BUREAU OF QUALITY IMPROVEMENT

Florida Department of Juvenile Justice Residential Quality Improvement Report Office of Program Accountability of 27

S TA TE O F FL OR I D A D E P AR TM E N T O F JU V ENI LE JU S T I C E

BUREAU OF QUALITY IMPROVEMENT PROGRAM REPORT FOR

Adolescent Residential Campus Center for Drug-Free Living, Inc.

(Contract Provider) 5970 S. Orange Blossom Trail

Intercession City, Florida 33848

Review Date(s): January 31 - February 2, 2012

PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY

IN JUVENILE JUSTICE PROGRAMS AND SERVICES

W A N SL E Y W AL TE R S , S EC R E TAR Y

J E N N I F ER RE CHI C HI , B U RE AU C H I E F

Florida Department of Juvenile Justice Residential Quality Improvement Report Office of Program Accountability of 27 (Revised January, 2012)

Residential Rating Profile

Program Name: Adolescent Residential Campus QA Program Code: 1147

Provider Name: Center for Drug-Free Living, Inc. Contract Number: R2105

Location: Osceola County / Circuit 9 Number of Beds: 94

Review Date(s): January 31 - February 2, 2012 Lead Reviewer Code: 77

1.01 Satisfactory 3.05 Limited

1.02 Satisfactory 3.06 Satisfactory



1.05 Satisfactory 75%



1.08 Satisfactory

1.09 Satisfactory




100% 12 4.04 Satisfactory



12 4.07 Satisfactory

4.08 Satisfactory




2.04 Satisfactory 4.12 Non-Applicable




2.08 Satisfactory

2.09 Satisfactory








13 5.08 Non-Applicable

5.09 Satisfactory




3.04 Limited 3 0%

1 0%

0

96%

4%

0%* Percentages have been rounded to the nearest whole number. Percentages may not total 100% due to rounding.

MH and SA Assessment/Evaluation

Overall Rating Summary

Sick Call

Medication Administration

Controlled Observation

% Indicators Rated Failed Compliance:


3. Mental Health and Substance Abuse Services

5. Safety and Security

Pre-Service/Certification Requirements

Sexually Transmitted Diseases

% Indicators Rated Limited Compliance:




Designated Health Authority

Comprehensive Physical Assessment

% Indicators Rated Satisfactory Compliance:

Contraband and Searches

Supervision of Youth

Treatment Plan/Team/Service Delivery

3. Mental Health and Substance Abuse Services (cont.)

Provision of an Abuse Free Environment

In-Service Training Requirements

Logbook Maintenance


2. Intervention and Case Management

Internal Alert System



Healthcare Admission Screening

Prenatal/Neonatal Care

Mental Health Crisis Intervention

Emergency Services

Indicator Ratings

1. Management Accountability

Incident Reporting

Assessment

Protective Action Response (PAR)

Background Screening of Employees/Vol.




4. Health Services

Specialized Treatment Services



Suicide Prevention

Delinquency Programming

Staff Characteristics

Gang Prevention and Intervention

Transportation

Flammable, Poisonous, and Toxic Items

Key Control

Performance Review and Reporting

Performance Plan

Intervention and Treatment Team

(continued above)

Escapes

Youth Records

Community Partnerships

Facility Integration and Stability

Vocational Programming

Gender-Specific Programming

Chronic Illness Treatment

Infection Control

Medication Control

Behavior Management System

Water Safety

Disaster/Continuity of Operations Plan

Tool Management

Consent and Notification

Episodic and Emergency Care

Behavior Management Unit

Satisfactory Compliance:

Limited Compliance:

Failed Compliance:

Classification

Designated Mental Health Authority

MH and SA Admission Screening

Grievance Process

Transition Planning and Release

Parent/Guardian Communication


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

3 # Case Managers 2 # Clinical Staff

1 # Food Service Personnel 3 # Healthcare Staff 1 # Maintenance Personnel 3 # Program Supervisors 7 # Other (listed by title): Chief Operating Officer, Quality

Manager, Unit Manager, Finance and Operations Director, Intake Coordinator, Training Coordinator, Vice President of Human Resources

Documents Reviewed

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

Vehicle Inspection Reports Visitation Logs Youth Handbook

9 # Health Records 9 # MH/SA Records 9 # Personnel Records 9 # Training Records/CORE 3 # Youth Records (Closed) 9 # Youth Records (Open) 25 # Other: Background screening reports for new-hires and five-year rescreenings

Surveys

9 # Youth 8 # 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

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

Comments

Items not marked were either not applicable or not available for review.


Rating Definitions Ratings were assigned to each indicator by the review team using the following definitions:

Satisfactory

Compliance

No exceptions to the requirements of the indicator; limited, unintentional, and/or non-systemic exceptions that do not result in reduced or substandard service delivery; or exceptions with corrective action already applied and demonstrated.

Limited

Compliance

Exceptions to the requirements of the indicator that result in the interruption of service delivery, and typically require oversight by management to address the issues systemically.

Failed

Compliance

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 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: Paul Czigan, Lead Reviewer, DJJ Bureau of Quality Improvement Nawal Aboul-Hosn, Clinical Director, Avon Park Youth Academy, G4S Donna Connors, Program Administrator, DJJ Bureau of Quality Improvement Ashley Davies, Review Specialist, DJJ Bureau of Quality Improvement Caldernett Davis, Program Monitor, Residential Services, Central Region Pamela Graves, Review Specialist, DJJ Bureau of Quality Improvement Irma Terry, Assistant Superintendent, Volusia Regional Juvenile Detention Center


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 Improvement website, at http://www.djj.state.fl.us/QI/index.html.

Strengths and Innovative Approaches

In an effort to encourage youth to read independently, the program and the Osceola County School Librarian’s Association sponsored a countywide ‘Battle of the Books’, in which the program placed third in 2011. To keep up the intensity for the 2012 competition, the program established a Book Nic; each student was expected to bring a book for admittance to a picnic and asked to slow down and take the time to read the book while they ate their meal. Forty-four youth participated in the first Book Nic. The program selects youth to participate in ‘Men of Distinction’, which is designed to give young men a sense of self-esteem. It also provides exposure to cuisine from different cultures while teaching the youth proper etiquette. Pictures of the youth involved in the ‘Men of Distinction’, which feature the youth dressed in shirts and ties, are displayed in the administration building for a month. The program hosts career fairs in which community partners such as Job Corps, Devry University, Valencia College, Home Builders Institute and the Armed Forces visit the campus to talk to youth about choosing a career and finding opportunities in a variety of fields. NOAH’s ARC is a restorative justice project in which the program youth visit local elementary, middle and high schools to speak to the students about making good decisions, to caution the students from making some of the poor choices they have made.

Standard 1: Management Accountability

Overview

The Adolescent Residential Campus is operated by the Center for Drug-Free Living, Inc., a not-for-profit contract provider with the Department of Juvenile Justice. The Campus includes a Moderate Risk Halfway House and a Developmental Disability (commonly referred to as Low Functioning) program that serves youth with a borderline developmental disability. Each program has its own director and staff supervised by a corporate administrator. The program capacity is ninety-four youth, with sixty-six slots designated to the Halfway House (HH) and twenty-eight slots designated to the Developmental Disability (DD) program. There were eighty-one youth in the combined programs (fifty-six in the HH and twenty-five in the DD program) at the beginning of the Quality Improvement review. Each of the four cottages has a program manager that supervises direct care staff and program supervisors. The Finance and Operations Director has oversight of administrative, security, maintenance and food service personnel. The Clinical Manager supervises all clinical staff, and the Case Manager Supervisor is in charge of all case management staff.

http://www.djj.state.fl.us/QI/index.html


All staff hired by the program complete a comprehensive orientation training. The training is completed over a three-week period, with one week focusing on corporate training, one week on divisional training and one week of Protective Action Response (PAR) training. All trainings that are required by the Department are covered during these three weeks of training. The program maintains a computer lab in the administration building in which staff can complete training on the Department’s CORE Learning Management System. The provider has a Food Service Manager who oversees the kitchen operations.

1.01: Background Screening of Employees/Volunteers Satisfactory Compliance

The program processed all six five-year re-screenings with the Background Screening Unit (BSU) within the required time frame. All six personnel records contained an eligible status report from the BSU. Three additional staff hire dates appeared to be eligible for five-year re-screenings, but had a break in service and were re-hires since the last Quality Improvement review. Sixteen new staff records contained an eligible background screening from the BSU completed prior to hiring. The program also performs local law enforcement and a Florida Department of Law Enforcement check, driver’s license check, e-verify check, and drug screening prior to making an offer of hire. The program submitted its Annual Affidavit of Compliance with Level 2 Screening requirements to the Department within the required time frame.

1.02: Provision of an Abuse Free Environment Satisfactory Compliance

The program placed posters of the abuse hotline in prominent places around the campus, including in living areas and classrooms. All staff records reviewed documented child abuse reporting as part of the pre-service training element. One of the grievances reviewed included a complaint against staff use of profanity. The document indicated the manager resolved it by addressing staff behavior and the youth indicated satisfaction with the resolution. A review of personnel records did not reveal any disciplinary action taken against staff related to abuse. Nine youth responded to the survey; a majority of the youth reported staff treats them respectfully in conversation. Two youth reported staff used profanity when the youth did not move fast enough. Two additional youth indicated they complained to supervisors about staff profanity, but did not know the action taken by program administration. One youth stated he did not feel safe; a follow-up interview indicated it was because of spiders he had seen. This same youth alleged he wanted to call the Florida Abuse hotline to report an abuse allegation and was denied. He could not remember the circumstance, and did not want to place a call during the Quality Improvement review. He also said a supervisor asked him if he had anything to get off his chest. He felt that management would address the issue if he reported it. The youth sign a form to acknowledge they have been advised of their right to call the Florida Abuse hotline, if necessary. This form was located in all nine records that were reviewed. Eight staff responded to the surveys; all eight reported never hearing another employee use profanity or deny youth an abuse call. A majority reported they would take or refer a youth wanting to call the abuse registry to a supervisor or manager to talk with them and/or make the call.


1.03: Incident Reporting Satisfactory Compliance

Nine incident reports were reviewed that had been submitted within the last six months. All nine reports were called to the Central Communications Center (CCC) within the two-hour time frame. All nine reports were documented in either the Cottage or Master Control log books. All nine incidents were highlighted and clearly visible in the log books.

1.04: Protective Action Response (PAR) Satisfactory Compliance

A review of three Protective Action Response (PAR) incidents, one from September and two from December revealed most requirements were documented within the required time frame. One report did not contain statements from all staff involved in the incident, while another was not placed on the required form. One report was not reviewed or processed within the time frame. Two applicable reports indicated a PAR Medical Review was needed. The staff stated both youth were sent off campus to the emergency room for care. Transportation records and CCC reports were reviewed indicating youth were transported for medical care. However, no documentation was presented from the Individual Health Care Record for review to validate this while the Quality Improvement team was on-site. A review of the report containing the PAR incidents revealed there had been no PAR activity in October and November 2011.

1.05: Pre-Service/Certification Requirements Satisfactory Compliance

A review of four new-hire training records revealed all received the required elements prior to working with youth. All training records documented staff were trained in the use of an Automated External Defibrillator (AED) though there is no requirement for this service or training. The program has two of these devices. The initial training plan exposes the staff to a wide variety of corporate personnel, including the Clinical Director, and Vice-Presidents of Human Resources and Risk Management. The program submitted their training plan and annual training calendar to Staff Development and Training.

1.06: In-Service Training Requirements Satisfactory Compliance

All five records reviewed documented all of the required training within the required time frame. All records contained a current CPR and first aid certification including the AED element. The five staff completed between 78 and146 hours of instruction or CORE competency elements. A review of three management staff revealed they received between eight and nineteen hours of supervisory instruction in all required areas, except fiscal. The program submitted their training plan and annual training calendar to Staff Development and Training.


1.07: Logbook Maintenance Satisfactory Compliance

The program maintains a logbook in all four cottages and master control, in accordance with the Florida Administrative Code. The logbooks are bound and numbered at the top of each page. During the Quality Improvement review, six months of logbook entries were reviewed. The staff members consistently documented his or her reviews at the beginning of their shifts. When making an entry, the staff member documented the time of day, and signed his or her name after the entry. There were detailed descriptions of day-to-day incidents that occur at the program placed in the logbooks, as well as highlighting of significant events.

1.08: Internal Alert System Satisfactory Compliance

A review of nine records revealed all required alerts were logged into the Juvenile Justice Information System (JJIS) and in the program logbook by the appropriate staff. The clinical staff logged in suicide alerts, and removed the alerts when approved by the licensed professional in three instances reviewed. Dietary alerts, along with other pertinent alerts, were distributed to all departments, including the manager-on-duty and supervisors. The system in place to notify direct care staff included notes in the unit logbooks, alert lists and dietary alerts.

1.09: Escapes Satisfactory Compliance

The program had not had an escape within the last six months prior to the Quality Improvement review. The program has an escape prevention and response plan in an effort to prevent escapes from occurring. The program maintains escape backpacks, in the event an escape occurs to help the staff members apprehend the youth. The backpacks included insect repellent, binoculars, a flashlight, flex cuffs, a poncho, and a map. The program conducted three escape drills; on October 20, 2011, November 28, 2011 and December 19, 2011. There were sign-in sheets from the monthly all-team staff meetings that provided documentation that staff received training on escape awareness and prevention.

1.10: Youth Records Satisfactory Compliance

The program uses youth individual healthcare and individual management records to document the youth’s progress while in the program. The management records contained all of the required sections, in an organized manner. The applicable alerts and face sheets were located in the youth’s case management records. Nine records were reviewed, all marked confidential. The records are located in the Financial Services Case Manager’s office behind a key and magnetic lock.

1.11: Community Partnerships Satisfactory Compliance

In August 2011, the Program Director sent letters to various community leaders to solicit their participation on the program’s newly established advisory board. There were letters sent to


solicit all required members for an advisory board, and positive responses were received for all required representatives. The program held their initial advisory board meeting in September 2011; in attendance were four members of the local judiciary, as well as representatives from law enforcement, community business, faith community, a victim advocate and a parent whose child was previously involved in the juvenile justice system. A second meeting was conducted in December 2011. The minutes from both meetings were reviewed; the members appeared to be enthusiastic about working with the program.

1.12: Facility Integration and Stability Satisfactory Compliance

The program has established a Morale Committee, to assist with retaining staff. The Morale Committee maintains a list of employee birthdays, and a celebration is held monthly for the applicable staff. The committee is also instrumental in the various holiday celebrations hosted by the program, such as for Thanksgiving, Christmas, Mother’s Day and Father’s Day. To show the program’s appreciation for various staff members, plaques were purchased and presented by the Morale Committee. The committee also purchased portfolios for the advisory board members. In another personnel retention effort, any employee who had not received a reprimand for a year is eligible to receive a monetary bonus. A review of the personnel records of several staff documented their receipt of the bonus. The program management is seeking new ways to attract staff members who are dedicated to working with the youth; there was documentation regarding information about the program being sent to various job fairs. All applicable program staff received an annual evaluation, which appeared to be based on their job descriptions. A review of personnel records documented the completion of the annual evaluations.

Standard 2: Intervention and Case Management

Overview

The program has an Intake Specialist who is responsible for completing all of the intake paperwork and providing orientation to each new youth to the program. The nurse is responsible for completing all healthcare admission screenings. The mental health counselors are responsible for completing the majority of mental health, substance abuse and suicide risk screenings; the only exception is the Massachusetts Youth Screenings Instrument, Second Version (MAYSI-2). The MAYSI-2 is completed by the Intake Specialist and provided to the youth’s assigned mental health counselor for review. During orientation to the program, the youth receive information on evacuation procedures, the daily schedule, the services offered, and various other procedures, policies and rules. This signed form was located in all records reviewed. The program employs four case managers, one of whom is designated as the case manager supervisor. The case managers are responsible for competing the initial Residential Positive Achievement Change Tool (R-PACT), R-PACT re-assessments and needs assessments,


developing the performance plans, preparing performance summaries, participating in treatment team reviews and transitioning the youth out of the program. The case managers have offices in the administration building. The week prior to the Quality Improvement review, two Senior Youth Counselors who had been trained in and delivered Thinking For a Change (T4C) curriculum resigned from their positions. At the time of the Quality Improvement review, there were no staff trained to facilitate T4C.

2.01: Classification Satisfactory Compliance

Upon admission to the program, the Intake Coordinator completes the Admission Classification Form, which includes all classification requirements, as well as a summary to document communication with the youth’s parent or guardian, the name of the youth’s case manager and counselor and any alerts that may be in place for the youth. All youth admitted to the program sleep in the hallway for the first twenty-one days, then are re-assessed by the treatment team and assigned to a room. All youth are maintained on High Security for the first five days in the program and must wear an orange jumpsuit. All nine records reviewed documented the Admission Classification Form was completed by the Intake Coordinator on the day the youth was admitted to the program. Two of the nine classification forms reviewed documented the youth scored in the Standard-Risk Status range, however, the summary included with the form documented the youth scored in the Intensive-Risk Status range. All nine youth were placed on High Security watch for the first five days, as prescribed by the program’s process. All youth were then re-assessed by the treatment team and assigned to a room. All applicable information gathered during the classification process, including all alerts, was documented in the program logbook on the day the youth was admitted. All youth were re-assessed prior to an increase in privileges, participation in work activities or participation in off-campus activities.

2.02: Assessment Satisfactory Compliance

The program completed an initial Residential Positive Achievement Change Tool (R-PACT) and a Youth Needs Assessment Summary (YNAS) in the Juvenile Justice Information System (JJIS), within the youth’s first thirty days in the program. An R-PACT re-assessment was completed on each youth every ninety-days and prior to completion of the ninety-day performance summary. The program maintained all re-assessment documentation in the youth’s case record.

2.03: Intervention and Treatment Team Satisfactory Compliance

All nine records reviewed documented a formal treatment team review conducted at least every thirty days, and an informal review conducted bi-weekly. All required members were documented at the formal reviews, including the psychiatrist, if the youth was taking psychiatric medication. The youth’s parent or guardian participated via telephone; contact attempts were documented if they did not participate. All informal treatment team reviews documented the youth, counselor, case manager and a representative from administration were present for the meeting.


In four of the nine records reviewed, the formal treatment team reviews documented all required information, including the youth’s progress on performance plan goals, positive and negative behaviors, treatment progress and a brief synopsis of the youth’s progress in the program. The remaining five records inconsistently documented the youth’s progress on performance plan goals; information documented was vague, stating “youth doing very good” or “up to date.” In one file, for four months, the treatment team reviews stated “5 of 11 objectives completed”; when reviewing the performance plan, it was noted that during each of those four months more objectives had actually been completed. In another file, the reviews stated “youth is not actively working on performance plan” for three months after the performance plan had been developed. Upon reviewing the youth’s performance plan, it was noted that the youth had been working on objectives and had been completing objectives each month. None of the nine records reviewed documented R-PACT re-assessment results in the treatment team reviews. During the Quality Improvement review, treatment team meetings were observed. All required members were present and actively involved in the meeting, providing positive and useful feedback to the youth. The team helped the youth process negative behaviors and praised the youth for positive behaviors. All members of the team were knowledgeable of each youth, the goals the youth were working on, the youth’s behavior during the previous two weeks and any medications the youth was taking. The team helped each youth come up with three goals to work on during the next two weeks, as well as ways to accomplish the goals. Each youth was required to provide feedback at the end of the meeting, including what positive feedback he heard the team give him.

2.04: Performance Plan Satisfactory Compliance

All nine records reviewed documented a performance plan was developed within thirty days of admission and after the initial assessment. Four of the nine performance plans reviewed documented all required elements. Two of the remaining five records documented each plan contained one goal that did not include the program’s responsibilities to enable the youth to complete the goal. Two plans listed court-ordered sanctions that could be completed while the youth was in the program, however, did not document whether the youth was actually working on the goals, or if any progress was made on them. Two plans did not document any transition activities targeted for the last sixty days of the youth’s anticipated stay. Two plans documented most of the target completion dates had expired and there was no revision to the dates or objectives. One plan included one goal that had no target completion dates. All nine plans were signed by all required parties and mailed within ten days of completion to the committing court, the youth’s parent or guardian and Juvenile Probation Officer (JPO).

2.05: Performance Review and Reporting Satisfactory Compliance

All eight applicable records reviewed documented a ninety-day performance summary was completed. Six of the eight summaries addressed all required information. One performance summary documented five of eleven performance plan objectives had been completed; when reviewing the performance plan, it was noted that ten of the eleven objectives had been completed at the time the summary was developed. Another performance summary documented performance plan goals were “open” and did not include any comments or progress on the goals. The same summary also did not address the youth’s interactions with


peers or staff. All original summaries were maintained in the youth’s case file. All summaries were signed by all required parties and were mailed to the committing court, the youth’s parent or guardian and JPO within ten working days of completion.

2.06: Parent/Guardian Communication Satisfactory Compliance

All nine records reviewed documented that the youth’s parent or guardian was notified by telephone within twenty-four hours of admission. An admission notification letter was also mailed to the youth’s parent or guardian within forty-eight hours of admission. All nine records contained documentation the youth’s parent or guardian was contacted during the assessment process to provide input in areas the parent felt the youth needed to work on. This information was also used when developing the performance plan. All records documented the parent or guardian was contacted via telephone to participate in each treatment team meeting. The program also mailed letters to parents notifying them of the youth’s treatment team dates, encouraging them to participate. All parents were sent copies of the youth’s performance plan and performance summaries. One youth was eighteen years old and there was written consent from the youth to provide the parent with information relating to physical and mental health screening, assessment and treatment. None of the nine records contained written consent from the youth to share substance abuse information with their parent or guardian. The program conducts a New Admission Parent Orientation Night each month. This is a two-hour orientation for parents of newly admitted youth that includes information relating to program operations, codes of conduct, rules and regulations, expectations, treatment, program contact information and introduction to program staff. The parents are given a parent handbook and an opportunity to visit with their child during the last thirty minutes of the orientation. During the last six months, the program conducted a Family Fall Festival which included a full day of educational orientation for parents, learning activities, entertainment and food for the youth and their families. Around each holiday, the program also holds a Holiday Dinner where parents are invited to have dinner and visit with their child.

2.07: Transition Planning and Release Satisfactory Compliance

Three closed records were reviewed for transition activities. In all three records, the transition conference and the exit conference were held as required. All of the required attendees either attended the conferences in person or via telephone. The transition staffing documentation did not include target dates for completion of items or the person responsible for completion on a consistent basis. All of the required documents were located in the records. For one youth, the Pre-Release Notification (PRN) was sent to the judge on October 10, 2011; the judge approved the youth’s transfer to conditional status on December 16, for a December 29 release. There was no documentation of the youth’s parent or guardian being notified in writing after the court’s approval. The program staff stated that in Polk County, which was the youth’s home county, the judge often released the youth at the court hearing; therefore there was no time to provide the parent with written notification. In this file, there were two weeks from the date of judicial approval to the date of the youth’s release.


There were Exit Residential Positive Achievement Change Tool (R-PACT) assessments in two of the three records reviewed. For one youth, whose discharge date was December 29, 2011, there was an Exit R-PACT with a completion date of September 21. The program staff stated that this was incorrect, but no revised Exit R-PACT was presented for review while the Quality Improvement team was on-site. None of the youth reviewed were eligible as sexually violent predators, requiring specific notification of their release dates.

2.08: Grievance Process Satisfactory Compliance

The program has a formal grievance process in place, as well as a less formal process in which the youth complete ‘speak out’ forms if they wish to speak to a staff member about an issue. The grievance process, which the program defines as their complaint process, is documented in the client handbook. During their admission to the program, the youth sign to acknowledge receipt of the complaint process; this signed document was found in all records reviewed. The description of the process in the handbook and on the acknowledgement form is brief, and does not provide information on the various phases of the system, or of the ‘speak out’ process. Eight of the twenty-five formal complaints filed in the past six months were reviewed. All had been resolved in a timely manner, at the supervisor phase. The completed grievance forms were maintained in a binder. Nine youth responded to the survey; all of the youth reported that they had filed a grievance during their time in the program. Half of the youth reported that the grievance process was either good or very good, and half reported that the process was poor. Follow-up interviews confirmed the youth understood the questions and validated their responses.

2.09: Gang Prevention and Intervention Satisfactory Compliance

The program is involved in several gang awareness activities. There is a gang unit, which is comprised of the program management staff. Several staff are part of the statewide criminal street gang investigators, and attend meetings and training sessions regarding gang awareness. After attending meetings at the Orange County Sheriff’s Office for criminal street gang investigators, a staff member provides a synopsis of the meeting in minutes for the members of the program’s gang unit not able to attend the meeting. Upon admission to the program, the intake officer makes an entry into the logbook, with all of the pertinent information on the youth, which includes any applicable gang involvement. If there is any reason that the program suspects that a youth is active in a gang, or an associate of a gang, the youth is interviewed by the Gang Manager. The resulting information is forwarded to local law enforcement, the youth’s juvenile probation officer and the education staff. There was documentation of this being conducted for all youth suspected of gang activity. All youth for whom the program has interviewed regarding possible gang activity are convened for a monthly meeting. The topics of these meetings included a discussion of the gang statute, and reading of documents written by former gang members who are now incarcerated. Upon admission to the program, all youth receive an orientation on gangs, which includes the members of the gang unit, and the possible consequences of participating in gang activities while in the program. This form was found in all records reviewed.


The records of nine youth suspected of gang involvement were reviewed. Three of the youth had been placed on the Juvenile Justice Information System (JJIS) alert. The program stated that their training required that the youth not be placed on JJIS until they have received certification from law enforcement that the youth is a gang member. A review of the JJIS business rules revealed that suspected gang members are required to be placed on the JJIS alert system.

2.10: Staff Characteristics Satisfactory Compliance

A review of personnel records documented that all of the therapists have a master’s degree, and a history of working with delinquent youth. The therapists have received Motivational Interviewing (MI) training to help engage youth in constructive dialogue. The case managers all have either a bachelor’s degree or a history of working with delinquent youth. The therapists and counselors are trained in crisis management to assist a youth who may be in crisis. The LifeSkills Training (LST) groups are led by two cottage managers, who have excellent communication skills, as well as good relationships with the youth. Both cottage managers received MI training. During the Quality Improvement review, observations of the interactions between the staff members and the youth were professional.

2.11: Delinquency Programming Satisfactory Compliance

The program uses several evidence-based practices, such as Thinking for a Change (T4C), LifeSkills Training (LST), Seven Challenges for Substance Abuse, and Focused Cognitive Behavior Therapy. The program provides social and cognitive skill development groups for the youth in various ways, including having the youth crochet items such as blankets and socks for the homeless shelter and the children at the Ronald McDonald House in Orlando. The youth use their leisure time to read, play board games that stimulate their minds, and receive outside recreation daily to play tag football, volleyball, and basketball. The program allows volunteers to visit and provide services to assist the youth with community service hours. Campfire USA is an organization which takes the youth into the community, to assist the elderly with yard work, cleaning and other projects. To thank the youth for a job well done, Campfire USA donated items to the program. The program has implemented a program called “Choices”, which offers in-school or after hours presentations for grades 6-12. The program uses twelve one-hour sessions that instruct the youth to become more interactive and engaging, and to help the youth become positive leaders.

2.12: Gender-Specific Programming Satisfactory Compliance

The program provides on-site parenting classes for the youth who have children or who are expecting a child. These sessions, which are held every Friday, teach the youth how to properly care for a child and the expecting mother. The program has established the “Men of Distinctions” program, which is intended to increase the youth’s self-esteem. This program helps the youth learn about proper etiquette, and how to tie a tie. The program provides the youth with outside recreation to include basketball, football, and volleyball. These activities help to promote good sportsmanship and respect for each other.


2.13: Vocational Programming Satisfactory Compliance

The program partners with several sources to provide vocational and education services for the youth. These services included taking applicable youth to the weekly Job Corps orientation, and having the youth involved in a mentoring program in Orlando called “Wake Up Mentoring”. There is documentation of the youth in transition completing job applications and work source questionnaires. The youth are also provided with a list of all the One Stop Centers in the state, in an effort to find employment upon their release from the program. All of the youth attend a daily vocational class. There was documentation that the youth are provided instructional information on resume writing, however completed samples were not provided during the Quality Improvement review. During the Quality Improvement review, a discussion was held with a youth in transition regarding the services provided; he stated that he has received a lot of assistance in finding a job, as well as getting into college.

Standard 3: Mental Health and Substance Abuse Services

Overview

The mental health services are provided by the clinical department, which is comprised of the acting clinical manager, a psychologist and eight senior youth counselors. Two Licensed Mental Health Counselors (LMHC) from other Center for Drug-Free Living programs shared the responsibility for the mental health services for several few weeks prior to the Quality Improvement review, due to the resignation of the clinical manager in December. Two of the senior counselor positions were vacant during the review. The program has a psychiatrist under contract who visits the campus weekly and attends treatment team. The senior youth counselors have offices in the cottages, as well as the use of a computer lab in administration to complete documentation. One of the cottages has been designated for the Developmental Disabled (DD) youth; a second cottage is considered the same designation, but has some Halfway House youth as residents. The staff in both of these cottages received training for treating this specialized group of youth.

3.01: Designated Mental Health Authority (DJJ Program) Satisfactory Compliance

The acting clinical manager serves with another clinician from within the provider’s corporation; both of these positions are part time, to provide oversight and supervision of the master’s level senior youth counselors. There were times the licensed psychologist assigned to the DD program provided clinical supervision in the absence of the clinical manager. A review of clinical supervision revealed twenty-four of twenty-six weeks were documented for most of the counselors. The content of the notes inconsistently included a sample of cases reviewed, treatment summary notes, recommendations, directions and instructions by the licensed provider. Measures to provide individual supervision for staff that missed the weekly supervision was not found.


No documentation was found to support that the senior counselors performing the Assessments of Suicide Risk (ASR) had received the required twenty hours of suicide training, which includes the co-facilitating of an ASR for five youth. Interviews with staff indicated the previous clinical manager had provided the training, however there was no documentation in the training file to support this accomplishment. An intake coordinator completes the screening and escorts the youth to medical for intake assessment, and later escorts the youth to the mental health counselor. All intakes are completed in the intake office, which is part of the healthcare suite whose access doors are locked from the inside and outside.

3.02: Mental Health and Substance Abuse Admission Screening Satisfactory Compliance

A review of nine records revealed that the mental health and substance abuse needs of youth are identified through a comprehensive screening process that ensured referrals are made when youth have identified mental health or substance abuse needs, or are identified as a suicide risk. All nine records reviewed documented youth were screened by trained staff at admission using the Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) and scored on-line within the Juvenile Justice Information System (JJIS). All youth requiring a further assessment received a written referral for services. Two applicable records contained a MAYSI-2 indicating the youth required further assessment for suicide risk. Both records documented that a suicide risk alert was placed in JJIS, however there were no observation logs completed until the senior youth counselor completed an ASR. The completed ASR documented the licensed professional was contacted upon completion of the assessment, but the time of the consultation was inconsistently noted. The ASR documented notification to the Program Administrator upon conclusion of the assessment.

3.03: Mental Health/Substance Abuse Assessment/Evaluation Satisfactory Compliance

A review of nine records revealed a completed mental health evaluation and substance abuse assessment had been completed and reviewed by a licensed professional within the required time frame. It is apparent that there is a process in place to ensure completion of the comprehensive. The process included identifying information, the reason for the evaluation, a records review, observations, a mental status exam, interviews with youth and the youth’s parent or guardian and additional clinical assessments. All nine comprehensives reviewed included a discussion of findings, diagnostic impressions and recommendations, and were responsive the specific issues that arose during the screening.

3.04: Treatment Plan, Treatment Team, and Service Delivery Limited Compliance

Two of three applicable initial treatment plans did not include the psychotropic medication the youth was taking at admission to the program as the reason for the initial plan. Five of nine records reviewed did not contain a signed written consent to provide substance abuse treatment at admission. Two records had the consent signed during the Quality Improvement review, and


three others were signed within the two to three weeks prior to the Quality Improvement review. The consents ranged from three to five months late; there was documentation that services were being provided to the youth during that time. All nine plans contained the required signatures; two contained signatures from the youth’s parent or guardian. The records also contained copies of letters sent to the youth’s parent or guardian at the time the plan was completed. All nine records contained an individualized treatment plan completed either on the day the Comprehensive Mental Health and Substance Abuse Assessment was completed or after its completion. Most plans addressed the recommendations of the comprehensive evaluation. The schedule for services for all youth consistently called for five mental health groups per week, one family therapy session per month and two individual therapy sessions per month. None of the nine records reviewed provided all services on the schedule consistently during the Quality Improvement review period. None of the records documented five mental health groups per week; in the nine records reviewed, half of the weeks documented the provision of five groups per week. The remainder of the records documented between two and four mental health or substance abuse groups weekly. The reasons for not providing the required groups were not documented. Of the nine records reviewed, there was a total of thirty-one months in which a family therapy group was required; there was documentation of two family therapy sessions in the nine records. The weekly notes included many family contacts, the majority of which documented an update for the family on youth progress. The notes rarely documented attempts of the staff to arrange family therapy. The comprehensive evaluation for one youth did not recommend substance abuse therapy, nor did his individualized plan contain a substance abuse goal or objective. However, a review of weekly treatment notes revealed the youth was attending substance abuse treatment groups regularly, including one entitled “How to deal with your cravings” from the curriculum ‘Quitting Marijuana’, which indicated the youth was a continual part of this substance abuse group. Most of the treatment plan reviews (TPRs) were completed within the required time frames, however did not include the dates of signatures, especially of the licensed professional. The reviewer was unable to determine that the licensed reviewer was present during the TPR, or whether it was reviewed within the required time frame.

3.05: Suicide Prevention Limited Compliance

Five reports of precautionary observation were reviewed. Three of the five reports documented all requirements, including observation logs completed correctly, as well as the authorization, the supportive services, the Assessments of Suicide Risk (ASR) the follow-up ASRs and appropriate step-down procedures. One of the remaining two precautionary observation reports reviewed documented an ASR was completed at 11:00 PM; the observation sheet documented the youth was sleeping. However, another ASR was completed the following morning therefore the youth had an ASR completed within twenty-four hours of placement. This same youth was appropriately stepped down to


close supervision, however the following day this youth was placed back on constant supervision with no reasons documented. The ASR that was completed stated the youth’s behavior or risk had not changed, the youth had decreased his statements of self-harm and had no high-risk indicators, however the youth was placed back on constant supervision. In this same report, an ASR completed by an unlicensed counselor was signed by the Licensed Mental Health Counselor (LMHC) ten minutes before it was documented as being completed by the unlicensed counselor. In another report of precautionary observation, the dates documented on the initial ASR completed by the counselor conflicted with dates the event was documented in the logbook. Dates on the ASR were off by one day, which resulted in the youth not receiving an ASR within twenty-four hours of placement. There was no documentation that two unlicensed counselors completing ASRs had completed five co-assessments with a licensed professional. All staff received at least six hours of suicide prevention training annually that included “mock drills.” The program had a suicide response kit that included a knife-for-life, wire cutters and needle-nose pliers.

3.06: Mental Health Crisis Intervention Satisfactory Compliance

The program keeps a log of crisis assessments documenting all the required elements. A review of the assessments revealed they consistently documented the reasons for the assessment, mental status exam, danger to self or others, clinical impressions, and supervision and treatment recommendations. All the assessments were reviewed or performed by a licensed professional within the required time frame.

3.07: Emergency Services Satisfactory Compliance

There were three instances of Baker Acts reviewed. In two of the three instances, there was no documentation of one-to-one supervision while the youth was waiting to be transported to the crisis unit. All three youth records documented an ASR and a Baker Act assessment was completed by the LMHC, and law enforcement was contacted to transport the youth. All required notifications were made. All three youth were placed on precautionary observation upon returning from the crisis unit until seen and assessed by a LMHC within the time frame. The program has an emergency mental health and substance abuse plan in place that includes procedures for immediate staff response, supervision of the youth, notification requirements and authorization to transport. All staff received semi-annual training on emergency mental health and substance abuse services that included mock drills.

3.08: Specialized Treatment Services Satisfactory Compliance

The program provides services to youth who have been designated as Developmentally Disabled, as well as Behavior Overlay Services (BHOS). A psychologist is on-site three days per week for ten hours a day, for the youth in the Developmentally Disability or low functioning program, though the requirement is for a weekly on-site visit. She provides oversight for the therapists. The program provided BHOS services that are monitored by a healthcare provider.


The program documented Medicaid/Psychiatric medication monitoring monthly that was reviewed every nine months. According to the BHOS requirements, this review must be completed on a six month basis. The group and family counseling sessions are not being completed on a consistent basis as required by the youth’s treatment plans.

According to BHOS regulations, for youth with no evidence of substance abuse issues, the youth cannot be provided substance abuse treatment, but must receive substance abuse prevention. This was not consistently followed.

Standard 4: Health Services

Overview

The Center for Drug Free Living, Inc. has a contract with a psychiatrist to provide on-site psychiatric service, and to serve as the Designated Health Authority (DHA) as well as the Designated Mental Health Authority (DMHA) for Adolescent Residential Campus (ARC). The psychiatrist is on-site one day per week to conduct psychiatric evaluations, prescribe psychiatric medications, and monitor youth on psychiatric medications. As the DHA, the psychiatrist is also responsible for oversight of medical care, and for reviewing and signing off on facility operating procedures and nursing protocols. The on-site clinical responsibilities have been delegated to an Advanced Registered Nurse Practitioner (ARNP) who is also contracted by the Center for Drug Free Living. The ARNP visits the program once per week to complete comprehensive physical assessments, periodic evaluations and sick call referrals. At the time of the Quality Improvement review, the on-site medical staff included two Registered Nurses (RN), including one serving as the Lead Nurse, two full-time Licensed Practical Nurses, one part-time LPN, and the use of an agency nurse to cover shifts as needed. The program has nursing staff on-site seven days a week, with coverage from morning until after evening med-pass. The program has an agreement for off-site dental care, and an agreement for eye examinations and services to be provided on-site. The program has a modified class II Type B pharmacy permit. All nine youth surveyed reported the medical care provided to them at the program was good or very good. All of the youth also reported that they can ask for an HIV test. Many of the ARNP’s medical entries were illegible and the reviewer could not determine what care was provided to the youth without the nurse’s assistance.

4.01: Designated Health Authority Satisfactory Compliance

The Designated Health Authority (DHA) for the program is a licensed psychiatrist. He is on-site once per week for mental health and medication management. A review of the sign-in-sheets provided documentation that he was on-site weekly for two hours. The DHA provided the administrative functions, such as signing protocols and participating in treatment team reviews. An Advanced Registered Nurse Practitioner (ARNP) has been delegated to conduct the medical


services on the youth. There is a collaborative practice agreement between the DHA and the ARNP.

The DHA was unable to provide direct care services to the youth from December 13, 2011 to January 23, 2012, due to an expired background screening. In addition, a review of the sign-in-sheets revealed the DHA was not at the program the week of September 12, 2011 and the week of October 11, 2011. There is no process in place to provide back-up in the event the DHA is unable to be at the program.

4.02: Healthcare Admission Screening Satisfactory Compliance

The program has an intake staff that completes all of the Facility Entry Physical Health Screening form (FEPHS). The forms are completed in the intake office, which is located inside the medical area. After the screening is completed, the youth are seen by the nurse, who completes any additional screenings and the youth’s orientation to the medical processes and forms. The medical orientation includes the hours of operations, the sick call process, as well as health education. The licensed nurses sign the completed FEPHS form on the day youth are admitted to the program. All nine records reviewed contained the competed FEPHS forms. After the nursing staff complete their assessment of the youth and document their findings on the Initial Progress Intake Note form, a call is placed to the designated health authority (DHA), the advanced registered nurse practitioner (ARNP) or the designated mental health authority (DMHA) to report the youth’s admission and any applicable chronic conditions, or if the youth was taking any medications. All applicable records reviewed contained this information. Three youth had been readmitted to the program, and all three records included the completed FEPHS form upon the youth’s return to the program.

4.03: Comprehensive Physical Assessment Satisfactory Compliance

All nine reviewed records contained a new completed Health Related History (HRH) completed by the nursing staff, and a new Comprehensive Physical Assessment (CPA) completed by the ARNP within the required time frame. All youth were placed on activity restriction until seen by the ARNP for the completion of the CPA. The ARNP documented the review of the HRH on the form and on the CPA. One youth was admitted on August 24, 2012; the program did not identify the youth as having hypertension until January 2012. The youth was referred to a cardiologist, who saw the youth on January 19, 2012. The youth’s file contained documentation that hypertension issues had been identified during a commitment at a previous program. On the majority of CPAs reviewed, the ARNP documented that the Tanner Stage was deferred. Also, on a majority of the CPAs, the medical grades were revised after the completion of the CPA; however the program inconsistently used a progress note or the appropriate health service form to document the change. The problem list consistently identified the correct medical grades, with the date of the change or changes.


4.04: Sexually Transmitted Diseases Satisfactory Compliance

For all applicable admissions and readmissions, the completed Infectious and Communicable Disease (ICD) form was in the youth’s medical record, and all of the youth were tested for sexually transmitted diseases (STDs). The ICD form was inconsistently completed as required. The program’s practice is to use the Juvenile Justice Standing Admission Orders for the STD testing to be completed, which is in direct conflict with the program’s operating procedure. If the results of the screening indicated the youth was sexually active and required STD testing, the FOP required the youth to be referred to the DHA or ARNP for further evaluation and testing. The records did not contain orders written by the ARNP or DHA directly after they had completed the CPA to indicate the youth required STD testing. Youth were offered HIV education, and those who indicated a wish to receive HIV testing were tested and were provided pre and post-test counseling. The program has a certified HIV educator that can provide the testing and counseling at the facility. In all records reviewed, the pre and post-test counseling was recorded in the youth’s Health Education Record.

4.05: Sick Call Satisfactory Compliance

Seven of the nine records reviewed contained documentation of sick calls. All of the sick calls were completed by the LPN or RN; if completed by the LPN, the sick call forms included a review and signature of the RN as required. All of the sick calls were recorded on the sick call index and on the sick call log. If the youth needed a referral, this was recorded and the youth were seen by the ARNP. For youth that required additional follow-up, this was documented on the ARNP’s log. The program has treatment protocols that have been approved by the DHA. During their admission to the program, youth receive information on the program’s sick call process. The sick call hours are posted. The program uses a private room for health-related examinations.

4.06: Medication Administration Satisfactory Compliance

In eight of the nine records reviewed, medication was prescribed and administered. All medication orders were current and were administered according to the prescription order. The Medication Administration Record (MAR) matched the youth’s prescription and there were no time lapses between ordering and administration of the medication. Allergies and common side effects were clearly written on the MAR. The program was using the front part of the Department’s MAR for prescribed medications, and the front and back part of a pharmacy-generated MAR for the authorized over-the-counter (OTC) medications. The non-healthcare staff administering OTC medications when there was no medical staff in the building consistently used the Report of On-Site Healthcare by Non-Healthcare Staff (HS-049) to document the reason and medication given. There was documentation reviewed to support that the nursing staff consistently checked the medications given and entered it onto the back of the pharmacy MAR on the morning following the medication administration. The form was inconsistently signed by the youth to indicate his receipt of the medication. The program


inconsistently documented the vaccines on the MAR, though the vaccinations were documented on a different form.

4.07: Medication Control Satisfactory Compliance

All medications and sharps were secured, inventoried, stored and disposed of as required. The staff authorized to have access to medications were trained and designated in writing. Medications were all stored as required. The program maintained perpetual inventories, with running balances on all controlled medications. Shift-to-shift inventories were conducted and documented for controlled substances. Syringes and sharps had perpetual balances, as well as weekly inventories. Open over-the-counter medications were inventoried weekly. The program has a consulting Pharmacist that reviews the compliance and disposal of medications.

4.08: Infection Control Satisfactory Compliance

All staff had been trained on the program’s Exposure Control Plan. All staff are offered the Hepatitis B immunization. The program provided training on various topics regarding infection control. The program’s corporate office has an Infection Control Nurse who visits the program regularly to ensure compliance with the infection control processes and to implement any necessary corrective action. Each living unit has a fanny pack that is equipped with first aid supplies, antibacterial hand gel, a CPR mask, disposable gloves, and a biohazard waste disposable bag. The staff consistently carried the fanny pack when youth leave the living unit and move throughout the campus. The program conducts monthly safety and sanitation inspections of the living units and clinic, addressing compliance with infection control process.

4.09: Chronic Illness Treatment Satisfactory Compliance

The program maintained a schedule and calendar on which they documented the dates for periodic reviews. The ARNP conducted the reviews for the youth not prescribed psychiatric medications. The reviews were conducted within the required time frames. The DMHA who prescribed psychiatric medications was not physically on-site from December 13, 2011 until January 23, 2012. The records indicated the reviews were conducted during those dates by him, even though he was not on-site. The documentation of the DHA conducting the medication reviews as required prior to December and after January 23, 2012.

4.10: Episodic and Emergency Care Satisfactory Compliance

The program has a policy and procedure that identified the contents for the first aid kits. The contents of the kits had been inventoried as required. All of the first aid kits reviewed during the Quality Improvement review contained the required items. The first aid kits that were maintained in the vehicles had two heat sensitive items, eyewash and antibacterial ointment. The program


has two AEDs on-site and all staff had been trained in its use. The knife-for life and wire cutters were also stored in the appropriate locations. The program conducted mock emergency medical drills on all three shifts monthly. Emergency care was documented in the individual health care record for four applicable youth that required first aid or emergency care. One youth was seen off-site for dental pain, one for a hand injury and one for a shoulder injury. These records included documented referrals for off-site care and follow-up. All were documented as required with signatures and dated by the ARNP. The other youth were seen on-site by direct care staff using the Report of On-Site Health Care by Non-Health Care Staff form, for symptoms such as nosebleed and indigestion.

4.11: Consent and Notification Satisfactory Compliance

All of the youth’s records contained the Authority for Evaluation and Treatment form (AET) completed and marked “original” or “copy.” One youth turned eighteen years of age while in the program, and there was no new AET signed by the youth. All applicable notifications reviewed had been completed, using the correct form sent to the youth’s parent or guardian, as well as documentation of phone contacts. The majority of the records contained the consents that had been signed by the youth’s parents or guardians. The program consistently provided a list of medications that are beyond those found on the AET to the youth’s parent or guardian.

4.12: Prenatal/Neonatal Care Non-Applicable

This program serves only male youth, therefore this indicator is rated Non-Applicable.

Standard 5: Safety and Security

Overview

The Assistant Director for Finance and Operations manages all security aspects of the program, including personnel who oversee the day-to-day maintenance. The entrance to the facility has an intercom and a camera that is monitored by a receptionist or other staff in the main building. Visitors must identify themselves before the receptionist will electronically open the single gate. Visitors and staff park vehicles inside the secure fence and sign-in at the administration building. The facility grounds include five acres cleared in a wooded area with four cottages, an Administration building including offices, the health care/intake area, the kitchen and dining hall, an external refrigerator and freezer building, gymnasium and maintenance/laundry complex. In addition the Osceola School Board has four portable classroom structures. Each cottage has a small fenced-in recreation area. The grounds of the campus also have two volleyball courts, a baseball diamond and a high-ropes challenge course. The entire facility is surrounded by barbed wire fencing, and cameras record various areas of the facility. The program management and supervisors oversee staff shift assignments, security and perimeter


checks and youth counts. A master control logbook is maintained in administration and each Cottage maintains a unit log.

5.01: Supervision of Youth Satisfactory Compliance

A review of the schedule and logbooks, as well observations during the Quality Improvement review revealed staff kept the youth active throughout the day, and conducted the required counts consistently. Staff and youth interactions observed were positive, including when giving instructions for line movement expectations. Unacceptable behavior was addressed in a timely manner with positive responses. Staff maintained control of all youth in the classrooms, common areas and day rooms. The Quality Improvement team conducted a review of ten-minute checks during sleeping hours at varied times by viewing recorded videotape. Staff were observed on post maintaining visual supervision at all times. Any youth identified as new admissions, High Security, or contract individuals were properly documented as evidenced by program logbooks and internal lists. No discrepancies were noted between observations and documentation of checks. Ten-minute checks were consistently recorded in real time and within the required time boundaries.

5.02: Key Control Satisfactory Compliance

The program completes a monthly key audit of the keys for all personnel. The audit sheet included the staff member’s initials to indicate they have their correct keys. One set of keys did not match the monthly key audit; this matter was brought to the attention of program management, and was fixed immediately. There is a key control form that included the set number and the number of keys on the ring. The form also indicates the staff’s name, department and position, as well as the date. The key rings included a tag indicating the number of keys on the ring and the assigned number to the set of the keys, in order to identify them. During the Quality Improvement review, ten sets of keys were observed, and with the exception of one set of keys, the rings had the tag and the correct number of keys. The employee’s personal keys, as well as visitor’s keys are maintained in secured cabinets located in the Master Control behind a locked door. Only authorized staff has access to the keys. The program has procedures in place for missing, broken and replacement keys.

According to the program’s FOPs all staff shall maintain their assigned keys on their person at all times. Several staff were asked to show their keys to the Quality Improvement review team; one person had to go retrieve their keys from a different location to show the reviewer.

5.03: Contraband and Searches Satisfactory Compliance

A daily perimeter check was consistently completed by the safety manager, and findings were documented in the logbook. The youth’s rooms were searched randomly, and any time contraband was suspected. The searches of the common area were completed by staff daily and documented in the logbooks. A client search protocol checklist was completed each time a full youth search is conducted.


The contraband list is posted in each cottage and is outlined in the client and parent handbooks. There is a clear practice for inspecting all incoming and outgoing mail. Interviews of staff and youth indicate mail monitoring is consistently completed according to the policy. The facility utilizes a personal property inventory form and a correspondence checklist that was signed by both youth and staff.

5.04: Transportation Satisfactory Compliance

The program uses three vans to transport youth. All three vans had proper working seat belts, window punches, and seat belt cutters. Two of the vans are minivans; since these vans do not have a protection screen between the front and back areas, the second row is used for seating. This gives the driver and the youth plenty of distance, to help ensure the safety and security of the driver. There was documentation to confirm that the program used two staff members on the majority of transports. The vehicles were inspected monthly and received annual inspections. The annual inspection has been completed for the 2011-2012 year. All three vans had sealed first aid kits, that contained the appropriate supplies in case of a minor incident. There was eye wash in all three vans, which is a heat sensitive item. All three vans had AAA roadside assistance kits. These kits include jumper cables, hazard sticks, maps and other items.

5.05: Tool Management Satisfactory Compliance

All Class A tools were arranged on a shadow board. The items on the board were numbered and each tool marked for easy reference. All maintenance tools were secured in the maintenance office, which is inside a limited access area. All Class A tools were inventoried daily; Class B tools were inventoried monthly and a full review was signed by management annually. During the Quality Improvement review, it was noted that there were three tools on the shadow board that were not listed on the inventory. One tool, a 9 ½ inch screwdriver, was missing and unaccounted for during the tour of the facility; staff retrieved the tool within an hour and returned it to the board. Youth risk assessment forms were completed as required for all work project activities assigned at the time. The forms were discussed and approved by the treatment team and maintained in the youth’s case management record and food service binder. Staff training records documented training in the safe use of tools. The youth are permitted to crochet at various times during their time at the program; there was no documented inventory of the crochet needles. All kitchen utensils were secured in a locked box and shadow board. During the Quality Improvement review of the kitchen tools, utensil # 4 was identified as a 7” cook’s fork; the item on the # 4 hook was a cook’s knife. The inventory list was revised during the Quality Improvement review to reflect the cook’s knife.


5.06: Disaster and Continuity of Operations Planning Satisfactory Compliance

The program had a Continuity of Operations Plan (COOP) that had been updated annually and submitted to the Residential Services Office, Central Region. The plan included all of the required components. There was documentation of the program conducting emergency drills on each shift. The egress plans were posted in all cottages and throughout the facility.

This current plan indicated Desoto Juvenile Correctional Facility, in Arcadia, Florida, as the program’s evacuation site; this program closed in August 2011; therefore the plan will need to be revised when the program determines a new evacuation site.

5.07: Flammable, Poisonous, and Toxic Items Satisfactory Compliance

The program stored all chemicals in a secured area, with restricted key access. A chemical count and daily inventory was consistently maintained for the Quality Improvement review period. All items in the chemical storage area were on the inventory list. The program provided a list of staff, by title, of those authorized to handle flammable, poisonous and toxic items. The program does not allow youth to clean with hazardous materials. All nine youth surveyed indicated that during the cleaning routine, staff sprays on chemicals and youth wipe it off. Material Safety Data Sheets (MSDS) were maintained for all applicable chemicals in the storage area and in the residential units.

5.08: Water Safety Non-Applicable

The program does not have a water safety program and prohibits such activity, therefore this indicator is rated Non-Applicable.

5.09: Behavior Management System Satisfactory Compliance

The facility offers a variety of positive reinforcements to foster acceptable behavior. The facility has a well-written Behavior Management System (BMS) to assist staff with their knowledge of the system and offer tools to assist staff in identifying potential problems. The client handbook provides a detailed description of program guidelines and the BMS rules were posted in all residential units. Treatment team reviews consistently documented the points the youth earned in their cottage, in group and in school. During the treatment team reviews, the number of positive and negative write-ups for the current period was compared to the number at the previous treatment team. The forms also included a section to document any positive awards received or involvement with a Protective Action Response (PAR) restraint. Nine youth responded to the survey; all nine youth reported receipt of the written description of the behavior management system. A majority of the youth rated the BMS good or very good, and that they had received fair consequences. All nine youth reported that they felt staff gave rewards and/or consequences consistently. Follow-up interviews confirmed that staff did not engage in favoritism when giving out rewards or consequences.


5.10: Behavior Management Unit Non-Applicable

The program does not have a Behavior Management Unit, therefore this indicator is rated Non-Applicable.

5.11: Controlled Observation Non-Applicable

The program policy and procedure does not support the practice of controlled observation, therefore this indicator is rated Non-Applicable.

96%

4%

0%* Percentages have been rounded to the nearest whole number. Percentages may not total 100% due to rounding.

Overall Rating Summary

Satisfactory Compliance:

Limited Compliance:

Failed Compliance:

BUREAU OF QUALITY IMPROVEMENT

Documents

Transcript of BUREAU OF QUALITY IMPROVEMENT