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 Miami-Dade North AMIkids, Inc (Contract Provider) 2701 North East 151 Street North Miami Beach, Florida Review Date(s): October 14-16, 2014 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: Gabriel Medina, Office of Program Accountability, Lead Reviewer Maria Gilhooley, Reform Specialist, Probation, Circuit 11 Mary Johnson, Office of Program Accountability, Regional Monitor Thomas Mahoney, Office of Program Accountability, Regional Monitor

3 Program Name: AMIkids Miami-Dade North QI Program Code: 1249 Provider Name: AMIkids, Inc. Contract Number: P2121/19 Location: Miami-Dade County / Circuit 11 Number of Beds: 48 Review Date(s): October 14-16, 2014 Lead Reviewer Code: 50 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 3 # Case Managers 1 # Clinical Staff # Food Service Personnel # Healthcare Staff Documents Reviewed # Maintenance Personnel # Program Supervisors 6 # Other (listed by title): Interns (5), SJPO (1) 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 Vehicle Inspection Reports Visitation Logs Surveys Youth Handbook 7 # Health Records 10 # MH/SA Records 7 # Personnel Records 7 # Training Records/CORE 8 # Youth Records (Closed) 7 # Youth Records (Open) 12 # Other: Contracts (2), Intern files (6), Program Manual, Water Activities Manual, COOP Plan, JJIS. 7 # Youth 7 # 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 28 (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 1.16 *Incident Reporting (CCC) 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 28 (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 28 (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 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 28 (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 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 28 (Revised September 2014)

8 Strengths and Innovative Approaches The program has an electronic monitoring system, Biotrak, which records each youth s attendance, breakfast, lunch, and snack on a daily basis by using the youth s thumb print and a photograph. The system notifies the youth s assigned juvenile probation officer (JPO) by when the youth is absent from the program, and creates attendance and lunch reports. Youth are provided the opportunity to join the AMIkids scuba team, with the potential to earn their scuba certification. Joining the scuba team affords each youth to attend a dive trip to the Florida Keys, learn to work as part of a team, receive swim lessons in a pool, learn to use all scuba diving gear, and participate in scuba training. As a part of the program s community service project youth participate in off-site cleanups at Virginia Key Beach, and also have the opportunity to earn community service hours through their participation in the Service From The Heart program by visiting nursing homes, interact with its residents in arts and craft projects, play games with them, and complete landscaping projects. Through the Fisher Island Philanthropic Fund the program provides opportunities to exceptional youth who have graduated from the program to pursue a college education or vocational training by offering scholarship assistance that includes tuition and books. In addition, the program provides a weekly perfect attendance hot breakfast to applicable youth. AMIkids, Inc. has been nationally recognized by the substance abuse mental health services administration (SAMHSA) as an evidence-based model for improving academic achievement of at-risk students, and for reducing delinquent behavior. The program was awarded an accreditation through AdvanceEd, this award provides the program s youth with the opportunity to receive a diploma and transcripts that will hold the same accreditation of any certified public and private high school. The program received an award for the lowest turnover rate, and an award for the highest utilization rate in the AMIkids organization. The program s executive director received the 2013 Rookie Executive Director of the Year award. AMIkids, Inc. has been designated as a promising model by the United States Department of Justice for reducing reoffending behaviors. The AMikids, Inc. Personal Growth Model is a comprehensive approach to intervention for teens that are failing and need critical redirection. The approach is a combination of academic, behavior, and treatment services designed to target risk factors many youth face in today s society. In addition, program youth s yearly participate in the legislative day in Tallahassee, in the annual presidential dive in Key West, Florida, and in the Nantahala North Carolina White Water Rafting trip. Office of Program Accountability Page 8 of 28 (Revised September 2014)

9 Standard 1: Management Accountability Overview AMIkids Miami-Dade North is a non-residential day treatment program operated by AMIkids, Inc., under contracts numbers P2121 and P2119 with the Department. The program is located in the Oleta River State Park, next to Florida International University (FIU) north campus in North Miami Beach. The facility includes nine administrative offices, six classrooms, a pantry, and a large group room. The management team consists of the executive director, (ED), director of administration, licensed mental health counselor (LMHC), director of education, director of operations, director of case management, and behavior interventionist. In addition, the program had a contracted licensed clinical social worker (LCSW) who serves as the program s designated mental health authority (DMHA), four certified teachers, two case managers, one regional care coordinator, one community safety specialist, and two aquatics/scuba instructors. The length of stay for youth in the program is between three and five months, depending on their performance. At the time of the annual compliance review the program was providing services to fifty-five probation day treatment youth and nine commitment non-residential youth, ages thirteen to eighteen. The program maintains a current staff training plan and individual training files for each staff member. A component of the program is the incorporation of various marine activities. The program is contracted with and funded by the Department, the Miami-Dade County Public School District, United Way, and the Fisher Island Philanthropic Fund 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. A review of six volunteer/intern personnel files found that each staff received an eligible background screening rating prior to an offer to utilize their services. A review of six staff personnel files found that each staff received an eligible background screening rating prior to an offer of employment. The Annual Affidavit of Compliance with Level 2 Screening Standards was completed and submitted to the Department on January 8, 2014, meeting the annual requirement. Prior to hire, the program conducts a sexual offenders and predators check with the Florida Department of Law Enforcement on all new staff 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. Reviewed staff personnel files found no staff applicable for the five-year background rescreening requirement. The program had policy and procedures in place to appropriately conduct five-year background screening adhering to Department guidelines. The program conducts semi-annual driver s license checks of all staff. Office of Program Accountability Page 9 of 28 (Revised September 2014)

10 1.03 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. The program has a Department approved plan for Protective Action Response (PAR) in place. The program maintains a folder for PAR reports that includes supporting documentation for each applicable PAR. The program has had four documented PAR reports in the past six months. According to program policies and staff interviews, the program does not use mechanical restraints. All staff maintained current PAR re-certifications. Reviewed documentation found that the program maintains monthly trend analysis of the number of PAR utilized 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. A review of three training files applicable to pre-service certification training found that each staff member completed all the required elements, and exceeded the required minimum of 120 hours of training completed within 180 days of being hired. The program submitted a master training schedule to the Department s Office of Staff Development and Training that included scheduled training topics 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. A review of four staff training files for in-service training requirements validated that each staff averaged over eighty hours of in-service training, exceeding the twenty-four hour annual requirement. Two supervisory staff training files were reviewed. All reviewed staff training files documented that staff received all the mandatory required trainings. The program documented all in-service requirements in the Department s Learning Management System (Skill-Pro). The program submitted the in-service training plan to the Department s Office of Staff Development and Training, as required on January 16, Office of Program Accountability Page 10 of 28 (Revised September 2014)

11 1.06 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 youth alert system that is reviewed and signed by each staff member daily, and updated when a youth is admitted or terminated from the program. The program s alert system addressed medical, mental health, and suicide alerts. A review of seven youth case management files found that five were applicable to program alerts, and each applicable alert was timely placed in the program alert system. Staff surveyed indicated that they are informed of the youth s medical alerts during the staff morning meetings and through the daily log list of alerts 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 a written comprehensive process for the provision of episodic care, first aid and emergency care. The process mandated that the program conducted information to all the program staff on a routine basis of potential emergency situations that may arise. A tour of the facility found that the program had emergency equipment, first aid kits, knife-for-life, and wire cutters available to staff in designated areas. Reviewed documentation revealed that all the emergency equipment was monitored monthly and the first aid kits were replenished by Zee Medical Services, as needed. The program does not have an automated external defibrillator (AED). Reviewed logbooks for the last six months confirmed that the program conducted emergency drills monthly. All instances of first aid and emergency care were documented as outlined by the Department s Health Services Manual. The review of one applicable off-site emergency care incident revealed that it was documented and managed as required 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. The program does not have any licensed medical staff on-site and does not directly provide medication to any youth in the program. Observations confirmed that although the program does not have any medication on-site, the program had a key-locking storage and a refrigerator for storage of medication, when needed. Reviewed training documentation confirmed that the program director and the designated mental health authority received training in medication administration Cleanliness and Sanitation Compliance The program provides a safe and appropriate treatment environment that includes maintenance and sanitation of the facility. A tour of the facility found that the program was clean and well-maintained, without evidence of hazards and graffiti, and provides a safe environment for youth and staff. The program has Office of Program Accountability Page 11 of 28 (Revised September 2014)

12 adequate space for visitation, private counseling, group sessions, and education. The program has separate and operational restrooms for female and males. The program has a daily security check log documenting daily checks of the front and back perimeters of the program, all general interior areas, the van, and the tools. The program also has a log for the chemicals that contains the applicable Material Safety Data Sheets (MSDS). Reviewed documentation found that the program contracts the provision of waste management and pest control with outside providers 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 continuity of operations plan (COOP) that was revised on February 27, The COOP contains structural fire procedures, alternative site locations, and a staff telephone cascade with emergency notification numbers for each staff member. The program maintained a fire safety plan last reviewed on May 21, 2014 by the Miami-Dade Fire Rescue Department, and approved by the Fire Marshal s Office. Reviewed training documentation found that all the program staff were trained in the proper operation and use of available fire prevention equipment. The program has a fire safety log that contains all the required elements. Reviewed documentation and facility logbooks completed since the last annual compliance review supported that the program consistently conducted monthly fire drills. A tour of the program found that there were evacuation plans posted, and signs of no smoking permitted throughout the program. All surveyed youth indicated that they have been instructed on what to do in the case of a fire Water Activities Compliance The program provides a safe and appropriate treatment environment that includes procedures for water activities. The program has an extensive corporate water activities policy manual. Reviewed documentation indicated that the program has a log that contains swim evaluations and tests for all applicable youth. The program has one current certified waterfront lifeguarding, cardiopulmonary resuscitation, and first aid instructor. An interview with the executive director indicated that the program maintained an instructor-to-youth ratio of one-to-four for water activities. Three of the seven surveyed youth confirmed that each participates in water activities at this program, and each youth indicated that they take a swim test. Observation of the facility pictures and reviewed documentation confirmed that youth in the program participated in the annual presidential dive in Key West, Florida and in the Nantahala North Carolina White Water Rafting trip Food Services Compliance The program provides a safe and appropriate treatment environment that includes food service. The program contracts with a local caterer for daily food services. Observations found that the food storage and serving area was clean and well-maintained. Observations confirmed that each youth is required to utilize the Biotrak electronic monitoring system when checking into the program each morning. Observations of a lunch revealed that the meal was provided in the multi-purpose room. There was no evidence of withholding food as a disciplinary measure. The program provides special diets as needed. All surveyed youth and staff indicated that the Office of Program Accountability Page 12 of 28 (Revised September 2014)

13 program offers the same menu to the youth and staff. Reviewed documentation supported that the program monitors the youth receiving breakfast and lunch meals daily and sends a monthly report to the AMIkids, Inc. corporate office. Each of the last three Department s food service inspection reports were rated satisfactory Transportation Compliance The program provides a safe and appropriate treatment environment that includes transportation. The program has one eight-passenger van that is utilized to transport youth for off-campus activities, when needed. The inspection indicated that the vehicle appears to be in a safe and sound condition, and is locked when not in use. The van was equipped with a fire extinguisher, first aid kit, knife-for-life, and window punch. Documentation of current insurance and vehicle registration was reviewed. The program has a vehicle maintenance log, and a monthly preventive maintenance schedule that were reviewed. Reviewed training documentation confirmed that program staff received several training courses related to driving and the transportation facilitated by program management staff, and one annually on-line defensive driver training provided by the Philadelphia Insurance Company. In addition, the program received monthly copies of the Driver Letter from The Hartford, which contained valuable recommendations for each program staff. All surveyed youth and staff indicated that when transporting a youth, the youth and staff wear seat belts. The program conducts semi-annual driver s license checks of all staff Administration Compliance The program provides a safe and appropriate treatment environment that includes administrative and operational oversight. Reviewed documentation confirmed that the executive director (ED) maintains program statistical information, including admission data, releases, transfers, absconds, abuse reports, emergencies, incidents, and length of stay. The ED completes a population and incident data report and submits it to the Department monthly. A tour of the program indicated that the program provided a safe and appropriate treatment environment that includes administrative and operational oversight. Reviewed documentation confirmed that youth listed on the program roster matched the census report in the Department s Juvenile Justice Information System (JJIS). Reviewed program logbooks indicated that the program documented daily staff work status, security of personal keys, security, perimeter and cleanliness, vehicles, tools, heat, JJIS updates, and attendance. There was consistent documentation in each reviewed logbook that program staff reviewed the program operations, and signed the logbook daily. A review of the program logbooks completed since the last annual compliance review found that each log entry did consistently include the name of the youth, facility staff involved in incidents, brief statement of pertinent information, and the name of the person making the entry, as required. A review of six months of the program logbooks indicated that the ED daily review of the logs was consistent Ninety-Day Supervisory Reviews 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 Office of Program Accountability Page 13 of 28 (Revised September 2014)

14 during the subsequent review. Seven applicable youth case management files were reviewed for the completion of the ninetyday supervisory reviews. Each reviewed file confirmed that a supervisory review was conducted at least once every ninety calendar days and confirmed that youth received the appropriate interventions. All seven youth files documented that the supervisor reviewed and signed the Youth-Empowered Success (YES) Plan within fourteen days of each youth s admission to the program. The YES Plan and the Positive Achievement Change Tool (PACT) were updated prior to the supervisory review Incident Reporting (CCC) Compliance Whenever a reportable incident occurs, the program notifies the Department s Central Communications Center (CCC) within two hours of the incident, or within two hours of becoming aware of the incident. The program had thirteen Central Communications Center (CCC) reports in the past six months that were in compliance with CCC reporting procedures. Reviewed documentation supported that all CCC incidents were reported by the program within the required time frame 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 provides an environment in which youth, staff, and others feel safe, secure, and not threatened by any form of abuse or harassment. All staff signed a code of conduct that forbids staff from using physical abuse, profanity, threats, or intimidation. Abuse reporting procedures were included in the youth s handbook. Youth and staff surveys confirmed that youth have unimpeded access to self-report alleged abuse, and that they never saw a coworker telling a youth they could not call the Florida Abuse Hotline, or observing a co-worker using threats, intimidation, or humiliation when interacting with the youth. The telephone numbers to the Florida Abuse Hotline and the Central Communications Center (CCC) for youth eighteen years or older was observed posted throughout the program. There have been no allegations of abuse since the last annual compliance review. Standard 2: Assessment Services Overview The local care counselors in the program are responsible for the completion of the assessment services provided to each youth in the program, including the admission, orientation and screening. During the admission process, each youth receives a medical screening, a complete Positive Achievement Change Tool (PACT) screening report, referral for mental health and substance abuse assessment, and a Department s referral summary form, when applicable. The program employs one licensed mental health counselor who serves as the designated Office of Program Accountability Page 14 of 28 (Revised September 2014)

15 mental health authority (DMHA). Each youth admitted into the program receive intake, orientation, screening, assessment, individualized service and treatment planning, and evidence-based and promising practice interventions based on each youth needs 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. A review of seven youth case management files indicated that the program conducted face-to face contacts with each youth within the required time frame. All reviewed youth files had supporting documentation that each youth participated in the orientation process beginning on the day of admission and received a youth handbook. The program s handbook included the program expectation and rules, review of the performance planning process, telephone guidelines, search policy, youth rights and grievances, abuse and complaint telephone numbers, facility rules governing youth conduct, and consequences for rule violations. Each reviewed youth file revealed that the program staff conduct an orientation that includes an introduction to the program staff and a tour of the program s grounds, review of expectations, rules, and the behavior management system. Review of the daily activities schedule governing daily operations, review of emergency medical and mental health services, emergency safety, and the evacuation procedures for the program. The handbook also contained a list of contraband items and materials, and the consequences for introducing contraband into the program, review of the performance planning process, average anticipated length of stay to consistently notify of the rules and processes used by the program 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. Review of seven youth healthcare records indicated that each youth was screened for health related conditions at the time of admission to determine if the youth had any health-related condition that required medical attention. The reviewed records found that three were applicable for the review of the health discharge summary. Of the three, one case had the discharge summary for review. All seven reviewed records documented contact with the parent/guardian for concerns regarding the youth s medical condition and all medical, mental health, and substance abuse information was documented in the youth s healthcare record Medication Management Verification of Medications Compliance The program shall determine a youth s medication regimen upon admission to the program. The program has a written policy in place that clearly outlines the procedures for medication verification upon each youth s entry into the program. The program also has a medication distribution log in place, if needed. A review of seven youth healthcare records indicates that all Office of Program Accountability Page 15 of 28 (Revised September 2014)

16 youth and parents/guardians are interviewed regarding youth s medication regimen. Currently, all youth on medication take their medication before and after attending 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 Quality Improvement FY Day Treatment indicators.) Reviewed documentation confirmed that the program screened each youth for mental health and substance issues at the time of admission. The review of the healthcare records indicated that for each youth admitted the program s staff completed the Positive Achievement Change Tool (PACT) mental health and substance abuse screening report for referral for mental health and substance abuse assessment and the Massachusetts Youth Screening Instrument (MAYSI- 2). Four out of seven reviewed records had an elevated risk of suicide due to PACT results, MAYSI-2 results, and/or current history. In the four applicable records the clinical mental health staff completed an Assessment of Suicide Risk (ASR). Documentation supported that all four youth were placed on precautionary observation and stepped down to standard supervision during the intake process, as required. Reviewed ASR s supported that the executive director (ED) or his designee documented that they were contacted and provided their signature on the ASR 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. A review of seven youth case management files indicated each contained a completed Positive Achievement Change Tool (PACT) Full Assessment completed on the day of admission. The risk to reoffend was documented on each PACT 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. A review of seven youth case management files found that three were applicable for a Positive Achievement Change Tool (PACT) reassessment. The PACT reassessment was completed every ninety days, regardless of the youth s risk to reoffend. Office of Program Accountability Page 16 of 28 (Revised September 2014)

17 2.07 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. A review of seven youth case management files indicated that three were applicable for progress reports to be completed every ninety calendar days. Reviewed progress report documentation supported that a cover letter was included and each youth was provided an opportunity to review and add comments to the report. Each reviewed report was signed and dated by the youth, staff, and executive director. Standard 3: Intervention Services Overview The program s four local care counselors and the five certified teachers are responsible for the provision of intervention services to each youth in the program. The services provided by the program are guided by the youth Positive Achievement Change Tool (PACT) goals elements and the implementation of the Youth-Empowered Success (YES) Plan. The program provides academic instruction, life skills, vocational enhancement, and community service opportunities for each youth. Reviewed documentation found that the program utilizes the AMIkids Personal Growth Model intervention approach for youth who are failing and need critical direction to help them get back on the right track. This approach is a thoughtful combination of academic, behavioral, and treatment services and is designed to target risk factors that many youth face today. All youth admitted to the program are assigned to the appropriate gender-specific model. Male youth in the program participate in the Council for Boys and Young Men, which is a gender-specific structured support group model recognized to demonstrate effectiveness related to male issues. Both models engage youth regarding concerns related to topics such as authority, trust, sexuality, dating violence, drug use, stress, goal setting, diversity, role models, healthy relationships, and conflict resolution Vocational Programming Compliance Staff shall develop and implement a vocational competency development program. Reviewed documentation and an interview with the director of education found that the program provides a Type A/Level 1 vocational programming that teaches youth personal accountability skills and appropriate behaviors and ability levels that help maintain employment and living standards. The program conducts CHOICES Interest Profiles for vocational assessments at entry, and the program s teachers utilized the results for the youth s vocational goals, resumes, and job applications purposes Educational Access Compliance The facility shall integrate educational instruction (career and technical education, as well as Office of Program Accountability Page 17 of 28 (Revised September 2014)

18 academic instruction) into their daily schedule in such a way that ensures the integrity of required instructional time. Interview with the program s director of education and a review of the school schedule confirmed that the program operates on a year-round basis. The program educational component exceeds the number of required days of instruction. The program s scheduled activities do not interfere with the educational instruction activities 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. A review of seven youth case management files revealed that the local care counselors completed a Positive Achievement Change tool (PACT) prior to the development of the initial Youth-Empowered Success (YES) Plan. All reviewed files reflected that youth and parents/guardians participated in the development of the youth requirements. All seven surveyed youth confirmed that they participate in the development of their YES plans and each indicated that they received 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). A review of seven youth case management files found that each youth requirement and Positive Achievement Change Tool (PACT) goals contain at least one specific action step for youth, parents/guardians, juvenile probation officer (JPO), contained at least one of the youth s top three criminogenic need goals, and the applicable court-ordered sanctions Transitional Planning/Reintegration Compliance 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. A review of seven youth case management files found that four were applicable to transition planning and reintegration, and each supported that the program maintains communication with youth, parents/guardians, and the residential commitment. In three applicable case management files the program staff documented participation in the youth s residential program s exit conference. Case planning for the youth s transition to the community began at the commitment conference. Office of Program Accountability Page 18 of 28 (Revised September 2014)

19 3.06 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. Observations and a review of seven youth case management notes found that each youth was supervised by the program staff in a manner that ensured compliance with court-ordered sanctions and the Youth-Empowered Success (YES) Plan Effective Response System Compliance Staff responds to noncompliance in a manner that is consistent with the program s progressive response system. Reviewed documentation confirmed that the program had an Effective response system approved by chief probation officer in Circuit 11, to respond when youth under supervision violate the conditions of their probation. The program s effective response system is set up to address up to four occurrences and/or violations identifying what sanctions will be administered to the youth 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 had a behavior management system that provides privileges and consequences to encourage youth to fulfill programmatic expectations. The system had a rank/phase system component, a token economy component, and a point card component. The system provided behavioral expectations for youth, immediate reinforcement for target behaviors, and access to privileges. The program s system includes a point system, rank system, token economy, improvement plans, and a functional behavioral assessment matrix. The program had a Bid Store that was observed. All seven surveyed youth indicated that they cannot discipline or have control over other youth 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. Office of Program Accountability Page 19 of 28 (Revised September 2014)

20 A review of seven youth case management files found that three were applicable to ninety-day updates of the Youth-Empowered Success (YES) Plan, and in each reviewed file the updates required were timely completed and saved in the Department s Juvenile Justice Information System (JJIS), prior to the supervisory review of the plan. The applicable reviewed case notes confirmed the practice Education Transition Compliance Staff and youth complete an education transition plan prior to release that includes provisions for continuation of education and/or employment. A review of five case management files revealed that each had an education transition plan signed by all required parties. The plans had provisions for the continuation of each youth s education and treatment, when applicable. A review of three applicable youth files indicated that the program staff recommended termination to the Department for youth on probation, conditional release, or post-commitment probation. The program staff completed a copy of the termination letter, and reviewed documentation validated that the program works with the juvenile probation officer (JPO) in checking with local law enforcement, and the facilitation of the youth s release. The Pre-Release Notification (PRN) and final progress report were completed as required 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. A review of three applicable youth files indicated that the program staff recommended termination to the Department for youth on probation, conditional release, or post-commitment probation. The program staff completed a copy of the termination letter, and reviewed documentation reviewed validated that the program works with the juvenile probation officer (JPO) in checking with local law enforcement, and the facilitation of the youth s release. Only one of three files required Pre-Release Notification (PRN) and a final progress report, and both were completed as required. Office of Program Accountability Page 20 of 28 (Revised September 2014)