent medical information. 4.03: Comprehensive Physical Assessment Exceptional (10) The Health Related History was completed/updated/reviewed on all youth the day of the youth s admission. All youth have their Body Mass Index (BMI) assessed and graphed to exhibit their status at the time of admission. Youth on the high or low end of the continuum are placed on a special diet to increase or reduce their caloric intake. All youth were seen within seven days of admission by the DHA. This included the completion of a new Comprehensive Physical Assessment (CPA). The new CPA was completed regardless of the date of the previous assessment. 4.04: Sexually Transmitted Diseases Exceptional (10) All youth are screened for Sexual Transmitted Diseases (STD) on the day of the youth s admission by a licensed healthcare staff regardless of their sexual history. All youth are tested for Gonorrhea and Chlamydia upon admission per the Designated Health Authority s admission orders. The Designated Health Authority reviews, evaluates and signs all STD screenings regardless if the youth met the criteria for a referral. Office of Program Accountability Page 13 of 18

4.05: Sick Call Acceptable (7) One file contained documentation that indicated the youth had complained of headaches three times within a fourteen day time frame in August and a referral was made to the DHA and the Optometrist. However the same youth complained of headaches six times within a fourteen day period in September and eight times in October occurring within two fourteen time day frames. There was no documentation of an additional referral to the DHA. The youth was treated with over-the-counter medications. 4.06: Medication Administration Acceptable (7) Two files contained Medication Administration Records (MAR) that contained a discrepancy for a youth that refused her medication althought the MAR indicated the medication had been administered. 4.07: Medication Control Acceptable (7) The over-the-counter inventory was missing three items to include rubbing alcohol, peroxide and lubricating jelly. The inventory list was immediately corrected to include the items not being inventoried. 4.08: Infection Control Exceptional (10) All youth were provided the H1N1 vaccine once the medical staff obtained parental permissions and youth are provided influenza vaccine upon admission. All staff were offered the H1N1 vaccine at no cost to the employee. Hand Sanitizer stations are located throughout the facility as an additional infection control preventative practice. Training files indicated staff received Bio-Medical Waste Training annually in addition to the annual Infection Control Training. 4.09: Chronic Illness Treatment Commendable (8) 4.10: Episodic and Emergency Care Exceptional (10) The program had documentation of conducting monthly mock emergency drills usually on all shifts. The program maintained nine first aid kits that were checked daily by the nursing staff to determine if the kits had been opened and were monitored monthly for expired contents and the need for replenishing. Office of Program Accountability Page 14 of 18

4.11: Consent and Notification Acceptable (7) One of five files was missing documentation that the parental notification had been sent certified mail for the H1N1 vaccination. One file contained documentation that the parental notification for a new prescription was mailed however the notification did not include the significant side effects of the medication or the potential adverse effects. One file contained documentation that a parental notification had been sent however should not have been sent due to the medication being prescribed for a sexually transmitted disease. 4.12: Prenatal/Neonatal Care Commendable (8) Standard 5: Safety and Security Failed Minimal Acceptable Commendable Exceptional Overview The Facility Administrator and the Assistant Facility Administrator, and Director of Maintenance are responsible for the safety and security of the facility. The program had operational cameras with recording capability in the living quarters, dayrooms, dining hall and entrance/exits to the program. Radio communication, shift meetings, and electronic monitoring were used as primary communication methods. The program did not utilize room restriction, controlled observation or a behavior management unit. 5.01: Supervision of Youth Acceptable (7) The resident count logs reviewed contained numerous write-overs. Staff did not always draw a single line through the error or initial the error. 5.02: Key Control Exceptional (10) Weekly Safety Inspections by designated staff contained a review of key control to include emergency key safety check and check of all keys for general repair status. The program uses a color coded key identification system for easy sight identification of designated location of keys within key control cabinet: red = restricted, yellow = permanent, green = active. The program has a color coded key control access log that denotes facility staff and their accessibility level to keys. All sets of keys contain a coded sticker that denotes level of key accessibility and/or restrictiveness. Office of Program Accountability Page 15 of 18

The program has a color coded key ring reference file (red = restricted, yellow = permanent, green = active) for easy staff reference and identification. The Risk Management System includes weekly reviews of key control systems and related documentation. The on-site Quality Assurance Manager completes a monthly review of key control systems to include observations and review of documentation. Pasco Girls Academy maintains strict control of keys and has had no incidents of missing, lost or stolen keys. 5.03: Contraband and Searches Exceptional (10) A Weekly Safety Inspection is completed by designated staff to include a mechanical inspection of security alarms, as well as perimeter and interior lighting. Weekly safety inspection also includes review of the various zones and/or of campus for any safety related issues and location of potential safety hazards. In addition, on a weekly basis, the Facility Administrator completes an inspection of the physical structure and grounds to include an inspection of youth rooms, day rooms, cafeteria, class rooms, recreation area, parking area, and overall facility grounds to ensure no contraband introduced into or onto facility grounds. The facility conducts room searches weekly as an increased measure to ensure no contraband is entered into the facility. As part of internal risk management systems the Assistant Facility Administrator (AFA) completes weekly documentation reviews of security audits and safety inspections, as well as room searches. The AFA also completes fidelity checks/ observations of random search practices to ensure proper completion of searches by staff. The Risk Management System includes a monthly review of the contraband and search practices, to include review of documentation and observation of practices. As part of this internal risk management system, the Risk Manager will also complete random fidelity checks of internal search practices. 5.04: Transportation Commendable (8) 5.05: Tool Management Exceptional (10) All tools are identified on a shadow board, along with a picture for easy reference. The picture of the tool and shadow board is numbered for easy reference and if a tool is in use, a picture of the tool is located on the shadow board identifying the tool. Both Class A and Class B tools are located on a shadow board. The Maintenance Director completes a Semi-Annual Master Tool Inventory Inspection, detailing condition of each tool. A monthly inspection of the tool area, to include inspection for overall safety, cleanliness, and inventory is completed by the Director of Maintenance and verified by the Facility Administrator. As part of the Risk Management process, the Quality Assurance Manager completes a monthly evaluation of tools to include inspections, verification checks and a review of tool related documentation. Office of Program Accountability Page 16 of 18

5.06: Disaster and Continuity of Operations Planning Acceptable (7) The Continuity of Operations Plan (COOP) was not updated to include changes in administrative staff. 5.07: Flammable, Poisonous, and Toxic Items Acceptable (7) The daily inventory on January 4, 2011 did not reflect the chemical count in the kitchen s chemical storage room. 5.08: Water Safety Non-Applicable (NA) The program s policy, procedure, and practice confirm the requirements of the indicator were not applicable for this program. 5.09: Behavior Management System Exceptional (10) The behavior management system utilized principles of Cognitive Behavioral Theory (CBT), Girls Matter, and Sanctuary. Positive behavior is recognized and rewarded at a minimum of 4:1, to include Youth of the Month, Student of the Month, weekly cleanest room incentive, sewing class participation, weekly incentive for no phases, PAR free/physical aggression parties, and other related behavioral incentives to include privilege outings, movie nights, etc. Youth must complete level advancement packets that demonstrate their understanding and knowledge of the Seven Commitments and the impact that their behavior has had on themselves and others. Once the youth has advanced in a level, the youth is recognized in front of all during weekly community meeting. The system tracks negative as well as positive behaviors on a point system. A youth s points can be turned in for tokens, which are then cashed in to purchase items in the canteen, as well as snacks in the store. The program utilizes a Youth Advisory Board that meets on a monthly basis with the Facility Administrator and/or AFA to address concerns, unit issues, and provide administration with recommendations to improve programming, as well as recommendations for events. The fidelity and effectiveness of the Behavior Management System is reviewed monthly by the on-site Quality Assurance Manager and documented through the scorecard process which is also reviewed in monthly management meetings. The AFA also completes a daily review of behavior motivation, as well as weekly review of youth points/levels to ensure effective delivery of behavior management system by staff. Office of Program Accountability Page 17 of 18

5.10: Behavior Management Unit Non-Applicable (NA) The program s policy, procedure, and practice confirm the requirements of the indicator were not applicable for this program. 5.11: Controlled Observation Non-Applicable (NA) The program s policy, procedure, and practice confirm the requirements of the indicator were not applicable for this program. Overall Program Performance COMMENDABLE 88% Failed Minimal Acceptable Commendable Exceptional Office of Program Accountability Page 18 of 18