BUREAU OF MONITORING AND QUALITY IMPROVEMENT 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 MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR Polk Halfway House G4S Youth Services, LLC. (Contract Provider) 2145 Bob Phillips Road Bartow, Florida 33830 Review Date(s): February 28 - March 3, 2017 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES

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: Canitha Taylor, Office of Program Accountability, Lead Reviewer (Standard 1) Teresa Andersen, Office of Program Accountability, Deputy Regional Supervisor, (Standard 1) Norma Bolton, AMIkids Melbourne Center for Personal Growth, Director of Case Management, (Standard 2) Stephanie Lobzun, Office of Program Accountability, Regional Monitor, (Standard 3) Scott Luciano, Office of Program Accountability, Regional Monitor, (Standard 4) Bonita Williams, Office of Program Accountability, Regional Monitor, (Standard 5)

Program Name: Polk Halfway House QI Program Code: 1049 Provider Name: G4S Youth Services, LLC. Contract Number: R2095 Location: Polk County / Circuit 10 Number of Beds: 24 Review Date(s): February 28 - March 3, 2017 Lead Reviewer Code: 152 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 and Performance Plan, (3) Mental Health and Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included in the Residential Standards. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee 1 # Case Managers 3 # Clinical Staff 0 # Food Service Personnel 1 # Healthcare Staff 1 # Maintenance Personnel 5 # Program Supervisors Documents Reviewed 5 # Staff 5 # Youth 3 # Other (listed by title): assistant facility administraor, psychiatrist, lead teacher Accreditation Reports Affidavit of Good Moral Character CCC Reports Confinement Reports Continuity of Operation Plan Contract Monitoring Reports Contract Scope of Services Egress Plans Escape Notification/Logs Exposure Control Plan Fire Drill Log Fire Inspection Report Fire Prevention Plan Grievance Process/Records Key Control Log Logbooks Medical and Mental Health Alerts PAR Reports Precautionary Observation Logs Program Schedules Sick Call Logs Supplemental Contracts Table of Organization Telephone Logs Surveys Vehicle Inspection Reports Visitation Logs Youth Handbook 5 # Health Records 5 # MH/SA Records 5 # Personnel Records 5 # Training Records/CORE 5 # Youth Records (Closed) 5 # Youth Records (Open) # Other: 5 # Youth 5 # Direct Care Staff # Other: Observations During Review Admissions Confinement Facility and Grounds First Aid Kit(s) Group Meals Medical Clinic Medication Administration Posting of Abuse Hotline Program Activities Recreation Searches Security Video Tapes Sick Call Social Skill Modeling by Staff Staff Interactions with Youth Comments Staff Supervision of Youth Tool Inventory and Storage Toxic Item Inventory and Storage Transition/Exit Conferences Treatment Team Meetings Use of Mechanical Restraints Youth Movement and Counts Items not marked were either not applicable or not available for review. Office of Program Accountability Page 3 of 67 (Revised July 2016)

Standard 1: Management Accountability Residential Rating Profile Indicator Ratings 1.01 Standard 1 - Management Accountability * Initial Background Screening 1.02 Five-Year Rescreening 1.03 * Provision of an Abuse-Free Environment 1.04 * Management Response to Allegations Non-Applicable 1.05 * Incident Reporting (CCC) 1.06 Protective Action Response (PAR) and Physical Intervention Rate Non-Applicable 1.07 * Pre-Service/Certification Requirements 1.08 In-Service Training 1.09 Grievance Process Training 1.10 Grievance Process 1.11 Grievance Process Documentation 1.12 Life Skills Training Provided to Youth 1.13 Staff Training: Delinquency Interventions 1.14 Restorative Justice Awareness for Youth 1.15 Delinquency Intervention Services 1.16 Gender-Specific Programming 1.17 Logbook Entries and Shift Report Review 1.18 * Internal Alerts System 1.19 * Alerts (JJIS) 1.20 Education Acces 1.21 Youth Records (Healthcare and Management) 1.22 Youth Input 1.23 Advisory Board 1.24 Program Planning 1.25 Staff Performance * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 4 of 67 (Revised July 2016)

Standard 2: Assessment and Performance Plan Residential Rating Profile Indicator Ratings Standard 2 - Assessment and Performance Plan 2.01 Initial Contacts to Parent/Gaurdian 2.02 Court Notification 2.03 Youth Orientation 2.04 Written Consent of Youth Eighteen or Older 2.05 Classification Factors 2.06 Classification Procedures 2.07 Reassessment for Activities 2.08 Gang Identification: Notification of Law Enforcement 2.09 Gang Identification: Prevention and Intervention Activities 2.10 R-PACT Assessment 2.11 Youth Needs Assessment Summary Limited 2.12 R-PACT Reassessments 2.13 Parent/Guardian Involvement in Case Management Services 2.14 Members of Treatment Team 2.15 Performance Plan Development Limited 2.16 *Performance Plan Goals 2.17 Performance Plan Transmittal 2.18 Incorporation of Other Plans Into Performance Plan 2.19 Treatment Team Meetings (Formal Reviews) 2.20 Treatment Team Meetings (Informal Reviews) 2.21 Performance Plan Revisions 2.22 Performance Summaries 2.23 Performance Plan Summary Transmittal 2.24 Career Education 2.25 Education Transition Plan 2.26 Transition Planning and Conference 2.27 Exit Portfolio 2.28 Exit Conference * 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 67 (Revised July 2016)

Standard 3: Mental Health and Substance Abuse Services Residential Rating Profile Indicator Ratings Standard 3 - Mental Health and Substance Abuse Services 3.01 Designated Mental Health Clinician Authority or Clinical Coordinator 3.02 * Licensed Mental Health and Substance Abuse Clinical Staff 3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff 3.04 Mental Health and Substance Abuse Admission Screening 3.05 Mental Health and Substance Abuse Assessment/Evaluation 3.06 Mental Health and Substance Abuse Treatment 3.07 * Treatment and Discharge Planning Limited 3.08 * Specialized Treatment Services 3.09 * Psychiatric Services 3.10 * Suicide Prevention Plan 3.11 * Suicide Prevention Services Limited 3.12 * Suicide Precaution Observation Logs 3.13 * Suicide Prevention Training Limited 3.14 * Mental Health Crisis Intervention Services 3.15 * Crisis Assessments 3.16 * Emergency Mental Health and Substance Abuse Services 3.17 * Baker and Marchman Acts Non-Applicable * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 6 of 67 (Revised July 2016)

Standard 4: Health Services Residential Rating Profile Indicator Ratings Standard 4 - Health Services 4.01 * Designated Health Authority/Designee 4.02 * Psychiatrist/Designee 4.03 Facility Operating Procedures 4.04 Authority for Evaluation and Treatment 4.05 Parental Notification 4.06 Notification - Clinical Psychotropic Progress Note 4.07 Immunizations 4.08 Healthcare Admission Screening Form 4.09 Medical Alerts 4.10 Youth Orientation to Healthcare Services 4.11 Designated Health Authority/Designee Admission Notification 4.12 Healthcare Admission Rescreening 4.13 Health Related History 4.14 Comprehensive Physical Assessment 4.15 Female-Specific Screening/Examination Non-Applicable 4.16 Tuberculosis Screening 4.17 Sexually Transmitted Infection Screening 4.18 HIV Testing 4.19 Sick Call Process - Requests/Complaints 4.20 Sick Call Process - Visits/Encounters 4.21 Restricted Housing 4.22 Episodic/First Aid Care 4.23 Emergency Care 4.24 Off-Site Care/Referrals 4.25 Chronic Illness/Periodic Evaluations 4.26 Medication Management - Verification 4.27 Medication Management - Orders/Prescriptions 4.28 Medication Management - Storage 4.29 Medication Management - Medication and Sharps Inventory 4.30 Medication Management - Controlled Medications 4.31 Medication Management - Medication Administration Record 4.32 Medication Management - Medication Administration By Licensed Staff 4.33 Medication Management - Medication Provided By Non-Licensed Staff 4.34 Medication Management - Psychotropic Medication Monitoring 4.35 Infection Control - Surveillance, Screening, and Management 4.36 Infection Control - Education 4.37 Infection Control - Exposure Control Plan 4.38 Prenatal Care - Physical Care of Pregnant Youth Non-Applicable 4.39 Prenatal and Neonatal Care - Nutrition, Education of Youth, and Lactation Non-Applicable 4.40 Prenatal and Neonatal Staff Education Non-Applicable * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 7 of 67 (Revised July 2016)

Standard 5: Safety and Security Residential Rating Profile Indicator Ratings Standard 5 - Safety and Security 5.01 Youth Supervision 5.02 * Ten-Minute Checks Limited 5.03 Census, Counts, and Tracking 5.04 Key Control 5.05 Contraband Procedure 5.06 Frisk and Strip Searches 5.07 Vehicles and Maintenance 5.08 Transportation of Youth 5.09 Tool Inventory and Management 5.10 Youth Tool Handling and Supervision 5.11 Outside Contractors 5.12 Fire, Safety, and Evacuation Drills 5.13 Disaster and Continuity of Operations Planning 5.14 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials 5.15 Youth Handling and Supervision for Flammable, Poisonous, and Toxic Items and Materials 5.16 Disposal of All Flammable, Toxic, Caustic, and Poisonous Items 5.17 Recreation and Leisure Activites 5.18 Elements of the Water Safety Plan Non-Applicable 5.19 Staff Training: Water Safety Non-Applicable 5.20 * Swim Test Non-Applicable 5.21 Visitation and Communication 5.22 Comprehensive Behavior Management System 5.23 Implementation and Consistency of Behavior Management System 5.24 Behavior Management System Infractions 5.25 Staff Training: Behavior Management System 5.26 Behavior Management System Monitoring 5.27 Search and Inspection of Controlled Observation Room Non-Applicable 5.28 Controlled Observation Non-Applicable 5.29 Controlled Observation Safety Checks Non-Applicable 5.30 Controlled Observation Release Procedures Non-Applicable * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 8 of 67 (Revised July 2016)

Strengths and Innovative Approaches The program has an aquaponics system as part of the daily education schedule. The youth participate in various recreational activities to allow them to engage in competition while displaying positive sportsmanship, encouraging a sense of unity and building morale. Youth participate in a Boys to Men group on a bi-monthly basis to discuss and participate in activities exclusively geared towards males. The program has a youth advisory board which meets monthly and provides input into their community and offer recommendations into programming. Youth representatives regularly attend community advisory board meetings where they are encouraged to provide input into programming. The program holds weekly community meetings where the youth provide input into their community, ask questions of staff, and resolve issues. The program regularly surveys the youth and parents/guardians for input. Office of Program Accountability Page 9 of 67 (Revised July 2016)

Standard 1: Management Accountability Overview Polk Halfway House is a twenty-four bed non-secure residential commitment program located in Bartow, Florida. The program serves male youth ages ten to fourteen. The program provides mental health overlay services (MHOS) to youth with moderate to severe mental or emotional disturbances whose level of impairment and maladaptive behavior make them unsuitable for a non-specialized program. The program provides evidenced-based practices and specialized treatment which includes Thinking for a Change (T4C), Impact of Crime, (IOC), Young Men s Work (YMW), and Cognitive Behavioral Therapy (CBT). Program staff includes a facility administrator, assistant facility administrator, registered nurse, part-time licensed practical nurse, a clinical director, two master s-level therapists, a case manager, and fourteen direct care staff. At the time of the annual compliance review, there were staff vacancies for four youth care worker. The anticipated length of stay is six to nine months. 1.01 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 policy and procedures requiring background screening on each of their staff, contract providers, and volunteers. The program also conducts a criminal history, local law enforcement checks, and driver s license checks through the Department of Highway Safety and Motor Vehicles prior to each hire. The program also conducts monthly driver s licenses checks throughout the year. The program completed and submitted their Annual Affidavit of Compliance with Level 2 Screening Standards for staff and the Polk County School Board to the Department s Background Screening Unit (BSU) on January 24, 2017. Three new staff have been hired since the last annual compliance review and were eligible for an initial background screening. The program submitted a background screening request for each employee and each received a favorable rating from the BSU prior to their date of hire. 1.02 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 policy and procedures regarding five-year background re-screening to be conducted on each of their staff, contract providers, and volunteers every five years. The program was required to complete one re-screening since the last annual compliance review. One contracted provider staff received a five-year rescreening prior to their five-year anniversary date, but not more than twelve months prior. Office of Program Accountability Page 10 of 67 (Revised July 2016)

1.03 Provision of an Abuse-Free Environment Compliance The program provides an environment in which youth, staff, and others feel safe, secure, and not threatened by any form of abuse or harassment. Posting of the Florida Abuse Hotline telephone number and the Central Communications Center for youth 18 years of age and older telephone number. All allegations of child abuse or suspected child abuse are immediately reported to the Florida Abuse Hotline. Youth and staff have unhindered access to report alleged abuse to the Florida Abuse Hotline pursuant to Section 39.201 (1)(a), F.S. The environment is free of physical, psychological, and emotional abuse. A code of conduct for staff who clearly communicates expectations for ethical and professional behavior, including the expectation for staff to interact with youth in a manner promoting their emotional and physical safety. The program has a policy and procedure which promotes an abuse or harassment free environment for youth, staff, and others to feel safe and secure. The program has all staff review and sign a code of conduct which clearly communicates expectations for ethical and professional behavior. The program has the Florida Abuse Hotline and the Department s Central Communications Center (CCC) contact information posted throughout the facility. The facility operating procedure (FOP) states all allegations of abuse or suspected abuse will be immediately reported to the Florida Abuse Hotline and both youth and staff have unrestricted access to report allegations. In the event a youth wants to make a report, the youth notifies a staff member, the staff member contacts a supervisor, and the supervisor will then escort the youth to a phone in order to call the Florida Abuse Hotline. The program had no substantiated allegations of abuse since the last annual compliance review. Five youth were surveyed and interviewed and all indicated they felt safe at the program, had never been stopped from reporting abuse, and staff treat them with respect. Three of the five youth responded to the survey question stating they hear staff use profanity on occasion; however, it was never directed at any youth. Five surveyed staff and five interviewed staff members were all able to explain the program s policy for allowing youth to call the Florida Abuse Hotline or the CCC to report allegations of abuse and have never seen a staff deny a youth from calling either. 1.04 Management Response to Allegations Non-Applicable Management shall be cognizant of youth and staff needs and provide direction to each on how to access the Florida Abuse Hotline. There is evidence management takes immediate action to address incidents of physical, psychological, and emotional abuse. The program had no incidents of physical, psychologic, or emotional abuse in the facility during this review period; therefore, this indicator rates as non-applicable. Office of Program Accountability Page 11 of 67 (Revised July 2016)

1.05 Incident Reporting (CCC) Compliance Whenever a reportable incident occurs, the program notifies the Department s Central Communications Center (CCC) within two hours of the incident, or within two hours of becoming aware of the incident. The program has a policy and procedures in place regarding reporting incidents. A total of five Central Communications Center (CCCs) reportable incidents were reviewed for this annual compliance review. All CCC calls are discussed during the daily management meetings. The five reviewed CCC s were reported within the two hours of the incident or within two hours of staff becoming aware. A review of internal incident reports and youth records did not reveal any other incidents of physical, psychologic, or emotional abuse which should have been reported to the CCC. 1.06 Protective Action Response (PAR) and Physical Intervention Non-Applicable Rate The program uses physical intervention techniques in accordance with Florida Administrative Code. Any time staff uses a physical intervention technique, such as countermoves, control techniques, takedowns, or application of mechanical restraints (other than for regular transports), a PAR Incident Report is completed and filed in accordance with the Florida Administrative Code. There have been no Protective Action Response (PAR) incidents during this review period; therefore, this indicator rates as non-applicable. 1.07 Pre-Service/Certification Requirements Compliance Contracted and State residential staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. The program has a policy and procedures regarding pre-service training for all hired staff. Three staff training files were reviewed for pre-service training. Each staff completed skills training to include certification in cardiopulmonary resuscitation (CPR), first aid, automated external defibrillator (AED), Protective Action Response (PAR), suicide prevention, child abuse reporting, and emergency procedures prior to contact with youth. All required training could be found in the staff training files and was listed in the Department s Learning Management System (SkillPro). There was documentation to support all instructors were qualified to deliver the provided training. The pre-service training plan was submitted to the Department s Office of Staff Development and Training and was approved on February 24, 2016. Office of Program Accountability Page 12 of 67 (Revised July 2016)

1.08 In-Service Training Compliance Residential staff complete twenty-four hours of in-service training, including mandatory topics specified in Florida Administrative Code, each calendar year, effective the year after preservice/certification training is completed. Supervisory staff completes eight hours of training (as part of the twenty-four hours of annual inservice training) in the areas specified in Florida Administrative Code. The program has a policy and procedures regarding staff training. Five staff training files were reviewed for annual in-service training. Each reviewed training file documented staff exceeded the twenty-four-hour annual training requirement. All reviewed training files contained current certifications in first aid, cardiopulmonary resuscitation (CPR), use of automated external defibrillator (AED), and eight hours of Protective Action Response (PAR). Training updates were documented in the Department s Learning Management System (SkillPro). Additional training was documented in professionalism and ethics, suicide prevention, restorative justice, and the program s behavior modification system. Three supervisory training files were reviewed for the required annual eight hours of supervisory training. All three supervisors completed over the eight hours annual training and updates were documented in SkillPro. The in-service training plan was approved by the Department s Office of Staff Development and Training on February 10, 2016. 1.09 Grievance Process Training Compliance Program staff shall be trained on the program s youth grievance process and procedures. The program has a policy and procedures regarding training in the grievance process. The policy requires all staff to be trained in the grievance process. A review of five pre-service and five in-service training files indicated all staff were trained on the grievance process during their initial training. 1.10 Grievance Process Compliance The program adheres to their grievance process and shall ensure it is explained to youth during orientation and grievance forms are available throughout the facility. The program s grievance procedure includes an informal, formal, and appeal phase. The informal phase is called Speak-Out, which gives the youth the opportunity to address concerns with the staff. If the youth does not agree with the resolution, a formal grievance is filed and reviewed by a supervisor within forty-eight hours with a resolution. If the youth is not in agreement to the resolution, the youth may appeal the resolution. An appeal grievance is reviewed by the facility administrator within five working days with the final resolution. Grievance forms are located in the general living area accessible to the youth. The program had a total of eleven Speak-Outs in the last six months, which were related to youth requesting to speak to a case manager, therapist, nurse, or facility administrator. All Speak-Outs were handled within twenty-four hours. There was only one grievance filed within the past six months. The program handled it within the forty-eight hours and the youth agreed with the investigation findings and recommendations. Five youth were surveyed and indicated they understand the grievance process and could request assistance when filling out a grievance form. One youth rated the Office of Program Accountability Page 13 of 67 (Revised July 2016)

process fair and four youth stated they had never filed a grievance. All five staff surveyed were able to explain the youth grievance process and reported any staff can assist youth in completing a grievance. 1.11 Grievance Process Documentation Compliance Completed grievances shall be maintained by the program for a minimum of twelve months. The program maintains a grievance log binder. There was only one grievance filed in the past six months. The grievance contained the date it was filed, date of response, and final outcome, which was resolved within the required time frame of twenty-four hours of submission. 1.12 Life Skills Training Provided to Youth Compliance The program shall provide interventions or instruction focusing on developing life and social skill competencies in youth. The program provided group cycles of Thinking for a Change (T4C) and Young Men Work (YMW) twice in the last year with less than ten youth in each group. A review of sign-in sheets, as well as the activity schedule, confirmed the group sessions were being delivered to the youth. Facilitators were trained by qualified staff in the T4C and YMW intervention. Youth also participate in a Boys to Men group on a bi-monthly basis to discuss and participate in activities exclusively geared towards males. The program also integrates life skills into individual therapy sessions. Therapists delivering the life skills groups were qualified to deliver the life skills associated with the substance abuse, conflict management, and anger management skills. Interviews with youth revealed they were receiving anger and conflict management skills, recognizing triggers, avoidance skills, and focusing on long term goals. 1.13 Staff Training: Delinquency Interventions Compliance Staff whose regularly assigned job duties include implementation of a specific delinquency intervention model, strategy, or curriculum receive training in its effective implementation. The program provides Impact of Crime (IOC), Thinking for a Change (T4C), and Young Men s Work (YMW). There are four staff trained to provide IOC and two staff trained to provide T4C and YMW. Each staff met the educational requirements and had the work experience to facilitate delinquency intervention groups. A review of the training files verified each staff s assigned job duties includes implementation of a specific delinquency intervention model, strategy, or curriculum. An interview was conducted with the facility administrator (FA) to determine how the program considers what staff should facilitate delinquency interventions. The FA stated educational background and prior training are considered for a facilitator role. Additionally, the FA ensures the staff have great communication and listening skills to provide an effective curriculum based on youth needs. Office of Program Accountability Page 14 of 67 (Revised July 2016)

1.14 Restorative Justice Awareness for Youth Compliance The program shall provide activities or instruction intended to increase youth awareness of, and empathy for, crime victims and survivors, and increase personal accountability for youths criminal actions and harm to others. The program provides Impact of Crime (IOC) groups. The program schedule provides for two IOC groups a week. Documentation confirmed the IOC groups were conducted as scheduled. All youth receive the IOC curriculum. The training files for staff who facilitate the IOC groups indicated staff have been trained in the curriculum. IOC groups for the youth are held on Tuesdays and Thursdays. During the annual compliance review, an IOC group was observed by an annual compliance review team member. The facilitator provided the team member with a copy of the lesson being delivered. The program maintains group sign-in sheets and fidelity monitoring reports, which are kept in a three-ring binder. The program has guest speakers scheduled to present through the education department. The youth are to complete letters of apology, and community service work hours through local food bank as part of their case plan. 1.15 Delinquency Intervention Services Compliance The program shall implement a delinquency intervention model or strategy that is an evidencebased practice, promising practice, or a practice with demonstrated effectiveness, for each youth. The program delivered Thinking for a Change (T4C) curriculum for two group cycles of ten youth each in the last year. The program also delivered Impact of Crime (IOC) practice with demonstrated effectiveness to two group cycles of ten youth each. A review of five performance plans revealed the youth received the services based on identified needs. Facilitators of the delinquency intervention services were trained by qualified staff. During the annual compliance review, a team member observed delivery of an IOC and T4C group. The groups were delivered by a licensed therapist who maintained control of the group, engaged all youth, and used motivational interviewing skills. The program maintains group sign-in sheets and fidelity monitoring reports, which are kept in a three-ring binder. 1.16 Gender-Specific Programming Compliance The program provides delinquency intervention and gender-specific treatment services. The program provides delinquency intervention and treatment services which are genderspecific for male youth. The program promotes appropriate health and hygiene, life skills, social skills training, recreation activities, and leisure activities as key components in providing genderspecific programming. A review of five records indicated each youth received gender-specific services by participating in Young Men s Work and Boys to Men groups on a bi-monthly basis. A review of the program s daily activity schedule verified the delivery of the gender-specific curriculum, which is gender-relevant support curriculum for male youth from ages fourteen through nineteen. The curriculum aims to help male youth work together to solve problem topics such as fears, anxieties, gangs, drugs, or work ethic. Five youth were interviewed and each indicated they participated in at least one of the groups. Office of Program Accountability Page 15 of 67 (Revised July 2016)

1.17 Logbook Entries and Shift Report Review Compliance The program maintains a chronological record of events, incidents, and activities in a central log-book maintained at master control, living unit logbooks, or both, in accordance with Florida Administrative Code. The program ensures direct care staff, including each supervisor, are briefed when coming on duty. The program uses a pre-printed shift report formatted form in a bound book, which includes census information, youth on alerts, staff shift assignments, youth movements, drills conducted, and security checks. The logbook is bound with sequentially numbered pages. A staff supervisor is assigned to maintain the log and make entries regarding chronological events for each shift. A review of logbooks for the past six months were found to include the date, time, staff and youth involved, a brief description of the event, name, and signatures of the staff making the entry. Entries regarding medical, special needs, and mental health alert issues which may impact the safety and security were highlighted. Any errors were struck through with a single line and were initialed by the person making the correction. The assigned staff member on each shift signs the log indicating they have reviewed entries from previous shifts. There were no internal incidents required to be reported to the Florida Abuse Hotline and/or the Central Communications Center. 1.18 Internal Alerts System Compliance The program shall maintain and use an internal alert system easily accessible to program staff and keeps them alerted about youth who are security or safety risks, and youth with healthrelated concerns, including food allergies and special diets. When risk factors or special needs are identified during or subsequent to the classification process, the program immediately enters this information into its internal alert system. The program ensures only appropriate staff may recommend downgrading or discontinuing a youth s alert status. The program has a policy outlining the internal alert system and requirements for entering alerts into the Department s Juvenile Justice Information System (JJIS). The program maintains an alert board in the staff office containing information regarding safety, security, medical issues, allergies, and special diets. The alert board information is updated daily by clinical, medical, and case management staff. Program management reviews all alerts during the daily management meetings and the board is updated, as necessary. The internal alert board was compared to information contained in the JJIS and the alert board accurately reflected all youth alerts. The nurse updates a list of youth food allergies and special diets weekly and posts it in the dining room in an area which is out of the view of the youth, but easily accessed by the food service workers. The alerts are easily accessible to program staff. Five staff were interviewed and indicated they received information regarding youth alerts from reviewing the alert board, through the logbook, the shift meetings, and alert forms. 1.19 Alerts (JJIS) Compliance When risk factors or special needs are identified during or subsequent to the classification process, the program immediately enters this information into the Juvenile Justice Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are downgraded or discontinued. The program has a written policy and procedures on how alerts are identified, documented, updated, and communicated to staff. A review of alerts in the Department s Juvenile Justice Office of Program Accountability Page 16 of 67 (Revised July 2016)

Information System (JJIS) found they were consistent with the program s internal alert system. A review of five youth healthcare records, five mental health and substance abuse records, and five case management records confirmed all required alerts were in JJIS. An interview with the program director confirmed alerts are downgraded or discontinued by an appropriate staff member, when necessary. 1.20 Educational Access Compliance The facility shall integrate educational instruction (career and technical education, as well as academic instruction) into their daily schedule in such a way ensuring the integrity of required instructional time. The program maintains an interagency agreement with the Polk County School Board to provide year-round educational instruction to all youth. Assigned to the program are two teachers, a computer lab assistant, and a lead teacher/principal. Five case management records were reviewed and each youth was receiving educational instruction. Each applicable youth receives credit for their educational and career course work through the Polk County School Board. An interview with the lead teacher indicated the program provides 315 minutes of daily instruction five days a week. A review of the daily schedule documented minimal interruption to the youth s educational program. The logbook entries documented youth are attending school during the times indicated on the activity schedule. Five staff were interviewed and indicated there are rare schedule changes. During this annual compliance review, the classrooms were observed to be quiet with youth well behaved and engaged in the curriculum. 1.21 Youth Records (Healthcare and Management) Compliance The program maintains an official case record, labeled Confidential, for each youth, which consists of two separate files: An individual healthcare record An individual management record. The program uses three separate records to maintain information regarding each youth, including a case management record, an individual health care record, and a mental health and substance abuse record. Each individual case management record contained the youth s name, Department of Juvenile Justice Identification (DJJID), date of birth, county of residence, committing offense, legal information, demographic and chronological information, correspondence, case management and treatment services, and was labeled confidential. Each reviewed record contained the required information and was organized as required. Observations made during a tour of the facility found the program maintains youth records securely in locked file cabinets clearly identified as, confidential. Youth records were securely maintained in the respective case management office, clinic, or mental health staff office. 1.22 Youth Input Compliance The program has a formal process to promote constructive input by youth. The program has a youth advisory board to promote constructive input from the youth. The youth advisory board consists of youth selected by the staff based on their behavior and attitude. Documentation of sign-in sheets, agendas, and minutes confirmed the youth advisory board meets monthly. A review of agendas indicated youth discuss food issues, house rules, and positives rewards. Daily community meetings are held for youth to express comments or Office of Program Accountability Page 17 of 67 (Revised July 2016)

concerns of the daily activities with staff. The program conducts random surveys with the youth and parent/guardians on a quarterly basis to express any concerns. Youth also have access to Speak-Outs to communicate non-grievance issues. Five surveyed youth indicated they are provided the opportunity to provide input about what happens at the program. During an interview with the facility administrator (FA), he indicated there is a weekly open discussion group with staff, shift supervisors, and youth. He brings any concerns to the daily management team meetings for discussion. 1.23 Advisory Board Compliance The program has a community support group or advisory board meeting at least quarterly. The program director solicits active involvement of interested community partners. The program has a community advisory board with representatives from law enforcement, the business community, the school board, and faith-based community. At the time of the annual compliance review, there was no parent/guardian of a youth formerly involved in the juvenile justice system; however, there is documentation of the facility administrator s efforts to solicit membership from a former parent/guardian. Reviewed documentation revealed the program conducted community advisory board meetings quarterly. This documentation included attendance sheets, agendas, and meeting minutes. The advisory board helps to provide youth with educational opportunities, vocational experiences, and assists the community with information related to the program. An interview with the facility administrator (FA) indicated the advisory board meets every quarter, he also stated he felt the board members continue to explore ways to involve the community, and to solicit new members. 1.24 Program Planning Compliance The program uses data to inform their planning process and to ensure provisions for staffing. The program conducts morning management meetings Monday through Friday each week. The meeting includes the clinical director, business manager, nurse, facility administrator, assistant facility administrator, compliance manager, and corporate staff. Information on admissions, pending transition and exit meetings, pending releases, incident reports, physical interventions, alerts, grievances, medical and mental health concerns, and education issues are discussed during these meetings. Weekly meetings are held with management staff to discuss admissions and releases, Protective Action Response (PAR) reports, emergency room visits, injuries, grievances, altercations, length of stay, and overtime. Monthly all-staff meetings are conducted to inform staff of important developments and provide an opportunity for staff to have input into program operations. The program conducts youth and parent/guardian surveys to provide the program with opinions used to identify issues. Also, the surveys are critical in the development of a more effective interaction with the program staff, which can affect the youth s behavior in the program. Five staff were interviewed and indicated communication is overall good, one staff indicated there is a high level of communication, and stated administration encourages feedback on the programs practices and procedures. Office of Program Accountability Page 18 of 67 (Revised July 2016)

1.25 Staff Performance Compliance The program ensures a system for evaluating staff, at least annually, based on established performance standards. The program has a policy and procedures requiring each staff be evaluated after ninety days of employment and annually thereafter. A review of performance evaluations for both management and direct care staff indicated all staff received a ninety-day probationary evaluation and applicable staff were evaluated annually in October of 2016. All reviewed personnel files contained a job description specific for the duties performed by the staff. A review of job descriptions for management and direct care staff confirmed performance standards corresponded to the expectations in the annual evaluation. Annual evaluations addressed effective communication, use of motivational interviewing, understanding the youth s stages of change, understanding of program and facility fundamentals, and effective use of the program s behavior motivation system. Four of the five surveyed staff indicated they receive yearly performance evaluations; one did not answer all the questions. Office of Program Accountability Page 19 of 67 (Revised July 2016)

Standard 2: Assessment and Performance Plan Overview The program has one full-time case manager who serves as the treatment team leader for all twenty-four youth in the program. The case manager is responsible for notifications and contacts with the parent/guardian, juvenile probation officer, and the court. Additional duties of the case manager include risk classifications, the Residential Positive Achievement Change Tool (R-PACT), the Youth Needs Assessment Summary (YNAS), performance plans, progress reports, and transition planning. The treatment team meets monthly to review each youth s progress on performance and treatment plans. 2.01 Initial Contacts to Parent/Guardian Compliance The program notifies the youth s parent/guardian by telephone within twenty-four hours of the youth s admission, and by written notification within forty-eight hours of admission. A review of five case management records contained documentation indicating the program made verbal and written contact with the youth s parent/guardian within twenty-four hours of admission. A letter was sent to the parent/guardian advising them of the youth s admission to the program and identified key staff contacts including the case manager and the assigned therapist, a handbook with information on the treatment team meetings, performance plan, and visitation. 2.02 Court Notification Compliance The program notifies the youth s committing court(s) by written notification within five working days of admission. All five reviewed case management records contained documented copies of the letters sent to the committing court, dated within five working days of the youth being admitted to the program, along with a copy sent to the assigned juvenile probation officer. 2.03 Youth Orientation Compliance The program shall provide each youth an orientation to the program rules, procedures, schedules, and services applicable to youth, to begin within twenty-four hours of admission. Five reviewed case management records documented an orientation checklist is completed on each youth upon admission and is placed in the case record. The orientation checklist includes information which the case manager reviews, including the availability of and access to medical and mental health services. Each youth is given a copy of the Florida Abuse Hotline phone number or the Department s Central Communications Center (CCC) incident reporting hotline number if the youth is eighteen years old. The daily schedule is conspicuously posted in the dorm areas and the classroom/activity areas for the youth to have easy access to this information. The youth are given a copy of the resident handbook, which is reviewed with the youth for the program s expectations, responsibilities including rules governing conduct and consequences for negative and positive behaviors, an overview of the behavior management system, items considered contraband, a review of the performance planning process, dress code and hygiene practices, visitation, mail and use of the telephone, anticipated length of stay, grievance procedures, community access, and emergency procedures dealing with fires and Office of Program Accountability Page 20 of 67 (Revised July 2016)

building evacuations. A copy of the parent handbook is mailed with the admission letter upon intake. Five case management records contained documentation the program began the orientation process within twenty-four hours of the time of admission. Five youth were surveyed and indicated the orientation process began within twenty-four hours of their admission. 2.04 Written Consent of Youth Eighteen Years or Older Compliance The program obtains written consent of any youth eighteen years of age or older, unless the youth is incapacitated and has a court-appointed guardian, before providing or discussing with the parent/guardian any information related to the youth s physical or mental health screening, assessment, or treatment. There have been no youth admitted to the program eighteen years or older since the last annual compliance review; therefore, this indicator rates as non-applicable. 2.05 Classification Factors Compliance The program utilizes a classification system, in accordance with Florida Administrative Code, promoting safety and security, as well as effective delivery of treatment services. The program has a policy and procedures in place detailing each youth s classification. The program uses a classification form which contains detailed information such as physical characteristics, age, maturity level, identified special needs, history of violence, gang affiliation, sexual aggression, and vulnerability thus meeting all requirements for risk factors. The case manager completes a classification on each youth prior to the youth s arrival. The treatment team then makes the decision determining the most appropriate placement on the living unit, which is then documented in each youth s case management record. A review of five case management records contained a competed classification form. An interview with the facility administrator (FA) confirmed the admission classification meeting is conducted to assist staff in identifying potential safety and security issues which would directly impact the living unit. 2.06 Classification Procedures Compliance Initial classification should be used for the purposes of assigning each newly admitted youth to a living unit, sleeping room, and youth group or staff advisor. The program classifies youth during the initial intake process for the purpose of assigning the youth to the most appropriate living area. The classification of each youth is determined by the youth s risk, physical characteristics, age and maturity level, identified special needs, history of violence, gang affiliations, criminal behavior, sexual aggression, and vulnerability. The program has a system alerting staff when physical, mental health, substance abuse, security risk factors, and special youth needs are identified during or subsequent to the classification process. Five youth case management records were reviewed and each had documentation the youth was assigned a living unit based on the program s classification system. Office of Program Accountability Page 21 of 67 (Revised July 2016)