BUREAU OF MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR

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 Juvenile Diversion Alternative Program (JDAP)- Circuit 14 DISC Village, Inc. (Contract Provider) 910 Harrison Avenue Panama City, Florida 32401 Review Date(s): September 29-30, 2015 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES

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: Kathy Parrish, Office of Program Accountability, Lead Reviewer (Standard 1) Warren Garrison, Office of Program Accountability, Regional Monitor (Standard 2)

Program Name: JDAP Circuit 14 QI Program Code: 1324 Provider Name: Disc Village, Inc Contract Number: 10064 Location: Bay County / Circuit 14 Number of Beds: 40 Review Date(s): September 29-30, 2015 Lead Reviewer Code: 129 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 and (2) Assessment Services, which are included in the Juvenile Diversion Alternative Programs Standards. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee # Case Managers # Clinical Staff # Food Service Personnel # Healthcare Staff Documents Reviewed # Maintenance Personnel # Program Supervisors # Other (listed by title): Accreditation Reports Affidavit of Good Moral Character CCC Reports Confinement Reports Continuity of Operation Plan Contract Monitoring Reports Contract Scope of Services Egress Plans Escape Notification/Logs Exposure Control Plan Fire Drill Log Fire Inspection Report Fire Prevention Plan Grievance Process/Records Key Control Log Logbooks Medical and Mental Health Alerts PAR Reports Precautionary Observation Logs Program Schedules Sick Call Logs Supplemental Contracts Table of Organization Telephone Logs Surveys Vehicle Inspection Reports Visitation Logs Youth Handbook # Health Records # MH/SA Records 3 # Personnel Records 3 # Training Records/CORE 5 # Youth Records (Closed) 5 # Youth Records (Open) # Other: # Youth # 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 12 (Revised July 2015)

Standard 1: Management Accountability JDAP Rating Profile Indicator Ratings Standard 1 - Management Accountability 1.01 * Initial Background Screening 1.02 Five-Year Rescreening 1.03 Protective Action Response (PAR) Non-Applicable 1.04 Pre-Service/Certification Training 1.05 In-Service Training 1.06 * Incident Reporting (CCC) Non-Applicable 1.07 * Abuse-Free Environment * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 4 of 12 (Revised July 2015)

Standard 2: Assessment Services JDAP Rating Profile Indicator Ratings Standard 2 - Assessment Services 2.01 Youth Eligibility 2.02 Case Assignment, Initial Contact, and Positive Achievement Change Tool (PACT) Full Assessment 2.03 Individual Service Plan 2.04 *Referrals for Mental Health and Substance Abuse Assessment and Treatment Services 2.05 Individual Service Plan Implementation/Supervision 2.06 PACT Final Assessment 2.07 Release * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 5 of 12 (Revised July 2015)

Strengths and Innovative Approaches Circuit fourteen offers an Educational Group Session to youth each month. Sessions take place in Bay and Jackson Counties. Juvenile Diversion Alternative Program utilizes a default email address for all referrals; the email is monitored to ensure referrals are processed in a timely manner. DISC Village s Juvenile Diversion Alternative Programs have converted to QUEST, a database system which tracks referrals, service plans, outcomes, and generates end of month invoices. Filling the Clinical Clinician s role has created a consistent opportunity for staffing high risk and unusual circumstances. The clinician provides supervision in all three circuits where DISC offers Juvenile Diversion Alternative Program services. Office of Program Accountability Page 6 of 12 (Revised July 2015)

Standard 1: Management Accountability Overview The contracts with Bay Area Youth Service (BAYS) in Tampa, Florida to provide Juvenile Diversion Alternative Program (JDAP) services based on individual youth and family needs in Circuit fourteen. The Juvenile Diversion Alternative Program has been in existence since February 1, 2014. BAYS subcontracts with Disc Village, Inc. to provide services in Jackson, Bay, Holmes, Washington, Calhoun, and Gulf counties. One of the primary purposes of the program is to minimize youth risk of becoming repeat offenders by becoming crime free through positive interactions. The program services youth ages seventeen and under who are referred by the Department of Juvenile Justice referral process. The program had forty youth and three case managers during the annual compliance review. 1.01 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 currently employs three staff; documentation was provided to show all background screenings were completed prior to their hire dates, as required. Two of the three staff began in 2014. The other staff member began in February 2015. The Annual Affidavit of Compliance with Level 2 Screening Standards was signed February 17, 2015, which is seventeen days later than the required time frame of January 31, 2015. 1.02 Five-Year Rescreening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient employees, volunteers, mentors, and interns with access to youth. Employees and volunteers are rescreened every five years from the initial date of employment. None of the three staff have been employed at the program for five years. The program has been in existence since February 2014. Therefore, these staff were not applicable for five-year rescreening. The program provided documentation, which was reviewed and contained the guidelines and procedures for conducting background rescreening of all staff with increments of five years of employment. 1.03 Protective Action Response (PAR) Non-Applicable The program uses physical intervention techniques in accordance with Florida Administrative Code. Any time staff uses a physical intervention technique, such as countermoves, control techniques, takedowns, or application of mechanical restraints (other than for regular transports), a PAR Incident Report is completed and filed in accordance with the Florida Administrative Code. The program has not had any Protective Action Response (PAR) incidents within the last year; therefore this indicator rates as non-applicable. Office of Program Accountability Page 7 of 12 (Revised July 2015)

1.04 Pre-Service/Certification Training Compliance Contracted non-residential staff are trained in accordance with Florida Administrative Code. Contracted non-residential staff satisfies pre-service/certification requirements specified by Florida Administrative Code within 180 days of hiring. Contracted non-residential staff who have not completed essential skills training, as defined by Florida Administrative Code, do not have any direct contact with youth. Contracted non-residential staff who have not completed pre-service/certification training do not have direct, unsupervised contact with youth. All three staff had the required pre-service certification training. All trainings were completed within 180 days of the hire date. The essential training skills for each staff were completed prior to contact with youth, as required. The program provided documentation of Pre-Service New Hire Training Plan requirements approved and signed by the Department s Office of Staff Development and Training on February 23, 2015. 1.05 In-Service Training Compliance Contracted non-residential staff completes in-service training in accordance with Florida Administrative Code. Contracted non-residential staff must complete twenty-four hours of annual in-service training, beginning the calendar year after the staff has completed pre-service training. Supervisory staff shall complete eight hours of training in the areas listed below, as part of the twenty-four hours of annual in-service training. None of the three staff met the criteria for in-service training due to their hire dates. The program provided documentation of an approved annual training plan outlining trainings to be completed after pre-service training. 1.06 Incident Reporting (CCC) Non-Applicable 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 did not have any Central Communications Center (CCC) incidents within the past year. This indicator is rated as non-applicable. Office of Program Accountability Page 8 of 12 (Revised July 2015)

1.07 Abuse-Free Environment Compliance Any person who knows, or has reasonable cause to suspect, a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or other person responsible for the child's welfare, as defined by Florida Statute, or a child is in need of supervision and care and has no parent, legal custodian, or responsible adult relative immediately known and available to provide supervision and care, reports such knowledge or suspicion to the Florida Abuse Hotline. The program did not have any reports of youth being abused. The program has a procedure in place to report to the Central Communications Center in the event of suspected child abuse. All staff employed at the program are mandated reporters to the Department of Children and Families (DCF) if a youth has been found as being abused by a parent, legal guardian, caregiver, or any person who is responsible for the youth s welfare. Standard 2: Assessment Services Overview The Juvenile Diversion Alternative Program (JDAP) program serves youth age seventeen and under who are referred by the Department who committed misdemeanor offenses with prior adjudication, violent first degree misdemeanor offenses, and first time felony offenses. Once admitted to the program, the staff determines the needs of the youth by using the Positive Achievement Change Tool (PACT), completing a full assessment, and creating an Individual Service Plan. The program addresses mental health and substance abuse issues for youth in need of these services. All youth needs are met utilizing these tools to help the youth successfully complete the program. 2.01 Youth Eligibility Compliance Youth admitted to the program meet the admission criteria defined by the provider s contract: The program shall serve male and female youth aged 17 and under. Admission/Eligibility criteria should include, but not limited to any misdemeanor offender and first-time felony offenders. A review of five files revealed each youth met the admission/eligibility criteria. Each youth was a misdemeanor offender under the age of seventeen. 2.02 Case Assignment, Initial Contact, and Positive Compliance Achievement Change Tool (PACT) Full Assessment The program shall ensure each youth is assigned a case manager and shall conduct a PACT Full Assessment on all youth within ten (10) calendar days of the date the provider receives the youth s complete referral packet. Each of the five youth selected had a Positive Achievement Change Tool (PACT) Full Assessment completed within ten days. A referral packet was also completed within the required time frame to include the following when applicable: police report, notice of referral from state attorney s office, victim/restitution information, comprehensive assessment and additional information regarding the youth s mental health or substance abuse issues if applicable. Three of the five youth selected were applicable to have information regarding Office of Program Accountability Page 9 of 12 (Revised July 2015)

substance abuse issues. In these three instances, documentation included urine analysis results and case notes regarding additional information. The program s intake documentation included signatures of the youth and parent/guardian on the participation agreement. The program s participation agreement outlined the youth and parent/guardian s understanding of the expectations of the program. Each youth placement entered into the Department s Juvenile Justice Information System (JJIS) matched the date of their signatures. Each youth was assigned a case manager within the proper time frame. 2.03 Individual Service Plan Compliance The results of the initial PACT Full Assessment will outline the risks and needs of the child and will assist in case planning. The PACT Risk Report must be viewed to determine if any of the dynamic domains have moderate-high or high risk scores. For youth with no moderate-high or high risk domain scores, case planning should be focused on a sixty-day schedule for program completion. For youth with any moderate-high or high risk domain scores, case planning should be focused on a 90 to 120-day schedule for program completion addressing the specific identified needs. The program has 21 calendar days from program admission to develop the individualized service plan. Five files were reviewed to determine if the PACT Full Assessment completed for each youth outlined the risks and needs of the youth. Each youth was designated low risk to reoffend except for one, who was designated moderate risk to reoffend. In each instance, case planning focused on a sixty-day schedule for program completion. The case manger s notes indicated how the youth and family participated in the creation of the Individual Service Plan. The Individual Service Plan s action steps were clear and included who, what, and how often each goal would be completed. 2.04 Referrals for Mental Health and Substance Abuse Compliance Assessment and Treatment Services The provider shall provide services based on individual youth and family needs. If needs are identified requiring a referral for services outside the program, staff ensure all referrals are made to address criminogenic needs and mental health and substance abuse service needs identified by the PACT. Staff develops a follow-up and monitoring plan for all outside referrals made as a result of program participation. Provide is defined as arranging/referring/brokering or actually providing the service directly to the youth and family. Three of the five files were applicable for mental health or substance abuse services. In each instance, the youth was referred for services and the case manager followed up with each referral within the proper timeframe. Case notes did not include any instances of negative reports. Each mental health and substance abuse service plan focused mental health and substance abuse treatment. Office of Program Accountability Page 10 of 12 (Revised July 2015)

2.05 Individual Service Plan Implementation/Supervision Compliance Youth are supervised in a manner ensuring completion of the Individual Service Plan. Staff documents all case activities, including face-to-face interaction and telephone contact with the youth, parent(s)/guardian(s), and providers, and review of written or verbal reports from collateral sources, such as educational institutions, employers, counselors, electronic databases, etc. Case notes demonstrate compliance (or attempted compliance) with youth, parent/guardian, and staff action steps contained in the Individual Service Plan. Each of the five files selected contained a completed individual service plan. Case notes documented face-to-face meetings and telephone contact between the case manager, youth, parents/guardians, and collateral sources. Each Individual Service Plan contained action steps. Case notes documented the youth s progress for each action step. 2.06 PACT Final Assessment Compliance A PACT Full Assessment shall be completed prior to the request for case closure. The PACT assessment shall document pre- and post-testing. No R-PACT reassessments during the program participation are required. Five closed files were selected to ensure a PACT Full Assessment was completed prior to the request for the a case to be closed Two youth cases were closed unsuccessfully due to the youth s unwillingness to participate. Three of the youth cases were closed successfully. In each instance of a case being closed, a PACT Full Assessment was completed beforehand. The program updated the youth s risk and needs assessment as well. 2.07 Release Compliance The program releases youth upon completion of the program, or otherwise as indicated by the provider s contract. Two of the five files selected were closed unsuccessfully. In each instance, none of the youth remained in the program more than four months.. In each unsuccessful completed file, the program immediately notified the Juvenile Probation Officer and the Office of the State Attorney in writing via email. Office of Program Accountability Page 11 of 12 (Revised July 2015)

Program Name: JDAP Circuit 14 QI Program Code: 1324 Provider Name: DISC Village Contract Number: 10064 Location: Bay County / Circuit 14 Number of Beds: 40 Review Date(s): September 29-30, 2015 Lead Reviewer Code: 129 Overall Rating Summary Overall Rating Summary All indicators have been rated and no corrective action is needed at this time. Office of Program Accountability Page 12 of 12 (Revised July 2015)