BUREAU OF MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR

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1 S T A T E O F F L O R I D A D E P A R T M E N T O F J U V E N I L E J U S T I C E BUREAU OF MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR AMIkids Volusia AMIkids, Inc. (Contract Provider) 1420 Mason Avenue Daytona Beach, Florida Review Date(s): May 12-14, 2015 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES

2 Rating Definitions Ratings were assigned to each indicator by the review team using the following definitions: Compliance Limited Compliance Failed Compliance No exceptions to the requirements of the indicator; or limited, unintentional, and/or non-systemic exceptions that do not result in reduced or substandard service delivery; or systemic exceptions with corrective action already applied and demonstrated. Systemic exceptions to the requirements of the indicator; exceptions to the requirements of the indicator that result in the interruption of service delivery; and/or typically require oversight by management to address the issues systemically. The absence of a component(s) essential to the requirements of the indicator that typically requires immediate follow-up and response to remediate the issue and ensure service delivery. Review Team The Bureau of Monitoring and Quality Improvement wishes to thank the following review team members for their participation in this review, and for promoting continuous improvement and accountability in juvenile justice programs and services in Florida: Janet Hampton, Office of Program of Accountability, Lead Reviewer Kelley Brault, Circuit 5 Probation Services, Juvenile Probation Officer Lori Bright, Circuit 5 Probation Services, Assistant Chief Probation Officer Angela Mills, North Probation Services, Operations Specialist Randy Reynolds, Circuit 5 Probation Services, Reform Specialist

3 Program Name: AMIkids Volusia QI Program Code: 1239 Provider Name: AMIkids, Inc. Contract Number: P2107 Location: Volusia County / Circuit 7 Number of Beds: 36 Review Date(s): May 12-14, 2015 Lead Reviewer Code: 9 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, (3) Intervention Services, and (4) Medical, Mental Health, and Substance Abuse Services, which are included in the Day Treatment Standards. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHA or designee 1 # Case Managers # Clinical Staff # Food Service Personnel # Healthcare Staff Documents Reviewed # Maintenance Personnel # Program Supervisors # Other (listed by title): Accreditation Reports Affidavit of Good Moral Character CCC Reports Confinement Reports Continuity of Operation Plan Contract Monitoring Reports Contract Scope of Services Egress Plans Escape Notification/Logs Exposure Control Plan Fire Drill Log Fire Inspection Report Fire Prevention Plan Grievance Process/Records Key Control Log Logbooks Medical and Mental Health Alerts PAR Reports Precautionary Observation Logs Program Schedules Sick Call Logs Supplemental Contracts Table of Organization Telephone Logs Surveys Vehicle Inspection Reports Visitation Logs Youth Handbook 5 # Health Records 5 # MH/SA Records # Personnel Records 3 # Training Records/CORE 5 # Youth Records (Closed) 5 # Youth Records (Open) # Other: 5 # Youth 3 # Direct Care Staff NA # 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 27 (Revised September 2014)

4 Standard 1: Management Accountability Day Treatment Rating Profile Indicator Ratings Standard 1 - Management Accountability 1.01 * Initial Background Screening 1.02 Five-Year Rescreening 1.03 Protective Action Response (PAR) 1.04 Pre-Service/Certification Training 1.05 In-Service Training 1.06 Medical Alerts, Mental Health Alerts and Suicide Risk Alerts in JJIS 1.07 Episodic/Emergency Care 1.08 Medication Management - Medication Storage 1.09 Cleanliness and Sanitation 1.10 Fire Prevention and Evacuation Procedures 1.11 Water Activities 1.12 Food Services 1.13 Transportation 1.14 Administration 1.15 Ninety-Day Supervisory Reviews Limited 1.16 *Incident Reporting (CCC) Non-Applicable 1.17 * Abuse-Free Environment * 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 27 (Revised September 2014)

5 Standard 2: Assessment Services Day Treatment Rating Profile Indicator Ratings Standard 2 - Assessment Services 2.01 Admission and Orientation 2.02 * Medical Screening 2.03 Medication Management - Verification of Medications 2.04 * Mental Health/Substance Abuse Screening 2.05 Positive Achievement Change Tool (PACT) Full Assessment 2.06 PACT Reassessment 2.07 Progress Reports * 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 27 (Revised September 2014)

6 Standard 3: Intervention Services Day Treatment Rating Profile Indicator Ratings Standard 3 - Intervention Services 3.01 Vocational Programming 3.02 Educational Access 3.03 Youth-Empowered Success (YES) Plan Development 3.04 Youth Requirements/PACT Goal Elements 3.05 * Transitional Planning/Reintegration Non-Applicable 3.06 YES Plan Implementation/Supervision 3.07 Effective Response System 3.08 Behavior Management System 3.09 Ninety-Day YES Plan Updates 3.10 Educational Transition 3.11 Termination/Release * 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 27 (Revised September 2014)

7 Standard 4: Medical, Mental Health, and Substance Abuse Services Day Treatment Rating Profile Indicator Ratings Standard 4 - Medical, Mental Health, and Substance Abuse Services 4.01 Medication Management - Delivery of Medications 4.02 Designated Mental Health Authority or Clinical Coordinator 4.03 * Licensed MH/SA Clinical Staff 4.04 Non-Licensed MH/SA Clinical Staff 4.05 MH and SA Admission Screening Limited 4.06 MH and SA Assessment/Evaluation 4.07 MH and SA Treatment 4.08 Treatment and Discharge Planning 4.09 * Suicide Prevention Plan 4.10 * Suicide Prevention Services 4.11 * Suicide Precaution Observation Logs 4.12 * Suicide Prevention Training 4.13 * Mental Health Crisis Intervention Services 4.14 * Crisis Assessment 4.15 * Emergency MH and SA Services 4.16 * Baker and Marchman Acts * 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 27 (Revised September 2014)

8 Strengths and Innovative Approaches The program had stabilization in staff positions. There were no staff vacancies at the time of the annual compliance review. Office of Program Accountability Page 8 of 27 (Revised September 2014)

9 Standard 1: Management Accountability Overview AMIkids is located at 1420 Mason Avenue, Daytona Beach, Florida. It is a day treatment program. Youth are placed at the program as a condition of probation or a non-secure commitment. There were no conditional release or post-commitment youth attending the program. The contract allocates thirty-six slots to AMIkids Volusia. At the time of the annual compliance review, twenty-four youth were listed on the Juvenile Justice Information System (JJIS). There were no staff vacancies at the time of the annual compliance review. The program employs an executive director, a business manager, a para-mental health professional, and two local care counselors. The two local care counselors were hired since the last annual compliance review 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. Twelve staff required a background screening clearance from the Department s Background Screening Unit (BSU). Twelve background screening clearances were reviewed on the BSU database. All staff and one volunteer were screened by the BSU before their date of hire. The Affidavit of Compliance with Level 2 Screening Standards was submitted to the BSU on January 6, 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 had policy and procedures addressing five-year rescreening of staff and volunteers. At the time of the annual compliance review, there were no staff or volunteers requiring a five-year rescreening by the Department s BSU Protective Action Response (PAR) Compliance 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. Two incidents involved the use of Protective Action Response (PAR) techniques. The staff applied techniques, which were approved by the Department. Each PAR report was completed Office of Program Accountability Page 9 of 27 (Revised September 2014)

10 at the end of the staff member s workday. Mechanic restraints were not applied in either case. No youth were injured and neither alleged abuse by staff. Both PAR reports were reviewed by the executive director. A post-par interview was conducted with one youth within the required time frame. One youth was not interviewed as the Daytona Beach Police Department transported the youth to a local crisis stabilization unit (CSU). PAR reports were kept in a central binder Pre-Service/Certification Training Compliance Contracted non-residential staff are trained in accordance with Florida Administrative Code. Contracted non-residential staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. Contracted non-residential staff that have not completed essential skills training, as defined by Florida Administrative Code, do not have any direct contact with youth. Contracted non-residential staff that have not completed pre-service/certification training do not have direct, unsupervised contact with youth. One staff completed pre-service training during this review period. The staff was certified in Protective Action Response (PAR), cardio-pulmonary resuscitation (CPR), and first aid. The staff had also taken courses on suicide prevention, ethics, and emergency procedures. These trainings were completed prior to staff having any interaction with youth. The staff had also taken sexual harassment, case management, behavior management, and other training topics. The staff had received over 132 hours of training in first 180 days of employment. There was no documentation of the staff receiving human diversity training In-Service Training Compliance Contracted non-residential staff completes in-service training in accordance with Florida Administrative Code. Contracted non-residential staff must complete twenty-four hours of annual in-service training, beginning the calendar year after the staff has completed pre-service training. Supervisory staff shall complete eight hours of training in the areas listed below, as part of the twenty-four hours of annual in-service training. Two staff were applicable for in-service training requirements. Both staff had Protective Action Response (PAR) update training. Each staff was current in first aid and CPR certification. Staff had also taken a course on professionalism and ethics. Each staff received over twenty-four hours of training in the 2014 calendar year. One staff was applicable for management training topics. The staff received over eight hours of training in management related topics Medical Alerts, Mental Health Alerts, and Suicide Risk Alerts Compliance in JJIS The program shall alert staff of medical issues that may affect the security and safety of the youth in the program. The program has a process for informing staff of youth s medical conditions. A review of the medical alert log found staff were required to read the alerts and acknowledge review of the information by their signatures. Alert sheets documented youth names, date of entry, medical Office of Program Accountability Page 10 of 27 (Revised September 2014)

11 conditions, allergies, and symptoms associated with them. Another alert sheet documented side effects of medication youth were taking at home, but not during school hours. Three staff surveys were reviewed and all confirmed the sharing of medical alert information Episodic/Emergency Services Compliance The program shall have a comprehensive process for the provision of Episodic Care, First Aid, and Emergency Care. The program shall be capable of facilitating an appropriate response to an emergency situation. The program had policy and procedures addressing emergency and episodic services. The program had a first aid kit, which was located in the common area near the classrooms. It was restocked on a monthly basis by a local medical supply company. The knife-for-life, needle nosed pliers, and wire cutters were secured and located in the administrative area. The program conducted emergency drills each month during the past six months. The drill scenarios addressed unconsciousness, asthma, shortness of breath, suicide, and open head injury. CPR demonstrations were conducted with the suicide drills. The program also had an episodic care log. There were eight instances of episodic care being given by staff during the past six months. Most instances involved applying band-aids or antibiotic creams to cuts or rashes. No youth were taken off-site for emergency medical care. The program did not have a death or serious adverse medical event during the past year. Staff are advised of potential emergency situations by entries in the logbooks Medication Management Medication Storage Compliance All medications (prescriptions, over-the-counter, topical, etc.) shall be stored in separate, secure (locked) areas that are inaccessible to youth and ensures proper inventory control. At the time of the annual compliance review, there were no youth taking any type of medications at the program. The program had a refrigerator for medications needing refrigeration. It was housed in a locked closet and was empty upon observation. Controlled medications would be placed in a locked box and placed in the locked first aid kit. The medication storage areas were clean and free from moisture and extreme temperatures Cleanliness and Sanitation Compliance The program provides a safe and appropriate treatment environment that includes maintenance and sanitation of the facility. The program was toured by team members. It was clean and maintained. No graffiti was observed on walls, doors, and/or windows. The program does not operate in the evening hours. There are separate restroom facilities for male and female youth. The program had the required number of toilets. There was space for academic classes, large and small group meetings as well as for private counseling sessions. The program had documentation of weekly inspections. Inspected items included lights, exit signs, windows/blinds, fire extinguishers, egress plans, pull stations, doors, walls, restrooms, all rooms, and perimeter checks. Zone cleaning charts were completed as well. Inspections were conducted as required. Office of Program Accountability Page 11 of 27 (Revised September 2014)

12 1.10 Fire Prevention and Evacuation Procedures Compliance The program provides a safe and appropriate treatment environment that includes fire prevention and evacuation procedures. The program has a fire safety prevention plan. Fire drills were conducted each month during the past six months. Three months had documentation of two fire drills. The fire drill report documented the number of youth participants, time, day, evacuation time, method of alarm activation, and general comments. Egress plans were posted in the program in various locations. Fire extinguishers were checked by staff during weekly inspections. The extinguishers were also inspected by a local fire equipment company on a quarterly basis. The fire alarm system was inspected in July 2014 by another company. Local fire officials inspected the building in September 2014 and no violations were noted. Smoking is prohibited at the program. Two staff had documentation of fire safety training. Three staff received fire safety training in the 2014 calendar year. There was no documentation of youth receiving training on the use of fire extinguishers and the alarm system. Five youth completed a survey, and all said they learned how to evacuate the building in the event of a fire Water Activities Compliance The program provides a safe and appropriate treatment environment that includes procedures for water activities. The program had a copy of AMIkids, Inc. aquatics policy. It was comprehensive in its scope. It addressed scuba diving, canoeing, kayaking, rafting, tubing, swimming in pools and at the beach, waterskiing, water theme parks, and other venues. It included aquatic ratings for staff and youth. Youth are to be swim tested before participation in aquatic activities. The swimmer to lifeguard ratio is seven to one. The policy also included the safety items needed for the various aquatic activities. Seven youth participated in a white water rafting trip in September The executive director completed an aquatics trip plan. The plan documented the safety items for the trip, safety rules for youth, and youth s risk classification and swim level. All youth were swim tested prior to the trip. Each youth was determined to be a basic swimmer. The executive director was certified as a lifeguard at the time of the trip. Five youth completed a survey. None of these youth participated in aquatic activities while attending the program Food Services Compliance The program provides a safe and appropriate treatment environment that includes food service. The kitchen area was inspected by the county health department on May 12, The health inspector was at the program on May 12, 2015 for an inspection. No violations were noted. The program had menus for lunch and breakfast. The menus were approved by a registered dietitian. Youth are offered a choice of 1% white milk or fat free chocolate milk at each meal. Snacks are included on the menus as well. Five youth completed a survey. Four youth said there is the same menus for youth and staff. Four youth said the program makes substitutions for youth with food allergies. Three staff completed a survey. Two staff said there is one menu for staff and youth. One youth said the staff and youth have different menus. One youth said the program did not make substitutions for youth with food allergies. One staff said there was not one menu for staff and youth. According to the one staff, the program only purchases enough food for youth. Office of Program Accountability Page 12 of 27 (Revised September 2014)

13 1.13 Transportation Compliance The program provides a safe and appropriate treatment environment that includes transportation. The program has two vans, which are used to transport youth if a need arises. Both vans were insured and had current vehicle registration. The vans were locked and parked in a secured area. The vans were equipped with first aid kits and fire extinguishers. Five staff had valid driver s licenses. Both vans had been serviced in recent months. One in December 2014 and the other February The program also has a contract for transportation with Volusia County Schools Transportation Services. The contract expires in June Five youth completed a survey. All youth said they wear seatbelts when transported by staff Administration Compliance The program provides a safe and appropriate treatment environment that includes administrative and operational oversight. Logbooks were reviewed from the past six months. The program had pre-printed logbooks. One staff was responsible for the entries. As staff arrived, they initialed by their name with the time. There was documentation of youth being searched at the beginning of the day. Perimeter, safety, vehicle, and emergency checks were documented as well. One youth was Baker Acted from the program and it was annotated in the logbook. The executive director was reviewing the logbooks more frequently than required. Emergency and episodic drills were not documented in the logbooks Ninety-Day Supervisory Reviews Limited Compliance Cases under supervision (i.e., probation, conditional release, post-commitment probation) are reviewed by the supervisor at least once every ninety calendar days. The supervisor ensures that staff review any instructions given during the review, and ensures that they were followed during the subsequent review. Five sets of case notes were reviewed for supervisory reviews. Two cases were non-applicable as ninety days had not passed. One case was reviewed as required. The two remaining cases required a ninety-day supervisory review that wasn t completed at the time of the annual compliance review. In both cases, the reviews were due the week before the annual compliance review Incident Reporting (CCC) Non-Applicable Whenever a reportable incident occurs, the program notifies the Department s Central Communications Center (CCC) within two hours of the incident, or within two hours of becoming aware of the incident. There were no incidents reported to the Central Communications Center (CCC) during this review period; therefore, this indicator rates as non-applicable. Office of Program Accountability Page 13 of 27 (Revised September 2014)

14 1.17 Abuse-Free Environment Compliance Any person who knows, or has reasonable cause to suspect, that 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 that 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 had policy and procedures for the reporting of abuse allegations. Staff received training on reporting child abuse allegations. Five youth case management records were reviewed for orientation on reporting child abuse allegations. All five youth received orientation on reporting child abuse allegations. Four staff personnel files were reviewed for disciplinary action. None of the staff were disciplined for inappropriate interactions with youth or staff or for failure to report child abuse allegations. Five youth completed a survey. All said they had not been denied a telephone call for reporting a child abuse allegation. A review of the five youth surveys found their interactions with staff were appropriate. Three staff completed a survey. All staff said any abuse allegation made by a youth would be reported by the youth or staff. Standard 2: Assessment Services Overview Two local care counselors and the para-mental health professional are responsible for coordinating admission activities and duties. Local care counselors are responsible for administering the Positive Achievement Change Tool full assessment (PACT) on all new admissions. Every ninety days, local care counselors are required to complete a PACT reassessment. Progress reports are completed on a monthly and quarterly basis. Medical screening is conducted during the admission process as well. Staff reviews the Juvenile Justice Information System (JJIS) alerts and interview youth and parents/guardians to identify any medical issues. At the time of the annual compliance review, there were no youth taking medications while at the program Admission and Orientation Compliance Facility orientation shall be conducted within twenty-four hours of a youth s admission to the facility. Case notes should document the date and time of the orientation and that the youth received orientation documents. Five case management records were reviewed for completion of admission and orientation. In all five cases, orientation was completed within twenty-four hours of admission into the program. An orientation handbook was provided to youth. The youth handbook addressed all required elements. Youth were introduced to staff and had a tour of the facility. Program expectations, rules, the behavior management system, a list of contraband, daily activity schedule were among some of the orientation topics. Evacuation procedures were reviewed with each youth as well. Orientation also included a discussion of the performance planning process. In four of five cases, the case notes documented the date and time of the orientation. In three of five cases, case notes reflected youth received the orientation documents. One case note did not reflect youth received an orientation. Two case notes did not reflect youth received orientation documents, though each youth had signed documents indicating they received orientation. Office of Program Accountability Page 14 of 27 (Revised September 2014)

15 2.02 Medical Screening Compliance Youth are screened for health-related conditions at the time of admission to determine if the youth has any conditions that require medical attention. The screening includes a review of the most recent Health Discharge Summary (Form HS 012) or Medication receipt/transfer disposition (Form HS053), if applicable, and documented contact with the parent/guardian if there are any questions or concerns regarding the youth s medical condition. Screening may be performed by non-licensed staff during the admission process. All medical, mental health, and substance abuse information is documented in the youth s Individual Health Care Record. Five case management records were reviewed for medical screening practices. In all five cases, youth were screened at admission to determine any medical issues that might require medical care while in the program. In all five cases, none of the youth had a recent Health Discharge Summary or Medication Receipt/transfer disposition (Form HS 053) to review during the screening process. In all five cases, concerns or questions regarding medical conditions appeared to be addressed by local care counselors with the parent during the admission process. All medical, mental health and substance abuse information was documented in the youth s Individual Healthcare Record (IHCR) Medication Management Verification of Medications Compliance The program shall determine a youth s medication regimen upon admission to the program. Five case management records were reviewed for completion and verification of medication management. In all five cases, youth and parents/guardians were interviewed about current medications. At the time of the annual compliance review, no youth were taking medications at the program Mental Health/Substance Abuse Screening Compliance Youth are screened for mental health/substance abuse issues at the time of admission to determine if the youth has any conditions that require further assessment and/or immediate attention. The screening includes a review of available information and completion of the Positive Achievement Change Tool (PACT) and the PACT Mental Health and Substance Abuse Report and Referral Form when further assessment is indicated by the PACT, or administration of the Massachusetts Youth Screening Instrument (MAYSI-2). The program ensures further assessment of the youth, or immediate intervention/treatment, as indicated by the mental health/substance abuse screening or through collateral information or behavior observation which indicates the need for further mental health/substance abuse assessment. (For the entire indicator statement, please reference the Monitoring and Quality Improvement FY Day Treatment indicators.) Five case management records were reviewed for completion of mental health and substance abuse screening instruments. In all five cases, medical, mental health and substance abuse information was documented in the youth s Individual Healthcare Record (IHCR). The local care counselors completed a positive achievement change tool (PACT) and a PACT Mental Health and Substance Abuse Referral form on each youth s admission date. In all five cases, a referral was needed, but only sent in four cases. Comprehensive assessments were completed in all five cases. In three of five cases, an assessment of suicide risk (ASR) was needed, but only completed on three of five cases. Two youth were detained and upon return to the program a Office of Program Accountability Page 15 of 27 (Revised September 2014)

16 rescreening was not conducted by local care counselors. Both youth had been on suicide precautions while at detention Positive Achievement Change Tool (PACT) Full Assessment Compliance The PACT Full Assessment is completed by program staff for all youth, regardless of risk to reoffend, within seven calendar days of admission. Five case management records were reviewed for the completion of a Positive Achievement Change Tool (PACT) full assessment. In all five cases, a PACT full assessment was completed on each youth s admission date PACT Reassessment Compliance Staff complete PACT Reassessments for youth on probation, conditional release, and postcommitment probation, as well as minimum-risk non-residential commitment youth. Regardless of risk to reoffend, the PACT Full Assessment is completed every ninety days. Five case management records were reviewed for the completion of a Positive Achievement Change Tool (PACT) reassessment. Four case management records were applicable for a PACT reassessment. In two cases, a PACT reassessment was completed within the required time frame. Two PACT full assessments were completed a week late Progress Reports Compliance Progress reports are prepared and distributed in accordance with Florida Administrative Code. The report details the youth s progress and status of youth requirements and PACT goals contained in the YES Plan. The youth is given an opportunity to review the report and provide comments. The report is signed and dated by the youth and the staff that prepared the report. The report is reviewed and signed by the program director or designee. Five case management records were reviewed for completion of progress reports. Three case management records required the completion of ninety-day progress reports. Each case management record had a ninety-day progress report. The three case management records had a cover letter, which provided a brief description of the youth s overall progress in the program. Each youth was given the opportunity to review the progress report and provide comments. The progress reports were signed and dated by youth and the staff that prepared the report. Progress reports were reviewed and signed by the executive director. Juvenile probation officers (JPOs) were sent copies of the progress reports. Local care counselors also completed monthly progress reports. Youth signatures and comments were not consistently documented on the monthly progress reports. Monthly progress reports were forwarded to JPOs for their review. Standard 3: Intervention Services Overview Two local care counselors and a para-mental health professional are responsible for intervention services. Local care counselors complete the Positive Achievement Change Tool Office of Program Accountability Page 16 of 27 (Revised September 2014)

17 (PACT) full assessment and develop a Youth-Empowered Success (YES) Plan. YES Plans goals are developed and based on the PACT full assessment results. All youth are to have at least one PACT goal on their YES Plan. YES Plans are reviewed and updated every ninety days. Youth attend school at the program. Academic instructors use the CHOICES program to assist youth with planning for college and careers. School is conducted Monday through Friday. Each youth receives 300 minutes of academic instruction per day. The program has a behavior management system, which is based on levels and points. As youth advance in the system, they receive more privileges Vocational Programming Compliance Staff shall develop and implement a vocational competency development program. Education services at the program included Level 2 vocational services. The components teach accountability skills and behaviors, which lead to work habits helping to maintain employment and living skills plus an orientation to career choices based on abilities, aptitudes and interests. The CHOICES program, which focuses on career and college plans is provided by the program. Career portfolios are completed by students who take the course as an elective. The career portfolios of two youth were observed during the review period 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 that ensures the integrity of required instructional time. An interview was conducted with the program s principal. The program has a daily master schedule, curriculum and bell schedule posted in the principal s office. The principal maintained a notebook of each youth s schedule. Youth are required to attend 300 minutes of school per day. Youth s Youth-Empowered Success (YES) Plans were updated monthly. It was reported that a One Stop Career representative will be invited to the program each semester to provide a presentation. A representative visited the program in April Information was shared with multidisciplinary staff through monthly updates of the youth YES Plans. The principal and program maintained school records through the Engrade program and were able to access the Volusia County public school records through Cross Pointe on-line Youth-Empowered Success (YES) Plan Development Compliance The YES Plan (Form DJJ/PACTFRM 4) is cooperatively developed for youth on Probation, Conditional Release, and Post-Commitment Probation. Youth and parent/guardian signatures do not indicate cooperative development of the YES Plan. Case notes clearly reflect that the youth and/or parent/guardian was involved, or refused to be involved, in the development of the YES Plan. All parties sign the YES Plan within fourteen calendar days of youth s admission to the facility. Five case management records were reviewed for the development of Youth-Empowered Success (YES) Plans. In each case, a Positive Achievement Change Tool (PACT) was completed prior to the development of the YES Plan. All YES Plans were developed within fourteen days of each youth s admission into the program. In all cases, there was documentation of youth and parents participating in the development of the YES Plans. This was documented in the case notes. There was documentation of youth and parents/guardians Office of Program Accountability Page 17 of 27 (Revised September 2014)

18 being advised of consequences for non-compliance with sanctions and completion of goals. Five youth completed a survey. All five youth said they had a copy of their YES Plan Youth Requirement/PACT Goal Elements Compliance The YES Plan provides appropriate and individualized target dates for the completion of each youth requirement and PACT goal. All youth requirement and PACT goal action steps include the intervention plan elements (i.e., who, what, and how often). Five case management records were reviewed for Youth-Empowered Success (YES) Plan elements. The team found the same practice as was noted in the 2014 annual compliance report. Juvenile probation officers are entering the court ordered sanctions on the YES Plans. AMIkids staff then enter the goals youth must complete while in the program. All five YES Plans had a goal addressing one of the top three criminogenic needs of youth. Youth were to participate in Aggression Replacement Training (ART), Cannabis Youth Treatment (CYT), and/or Boy s Council. All PACT goals contained at least one specific action step for the youth, parent/guardian, and staff. All required elements were addressed in the PACT goal Transitional Planning/Reintegration Non-Applicable Program staff actively participates in the transitional planning process for youth who are being released from a residential program on conditional release (CR) or post-commitment probation (PCP). For conditional release and post-commitment probation youth, the YES Plan must address recommendations from the residential program during transition. This review focused on probation and non-secure youth; therefore, the indicator rates as nonapplicable YES Plan Implementation/Supervision Compliance Youth on supervision (i.e., probation, conditional release, or post-commitment probation) are supervised in a manner that ensures compliance with the court order and completion of YES Plan (youth requirements and PACT goals). Case notes demonstrate compliance (or attempted compliance) with youth, parent/guardian, and staff action steps contained in the YES Plan. Five case management records were reviewed for Youth-Empowered Success (YES) Plan implementation and supervision. A review of case notes demonstrated compliance (or attempted compliance) with youth, parent/guardian, staff action steps and sanctions contained in the YES Plan. All five YES Plans contained measurable goals for the youth to achieve. Frequent contacts were made and entered by the local care counselors Effective Response System Compliance Staff responds to noncompliance in a manner that is consistent with the program s progressive response system. Five case management records were reviewed in regard to staff s responses to youth noncompliance in a manner consistent with the program s effective response. A review of case notes indicated four of the youth non-compliance was addressed according to the effective response plan. One case reflected no non-compliance issues of that particular youth. The program has a manual addressing the effective response system and action to be taken based Office of Program Accountability Page 18 of 27 (Revised September 2014)

19 on the infraction, degree of severity, and responses to be taken based on the number of occurrences Behavior Management System Compliance The program utilizes a behavior management system that provides privileges and consequences to encourage youth to fulfill programmatic expectations. Consequences are fair and directly correlate with the behavior problem. The use of facility restriction does not exceed seven consecutive days. Disciplinary procedures are carried out promptly. Youth are not allowed to have control over or discipline other youth. Time-out is used in accordance with Florida Administrative Code. All behavior problems, time-outs, in-facility suspensions, and privilege suspensions are documented in the facility log and case file in accordance with Florida Administrative Code. The program utilizes a behavior management system that provides privileges and consequences to encourage youth to fulfill programmatic expectations. Consequences were fair and directly correlated with the behavior problem. The use of program restrictions did not exceed seven consecutive days. Disciplinary procedures were carried out promptly. Youth were not allowed to have control over or discipline other youth. Time-out was not used during the past year. All behavior problems, time-outs, in-program suspensions, and privilege suspensions were documented in the program s logbook and case records. These practices were confirmed in a review of five youth surveys. The program has a mission statement posted as well as daily activity schedules. The program maintained a logbook for incidents regarding discipline. The program allows youth to earn snacks as incentives for positive behavior. The policy and procedures manual was reviewed and listed and addressed the effective response system and behavior management system. Student rights, values, and expectations were also posted. The program maintained a perfect attendance board as well as a star growth board to track statistics in math and reading. The attendance board and star growth board were posted in the program Ninety-Day YES Plan Updates Compliance Staff adjust the YES Plan to reflect any new needs and progress made during the course of supervision. Staff must make necessary updates to youth requirements and PACT goals and save a new YES Plan in the Juvenile Justice Information System (JJIS) prior to ninety-day supervisory reviews. When updates are made to the YES Plan that reasonably require the input of the youth and parent/guardian, this discussion is clearly documented in the case notes. Use of the case notations or a similar form that the youth and/or parent/guardian initials to indicate that the YES Plan was reviewed does not signify compliance. The case notes clearly document any communication regarding the YES Plan. Three cases were applicable for ninety-day updates of Youth-Empowered Success (YES) Plans. In each case, a YES Plan was saved on the Juvenile Justice Information System (JJIS) prior to the supervisor s review. When changes were made to the YES Plans, it was discussed with youth and parents/guardians at the multi-disciplinary treatment team meetings. Four of five records reviewed had updates to youth requirements and Positive Achievement Change Tool (PACT) goals. One case management record was not applicable as the ninety-day review was not due at the time of the annual compliance review. Office of Program Accountability Page 19 of 27 (Revised September 2014)

20 3.10 Education Transition Compliance Staff and youth complete an education transition plan prior to release that includes provisions for continuation of education and/or employment. Three closed records were reviewed for this indicator. Of the three closed records, all three records contained an exit treatment plan prior to release, which listed provisions for continuation of education. One file contained a resume. One of the records listed a tentative date for an appointment with One Stop. The exit treatment plan was signed by all parties to include the youth and parent/guardian Termination/Release Compliance The program shall recommend termination to the Department for youth on probation, conditional release, or post-commitment probation, as well as minimum-risk commitment youth, upon successful completion of court-ordered sanctions and substantial compliance with restitution and/or court fees. For youth on probation, conditional release, or post-commitment probation, the program works with the Juvenile Probation Officer (JPO) to facilitate the release of the youth upon completion of the program. For youth on minimum-risk commitment, staff completes the Pre-Release Notification and Acknowledgement (PRN) (DJJ/BCS Form 19) and follows the required procedure. Three closed records were reviewed in regard to termination and release activities. Of the three records, only one had probation terminated. While all three had completed the day treatment program, two of the three remained on DJJ supervised probation. In regard to the one case where probation was terminated, a law enforcement check and FCIC/NCIC was not completed as the case was terminated in court. Loss of jurisdiction was not an issue regarding this case closure. The case was terminated and closed in JJIS within five working days of the termination. A termination letter was documented and mailed to the youth and parent/guardian. Standard 4: Medical, Mental Health, and Substance Abuse Services Overview The program has a corporate AMIkids employee serving as the designated mental health clinician authority (DMHCA). The employee began serving in the role of DMHCA in December The DMHCA is a licensed mental health counselor (LMHC). The LMHC is on-site weekly. The LMHC is responsible for the oversight and management of the mental health substance abuse services at the program. The program is licensed through Department of Children and Families (DCF) Chapter 397 to provide outpatient substance abuse services for adolescents. The license is effective through August 3, The LMHC reviews and signs the Assessments of Suicide Risk (ASRs). The program provides Aggression Replacement Training (ART), Cannabis Youth Treatment (CYT), and Council for Boys and Young Men. Staff conducting the groups are trained to facilitate the curriculums. Office of Program Accountability Page 20 of 27 (Revised September 2014)

21 4.01 Medication Management Delivery of Medications Compliance The program shall have a process in place to assist youth with self-administration of oral medications. The program has a written policy in place to assist youth with the self-administration of oral medications. The written policy clearly articulates staff training requirements and procedures for medication delivery. The policy includes all Department requirements. The business manager and executive director are the only two staff responsible for assisting youth with selfadministration of medication. Both staff are responsible for completing the medication distribution log. The two staff were trained by a registered nurse (RN) on September 14, There was only one youth in the last six month who had prescribed (as needed) medication at the program. This youth was no longer at the program at the time of this review. The medical distribution logs from July 2014 to December 2014 were reviewed. The forms were completed as required Designated Mental Health Authority or Clinical Coordinator Compliance Each program director is responsible for the administrative oversight and management of mental health and substance abuse services in the program. Each day treatment program must designate either a Designated Mental Health Authority or a Clinical Coordinator to be responsible for coordinating and verifying implementation of necessary and appropriate mental health and substance abuse services in the program. The program experienced turnover in the designated mental health clinician authority (DMHCA) position. A licensed clinical social worker (LCSW) left the program in November The program now has a corporate employee, who serves as the DMHCA. The corporate employee is a LMHC. Both were licensed professionals under Chapter 458 and 459. A review of the clinical supervision log confirms the DMHCA has been on-site at least once a week for the past six months. The LMHC is responsible for the administrative oversight and management of mental health and substance abuse services provided by the program. The DMHCA reviews and signs comprehensive assessments, treatment plans, treatment plan reviews, ASRs, crisis assessments, and alert supervision logs Licensed Mental Health and Substance Abuse Clinical Staff Compliance The program director is responsible for ensuring that mental health and substance abuse services are provided by individuals with appropriate qualifications. Clinical supervisors must assure that clinical staff working under their supervision are performing services that they are qualified to provide based on education, training, and experience. The program has one licensed mental health professional who services as the designated mental health clinician authority (DMHCA). The DMHCA supervises one unlicensed treatment staff. The DMHCA visits the program once a week for the provision of clinical supervision for the unlicensed treatment staff. The DMHCA is responsible for reviewing Assessments of Suicide Rick, crisis assessments, treatment plans, and other treatment related documentation. Clinical supervision with the unlicensed treatment staff was documented on the Department s form during the past six months. Office of Program Accountability Page 21 of 27 (Revised September 2014)