program report for

Florida Department of Juvenile Justice Residential Quality Assurance Report Office of Program Accountability of 11

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 ASSURANCE PROGRAM REPORT FOR

Broward Girls Academy Youth Services International

(Contract Provider) 8301 South Palm Dr.

Pembroke Pines, Florida 33025

Review Date(s): October 26-28, 2010 ADDENDUM ATTACHED, Exempt Review Date(s): August 24, 2011

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 F F W EN H OLD , BU R EA U C H I E F


Residential Performance Rating Profile

Program Name: Broward Girls Academy QA Program Code: 1175

Provider Name: Youth Services International, Inc. Contract Number: R2074

County/Circuit #: Broward/Circuit 17 Number of Beds: 30

Review Date(s): October 26-28, 2010 Lead Reviewer Code: 105

Program Performance by Indicator/Standard

1.01 Background Screening of Employees/Vol. 10 Exceptional4.01 Designated Health Authority 10

1.02 Provision of an Abuse Free Environment 10 Exceptional4.02 Healthcare Admission Screening 10

1.03 Incident Reporting 8 Commendable4.03 Comprehensive Physical Assessment 8

1.04 Protective Action Response (PAR) 8 Commendable4.04 Sexually Transmitted Diseases 8

1.05 Pre-Service/Certification Requirements 5 Minimal4.05 Sick Call 8

1.06 In-Service Training Requirements 7 Acceptable4.06 Medication Administration 7

1.07 Logbook Maintenance 10 Exceptional4.07 Medication Control 8

1.08 Internal Alert System 8 Commendable4.08 Infection Control 8

1.09 Escapes 10 Exceptional4.09 Chronic Illness Treatment 7

Commendable 84% 76 4.10 Episodic and Emergency Care 8

90 4.11 Consent and Notification 8

4.12 Prenatal/Neonatal Care 8

2.01 Classification 7 Acceptable Commendable 82%

2.02 Assessment 8 Commendable

2.03 Intervention and Treatment Team 8 Commendable

2.04 Performance Plan 7 Acceptable5.01 Supervision of Youth 10

2.05 Performance Review and Reporting 8 Commendable5.02 Key Control 8

2.06 Parent/Guardian Communication 8 Commendable5.03 Contraband and Searches 8

2.07 Transition Planning and Release 5 Minimal5.04 Transportation 10

2.08 Grievance Process 8 Commendable5.05 Tool Management 8

2.09 Gang Prevention and Intervention 7 Acceptable5.06 Disaster/Continuity of Operations Planning 8

Acceptable 73% 66 5.07 Flammable, Poisonous, and Toxic Items 8

90 5.08 Water Safety NA

5.09 Behavior Management System 10

3.01 Designated Mental Health Authority 10 Exceptional5.10 Behavior Management Unit NA

3.02 MH and SA Admission Screening 10 Exceptional5.11 Controlled Observation NA

3.03 MH and SA Assessment/Evaluation 10 Exceptional Commendable 88%

3.04 Treatment Plan/Team and Service Delivery 10 Exceptional

3.05 Suicide Prevention 8 Commendable

3.06 Mental Health Crisis Intervention 7 Acceptable

3.07 Emergency Services 8 Commendable

3.08 Specialized Treatment Services 7 Acceptable

Commendable 88% 70

3. Mental Health and Substance Abuse Services

1. Management Accountability 4. Health Services

2. Intervention and Case Management

5. Safety and Security

StandardProgram

Score

Max.

ScoreRating

Failed

0-59%

Minimal

60-69%

Acceptable

70-79%

Commendable

80-89%

Exceptional

90-100%

1. Management Accountability 76 90 84% X

2. Intervention and Case Management 66 90 73% X

3. Mental Health and Substance Abuse Services 70 80 88% X

4. Health Services 98 120 82% X

5. Safety and Security 70 80 88% X

Overall Program Performance

COMMENDABLE 83%


Methodology This review was conducted in accordance with Florida Administrative Code 63L-2 (Quality Assurance, 6/10/10 Hearing Draft), 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 2010).

Persons Interviewed

Program Director DJJ Monitor DHA or designee DMHA or designee

2 # Case Managers 4 # Clinical Staff # Food Service Personnel 2 # Healthcare Staff

# Maintenance Personnel # Program Supervisors # Other (listed by title):

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

5 # Health Records 5 # MH/SA Records 5 # Personnel Records 5 # Training Records/CORE 3 # Youth Records (Closed) 5 # Youth Records (Open) # Other:

Surveys

5 # Youth 5 # Direct Care Staff 8 # Other: Tier II

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. The program did not utilize room restrictions or controlled observation. There was no use of mechanical restraints or youth being admitted during the quality assurance review to observe.


Performance Ratings Performance ratings were assigned to each indicator by the review team using the following definitions and numerical values defined by F.A.C. 63L-2.002(10)(a) (6/10/10 Hearing Draft):

Exceptional (10)

The program consistently meets all requirements, and a majority of the time exceeds most of the requirements, using either an innovative approach or exceptional performance that is efficient, effective, and readily apparent.

Commendable (8)

The program consistently meets all requirements without exception, or the program has not performed the activity being rated during the review period and exceeds procedural requirements and demonstrates the capacity to fulfill those requirements.

Acceptable (7)

The program consistently meets requirements, although a limited number of exceptions occur that are unrelated to the safety, security, or health of youth, or the program has not performed the activity being rated during the review period and meets all procedural requirements and demonstrates the capacity to fulfill those requirements.

Minimal (5)

The program does not meet requirements, including at least one of the following: an exception that jeopardizes the safety, security, or health of youth; frequent exceptions unrelated to the safety, security, or health of youth; or ineffective completion of the items, documents, or actions necessary to meet requirements.

Failed (0)

The items, documentation, or actions necessary to accomplish requirements are missing or are done so poorly that they do not constitute compliance with requirements, or there are frequent exceptions that jeopardize the safety, security, or health of youth.

Review Team The Bureau of Quality Assurance wishes to thank the following review team members for their participation in this review, and for promoting continuous improvement and accountability in juvenile justice programs and services in Florida: Shandria Striggles, Lead Reviewer, DJJ Bureau of Quality Assurance Patrick Morse, Program Administrator, DJJ Bureau of Quality Assurance Gabriel Medina, Review Specialist, DJJ Bureau of Quality Assurance Patrice Starks, Review Specialist, DJJ Bureau of Quality Assurance Cheryl Surls, Program Monitor, DJJ South Residential Services Linda Bellamy, Senior Juvenile Probation Officer, DJJ Circuit 17 Probation


Please note that this report refers to each indicator by number and title only. Please see the applicable standards for the full text of each indicator. The standards are available on the Bureau of Quality Assurance website, at http://www.djj.state.fl.us/QA/index.html.

Standard 1: Management Accountability

Failed ExceptionalCommendableAcceptableMinimal

Overview

Broward Girls Academy is a thirty-bed, Intensive Mental Health residential program for low-risk and moderate-risk females, 14-18 years of age, that are committed to the Department after being assessed and classified as moderate-risk to re-offend with serious to severe mental disturbance. The program is contracted by Youth Services International, Inc. (YSI) with the Department of Juvenile Justice. The program provides custody, treatment and supervision in a secure setting utilizing a therapeutic community model. The program's services include mental health group, individual and family counseling, psychiatric and psychological services. Education services are provided by the Broward County School System. The program's management team is comprised of the Facility Administrator, Assistant Facility Administrator, Clinical Director/Designated Mental Health Authority (DMHA), Registered Nurse and Business Manager. The program contracts services with a licensed physician to serve as the facility's Designated Health Authority, and a licensed psychiatrist to oversee the psychiatric services. In addition, the program contracts with a part-time Advanced Registered Nurse Practitioner (ARNP), licensed optometrist and a licensed dentist.

1.01: Background Screening of Employees/Volunteers Exceptional (10)

The program conducts monthly driver’s license checks on all staff.

All staff and volunteers are screened utilizing the Florida Department of Law Enforcement Florida Sexual Offenders and Predators Registry.

All volunteers are screened prior to facility access and receive a full background screening.

1.02: Provision of an Abuse Free Environment Exceptional (10)

The facility has each staff review and sign a statement defining child abuse and neglect. During orientation staff are provided with in-service training in Florida abuse laws and program guidelines. In addition, they are provided with warning signs to look out for in case of abuse.

A review of the Department’s Learning Management System (LMS) CORE it was determined that all staff received training in Child Abuse Reporting.

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


1.03: Incident Reporting Commendable (8)

The program consistently met all requirements for this indicator without exception.

1.04: Protective Action Response (PAR) Commendable (8)


1.05: Pre-Service/Certification Requirements Minimal (5)

A review of five applicable staff pre-service training files found that one did not complete all required trainings prior to contact with the youth. In addition, she did not complete all required trainings within the first 180 days of employment. This employee was taken off the floor a week prior to the quality assurance review to complete the required pre-service trainings.

All trainings were not documented in the Department’s CORE Learning Management System.

1.06: In-Service Training Requirements Acceptable (7)

The facility has not performed the activity being rated during this review period. The program meets all procedural requirements and does not exceed the procedural requirements.

1.07: Logbook Maintenance Exceptional (10)

The program utilizes a shift report to ensure staff are aware of past shift incidents as well as staff review and sign the logbook.

Shift reports are maintained in a binder at master control for easy access by all staff.

The program staff signed a review of both the logbook and shift reports prior to starting their shift.

The program maintains all shift reports beyond the forty-eight hour minimum requirement. This allows staff easy access to review when needed.

1.08: Internal Alert System Commendable (8)


1.09: Escapes Exceptional (10)

The program conducts routine escape drills with staff and discusses the information at all-staff meetings.

The program has an Escape Bag located in master control that contains a first aid kit, flash light with batteries, blood borne pathogen kit, light-reflective vest, maps of the


compound and surrounding areas, and a contact list of all required information for staff to utilize in case of an escape.

Standard 2: Intervention and Case Management


Overview

Oversight of the programs case management services is the responsibility of the Clinical Director that is also the Designated Mental Health Authority. The program employs two case managers that are responsible for initial classification, assessments, performance plan development, performance summaries and transitional planning. The program utilizes the Positive Achievement Change Tool (PACT) completed by Probation and Community Intervention at admission and the Residential- Positive Achievement Change Tool (R-PACT) for re-assessments. Youth have access to weekly visitation, telephone calls and religious activities. There is a grievance system in place for the youth as well.

2.01: Classification Acceptable (7)

A review of five youth case management files found that the all youth are screened for gang involvement as part of their initial classification process. One youth was admitted with a gang alert on the Juvenile Justice Information System (JJIS) Face Sheet; however, this youth was not initially classified as a gang member by the intake staff.

2.02: Assessment Commendable (8)


2.03: Intervention and Treatment Team Commendable (8)


2.04: Performance Plan Acceptable (7)

A review of five youth case management files found that the program was not consistently changing/updating target goal dates when the dates expired.

2.05: Performance Review and Reporting Commendable (8)



2.06: Parent/Guardian Communication Commendable (8)


2.07: Transition Planning and Release Minimal (5)

There was no clear documentation to support that all participants were notified of the transition or exit conferences.

The transition conference plan did not consistently document additional transition activities, target dates, and persons responsible for completion of transition activities.

There was no documentation to support that the transition plan was sent to the parent/guardian and assigned Juvenile Probation Officer or aftercare counselor.

None of the pre-release notifications were sent to the judge at least forty-five days prior to release.

2.08: Grievance Process Commendable (8)


2.09: Gang Prevention and Intervention Acceptable (7)

There was no clear documentation to support that the information was sent to the local law enforcement.

Standard 3: Mental Health and Substance Abuse Services


Overview

The program had a full-time Licensed Mental Health Counselor (LMHC) that served as the Designated Mental Health Authority (DMHA) and Clinical Director, responsible for the appropriate coordination, implementation and oversight of the mental health and substance abuse services provided. The program had two full-time unlicensed mental health therapists and one full-time Registered Mental Health Counselor Intern, that provided daily clinical services, including weekends, to all youth in the program. The program had an Agreement for Professional Services with a licensed psychologist, and an Agreement for Professional Services with a licensed psychiatrist, for the provision of services to the youth in the facility. The DMHA, the psychologist and the psychiatrist were on call twenty-four hours per day, seven days a week. The program provided intensive mental health treatment services to all youth in the facility. The program utilized Memorial Regional Hospital as the crisis stabilization unit for the facility.


3.01: Designated Mental Health Authority (DJJ Program) Exceptional (10)

The program has one full-time licensed mental health therapist and two full-time unlicensed mental health therapists. In addition, the program has a Registered Mental Health Counselor Intern. All staff are on-call twenty-four hours a day, seven days per week.

The licensed mental health therapist is the Clinical Director. The Clinical Director also serves as the program’s Designated Mental Health Authority.

The program has a professional agreement with a licensed psychologist to provide supervision to the unlicensed mental health therapists. She is on-call twenty-four hours a day and serves as back up to the Designated Mental Health Authority.

3.02: Mental Health and Substance Abuse Admission Screening Exceptional (10)

In addition to completing the Massachusetts Youth Screening Inventory – Second Version (MAYSI-2), the program conducts the Beck Depression Inventory, Suicide Probability Scale, Substance Abuse Subtle Screening Inventory, Children’s Functional Assessment Rating Scale, and a brief clinical bio-psychosocial evaluation during the intake assessment process.

All youth receive an Assessment of Suicide Risk, regardless of the initial suicide screening results, as part of the initial assessment process.

3.03: Mental Health and Substance Abuse Assessment/Evaluation Exceptional (10)

All youth receive a new in-depth comprehensive mental health/substance abuse evaluation within twenty-one days of admission.

All youth receive a Diagnostic Interview for Children and Adolescents (DICA-IV) Report as part of the comprehensive evaluation.

Clinical staff conduct a Youth Self-Statement survey with all youth and utilize the information as part of the overall comprehensive evaluation process.

Clinical staff conduct a quarterly youth mental health survey and utilize the results to modify/enhance services within the program.

All youth receive a psychiatric evaluation within fourteen days of admission.

3.04: Treatment Plan, Treatment Team, and Service Delivery Exceptional (10)

All youth undergo an initial treatment plan within twenty-four hours of admission into the program.

Documentation reviewed validated that treatment plan reviews were conducted more often than required.

The program utilized a parent/guardian response form to request information and input regarding treatment goals.

The program utilized a staff response form from all areas of the program to request information and input regarding treatment goals.


3.05: Suicide Prevention Commendable (8)


3.06: Mental Health Crisis Intervention Acceptable (7)

A review of the program’s crisis assessment instrument addressed all required areas with the exception of notification of parent/guardian regarding follow-up treatment.

3.07: Emergency Services Commendable (8)


3.08: Specialized Treatment Services Acceptable (7)

All required staffing patterns are in place with the exception of having a registered nurse on-site daily, and preferably during each shift for medication administration.

Standard 4: Health Services


Overview

The program has a Health Services Agreement with Convenient Practitioners Services (CPS) to provide a licensed physician to serve as the program’s Designated Health Authority (DHA). The DHA is the physician that provides and/or supervises the provision of necessary and appropriate health care to youth in the care and custody of the program. The DHA is on-site weekly and provides routine medical care and monitoring of medication administration. In addition to the DHA, the program also has an Advanced Registered Nurse Practitioner (ARNP) that is also on-site weekly. There were collaborative practice protocols in place for the ARNP. The program had an Agreement for Professional Services with a licensed psychiatrist for the provision of psychiatric services to the youth in the facility. The DMHA, Psychiatrist, and ARNP were on call twenty-four hours per day, seven days a week. The program had a full-time Registered Nurse (RN) working Monday through Friday. The RN was responsible for the overall day-to-day operations of the medical clinic. The RN had a good working relationship with the DHA and ARNP with open lines of communication. The RN provided sick call two times daily, five days per week. The program utilized the City Place Pharmacy in West Palm Beach, Florida for the procurement of medications. Emergency procurement of medications was purchased through the local Wal-mart. In addition, the program had an Agreement for Professional Services with Consulting Pharmacists, Inc. to provide a consultant pharmacist. The program also had agreements with a licensed dentist and a licensed optometrist to provide services. The program utilized the Broward County Health Department for routine immunizations, human immunodeficiency syndrome (HIV) testing and treatment, sexually transmitted disease (STD)


testing and treatment, pre-natal care and gynecological care. The program utilized Memorial Regional Hospital for emergency services.

4.01: Designated Health Authority Exceptional (10)

The Designated Health Authority (DHA) and Advanced Registered Nurse Practitioner (ARNP) are both on-site weekly.

Documentation reviewed validated that the DHA and/or ARNP provide training to both staff and youth.

4.02: Healthcare Admission Screening Exceptional (10)

All youth are screened upon admission for healthcare concerns by a licensed nursing staff.

The Designated Health Authority (DHA) or the Advanced Registered Nurse Practitioner (ARNP) is routinely notified of all admissions, regardless of the youth’s medical history.

4.03: Comprehensive Physical Assessment Commendable (8)


4.04: Sexually Transmitted Diseases Commendable (8)


4.05: Sick Call Commendable (8)


4.06: Medication Administration Acceptable (7)

A review of the Medication Administration Record’s (MARs) produced by the pharmacy found that they did not consistently have dates above where staff and youth are to initial.

One youth had medications discontinued on October 5, 2010; however, direct care staff documented on the back of the MAR that the medication was unavailable from October 5-11, 2010. The registered nurse caught that this was going on and met with both staff to stop this documentation.

One youth MAR reviewed documented that there was one lapse in medication administration (vitamin) on October 11, 2010.

4.07: Medication Control Commendable (8)



4.08: Infection Control Commendable (8)


4.09: Chronic Illness Treatment Acceptable (7)

There was no clear evidence to support that youth taking anti-tuberculosis medication received monthly evaluations during the first two months.

4.10: Episodic and Emergency Care Commendable (8)


4.11: Consent and Notification Commendable (8)


4.12: Prenatal/Neonatal Care Commendable (8)


Standard 5: Safety and Security


Overview

The Assistant Program Director is responsible for the oversight of safety and security provided at the program (tool management, and flammable, poisonous and toxic items). The program had video surveillance to record the daily activities of the program. The program operates on three eight-hour shifts per day (7:00 am - 3:00 pm; 3:00 pm - 11:00 pm; 11:00 pm - 7:00 am). Staff communication is accomplished by two-way radio, logbooks and shift reports maintained by direct care staff. The programs behavior management system is based on the company’s strategic model. It is a multi-stage system with privileges available to the youth at each succeeding stage and includes elements to achieve the desired one-to-four punishment-to-reward ratio. Consequences are imposed by staff and reviewed by the treatment team. The program does not utilize room restriction, controlled observation or maintain a behavior management unit. Good order and control was observed during the review week.

5.01: Supervision of Youth Exceptional (10)

Ten-minute checks were conducted when youth were in their sleeping room. Staff ensured that they can visibly see the youths skin and observe respirations of the youth.


The Assistant Program Director verifies ten-minute checks every day and documents accuracy.

The Assistant Program Director or Program Director conducts administrative reviews of the camera footage on a weekly basis, at a minimum.

The Program Director and the Assistant Director routinely stop by during off hours and weekends to conduct spot checks, which were evidenced by logbook entries.

All staff at the facility, with the exception of the Human Resource staff, are female. Should male staff be hired, the program has a facility operating procedure in place to ensure the male staff supervises no more than three youth at a time.

5.02: Key Control Commendable (8)


5.03: Contraband and Searches Commendable (8)


5.04: Transportation Exceptional (10)

The Maintenance Supervisor is responsible for maintaining proper operating conditions of the facility vehicle. In reviewing the service records for the vehicle it was determined that the vehicle was serviced quarterly.

A medical transportation binder is sent all on transports, along with a route binder and an extra first aid bag.

The facility conducts transportation quarterly drills as a form of in-service training for staff to ensure staff are following all guidelines for transportation.

The Vehicle Inspection Sheets were completed routinely and captured the pre and post inspections of the vehicles.

5.05: Tool Management Commendable (8)


5.06: Disaster and Continuity of Operations Planning Commendable (8)


5.07: Flammable, Poisonous, and Toxic Items Commendable (8)



5.08: Water Safety Non-Applicable (NA)

The program’s policy, procedure, and practice confirm the requirements of the indicator were not applicable for this program.

5.09: Behavior Management System Exceptional (10)

The program conducts “Fantastic Fridays” for youth that have demonstrated appropriate behaviors.

Youth are rewarded once per week for cleanest room, highest point average, the most outstanding youth, and for having a week of having no restraints.

The program maintains a canteen for youth that is used to reward youth for positive behaviors, achievements, or recognition.

5.10: Behavior Management Unit Non-Applicable (NA)


5.11: Controlled Observation Non-Applicable (NA)


Overall Program Performance

COMMENDABLE 83%


Florida Department of Juvenile Justice Exempt Review Addendum Office of Program Accountability Page 1 of 5

BUREAU OF QUALITY ASSURANCE EXEMPT REVIEW ADDENDUM

Program Name: Broward Girls Academy QA Program Code: 1175

Program Type: Residential Contract Number: R2074

Provider Name: Youth Services International, Inc. Number of Beds/Slots: 30

Location: Broward County / Circuit 17 Lead Reviewer Code: 107

Original Review Date(s): October 26-28, 2010

Exempt Review Date: August 24, 2011

Review Team

The Bureau of Quality Assurance wishes to thank the following review team members for their participation in this review, and for promoting continuous improvement and accountability in juvenile justice programs and services in Florida:

Tom Mahoney, Lead Reviewer, DJJ Bureau of Quality Assurance Patrice Starks, Review Specialist, DJJ Bureau of Quality Assurance Keyla Osorno, Program Monitor, DJJ Residential Services, South Region

Summary

This review was conducted in accordance with FDJJ-1720 (Quality Assurance Policy and Procedures).

Broward Girls Academy is a thirty-bed, intensive mental health residential program for low-risk and moderate-risk females, ages fourteen to eighteen. The youth are committed to the Department of Juvenile Justice (DJJ) after being assessed and classified as moderate-risk to re-offend with serious to severe mental disturbance. The program is contracted by Youth International Services, Inc. (YSI) with the Department of Juvenile Justice. The program provides custody, treatment and supervision in a secure setting utilizing a therapeutic community model. A quality assurance review was conducted on October 26-28, 2010, at which time the program received an overall Commendable performance rating, placing the program on Exempt Status with the Department of Juvenile Justice. This present Quality Assurance review was conducted on August 24, 2011, in order to determine whether the program is continuing to maintain an acceptable level of performance in nineteen key areas, to include: background screening, abuse-free environment, incident reporting, protective action response, pre-service training, classification, performance planning, grievance process, mental health and substance abuse admission screening, mental health and substance abuse evaluations, suicide prevention, healthcare admission screening, comprehensive physical assessment, sick call, medication administration, episodic and emergency care, supervision of youth, tool management, and control of flammable, poisonous, and toxic items. The program’s management team is comprised of the Facility Administrator, Assistant Facility Administrator, Clinical Director/Designated Mental Health Authority (DMHA), Registered Nurse and Business Manager. The methodology used for this review included observations of the youth and staff while at the program; formal and informal surveys/interviews with staff and youth; a review of applicable policy and procedures, the DJJ contract scope of services, the resident handbook, logbooks, twelve personnel files, three employee training files, three case management files, three mental


health files, three individual healthcare records, and other items that were relevant to the completion of the review. Twelve personnel files were reviewed for compliance with the DJJ background screening policy. Six files were for new hires, six files were for volunteers, and each documented an eligible background screening had been received prior to the date of hire. No staff were applicable for a five-year re-screening. The Annual Affidavit of Compliance with Level Two Screening Standards was completed on January 27, 2011. In addition, the program continues to conduct monthly driver’s license checks on all staff. The program also continues to conduct screening of all staff and volunteers utilizing the Florida Department of Law Enforcement (FDLE) Florida Sexual Offenders and Predatory Registry. The program has an extensive code of conduct to which all staff are expected to comply. During orientation all staff are provided with in-service training in Child Abuse Reporting and each staff reviews and sign a statement on the program’s Code of Ethics and Conduct. In response to compliance with an abuse free environment, during this review period management took immediate action to terminate the employment of a staff member that tested positive for cocaine. All youth and staff surveyed responded that youth are allowed to contact the Abuse Hotline. All youth surveyed reported that they felt “safe” in the program. The program had ten documented incidents reported to the Central Communications Center (CCC). All incidents were reported within the required timeframes. The program uses physical intervention techniques and mechanical restraints in accordance with Florida Administrative Code. Any time staff utilize a physical intervention technique, a Protective Action Response (PAR) Incident Report is generated and appropriately filed. Monthly PAR summaries were submitted to the DJJ Residential Regional Director, as required. Three staff training files were reviewed for pre-service training requirements. All three files reflected documented training that exceeded the required 120 hours of training during the first 180 days of employment. Direct care staff successfully completed PAR training requirements within ninety days of their date of hire. Pre-service/certification training and examinations were documented in the Department’s CORE Learning Management System. The program utilizes a classification system that promotes safety and security, as well as effective delivery of treatment services. The classification team consists of the Clinical Director, Case Manager, Nurse, Facility Administrator, Education Department, and therapist. Based on a review of all documentation and interactions with a newly admitted youth, the program classifies the youth for purposes of assigning her to a room or living area. Youth are reassessed and reclassified, when warranted. A review of three case management files confirmed this practice. The program has a grievance process that includes an informal phase, a formal phase, and an appeal phase. The grievance process is reviewed with the youth upon admission to the program, is detailed in the resident handbook, and was observed posted in the facility. Grievance forms are printed in Spanish and English and are available to all youth. Both staff and youth are trained in the grievance process. The program has a full-time Licensed Mental Health Counselor (LMHC) that serves as the Designated Mental Health Authority (DMHA) and Clinical Director. The DMHA is responsible for the appropriate coordination, implementation, and oversight of the mental health and substance abuse services provided. The program has three full-time unlicensed mental health therapists that provide daily clinical services, including weekends, to all youth in the program. The program has an Agreement for Professional Services with a licensed psychiatrist and a licensed psychologist for the provision of services to the youth in the facility. The DMHA, the


psychologist, and the psychiatrist are on call twenty-four hours per day, seven days a week. The program provides intensive mental health treatment services to all youth. The program utilizes Memorial Regional Hospital as the crisis stabilization unit for the facility .A review of three mental health files revealed that the Massachusetts Youth Screening Instrument-Second Version (MAYSI-2) was completed on all youth during their admission screening to the program. In addition to completing the MAYSI-2, the program also conducts the Beck Depression Inventory, Suicide Probability Scale, Substance Abuse Subtle Screening Inventory, Children’s Functional Assessment Rating Scale, and a Brief Clinical Bio-Psychological Evaluation during the intake assessment process. All youth receive an Assessment of Suicide Risk, regardless of the initial suicide screening results, as part of the initial assessment process. All three youth files documented that youth receive a new in-depth comprehensive mental health/substance abuse evaluation within twenty-one days of admission. Youth receive a Diagnostic Interview for Children and Adolescents (DICA-IV) Report as part of the comprehensive evaluation. Clinical staff conduct a Youth Self-Statement survey with all youth and utilize the information as part of the overall comprehensive evaluation process. All youth receive a psychiatric evaluation within fourteen days of admission. Youth who present suicidal tendencies/behaviors are administered the Suicide Risk Assessment to determine whether the youth needs to be placed on suicide precautionary observation. The program enters suicide alerts into the Juvenile Justice Information System (JJIS) and close the alerts when youth are removed from suicide precaution. Clinical staff complete a Follow-up Assessment of Suicide Risk every twenty-four hours and direct care staff complete the Suicide Precautions Observation Log. The program has a Suicide Prevention Plan, which incorporates all required elements as outlined in the Department of Juvenile Justice Mental Health and Substance Abuse Services Manual. The program has a Health Services Agreement with Convenient Practitioners Services (CPS) to provide a licensed physician to serve as the program’s Designated Health Authority (DHA). The DHA is the physician that provides and/or supervises the provision of necessary and appropriate health care to youth in the care and custody of the program. The DHA is on-site weekly and provides routine medical care and monitoring of medication administration. In addition to the DHA, the program has an Advanced Registered Nurse Practitioner (ARNP) that is also on-site weekly. There are collaborative practice protocols in place for the ARNP. The program also has an Agreement for Professional Services with a licensed psychiatrist for the provision of psychiatric services to the youth in the facility. The DMHA, psychiatrist, and ARNP are on-call twenty-four hours per day, seven days a week. The program utilizes the City Pace Pharmacy in West Palm Beach, Florida for the procurement of medications. Emergency procurement of medications is purchased through the local Wal-mart Pharmacy. In addition, the program has an Agreement for Professional Services with Consulting Pharmacists, Inc. to provide a consultant pharmacist. The program also has agreements with a licensed dentist and a licensed optometrist to provide services. The program utilizes the Broward County Health Department for routine immunizations, human immunodeficiency syndrome (HIV) testing and treatment, sexually transmitted disease (STD) testing and treatment, pre-natal and gynecological care. The program also utilizes Memorial Regional Hospital for emergency services. Three individual healthcare files were reviewed for compliance with the DJJ Health Services Manual. Each record contained a Facility Entry Physical Health Screening (FEPHS) form completed by licensed nursing staff within twenty-four hours of the youth’s admission to the program. It is the practice of the program to notify the Designated Health Authority (DHA) or the Advanced Registered Nurse Practitioner (ARNP) of all admissions, regardless of the youth’s medical history. Baseline health and risk factors are identified using the Comprehensive


Physical Assessment (CPA) and Health-Related History (HRH). The CPA and HRH are completed no later than seven calendar days from the date of admission. In one of the three files reviewed, there was no documentation that the youth received a qualitative urine pregnancy test. There was no documentation that sexually active youth received a gynecological examination. The program ensures that all youth have timely access to healthcare services through an established sick call system, which includes designated times for sick call two times a day, Monday through Friday. All youth are oriented to the sick call process. The sick call forms did not consistently document the youth’s weight; however, the program documented the weight of the youth in the progress notes or on the youth’s monthly weight chart. All sick calls were documented on the Sick Call Index; however, one sick call was not documented on the Sick Call Referral Log. Treatment protocols are developed and approved by the Designated Health Authority (DHA). There is an established referral process that is understood by all staff, including a tracking mechanism to ensure referrals and follow-ups are accomplished. Sick call is conducted in a manner that maintains the youth’s privacy. The program utilized the Department of Juvenile Justice Medication Administration Record (MAR) to document medication administration. All required elements of the MAR were completed as outlined in the Department of Juvenile Justice Health Services Manual. The program documented medication refusals on the Refusal of Treatment Form or on the back of the MAR; however, there was no consistent practice of either forms of documentation. There was one instance of a youth not documenting receiving or refusing medication. The program had one Automated External Defibrillator (AED) and five first aid kits throughout the program. The program maintained Knife-for-Life, wire cutters and needle-nose pliars in various locations within the program. The program did not consistently document episodic and emergency care as outlined in the Department of Juvenile Justice Health Services Manual. The name, credentials, and time of the incident was not consistently documented. The incidents did not consistently note whether the incident was “episodic,” “first aid” or “emergency.” Medical staff did not consistently follow-up with youth when non-healthcare staff provided first aid to the youth. The DHA or the ARNP followed-up with youth who received medical instructions from outside facilities. Ten-minute checks are conducted when youth are in their room sleeping. Interviews confirmed that staff ensures that they can visibly see the youth’s skin and observe respirations of youth. The Assistant Program Director verifies ten-minute checks on a daily basis and documents accuracy. The Assistant Program Director or Program Director conducts administrative reviews of the camera footage on a weekly basis, at a minimum. The Program Director and the Assistant Program Director routinely stop by during off hours and weekends to conduct spot checks, which were evidenced by logbook entries. The program has procedures in place for the management of tools. All staff and youth are trained in the proper use of tools. A Youth Risk Assessment is completed before a youth can participate in any activity involving tools and youth are frisk-searched at the conclusion of such activities. Sharp edged tools are maintained on a shadow board with mesh wire behind two locks and are inventoried daily. Other tools are checked daily by all three shifts and are signed in/out when in use. Flammable, poisonous, and toxic items are restricted from use by the youth, and maintained in a locked cabinet within a shed located outside the facility behind a locked fence. Material Safety Data Sheets (MSDS) are maintained and up-to-date. A daily inventory is documented. Disposal of hazardous chemicals is accomplished through an agreement with Broward County Hazard Waste Disposal.


Findings

As a result of this deemed review, the review team determined that the program:

would receive an overall program performance rating of at least Acceptable on a regular review. Accordingly, the program RETAINS EXEMPT STATUS.

would not receive an overall program performance rating of at least Acceptable on a regular review.

Accordingly, EXEMPT STATUS IS REVOKED, and a regular review will be conducted within 90 days.