state: FL

summary: PREA

raw_content:
A PREA AUDIT: AUDITOR’S SUMMARY
REPORT JUVENILE FACILITIES
Name of Facility: Marion Youth Academy
Physical Address: 10420 NW Gainesville Rd., Ocala, FL 34482
Date report submitted: March 24, 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: March 11-12, 2015
Facility Information
Facility Mailing Address: 10420 NW Gainesville Rd., Ocala, FL 34482
Telephone Number: (352) 840-8240
The Facility is: Military County Federal
X Private for profit Municipal State
Private not for profit
Facility Type: Detention X Correction Other:
Name of PREA Compliance Manager: Keenan Bullard Title: Facility Administrator
Email Address: Keenan.Bullard@youthservices.com Telephone Number:
(352) 840-8240
Agency Information
Name of Agency: Youth Services International, Inc.
Governing Authority or Parent Agency: NA
Physical Address: 6000 Cattle Ridge Dr., Suite 200, Sarasota, FL 34232
Mailing Address: Same as Above
Telephone Number: (941) 953-9199
Agency Chief Executive Officer
Name: James Slattery Title: President & Chief Executive Officer
Telephone (941) 9533-9199
Email Address: Jim.Slattery@ysii.com
Number:
Agency Wide PREA Coordinator
Name: Jesse Williams Title: PREA Coordinator
Email Address: Jesse.Williams@youthservices.com Telephone (941) 704-8796
Number:
1
AUDIT FINDINGS
NARRATIVE:
The Marion Youth Academy is located in Ocala, Florida and is a 42-bed moderate risk facility that
houses male juvenile offenders that range from ages 14 to 18. The facility is operated by Youth
Services International, Inc. (YSI) through a contract with the Florida Department of Juvenile Justice
(DJJ). The average length of stay is 10 months. During their stay in the facility, residents participate
in a daily schedule that includes education/vocational classes; case management services; mental
health services; and recreation. At least ninety-two residents have been admitted to the facility during
the past 12 months.
The number of staff currently employed at the facility who may have contact with the residents is 43.
Medical services are provided on-site by a full-time Registered Nurse who serves in the position of
Lead Nurse and a full-time Licensed Practical Nurse. The contract physician visits the facility on a
weekly basis. Mental health staff includes the Clinical Director and three Therapists. The position of
the Clinical Director is currently vacant and the role is being temporarily filled by qualified staff from
other areas in the capacity of Acting Clinical Director. A contract psychiatrist visits the facility twice
a month. Case management services are provided by two Case Managers, supervised by the Case
Manager Supervisor. Education services are provided on-site by contract staff through the Marion
County Public Schools. Youth Care Workers and Supervisors provide supervision and oversight of
residents during their involvement in activities on and off facility grounds and throughout the
residents’ movement within the facility.
An individualized treatment plan is completed for each resident and a monthly review of each
resident’s treatment plan is conducted. Parents/legal guardians are invited and encouraged to take an
active part in the review as well as to be supportive to their child in his efforts to achieve his treatment
goals. The facility conducts Family Day on a quarterly basis and parents/legal guardians are invited to
spend the afternoon with their son and eat lunch with him. During Family Day, treatment staff is also
available to interact with parents/guardians and discuss each resident’s treatment and progress in the
program. A behavior management system exists for the residents that supports accountability and
provides for consequences when the program rules and expectations are not followed.
DESCRIPTION OF FACILITY CHARACTERISTICS:
The entrance to the building contains the control room and administrative offices are located in the
front area of the building. Through the adjacent doorways are the kitchen; dining area; and two
wings, Phase I and Phase II. Ten rooms are located on Phase I that houses two residents; 13 rooms
are on the Phase II wing where two are single rooms and 11 rooms that house two residents each.
Each Phase or wing contains a dayroom; inside recreation court or the basketball court; a laundry
2
room and classrooms. The section of the building beyond the main doorways also contains additional
offices, medical clinic, library; conference room; maintenance office; and storage closets. Phase I and
Phase II have bathrooms that afford residents a reasonable amount of privacy while they shower,
change clothes and perform bodily functions.
A garden is maintained outside in the back of the building. The garden serves as an educational
activity for residents as well as an opportunity in life skills and a positive behavior incentive. The
residents tend to the garden and consume its contents under the supervision of one of the teachers.
The outside grounds contain ample space for recreation and other activities, as well as the garden.
SUMMARY OF AUDIT FINDINGS:
The process began with a conference call which included the Facility Administrator, PREA Auditor
and other YSI and DJJ staff to discuss the audit process. The notifications of the on-site audit were
later posted in various parts of the facility 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. 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.
After reviewing the information on the flash drive, a follow-up call was made to the Facility
Administrator to discuss data and for clarification of information. Additional information was
provided or clarified as requested.
The on-site audit was conducted March 11-12, 2015. An entrance meeting was held with the Facility
Administrator and afterwards, a comprehensive tour of the facility was conducted by the Facility
Administrator. This Auditor observed staff members directly supervising and interacting with the
residents. The interviews conducted included random staff, specialized staff and residents.
PREA file folders were set up in a very neat and organized manner that contained supplemental
documentation. A close-out meeting was held at the conclusion of the on-site audit and a summary of
the audit findings was provided to the Facility Administrator, Assistant Facility Administrator and
the YSI PREA Coordinator participated by telephone.
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:
Policy 1.26, Prison Rape Elimination Act (PREA), provides guidelines for implementing
compliance with the requirements of the PREA standards. The Policy provides for zero-
tolerance toward all forms of sexual abuse and sexual harassment. The Policy contains
definitions of the prohibited behaviors and sanctions for those who participate in such
behaviors. The Florida Department of Juvenile Justice Policy 1919 (FDJJ 1919) is used as the
overarching Policy that must be adhered to.
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:
Policy 1.26 provides for the implementation of a staffing plan with adequate staffing levels to
protect residents against sexual abuse and refers to the current staffing assignments per the
current contract. The operational work schedules and a hold-over system are implemented to
maintain the required staff ratios during the awake and sleeping hours. The annual assessment
of the staffing plan has been conducted and documented.
Unannounced rounds of the facility for the maintenance of a safe environment are conducted
and documented by the appropriate staff, including the Facility Administrator. The Policy and
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facility’s practice prohibit staff from alerting other staff while the unannounced rounds are
being conducted. Staff interviews and a review of documentation, including the camera
system, confirmed the practice of unannounced rounds being conducted.
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:
According to Policy 1.26, cross-gender pat-down searches, cross-gender strip searches and
cross-gender visual body cavity searches of residents are prohibited, except in exigent
circumstances or when performed by medical practitioners. In the event of any occurrence,
documentation of the situation is required. According to the staff interviews, the facility
practice is that no type of cross-gender searches should occur. All of the residents interviewed
stated that they have not been searched by a female staff member during their stay at the
facility.
The PREA Policy, 1.26, provides for residents to shower, perform bodily functions, and
change clothes without being observed by staff of the opposite gender. Interviews with staff
and residents confirm these practices. Policy 1.26 states that staff shall not search a
transgender or intersex resident to determine the resident’s genital status and all staff
interviewed were aware of the facility policy. Additionally, the Policy directs staff to ask a
transgender or intersex resident which gender they would prefer to conduct the search.
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:
According to Policy 1.26, support services are provided for residents with disabilities and
residents who are limited English proficient so that they may benefit from and participate in
PREA education. Resident education materials are accessible in languages other than
English. Policy 1.26 states that the facility will not rely on resident interpreters or resident
readers to provide information to other residents. The Policy provides for the use of outside
resources and the services of the education and mental health units. A review of the
documentation provided and staff interviews confirmed that residents are not to be used as
interpreters or readers to assist other residents.
5
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:
Policy 1.26 and Florida DJJ Policy 1919 provide for background checks on all employees,
contractors and volunteers through a process that meets the requirements of the standard and
used statewide. Related documentation and staff interviews revealed that prior to the hiring
of an employee or contractor or the use of a volunteer’s services, background checks are
conducted. The facility’s PREA Policy and DJJ 1919 require that criminal background
checks be conducted every five years on employees and on contractors who may have
contact with residents.
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. The facility reports that there has not been a substantial
expansion or modification to the facility and the camera system has not been updated during
the time period since August 20, 2012.
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:
Policy 1.26 states that staff will cooperate in investigations conducted by the FDJJ Office of
the Inspector General (OIG). The OIG is responsible for administrative investigations and
investigations are conducted by the Florida Department of Children and Families (DCF) and
local law enforcement. Policy 1.26 further states that forensic medical examinations will be
completed at no financial cost to the victim. The facility provided documentation of efforts
to obtain advocacy services that would be accessible to the residents, if needed .
6
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:
Policy 1.26 and FDJJ 1919 require that staff report all allegations of sexual abuse and sexual
harassment. There has been one allegation from a resident during this audit period. The
allegation was reported as required and investigated by the Marion County Sheriff’s Office
and the OIG. The findings of the report from the Sheriff’s Office stated that the case was
closed as Unfounded. The administrative investigation findings by the OIG stated that the
case was Closed as Information Only regarding the allegations. Concerning staff, the OIG
investigation resulted in findings that caused the Facility Administrator to provide additional
specific training for staff.
The facility posts related information regarding reporting allegations of sexual abuse and
sexual harassment in areas which are accessible to the public. The DJJ website contains
information regarding the referral of allegations for investigations of sexual abuse.
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:
Policy 1.26 and FDJJ 1919 provides for the PREA training of all staff. The facility staff
received the DJJ training and the facility has conducted refresher training in the key areas
referenced in the standards. Documentation of staff participating in training is maintained and
staff interviews confirmed that training occurs.
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:
Policy 1.26 contains information regarding the training of volunteers and contractors who
have contact with residents. Receipt of the training is documented and the training contains a
review of the PREA Policy.
7
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:
Resident education is provided to residents as confirmed by interviews with residents and
staff and a review of documents. Residents receive information about the facility’s zero-
tolerance policy and how to report incidents or suspicions of sexual abuse or sexual
harassment. As determined through resources identified in Policy 1.26, a review of other
documentation and staff interviews, the facility will provide support services in accessible
formats for residents who are limited English proficient, deaf, visually impaired, or
otherwise disabled.
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 states that investigators 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 DJJ settings.
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:
Policy 1.26 addresses PREA training for medical and mental health staff. A review of
documentation and staff interviews confirmed the specialized training for medical and
mental health staff. Forensic medical examinations are not conducted by the facility medical
staff.
8
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 initial risk screening is conducted during the intake process. Policy 1.26 and staff
interviews provide for residents to receive reassessments within the first 30 days. After that
period, they are conducted periodically through the treatment team process. A review of
documentation and staff and resident interviews confirmed that the risk screening is being
conducted on each admission to the facility.
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:
According to Policy 1.26, the facility prohibits placing gay, bisexual, transgender, or intersex
residents into confinement based solely on such identification or status. Policy 1.26 states
that housing and program assignments require determinations on each transgender or
intersex resident on a case by case basis. Additionally, Policy 1.26 prohibits considering gay,
bisexual, transgender, or intersex identification or status as an indicator of likelihood of
being sexually abusive.
The facility reports that during this audit period there have been no residents placed in
isolation because of being at risk for victimization. Policy 1.26 provides that residents may
be isolated from others only as a last resort when less restrictive measures are inadequate and
until other arrangements can be made to keep the resident safe. Where isolation may be used,
Policy 1.26 provides that residents receive the required services.
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:
Policy 1.26 states and staff and resident interviews confirmed that there are internal ways a
resident may report. A “Speak Out Form” may be completed where the resident states what
9
they would like to discuss with a specific staff member identified on the Form; complete a
grievance form; talk to any staff member; and third parties may report allegations to staff.
The grievance and other written requests may be placed in the locked grievance box. PREA
related information is posted in various locations. Residents are provided access to a
telephone to report allegations of sexual abuse and sexual harassment to the abuse reporting
hotline.
Interviews revealed that staff members are aware of their responsibility to report any
allegations or suspicions of sexual abuse or sexual harassment. Staff members are also aware
of their responsibility to accept reports of sexual abuse and sexual harassment made verbally,
in writing, anonymously, and from third parties as stated in Policy 1.26 and FDJJ 1919. Staff
members are directed to immediately document verbal reports.
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:
Residents may put a completed grievance form in the grievance box. Residents are not
required to use an informal grievance process regarding allegations of sexual abuse and
sexual harassment. The facility considers an emergency grievance as a resident’s allegation
and when one is received, Policy 1.26 provides for the implementation of the procedures for
reporting allegations of sexual abuse and sexual harassment to be initiated.
Standard 115.353 Resident Access to Outside Confidential Support 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:
Policy 1.26 requires the facility to provide the residents with access to outside victim
advocacy services. The facility has provided documentation of their continued efforts to
obtain victim advocacy services for residents when needed.
Visitation is held at the facility at least weekly where residents may see their
parents/guardians and the residents are allowed to make weekly telephone calls. Family Day is
held quarterly at the facility where the parents/guardians may share lunch and spend the
afternoon together. Attorneys or other legal representation may visit the facility and these
visits may be conducted in a confidential manner.
10
Standard 115.354 Third-Party Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 1.26 provides guidelines regarding third-party reporting. Information about reporting
incidents of sexual abuse is posted in the facility, accessible to the public. Staff and resident
interviews confirmed that the facility has a method for third-party reporting. The YSI
website contains a link to the DJJ website which provides information on how to report
resident sexual abuse or sexual harassment.
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:
Policy 1.26 and Florida Statute directs that all staff members are mandated reporters. Staff
should immediately report any knowledge, suspicion or information they receive regarding
sexual abuse and 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 or retaliation. Policy 1.26 prohibits staff from sharing information regarding sexual
abuse other than as needed to make treatment, investigation, and other security and
management decisions. The interviews conducted with staff confirmed their knowledge of
this information.
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:
According to Policy 1.26, when a staff member learns that a resident is subject to substantial
risk of imminent sexual abuse, immediate action will be taken to protect the resident. The
facility reports that there have been no incidents in the last 12 months where any action was
taken regarding a resident being in substantial risk of imminent sexual abuse. Interviews
with staff revealed the protective measures that may be taken when a resident is at risk.
11
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:
According to Policy 1.26, upon receiving an allegation that a resident was sexually abused
while confined in another facility, the Facility Administrator (FA) will notify the Central
Communications Center (CCC) of the allegation within two hours. The Policy also provides
that the FA will notify the facility of which the allegation was made, no later than 24 hours.
Standard 115.364 Staff First Responder Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 1.26 provides an account of first responder duties and responses. There has been one
allegation by a resident regarding sexual abuse within the last 12 months which was reported
as required. The allegations were investigated by the Marion County Sheriff’s Office and the
OIG and both investigations have been closed.
Standard 115.365 Coordinated Response
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility has a written Coordinated Response Plan. A review of training records and
interviews with staff confirmed the staff’s knowledge of their responsibilities. The Plan
outlines the actions to be taken among staff including first responders, leadership, medical
and mental health in response to an incident 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)
12
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:
Directions are provided in Policy 1.26 regarding protection against retaliation for residents
and staff who report allegations of sexual abuse or sexual harassment. Staff has been
identified and given the responsibility of monitoring for possible retaliation. If the conduct of
retaliation is identified, the facility practice is that the monitoring is ongoing. The facility
reports that no incidents of retaliation have occurred during the past 12 months.
Standard 115.368 Post Allegation Protective Custody
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 1.26 ensures that if there is any use of segregated housing or isolation, it is used as a
last resort and that the resident is afforded access to the required program and services
provided by the facility. Staff interviews supported that a resident placed in isolation will
receive programming and services as required.
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)
13
Auditor Comments:
Policy 1.26 and FDJJ 1919 address this standard. Administrative investigations are
conducted by OIG and criminal investigations are conducted by DCF and local law
enforcement. Both Policies direct facility staff to cooperate with the OIG investigations. The
Policies provide for substantiated allegations of conduct that appear to be criminal to be
referred for prosecution. A Memorandum of Understanding exists between the facility and
the Marion County Sheriff’s Office.
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:
FDJJ 1919 supports that a standard of the preponderance of the evidence is used for
determining if allegations are substantiated.
Standard 115.373 Reporting to Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 1.26 and FDJJ 1919 provide for notifying residents following an investigation of
whether an allegation has been determined to be substantiated, unsubstantiated, or
unfounded. The Policies require that all notifications or attempted notifications be
documented.
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:
Policy 1.26 and FDJJ 1919 provide for disciplinary sanctions for staff to be up to and
including termination for violation of the sexual abuse and sexual harassment policies. Both
Policies require that staff terminations or resignations by staff who would have been
14
terminated for violating the PREA Policies, be reported to local law enforcement and to
relevant licensing bodies. No staff has been terminated or has resigned for violating PREA
related policies during this audit period.
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:
According to Policy 1.26, the contractor or volunteer who engages in sexual abuse will have
no contact with residents and will be reported to law enforcement, unless the activity was
clearly not criminal, and to relevant licensing bodies. The Policy requires that remedial
measures be taken and prohibits future contact with residents in the case of any other violation
of the PREA related policies. The facility reports that 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)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 1.26 provides for a resident who engages in resident-on-resident sexual abuse to be
placed in a DJJ Juvenile Detention Center. The resident will receive the required court
hearings and a determination will be made regarding the subsequent placement.
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:
Policy 1.26 states that residents who disclose a history of sexual abuse or who disclose
previously perpetrating sexual abuse will be referred for a follow-up meeting with a medical
or mental health practitioner within 24 hours of the screening. Staff interviewed confirmed
awareness of the policy and explained the practice regarding mental health and medical
screenings.
15
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:
Policy 1.26 provides for timely access to emergency medical treatment and crisis
intervention services for victims of sexual abuse. According to Policy 1.26 and staff
interviews, the nature and scope of the services are determined by medical and mental health
practitioners based on their professional judgment. Staff interviews and Policy 1.26 provide
for emergency medical and mental health services to be provided at no financial cost to the
victim and whether or not the abuser is named.
Standard 115.383 Ongoing Medical and Mental Health Care for Sexual Abuse Victims and
Abusers
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to Policy 1.26, ongoing medical and mental health care for sexual abuse victims
is provided. It also provides for medical and mental health evaluations and appropriate
treatment and follow-up services as referred to in the standard. Policy 1.26 and staff
interviews agree that the medical and mental health services provided are 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:
Policy 1.26 will serve as the guide for staff in conducting incident reviews. The incident
review team has been identified and interviews revealed an understanding of the purpose of
the process.
16
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:
According to Policy 1.26, the facility reports data to DJJ on a monthly basis. Additionally,
Policy 1.26 and FDJJ 1919 state that there is the collection of accurate, uniform data for
every allegation of sexual assault. The DJJ 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)
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:
Policy 1.26 and FDJJ 1919 address this standard. The Policies require the review of data for
corrective action towards improving the effectiveness of the agencies’ prevention, protection
and response policies, practices, and training regarding sexual abuse and sexual harassment.
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:
Policies 1.26 and FDJJ 1919 require that data is collected and securely retained for 10 years.
The aggregated PREA data is reviewed, all personal identifiers are removed, and the
information is posted on the DJJ 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.
March 24, 2015
Auditor Signature Date
17

source: DJJ

report_type: PREA


facility_name: Marion Regional Juvenile Detention Center

summary: SPEP - FY16-17

raw_content:
Standardized Program Evaluation
Protocol [SPEP] Report
Marion Youth Academy
Sequel TSI of Florida, LLC
(Contract Provider)
10420 NW Gainesville Road
Ocala, Florida 34482
Primary Service: Impact of Crime (IOC)
SPEP Review Date(s): May 23-26, 2017
Florida Department of Juvenile Justice
Report Date(s): 1/16/2018
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: Marion Youth Academy MQI Program Code: 1205
Provider Name: Sequel Contract Number: 10321
Location: Ocala County / Circuit: 5 Number of Beds: 42
Review Date(s): May 23-26, 2017 Lead Reviewer Code: 144
Persons Interviewed
Program Director Corporate QI/QA staff NA # Program Supervisors
DJJ Monitor NA # Case Managers NA # Youth
DHA or designee NA # Clinical Staff NA # Other (listed by title):
DMHCA or designee NA # Healthcare Staff
Documents Reviewed
Written Protocol/Manual Logbooks NA # Personnel Records
Fidelity Monitoring Documents Program Schedules NA # Training Records/CORE
Internal Corrective Action Reports Supplemental Contracts NA # Youth Records (Closed)
Staff Evaluations Table of Organization NA # Youth Records (Open)
Accreditation Reports Youth Handbook NA # Other:
Contract Monitoring Reports NA # Health Records
Contract Scope of Services NA # 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 Marion Youth Academy has three staff certified to deliver Impact of Crime (IOC); Lead Case
Manager, Transition Specialist, and a Case Manager. Each of these staff have completed
formalized training by the Department of Juvenile Justice. Only two of the three IOC facilitators
have conducted training within the past eight months.
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 Marion Youth Academy has an Impact of Crime (IOC) facilitator’s manual. The Impact of
Crime facilitator manual consist of seven chapters detailing the specific path (learning objectives)
both the facilitator and participant should follow. There is a separate student handbook which is
provided to each youth.
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.
Unable to observe service delivery for the Impact of Crime (IOC), during this annual compliance
review.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 5
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.
The Marion Youth Academy has had no facilitator turnover in the Impact of Crime (IOC)
curriculum.
Basic Score: 2 Point(s)
e. Internal Fidelity Monitoring
Maximum Possible Score: 2 Points
The program has a process to monitor the delivery of the intervention to examine how closely
actual implementation matches the model protocol.
The Marion Youth Academy utilizes other trained facilitators to provide oversight and conduct
monthly fidelity monitoring. The program utilizes a fidelity monitoring tool specific to the Impact of
Crime (IOC) group. The monitoring has been conducted monthly by each of the three trained IOC
facilitators.
Basic Score: 1 Point
f. Corrective Action based on Fidelity Monitoring
Maximum Possible Score: 1 Point
The program has a process by which corrective action is applied and demonstrated based on
the fidelity monitoring of the delinquency intervention/therapeutic service.
There has been no corrective action based on fidelity monitoring over the period reviewed.
g. Evaluation of Facilitator Skill Delivering the Basic Score: 1 Point
Intervention Maximum Possible Score: 1 Point
Performance evaluations of the facilitators of the specific intervention/service include
evaluation of skill in delivering the intervention/service.
Marion Youth Academy began operations on September 1, 2016. Staff have not been provided
with an annual performance evaluation as of this annual compliance review. Specific interventions
and facilitator deliverance skills are part of the programs performance evaluations.
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: 8 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 80%
Research indicates a target of 24 contact hours for this type of service. Of the 9 youth in the
sample, 89% (8 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: 20 Points
Program Optimization Score: 25 Points
Program Optimization Percentage: 80%
Percentage of Youth with Moderate, Moderate-High, and High-Risk Levels to Reoffend: 89%
Moderate to High Score: 10 Points
Program Optimization Score: 12 Points
Program Optimization Percentage: 83%
Table 1
Moderate = 2 youth
Moderate-High = 3 youth
High = 3 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: 33%
High Score: 10 Points
Program Optimization Score: 13 Points
Program Optimization Percentage: 77%
Table 2
High = 3 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, 89% (8 of 9) youth scored Moderate to High-Risk to reoffend, for a score of
10 points.
Of the SPEP sample, 33% (3 of 9) youth scored High-Risk to reoffend, for a score of 10 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 8 10 80%
Risk Level of Youth Served 20 25 80%
Totals 68 85 80%
This SPEP report evaluates Impact of Crime (IOC), an intervention delivered at Marion Youth
Academy.
The program scored High for Quality of Service Delivery.
The program earned 0 points for Amount of Service: Duration. Of the nine total youth sampled,
only one included dosage with an end date in the EBS Module. The lone youth with an end date
completed 15 weeks of service.
The program earned 8 points for Amount of Service: Contact Hours. Of the nine total youth
sampled, 8 received at least the recommended hours of service. Youth in the sample completed
between 21 and 30 hours of service, with an average of 28 hours.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 8
The program was awarded 20 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 just prior to the youths' admission.
RECOMMENDATION(S):
Marion Youth Academy can optimize their SPEP Amount of Service score by ensuring that data is
entered accurately in the EBS Module and by ensuring all youth receive the full targeted dosage
of service.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 9

report_type: SPEP

program_name_raw: Marion Youth Academy

program_status_note: Closed

service_type: Impact of Crime


summary: SPEP - FY16-17

raw_content:
Standardized Program Evaluation
Protocol [SPEP] Report
Marion Youth Academy
Sequel TSI of Florida, LLC
(Contract Provider)
10420 NW Gainesville Road
Ocala, Florida 34482
Primary Service: Anger Management for Substance Abuse and Mental
Health: A CBT Manual
SPEP Review Date(s): May 23-26, 2017
Florida Department of Juvenile Justice
Report Date(s): 1/16/2018
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: Marion Youth Academy MQI Program Code: 1205
Provider Name: Sequel Contract Number: 10321
Location: Ocala County / Circuit: 5 Number of Beds: 42
Review Date(s): May 23-26, 2017 Lead Reviewer Code: 144
Persons Interviewed
Program Director Corporate QI/QA staff NA # Program Supervisors
DJJ Monitor NA # Case Managers NA # Youth
DHA or designee NA # Clinical Staff NA # Other (listed by title):
DMHCA or designee NA # Healthcare Staff
Documents Reviewed
Written Protocol/Manual Logbooks NA # Personnel Records
Fidelity Monitoring Documents Program Schedules NA # Training Records/CORE
Internal Corrective Action Reports Supplemental Contracts NA # Youth Records (Closed)
Staff Evaluations Table of Organization NA # Youth Records (Open)
Accreditation Reports Youth Handbook NA # Other:
Contract Monitoring Reports NA # Health Records
Contract Scope of Services NA # 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: 30 Points
1. Primary Service and Supplemental Service Types POS: 30 Points
POP: 100%
There are five Primary Service Types that have been classified into Groups with a maximum
number of points possible for rating purposes. Some Primary Service Types may also have
qualifying Supplemental Service Types that could earn a program an additional 5 points.
The Primary Service for this program is Anger Management for Substance Abuse and Mental
Health: A CBT Manual. The program was awarded 25 points because the Primary Service is
identified as a Group 4 Service. The specific Sub-Component Service Type identified is
Group Counseling. The Primary Service was identified as this type of service as it focuses on
psychological or interpersonal problems or issues faced by an individual and involves a group of
youths interacting with each other.
An additional 5 points was awarded based on a Qualifying Supplemental Service. The Qualifying
Supplemental Service was identified as None (automatic 5 points added to score), which was not
demonstrated to have been implemented.
The Primary and Supplemental Service Raw Score is equal to the sum of the Primary Service
points plus the Qualifying Supplemental Service points.
Note: Quality information is evaluated 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): 5 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 completes training for 'Anger Management for Substance Abuse and Mental Health:
A CBT Manual' by having the licensed mental health counselor (LMHC) train the master's level
therapists. Four therapists were trained at the time of the review. The training is four hours in
lengthand all the therapists have completed training and delivered groups within the past eight
months.
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 has the 'Anger Management for Substance Abuse and Mental Health: A CBT
Manual' facilitator book and student guide. The manual is detailed. Youth complete this
intervention if it matches the priortized needs listed in their treatmen plan.
Basic Score: N/A Point(s)
c. Observed Adherence to the Manual/Protocol
Maximum Possible Score: 1 Point
Upon observation of the Primary Service by the Quality Improvement reviewer, the facilitator of
that service adhered to the written protocol/manual.
This curriculum was not able to be observed; therefore, this indicator rates as non-applicable.
d. Facilitator Turnover Basic Score: 1 Point(s)
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 5
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.
The program has had one incident of facilitator turnover in this service during the review period.
One therapist resigned and another master's level therapist was able to pick up the group and
continue.
Note, the program began operations under new contract on September 1, 2016; unable to review
a complete twelve-month period.
The program can earn 2 points if facilitator turnover does not impact groups.
At the time of the review, the program did not meet criteria to earn a score of 2.
Basic Score: 0 Point(s)
e. Internal Fidelity Monitoring
Maximum Possible Score: 2 Points
The program has a process to monitor the delivery of the intervention to examine how closely
actual implementation matches the model protocol.
The program uses the LMHC to provide oversight and conduct monthly fidelity monitoring. The
program utilizes a fidelity monitoring tool specific to the 'Anger Management' groups. The
monitoring has only been conducted once during the seven months reviewed.
The program can earn 2 points if fidelity monitoring is completed every month for each facilitator.
At the time of the review, the program did not meet criteria to earn a score of 2.
Basic Score: 0 Point
f. Corrective Action based on Fidelity Monitoring
Maximum Possible Score: 1 Point
The program has a process by which corrective action is applied and demonstrated based on
the fidelity monitoring of the delinquency intervention/therapeutic service.
There was no corrective actions identified based on the one fidelity monitoring completed. The
program does have a process in place to address any specific issues needing improvement
regarding this serice.
The program can earn 1 point if any corrective action needed is identified, applied, and
demonstrated.
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: 1 Point
Intervention Maximum Possible Score: 1 Point
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 6
Performance evaluations of the facilitators of the specific intervention/service include
evaluation of skill in delivering the intervention/service.
Marion Youth Academy began operations on September 1, 2016, under a new contract. Staff
have not been provided with an annual performance evaluation as of this annual compliance
review. Specific interventions and facilitator skills are part of the program's performance
evaluations.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 7
3. Amount of Service - Duration
Basic Score: 0 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 0%
Research indicates the target duration of 24 weeks for this type of service. Of the 35 youth in the
sample, 0% (0 of 35) 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 40 contact hours for this type of service. Of the 35 youth in the
sample, 0% (0 of 35) 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: 23 Points
Program Optimization Score: 25 Points
Program Optimization Percentage: 92%
Percentage of Youth with Moderate, Moderate-High, and High-Risk Levels to Reoffend: 94%
Moderate to High Score: 10 Points
Program Optimization Score: 12 Points
Program Optimization Percentage: 85%
Table 1
Moderate = 3 youth
Moderate-High = 13 youth
High = 17 youth
Total Youth in Sample = 35 youth
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 8
Percentage of Youth with High-Risk Level to Reoffend: 49%
High Score: 13 Points
Program Optimization Score: 13 Points
Program Optimization Percentage: 100%
Table 2
High = 17 youth
Total Youth in Sample = 35 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, 94% (33 of 35) youth scored Moderate to High-Risk to reoffend, for a score
of 10 points.
Of the SPEP sample, 49% (17 of 35) 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 30 30 100%
Quality of Service Delivery 10 20 50%
Amount of Service: Duration 0 10 0%
Amount of Service: Contact Hours 0 10 0%
Risk Level of Youth Served 23 25 92%
Totals 63 95 66%
This SPEP report evaluates Anger Management for Substance Abuse and Mental Health: A CBT
Manual, an intervention delivered at Marion Youth Academy.
The program scored Medium for Quality of Service Delivery.
The program earned 0 points for Amount of Service: Duration. Of the 35 total youth sampled, 35
included dosage with an end date in the EBS Module. The youth in the sample completed
between 4 and 13 weeks of service, with an average of 9 weeks.
The program earned 0 points for Amount of Service: Contact Hours. Of the 35 total youth
sampled, 0 received at least the recommended hours of service. Youth in the sample completed
between 9 and 22 hours of service, with an average of 19 hours.
The program was awarded 23 available points for Risk Level of Youth Served. This is calculated
using data from the Community - Positive Achievement Change Tool (C-PACT) assessment. This
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 9
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 just prior to the youths' admission.
RECOMMENDATION(S):
Marion Youth Academy can optimize their SPEP Quality of Service score by minimizing the
impact of turnover and ensuring that fidelity monitoring is completed monthly for each therapist.
Marion Youth Academy can optimize their SPEP Amount of Service score by ensuring that data is
entered accurately in the EBS Module and by ensuring all youth receive the full targeted dosage
of service.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 10

service_type: Anger Management for Substance Abuse and Mental Health Clients


summary: SPEP - FY17-18

raw_content:
Standardized Program Evaluation
Protocol [SPEP] Report
Marion Youth Academy
Sequel Youth and Family Services
(Contract Provider)
10420 NW Gainesville Road
Ocala, Florida 34482
Primary Service: Anger Management for Substance Abuse and Mental
Health Clients
SPEP Review Date(s): June 4, 2018
Florida Department of Juvenile Justice
Report Date(s): October 5, 2018
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: Marion Youth Academy MQI Program Code: 8304
Provider Name: Sequel Youth and Family Services Contract Number: 10321
Location: Marion County / Circuit: 5 Number of Beds: 48
Review Date(s): June 4, 2018 Lead Reviewer Code: 157
Persons Interviewed
Program Director Corporate QI/QA staff # Program Supervisors
DJJ Monitor # Case Managers # Youth
DHA or designee 1 # Clinical Staff # Other (listed by title):
DMHCA or designee # Healthcare Staff
Documents Reviewed
Written Protocol/Manual Logbooks # Personnel Records
Fidelity Monitoring Documents Program Schedules 4 # 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: 30 Points
1. Primary Service and Supplemental Service Types POS: 30 Points
POP: 100%
There are five Primary Service Types that have been classified into Groups with a maximum
number of points possible for rating purposes. Some Primary Service Types may also have
qualifying Supplemental Service Types that could earn a program an additional 5 points.
The Primary Service for this program is Anger Management for Substance Abuse and Mental
Health Clients. The program was awarded 25 points because the Primary Service is identified as
a Group 4 Service. The specific Sub-Component Service Type identified is Group Counseling.
The Primary Service was identified as this type of service as it focuses on psychological or
interpersonal problems or issues faced by an individual and involves a group of youths interacting
with each other.
An additional 5 points was awarded based on a Qualifying Supplemental Service. The Qualifying
Supplemental Service was identified as None (automatic 5 points added to score), which was not
demonstrated to have been implemented.
The Primary and Supplemental Service Raw Score is equal to the sum of the Primary Service
points plus the Qualifying Supplemental Service points.
Note: Quality information is evaluated 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 has a formal training specific to this primary service, Anger Management for
Substance and Mental Health Clients. There are four staff members trained to provide the
intervention.
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 a manual for this intervention which is produced by the United States
Department of Health and Human Services.The manual specifies the frequency and duration of
the service. Additionally, the manual outlines twelve sessions which include suggested remarks,
group rules, outline of session, and homework assignments.
Basic Score: N/A Point(s)
c. Observed Adherence to the Manual/Protocol
Maximum Possible Score: 1 Point
Upon observation of the Primary Service by the Quality Improvement reviewer, the facilitator of
that service adhered to the written protocol/manual.
This intervention was not observed during this review.
This curriculum was not able to be observed; therefore, this indicator rates as non-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
There has been no gap in service delivery and no turnover of therapist since the last SPEP
evaluation. One therapist is the primarily provides the intervention. In the event he is unable to
provide the intervention on a given day, another trained therapist fills in.
Basic Score: 2 Point(s)
e. Internal Fidelity Monitoring
Maximum Possible Score: 2 Points
The program has a process to monitor the delivery of the intervention to examine how closely
actual implementation matches the model protocol.
Twelve months of internal fidelity monitoring reports were reviewed. The program has an internal
process to perform internal fidelity monitoring. During the past twelve months, twelve instances of
internal fidelity monitoring were required and each was completed.
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 for corrective action based on internal fidelity monitoring. Each fidelity
monitoring checklist includes a section for feedback and recommendations for facilitator
improvement. During the last twelve months, there were no corrective actions noted.
g. Evaluation of Facilitator Skill Delivering the Basic Score: 1 Point
Intervention Maximum Possible Score: 1 Point
Performance evaluations of the facilitators of the specific intervention/service include
evaluation of skill in delivering the intervention/service.
Facilitators for this intervention received performance evaluation which included specific
information about their delivery of the intervention.
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 24 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: 0 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 0%
Research indicates a target of 40 contact hours for this type of service. Of the 9 youth in the
sample, 0% (0 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: 10 Points
Program Optimization Score: 25 Points
Program Optimization Percentage: 40%
Percentage of Youth with Moderate, Moderate-High, and High-Risk Levels to Reoffend: 89%
Moderate to High Score: 10 Points
Program Optimization Score: 12 Points
Program Optimization Percentage: 83%
Table 1
Moderate = 2 youth
Moderate-High = 5 youth
High = 1 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: 11%
High Score: 0 Points
Program Optimization Score: 13 Points
Program Optimization Percentage: 0%
Table 2
High = 1 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, 89% (8 of 9) youth scored Moderate to High-Risk to reoffend, for a score of
10 points.
Of the SPEP sample, 11% (1 of 9) youth scored High-Risk to reoffend, for a score of 0 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 30 30 100%
Quality of Service Delivery 20 20 100%
Amount of Service: Duration 0 10 0%
Amount of Service: Contact Hours 0 10 0%
Risk Level of Youth Served 10 25 40%
Totals 60 95 63%
This SPEP report evaluates Anger Management for Substance Abuse and Mental Health Clients,
an intervention delivered at Marion Youth Academy.
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
8 included dosage with end dates in the EBS Module. Of those youth with correct dosage, 0
received at least the recommended weeks of service. Youth in the sample completed between 10
and 11 weeks of service, with an average of 10 weeks.
The program earned 0 points for Amount of Service: Contact Hours. Of the 9 total youth sampled,
all 9 included dosage in the EBS Module. Of those youth, 0 received at least the recommended
hours of service. Youth in the sample completed between 17 and 21 hours of service, with an
average of 20 hours.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 8
The program was awarded 10 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 just prior to the youths' admission.
RECOMMENDATION(S):
Marion Youth Academy can maintain their SPEP Quality of Service Delivery score by continuing
the processes in place at the time of this review.
Marion Youth Academy can optimize their SPEP Amount of Service score by ensuring that
dosage for all youth is recorded accurately in EBS and by ensuring that youth receive the full
targeted dosage of service.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 9


summary: SPEP - FY17-18

raw_content:
Standardized Program Evaluation
Protocol [SPEP] Report
Marion Youth Academy
Sequel Youth and Family Services
(Contract Provider)
10420 NW Gainesville Road
Ocala, Florida 34482
Primary Service: Impact of Crime
SPEP Review Date(s): June 4, 2018
Florida Department of Juvenile Justice
Report Date(s): October 5, 2018
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: Marion Youth Academy MQI Program Code: 8304
Provider Name: Sequel Youth and Family Services Contract Number: 10321
Location: Marion County / Circuit: 5 Number of Beds: 48
Review Date(s): June 4, 2018 Lead Reviewer Code: 157
Persons Interviewed
Program Director Corporate QI/QA staff # Program Supervisors
DJJ Monitor # Case Managers # Youth
DHA or designee 1 # Clinical Staff # Other (listed by title):
DMHCA or designee # Healthcare Staff
Documents Reviewed
Written Protocol/Manual Logbooks # Personnel Records
Fidelity Monitoring Documents Program Schedules 3 # 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. 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 documentation reviewed reflected the program has a formal training protocol which is
provided through a qualified trained. The program has three staff members who are trained to
conduct this intervention. One serves as a regular facilitator, the other assists as needed, and one
serves as the fidelity monitor.
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 uses the Department of Juvenile Justice manual for the intervention. The manual
includes seven chapters to cover topics including: Victim Impact, Personal Accountability,
Introduction to Harm, Consequences of Making Decisions, Ripple Effect of Crime, Managing
Conflict, The Road to Reparation. The manual is detailed to the extent that it explains how each
session is delivered and there is an outline for each session.
Basic Score: N/A Point(s)
c. Observed Adherence to the Manual/Protocol
Maximum Possible Score: 1 Point
Upon observation of the Primary Service by the Quality Improvement reviewer, the facilitator of
that service adhered to the written protocol/manual.
This intervention was not observed during this review.
This curriculum was not able to be observed; therefore, this indicator rates as non-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.
There has been no gap in service delivery of this intervention. There are two case managers and
the lead case manager who are trained to deliver the intervention. In the event the case manager
who typically provides the intervention was unavailable, the other case manager or lead case
manager could provide the intervention.
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.
Twelve months of internal fidelity monitoring reports were reviewed. The program has an internal
process to perform internal fidelity monitoring. During the past twelve months, fifteen instances of
internal fidelity monitoring were required and each was completed.
Basic Score: 1 Point
f. Corrective Action based on Fidelity Monitoring
Maximum Possible Score: 1 Point
The program has a process by which corrective action is applied and demonstrated based on
the fidelity monitoring of the delinquency intervention/therapeutic service.
The program has a process for corrective action based on internal fidelity monitoring. Each fidelity
monitoring checklist includes a section for feedback and recommendations for facilitator
improvement. During the last twelve months, there were no corrective actions needed.
g. Evaluation of Facilitator Skill Delivering the Basic Score: 1 Point
Intervention Maximum Possible Score: 1 Point
Performance evaluations of the facilitators of the specific intervention/service include
evaluation of skill in delivering the intervention/service.
Facilitators for this intervention received performance evaluations which included specific
information about their delivery of the intervention.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 6
3. Amount of Service ‐ Duration
Basic Score: 4 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 40%
Research indicates the target duration of 16 weeks for this type of service. Of the 17 youth in the
sample, 53% (9 of 17) reached at least the indicated target duration. Further explanation is
detailed in the Summary and Recommendations below.
Note: Dosage information (duration) is calculated from the Juvenile Justice Information System
(JJIS) Evidence-Based Services module. Duration is included for the youth in the SPEP sample.
4. Amount of Service – Contact Hours
Basic Score: 8 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 80%
Research indicates a target of 24 contact hours for this type of service. Of the 17 youth in the
sample, 94% (16 of 17) 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: 20 Points
Program Optimization Score: 25 Points
Program Optimization Percentage: 80%
Percentage of Youth with Moderate, Moderate-High, and High-Risk Levels to Reoffend: 82%
Moderate to High Score: 7 Points
Program Optimization Score: 12 Points
Program Optimization Percentage: 58%
Table 1
Moderate = 2 youth
Moderate-High = 3 youth
High = 9 youth
Total Youth in Sample = 17 youth
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 7
Percentage of Youth with High-Risk Level to Reoffend: 53%
High Score: 13 Points
Program Optimization Score: 13 Points
Program Optimization Percentage: 100%
Table 2
High = 9 youth
Total Youth in Sample = 17 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, 82% (14 of 17) youth scored Moderate to High-Risk to reoffend, for a score
of 7 points.
Of the SPEP sample, 53% (9 of 17) 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 4 10 40%
Amount of Service: Contact Hours 8 10 80%
Risk Level of Youth Served 20 25 80%
Totals 72 85 85%
This SPEP report evaluates Impact of Crime, an intervention delivered at Marion Youth Academy.
The program scored High for Quality of Service Delivery.
The program earned 4 points for Amount of Service: Duration. Of the 17 total youth sampled, only
16 included dosage with end dates in the EBS Module. Of those youth with correct dosage, 9
received at least the recommended weeks of service. Youth in the sample completed between 13
and 20 weeks of service, with an average of 17 weeks.
The program earned 8 points for Amount of Service: Contact Hours. Of the 17 total youth
sampled, all 17 included dosage in the EBS Module. Of those youth, 16 received at least the
recommended hours of service. Youth in the sample completed between 23 and 38 hours of
service, with an average of 30 hours.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 8
The program was awarded 20 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 just prior to the youths' admission.
RECOMMENDATION(S):
Marion Youth Academy can maintain their SPEP Quality of Service Delivery score by continuing
the practices in place at the time of this review.
Marion Youth Academy can optimize their SPEP Amount of Service score by ensuring that
dosage for all youth is recorded accurately in EBS and by ensuring that youth receive the full
targeted dosage of service.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 9