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 Redirections Services - Circuits 11 and 16 Chrysalis Health Services, Inc. (Contract Provider) 1868 Northeast 164 th Street Miami, Florida 33162 Review Date(s): May 24-26, 2016 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: Gary L. Mogan, Office of Program Accountability, Lead Reviewer (Standards 1 & 2) Keith Bennis, Office of Program Accountability, Regional Monitor (Standards 3 & 4)

Program Name: Redirection Services - Circuits 11 & 16 MQI Program Code: 1343 Program Name: Chrysalis Health Services, Inc. Contract Number: 10157 Location: Miami Dade County / Circuit 11 Number of Beds: 12 Review Date(s): May 24-26, 2016 Lead Reviewer Code: 149 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 Services, and (3) Intervention Services, which are included in the Probation and Community Intervention Standards. Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee # Case Managers 2 # Clinical Staff # Food Service Personnel # Healthcare Staff Documents Reviewed # Maintenance Personnel # Program Supervisors 1 # Other (listed by title): HR 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 3 # Youth Records (Closed) 3 # Youth Records (Open) # Other: n/a # Youth n/a # Direct Care Staff n/a # 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 20 (Effective July 2015)

Standard 1: Management and Accountability Redirection Services Rating Profile Indicator Ratings Standard 1 - Management Accountability 1.01 Initial Background Screening* 1.02 Five-Year Rescreening 1.03 Pre-Service and/or In-Service Training 1.04 Incident Reporting (CCC)* Non-Applicable 1.05 Administration 1.06 JJIS and Data Requirements 1.07 Mental Health Services Staffing Requirements/Qualifications 1.08 Substance Abuse Services Staffing Requirements/Qualifications * 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 20 (Effective July 2015)

Standard 2: Assessment Services Redirection Services Rating Profile Indicator Ratings 2.01 Standard 2 - Assessment Services Referral Process 2.02 Admission and Services Provision Processes 2.03 Intake Conference and Orientation 2.04 Clinical Assessments 2.05 Clinical Assessment Qualifications* 2.06 Abuce Reporting (DCF)* * 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 20 (Effective July 2015)

Standard 3: Intervention Services Redirection Services Rating Profile Indicator Ratings Standard 3 - Intervention Services 3.01 Individualized Plan of Care 3.02 Practitioner Qualifications 3.03 Individualized Plan of Care Development and Approval Process 3.04 Redirection Therapy Services 3.05 Mental Health and/or Substance Abuse Treatment Planning 3.06 Mental Health and/or Substance Abuse Sevices 3.07 Release/Discharge * 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 20 (Effective July 2015)

Standard 4: Fidelity Monitoring Redirection Services Rating Profile Indicator Ratings Standard 4 - Fidelity Monitoring 4.01 Treatment Manual/Protocol 4.02 Facilitator Training 4.03 Internal Fidelity Monitoring* 4.04 Corrective Action Based on Fidelity Monitoring 4.05 Evaluation of Facilitator Skill in Delivering the Intervention * 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 20 (Effective July 2015)

Strengths and Innovative Approaches The program offers individual and family therapy within the homes of the youth and families referred by the Department. Office of Program Accountability Page 8 of 20 (Effective July 2015)

Standard 1: Management Accountability Overview Chrysalis Health Services, Inc (Chrysalis) and the Department of Juvenile Justice (DJJ) have collaborated to provide redirection services in Circuits 11 and 16 under contract #10157. The program has a capacity of up to twelve youth and is designed to provide evidenced-based therapeutic intervention for youth on probation, conditional release, and/or post commitment probation, along with their family members. The program is also designed to provide services to youth on non-secure minimum-risk commitment status attending a day treatment program. Chrysalis utilizes cognitive behavioral therapy (CBT) as the treatment modality. The services are provided in-home, offering individual and family therapy for an average length of stay from fifteen to eighteen weeks. The program s organizational chart consists of a regional director, a program director, and a therapist working under the supervision of a licensed mental health therapist. 1.01 Initial Background Screening Compliance Background screening is conducted for all Department employees, contracted program 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. A review of three staff files associated with the program found each staff had been cleared by the Departments Background Screening Unit (BSU) prior to working with Department youth. The program does not utilize volunteers, mentors and/or guest speakers. The Annual Affidavit of Compliance with Level 2 Screening Standards was submitted to the Department on January 8, 2016, meeting the annual requirement. 1.02 Five-Year Rescreening Compliance Background screening is conducted for all Department employees, contracted program 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. At the time of the annual compliance review there were no staff eligible for the five year rescreening process. The program has a process in place whereby staff hire dates are recorded into an internal database and reviewed annually to ensure staff receive background rescreening within the required timeframes. Office of Program Accountability Page 9 of 20 (Effective July 2015)

1.03 Pre-Service and/or In-Service Training Compliance All applicable Redirections staff successfully complete training requirements as set forth below. The following training shall be completed prior to the delivery of direct services to Department youth and/or as in-service training to Redirections staff: Juvenile Justice Information System (JJIS) - Pre-Service Information Safety Awareness - Pre and In-Service Motivational Interviewing (MI) - Pre-Service Critical Incident Reporting Requirements - Pre-Service Trauma Informed Care - Pre-Service Adolescent Behavior - Pre-Service There were three applicable staff files reviewed for pre-service training requirements. Supporting documentation reflected each staff completed the required pre-service training within ninety-days of their initial start date. Two staff who had completed the Department s Juvenile Justice Information System (JJIS) training, while the third staff does not have permissions to access this database since the job duties will not include them to perform data entry or access to the JJIS system. According to the program s orientation and first year training plan requirements, in-service training requirements amount to a total of seventy-two hours for the first year of employment. The program annual training plan requirements reflected a total of twenty-four hours are required for staff to complete after their first year of employment. 1.04 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. There have not been any reports to the Department s Central Communications Center (CCC) during this review period; therefore, this indicator rates as non-applicable. 1.05 Administration Compliance The Redirections program provides a safe and appropriate treatment environment including administrative and operational oversight. Reviewed supporting documentation reflected the program was maintaining statistical data on youth monthly progress reports, discharge summary reports, monthly services summary reports, admissions, youth census reports, and staff vacancy reports. In a review of three closed files, the youth s admission and termination dates were compared with the Department s Juvenile Justice Information System (JJIS) database for accuracy. It was noted the dates of admission and dates of termination were consistent with the dates recorded in JJIS. 1.06 JJIS and Data Requirements Compliance The Redirections program and subcontracted service programs shall utilize the Department s Juvenile Justice Information System (JJIS) for data entry and shall monitor accuracy at all times. Three closed clinical youth records were reviewed and each contained supporting documentation the program had accepted the referral from the Department within the forty-eight Office of Program Accountability Page 10 of 20 (Effective July 2015)

hour requirement. The records further reflected all three youth s placement had been recorded in the Departments Juvenile Justice Information System (JJIS) database. The reviewed records reflected the youth had been released from the program within twenty-four hours of discharge from the program. The program had maintained an excel spreadsheet capturing all details on the admission, placement, release dates, coupled with the justification of the release. 1.07 Mental Health Services Staffing Requirements and Compliance Qualifications All Redirections staff providing mental health services shall meet the requirements identified in the guidelines and have completed the prerequisite training to provide such services according to Florida law. There were three applicable staff records reviewed for educational transcripts and qualifications. All three staff were master s-level or higher. One staff had advanced to a licensed clinical social worker and a second progressed to a licensed mental health counselor. Reviewed documentation reflected each staff had a minimum of two years of direct experience working with youth prior to their hire date. The licensed clinical social worker provided oversight on a weekly basis for the non-licensed master s-level mental health staff. The staff records reflected they had participated in trainings for crisis intervention, behavior management, basic counseling, program philosophy, and client rights. 1.08 Substance Abuse Services Staffing Requirements and Compliance Qualifications All Redirections staff providing substance abuse services must be fully licensed or have completed the prerequisite training as required by Florida law. There were two licensed clinical staff qualified to provide substance abuse services and one master s-level non-licensed therapist working under the direct weekly supervision of a licensed staff qualified to provide substance services. The program is licensed through the Department of Children and Families (DCF) to provide outpatient substance abuse services. Office of Program Accountability Page 11 of 20 (Effective July 2015)

Standard 2: Assessment Services Overview Youth are referred to the Redirection program by the Department. Each youth accepted into the program has an initial face-to-face interview on the day the youth is admitted. Staff go over an orientation with the youth and parent/guardian, which is conducted at the intake conference. A clinical assessment is conducted on each youth enrolled. The program evaluates each youth with a bio-psychosocial evaluation, which is reviewed by the program director who is a licensed clinical social worker. The program has a code of conduct prohibiting the use of physical force, profanity, and/or intimidation. There have been no allegations of staff abusing youth during this review period. There have been no referrals for Circuit 16 over the last twelve months. 2.01 Referral Process Compliance The Redirection program shall accept or reject all service referrals via the Juvenile Justice Information System (JJIS) within two (2) business days of referral from the Department of Juvenile Justice (DJJ). Three youth clinical records were reviewed for the referral process. For each of the records, it was verified with the program director the referrals were accepted or rejected within forty-eight hours. The program director maintains a spreadsheet in order to track when referrals are received from the Department and when the referral is accepted or rejected by the program. Each of the youth records indicated the program contacted the juvenile probation officer (JPO) to review the referral. The program director confirmed there have not been any rejected referrals for Circuit 11 or Circuit 16 during this review period. An interview with the program director confirmed she was able to explain in detail the rejected referral process. 2.02 Admission and Services Provision Processes Compliance Each youth is assessed within 17 calendar days of referral from the Department of Juvenile Justice (DJJ) and placed in the Juvenile Justice Information System (JJIS). Reviewed documentation from three youth records validated the program conducts an initial face-to-face interview with the youth and parent/guardian on the date of each youth s admission. Each reviewed record confirmed the youth were assessed within seventeen calendar days of receiving the referral from the Department. This information was reflective in the Department s Juvenile Justice Information System (JJIS) as well. The youth and parent/guardian sign an agreement to participate in family-centered therapy to receive training, treatment, and support assisting the family in overcoming obstacles, which may contribute to further delinquency. Each reviewed record contained documentation of emails between treatment staff and the youth s assigned juvenile probation officer (JPO) discussing barriers to interventions and alternatives. The therapist maintained contact with the JPO in each of the reviewed records. Office of Program Accountability Page 12 of 20 (Effective July 2015)

2.03 Intake Conference and Orientation Compliance Upon acceptance and intake of the youth for services, the Redirections program/practitioner shall ensure youth and his/her parents receive a face-to-face orientation by the date of first clinical session by the program/practitioner. Upon acceptance and intake of the youth for services, the program ensures youth and their parent/guardians receive a face-to-face orientation no later than the date of the first session. Three youth records were reviewed for intake conferences and orientation. Each youth had a face-to-face intake conference with their parent/guardian and orientation was conducted the same day as the intake conference. Consent forms were signed by all required parties prior to the delivery of services and were maintained in each youth s record. Receipt of orientation information is documented on an orientation verification form signed by all parties to acknowledge all applicable information was provided to the youth and parent/guardian. Each youth and parent/guardian were given a program handbook detailing the program description, client rights, emergency and first aid procedures, emergency contact information, incident reporting procedures, and the grievance process. 2.04 Clinical Assessments Compliance Each youth must receive a Clinical Assessment of his or her emotional and behavioral functioning through structured clinical interview of the youth and parent, guardian, or caregiver and administration of appropriate standardized assessment instruments, such as symptom checklists and behavioral rating scales, when clinically indicated. The program ensures each youth receives a clinical assessment of his/her emotional and behavioral functioning through a structured interview with the youth and parent/guardian or caregiver. Three youth records were reviewed for clinical assessments. Reviewed documentation validated treatment staff completed a bio-psychosocial evaluation for each youth upon admission. The assessment documented identifying information, presenting problems, past and current behavioral health services, past exposure to any abuse, legal involvement, academic history, general health, medications, a mental status examination, and a summary of findings. Mental health and substance abuse diagnoses were documented on each reviewed assessment. 2.05 Clinical Assessment Qualifications Compliance Clinical Assessments must be conducted by a licensed practitioner or non-licensed clinician working under the direct supervision of the licensed practitioner. Clinical assessments must be conducted by a licensed therapist or non-licensed therapist working under the direct supervision of the licensed therapist. Three youth records were reviewed for clinical assessments. A bio-psychosocial evaluation was completed for each youth. The assessments contained detailed information on mental health and substance abuse issues. The assessments were completed by non-licensed treatment staff. The program director, a licensed clinical social worker, reviewed each assessment within the required timeframe. Office of Program Accountability Page 13 of 20 (Effective July 2015)

2.06 Abuse Reporting (DCF) 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 has written policies and procedures for abuse reporting. The program had postings for the Florida Abuse Hotline throughout the office. The program provides an environment in which youth, staff, and others feel safe and not threatened by any form of abuse. Three personnel records were reviewed for code of conduct information. Reviewed documentation reflected each staff signed acknowledgements of receiving information on the abuse and neglect policy and a corporal and degrading punishment policy. Three youth records were reviewed and there were no indications of abuse not reported to the Florida Abuse Hotline. An interview with the director of projects, as well as the program director, confirmed there were no allegations of abuse made against staff during this review period. Office of Program Accountability Page 14 of 20 (Effective July 2015)

Standard 3: Intervention Services Overview The program has an active Chapter 397 license effective January 24, 2016 and expiring January 22, 2017. The program has one master s-level non-licensed clinical professional who evaluates each youth via a bio-psychosocial evaluation upon the youth s admission to the program. These assessments are completed under the supervision of the program director, who is a licensed clinical social worker. Under the supervision of the program director, the program s non-licensed mental health therapist develops the master treatment plan with the youth and parent/guardian. The program provides mental health and substance abuse services to the youth and families in accordance with each individualized treatment plan. Services include weekly individual and family therapy sessions with the youth and parent/guardian. 3.01 Individualized Plan of Care Compliance The program shall develop an individualized treatment plan based on the Clinical Assessment. Reviewed documentation validated the program develops each youth s individualized treatment plans based on their clinical assessments. A review of three youth records confirmed an individualized treatment plan was developed for each youth. For each plan, a non-licensed mental health therapist in consultation with the youth, parent/guardian, and treatment care professionals completed each of the individual treatment plans. The treatment plans identified the youth s mental and physical health support needs, preferences, strengths, and desired outcomes. Reviewed documentation supported the youth and parent/guardian were provided opportunities to participate in the planning and development of the individualized goals and objectives of the treatment plan. 3.02 Practitioner Qualifications Compliance Treatment plans shall be developed and therapies provided by one of the following qualified practitioners: Physician; Psychiatrist; Psychiatric physician assistant; Psychiatric advanced registered nurse practitioner; Licensed Practitioner of the healing arts (LPHA); Master s level practitioner; or Bachelor s level practitioner. A review of staff personnel records supported each clinician has a master s-level education degree and had at least two years of direct experience working with emotionally disturbed children with criminogenic factors. The program has one non-licensed mental health therapist who develops the master treatment plans with the youth and parent/guardian under the supervision of a licensed clinical social worker. The non-licensed therapist provides mental health and substance abuse services to each youth and parent/guardian. A review of direct supervision logs supported the non-licensed therapist receives weekly supervision by the program director, who is a licensed clinical social worker. Office of Program Accountability Page 15 of 20 (Effective July 2015)

3.03 Redirection Therapy Services Compliance The program shall provide the following for Redirections youth: Individual therapy services Family therapy services Group therapy services A combination of therapy services, aside from Redirection 24 hour crisis therapeutic support services, must be provided weekly unless youth and family are unavailable. A review of three youth clinical records revealed the program provided weekly services to each youth in the program including individual and family therapy, unless the youth and family were unavailable. The services offered by the program are based on the cognitive behavioral therapy (CBT) modality, which does not require group therapy. The program also provides twenty-fourhour crisis therapeutic support services to the youth and the families. 3.04 Mental Health and/or Substance Abuse Treatment Compliance Planning If the services to be provided are mental health and/or substance abuse treatment (individual, group or family counseling or other therapy service) the service program and/or subcontracted service program shall develop an individualized treatment plan for each youth receiving mental health and/or substance abuse services. A review of three youth clinical records found the program developed an individualized treatment plan within the required timeframe and provided individual and family counseling with the youth and parent/guardian. The reviewed plans contained all the required elements and were based on each youth s bio-psychosocial evaluation. Each plan was created in consultation with the youth, family members, and other collateral contacts including applicable treating and consulting professionals. Goals from each youth s individualized treatment plan were reviewed regularly for their current status and compliance. Reviewed documentation reflected each plan was reviewed, signed, dated, and distributed to the required parties. 3.05 Mental Health and/or Substance Abuse Treatment Compliance Services The program shall ensure youth have access to necessary and appropriate mental health and substance abuse services (on or off-site) performed by qualified mental health and substance abuse professionals or service program(s). The program s practice is to conduct a bio-psychosocial evaluation with the youth and parent/guardian upon each youth s admission to determine if there are any immediate mental health or substance abuse needs. A review of three youth records reflected each youth was assessed upon enrolling and each youth record contained an individual treatment plan covering specific mental health and/or substance abuse goals and objectives identified in the youth s clinical assessment. A review of each plan s goals found they were written in achievable and measurable terms. Each of the three youth had their treatment plans developed within the required timeframe and prior to the initiation of treatment. The program provides suicide prevention, crisis intervention assessments, and emergency management services as needed. Probation and Community Intervention Quality Improvement Report Office of Program Accountability Page 16 of 20 (Effective July 1, 2015)

3.06 Release/Discharge Compliance Prior to release or discharge of a youth from services (prior to completion of the intervention) the Redirection Service program must coordinate discharge planning with the youth s Redirection Program Operations staff, via phone call and e-mail. A review of three closed youth records was completed. For each of the three closed records, a copy of the youth s discharge summary was uploaded into the Department s Juvenile Justice Information System (JJIS). Reviewed documentation and an interview with the program director validated prior to each youth s discharge, the program coordinates the discharge planning with the youth s assigned juvenile probation officer (JPO) via email or telephone communication. Program staff notified the JPO of the discharge summary being uploaded into JJIS for their review. Each youth s release date was accurately entered in the JJIS. The program completes a discharge report and an individualized formal aftercare and sustainability plan for each youth upon discharge. Each of the reviewed discharge summaries were signed and dated by program staff as required; however, the youth and parent/guardian did not make themselves available to sign. Office of Program Accountability Page 17 of 20 (Effective July 2015)

Standard 4: Fidelity Monitoring Overview The program provides cognitive behavioral therapy (CBT), which is an evidenced based intervention. The program s staff have all been trained in the delivery of the specific CBT modality used during individual and family sessions. The program director is responsible for observing staff and conducting fidelity monitoring on the actual service delivery. This information is then recorded on a Cognitive Therapy Rating Scale (CTRS). The treatment services are further discussed in a weekly clinical supervision meeting between the program director and therapist. This information is compiled and forwarded to the Department s contract manager on a quarterly basis by the program s corporate staff. Staff evaluations occur monthly during the staff s probationary period and on an annual basis thereafter. 4.01 Treatment Manual/Protocol Compliance There is a specific written manual or protocol for the treatment service(s). The facilitators of that service(s) adhere to the written manual or protocol. The program offers one evidenced based service to youth referred from the Department. The program has developed a comprehensive cognitive behavioral therapy (CBT) manual outlining the protocol for individual and family treatment services. The manual includes topics on understanding mental illness, the behavioral approach for delinquent youth, therapist preparation, treatment services and sessions, and the knowledge and skills required for the CBT model. 4.02 Facilitator Training Compliance All facilitators of the service(s) must have received formal training specific to the intervention or model/protocol by a qualified trainer in each specific service(s). The program has two staff members who have been trained to provide cognitive behavioral therapy (CBT) training to staff. In a review of training files, the regional director and the program director have received training in the CBT curriculum making them eligible to train other staff in this model. 4.03 Internal Fidelity Monitoring Compliance The Redirection program has an internal process to monitor the delivery of the evidence-based practice, promising practice or alternative family centered therapy to examine how closely actual implementation matches the model protocol. The program has established an internal monitoring process to summarize the delivery of the evidenced based practice they provide to Department youth. The program only uses cognitive behavioral therapy (CBT). In the review of supporting records, the program director has been reviewing each case weekly with the therapist, whereby exceeding the expectation established by the Department. During the case review, the program director listened to a voice recording of the session and then discussed the therapist s approach in a face-to-face meeting. A rating system has been established on their Therapy Rating Scale (TRS) form, designed to measure Office of Program Accountability Page 18 of 20 (Effective July 2015)

the therapist proficiency and ability to effectively deliver the service model. In addition, the fidelity monitoring by the supervisor provides helpful information regarding the youth s progress. In a review of all training files, it was verified each staff had been trained and was qualified to deliver the treatment service. 4.04 Corrective Action Based on Fidelity Monitoring Compliance The Redirection program has a process by which corrective action is applied and demonstrated based on the fidelity monitoring of the delivery of the evidence-based practice, promising practice or alternative family centered therapy. The program has developed a process through human resources (HR) to address issues related to the fidelity monitoring outcome. A review of staff personnel files reflected one staff therapist had received counseling/disciplinary action and was placed on a performance improvement plan (PIP) for not adhering to the CBT model, which required a specific frequency for the therapist to meet with the youth and family. The PIP outlined specific goals for the staff to achieve and contained signatures from the staff, program director, and the HR officer. The goals and other related topics were discussed on a weekly basis with the staff and the staff s supervisor. Near the end of the PIP, as a follow-up, the supervisor provided documentation where she had called each youth and parent/guardian to ensure the therapist was reaching his established goals on the PIP. 4.05 Evaluation of Facilitator Skill in Delivering the Compliance Intervention Performance evaluations of the facilitators of the specific intervention/service include the evaluation of skill in delivering the interventions/services. The program has established a system for staff performance evaluations. They provide a monthly performance evaluation for a probationary period, and an annual performance evaluation thereafter. The performance prospects are measured numerically addressing eleven separate areas of performance projections. Staff are given a numerical score in each of the performance expectations measuring the staff s skills and abilities in the manner they deliver services. Reviewed documentation confirmed the therapists received an annual performance evaluation encompassing the staff s skills and abilities in delivering cognitive behavioral therapy services. Office of Program Accountability Page 19 of 20 (Effective July 2015)

Program Name: Redirection Services - Circuits 11 & 16 MQI Program Code: 1345 Program Name: Chrysalis Health Services, Inc. Contract Number: 10157 Location: Miami Dade County / Circuit 11 Number of Beds: 12 Review Date(s): May 24-26, 2016 Lead Reviewer Code: 149 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 20 of 20 (Effective July 2015)