BUREAU OF QUALITY ASSURANCE 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 ASSURANCE PROGRAM REPORT FOR Avon Park Youth Academy G4S Youth Services, LLC (Contract Provider) 242 South Blvd. Avon Park, Florida Review Date(s): March 29-31, 2011 ADDENDUM ATTACHED, Exempt Review Date(s): November 9, 2011 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES W A N S L E Y W A L T E R S, S E C R E T A R Y J E F F W E N H O L D, B U R E A U C H I E F Office of Program Accountability Page 1 of 11

2 Residential Performance Rating Profile Program Name: Avon Park Youth Academy QA Program Code: 767 Provider Name: G4S Youth Services, LLC Contract Number: J7G01 County/Circuit #: Polk/Circuit 10 Number of Beds: 165 Review Date(s): March 29-31, 2011 Lead Reviewer Code: 77 Program Performance by Indicator/Standard 1. Management Accountability 4. Health Services 1.01 Background Screening of Employees/Vol. 10 Exceptional 4.01 Designated Health Authority Provision of an Abuse Free Environment 7 Acceptable 4.02 Healthcare Admission Screening Incident Reporting 10 Exceptional 4.03 Comprehensive Physical Assessment Protective Action Response (PAR) 10 Exceptional 4.04 Sexually Transmitted Diseases Pre-Service/Certification Requirements 10 Exceptional 4.05 Sick Call In-Service Training Requirements 8 Commendable 4.06 Medication Administration Logbook Maintenance 7 Acceptable 4.07 Medication Control Internal Alert System 10 Exceptional 4.08 Infection Control Escapes 5 Minimal4.09 Chronic Illness Treatment 8 Commendable 86% Episodic and Emergency Care Consent and Notification Intervention and Case Management 4.12 Prenatal/Neonatal Care NA 2.01 Classification 10 Exceptional Commendable 89% 2.02 Assessment 10 Exceptional 2.03 Intervention and Treatment Team 10 Exceptional 5. Safety and Security 2.04 Performance Plan 8 Commendable 5.01 Supervision of Youth Performance Review and Reporting 8 Commendable 5.02 Key Control Parent/Guardian Communication 10 Exceptional 5.03 Contraband and Searches Transition Planning and Release 10 Exceptional 5.04 Transportation Grievance Process 10 Exceptional 5.05 Tool Management Gang Prevention and Intervention 8 Commendable 5.06 Disaster/Continuity of Operations Planning 10 Exceptional 93% Flammable, Poisonous, and Toxic Items Water Safety NA 3. Mental Health and Substance Abuse Services 5.09 Behavior Management System Designated Mental Health Authority 10 Exceptional 5.10 Behavior Management Unit NA 3.02 MH and SA Admission Screening 10 Exceptional 5.11 Controlled Observation NA 3.03 MH and SA Assessment/Evaluation 8 Commendable Exceptional 91% 3.04 Treatment Plan/Team and Service Delivery 7 Acceptable 3.05 Suicide Prevention 7 Acceptable 3.06 Mental Health Crisis Intervention 10 Exceptional 3.07 Emergency Services 10 Exceptional 3.08 Specialized Treatment Services 8 Commendable Commendable 88% 70 Standard Program Max. Score Score Rating Failed Minimal Acceptable Commendable Exceptional 0-59% 60-69% 70-79% 80-89% % 1. Management Accountability % X 2. Intervention and Case Management % X 3. Mental Health and Substance Abuse Services % X 4. Health Services % X 5. Safety and Security % X Overall Program Performance Commendable 89% Office of Program Accountability Page 2 of 18

3 Methodology This review was conducted in accordance with Florida Administrative Code 63L-2 (Quality Assurance, 6/10/10 Hearing Draft), and focused on the areas of (1) Management Accountability, (2) Intervention and Case Management, (3) Mental Health and Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included in the Residential Standards (July 2010). Persons Interviewed Program Director DJJ Monitor DHA or designee DMHA or designee 3 # Case Managers 3 # Clinical Staff 1 # Food Service Personnel 1 # Healthcare Staff 0 # Maintenance Personnel 1 # Program Supervisors 8 # Other (listed by title): Regional Director, Regional Compliance Documents Reviewed Manager, Director of Health Services, Director of Nursing, Compliance Specialist, Chief of Security, Safety/Risk Officer, Director of Staff Development 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 11 # Health Records 11 # MH/SA Records 12 # Personnel Records 12 # Training Records/CORE 5 # Youth Records (Closed) 9 # Youth Records (Open) 8 # Other: PAR Reports 9 # Youth 9 # 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 18

4 Performance Ratings Performance ratings were assigned to each indicator by the review team using the following definitions and numerical values defined by F.A.C. 63L-2.002(10)(a) (6/10/10 Hearing Draft): Exceptional (10) Commendable (8) Acceptable (7) Minimal (5) Failed (0) The program consistently meets all requirements, and a majority of the time exceeds most of the requirements, using either an innovative approach or exceptional performance that is efficient, effective, and readily apparent. The program consistently meets all requirements without exception, or the program has not performed the activity being rated during the review period and exceeds procedural requirements and demonstrates the capacity to fulfill those requirements. The program consistently meets requirements, although a limited number of exceptions occur that are unrelated to the safety, security, or health of youth, or the program has not performed the activity being rated during the review period and meets all procedural requirements and demonstrates the capacity to fulfill those requirements. The program does not meet requirements, including at least one of the following: an exception that jeopardizes the safety, security, or health of youth; frequent exceptions unrelated to the safety, security, or health of youth; or ineffective completion of the items, documents, or actions necessary to meet requirements. The items, documentation, or actions necessary to accomplish requirements are missing or are done so poorly that they do not constitute compliance with requirements, or there are frequent exceptions that jeopardize the safety, security, or health of youth. Review Team The Bureau of Quality Assurance wishes to thank the following review team members for their participation in this review, and for promoting continuous improvement and accountability in juvenile justice programs and services in Florida: Paul Czigan, Lead Reviewer, DJJ Bureau of Quality Assurance Dave Bassler, Program Monitor, DJJ Residential Services, Central Region Pamela Graves, Review Specialist, DJJ Bureau of Quality Assurance Jason Kent, Technical Assistance Specialist, DJJ Office of Program Accountability Omar Mestre, Review Specialist, DJJ Bureau of Quality Assurance Lorri Watson, Business Manager, Florida Environmental Institute, AMIkids, Inc. Office of Program Accountability Page 4 of 18

5 Please note that this report refers to each indicator by number and title only. Please see the applicable standards for the full text of each indicator. The standards are available on the Bureau of Quality Assurance website, at Standard 1: Management Accountability Failed Minimal Acceptable Commendable Exceptional Overview Through a contract with the Department of Juvenile Justice, G4S Youth Services LLC operates Avon Park Youth Academy (APYA), a moderate risk residential program in Polk County for male youth. The program is designed to provide vocational education to eighty of the one hundred sixty-five youth at APYA. Home Builders Institute (HBI) has a contract to provide vocational education to the youth, with education in construction trades such as carpentry, plumbing, electrical and masonry. There are other vocational opportunities for the youth such as graphic arts, auto repair and detailing and food service. The on-site management of this program is the responsibility of the Facility Administrator. The management staff includes a school Principal, a Director of Clinical Services, an Assistant Facility Administrator for Operations, a Business Manager, a Director of Case Management, a Director of Nursing, a Safety/Risk Officer, a Community Administrator, a Dietary Manager, a Physical Plant Manager, a Chief of Security, and a Youth Advocate. The HBI Director is included as an integral part of the management team. The Facility Administrator is directly supported by an Administrative Assistant and the Compliance Manager, and also receives support and oversight from the provider s corporate team. The responsibilities for various aspects of programming and maintenance are divided among the management staff. The program is situated on thirty-seven acres on the site of the McDill Auxiliary Air Field/Avon Park Bombing Range and occupies buildings formerly used for family housing. The program has built several other permanent structures, among which are a school, administration office, a dining facility and various vocational buildings. The former bowling alley is operated under the auspices of the program, utilizing the snack bar to provide food service vocational training in conjuction with offering meals to program staff and visitors. G4S operates the school under contract to the Polk County School Board, and HBI employs a Director and several vocational instructors who are on-site. HBI teaches six different construction trades: Landscaping, Carpentry, Plumbing, Masonry, Electrical and Painting. There were no students assigned to Masonry during the time of the quality assurance review. The program augments these trades by teaching Culinary Arts, Horticulture, Auto Essentials, Flooring Installation, Digital Publishing and Computer Aided Drafting. During the the time of the quality assurance review there were no students assigned to the Computer Aided Design or Horticulture programs. At the time of the quality assurance review, the program had three vacant positions: one therapist, and two Behavioral Health Overlay Services (BHOS) Youth Care Workers (YCW). Office of Program Accountability Page 5 of 18

6 The program has been accredited by the American Correctional Association for eight years. They received a successful Compliance Reaccreditation Audit on January 12-14, There were noted deficincies in the provision of an abuse-free environment and in logbook maintainance. The program had an escape since the last quality assurance review. 1.01: Background Screening of Employees/Volunteers Exceptional (10) All pending and scheduled background screenings are reviewed daily during the management meetings. The program conducts driver s license and local law enforcement checks prior to hire for all employment candidates. A review of background screening is conducted each month by the on-site quality assurance manager, with the results documented on the program s score card process. 1.02: Provision of an Abuse Free Environment Acceptable (7) Nine youth responded to the survey; three reported hearing staff once use profanity when speaking with youth. Two reported hearing profanity occasionally, and one youth reported often. Two youth reported hearing staff threaten youth; follow-up interviews indicated staff had been heard threatening youth with physical intervention if unacceptable behavior continued. Nine staff responded to the survey; one reported hearing another staff using profanity occasionally. 1.03: Incident Reporting Exceptional (10) The program conducts a review of all incidents during both daily and monthly management meetings, which were documented through minutes and agenda items. The on-site quality assurance manager and the regional compliance manager review all facility incident reports on a weekly basis, and produce a report of all incidents and trends, which is forwarded for additional review by the corporate staff. The G4S internal risk management system provides monthly evaluations of all incident reporting. The quality assurance manager evaluates events, the program s action, reporting and documentation, and provides a rating of the program s response and adherence to contractual and regulatory requirements for the reporting of incidents. 1.04: Protective Action Response (PAR) Exceptional (10) The program documented a Power Struggle Fidelity Review that was conducted following each use of Protective Action Response (PAR). The fidelity review included interviews with the youth, staff and management involved in the incident, a review of the events, actions alternatives and preventative strategies related to each incident. The use of PAR is reviewed on-site at the daily management meeting, at the monthly all staff meetings and at the monthly safety committee meetings, which was documented in minutes and agendas. Office of Program Accountability Page 6 of 18

7 1.05: Pre-Service/Certification Requirements Exceptional (10) A review of four applicable files revealed all received the required pre-service courses within the first thirty days of employment. All staff received between 164 and 191 hours of training, with from one to two months in their training cycle to acquire more training hours. All files reviewed documented training on the use of an Automated External Defibrillator (AED). The program conducts monthly audits and fidelity checks of training documentation, especially of new hires. 1.06: In-Service Training Requirements Commendable (8) 1.07: Logbook Maintenance Acceptable (7) Two youth were admitted to the program with medical needs, which were not noted in the logbook. Several late entries were observed which had been entered after the log was closed for the shift; the staff did not document the date/time of the late entries. 1.08: Internal Alert System Exceptional (10) Alerts are discussed in the daily management meeting and at shift briefings, especially noting youth physical restrictions. The youth placed on key alert status for safety/security, suicide and heart conditions wear specially colored clothing items. The youth placed on physical restrictions for medical reasons or injuries wear a colored wrist band listing the condition and restrictions; the quality assurance manager conducts regular reviews of youth on restrictions, monitoring the youth and the list for accuracy. 1.09: Escapes Minimal (5) The program had one escape since the last quality assurance review. The documented notifications that are required to the judge, the Department of Juvenile Justice, Detention Screening and the youth s Juvenile Probation Officer (JPO) were not made in a timely manner. There was no documentation of required notifications upon the apprehension of the youth. Office of Program Accountability Page 7 of 18

8 Standard 2: Intervention and Case Management Failed Minimal Acceptable Commendable Exceptional Overview The program uses a multi-disciplinary treatment team approach to address the youth s progress through his performance plan. The treatment team meets to discuss the youth s progress, with and representatives from the school, mental health, medical and Home Builders Institute (HBI), supervisors and administration included in the meetings. There is written input provided if members are unable to attend a staffing. The program s intake specialist and case managers are responsible for all admission related functions and coordination. The medical staff and the mental health staff meet with the youth as part of the admission process. The youth receive an orientation into the program by each of the program s treatment areas that encompass all aspects of the program. During this phase, the youth are assigned to the orientation unit. The case management staff consists of a Supervisor and six case managers, who are responsible for treatment team planning, including needs assessments, performance planning, progress summaries, treatment team meetings, transition planning and exit conferences. The grievance forms are available in the living units, at the entrance to the residential area and the vocational areas. There is a box at the entrance to the residential area in which to deposit completed grievance forms. The Youth Advocate and the Community Administrator check the box daily and assign a manager or appropriate staff for resolution. The Youth Advocate is responsible for coordination of grievances, while the Facility Administrative Assitant keeps track of submitted grievances. 2.01: Classification Exceptional (10) A formal classification meeting is held with each new admission to share information on the youth that has been gathered during the intake process. Those represented include the intake specialist, nurse, case manager, therapist and administrator. Youth with medical restrictions, or those which have not been cleared by the Designated Health Authority (DHA) wear white wrist bands. Any youth with a cardiac condition wears blue clothing, youth classified as a security threat wears orange clothing, and youth on suicide watch wear purple clothing. 2.02: Assessment Exceptional (10) The case management supervisor has acquired certification as a Qualified Residential- Positive Achievement Change Tool (R-PACT) Trainer. Nine files were reviewed; all documented a formal monthly review of the youth needs assessment. In addition to the R-PACT, the program completed a Substance Abuse Subtle Screening Inventory (SASSI), Leeds Dependence Questionnaire, Rothberg Self Esteem Scale, Office of Program Accountability Page 8 of 18

9 Zung Self Rated Depression Scale, Clinical Anger Scale (CAS), and a psychiatric evaluation for each youth. Needs assessments are evaluated monthly as part of the risk management processes. 2.03: Intervention and Treatment Team Exceptional (10) The quality assurance staff completes monthly fidelity checks based on observational findings using a protocol. The findings are documented on the score card, and performance improvement initiatives are reviewed and developed with the on-site management as indicated. Each formal treatment team meeting contains a section in which the youth is questioned regarding his access to abuse reporting and the grievance process, whether or not he had been allowed visitation, had been threatened, and if he felt safe in the program. The program conducts monthly surveys in which youth reflect their knowledge of their goals on their performance plan, as well as their belief that their treatment team understands their problems, needs and goals. 2.04: Performance Plan Commendable (8) 2.05: Performance Review and Reporting Commendable (8) 2.06: Parent/Guardian Communication Exceptional (10) The case manager sends a written summary to the youth s parent or guardian who are unable to participate in the formal treatment team meetings. The program provides special visitation to meet the needs of parents or guardians that may be unable to attend regular visitation. Family fun days and special holiday events are held to promote family reunification. The program and the corporate office send monthly surveys to the youth s parents or guardians to solicit input into programming and the provision of services. 2.07: Transition Planning and Release Exceptional (10) There are discharge file reviews and transition meeting fidelity checks completed monthly by the program s quality assurance staff, which are scored based on observations and findings each moth within the score card process. All youth are tested for the Florida Ready to Work Program and receive credentials. Home Builders Institute (HBI) provides all youth with transition packets that include their vocational certificate, a resume, a community resource guide for their respective local county, job interview tips and job search resources and website. HBI also has a scholarship program. The program provides gift cards, tools and bicycles for youth with limited resources. Office of Program Accountability Page 9 of 18

10 The Department of Transportation comes to the facility periodically to provide the written portion of the driver s license test for the youth. 2.08: Grievance Process Exceptional (10) Eight grievances were reviewed during the quality assurance review; two were responded to within twelve hours; three within twenty-four hours and three within fortyeight hours. Six were resolved at the first level, and two were appealed to the next level. The program uses a written Let s Talk request system to promote the youth s communication and problem resolution skills on an informal basis. The program reviews all grievances and Lets Talk requests at the management meeting, which were documented on meeting minutes and agendas. 2.09: Gang Prevention and Intervention Commendable (8) Standard 3: Mental Health and Substance Abuse Services Failed Minimal Acceptable Commendable Exceptional Overview The Treatment Director/Designated Mental Health Authority (DMHA) is a Licensed Mental Health Counselor (LMHC). There is support provided by a contracted psychiatrist who is on campus four times a month, providing evaluations and medication monitoring. The Treatment Department also includes Behavioral Health Overlay Services (BHOS) Quality Assurance staff, a BHOS System Specialist, a Data Coordinator, a Compliance Specialist and an Administrative Assistant. The program has ten clinical counselor positions, five of which are master s level, and ten BHOS Youth Care Worker positions. The program has a Licensed Therapist that assists the DMHA with the day-to-day operations of the clinical department. There is one building on the campus designated for the counselors, in which most of the counselors have offices, and where the mental health files are kept. There are weekly staff supervision meetings held in the counselor s building. The facility is licensed under Chapter 397, Florida Statutes and provides BHOS services to all eligible youth. There were noted deficiencies in the delivery of mental health treatment and in the suicide prevention documentation. 3.01: Designated Mental Health Authority (DJJ Program) Exceptional (10) The Clinical Director, who is the Designated Mental Health Authority (DMHA), is a qualified supervisor for individuals seeking licensure (Licensed Mental Health Counselor Office of Program Accountability Page 10 of 18

11 and Licensed Marriage & Family Therapist). The Clinical Director is a Medicaid Provider, is certified in Eye Movement Desensitization and Reprocessing (EMDR) and is a Grief Therapist Specialist. The DMHA conducts weekly face-to-face group supervision sessions. In addition, therapists receive periodic individual supervision sessions, consistent individualized supervision interventions that are specific to treatment planning and individual case reviews. The DMHA conducts psychiatric treatment supervision meetings weekly with the psychiatrist and the program s clinical staff members. Individualized treatment planning reviews are conducted with the DMHA, psychiatrist and therapist for all assigned clients. The DMHA provides monthly trainings to the clinical staff, and for other staff as applicable, to review pertinent clinical information, as well as identified and targeted areas for ongoing improvement. The DMHA is involved in all aspects of the youth s mental health and substance abuse treatment. This was clearly evident in a review of all nine files that were reviewed. 3.02: Mental Health and Substance Abuse Admission Screening Exceptional (10) The program completes a Children s Functional Assessment Rating Scale (CFARS) for all newly admitted youth, as a part of the initial screening process. There are reviews conducted every six months following admission, and at discharge. All files reviewed revealed that the program conducts the following screening instruments on the youth during the initial screening process: the Parent/Guardian Questionnaire, Leeds Dependence Questionnaire, Rosenberg Self Esteem Scale, Substance Abuse Subtle Screening Inventory (SASSI), Zung Self Rated Depression Scale and Clinical Anger Scale (CAS). 3.03: Mental Health and Substance Abuse Assessment/Evaluation Commendable (8) 3.04: Treatment Plan, Treatment Team, and Service Delivery Acceptable (7) A review of nine files revealed that in two files, group counseling and family counseling were not delivered as stated in the youth s treatment plan. All youth receiving substance abuse treatment attended specific drug abuse groups twice a week, however, those groups were not clearly documented in the treatment plans. 3.05: Suicide Prevention Acceptable (7) On one observation log sheet, two hours of observations by the staff were not documented. On two observation log sheets, the mental health staff did not sign the sheets as required by the Department of Juvenile Justice Mental Health and Substance Abuse Services Manual. Office of Program Accountability Page 11 of 18

12 3.06: Mental Health Crisis Intervention Exceptional (10) When there is a crisis at the program, the mental health staff explores individualized clinical interventions that are best suited for the crisis, such as a formal risk screening, Functional Behavior Assessment or a Behavior Intervention Plan. The program has identified Crisis Response Teams, which consists of the Clinical Director and other clinical counselors appointed by the Clinical Director. The team is typically composed of the Facility Administrator, the Clinical Director, the youth s primary counselor, the case manager, the nurse, and direct care staff. If there is a crisis event related to a family tragedy, the youth s family is invited to the facility for therapeutic interventions. All crisis interventions reviewed were handled properly; the clinical staff, as well as the direct care staff provided the necessary counseling to defuse the situation and help the youth with their crisis. 3.07: Emergency Services Exceptional (10) The program provides training for all staff on emergency procedures during pre-service and in-service trainings. The program documented quarterly emergency mental health drills. One applicable file was reviewed, and the program performed all of the required services well. The program provided a direct care staff with the youth all three shifts at the crisis unit throughout the seventy-two hours of the youth stay. The DMHA called the emergency crisis unit daily to get an update on the youth while he was in the crisis unit. 3.08: Specialized Treatment Services Commendable (8) Standard 4: Health Services Failed Minimal Acceptable Commendable Exceptional Overview Avon Park Youth Academy has a written agreement with Watson Clinic, LLP to provide medical services for the youth in the program. The Watson Clinic provides a licensed physician to serve as the Designated Health Authority. The program also has a contract with a licensed ARNP associated with the Watson Clinic, who is on-site one day a week, for a minimum of two hours, to provide clinical services as required by the contract. The DHA is also on-site a minimum of two hours per week to provide oversight and clinical duties. The DHA or ARNP conduct complete physicals, periodic evaluations, medication management and sick call referrals. At the time of the quality assurance review, the on-site medical staff included a full-time Registered Office of Program Accountability Page 12 of 18

13 Nurse (RN), three full-time Licensed Practical Nurses (LPN), one part-time LPN and a Medical Support Technician performing tasks of a medical records clerk. The clinic is a designated building inside the residential community. There is ample space to provide for sick calls, examinations, record maintenance, and offices for the medical records clerk, health service manager and quality assurance manager. The program also has a contract with a psychiatrist who is on-site once a week, and an optometrist who provides services bi-monthly. The Polk County Health Department provides onsite Human Immunodeficiency Virus (HIV) pre and post test counseling and testing. Dental care is provided through off-site referrals. The program has a Modified Class II Type B pharmacy permit. 4.01: Designated Health Authority Exceptional (10) In addition to the written agreement for the Designated Health Authority (DHA) G4S contracts with a medical doctor to provide consultation services for their programs. The consultant provides support to the DHA and nursing staff, which includes on-site visits and telephone consultations. The medical consultant participates in monthly conference calls with the Health Service Administrator from the various G4S programs. 4.02: Healthcare Admission Screening Exceptional (10) The licensed healthcare professional (RN or LPN) completed the Facility Entry Physical Health Screening Form (FEPHS) at the youth s admission to the program in all nine files reviewed. In two applicable instances, both re-screenings were performed by a licensed healthcare professional. The DHA was notified of all admissions, regardless of whether the screening indicated a chronic condition. The program completes an admission form for all newly admitted youth that includes a detailed admission progress note completed by the admitting nurse. The DHA or ARNP documented a review of the admission note and the admission form in all nine files reviewed. The nursing note revealed that the nurses make a concerted effort to contact the youth s parent or guardian, regardless of the youth s condition, to confirm information supplied by the youth. There were documented continued attempts until the parent or guardian was contacted and provided information about the youth s medical history. 4.03: Comprehensive Physical Assessment Commendable (8) 4.04: Sexually Transmitted Diseases Exceptional (10) There was documentation in all nine files reviewed that the youth are screened for Sexually Transmitted Diseases (STD) by a licensed healthcare professional. All of the youth were referred to the DHA, regardless of the screening results. Documentation Office of Program Accountability Page 13 of 18

14 supported the DHA consistently discussed the screening results with the youth, either during the CPA or during subsequent clinic visit. The program documented that a risk assessment form specifically for HIV issues was completed by a healthcare professional on the day of the youth s admission to the program. All youth were referred to the DHA, regardless of the HIV risk assessment screening results. After completing the youth s CPA, the DHA documented whether the youth wanted to be tested, or refused to be tested. Three of the files reviewed documented the youth were referred and received the applicable test. 4.05: Sick Call Commendable (8) 4.06: Medication Administration Commendable (8) 4.07: Medication Control Commendable (8) 4.08: Infection Control Exceptional (10) Upon the youth s admission to the program, the nursing staff sends a packet to the youth s parent or guardian that includes the Parental Notification of Health Related Care Vaccination/Immunization form and information on the vaccines to be given. There was documentation to support that all youth received the influenza vaccine and the Meningococcal vaccine when their parent or guardian returned the signed permission. There were hand sanitizers available to the youth in all the living units, as well as in the school areas visited by the quality assurance review team. 4.09: Chronic Illness Treatment Commendable (8) 4.10: Episodic and Emergency Care Commendable (8) 4.11: Consent and Notification Exceptional (10) On the day of the youth s admission to the program, the nursing staff sends a packet to the youth s parent or guardian that contains the over-the-counter medication list, as well as a new Authorization for Evaluation and Treatment (AET). This packet, as well as all Office of Program Accountability Page 14 of 18

15 parental notifications, is sent to the parent or guardian by certified mail, with a return self-addressed envelope included. The program has a specialized form for disclosure of protected information for youth who are eighteen years of age, who are willing to authorize what, if any, information they would like to be shared with their parent or guardian. 4.12: Prenatal/Neonatal Care Non-Applicable (NA) The program policy, procedure, and practice confirm the requirements of the indicator were not applicable for this program as this program serves only male youth. Standard 5: Safety and Security Failed Minimal Acceptable Commendable Exceptional Overview The program provides for the safety and security of youth through three shifts daily, managed by a shift supervisor. Some staff are assigned to the residential units, while others assist the supervisor performing perimeter checks and roving security back-up. Master Control maintains the master control logbook, coordinates youth counts, coordinates the main vehicle and personal entrance to the campus and issues keys and radios. The shift supervisor conducts a shift meeting fifteen minutes prior to each shift to brief the staff on pertinent issues and assignments. Individual living units maintain logbooks during afternoon and evening hours. There is no video monitoring equipment on the campus. The program is secured behind a barbed wire fence. The residential units are surrounded by a separate internal fence, with one entrance/exit utilized by youth to control counts and manage searches. The supervisory staff are responsible for performing perimeter and security checks. Due to the design of this program's vocational education in the various trades, the youth are allowed to carry tools on campus for their work projects that are supervised by staff. The program does not operate a Behavior Management Unit or controlled observation rooms. The policy prohibits use of room restriction. The safety officer is responible for tool management and flammable, poisonous and toxic item control. HBI manages it s own tool control and reports discrepancies to the safety officer. The Behavior Motivation Program is a five-phase system consisting of Orientation and four training based phases: Trainee, Apprentice, Journeyman, and Skillsman. The youth earn credits daily and have minimum thresholds to meet in order to advance through the phase system. There are clear expectations, including behavioral attitudes, responsibilities and privileges, with violations that include set sanctions. The treatment team coordinates all awards of credits and sanctions, phase advances and qualification for discharge. There were noted deficiencies in the inventories of toxic items. Office of Program Accountability Page 15 of 18

16 5.01: Supervision of Youth Commendable (8) 5.02: Key Control Exceptional (10) There are daily key inventories completed during each shift. The risk management system included monthly reviews of key control measures and related documentation. In addition, the Chief of Security reviews the key control process on a weekly basis. The program conducted three lost key drills in the last six months. 5.03: Contraband and Searches Exceptional (10) There were perimeter checks documented three times daily consistently in the logbook by the supervisor or designee. The Chief of Security documented posting of Bring Me Back Tags throughout the facility to monitor and ensure the completion of perimeter checks. The program consistently utilized an electronic walk-through device to screen the daily youth movements from and to the residential housing area. The facility participates in semi-annual, and as needed K-9 campus searches. One applicable K-9 search was documented in the past three months. 5.04: Transportation Exceptional (10) The staff-to-youth ratio on transports was consistently exceeded by one staff over the required number. Administrative staff complete random driver s license checks for eligible drivers on a monthly basis. All eligible staff had completed job-specific transportation training. Documentation in the logbook supported that drivers on transport consistently report arrival at and departure from the destination point. 5.05: Tool Management Commendable (8) 5.06: Disaster and Continuity of Operations Planning Exceptional (10) The facility conducted the following drills in the six months prior to the quality assurance review: Chemical Spill, Contraband, Control, Transportation, Bomb Threat, Power Outage and Evacuation. There were five fire drills documented monthly, and weekly generator drills were documented. Office of Program Accountability Page 16 of 18

17 5.07: Flammable, Poisonous, and Toxic Items Acceptable (7) The gasoline inventories were inconsistently maintained through the quality assurance review period. Nine youth responded to the survey; a majority reported they do not just wipe with cleaning chemicals. Follow-up interviews indicated youth are allowed to clean with chemicals, but are inconsistently following safety guidelines posted on the applicable Material Safety Data Sheet. 5.08: Water Safety Non-Applicable (NA) The program policy, procedure, and practice confirm the requirements of the indicator were not applicable for this program. 5.09: Behavior Management System Exceptional (10) There was documented use of the Motivational Interviewing strategies by most of the program staff. The program's behavior management system included a "Unit of the Month" award, in which the unit can earn additional points in the areas of Progress on Performance Plans, Behavior, and Unit Cleanliness. In addition, there are off campus activies in which the youth can participate. The program has implemented the use of High Roads, which are a form of positive reinforcement for the youth. These forms may be given by any staff member, and their use is tracked by the treatment team. The program utilizes a token economy, which also includes independent living components. The youth earn monetary tokens, from which their rent and other basic necessities are deducted. The remainder of the money can be spent in the program s point store. The program has a game room, which includes a pool table, gaming systems, a television with a DVD player on which to watch movies, and a television with the NFL package installed. The youth with no negative write-ups are permitted an hour per week in the game room. 5.10: Behavior Management Unit Non-Applicable (NA) The program policy, procedure, and practice confirm the requirements of the indicator were not applicable for this program. 5.11: Controlled Observation Non-Applicable (NA) The program policy, procedure, and practice confirm the requirements of the indicator were not applicable for this program. Office of Program Accountability Page 17 of 18

18 Overall Program Performance Commendable 89% Failed Minimal Acceptable Commendable Exceptional Office of Program Accountability Page 18 of 18

19 BUREAU OF QUALITY ASSURANCE EXEMPT REVIEW ADDENDUM Program Name: Avon Park Youth Academy QA Program Code: 767 Program Type: Residential Contract Number: J7G01 Provider Name: G4S Youth Services, LLC Number of Beds/Slots: 165 Location: Polk County / Circuit 10 Lead Reviewer Code: 91 Original Review Date(s): March 29-31, 2011 Exempt Review Date: November 9, 2011 Review Team The Bureau of Quality Assurance wishes to thank the following review team members for their participation in this review, and for promoting continuous improvement and accountability in juvenile justice programs and services in Florida: Ashley Davies, Lead Reviewer, DJJ Bureau of Quality Assurance Donna Connors, Program Administrator, DJJ Bureau of Quality Assurance Dave Bassler, Program Monitor, DJJ Residential Services, Central Region Summary This review was conducted in accordance with FDJJ-1720 (Quality Assurance Policy and Procedures). Through a contract with the Department of Juvenile Justice, G4S Youth Services LLC operates Avon Park Youth Academy (APYA), a moderate risk residential program in Polk County for male youth. The program is designed to provide vocational education to eighty of the one hundred sixty-five youth at APYA. Home Builders Institute (HBI) has a contract to provide vocational education to the youth, with education in construction trades such as carpentry, plumbing, electrical and masonry. There are other vocational opportunities for the youth such as graphic arts, auto repair and detailing, and food service. At the time of the quality assurance review, there were one hundred fifty-five youth in the program. A quality assurance review was conducted on March 29 31, 2011, at which time the program received an overall Commendable performance rating, placing the program on Exempt status with the Department of Juvenile Justice. The quality assurance review conducted on November 9, 2011 was to determine whether the program is continuing to maintain an acceptable level of performance in the following nineteen key areas: background screening, abuse-free environment, incident reporting, protective action response, pre-service training, classification, screening, performance planning, grievances, mental health and substance abuse assessment/evaluation, suicide prevention, healthcare admission screening, comprehensive physical assessment, sick call, medication administration, episodic and emergency care, supervision of youth, tool management, and control of flammable, poisonous, and toxic items. The on-site management of this program is the responsibility of the Facility Administrator. The management staff includes a school Principal, a Director of Clinical Services, an Assistant Facility Administrator for Operations, a Business Manager, a Director of Case Management, a Director of Nursing, a Safety/Risk Officer, a Community Administrator, a Dietary Manager, a Physical Plant Manager, a Chief of Security, and a Youth Advocate. Exempt Review Addendum Office of Program Accountability Page 1 of 6

20 The methodology used for this review included observations of the youth and staff while at the program; formal and informal surveys and interviews with the youth and staff; a review of applicable policy and procedures, the DJJ contract scope of services, the resident handbook, logbooks, twenty-one personnel files, three employee training files, three youth case management, mental health and individual healthcare records, and other items that were relevant to the completion of the review. The program hired twenty-one new staff since the last quality assurance review; all had received clearance from the Background Screening Unit prior to starting work. There were thirteen staff eligible for five-year re-screenings; of the thirteen, one was conducted ten days late, and one was conducted nineteen days late. The Affidavit of Compliance with Level 2 Screenings was received by the Background Screening Unit on January 10, The program has an extensive code of conduct to which all staff are expected to follow. When a youth makes a call to the abuse hotline or Central Communications Center (CCC), program staff completes a Documentation of Resident Abuse/CCC Hotline Call form, which documents the youth s complaint, if the call was accepted and what action staff took. The youth also sign the form stating they were able to make the call. All youth are asked during each treatment team meeting if their access to report abuse has been impeded in any way, if they have been threatened or intimidated by anyone and if they feel safe. Youth are also given a survey each month, on which they are asked about different areas of the program, such as their rights, treatment planning, admission/orientation, quality of care, quality of life, cultural competency and accessibility; the youth are encouraged to provide feedback about the program. Surveys are also mailed to the youth s parents or guardians, which ask if the youth has ever expressed any concerns regarding lack of access to the abuse hotline. Two of the three youth responding to the survey reported they have heard staff use profanity, one youth reported hearing it once and the other youth reported hearing it occasionally. All three youth reported they are able to report abuse to the hotline and they feel safe in the program. One of the three staff responding to the survey reported hearing another co-worker use profanity occasionally. All applicable incidents were reported to the Central Communications Center (CCC) within the required timeframe. The program conducts a review of all incidents during both daily and monthly management meetings. The on-site quality assurance manager and the regional compliance manager review all facility incident reports on a weekly basis, and produce a report of all incidents and trends, which is forwarded for additional review by the corporate staff. The program s corporate office provides monthly evaluations of all incident reporting. Three Protective Action Response (PAR) reports were reviewed, and all reports were completed as required. All three reports were reviewed by all required parties within twenty-four hours of the incident. All youth receive a post PAR medical evaluation by the nurse, regardless of whether it is needed or not. A Power Struggle Fidelity Check is completed after each incident that describes the incident, reviews staff and youth behaviors, reviews techniques used or that could have been used, and identifies if there was a power struggle between the youth and staff. Three staff training files were reviewed for pre-service training requirements. All three staff documented well over the required 120 hours of training within the first 180 days of employment. The staff documented 183, and 172 hours of training. All required trainings were completed within the first two weeks of employment and all three staff documented over 120 hours of training within one month of hire. Exempt Review Addendum Office of Program Accountability Page 2 of 6

21 Three case management files were reviewed for classification and performance planning. An admission classification form was completed on each youth on their day of admission to the program. The classification form incorporates all required classification factors. All newly admitted youth sleep on a bed located in the staff office for their first seventy-two hours in the program, and are then assigned to a room on the orientation unit for a minimum of thirty days. After the youth completes the orientation phase, a gang assessment is completed, which is used with the initial classification form to assign the youth to a living unit. A separate risk assessment is completed prior to the youth s participation in off-campus activities or an activity involving tools. In all of the case management files that were reviewed, a performance plan was developed and signed by all parties within thirty days of the youth s admission to the program. The performance goals were individualized, and based on the youth s Residential Positive Achievement Change Tool (RPACT). Each goal specified a target date for completion, as well as the youth and staff responsibilities for achieving the goal. Transition activities and a reference to the youth s treatment plan were included on each performance plan. Court-ordered sanctions were included on one performance plan; the other two youth had completed all court ordered sanctions prior to entering the program. Revisions were made to the performance plan to reflect the youth s progress on meeting their goals. The original performance plan was maintained in the youth s file. All youth responding to the survey reported they had participated in the development of their plan, and had a copy of the plan. The program has a grievance process that includes three phases: informal, formal and appeal. Information regarding the grievance process is included in the orientation handbook the youth receive upon their admission to the program, and in the resident handbook. In addition to the grievance process, the program utilizes Let s Talk forms, which allows the youth to discuss an issue with a particular member of the staff. All of the grievance and Let s Talk forms are discussed during the daily management meetings, and assigned to the most appropriate staff to review and formulate a response. The program tracks the grievances monthly, and youth are asked at their treatment team meetings whether they have filed a grievance. During the quality assurance review, three grievances were reviewed. All youth had received an initial response within twenty-four hours of submission; one youth appealed the supervisor s decision, and this was responded to the following day. Three youth responded to the survey; one rated the grievance process very good, and the other two youth reported they had never filed a grievance. The Treatment Director/Designated Mental Health Authority (DMHA) is a Licensed Mental Health Counselor (LMHC). There is support provided by a contracted psychiatrist who is on campus four times a month, providing evaluations and medication monitoring. The program has eleven clinical counselor positions and ten Behavioral Health Overly Services (BHOS) Youth Care Worker positions. The program has a Licensed Therapist that assists the DMHA with the day-to-day operations of the clinical department. The facility is licensed under Chapter 397, Florida Statutes and provides BHOS services to all eligible youth. All three mental health files reviewed contained the Massachusetts Youth Screening Instrument, Second Version (MAYSI 2) that had been completed during the youth s admission to the program, by staff that had received the required training. All youth were administered the Assessment of Suicide Risk (ASR) upon their admission, regardless of whether there was a need for one or not. Two files documented a hit on the MAYSI 2 in the area of suicide ideation, and all of the required procedures were followed. All files contained an initial Mental Health and Substance Abuse Screening and Record Review that documented a review of all available Exempt Review Addendum Office of Program Accountability Page 3 of 6