BUREAU OF QUALITY ASSURANCE 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 QUALITY ASSURANCE PROGRAM REPORT FOR Orlando Intensive and Orange Youth Academies G4S Youth Services, LLC (Contract Provider) th Street Orlando, Florida Review Date(s): February 22-24, 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 17

2 Residential Performance Rating Profile Program Name: Orlando Intensive and Orange Youth Academies QA Program Code: 1127 Provider Name: G4S Youth Services, LLC County/Circuit #: Orange/Circuit #9 Number of Beds: 64 Review Date(s): February 22-24, 2011 Lead Reviewer Code: 77 Program Performance by Indicator/Standard Contract Number: R Management Accountability 4. Health Services 1.01 Background Screening of Employees/Vol. 10 Exceptio4.01 Designated Health Authority Provision of an Abuse Free Environment 7 Accept 4.02 Healthcare Admission Screening Incident Reporting 10 Exceptio4.03 Comprehensive Physical Assessment Protective Action Response (PAR) 10 Exceptio4.04 Sexually Transmitted Diseases Pre-Service/Certification Requirements 10 Exceptio4.05 Sick Call In-Service Training Requirements 10 Exceptio4.06 Medication Administration Logbook Maintenance 8 Comme 4.07 Medication Control Internal Alert System 10 Exceptio4.08 Infection Control Escapes 5 Minima 4.09 Chronic Illness Treatment 8 Commendable 89% Episodic and Emergency Care Consent and Notification 7 2. Intervention and Case Management 4.12 Prenatal/Neonatal Care NA 2.01 Classification 10 Exceptional Commendable 81% 2.02 Assessment 10 Exceptional 2.03 Intervention and Treatment Team 10 Exceptio 5. Safety and Security 2.04 Performance Plan 7 Accept 5.01 Supervision of Youth Performance Review and Reporting 8 Comme 5.02 Key Control Parent/Guardian Communication 10 Exceptio5.03 Contraband and Searches Transition Planning and Release 7 Accept 5.04 Transportation Grievance Process 10 Exceptio5.05 Tool Management Gang Prevention and Intervention 8 Comme 5.06 Disaster/Continuity of Operations Planning 8 Commendable 89% Flammable, Poisonous, and Toxic Items Water Safety NA 3. Mental Health and Substance Abuse Services 5.09 Behavior Management System Designated Mental Health Authority 10 Exceptio5.10 Behavior Management Unit NA 3.02 MH and SA Admission Screening 10 Exceptio5.11 Controlled Observation NA 3.03 MH and SA Assessment/Evaluation 8 Commendable Exceptional 91% 3.04 Treatment Plan/Team and Service Delivery 7 Acceptable 3.05 Suicide Prevention 10 Exceptional 3.06 Mental Health Crisis Intervention 8 Commendable 3.07 Emergency Services 8 Commendable 3.08 Specialized Treatment Services 8 Commendable Commendable 86% 69 Standard Program Max. Score Score Rating Failed Minimal Acceptable Commendable Exceptional 0-59% 60-69% 70-79% 80-89% % 1. Management Accountability % X 2. Intervention and Case Management % X 3. Mental Health and Substance Abuse Services % X 4. Health Services % X 5. Safety and Security % X Overall Program Performance COMMENDABLE 87% Office of Program Accountability Page 2 of 17

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, (2) Intervention and Case Management, (3) Mental Health and Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included in the Residential Standards (July 2010). Persons Interviewed Program Director DJJ Monitor DHA or designee DMHA or designee 1 # Case Managers 2 # Clinical Staff 0 # Food Service Personnel 1 # Healthcare Staff 2 # Maintenance Personnel 2 # Program Supervisors 9 # Other (listed by title): Regional Compliance Manager, OYA Risk Documents Reviewed Manager, Regional Director, Unit Manager, Assistant Facility Administrator, Compliance Manager, Physical Plant Manager, Director Staff Development, Contracted Medical Consultant 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 9 # Health Records 9 # MH/SA Records 9 # Personnel Records 9 # Training Records/CORE 3 # Youth Records (Closed) 7 # Youth Records (Open) # Other: 7 # Youth 8 # 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. The team also reviewed vehicle repair documentation. One member of the team participated in a facility tour and observed staff shift change meetings. Several team members attended an awards program. Office of Program Accountability Page 3 of 17

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: Paul Czigan, Lead Reviewer, DJJ Bureau of Quality Assurance Donna Connors, Program Administrator, DJJ Bureau of Quality Assurance Ann Little, Review Specialist, DJJ Bureau of Quality Assurance Wendell Watson, Regional Director, AMIkids, Inc. Monica Webb, Program Monitor, DJJ Residential Services, Central Region Office of Program Accountability Page 4 of 17

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 The program is operated under contract with G4S Youth Services, LLC in a state-owned facility. There are two programs on the site, Orange Youth Academy, which offers treatment for fortyeight high risk youth, and Orlando Intensive Youth Academy, which offers treatment for sixteen intensive mental health moderate risk youth. The programs are located in Orlando, Florida. The programs are managed on-site by a Facility Administrator, who is supported by an Assistant Facility Administrator for Operations, a Unit Manager, a Clinical Director, a Business Manager, a Risk Manager, a Food Services Manager, a Physical Plant Manager, the Head Nurse and a Human Resources Technician. There is also oversignt and support provided to the program by the provider s corporate team. The corporate office operates a two-week training academy in Tampa for all new employees, while in-service training is conducted on campus in person or online. At the time of the quality assurance review, there were five vacant positions; two youth care worker I, two youth care worker II and a youth care worker supervisor. The high-risk program is housed in three units of the facility. The sixteen moderate-risk intensive mental health youth are housed in a separate unit. Both programs share the dining facility, school buildings and recreation grounds. The program conducts daily management meetings to discuss relevant issues such as safety, training, daily activities, transports and specific issues with youth. There are audits and fidelity checks conducted on a regular basis, with corporate staff, as well as staff from other programs operated by the provider. The program has current operational policies and procedures in place. The program s alert process, background screening and incident reporting practices are exceptional. There was a minor deficiency noted in the provision of an abuse free environment. 1.01: Background Screening of Employees/Volunteers Exceptional (10) The program conducts a driver s license checks on all new employees. On a daily basis, the program management team reviews the status of all background screens as part of the daily management meeting. Review of backgound screening is conducted each month by the program s Quality Assurance Manager, with the results documented in the score card process. Office of Program Accountability Page 5 of 17

6 1.02: Provision of an Abuse Free Environment Acceptable (7) Seven youth responded to the survey; two reported hearing staff use profanity when speaking with youth. One youth indicated once, and one youth indicated occasionally. Follow-up interviews validated youth responses. 1.03: Incident Reporting Exceptional (10) The program s Internal Risk Manager provides documentation to the regional compliance management on items such as grievances, Protective Action Response (PAR) events and other reportable incidents. Documentation includes the number of incidents and nature of grievances, PARs and other pertinent information. During the daily management meeting, all reportable events since the last meeting are reviewed, with discussions documented in the minutes. The regional compliance staff created a performance score card that is reviewed by regional management with the Facility Administrator on a regular basis. Incident trends, patterns and data are reviewed weekly through corporate grievance and incident reporting and trends analysis. 1.04: Protective Action Response (PAR) Exceptional (10) The program consistently convened a Physical Intervention Review Committee following each PAR incident, which were attended by the staff members involved. The committee included a supervisor and the youth, and processed the event to discover how the event could have been avoided. There was documentation of this Review Committee meeting for each PAR event reviewed. 1.05: Pre-Service/Certification Requirements Exceptional (10) New staff files consistently documented completion of over 120 hours of training in the first three weeks of employment, with all required training consistently documented as completed within the first ninety days of hire. All new employees receive the initial two weeks of training at a corporate Training Academy in Tampa, Florida. Each employee receives a job specific training plan. Monthly audits and fidelity checks of training files, and Learning Management System (LMS) entries are completed by the Risk Manager and the corporate Staff Development and Training Manager. 1.06: In-Service Training Requirements Exceptional (10) Seven files were reviewed for the receipt of in-service training; all documented in excess of forty hours of in-service training in the calendar year reviewed. All staff had an individualized annual training plan, which documented that most training had been completed well in advance of the end of year. Office of Program Accountability Page 6 of 17

7 There are monthly reviews and audits of the in-service training that is conducted; these audits are performed by the Risk Manager and the corporate Staff Development and Training Manager. 1.07: Logbook Maintenance Commendable (8) 1.08: Internal Alert System Exceptional (10) All internal alerts and documented actions are reviewed during the daily management meeting. The program maintains an alert board in the supervisor shift change room that documents all youth on alerts in numerous categories, including medical, mental health/substance abuse, sports restriction, sexual predator, escape, assaultive/violent behavior, security/safety and gang affiliation. The program s policy allows that Administrators are the only staff allowed to change the alert following a management meeting in which a youth s risk or alert level has been adjusted. The various applicable risks are delineated with a colored push pin that is placed adjacent to each youth s colored photograph. Alert notifications are reviewed monthly by the Risk Manager. 1.09: Escapes Minimal (5) The program had an incident in August 2010 that had been initially classified as an attempted escape; subsequent information was reviewed and the incident was classified as an escape. Standard 2: Intervention and Case Management Failed Minimal Acceptable Commendable Exceptional Overview The case management services for the youth are provided by a Case Manager Supervisor and three case managers. During the admission process, the youth are presented a handbook, and are quizzed upon the contents of the handbook. The Clinical Director has supervisory responsibilities over the Case Management Supervisor. The case managers have offices in a space adjacent to the west wing of the facility. The case managers work with youth during their entire stay at the program, from intake through discharge, and are responsible for conducting assessments, performance planning, leading the treatment teams and discharge planning. There are formal treatment team meetings every twenty-eight days. During the quality assurance review, treatment teams for several youth were observed; in attendance were representatives from education, direct care, mental health and administration, and the youth. The youth s parent was contacted via the telephone during the treatment team. All members of Office of Program Accountability Page 7 of 17

8 the treatment team were active participants, offering praise, encouragement and instructions to the youth. In addition to leading the treatment team, the case managers track the youth s points, behavior reports and levels. Upon admission, all youth are screened using the Residential Positive Acheivement Change Tool (RPACT), as well as other instruments. The program has effective grievance and gang awareness processes. The program makes an effort to involve the youth s family by conducting Family Days, allowing for special visitation and by consistent contact with the families. There were minor deficiencies noted in the performance plans and in the transition planning. 2.01: Classification Exceptional (10) During the classification process, youth classified as an escape risk are placed in an orange jumper for observation. Prior to the youth s admission, the management team reviews the youth s case, during the daily management meeting, to discuss the youths needs/risks. There are risk assessments conducted monthly to re-assess the youth s risk level, which are documented in the youth s file. Prior to being placed in a sleeping room, the youth complete a Security Threat Group questionnaire; all files reviewed contained this form. The risk classification form contains additional bullets beyond those required by the Department. 2.02: Assessment Exceptional (10) The youth s parents or guardians are mailed a Parent Notification Input form to solicit input for a youth s needs assessment and the development of the performance plans. Six of seven files reviewed revealed the forms had been returned to the program. A needs assessment meeting is conducted and documentation is placed in the youth s file prior to the needs assessment being completed. 2.03: Intervention and Treatment Team Exceptional (10) The Case Manager Supervisor completes a treatment team overview form, containing a review of the youth s goals and treatment. The treatment team meets to review the youth s requests for level advancement and all parties sign the promotion/recommendation form. If the youth s parent or guardian is unable to participate on the treatment via telephone, the Case Manager Supervisor sends a formal treatment team overview form to the parents that provides information of the youth s progress in treatment. The program sends monthly parent surveys to gain feedback and to solicit parental involvement. There are fidelity checks completed on the treatment team monthly that are scored by the program s corporate office. Office of Program Accountability Page 8 of 17

9 2.04: Performance Plan Acceptable (7) Four of seven performance plans reviewed did not include staff responsibilities in assisting the youth in completing the plan goals. 2.05: Performance Review and Reporting Commendable (8) 2.06: Parent/Guardian Communication Exceptional (10) The program conducts a Family Day every quarter in an effort to promote family reunification and the family s involvement in the treatment process. The program offers special visitation, upon request and approval. A therapist and case manager are on-site during each visitation to speak with the youth s parents or guardians. Written parental notifications were consistently sent on the day of the youth s admission to the program. The cases contained documentation of telephonic notification of admission, or of multiple failed attempts until the youth s parents were reached on the day of admission. 2.07: Transition Planning and Release Acceptable (7) A review of three applicable files revealed the program did not make written notification to the youth s parent or guardian upon receiving approval of the Pre-Release Notification (PRN). The review of transition activities on the youth s performance plans was inconsistently documented on the transition plan. 2.08: Grievance Process Exceptional (10) The program reviews grievances daily during the management meeting. In addition, grievances are reviewed and evaluated on a monthly basis by the Risk Manager, in an effort to observe any trends. Eight grievances were reviewed; all were initialed by the Facility Administrator, indicating his review and approval. The grievances had been resolved within seventy-two hours of submission. The program uses a speak out form as an informal grievance to promote active communication. All formal and informal grievances are picked up daily and stamped with a red ink pad to indicate the date received. 2.09: Gang Prevention and Intervention Commendable (8) Office of Program Accountability Page 9 of 17

10 Standard 3: Mental Health and Substance Abuse Services Failed Minimal Acceptable Commendable Exceptional Overview The program provides mental health and substance abuse services to the youth through a Licensed Mental Health Counselor (LMHC), who also serves as the program s Designated Mental Health Authority (DMHA). There is another LMHC, and three unlicensed master s level clinicians to provide direct services to the youth. The program has a contract with a psychiatrist to provide psychiatric evaluations and medication monitoring, and a separate contract with a psychologist to provide services to the youth on the moderate risk Intensive Mental Health Unit. The clinicians have offices on the units, while the Clinical Director has an office in the administrative area. The DMHA carries a small caseload from the Intensive Mental Health Unit, in addition to performing the administrative duties. The program screens the youth utilizing a variety of instruments, including the Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) and the Substance Abuse Subtle Screening Inventory (SASSI). The treatment services for the youth primarily include group sessions, which are supplemented with individual and family sessions. The program developed plans to address crisis intervention and emergency services. There were minor deficiencies noted in the treatment planning practices. 3.01: Designated Mental Health Authority (DJJ Program) Exceptional (10) All unlicensed therapists are registered mental health counselor interns with the Department of Health, Division of Medical Quality Assurance. The program documented weekly supervision by the psychologist for the Designated Mental Health Authority (DMHA) and the licensed therapist working with the Intensive Youth Academy. The weekly clinical supervision provided by the DMHA consistently included all of the case management staff. The DMHA also documented individual supervision monthly for all licensed and unlicensed therapists. 3.02: Mental Health and Substance Abuse Admission Screening Exceptional (10) Upon admission to the program, all youth are screened using the following instruments: Readiness to Change Questionnaire (RTC), Substance Abuse Subtle Screening Inventory (SASSI), Adolescent Psychopathology Scale (APS), Social Skills Questionnaire (SSQ), Risk/Needs Assessment and the Reynolds Adolescent Depression Scale. For the youth whose needs indicate further assessments, the Trauma Symptom Inventory (TSI) is conducted. Office of Program Accountability Page 10 of 17

11 3.03: Mental Health and Substance Abuse Assessment/Evaluation Commendable (8) 3.04: Treatment Plan, Treatment Team, and Service Delivery Acceptable (7) One individualized treatment plan did not include group or family therapy as a method of treatment, though the comprehensive assessment recommended both. Two files included addendums to treatment plans related to youth being prescribed psychotropic medications; ancillary documentation indicated a new diagnosis had been determined, however the addendums did not include the new diagnosis. 3.05: Suicide Prevention Exceptional (10) For youth placed on suicide precautions, the program documents on-going supportive care every twenty-four hours, using a Follow-up Assessment of Suicide Risk (ASR). A suicide alert form is used for each event of Precautionary Observation (PO), to provide all departments with individualized instructions for the youth on precautions. Every youth placed on PO is reviewed by the management team daily during the management meeting. The Risk Management system evaluates suicide precautions on a monthly basis using a score card system. Documentation reviewed included fidelity checks of observation practices and staff involvement. The program uses an alert board that is located in the shift briefing area for easy reference and identification. Alerts are reviewed daily and updated by the DMHA or designee, following consultation at the management meeting or other documented consultation. The DMHA facilitated simulated suicide prevention drills and provided debriefings during the staff meetings following the events. 3.06: Mental Health Crisis Intervention Commendable (8) 3.07: Emergency Services Commendable (8) The program did not have any events requiring emergency services. However, there were documented drills that clearly followed the comprehensive emergency services plan. Also documented was the training that was provided during an all-staff meeting. 3.08: Specialized Treatment Services Commendable (8) Office of Program Accountability Page 11 of 17

12 Standard 4: Health Services Failed Minimal Acceptable Commendable Exceptional Overview The program has a written agreement with the Watson Clinic to provide medical services for the youth. The Clinic provides a licensed physician to serve as the Designated Heath Authority and provides clinical services and administrative oversight. The physician is on-site one day a week as required by contract. At the time of the quality assurance review, the on-site medical staff included a full-time Registered Nurse (RN), two full-time Licensed Practical Nurses (LPN), and one part-time LPN. In addition to the licensed physician, the program has agreements in place with an optometrist and dentist to provide any necessary services for the youth. The youth are provided Human Immunodeficiency Virus (HIV) counseling and testing services on-site by the local health department. The program has a Modified Class II Type B pharmacy permit. The healthcare staff occupy a clinic on the living units, which contains space for examination, sick call and records maintenance. There were noted deficiencies in the program s provisions of sick call and in Medical Administration Record documentation. 4.01: Designated Health Authority Exceptional (10) In addition to the written agreement for the Designated Health Authority (DHA), G4S contracts with a medical doctor to provide consultation services for their programs. The consultant provides support to the DHA and nursing staff, which includes on-site visits and telephone consultations. The medical consultant also participates in monthly conference calls with the Health Service Administrators from the various G4S programs. 4.02: Healthcare Admission Screening Exceptional (10) In each of the files reviewed for this indicator, an LPN completed the Facility Entry Physical Health Screening (FEPHS) forms at the youth s admission to the program, as well as any applicable re-screenings. The FEPHS forms were signed and dated by the DHA to indicate a review. The DHA is notified of all new admissions, whether the youth enters the program with a chronic condition and/or condition requiring medication or not. The nurse completes a detailed admission progress note, documenting a review of the youth s medical information, such as any chronic conditions, medications, immunizations, or allergies, health education provided and notification to the DHA. During the admission process, the nurse makes a concerted effort to contact the youth s parent or guardian to verify the youth s medical history, such as chronic conditions, medications and allergies. The contacts and/or attempts to contact the parent or guardian, along with the information that is gathered, are included in the progress notes. Office of Program Accountability Page 12 of 17

13 4.03: Comprehensive Physical Assessment Commendable (8) 4.04: Sexually Transmitted Diseases Commendable (8) 4.05: Sick Call Acceptable (7) There was documentation in the file of a youth with multiple headache complaints, and a referral was not made to the DHA. One youth submitted a sick call complaint for muscle pain, and the nurse indicated the youth was provided analgesic balm. A review of the medical record revealed that the youth s parent had specifically indicated the youth was not to be provided this medication. Upon inquiry, the program advised the nurse had not given the youth the analgesic balm, but did not document the change in treatment provided. One sick call conducted by the LPN was not reviewed by the RN until two days later, however a chart check was indicated by the RN on the date the sick call was completed. 4.06: Medication Administration Acceptable (7) A review of medication administration records (MARs) revealed the title of nonhealthcare staff and the full printed name of the staff member who initials a dosage was not recorded on the form. A review of MARs revealed the full printed name and signature of the youth was not recorded on the form. There were a couple instances in which the provision of over-the-counter medications was not recorded on the face of the MAR. 4.07: Medication Control Commendable (8) 4.08: Infection Control Commendable (8) 4.09: Chronic Illness Treatment Commendable (8) Office of Program Accountability Page 13 of 17

14 4.10: Episodic and Emergency Care Commendable (8) 4.11: Consent and Notification Acceptable (7) Six of the seven files reviewed had a signed Authority for Evaluation and Treatment form; in one file, the youth was identified at admission as being in the custody of the Department of Children and Families, however there was no consent on file from the Court authorizing treatment. Three separate instances in which a youth was sent off-site to the emergency room were reviewed and written notification was sent to the youth s parent or guardian as required, however in one instance, the notification inconsistently specified the treatment provided. 4.12: Prenatal/Neonatal Care Non-Applicable (NA) The program policy, procedure, and practice confirm the requirements of the indicator were not applicable for this program, as this program serves male youth only. Standard 5: Safety and Security Failed Minimal Acceptable Commendable Exceptional Overview Orange Youth and Orlando Intensive Youth Academies are hardware-secure programs. The Assistant Facility Administrator and supervisory staff oversee the safety and security activities of the facility. The program uses the electronic wand system, Pipe Guard System, for performing ten-minute observations when youth are in their sleeping rooms. The facility is surrounded by fencing and razor wire. An intercom system to master control allows visitors to state who they are before the gate is opened. Upon entry into the facility, a search is conducted of all visitor s bags, and a metal detecting wand is used. There is ample room for the youth to participate in outdoor recreational activities. The facility conducts shift briefings, whereby all staff sign the briefing sheet to indicate their participation and review. The program maintains a video monitoring system of key areas, as well as entry gates. All doors, locks and windows are secured and are included in the facility checks that are conducted on each shift. All gates and doors worked properly during the quality assurance review. The program has a Continuity of Operations Plan (COOP) that has been approved by the Department of Juvenile Justice Residential Services, and several disaster drills were conducted during the year. The program maintains strict control over the keys, tools and toxic items. There are separate Behavior Management Systems for the two programs, with the major difference being that the youth in the moderate risk intensive program are allowed to leave the campus for activities when they have reached a certain level. The program does not have a Behavior Office of Program Accountability Page 14 of 17

15 Management Unit, nor use controlled observation. The youth do not participate in water related activities. 5.01: Supervision of Youth Acceptable (7) There was an incident in August 2010 in which a youth ran from the program. Several staff ran after the youth; however, this left the remaining youth in the program without proper supervision. The staff were reprimanded and required to complete additional training. 5.02: Key Control Exceptional (10) The key control procedures include a color-coded system enabling master control to determine the location of all keys, including permanent issue, restricted and active keys. The procedures include a photograph of each staff assigned a key and photograph of each key type. The master key inventory is color-coded and photographed. The key access binder also includes a photograph of each staff, identifying key type assignment, including any approvals for vehicle or restricted key access. 5.03: Contraband and Searches Commendable (8) 5.04: Transportation Exceptional (10) Staff-to-youth ratios for moderate risk youth were consistently exceeded on transports. The program conducts random driver s license checks on several individuals on a monthly basis. In addition to documenting youth transports in the logbook as required, the staff providing transports report consistently by cell phone to master control to advise of the time of arrival at the destination and time of departure back to the facility. All of these reports were consistently noted in the logbook. 5.05: Tool Management Exceptional (10) All tools were identified on a shadow board and identified with a picture and a number. When a tool is checked out, a picture of the tool identifies the missing/checked out tool on the shadow board. All Class A tools are painted or marked in red, and all Class B tools are painted or marked in blue. The facility conducted a missing tool drill in November with the staff. The Risk Manager completes a monthly evaluation of tools including inspections, verification checks and a review of all tool related documentation. Office of Program Accountability Page 15 of 17

16 5.06: Disaster and Continuity of Operations Planning Commendable (8) 5.07: Flammable, Poisonous, and Toxic Items Exceptional (10) The key to the hazardous materials locker is maintained with the restricted keys in master control. Each item in the hazardous storage cabinet is identified by a color photograph, along with the Material Safety Data Sheet (MSDS). All chemicals are inventoried and reviewed by the Risk Manager on a weekly basis. All chemicals used on the units are checked in and out daily, and are reviewed by the shift supervisor. 5.08: Water Safety Non-Applicable (NA) The program policy, procedure, and practice confirm the requirements of the indicator were not applicable for this program. 5.09: Behavior Management System Exceptional (10) There are two separate Behavior Management Systems (BMS), one for the youth in the high risk program, and one for the youth in the moderate risk program. The major difference is that the youth in the moderate risk program are able to attend off campus events when they have reached the maintenance phase. Both BMS offer many rewards such as cleanest room, cottage of the week, a dining award, and various education awards, which are handed out during a monthly awards ceremony. The program provides two weekly parties: one for youth who have no sanctions and another for the youth with minor sanctions for the last seven days. There are also many sanctions when the youth s behavior needs to be redirected, including writing essays, early bedtime, not attending parties or other privileges, and losing their level. The youth were able to explain the BMS, and what the rewards and sanctions were for maladaptive behavior. A majority of the youth responding to the survey reported that the BMS was very good. All of the staff responding to the survey reported that the BMS was good or very good. 5.10: Behavior Management Unit Non-Applicable (NA) The program policy, procedure, and practice confirm the requirements of the indicator were not applicable for this program. 5.11: Controlled Observation Non-Applicable (NA) The program policy, procedure, and practice confirm the requirements of the indicator were not applicable for this program. Office of Program Accountability Page 16 of 17

17 Overall Program Performance COMMENDABLE 87% Failed Minimal Acceptable Commendable Exceptional Office of Program Accountability Page 17 of 17