facility_name: Les Peters Academy

summary: PREA

raw_content:
PREA AUDIT: Auditor’s Summary Report
JUVENILE FACILITIES
Name of Facility: LES PETERS YOUTH ACADEMY
Physical Address: 3930 WEST DRIVE MARTIN LUTHER KING JR. BOULEVARD, TAMPA, FLORIDA 33614
Date report submitted
Auditor information: Mr. Tracy S. Maxwell
Address: 1761 REDWOOD LANE, MIDDLEBURG 32068
Email: TORCHLIGHT4CHANGE@GMAIL.COM
Telephone number: 904-349-0045
Date of facility visit June 9-10
Facility Information
Facility Mailing Address:
(if different from above)
Telephone Number: 813-871-7655
The Facility is: Military County Federal
Private for profit Municipal State
X Private not for profit
Facility Type: Detention Correction Other:
Name of PREA Compliance Manager: Freddie Anderson Jr. Title:
813-871-7655
Email Address: Freddie.Anderson@us.G4s.com Telephone Number:
Agency Information
Name of Agency: G4S YOUTH SERVICES, LLC
Governing Authority or
Parent Agency: (if
applicable)
Physical Address: 6302 Benjamin Road, Suite 400, Tampa Florida 33634
Mailing Address: (if
different from above)
630
Telephone Number:
Agency Chief Executive Officer
Name: Jim Hill Title: President
Email Address: Jim.Hill@us.G4s.com
Telephone
Number: 813-514-6275 ext. 202
Agency Wide PREA Coordinator:
Name: Bobbi.Pohlman-Rodgers Title: PREA Coordinator
Email Address:
Bobbi.Pohlman@us.G4S.com Telephone
Number: 954-818-5131
1
AUDIT FINDINGS
NARRATIVE:
The Les Peters Academy is a 24-bed residential program for moderate-risk boys, ages 14 to 18, who are in
need of comprehensive mental health services. The program is designed as a transitional and vocational
preparation program that operates as a step-down facility for youth transitioned from the Tampa Residential
Facility.
The Les Peters Academy is equipped to continue the comprehensive mental health treatment services initiated
at the Tampa Residential Facility. The anticipated average length of stay is 9 to 12 months from the time the
youth is admitted to the Tampa Residential Facility until release from the Les Peters Academy.
The Les Peters Academy (school number 295048) is a Type 3 program offering English, Math, Science, Social
Studies, and one elective course. The elective course is typically used to provide additional reading assistance
to needy students or vocational training.
The Hillsborough County Public School System provides general academic instruction for the youth at the Les
Peters Academy. Vocational programming also is offered and includes pre-vocational services that identify a
youth's interests, aptitudes and skills. Vocational programs include an auto body course and wood shop
classes. The youth also are offered a CPR and First Aid certification class and are eligible to participate in a
Food Handler Certificate program. The program offers GED preparation.
DESCRIPTION OF FACILITY CHARACTERISTICS:
The Les Peters Academy is a 24-bed residential program for moderate-risk boys. The facility is equipped with
surveillance cameras throughout the facility and the outdoor recreational areas to ensure the safety and
security of staff and youth. The facility is primarily comprised of eight(8) buildings. The main building houses
all of the residents and has a multi-purpose room for resident leisure recreation and activities. This room also
serves as the cafeteria dining area. The additional buildings include education and counseling portable
classrooms, Maintenance/Instructional Vocational portable building and Auto body Instructional Vocational
Building. The resident sleeping areas are comprised of single and two-person rooms without doors. The
residents’ toilets and showers are located within the residents sleeping area and monitored by constant and
direct supervision of male staff.
SUMMARY OF AUDIT FINDINGS:
The notification of the on-site audit was posted on April 28, 2014, six weeks prior to the first date of the on-site
audit. The posting of the notices was verified by photographs received electronically from the PREA
Coordinators. The photographs indicated notices were posted in various locations throughout the facility
including the housing unit and administrative areas. The Pre-Audit Questionnaire, policies and supporting
documentation were received on April 28, 2014. The documents were uploaded to a UBS flash drive.
The on-site audit was conducted June 9-10, 2014. An in-brief was conducted with the Facility Administrator
and Assistant Facility Administrator. At the conclusion of the in-brief a complete tour of the facility was
conducted including the resident sleeping, showering areas and areas where residents primarily spend their
time.
PREA AUDIT: AUDITOR’S FINAL REPORT 2
My initial assessment of the facility was the youth were under direct supervision of the staff while engaged in
various activities. The sanitation was acceptable throughout the facility. Staff acknowledge where the blind
spots were located in the facility but noted that residents are never left without supervision. The surveillance
system does not capture youth in showers or in their rooms.
During the two-day on-site visit, 13 staff including those from all three shifts were interviewed. All interviews
validated staff knowledge of PREA standards and their responsibilities as first responders. Eleven residents
were also interviewed. Residents were well informed of their right to be free from sexual abuse and
harassment, how to report sexual abuse and harassment, and the services that the community based victims
advocate provides.
The victims’ advocacy Memorandum of Understanding (MOU) service was established; however, the contract
had now been sign during the audit.
Secondary documentation to include two PREA related complaints and one report to law enforcement
concerning an incident which allegedly took place at another facility were thoroughly reviewed.
Number of standards exceeded: 0
Number of standards met: 38
Number of standards not met: 0
Number of standards Not Applicable: 3
PREA AUDIT: AUDITOR’S FINAL REPORT 3
Standard 115.311- Zero Tolerance of Sexual Abuse and Sexual Harassment; PREA
Coordinator
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
The initial review of G4S Les Peters facility policy (10-25 page #3) met the intent of the
PREA Standard. The policy sufficiently met the zero-tolerance standard prohibiting all forms of
sexual abuse and harassment. My interview with the Facility Administrator who also serves
as the PREA Compliance Manager was fully involved and inculcated a zero-tolerance
environment towards all forms of sexual abuse and harassment with the facility. The policy
outlined in the facility’s approach to preventing, detecting and responding to sexual abuse and
harassment, including definitions of prohibited behaviors and sanctions for prohibited behaviors.
The agency has one dedicated PREA Coordinator and one PREA Manager, who is also performing
duties as the Facility Administrator. Interviews with the PREA Coordinator and PREA
Manager/Facility Administrator both validated their responsibilities and both conveyed sufficient
time to oversee the facility’s PREA compliance efforts and to perform their other duties.
Standard 115.312- Contracting with Other Entities for the Confinement of Residents
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
X Non- Applicable Standard
Auditor comments:
G4S Les Peters Youth Academy is a stand-alone facility contracted and govern by The Florida
Department of Juvenile Justice and does not contract for confinement of its residents.
Standard 115.313- Supervision and Monitoring
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
PREA AUDIT: AUDITOR’S FINAL REPORT 4
Auditor comments:
In reviewing the facility’s documentation and submitted staffing plan assessment,
considerations were documented and validated for staffing ratios of 1.8 staff to resident during
waking hours. It is important to note that this ratio was also maintained during the evening and
midnight shifts. An assessment was conducted on the physical plant layout, blind-spots and
unannounced upper-level supervisors’ rounds. There were no documented occurrences of exigent
needed for deviations from the facility staffing plan.
In review of the facility’s PREA Policy 10-25 and the documentation submitted, The facility is
validated compliant with the requirement to document intermediate-level or higher-level staff
unannounced rounds to monitor, deter sexual harassment and sexual abuse.
Standard 115.314- Reserved
Standard 115.315- Limits to Cross-Gender Viewing and Searches
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
G4S Les Peters Policy 10-25 prohibits cross-gender searches only in exigent circumstances and
must document reasoning for the opposite gender search. The policy additionally prohibited staff
from examining a transgender or intersex youth for the sole purpose of determining the resident’s
genital status. Body cavity searches require the Director’s authorization and must be conducted
by licensed medical personnel in a medical establishment. The Search Log indicated there were
no cross-gender strip searches or body cavity searches of residents in the past 12 months. This
standard was validated compliant during resident and staff interviews.
The policy limits pat-down searches to male staff absent exigent circumstances. This was
validated during interviews with both residents and staff.
Policy requires female staff, volunteers and contractors entering the housing unit to announce
themselves upon entering the areas where the likelihood of residents performing bodily functions
occur and shower except in exigent circumstances or when viewing is incidental to routine room
checks. There was no documented deviation from this policy.
Staff and Contractor training records along with staff interviews validated 100% compliance
training on cross-gender pat searches, searches of transgender and intersex residents and Zero
tolerance policy concerning sexual harassment and sexual abuse of Residents and Staff.
Standard 115.316- Residents with Disabilities and Residents Who are Limited English
Proficient
Exceeds Standard (substantially exceeds requirement of standard)
PREA AUDIT: AUDITOR’S FINAL REPORT 5
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
G4S Les Peters Youth Academy has identified the Columbus Juvenile Residential and the Florida
Department of Juvenile Justice to provide interpreter services, a hearing impaired specialist, a
vision impaired specialist, an audiologist, an English as a second language specialist, equipment
and technology for residents, as needed. G4S Les Peters Policy 10-25 requires the PREA Facility
Compliance Manager to take steps to ensure residents with disabilities or who are limited
English proficient are provided meaningful access to all aspects of the facility’s efforts to
prevent, protect and respond to sexual abuse and harassment.
This policy also states the facility will not rely on resident interpreters, resident readers or any
kind of resident assistants except when a delay in obtaining interpreters services could
jeopardize residents’ safety. Resident interviews validates compliance the facility does not use
resident assistants and there were no instances of resident interpreter or readers being used in
the past 12 months.
Standard 115.317- Hiring and Promotion Decisions
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
G4S Les Peters Youth Academy Policy 3-16 specifically addresses all elements as required by
this standard. A review of full-time employees and contractors files interviewed revealed that all
eleven hired during the past 12 months had documented criminal background checks.
Questions regarding past conduct were asked during the interview process. Additionally, signed
acknowledgement forms concerning zero-tolerance of sexual harassment and sexual abuse
were present in the files.
The policy also validated compliance based on the requirement to conduct background checks
every five years.
Standard 115.318- Upgrades to Facilities and Technology
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
G4S Les Peters Youth Academy has not acquired any new facilities since August 20, 2012.
PREA AUDIT: AUDITOR’S FINAL REPORT 6
Additionally the facility has identified the need for the additional cameras and video monitoring
system upgrades.
Standard 115.321- Evidence Protocol and Forensic Medical Examinations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
G4S Les Peters Policy 10-25 requires the Facility Director contact local law enforcement and the
Department of Children and Families who will conduct administrative investigations of abuse
allegations; however, criminal investigations are conducted by the Hillsborough County Sheriff’s
Office. The Office of the Inspector General will also conduct an administrative investigation apart
from any criminal investigation to identify staff misconduct.
G4S Les Peters Youth Academy has submitted a Memorandum of Understanding with the Crisis
Center of Tampa Bay and is currently waiting for the agreement signing. Hillsborough County
Sheriff’s Office verbally acknowledged that a uniform evidence protocol would be followed to
maximize the potential for obtaining usable physical evidence for administrative proceedings and
criminal prosecutions.
Standard 115.322- Policies to Ensure Referrals of Allegations for Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
G4S Les Peters Youth Academy Policy 10-25 requires referrals of sexual abuse allegations to be
submitted to the Hillsborough County Sheriff’s Office, Florida Department of Children and
Families and the Office of the Inspector General. In the past 12 months, Les Peters Youth
Academy had one allegation of sexual abuse, which occurred at the facility involving one resident
making an allegation on another resident. The allegation was reported by the resident accuser to
a staff member of the facility. Les Peters Youth Academy referred the allegations to Hillsborough
County Sherriff’s Office. Both residents; the alleged victim and the abuser were housed at Les
Peters Youth Academy and documentation validates both were kept separated. The facility
followed all protocols and documentation of the allegation and follow-up procedures were
reviewed and found to be in compliance with this standard. The Florida Department of Juvenile
Justice (FDJJ) Division of Youth Services’ website describes the investigative responsibilities for
conducting investigations for the facilities it operates and funds. FDJJ’s website also includes its
PREA policy which describes how investigative responsibilities are handled for allegations of
sexual abuse.
PREA AUDIT: AUDITOR’S FINAL REPORT 7
Standard 115.331- Employees Training
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
G4S Les Peters Academy Policy 10-25 and Florida Department of Juvenile Justice Policy 1919
documents training requirements for PREA. The training curriculums, documented staff training
records and staff interviews validates compliance. The PREA training covered requirements for
direct care, workers, medical personnel and contractors during initial training and annually
refresher training. Specific topics covered during PREA training are consistent with this standard’s
requirements and is tailored to the facility’s male resident population. All employees are trained
as new hires regardless of their previous experience. Employees sign training rosters and are
required to score 70% on a final exam verifying comprehension of PREA training.
Standard 115.332- Volunteer and Contractor Training
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
G4S Les Peters Academy Policy 10-25 and The Florida Department of Juvenile Justice Policy 1919
require volunteers and contractors who have contact with residents to receive PREA training.
This training is provided online. Employees sign training rosters and are required to score 70%
on a final exam verifying comprehension of PREA training. Acknowledge completion Certificates
were reviewed for volunteers and contractors. Interviews with volunteers and contractors
revealed they are knowledgeable concerning their responsibilities relative to PREA and the
agency’s zero tolerance policy regarding sexual abuse and harassment.
Standard 115.333- Resident Education
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
G4S Les Peters Policy 10-25 requires residents to receive information during intake within 24-
hours regarding the facility’s zero tolerance policy and how to report sexual abuse and
harassment. Additionally The Florida Department of Juvenile Justice requires Residents
participate in comprehensive training that is conducted within 10-days of arrival. Residents are
provided a handout entitled “What You Should Know about Sexual Abuse/Assault/Harassment”
which includes information on prevention/intervention, self-protection, reporting and
treatment/counseling. Intake staff or case management staff reviews the handout with the
PREA AUDIT: AUDITOR’S FINAL REPORT 8
residents and residents sign verifying receipt of the information. Documentation of residents’
signatures were reviewed and confirmed during resident interviews. All residents interviewed
stated they received this information the same day they arrived at the facility and periodically
thereafter. Case management staff presents the PREA information in a manner that is
accessible to all residents. During the facility tour PREA posters and reporting instructions were
posted throughout the facility including. If needed, the facility has an agreement to provide
translation services, hearing and visual impairment services for residents with disabilities or who
may be limited English deficient.
Standard 115.334- Specialized Training: Investigation
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
X Non-Applicable Standard
Auditor comments:
There are no facility investigators. All criminal and administrative investigations are referred to
outside agencies.
Standard 115.335- Specialized Training: Medical and Mental Health Care
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
The Florida Department of Juvenile Justice Policy# 1919 requires that all G4S Les Peters Youth
Academy full-time, part-time medical and mental health care practitioners receives specialize
training. The training documentation reviewed validated that all staff received this training from
the National Institution of Corrections. While conducting interviews with the Health Services
Administrator and two registered nurses, it was validated that medical staff do-not conduct
forensic examinations.
Standard 115.341- Obtaining information from Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
G4s Les Peters Policy 9-1 addresses the screening process for vulnerability to victimization and
PREA AUDIT: AUDITOR’S FINAL REPORT 9
sexual aggressive behavior by using the Florida Department of Juvenile Justice Form RC 8050-2.
All facility residents are screened within twenty-four hours upon arrival at the facility. Those
residents who score vulnerable to victim or sexually aggressive are included into the alert
system, as well as receiving further assessments, as identified. Residents who are identified or
report as prior sexual victims are referred to the medical and mental health professionals within
14 days. The screening documentation instrument met the tenets of the standard.
Standard 115.342- Placement of Residents in housing, bed, program, education and work
Assignments.
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
G4S Les Peters Academy has single occupancy rooms for residents. Victimization screening
information may be used to determine a resident’s room assignment and its proximity to direct
care staff in the housing unit to ensure resident’s safety.
G4S Les Peters Policy 8-14, Policy 9-1 and Florida Department of Juvenile Justice Policy 1919
precludes gay, bi-sexual, transgender and intersex residents being placed in a particular
housing unit. Isolation rooms are prohibited by the Florida Department of Juvenile Justice.
Facility staff and residents interviews validated compliance.
Standard 115.343- Reserved
Standard 115. 351- Resident Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
G4S Les Peters Academy Policy 8.3 provides a plethora of ways for residents to report sexual
abuse and harassment including; a pre-programmed telephone line to an outside agency; the
facility provides the addresses in resident’s handbooks and posters throughout the facility.
Instructions for reporting are provided to all residents during the intake process. Instructions
include the Victims Assistance Program so they or their family member can write to an outside
agency; and they may report to any staff member or family member. The facility also has
reporting mechanisms’ in place for staff to privately report. Resident and staff interviews
validated compliance with this standard.
PREA AUDIT: AUDITOR’S FINAL REPORT 10
Standard 115. 352- Exhaustion of Administrative Remedies
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
G4S Les Peters Policy 8-4 outlines procedures for the administrative resident’s grievances
regarding sexual abuse or sexual harassment. The elements of this policy address and comports
with the intent of the standard. There have been no grievances relating to sexual abuse filed in
the past 12 months. Staff and resident interviews validate their knowledge of how the grievance
process is used to report sexual abuse or harassment.
Standard 115. 353- Resident Access to Outside Support Services and Legal Representation
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
G4S Les Peters Academy staff are mandated reporters and are required by G4S Les Peters Policy
10-25 and Florida Department of Juvenile Justice Policy 1919 to immediately report any
knowledge, suspicion or information they receive regarding sexual abuse and harassment,
retaliation against residents or staff who report any incidents or any staff neglect or violation of
responsibilities that may have contributed to an incident or retaliation. Random staff and resident
interviews validated the facility’s compliance with this standard.
Interviews with the case management staff and health service professional validated their
responsibility to inform residents 18 years old of their duty to report and limitations of
confidentiality.
Standard 115. 354- Third Party Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
PREA AUDIT: AUDITOR’S FINAL REPORT 11
Auditor comments:
G42 Les Peters Youth Academy through The Florida Department of Juvenile website informs the
public with information regarding third-party reporting of sexual abuse or sexual harassment on
behalf of any facility resident. Also, parents receive information regarding–party reporting.
Resident interviews revealed their awareness of reporting sexual abuse or harassment to others
outside of the facility.
Standard 115. 361- Staff and Agency Reporting Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
Under Florida Department of Juvenile Justice Policy 1919 and G4S Les Peters Policy all facility
staff are mandated reporters. Staff is required to immediately report any knowledge, suspicion
or information they receive regarding sexual abuse and harassment, retaliation against residents
or staff who report any incidents or any staff neglect or violation of responsibilities that may
have contributed to an incident or retaliation. Random staff and health professional interviews
validated their technical knowledge and compliance with this standard.
Standard 115. 362- Agency Protection Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
G4S Les Peters Policy 10-25 requires residents identified as being at risk for sexual victimization
to be monitored and to receive ongoing counseling from mental health or other qualified staff.
Residents are provided services consistent with the community of care. There were no residents
identified as being at risk for sexual abuse in the past 12 months, as indicated on a log
maintained by the facility and as revealed in interviews with the Facility Director and other
random staff.
Standard 115. 363- Reporting to other Confinement Facilities
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
PREA AUDIT: AUDITOR’S FINAL REPORT 12
Auditor comments:
G4S Les Peters Academy received no allegations of sexual abuse from other facilities during the
past 12 months. Upon receiving an allegation that a resident was sexually abused while confined
at another facility, G4s Les Peters Academy Policy 10-25 and Florida Department of Juvenile
(FDJJ) Justice Policy 1919 requires facility leadership immediately notify the Florida Department
of Juvenile Justice Central Communications Center. The FDJJ will in turn notify the facility the
facility management overseeing the facility where the alleged abuse occurred.
Standard 115. 364- Staff First Responder Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
There was one allegation of sexual abuse during the past 12 months. G4S Les Peters Policy
10-25 and The Florida Department of Juvenile Justice Policy 1919 requires staff to take specific
steps to respond to a report of sexual abuse including; separating the alleged victim from the
abuser; preserving any crime scene within a period that still allows for the collection of physical
evidence; request that the alleged victim not take any action that could destroy physical
evidence; and ensure that the alleged abuser does not take any action to destroy physical
evidence, if the abuse took place within a time period that still allows for the collection of physical
evidence. Random staff and first responder interviews validated their technical knowledge of
actions to be taken upon learning that a resident was sexually abused.
Standard 115. 365- Coordinated Response
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
Interviews with the Facility Administrator, Assistant Facility Administrator and other professional
staff validated their technical knowledgeable of their duties in response to a sexual assault. G4S
Les Peter’s Academy Policy 10-25, Policy 7-30 and The Florida Department of Juvenile Justice
Policy 1919 gives technical directions concerning coordinated actions taken in response to an
incident of sexual assault among staff first responders, medical, and facility leadership.
Standard 115. 366- Preservation of Ability to Protect Residents from Contact with Abusers
Exceeds Standard (substantially exceeds requirement of standard)
PREA AUDIT: AUDITOR’S FINAL REPORT 13
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
X Non-Applicable Standard
Auditor comments:
Les Peters Youth Academy is not in a Collective bargaining Agreement.
Standard 115. 367- Agency Protection against Retaliation
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
All G4S Les Peters Youth Academy staff are charged with monitoring for possible retaliation.
There were no incidents of retaliation in the past 12 months reported. This was validated during
my interview with the PREA Manager/ Facility Administrator. G4S Les Peters Policy 10-25, Policy
8-3 and The Florida Department of Juvenile Justice Policy 1919 all require the monitoring of
residents and staff who have reported sexual abuse or harassment or who have cooperated in a
sexual abuse or harassment investigation. The monitoring will take place for a period of 90 days
or longer, as needed.
Standard 115. 368- Post-Allegation Protective Custody
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
G4S Les Peters Youth Academy does not have isolation rooms or segregation housing. Les Peters
Youth Academy use single occupancy rooms to protect residents who alleged to have suffered
sexual abuse. Random staff interviewed validated resident(s) are monitored constantly by staff.
G4S Les Peter’s Policy 10-25 and The Florida Department of Juvenile Justice Policy 1919 provide
guidelines for the use of room restriction as a last measure to keep residents who alleged sexual
abuse safe only until an alternative means for keeping the resident safe can be arranged.
Standard 115. 371- Criminal and Administrative Agency Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
PREA AUDIT: AUDITOR’S FINAL REPORT 14
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
There was one reported investigation of alleged resident sexual abuse in the facility in the past
12 months. The investigation is currently ongoing. G4S Les Peter’s Policy 1-5, Policy 10-25 and
The Department of Juvenile Justice Policy 1919 establishes investigation guidelines for reporting
allegations of sexual abuse to the Hillsborough County Sheriff’s Office, The Office of The
Inspector General and The Florida Department of Children Services for investigations.
Standard 115. 372- Evidentiary Standards for Administrative Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
The Florida Department of Juvenile Justice Policy 1919 states the outside investigative entities,
the Hillsborough County Sheriff’s office and the Florida Department of Children Services, shall
impose a standard of preponderance of evidence or lower standards of proof for determining if
allegations are substantiated.
Standard 115. 373- Reporting to Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
There was one criminal and administrative investigation during the past 12 months. There has
been no notice sent to the residents because the case is still ongoing. G4S Les Peter’s Policy 10-
25 and The Florida Department of Juvenile Justice Policy 1919 establishes processes to notify
residents should the need arise and an allegation proves substantiated, unsubstantiated or
unfounded. The Agencies PREA Coordinators and PREA Compliance Manager validated their
technical knowledge of the process during their interviews.
Standard 115. 376- Disciplinary for Staff
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
PREA AUDIT: AUDITOR’S FINAL REPORT 15
Does Not Meet Standard (requires corrective action)
Auditor comments:
There were no employee terminated or disciplined in the past 12 months for violation of the
facility’s sexual abuse or harassment policies. G4s Employee Handbook, G4S Les Peter’s
Policy 3-3 and Policy 3-5 requires staff disciplinary sanctions up to and including termination for
violating facility’s sexual abuse or harassment policies. The policy also mandates that the
violation be reported to law enforcement.
Standard 115. 377- Corrective Action for Contractors and volunteers
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
The Florida Department of Juvenile Justice Policy 1919 requires volunteers and contractors in
violation of the facility’s policies and procedures regarding sexual abuse and harassment of
residents will be reported to local law enforcement and relevant licensing bodies unless the
activity was clearly not criminal. During the interview with the Facility Administrator/PREA
Compliance Manager, it was reported that their have been no volunteers or contractors reported
in the past 12 months.
The policy also requires the facility staff to take remedial measures and prohibit future contact
with residents in the case of any violation of the facility’s sexual abuse and harassment policies
by contractors or volunteers.
Standard 115. 378- Disciplinary sanctions for Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
There has been one reported case of resident-on-resident sexual abuse case that is still an
active case in the past 12 months. There have been no administrative or criminal findings or
rulings on this case.
Standard 115. 381- Medical and Mental screening; History of Sexual Abuse
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
PREA AUDIT: AUDITOR’S FINAL REPORT 16
Does Not Meet Standard (requires corrective action)
Auditor comments:
There were six residents who disclosed prior victimization during their initial screening process.
During the interview with the Health Services Administrator, she validated that all six were
offered follow-up meetings with medical and mental health providers. The Florida Department of
Juvenile Justice Policy 1919 requires mental health and medical staff to monitor and provide
counseling on an on-going basis for residents who disclose a history of sexual abuse or who
disclose previously perpetrating sexual abuse.
Standard 115. 382- Access to Emergency Medical and Mental Health Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
There has been one reported case of sexual abuse in the past 12 months. The Health Services
Administrator interview validated through documentation the resident’s access to medical and
mental care of the alleged incident. The Florida Department of Juvenile Justice Policy 1919
mandates residents receive timely, unimpeded care on-site and off-site emergency care and
crisis intervention services.
Standard 115. 383- Ongoing Medical and Mental Health Care for Sexual Abuse Victims and
Abusers
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
There has been one alleged sexual assault victim in the past 12 months. The investigation is still
ongoing. The Facility Administrator/ PREA Compliance Manager’s interview revealed that both
the alleged victim and accuser receive ongoing counseling during individual and group
counseling sessions as needed.
Standard 115. 386- Sexual Abuse Incident Reviews
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
PREA AUDIT: AUDITOR’S FINAL REPORT 17
Auditor comments:
The Florida Department of Juvenile Justice Policy 1919 and G4S Policy 10-25 require a incident
review team of every sexual abuse allegation at the conclusion of the investigation within 30
days. The review team includes the PREA Compliance Manager, Department program staff
mental and medical health providers and upper-level management with input from line
supervisors. The facility has a specific review form to capture all aspects of the incident.
Standard 115. 387- Data Collection
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
The Florida Department of Juvenile Justice Policy 1919 Definitions, requires the collection of
accurate, uniform data for every allegation of sexual assault. The facility’s PREA Coordinators
collect all data relating to PREA.
Standard 115. 388- Data Review for Corrective Action
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
There has been one alleged sexual abuse allegations within the past 12 months. The case is still
an active case; however, The Florida Department of Juvenile Justice Policy 1919 requires the
review of data for corrective action to improve the effectiveness of its prevention, protection and
response policies, practices and training.
Standard 115. 389- Data Storage, Publication, and Destruction
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor comments:
The Florida Department of Juvenile Justice Policy 1919 directs that data from every allegation of
sexual misconduct at its facilities shall be collected at Central Communications Center. The
PREA Coordinator will review data collected in order to assess and improving the effectiveness
PREA AUDIT: AUDITOR’S FINAL REPORT 18
of the Department’s sexual misconduct prevention, detection and response polices, practices
and training. The policy established that aggregated sexual abuse data be reviewed annually
and place on the facility’s website after all personal identifiers are removed. All data collected
will be maintained for at least 10 years after the date of the initial collection.
AUDITOR CERTIFICATION:
The auditor certifies that the contents of the report are accurate to the best of his/her knowledge and
no conflict of interest exists with respect to his or her ability to conduct an audit of the agency under
review.
Auditor’s Signature Date: June 27, 2014
PREA AUDIT: AUDITOR’S FINAL REPORT 19

report_type: PREA

program_name_raw: les peters youth academy


state: FL

summary: PREA - Year 1 Cycle 4

raw_content:
Program: Les Peters Academy
Report Type: PREA
Fiscal Year:
Status:
PDF URL: https://www.djj.state.fl.us/content/download/766182/file/Florida_Les Peters Academy_year1cycle4.pdf?version=1

source: DJJ

program_name_raw: Les Peters Academy

cycle: Year 1 Cycle 4


summary: SPEP - FY20-21

raw_content:
Standardized Program Evaluation
Protocol [SPEP] Report
Les Peters Girls Academy
TrueCore Behavioral Solutions, LLC
(Contract Provider)
3930 West Martin Luther King Jr. Blvd.
Tampa, Florida 33614
Primary Service: Female Healthy Relationships
SPEP Review Period: 8/1/2019 - 7/31/2020
SPEP Review Conducted: 8/12/2020
Florida Department of Juvenile Justice
Report Date: 10/28/2020
Introduction
The Standardized Program Evaluation Protocol (SPEP) is data-driven rating system for
evaluating program effectiveness. The SPEP was developed by relying on hundreds of studies
that have examined key characteristics of programs that demonstrated their ability to reduce
recidivism. To determine a SPEP score, the program’s services are compared to characteristics
of effective programs in the research of a similar type.
The SPEP score is composed of four principle characteristics that have been shown to predict
reductions in youth recidivism; service type, quality of service, dosage (amount of service), and
youth level of risk.
• Service Type: service type points are awarded based on the group category that the
service falls within
• Quality of Service: quality points are awarded by determining the extent to which the
program is delivered in what research suggests is a high-quality manner
• Amount of Service: or “dosage” refers to the amount and duration of services that were
received
• Risk Level: refers to the level of criminogenic risk for youth involved in the intervention.
The final output of the SPEP review is the Program Optimization Percentage (POP). This rate is
derived from the Basic Score and Program Optimization Score. The POP rate is a percentage
score that indicates how the service rates in effectiveness when compared to the potential
effectiveness if optimized to match the most effective services in the research. This means the
POP rate represents how close the program’s Primary Service is to its potential for that Primary
Service Type. For example, a POP rate of 55% would indicate that the program’s Primary
Service is operating at 55% of its potential effectiveness for recidivism reduction based on the
SPEP research.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 2
Basic Score: 30 Points
1. Primary Service and Supplemental Service Types POS: 30 Points
POP: 100%
There are five Primary Service Types that have been classified into Groups with a maximum
number of points possible for rating purposes. Some Primary Service Types may also have
qualifying Supplemental Service Types that could earn a program an additional 5 points.
The Primary Service for this program is Female Healthy Relationships.
The program was awarded 25 points because the Primary Service is identified as a Group 4
Service. The specific Sub-Component Service Type identified is Group Counseling. The Primary
Service was identified as this type of service as it focuses on psychological or interpersonal
problems or issues faced by an individual and involves a group of youths interacting with each
other.
An additional 5 points was awarded based on a Qualifying Supplemental Service. The Qualifying
Supplemental Service was identified as None (automatic 5 points added to score), which was not
demonstrated to have been implemented.
The Primary and Supplemental Service Raw Score is equal to the sum of the Primary Service
points plus the Qualifying Supplemental Service points.
Note: Quality information is evaluated during quarterly and annual reviews.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 3
Basic Score: 20 Points
2. Overall Quality of Service Delivery Score POS: 20 Points
POP: 100%
The Quality of Service Delivery Score is the sum of the scores for the seven treatment quality
indicators. The Program Optimization Percentage Rating determines the Overall Quality of
Service Level:
Indicator Sum Score 0-3 = Low; Sum Score 4-7 = Medium; Sum Score 8-10 = High.
Sum of all Indicator Scores (a – g below): 10 Points
Overall Quality of Service Delivery Level:
Low (Raw Score = 5)
Medium (Raw Score = 10)
High (Raw Score = 20 Points)
Basic Score: 1 Point(s)
a. Facilitator Training
Maximum Possible Score: 1 Point
All facilitator(s) of the Primary Service must have received formal training specific to the
intervention or model/protocol.
The program has a training protocol for Female Healthy Relationships. There were six staff
trained in the curriculum, one Director of Clincial Services, one Assistant Clinical Director and four
Therapists. Three facilitated Female Healthy Relationships during the review period.
Basic Score: 2 Point(s)
b. Treatment Manual/Protocol
Maximum Possible Score: 2 Points
There is a specific written manual/protocol detailing delivery of the Primary Service.
The Female Healthy Relationships bundle consists of two curricula - The Teen Relationships
Workbook and VOICES- A Program of Self-Discovery and Change. Both manuals and
accompanying protocols were provided for review. The manuals both contain scripts for the
facilitator for the groups. They both provide the lessons and include implementation guidelines,
identifies the order the lessons should be delivered in and includes detailed instructions for the
delivery of each lesson for both groups.
Basic Score: 1 Point(s)
c. Observed Adherence to the Manual/Protocol
Maximum Possible Score: 1 Point
Upon observation of the Primary Service by the Quality Improvement reviewer, the facilitator of
that service adhered to the written protocol/manual.
A session of Female Healthy Relationships was observed via Facetime due to the COVID19
Pandemic. The facilitator adhered to the lesson plan.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 4
Basic Score: 2 Point(s)
d. Facilitator Turnover
Maximum Possible Score: 2 Points
Measures the extent to which facilitators of the specific intervention/service have changed as
well as gaps in service of that Primary Service.
Upon review of documentation and an interview with the Director of Clinical Services, it was
determined there has been some facilitator turnover during the review period; however, it was
discovered the turnover did not adversely affect the services of Female Healthy Relationships.
There were two gaps in service of 33 and 40 days. These gaps were due to the lack of enrollment
of enough new youth to start new groups. The program, in the case of turnover, uses other trained
staff to facilitate the curriculum.
Basic Score: 2 Point(s)
e. Internal Fidelity Monitoring
Maximum Possible Score: 2 Points
The program has a process to monitor the delivery of the intervention to examine how closely
actual implementation matches the model protocol.
According to a review of the Female Healthy Relationships documentation provided, all fidelity
monitoring was completed for each facilitator during each month of the review period.
Basic Score: 1 Point
f. Corrective Action based on Fidelity Monitoring
Maximum Possible Score: 1 Point
The program has a process by which corrective action is applied and demonstrated based on
the fidelity monitoring of the delinquency intervention/therapeutic service.
An interview with the Director of Clinical Services verified the program has a process for
corrective actions based on the fidelity monitoring conducted. The program uses internal fidelity
monitoring/corrective action checklists specific to Female Healthy Relationships. A review of
documentation provided and an interview with the Director of Clinical Services verified there was
no corrective action taken during the review period.
g. Evaluation of Facilitator Skill Delivering the Basic Score: 1 Point
Intervention Maximum Possible Score: 1 Point
Performance evaluations of the facilitators of the specific intervention/service include
evaluation of skill in delivering the intervention/service.
The performance evaluations of the current trained facilitators found entries of the staff's
performance in delivering Female Healthy Relationships. These included comments on any
strengths or weaknesses of which the facilitator should be aware.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 5
3. Amount of Service - Duration
Basic Score: 2 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 20%
Research indicates the target duration of 24 weeks for this type of service. Of the 15 youth in the
sample, 33% (5 of 15) reached at least the indicated target duration. Further explanation is
detailed in the Summary and Recommendations below.
Note: Dosage information (duration) is calculated from the Juvenile Justice Information System
(JJIS) Evidence-Based Services module. Duration is included for the youth in the SPEP sample.
4. Amount of Service – Contact Hours
Basic Score: 8 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 80%
Research indicates a target of 40 contact hours for this type of service. Of the 15 youth in the
sample, 93% (14 of 15) reached the indicated target contact hours. Further explanation is detailed
in the Summary and Recommendations below.
Note: Dosage information (contact hours) is calculated from the Juvenile Justice Information
System (JJIS) Evidence-Based Services module. Contact hours are included for the youth in the
SPEP sample.
5. Risk Level of Youth Served:
Basic Score: 15 Points
Program Optimization Score: 25 Points
Program Optimization Percentage: 60%
Percentage of Youth with Moderate, Moderate-High, and High-Risk Levels to Reoffend: 67%
Moderate to High Score: 5 Points
Program Optimization Score: 12 Points
Program Optimization Percentage: 42%
Table 1
Moderate = 1 youth
Moderate-High = 4 youth
High = 5 youth
Total Youth in Sample = 15 youth
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 6
Percentage of Youth with High-Risk Level to Reoffend: 33%
High Score: 10 Points
Program Optimization Score: 13 Points
Program Optimization Percentage: 77%
Table 2
High = 5 youth
Total Youth in Sample = 15 youth
The risk level score is compiled by calculating the total percent of the SPEP sample that score
Moderate to High-Risk to reoffend and also the total percent of the SPEP sample that score High-
Risk to reoffend.
Of the SPEP sample, 67% (10 of 15) youth scored Moderate to High-Risk to reoffend, for a score
of 5 points.
Of the SPEP sample, 33% (5 of 15) youth scored High-Risk to reoffend, for a score of 10 points.
Note: The latest Community Assessment Tool (CAT) prior to the placement date was used in the
derivation of the risk level score. This CAT provides the best indication of the risk to re-offend
level of the youth when the youth was first placed in the program.
Summary and Recommendations
Program Program
Category Basic Score Optimization Optimization
Score Percentage
Primary and Supplemental Service Type 30 30 100%
Quality of Service Delivery 20 20 100%
Amount of Service: Duration 2 10 20%
Amount of Service: Contact Hours 8 10 80%
Risk Level of Youth Served 15 25 60%
Totals 75 95 79%
This SPEP report evaluates Female Healthy Relationships, an intervention delivered at Les
Peters Girls Academy.
15 youth completed the program during the review period. Of those youth, all 15 were included in
the sample.
The program scored High for Quality of Service Delivery.
The program earned 2 points for Amount of Service: Duration. Of the 15 total youth sampled, only
14 included dosage with end dates in the EBS Module. Of those youth with correct dosage, 5
received at least the recommended weeks of service. Youth in the sample completed between 6
and 37 weeks of service, with an average of 22 weeks.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 7
The program earned 8 points for Amount of Service: Contact Hours. Of the 15 total youth
sampled, all 15 included dosage in the EBS Module. Of those youth, 14 received at least the
recommended hours of service. Youth in the sample completed between 28 and 99 hours of
service, with an average of 68 hours.
The program was awarded 15 available points for Risk Level of Youth Served. This is calculated
using data from the Community Assessment Tool (CAT) assessment. This score reflects youths'
most recent CAT score prior to placement at the program. The program itself has no control over
youths' CAT risk level because the scored assessment was administered prior to the youths'
admission.
Had the percentage of youth served with Moderate-High and High risk to reoffend been higher,
and this report awarded each 25 of the available points for this section, the Program Optimization
Percentage for this service would increase to 89%. As stated previously, the Risk Level of Youth
Served score is not under the control of the program.
RECOMMENDATION(S):
Les Peters Girls Academy can maintain their SPEP Quality of Service Delivery score by
continuing the practices in place at the time of this review.
Les Peters Girls Academy can optimize their SPEP Amount of Service score by ensuring that
dosage for all youth is recorded accurately in EBS and by ensuring that youth receive the full
targeted dosage of service.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 8

report_type: SPEP

program_name_raw: Les Peters Academy - Females

program_status_note: Closed

service_type: Female Healthy Relationships


summary: SPEP - FY20-21

raw_content:
Standardized Program Evaluation
Protocol [SPEP] Report
Les Peters Girls Academy
TrueCore Behavioral Solutions, LLC
(Contract Provider)
3930 West Martin Luther King Jr. Blvd.
Tampa, Florida 33614
Primary Service: Impact of Crime
SPEP Review Period: 8/1/2019 - 7/31/2020
SPEP Review Conducted: 8/12/2020
Florida Department of Juvenile Justice
Report Date: 10/28/2020
Introduction
The Standardized Program Evaluation Protocol (SPEP) is data-driven rating system for
evaluating program effectiveness. The SPEP was developed by relying on hundreds of studies
that have examined key characteristics of programs that demonstrated their ability to reduce
recidivism. To determine a SPEP score, the program’s services are compared to characteristics
of effective programs in the research of a similar type.
The SPEP score is composed of four principle characteristics that have been shown to predict
reductions in youth recidivism; service type, quality of service, dosage (amount of service), and
youth level of risk.
• Service Type: service type points are awarded based on the group category that the
service falls within
• Quality of Service: quality points are awarded by determining the extent to which the
program is delivered in what research suggests is a high-quality manner
• Amount of Service: or “dosage” refers to the amount and duration of services that were
received
• Risk Level: refers to the level of criminogenic risk for youth involved in the intervention.
The final output of the SPEP review is the Program Optimization Percentage (POP). This rate is
derived from the Basic Score and Program Optimization Score. The POP rate is a percentage
score that indicates how the service rates in effectiveness when compared to the potential
effectiveness if optimized to match the most effective services in the research. This means the
POP rate represents how close the program’s Primary Service is to its potential for that Primary
Service Type. For example, a POP rate of 55% would indicate that the program’s Primary
Service is operating at 55% of its potential effectiveness for recidivism reduction based on the
SPEP research.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 2
Basic Score: 20 Points
1. Primary Service and Supplemental Service Types POS: 20 Points
POP: 100%
There are five Primary Service Types that have been classified into Groups with a maximum
number of points possible for rating purposes. Some Primary Service Types may also have
qualifying Supplemental Service Types that could earn a program an additional 5 points.
The Primary Service for this program is Impact of Crime.
The program was awarded 15 points because the Primary Service is identified as a Group 3
Service. The specific Sub-Component Service Type identified is Social Skills Training. The
Primary Service was identified as this type of service as it focuses on developing social skills
required for an individual to interact in a positive way with others.
An additional 5 points was awarded based on a Qualifying Supplemental Service. The Qualifying
Supplemental Service was identified as None (automatic 5 points added to score), which was not
demonstrated to have been implemented.
The Primary and Supplemental Service Raw Score is equal to the sum of the Primary Service
points plus the Qualifying Supplemental Service points.
Note: Quality information is evaluated during quarterly and annual reviews.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 3
Basic Score: 20 Points
2. Overall Quality of Service Delivery Score POS: 20 Points
POP: 100%
The Quality of Service Delivery Score is the sum of the scores for the seven treatment quality
indicators. The Program Optimization Percentage Rating determines the Overall Quality of
Service Level:
Indicator Sum Score 0-3 = Low; Sum Score 4-7 = Medium; Sum Score 8-10 = High.
Sum of all Indicator Scores (a – g below): 10 Points
Overall Quality of Service Delivery Level:
Low (Raw Score = 5)
Medium (Raw Score = 10)
High (Raw Score = 20 Points)
Basic Score: 1 Point(s)
a. Facilitator Training
Maximum Possible Score: 1 Point
All facilitator(s) of the Primary Service must have received formal training specific to the
intervention or model/protocol.
There were three staff trained in the Impact of Crime curriculum, two Case Managers and one
Lead Case Manager. One Case Manager facilitated and the Lead Case Manager provided fidelity
monitoring.
Basic Score: 2 Point(s)
b. Treatment Manual/Protocol
Maximum Possible Score: 2 Points
There is a specific written manual/protocol detailing delivery of the Primary Service.
The manual provided for review was Impact of Crime-Addressing the Harm. The manual contains
a script for the facilitator for the group. It provides the lessons and includes implementation
guidelines, identifies the order the lessons should be delivered in and includes detailed
instructions for delivery of each lesson.
Basic Score: 1 Point(s)
c. Observed Adherence to the Manual/Protocol
Maximum Possible Score: 1 Point
Upon observation of the Primary Service by the Quality Improvement reviewer, the facilitator of
that service adhered to the written protocol/manual.
The Impact of Crime group was observed via Facetime, due to the COVID19 pandemic. The
facilitator adhered to the lesson plan.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 4
Basic Score: 2 Point(s)
d. Facilitator Turnover
Maximum Possible Score: 2 Points
Measures the extent to which facilitators of the specific intervention/service have changed as
well as gaps in service of that Primary Service.
Upon review of documentation and an interview with the Lead Case Manager, there has been
some facilitator turnover during the review period; however, it was discovered the turnover did not
adversely affect the services of Impact of Crime to the youth. There were no gaps in the services
of Impact of Crime to the youth.
Basic Score: 2 Point(s)
e. Internal Fidelity Monitoring
Maximum Possible Score: 2 Points
The program has a process to monitor the delivery of the intervention to examine how closely
actual implementation matches the model protocol.
According to a review of documentation provided, fidelity monitoring was completed on Impact of
Crime for all months during the review period, without exception.
Basic Score: 1 Point
f. Corrective Action based on Fidelity Monitoring
Maximum Possible Score: 1 Point
The program has a process by which corrective action is applied and demonstrated based on
the fidelity monitoring of the delinquency intervention/therapeutic service.
An interview with the Lead Case Manager verified the program has a process for corrective
actions based on the fidelity monitoring conducted. The program uses internal fidelity monitoring /
corrective action checklists specific to the Impact of Crime curriculum. A review of documentation
provided and an interview with the Lead Case Manager verified there were no corrective actions
noted nor taken during the review period.
g. Evaluation of Facilitator Skill Delivering the Basic Score: 1 Point
Intervention Maximum Possible Score: 1 Point
Performance evaluations of the facilitators of the specific intervention/service include
evaluation of skill in delivering the intervention/service.
The performance evaluations of the current trained facilitators found entries of the staff's
performance in delivering Impact of Crime. These included comments on any strengths or
weaknesses of which the facilitator should be aware.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 5
3. Amount of Service - Duration
Basic Score: 4 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 40%
Research indicates the target duration of 16 weeks for this type of service. Of the 15 youth in the
sample, 47% (7 of 15) reached at least the indicated target duration. Further explanation is
detailed in the Summary and Recommendations below.
Note: Dosage information (duration) is calculated from the Juvenile Justice Information System
(JJIS) Evidence-Based Services module. Duration is included for the youth in the SPEP sample.
4. Amount of Service – Contact Hours
Basic Score: 10 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 100%
Research indicates a target of 24 contact hours for this type of service. Of the 15 youth in the
sample, 100% (15 of 15) reached the indicated target contact hours. Further explanation is
detailed in the Summary and Recommendations below.
Note: Dosage information (contact hours) is calculated from the Juvenile Justice Information
System (JJIS) Evidence-Based Services module. Contact hours are included for the youth in the
SPEP sample.
5. Risk Level of Youth Served:
Basic Score: 15 Points
Program Optimization Score: 25 Points
Program Optimization Percentage: 60%
Percentage of Youth with Moderate, Moderate-High, and High-Risk Levels to Reoffend: 67%
Moderate to High Score: 5 Points
Program Optimization Score: 12 Points
Program Optimization Percentage: 42%
Table 1
Moderate = 1 youth
Moderate-High = 4 youth
High = 5 youth
Total Youth in Sample = 15 youth
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 6
Percentage of Youth with High-Risk Level to Reoffend: 33%
High Score: 10 Points
Program Optimization Score: 13 Points
Program Optimization Percentage: 77%
Table 2
High = 5 youth
Total Youth in Sample = 15 youth
The risk level score is compiled by calculating the total percent of the SPEP sample that score
Moderate to High-Risk to reoffend and also the total percent of the SPEP sample that score High-
Risk to reoffend.
Of the SPEP sample, 67% (10 of 15) youth scored Moderate to High-Risk to reoffend, for a score
of 5 points.
Of the SPEP sample, 33% (5 of 15) youth scored High-Risk to reoffend, for a score of 10 points.
Note: The latest Community Assessment Tool (CAT) prior to the placement date was used in the
derivation of the risk level score. This CAT provides the best indication of the risk to re-offend
level of the youth when the youth was first placed in the program.
Summary and Recommendations
Program Program
Category Basic Score Optimization Optimization
Score Percentage
Primary and Supplemental Service Type 20 20 100%
Quality of Service Delivery 20 20 100%
Amount of Service: Duration 4 10 40%
Amount of Service: Contact Hours 10 10 100%
Risk Level of Youth Served 15 25 60%
Totals 69 85 81%
This SPEP report evaluates Impact of Crime, an intervention delivered at Les Peters Girls
Academy.
15 youth completed the program during the review period. Of those youth, all 15 were included in
the sample.
The program scored High for Quality of Service Delivery.
The program earned 4 points for Amount of Service: Duration. Of the 15 total youth sampled, all
15 included dosage with end dates in the EBS Module. Of those youth, 7 received at least the
recommended weeks of service. Youth in the sample completed between 12 and 16 weeks of
service, with an average of 15 weeks.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 7
The program earned 10 points for Amount of Service: Contact Hours. Of the 15 total youth
sampled, all 15 included dosage in the EBS Module. Of those youth, 15 received at least the
recommended hours of service. Youth in the sample completed between 31 and 42 hours of
service, with an average of 37 hours.
The program was awarded 15 available points for Risk Level of Youth Served. This is calculated
using data from the Community Assessment Tool (CAT) assessment. This score reflects youths'
most recent CAT score prior to placement at the program. The program itself has no control over
youths' CAT risk level because the scored assessment was administered prior to the youths'
admission.
Had the percentage of youth served with Moderate-High and High risk to reoffend been higher,
and this report awarded each 25 of the available points for this section, the Program Optimization
Percentage for this service would increase to 93%. As stated previously, the Risk Level of Youth
Served score is not under the control of the program.
RECOMMENDATION(S):
Les Peters Girls Academy can maintain their SPEP Quality of Service Delivery score by
continuing the practices in place at the time of this review.
Les Peters Girls Academy can optimize their SPEP Amount of Service score by ensuring that
dosage for all youth is recorded accurately in EBS and by ensuring that youth receive the full
targeted dosage of service.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 8

service_type: Impact of Crime


summary: SPEP - FY20-21

raw_content:
Standardized Program Evaluation
Protocol [SPEP] Report
Les Peters Girls Academy
TrueCore Behavioral Solutions, LLC
(Contract Provider)
3930 West Martin Luther King Jr. Blvd.
Tampa, Florida 33614
Primary Service: Individual Counseling
SPEP Review Period: 8/1/2019 - 7/31/2020
SPEP Review Conducted: 8/12/2020
Florida Department of Juvenile Justice
Report Date: 10/28/2020
Introduction
The Standardized Program Evaluation Protocol (SPEP) is data-driven rating system for
evaluating program effectiveness. The SPEP was developed by relying on hundreds of studies
that have examined key characteristics of programs that demonstrated their ability to reduce
recidivism. To determine a SPEP score, the program’s services are compared to characteristics
of effective programs in the research of a similar type.
The SPEP score is composed of four principle characteristics that have been shown to predict
reductions in youth recidivism; service type, quality of service, dosage (amount of service), and
youth level of risk.
• Service Type: service type points are awarded based on the group category that the
service falls within
• Quality of Service: quality points are awarded by determining the extent to which the
program is delivered in what research suggests is a high-quality manner
• Amount of Service: or “dosage” refers to the amount and duration of services that were
received
• Risk Level: refers to the level of criminogenic risk for youth involved in the intervention.
The final output of the SPEP review is the Program Optimization Percentage (POP). This rate is
derived from the Basic Score and Program Optimization Score. The POP rate is a percentage
score that indicates how the service rates in effectiveness when compared to the potential
effectiveness if optimized to match the most effective services in the research. This means the
POP rate represents how close the program’s Primary Service is to its potential for that Primary
Service Type. For example, a POP rate of 55% would indicate that the program’s Primary
Service is operating at 55% of its potential effectiveness for recidivism reduction based on the
SPEP research.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 2
Basic Score: 10 Points
1. Primary Service and Supplemental Service Types POS: 10 Points
POP: 100%
There are five Primary Service Types that have been classified into Groups with a maximum
number of points possible for rating purposes. Some Primary Service Types may also have
qualifying Supplemental Service Types that could earn a program an additional 5 points.
The Primary Service for this program is Individual Counseling.
The program was awarded 5 points because the Primary Service is identified as a Group 1
Service. The specific Sub-Component Service Type identified is Individual Counseling. The
Primary Service was identified as this type of service as it includes any range of treatment
techniques that focus on psychological or interpersonal problems or issues faced by an individual
that involves a one-on-one relationship with a therapist or counselor.
An additional 5 points was awarded based on a Qualifying Supplemental Service. The Qualifying
Supplemental Service was identified as None (automatic 5 points added to score), which was not
demonstrated to have been implemented.
The Primary and Supplemental Service Raw Score is equal to the sum of the Primary Service
points plus the Qualifying Supplemental Service points.
Note: Quality information is evaluated during quarterly and annual reviews.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 3
Basic Score: 20 Points
2. Overall Quality of Service Delivery Score POS: 20 Points
POP: 100%
The Quality of Service Delivery Score is the sum of the scores for the seven treatment quality
indicators. The Program Optimization Percentage Rating determines the Overall Quality of
Service Level:
Indicator Sum Score 0-3 = Low; Sum Score 4-7 = Medium; Sum Score 8-10 = High.
Sum of all Indicator Scores (a – g below): 9 Points
Overall Quality of Service Delivery Level:
Low (Raw Score = 5)
Medium (Raw Score = 10)
High (Raw Score = 20 Points)
Basic Score: 1 Point(s)
a. Facilitator Training
Maximum Possible Score: 1 Point
All facilitator(s) of the Primary Service must have received formal training specific to the
intervention or model/protocol.
There were five clinicians trained to provide Individual Counseling to the youth. There were three
Therapists, one Assistant Clinical Director and one Director of Clinical Services. Four facilitated
and the Director of Clinical Services provided fidelity monitoring. The program maintains all
information regarding counseling in the youth's mental health/substance abuse record. There was
documentation to support that each therapist had the education and experience to provide
counseling. Individual counseling was facilitated by four clinicians during the review period. For
this service, which does not have a formal curriculum, the facilitator receives training from a
licensed clinician. The facilitator receives additional training as needed, which is documented
during their clinical supervision.
Basic Score: 2 Point(s)
b. Treatment Manual/Protocol
Maximum Possible Score: 2 Points
There is a specific written manual/protocol detailing delivery of the Primary Service.
There is no formal curriculum/manual for Individual Counseling. The program has a written
protocol for this intervention. The dosage is stated on the youth's individualized treatment plan.
This plan is then reviewed and signed by a licensed clinician. All youth at the program receive
weekly individual counseling for one hour.
Basic Score: N/A Point(s)
c. Observed Adherence to the Manual/Protocol
Maximum Possible Score: 1 Point
Upon observation of the Primary Service by the Quality Improvement reviewer, the facilitator of
that service adhered to the written protocol/manual.
This intervention was not observed during the review due to the nature of Individual Counseling;
therefore this indicator rates as non-applicable.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 4
Basic Score: 2 Point(s)
d. Facilitator Turnover
Maximum Possible Score: 2 Points
Measures the extent to which facilitators of the specific intervention/service have changed as
well as gaps in service of that Primary Service.
Upon review of documentation and an interview with the Director of Clinical Services, it was
determined there has been no facilitator turnover during the review period which adversely
affected Individual Counseling services to the youth. In the event of turnover, other trained
Therapists would facilitate individual counseling.
Basic Score: 2 Point(s)
e. Internal Fidelity Monitoring
Maximum Possible Score: 2 Points
The program has a process to monitor the delivery of the intervention to examine how closely
actual implementation matches the model protocol.
The program has documented fidelity monitoring for observations of individual counseling. The
fidelity monitoring was completed by the program's Director of Clinical Services. The monitoring is
completed through a review of therapy notes to verify effective and appropriate interventions
which are in line with the youth's treatment plan. The Director of Clinical Services reviews trackers
to ensure compliance with frequency and duration. There was documentation of the Director of
Clinical Services conducting this review. The monitoring was completed monthly and the service
was provided from 02/01/20-07/31/20.
Basic Score: 1 Point
f. Corrective Action based on Fidelity Monitoring
Maximum Possible Score: 1 Point
The program has a process by which corrective action is applied and demonstrated based on
the fidelity monitoring of the delinquency intervention/therapeutic service.
The Director of Clinical Services provides monthly fidelity monitoring. There was no
documentation on any reviewed monitoring sheets which suggested any corrective action had
been noted or taken.
g. Evaluation of Facilitator Skill Delivering the Basic Score: 1 Point
Intervention Maximum Possible Score: 1 Point
Performance evaluations of the facilitators of the specific intervention/service include
evaluation of skill in delivering the intervention/service.
Four Therapists provided Individual Counseling to the youth in the program. There was an annual
performance evaluation completed on all staff, identifying their strengths and weaknesses in
providing individual counseling.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 5
3. Amount of Service - Duration
Basic Score: 4 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 40%
Research indicates the target duration of 25 weeks for this type of service. Of the 15 youth in the
sample, 47% (7 of 15) reached at least the indicated target duration. Further explanation is
detailed in the Summary and Recommendations below.
Note: Dosage information (duration) is calculated from the Juvenile Justice Information System
(JJIS) Evidence-Based Services module. Duration is included for the youth in the SPEP sample.
4. Amount of Service – Contact Hours
Basic Score: 2 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 20%
Research indicates a target of 30 contact hours for this type of service. Of the 15 youth in the
sample, 20% (3 of 15) reached the indicated target contact hours. Further explanation is detailed
in the Summary and Recommendations below.
Note: Dosage information (contact hours) is calculated from the Juvenile Justice Information
System (JJIS) Evidence-Based Services module. Contact hours are included for the youth in the
SPEP sample.
5. Risk Level of Youth Served:
Basic Score: 15 Points
Program Optimization Score: 25 Points
Program Optimization Percentage: 60%
Percentage of Youth with Moderate, Moderate-High, and High-Risk Levels to Reoffend: 67%
Moderate to High Score: 5 Points
Program Optimization Score: 12 Points
Program Optimization Percentage: 42%
Table 1
Moderate = 1 youth
Moderate-High = 4 youth
High = 5 youth
Total Youth in Sample = 15 youth
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 6
Percentage of Youth with High-Risk Level to Reoffend: 33%
High Score: 10 Points
Program Optimization Score: 13 Points
Program Optimization Percentage: 77%
Table 2
High = 5 youth
Total Youth in Sample = 15 youth
The risk level score is compiled by calculating the total percent of the SPEP sample that score
Moderate to High-Risk to reoffend and also the total percent of the SPEP sample that score High-
Risk to reoffend.
Of the SPEP sample, 67% (10 of 15) youth scored Moderate to High-Risk to reoffend, for a score
of 5 points.
Of the SPEP sample, 33% (5 of 15) youth scored High-Risk to reoffend, for a score of 10 points.
Note: The latest Community Assessment Tool (CAT) prior to the placement date was used in the
derivation of the risk level score. This CAT provides the best indication of the risk to re-offend
level of the youth when the youth was first placed in the program.
Summary and Recommendations
Program Program
Category Basic Score Optimization Optimization
Score Percentage
Primary and Supplemental Service Type 10 10 100%
Quality of Service Delivery 20 20 100%
Amount of Service: Duration 4 10 40%
Amount of Service: Contact Hours 2 10 20%
Risk Level of Youth Served 15 25 60%
Totals 51 75 68%
This SPEP report evaluates Individual Counseling, an intervention delivered at Les Peters Girls
Academy.
15 youth completed the program during the review period. Of those youth, all 15 were included in
the sample.
The program scored High for Quality of Service Delivery.
The program earned 4 points for Amount of Service: Duration. Of the 15 total youth sampled, all
15 included dosage with end dates in the EBS Module. Of those youth, 7 received at least the
recommended weeks of service. Youth in the sample completed between 11 and 46 weeks of
service, with an average of 26 weeks.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 7
The program earned 2 points for Amount of Service: Contact Hours. Of the 15 total youth
sampled, all 15 included dosage in the EBS Module. Of those youth, 3 received at least the
recommended hours of service. Youth in the sample completed between 8 and 47 hours of
service, with an average of 27 hours.
The program was awarded 15 available points for Risk Level of Youth Served. This is calculated
using data from the Community Assessment Tool (CAT) assessment. This score reflects youths'
most recent CAT score prior to placement at the program. The program itself has no control over
youths' CAT risk level because the scored assessment was administered prior to the youths'
admission.
Had the percentage of youth served with Moderate-High and High risk to reoffend been higher,
and this report awarded each 25 of the available points for this section, the Program Optimization
Percentage for this service would increase to 81%. As stated previously, the Risk Level of Youth
Served score is not under the control of the program.
RECOMMENDATION(S):
Les Peters Girls Academy can maintain their SPEP Quality of Service Delivery score by
continuing the practices in place at the time of this review.
Les Peters Girls Academy can optimize their SPEP Amount of Service score by ensuring that
dosage for all youth is recorded accurately in EBS and by ensuring that youth receive the full
targeted dosage of service.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 8

service_type: Individual Counseling


summary: SPEP - FY21-22

raw_content:
Standardized Program Evaluation
Protocol [SPEP] Report
Les Peters Girls Academy
TrueCore Behavioral Solutions, LLC
(Contract Provider)
3930 West Martin Luther King Jr. Blvd.
Tampa, Florida 33614
Primary Service: Female Healthy Relationships
SPEP Review Period: 08/01/20-07/31/21
SPEP Review Conducted: 08/03/21
Florida Department of Juvenile Justice
Report Date: 10/13/2021
Introduction
The Standardized Program Evaluation Protocol (SPEP) is data-driven rating system for
evaluating program effectiveness. The SPEP was developed by relying on hundreds of studies
that have examined key characteristics of programs that demonstrated their ability to reduce
recidivism. To determine a SPEP score, the program’s services are compared to characteristics
of effective programs in the research of a similar type.
The SPEP score is composed of four principle characteristics that have been shown to predict
reductions in youth recidivism; service type, quality of service, dosage (amount of service), and
youth level of risk.
• Service Type: service type points are awarded based on the group category that the
service falls within
• Quality of Service: quality points are awarded by determining the extent to which the
program is delivered in what research suggests is a high-quality manner
• Amount of Service: or “dosage” refers to the amount and duration of services that were
received
• Risk Level: refers to the level of criminogenic risk for youth involved in the intervention.
The final output of the SPEP review is the Program Optimization Percentage (POP). This rate is
derived from the Basic Score and Program Optimization Score. The POP rate is a percentage
score that indicates how the service rates in effectiveness when compared to the potential
effectiveness if optimized to match the most effective services in the research. This means the
POP rate represents how close the program’s Primary Service is to its potential for that Primary
Service Type. For example, a POP rate of 55% would indicate that the program’s Primary
Service is operating at 55% of its potential effectiveness for recidivism reduction based on the
SPEP research.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 2
Basic Score: 30 Points
1. Primary Service and Supplemental Service Types POS: 30 Points
POP: 100%
There are five Primary Service Types that have been classified into Groups with a maximum
number of points possible for rating purposes. Some Primary Service Types may also have
qualifying Supplemental Service Types that could earn a program an additional 5 points.
The Primary Service for this program is Female Healthy Relationships.
The program was awarded 25 points because the Primary Service is identified as a Group 4
Service. The specific Sub-Component Service Type identified is Group Counseling. The Primary
Service was identified as this type of service as it focuses on psychological or interpersonal
problems or issues faced by an individual and involves a group of youths interacting with each
other.
An additional 5 points was awarded based on a Qualifying Supplemental Service. The Qualifying
Supplemental Service was identified as None (automatic 5 points added to score), which was not
demonstrated to have been implemented.
The Primary and Supplemental Service Raw Score is equal to the sum of the Primary Service
points plus the Qualifying Supplemental Service points.
Note: Quality information is evaluated during quarterly and annual reviews.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 3
Basic Score: 20 Points
2. Overall Quality of Service Delivery Score POS: 20 Points
POP: 100%
The Quality of Service Delivery Score is the sum of the scores for the seven treatment quality
indicators. The Program Optimization Percentage Rating determines the Overall Quality of
Service Level:
Indicator Sum Score 0-3 = Low; Sum Score 4-7 = Medium; Sum Score 8-10 = High.
Sum of all Indicator Scores (a – g below): 9 Points
Overall Quality of Service Delivery Level:
Low (Raw Score = 5)
Medium (Raw Score = 10)
High (Raw Score = 20 Points)
Basic Score: 1 Point(s)
a. Facilitator Training
Maximum Possible Score: 1 Point
All facilitator(s) of the Primary Service must have received formal training specific to the
intervention or model/protocol.
There were five staff members formally trained in the Female Healthy Relationships service- one
Clinical Director, one Assistant Clinical Director, two Therapists and one as needed (PRN)
Therapist. All five facilitated group and all received training from a qualified trainer of Female
Healthy Relationships.
Basic Score: 2 Point(s)
b. Treatment Manual/Protocol
Maximum Possible Score: 2 Points
There is a specific written manual/protocol detailing delivery of the Primary Service.
The Female Healthy Relationships bundle consists of two curricula -The Teen Relationships
Workbook and VOICES-A Program of Self-Discovery and Change. Both manuals and
accompanying protocols were provided for review. Both manuals provide the script for the
facilitator, the lessons, an implementation guide, the order the lessons are to be delivered in and
instructions for the delivery of each lesson.
Basic Score: 1 Point(s)
c. Observed Adherence to the Manual/Protocol
Maximum Possible Score: 1 Point
Upon observation of the Primary Service by the Quality Improvement reviewer, the facilitator of
that service adhered to the written protocol/manual.
A session of Female Healthy Relationships was observed on Tuesday, 08/03/21, from 11:30 to
12:30. The facilitator followed the lesson plan, did not read verbatim, explained the lesson in her
own words and was easy for the youth to understand. The facilitator adhered to the lesson plan in
every aspect.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 4
Basic Score: 2 Point(s)
d. Facilitator Turnover
Maximum Possible Score: 2 Points
Measures the extent to which facilitators of the specific intervention/service have changed as
well as gaps in service of that Primary Service.
A review of documentation provided and an interview with the Director of Clinical Services
confirmed there was no facilitator turnover which adversely affected the services of Female
Healthy Relationships to the youth. There were no gaps in the services of Female Healthy
Relationships to the youth.
Basic Score: 2 Point(s)
e. Internal Fidelity Monitoring
Maximum Possible Score: 2 Points
The program has a process to monitor the delivery of the intervention to examine how closely
actual implementation matches the model protocol.
Internal fidelity monitoring of Female Healthy Relationships was completed by each one of the
facilitating staff for one another for all months during the review. There was no missing fidelity
monitoring.
Basic Score: 1 Point
f. Corrective Action based on Fidelity Monitoring
Maximum Possible Score: 1 Point
The program has a process by which corrective action is applied and demonstrated based on
the fidelity monitoring of the delinquency intervention/therapeutic service.
The program uses internal fidelity monitoring checklists specific to Female Healthy Relationships.
A review of documentation provided and an interview with the Director of Clinical Services
confirmed there was no corrective action taken during this review period.
g. Evaluation of Facilitator Skill Delivering the Basic Score: N/A Point
Intervention Maximum Possible Score: 1 Point
Performance evaluations of the facilitators of the specific intervention/service include
evaluation of skill in delivering the intervention/service.
All trained facilitators are new; therefore, this indicator is rated as non-applicable. TrueCore does
not complete 90-day evaluations on their staff. Their yearly evaluations are not due until October
2021.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 5
3. Amount of Service - Duration
Basic Score: 8 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 80%
Research indicates the target duration of 24 weeks for this type of service. Of the 18 youth in the
sample, 89% (16 of 18) reached at least the indicated target duration. Further explanation is
detailed in the Summary and Recommendations below.
Note: Dosage information (duration) is calculated from the Juvenile Justice Information System
(JJIS) Evidence-Based Services module. Duration is included for the youth in the SPEP sample.
4. Amount of Service – Contact Hours
Basic Score: 8 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 80%
Research indicates a target of 40 contact hours for this type of service. Of the 18 youth in the
sample, 94% (17 of 18) reached the indicated target contact hours. Further explanation is detailed
in the Summary and Recommendations below.
Note: Dosage information (contact hours) is calculated from the Juvenile Justice Information
System (JJIS) Evidence-Based Services module. Contact hours are included for the youth in the
SPEP sample.
5. Risk Level of Youth Served:
Basic Score: 5 Points
Program Optimization Score: 25 Points
Program Optimization Percentage: 20%
Percentage of Youth with Moderate, Moderate-High, and High-Risk Levels to Reoffend: 72%
Moderate to High Score: 5 Points
Program Optimization Score: 12 Points
Program Optimization Percentage: 42%
Table 1
Moderate = 4 youth
Moderate-High = 7 youth
High = 2 youth
Total Youth in Sample = 18 youth
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 6
Percentage of Youth with High-Risk Level to Reoffend: 11%
High Score: 0 Points
Program Optimization Score: 13 Points
Program Optimization Percentage: 0%
Table 2
High = 2 youth
Total Youth in Sample = 18 youth
The risk level score is compiled by calculating the total percent of the SPEP sample that score
Moderate to High-Risk to reoffend and also the total percent of the SPEP sample that score High-
Risk to reoffend.
Of the SPEP sample, 72% (13 of 18) youth scored Moderate to High-Risk to reoffend, for a score
of 5 points.
Of the SPEP sample, 11% (2 of 18) youth scored High-Risk to reoffend, for a score of 0 points.
Note: The latest Community Assessment Tool (CAT) prior to the placement date was used in the
derivation of the risk level score. This CAT provides the best indication of the risk to re-offend
level of the youth when the youth was first placed in the program.
Summary and Recommendations
Program Program
Category Basic Score Optimization Optimization
Score Percentage
Primary and Supplemental Service Type 30 30 100%
Quality of Service Delivery 20 20 100%
Amount of Service: Duration 8 10 80%
Amount of Service: Contact Hours 8 10 80%
Risk Level of Youth Served 5 25 20%
Totals 71 95 75%
This SPEP report evaluates Female Healthy Relationships, an intervention delivered at Les
Peters Girls Academy.
18 youth completed the program during the review period. Of those youth, all 18 were included in
the sample.
The program scored High for Quality of Service Delivery.
The program earned 8 points for Amount of Service: Duration. Of the 18 total youth sampled, all
18 included dosage with end dates in the EBS Module. Of those youth, 16 received at least the
recommended weeks of service. Youth in the sample completed between 15 and 47 weeks of
service, with an average of 28 weeks.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 7
The program earned 8 points for Amount of Service: Contact Hours. Of the 18 total youth
sampled, all 18 included dosage in the EBS Module. Of those youth, 17 received at least the
recommended hours of service. Youth in the sample completed between 36 and 79 hours of
service, with an average of 62 hours.
The program was awarded 5 available points for Risk Level of Youth Served. This is calculated
using data from the Community Assessment Tool (CAT) assessment. This score reflects youths'
most recent CAT score prior to placement at the program. The program itself has no control over
youths' CAT risk level because the scored assessment was administered prior to the youths'
admission.
Had the percentage of youth served with Moderate-High and High risk to reoffend been higher,
and this report awarded each 25 of the available points for this section, the Program Optimization
Percentage for this service would increase to 96%. As stated previously, the Risk Level of Youth
Served score is not under the control of the program.
RECOMMENDATION(S):
Les Peters Girls Academy can maintain their SPEP Quality of Service Delivery score by
continuing the practices in place at the time of this review.
Les Peters Girls Academy can optimize their SPEP Amount of Service score by ensuring that
dosage for all youth is recorded accurately in EBS and by ensuring that youth receive the full
targeted dosage of service.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 8

file_name: FY2021-22 LPGA FHR.pdf