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 Redirection Service - Circuit 7 The Chrysalis Center, Inc. (Contract Provider) 412 S. Palmetto Avenue Daytona Beach, Florida 32114 Review Date(s): November 14-15, 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 which 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 which 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 which 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: Mike Marino, Office of Program Accountability, Lead Reviewer (Standards 1 and 4) Amy Tyson, Office of Program Accountability, Regional Monitor (Standards 2 and 3)

Program Name: Redirection Service - Circuit 7 MQI Program Code: 1352 Provider Name: The Chrysalis Center, Inc. Contract Number: 10157 Location: Volusia County / Circuit 7 Number of Beds: 12 Review Date(s): November 14-15, 2017 Lead Reviewer Code: 37 Methodology This review was conducted in accordance with FDJJ-2000 (Contract Management and Program Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1) Management Accountability, (2) Assessment Services, and (3) Intervention Services, which are included in the Probation and Community Intervention Standards. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee # Case Managers # Clinical Staff # Food Service Personnel # Healthcare Staff Documents Reviewed # Maintenance Personnel 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 # Health Records # MH/SA Records 3 # Personnel Records 3 # Training Records/CORE 4 # Youth Records (Closed) 5 # Youth Records (Open) # Other: # Youth # Direct Care Staff # Other: Observations During Review Admissions Confinement Facility and Grounds First Aid Kit(s) Group Meals Medical Clinic Medication Administration Posting of Abuse Hotline Program Activities Recreation Searches Security Video Tapes Sick Call Social Skill Modeling by Staff Staff Interactions with Youth Comments Staff Supervision of Youth Tool Inventory and Storage Toxic Item Inventory and Storage Transition/Exit Conferences Treatment Team Meetings Use of Mechanical Restraints Youth Movement and Counts Items not marked were either not applicable or not available for review. Office of Program Accountability Page 3 of 18 (Effective July 2016)

Standard 1: Management and Accountability Redirection Services Rating Profile Indicator Ratings Standard 1 - Management Accountability 1.01 Initial Background Screening* 1.02 Five-Year Rescreening 1.03 Pre-Service and/or In-Service Training 1.04 Incident Reporting (CCC)* 1.05 Abuse Reporting (DCF) 1.06 Administration 1.07 JJIS and Data Requirements 1.08 Mental Health Services Staffing Requirements and Qualifications 1.09 Substance Abuse Services Staffing Requirements and Qualifications * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Probation and Community Intervention Annual Compliance Report Office of Program Accountability Page 4 of 18 (Effective July 2015)

Standard 2: Assessment Services Redirection Services Rating Profile Indicator Ratings Standard 2 - Assessment Services 2.01 Referral Process 2.02 Admission and Services Provision Processes 2.03 Intake Conference and Orientation 2.04 Clinical Assessments 2.05 Clinical Assessment Qualifications* * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 5 of 18 (Effective July 2016)

Standard 3: Intervention Services Redirection Services Rating Profile Indicator Ratings Standard 3 - Intervention Services 3.01 Individualized Plan of Care 3.02 Practitioner Qualifications 3.03 Redirection Therapy Services 3.04 Mntl Hlth/ Subst Abuse Treatment Services 3.05 Release/Discharge * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 6 of 18 (Effective July 2016)

Standard 4: Fidelity Monitoring Redirection Services Rating Profile Indicator Ratings Standard 4 - Fidelity Monitoring 4.01 Treatment Manual/Protocol 4.02 Facilitator Training 4.03 Internal Fidelity Monitoring* 4.04 Corrective Action Based on Fidelity Monitoring 4.05 Evaluation of Facilitator Skill in Delivering the Intervention * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 7 of 18 (Effective July 2016)

Strengths and Innovative Approaches All program therapists are trained in Collaborative Documentation. The use of Collaborative Documentation is designed to encourage therapists and youth to work together to reflect on each session. Therapists use the end of therapy sessions to collaboratively agree on, and document, what occurred during each session. The youth and therapists collaborate on the record of the session, interventions, responses to interventions, and the plan for the next session. Office of Program Accountability Page 8 of 18 (Effective July 2016)

Standard 1: Management Accountability Overview Redirection Services Circuit 7 is operated by Chrysalis Center through a contact with the Department. The contract includes redirection services for multiple circuits statewide. The office for the program is located in Daytona Beach, Florida. The program serves male and female youth ages eleven to nineteen who have been placed on probation, conditional release, or postcommitment probation. The program is designed to provide evidence-based practices, promising practices, and/or alternative family centered therapy for up to twelve youth. The program provides cognitive behavioral therapy (CBT) services, which are provided in the home and include individual and family counseling sessions. CBT services are provided weekly and the average length of service is twelve to sixteen weeks. Program staffing includes one program director and one therapist. The program director is a licensed mental health counselor (LMHC) who is also the program director for redirection services in Circuit 5. The regional clinical director for Chrysalis, who is a LMHC and provides oversight for redirection services programs throughout the state, is located at the Redirection Services Circuit 7 office. The therapist, who is a non-licensed, master s-level counselor, receives weekly supervision from the program director or regional director. All staff have the education and experience required by the contract. The provider receives clearance from the Department s Background Screening Unit prior to staff working with youth. 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 not hired any new staff or recruited any volunteers since the last annual compliance review. The program s policy and procedures states staff and volunteers will be background screened in accordance with the Department s background screening requirements. The provider also conducts additional screenings on new staff, which include the Department of Children and Families background screening process, a local county sheriff office check, driving history check, Florida Sexual Offender Registry search, and the National Sexual Offender Registry search. An Affidavit of Compliance with Level 2 Screening Standards was completed by the Chrysalis corporate office for all Chrysalis programs and submitted to the Department s Background Screening Unit on January 4, 2017. 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 not had any staff or volunteers requiring a five-year rescreening since the last annual compliance review. The program has a written policy and procedures addressing the five-year rescreening of staff and volunteers. Office of Program Accountability Page 9 of 18 (Effective July 2016)

1.03 Pre-Service and/or In-Service Training Compliance All applicable Redirections staff successfully complete training requirements as set forth below. The following training shall be completed prior to the delivery of direct services to Department youth and/or as in-service training to Redirections staff: Juvenile Justice Information System (JJIS) - Pre-Service Information Safety Awareness - Pre and In-Service Motivational Interviewing (MI) - Pre-Service Critical Incident Reporting Requirements - Pre-Service Trauma Informed Care - Pre-Service Adolescent Behavior - Pre-Service The program has not hired any new staff since the last annual compliance review, and thus none of the staff were applicable for pre-service training. Policy and procedures did address pre-service training, stating new hires will receive training on all required topics within ninetydays of their hire date. The three staff for the program received the required in-service training on information security awareness, with two staff completing the training in 2016 and one receiving training the first week of 2017. 1.04 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. Three incidents were reported to and accepted by the Central Communications Center (CCC) in the past six months. The incidents were related to a youth receiving a new charge which resulted in media attention, an allegation against staff (not related to abuse), and program closure due to Hurricane Irma. All incidents were reported to the CCC within two hours of the program having knowledge of the incidents. There was no indication in administrative documentation or youth records reviewed of any reportable incidents not being reported to the CCC. 1.05 Abuse Reporting (DCF) Compliance Any person who knows, or has reasonable cause to suspect, a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or other person responsible for the child's welfare, as defined by Florida Statute, or a child is in need of supervision and care and has no parent, legal custodian, or responsible adult relative immediately known and available to provide supervision and care, reports such knowledge or suspicion to the Florida Abuse Hotline. The program has a written policy and procedures for abuse reporting. Any staff member who is informed of or becomes aware of any type of abuse and/or neglect of a child or vulnerable adult must report this information to their direct supervisor and the executive vice president. Any employee of Chrysalis Health who has knowledge of, or observes, a child or vulnerable adult in his/her professional capacity or within the scope of his/her employment who he/she knows or reasonably suspects has been the victim of abuse is responsible and mandated to formally report the known or suspected instance of abuse to the Florida Abuse Hotline. There have not been any abuse allegations made against staff. The program made two reports to the Florida Office of Program Accountability Page 10 of 18 (Effective July 2016)

Abuse Hotline to report suspected abuse of a youth by a parent/guardian, one of which was accepted for investigation. 1.06 Administration Compliance The Redirection Service program provides a safe and appropriate treatment environment including administrative and operational oversight. The program submitted monthly reports to the Department s contract manager and the Department s statewide redirection coordinator. The reports addressed all information required by the contract, including admissions, releases, abuse reports, personnel actions, incidents, and other pertinent information. Youth listed on the program s roster matched the Department s census report. 1.07 JJIS and Data Requirements Compliance The Redirection Service provider and subcontracted service providers shall utilize the Department s Juvenile Justice Information System (JJIS) for data entry and shall monitor accuracy at all times. The program maintains a spreadsheet to track youth referred to the program. The spreadsheet includes when referrals are received from the Department through the Department s Juvenile Justice Information System (JJIS) booking module and when the referrals are accepted by the program. The spreadsheet documented all referrals were accepted within two business days. Admission and release dates on the program roster matched those dates in JJIS. The admission date was the first face-to-face contact with the youth and family. Release dates were entered into JJIS within twenty-four hours. Monthly youth progress reports were uploaded in JJIS for each youth record reviewed. In one record, one monthly summary was uploaded late. Release reasons were documented in JJIS in each of the four closed records reviewed, with the reason for release matching in the records and JJIS for three youth. For one youth, the discharge summary documented the youth had issues while in the program, though he had reached his maximum benefit and was closed as successful. In JJIS, the reason for release was listed as, Non-compliance, referred back to court. 1.08 Mental Health Services Staffing Requirements and Compliance Qualifications All Redirection Service staff providing mental health services shall meet the requirements identified in the guidelines, must have appropriate licensure or qualifications, and have completed the prerequisite training to provide such services according to Florida law. Three personnel records were reviewed for educational transcripts and qualifications. Two staff had master s-level degrees in mental health counseling and psychology. The one non-licensed staff had documentation of training for basic counseling skills, program philosophy, therapeutic environment, behavior management, client rights, crisis intervention, early intervention, documentation requirements, and adolescent development. The one non-licensed staff received weekly clinical supervision from the program director or regional director, both of whom are licensed mental health counselors (LMHC). Office of Program Accountability Page 11 of 18 (Effective July 2016)

1.09 Substance Abuse Services Staffing Requirements and Compliance Qualifications Substance abuse services must be provided by appropriately licensed providers and practitioners. The program is licensed under F.S. Chapter 397 for the provision of outpatient substance abuse services. Substance abuse treatment services are provided by the non-licensed therapist under the direct supervision of the program director or regional director, both of whom are licensed. The non-licensed treatment staff received weekly supervision from a licensed mental health counselor. Standard 2: Assessment Services Overview When youth are admitted to the program, the youth and their parent/guardian meet with a therapist for a face-to-face interview. Treatment staff use this information to complete a clinical assessment. The results of these assessments are then used to identify the youth s goals when developing the individualized treatment plan. The initial face-to-face interview includes the program orientation, during which the youth and parent/guardian receive a written program description of services. 2.01 Referral Process Compliance The Redirection Service provider shall accept or reject all service referrals via Juvenile Justice Information System (JJIS) within two (2) business days of referral from the Department of Juvenile Justice (DJJ). Five youth records were reviewed regarding the referral process. In each record, the program documented the acceptance of the referral within two business days of receiving the referral from the Department. An interview with the program staff indicated they are knowledgeable of the referral process. The program uses a referral tracking form, which documents the date the referral was booked in the Department s Juvenile Justice Information System (JJIS), the date it was accepted by the program, the date of actual placement in the program, and the release date. 2.02 Admission and Services Provision Processes Compliance Each youth is assessed within 17 calendar days of referral from the Department of Juvenile Justice (DJJ) and placed in the Juvenile Justice Information System (JJIS). Five youth records were reviewed for services. Each youth began services within seventeen calendar days of placement. Each youth s Youth Empowered Success (YES) Plan included a goal incorporating the intervention services provided by the program. Each youth s family agreed to participate in family therapy. Through progress reports and e-mails, the program collaborated with the assigned juvenile probation officer (JPO) to ensure the youth was actively engaged in and progressed in meeting the requirements of counseling. Office of Program Accountability Page 12 of 18 (Effective July 2016)

2.03 Intake Conference and Orientation Compliance Upon acceptance and intake of the youth for services, the Redirections provider/practitioner shall ensure youth and his/her parents/guardians receive a face-to-face orientation by the date of first clinical session by the provider/practitioner. Five youth records were reviewed for youth and family participation in program orientation. Each youth and parent/guardian signed a consent for services and release of information form. The orientation consisted of the delivery of a handbook, which detailed service goals, expectations of the youth and parent/guardian, hours and location of intervention services, emergency contact information, and identification of key staff for contact. 2.04 Clinical Assessments Compliance Each youth must receive a Clinical Assessment of his or her emotional and behavioral functioning through structured clinical interview of the youth and parent/guardian, or caregiver and administration of appropriate standardized assessment instruments, such as symptom checklists and behavioral rating scales, when clinically indicated. Five youth records were reviewed for clinical assessments. A clinical assessment utilizing a standard assessment instrument was completed in all five records. The clinical assessment included: identifying information, reason for assessment, relevant background information, history of abuse/trauma, behavioral functioning, physical health, mental health history, substance abuse history, and education history. Documentation of the clinical assessments included clinical impressions, diagnostic formulation, and summary of findings. A statement by the licensed mental health counselor confirming their review of the assessment and agreement with the findings and treatment recommendations was documented in each clinical assessment. 2.05 Clinical Assessment Qualifications Compliance Clinical Assessments must be conducted by a licensed practitioner or non-licensed clinician working under the direct supervision of the licensed practitioner. Five clinical assessments were reviewed for staff credentials. In each record, the assessments were completed by non-licensed staff and reviewed by the licensed mental health professional. Standard 3: Intervention Services Overview After completion of the clinical assessment, the individualized treatment plan is developed by a therapist with the input of the youth and their parent/guardian. Individual and family therapy sessions are provided. Youth participated in individual therapy sessions once a week and family therapy also occurred once a week. The program uses cognitive behavioral therapy in treatment services. Office of Program Accountability Page 13 of 18 (Effective July 2016)

3.01 Individualized Treatment Plan/Plan of Care Compliance The provider shall develop an individualized treatment plan based on the clinical assessment, which is developed with a person-centered process in consultation with the youth, and others at the option of the youth such as the youth s family, guardian, and treating and consulting health care and support professionals. The person-centered planning process must identify the individual s physical and mental health support needs, strengths and preferences, and desired outcomes. Five youth records were reviewed for the development of individualized treatment plans (ITPs). The program developed an ITP based on the clinical assessment in all five records. Each of the ITPs were developed with a person-centered process in consultation with the youth and their parent/guardian. The person-centered planning process identified the individual s physical and mental health support needs, strengths and preferences, and desired outcomes, prevented the provision of unnecessary or inappropriate care, identified the service the youth was assessed to need, and addressed diagnoses and symptoms identified in the youth s Clinical Assessment. All of the ITPs were signed by the youth and the parent/guardian. All five of the ITPs reviewed were authorized by the licensed mental health counselor and were developed by a licensed practitioner or a non-licensed counselor working under the direct supervision of the licensed practitioner. 3.02 Practitioner Qualifications Compliance Treatment Plans and Therapy shall be provided by a licensed practitioner or a clinician meeting the qualifications set forth in the contract. Three personnel records were reviewed. Each record indicated staff have had a minimum of nine years of direct experience providing mental health services to at-risk youth. Both mental health and substance abuse treatment services are provided by qualified mental health counselors with master s-level degrees from accredited universities or colleges in the field of counseling or related human services field. One staff, the therapist, is a non-licensed master slevel mental health clinical staff working under the supervision of a licensed mental health professional. Two staff, the program director and regional director, are licensed mental health counselors (LMHC) pursuant to Chapter 491, F.S. 3.03 Redirection Therapy Services Compliance The provider shall provide the following for Redirections youth: Individual therapy services Family therapy services Group therapy services A combination of therapy services, aside from Redirection 24 hour crisis therapeutic support services, must be provided two times weekly unless youth and family are unavailable and/or once a week as dictated by modality. Five youth records were reviewed for redirection therapy services. Each record reflected the youth received individual and family therapy, and the therapists designated cognitive behavioral therapy as the treatment modality in each case. All five records reflected the youth received therapy as directed by modality unless the youth and family were unavailable. Mental Office of Program Accountability Page 14 of 18 (Effective July 2016)

health/substance abuse treatment were documented in the progress notes. A written report of the youth s progress in therapy was provided to the juvenile probation officer through documents uploaded into the Department s Juvenile Justice Information System (JJIS) every thirty days in four of the five records. For one youth, the written report of the youth s progress was uploaded late. The program also provides twenty-four-hour crisis services intended to assist youth and their families manage crisis situations, should the need arise. 3.04 Mental Health and/or Substance Abuse Treatment Compliance Planning The provider shall ensure youth have access to necessary and appropriate mental health and substance abuse services (on-site or off-site) performed by qualified mental health and substance abuse professionals or service provider(s). Each youth was required to participate in individual and family counseling sessions. The counseling services provided included the provision of interventions to address criminogenic risk factors and mental disorders and/or substance use disorders. Individual and family sessions were each one hour in duration. Group therapy is not used and not required by contract. The program provides twenty-four-hour crisis services intended to assist youth and their families manage crisis situations. None of the five youth reviewed utilized or appeared to need this service. Therapists provided case coordination to ensure there is consistent communication with the juvenile probation officer and family, and to ensure the youth can complete treatment successfully. 3.05 Release/Discharge Compliance Prior to release or discharge of a youth from services (prior to completion of the intervention) the Redirection Service provider must coordinate discharge planning with the youth s JPO. Four closed records were reviewed. Three youth successfully completed the program and one youth was discharged unsuccessfully. In each record, a copy of the youth s discharge summary was uploaded into the Department s Juvenile Justice Information System (JJIS) and the juvenile probation officer (JPO) was notified by e-mail when the summary was uploaded. The case notes were also updated to reflect service activity. In all four cases, the program entered the youth s release date into the appropriate module in JJIS. Standard 4: Fidelity Monitoring Overview The program provides the primary service of Cognitive Behavior Therapy (CBT), which is an evidence-based intervention. The therapist facilitates CBT services through individual and family therapy sessions. Staff receive training on CBT during new-hire orientation. The program director is responsible for monitoring the therapist s delivery of CBT, and does so through observations or by reviewing recordings of individual and family therapy sessions. The director s observations are documented on a Cognitive Therapy Rating Scale (CTRS). The assessed areas are general therapeutic skills, conceptualization, strategy, and techniques. The delivery of CBT is discussed weekly during clinical supervision. Primary service information for all Chrysalis programs is compiled by corporate staff and sent to the Department s contract Office of Program Accountability Page 15 of 18 (Effective July 2016)

manager on a quarterly basis. Staff are evaluated on the delivery of the primary service during their ninety-day probationary period and annually thereafter. 4.01 Treatment Manual/Protocol Compliance There is a specific written manual or protocol for the treatment service(s). The facilitators of the service(s) adhere to the written manual or protocol. The program has the Cognitive Behavioral Therapy (CBT) Manual for Pre-Adolescent and Adolescent Treatment Protocol. The manual outlines treatment sessions and provides a guide for facilitators. Case notes documented youth received CBT services through individual and family therapy sessions, which are scheduled to occur weekly. No individual or family therapy sessions were observed during the annual compliance review. 4.02 Facilitator Training Compliance All facilitators of the service(s) must have received formal training specific to the intervention or model/protocol by a qualified trainer in each specific service(s). All three staff reviewed records contained documentation showing the staff were trained on the Cognitive Behavior Therapy/Motivational Interviewing Using Empirically Based Practices, Parts One and Two. The training was delivered by a trainer qualified to do so. 4.03 Internal Fidelity Monitoring Compliance The Redirection program has an internal process to monitor the delivery of the evidence-based practice, promising practice or alternative family centered therapy to examine how closely actual implementation matches the model protocol. Internal fidelity monitoring is accomplished through weekly supervision. The program director listens to tapes of Cognitive Behavior Therapy (CBT) sessions to provide direction for the therapist. The program director has been trained to utilize the Cognitive Therapy Rating Scale (CRTS). The provider completes quarterly fidelity monitoring reports for service delivery of evidence-based practices, promising practices, and alternative family centered therapy conducted at Redirections programs statewide. The quarterly report is submitted to the Department s contract manager. 4.04 Corrective Action Based on Fidelity Monitoring Compliance The Redirection program has a process by which corrective action is applied and demonstrated based on the fidelity monitoring of the delivery of the evidence-based practice, promising practice or alternative family centered therapy. The program has a policy and procedures in place by which corrective action is applied based on fidelity monitoring. No staff were placed on a performance improvement plan during this annual compliance review period. Weekly supervision notes documented the therapist was provided guidance and suggestions for the delivery of Cognitive Behavior Therapy (CBT). Office of Program Accountability Page 16 of 18 (Effective July 2016)

4.05 Evaluation of Facilitator Skill in Delivering the Compliance Intervention Performance evaluations of the facilitators of the specific intervention/service include the evaluation of skill in delivering the interventions/services. The personnel records for the program director and therapist were reviewed for performance evaluations. The performance evaluations for the therapist addressed the delivery of clinical services, which included Cognitive Behavior Therapy (CBT). The program director s performance evaluation addressed the evaluation of clinical services by staff, to include delivery or CBT. Evaluations were completed annually. Office of Program Accountability Page 17 of 18 (Effective July 2016)

Program Name: Redirection Services Circuit 7 MQI Program Code: 1352 Provider Name: Chrysalis Center, Inc. Contract Number: 10157 Location: Volusia County / Circuit 7 Number of Beds: 12 Review Date(s): November 14-15, 2017 Lead Reviewer Code: 37 Overall Rating Summary All indicators have been rated and no corrective action is needed at this time. Office of Program Accountability Page 18 of 18 (Effective July 2016)