BUREAU OF QUALITY ASSURANCE PROGRAM REPORT FOR

Transcription

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 QUALITY ASSURANCE PROGRAM REPORT FOR Eckerd Contracted Supervision-Circuit 11 Eckerd Youth Alternatives, Inc. (Contract Provider) North West 2 nd Avenue, Suite #403 Miami Gardens, Florida Review Date(s): April 26-27, 2011 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES W A N S L E Y W A L T E R S, S E C R E T A R Y J E F F W E N H O L D, B U R E A U C H I E F Office of Program Accountability Page 1 of 8

2 Community Supervision Performance Rating Profile Program Name: Eckerd Contracted Supervision-Circuit 11 QA Program Code: 1120 Provider Name: Eckerd Youth Alternatives, Inc. Contract Number: P2007 County/Circuit #: Miami-Dade/11 Number of Slots: 80 Review Date(s): April 26-27, 2011 Lead Reviewer Code: 105 Program Performance by Indicator/Standard 1. Management Accountability 2. Assessment and Intervention 1.01 Background Screening of Employees/Vol. 10 Exceptional 2.01 Positive Achievement Change Tool NA 1.02 Provision of an Abuse Free Environment 10 Exceptional 2.02 State Attorney Recommendation (SAR) NA 1.03 Incident Reporting NA Non-Applicable 2.03 Pre-Disposition Report (PDR) NA 1.04 Pre-Service/Certification Requirements 8 Commendable 2.04 YES Plan Development In-Service Training Requirements 10 Exceptional 2.05 YES Plan Implementation/Supervision Supervisory Reviews 7 Acceptable 2.06 Service Delivery/Referrals 7 Exceptional 90% PACT Reassessments/YES Plan Updates Termination of Supervision 7 78 Minimal 66% Program Max. Standard Score Score Rating Failed Minimal Acceptable Commendable Exceptional 0-59% 60-69% 70-79% 80-89% % 1. Management Accountability % X 2. Assessment and Intervention % X Overall Program Performance Acceptable 78% Office of Program Accountability Page 2 of 8

3 Methodology This review was conducted in accordance with Florida Administrative Code 63L-2 (Quality Assurance, 6/10/10 Hearing Draft), and focused on the areas of (1) Management Accountability and (2) Assessment and Intervention, which are included in the Community Supervision Standards (July 2010). Persons Interviewed Program Director DJJ Monitor DHA or designee DMHA or designee 3 # 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 8 # Youth Records (Closed) 8 # 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 8

4 Performance Ratings Performance ratings were assigned to each indicator by the review team using the following definitions and numerical values defined by F.A.C. 63L-2.002(10)(a) (6/10/10 Hearing Draft): Exceptional (10) Commendable (8) Acceptable (7) Minimal (5) Failed (0) The program consistently meets all requirements, and a majority of the time exceeds most of the requirements, using either an innovative approach or exceptional performance that is efficient, effective, and readily apparent. The program consistently meets all requirements without exception, or the program has not performed the activity being rated during the review period and exceeds procedural requirements and demonstrates the capacity to fulfill those requirements. The program consistently meets requirements, although a limited number of exceptions occur that are unrelated to the safety, security, or health of youth, or the program has not performed the activity being rated during the review period and meets all procedural requirements and demonstrates the capacity to fulfill those requirements. The program does not meet requirements, including at least one of the following: an exception that jeopardizes the safety, security, or health of youth; frequent exceptions unrelated to the safety, security, or health of youth; or ineffective completion of the items, documents, or actions necessary to meet requirements. The items, documentation, or actions necessary to accomplish requirements are missing or are done so poorly that they do not constitute compliance with requirements, or there are frequent exceptions that jeopardize the safety, security, or health of youth. Review Team The Bureau of Quality Assurance wishes to thank the following review team members for their participation in this review, and for promoting continuous improvement and accountability in juvenile justice programs and services in Florida: Shandria Striggles, Lead Reviewer, DJJ Bureau of Quality Assurance Patrice Starks, Review Specialist, DJJ Bureau of Quality Assurance George Wright, Program Monitor, DJJ Residential Services, South Region Office of Program Accountability Page 4 of 8

5 Please note that this report refers to each indicator by number and title only. Please see the applicable standards for the full text of each indicator. The standards are available on the Bureau of Quality Assurance website, at Standard 1: Management Accountability Failed Minimal Acceptable Commendable Exceptional Overview Eckerd Contracted Supervision-Circuit 11 provides community supervision services to eighty male and female youth in Miami-Dade County, ages thirteen to twenty. The program has a Program Director/Re-Entry Manager, three Re-Entry Counselors and two Re-Entry Counselors/ Case Managers. The overall management of the program is provided by the Program Director/ Re-Entry Manager, and includes the day-to-day operations of the program, staff supervision, review of paperwork and facilitating staff meetings. The program had one Re-Entry Counselor and one clinical staff vacancy at the time of the review. The program maintains an individual training and personnel file for each employee. Training is received in-house and through the Department of Juvenile Justice. Training is documented in the Department s CORE Learning Management System (LMS). 1.01: Background Screening of Employees/Volunteers Exceptional (10) The program conducted driver s license checks on all staff prior to hire and semiannually thereafter. The program implemented an internal tracking system to track five-year re-screening of staff. The program conducted a nationwide criminal database search, a National Sex Offender Registry search, and a county-level court records search on all employees and volunteers prior to hire. All potential staff transfers are required to go through the background screening process prior to re-location. 1.02: Provision of an Abuse Free Environment Exceptional (10) All staff received pre-service training on the company s Code of Conduct at the time of hire and through in-service training twice a year thereafter. Supervisors conduct surveys with parents/guardians and youth and random telephone calls to parents/guardians are conducted to ensure an abuse free environment. Office of Program Accountability Page 5 of 8

6 1.03: Incident Reporting Non-Applicable (NA) The program has not had any reportable incidents during the scope of the review; therefore, the requirements of the indicator were not applicable for this program during this reporting period. 1.04: Pre-Service/Certification Requirements Commendable (8) The program consistently met all requirements for this indicator without exception. 1.05: In-Service Training Requirements Exceptional (10) Staff training files reflected that staff received instructor-led in-service training, as well as DJJ CORE training, and each staff exceeded the required twenty-four hours of in-service training by a minimum of thirty-six hours. The program implemented an internal training system, a web-based site used to train and track training for all staff in areas such as orientation and quality improvement. 1.06: Supervisory Reviews Acceptable (7) In two of six instances where one was required, a supervisory review was not conducted within the required 90-day timeframe. There was one instance where a 90-day supervisory review was required, but one was never completed. Standard 2: Assessment and Intervention Failed Minimal Acceptable Commendable Exceptional Overview Eckerd Contracted Supervision-Circuit 11 provides community supervision services. All youth served are on Conditional Release, and the program s anticipated length of stay ranges from three to six months. Re-Entry Counselors supervise youth on community supervision, and Re- Entry Case Managers provide transitional services for youth that are in residential programs. 2.01: Positive Achievement Change Tool (PACT) Non-Applicable (NA) The program s contract confirms the requirements of the indicator were not applicable for this program during this reporting period. Office of Program Accountability Page 6 of 8

7 2.02: State Attorney Recommendation (SAR) Non-Applicable (NA) The program s contract confirms the requirements of the indicator were not applicable for this program during this reporting period. 2.03: Pre-Disposition Report (PDR) Non-Applicable (NA) The program s contract confirms the requirements of the indicator were not applicable for this program during this reporting period. 2.04: Youth-Empowered Success (YES) Plan Development Minimal (5) In three of seven applicable files, the initial YES Plan did not address recommendations made by the residential program during the youth s transition. In seven of eight applicable files, there was at least one Youth Requirement/PACT Goal in the initial YES Plan that did not contain the intervention plan elements (who, what, and how often). Fifteen of thirty-three Youth Requirements/PACT Goals in the initial YES Plan contained the intervention plan elements (who, what, and how often). In two of eight applicable files, there was at lest one Youth Requirement/PACT Goal in the initial YES Plan that did not provide an appropriate target date for completion. Twenty-nine of thirty-three Youth Requirements/PACT Goal actions steps in the initial YES Plan contained an appropriate target date for completion. In two of eight applicable files, youth and/or parent/guardian participation in the development of the initial YES Plan was not documented. In one of eight applicable files, the initial YES Plan was not signed by the youth, parent/ guardian, JPO/case manager, and/or supervisor within 30 days of disposition/placement. 2.05: YES Plan Implementation/Supervision Acceptable (7) In two of twelve applicable 90-day supervision periods, case notes did not reflect consistent compliance with JPO/case manager action steps contained in the YES Plan. 2.06: Service Delivery/Referrals Acceptable (7) In one of eight applicable files, referrals for services were not made as required by the court order and/or action steps contained in the YES Plan. In two of seven applicable files, the JPO/case manager did not follow up with the service provider within 30 days to verify enrollment and/or initiation of services. In one of eight applicable files, the JPO/case manager did not receive (or attempt to solicit), review, and/or document progress reports (written or verbal) from the provider. In one of two applicable files, the JPO/case manager did not address negative progress reports from the provider (e.g. missed appointments, non-participation, etc.). Office of Program Accountability Page 7 of 8

8 2.07: PACT Reassessments and YES Plan Updates Acceptable (7) In two of six applicable 90-day supervision periods, a new YES Plan was not saved in JJIS prior to the 90-day supervisory review. 2.08: Termination of Supervision Acceptable (7) In two of eight files reviewed for this indicator, the Pre-Release Notification (PRN) was not completed when termination was requested or the Department lost jurisdiction. Overall Program Performance Acceptable 78% Failed Minimal Acceptable Commendable Exceptional Office of Program Accountability Page 8 of 8