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 Miami-Dade South (Front End) AMIkids, Inc. (Contract Provider) 1820 Arthur Lamb Jr. Road Miami, Florida Review Date(s): April 22-23, 2014 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: Tom Mahoney, Lead Reviewer, DJJ Bureau of Quality Improvement Gabriel Medina, Monitor, DJJ Bureau of Monitoring and Quality Improvement, South Region Angela Mitchell, Supervisor, Miami-Dade County Juvenile Services Department Johnny Richardson, Monitor, DJJ Bureau of Monitoring and Quality Improvement, South Region

3 Program Name: AMIkids Miami-Dade South (Front End) QI Program Code: 1250 Provider Name: AMIkids, Inc. Contract Number: P2121 Location: Miami-Dade County / Circuit 11 Number of Beds: 40 Review Date(s): April 22-23, 2014 Lead Reviewer Code: 107 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 1 # 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 7 # Health Records 7 # MH/SA Records 7 # Personnel Records 7 # Training Records/CORE 7 # Youth Records (Closed) 7 # Youth Records (Open) # Other: 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 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) Non-Applicable 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) * 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 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 Limited 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). The following limited and/or failed indicators require immediate corrective action PACT Reassessment Office of Program Accountability Page 5 of 28 (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 Non-Applicable 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 28 (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 * 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 August 2013)

8 Strengths and Innovative Approaches The program has an electronic monitoring system (Biotrak) that 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. The program provides opportunities for all youth to pursue a college education or vocational training, offering scholarship assistance that includes tuition and books, to exceptional graduates from the program, through the Fisher Island Philanthropic Fund and the Second Step Education Scholarship Fund. The program has a thirteen-member board of trustees, shared with the AMIkids Miami-Dade North program, responsible for the financial oversight and strategic planning of the program. As a component of the program s restorative justice efforts, the youth in the program participate in community service projects with local organizations including the United Way, the Hearts for Seniors, and the Coastal Beach Clean-Up. The program provides youth who have perfect attendance a hot breakfast and special recreational activities on Fridays. Youth are provided the opportunity to join the scuba team and earn a scuba certification, attend a dive trip to the Florida Keys, learn how to use all scuba diving gear, and participate in scuba training and certification. Applicable youth are allowed the opportunity to travel to Key West to swim with the dolphins. Some youth participate annually in white water rafting in Nantahala, North Carolina. In addition, some youth participate in the Tallahassee Legislative Day, in the winter experiential challenge event in Gainesville, Florida, and in the dive invitation in Florida City, Florida. Office of Program Accountability Page 8 of 28 (Revised August 2013)

9 Standard 1: Management Accountability Overview AMIkids Miami-Dade South (Front End) is a non-residential day treatment program operated by AMIkids, Inc., under contract with the Department of Juvenile Justice (DJJ). This annual compliance review is only applicable to all youth placed on probation or classified as minimumrisk commitment by the court. The program is located in Virginia Key, Miami, Florida, in a facility owned by AMIkids, Inc., located on land owned by Miami-Dade County. The program s staff is comprised of an executive director (ED), a lead behavior interventionist, a director of administration, a community safety specialist, a licensed mental health counselor, and a director of education. Services provided are designed to address criminogenic risk factors, according to the youth s risk and needs. The program s management proactively monitors potential incidents and risks to the program. A tour of the program found that the program is maintained in a clean and orderly condition that supports positive interactions between staff and youth. The program provides daily breakfast, lunch, and one snack to all youth and staff, catered by Exquisite Catering by Robert. In addition, the program participates in the National School Lunch and Breakfast program. The program held comprehensive staff meetings daily with representatives from each program component. The program does not have licensed medical staff on site. The program maintains a master training plan. The program maintains an internal alert system that is updated daily. Youth are provided numerous opportunities to participate in community activities to enhance their learning experience, and to comply with the community service hour requirements. All youth in the program receive instruction in various aquatic skills such as boating, seamanship, scuba diving, marine mechanics, marine sciences, biodiversity, and maintenance. All surveyed youth indicated that they feel safe in the program. Miami-Dade County Public Schools provides oversight and support to the program s educational component, as well as academic assistance and transportation. The program has a supportive relationship with the local community and the juvenile justice community 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 five volunteer/interns personnel files found that all five volunteer/interns received an eligible background screening rating prior to an offer to utilize their services. A review of eight staff personnel files found that all 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 s Background Screening Unit on January 7, 2014, meeting the annual requirement. Prior to hire, the program conducts a Florida Sexual Offenders and Predators check with the Florida Department of Law Enforcement on all new staff. Office of Program Accountability Page 9 of 28 (Revised August 2013)

10 1.02 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 had policy and procedure in place to appropriately conduct five-year background screening. The program conducts semi-annual driver s license checks of all staff. There were no staff applicable for the five-year rescreening requirements Protective Action Response (PAR) Non-Applicable The program uses physical intervention techniques in accordance with Florida Administrative Code. Any time staff uses a physical intervention technique, such as countermoves, control techniques, takedowns, or application of mechanical restraints (other than for regular transports), a PAR Incident Report is completed and filed in accordance with the Florida Administrative Code. There have been no Protective Action Response (PAR) incidents during this review period; therefore, this indicator rates as non-applicable Pre-Service/Certification Training Compliance Contracted non-residential staff are trained in accordance with Florida Administrative Code. Contracted non-residential staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. Contracted non-residential staff 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 all staff averaged over seventy hours of in-service training, exceeding the twenty-four hour annual Office of Program Accountability Page 10 of 28 (Revised August 2013)

11 requirement. One supervisory staff training file was reviewed. The supervisor received over ninety hours of supervisory training, far exceeding the eight-hour requirement. 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 (CORE). The program submitted the in-service training plan to the Department s Office of Staff Development and Training, as required 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 written policy and procedure for identifying and documenting youth medical alerts. Seven youth healthcare records presented documentation of a medical related issue. The program maintained an updated youth alert log containing youth names, allergies, special diets, current suicide alerts, medical alerts, and any applicable medication(s) prescribed. A review of six program logbooks indicated practice of documenting medical events, environmental stressors, and alternative activities. All seven surveyed staff indicated being informed of youth s medical alerts by daily communicating among staff 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 has a written policy and procedure that provides trainings for the provision of episodic care, first aid, and emergency care. A review of the episodic care log indicated that staff documents the providing of care to youth for minor injury. Reviewed documentation indicated a monthly episodic drill was conducted. All drills had a written critique and included multiple staff participants and at least one youth. The program does not maintain an automated external defibrillator (AED) on site. All nine staff training files presented certification of first aid and cardiopulmonary resuscitation (CPR). The program has a contract with Zee Medical Services for first aid kit supplies and documents the use of and replenishing items. There were no emergency room or off-site for treatment services during this review period. The program communicates potential emergency information to all staff during daily staff meetings 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 of medications. The program staff do not directly provide medication administration to youth, but coordinate with the parent/guardian to have the youth s medication need handled before and after program daily attendance. Observation of the area where medication would be stored indicated a refrigerator with a combination lock in a secure mental health office. There were medication distribution logs available to be used for tracking any medication administration and storage. There were no medications stored at program during this review period. Office of Program Accountability Page 11 of 28 (Revised August 2013)

12 1.09 Cleanliness and Sanitation Compliance The program provides a safe and appropriate treatment environment that includes maintenance and sanitation of the facility. The program conducts daily inspections that were documented on the daily security check form and signed by the staff conducting the inspections. The executive director also reviews and signs the form. The program has adequate space for private counseling, group sessions, and education services. A tour of two buildings and program grounds indicated areas were observed clean and orderly, free of obstructions, and had ample displays of information boards. There were separate restrooms for females and males that were operational, and with hot and cold running water from two sinks. There was one urinal and one toilet in the male restroom and two toilets in the female restroom 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 written comprehensive fire prevention and safety plan. A review of seven staff training files supported that staff are trained on the plan and the use of fire equipment and alarms at least annually. Observations of multiple rooms and offices at the program indicated legible evacuation route postings and emergency lights pointing in the direction for safe evacuation. The facility has an activated fire alarm and automatic detection system, which is annually inspected by a contracted vendor. Reviewed documentation supports that the program maintains a fire safety log that includes the annual fire safety inspection, notation of any deficiencies, and quarterly inspections. There was no evidence of smoking occurring in the facility, and there are postings of no smoking permitted at the check-in area. All surveyed youth and staff confirmed that they knew what to do in the event of a fire and/or evacuation. Reviewed color-coded documentation in the facility logbook indicated that fire drills are conducted monthly at various times Water Activities Compliance The program provides a safe and appropriate treatment environment that includes procedures for water activities. The program maintains a written water safety plan addressing the youth s water-related activities that required youth swim testing and diver certification. Reviewed documentation indicated that at least one staff is a certified lifeguard, who is also the dive instructor. Review of three youth swim tests indicate youth completed the swim test while in the program. All water activities are conducted off-site. Youth have the opportunity to participate in swimming, snorkeling, scuba diving, and boating. Three interviewed youth indicated each was swim tested prior to participating in water activities Food Services Compliance The program provides a safe and appropriate treatment environment that includes food service. The program maintains a written agreement with the licensed Exquisite Catering by Robert for daily food services to youth and allows for on-duty staff to eat the same food as the youth. The Office of Program Accountability Page 12 of 28 (Revised August 2013)

13 food storage and serving area was observed clean and maintained. All meals are provided in the multi-purpose room, where adequate seating was available. Reviewed county and state inspections and certification documentation indicated there were no issues and all certifications and licenses were current. All seven surveyed youth and six of seven surveyed staff confirmed that the program offered the same menu for staff and youth. Youth are provided substitutes for special diets and observations found that the current menus were displayed in the foodservice area Transportation Compliance The program provides a safe and appropriate treatment environment that includes transportation. The program maintains a written transportation policy. The program utilizes one passenger van and one four-door sedan, which were inspected during the review. Both vehicles contained a first aid kit with appropriate items for first responder care and a fire extinguisher with a valid inspection tag. Review of current insurance and vehicle registration indicated vehicles are properly insured and lawful. Transportation is contracted through Miami-Dade County School District and a private bus transports all youth for all morning and evening transports. Reviewed program documentation of staff semi-annual driver s license checks indicated management monitors driving issues closely. The program recently implemented a Global Positioning System (GPS) in the program van. All staff were trained on GPS and expectations of operating company vehicles and transporting youth. All surveyed youth and staff confirmed youth and staff utilized the seat belts during transportation 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 the assigned Department of Juvenile Justice (DJJ) contract manager and program monitor on a monthly basis. The program uses a daily logbook, and as a shift report for ongoing documenting of events that records significant activities, incidents, and events. The logbook entries that impacted the safety and security of the program were highlighted. The executive director reviewed and signed the logbook entries on a daily basis. Errors within logbook entries indicated usage of a single line strike-through and the word void written, as required. Off-campus activities were documented in the program s daily logbook. Each pertinent logbook entry did consistently mention the name of the youth and program staff involved, with a brief statement of pertinent information 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. Seven youth case management files were reviewed for the completion of the ninety-day supervisory reviews. All six applicable reviewed files documented that the supervisor reviewed and signed the Youth-Empowered Success (YES) Plan within fourteen days of the youth s admission to the program. The program documented supervisory reviews every ninety days in Office of Program Accountability Page 13 of 28 (Revised August 2013)

14 the reviewed files. A review of the files found that the executive director ensures that staff review any instructions given during the review, and ensures that they were followed during the subsequent 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 six 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 within the required time frame. Standard 2: Assessment Services Overview The program provides an array of appropriate assessment services to each youth admitted. The program has two local care counselors and other designated staff members responsible for the admission process of each youth. The program s admission process includes the completion of a medical screening utilizing the Department s Facility Entry Physical Health Screening (FEPHS) form, to determine if the youth has any medical condition that requires medical attention, although the program has no medical staff on site. The multidisciplinary treatment team incorporates individual medical needs into the youth s individual Youth-Empowered Success (YES) Plan and/or academic plan, as needed. Assessment services also covered the completion of the Positive Achievement Change Tool (PACT), and the development and implementation of the YES Plan. In addition, the local care counselors and/or the mental health counselor screened, at admission, each youth for mental health and substance abuse conditions and completed the applicable referrals, as required. At admission the program also conducted an orientation process for each youth that covered relevant program information, including all rules and expectation of the program. Each youth received a copy of the youth orientation handbook at intake that contained program guidelines 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 maintains written policy and procedures for admission and orientation of youth. A review of seven youth case management files found that the program staff conducted face-toface contacts with youth within three working days of the probation disposition referral date. The review of the files revealed that the program staff completed each youth orientation to the program within twenty-four hours of admission. Each reviewed youth file contained an orientation acknowledgment checklist signed by the youth, parent/guardian, and program staff. Office of Program Accountability Page 14 of 28 (Revised August 2013)

15 Each reviewed file indicated that youth receive a copy of the program s youth orientation handbook to include the introduction to the facility staff and a tour of the facility grounds. In addition, youth receive information on program expectations, rules, a review of the behavior management system, daily activity schedule, medical and mental health/substance abuse services, drug policy, consent for urinalysis testing, evacuation procedures, contraband guidelines, curfew policy, internet user policy, performance planning process, and the anticipated length of stay in 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), 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. The program maintains written policy and procedures for medical screening that requires staff to screen each youth at the time of admission and determine if the youth has a condition that required medical intervention. A review of seven youth records found that the program s mental health professional completed the Department s Facility Entry Physical Health Screening (FEPHS) form to ensure that the youth can be safely placed in the general population and that the youth is not in need of immediate medical attention. The review of the records also indicated that the mental health professional also reviewed the Health Discharge Summary, when available, the Healthcare Admission Screening form, and contacted the youth s parent/guardian related to medical needs Medication Management Verification of Medications Compliance The program shall determine a youth s medication regimen upon admission to the program. A review of seven youth records revealed that four youth were prescribed medications requiring parental verification, and in each incident, the parents/guardians were interviewed about the youth s current medication regimen. The program does not practice direct involvement with youth medication administration; however, all the non-healthcare staff were trained and able to assist youth with self-administration of oral medication 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.) Office of Program Accountability Page 15 of 28 (Revised August 2013)

16 A review of seven youth mental health and substance abuse records found that the program staff reviewed the referral packet documentation, and any information applicable to mental health and substance abuse issues were documented and reported to the appropriate administrator and clinical staff. All seven reviewed youth records had a Massachusetts Youth Screening Instrument - Second Version (MAYSI-2) completed on each youth s admission date, and each youth was placed on precautionary observation (PO) due to elevation in risk as outlined on the MAYSI-2 or the youth was admitted on prescribed psychotropic medications. In each reviewed record, the youth was referred for a comprehensive assessment and remained on PO until the trained mental health clinician assessed the youth utilizing the Department s Assessment of Suicide Risk (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 revealed that the program staff completed a Positive Achievement Change Tool (PACT) Full Assessment within seven calendar days of each youth s admission into the program. In each reviewed file, the youths risk to reoffend was identified; four low, one moderate, one moderate-high, and one high-risk. A review of the PACT documentation indicated that the program staff utilized observations and information received from the parents/guardians, other program staff, law enforcement, and other informed parties who have knowledge of the youth s behavior and background during the completion of the PACT PACT Reassessment Limited 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 six were applicable for the Positive Achievement Change Tool (PACT) Reassessments. The review of the six applicable files indicated that the program staff completed a PACT Reassessment every ninety days and utilized the Youth-Empowered Success (YES) Plan to document each youth s needs and progress. Although the PACT Reassessments were completed, three of the applicable reassessments were conducted late 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 found that six were applicable for progress reports. The review of the six applicable files indicated that the program staff prepared and distributed monthly progress reports completed in accordance with Departmental requirements. The reports detailed each youth s progress and status of youth requirements and Positive Office of Program Accountability Page 16 of 28 (Revised August 2013)

17 Achievement Change Tool (PACT) goals contained in the Youth-Empowered Success (YES) Plan. In each applicable reviewed file, the progress reports contained a cover letter providing a brief description of the youth s performance, and confirmed that each youth had the opportunity to review the report and provide comments. All reviewed reports were signed and dated by each youth and the staff that prepared the report, as well as reviewed and signed by the executive director or designee, and distributed as required 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 procedures found that there were no applicable incidents that required the notification to the Central Communications Center (CCC) for abuse allegations reported on behalf of the youth during this review period. The Florida Abuse Hotline telephone numbers were observed posted throughout the facility. Reviewed documentation supported that each youth signed the youth rights and abuse reporting form during his/her orientation to the program. All surveyed staff indicated that they never observed a coworker using profanity when speaking with youth or using threats, intimidation, or humiliation when interacting with the youth. All surveyed youth revealed that they were never stopped from reporting abuse to the Florida Abuse Hotline, and the program staff are respectful when talking with them and to other youth. Standard 3: Intervention Services Overview The program s local care counselors and the program teachers are responsible for the provision of intervention services to all youth placed on probation or classified as minimum-risk commitment by the court. The services provided are guided through the implementation of the Youth-Empowered Success (YES) Plan and the utilization of the AMIkids Personal Growth Model as a delinquency intervention strategy for the services provided. The program provides each youth education, life skills, behavior modification, an introduction to vocational enhancement, and community service opportunities. Observations of the program activities determined that the program provides structured and planned programming for each youth in the program. Youth files and reviewed documentation confirmed that the program staff also coordinate with the Department, other agencies, and members of the community for the provision of the intervention services. Reviewed documentation revealed that the program conducts interventions prior to each youth s admission, during the youth s attendance, and prior to transitioning each youth from the program Vocational Programming Compliance Staff shall develop and implement a vocational competency development program. Office of Program Accountability Page 17 of 28 (Revised August 2013)

18 The program provides Type B/Level 2 vocational programming. All youth are required to attend and complete the Aggression Replacement Training (ART), per their contract requirement, and upon successful completion, they are required to attend the daily job skill groups. Upon admission, each youth is assessed with the CHOICES Interest Profile in order to explore their personal abilities, aptitudes, and vocational interests. Youth with employability goals, and who meet the age requirement, are provided with assistance in résumé building, completing an employment application, and obtaining a Florida identification card. Youth are required to attend job skills training and education courses based on their grade level. The program provides each youth with the Starting Out! The Re-Entry Handbook as the main textbook for the career courses. Youth also have an opportunity to practice interview role plays, conduct internet searches, and complete online applications. Outside of the classroom, each youth who is eligible has an opportunity to earn their Professional Association of Diving Instructors (PADI) scuba license through the program s marine component. After reviewing case management files and the program career binder, and after conducting several informal interviews with the director of education, and the guidance counselor, it was confirmed that each youth receives assistance with obtaining Florida identification cards, creating a résumé, and completing employment application in print form and on-line 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 found that, in each file, the local care counselors completed a Positive Achievement Change Tool (PACT) prior to the development of the initial Youth-Empowered Success (YES) Plan. The reviewed files revealed that the local care counselors or designee completed the YES Plan within fourteen calendar days of each youth s admission into the program and obtained signatures from the youth, parent/guardian, program staff, and executive director. All reviewed plans were performance-based and contained measurable and positive objectives and described outcomes. In seven reviewed files, the case notes clearly reflected the participation of each youth and the parent/guardian in the development of the action steps and target dates for completion of all sanctions and goals of the plan. All reviewed plans were based on prioritized needs and addressed the completion of court-ordered sanctions, as applicable. All surveyed youth confirmed that they participated in the development of the YES Plan, and that each youth received a copy of the 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 revealed that all Youth-Empowered Success (YES) Plans contained appropriate and individualized target dates for the completion of each youth requirement, including court-ordered sanctions and at least one Positive Achievement Change Tool (PACT) goal. Office of Program Accountability Page 18 of 28 (Revised August 2013)

19 3.04 Transitional Planning/Reintegration Non-Applicable 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. This review focused on probation and minimum-risk youth; therefore, the indicator rates as nonapplicable 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. A review of seven youth case management files indicated that the case notes confirmed compliance or attempted compliance with each youth, parent/guardian, and staff action steps contained in the Youth-Empowered Success (YES) Plan. The review of the curfew log also documented compliance with staff action steps contained in the YES Plans. The review of the files also validated that the program staff made referrals to appropriate community providers to ensure each youth s compliance with the YES Plan s measurable goals and sanctions Effective Response System Compliance Staff responds to noncompliance in a manner that is consistent with the program s progressive response system. Reviewed documentation indicated that the program has a progressive response plan approved by the chief probation officer (CPO) and the assistant chief probation officer (ACPO) in Circuit 11. The plan outlines how the program addresses program violations and technical violations and describes in detail how the program responds when youth under supervision are noncompliant with the supervision conditions. A review of youth case management files found that staff responded to the non-compliance behavior in a manner that is consistent with the program s progressive response plan 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 maintains policies and procedures regarding the behavior management system. The program utilizes a behavior management system that has three primary components to include a point card system, a token economy, and a rank system. Each of the components Office of Program Accountability Page 19 of 28 (Revised August 2013)

20 work together to help modify behavior, but each has its own unique purpose and role within the system. The system is designed to foster compliance with the program rules and teach alternative pro-social methods for dealing with problems using rewards and a system of progressive discipline. Disciplinary procedures are carried out promptly. Consequences are fair and directly correlate with the behavior problem. The system is addressed extensively in the program s behavior modifications manual, in the behavior modification/progressive sanctions handout and in the youth orientation handbook. The program has a daily activity schedule that was observed posted throughout the program, and substantially followed. All surveyed youth indicated that no youth or group of youth can 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. A review of seven youth case management files indicated that all necessary updates of the Youth-Empowered Success (YES) Plan requirements and Positive Achievement Change Tool (PACT) goals were completed and saved, and a new YES Plan was generated in the Department s Juvenile Justice Information System (JJIS) prior to the supervisory review. Reviewed documentation confirmed that input and involvement from youth and parents/guardians were made to the YES Plan. The discussion of the YES Plan was clearly documented in the case notes. The case notes reviewed also confirmed involvement of the treatment team members in the plan updates Education Transition Compliance Staff and youth complete an education transition plan prior to release that includes provisions for continuation of education and/or employment. The review of five closed files revealed a transition plan in each case management file. Each educational transition plan was completed and signed by each youth and the parent/guardian prior to the release. All five youth case management files contained written résumés. All case management files reviewed verified that each youth had received job skill trainings, verified by sign-in sheets and evidence that the parents/guardians and youth were aware of the educational plan for each youth 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 Office of Program Accountability Page 20 of 28 (Revised August 2013)