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 Ft. Walton Adolescent Substance Abuse Program Gulf Coast Youth Services, Inc. (Contract Provider) 1015 MarWalt Drive Ft. Walton Beach, Florida 32547 Review Date(s): July 12-14, 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 17
Residential Performance Rating Profile Program Name: Ft. Walton Adolescent Substance Abuse Program QA Program Code: 1030 Provider Name: Gulf Coast Youth Services, Inc. Location: Okaloosa County / Circuit 1 Number of Beds: 40 Review Date(s): July 12-14, 2011 Lead Reviewer Code: 44 Program Performance by Indicator/Standard Contract Number: R2027 1. Management Accountability 3. Mental Health and Substance Abuse Services (cont.) 1.01 Background Screening of Employees/Vol. 8 Commendable 3.05 Suicide Prevention 7 1.02 Provision of an Abuse Free Environment 8 Commendable 3.06 Mental Health Crisis Intervention 8 1.03 Incident Reporting 8 Commendable 3.07 Emergency Services 7 1.04 Protective Action Response (PAR) 8 Commendable 3.08 Specialized Treatment Services 8 1.05 Pre-Service/Certification Requirements 10 Exceptional Acceptable 76% 1.06 In-Service Training Requirements 10 Exceptional 1.07 Logbook Maintenance 7 Acceptable 4. Health Services 1.08 Internal Alert System 7 Acceptable 4.01 Designated Health Authority 8 1.09 Escapes 10 Exceptional 4.02 Healthcare Admission Screening 10 1.10 Youth Records 8 Commendable 4.03 Comprehensive Physical Assessment 10 1.11 Community Partnerships 8 Commendable 4.04 Sexually Transmitted Diseases 8 1.12 Facility Integration and Stability 7 Acceptable 4.05 Sick Call 8 Commendable 83% 99 4.06 Medication Administration 5 120 4.07 Medication Control 5 2. Intervention and Case Management 4.08 Infection Control 10 2.01 Classification 8 Commendable 4.09 Chronic Illness Treatment 8 2.02 Assessment 7 Acceptable 4.10 Episodic and Emergency Care 8 2.03 Intervention and Treatment Team 8 Commendable 4.11 Consent and Notification 8 2.04 Performance Plan 8 Commendable 4.12 Prenatal/Neonatal Care NA 2.05 Performance Review and Reporting 7 Acceptable Commendable 80% 2.06 Parent/Guardian Communication 8 Commendable 2.07 Transition Planning and Release 7 Acceptable 5. Safety and Security 2.08 Grievance Process 8 Commendable 5.01 Supervision of Youth 7 2.09 Gang Prevention and Intervention 10 Exceptional 5.02 Key Control 7 2.10 Staff Characteristics 8 Commendable 5.03 Contraband and Searches 8 2.11 Delinquency Programming 8 Commendable 5.04 Transportation 8 2.12 Gender-Specific Programming 8 Commendable 5.05 Tool Management 10 2.13 Vocational Programming 5 Minimal 5.06 Disaster/Continuity of Operations Planning 10 Acceptable 77% 100 5.07 Flammable, Poisonous, and Toxic Items 10 130 5.08 Water Safety NA 3. Mental Health and Substance Abuse Services 5.09 Behavior Management System 8 3.01 Designated Mental Health Authority 8 Commendable 5.10 Behavior Management Unit NA 3.02 MH and SA Admission Screening 8 Commendable 5.11 Controlled Observation 8 3.03 MH and SA Assessment/Evaluation 8 Commendable Commendable 84% 3.04 Treatment Plan/Team and Service Delivery 7 Acceptable Standard Program Max. Score Score Rating Failed Minimal Acceptable Commendable 0-59% 60-69% 70-79% 80-89% 1. Management Accountability 99 120 83% X 2. Intervention and Case Management 100 130 77% X 3. Mental Health and Substance Abuse Services 61 80 76% X 4. Health Services 88 110 80% X 5. Safety and Security 76 90 84% X Exceptional 90-100% Overall Program Performance Commendable 80% Office of Program Accountability Page 2 of 17
Methodology This review was conducted in accordance with FDJJ-1720 (Quality Assurance Policy and Procedures), 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 2011). Persons Interviewed Program Director DJJ Monitor DHA or designee DMHA or designee 2 # Case Managers 3 # Clinical Staff 1 # Food Service Personnel 2 # Healthcare Staff Documents Reviewed 1 # Maintenance Personnel 1 # Program Supervisors 0 # Other (listed by title): Accreditation Reports Affidavit of Good Moral Character CCC Reports Confinement Reports Continuity of Operation Plan Contract Monitoring Reports Contract Scope of Services Egress Plans Escape Notification/Logs Exposure Control Plan Fire Drill Log Fire Inspection Report Fire Prevention Plan Grievance Process/Records Key Control Log Logbooks Medical and Mental Health Alerts PAR Reports Precautionary Observation Logs Program Schedules Sick Call Logs Supplemental Contracts Table of Organization Telephone Logs Surveys Vehicle Inspection Reports Visitation Logs Youth Handbook 7 # Health Records 7 # MH/SA Records 12 # Personnel Records 8 # Training Records/CORE 4 # Youth Records (Closed) 7 # Youth Records (Open) 0 # Other: 7 # Youth 6 # Direct Care Staff 0 # 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 17
Performance Ratings Performance ratings were assigned to each indicator by the review team using the following definitions and numerical values defined by FDJJ-1720: 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: Bruce Morton, Lead Reviewer, DJJ Bureau of Quality Assurance Steve Bushore, Program Administrator, DJJ Bureau of Quality Assurance Martina Leverett, Juvenile Probation Officer Supervisor, DJJ Probation, Circuit 1 Shelley McKinney, Program Monitor, DJJ Residential Services, North Region Dan Fox, Assistant Superintendent, Bay Regional Juvenile Detention Center Randy Hardin, Clinical Director, Juvenile Unit for Specialized Treatment (JUST) Office of Program Accountability Page 4 of 17
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 http://www.djj.state.fl.us/qa/index.html. Standard 1: Management Accountability Failed Minimal Acceptable Commendable Exceptional Overview The management at Ft. Walton Adolescent Substance Abuse Program (ASAP) consists of a Program Director and Assistant Program Director. The Program Director and Assistant Director are new employees recently hired or promoted from other Gulf Coast Youth Services programs. There continues to be additional support from the program s corporate office. At the time of the Quality Assurance review the program had no employees eligible for a five (5) year rescreen by the Department of Juvenile Justice (DJJ) Background Screening Unit (BSU). All of the employees hired since the last Quality Assurance review had the required background screening by the BSU prior to the date of hire. There was also documentation of a driver s license check. Documentation of staff training for annual training hours for both Pre-Service and In-Service staff far exceeded the number of required hours of training. In each case there was over half of the training documented as instructor lead training on the CORE system. The Community Advisory Board is shared with ASAP and Gulf Coast Youth Academy. There was a meeting held during the Quality Assurance review and was attended by representatives from four (4) community agencies including the Mayor of Fort Walton and a representative from the Young Men s Christian Association (YMCA). There were very little recommendations from the board or input into programming at the facility. The Program Director at Gulf Coast Youth Academy conducted the meeting and provided a report of the status of the programs and any initiatives that would be conducted during the next quarter. A review of youth records found them to be clearly labeled and organized in separate sections to included legal information, demographic and chronological information, correspondence, case management and treatment activities and miscellaneous. Each file was clearly labeled confidential and stored in a secure cabinet marked confidential. 1.01: Background Screening of Employees/Volunteers Commendable (8) Office of Program Accountability Page 5 of 17
1.02: Provision of an Abuse Free Environment Commendable (8) 1.03: Incident Reporting Commendable (8) 1.04: Protective Action Response (PAR) Commendable (8) 1.05: Pre-Service/Certification Requirements Exceptional (10) A review of four (4) employee training files for pre-service training found that all of the employees exceeded the required 120 hours of training in the first 180 days by at least fifty (50) hours. The majority of the training was instructor-led. 1.06: In-Service Training Requirements Exceptional (10) A review of four (4) employee training files for in-services training found all of the employees exceeded the required twenty-four (24) hours of annual training by at least forty (40) hours. Two (2) supervisors were selected and both met the required eight (8) hours of supervisory training. Again, the majority of the training was instructor lead. 1.07: Logbook Maintenance Acceptable (7) The condition of the book was poor with the binder separated from the pages. On some of the pages reviewed, the program did not use their own color coding system. Entries are one-liners minus details. Entries regarding confinements were made however, very little information regarding the take down or reason for behavior incidents and confinement were entered. Shift reports reviewed did not provide details of confinements making it difficult to ascertain information. Three (3) PAR reports that ended in takedowns by multiple staff and confinement were reviewed. All three incidents were found to be documented in the logbook but absent of detail regarding youth behavior, reason for confinement or pertinent information. 1.08: Internal Alert System Acceptable (7) Although there were internal alerts for food services, security and medical, there were no internal alerts for mental health and substance abuse youth that were identified on the Juvenile Justice Information System (JJIS) list of open alerts. Office of Program Accountability Page 6 of 17
1.09: Escapes Exceptional (10) The program maintains escape bags/kits in the master control room to be used by staff to facilitate a quick and effective response to an escape by a youth. The bags contain supplies to make a recovery of the youth easier and quick. There are maps to orient the staff to possible escape routes, a compass, quick-tie cuff, gloves, Global Positioning System (GPS) hand-held units, flashlight with batteries, and a first aid kit in the bags. It was evident through documentation that the facility staff have been trained on escape procedures and protocols to ensure that all youth are accounted for at all times. 1.10: Youth Records Commendable (8) 1.11: Community Partnerships Commendable (8) 1.12: Facility Integration and Stability Acceptable (7) A review of the personnel and training files of the delinquency intervention staff found that the annual evaluations of the therapists did not address requirements from the job description. Missing was an assessment of their knowledge of Motivational Interviewing, 7-Challenges treatment curriculum, and individual, group and family therapy. It was difficult to determine if the information obtained from youth and parent surveys as well as reports published annually by the Department of Juvenile Justice are included in the program planning and assessment process (i.e. discussed at management and staff meetings). There was no evidence to support a system of communication existed that provided opportunities for staff to give input and feedback pertaining to operation of the program. Standard 2: Intervention and Case Management Failed Minimal Acceptable Commendable Exceptional Overview The Ft. Walton Adolescent Substance Abuse Program (ASAP) has two (2) full-time case managers. The case managers are responsible for conducting criminogenic needs assessments, completing performance plans, and acting as the treatment team leader for all youth in the program. The case managers complete an initial admission/classification screening tool that includes a gang screening based on youth self-report. There was evidence that the case managers reviewed pertinent file information prior to completing these classification forms. Office of Program Accountability Page 7 of 17
All youth files contained a completed Residential Positive Achievement Change Tool (RPACT), Youth Needs Assessment Summary (YNAS), and Performance Plan, as required by administrative rules. All youth were reassessed on a routine basis and prior to allowing any increase on privileges, participation in work projects, access to tools and any off-campus activities. Observation of a transition conference found that all parties were present and the youth s parents were on the telephone. There was an effort by all parties to inform the youth and his parents of the contents of the transition plan. However, the written transition plans contained very little information as to how the plan would be accomplished or additional information from the transition conference. The bulk of substance abuse treatment is the 7-Challenges curriculum. However, the youth also receive groups using the Thinking for a Change (T4C), ARISE, Lifestyles and Restorative Justice Curricula. Interviews with the therapist indicated that there is regular fidelity monitoring by the DJJ Technical Assistance staff of only the T4C groups. There is one (1) gender-specific activity provided called the Fathers in Training (FIT). The activity addresses the issues of pregnancy and for the youth to gain awareness of the problems that women go through while pregnant. 2.01: Classification Commendable (8) 2.02: Assessment Acceptable (7) In six (6) of the seven (7) case files the initial Residential Positive Achievement Change Tool (RPACT) were completed within thirty (30) days of admission. One (1) was completed ten (10) days late. In six (6) of the seven (7) youth files found the Youth Needs Assessment (YNAS) were completed within thirty (30) days of admission. One (1) was completed eleven (11) days late. Six (6) of the seven (7) re-reassessments were completed in the required ninety (90) day time frame. One (1) re-assessment was completed seventeen (17) days late. 2.03: Intervention and Treatment Team Commendable (8) 2.04: Performance Plan Commendable (8) Office of Program Accountability Page 8 of 17
2.05: Performance Review and Reporting Acceptable (7) A review of seven (7) youth files found one ninety (90) day performance review was not completed as required. 2.06: Parent/Guardian Communication Commendable (8) 2.07: Transition Planning and Release Acceptable (7) A review of one (1) open youth file and two (2) closed files found the Transition Conference in one (1) of the files not held prior to sixty (60) days of the target release date. The transition plans in all three (3) files were vague and addressed goals such as get a job, stay out of trouble and avoid drugs. There were no plans on how to accomplish these goals. 2.08: Grievance Process Commendable (8) 2.09: Gang Prevention and Intervention Exceptional (10) A review of one youth file that was identified as a gang member was entered as an alert on the JJIS system on the date of admission. The program also completed the necessary gang related screening instruments: Security Threat Group Youth/Activity Referral Form, Security Threat Group Task Force Acknowledgement of Affiliation form and STG Criteria FSS 874.03 Checklist form. These are internal documents by which the youth admits to gang involvement, develops a plan to address gang activity, and participates in the facility s security threat group council meetings. In addition, the program maintains a gang notebook that includes a list of youth that have been identified or have suspected gang in affiliation, with the youth s tentative release date; current gang information from the Department of Corrections; monthly meeting minutes from the Florida Gang Reduction Task Force for Circuit One (1). Finally, corporate-level employees hold officer positions on the Circuit One (1) Task Force. 2.10: Staff Characteristics Commendable (8) Office of Program Accountability Page 9 of 17
2.11: Delinquency Programming Commendable (8) 2.12: Gender-Specific Programming Commendable (8) 2.13: Vocational Programming Minimal (5) Vocational programming was very limited, e.g. youth are not provided with work related experience beyond completing masonry class. Not all of the youth participated in the class. Training by the One Stop Center training coordinator was available only to the Special Education youth. Vocational services for the other youth were developed by the teachers from the Okaloosa School Board and the program s case managers. Interviews with the teachers found that although they conduct a class on resume writing and filling out a job application, they throw out the resumes and the job applications when the class is over. Thus, no youth were ever equipped to leave the program with a professional resume. The transition plans that were developed by the teachers and the case managers were very poor and typically stated to stay drug free, get a job and complete probation or attend school (GED/High School Diploma) There is no evidence to ensure the program director provides work-related experience, such as internships, cooperative education, school-based enterprises, entrepreneurship, and job shadowing for youth. Standard 3: Mental Health and Substance Abuse Services Failed Minimal Acceptable Commendable Exceptional Overview The Ft. Walton Adolescent Substance Abuse Program in Ft. Walton Beach, Florida is a specialized substance abuse program for youth with a primary Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revised (DSM-IV-TR) diagnosis of substance abuse. The youth may also have an additional DSM-IV-TR axis 1 diagnosis of a mental health disorder. The program is identified as a Residential Substance Abuse Treatment Program (RSAT) and receives additional funding from the Department of Juvenile Justice to provide intensive substance abuse treatment. The corporate licensed mental health professional is also the Designated Mental Health Authority (DMHA). He conducts the weekly clinical supervision for the non-licensed therapist, Baker Act assessments and reviews clinical assessment such as Suicide Risk Assessments (ASR). Interviews with the clinical staff including the newly Licensed Clinical Social Worker (LCSW) found little training or knowledge of basic theories of substance Office of Program Accountability Page 10 of 17
abuse and addiction with adults and adolescents beyond college courses. The foundation of the substance abuse treatment is the 7-Challenges evidence based curriculum. The therapists were well versed in the 7-Challenges curriculum. However, there is no indication that there has been any fidelity monitoring of the implementation of that curriculum since the last program director left. All of the youth are screened using both the Massachusetts Youth Screening Instrument, Second Version (MASYI-2) and Substance Abuse Subtle Screening Inventory (SASSI) instruments. Information from the SASSI screenings was not used with the findings in the biopsychosocial and substance abuse assessments in the development of the youth s Individualized Treatment Plan. Findings in the MAYSI-2 were primarily used in the detection of youth at risk for suicide. There was documentation of bi-annual suicide drills and one very limited Baker Act drill. The Baker Act drill was rushed to be completed by the program on the same afternoon following discussion during the on-site Quality Assurance review daily debriefings. The discussions during the daily debriefing focused on the program s youth population and potential need for understanding of the Baker Act and Marchman procedures for all staff. The Baker Act drill presented was limited to a small portion of program staff and only included reading the steps that should be followed. Additionally, the steps described were not inclusive of all of the facility s Emergency Mental Health and Substance Abuse Plan procedures. There was no discussion or information to express the seriousness of Baker Acting any youth and the consequences that will follow that youth. The Baker Act training was not shared with all supervisors and program staff. 3.01: Designated Mental Health Authority (DJJ Program) Commendable (8) 3.02: Mental Health and Substance Abuse Admission Screening Commendable (8) 3.03: Mental Health and Substance Abuse Assessment/Evaluation Commendable (8) 3.04: Treatment Plan, Treatment Team, and Service Delivery Acceptable (7) Treatment plans were not individualized in a manner to reflect that the individual substance abuse needs of youth were appropriately addressed. The goals and objectives of each substance abuse goal were similar. There was evidence in one youth mental health record that the assessment indicated a family history of cannabis dependence, but there was no information in the treatment plan to address this need. Office of Program Accountability Page 11 of 17
3.05: Suicide Prevention Acceptable (7) It was difficult to determine if staff attended the April 2011 suicide drill as there was no sign in sheet. One youth placed on suicide precautions was not entered on the JJIS Alert system. An interview with the DMHA, however, indicated that youth alerts are not immediately entered into JJIS. 3.06: Mental Health Crisis Intervention Commendable (8) 3.07: Emergency Services Acceptable (7) The program has a written emergency services plan that addresses all required elements. However, there was no evidence of any youth requiring emergency services or that the program had incorporated a system of drills that would educate and assist staff in fulfilling functions required in the event of an actual emergency. 3.08: Specialized Treatment Services Commendable (8) Standard 4: Health Services Failed Minimal Acceptable Commendable Exceptional Overview Medical services at Ft. Walton Adolescent Substance Abuse Program (ASAP) are provided by a Florida-licensed Medical Doctor who serves as the Designated Health Authority (DHA), one Registered Nurse (RN) and one Licensed Practical Nurse (LPN). Interviews indicated that the RN is used at other programs operated by Gulf Coast Youth Services in a floater capacity. The DHA is on-site two (2) hours per week and conducts new physical assessments, sick call, and other clinical services, as needed. In addition, this individual reviews medical procedures and protocols, at least annually, as required. Further oversight of nursing is provided by the Director of Nursing, a licensed Registered Nurse (RN). Facility Health Entry Screenings are completed by a licensed medical professional for each youth at the time of admission. A new Health Related History (HRH) and Comprehensive Physical Assessment (CPA) are also conducted for all youth, regardless of whether the youth had a CPA that was considered current. Office of Program Accountability Page 12 of 17
Sick call is conducted seven (7) days per week at 2:30 PM. However, if a youth complains of an illness the youth is seen by the nursing staff at that time rather than waiting for the scheduled sick call. The program s Medication Administration Record (MAR) binder contains a lists of medication not to be crushed, potential interactions between medications, side effects, etc. The review of Medication Administration Records (MARs) binder showed that some contained documentation discrepancies. The discrepancies included certain days when there was no documentation (left blank) to determine if the youth was given a specific medication as originally ordered by the DHA or if the youth refused that medication on that particular day. An interview with the program s Director of Nursing indicated that the DHA has identified certain medications that can be changed from the original written prescription to a PRN (as needed) if the youth refuses the original prescribed order for a particular medication. The program provided a list of those medications with the signature of the DHA indicating approval. None of the missed days on the MAR s reviewed showed that these prescribed medications were changed to a PRN. During the course of the Quality Assurance review, the days that were left blank on the MAR s were altered to document the change from the original prescribed medication to a PRN. This change was made by writing over the original transcribed prescription information in large letters PRN. Therefore, the changes on the MAR were not appropriately struck through, initialed, and voided, as required by the Department of Juvenile Justice Health Services Manual. In addition, all data collected during the on-site Quality Assurance review was also shared with the Department of Juvenile Justice Office of Health Services and found the program s practice of changing a prescribed medication to a PRN did not meet the requirements as outlined in the Department of Juvenile Justice Health Services Manual. The provider does maintain required inventory for over-the-counter (OTC) bulk medications, shift to shift perpetual inventory of controlled medications, but there were deficiencies in weekly sharps counts and a perpetual inventory whenever these items were used. The provider also has processes in place for appropriately managing youth with chronic conditions, ensuring that episodic or emergency care is timely and appropriate, and for minimizing potential infectious exposures. The program sends consents and notifications for any medical condition changes or increase/decrease of medications and treatment. 4.01: Designated Health Authority Commendable (8) 4.02: Healthcare Admission Screening Exceptional (10) Licensed medical professionals conducted all admission screenings and completed the Facility Entry Physical Health Screening form (FEPHS) in each of the seven (7) youth medical records reviewed. 4.03: Comprehensive Physical Assessment Exceptional (10) All seven (7) medical records contained a new comprehensive physical assessment (CPA) completed by the DHA even though there already was an up-to-date CPA. Office of Program Accountability Page 13 of 17
All seven (7) medical records contained a new health related history (HRH) completed by a licensed medical professional prior to the CPA being completed rather than just updating the HRH that was included with the admission paperwork. 4.04: Sexually Transmitted Diseases Commendable (8) 4.05: Sick Call Commendable (8) 4.06: Medication Administration Minimal (5) The Medication Administration Records (MARs) reviewed contained documentation discrepancies. The discrepancies included missed medication ordered by the DHA that included a specific dosage and frequency. Some of the missed medications were associated with the programs practice of changing a prescribed medication to a PRN/as needed when a youth refused the original prescribed medication. However, there was no documentation on the MAR s to provide evidence that the youth refused the medication and/or for what reason. There was no new MAR indicating that the original prescribed medication would now be considered a PRN medication either. It was difficult to validate the program s practice for administration of medication because of alterations made to the MAR s after the initial review of the MAR s was conducted. 4.07: Medication Control Minimal (5) The program was unable to provide a consistent practice of weekly inventory of sharps or to show a perpetual inventory whenever sharps were used as required by the Florida Department of Juvenile Justice Health Services Manual on page 11-13(A)(D). Further review showed that the medical professionals at ASAP did not follow their own policy and procedures regarding weekly inventories of sharps. 4.08: Infection Control Exceptional (10) The program s infection control plan and training materials were developed by a medical professional who is a member of the Association of Professionals in Exposure Control (APIC). The plan contains all key required infectious diseases and has identified diseases that extend well beyond those identified in the Department of Juvenile Justice Health Services Manual. The program completes a monthly infection report that identifies the youth, location of the infection, the type of infection, any antibiotic treatment initiated, and the treatment end date along with whether or not a culture was required. The program monitor s the infection rates of Okaloosa County through My Florida. Com and compares the infection rates of the program to that of the county and state. All employees are offered the influenza Vaccination free of charge. Office of Program Accountability Page 14 of 17
4.09: Chronic Illness Treatment Commendable (8) 4.10: Episodic and Emergency Care Commendable (8) 4.11: Consent and Notification Commendable (8) 4.12: Prenatal/Neonatal Care Non-Applicable (NA) The program s policy and procedure confirm that the requirements for this indicator are non-applicable for this program. Standard 5: Safety and Security Failed Minimal Acceptable Commendable Exceptional Overview Ft. Walton ASAP is a hardware security facility, co-located with another Gulf Coast Youth Services program. The Assistant Program Director is responsible for the oversight of safety and security provided at the program (tool management, and flammable, poisonous and toxic items) and supervision of the direct care staff and supervisors. There is a system to identify and prevent contraband from entering the facility. Youth receive a reward if they find contraband. Youth rooms are searched on a random basis and also anytime contraband is suspected. Youth are also searched during every movement, entering/leaving vocational areas, before and after recreation activities, and following home visits or visitation. The program has a system to document the use and control of tools, and all staff are trained in tool usage and safety. Observation of the tools in the facility found that they were kept in a secure area and marked for identification to facilitate the control and location of the tools. The tools are counted at the end of vocational training classes. The program s behavior management system titled, Adolescent Behavioral/Development Incentive Program (ABDIP) is understood by all program staff and youth interviewed. Eight (8) behaviors form the basis of the ABDIP behavior management system. These include; cleanliness, time management, attitude, interactive behavior, respect, communication, social skills and acceptance. Daily points are earned and level advancement are awarded based on Office of Program Accountability Page 15 of 17
earning a specific number of points. Each of the eight behaviors are rated each day with either a zero (0), one (1), two (2) or three (3). The youth does not have to complete all of the levels to successfully complete the program. This type of Behavior Management System is usually identified as a Token Economy with the use of positive reinforcement in the form of points and levels to shape the youth s behavior towards the target behavior. 5.01: Supervision of Youth Acceptable (7) While youth are in their individual rooms, staff are assigned to constantly walk the hallway. The documentation provided does not indicate that individual youth were observed, only the time the mod was checked. The form did not have any youth s name on it or room numbers to indicate that a specific youth was checked. In addition, with the observed staff constantly walking the floor, it cannot be substantiated that the program staff walking the floor was signing the provided form in real time. 5.02: Key Control Acceptable (7) Observation by the review team during the morning found that the Assistant Program Director kept his personal keys when entering the building. An interview with the Assistant Program Director indicated that the keys were locked in his desk. 5.03: Contraband and Searches Commendable (8) 5.04: Transportation Commendable (8) 5.05: Tool Management Exceptional (10) All Class A and B tools were labeled and identified by a number on a shadow-board either on the wall or in the locked tool tower in shadow-board style. All tools on the hanging shadow board are identified by a hook number and any hook that had multiple tools such as wrenches also had a tab that identified the number of wrenches on the hook. Each drawer in the program s tool box contained styro-form cut outs of the actual tool to ensure returned tool is placed in the appropriate location. In addition, the tool box contained a photograph of each drawer and the contents of that drawer. 5.06: Disaster and Continuity of Operations Planning Exceptional (10) There is documented monthly Continuity of Operations Plan (COOP).drills on a variety of events listed in the COOP plan. These drills are conducted on various shifts to ensure Office of Program Accountability Page 16 of 17
awareness by all program staff. The drills included analysis/critique, description and a checklist of time lines that outlines the course of action for the program. There is an agreement with a food service vendor to provide a refrigerated trailer in the event of a major power outage or emergency to ensure an adequate supply of food. The program has access to a satellite telephone to ensure that all of the provider s programs have a constant line of communication in the event of an emergency. The program has obtained a new contract to continue to provide service for these satellite telephones. 5.07: Flammable, Poisonous, and Toxic Items Exceptional (10) Material Safety Data Sheets (MSDS) books are present at all storage sites. The MSDS books are specific to the chemicals located in that storage area, thereby facilitating expedient location of specific items in the case of an emergency. Each MSDS sheet has an accompanying photograph of the chemical in question to further assist program staff in identifying accurate and correct information in an emergency. 5.08: Water Safety Non-Applicable (NA) The program s policy and procedure confirm that the requirements for this indicator are non-applicable for this program. 5.09: Behavior Management System Commendable (8) 5.10: Behavior Management Unit Non-Applicable (NA) The program s policy and procedure confirm that the requirements for this indicator are non-applicable for this program. 5.11: Controlled Observation Commendable (8) Overall Program Performance Commendable 80% Failed Minimal Acceptable Commendable Exceptional Office of Program Accountability Page 17 of 17