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 Paxen - Pasco Paxen Learning Corporation (Contract Provider) 8730 State Road 52 Port Richey, Florida Review Date(s): June 3-4, 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: Scott Luciano, Lead Reviewer, DJJ Bureau of Quality Improvement Katie Mabe, Juvenile Probation Officer, DJJ Probation, Circuit 13 Kent Rinehart, Program Administrator, DJJ Bureau of Quality Improvement Ramona Salazar, Program Monitor, DJJ Residential Services, Central Region Paul Sheffer, Review Specialist, DJJ Bureau of Quality Improvement

3 Program Name: Paxen - Pasco QI Program Code: 1258 Provider Name: Paxen Learning Corporation Contract Number: P2120 Location: Pasco County / Circuit 6 Number of Beds: 20 Review Date(s): June 3-4, 2014 Lead Reviewer Code: 119 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 1 # Case Managers # Clinical Staff # Food Service Personnel # Healthcare Staff # Maintenance Personnel # Program Supervisors Documents Reviewed 3 # Other (listed by title): regional director of treatment services, regional program manager, program support specialist Accreditation Reports Affidavit of Good Moral Character CCC Reports Confinement Reports Continuity of Operation Plan Contract Monitoring Reports Contract Scope of Services Egress Plans Escape Notification/Logs Exposure Control Plan Fire Drill Log Fire Inspection Report Fire Prevention Plan Grievance Process/Records Key Control Log Logbooks Medical and Mental Health Alerts PAR Reports Precautionary Observation Logs Program Schedules Sick Call Logs Supplemental Contracts Table of Organization Telephone Logs Surveys Vehicle Inspection Reports Visitation Logs Youth Handbook 5 # Health Records 7 # MH/SA Records 4 # Personnel Records 4 # Training Records/CORE 5 # Youth Records (Closed) 5 # Youth Records (Open) # Other: 5 # 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 25 (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 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 25 (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 Limited 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 Progress Reports Office of Program Accountability Page 5 of 25 (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 Non-Applicable 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 25 (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 Limited 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). The following limited and/or failed indicators require immediate corrective action Suicide Prevention Services* Office of Program Accountability Page 7 of 25 (Revised August 2013)

8 Strengths and Innovative Approaches The program utilizes a restorative justice approach in rehabilitating all youth who attend their program. This entails holding the youth accountable for their actions, helping them develop confidence and competency in vital life skills and educational areas, and leading them to acceptance and personal responsibility. Youth admitted to the program receive a combination of evidence-based services, gender-responsive delinquency interventions, case management, community supervision, community service work projects, and life skills training. Evidence-based and promising-practices delinquency interventions are delivered in a group setting and include Thinking for a Change (T4C), a cognitive restructuring curriculum, Impact of Crime, a curriculum focused on restorative justice, and Girls Circle and the Council for Boys and Young Men curricula, which address gender-responsive delinquency interventions. The program has utilized poster contests to allow the youth to expand upon some of the core themes of the evidence-based curriculum. These creative posters serve as a reminder of what was learned, and also assist in creating a warm atmosphere for the youth at the program. Office of Program Accountability Page 8 of 25 (Revised August 2013)

9 Standard 1: Management Accountability Overview The program provides day treatment services through a contract with Paxen Learning Corporation and the Department of Juvenile Justice initiated in July The program contract calls for twenty slots. The program is designed to serve males and females aged fourteen to nineteen on minimum-risk commitment and probation. The program s organizational chart consists of an executive director, east regional program manager, program coordinator, case manager, and two program support specialists. The program had no vacancies at the time of the review. The program provides food from an assortment of local vendors. Transportation services are provided by the program 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. There were two new hires since the last Quality Improvement review. The program has a written policy and procedure in place for conducting initial background screenings. Both newly hired staff members were screened by the Department s Background Screening Unit before their date of hire and each received a rating of eligible or eligible with charges. The Affidavit of Compliance with Level 2 Screening Standards was submitted to the Department s Background Screening Unit on January 6, 2014, meeting the annual requirement. The program does not have any volunteers at this time. The program conducts a monthly driver s license check on all staff Five-Year Rescreening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. Employees and volunteers are rescreened every five years from the initial date of employment. The program has a written policy and procedure for conducting a five-year background rescreening for all staff, volunteers, and interns. There was not any staff eligible for the five-year rescreening during the Quality Improvement review period 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. Office of Program Accountability Page 9 of 25 (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. There were two new staff hired during this review period applicable for pre-service training requirements. Their pre-service training exceeded the minimum of 120 hours of web-based and/or instructor-led training. The training was a part of their completed pre-service training requirements, which was completed within 180 days of hire. The list of pre-service training topics was submitted to the Department s Office of Staff Development and Training on February 18, 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 had two staff applicable for the requirements of in-service training in accordance with the Florida Administrative Code. The staff completed and exceeded the required twentyfour hours of annual in-service training. The program coordinator received eight hours of management related training within the past year. Each staff member s training file contained an annual training calendar for the current year based on their position description and all four program staff had been trained by a medical doctor on the proper medication administration methods in accordance with the Department s Health Services Manual. The program s annual training plan was submitted to the Department on February 18, 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 policies and procedures for the implementation of a medical alert system. Each youth is screened upon admission for any identified medical condition. The screening includes an interview with the youth s parent/guardian to verify the medical condition of the youth prior to entering the program. Each identified chronic medical condition is entered into the Juvenile Justice Information System (JJIS) and the program s medical alert system in the individual healthcare record (IHCR). The alert information was reviewed and five applicable youth files required medical alerts. All five applicable youth with medical alerts were identified Office of Program Accountability Page 10 of 25 (Revised August 2013)

11 through the program s medical alert system and JJIS at the time of the Quality Improvement review 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 for the provision of episodic care, first aid, and emergency care. The program has a knife-for-life, wire cutters, and needle-nose pliers that are kept in the program coordinator s office and are accessible to all staff. The program does not maintain an automated external defibrillator (AED) on site. They also have a first aid kit that is checked monthly and replenished on an ongoing basis. Emergency drills were held by the program quarterly that addressed different types of emergency situations. Two youth required first aid or emergency care during this review cycle. One youth required an ice pack and the other a bandaid 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 written policies and procedures in place for the storing of medications. The program has a locked box kept in a locked file cabinet to be used if they have any youth requiring a controlled substance given during program hours. They also have a mini-refrigerator with a locking mechanism to use for medications that require refrigeration. The program maintains a medication distribution log on site. One youth required medication to be given during program hours during this review cycle. The youth s medication was returned to the parents or legal guardian upon the youth s release from the program on May 29, Cleanliness and Sanitation Compliance The program provides a safe and appropriate treatment environment that includes maintenance and sanitation of the facility. The program was found to be clean and well maintained during the course of the Quality Improvement review. All indoor areas and attached buildings were clean and neat. There was no graffiti on any walls, doors, or windows. The program conducts weekly sanitation safety inspections of all internal and external areas. The program has a maintenance and housekeeping plan to ensure the facility remains in good condition. Separate bathroom facilities are provided for males and females. 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 has written policies and procedures that include fire prevention and evacuation procedures during an emergency situation. Each staff member was trained on safety procedures as part of their initial orientation. All youth have the evacuation plan explained to Office of Program Accountability Page 11 of 25 (Revised August 2013)

12 them as part of their intake and orientation. The program provided a fire safety log, which had documentation of unannounced monthly fire drills. The program had a fire inspection completed by the Pasco County Fire Rescue fire marshal on December 26, 2013 and the fire safety equipment is checked monthly by program staff Water Activities Non-Applicable The program provides a safe and appropriate treatment environment that includes procedures for water activities. 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 has one menu for both staff and youth. The food service area is clean and maintained well. The program provides a meal nightly from a local restaurant. Five youth were surveyed and they all indicated that food is never withheld as a punishment Transportation Compliance The program provides a safe and appropriate treatment environment that includes transportation. The program utilizes two large passenger vans to provide daily transportation for youth to and from the facility. Both vehicles were in sound mechanical condition and had current proof of insurance and registration. The vans are inspected by staff prior to every use and documentation included an annual safety inspection done by a certified mechanic, along with numerous inspections performed at the time of service. All four staff had a valid Florida driver s license Administration Compliance The program provides a safe and appropriate treatment environment that includes administrative and operational oversight. The program maintains statistical information on admissions, releases, transfers, abuse reports, episodic emergencies, incidents, personnel actions, and average length of stay. This information is documented and submitted to the Department on a monthly basis. The program maintains a daily facility log utilized to record significant facility activities, incidents, and events. Entries impacting the safety and security of the facility are highlighted for easy identification by staff. No recording errors were noted during the review. The facility utilizes the logbook as an ongoing record of documentation that can be reviewed by staff at any time. The logbook was reviewed by the facility director on a daily basis, exceeding the biweekly requirement, and direction was provided to all staff when applicable Ninety-Day Supervisory Reviews Compliance Cases under supervision (i.e., probation, conditional release, post-commitment probation) are Office of Program Accountability Page 12 of 25 (Revised August 2013)

13 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 applicable files were reviewed for documentation of supervisory reviews. All five files contained reviews, and all were conducted within the ninety-day time frame including a thorough summary of the youth s performance and instructions for the case manager. All of these reviews listed the supervisor's name and indicated it was a supervisory review Incident Reporting (CCC) Compliance Whenever a reportable incident occurs, the program notifies the Department s Central Communications Center (CCC) within two hours of the incident, or within two hours of becoming aware of the incident. The program has a written policy and procedure for reporting incidents to the Department's Central Communications Center (CCC) within two hours of the incident. There was one reportable incident within the last six-month period. This report was made within the two-hour time frame and all incidents were documented in the programs CCC log. The program had no internal incidents/grievances during this review cycle. Standard 2: Assessment Services Overview The program utilizes one program coordinator, one case manager, and two program support specialists to provide case management services to youth in the program. The staff are responsible for notifications and contacts with the parents/guardians, juvenile probation officers (JPO), and courts. The case manager completes risk classifications, the Community Positive Achievement Change Tool (C-PACT), Youth Empowerment Success (YES) Plan, the Youth Needs Assessment Summary, Progress Reports, and transition planning 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. Five case management files were reviewed for documentation of the admission and orientation process. All five files contained documentation to support orientation was completed within twenty-four hours of admission. All five files contained the following intake orientation forms signed by the youth and parent/guardian (unless the child was eighteen years of age): student rights, family involvement, attendance policy, search, contraband, dress code, bullying policy, emergency procedures, and grievance policy. The program provides a handbook to each youth that contains an orientation checklist, which includes the program rules, procedures, schedules, Office of Program Accountability Page 13 of 25 (Revised August 2013)

14 and services that apply to youth. All of the reviewed files contained youth signatures indicating receipt of the student handbook on their orientation acknowledgement form 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. Five individual health care records were reviewed for medical screening. This was done using the Facility Entry Physical Health Screening form. Each record contained a copy of the screening done at the time of admission, which was completed by a non-licensed staff and included parent/guardian and youth concerns when applicable Medication Management Verification of Medications Compliance The program shall determine a youth s medication regimen upon admission to the program. The program has a policy for medication management that includes ordering, receipt, storage, inventory, administration, documentation, and disposal of medication. Medications were addressed during the orientation process. The Facility Entry Physical Health Screening form addressed medications. All five reviewed case management files contained the completed form. The youth and parent/guardian were present at the orientation and available to answer any questions there may have been concerning medications. None of the five reviewed youth required 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.) Five case management files were reviewed for mental health and substance abuse screening. The program is using the Massachusetts Youth Screening Instrument-Second Version (MAYSI- 2) as their screening instrument. Each reviewed file contained a MAYSI-2 instrument which was administered on the youth s date of admission and were completed on the Juvenile Justice Information System (JJIS). One youth was referred for a comprehensive mental health and substance abuse evaluation. Four reviewed records were applicable for further assessment of suicide risk. Each of these records had evidence that a referral was done immediately to the Office of Program Accountability Page 14 of 25 (Revised August 2013)

15 clinical coordinator, a suicide risk alert was entered in JJIS, and an Assessment of Suicide Risk (ASR) was completed within twenty-four hours 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. Five case management files were reviewed for Positive Achievement Change Tool (PACT) Full Assessments. All five PACT Full Assessments were completed within seven days of the youth s admission to the program. One file was low-risk to reoffend, two were moderate-risk to reoffend, and the remaining two were high-risk to reoffend 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. Five case management files were reviewed for the ninety-day PACT Reassessments. All five files contained a ninety-day PACT Reassessment completed within the required time frame. Five closed files were reviewed for completion of a final PACT Reassessment. All five had one completed within the required time frame, and no earlier than fourteen days prior to their discharge Progress Reports Limited 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. Five case management files were reviewed for completion of a ninety-day progress report. Five of twelve reviewed progress reports were missing youth signatures. The youth were absent at the time of completion, and there was no evidence to support that the program allowed them to review the reports and provide comments. A cover letter was included with all progress reports, which included a brief description of the youth s overall progress. One progress report was missing a signature from the program director or designee. The program has an internal policy to conduct a progress report every thirty days, however, nine of the twelve reviewed reports exceeded their thirty day time frame and were not completed after the YES Plan update 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. All five reviewed files contained a document signed during orientation that contained abusereporting procedures. The youth and parent/guardian both signed the form. Abuse reporting Office of Program Accountability Page 15 of 25 (Revised August 2013)

16 procedures are included in the youth and parent/guardian handbook. Review of the internal incident log and CCC reports indicate no incidents or allegations of abuse. The program s Code of Conduct addresses appropriate staff behavior, and the staff and youth surveys all indicated the program is an abuse free environment. Standard 3: Intervention Services Overview The program s day treatment supervisor and day treatment case manager provide intervention services to the youth in the program. The services are guided through the implementation of a Youth-Empowered Success (YES) Plan. The program provides academic assistance opportunities through General Educational Degree (GED) test preparation, life skills instruction, introduction to vocational enhancement, and community service for youth in the program Vocational Programming Compliance Staff shall develop and implement a vocational competency development program. The program provides Type A/Level 1 vocational programming that teaches accountability skills and behaviors that are appropriate for youth in all age groups and ability levels that lead to work habits that help maintain employment and living standards. The vocational programing is delivered through groups using the Paxen Career Pathways curriculum, as well as various work readiness materials and assessments that help the youth learn about available career choices and requirements for job placement. A review of five youth files found evidence of completion of work-related, work-search and/or work-preparation type worksheets. The youth also attended a recent job fair where they were able to present a resume to prospective employers. Each youth receives a complete set of the Career Pathways training manuals to take home when they are released from the program 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 five youth files found that a PACT was completed for each youth prior to the development of the Youth Empowered Success (YES) Plan. All five files contained a YES Plan that was developed with fourteen days of a youth s admission, and was signed by all parties. JJIS case notes reflect that there is participation by the youth and parent/guardian in the development of the YES Plan. The case notes also contained evidence that youth and their parent/guardian were informed of the importance of complying with the goals of the plan. Reviewed documentation reflected that each plan was signed by all parties, and that a copy of the plan was given to the youth and parent/guardian. Office of Program Accountability Page 16 of 25 (Revised August 2013)

17 3.03 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). Each of the five reviewed case files contained court-ordered sanctions entered in the Juvenile Justice Information System (JJIS) youth requirements module. All youth requirements included at least one detailed action step for the youth, parent/guardian, and case manager that clearly defined responsibility and the action to be taken by each party. Each YES Plan addressed at least one of the youth s top three criminogenic needs through the PACT goal. All PACT goals on the YES Plan contained at least one detailed action step for the youth, parent/guardian, and case manager that clearly defined who was responsible and what action should be taken. All five surveyed youth were aware of the current YES Plan goals 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. The program does not serve conditional release or post-commitment probation youth; therefore, this indicator rates as non-applicable 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. Five youth files were reviewed to determine compliance with YES Plan implementation and supervision. The case notes demonstrated compliance, attempted compliance, and/or noncompliance with youth, parent/guardian, and staff action steps enclosed in the YES Plan. The monthly progress reports submitted to the JPO and the court included information regarding the progression on all court ordered sanctions. All five of the reviewed YES Plans contained measurable goals each youth must complete. There were ongoing revisions made to all applicable reviewed YES Plans Effective Response System Compliance Staff responds to noncompliance in a manner that is consistent with the program s progressive response system. The case notes in five youth files were reviewed to determine staff response to noncompliance with YES Plan goals. Case notes clearly documented in all five files that the staff were familiar with and were implementing the program s progressive response system. Reviewed documentation also reflected the case manager has ongoing communication with youth and their JPO as it relates to any of the youth s non-compliance with their YES Plan goals. Office of Program Accountability Page 17 of 25 (Revised August 2013)

18 3.07 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 uses a behavior management system that includes privileges and consequences designed to encourage completion of programmatic goals, teach positive behavior, and maintain a safe program environment. Youth receive points on a daily basis for making progress on their goals and for maintaining positive behavior. Points are used to receive incentives such as extra snacks. The program has the Department s mission statement posted in the lobby, as well as the program s activity schedule. Disciplinary procedures are carried out promptly as evidenced by review of the youth point cards. The youth surveys indicate youth are not allowed to control or discipline 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. Three of the five reviewed files were applicable for a ninety-day YES Plan update. Each file had evidence that the case manager made the needed updates to youth requirements and saved a new YES Plan in JJIS prior to their review. All were completed within the required time frame, and any revisions were communicated with the youth and parent/guardian as evidenced in the JJIS case notes. Reviewed documentation also indicated the case manager has ongoing and regular communication with the JPO Education Transition Non-Applicable Staff and youth complete an education transition plan prior to release that includes provisions for continuation of education and/or employment. The program does not provide educational services to the youth; therefore, this indicator is rated as non-applicable 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. Office of Program Accountability Page 18 of 25 (Revised August 2013)

19 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. Five closed youth case management files were reviewed for termination and release. One of the five youth was recommended for termination from minimum-risk commitment status. The program completed the release progress report and Pre-Release Notification within the required forty-five day time frame. Once a termination order was received from the court, the program communicated this information to the youth and parent/guardian, in conjunction with the JPO, and closed the case in JJIS within five days of receipt of the order. No other examples of youth being terminated upon their discharge were available for review. Each of the remaining four files were for youth who were transitioned back to community supervision after successful completion of the program. All four files contained documentation that the program worked with the JPO to facilitate the release of the youth upon completion of the program requirements. The program had no community supervision youth that had been recommended for termination or had a loss of jurisdiction within this review period. Standard 4: Medical, Mental Health, and Substance Abuse Services Overview The program has a part-time contracted licensed mental health counselor (LMHC) on site at least once per week to provide mental health and substance abuse services. They are primarily responsible for preparing and/or reviewing clinical documentation, which includes the Substance Abuse and Mental Health (SAMH-2) assessments, initial treatment plans, individualized treatment plans, discharge plans, and Assessments of Suicide Risk (ASR). The LMHC also serves as the clinical coordinator for the program. The program offers mental health and substance abuse services to those youth that have an identified treatment need in one of these areas Medication Management Delivery of Medications Compliance The program shall have a process in place to assist youth with self-administration of oral medications. The program has a written policy in place to address medication distribution. The program uses a binder to monitor the appropriate medication distribution logs, if necessary. The program had one youth who was prescribed an Epipen during this review period, but the youth never had the need to utilize it while he was in attendance. Evidence was found indicating that staff members were trained to assist youth with the self-administration of medication. This training was conducted by a licensed medical doctor. Office of Program Accountability Page 19 of 25 (Revised August 2013)

20 4.02 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 has a licensed mental health counselor (LMHC) who serves as the clinical coordinator. The program provided the LMHC s current and active license. The LMHC was on site one or two times per week to provide services at the program, as evidenced by a review of sign-in logs. The program s regional director of treatment services is also an LMHC and will provide coverage in the absence of the clinical coordinator 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 clinical coordinator is a LMHC and is the only licensed staff member working at the program. The LMHC provides all of the mental health and substance abuse services at the program. The program was able to verify the LMHC s qualifications by providing a copy of the current and active license 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. The program does not currently have any non-licensed mental health or substance abuse staff members. Their current suicide prevention plan and mental health crisis intervention plan require that if a non-licensed mental health staff person conducts an Assessment of Suicide Risk (ASR) or a Crisis Assessment instrument, a licensed staff member must then review, sign, and date the assessment 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. Five youth records were reviewed for completion of the Massachusetts Youth Screening Instrument-Second Version (MAYSI-2). All five reviewed records documented that each youth had this screening completed at their intake by a trained staff member. All five of the reviewed records had hits on the MAYSI-2, which would require further assessment. The request for a comprehensive mental health and substance abuse evaluation was made in two applicable Office of Program Accountability Page 20 of 25 (Revised August 2013)

21 records. Four of the five reviewed records were applicable for suicide risk screening. They were each placed on precautionary observation and were seen by the LMHC for the completion of an ASR within twenty-four hours. Each applicable record was found to have the required suicide risk alert entered in the JJIS 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. Three of the four applicable reviewed records showed that the program s LMHC completed a new Substance Abuse and Mental Health (SAMH-2) assessment within thirty days of the referral. All required evaluation items were addressed utilizing the SAMH-2. Each had a summary, and recommendations were included for treatment. The other reviewed record contained a SAMH-2 assessment that had been completed at another Paxen program three months prior. The LMHC reviewed this assessment and concurred with the recommendations for treatment. Each of the assessments recommended each youth receive both individual and group counseling for substance abuse 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. Four applicable records were reviewed for youth needing substance abuse or mental health services. Each of these youth was assigned to a treatment team that included the required members. All four applicable records contained documentation of substance abuse services provided to the youth by the LMHC, as set forth in their individual treatment plan. These sessions were documented on the Department s form and were kept in the mental health record. This was through both individual and group psycho-educational sessions. Each reviewed record contained a valid, signed Authorization for Evaluation and Treatment (AET) form. When applicable, each mental health record was found to contain the appropriate signed Youth Consent for Substance Abuse Treatment and Youth Consent for Release of Substance Abuse Treatment Records forms. Three of the youth were court-ordered for substance abuse treatment; therefore, they did not require a signed Youth Consent for Release of Substance Abuse Treatment Records form 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 Office of Program Accountability Page 21 of 25 (Revised August 2013)