summary: PREA

raw_content:
PREA AUDIT: AUDITOR’S SUMMARY
REPORT JUVENILE FACILITIES
Name of Facility: Juvenile Unit for Specialized Treatment
Physical Address: 29841 Liberty Wilderness Road at Highway 65 South, Sumatra, FL 32335
Date report submitted: February 17, 2015
Auditor information: Shirley L. Turner
Address: 3199 Kings Bay Circle, Decatur, GA 30034
Email: shirleyturner3199@comcast.net
Telephone number: 678-895-2829
Date of facility visit: January 26-27, 2015
Facility Information
Facility Mailing Address: 29841 Liberty Wilderness Road at Highway 65 South, Sumatra, FL 32335
Telephone Number: (850) 379-8344
The Facility is: Military County Federal
Private for profit Municipal State
X Private not for profit
Facility Type: Detention Correction X Other: Residential
Name of PREA Compliance Manager: Donald Valentine Title: Facility Trainer
Email Address: dvalentine@twinoaksfl.org Telephone Number:
(850) 379-8344
Agency Information
Name of Agency: Twin Oaks Juvenile Development, Inc.
Governing Authority or Parent Agency: NA
Physical Address of Agency: 11939 NW SR 20, Bristol, FL 32321
Mailing Address: Same as Above
Telephone Number: (850) 643-1090
Agency Chief Executive Officer
Name: Donald B. Read Title: Chief Executive Officer
Telephone (850) 643-1090
Email Address: dread@twinoaksfl.org
Number:
Agency Wide PREA Coordinator
Name: Charles Chervanik Title: Chief Operating Officer
Email Address: cchervanik@twinoaksfl.org Telephone Number: ( 8 5 0 ) 6 4 3 - 1 0 9 0
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AUDIT FINDINGS
NARRATIVE:
The Juvenile Unit for Specialized Treatment (JUST) is located near Sumatra, Florida; the designed
capacity is 44. The facility serves male juvenile offenders in the age range of 10-18. The facility is
operated by Twin Oaks Juvenile Development, Inc. through a contract with the Florida Department of
Juvenile Justice (DJJ) to provide treatment services for committed youth. The length of stay is 6-12
months and the program serves moderate risk residents. While in the facility residents participate in
programming that include education and vocational services; social services; case management,
mental health; medical; recreation; and transition planning.
On-site medical care is provided by one Registered Nurse and one Licensed Practical Nurse. The
contract physician visits the facility weekly. Mental health services are also provided on-site and the
staff under the supervision of the Clinical Director includes four Clinical Coordinators and three Case
Managers. The contract psychiatrist and contract psychologist visit the facility regularly. Education
and vocational services are provided by one teacher, one education assistant, and two vocational
instructors. Education strategies are designed to meet the individual needs of the residents. Based on
needs and interest assessments, residents are also enrolled in one of the two vocational training areas,
Building Construction Technology or Welding Technology. Case Managers ensure coordinated
efforts for individualized treatment. The direct care staff provides direct supervision of the residents in
daily activities and during movement to and from activities and services.
The JUST is accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF). An
overview of the facility’s stated goals include: utilizing a balance of treatment and security; creating a
therapeutic, restraint free environment; providing high quality medical and mental health services;
maintaining adequate staffing; maintaining excellent partnerships with relevant community based
agencies; and providing educational and vocational services and opportunities. The facility provides
various opportunities for residents to participate in and complete community service projects.
Through a partnership between Twin Oaks Juvenile Development, Inc. and the Boys and Girls Club
of America, JUST operates a full service Boys and Girls Club that provide services and activities
comparable to those found in the community. Transition planning for the resident’s return to the
community includes assisting him in maintaining membership in the Boys and Girls Club located in
the local community once the resident has been released from the facility.
DESCRIPTION OF FACILITY CHARACTERISTICS:
The program is located on 72 acres, in a wilderness setting, surrounded by the Apalachicola National
Forest. The main building contains the entrance lobby and administrative and other offices. There
are five dormitories, including one honor dormitory; chow hall; medical station; education building;
vocational building; and a building that houses the Boys and Girls Club. The meals for the residents
are prepared in the large kitchen at another agency program facility located on adjacent property and
transported and served in the JUST chow hall.
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Each dormitory has a day room and full bathrooms that provide a reasonable amount of privacy for
the residents. The outside grounds contain a recreation area in ample size to accommodate various
recreation and other activities. The grounds also contain a large garden that is tended to by the
residents under the supervision of staff.
SUMMARY OF AUDIT FINDINGS:
The notifications of the on-site audit were posted in various parts of the facility at least six weeks
prior to the site visit. Photographs were taken of the various sites where the notices had been posted
and the photographs were electronically sent to this Auditor, noting their locations. An initial
conference call was conducted with identified staff from the facility and the parent agency, the
statewide PREA Coordinator, and this Auditor to discuss the audit process and data gathering. The
Pre-Audit Questionnaire and the supporting documentation were uploaded to a flash drive, which
was received approximately four weeks prior to the on-site audit. During the review of the
information on the flash drive, communication was maintained with the facility and agency staff and
additional information was provided or clarified as requested. The Chief Operating Officer (COO)
for Twin Oaks Juvenile Development, Inc. serves as the agency’s PREA Coordinator.
The on-site audit was conducted January 26-27, 2015. An entrance meeting was held with the
Program Director, Facility Trainer who also serves as the PREA Compliance Manager, COO/PREA
Coordinator, another staff from the corporate office. After the meeting a comprehensive tour of the
facility was provided by the Program Director, accompanied by the staff that was present during the
entrance meeting. During the tour, staff members were observed to be directly supervising and
interacting with the residents. Random staff, specialized staff and residents were interviewed during
the on-site audit process.
Additional information for the audit process was provided upon request and in a timely manner while
on-site. A close-out meeting was held at the conclusion of the site visit and a summary of the audit
findings was provided to the facility and agency staff that were in attendance.
Number of Standards Exceeded: 0
Number of Standards Met: 38
Number of Standards Not Met: 0
Number of Standards Not Applicable: 3
3
Standard 115.311 Zero Tolerance of Sexual Abuse and Sexual Harassment.
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 facility adheres to the Twin Oaks Juvenile Development, Inc. Prison Rape Elimination
Act (PREA) Policy. It affords guidelines for implementing the agency’s approach to
complying with the requirements of the PREA standards. The Policy provides for a zero
tolerance approach regarding all forms of sexual abuse and sexual harassment. It contains
definitions of the prohibited behaviors and sanctions for those who participate in such
behaviors. The agency’s PREA Policy and the facility procedures are aligned with the Florida
Department of Juvenile Justice PREA Policy (FDJJ 1919).
Standard 115.312 Contract 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 Standard Not Applicable
Auditor Comments:
The facility does not contract with other facilities for the confinement of 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)
Auditor Comments:
The PREA Policy and practices provide for the implementation of a staffing plan with
adequate staffing levels to protect residents against sexual abuse and provides that the staffing
ratios are per the current program contract. According to the staffing plan and staff interviews
the ratios within the facility are 1:8 during the awake hours and 1:8 during the sleeping hours.
The assessment of the staffing plan determines whether adjustments are needed in accordance
with the standard. The staffing plan details the methodology that ensures adherence to the
staffing ratios.
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Unannounced rounds of the facility for the maintenance of a safe environment are conducted
and documented by members of the management team. Policy and practice provide that staff
members are prohibited from alerting other staff regarding unannounced rounds occurring.
Interviews with staff confirmed the practice.
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:
The PREA Policy prohibits cross-gender pat-down searches and also prohibits staff from
conducting cross-gender strip or cross-gender visual body cavity searches of residents. All
residents are able to shower, perform bodily functions, and change clothes without being
observed by staff of the opposite gender. Interviews with staff and residents confirmed this
practice.
The PREA Policy supports that staff shall not search or physically examine a transgender or
intersex resident to determine the resident’s genital status. Signs are posted stating that female
staff should announce themselves when entering the dormitories and the PREA Policy directs
that staff of the opposite gender shall announce themselves when entering an area where
residents may be showering, performing bodily functions or changing clothes.
Standard 115.316 Residents With Disabilities and Residents Who are Limited English
Proficient
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:
Resources are available for the provision of support services for residents with disabilities
and residents who are limited English proficient so that they may benefit from and
participate in PREA education. Interpreter and other support services can be provided by
Language Line through an agreement with the Florida Department of Health, as well as
facility staff. Resident education materials are accessible in dominant languages other than
English. The facility does not rely on resident interpreters. A review of documentation and
staff interviews confirmed that the resources will be used as needed.
.
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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:
The PREA Policy and FDJJ 1919 provide for background checks on all employees and
contractors through a process that is used statewide. A review of documentation and
interviews with staff confirmed that prior to the hiring of an employee or contractor,
background checks are conducted as required.
Standard 115.318 Upgrades to Facilities and Technology
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 Standard Not Applicable
Auditor Comments:
This standard is not applicable; there are no cameras at the facility. Direct staff supervision is
used.
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:
The PREA Policy addresses this standard and states that staff is expected to cooperate in
investigations conducted by the FDJJ Office of the Inspector General (OIG). Administrative
investigations are conducted by OIG and criminal investigations are conducted by the
Florida Department of Children and Families and local law enforcement. The PREA Policy
states that upon the arrival of law enforcement investigators, a copy of the PREA
Compliance Form will be provided to them which contain the PREA standards requirements
regarding investigations.
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The PREA Policy further provides for forensic medical examinations to be completed at no
financial cost to the victim. There have been no forensic examinations conducted during this
audit period. The agency has a written Agreement with Panhandle Forensic Nurse
Specialist, Inc. for the provision of forensic medical examinations for residents when
needed. Documentation was provided showing attempts to make arrangements for advocacy
services through the community resources of the Sheriff’s Department and the rape crisis
center. The facility has a written Professional Services Agreement with an agency staff
member who is a Licensed Mental Health Counselor that will be able to provide supportive
services to residents as needed.
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:
The facility’s PREA Policy and FDJJ 1919 provide that staff report all allegations of sexual
abuse and sexual harassment and that the appropriate investigative entity be contacted when
allegations of sexual abuse are made. There was one allegation from a resident at this facility
that was reported during this audit period and it was investigated according to policy. A
review of the documentation and interviews revealed that the incident was reported and
documented as required. The investigation was closed by both investigative agencies with no
findings.
The Twin Oaks Juvenile Development, Inc. website contains information regarding the
referral of allegations for investigations of sexual abuse and it has related information
posted, which is accessible to the public. The website is very informative and educational to
the public as well as the staff.
Standard 115.331 Employee 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:
The facility ensures that all staff members participate in the PREA training. The staff has
received the required training and additional training has been provided or coordinated as
needed. Documentation of staff participating in training is maintained. The Facility Trainer
coordinates and assigns training and maintains the staff training records. Staff interviews and
a review of documents confirmed that staff training occurs.
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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:
The PREA Policy contains information regarding the training of volunteers and contractors
who have contact with residents. Receipt of the training is documented and it contains a
review of the agency’s zero tolerance (PREA) policy.
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:
A review of the PREA Policy, other documentation and interviews with residents and staff
confirm that residents receive information about the contents of the Policy, including how to
report incidents of sexual abuse or sexual harassment. According to the PREA Policy, the
facility will provide support services in accessible formats for residents who are limited
English proficient, deaf, visually impaired, or otherwise disabled. PREA information is
posted and readily available to residents.
Standard 115.334 Specialized Training: 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:
FDJJ 1919 and the PREA Policy state that staff in the OIG will be trained on the related
policies and procedures regarding the handling of sexual misconduct incidents and reports.
Training is provided to investigative staff regarding conducting investigations in the facility
settings.
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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:
A review of training documentation and staff interviews confirm that the specialized training
occurs for medical and mental health staff. The facility medical staff does not conduct
forensic medical examinations.
Standard 115.341 Screening for Risk of Victimization and Abusiveness
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 PREA Policy and FDJJ 1919 address this standard. The screening for risk of sexual
abuse victimization or sexual abusiveness toward other residents is being conducted on each
resident. The initial screening is done during the intake process and the PREA Policy states
that the treatment teams should continually review the resident’s adjustment. Interviews with
residents and staff and a review of documentation confirmed the practices.
Standard 115.342 Use of Screening Information
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 PREA Policy prohibits placing gay, bisexual, transgender, or intersex residents in
particular housing based solely on such identification or status. Housing and program
assignments will be made for each transgender or intersex resident on a case by case basis
and the resident’s view regarding safety will be seriously considered. According to the
PREA Policy, the facility prohibits considering gay, bisexual, transgender, or intersex
identification or status as an indicator of the likelihood of being sexually abusive.
9
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:
According to the PREA Policy, there are internal ways a resident may report allegations of
sexual abuse; sexual harassment; retaliation for reporting; and staff neglect or other violations
that lead to abuse. A resident may place a note or grievance form in the Sick Call/PREA Box;
complete a form requesting to see a specific staff member; talk to a staff member; and third
parties may report allegations to staff or through the Florida abuse hotline. Interviews with
staff and residents and a review of documentation support the practices.
PREA related information is posted in each dormitory. Residents are provided access to a
telephone to report allegations of sexual abuse and sexual harassment to the abuse reporting
hotline. The abuse reporting hotline number is posted in the dormitories. Interviews revealed
that staff members are aware of their responsibility to report sexual abuse and sexual
harassment. They are also aware that they may accept reports of sexual abuse and sexual
harassment made verbally, in writing, anonymously, and from third parties.
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:
The PREA Policy prohibits the use of an informal grievance process regarding allegations of
sexual abuse and sexual harassment. The facility considers resident grievances regarding
sexual abuse to be an allegation of sexual abuse and when such a complaint is received, the
procedures regarding reporting allegations are initiated. Residents may place written
allegations of sexual abuse or sexual harassment in the Sick Call/PREA Box, located on the
outside of the medical building which is accessible to all residents. Residents may also give a
written complaint to a staff member who is not the subject of the complaint. The PREA and
Grievance Policies provide the timeline for the response to the complaints.
Standard 115.353 Resident Access to Outside Confidential Support Services
Exceeds Standard (substantially exceeds requirement of standard)
10
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 PREA Policy requires the facility to provide the residents with access to outside victim
advocacy services. The facility has documentation showing their efforts to obtain outside
victim advocacy services. A written Professional Services Agreement exists with a Licensed
Mental Health Counselor who is employed with the agency but does not work within the
facility.
Residents are allowed to see their parents at visitation on Sundays and may talk to them one-
two times per week. Attorneys or other legal representation may visit residents in a
confidential manner.
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 s tandard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides guidelines regarding third-party reporting. The agency website
and the DJJ website provide the public with information regarding the reporting of abuse.
Parents and other visitors are informed about reporting incidents of sexual abuse through
information posted in 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:
According to the PREA Policy, all staff members are mandated reporters. Staff members are
to immediately report any knowledge, suspicion or information they receive regarding sexual
abuse, sexual 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. All
staff interviewed are aware of their reporting duties.
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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:
The PREA Policy provides that when it is learned that a resident is subject to substantial risk
of imminent sexual abuse, immediate action is taken to protect the resident. There have been
no incidents in the last 12 months where the facility took any action in regards to a resident
being in substantial risk of imminent sexual abuse.
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)
Auditor Comments:
The PREA Policy and FDJJ 1919 address this standard. Upon receiving an allegation that a
resident was sexually abused while confined in another facility, the Program Director will
notify the Central Communications Center (CCC) and the Department of Children and
Families of the allegation. Additionally, the facility head of the other facility will be notified.
The notifications will be made within 72 hours of receipt of the allegation.
Standard 115.364 St aff 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:
The PREA Policy and FDJJ 1919 guide the response to this standard. The Policies provide
direction to staff in responding to allegations of sexual abuse. Staff training has been
provided.
Standard 115.365 Coordinated Response
Exceeds Standard (substantially exceeds requirement of standard)
12
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 institutional plan, Coordinated Response, is detailed in its guidance to staff regarding
steps to take in the event of an incident or allegation of sexual abuse.
Standard 115.366 Preservation of Ability to Protect Residents from Contact with Abusers
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 Standard Not Applicable
Auditor Comments:
This standard is not applicable. The facility does not maintain any collective bargaining
agreements.
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:
The PREA Policy supports protection against retaliation for residents and staff who report
allegations of sexual abuse or sexual harassment. A facility staff member has been identified
to monitor for the occurrence of retaliation. The Policy identifies areas to monitor regarding
possible retaliation of residents and staff.
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)
13
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility does not use segregated housing; however, staff interviews revealed that
protective measures may be used that include one to one supervision by staff and assigning
the resident to another dormitory. There is also a dormitory that houses only four residents at
a time and the staff to resident ratio of 1:4 is maintained.
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
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy and FDJJ 1919 address this standard. Administrative investigations are
conducted by the DJJ Office of Inspector General and criminal investigations are conducted
by the Department of Children and Families and local law enforcement. Both Policies direct
facility staff to cooperate with investigations. According to FDJJ 1919, an investigation is
not terminated solely because the source of the investigation recants the allegation.
Substantiated allegations of conduct that appear to be criminal are referred for prosecution.
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 OIG, responsible for administrative investigations, imposes a standard of a preponderance
of the evidence for determining whether 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)
14
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy and FDJJ 1919 provides the process for notifying residents, following an
investigation, of whether an allegation has been determined to be substantiated,
unsubstantiated, or unfounded.
Standard 115.376 Disciplinary Sanctions 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)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides for disciplinary sanctions for staff to be up to and including
termination for violation of the sexual abuse and sexual harassment policies. The Policy
requires that the violation be reported to local law enforcement and provides for contacting
relevant licensing bodies. In the past 12 months, no staff has been terminated or has resigned
for violating PREA related policies.
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:
An incident regarding sexual abuse by a contractor or volunteer will be reported as required,
including to relevant licensing bodies, according to the PREA Policy. The facility will prohibit
future contact with residents in the case of any violation of the facility’s PREA related
policies. During the past 12 months, no contractor or volunteer has been reported to law
enforcement or any investigative entity for allegations of sexual abuse.
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)
15
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides that any resident found in violation of the Policy may be subject
to disciplinary action, following a formal process. The resident may be transferred to another
facility following an administrative or criminal finding of resident-on-resident sexual abuse.
During the past 12 months there have been no incidents of resident-on-resident sexual abuse.
Standard 115.381 Medical and Mental Health Screenings; 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)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Residents who disclose a history of sexual abuse or who disclose previously perpetrating
sexual abuse will be offered a follow-up meeting with a medical or mental health practitioner
within 14 days of the intake screening. Staff interviewed confirmed awareness of the policy
and the requirements of the standard. The PREA Policy addresses the elements of this
standard.
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:
According to the PREA Policy, timely and unimpeded access to emergency medical
treatment and crisis intervention services for victims of sexual abuse will be provided. The
nature and scope of the services are determined by medical and mental health practitioners
according to their professional judgment. Interviews confirmed what is stated in the PREA
Policy.
Standard 115.383 Ongoing Medical and Mental Health Care for Sexual Abuse Victims and
Abusers
Exceeds Standard (substantially exceeds requirement of standard)
16
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 PREA Policy provides for ongoing medical and mental health care for sexual abuse
victims. It also provides for medical and mental health evaluations and appropriate treatment
in accordance with the standard. According to staff interviews and a review of
documentation, health care is consistent with the community level of care.
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)
Auditor Comments:
The PREA Policy will serve as the guide for staff in conducting incident reviews. The Policy
details the requirements of the standard and states that the incident review will occur within
30 days of the conclusion of the investigation. The incident review team has been identified.
Staff interviews indicated familiarity with the role of the incident review team regarding
incidents of sexual abuse.
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 agency’s PREA Policy requires the collection of accurate, uniform data for every
allegation of sexual abuse. The agency uses a system called TRENDSTAT for their facilities
to collect, analyze and submit monthly data to the corporate leadership team. The agency has
developed a data collection instrument that includes the required data.
Standard 115.388 Data Review for Corrective Action
Exceeds Standard (substantially exceeds requirement of standard)
17
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 PREA Policy and FDJJ 1919 address this standard. Part of the process in analyzing the
data is to identify trends and/or problem areas and to develop corrective actions where
indicated. The Policies require the review of data with the goal of improving the
effectiveness of the agencies’ PREA initiatives in the areas of 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 PREA Policy requires that data is collected and securely retained for 10 years, unless
otherwise required by law. The aggregated PREA data is reviewed and all personal
identifiers are removed. The agency has a report posted on its website.
AUDITOR CERTIFICATION:
The auditor certifies that the contents of the report are accurate to the best of her knowledge and no
conflict of interest exists with respect to her ability to conduct an audit of the agency under review.
February 17, 2015
Auditor Signature Date
18

report_type: PREA


state: FL

summary: SPEP - FY15-16

raw_content:
Standardized Program Evaluation
Protocol [SPEP] Report
Juvenile Unit for Specialized Treatment (JUST)
Twin Oaks Juvenile Development, Inc.
(Contract Provider)
Highway 64 South
Sumatra, Florida 32335
Primary Service: Impact of Crime
SPEP Review Date(s): February 2‐5, 2016
Florida Department of Juvenile Justice
Report Date(s): 8/26/16
Introduction
The Standardized Program Evaluation Protocol (SPEP) is an assessment tool derived from
meta-analytic research on the effectiveness of juvenile justice interventions. The tool is
designed to compare existing intervention services, as implemented in the field, to the
characteristics of the most effective intervention services found in the research.
The SPEP scoring system allows service providers to identify specific areas in which program
improvements can be made to their existing Primary Services. These improvements can be
expected to increase the effectiveness of those Primary Services in the reduction of recidivism
for youth receiving the Primary Service. A separate SPEP evaluation is conducted, at the time
of the program’s Quality Improvement Review, for each Primary Service provided by the
program.
This report provides two types of SPEP scores: a Basic Score, equivalent to the number of
points received, and a Program Optimization Score (POS) that is equivalent to the maximum
number of possible points that could be received based on the SPEP domains under the control
of the program. The Basic Score compares the Primary Service being evaluated to other
intervention services found in the research to be effective, regardless of service type. It is meant
as a reference to the expected overall recidivism reduction when compared to other Primary
Services of any Type.
A Program Optimization Percentage (POP) rate is derived from the Basic Score and Program
Optimization Score. The POP rate is a percentage score that indicates where the rate of
effectiveness of the Primary Service is when compared to its potential effectiveness if optimized
to match the characteristics of similar Primary Services found to be most effective in the
research. The POP rate is likely more meaningful to service providers as it 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 that has been found for a similar
Primary Service Type with research evidence of effectiveness.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 2
Program Name: Juvenile Unit for Specialized Treatment QI Program Code: 1086
Provider Name: Twin Oaks Juvenile Development, Inc. Contract Number: R2058
Location: Liberty County / Circuit: 2 Number of Beds: 44
Review Date(s): February 2-5, 2016 Lead Reviewer Code: 145
Persons Interviewed
Program Director Corporate QI/QA staff 2 # Program Supervisors
DJJ Monitor 3 # Case Managers 5 # Youth
DHA or designee 1 # Clinical Staff 5 # Other (listed by title): Staff
DMHCA or designee 1 # Healthcare Staff
Documents Reviewed
Written Protocol/Manual Logbooks 5 # Personnel Records
Fidelity Monitoring Documents Program Schedules 5 # Training Records/CORE
Internal Corrective Action Reports Supplemental Contracts 4 # Youth Records (Closed)
Staff Evaluations Table of Organization 7 # Youth Records (Open)
Accreditation Reports Youth Handbook # Other:
Contract Monitoring Reports 7 # Health Records
Contract Scope of Services 7 # MH/SA Records
Observations During Review
Group/Session of Primary Service(s)
Program Activities
Recreation
Social Skill Modeling by Staff
Staff Interactions with Youth
Staff Supervision of Youth
Transition/Exit Conferences
Treatment Team Meetings
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 3
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 by the Bureau of Monitoring and Quality Improvement while
on-site during the annual compliance review.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 4
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.
Documentation was provided for staff training in the Impact of Crime curriculum. The program has
four staff who are currently trained to facilitate this group.
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 program utilizes the Impact of Crime manual for groups. Students are each provided a
student workbook. The instructor manual includes the facilitator guides, youth workbook
information, and videos for specific lessons.
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.
The program conducts the Impact of Crime groups on weekends. The reviewer was unable to
observe a session of the intervention during this annual compliance review period, therefore, this
indicator rates as not applicable.
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.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 5
The program has four staff who have been trained to provide the service. The program reports
that staff are required to cover in the event of a staff turnover. There have been no gaps in service
for more than one month.
BasicScore: 2Point(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 a trained mental health therapist who is responsible for conducting internal
fidelity monitoring each month. No monitoring reports were reported as missing for the scope of
this review period.
BasicScore: 1Point
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 has a process to provide corrective action, if the facilitator is not following the
prescribed curriculum for the groups provided. At the time of the program’s annual compliance
review, and based on a review of the program’s fidelity monitoring tools completed, there was no
documentation that indicated any corrective action was required.
g. Evaluation of Facilitator Skill Delivering the Basic Score: 1Point
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.
A review of the facilitators’ annual performance evaluation found each staff facilitating the
service/intervention is assessed on the proficiency of facilitating the Impact of Crime groups.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 6
3. Amount of Service ‐ Duration
Basic Score: 8 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 80%
Research indicates the target duration of 16 weeks for this type of service. Of the 20 youth in the
sample, 85% (17 of 20) 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: 0 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 0%
Research indicates a target of 24 contact hours for this type of service. Of the 20 youth in the
sample, 0% (0 of 20) 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: 25 Points
Program Optimization Score: 25 Points
Program Optimization Percentage: 100%
Percentage of Youth with Moderate, Moderate-High, and High-Risk Levels to Reoffend: 95%
Moderate to High Score: 12 Points
Program Optimization Score: 12 Points
Program Optimization Percentage: 100%
Table 1
Moderate = 1 youth
Moderate-High = 10 youth
High = 8 youth
Total Youth in Sample = 20 youth
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 7
Percentage of Youth with High-Risk Level to Reoffend: 40%
High Score: 13 Points
Program Optimization Score: 13 Points
Program Optimization Percentage: 100%
Table 2
High = 8 youth
Total Youth in Sample = 20 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, 95% (19 of 20) youth scored Moderate to High-Risk to reoffend, for a score
of 12 points.
Of the SPEP sample, 40% (8 of 20) youth scored High-Risk to reoffend, for a score of 13 points.
Note: The latest Community Positive Achievement Change Tool (C-PACT) prior to the placement
date was used in the derivation of the risk level score. This C-PACT 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 8 10 80%
Amount of Service: Contact Hours 0 10 0%
Risk Level of Youth Served 25 25 100%
Totals 73 85 86%
This SPEP report evaluates Impact of Crime, an intervention delivered at Juvenile Unit for
Specialized Treatment.
The program scored High for Quality of Service Delivery.
The program earned 8 points for Amount of Service: Duration. Of the 20 total youth sampled, only
17 included dosage with end dates in the EBS Module. Of those youth with correct dosage, all 17
received at least the recommended weeks of service. Youth in the sample completed between 42
and 64 weeks of service, with an average of 45 weeks.
The program earned 0 points for Amount of Service: Contact Hours. Of the 20 total youth
sampled, 0 received at least the recommended hours of service. Youth in the sample completed
between 7 and 20 hours of service, with an average of 13 hours.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 8
The program was awarded 25 available points for Risk Level of Youth Served. This is calculated
using data from the Community - Positive Achievement Change Tool (C-PACT) assessment. This
score reflects youths' most recent C-PACT score prior to placement at the program. The program
itself has no control over youths' C-PACT risk level because the scored assessment was
administered prior to the youths' admission.
RECOMMENDATION(S):
Juvenile Unit for Specialized Treatment 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 9

source: DJJ

report_type: SPEP

program_name_raw: Juvenile Unit For Specialized Treatment

program_status_note: Open

service_type: Impact of Crime


summary: SPEP - FY15-16

raw_content:
Standardized Program Evaluation
Protocol [SPEP] Report
Juvenile Unit for Specialized Treatment (JUST)
Twin Oaks Juvenile Development, Inc.
(Contract Provider)
Highway 64 South
Sumatra, Florida 32335
Primary Service: Thinking for a Change
SPEP Review Date(s): February 2‐5, 2016
Florida Department of Juvenile Justice
Report Date(s): 8/26/16
Introduction
The Standardized Program Evaluation Protocol (SPEP) is an assessment tool derived from
meta-analytic research on the effectiveness of juvenile justice interventions. The tool is
designed to compare existing intervention services, as implemented in the field, to the
characteristics of the most effective intervention services found in the research.
The SPEP scoring system allows service providers to identify specific areas in which program
improvements can be made to their existing Primary Services. These improvements can be
expected to increase the effectiveness of those Primary Services in the reduction of recidivism
for youth receiving the Primary Service. A separate SPEP evaluation is conducted, at the time
of the program’s Quality Improvement Review, for each Primary Service provided by the
program.
This report provides two types of SPEP scores: a Basic Score, equivalent to the number of
points received, and a Program Optimization Score (POS) that is equivalent to the maximum
number of possible points that could be received based on the SPEP domains under the control
of the program. The Basic Score compares the Primary Service being evaluated to other
intervention services found in the research to be effective, regardless of service type. It is meant
as a reference to the expected overall recidivism reduction when compared to other Primary
Services of any Type.
A Program Optimization Percentage (POP) rate is derived from the Basic Score and Program
Optimization Score. The POP rate is a percentage score that indicates where the rate of
effectiveness of the Primary Service is when compared to its potential effectiveness if optimized
to match the characteristics of similar Primary Services found to be most effective in the
research. The POP rate is likely more meaningful to service providers as it 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 that has been found for a similar
Primary Service Type with research evidence of effectiveness.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 2
Program Name: Juvenile Unit for Specialized Treatment QI Program Code: 1086
Provider Name: Twin Oaks Juvenile Development, Inc. Contract Number: R2058
Location: Liberty County / Circuit: 2 Number of Beds: 44
Review Date(s): February 2-5, 2016 Lead Reviewer Code: 145
Persons Interviewed
Program Director Corporate QI/QA staff 2 # Program Supervisors
DJJ Monitor 3 # Case Managers 5 # Youth
DHA or designee 1 # Clinical Staff 5 # Other (listed by title): Staff
DMHCA or designee 1 # Healthcare Staff
Documents Reviewed
Written Protocol/Manual Logbooks 5 # Personnel Records
Fidelity Monitoring Documents Program Schedules 5 # Training Records/CORE
Internal Corrective Action Reports Supplemental Contracts 4 # Youth Records (Closed)
Staff Evaluations Table of Organization 7 # Youth Records (Open)
Accreditation Reports Youth Handbook # Other:
Contract Monitoring Reports 7 # Health Records
Contract Scope of Services 7 # MH/SA Records
Observations During Review
Group/Session of Primary Service(s)
Program Activities
Recreation
Social Skill Modeling by Staff
Staff Interactions with Youth
Staff Supervision of Youth
Transition/Exit Conferences
Treatment Team Meetings
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 3
Basic Score: 35 Points
1. Primary Service and Supplemental Service Types POS: 35 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 Thinking for a Change (T4C). The program was awarded
30 points because the Primary Service is identified as a Group 5 Service. The specific Sub-
Component Service Type identified is Cognitive Behavioral Therapy. The Primary Service was
identified as this type of service as it is intended to correct faulty cognitions and perceptions and
provides skills individuals can use to monitor thought patterns and correct behaviors.
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 by the Bureau of Monitoring and Quality Improvement while
on-site during the annual compliance review.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 4
Basic Score: 10 Points
2. Overall Quality of Service Delivery Score POS: 20 Points
POP: 50%
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): 7 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’s clinical director has received training in this primary service, and is responsible for
facilitating the T4C curriculum.
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 program utilizes the T4C manual and lesson plans, as well as video and worksheets to
provide to participants.
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 facilitator was observed following the manual throughout the delivery of the session in the
workbook. The lesson presented was entitled ‘Introduction to Problem Solving’.
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.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 5
The program reported no facilitator turnover for this review period. In the event of a turnover, the
program is currently in the process to have the clinical director complete the training requirements
for T4C in order to train additional staff to deliver the primary service. There were no gaps in
service identified.
BasicScore: 0Point(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 last fidelity monitoring was conducted January of 2015. The primary service requires that only
a master trainer for T4C may conduct fidelity monitoring. The program is in the process to have
the clinical director complete the training requirements for T4C in order to train additional staff to
deliver the primary service.
The program can earn 2 points if internal fidelity monitoring is conducted at least monthly for all
T4C facilitators by an individual also trained to deliver T4C.
At the time of the review, the program did not meet criteria to earn a score of 2.
BasicScore: 0Point
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.
Fidelity monitoring has not taken place in the past twelve months so there has been no
opportunity for corrective action.
The program can earn 1 point if the program conducts internal fidelity monitoring and utilizes a
corrective action plan.
At the time of the review, the program did not meet criteria to earn a score of 1.
g. Evaluation of Facilitator Skill Delivering the Basic Score: 1Point
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.
A review of the facilitator’s annual performance evaluation found there was a section for
assessing the staff level of proficiency in providing the Thinking for a Change (T4C) curriculum.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 6
3. Amount of Service ‐ Duration
Basic Score: 2 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 20%
Research indicates the target duration of 15 weeks for this type of service. Of the 4 youth in the
sample, 25% (1 of 4) 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: 0 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 0%
Research indicates a target of 45 contact hours for this type of service. Of the 4 youth in the
sample, 0% (0 of 4) 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: 25 Points
Program Optimization Score: 25 Points
Program Optimization Percentage: 100%
Percentage of Youth with Moderate, Moderate-High, and High-Risk Levels to Reoffend: 100%
Moderate to High Score: 12 Points
Program Optimization Score: 12 Points
Program Optimization Percentage: 100%
Table 1
Moderate = 0 youth
Moderate-High = 2 youth
High = 2 youth
Total Youth in Sample = 4 youth
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 7
Percentage of Youth with High-Risk Level to Reoffend: 50%
High Score: 13 Points
Program Optimization Score: 13 Points
Program Optimization Percentage: 100%
Table 2
High = 2 youth
Total Youth in Sample = 4 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, 100% (4 of 4) youth scored Moderate to High-Risk to reoffend, for a score
of 12 points.
Of the SPEP sample, 50% (2 of 4) youth scored High-Risk to reoffend, for a score of 13 points.
Note: The latest Community Positive Achievement Change Tool (C-PACT) prior to the placement
date was used in the derivation of the risk level score. This C-PACT 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 35 35 100%
Quality of Service Delivery 10 20 50%
Amount of Service: Duration 2 10 20%
Amount of Service: Contact Hours 0 10 0%
Risk Level of Youth Served 25 25 100%
Totals 72 100 72%
This SPEP report evaluates Thinking for a Change (T4C), an intervention delivered at Juvenile
Unit for Specialized Treatment.
The program scored Medium for Quality of Service Delivery. This score can be optimized by
ensuring that internal fidelity monitoring and corrective action is conducted at least monthly by a
trained facilitator for all individuals facilitating T4C.
The program earned 2 points for Amount of Service: Duration. Of the 4 total youth sampled, 1
received at least the recommended weeks of service. Youth in the sample completed between 12
and 30 weeks of service, with an average of 18 weeks.
The program earned 0 points for Amount of Service: Contact Hours. Of the 4 total youth sampled,
0 received at least the recommended hours of service. Youth in the sample completed between
12 and 30 hours of service, with an average of 13.75 hours.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 8
The program was awarded 25 available points for Risk Level of Youth Served. This is calculated
using data from the Community - Positive Achievement Change Tool (C-PACT) assessment. This
score reflects youths' most recent C-PACT score prior to placement at the program. The program
itself has no control over youths' C-PACT risk level because the scored assessment was
administered prior to the youths' admission.
RECOMMENDATION(S):
Juvenile Unit for Specialized Treatment can optimize their SPEP Quality of Service Delivery score
by ensuring that internal fidelity monitoring and corrective action is conducted at least monthly by
a trained facilitator for all individuals facilitating T4C.
Juvenile Unit for Specialized Treatment 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 9

service_type: Thinking for a Change


summary: SPEP - FY16-17

raw_content:
Standardized Program Evaluation
Protocol [SPEP] Report
Juvenile Unit for Specialized Treatment (JUST)
Twin Oaks Juvenile Development, Inc.
(Contract Provider)
Highway 64 South
Sumatra, Florida 32335
Primary Service: Impact of Crime (IOC)
SPEP Review Date(s): December 6‐9, 2016
Florida Department of Juvenile Justice
Report Date(s): 6/7/2017
Introduction
The Standardized Program Evaluation Protocol (SPEP) is an assessment tool derived from
meta-analytic research on the effectiveness of juvenile justice interventions. The tool is
designed to compare existing intervention services, as implemented in the field, to the
characteristics of the most effective intervention services found in the research.
The SPEP scoring system allows service providers to identify specific areas in which program
improvements can be made to their existing Primary Services. These improvements can be
expected to increase the effectiveness of those Primary Services in the reduction of recidivism
for youth receiving the Primary Service. A separate SPEP evaluation is conducted, at the time
of the program’s Quality Improvement Review, for each Primary Service provided by the
program.
This report provides two types of SPEP scores: a Basic Score, equivalent to the number of
points received, and a Program Optimization Score (POS) that is equivalent to the maximum
number of possible points that could be received based on the SPEP domains under the control
of the program. The Basic Score compares the Primary Service being evaluated to other
intervention services found in the research to be effective, regardless of service type. It is meant
as a reference to the expected overall recidivism reduction when compared to other Primary
Services of any Type.
A Program Optimization Percentage (POP) rate is derived from the Basic Score and Program
Optimization Score. The POP rate is a percentage score that indicates where the rate of
effectiveness of the Primary Service is when compared to its potential effectiveness if optimized
to match the characteristics of similar Primary Services found to be most effective in the
research. The POP rate is likely more meaningful to service providers as it 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 that has been found for a similar
Primary Service Type with research evidence of effectiveness.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 2
Program Name: Juvenile Unit for Specialized Treatment MQI Program Code: 1086
Provider Name: Twin Oaks Juvenile Development, Inc. Contract Number: R2105
Location: Liberty County / Circuit: 2 Number of Beds: 32
Review Date(s): December 6-9, 2016 Lead Reviewer Code: 145
Persons Interviewed
Program Director Corporate QI/QA staff # Program Supervisors
DJJ Monitor # Case Managers # Youth
DHA or designee # Clinical Staff 1 # Other (listed by title): Clinical
DMHCA or designee # Healthcare Staff Director
Documents Reviewed
Written Protocol/Manual Logbooks # Personnel Records
Fidelity Monitoring Documents Program Schedules 2 # Training Records/CORE
Internal Corrective Action Reports Supplemental Contracts # Youth Records (Closed)
Staff Evaluations Table of Organization # Youth Records (Open)
Accreditation Reports Youth Handbook # Other:
Contract Monitoring Reports # Health Records
Contract Scope of Services # MH/SA Records
Observations During Review
Group/Session of Primary Service(s)
Program Activities
Recreation
Social Skill Modeling by Staff
Staff Interactions with Youth
Staff Supervision of Youth
Transition/Exit Conferences
Treatment Team Meetings
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 3
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 (IOC). 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 by the Bureau of Monitoring and Quality Improvement while
on-site during the annual compliance review.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 4
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.
The program currently has two staff (one – Behavior Technician and one – Clinical Coordinator)
who are responsible for facilitating this primary service. Documentation was provided indicating
staff received training through the Department of Juvenile Justice (DJJ).
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 program utilizes the Impact of Crime manual – provided by the Department of Juvenile
Justice (DJJ). Reviewer personally reviewed the manual on-site during the annual compliance
review. The program does not utilize a separate facilitator/student manual. The manual is a step-
by-step instruction guide, which incorporates activities and scenarios for discussion.
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.
The reviewer was unable to observe a session of the intervention during this review period,
therefore, this indicator rates as not applicable.
Basic Score: 2 Point(s)
d. Facilitator Turnover
Maximum Possible Score: 2 Points
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 5
Measures the extent to which facilitators of the specific intervention/service have changed as
well as gaps in service of that Primary Service.
The program’s Clinical Director reported no facility turnover this reporting period. There was no
gap in service delivery. Currently, the program plans to send additional staff to be trained to
facilitate the groups.
BasicScore: 2Point(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.
Fidelity monitoring was conducted by a Clinical Coordinator from the program. Documentation
provided revealed evidence of fidelity monitoring on three occasions during this reporting period.
BasicScore: 1Point
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’s Clinical Director reports re-training would be conducted in the event corrective
action was needed. Fidelity monitoring reports provided revealed no corrective action was
required during the reviewed period.
g. Evaluation of Facilitator Skill Delivering the Basic Score: 1Point
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.
Copies of employee evaluations were provided for each staff who facilitated this primary service.
The evaluations included specific information regarding the staffs’ delivery of the primary service.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 6
3. Amount of Service ‐ Duration
Basic Score: 0 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 0%
Research indicates the target duration of 16 weeks for this type of service. Of the 9 youth in the
sample, 0% (0 of 9) 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: 6 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 60%
Research indicates a target of 24 contact hours for this type of service. Of the 9 youth in the
sample, 78% (7 of 9) 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: 25 Points
Program Optimization Score: 25 Points
Program Optimization Percentage: 100%
Percentage of Youth with Moderate, Moderate-High, and High-Risk Levels to Reoffend: 100%
Moderate to High Score: 12 Points
Program Optimization Score: 12 Points
Program Optimization Percentage: 100%
Table 1
Moderate = 0 youth
Moderate-High = 3 youth
High = 6 youth
Total Youth in Sample = 9 youth
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 7
Percentage of Youth with High-Risk Level to Reoffend: 67%
High Score: 13 Points
Program Optimization Score: 13 Points
Program Optimization Percentage: 100%
Table 2
High = 6 youth
Total Youth in Sample = 9 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, 100% (9 of 9) youth scored Moderate to High-Risk to reoffend, for a score
of 12 points.
Of the SPEP sample, 67% (6 of 9) youth scored High-Risk to reoffend, for a score of 13 points.
Note: The latest Community Positive Achievement Change Tool (C-PACT) prior to the placement
date was used in the derivation of the risk level score. This C-PACT 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 0 10 0%
Amount of Service: Contact Hours 6 10 60%
Risk Level of Youth Served 25 25 100%
Totals 71 85 84%
This SPEP report evaluates Impact of Crime (IOC), an intervention delivered at Juvenile Unit for
Specialized Treatment (JUST).
The program scored High for Quality of Service Delivery.
The program earned 0 points for Amount of Service: Duration. Of the 9 total youth sampled, only
7 included dosage with end dates in the EBS Module. Of those youth with correct dosage, none
received at least the recommended weeks of service. All youth completed 8 weeks of service.
The program earned 6 points for Amount of Service: Contact Hours. Of the 9 total youth sampled,
7 received at least the recommended hours of service. Youth in the sample completed between
13 and 24 hours of service, with an average of 23 hours.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 8
The program was awarded 25 available points for Risk Level of Youth Served. This is calculated
using data from the Community - Positive Achievement Change Tool (C-PACT) assessment. This
score reflects youths' most recent C-PACT score prior to placement at the program. The program
itself has no control over youths' C-PACT risk level because the scored assessment was
administered prior to the youths' admission.
RECOMMENDATION(S):
Juvenile Unit for Specialized Treatment (JUST) 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 9


summary: SPEP - FY16-17

raw_content:
Standardized Program Evaluation
Protocol [SPEP] Report
Juvenile Unit for Specialized Treatment (JUST)
Twin Oaks Juvenile Development, Inc.
(Contract Provider)
Highway 64 South
Sumatra, Florida 32335
Primary Service: Thinking For A Change (T4C)
SPEP Review Date(s): December 6‐9, 2016
Florida Department of Juvenile Justice
Report Date(s): 6/7/2017
Introduction
The Standardized Program Evaluation Protocol (SPEP) is an assessment tool derived from
meta-analytic research on the effectiveness of juvenile justice interventions. The tool is
designed to compare existing intervention services, as implemented in the field, to the
characteristics of the most effective intervention services found in the research.
The SPEP scoring system allows service providers to identify specific areas in which program
improvements can be made to their existing Primary Services. These improvements can be
expected to increase the effectiveness of those Primary Services in the reduction of recidivism
for youth receiving the Primary Service. A separate SPEP evaluation is conducted, at the time
of the program’s Quality Improvement Review, for each Primary Service provided by the
program.
This report provides two types of SPEP scores: a Basic Score, equivalent to the number of
points received, and a Program Optimization Score (POS) that is equivalent to the maximum
number of possible points that could be received based on the SPEP domains under the control
of the program. The Basic Score compares the Primary Service being evaluated to other
intervention services found in the research to be effective, regardless of service type. It is meant
as a reference to the expected overall recidivism reduction when compared to other Primary
Services of any Type.
A Program Optimization Percentage (POP) rate is derived from the Basic Score and Program
Optimization Score. The POP rate is a percentage score that indicates where the rate of
effectiveness of the Primary Service is when compared to its potential effectiveness if optimized
to match the characteristics of similar Primary Services found to be most effective in the
research. The POP rate is likely more meaningful to service providers as it 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 that has been found for a similar
Primary Service Type with research evidence of effectiveness.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 2
Program Name: Juvenile Unit for Specialized Treatment MQI Program Code: 1086
Provider Name: Twin Oaks Juvenile Development, Inc. Contract Number: R2105
Location: Liberty County / Circuit: 2 Number of Beds: 32
Review Date(s): December 6-9, 2016 Lead Reviewer Code: 145
Persons Interviewed
Program Director Corporate QI/QA staff # Program Supervisors
DJJ Monitor # Case Managers # Youth
DHA or designee # Clinical Staff 1 # Other (listed by title): Clinical
DMHCA or designee # Healthcare Staff Director
Documents Reviewed
Written Protocol/Manual Logbooks # Personnel Records
Fidelity Monitoring Documents Program Schedules 1 # Training Records/CORE
Internal Corrective Action Reports Supplemental Contracts # Youth Records (Closed)
Staff Evaluations Table of Organization # Youth Records (Open)
Accreditation Reports Youth Handbook # Other:
Contract Monitoring Reports # Health Records
Contract Scope of Services # MH/SA Records
Observations During Review
Group/Session of Primary Service(s)
Program Activities
Recreation
Social Skill Modeling by Staff
Staff Interactions with Youth
Staff Supervision of Youth
Transition/Exit Conferences
Treatment Team Meetings
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 3
Basic Score: 35 Points
1. Primary Service and Supplemental Service Types POS: 35 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 Thinking For A Change (T4C). The program was
awarded 30 points because the Primary Service is identified as a Group 5 Service. The specific
Sub-Component Service Type identified is Cognitive Behavioral Therapy. The Primary Service
was identified as this type of service as it is intended to correct faulty cognitions and perceptions
and provides skills individuals can use to monitor thought patterns and correct behaviors.
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 by the Bureau of Monitoring and Quality Improvement while
on-site during the annual compliance review.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 4
Basic Score: 10 Points
2. Overall Quality of Service Delivery Score POS: 20 Points
POP: 50%
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): 7 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’s Clinical Director, who is also a Licensed Mental Health Counselor, is primarily
responsible for facilitating the curriculum. Documentation of training for the Thinking for a Change
(T4C) curriculum was provided.
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 program utilizes the Thinking for a Change (T4C) version 3.1 manual, hard-copy format.
Manual 4.0 is also utilized on the computer. There are no separate facilitator/student manuals
utilized by the program. The manual contains step-by-step instructions for cognitive behavioral
interventions.
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.
Observed facilitator utilizing the manual during delivery of the primary service. The session
adhered to the manual and protocol. Facilitator posted ‘Step Goals’ for youth and reviewed
scenarios on computer worksheet provided to all participants. Facilitator was observed engaging
all youth participants by asking questions and reviewing material.
Basic Score: 2 Point(s)
d. Facilitator Turnover
Maximum Possible Score: 2 Points
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 5
Measures the extent to which facilitators of the specific intervention/service have changed as
well as gaps in service of that Primary Service.
The program’s Clinical Director reported no facility turnover this reporting period. There was no
gap in service delivery. Currently, the program plans to send additional staff to be trained by
Department of Juvenile Justice (DJJ) to facilitate the groups.
BasicScore: 0Point(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 currently does not have an in-house process to perform fidelity monitoring. The
program’s Clinical Director is the only individual trained within the program to facilitate this primary
service.
The program can earn 2 points by ensuring that there is a process to conduct internal fidelity
monitoring and that monitoring is conducted at least monthly for each facilitator.
At the time of the review, the program did not meet criteria to earn a score of 2.
BasicScore: 0Point
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 currently does not have an in-house process to perform fidelity monitoring and give
corrective actions based on fidelity monitoring. The program’s Clinical Director is the only
individual trained within the program to facilitate this primary service.
The program can earn 1 point by ensuring that there is a process for corrective action based on
fidelity monitoring.
At the time of the review, the program did not meet criteria to earn a score of 1.
g. Evaluation of Facilitator Skill Delivering the Basic Score: 1Point
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.
A copy of employee evaluations was provided for the staff responsible for facilitating this primary
service. The evaluation contained to include specific information regarding the staffs’ delivery of
the primary service.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 6
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 7
3. Amount of Service ‐ Duration
Basic Score: 10 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 100%
Research indicates the target duration of 15 weeks for this type of service. Of the 2 youth in the
sample, 100% (2 of 2) 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: 0 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 0%
Research indicates a target of 45 contact hours for this type of service. Of the 2 youth in the
sample, 0% (0 of 2) 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: 12 Points
Program Optimization Score: 25 Points
Program Optimization Percentage: 48%
Percentage of Youth with Moderate, Moderate-High, and High-Risk Levels to Reoffend: 100%
Moderate to High Score: 12 Points
Program Optimization Score: 12 Points
Program Optimization Percentage: 100%
Table 1
Moderate = 1 youth
Moderate-High = 1 youth
High = 0 youth
Total Youth in Sample = 2 youth
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 8
Percentage of Youth with High-Risk Level to Reoffend: 0%
High Score: 0 Points
Program Optimization Score: 13 Points
Program Optimization Percentage: 0%
Table 2
High = 0 youth
Total Youth in Sample = 2 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, 100% (2 of 2) youth scored Moderate to High-Risk to reoffend, for a score
of 12 points.
Of the SPEP sample, 0% (0 of 2) youth scored High-Risk to reoffend, for a score of 13 points.
Note: The latest Community Positive Achievement Change Tool (C-PACT) prior to the placement
date was used in the derivation of the risk level score. This C-PACT 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 35 35 100%
Quality of Service Delivery 10 20 50%
Amount of Service: Duration 10 10 100%
Amount of Service: Contact Hours 0 10 0%
Risk Level of Youth Served 12 25 48%
Totals 67 100 67%
This SPEP report evaluates Thinking For A Change (T4C), an intervention delivered at Juvenile
Unit for Specialized Treatment (JUST).
The program scored Medium for Quality of Service Delivery. This score can be optimized by
ensuring that there is a process to conduct internal fidelity monitoring and that monitoring is
conducted at least monthly for each facilitator, and ensuring that there is a process for corrective
action based on fidelity monitoring.
The program earned 10 points for Amount of Service: Duration. Of the 2 total youth sampled, both
received at least the recommended weeks of service. Youth in the sample completed 33 and 44
weeks of service.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 9
The program earned 0 points for Amount of Service: Contact Hours. Of the 2 total youth sampled,
neither received at least the recommended hours of service. Youth in the sample completed 35
and 10 hours of service.
The program was awarded 12 available points for Risk Level of Youth Served. This is calculated
using data from the Community - Positive Achievement Change Tool (C-PACT) assessment. This
score reflects youths' most recent C-PACT score prior to placement at the program. The program
itself has no control over youths' C-PACT risk level because the scored assessment was
administered prior to the youths' admission.
RECOMMENDATION(S):
Juvenile Unit for Specialized Treatment (JUST) can optimize their SPEP Quality of Service
Delivery score by ensuring that there is a process to conduct internal fidelity monitoring and that
monitoring is conducted at least monthly for each facilitator, and ensuring that there is a process
for corrective action based on fidelity monitoring.
Juvenile Unit for Specialized Treatment (JUST) 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 10