BUREAU OF MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR

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1 S T A T E O F F L O R I D A D E P A R T M E N T O F J U V E N I L E J U S T I C E BUREAU OF MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR Okeechobee Youth Development Center G4S Youth Services, LLC (Contract Provider) 7200 Highway 441 North Okeechobee, Florida Review Date(s): April 5-8, 2016 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES

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 Monitoring and 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: Yvrose Sylvain, Office of Program Accountability, Lead Reviewer (Standard 1) Sharon Coplin, Office of Program Accountability, Regional Monitor (Standard 4) Paula Friedrich, Office of Program Accountability, Regional Monitor (Standard 2 & SPEP) Douglas Kane, St. Lucie Detention Center, Assistant Superintendent II (Standard 5) Patrick Morse, Office of Program Accountability, South Regional Supervisor (Standard 3) Michaelas Ogunlade, Senior Juvenile Probation Officer, DJJ Probation, Circuit 11 (Standard 2) Patrice Starks, Office of Program Accountability, Regional Deputy Supervisor, (Standards 2 & 5) Regina Washington, Senior Juvenile Probation Officer, DJJ Probation, Circuit 11 (Standard 2)

3 Program Name: Okeechobee Youth Development Center MQI Program Code: 1160 Provider Name: G4S Youth Services, LLC Contract Number: Location: Okeechobee County / Circuit 19 Number of Beds: 30 Review Date(s): April 5-8, 2016 Lead Reviewer Code: 125 Methodology This review was conducted in accordance with FDJJ-2000 (Contract Management and Program Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1) Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included in the Residential Standards. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee 1 # Case Managers 1 # Clinical Staff # Food Service Personnel 2 # Healthcare Staff 1 # Maintenance Personnel 1 # Program Supervisors Documents Reviewed 1 # Staff 8 # Youth 2 # Other (listed by title): Regional Compliance Manager, School Lead Teacher Accreditation Reports Affidavit of Good Moral Character CCC Reports Confinement Reports Continuity of Operation Plan Contract Monitoring Reports Contract Scope of Services Egress Plans Escape Notification/Logs Exposure Control Plan Fire Drill Log Fire Inspection Report Fire Prevention Plan Grievance Process/Records Key Control Log Logbooks Medical and Mental Health Alerts PAR Reports Precautionary Observation Logs Program Schedules Sick Call Logs Supplemental Contracts Table of Organization Telephone Logs Surveys Vehicle Inspection Reports Visitation Logs Youth Handbook 9 # Health Records 7 # MH/SA Records 7 # Personnel Records 4 # Training Records/CORE 3 # Youth Records (Closed) 7 # Youth Records (Open) # Other: 7 # Youth 7 # Direct Care Staff # Other: Observations During Review Admissions Confinement Facility and Grounds First Aid Kit(s) Group Meals Medical Clinic Medication Administration Posting of Abuse Hotline Program Activities Recreation Searches Security Video Tapes Sick Call Social Skill Modeling by Staff Staff Interactions with Youth Comments Staff Supervision of Youth Tool Inventory and Storage Toxic Item Inventory and Storage Transition/Exit Conferences Treatment Team Meetings Use of Mechanical Restraints Youth Movement and Counts Items not marked were either not applicable or not available for review. Office of Program Accountability Page 3 of 68 (Revised July 2015)

4 Standard 1: Management Accountability Residential Rating Profile Indicator Ratings Standard 1 - Management Accountability 1.01 * Initial Background Screening 1.02 Five-Year Rescreening 1.03 * Provision of an Abuse-Free Environment 1.04 * Management Response to Allegations 1.05 * Incident Reporting (CCC) 1.06 Protective Action Response (PAR) and Physical Intervention Rate 1.07 * Pre-Service/Certification Requirements 1.08 In-Service Training 1.09 Logbook Entries and Shift Report Review 1.10 * Internal Alerts System 1.11 * Alerts (JJIS) 1.12 Youth Records (Healthcare and Management) 1.13 Advisory Board 1.14 Program Planning 1.15 Staff Performance * 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 68 (Revised July 2015)

5 Standard 2: Assessment and Performance Plan Residential Rating Profile Indicator Ratings Standard 2 - Assessment and Performance Plan 2.01 Initial Contacts to Parent/Gaurdian 2.02 Youth Orientation 2.03 Court Notifications 2.04 Classification Factors 2.05 Classification Procedures 2.06 Reassessment for Activities 2.07 R-PACT Assessment 2.08 Youth Needs Assessment Summary 2.09 R-PACT Reassessments 2.10 Parent/Guardian Involvement in Case Management Services 2.11 Members of Treatment Team Limited 2.12 Performance Plan Development 2.13 Treatment Team Meetings (Formal Reviews) 2.14 Treatment Team Meetings (Informal Reviews) 2.15 * Performance Plan Goals 2.16 Performance Plan Transmittal 2.17 Performance Plan Revisions 2.18 Incorporation of Other Plans Into Performance Plan 2.19 Performance Summaries 2.20 Performance Summary Transmittal 2.21 Visitation and Communication 2.22 Written Consent of Youth Eighteen Years or Older 2.23 Transition Planning and Conference 2.24 Exit Portfolio 2.25 Exit Conference 2.26 Grievance Process Training 2.27 Grievance Process 2.28 Grievance Process Documentation 2.29 Gang Identification: Notification of Law Enforcement 2.30 Gang Identification: Intervention Activities 2.31 Life Skills Training Provided to Youth 2.32 Staff Training: Delinquency Interventions 2.33 Restorative Justice Awareness For Youth 2.34 Delinquency Intervention Services 2.35 Recreation and Leisure Activities 2.36 Youth Input Limited 2.37 Gender-Specific Programming 2.38 Career Education 2.39 Educational Access 2.40 Education Transition * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 5 of 68 (Revised July 2015)

6 Standard 3: Mental Health and Substance Abuse Services Residential Rating Profile Indicator Ratings Standard 3 - Mental Health and Substance Abuse Services 3.01 Designated Mental Health Clinician Authority or Clinical Coordinator 3.02 * Licensed Mental Health and Substance Abuse Clinical Staff 3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff 3.04 Mental Health and Substance Abuse Admission Screening 3.05 Mental Health and Substance Abuse Assessment/Evaluation 3.06 Mental Health and Substance Abuse Treatment 3.07 * Treatment and Discharge Planning 3.08 * Specialized Treatment Services 3.09 * Psychiatric Services 3.10 * Suicide Prevention Plan 3.11 * Suicide Prevention Services 3.12 * Suicide Precaution Observation Logs 3.13 * Suicide Prevention Training 3.14 * Mental Health Crisis Intervention Services 3.15 * Crisis Assessments 3.16 * Emergency Mental Health and Substance Abuse Services 3.17 * Baker and Marchman Acts * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 6 of 68 (Revised July 2015)

7 Standard 4: Health Services Residential Rating Profile Indicator Ratings Standard 4 - Health Services 4.01 * Designated Health Authority/Designee 4.02 * Psychiatrist/Designee 4.03 Facility Operating Procedures 4.04 Authority for Evaluation and Treatment 4.05 Parental Notification 4.06 Notification - Clinical Psychotropic Progress Note 4.07 Immunizations 4.08 Healthcare Admission Screening Form 4.09 Medical Alerts 4.10 Youth Orientation to Healthcare Services 4.11 Designated Health Authority/Designee Admission Notification 4.12 Healthcare Admission Rescreening 4.13 Health Related History 4.14 Comprehensive Physical Assessment 4.15 Female-Specific Screening/Examination Non-Applicable 4.16 Tuberculosis Screening 4.17 Sexually Transmitted Infection Screening 4.18 HIV Testing 4.19 Sick Call Process - Requests/Complaints 4.20 Sick Call Process - Visits/Encounters 4.21 Restricted Housing 4.22 Episodic/First Aid Care 4.23 Emergency Care 4.24 Off-Site Care/Referrals 4.25 Chronic Illness/Periodic Evaluations 4.26 Medication Management - Verification 4.27 Medication Management - Orders/Prescriptions 4.28 Medication Management - Storage 4.29 Medication Management - Medication and Sharps Inventory 4.30 Medication Management - Controlled Medications 4.31 Medication Management - Medication Administration Record 4.32 Medication Management - Medication Administration By Licensed Staff 4.33 Medication Management - Medication Provided By Non-Licensed Staff 4.34 Medication Management - Psychotropic Medication Monitoring 4.35 Infection Control - Surveillance, Screening, and Management 4.36 Infection Control - Education 4.37 Infection Control - Exposure Control Plan 4.38 Prenatal Care - Physical Care of Pregnant Youth Non-Applicable 4.39 Prenatal Care - Nutrition and Education of Youth Non-Applicable 4.40 Neonatal Care - Infant Physical Care and Nutrition of Infants Non-Applicable 4.41 Neonatal Care - Supervision of Infants Non-Applicable 4.42 Neonatal Care - Education and Lactation Non-Applicable 4.43 Prenatal and Neonatal Staff Education Non-Applicable * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 7 of 68 (Revised July 2015)

8 Standard 5: Safety and Security Residential Rating Profile Indicator Ratings 5.01 Standard 5 - Safety and Security Youth Supervision 5.02 * Ten-Minute Checks 5.03 Census, Counts, and Tracking 5.04 Key Control 5.05 Contraband Procedure 5.06 Frisk and Strip Searches 5.07 Vehicles and Maintenance 5.08 Transportation of Youth 5.09 Tool Inventory and Management 5.10 Youth Tool Handling and Supervision 5.11 Outside Contractors 5.12 Fire, Safety, and Evacuation Drills 5.13 Mental Health and Medical Drills 5.14 Disaster and Continuity of Operations Planning 5.15 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials 5.16 Youth Handling and Supervision for Flammable, Poisonous, and Toxic Items and Materials 5.17 Disposal of All Flammable, Toxic, Caustic, and Poisonous Items 5.18 Elements of Water Safety Plan Non-Applicable 5.19 Staff Training: Water Safety Non-Applicable 5.20 * Swim Test Non-Applicable 5.21 Comprehensive Behavior Management System 5.22 Implementation and Consistency of Behavior Management System 5.23 Behavior Management System Infractions 5.24 Staff Training: Behavior Management System 5.25 Behavior Management System Monitoring 5.26 Controlled Observation Limited 5.27 Search and Inspection of Controlled Observation Room 5.28 Controlled Observation Safety Checks 5.29 Controlled Observation Release Procedures * 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 8 of 68 (Revised July 2015)

9 Strengths and Innovative Approaches The program conducts quarterly family day events to promote family reunification and involvement in the treatment team process. Office of Program Accountability Page 9 of 68 (Revised July 2015)

10 Standard 1: Management Accountability Overview The program is a thirty-bed facility serving male youth ages thirteen to twenty-one. Okeechobee Youth Development Center (OYDC) is a secure high-risk program and is co-located with Okeechobee Youth Correctional Center (OYCC) secure maximum-risk program. There is one program director who is responsible for both programs along with the rest of the management team. The program is located in Okeechobee, Florida. The program has two living modules to house youth. The program has a facility administrator who is responsible for all seven on-site programs. The management team consists of a program director, unit manager, shift supervisor, director of case management, transitional service manager, director of clinical services, health services administrator, food service manager, compliance manager, and a human resource manager. The program provides mental health overlay services (MHOS), delinquency interventions, life skills, on-site educational classes, and vocational programming. The educational services are provided by the Washington County School System. At the time of the annual compliance review, the program had five vacant positions; three youth care workers, one clinical therapist, and shift supervisor 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. The program has written policies and procedures requiring compliance with the Department s background screening requirements. The program had twenty-eight staff members and no volunteers who were applicable for an initial background screening. A review of initial background screenings for twenty-eight newly hired staff found the program received a background screening from the Department s Background Screening Unit (BSU) prior to each staff s hire date. The Annual Affidavit of Compliance with Level 2 Screening Standards was completed and submitted to BSU on January 5, 2016, meeting the annual requirement Five-Year Rescreening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. Employees and volunteers are rescreened every five years from the initial date of employment. The program has written policies and procedures requiring compliance with the Department s five-year background re-screening requirements. The program s human resource manager tracks the five-year anniversary of hire dates, and processes the five-year re-screenings for all staff. The program had two staff who were applicable for a five-year background rescreening. Each re-screening was completed and submitted to the Department s Background Screening Unit at least ten business days prior to their five-year anniversary date. There were no volunteers applicable for five-year re-screening. Office of Program Accountability Page 10 of 68 (Revised July 2015)

11 1.03 Provision of an Abuse-Free Environment Compliance The program provides an environment in which youth, staff, and others feel safe, secure, and not threatened by any form of abuse or harassment. Posting of the Florida Abuse Hotline telephone number and the Central Communications Center for youth 18 years of age and older telephone number. All allegations of child abuse or suspected child abuse are immediately reported to the Florida Abuse Hotline. Youth and staff have unhindered access to report alleged abuse to the Florida Abuse Hotline pursuant to Section (1)(a), F.S. The environment is free of physical, psychological, and emotional abuse. A code of conduct for staff who clearly communicates expectations for ethical and professional behavior, including the expectation for staff to interact with youth in a manner promoting their emotional and physical safety. The program has written policies and procedures in place for an environment in which youth, staff, and others feel safe, secure, and not threatened by any form of abuse or harassment. The program s practice is once a youth requests to call the Florida Abuse Hotline, the youth care worker will use the radio to call the shift supervisor, and the shift supervisor will take the youth to place the call. The program s policy stated the supervisor is to immediately contact the Florida Abuse Hotline and Central Communication Center (CCC), and begin an immediate review of all documents, statements, and video to determine if abuse did occur. Observations made during a tour of the program found signs posted throughout the program listing the telephone numbers for the Florida Abuse Hotline and CCC. The staff sign a form acknowledging their understanding of the code of conduct. A resident handbook is provided to each youth upon admission. The resident handbook includes the youth s rights, the program s grievance process, and the telephone numbers for the Florida Abuse Hotline and CCC. There were two abuse allegations reported to the Florida Abuse Hotline and CCC during the annual compliance review period and are both still pending investigation. Seven surveyed youth reported never being stopped from reporting abuse to the Florida Abuse Hotline. Seven youth reported staff are respectful when speaking with them. One youth reported on one occasion hearing staff use curse words when speaking to a youth, two reported once, and four reported never. None of the seven youth reported hearing staff using threats or intimidation towards a youth. All seven youth reported feeling safe at the program. None of the seven surveyed staff reported ever seeing a co-worker deny a youth an abuse call, using profanity when speaking to a youth, or observing a co-worker using threats or intimidation towards a youth. One staff member was interviewed and reported the youth have access to report abuse allegations. Office of Program Accountability Page 11 of 68 (Revised July 2015)

12 1.04 Management Response to Allegations Compliance Management shall be cognizant of youth and staff needs and provide direction to each on how to access the Florida Abuse Hotline. There is evidence management takes immediate action to address incidents of physical, psychological, and emotional abuse. A review of the program s policy outlined procedures regarding abuse reporting in compliance with the Department s criteria for reporting abuse. The program s practice is to initiate an internal investigation regarding the complaint and remove the staff member from contact with youth when necessary. The program had a total of twenty-three reportable and accepted incidents documented in the Department s Central Communication Center (CCC) database within the last six months. The program had two allegations with three staff members allegedly involved with an allegation of abuse within the last six months. Reviewed documentation found management took immediate action regarding the incident by initiating an internal investigation regarding staff 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 maintains written procedures regarding response to incidents, which is in accordance with Florida Administrative Code. The program had twenty-three reportable incidents during this annual compliance review period. A review of ten incident reports found all were reported to the Department s Central Communications Center (CCC) within two hours, as required. Seven of the ten applicable incidents were documented in the program s master control logbook. In reviewing the program s internal incident reports, there were no incidents which should have been reported to the CCC and were not reported. The program has experienced an increase in the number of reportable incidents to the CCC compared to last annual compliance review Protective Action Response (PAR) and Physical Compliance Intervention Rate 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. The program had ten Protective Action Response (PAR) reports in the past year and one report the program was unable to locate. There was documentation to support a monthly summary of PAR reports was submitted to the Department as required. Nine of the ten reviewed PAR reports found all staff completed appropriate statements prior to the end of their shift. Nine of the ten PAR reports were reviewed and processed within seventy-two hours by all required parties. Nine of the ten PAR reports included a post-par interview and medical review. The program s PAR plan was approved by the Department s Office of Staff Development and Training on February 10, The program s morning management team meets Monday through Friday and reviews all PARs, Central Communication Center (CCC) reports, internal incidents, and security alerts. Office of Program Accountability Page 12 of 68 (Revised July 2015)

13 The programs PAR rate during the annual compliance review period was 1.11, which is below the statewide Residential PAR rate of Pre-Service/Certification Requirements Compliance Contracted and State residential staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. The program maintains a pre-service training plan for all new staff. The pre-service training plan was approved by the Department s Office of Staff Development and Training on January 23, The pre-service training is provided in a combination of instructor-led and web-based courses. Four staff training files were reviewed for pre-service certification training. All four reviewed training files documented each staff completed the certification process within 180 days of hire. The staff completed the required trainings related to Protective Action Response (PAR), first aid, cardiopulmonary resuscitation (CPR), and automated external defibrillator (AED). All completed training was documented in the Department's Learning Management System (SkillPro). All training was delivered by qualified trainers In-Service Training Compliance Residential staff complete twenty-four hours of in-service training, including mandatory topics specified in Florida Administrative Code, each calendar year, effective the year after preservice/certification training is completed. Supervisory staff completes eight hours of training (as part of the twenty-four hours of annual inservice training) in the areas specified in Florida Administrative Code. Three staff training files were reviewed for in-service training. All reviewed staff training files documented each staff member exceeded the twenty-four hours of annual in-service training requirements. All staff had current certifications in Protective Action Response (PAR), first aid, automated external defibrillator (AED), and cardiopulmonary resuscitation (CPR). All staff had professionalism, ethics, and suicide prevention training. One applicable staff completed the eight hours of management/supervisory training. The program had a training calendar, which is updated as necessary. All completed training was documented in the Department's Learning Management System (SkillPro). All training was delivered by qualified trainers. The program maintains a written in-service training plan, which was reviewed and accepted by the Department s Office of Staff Development and Training on January 23, Logbook Entries and Shift Report Review Compliance The program maintains a chronological record of events, incidents, and activities in a central logbook maintained at master control, living unit logbooks, or both, in accordance with Florida Administrative Code. The program ensures direct care staff, including each supervisor, is briefed when coming on duty. The program maintains a master control logbook containing a chronological record of events, incidents, and activities. The master control logbooks were reviewed from October 2015 to March 2016; all logbook entries were brief and legible, written in ink, included the date and time of the event, and any exceptional applicable entries had consistent color-coded highlighting. All logbook corrections were made as required, with a single line struck through the error, dated Office of Program Accountability Page 13 of 68 (Revised July 2015)

14 and initialed by the person correcting. The master control logbook was also reviewed for reporting incidents to the Department s Central Communications Center (CCC). The program shift briefings were reviewed from October 2015 to April 3, The program conducts shift briefings prior to each shift with significant issues identified on the shift report. All staff signed the shift-briefing log to document their presence at the briefing Internal Alerts System Compliance The program shall maintain and use an internal alert system easily accessible to program staff and keeps them alerted about youth who are security or safety risks, and youth with healthrelated concerns, including food allergies and special diets. When risk factors or special needs are identified during or subsequent to the classification process, the program immediately enters this information into its internal alert system. The program ensures only appropriate staff may recommend downgrading or discontinuing a youth s alert status. The program has an alert board in master control, which identifies each youth s special alerts, escape risk, and/or gang affiliation. The board also identifies youth placed on any type of mental health alert. The alert board has each youth s picture, arranged by dormitory, and the alert associated with the youth. Reviewed documentation indicated the alert report is reviewed daily during shift briefings by the program's supervisory staff. An extra copy of the program s internal alert is located in master control near the door in a hall folder and is accessible to all staff. All internal alerts were downgraded or discontinued by the appropriate staff member Alerts (JJIS) Compliance When risk factors or special needs are identified during or subsequent to the classification process, the program immediately enters this information into the Juvenile Justice Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are downgraded or discontinued. Seven youth records were reviewed for case management, medical, and mental health and substance abuse and all alerts were accurately entered into Department s Juvenile Justice Information System (JJIS). The program will enter any alerts, which may not have been entered prior to the youth s admission. All JJIS alerts were downgraded or discontinued by the clinical director and treatment director Youth Records (Healthcare and Management) Compliance The program maintains an official case record, labeled Confidential, for each youth, which consists of two separate files: An individual healthcare record An individual management record The program maintains individual healthcare, mental health and substance abuse, and case management records for each youth. All seven case management, healthcare, and mental health and substance abuse records were marked Confidential and each record contained the required documents. The case management records contained all required documentation on the spine of the binder, including each youth s name, Department of Juvenile Justice identification number (DJJID), and date of admission. The documents were organized into the required sections. All case management records, mental health and substance abuse records, Office of Program Accountability Page 14 of 68 (Revised July 2015)

15 and healthcare records were secured in a designate locked room when not in use. The room door and shelves were clearly marked Confidential Advisory Board Compliance The program has a community support group or advisory board, meeting at least quarterly. The program director solicits active involvement of interested community partners. The program has an advisory board, which serves six programs located in Okeechobee County. The advisory boards were combined due to a limited amount of people living in this rural community and the number of boards the local representatives participate. Reviewed documentation supported the program s community advisory board meets at least quarterly; however, attendance is low. There was documentation to support the program made attempts to schedule meeting dates to work around community advisory board member s schedules by mailing a letter thirty days in advance to increase attendance. The program has board members from the school board, law enforcement officials, community partners, faith-based organizations, the local domestic violence shelter, judiciary, business community, and a parent/guardian of a former/present resident. Reviewed community advisory board meeting minutes documented the program provides the board members with information about the on-site programs Program Planning Compliance The program uses data to inform their planning process and to ensure provisions for staffing. The program maintains written procedures identifying service, recognition, and referrals for the staff. The program conducts daily management meetings, shift briefings, and monthly meetings for all staff to discuss relevant issues affecting the program s operation and to keep staff informed of corporate objectives. The program daily management meetings follow a pre-set agenda including the discussion of Protective Action Response (PAR) incidents, calls to the Florida Abuse Hotline or Central Communication Center (CCC), grievances, personnel issues, youth behaviors, off-site medical appointments, admissions and discharges, and any upcoming events. The program s monthly all-staff meetings discussed security issues, training, community projects, safety drills, medical and mental health alerts, and upcoming events. There was documentation the program provides staff information about PAR reports, incident reports, the level system along with red flag issues, and information about the various reports from the Department. The program has a recognition program called G4S Way entailing three chips labeled to recognize positive culture, teamwork, and going above and beyond, which staff can provide to each other. Reviewed documentation found the staff recognition program information is shared with staff and the number of rewards handed out monthly depends on the number of staff working in the program. The program conducts youth surveys upon each youth s discharge from the program and parent/guardian surveys every ninety days during the family day event. The program also utilizes family day as an opportunity to speak with the parents/guardians and youth to obtain input into the treatment process to discuss any relevant concerns. However, reviewed documentation found the results were not incorporated into the program monthly meeting and/or daily management meeting. Five of the seven staff surveys reported staff are not briefed on the youth and parent/guardian surveys and/or the Department s annual compliance report. Six of the seven staff reported staff meetings are held monthly and one reported daily. Five staff reported the communication process is very good, and two reported the process is good. One of the staff reported they were able to provide feedback on the facility operations by speaking at the daily meeting. Office of Program Accountability Page 15 of 68 (Revised July 2015)

16 1.15 Staff Performance Compliance The program ensures a system for evaluating staff, at least annually, based on established performance standards. The program conducts ninety-day performance evaluations for newly hired staff, and annual evaluations for all staff. Four personnel files were reviewed of which two contained an annual performance evaluation, and two contained a ninety-day performance evaluation. The performance evaluations were specific to the applicable staff s job description. All reviewed performance evaluations found each staff s evaluation was based on the performance standards for the position. The annual performance evaluation process included the effective delivery of any specific evidence-based curriculum being delivered by staff. The evaluations rate the staff s quality of work, modeling appropriate behavior, a positive reinforcement in a four-toone ratio, and each evaluation included ratings on the staff s specific job responsibilities. Five of the seven surveyed staff reported receiving an evaluation yearly, one reported every six months, and one reported never. Office of Program Accountability Page 16 of 68 (Revised July 2015)

17 Standard 2: Assessment and Performance Plan Overview The program s case management director provides oversight for all case management services provided by the case managers in the program. The case managers complete risk classifications, the Residential Positive Achievement Change Tool (R-PACT), the Youth Needs Assessment Summary (YNAS), individual performance plans, progress reports, and provides transitional planning with the youth. The case managers are members of the treatment team and meet formally once per month and informally twice per month with each youth to discuss the youth s progress. The case managers are the primary liaison between the youth and their family, assigned juvenile probation officer (JPO), and committing judge. The youth are provided educational services including academic courses through Washington County Public Schools. The youth receive academic credits and have the opportunity to work towards the General Educational Development (GED) test. The program has identified several staff members to provide effective interventions to include Impact of Crime (IOC), The Teen Relationship, and Thinking for a Change (T4C) Initial Contacts to Parent/Guardian Compliance The program notifies the youth s parent/guardian by telephone within twenty-four hours of the youth s admission, and by written notification within forty-eight hours of admission. The program s policies and procedures require telephone notification of each youth s parent/guardian within twenty-four hours of the youth s admission and written notification within forty-eight hours of the youth s arrival at the program. Seven youth case management records were reviewed and found all reviewed records documented the program notified each youth s parent/guardian by telephone within twenty-four hours of admission. All records also indicated the program notified each youth s parent/guardian in writing within forty-eight hours of admission into the program Youth Orientation Compliance The program shall provide each youth an orientation to the program rules, procedures, schedules, and services applicable to youth, to begin within twenty-four hours of admission. Seven youth case management records were reviewed and found all records documented each youth was provided an orientation within twenty-four hours of admission into the program. Orientation to the program included a review of services available, a daily schedule, procedures on visitation, and access to the Florida Abuse Hotline and the Central Communications Center (CCC). In addition, orientation addressed items considered to be contraband, performance planning process, dress code and hygiene practices, mail and telephone call procedures, anticipated length of stay and expectation for release from the program, explanation of expectations and responsibilities of youth, and the written behavior management system provided in the resident handbook. The youth also receive a resident handbook, which provides additional information to youth regarding the program s expectations. Seven youth responded to the survey; all reported receiving an orientation to the program within twenty-four hours of admission, including the program rules, procedures, schedules and services. Office of Program Accountability Page 17 of 68 (Revised July 2015)

18 2.03 Court Notification Compliance The program notifies the youth s committing court(s) by written notification within five working days of admission. Seven youth case management records were reviewed. Each contained documentation the program sent written notification to the committing court within five-working days of each youth s admission into the program. The written notification included a description of the program mission and services provided Classification Factors Compliance The program utilizes a classification system, in accordance with Florida Administrative Code, promoting safety and security, as well as effective delivery of treatment services. The program s policies and procedures outlines the requirements for the initial classification.. Seven youth case management records were reviewed and documented an initial classification was conducted for each youth. The classification factors included the youth s physical characteristics, age, maturity level, gang affiliation, identified special needs, history of violence, medical, criminal behavior, intellectual and physical disabilities, sexual aggression or vulnerability to victimization, as well as identifying suspected risk factors for suicide, escape, and/or security. The classification form was signed by the youth, treatment director, case manager, living unit representative, and up to two additional staff Classification Procedures Compliance Initial classification should be used for the purposes of assigning each newly admitted youth to a living unit, sleeping room, and youth group or staff advisor. The program has policies and procedures regarding the classification of youth. Seven youth case management records were reviewed and indicated each newly admitted youth received an initial classification for the purpose of assigning the youth to the living area, sleeping room, and youth group. There is an internal alert system in place to identify any medical, mental health, security risk, or special needs identified during the initial or subsequent classification process Reassessment for Activities Compliance Youth are reassessed and reclassified, if warranted, prior to considering an increase in privileges or freedom of movement, participation in work projects, or other activities involving tools or instruments that may be used as potential weapons or means of escape, or participation in any off-campus activity. The program has written policies and procedures requiring the completion of risk assessments and when youth are considered for campus work activities or details. The program conducts a risk assessment for each youth upon admission into the program. Seven reviewed case management records contained copies of re-assessments conducted to identify needs and risk in order to increase privileges and participate in campus activities. Due to the level of commitment of this program, none of the youth participate in any off-campus activities. Office of Program Accountability Page 18 of 68 (Revised July 2015)

19 2.07 R-PACT Assessment Compliance The program shall ensure an initial assessment of each youth is conducted within thirty days of admission. The program shall maintain all documentation of the initial assessment process in JJIS. Seven youth case management records were reviewed and the Residential Positive Achievement Change Tool (R-PACT) was completed within thirty days of each youth s admission into the program. Each youth s R-PACT initial assessment was maintained in the Department s Juvenile Justice Information System (JJIS) Youth Needs Assessment Summary (YNAS) Compliance The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is conducted within thirty days of admission. The program shall maintain all documentation of the YNAS. Seven youth case management records were reviewed. Six of the seven Youth Needs Assessment Summary (YNAS) was completed within thirty days of admission and one was completed fifty eight days late. Each youth YNAS was maintained in the Department s Juvenile Justice Information System (JJIS) R-PACT Reassessments Compliance The program shall ensure a reassessment of each youth is conducted within ninety days. The program shall ensure any other updates or reassessments are completed when deemed necessary by the intervention and treatment team to effectively manage the youth s case. The program shall maintain all reassessment documentation in the youth s official youth case record. Seven case management records were reviewed and six were applicable for completion of ninety-day Residential Positive Achievement Change Tool (R-PACT) re-assessments. Five of six youth records showed the R-PACT re-assessment was completed within ninety days. The one was completed on day ninety two. All six youth re-assessment documentation was maintained in the case management record and on the Department of Juvenile Justice Information System (JJIS) Parent/Guardian Involvement in Case Management Compliance Services The program shall, to the extent possible and reasonable, encourage and facilitate involvement of the youth s parent/guardian in the case management process. Seven youth case management records were reviewed and documentation confirmed involvement of the youth s parent/guardian in the case management process. Each reviewed record documented efforts had been made to include the parent/guardian in the assessment process and in the development of the performance plan. In all seven records documentation showed letters were sent to each youth's parent/guardian advising them of the date and time of performance plan development. The treatment team documentation showed parents/guardians were contacted to participate or did participate in treatment teams by telephone or provided input prior to the treatment team meeting. Office of Program Accountability Page 19 of 68 (Revised July 2015)

20 2.11 Members of Treatment Team Limited Compliance The team includes, at a minimum, the youth, representatives from the program s administration and residential living unit, and others responsible for providing or overseeing the provision of intervention and treatment services. The program assigns each youth to a treatment team upon admission into the program. The treatment teams are comprised of the youth, case manager, a representative from education, a mental health therapist, the youth s parent/guardian, assigned juvenile probation officer (JPO), medical staff, a representative from the living unit, and a representative from the program s administration. Seven youth case management records were reviewed. All records confirmed a representative from the youth s living unit was not actively participating in the treatment team meetings. However, in all seven records documentation indicated unit representative submitted written input, which is not acceptable as outlined in Florida Administrative Code; unit representatives must participate in person. Reviewed documentation validated each assigned youth s JPO was invited to participate in the treatment team in person or via telephone Performance Plan Development Compliance The intervention and treatment team, including the youth, shall meet and develop the performance plan, based on the findings of the initial assessment of the youth, within thirty days of admission. Seven youth case management records were reviewed for performance plan development. Each youth s performance plan was developed within thirty days of the youth s admission to the program and was signed by all required parties. Each youth s performance plan had been developed using information gathered from the youth s needs assessment and the results of any testing/assessment conducted by the education and mental health departments. All seven surveyed youth reported participating in the development of their performance plan Treatment Team Meetings (Formal Reviews) Compliance A residential commitment program shall ensure the intervention and treatment team meets every thirty days to review each youth s performance, to include R-PACT reassessment results, progress on individualized performance plan goals, positive and negative behavior, including behavior resulting in physical interventions. If the youth has a treatment plan, review their treatment progress. Seven youth case management records were reviewed. Each record showed documentation formal treatment team meetings were conducted every thirty days. Formal treatment team meeting documentation included the youth s signature, review date, attendees, comments by treatment team members, and a brief synopsis of the youth s progress in the program. Reviewed documentation supported the youth performance plan goals were discussed. All seven youth records contained documentation of the youth s input during treatment team meetings. Each reviewed record confirms the treatment team leader invited and encouraged participation of the youth s juvenile probation officer (JPO) and parent/guardian. Seven surveyed youth confirmed each is provided an opportunity during treatment team meetings to demonstrate skills learned in the program. All surveyed youth confirmed the treatment team meetings focused on performance plan goals, positive and negative behaviors, and treatment progress. Office of Program Accountability Page 20 of 68 (Revised July 2015)

21 2.14 Treatment Team Meetings (Informal Reviews) Compliance A residential commitment program shall ensure the intervention and treatment team reviews each youth s performance, including R-PACT reassessment results, progress on individualized performance plan goals, positive and negative behavior, including behavior resulting in physical interventions. If the youth has a treatment plan, review their treatment progress. Seven youth case management records were reviewed. Each showed informal treatment team meetings were conducted at least once per month and special treatment team meetings were held for youth having difficulty in the program allowing the treatment team to make necessary revisions to the individual performance plan. Each reviewed case management record included the youth s name, date of the review, those in attendance, comments by team members, and a brief synopsis of the youth s progress in the program Performance Plan Goals Compliance For each goal, the performance plan shall specify its target date for completion, the youth s responsibilities to accomplish the goal, and the program s responsibilities to enable the youth to complete the goal. Seven youth case management records were reviewed for the performance plan goals. Each reviewed case management record contained a performance plan with goals created by the treatment team and the youth. The performance plan goals were based on the information from each Youth Needs Assessment Summary (YNAS), which was developed from the youth s Residential Positive Achievement Change Tool (R-PACT). Reviewed documentation demonstrated the performance plans were completed with specific delinquency interventions and measurable outcomes, which will decrease risk factors and increase protective factors. Each reviewed record identified individual goals based on the prioritized needs reflect the risk and protective factors identified during the initial assessment process. When applicable, the performance plans included court ordered sanctions could be initiated or completed while the youth is in the program Performance Plan Transmittal Compliance Within ten working days of completion of the performance plan, the program shall send a transmittal letter and a copy of the plan to the committing court, the youth s JPO, the parent/guardian, and the DCF counselor, if applicable. Four of the seven youth records confirmed performance plan transmittal letters and copies of performance plans were sent to youth s committing court, juvenile probation officer, and parent/guardian within ten working days, as required. Three youth s performance plan transmittal letters and copies of performance plans were sent late. The original performance plan was maintained in each of the seven case management records and a copy was provided to each youth. Each reviewed performance plan was signed by the youth and treatment team members. None of the reviewed records contained a performance plan signed by a parent/guardian; however, parent/guardian input was documented. Six of the seven surveyed youth reported receiving a copy of their performance plan and one youth was not applicable. Office of Program Accountability Page 21 of 68 (Revised July 2015)