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 Juvenile Diversion Alternative Program - Circuit 11 Miami-Dade Juvenile Services (Contract Provider) 275 Northwest 2nd Street, 2nd Floor Miami, Florida Review Date(s): May 31, June 1, 2016 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: Odilanda Brito, Office of Program Accountability, Lead Reviewer (Standard 1) Keith Bennis, Office of Program Accountability, Regional Monitor (Standard 2)

3 Program Name: Miami-Dade Juvenile Services JDAP- Circuit 11 MQI Program Code: 1228 Provider Name: Miami-Dade Juvenile Services Department Contract Number: X1698 Location: Miami-Dade County / Circuit 11 Number of Beds: 187 Review Date(s): May 31, June 1, 2016 Lead Reviewer Code: 138 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 and (2) Assessment Services, which are included in the Juvenile Diversion Alternative Programs Standards. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee # Case Managers # Clinical Staff # Food Service Personnel # Healthcare Staff # Maintenance Personnel 2 # Program Supervisors Documents Reviewed # Other (listed by title): Grants & Fiscal Specialist, Supervisor, Manager, and Training Specialist. 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 9 # Personnel Records 9 # Training Records/CORE 9 # Youth Records (Closed) 9 # 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 13 (Revised July 2015)

4 Standard 1: Management Accountability JDAP Rating Profile Indicator Ratings 1.01 Standard 1 - Management Accountability * Initial Background Screening 1.02 Five-Year Rescreening 1.03 Protective Action Response (PAR) Non-Applicable 1.04 Pre-Service/Certification Training 1.05 In-Service Training Limited 1.06 * Incident Reporting (CCC) Non-Applicable 1.07 * 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 13 (Revised July 2015)

5 Standard 2: Assessment Services JDAP Rating Profile Indicator Ratings 2.01 Standard 2 - Assessment Services Youth Eligibility 2.02 Case Assignment, Initial Contact, and Positive Achievement Change Tool (PACT) Full Assessment 2.03 Individual Service Plan 2.04 *Referrals for Mental Health and Substance Abuse Assessment and Treatment Services 2.05 Individual Service Plan Implementation/Supervision 2.06 PACT Final Assessment 2.07 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 5 of 13 (Revised July 2015)

6 Strengths and Innovative Approaches The Miami-Dade Juvenile Services Department (JSD) has four offices throughout Miami- Dade County in order to accommodate youth and families served by the program. The JDAP program staff and youth participate with local non-profit organizations throughout the year to give back to the community. Some of these efforts include a diaper drive for teen parents, collecting food for a no-kill animal shelter, providing toiletries for Homeless Awareness Month, collecting school supplies, and toy drives during the holiday season. Through Mayor Carlos Gimenez s Engage 305, JSD has enhanced its community-based organization contacts to include faith-based organizations such as Share your Heart. JSD created Trends for Success Boutique to provide job skills training and business attire for youth served by JSD. This will equip youth with the right tools to compete for jobs within the community. Office of Program Accountability Page 6 of 13 (Revised July 2015)

7 Standard 1: Management Accountability Overview The Miami-Dade Juvenile Diversion Alternative Program (JDAP) is a diversion program under contract with the Department of Juvenile Justice (DJJ) serving male and female youth under the age of seventeen, referred by the Department and approved by the State Attorney s Office in the 11th Judicial Circuit. The program is operated by Miami-Dade Juvenile Services Department in four locations: Miami Gardens, Edison, Miami Downtown Central, and South Cutler Ridge. The program is composed of two juvenile assessment supervisors, ten juvenile assessment counselors, and two office support specialists. The program s average length of stay is three to six months and provides intensive case management services. The program maintains an average youth population of 200 youth. The program did not utilize the services of any volunteers, mentors, or interns during the annual compliance review period 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 written policies and procedures requiring compliance with the Department s background screening requirements. The program hired one new staff since the last annual compliance review. A review of one applicable file confirmed a background screening check from the Department s Background Screening Unit (BSU) was received prior to staff hire date. The program did not utilize the services of any volunteers, mentors, or interns since the last annual compliance review. The Annual Affidavit of Compliance with Level 2 Screening Standards was submitted to the Department s BSU on January 15, 2016, meeting the annual requirement 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 written policies and procedures requiring the completion of a five-year background screening on staff. The center had five staff applicable for a five-year rescreening. All staff re-screenings were conducted within the required time frame. Office of Program Accountability Page 7 of 13 (Revised July 2015)

8 1.03 Protective Action Response (PAR) Non-Applicable The program uses physical intervention techniques in accordance with Florida Administrative Code. Any time staff uses a physical intervention technique, such as countermoves, control techniques, takedowns, or application of mechanical restraints (other than for regular transports), a PAR Incident Report is completed and filed in accordance with the Florida Administrative Code. There have been no Protective Action Response (PAR) incidents during this review period; therefore, this indicator rates as non-applicable 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 who have not completed essential skills training, as defined by Florida Administrative Code, do not have any direct contact with youth. Contracted non-residential staff who have not completed pre-service/certification training do not have direct, unsupervised contact with youth. The program has policies and procedures in place adhering to the Department s pre-service training requirements for newly hired staff and they maintain a pre-service training calendar. The program had one new hire within the annual compliance review period. One applicable staff training file was reviewed for pre-service certification training. The training file documented the staff completed the required trainings related to Protective Action Response (PAR), first aid, cardiopulmonary resuscitation (CPR), and automated external defibrillator (AED). All completed training was documented in the Department's Learning Management System (SkillPro) In-Service Training Limited 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. A review of ten staff training files supported each staff member exceeded the minimum twentyfour hours of annual in-service training requirements, ranging from twenty-six hours to sixtythree hours. Six of ten staff completed the required trainings as outlined in Florida Administrative Code. Four of ten reviewed files had no supportive documentation of Protective Action Response (PAR) training, required by the Department on an annual basis. All required training and certifications were maintained in the applicable staff member s training file. The trainings were documented in the Department s Learning Management System (Skillpro). A review of two supervisor training files indicated the supervisor completed eight hours of supervisory training. The program has an annual in-service training calendar, which is updated as changes occur. The program submitted an updated in-service training plan to the Office of Program Accountability Page 8 of 13 (Revised July 2015)

9 Department s Office of Staff Development and Training on January 6, 2015 and again on May 19, 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 have not been any reports to the Central Communications Center (CCC) during this review period; therefore, this indicator rates as non-applicable Abuse-Free Environment 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 provides for an environment in which youth, staff, and others feel safe, secure, and not threatened by any form of abuse or harassment. Each staff member signs an Ethical Conduct Ordinance with Miami-Dade County at the time of hire. The staff adheres to the code of conduct, which forbids staff from using physical abuse, profanity, threats, or intimidation. The program adheres to the Department s procedures to ensure all allegations of child abuse or suspected child abuse are immediately reported to the Florida Abuse Hotline. Reviewed documentation supported there have been no incidents requiring reports of allegations of abuse to the Florida Abuse Hotline since the last annual compliance review. Office of Program Accountability Page 9 of 13 (Revised July 2015)

10 Standard 2: Assessment Services Overview The program serves youth who are determined to be at-risk of re-offending based on their preeligibility criteria of school behavior and performance problems, family concerns, substance abuse, and pre-delinquent behaviors. The program works with youth to complete sanctions and services to increase responsible behaviors, protect the public, and reduce recidivism. Upon each youth s admission, the youth are assessed using the Positive Achievement Change Tool (PACT) Full Assessment and a Youth-Empowered Success (YES) Plan/individual service plan is created to outline the sanctions the youth will complete while in the program. Juvenile assessment counselors are actively involved in the supervision of each youth. Staff are responsible for the development of the YES Plan with the youth and parent/guardian. The juvenile assessment counselors are responsible for the development of the YES Plan, overseeing community service work-site activities and completing court ordered sanctions, documenting the youth s attendance at school, ensuring needed services are being provided, conducting conferences with the youth, family, and/or school officials, and conducting follow-ups with service providers when referred for additional services. If a youth is identified in need of mental health and/or substance abuse treatment, the program s juvenile assessment counselors are responsible for making referrals and/or counseling appointments to appropriate community providers. All case activities are documented in the Department s Juvenile Justice Information System (JJIS) case notebook module. Youth who complete their program requirements are successfully discharged Youth Eligibility Compliance Youth admitted to the program meet the admission criteria defined by the provider s contract: The program shall serve male and female youth aged 17 and under. Admission/Eligibility criteria should include, but not limited to any misdemeanor offender and first-time felony offenders. Reviewed documentation of nine active youth case management files revealed each youth met the admission criteria required by the provider s contract. Each file documented the youth was seventeen years of age or younger and either was a misdemeanor offender or a first-time felony offender Case Assignment, Initial Contact, and Positive Compliance Achievement Change Tool (PACT) Full Assessment The program shall ensure each youth is assigned a case manager and shall conduct a PACT Full Assessment on all youth within ten (10) calendar days of the date the provider receives the youth s complete referral packet. Reviewed documentation of nine youth case management files found the program receives referral packets, which contain the State Attorney Recommendation (SAR), police report, the notice of referral, and victim/restitution information, when applicable. Reviewed progress notes for each of the nine records documented the youth and parent/guardian s participation in the development of the individual service plan. Each file indicated the case managers completed a Positive Achievement Change Tool (PACT) full assessment, regardless of the youth s risk to reoffend, within ten-calendar days of admission to the program, as required by their contract. Office of Program Accountability Page 10 of 13 (Revised July 2015)

11 2.03 Individual Service Plan Compliance The results of the initial PACT Full Assessment will outline the risks and needs of the child and will assist in case planning. The PACT Risk Report must be viewed to determine if any of the dynamic domains have moderate-high or high risk scores. For youth with no moderate-high or high risk domain scores, case planning should be focused on a sixty-day schedule for program completion. For youth with any moderate-high or high risk domain scores, case planning should be focused on a 90 to 120-day schedule for program completion addressing the specific identified needs. The program has 21 calendar days from program admission to develop the individualized service plan. A review of nine youth case management files found each file had a Positive Achievement Change Tool (PACT) Risk Report, which matched each youth s individual service plan (ISP). In all reviewed files, the ISP was created within twenty-one calendar days from the youth s date of admission into the program. Each of the nine reviewed ISPs addressed the identified needs from the PACT and each had clear action steps, as required Referrals for Mental Health and Substance Abuse Compliance Assessment and Treatment Services The provider shall provide services based on individual youth and family needs. If needs are identified requiring a referral for services outside the program, staff ensure all referrals are made to address criminogenic needs and mental health and substance abuse service needs identified by the PACT. Staff develops a follow-up and monitoring plan for all outside referrals made as a result of program participation. Provide is defined as arranging/referring/brokering or actually providing the service directly to the youth and family. A review of nine active youth case management files revealed all nine were applicable and had referrals for outside services. Reviewed chronological case notes confirmed the program s case managers completed the required follow-up contacts with the outside providers and monitored the services provided. When applicable, case notes documented negative reports due to lack of participation or missed appointments Individual Service Plan Implementation/Supervision Compliance Youth are supervised in a manner ensuring completion of the Individual Service Plan. Staff documents all case activities, including face-to-face interaction and telephone contact with the youth, parent(s)/guardian(s), and providers, and review of written or verbal reports from collateral sources, such as educational institutions, employers, counselors, electronic databases, etc. Case notes demonstrate compliance (or attempted compliance) with youth, parent/guardian, and staff action steps contained in the Individual Service Plan. Reviewed documentation from nine active youth case management files confirmed each youth in the program was consistently supervised to ensure the completion of their individual service plan. Reviewed chronological notes reflected case managers document all case activities and the youth s progress in meeting individual goals and requirements. Office of Program Accountability Page 11 of 13 (Revised July 2015)

12 2.06 PACT Final Assessment Compliance A PACT Full Assessment shall be completed prior to the request for case closure. The PACT assessment shall document pre- and post-testing. No R-PACT reassessments during the program participation are required. A review of nine closed youth files reflected program staff completed a Positive Achievement Change Tool (PACT) full assessment prior to the request for case closure. Each of the PACTs contained an updated risk and needs assessment to ensure the final results were reflective of the youth s current status Release Compliance The program releases youth upon completion of the program, or otherwise as indicated by the provider s contract. Nine closed youth files were reviewed to ensure the program released each youth upon completion of the program or as otherwise indicated by the provider s contract. Seven of the nine youth files reflected the youth were discharged successfully and each indicated the youth completed all requirements as outlined on their individual service plan. Two of the nine reviewed files were discharged as unsuccessful and found staff completed a case note notifying the Juvenile Probation Officer in writing and submitted the discharge information to the State Attorney in writing. Office of Program Accountability Page 12 of 13 (Revised July 2015)

13 Program Name: Miami Dade Juvenile Services MQI Program Code: 1228 Provider Name: Miami-Dade Juvenile Services Departmen Contract Number: X1698 Location: Miami Dade County / Circuit 11 Number of Beds: 187 Review Date(s): May 31, June 1, 2016 Lead Reviewer Code: 138 Overall Rating Summary The following limited and/or failed indicators require immediate corrective action. Limited Ratings Failed Ratings 1.05 In-Service Training Please choose an indicator Office of Program Accountability Page 13 of 13 (Revised July 2015)