BUREAU OF QUALITY IMPROVEMENT PROGRAM REPORT FOR

Transcription

1 S T A T E O F F L O R I D A D E P A R T M E N T O F J U V E N I L E J U S T I C E BUREAU OF QUALITY IMPROVEMENT PROGRAM REPORT FOR AMIkids Tallahassee (Back End) AMIkids, Inc. (Contract Provider) 2514 W Tharpe Street Tallahassee, Florida Review Date(s): December 10-13, 2013 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 N N I F E R R E C H I C H I, B U R E A U C H I E F

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 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: Barbara Campbell, Lead Reviewer, DJJ Bureau of Quality Improvement Michael Murphy, Senior Juvenile Probation Officer, DJJ Probation, Circuit 1 Kathy Parrish, Program Monitor, DJJ Residential Services, Northwest Region Juliet Westmoreland, Federal Grants Coordinator, DJJ Prevention & Victim Services

3 Program Name: AMIkids Tallahassee (Back End) QI Program Code: 1242 Provider Name: AMIkids, Inc. Contract Number: P2106 Location: Leon County / Circuit 2 Number of Beds: 15 Review Date(s): December 10-13, 2013 Lead Reviewer Code: 117 Methodology This review was conducted in accordance with FDJJ-1720 (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 (August 2012). Persons Interviewed Program Director DJJ Monitor DHA or designee DMHA or designee 2 # Case Managers # Clinical Staff # Food Service Personnel # Healthcare Staff Documents Reviewed # Maintenance Personnel 2 # Program Supervisors # Other (listed by title): Accreditation Reports Affidavit of Good Moral Character CCC Reports Confinement Reports Continuity of Operation Plan Contract Monitoring Reports Contract Scope of Services Egress Plans Escape Notification/Logs Exposure Control Plan Fire Drill Log Fire Inspection Report Fire Prevention Plan Grievance Process/Records Key Control Log Logbooks Medical and Mental Health Alerts PAR Reports Precautionary Observation Logs Program Schedules Sick Call Logs Supplemental Contracts Table of Organization Telephone Logs Surveys Vehicle Inspection Reports Visitation Logs Youth Handbook # Health Records 3 # MH/SA Records 5 # Personnel Records 3 # Training Records/CORE 3 # Youth Records (Closed) 3 # Youth Records (Open) # Other: 3 # Youth 3 # 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 24 (Revised August 2013)

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 Non-Applicable 1.12 Food Services 1.13 Transportation 1.14 Administration 1.15 Ninety-Day Supervisory Reviews 1.16 * Incident Reporting (CCC) * 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 24 (Revised August 2013)

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 2.08 *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 5 of 24 (Revised August 2013)

6 Standard 3: Intervention Services Day Treatment Rating Profile Indicator Ratings Standard 3 - Intervention Services 3.01 Vocational Programming 3.02 Youth-Empowered Success (YES) Plan Development 3.03 Youth Requirements/PACT Goal Elements 3.04 * Transitional Planning/Reintegration 3.05 YES Plan Implementation/Supervision 3.06 Effective Response System 3.07 Behavior Management System 3.08 Ninety-Day YES Plan Updates 3.09 Educational Transition 3.10 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 24 (Revised August 2013)

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 Non-Applicable * 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 24 (Revised August 2013)

8 Strengths and Innovative Approaches During the week of the review, the program was participating in the service from the heart charitable event. The youth were going into a local senior citizen home to assist in coordinating activities for the elderly residents to participate in for the holidays. The program has an agreement with the City of Tallahassee to assist in cutting yards and trimming bushes of elderly and handicap residents that have been given a citation by the city for overgrown yards. The program has recently signed an agreement with Goodwill Industries to provide education, employment training, and housing services, if applicable. Office of Program Accountability Page 8 of 24 (Revised August 2013)

9 Standard 1: Management Accountability Overview The program provides day treatment services through a contract with AMIkids, Inc. and the Department of Juvenile Justice. The program provides fifteen day treatment slots and is designed to serve youth aged fourteen to eighteen on probation and minimum-risk commitment. The program s organizational chart consists of a regional program director, executive director, business manager, two local care counselors, licensed mental health counselor, behavioral interventionist, and a community safety specialist who is also serves as the bus driver. The program has a contract with Elder Care Services, Inc. to provide lunch 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 one staff file and three volunteer files found that all had received an initial background screening prior to their hire date or services started with the program. The Annual Affidavit of Compliance with Level 2 Screening Standards was submitted to the Department s Background Screening Unit (BSU) on December 14, 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 for conducting a new background screening for all staff, volunteers, and interns every five years. A review of one applicable staff file found that a five-year rescreening was completed prior to the anniversary date of the initial date of hire. There were not any volunteers who had been at the program over five years 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. There has been one Protective Action Response (PAR) incident since the last Quality Improvement review period. The techniques applied in the PAR were not approved by the Department and a post-par interview was not conducted within thirty minutes of the PAR by the superintendent or designee. The program was placed on a corrective action plan (CAP) for this incident and has completed satisfactory per the program monitor. Office of Program Accountability Page 9 of 24 (Revised August 2013)

10 1.04 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. The program did not have any new hires since the last Quality Improvement review. There was one staff member that was transferred internally to the program in July This staff member had completed all of his pre-service training in his previous position 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. The program has policies and procedures addressing annual in-service training. A review of three staff training files for in-service training requirements validated that each staff completed at least twenty-four hours of training. One staff training file was also reviewed for supervisory training requirements. A review of the staff file validated that eight hours of management inservice training was completed. The program submitted, in writing, a list of in-service training to the Department s Office of Staff Development and Training on April 24, 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 written policy and procedures for the implementation of a medical alert system. Four of the five reviewed youth records had a medical condition that required an alert. All four youth were placed on the program s internal alert roster. The internal alert roster list the youth s name, medical alert, medications being taken and additional information from the parent/guardian concerning the medical alert. In addition to these items, the roster also listed out all of the possible medications the youth might be taking and list the side effects 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. Office of Program Accountability Page 10 of 24 (Revised August 2013)

11 The program has written policy and procedures for provision of episodic, first aid, and emergency care. The program s first aid kits were located in areas easily accessible to the staff throughout the building and on the school bus. The suicide response kits were located in two easily accessible locations in the building and one on the school bus. The program does not have an automated external defibrillator (AED). Documentation of mock emergency drills validated that they are being conducted quarterly for each shift. The mock emergency drills ranged from medical, suicide, and weather emergencies. There was one incident since the last Quality Improvement review that required a youth to receive an ice pack. This incident was not logged on the episodic care log. This incident was part of the PAR incident that resulted in the program being placed on a corrective action plan 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 has a written policy and procedure for the storage and maintenance of medications. Youth medications are not stored or distributed within the facility; this was confirmed in an informal interview with the program director Cleanliness and Sanitation Compliance The program provides a safe and appropriate treatment environment that includes maintenance and sanitation of the facility. The program was observed to be clean and well-maintained during the Quality Improvement review. All indoor areas were clean and neat. Graffiti was not observed to be on any of the walls, doors, or windows. The community safety specialist conducts weekly sanitation and safety inspections of all internal and external areas and equipment. A review of weekly inspection reports were reviewed for the review period. A schedule of housekeeping responsibilities for each week was observed. The outside perimeter of the program is lit during the early morning and evening hours. Separate bathroom facilities are provided for male and female youth. The program has adequate space for private counseling, group meetings, and classrooms Fire Prevention and Evacuation Procedures Compliance The program provides a safe and appropriate treatment environment that includes fire prevention and evacuation procedures. The program maintains written policy and procedures that include a comprehensive fire prevention and evacuation plan during an emergency situation. The program last received their fire extinguisher annual maintenance on December 6, Five fire extinguishers were strategically placed throughout the program and one on the school bus. A review of the fire safety log documented the annual fire safety inspections and fire drills. There was no documentation to support that the staff and youth were trained in the proper operation and use of available equipment Water Activities Non-Applicable The program provides a safe and appropriate treatment environment that includes procedures for water activities. Office of Program Accountability Page 11 of 24 (Revised August 2013)

12 The program does not participate in any water-related activities; therefore, this indicator rates as non-applicable Food Services Compliance The program provides a safe and appropriate treatment environment that includes food service. The program is supplied meals through Elder Care Services, Inc. and they participate in the National School Lunch and School Breakfast program. It is the program s responsibility to notify the vendor of any special diets. There are three youth at the program that are allergic to nuts which are not served on the menu. Staff are given the choice to eat the school lunch, but the majority of the staff provides their own lunch. There was no evidence to support that food is withheld as a disciplinary measure Transportation Compliance The program provides a safe and appropriate treatment environment that includes transportation. The program provides daily transportation to and from the facility or arranges for such transportation for each youth. The program utilizes one school bus to transport youth to the facility. There are three additional school buses on the property that are not operational. The operational bus has a knife-for-life, window punch, needle-nose pliers, first aid kits, an updated fire extinguisher, and current vehicle registration and insurance. There was also documentation of annual vehicle inspections and maintenance conducted. The community safety specialist is also the bus driver and has a current commercial driver s license (CDL) Administration Compliance The program provides a safe and appropriate treatment environment that includes administrative and operational oversight. The program submits the required statistical information to their contract manager on a monthly basis. The statistical information provided includes admissions, releases, transfers, average length of stay, and PAR incidents. The program maintains a daily logbook that records significant activities, incidents, and events. There was consistent documentation in the logbook that the executive director reviewed the entries and signed the logbook on a biweekly basis 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 during the subsequent review. Five youth files were reviewed for the completion of the ninety-day supervisory reviews. Only one of the five files was applicable due to the other youth not being in the program for more than ninety days. The one file showed documentation of a supervisory review being conducted within the allotted time frame. However, all five files documented that the supervisor reviewed and Office of Program Accountability Page 12 of 24 (Revised August 2013)

13 signed the Youth-Empowered Success (YES) plan within fourteen days of the youth s admission to the program 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 four Central Communications Center (CCC) reports in the past six months that were in compliance with the CCC reporting time frames. A review of additional internal incident reports determined that there were no additional incidents that should have been reported to the CCC. Standard 2: Assessment Services Overview AMIkids Tallahassee (Back End) provides day treatment and case management services for youth on probation, post commitment probation, and conditional release supervision in Leon County. The program employs two case managers who are supervised by the director of treatment services. The case management services provided include completion of the Positive Achievement Change Tool (PACT), assessment, negotiation and monitoring of the Youth- Empowered Success (YES) Plan, facilitating and monitoring the completion of court-ordered sanctions, and providing delinquency intervention services. Upon admission to the program each case manager completes an orientation checklist with the youth that addresses expectations for the youth while at the program. A copy of the youth handbook is provided upon admission that fully explains the AMIkids program and behavior management system Admission and Orientation Compliance Face-to-face contacts are conducted with youth within three working days of any probation disposition or release from a residential program, if the youth is on conditional release (CR) or post-commitment probation (PCP). Applicability of the face-to-face contact requirement depends on whether the youth has been admitted to the program at the time of disposition or release. All youth participate in a program orientation process, which includes the elements required by Florida Administrative Code, within twenty-four hours of admission. The program conducts an orientation with the youth on the day of the admission to the program. A youth handbook is provided to each youth that details the policies and expectations for the youth while at the program. A signed copy of the orientation checklist that details all areas covered during the orientation is maintained in the youth s file. Three files were reviewed for this admission and orientation. All three files had a signed orientation checklist that addressed all the required elements of orientation on the date of admission. Face-to-face contact was made by the case manager within three working days of the youth being released from their residential program. Transitional planning was not applicable in one of the files reviewed. The remaining two files documented participation in the transitional planning process. Face-to-face contact was made within the required time frame by the case managers. Office of Program Accountability Page 13 of 24 (Revised August 2013)

14 2.02 Medical Screening Compliance Youth are screened for health-related conditions at the time of admission to determine if the youth has any conditions that require medical attention. The screening includes a review of the most recent Health Discharge Summary (Form HS 012), 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. A review of three records documented that each contained the Department s Facility Entry Physical Health Screening (FEPHS) form, which was completed at the time of admission with the youth and parent/guardian. The records contained all the youth s medical, mental health, and substance abuse information Medication Management Verification of Medications Compliance The program shall determine a youth s medication regimen upon admission to the program. A review of three records contained documentation that each youth and parent/guardian was interviewed about the youth s medication regimen. The youth that are taking prescribed medications are administered the medication daily at home prior to coming to the program. The program does not administer medication on site and requires the parent/guardian to administer medication off site 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, as indicated by the mental health/substance abuse screening. (For the entire indicator statement, please reference the Quality Improvement FY Day Treatment indicators.) In each of the three files reviewed the program completed a Positive Achievement Change Tool (PACT) Screening Report and Referral Form for Mental Health and Substance Abuse Assessment for each youth at admission. Two of the three files reviewed were referred for further assessment based upon the results of the screening. Both referrals had a Massachusetts Youth Screening Instrument Second Version (MAYSI-2) completed. One of the files reviewed had a referral for further assessment due to a suicide risk or emergency crisis intervention. An internal alert was issued and the youth was immediately placed on precautionary observation. The procedures were in accordance with the program s procedure and an alert was entered into the Juvenile Justice Information System (JJIS). Office of Program Accountability Page 14 of 24 (Revised August 2013)

15 2.05 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 three files documented that each contained a completed PACT Full Assessment that was completed within seven days of the admission date. 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. One of the three files reviewed, was applicable for a PACT Full Assessment. The PACT Reassessment was completed every ninety days, regardless of the youth s risk to reoffend. Three closed files were reviewed and found that a PACT Final Assessment was completed prior to each youth completing the program in order to document their progress in meeting criminogenic needs 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. None of three reviewed files were applicable for a progress report due to the youth being recently admitted to the program 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. A review of the program s abuse reporting incidents found that there were no incidents called into the Florida Abuse Hotline within the last six months. Observations found that the Florida Abuse Hotline telephone number was posted in the facility and also highlighted in the youth and parent/guardian handbook. Documentation was found in the reviewed files that abuse orientation procedures were discussed with the youth during orientation. The Florida Abuse Hotline phone number was posted throughout the program. None of the five youth surveyed stated that they had been denied a telephone call to the Florida Abuse Hotline. Office of Program Accountability Page 15 of 24 (Revised August 2013)

16 Standard 3: Intervention Services Overview AMIkids Tallahassee (Back End) provides delinquency intervention and case management services for youth on conditional release and post-commitment probation. The program services are based on each youth s YES Plan and court-ordered sanctions. Upon completion of the program assessment, youth are enrolled in the Casey Life Skills program and Goodwill Services Work program where they assist in employability, career path, and decision making skills Vocational Programming Compliance Staff shall develop and implement a vocational competency development program. The program is a Type A/Level 1 vocational program. Two of the three files reviewed were applicable due to youth ages. For the two eligible files, there was documentation in one file of the YES Plan containing vocational goals. The program could only provide supporting documentation of vocational goals being completed for one of the two files. However, each file had documentation of each youth having an appointment with the local One-Stop Career Center and case notes that documented the case managers assisting the youth with seeking employment 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. All three files reviewed had a completed PACT prior to completion of each youth s initial YES Plan. All three YES Plans were developed within fourteen calendar days of each youth s admission to the program and signed by all parties including the youth, parent/guardian, and program staff. None of the three reviewed files indicated in the case notes that the parent/guardian was provided copies of the YES Plan upon their review and signature. However, documentation in the case notes did indicate that the parents/guardians were involved in completing the initial YES Plans 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 three files found that only one file had court-ordered sanction goals. Each file had at least one of the youth s top three criminogenic needs as part of the PACT and had at least one specific action should be taken for the youth, parent/guardian, and JPO. Office of Program Accountability Page 16 of 24 (Revised August 2013)

17 3.04 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. Two of the three files reviewed were applicable for transition planning/reintegration services. The one youth was referred to the program after already being released from the residential commitment program. Case note documentation in the two applicable files revealed that the case manager participated in the treatment team, transition, and exit meetings. The case manager did not have any face-to-face contact with the youth due to the residential commitment programs being over the fifty-mile radius 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. All three reviewed files showed compliance or attempted compliance with the action steps in the YES Plan. Each file reviewed had measurable goals that the youth must achieve. All three files had on-going revisions to the YES Plan when the goals were completed and other needs were addressed Effective Response System Compliance Staff responds to noncompliance in a manner that is consistent with the program s progressive response system. Staff responded to non-compliant behavior in a manner that was consistent with the program s progressive response system. The program uses a behavior management system that consists of color codes that addresses the youth s behavior. The program uses codes black, blue, and red. Documentation of the program responding to the youth s non-compliant behavior was consistent with the program s progressive response system 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 has a behavior management system (BMS) that utilizes positive and negative consequences for behavior. The program s BMS uses a ranking system and phase system for probation youth, which utilizes a token and point system. There are five ranks and four phases. To advance from one rank and phase to another, each youth is required to achieve a certain Office of Program Accountability Page 17 of 24 (Revised August 2013)

18 number of points for a targeted number of days and to demonstrate appropriate social and academic skills. Each increase in rank or phase allows for an increase in privileges such as offcampus activities. Both the rank system and phase system include consequences that are fair and directly correlate with the behavior problem, so that the youth understand the consequences of their behavior. Upon admission to the program, youth receive a handbook explaining the rules of the program, rank system, phase system, points, tokens, and consequences. The program logs behavior incidents in the program s daily facility log upon occurrence and completes an internal incident form 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. None of the three files reviewed were applicable for a ninety-day YES Plan update due to the youth admission dates Education Transition Compliance Staff and youth complete an education transition plan prior to release that includes provisions for continuation of education and/or employment. Three applicable closed files were reviewed and each file had educational plans signed by the parent/guardian and youth. The education transition plan included provisions for continuation of education and/or employment. The program partners with Goodwill Services in order to provide comprehensive employment and skills building Termination/Release Compliance The program shall recommend termination to the Department for youth on probation, conditional release, or post-commitment probation, as well as minimum-risk commitment youth, upon successful completion of court-ordered sanctions and substantial compliance with restitution and/or court fees. For youth on probation, conditional release, or post-commitment probation, the program works with the Juvenile Probation Officer (JPO) to facilitate the release of the youth upon completion of the program. For youth on minimum-risk commitment, staff completes the Pre-Release Notification and Acknowledgement (PRN) (DJJ/BCS Form 19) and follows the required procedure. Three closed files were reviewed. One of the files documented an abrupt termination due to the youth relocating to another city. The remaining two files successfully completed the program and were transitioned back to their school. Notification of program completion was completed and sent to the appropriate parties. Office of Program Accountability Page 18 of 24 (Revised August 2013)

19 Standard 4: Medical, Mental Health, and Substance Abuse Services Overview AMIkids Tallahassee (Back End) is a day treatment program located in Leon County, Florida designed to serve male and female youth ages fourteen to eighteen requiring conditional release and post-commitment probation supervision within the juvenile justice system. The program has an executive director, a director of operations, a behavioral interventionist, a licensed metal health counselor (LMHC), and a director of education. Additionally, there are two case managers and a business manager Medication Management Delivery of Medications Compliance The program shall have a process in place to assist youth with self-administration of oral medications. A review of the program policy and procedures found that the staff do not assist youth in selfadministering medications. The program will not store medications. If a youth requires mediations during the time they are in the program, their parent/guardian has to come to the program to assist the youth Designated Mental Health Authority or Clinical Coordinator Compliance Each program director is responsible for the administrative oversight and management of mental health and substance abuse services in the program. Each day treatment program must designate either a Designated Mental Health Authority or a Clinical Coordinator to be responsible for coordinating and verifying implementation of necessary and appropriate mental health and substance abuse services in the program. The program employs a full-time licensed mental health counselor (LMHC) who serves as the designated mental health authority (DMHA). The DMHA oversees all mental health/substance abuse services at the program, including screenings, assessments, treatment plans, mental health/substance services, and discharge planning Licensed Mental Health and Substance Abuse Clinical Staff Compliance The program director is responsible for ensuring that mental health and substance abuse services are provided by individuals with appropriate qualifications. Clinical supervisors must assure that clinical staff working under their supervision are performing services that they are qualified to provide based on education, training, and experience. The program has one DHMA who provides individual counseling and completes all comprehensive assessments for youth that have been referred for mental health and substance abuse services. A review of personnel documentation found this staff to be qualified and trained to provide groups to the youth in the program. Office of Program Accountability Page 19 of 24 (Revised August 2013)

20 4.04 Non-Licensed Mental Health and Substance Abuse Clinical Compliance Staff The program director is responsible for ensuring that mental health and substance abuse services are provided by individuals with appropriate qualifications. Clinical supervisors must assure that clinical staff working under their supervision are performing services that they are qualified to provide based on education, training, and experience. A review of the program s contract, organizational chart, and clinical documentation confirmed that the program s mental health and substance abuse service component is staffed in accordance with the requirements outlined in the current contract. There are no non-licensed staff members providing treatment services at the program Mental Health and Substance Abuse Admission Screening Compliance The mental health and substance needs of youth are identified through a comprehensive screening process that ensures referrals are made when youth have identified mental health and/or substance abuse needs or are identified as a possible suicide risk. A review of three records found that all received a Massachusetts Youth Screening Instrument - Second Version (MAYSI-2) and Positive Achievement Change Tool (PACT) during the admission process to the program. The designated mental health authority (DHMA) is notified of any youth requiring additional assessments through the Department s Mental Health and Substance Abuse Referral Summary form. The reviewed referrals documented the reason for a further assessment Mental Health and Substance Abuse Assessment/Evaluation Compliance The day treatment program director or designee must develop procedures whereby youth who demonstrate behaviors or symptoms indicative of mental disorder or substance abuse during the screening process or upon a youth's admission to the program are referred for a comprehensive mental health evaluation or comprehensive substance abuse evaluation or updated evaluation. The program has policies and procedures related to the comprehensive mental health and substance abuse assessments. Only one of the three reviewed records were applicable. The record contained a comprehensive evaluation completed within thirty days of the referral. The evaluation was completed by the LMHC and a summary and recommendations was included for treatment Mental Health and Substance Abuse Treatment Compliance Mental health and substance abuse treatment planning in departmental facilities focuses on providing mental health and/or substance abuse interventions to reduce or alleviate the youth's symptoms of mental disorder or substance abuse impairment and enable youth to function adequately in the juvenile justice setting. The treatment team is responsible for assessing the youth's rehabilitative treatment needs and assisting in developing, reviewing, and updating the youth's individualized and initial mental health/substance abuse treatment plans. Office of Program Accountability Page 20 of 24 (Revised August 2013)

21 The program has a policy and procedure related to mental health and substance abuse treatment. All three records reviewed were assigned to a multidisciplinary treatment team. The treatment team assessed each youth s rehabilitative treatment needs and assisted in developing, reviewing, and updating each youth s treatment plan. Youth that were recommended for mental health and substance abuse treatment as a result of the comprehensive evaluations were referred to community-based services in conjunction with individual and group services at the program Treatment and Discharge Planning Compliance Youth determined to have a serious mental disorder or substance abuse impairment, and are receiving mental health or substance abuse treatment in a program, must have an initial or individualized mental health or substance abuse treatment plan. When mental health or substance abuse treatment is initiated, an initial or individualized mental health/substance abuse treatment plan is completed. All youth who receive mental health and/or substance abuse treatment while in a day treatment program will have a discharge summary completed that documents the focus and course of the youth's treatment and recommendations for mental health and/or substance abuse services upon youth's release from the facility. Three closed records were reviewed for treatment planning and each record had an initial treatment plan completed within seven days of admission. None of the three records documented the frequency of monitoring by a psychiatrist on the initial treatment plan. Each record contained an individualized mental health/substance abuse treatment plan completed within thirty days of admission and approved within ten days of completion. Each youth and a licensed mental health professional consistently signed the initial and individualized treatment plans, but one record showed no other treatment team members involved. A review of documentation found that each record contained discharge summaries as required, however, did not document that a JPO attended the exit conference Suicide Prevention Plan Compliance The program follows a suicide prevention plan to safely assess and protect youth with elevated risk of suicide in the least restrictive means possible in accordance with the DJJ Mental Health and Substance Abuse Manual. A review of the program s suicide prevention plan found that it contained all of the required elements in accordance with the Department s Mental Health and Substance Abuse Services Manual Suicide Prevention Services Compliance Suicide Precautions are the methods utilized for supervising, observing, monitoring, and housing youth identified through screenings as having suicide risk factors or identified through assessment as a potential suicide risk. Any youth exhibiting suicide risk behaviors must be placed on Suicide Precautions (Precautionary Observation or Secure Observation), and a minimum of constant supervision. All youths identified as having suicide risk factors by screening, information obtained regarding Office of Program Accountability Page 21 of 24 (Revised August 2013)

22 the youth, or staff observations, must be placed on Suicide Precautions and receive an assessment of suicide risk. One youth was found to be at risk due to requiring psychotropic medication upon entry into the program. The youth was place on precautionary observation (PO) until the DMHA conducted an Assessment of Suicide Risk and found the youth not to be suicidal. If a youth is found to be suicidal after a suicide assessment, the program s policy and procedure is to continue the youth on PO until supervision is reduced close supervision and then back to general population. If the DHMA finds a youth to be in imminent danger of harming their self or others, law enforcement would be called to refer the youth for a Baker Act evaluation Suicide Precaution Observation Logs Compliance Youth placed on suicide precautions must be maintained on one-to-one or constant supervision. The staff member assigned to observe the youth must provide the appropriate level of supervision and record observations of the youth's behavior at intervals no greater than thirty minutes. A review of the Suicide Precautions Observation Logs found that the staff were correctly completing logs every thirty minutes, as required, with correct behavior codes documented. All of the observation logs were reviewed by the DHMA and supervisor Suicide Prevention Training Compliance All staff who work with youth must be trained to recognize verbal and behavioral cues that indicate suicide risk. The program maintains policy and procedures for suicide prevention training to ensure that staff recognize verbal and behavior cues that indicate suicide risk. Suicide-related mock drills are conducted at a minimum, semi-annually. Three staff training files were reviewed and found that all three files contained documentation of a minimum of six hours of annual training on suicide prevention and implementation of suicide precautions. Observation confirmed that the program has suicide response kits located throughout the building that are easily accessible to staff. Each kit contained the knife-for-life, wire cutters, and needle-nose pliers Mental Health Crisis Intervention Services Compliance Every program must respond to youth in crisis in the least restrictive means possible to protect the safety of the youth and others while maintaining control and safety of the facility. The program must be able to differentiate a youth that has an acute emotional problem or serious psychological distress from one that requires emergency services. A youth in crisis does not pose an imminent threat of harm to himself/herself or others which would require suicide precautions or emergency treatment. The program has a mental health crisis intervention plan that ensures the safety of the youth and others through an alert system, referral and assessment steps, supervision, and documentation Crisis Assessments Compliance A crisis assessment is a detailed evaluation of a youth demonstrating acute psychological Office of Program Accountability Page 22 of 24 (Revised August 2013)

23 distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a licensed mental health professional, or under the direct supervision of a licensed mental health professional, to deter-mine the severity of youth's symptoms, and level of risk to self or others. When staff observations indicate that a youth's acute psychological distress is extreme/severe and does not respond to ordinary intervention, the superintendent or designee must be notified of the crisis situation and need for crisis assessment. A Crisis Assessment is to be utilized only when the youth s crisis (psychological distress) is not associated with suicide risk factors or suicide risk behaviors. If the youth s behavior or statements indicate possible suicide risk, the youth must receive an Assessment of Suicide Risk instead of a Crisis Assessment. The program has policy and procedures related to crisis assessments. When deemed necessary, the program utilizes the Department s Crisis Assessment form. The program has not had any youth applicable to crisis assessment over the past year Emergency Mental Health and Substance Abuse Services Compliance Youth determined to be an imminent danger to themselves or others due to mental health and substance abuse emergencies that occur in facility require emergency care provided in accordance with the facility's emergency care plan. A review of the program s emergency services plan found a description of the emergency care plan and the steps for staff and administration to follow in the event a youth requires emergency services Baker and Marchman Acts Non-Applicable Individuals who are believed to be an imminent danger to themselves or others because of mental illness or substance abuse impairment require emergency mental health or substance abuse services. The program did not utilize a Baker Act or Marchman Act procedure during this review period; therefore, this indicator rates as non-applicable. Office of Program Accountability Page 23 of 24 (Revised August 2013)

24 Program Name: AMIkids Tallahassee (Back End) QI Program Code: 1242 Provider Name: AMIkids, Inc. Contract Number: P2106 Location: Leon County / Circuit 2 Number of Beds: 15 Review Date(s): December 10-13, 2013 Lead Reviewer Code: 117 Overall Rating Summary All indicators have been rated and no corrective action is needed at this time. Office of Program Accountability Page 24 of 24 (Revised August 2013)