summary: QI Residential - FY24-25 - 1 finding

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Cypress Creek Max Risk
TrueCore Behavioral Solutions LLC
(Contract Provider)
2856 West Woodland Ridge Drive
Lecanto, Florida 33461
Review Date(s): January 14-17, 2025
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Jeremy Curvan, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Crystal Blair-Gallon, Office of Accountability and Program Support, Regional Monitor (Standard
4)
Marvin Bliss, Office of Accountability and Program Support, Regional Monitor (Co-lead)
Jeff Campbell, Office of Education, Education Cordinator (Standard 6)
Carlametress Harrell, Office of Education, Workforce Education Cordinator (Standard 6)
Luis Rodriguez, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Jennifer Tummino,, Office of Accountability and Program Support, Regional Monitor (Standard
2)
Justin Terziu, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Bonita Williams, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Cypress Creek Treatment Center MQI Program Code: 1055
Provider Name: TrueCore Behavioral Solutions, LLC Contract Number: 10207
Location: Citrus County / Circuit 5 Number of Beds: 64
Review Date(s): January 14-17, 2025 Lead Reviewer Code: 213
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
3.14 Suicide Prevention Training *
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 68 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Non-Applicable
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Non-Applicable
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 68 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions and Incorporation of Other Plans Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.14 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.15 Exit Portfolio Satisfactory
2.16 Exit Conference Satisfactory
2.17 Youth Input Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 68 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Non-Applicable
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Secure Observation* Non-Applicable
3.13 Suicide Precaution Observation Logs * Satisfactory
3.14 Suicide Prevention Training * Limited
3.15 Mental Health Crisis Intervention Services * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.18 Baker and Marchman Acts * Non-Applicable
3.19 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 68 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 68 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Satisfactory
5.24 Controlled Observation Satisfactory
5.25 Controlled Observation Safety Checks and Release Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 68 (Revised September 2022)
Standard 6: Educational Services
Residential Rating Profile
Standard 6 - Educational Services
6.01 Contract Specific CTE Services (Residential Contract) Satisfactory
6.02 Educational Access (Residential Contract) * Satisfactory
6.03 Educational Access (Education Contract) * Non-Applicable
6.04 Career Education (Education Contract) Non-Applicable
6.05 Education Transition Plan (Education Contract) Non-Applicable
6.06 Qualified Intructional Personnel (Education Contract) Non-Applicable
6.07 Florida Youth College (Education Contract) Non-Applicable
6.08 Florida Youth College (Post-Secondary Contract) Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 68 (Revised September 2022)
Program Overview
The Cypress Creek Treatment Center is a sixty-four bed program, for fifteen to twenty-one-year
old males, located in Lecanto, Florida. The program is operated by TrueCore Behavioral
Solutions LLC, through a contract with the Department. The program provides mental health
and substance abuse services. In addition, the program fosters each youth by providing
Aggression Replacement Training (ART), Skillstreaming the Adolescent, the Passport Program,
the Bullying Workbook for Teens, Social Perception Training, the Stress Reduction Workbook
for Teens, Problem Solving Training, Empathy and Social Competence Training, Living in
Balance, Resilience Builder Program for Children and Adolescents, and Impact of Crime.
Additional treatment services provided include family and individual counseling. Program
administration is comprised of a facility administrator, assistant facility administrator of
operations, assistant facility administrator of support services, and a chief of security. Case
management services are provided by one director of case management, six case managers,
one intake specialist and two transition services managers. Mental health staff at the program
include one contracted psychiatrist, one clinical director, one assistant clinical director, seven
therapists, two recreational therapists, and one file technician. Medical services are offered 6:30
a.m. to 7 p.m. daily and are provided by one contracted designated health authority, one health
services administrator, and four registered nurses. Educational services are provided by the
educational staff. The layout of the program includes: one large building which houses all
dormitories, kitchen, classrooms, administration, clinic, offices, controlled observation rooms,
maintenance, mental health, case management, and master control. The program has 121
operating security cameras providing coverage, and all cameras were operational. At the time of
the annual compliance review, the program had twenty-nine vacant positions: twenty-four youth
care workers, one dietary associate, one master control operator, one file clerk, and two
unlicensed therapists.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 68 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures addressing pre-employment background screenings.
An informal interview with the facility administrator confirmed the program had one new
volunteer who assisted or interacted with youth on an intermittent basis for less than ten hours a
month and did not need to be background screened. The program’s policy requires a staff, who
is background screened, to always be present within the line of sight and sound of the volunteer
who is not background screened. An Annual Affidavit of Compliance with Level 2 Screening
Standards was completed and submitted to the Department’s Background Screening Unit (BSU)
on December 9, 2024, meeting the annual requirement. An annual Affidavit of Compliance with
Level 2 Screening Standards for teachers who are paid by the school board, or funding provided
by the school board or Department of Education, was completed, and submitted to the BSU on
December 12, 2024, meeting the annual requirement. A review of the program’s staff, volunteer,
and contractor rosters found thirty staff were applicable for an initial background screening
during the annual compliance review period. No volunteers were applicable for an initial
background screening during the annual compliance review period. Each of the thirty applicable
staff had a completed and eligible background screening, as required, prior to contact with
youth, and confidential youth records. Reviewed documentation validated a criminal history
report was reviewed for each staff. A pre-employment assessment tool was administered for
each direct care staff and a pre-employment assessment passing score was documented in
each reviewed direct care staff record. All thirty staff were added to the program’s roster in the
Agency for Healthcare Administration’s Clearinghouse system, as required. None of the thirty
staff reviewed had a break in service.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a policy and procedures addressing five-year background rescreening for
staff. The program had six staff and two contracted staff applicable for a five-year rescreening
during the annual compliance review period. All eight applicable staff received a five-year
rescreening within the required time frame and the rescreenings were submitted to the
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Office of Accountability and Program Support Page 11 of 68 (Revised September 2022)
Department’s Background Screening Unit (BSU) at least ten business days prior to the five-year
anniversary date, as required. There were no volunteers applicable for a five-year background
rescreening during the annual compliance review period.
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures to ensure program-related incidents, which place at
risk or have the potential to place at risk, the health, safety, or welfare of the public or of youth,
staff, visitors, the security of the facility, or the reputation of the provider are reported and
handled appropriately and in a timely fashion. The program has a zero-tolerance policy
regarding any abuse. All staff shall immediately report any knowledge or suspicion regarding an
incident of abuse which occurred in the program by calling the Florida Child Abuse Hotline, and
additionally the notification is made to the Department’s Central Communications Center (CCC)
and the program's regional director. The program had two incident reports of claims against staff
for physical abuse or emotional abuse. The program conducted the Trauma Response and
Caring Environment self-assessment on February 13, 2024. Staff adhere to a code of conduct,
as acknowledged by the review and signing of a code of conduct acknowledgement form during
their orientation and contained in the staff personnel records. Thirty staff Code of Conduct
acknowledgement forms were reviewed, and all were signed. Seven reviewed pre-service and
seven in-service training records reflected staff received training on child abuse reporting.
During the facility tour, the Florida Abuse Hotline and CCC telephone numbers were posted
throughout the facility. All five interviewed youth reported they feel safe in the program. All youth
also reported they have never been prevented from making a call to the Florida Abuse Hotline.
All five youth reported either knowing the telephone number for the Florida Abuse Hotline or
knowing where it was posted. All five interviewed youth reported the staff are respectful and
they never disrespect youth. Three interviewed youth reported never hearing staff curse around
youth and two youth stated occasionally hearing staff curse. Upon further explanation, one
youth stated it was spoken around them, and the second youth stated it was not spoken directly
at the youth. All five youth reported they have never exchanged emails, telephone numbers, or
social medica contact information with staff.
Each of the five staff interviewed were familiar with the program’s abuse reporting procedures.
All five interviewed staff reported they have never observed a coworker deny a youth the right to
report an abuse incident. Four of the five interviewed staff stated they have never observed
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Office of Accountability and Program Support Page 12 of 68 (Revised September 2022)
another staff using profanity while speaking with youth. One staff stated they have heard staff
occasionally use profanity around the youth. The facility administrator (FA) reported the
program’s code of ethics directs staff to provide youth with quality care and promotes excellent
customer service and states the abuse or youth (verbal or physical) will not be tolerated. Staff
are provided new hire training and discussions take place in all staff meetings to ensure staff
are knowledgeable in contacting the Florida Abuse Hotline and CCC. The youth handbooks and
youth information boards contain contact information as well. All calls at the program are
tracked in the master control logbook and are discussed in the daily management meetings.
The program incorporates trauma-responsive practices by utilizing the champion team to
develop a plan based on surveys, “Can We Discus”s forms, and additionally, they utilize
community meetings and educational handouts monthly for staff and youth.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program has a policy and procedures addressing management’s response to allegations.
Management shall be cognizant of youth and staff needs and provide direction to each on how
to access the Florida Abuse Hotline. There is evidence management takes immediate action to
address incidents of physical, psychological, and emotional abuse. There were two separate
incidents during the annual compliance review involving management response to allegations.
Documentation was reviewed and there is evidence management took immediate action to
address allegations of physical, psychological, and emotional abuse. The facility administrator
(FA) explained the management response to allegations of abuse involves suspending the staff
pending the investigation, notify the Florida Abuse Hotline and the Department’s Central
Communications Center (CCC), internal investigation conducted, and if applicable, the staff will
be terminated.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program has a policy and procedures addressing the process for contacting the
Department’s Central Communications Center (CCC). The program reported sixteen incidents
to the CCC during the annual compliance review period. A review of five reportable CCC
incidents during the annual compliance review period revealed all five incidents were reported to
the CCC within the required time frames, and each incident was documented in the center’s
logbook. There were no additional internal incidents or grievances during the annual compliance
review period which should have been reported to the CCC and were not. An interview with the
facility administrator (FA) indicated when a youth requests to make a call to the Florida Abuse
Hotline, the youth is taken to the telephone to make the call. Any reportable incident must be
reported to the CCC within two hours. The program ensures staff are knowledgeable in
contacting the Florida Abuse Hotline by providing trainings during new hire training, all staff
meetings, and a review of the abuse reporting policy. The youth are provided a handbook and
there are youth information boards which have information as well. Furthermore, calls made to
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the Florida Abuse Hotline are tracked in the master control logbook and are discussed in the
daily management meeting.
1.06 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program has a policy and procedures requiring a Right Interactions (RI) Incident Report be
completed and filed in accordance with the Florida Administrative Code, any time staff uses a
physical intervention technique, such as countermoves, control techniques, takedowns, or
application of mechanical restraints (other than for regular transports). The program had a total
of sixteen RI incidents during the annual compliance review period. A sample of five RI reports
were reviewed. All five reports were completed by the end of the staff’s workday and included
statements from all staff involved. None of the RI incidents required the use of mechanical
restraints; therefore, the Mechanical Restraint Supervision Log was not required. None of the RI
incidents resulted in injuries to youth or staff and there were no allegations of abuse. All the RI
reports were reviewed by a supervisor, a RI instructor, and the facility administrator (FA) within
seventy-two hours of the incident. None of the RI incidents required a medical review. Copies of
the RI reports were placed in a centralized file within forty-eight hours of approval/signature by
the FA. Monthly summaries of all RI incidents were submitted to the Department’s regional
office by the fifth of each month and are maintained by the program. The program last updated
the RI plan on April 29, 2024, and the plan was approved by the Department on May 1, 2024.
The program had a total of twenty-eight PAR incidents during the previous annual compliance
review. The program experienced a decrease in RI incidents from the time of the previous
annual compliance review. The program’s response regarding the increase involved more
training, and more staff meetings to discuss the increase. The program’s RI rate during the
annual compliance review period was 2.38, which is above the statewide Residential RI rate of
1.71. The FA was interviewed and advised RI incidents are reviewed daily during the
management meetings. Five staff were interviewed and all five could explain the escalation and
de-escalation process for when RI is used.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
The program has a policy and procedures outlining the training and certification requirements
for all new staff. The following staff are direct care staff and are counted in the staff to youth
ratio; youth care worker I, youth care worker II, master control technician, shift supervisor,
kitchen personnel, recreation therapist, career and technical education (CTE), case managers,
and medical staff. The program has an instructor who is qualified to deliver the following
trainings, Right Interactions (RI), first-aid, and cardiopulmonary resuscitation (CPR). The
program does have a pre-service training plan/calendar which outlines the program’s training.
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Furthermore, the training plan/calendar was approved by the facility administrator, assistant
secretary of residential services, and the director of the Department’s Talent, Leadership, and
Culture by evidence of their signatures.
Seven staff training records were reviewed for pre-service/certification requirements. All seven
staff completed all required pre-service trainings and essential skills prior to contact with any
youth. One exception was a registered nurse who is not required to complete the forty-hour RI
training, which if completed would have given him 130.5 hours. All seven staff completed
trainings required by Florida Administrative Code. Two supervisory staff completed an additional
forty hours of training in coaching, leadership, and personal accountability. All completed
trainings were documented in the Department’s Learning Management System (SkillPro), as
required.
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a policy and procedures outlining the in-service training requirements for staff.
Seven staff training records were reviewed for in-service trainings including five direct care staff
and two supervisory staff. All five direct care staff completed all required in-service trainings.
Each of the two supervisory staff training records included all required in-service trainings and
meet the required eight hours of supervisor trainings in the areas of coaching, leadership, and
personal accountability. All seven staff completed trainings as required by Florida Administrative
Code. All completed trainings were entered into the Department’s Learning Management
System (SkillPro). The program maintains an annual in-service training calendar which is
updated as changes occur. The program utilizes one instructor, and they are qualified to deliver
the trainings provided. The program did submit an in-service training plan/calendar prior to
implementation which was approved by the facility administrator, assistant secretary for
residential services, and the director of Talent, Leadership and Culture.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures which includes training requirements for the
grievance process, as well as the informal, formal, and appeal phase. Youth are encouraged to
resolve questions, disputes, and complaints through informal communication with program staff.
Staff are directed to use active listening skills, respectful conversation, and give youth the
opportunity for full expression of feelings regarding the conflict, with the goal of encouraging and
promoting open communication, and to assist the youth in the development of improved
problem resolution skills. Informal complaints should be handled within twenty-four hours. The
program maintained grievance logs for each month of the annual compliance review period;
however, there were no formal grievances filed during the annual compliance review period. All
five interviewed youth indicated they knew where to find a grievance form and four of five youth
stated they knew what to do with the form upon completion. One of the youth indicated they do
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Office of Accountability and Program Support Page 15 of 68 (Revised September 2022)
not know the process because they have never submitted one. All five interviewed youth
reported they could ask for assistance in completing a grievance form. All five interviewed staff
reported the grievance forms are placed throughout the program. All five staff stated youth can
request assistance in completing the forms; four staff stated the supervisor reviews the
grievances, and four staff indicated the facility administrator (FA) reviews them as well. Five
interviewed staff were able to describe the grievance review process. To ensure understanding,
the program reviewed the grievance process with staff during the all-staff meeting, during the
week of the annual compliance review The FA provided written documentation of the all-staff
meeting. The FA interview indicated the program's informal grievance process is resolved by
using the “Can We Discuss” forms. Youth place the completed grievance in the box, it is
collected, and then reviewed in the management meeting. The forms are logged and resolved
with the youth, and if not resolved, the FA will review the complaint.
1.10 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures to ensure youth are provided with instruction for the
development of life and social skills. The review of the curriculum, Life Skills streaming the
adolescent and activities confirmed the life skills group being utilized addresses communication,
interpersonal relationships and interactions, non-violent conflict resolution, anger management,
critical thinking skills, and needs of the targeted gender group of the program. A review of the
group sign-in sheets for the annual compliance review period was conducted and confirmed the
services were delivered as required. The services were provided in weekly groups. The sign-in
sheets included the topic, date of service, instructor/therapist delivering the service, each
youth’s signature in attendance, and each youth’s level of participation. In addition to the
groups, the program ensures the youth receive instruction on resume building, personal
finances and budgeting, and career selection and development. Additional activities provided for
life skill development are guest speakers and mentorship opportunities. The guest speakers
have provided information on human trafficking, hate crimes awareness, child welfare, and
bullying, at monthly community meetings. Five youth were interviewed and each youth was able
to provide at least one example of life and social skill activities provided by the program. The
facility administrator’s interview confirmed the program provided targeted gender related
instruction through the monthly community meetings. The program’s designated mental health
clinician authority (DMHCA) was able to confirm all services provided to the youth during the
annual compliance review period; along with the qualified instructor/therapist, method of
delivery, and discipline. The DMHCA also confirmed how the youth can demonstrate the newly
acquired skills while in the program.
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1.12 Restorative Justice Awareness for Youth Non-Applicable
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at the program. For details related specific to IOC service delivery, please refer
to the annual SPEP report.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures to address internal alerts system and the
Department’s Juvenile Justice Information System (JJIS), including how new alerts are
identified, documented, updated, and communicated to staff. All five youth were identified with
alert risks, for a total of seventeen alerts, and each youth was placed on the alert system, as
specified in the program’s policy and procedures. Each applicable alert was documented in the
logbook. All applicable alerts matched JJIS and the internal alert system. The facility
administrator (FA) interview indicated the medical department meets with the designated health
authority and the FA weekly to discuss important medical issues pertaining to youth at the
program. The program’s internal alert system process includes an internal alert form, as well as
a youth alert board. The different departments, case management, medical, and mental health
are responsible for entering and closing out alerts in JJIS. Management conducts alert reviews
during morning management meetings. The nursing staff interview indicated licensed nurses
update the medical alert system daily and master control confirms youth on security.
Five staff were interviewed and three of five staff indicated they are informed of youth alerts
during shift briefing. Three stated they are informed through reviewing the alert binder and one
said alert information is passed to one another on the dormitory.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Case Management Record
The program has a policy and procedures to ensure all youth records are maintained properly to
include, healthcare and case management, in a secure and confidential manner. All records
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observed during the annual compliance review week were found to be maintained securely
within a locked room and/or cabinet marked as confidential along with each physical record
marked as confidential. All required information was documented on record the record labels
and each record had information which was maintained in the required five sections.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
A review of sign-in sheets, agenda/meeting minutes for the annual compliance review period
indicated the program conducted community advisory board (CAB) meetings at least every
ninety to 120 days. The facility administrator (FA) actively solicits or recruits’ involvement from
law enforcement, judiciary community, other community partners, business community, school
board or district, faith community, LGBTQIA+ community, victim advocate, and a
parent/guardian whose child was previously involved in the juvenile justice system. The FA
interview indicated the CAB meets quarterly at the facility. Prior to Florida Virtual School
providing education services, the CAB approved the education calendar. The CAB meetings
give input on the school schedule, creative suggestions to keep youth occupied, and provides
suggestions on community contacts. A CAB member interview confirmed the CAB member
participates in quarterly meetings with the program. The board member indicated they had been
a chair of the CAB for over a year. It was stated the CAB is effective and important to the
community and to the youth being served in the program.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures for evaluating staff, performance standards, and the
frequency of evaluations. The program’s policy and procedures indicate evaluations are to be
completed after a ninety-day introductory period and annually and are to be completed by
supervision and management staff. A review of three position descriptions was conducted and
determined each staff member’s performance standards were clearly identified. A review of
seven performance evaluations confirmed annual evaluations have taken place consistent with
the program’s policy. Staff are evaluated on their established performance standards at the
ninety-day mark for first year employees and annually for all additional staff. The performance
standards matched position descriptions for each staff position reviewed. The program’s
contract requires the following positions to be maintained and performed: one facility
administrator, one assistant facility administrator, five registered nurses, one designated health
authority, one designated mental health clinician authority, one licensed therapist, two
transitional case managers, and two recreational therapists. An interview was conducted with
the facility administrator (FA) who stated staff turnover has been a consistent issue; staff have
cited their reasons for leaving as the demands/hours of the job and the pay for direct care staff.
The program has a staff morale committee which meets monthly and plans activities for staff to
participate and monitors an employee suggestion box. The program conducts hiring events to
hire new staff and reduce burnout. The FA additionally indicated staff evaluations are completed
after the first ninety days and then yearly thereafter. Five staff interviewed and were asked how
often a formal evaluation of performance is completed. Three staff stated yearly, one stated
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after ninety days for the first year, and one staff stated every ninety days for the first year and
then annually.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program’s contract with the Department includes four special contract conditions not
covered by the Monitoring and Quality Improvement indicators.
The first special contract condition requires either the president or the chief operating officer to
make a visit to the program at least once a quarter. A review of the facility visitor sign-in log
confirmed visits were made as required during the annual compliance review period (January
2024, April 2024, July 2024, October 2024).
The second special contract condition requires eighty percent of eligible youth work part-time or
full-time within thirty days of exiting the program. The transition specialist will track employment
of youth for thirty days following their exit. The transition specialist confirmed nine youth were
released from the program since the last annual compliance review. Five of the nine released
youth were contacted and currently have part time jobs. The remaining four released youth were
unable to be contacted and did not return their telephone calls.
The third special contract condition requires 100 percent of youth to complete, on average,
eighty percent of their community service hours prior to their release. During the annual
compliance review period only two youth were released from the program, who were assigned
community service hours, which they completed prior to release.
The final special contract condition requires an additional forty-five vocational slots will be made
available beyond those mentioned in the contract, covering computer programming in the future,
twenty driving certifications in commercial driver license (CDL) of forklift, five food service
manager certifications, and twenty Microsoft Office certifications. The program currently offers
agriculture services, where the youth receive high school credits. Food Handling and Food
Management are both offered, affording the youth certificates after completion. The program
has a Home Builders Institute (HBI) program on-site for youth to participate in, after vetted, and
accepted, where youth can receive a myriad of certificates. The vocational program offers basic
computer literacy programs such as Microsoft Word, PowerPoint, and Excel, where youth can
receive a certificate after completion. The program also offers Commercial Driver License (CDL)
courses, including opportunities in semi-truck, and forklift training, carpentry, electrical, brick
masonry, landscape, and painting. During the annual compliance review period, twenty youth
were enrolled in forklift Safety & Health Administration (OSHA); however, none had completed
because they haven’t been in the program long enough. Additionally, the program will offer
Microsoft slots once the forklift certification is completed. Youth are informally asked at the
beginning of each semester to gauge interest. The facility administrator explained education
staff previously provided food management and Microsoft trainings; however, with the new
Career and Technical Education (CTE) Coordinator recently passed the course for SERV Safe
and is currently offering it to youth. The facility administrator interview indicated the program
currently does not have a Memorandum of Negotiation.
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1.18 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a policy and procedures for reviewing and analyzing data trends to utilize in
decision-making practices. The provider uses several systems for the purpose of tracking data
and outcome measures. The provider has implemented an internal database and dashboard
system which allows for daily data entry by every program. This daily process and outcome
information is aggregated into weekly and monthly totals, displayed in interactive dashboards
specific to each program, and provided back to corporate as well as program management for
the purposes of tracking trends and informing risk management. The dashboards are updated
every Monday with the previous week's data. Additionally, the program compiles information
obtained from youth surveys and parent surveys completed upon exit from the program.
Information is shared with staff and administration during staff meetings, morning meetings, shift
briefings and during advisory board meetings. A review of staff meetings, morning meetings,
and shift briefings confirmed the information sharing with staff and administration. A review of
the quarterly community advisory board agendas, meeting minutes, and sign-in sheets
confirmed the information sharing with providers and stakeholders. The program also takes
information received during supplemental and annual compliance reviews conducted by the
Department’s Bureau of Monitoring and Quality Improvement and shares the outcome with staff.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures to address initial contacts to the parents/guardians
and court notification. Five youth case management records were reviewed and four of five
records contained documentation the parent/guardian was contacted by telephone on the day of
admission. The remaining youth record included an attempt at contact with the parent/guardian.
All five youth case management records indicated the parents/guardians were mailed a parent
admission letter on the day of admission which spoke about length of stay, visitation, and the
performance planning process. All five youth case management records contained a copy of the
Judge Notification of Admission Letter sent to the committing court informing them of the youth
placement, which was mailed on the day of admission. The documentation further indicated the
assigned juvenile probation officer (JPO) was copied on each notification.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures regarding the orientation process. Five youth case
management records were reviewed. All five youth received an orientation within twenty-four
hours of being admitted to the program. All five records contained a signed orientation brochure
addressing: services available, daily schedule, expectations and responsibilities of youth,
access to medical, mental health and substance abuse services, grievance procedures,
community access, visitation, telephone calls, access to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC), behavior expectations and related
consequences, emergency procedures, the program’s zero-tolerance policy regarding sexual
misconduct, including how to report incidents or suspicions of sexual misconduct, items
considered to be contraband, the performance planning process, dress code and hygiene
practices, a program tour, assignment to living unit, and Prison Rape Elimination Act (PREA)
related information. A youth orientation was observed on January 15, 2025, during the week of
the annual compliance review, which confirmed all elements of the orientation process were
discussed with the youth. Five youth were interviewed and all five confirmed they received
orientation to the program within twenty-four hours of arrival. All five youth were able to
articulate information provided during the orientation process and each orientation was provided
by the case manager.
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2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a policy and procedures to address written consent of any youth eighteen
years of age or older before providing or discussing any of the youth’s information with the
parent/guardian, which is contained within the orientation policy. Five youth case management
records were reviewed to determine if the program obtained written consent for providing youth
information with the parent/guardian, Department of Children and Families (DCF), or other
applicable agencies. Two of the five reviewed records were applicable as the remaining three
youth were under the age of eighteen. An additional youth record was reviewed to complete the
required sample size of three. All three records contained the Authorization to Release
Information form which was signed by the youth on their eighteenth birthday or upon admission
to the program for those youth who were already eighteen years of age at the time of
placement.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program has a policy and procedures which ensure a classification system is implemented
in accordance with Florida Administrative Code and promotes safety and security as well as the
effective delivery of treatment services. The system is designed to ensure the safest room and
dorm assignment for the arriving youth. Five youth case management records were reviewed
regarding classification. Each of the five youth records contained information concerning the
youth’s history and status. The classification process included information from the admission
documents, which reflected the youth’s gender, height, weight, age, level of aggression, mental
illness, intellectual disabilities, physical disabilities, history of violent behavior, history of human
trafficking, gang affiliation, criminal behavior, history of sexual offenses, the results of the
Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB), medical needs, suicide,
escape, and security risks. All reviewed youth room assignments were based on the youth
classification procedures, changes in behavior or status, and history of committing sexual
offenses. All five records contained a classification form completed on the day of the youth’s
admission to the program which addressed all requirements. In all five instances, hard copies of
the VSAB were completed by mental health staff on the day of the youth’s admission to the
program and reviewed with the treatment team during the classification process. None of the
five youth were identified with a suicide risk. One of the five youth was identified with both an
escape risk and other risk, and all five youth were identified with a medical risk and a security
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risk. A review of the Department’s Juvenile Justice Information System (JJIS) Alert List for any
issues affecting classification was completed for all five youth and each youth was classified for
purposes of assigning to a living area, sleeping room, and youth group or staff advisor. The
medical, mental health, substance abuse, security risk factors, and/or special needs identified
during or after the classification process were immediately entered into the program’s internal
alert system and JJIS for all five youth. Four of the five youth were applicable for reclassification
and the remaining youth was not applicable for reclassification due to length of stay. The
reclassifications for three of the four youth were due to safety and security and one
reclassification was due to the air conditioning not functioning. None of the four youth received
an increase in privileges or freedom of movement, or participation in work projects or off-
campus activities. The program’s policy is to complete a Residential Assessment of Youth
(RAY) reassessment every ninety days, while the youth is in the program, to include collateral
sources, such as treatment team meetings, using checklists or rating sheets for specified
domains by staff to provide input. Additionally, the program’s policy ensures subsequent risk
assessments will be conducted monthly or may occur at any time, if indicated, to include the
youth’s adjustment to and compliance with the program rules and procedures.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a policy and procedures which outline the notification of law enforcement
regarding youth entering the program with suspected gang affiliation or documented gang
membership, as well as for youth who are observed engaging in gang activities during their
commitment to the program. Five youth case management records were reviewed; however,
none of the youth in the sample size were applicable for gang affiliation or membership. The
program was able to provide three additional records for review for gang identification and
notification. All three identified youth were confirmed in the Department’s Juvenile Justice
Information System (JJIS) with gang alerts, as well as the program’s internal alert system. A
review of the three youth records established each contained a security threat questionnaire
which was completed at the time of admission to the program to gauge the level of gang
involvement. Documentation demonstrated the program ensured timely notification to local law
enforcement, law enforcement in the county of the program, the educational provider, the
youth’s juvenile probation officer, and the youth’s post-residential counselor, if applicable, for all
three reviewed youth. All documentation was maintained in the youth’s individual case
management record as well as in the gang binder.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures which address the implementation of gang prevention
and intervention strategies. Youth identified as being criminal street gang members, are
affiliated with any criminal street gang, or who are at a high risk of gang involvement are
required to participate in gang prevention and intervention activities. The program uses Gang
Resistance and Drug Education and Achieve Realistic Impact to Sustainable Enhancement
(ARISE) as part of their gang prevention and intervention strategies. Five youth case
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management records were reviewed; however, none of the youth in the sample size were
applicable for gang affiliation or membership. The program was able to provide three additional
records for review of gang identification and notification. A review of the three records confirmed
each youth was identified as a gang member or affiliated gang member. All three youth had a
gang goal listed on their Individualized Performance Plan (IPP). A review of the program’s gang
binder found the three applicable youth participated in monthly gang intervention sessions with
their assigned case manager as evidenced by observed sign-in sheets. The program’s gang
prevention and intervention policy indicated a youth will be provided the opportunity to “dis-
affiliate” from their identified criminal street gang if they so choose. The facility administrator’s
interview indicated the program utilizes the ARISE curriculum during the monthly community
meetings.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a policy and procedures to ensure an initial Residential Assessment for Youth
(RAY) is completed within thirty days of admission to the program, and RAY reassessments are
completed within ninety days after completion of the initial RAY assessment. Five youth case
management records were reviewed and all five records contained an initial RAY assessment
completed within thirty days of admission. Four of five initial RAY assessments were maintained
in the Department’s Juvenile Justice Information System (JJIS). The remaining initial RAY
assessment was not maintained in JJIS when the youth arrived at the program due to the
Department experiencing system-wide outages. Each youth also had a copy of their RAY
Overview Report filed within their individual case management record. Five youth case
management records were reviewed to determine whether a RAY reassessment was completed
within ninety days. Four of the five youth were applicable for RAY reassessments and the
remaining youth was not applicable due to length of stay. The four reviewed youth records
contained a total of eight RAY reassessments. Seven of the eight RAY reassessments were
completed at least every ninety-days, as required. The remaining RAY reassessment was due
on September 29, 2024. Documentation in the youth record indicated the youth was arrested on
August 16, 2024, and returned to the program on September 11, 2024. The youth was arrested
again on September 12, 2024, and returned to the program on November 26, 2024;
consequently, the third RAY reassessment was completed on December 3, 2024, which was
within the next ninety days the youth was at the program.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a policy and procedures to ensure the Youth Needs Assessment Summary
(YNAS) is conducted within thirty days of admission to the program. The assigned case
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manager is responsible for gathering information from all members of the treatment team as
well as collateral documents and incorporating this information into the YNAS report. Five youth
case management records were reviewed, and four records contained a YNAS, which was
completed within thirty days of admission and was documented in the Department’s Juvenile
Justice Information System (JJIS). The remaining youth record contained a YNAS was
completed prior to the youth’s admission and was documented in JJIS. The program provided
documentation from the Department indicating a new YNAS did not need to be completed after
transfer from another program.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
The program has a policy and procedures to ensure all members of the treatment team, youth,
juvenile probation officer (JPO), and parents/guardians are involved in the development of the
youth’s performance plan within thirty days of admission to the program. The findings of the
initial assessment completed on each youth, along with information and feedback from the
intervention and treatment team, are utilized by the assigned case manager to create the
Individualized Performance Plan (IPP). In addition, information provided by the parent/guardian
on the Parent Input form sent at admission is incorporated into the IPP. Five youth case
management records were reviewed. All five records contained documentation of the IPP being
developed within thirty days of admission, following the youth’s initial needs assessment, and
after the completion of the initial Residential Assessment for Youth (RAY), as required. The
intervention and treatment team were present during the development of each performance plan
and included participation from the following parties: treatment team leader, youth, program
administration, living unit representative, mental health treatment staff, education staff, and
medical staff. None of the five case management records were applicable for or included the
Department of Children and Families (DCF) caseworker or Adult Protective Department (APD)
waiver support coordinator. In all five records there was documentation sent to the
parents/guardians from the assigned case manager requesting they review and sign the
signature sheet and return it in the self-addressed, stamped envelope provided by the program.
Two of the five reviewed case management records contained an IPP signature sheet signed by
the youth’s parent/guardian, which was attached to the original IPP; however, the remaining
three parent/guardians did not return the signature sheet to the program. All five IPPs contained
individualized goals based on the prioritized needs of the youth, the top three criminogenic
needs were included, and delinquency interventions were listed on each IPP. Each performance
plan listed the transition activities targeted for the last sixty days of the youth’s anticipated stay,
responsibility of staff in completing the goal, responsibility of youth in completing the goal, start
date, and projected completion date. Documentation confirmed for the five youth, upon
development of the IPPs, and after signature by required parties, a transmittal letter and a copy
of the plan was mailed to the committing courts, juvenile probation officers, and
parents/guardians. In the five youth case management records, transmittal letters were
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distributed to these parties within ten working days. All five interviewed youth revealed they
participated in the development of their IPP.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
The program has a policy and procedures to ensure performance plan reviews will result in
revisions when determined necessary by the intervention and treatment team. The youth’s
performance plan shall reference or incorporate the youth’s treatment or care plan. Five youth
case management records were reviewed. Four of five reviewed youth were applicable for plan
revisions. The remaining youth has not been in the program long enough to require a review or
revision. Revisions were completed based on Residential Assessment for Youth (RAY)
reassessment results and progress youth made toward completing goals. None of the youth
were applicable for a plan revision to facilitate transition activities during the last sixty days of
the youth’s stay at the program. All five reviewed youth were applicable for the incorporation of
treatment and academic plans. Documentation confirmed each youth had treatment and
academic goals incorporated into their performance plan. The program did not have any youth
applicable for a DCF plan or Agency for People with Disabilities (APD) during the annual
compliance review period.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
The program has a policy and procedures to prepare a performance summary, at minimum,
every ninety days, or sooner if requested by the committing court, and prior to a youth’s release,
discharge, or transfer from the program. Five youth case management records were reviewed.
Four of five reviewed youth were applicable for the completion of a performance summary. The
remaining youth has not been in the program for ninety days. Three of the four applicable youth
had a performance summary completed within ninety days of the signing of the initial
performance plan. One youth warranted gaps in dates due to the youth being arrested multiple
times and then brought back to the program. This youth’s performance summary was completed
once the youth was back at the program and before being discharged. None of the four
applicable youth required a performance summary prepared prior to the youth’s discharge. . ￼A
review of documentation confirmed the performance summaries contained all required
elements. The reviewed records revealed the youth were afforded the opportunity to read and
add comments prior to signing the summary. Documentation confirmed each performance
summary was signed and dated by youth, program director or designee, and treatment team
leader or staff member preparing the summary. Each record contained documentation reflecting
the youth were provided with a copy of their performance summary once they were sent to all
required parties. Original summaries were maintained in the case management record.
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A review of three closed youth case management records found release summaries were
completed, as required. Each record contained a release summary and Pre-Release Notification
(PRN) sent at least forty-five days prior to planned release. A signed copy of the PRN was
maintained in each record. Each youth’s juvenile probation officer (JPO) was notified at least
ninety days prior to the youth’s release. Once approved the program completed a RAY exit
assessment for each youth and a written notification to each youth’s parent/guardian was sent
regarding the planned release. One of the three closed youth case management records were
applicable for requiring a Victim Notification of Release. The remaining youth’s charges did not
require victim notification. The program mailed a Victim Notification of Release at least ten days
prior to the youth’s release in the applicable record.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures to encourage and facilitate parent/guardian
involvement in the case management process. Upon admission, each youth’s parent/guardian is
mailed a letter which includes information about the services offered at the program. Included in
the letter are the dates and times of the youth’s treatment team meetings. Parents/guardians
are encouraged to participate in person; however, if this cannot be arranged, parents/guardians
may participate by telephone. Five youth case management records were reviewed. Each
record confirmed the program mailed the parent/guardian a letter on the day of admission with
program services and dates and times of youth’s treatment team meetings. A treatment team
meeting was observed during the annual compliance review week. The parent/guardian
participated by telephone and was an active participant in the treatment team meeting. The
parent/guardian was also made aware of the date and time of the next treatment team meeting.
An interview with the facility administrator confirmed parent/guardian involvement is encouraged
throughout the youth’s stay at the program. Five youth were interviewed and four youth reported
their parents are contacted by telephone by the case manager or therapist for family days,
treatment team, weekly telephone calls, therapy sessions, and any updates on the youth. The
remaining youth was eighteen years or older and does not require involvement.
2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
The program has a policy and procedures establishing the treatment team members and bi-
weekly formal or informal treatment team meetings. Five youth case management records were
reviewed, and documentation confirmed each youth had a formal treatment team meeting held
at least every thirty days. Documentation confirmed attendance of all required treatment team
members including the youth, case manager, a representative from education, a mental health
therapist, the youth’s parent/guardian, assigned juvenile probation officer (JPO), medical staff, a
representative from the living unit, and a representative from the program’s administration. If
staff from education or the medical clinic were unable to attend, they provided a written progress
report to be shared with the treatment team. Documentation for each of the formal treatment
team review meetings included the youth’s name, date of review, comments from treatment
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team members, a brief synopsis of the youth’s progress, performance plan revisions, positive
and negative behaviors, behaviors resulting in physical interventions, treatment progress, and
Residential Assessment for Youth (RAY) reassessment results. All information was included in
each formal treatment team review meeting. Each record confirmed formal and informal
treatment team meetings are held bi-weekly. Four of the five youth records documentation for
each of the informal treatment team review meetings included the youth’s name, date of review,
comments from treatment team members, a brief synopsis of the youth’s progress, positive and
negative behaviors, behaviors resulting in physical interventions, and treatment progress. The
reaming youth was missing behaviors resulting in physical interventions. Each meeting included
all required attendees and each youth was given the opportunity to demonstrate skills they
acquired at the program. Documentation for each of the informal treatment team reviews
included Residential Assessment for Youth (RAY) reassessment results and performance plan
revisions for applicable youth. All information was included in each youth’s case management
record. Documentation confirmed each youth’s JPO and parent/guardian were invited along with
the youth, program administrator, and a living unit representative. All parties were encouraged
to participate in treatment team meetings. A treatment team meeting was observed during the
annual compliance review week and all required members were in attendance. If medical staff,
education staff or the transition service manager was not present, they each gave written input
prior to the meeting. Five youth were interviewed and all five youth confirmed the program
discusses youth’s performance to include progress on performance plan goals, positive and
negative behavior, and treatment progress. All five youth confirmed the program gives youth
opportunities to demonstrate the skills they have learned in the program.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
The program has a policy and procedures to ensure the intervention and treatment team is
planning for the youth’s successful transition to the community upon release from the program.
Three closed youth case management records were reviewed for transition planning,
conferences, and Community Re-Entry team (CRT) meetings. Each of the three youth transition
conferences were held at least sixty days prior to the youth’s targeted release date. Each
transition conference included a review of transition activities on the youth’s performance plan,
targeted completion dates, persons responsible for completion, and other pertinent transition
activities. Documentation reflected all required transition conference attendees were invited and
encouraged to participate. A copy of the plan was sent with a request for return with signatures
to anyone not in attendance who had a responsibility for completion of transition goal tasks for
each youth. Each record confirmed all required treatment team members attended and
participated in the transition conference and signed and dated the transition conference forms.
The plans were transmitted electronically to the juvenile probation officers and Department of
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Children and Families counselors and the acknowledgement receipt was printed and placed in
each youth record. Each of the three youth records confirmed CRT meetings were conducted
prior to the youth’s release from the program with invitations for participation being sent out by
the juvenile probation officers. Chronological notes reflected each youth and case manager
participated in the CRT meetings as well as, education, mental health staff, parents/guardians,
and program administration.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures to ensure the program assembles an exit portfolio for
each youth in order to assist the youth once released back into the community. Three closed
youth case management records were reviewed. A review of each record confirmed the exit
portfolio was discussed and initiated for each youth during the transition conference. Each exit
portfolio required items include state-issued identification card, copy of youth’s transition plan,
calendar with all dates, times, and locations of upcoming community appointments, birth
certificate, education/vocational certificates earned in the program, education records, school
transcripts, social security card, resume, and sample employment application. Each of the three
youth were missing one or more items needed for the exit portfolio. One youth was missing a
state-issued identification card, social security card, and a birth certificate. One youth was
missing a state-issued identification card, and a birth certificate. The remaining youth was
missing a social security card; however, documentation confirmed the program made multiple
attempts to obtain a copy of each document for each of the three youth. Each record confirmed
the exit portfolio was verified during the exit conference. A copy of the exit portfolio was given to
each youth upon release and forwarded to each youth’s juvenile probation officer. All three
youth were provided with the completed forms and clear instructions as to how to obtain
documents for employment. During the transition conference all three youth were provided a
plan on who will be responsible for working with them to obtain those items.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a policy and procedures to ensure a meeting is conducted to review the status
of goals developed at the transition conference and finalize release plans. Three closed youth
case management records were reviewed. Documentation confirmed the exit conference was
conducted for each youth after the program notified each juvenile probation officer (JPO) of the
release and at least fourteen days prior to youth’s release. Two of the three records contained
the date of the exit conference, signatures of all required parties, and a summary of pending
transition goals. One youth record did not have an education staff signature but education did
attend the exit conference. The admission and release dates in the Department’s Juvenile
Justice Information System (JJIS) matched the dates in each youth record. The exit conference
form for each youth reflected the status of transition activities established at the transition
conference and plans finalized for the youth’s release reviewed, provisions for continued
education and/or employment, and documentation the parent/guardian and JPO are aware of
the youth’s vocational plan. Documentation in each youth record confirmed the case manager
and parent/guardian were aware of the plan, documents, and post-release discharge plans. All
required individuals participated in the exit conference for each youth. All records documented
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the exit conference was conducted separately from the transition conference and Community
Re-Entry Team meetings.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures to provide a formal process for youth to provide
constructive input to the program. A review of meeting sign-in sheets and agendas from April
2024 through December 2024 found evidence the program hosts weekly community meetings
and monthly Youth Advisory Board (YAB) meetings. The program provides Conference Request
Forms to allow youth to share ideas, needs, concerns, or to formally speak with program staff.
The forms are available on the living units. In addition, the program conducts quarterly surveys
for youth and parents/guardians. A review of survey documentation for the annual compliance
review period confirmed this practice. The program also completes the Trauma Responsive and
Caring Environment (TRACE) assessment and develops an action plan based on youth
responses. Documentation confirmed the program completed the yearly TRACE assessment
and action plan. An interview with the facility administrator (FA) confirmed the program has
weekly community meetings and monthly YAB meetings which allows the program to solicit
input from youth to improve the program. The FA stated youth can also submit a Conference
Request Form to provide input and program surveys. Five youth were interviewed and were
able to articulate ways to provide input at the program such as “Can We Discuss” forms, daily
meetings, YAB, and talking to administration.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program has a policy and procedures which provides for a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program. The DMHCA is a licensed mental health counselor (LMHC) with a clear
and active license which expires on March 31, 2025. There have been no other DMHCAs during
the annual compliance review period. The back-up DMHCA is a LMHC with a clear and active
license which expires on March 31, 2025. The DMHCA is on-site forty hours a week and on-call
twenty-four hours a day for emergencies. A review of sign-in logs and position description
confirmed DMHCA's hours. An interview with the DMHCA confirmed they are responsible for
coordination, implementation, and oversight of mental health and substance abuse services at
the program. The DMHCA provides weekly supervision for non-licensed clinical staff.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a policy and procedures to ensure mental health and substance abuse
services are provided by staff with the appropriate qualifications. The program has a contract
agreement with a certified behavior analyst to provide services to youth as needed. The
designated mental health clinician authority (DMHCA) ensures the licensed clinical staff working
under their supervision are performing services they are qualified to provide based on
education, training, and experience. The certified behavior analyst has an active certification
which expires on August 25, 2026. The program had two licensed clinical social workers
(LCSW) who provided services during the annual compliance review period. Both LCSWs had
clear and active licenses which expire on March 31, 2025. One of the LCSWs is no longer
employed with the program and the other is a regional clinical staff member who provides
services on pro re nata basis.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
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The program has six non-licensed mental health and substance abuse clinical staff. There were
two non-license clinical staff at the time of the annual compliance review week, one position has
been vacant since January 2025 and the other since December 2024. Each of the six non-
licensed clinical staff hold a master’s-level degree. The designated mental health clinician
authority (DMHCA) assures the non-licensed clinical staff are reforming services they are
qualified to provide based on education, training, and experience. A review of weekly clinical
supervision confirmed each non-licensed clinical staff received one hour a week of on-site, face-
to-face direct supervision by a licensed mental health professional. Each clinical supervision
was documented on a program form similar to the Department’s supervision log, which included
all required elements. The program does have a Chapter 397 license which expires September
6, 2025. The non-licensed clinical staff are on-site forty hours a week. Four of the six non-
licensed clinical staff completed twenty hours of Assessment of Suicide Risk training. The
remaining two non-license clinical staff are newly hired and were pending completion at the time
of the annual compliance review.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program has a policy and procedures regarding the mental health and substance abuse
admission screening process. Five youth mental health and substance abuse records were
reviewed for mental health and substance abuse admission screening. The program utilizes the
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) as the admission
screening. Each of the five youth were administered a MAYSI-2 upon their admission. The
MAYSI-2 was completed in full by a trained staff and entered in the Department’s Juvenile
Justice Information System (JJIS). The screener reviewed available information to include the
commitment packet, reports, records for existing documentation of mental health or substance
abuse problems, and/or history of human trafficking. The MAYSI-2 for each of the youth
indicated the need for an assessment, the program director was notified, and a referral was
made to alert the designated mental health clinician authority (DMHCA). The program director
ensured the Assessment of Suicide of Risk (ASR) was completed within twenty-four hours.
None of the youth were referred for an immediate assessment or emergency services. One of
the five youth was placed on precautionary observation upon admission. Each of the five youth
had a referral for a comprehensive evaluation and one had one for an ASR. Each of the
referrals had the reason for the referral documented.
The program’s policy and procedures were reviewed and included a standardized screening
process which included a review of the commitment packet, reports, records, administration of
the MAYSI-2 in JJIS, referrals for the youth as needed, staff training for mental health and
substance abuse, and Baker Act or Marchman Act procedures.
The facility administrator reported the program utilizes the MAYSI-2 and Assessment of Suicide
Risk (ASR) as a screening tool during admission.
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3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program has a policy and procedures regarding the mental health and substance abuse
assessment/evaluation process. The designated mental health clinician authority (DMHCA)
reported the clinical staff complete referrals for comprehensive mental health and substance
abuse evaluations and psychiatric evaluations upon admission if needed. Five youth mental
health and substance abuse records were reviewed for mental health and substance abuse
assessment and evaluation. Each youth had a completed combined mental health and
substance abuse evaluation within thirty days of their admission. Each youth had a signed
consent for substance abuse services in their records. Three of the five evaluations were
completed by a non-licensed clinical staff and the license clinical staff reviewed and signed
within ten calendar days after the evaluation was conducted. The remaining two evaluations
were completed by the licensed clinical staff. Each of the five evaluations included all required
elements.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has a policy and procedures regarding mental health and substance abuse
treatment. Five youth mental health and substance abuse records were reviewed for mental
health and substance abuse treatment. The Initial Mental Health/Substance Abuse plan was
completed within seven days of initiation of treatment for each of the five-youth reviewed. Each
initial individual plan included all required elements. Two of the five youth had psychiatric needs
and each Initial individual plan included medication and frequency of monitoring by the
psychiatrist. The Initial individual plans were signed by the mental health and substance abuse
clinical staff completing the form. When a non-licensed clinical staff completed the initial plan,
the license clinical staff signed the plan within ten days of completion. In addition, the youth,
treatment team leader, program management, and living unit representative signed the
treatment plan. The parents/guardians participated on the telephone, or the initial plan was
mailed to them. The juvenile probation officer (JPO) and education staff were not available at
the time of the Initial plan development. Five youth had a completed individualized treatment
plan which included all required elements. Two of the five youth individualized plans included
psychiatric services. All five plans included psychotropic medication and frequency of monitoring
by the psychiatrist. Four of the five youth had treatment plan reviews every thirty days, as
required. The remaining youth did not have reviews every thirty days due to being in detention
for an extended period of time. The mental health and substance abuse clinical staff completed
each of the five individualized treatment plans; when a non-licensed clinical staff completed the
plan, the licensed clinical staff signed within ten days. The plans and/or treatment team sign-in
sheets were signed by the youth, treatment team leader, program management, living unit
representative, parents/guardians, juvenile probation officers, education staff, and other
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treatment team members. Individual treatment plan reviews are conducted during treatment
teams. A review of progress notes confirmed each of the five youth received services according
to prescribed services on the Individual treatment plan and the goals and objectives were
individualized for each of the five youth. Video observation of three groups confirmed the groups
were held at the scheduled time, for the required length of time, and did not exceed the required
number of youth for mental health or substance abuse groups.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting. The treatment team is responsible for
assisting in developing, reviewing, and updating the youth's Individualized and Initial Mental
Health/Substance Abuse Treatment Plans. All youth who receive mental health and/or
substance abuse treatment while in a program shall have a discharge summary completed
documenting the focus and course of the youth's treatment and recommendations for mental
health and/or substance abuse services upon youth's release from the program.
The program has a policy and procedures regarding treatment and discharge planning. Five
youth mental health and substance abuse records were reviewed for treatment. At the time of
admission, each of the five youth were assigned to a treatment team. A review of both treatment
team sign-in sheets and individual treatment plan reviews confirmed all required staff either
participated in-person or by telephone. Each youth received mental health and substance
abuse group, family counseling, and individual counseling as prescribed on their treatment
plans. Each of the five youth had a signed Authority for Evaluation and Treatment (AET) and a
Youth Consent for Substance Abuse Treatment in their records. The clinical staff documented
mental health treatment or substance abuse treatment on progress notes which contained all
required elements. Mental health and substance abuse therapy included individual counseling,
psychosocial skills training, and the progress notes confirmed services were provided. Three
closed mental health and substance abuse records were reviewed for discharge plans. Each of
the plans were documented on the Department’s Mental Health and Substance Abuse
Treatment Discharge Summary form. None of the youth were released on suicide
alert/precautions. Each discharge summary included recommendations for future services
needed. A review of the Exit Conference Summary confirmed the discharge plan was discussed
with the youth, parents/guardians, and juvenile probation officers (JPO). A copy of the discharge
summary was provided to the youth, JPOs, and parents/guardians.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program has a policy and procedures which requires specialized mental health overlay
services to be provided to youth. The program’s required clinical groups according to the
contract are Aggression Replacement Therapy, Skillstreaming the Adolescent, The Passport
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Program, and Living in Balance. Seven youth were interviewed. Six of seven youth confirmed
they participate in individual and family therapy. The remaining youth was new to the program
and was going to be starting individual and family therapy. Seven staff were interviewed. All
seven staff confirmed only clinical staff facilitate mental health and substance abuse groups. An
interview with the designated mental health clinician authority (DMHCA) confirmed all youth
receive intensive mental health treatment services and substance abuse services according to
their individualized treatment plan. An interview with the facility administrator confirmed youth
receive mental health overlay services to include weekly mental health groups, career
counseling, individual therapy, and family therapy. The DMHCA is on-site forty hours a week and
clinical staff are on-site at least five days a week. A review of clinical staff caseloads confirmed
clinical staff have no more than sixteen youth to one therapist. Each of the non-licensed staff
hold a master’s level degree. The program has contracted with a certified behavior analyst to
provides services as needed. Documentation confirmed program mental health and substance
abuse groups are held at least four times a week, individual therapy is provided at minimum of
bi-weekly, family therapy is provided monthly, and the psychiatrist is on-site bi-weekly. The
program did not have any youth applicable for needing services during medical quarantine.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program has a psychiatrist who has an active and clear license with the State of Florida,
which expires on January 31, 2026. The psychiatrist is available for emergency consultation
twenty-four hours a day, seven days a week. The psychiatrist provides a brief synopsis of youth
for treatment team meetings and incorporates the psychiatrist evaluation and recommendations
into youth’s mental health and substance abuse treatment plans. A review of sign-in/out logs
confirmed the psychiatrist was on-site during the annual compliance review period as required
by contract. The psychiatrist actively participated in, managed, and supervised psychotropic
medication services in the program as evident in medication management reviews. The
psychiatrist reported providing psychiatric evaluations, prescribe medications, monitor
medications, and is available twenty-four hours a day for emergency consultations. The
designated mental health clinician authority (DMHCA) reported meeting with the psychiatrist bi-
weekly to discuss youth attending treatment team and other psychiatric services. Five youth
mental health and substance abuse records were reviewed for treatment services. Two records
were applicable for review. To meet the minimum requirement, the program provided one
additional record Each of the three applicable youth entered the program on psychotropic
medication and was referred for a psychiatric interview. The diagnostic interview was completed
within fourteen days of admission, as required, for each of the applicable youth. The initial
diagnostic psychiatric interview was clearly identified as an initial interview and contained all
required elements. There were no changes to prescription medications for any of the applicable
youth but, page three of the Clinical Psychotropic Progress Note (CPPN) was completed. A
review of each of the applicable youth records confirmed each had received a medication
review by the psychiatrist every thirty days. None of the applicable youth had any changes to
their medications nor were applicable for an updated psychiatric evaluation within six months. A
review of page three for each of the youth’s CPPNs confirmed each contained all required
elements. Each of the applicable CPPNs had the signature of the psychiatrist and date. There
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was documentation of telephone contact with each youth’s parent/guardian to discuss
medications on the CPPN.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a suicide prevention plan in place which was reviewed by the designated
mental health clinician authority (DMHCA) on February 26, 2024. The plan included procedures
for identification and assessment of youth at risk of suicide, staff training, suicide precautions,
levels of supervision, referral, communication, notification, documentation, immediate staff
response, and a review process. The review process included all required elements.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
Five youth mental health and substance abuse records were reviewed for suicide prevention
services; however, only one was applicable. The program had one additional record to provide
for review. The two applicable youth were determined to be at risk through staff observation.
Each of the youth were placed on precautionary observation (PO) when determined to be at-risk
and a referral was submitted on the same date. An Assessment of Suicide Risk (ASR) was
completed on the Department’s ASR form. The youth’s parent/guardian and juvenile probation
officer (JPO) were notified of each youth’s potential suicide risk and was documented on the
ASR. Clinical staff provided supportive services for each youth. One ASR was completed by a
non-licensed clinical staff and the licensed clinical staff reviewed and signed the ASR within
twenty-four hours of completion. The second ASR was completed by a licensed clinical staff.
Each ASR was completed within twenty-four hours of determined risk. Each ASR had
documentation of the actual date and time the clinician conferred with the facility administrator
or designee.
Each youth had a Follow-Up ASR completed prior to removal of youth from precautionary
observation. The Follow-Up ASR was completed on the Department’s form. Each youth was
maintained on PO and constant supervision until the Follow-Up ASR indicated PO could be
discontinued. Upon the Follow-Up ASR indicating PO could be discontinued, each youth was
stepped down to close supervision prior to transition to normal routine and standard supervision.
Close supervision was maintained until it was determined no longer necessary by the
designated mental health clinician authority (DMHCA) for each applicable youth. There was
documentation in each youth’s record a conference was held by the facility administrator and
licensed clinical staff to reduce level of supervision for each youth. The documentation for
discontinuation of close supervision, in accordance with the program’s suicide prevention plan,
was documented for each youth. A review of the Department’s Juvenile Justice Information
System (JJIS) confirmed a suicide alert was initiated and closed for each youth. A review of the
facility logbook confirmed there was evidence indicating staff was provided instructions related
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to the suicide risk assessment findings and suicide precaution decisions. While on PO, there
was documentation each at-risk youth were allowed to participate in selected activities with
other youth in designated safe housing/observation areas of the facility. During the annual
compliance review, there was only one applicable youth for video observation of PO. It was
observed the youth was never left alone and in staff sight at all times.
3.12 Secure Observation (Critical) Satisfactory Compliance
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated non-
applicable.
3.13 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
Five youth mental health and substance abuse records were reviewed for suicide prevention
services; however, only one was applicable. The program had one additional record to provide
for review. Each youth had a Suicide Precaution Observation Log while on precautionary
observation (PO). The appropriate level of supervision and observations of youth’s behavior
were documented in real time and not exceeding thirty-minute intervals for each applicable
youth PO logs. None of the applicable youth displayed any warning signs while on PO. Each PO
log was reviewed and signed by a shift supervisor and clinical staff. Each PO log had
documentation of safe housing requirements.
3.14 Suicide Prevention Training (Critical) Limited Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program has a policy and procedures outlining suicide prevention training. A review of five
pre-service and five in-service staff training records confirmed completion of suicide prevention
training. The program has ten suicide response kits which are co-located with first-aid kits. The
suicide kits are in master control, medical, kitchen, Home Builder’s Institute, and each of the five
dorms. A review of suicide mock drills completed during the annual compliance review period
was conducted. The mock suicide drills were held quarterly on each shift, for all staff who
encounter youth, including kitchen and maintenance staff. A review of written suicide mock drills
for each shift confirmed the program provided semi-annual training on emergency response
procedures and emergency response to a suicide attempt or incident of serious self-inflicted
injury using cardiopulmonary resuscitation (CPR). The program conducted thirty mock mental
health drills which were in response to a suicide attempt and/or incident of serious self-injury,
and nine were not simulated. The program reviews drills during staff meetings to give staff who
were not present during drills the opportunity to review each drill scenario and procedures. The
facility administrator reported the program conducts suicide drills on each shift and are reviewed
during monthly staff meetings. During interviews with five staff, it was reported when a youth
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expresses suicidal thoughts, direct care staff are responsible to notify mental health, place youth
on constant sight and sound, document supervision, and search youth/room for sharp objects.
Each of the five staff reported the suicide kits are in master control, sub control, and the medical
clinic. Three staff reported the suicide kit is in the supervisor office. During interviews with the
five staff, it was reported medical emergency and suicide drills are conducted once a month on
each shift, and one stated they have not participated in one. Video observation of the last thirty
days was conducted of five suicide mock drills. Two drills, which were the same scenario just
different shifts, the staff entered the classroom with the automated external defibrillator (AED)
and medical bag, signed the sign-in log, and left without simulating the drill. One drill was not
able to be observed due to not being able to locate on video; however, there was a written drill
form indicating the drill occurred. Two of the drills were the same scenario just different shifts
and same number of staff attending both drills. According to the drill documentation, staff
entered the room with the life saving devices and applied aid; however, the demonstrated life
saving measures applied could not be seen on video.
3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a crisis intervention plan which was reviewed annually by the facility
administrator and designated mental health clinician authority (DMHCA) on February 26, 2024.
The plan included notification, an alert system, means of referral including youth self-referral,
communication, supervision, documentation, and review.
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a policy and procedures outlining the process of crisis assessments. The
program did not have any applicable youth since the last annual compliance review.
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3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has an emergency mental health and substance abuse services plan separate
from the crisis intervention plan in place. The plan includes immediate staff response,
notifications, communication, supervision, authorization to transport for emergency mental
health or substance abuse services including Baker Act and Marchman Act, documentation,
training (including mock drills), and review.
3.18 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker Act or Marchman Act procedures during the annual
compliance review period; therefore, this indicator is rated non-applicable.
3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program has a policy and procedures outlining the safety planning process for youth. Five
youth mental health and substance abuse records were reviewed for safety plans. Four of the
five youth had their safety plan completed within fourteen days of their admission. One safety
plan was twenty days late. Each of the safety plans included all required elements. Each of the
five safety plans had clear documentation the plan was jointly prepared by the youth, the
program’s clinical staff, and parents/guardians. Two of the five plans incorporated
recommendations from previous or current clinical assessments or screening instruments and
incorporated trauma responsive practices; the remaining safety plans did not.
Each of the five safety plans were reviewed and/or updated at least every thirty days. None of
the five youth required a review or update because of any significant behavioral or mental health
event identified by the youth’s intervention and treatment team. All safety plans are in master
control for staff to review. Each of the five interviewed youth reported contributing to their safety
plans. The facility administrator reported safety plans are updated monthly during formal
treatment team, anytime it is warranted, or a crisis occurs.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program’s designated health authority (DHA) is a licensed physician (MD) who holds an
unrestricted license and meets all requirements for independent and unsupervised practice in
the State of Florida. The DHA’s license expires on January 31, 2027, and the specialty training
is in internal medicine. The DHA did not have any disciplinary cases or public complaints on
record. The program did not have a physician assistant or advanced practice registered nurse.
The back-up DHA is a MD who holds an unrestricted license and meets all requirements for
independent and unsupervised practice in the State of Florida. The back-up DHA’s license
expires on January 31, 2027, and the specialty training is in family medicine. A review of the
DHA sign-in and out logs for the annual compliance review period indicated the DHA was not
utilized and the back-up DHA was on-site once a week for the required two hours. The program
does not utilize tele-medicine. An interview with the DHA indicated availability is twenty-four
hours a day, seven day a week. Communication with the program staff regarding youth medical
needs are conducted on-site weekly, during monthly staff meetings, and if needed by telephone
twenty-four hours a day. The DHA or designee is on-site weekly to provide clinical services.
Meetings with the nurse are held on a weekly basis to review important medical issues
pertaining to the youth at the program. When the DHA is unavailable, the designee covers the
facility.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has one full-time health service administrator (HSA) who is a registered nurse
(RN), one pre-re nata RN, three full-time RNs and, one full-time licensed practical nurse (LPN)
providing nursing coverage on-site. The contractual requirement asks for four full-time RNs and
one RN serving as the full-time HSA. The Department’s Office of Health Services (OHS) has
given permission to substitute one full-time RN for a full-time LPN. The LPN was provided
direction by a RN. All six nurses had clear and active licenses. Two RN licenses expire on April
30, 2026, three RN licenses expire on July 31, 2026, and the LPN’s license expires on July 31,
2025. All nurses had current cardiopulmonary resuscitation (CPR) certifications.
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The designated health authority (DHA) and the facility administrator signed and dated all
respective treatment facility operating procedures (FOP). The psychiatrist signed and dated the
applicable FOPs on July 2, 2024, while conducting an annual review. The nursing staff
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reviewed, signed, and dated a cover page on which all FOPs, healthcare protocols, and other
procedures were listed. The program did not have any new or changes in policies during the
annual compliance review period. All newly employed health care personnel received a
comprehensive clinical orientation to the Department’s health care policy and procedures, given
by a registered nurse. The approval of treatment protocols or standing procedures was written
and authorized by the DHA.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a policy and procedures ensuring the completion of the Authority for
Evaluation and Treatment (AET) authorizing treatment of youth in the program’s custody. A
review of five youth Individual Healthcare Records (IHCRs) found each had a valid and legible
copy of an AET form filed. All youth records reviewed were not applicable for a court order. Each
of the AETs was signed by the parents/guardians and a Department representative. Two of the
five youth were eighteen years old while at the program, subsequently there was a Release of
Information Authorization form for youth eighteen years of age and older contained within the
IHCRs. Five reviewed youth records indicated none of the youth had been placed under the
care of the Department of Children and Families (DCF). An interview with the nurse revealed the
AET comes in the admission packet from the Department’s Juvenile Justice Information System
(JJIS). If there is no AET, the juvenile probation officer (JPO) is contacted to obtain a new AET.
Youth eighteen years or older are not required to have an AET. The facility completes a release
of information and has it signed by the youth, when applicable.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures to ensure the parent/guardian is notified of any
changes in the youth’s condition and to document informed consent for youth healthcare. A
review of five youth Individual Healthcare Records (IHCR) found the program had
documentation of parental notification for over-the-counter (OTC) medications beyond those
covered by the Authority for Evaluation and Treatment (AET) for three youth. The remaining two
youth were eighteen years old and not applicable. The three applicable youth had appropriate
notifications for the parent/guardian, with no exceptions. Two youth had documentation of new
medication ordered and attempts to contact parents/guardians in the progress notes. All five
youth records had documentation of written notifications sent utilizing the Department’s Parental
Notification of Health-Related Care. Three of five youth were applicable for prescribed
psychotropic medication. Documentation of a staff witnessing all telephone call attempts and
conversations for psychotropic medications were in the three youth records. Each of the three
IHCRs contained documentation on page three of the Department’s Clinical Psychotropic
Progress Note (CPPN) for prescribed, discontinued, and/or changes to psychotropic medication.
None of the five reviewed youth records were applicable for youth in the care of the Department
of Children (DCF). In each of the reviewed records, the youth vaccinations were verified within
thirty days of admission to the program, with no exceptions. None of the youth were applicable
for consent being obtained prior to administering vaccinations. All five youth had up-to-date
immunizations. None of the youth were applicable for religious exemption from immunization.
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An interview with the nurse revealed parental notifications are required for new medications and
for OTC medications not covered by an AET. Written notifications are sent for each youth’s
encounter with a medical provider. When a youth has an illness or injury requiring emergency
medical services, the youth is sent to the hospital. Parental notification is made verbally and in
writing. The procedures regarding informing the parent/guardian when obtaining consent for
new psychotropic medications is the CPPN, which is sent by certified mail and by regular mail to
the parent. The process for documenting parent/guardian exemption from immunization is to
obtain a copy of the medical exemption form from the parent/guardian, which is signed by the
youth’s medical doctor. The form will be filed in the IHCR behind the AET. Parent consent and
notifications are sent on the day the youth is seen by a medical provider.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a policy and procedures regarding youth healthcare admission screening and
rescreening each time the physical custody of the youth changes. Five youth Individual
Healthcare Records (IHCR) were reviewed for Facility Entry Physical Health Screening
(FEPHS) forms. All five FEPHS were completed by the registered nurse (RN) on the date of
each admission. Two of five youth screenings were completed by a RN. The three remaining
screenings were completed by a licensed practical nurse (LPN). One of five youth had a change
in physical custody and a new FEPHS rescreening of the youth was completed as required. The
interview with the RN confirmed all youth are seen the day of admission. Medical staff are
notified by email and verbally by the intake specialist when youth are being admitted to the
program. Admission screenings are not completed by direct care staff. When there is a change
in custody, a new facility body chart for the youth is completed by the nurse upon return to the
facility.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy and procedures ensuring all youth admitted to the program are
provided an orientation to healthcare services. A review of five youth Individual Healthcare
Records (IHCR) confirmed all youth were provided a general care orientation upon admission to
the program. The Health Education form in all five IHCRs included access to medical care, sick
call, what constitutes an “emergency,” medication process, right to refuse care, what to do in the
case of a sexual assault, non-disciplinary role of health care providers, and Standard Universal
Precautions, which were discussed with the youth as evidenced by their signature.
The frequency in which the program must provide Health Education is monthly. At a minimum
health education covers: seatbelt usage, alcohol and drug problems, sexually transmitted
disease, tobacco products, dental care, personal hygiene, immunizations, infection control,
prevention of sexual and physical violence, nutrition, physical fitness, breast and testicular
exams, parenting skills, and prenatal, postpartum, and parenting education.
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4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a policy and procedures to notify the designated health authority (DHA) or
designee, by telephone or verbally, for each youth arrival at the program and provide immediate
notification when any youth admitted to the program requires emergency care. The program’s
practice is to notify the DHA of all youth admissions, including youth with chronic conditions,
medical concerns, or any youth admitted on psychotropic medications. Five youth Individual
Healthcare Records (IHCR) were reviewed. Three youth were admitted with a known or
suspected chronic condition or required a referral to the DHA, and two youth were not. None of
the youth were identified as in need of an emergency response upon admission. Three youth
IHCRs documented the DHA notification in each youth Chronological Progress Notes and the
Chronic Conditions Log was updated after the notification. Three reviewed IHCRs documented
the DHA was notified within twelve hours of admission. Three reviewed IHCRs documented
each youth were taking psychotropic medications upon admission, and notification to the
psychiatrist was documented. According to an interview with the registered nurse (RN), the DHA
is notified at admission of youth with serious or chronic conditions by fax or a telephone call. A
licensed nurse is responsible for the notification. DHA notifications are documentation in the
progress notes section of the chart.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a policy and procedures ensuring the Department’s Health-Related History
(HRH) is completed prior to the Comprehensive Physical Assessment (CPA) and healthcare
needs are identified. A review of five youth Individual Healthcare Records (IHCR) found each
HRH was completed within seven calendar days of admission. All five IHCRs indicated the HRH
form was completed prior to the CPA as indicated by the date and signatures. In all five IHCRs,
the designated health authority (DHA) reviewed the HRH form as evidenced by a checkbox on
the CPA and focused note in the admission documentation. An interview with the registered
nurse (RN) confirmed a new HRH is completed on the day of admission for all new youth by the
nursing staff.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a policy and procedures ensuring the acute and chronic healthcare needs of
the youth are addressed by completing a Comprehensive Physical Assessment (CPA) within
seven days of youth admission. A review of five Individual Healthcare Records (IHCR)
confirmed the program utilized the Department’s CPA form. Five reviewed youth records
confirmed the CPAs were completed by the designated health authority (DHA) within seven
days of each youth admission to the program. Five reviewed youth IHCRs included
documentation of the youth Medical Grade on the CPA. Five reviewed youth records indicated a
current CPA on file at the time of admission. Five youth IHCRs indicated a licensed physician
(MD) completed the CPA. Five reviewed youth CPAs were completed utilizing “O” or “X”
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markings. Five youth refused a portion of the CPA exam, and each youth signed a refusal,
which matched the date of the exam. The Department’s Problem List was updated for each
youth. The CPA in all five IHCRs included documentation of the most recent verified
Tuberculosis Skin Test (TST) which was administered within the last year to determine exposure
to tuberculosis (TB). The results were documented on each CPA and matched the
documentation on the Department’s Infectious and Communicable Disease (ICD) forms. An
interview completed with the registered nurse (RN) confirmed the DHA completes a new CPA
within seven days of admission and then on a yearly basis for all youth.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures to ensure all youth admitted to the program are
screened, evaluated, and treated, if applicable, for sexually transmitted infections (STI) and
human immunodeficiency virus (HIV). A review of five Individual Healthcare Records (IHCR)
found all youth were clinically screened and evaluated for STIs on the date of admission. One
reviewed youth IHCR required further evaluation and the remaining youth were not applicable
for further evaluation, which was documented on the Department’s STI form. One reviewed
IHCR documented the referral on the STI screening tool and testing was ordered and performed
on date of admission. None of the reviewed youth were out of the Department’s physical
custody; therefore, a rescreening was not applicable. All reviewed youth records documented
evidence the youth were offered counseling, testing, and treatment for HIV. None of the
reviewed youth received HIV testing. The program’s policy ensures the youth HIV test results
are only disclosed to the youth’s legally authorized representative, healthcare providers during
treatment, the Department of Health (DOH) for purposes of reporting, health facility staff
committees conducting facility monitoring, medical personnel who have been subject to
significant exposure, and healthcare facility personnel or agents for healthcare providers who
have a need to know during patient care. Pre- and post-testing counseling services are provided
by the designated health authority (DHA). An interview with five youth confirmed they can
request an HIV test. An interview with the nurse confirmed all youth are screened at admission
by the DHA. Youth are examined by the DHA and if additional testing is needed, it is then
ordered. All STI screenings, evaluations, referrals, and testing are documented on STI and HIV
forms. If the youth have been out of the program’s physical custody for more than thirty days, a
new facility and STI screening is completed. Youth are told they can request HIV testing or
counseling at any time by speaking to a nurse. Pre- and post-tests are documented by the DHA
in the progress notes.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a policy and procedures confirming the shift supervisor reviews all sick call
requests as soon as possible and within two hours after the request is submitted when there is
not a licensed nurse on-site. Nurses are the only staff who conduct sick call. A review of five
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youth Individual Healthcare Records (IHCR) indicated three youth were not applicable for sick
calls. One additional youth record was selected for a total of three applicable youth records.
None of the three youth presented with similar sick call complaints three or more times within a
two-week period. All three youth IHCRs documented each youth and nurse completed each
Sick Call Request form. In one IHCR the licensed practical nurse (LPN) conducted the sick
calls, which was reviewed daily by a registered nurse (RN) and documented on the form. All
three IHCRs had the Sick Call Request forms filed in reverse chronological order and each was
documented in accordance with Health Services Rule. All three youth IHCRs for sick calls were
documented on the Sick Call Index. All sick call events for the three youth were documented on
the Sick Call Referral Log. None of the youth were in restricted housing when requesting sick
call. A review of the daily schedule, posted schedule, and nurse interview confirmed sick call
was conducted daily. The sick call hours were observed to be posted in the clinic and on all
dormitories, accessible to all youth. The Sick Call Request forms were available to youth in each
dormitory. Sick Call observation during the annual compliance review week indicated sick call is
conducted in the exam room utilizing an exam table. The youth was escorted to the clinic by a
youth care worker, who stayed outside of the exam room behind a curtain to afford privacy for
the nurse and youth, and able to still observe the youth. The nurse identified themselves and
stated what was documented on the Sick Call Request form. The nurse took vitals and
questioned the youth about any ailments. The sick call was concluded with a referral to the
designated health authority (DHA). Three of five youth interviews indicated they can see the
nurse immediately when requesting a sick call. One youth stated it takes one day. The
remaining youth stated they never requested a sick call. The nursing interview indicated if youth
want to see a nurse regarding any physical complaints, they have sick call forms to complete
and place in a sick call box on the dormitory. These boxes are checked several times a day, at
least once a shift, while a nurse is on-site. Youth are usually seen within twenty-four hours. Sick
calls are conducted by a RN or LPN once a day in the exam room and if a LPN completed the
sick call the RN will review it within twenty-four hours. The DHA will conduct sick call if on-site. A
youth is referred to the DHA if complaining of the same illness three or more times in a fourteen-
day period, if nursing protocols indicate, or due to a nurse’s judgement. The nurse stated the
program has DHA approved treatment protocols. The program does not utilize restricted
housing.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a policy and procedures addressing episodic and emergency care, including a
process for ensuring contents of the first-aid kits are maintained and stored in accordance with
guideless to prevent expiration or deterioration, and are replenished as needed. The program
policy includes the use, access, and inventory of Narcan. Five youth Individual Healthcare
Records (IHCR) were reviewed. Two of the five reviewed IHCRs had an indication each youth
required on-site first-aid or episodic care. One additional youth record was selected for a total of
three applicable youth. All three youth IHCRs indicated each youth required on-site first-aid or
episodic care. The remaining youth were not applicable. All three applicable IHCRs had on-site
care provided by a licensed healthcare staff which was documented in problem-oriented
charting. The program had ten first-aid kits, one each in the Home Builder Institute building,
south sub control, north sub control, kitchen, vocational/educational, controlled observation, and
master control; the three vehicle kits were also located in master control. Three first-aid kits
were observed to be fully stocked with designated health authority (DHA) approved contents.
One of the kits had an expired saline solution which the nurse exchanged while the annual
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compliance review team was on-site. A review of the first-aid kit checks for the annual
compliance review period indicated they were monitored weekly as required. The program has
one automated external defibrillator (AED) located in master control with the procedures in the
same box. The AED was found in working order during the annual compliance review week with
the pads expiring June 7, 2030, and the batteries in August 2025. The pads were exchanged
last in November 2021 and the batteries June 2024. A review of the AED checks for the annual
compliance review period indicated the nurses conduct weekly AED checks as required.
Emergency numbers were posted in the nurses’ office accessible to staff and inaccessible to
youth. A review of documentation indicated the authorized direct care staff were trained on the
administration of the epinephrine auto-injector by a registered nurse. A review of seven pre-
service and seven in-service training records indicated all fourteen staff received episodic, first-
aid, and emergency care training. During the annual compliance review week the program did
not have an episodic care event while the team was on-site; therefore, a first-aid event was
unable to be observed. A review of the medical drills for the annual compliance review period
indicated the program conducted emergency medical drills announced and unannounced at
least quarterly on each shift. All direct care staff participated in at least one drill which included
the use of cardiopulmonary resuscitation (CPR), annually. An effort is made to ensure all staff
with direct contact on a day-to-day basis have the opportunity to participate in at least one
emergency “man-down” drill annually. Staff who are not present have the opportunity to review
each scenario in an effort to understand the process and respond to the specific scenario. Video
observation was conducted of two medical drills which included medical responses. The two
medical drills were simulated as seen on video. A review of the medical drill documentation
indicated prior to June 2024 the drills were written as if conducted during training session. The
Department’s Office of Health Services (OHS) conducted a deficiency review in June 2024.
After the OHS review, drills were simulated as an episodic care event which called for
immediate first-aid and/or administration of CPR techniques, and the initiation of the emergency
procedures to follow when a life-threatening emergency does occur.
Observation during the annual compliance review week indicated the program maintains two
doses of Narcan in the medical cart, two doses in each “jump bags”, which are first response
kits used by the clinic, and two doses in a locked cabinet in the examination room. The program
maintains a list of staff which were trained and are allowed access to Narcan. Narcan is
inventoried perpetually and by shift-to-shift count. Four of five interviewed staff stated yes to
personally being allowed to call 9-1-1 if a youth has a medical emergency. One staff stated they
would notify a supervisor because no telephone is on the dormitories. All five youth interviews
indicated they can see a doctor and a dentist if needed. The nursing interview indicated if the
non-healthcare staff provide first-aid/emergency care to the youth it is documented on the non-
licensed health care form by the staff providing care. Youth who receive off-site care are tracked
in the off-site care logbook. The interview indicated mock medical drills are conducted once a
month on each shift. Sometimes they are done at all staff meetings. Drills are usually conducted
by having a staff member simulate the drill and the AED and CPR drills are completed using the
mannequin.
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4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
Four of the five reviewed youth Individual Healthcare Records (IHCR) were not applicable for
off-site care. Two additional youth IHCRs were selected for a total of three applicable youth. The
three youth IHCRs had youth who required off-site care and for each event the Summary of Off-
Site Care Consultation Report form was utilized and filed in each IHCR. All off-site care for each
youth was documented on the Episodic Care Log and the designed health authority (DHA)
reviewed and signed or initialed all off-site care findings, instructions, and information. One of
the three IHCRs had documentation parental notifications were attempted. The remaining two
records did not require parental notification due to the youth being eighteen years old. All three
youth records indicated discharge and additional applicable documents were filed in each IHCR.
One of the three youth required a follow-up appointment, which was tracked, and the youth
received the appropriate and timely follow-up care. The nursing staff interview indicated youth
who are sent off-site are tracked with an off-site logbook and an off-site schedule book. To
ensure all hospital orders are followed, facility doctors are called once a youth returns from off-
site to confirm all orders. To ensure the DHA is reviewing all off-site care findings, the youth is
logged in the DHA logbook. There is a logbook used to help the nurse track follow-up testing,
referrals, and appointments.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a policy and procedures to ensure any youth admitted to the program who
have chronic conditions receive regularly scheduled evaluations and follow-up care as needed.
Two of the five reviewed youth Individual Healthcare Records (IHCR) were applicable for
chronic conditions. One additional IHCR record was selected for a total of three applicable youth
IHCRs. Three youth were identified on the Department’s Facility Entry Physical Health
Screening (FEPHS) form with a chronic condition at admission. None of the youth were
identified as having a communicable disease. All three youth were taking prescribed medication
on an on-going basis. All three youth were undergoing treatment for a physical health condition.
All three youth were classified with a Medical Grade two to four. The three youth were placed on
the program’s Chronic Illness List and received periodic evaluations at least every ninety days.
None of the youth were applicable for taking anti-tuberculosis medications. Three youth were
applicable for having periodic evaluations conducted prior to renewing a prescription medication
which expired. None of the youth had an evaluation conducted off-site. There was no evidence
of any lapses in care or missed periodic evaluations. The Department’s Problem list was
updated for each youth. An interview with the facility administrator (FA) confirmed the medical
department meets with the Designated Health Service provider weekly to review important
youth medical issues. An interview with the designated health authority (DHA) confirmed
periodic evaluations for youth with chronic conditions are completed and tracked every sixty
days. Nurses have a chronic clinic log to ensure all youth with chronic conditions receive
periodic evaluations as required. An interview with the nursing staff confirmed youth on the
chronic clinic log are monitored every sixty days.
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4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
Five youth Individual Healthcare Records (IHCR) were reviewed for medication management.
Two of five reviewed IHCRs were not applicable for medication management. Three of the five
applicable IHCRs indicated each youth was admitted with medication and this was documented
in the progress notes and the Facility Entry Physical Health Screening (FEPHS) form. The three
IHCRs documented in the Chronological Progress Note and on the Prescription Medication
Verification Checklist form the medication was verified prior to each youth being admitted to the
program. The designed health authority (DHA) and, when applicable, the psychiatrist was
contacted to obtain an order to resume the specified medications prior to admission. The three
applicable youth all had all medication administered pursuant to a current prescription and all
medications had a current and valid order. For the three youth in which medications were
continued, discontinued, changed, or new ones ordered the DHA placed an order on the
Practitioner Order form. None of the youth were in restricted housing or on required parenteral
medication. All five IHCRs utilized a pre-printed pharmacy Medication Administration Record
(MAR) which included all required information, documented all medication and treatment, and
each MAR clearly indicated medication start and stop dates. Medication entries were initialed by
a nurse for each of the youth. There were no lapses or errors in medication administration for
any of the reviewed youth. All three IHCRs documented at a minimum weekly side-effect
monitoring on each MAR conducted by a nurse. In one of three records, youth signed a Refusal
of Treatment form indicating refusal of medication, which was clearly documented on the MAR.
Each of the MARs in all three IHCRs contained all required elements. Two youth were admitted
with current prescribed psychotropic medication. In both applicable IHCRs the DHA and
psychiatrist were notified upon admission and the psychiatrist conducted an initial diagnostic
psychiatric interview within fourteen days of admission. Two applicable youth received a
medication review every thirty days as required. The program did not have any standing orders,
emergency treatment orders, or pro re nata orders for psychotropic medications. During the
annual compliance review week observation of medication administration was conducted. The
observation indicated medication delivery was the sole responsibility of the nurse during the
time of administration. Each youth was escorted to medication administration by a youth care
worker and each youth approached the nurse individually. The nurse identified themselves and
stated why each youth was there. The nurse prepared and administered each medication, after
each youth’s allergy and alert status was verified. Each MAR was initialed by the youth and
nurse, as well as the nurse ensuring each youth swallowed the medication. No over-the-counter
(OTC) medications were administered and no medication was pre-poured. The Six Rights of
Medication Delivery and Administration was verified. Five youth were interviewed and three
youth stated the nurse provides them with their medication and two youth indicated they are not
on medication. The nursing interview indicated the MARs, orders, and prior facility paperwork is
checked for medication during youth admission and this is documented on the Health Related
History form, Facility Entry Physical Health Screening, DHA notification, and nurses’ admission
note. Non-healthcare staff do not verify medication, only nurses verify medications at admission.
Trained non-healthcare staff can provide OTC medications and are required to fill out the non-
licensed healthcare form. Medications are ordered through a local pharmacy while OTC
medications and stock medications are ordered through a medication provider.
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4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a policy and procedures addressing medication management including a
process for the destruction and disposal or return of expired or discontinued medications and a
process for inventory discrepancies and the reporting criteria. Observation of the program’s
medical clinic indicated the sharps and all medications were secured when not in use,
inaccessible to all youth. A review of the medication cart indicated it was locked when not in use,
clean and organized with stock items being separated from youth-specific medications, as well
as injectable, topical, drops, and liquids being separated. The medication cart included a locked
box for all narcotics and controlled medications. The clinic maintains a medication only
refrigerator and a specimen only refrigerator both being at forty-degree Fahrenheit. A review of
the sharps and the over the counter (OTC) medication inventories for the annual compliance
review period indicated all were inventoried perpetually and weekly as required. The program
only had one controlled medication on-site during the annual compliance review week and the
shift-to-shift inventory count was documented on the youth’s Individualized Controlled
Medication Inventory Record. Eighteen non-healthcare staff were trained in the delivery and
oversight of medication self-administration by a registered nurse. Observations of the nurse
conducting a count of three sharps indicated the ending count and the final count of the
inventory matched. A count of the only controlled medication on-site matched the count on the
inventory. A count of three OTC medications indicated one medication count matched the
inventory count. The remaining two counts were off; one medication was on the inventory but
there were two medications present. There were six on the inventory of the second OTC
medication, but only two medications were present. The nurses indicated they had just received
a new delivery for those OTC medications and had not documented them in the inventory
binder. The health service administrator was able to provide documentation for one of the
medications; however, was unable to provide any documentation for the other. The designated
health authority (DHA) and facility administrator (FA) shall be notified immediately of any
discrepancies with the daily controlled substance inventory count. The facility shall report and
investigate unexplained losses of controlled substances and report as required. The nursing
interview indicated all controlled substances are maintained in the medication cart behind two
locks. All medications are secured in cabinets or the medication cart. The process for disposal
of medications is to dispose of them in the approved liquid in the presence of the pharmacist,
who comes once a month.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a policy and procedures addressing infection control and exposure control,
including a process for needle stick post-exposure evaluation. The program’s infection control
procedures include prevention, containment, treatment, and reporting requirements related to
infectious diseases according to the Occupational Safety and Health Administration (OSHA)
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federal regulations and the Centers for Disease Control and Prevention (CDC) guidelines. The
designated health authority (DHA) and the facility administrator (FA) reviewed the infection
control procedures on July 9, 2021. The infection control procedures include common, infectious
diseases of childhood, self-limiting episodic contagious illnesses, viral or bacterial infectious
diseases, tuberculosis, Hepatitis A, B, and C, and human immunodeficiency virus (HIV)
infectious diseases caused by bloodborne pathogens, other outbreaks or epidemics caused by
any other infectious agent, whether spread directly or indirectly, outbreaks of pediculosis /or
scabies, Methicillin-Resistant Staphylococcus Aureus and other emerging antibiotic-resistant
micro-organisms, foodborne illnesses, bio-terrorist agents, and chemical exposures in the
workplace. The procedures address availability of Hepatitis B immunizations for staff, and staff
having access to protective equipment. The program did not have any instances in which the
local county health department, CDC, and/or the Department’s Central Communications Center
(CCC) had to be notified of an infectious disease. The human resource department of the
program will maintain a file to contain all documents for youth and staff who have experienced a
facility or occupational exposure, if needed. The exposure control plan was written in
accordance with OSHA standards, is in master control, administration, and the staff break room,
which is available to all staff.
The FA interview indicated the location of the exposure control and infection control plan, as well
as stating the plans are reviewed during training and bi-annually with all staff. The nursing
interview indicated infection control training is conducted during admission and annually with
youth. Infection control training and exposure control plan review is conducted by a registered
nurse or the health services administrator bi-annually with staff.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures which requires staff to maintain active supervision of
youth, including interacting positively with youth, engaging in a full schedule of constructive
activities, closely observing behavior of youth and changes in behavior, and consistently
applying the programs Behavior Management System (BMS). The program adheres to a staff-
to-youth ratio of one to eight during daytime activities and one to twelve during hours of sleep.
Observations during the annual compliance review week confirmed supervision ratios were
being followed according to contractual requirements. Additionally, observations found staff were
actively supervising youth during school, recreation activities, and during breaks and were
interacting positively with youth. The program has schedules of activities posted on each living
module and observed youth were engaged in activities and following the schedule. Three staff
were interviewed and asked how many youth they are supervising. All three interviewed staff
were able to answer the number of youth they were supervising.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program has a policy and procedures addressing the Behavior Management System (BMS)
and protocols regarding feedback given to staff about their implementation of the BMS during
their annual performance evaluations . The written description of the BMS was posted on each
of the four active living modules and in the youth handbook which included the rules governing
conduct and positive and negative consequences. The program’s BMS allows for youth and
staff to discuss behavior, impact on themselves and others, discussion of alternate behaviors
and peaceful conflict resolution. The program’s BMS includes several key components which
are designed to promote a positive and supportive environment for youth. These include
promoting safety, respect, and fairness for all participants, as well as protecting and promoting
youth rights. The system incorporates both positive and negative consequences, with an
emphasis on constructive disciplinary actions and are non-punitive in nature. It provides
opportunities for positive reinforcement, ensuring positive behaviors are recognized at a four-to-
one ratio as required by the program’s contract. The BMS also focuses on promoting socially
acceptable means for youth to meet their needs and includes a process for explaining to youth
the reasons behind any sanctions imposed. Youth are given the opportunity to explain their
behavior, and there are opportunities for both staff and youth to discuss the impact of behaviors
on others. The program encourages reasonable reparations for harm caused to others, while
also discussing alternate behaviors to prevent future issues. It emphasizes promoting positive
dialogue, peaceful conflict resolution, while minimizing the separation of youth from the general
population whenever possible. The program’s policy and procedures include a protocol for
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providing staff with feedback on their implementation of the BMS, which is incorporated into the
annual performance evaluation process. This ensures staff members receive regular,
constructive input on how effectively they are utilizing the BMS and helping to maintain a high
standard of practice throughout the program. In addition, the program has established an
agreement with the school as it pertains to the BMS, referred to as the Cooperative Training
Joint Plan. This agreement ensures there is a consistent approach to behavior management
across both the program and the educational environment. The facility administrator plays a key
role in training the education staff in this jointly combined BMS plan, ensuring the same
strategies and techniques are used during school hours. Further training is provided by the
facility administrator and the education liaison, who offer guidance to the education staff on how
to implement the BMS effectively. To verify the program’s adherence to its procedures, five
youth case management records were reviewed and confirmed youth orientation included a
detailed review of the BMS, ensuring all youth understand the system and its expectations.
Additionally, thirty-two position descriptions were reviewed for staff whose job functions include
the implementation of the BMS. This review confirmed staff are appropriately designated to
carry out these responsibilities. Five staff training records were also reviewed and it was
confirmed these staff members had completed training in the program’s BMS, further ensuring
the system is consistently and effectively implemented across the program. The program’s BMS
also includes a process wherein staff explain to youth the reason for any sanction imposed,
ensuring clarity, and understanding. This explanation takes place prior to the end of the staff
member’s workday. Furthermore, the youth are given an opportunity to explain their behavior,
which promotes open communication and reflection. Staff and youth are encouraged to discuss
the impact of the behavior on others, ensuring the youth understand the broader consequences
of their actions. The process also includes discussions on reasonable reparations for any harm
caused to others and the identification of alternative, acceptable behaviors, providing youth with
the tools to make more positive choices moving forward. Five staff members were interviewed
and asked to explain the program’s BMS. All five staff were able to explain the program’s BMS
as a level system, which includes written behavior reports, five level systems, and point cards.
Each of the five staff stated basic rights are not taken away from youth as a consequence. All
five staff stated staff inform youth of their consequences. Each of the five youth were able to
explain the BMS system and four confirmed youth are not allowed to punish other youth; one
youth stated youth are permitted to punish other youth; however, there was no further
explanation from the youth. All interviewed youth and staff reported youth can earn rewards
such as canteen, Monday burgers, Thursday sausage, pizza parties, special meals, and level
points. All interviewed youth and staff stated consequences consists of behavior reports, point
reductions, behavior contracts, and canteen restrictions. The facility administrator (FA) was
interviewed and stated staff implementation of the BMS is monitored through performance
evaluations and annual evaluations. Additionally, positive behavior reports, behavior reports,
and incident reports are reviewed daily in management meetings, where trends are discussed. If
staff are found not adhering to the BMS process, a discussion takes place to address the issue.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy states the program does not use restricted housing, to include room
restriction; therefore, this indicator is rated non-applicable.
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5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a policy and procedures requiring staff to observe youth at least every ten
minutes while they are in their sleeping quarters. These observations must be conducted in a
manner which ensures the safety and security of each youth. The checks are to be documented
in real time. The program is equipped with 121 cameras, all of which were operational at the
time of the review. The program retains thirty days of video recordings. A sample of video
recordings and corresponding logs was reviewed to verify the ten-minute checks. The sample
included three thirty-minute increments from each shift, for three days, using stored video
recording from each living module. The review confirmed all checks were conducted at eight-
minute intervals, which is below the required ten-minute interval and all checks were
documented in real time. A further review of the ten-minute check sheets confirmed staff
members who completed the checks initialed the check sheets. Video recordings also confirmed
the checks were conducted as required and staff did not simply walk by the rooms. The staff
were observed to pause and thoroughly observe the youth to ensure their safety. A review of the
check sheets for the annual compliance review period showed checks were conducted as
required. Five staff members were interviewed and confirmed checks are conducted every four
minutes.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program has a policy and procedures addressing census, counts and tracking. The
program’s census and counts are documented in the master control logbook with three formal
counts completed each shift. The program’s policy and procedures state there are to be six
formal counts completed every twenty-four hours. Observations during the week of annual
compliance review week found master control calling for and completing counts as required at
various times throughout the day. The program’s master control logbooks were reviewed during
the annual compliance review period confirming counts were completed three times a shift. A
review of a full day for each month, since the last annual compliance review, was conducted of
the logbooks, and each day contained documentation of total daily census counts, head counts,
youth movements, youth admissions and releases, and youth temporarily away from the
program. Five staff were interviewed and stated youth counts are conducted nine times a day, or
three times a shift. All five staff stated if a youth is unaccounted for, movement stops, and a
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recount is completed until the count is correct. The five staff indicated emergency counts are
conducted after an emergency or if there is a power outage.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has established a policy and procedures for logbook entries. Observations during
the annual compliance review week confirmed the program uses a single bound logbook with
numbered pages for each month. A review of the logbooks verified all entries were made in ink,
with no erasures or white-out areas, and no entries were destroyed or removed. The reviewed
logbook pages included entries with dates, times, brief descriptions of events, and the names of
staff making the entries. The program does not utilize living unit logbooks. A review of the
logbooks during the annual compliance review period showed minimal interference with the
educational instruction period. Youth movements to recreation were also documented. The
review of the logbooks indicated the documentation of incidents involving mechanical restraints,
population counts at the beginning and end of each shift, perimeter security checks, and
transports away from the facility, including the names of staff, youth involved, and the
destination. It also documented the removal of any youth from the mainstream population, such
as when youth are placed on room restriction or controlled observation, along with admissions
and releases, including the name, date, and time of anticipated arrival or departure.
The program utilizes shift reports, which include the census of all living units, incidents, youth
out of the facility, youth alerts, gang members, security alerts, staffing assignments, sick calls,
perimeter checks, and their findings. Shift reports are reviewed by the supervisor from the
previous shift and the incoming shift during staff briefings at shift change. Shift reports reviewed
during the annual compliance review period included signatures from staff and supervisors,
confirming their review of the shift report. A review of the master control logbooks and shift
reports, for the annual compliance review period confirmed internal incidents were reported to
the Department’s Central Communications Center (CCC) and/or the Florida Abuse Hotline.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has an established policy and procedures to address key control, which include
key assignment and usage, restrictions on usage, inventory and tracking of keys, secure
storage of keys not in use, procedures for handling missing or lost keys, and the reporting and
replacement of damaged keys. The program’s keys are stored in a padlocked, clear-view
cabinet located in master control, under camera surveillance. This area is secured and
inaccessible to youth. Staff personal keys are securely stored in a locked cabinet within master
control. Keys are issued by master control based on staff position. The key box in master control
is securely locked and not easily accessible. Each set of keys is assigned a specific number and
corresponding key ring. A review of five sets of r keys confirmed the actual key rings in use
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matched the inventory records. Keys are always locked in the cabinet when not in use. During
the annual compliance review week, observations of master control issuing keys confirmed the
key inventory matched the correct number of keys assigned to each individual key set. Key sets
in the administration area were stored in a locked box on the wall. Both key storage boxes were
locked when not actively in use. The facility administrator (FA) assigns permanent and restricted
keys based on position. An acknowledgment form is completed for each permanent key
assigned, which includes the staff member’s signature, the key number, and the return date.
Restricted keys are stored separately from non-restricted keys in a locked box and only
assigned staff members have access to the restricted key box. The program has a broken key
report procedure, which is submitted to the plant manager, the only individual authorized to
replace keys. Both key storage boxes are not easily accessible to unauthorized personnel. No
incidents related to key control were reported to the Department’s Central Communications
Center (CCC), nor were there any Program Monitoring and Management (PMM) deficiencies
related to key control during the annual compliance review period. The program maintains a
twenty-four hour key log, which is updated by the master control operator. The log includes the
keys issued, the date and time of issuance, the person receiving the key, the time the key was
returned, and the master control operator’s initials for each entry. Three random staff members
were informally interviewed and were able to identify the key set they were assigned and the
function of each key on the set. The key sets were verified against the master key inventory.
Additionally, five staff were interviewed and asked to explain the process for handling personal
and program keys from the time they arrive to begin their shift until they leave. All five staff
stated staff keys are given to master control upon entry, and personal keys are securely stored.
They also confirmed youth do not have access to the keys.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a policy and procedures in place to prevent contraband from entering the
facility. The policy includes items and materials considered as contraband, as well as
exemptions, providing youth with a list of items considered as contraband, informing program
youth of the consequences if found with contraband, searching the facility and grounds, and
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searching of youth, incoming mail, and outgoing mail. The policy includes the consequences if
any program staff is found in possession of contraband. The policy also includes contacting law
enforcement if any item found is considered illegal as defined in Florida Statutes, or if there is
any evidence of unlawful activities. The facility visitor log was reviewed and it was found to
include a contraband attestation statement. A review of the Department’s Central
Communications Center (CCC) reports showed there were three reports of contraband
confiscated during the annual compliance review period. A review of the facility logbooks and
youth room search reports for the annual compliance review period showed the program
conducted searches as required. Contraband items or illegal contraband is documented on the
search log and disposed of as required. The review of thirty new staff members hired since the
last annual compliance review indicated attestation forms were signed and completed. The
facility administrator’s interview stated the policy is to turn all contraband into the facility
administrator. All illegal contraband is secured and turned over to law enforcement. Non-legal
contraband is secured in the facility administrator's office and disposed of once the CCC report
closes. Five staff were interviewed and four confirmed the program’s process for youth room
searches is conducted daily on each shift. One staff stated contraband searches are completed,
youth rooms are searched, and staff ensure youth are not at the end of the hall in the dorm.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a policy and procedures to address searches and full body visual searches to
ensure no contraband is introduced into the facility. Staff were also observed searching youth
prior to and after movement. During the week of the annual compliance review staff were
observed searching a youth returning from a detention transport. The program had two
admissions and no releases during the annual compliance review week. Visitation did not take
place during week of annual compliance review nor were there any off-campus activities
scheduled. During observed searches youth were treated with dignity and respect to minimize
the youth’s stress and embarrassment. Observed searches were conducted by the same
gender as the youth and with appropriate number of staff. Youth were given instructions and
reason for search prior to search, which were in line with program policy. Five staff were
interviewed and stated youth searches are done at every movement. Five youth were
interviewed, and four confirmed searches occur at every movement. One youth stated searches
are completed after outdoor activities. Video footage was reviewed and indicated youth were
searched during movements throughout the facility.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has established a policy and procedures to address vehicle maintenance and
usage. The program utilizes three vehicles for youth transport. Reviewed documentation
confirmed the vehicles underwent annual safety inspections, and all required maintenance
records were properly documented. During the week of the annual compliance review, fifteen
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randomly selected personal vehicles and three facility vehicles were found to be securely
locked. Four of the five interviewed youth reported they had never been on a transport. The
remaining youth indicated they had been on transports and stated they were secured with
seatbelts, handcuffs, waist belts, and shackles. Five staff members were interviewed and asked
how youth are secured during transport. Each staff responded youth are secured using
shackles, handcuffs, a waist belt, and a seat belt. Observations during the annual compliance
review week confirmed each facility vehicle was equipped with a seatbelt cutter, window punch,
safety screen, fire extinguisher, an appropriate number of seat belts, and youth doors cannot be
opened from the inside. First-aid kits are issued when vehicles are checked out. A youth
transport was observed during the annual review week. During the observation, youth were
secured with shackles, handcuffs, a waist belt, and a seatbelt.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a policy and procedures to address transportation of youth and driver
eligibility. The review of the program’s policy and procedures states a program cellular
telephone is issued for all transports, the program’s policy states a minimum of two staff to one
youth is required, and a staff of the same gender of the youth is present during a transport. The
program provides transportation for the youth. During the week of the annual compliance
review, an observation was made of two staff members transporting two newly admitted youth.
Both staff members were of the same gender as the youth. The staff and youth were observed
removing seat belts prior to exiting the vehicle. Up on the return of the transport, the youth were
secured with shackles, handcuffs, a belt, and a seatbelt. All three facility vehicles have safety
screens installed. Reviewed documentation revealed the program maintains an approved driver
list and ensures each approved driver has a valid driver license. Youth are not permitted to drive
program or staff vehicles. The interview with the facility administrator (FA) indicated each vehicle
used for youth transports is equipped with a safety screen. Five staff were interviewed and two
staff revealed during youth transports, staff are provided a transport cellphone by the master
control operator. The remaining three had never transported a youth. The two staff who have
completed a transport stated youth are secured in the backseat by use of a seatbelt and
shackles and a first-aid kit, suicide kit, and fire extinguisher are on each transport. Five staff
were interviewed, and staff stated vehicles are searched prior to and after each use. Three of
the interviewed staff do not participate in youth transports. The two staff who have completed a
transport were able to explain the emergency process during a transport, stated first-aid kits,
suicide kits, fire extinguishers, and a cellular phone are taken on each transport. The two staff
further explained youth are secured by the seatbelt and shackles. Four of the interviewed staff
stated the use of a personal vehicle to transport youth is not permitted; one staff stated it is. Five
youth interviews confirmed youth have never witnessed anyone placing contraband in the
transport vehicles. Four of the youth stated they had been on a transport, and one stated they
have never been handcuffed to any part of the vehicle.
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5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has established a policy and procedures outlining weekly safety and security
audits. These procedures specify the program staff responsible for conducting the audits and
safety inspections, the development and implementation of corrective actions for any
deficiencies identified during inspections, an internal system to verify deficiencies are corrected,
and the improvement or introduction of systems as needed to maintain compliance. The weekly
audits are conducted by the facility administrator, assistant facility administrator, chief of
security, plant manager, and unit manager. During the annual compliance review period,
documentation confirmed weekly inspections were completed as required. No safety or security
audit related Program Monitoring and Management (PMM) deficiencies were identified during
the annual compliance review period. The program’s preventive maintenance schedule was
reviewed with the plant manager and repairs were conducted as outlined in the policy. The
facility administrator (FA) indicated in an interview the program conducts daily walk-throughs
and utilizes a weekly safety inspection sheet, work orders, and discussions during the daily
management meeting to address safety concerns.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a policy and procedures addressing the issuance, inventory, and control of
equipment and tools. The plant manager completes a monthly tool inventory which is signed off
by the facility administrator. The program’s policy prohibits machetes, bowie knives, or other
long blade knives. The program has procedures for missing or lost tools and disposal of
dysfunctional tools. The program did not have missing, lost, or damaged tools during the annual
compliance review period. A review of the program’s tool inventory records for the annual
compliance review period confirmed tools being issued were inventoried following return. Ten
tools were randomly selected, which included five from the maintenance shed and five from the
kitchen. All tools were secured, had easy identification, and accurately matched the inventory
list.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a policy and procedures addressing the supervision requirements when youth
use tools including one staff to five youth ratio, issuing tools to youth and staff, assessment to
determine a youth’s risk to self and others, tool distribution, collection, and search criteria during
work projects. The program does not utilize disciplinary work projects. There were no Home
Builder’s Institute (HBI) activities observed during the annual compliance review week.
Five case management youth records were reviewed and confirmed all five youth were trained
on the intended and safe use of tools. All five youth has risk assessments completed as
required. Five youth were interviewed, and one youth stated youth are permitted to use a
screwdriver, hammer, and saw. Three youth stated youth are permitted to use a scrub brush and
two stated mops and brooms. Five staff were interviewed and three stated youth who are in HBI
are able to use tools. Two stated youth are able to use mops, brooms, and scrub brushes.
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5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures to address outside contractors which includes tools
shall never be left unattended, tools should be limited to only the required tools necessary to
perform tasks, no tool shall be given to youth at any time and youth are restricted from any work
area. The plant manager or designee inspects all tools upon arrival and departure of outside
contractors, is responsible for providing approval if such tools as personal cellular telephone
and/or equipment/electronic devices capable of taking pictures and/or audio/video recordings
are required and is responsible for missing tool follow-up. The program has a vendor sign-in and
out sheet where the plant manager and/or designee as well as master control checks in the
vendors. Ten records of outside contractors and their tool inventory sign-in sheets were
reviewed. All contractors signed the contractor’s policies and contraband attestation form. Three
project invoices submitted to the program by the vendor were reviewed and indicated all tools
were inventoried before and after the arrival of the vendor.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program has a policy and procedures to address fire, safety, and evacuation drills. It was
confirmed through drill documentation, during the annual compliance review period, the program
conducted fire drills monthly on every shift. The drills included type of drill, date and time,
participants, brief scenario, findings, and recommendations. The fire evacuation routes, and
egress plans are posted throughout the facility. The program has twenty-one fire extinguishers
which were inspected annually. The last annual fire marshal extinguisher inspection date was
August 02, 2024. Five staff were interviewed, and all reported participating in various types of
drills during the past year, including fire, weather, disturbance, hostage, chemical spill, flooding,
escape, medical, mental health, tornado, and suicide drills. Five interviewed youth stated they
have been instructed on what to do in the event of a fire. The facility administrator (FA) was
interviewed and advised fire drills, Continuity of Operations Planning (COOP) drills, medical
drills, and mental health drills are conducted monthly on each shift.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
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The program maintains a Continuity of Operations Plan (COOP) and the COOP was last
reviewed and updated on April 11, 2024, by the facility administrator, and submitted to the
Department for approval. The plan was approved by the Department on April 15, 2024. Copies
of the program COOP plan are in the facility administrator’s and assistant facility administrator’s
offices and the staff break room. The plan addresses alternative relocation sites approved by
the Department’s regional director and the COOP includes all the required and relevant
information for continuous operation during an emergency. Supplies and equipment required for
COOP are in the plant manager area and food items are stored in the kitchen. Supplies
observed during the annual compliance review week were water, dry goods, can goods, non-
perishable items, and youth related items which are stored on the mods. The program COOP
plan included delegation of authority, new cooperative agreements, vendor contact list,
emergency, staff contact numbers, and county cooperation checklist. Five youth records were
reviewed and confirmed the program maintains an administrative hard-copy file for each youth
which every department will take during an emergency. An interview with the facility
administrator (FA) confirmed the COOP is in the staff break room, master control, and in the
facility administrator’s office.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program has a policy and procedures regarding the storage and inventory of flammable,
poisonous, and toxic items. Flammable, poisonous, and toxic items are secured in the locked
storage area, which is in the maintenance shop where youth do not have access. Inventories
are maintained for all flammable, poisonous, and toxic items. The program maintains a list of
positions authorized to handle flammable, poisonous, and toxic items which include the facility
administrator, assistant facility administrators, chief of security, maintenance staff, shift
supervisors and medical staff. The program maintains Safety Data Sheets (SDS) for all
materials on-site. Ten chemicals were randomly selected, all items matched inventory, were
secured, and had SDSs present, with no discrepancies noted. The maintenance manager was
interviewed and indicated the program uses the city landfill for disposal. The facility
administrator, in consultation with the physical plant manager, has designated the following staff
to dispose of flammable, poisonous, and toxic items and materials: assistant facility
administrator, chief of security, unit managers, maintenance staff, medical staff, shift managers,
youth care worker IIs, and food service. All disposal procedures were in accordance with
Occupational Safety and Health Administration (OSHA) standards. Hazardous liquid waste is
disposed of in accordance with the Safety Data Sheets (SDS). Grease is placed in a separate
container for proper disposal. In line with the program’s policy and procedures, chemical spills
are cleaned up as follows: upon discovering a chemical spill, staff are required to notify master
control of the location. The shift supervisor or master control will then direct the shutdown of all
air handlers and ventilation systems, ensuring all windows and doors are closed, as instructed
by the on-scene supervisor or facility administrator (FA). If necessary, assistance from outside
the facility is contacted in accordance with emergency procedures. The reviewed FA interview
results indicated the program utilizes the landfill for the disposal of hazardous items and obtains
a receipt for the disposal of these materials.
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5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures regarding youth handling and supervision of
flammable, poisonous, and toxic items. The program maintains strict control of flammable,
poisonous, and toxic items. The policy prohibits youth to use, handle, or the clean-up of
dangerous or hazardous chemicals by youth, except for youth in the Home Builders Institute
(HBI) program. These youth have access to paint, paint thinner, and wood stain under the direct
supervision of staff and only after being trained on how to handle these items. Youth were not
observed conducting cleaning activities during the week of annual compliance review. Five
youth were interviewed, and five said they do not handle any chemical/cleaning products. One
youth stated they are able to handle paint, paint thinner, and cleaning supplies when
participating in Home Builder’s Institute (HBI); however, the staff spray for the youth to spread
the paint.
5.20 Elements of the Water Safety Plan, Staff Training, and
Satisfactory Compliance
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
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in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures addressing visitation and communication, youth
correspondence, and use of the telephone by youth. The visitation schedule is posted in the
lobby and at the entrance of the facility. The program’s facility operating procedures (FOP) state
the program shall make every effort to assist youth in maintaining and strengthening positive
family and community ties in an environment which unobtrusively monitors and controls the
movement of visitors within the program. Each youth is provided an opportunity on a regular
basis to correspond with identified individuals specified on their approved correspondence list
and legal representatives. A review of the correspondence logs confirmed all incoming and
outgoing mail is searched and recorded in the correspondence logs. The facility administrator’s
(FA) interview indicated the program utilizes an interpreter service when necessary to ensure
effective communication. The five interviewed youth confirmed they can call their parent or
guardian or write letters to them as a means of communication. There was no visitation
scheduled during the week of the annual compliance review; therefore, visitation was not
observed. The program’s visitation hours are Saturdays and Sundays from 1:00 p.m. to 4:00
p.m. A review of the visitation logs validated visitations were taking place as scheduled.
Telephone calls and opening of mail are conducted by the youth with their case managers and
documented in each youth’s case management record. Telephone calls are offered weekly
according to the program’s policy and procedures. Each youth is allowed to make one
telephone call a week to approved family members. The case manager is responsible for
scheduling these telephone calls. The program provides postage for each youth within the
program and does not limit the number of letters a youth is able to mail each week.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program provides a variety of recreation and leisure activities for the youth. The program
activity schedule contains at least one hour of supervised and structured indoor and outdoor
recreation and leisure activities, to include large muscle activity, for youth each day. A review of
the logbook confirmed recreation and leisure activities were conducted as scheduled. The
activity schedule for the program documents a range of supervised and structured indoor and
outdoor recreation and leisure activities for the youth, ensuring at least one hour of such
activities is provided daily. The activities include large muscle activities, both indoors and
outdoors, and are designed to promote social and cognitive skill development, creativity,
teamwork, healthy competition, mental stimulation, and physical fitness. The program’s contract
requires the program to employ a recreational therapist. Five youth case management records
were reviewed, and recreational therapy was included in each youth's Individualized
Performance Plan and treatment plan. There were no discrepancies found with the recreational
therapist's credentials and all contract requirements were met. A review of the logbook
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confirmed recreation was conducted as scheduled. Recreational activities were observed to
ensure the program takes precautionary measures to prevent over-exertion, heat stress,
dehydration, frostbite, hypothermia, and exacerbation of existing illness or physical injury. Five
youth were interviewed, and all confirmed physical activities are provided for at least one hour
each day. Additionally five staff were interviewed and reported indoor and outdoor activities
provided to the youth include board games, card, football, basketball, pull-up bars, four square,
bowling, weight bags, and indoor ping pongs, all lasting at least one hour.
5.23 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program has a policy and procedures for the search and inspection of the controlled
observation room. The rooms used for controlled observation had a metal door with a shatter-
resistant window, was at least thirty-five unencumbered square feet, properly covered vents and
lighting, and no electrical outlets. Mattresses in the program are fire retardant. Five controlled
observation reports were reviewed and found staff documented an inspection of the room and a
search of each youth before the youth was placed in the room, as required. Staff of the same
gender searched each youth before the youth was left alone in the controlled observation room.
5.24 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program has a policy and procedures for controlled observation. The program had fifty-five
youth with documented controlled observations since the last annual compliance review. A
sample size of five were reviewed. None of the reports reflected youth in a mental health crisis
or suicide. Each youth met at least one of the required criteria for controlled observation. All five
contained documentation of supervisory or higher-level staff authorizing placement. There was
one youth who complained about injuries and staff reported to the medical staff and the health
status checklist was completed. Times of controlled observation ranged from one to two hours,
in which one report included facility administrator or designee approval to go over the two-hour
window.
5.25 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program has established a policy and procedures for controlled observation safety checks
and releases, including staff designations for controlled observation. A sample of five youth
records was reviewed since the last annual compliance review. All five reports included
documentation of staff responsible for placement, completion of the first page of the controlled
observation report, submission to the supervisor, and documentation of safety checks
conducted at least every ten minutes, observing the youth’s behavior on the controlled
observation safety check form. It was determined an internal alert was warranted for each
reviewed youth. The facility administrator or designee gave written approval before each youth
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was released from controlled observation. The Controlled Observation Report, Health Status
Checklist, and Controlled Observation Safety Checks forms were maintained in both an
administrative file and the youth’s individual management record. Each of the five reports
documented approval from the facility administrator or designee for the youth's release from
controlled observation, based on behavior. Additionally, all reports were reviewed and approved
by the facility administrator or designee within fourteen days of the youth’s release from
controlled observation. It was determined an internal alert was warranted when each youth was
released from controlled observation. Staff designations for controlled observation are included
in the program’s policies and procedures.
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Standard 6: Safety and Security
6.01 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
According to the program’s contract, the Career and Technical Education (CTE) services
required to be provided are ServSafe (Food Handlers) and Home Builder’s Institute (HBI).
These CTE services are provided Monday through Friday from 7:30am to 8:30am. The program
has two instructors who provide these services. Their qualifications include a bachelor’s degree
and CTE Associates. Currently, twenty-five youth are enrolled in coursework towards earning an
industry certification. Seventy-one youth received each of the career and technical education
services provided for the annual compliance review period. Seventy-four youth received their
cardiopulmonary resuscitation (CPR) and first-aid certificates. Forty-seven youth received an
Occupational Safety and Health Administration (OSHA)certification. 135 youth have earned the
Florida Ready to Work Soft Skills certificate. Five youth records were reviewed and all five youth
completed the following courses within the required time frame; Florida Ready to Work Soft
Skills, OSHA-10, and CPR/First-Aid. The facility administrator was interviewed and explained as
it relates to CTE, HBI, SafeServ, OSHA, Commercial driver’s licenses (CDL), Forklift, Microsoft,
Florida Ready to work, CPR/First-Aid, and Career Counseling all are offered.
6.02 Educational Access (Residential Contract Provider) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a written policy and procedures to provide educational access. The program
provides education services through Florida Virtual School (FLVS). A review of the facilities'
activity schedule and the daily academic schedule indicated the facilities' activity schedule
incorporates the daily school schedule. No discrepancies were found. The interview with the
lead teacher indicated all youth receive credit for completing a course. He also reported the
school schedule is adhered to. Seven youths were interviewed, and six reported no interruptions
during school. One youth reported they got chatty. A review of randomly selected days in the
logbook throughout the past year indicated education classes started and ended on time or
within a few minutes of the schedule. Observations of the program video on January 7, 2025,
January 10, 2025, and January 13, 2025, indicated classes started and ended on time as
scheduled.
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6.03 Educational Access (Education Contract Provider) Non-Applicable
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
Education services are provided through Florida Virtual School (FLVS). The 250-day calendar is
distributed over twelve months and includes twenty days for teacher training and planning. A
review of the daily school schedule revealed education provides six fifty-minute classes from
8:30 a.m. through 2:45 p.m. with a sixty-minute lunch break from 12:05 p.m. through 1:05 p.m.,
fulfilling the weekly requirement of twenty-five hours of instructional time. The interview with the
lead teacher indicated all youth receive credit for completing a course. He also reported the
school schedule is adhered to. Five youths were interviewed and reported no interruptions
during school. A review of randomly selected days in the logbook throughout the past year
indicated education instruction was provided according to the daily bell on time or within a few
minutes of the schedule. Observations of the program video on January 7, 2025, January 10,
2025, and January 13, 2025, indicated classes started and ended on time as scheduled.
6.04 Career Education (Education Contract Provider) Non-Applicable
Staff shall develop and implement a career education competency development program.
The education contract provider is responsible for developing a career education program
appropriate for the educational abilities and goals of youth in the program and appropriate for
the length of stay and classification of youth in the program. The career education program
provided does meet the above requirements including Type 2 and Type 3 levels, as well as
communication, interpersonal, and decision-making skills. The lead teacher was interviewed
and as it relates to Career and Technical Education Services (CTE), career education services
and assessments are provided to the youth in the program. This is documented by way of
Occupational Safety and Health Administration (OSHA), cardiopulmonary resuscitation (CPR),
Ready to Work, and Home Builder’s Institute (HBI) with various credentials.
6.05 Education Transition Plan (Education Contract Provider) Non-Applicable
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The educational provider maintains a policy and procedures requiring an Education Transition
Plan to be developed upon each youth’s admission. Upon entering a residential commitment
program, an Education Transition Plan must be developed for each youth. Three closed youth
records were reviewed; none contained an Education Transition Plan. Many youths entered the
program before July 1, 2024, when the new education provider, Florida Virtual School (FLVS),
started; therefore, they would not have had an Education Transition Plan developed. A request
was made for alternative student plans entered after July 1, 2024. Still, the response received
was Education Transition Plans had not been created for any youth before early December
2024; therefore there were none available to review. FLVS has recently developed an education
plan template and trained its staff to implement an Education Transition Plan for each youth
moving forward. The interview with the instructional leader indicated an Exceptional Student
Education (ESE) teacher and paraprofessional are developing the Education Transition Plan.
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6.06 Qualified Instructional Personnel (Education Contract
Non-Applicable
Provider)
The program director is responsible for ensuring qualified instructional personnel are provided
to teach and provide exceptional education and related services to students in the facility.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
In reviewing the educational instructional staff for the facility, including flex teachers who provide
virtual education at the program, it indicated all the teachers, but one, have an active
certification, according to the Florida Department of Education website. One instructor had a
statement of eligibility, which expired on December 15, 2024. Three of the five teachers were
teaching in the field, and two were teaching out of the field. The parent notification
documentation provided by Florida Virtual Schools (FLVS) didn’t match the closed youth
records provided.
6.07 Florida Youth College (Education Contract Provider) Non-Applicable
The education provider shall complete the Florida Youth College referral process for each
youth that earns their high school diploma or GED. Each youth will be assigned a Florida
Youth College Career Navigator.
The education contract provider is responsible for referring all youth who receive their high
school diploma or equivalent to Florida Youth College so they can work with a career navigator
on postsecondary courses and/or enrollment in a state or technical college. There was one
youth referral to Florida Youth College; however, the youth declined to participate. During an
informal interview with the Florida Scholars Academy instructor, there is awareness this is now
the process and referrals to Florida Youth College are no longer optional; they are a
requirement for all youth with a high school diploma or equivalent. The lead teacher was
interviewed as it relates to Career and Technical Education (CTE), there are two CTE programs,
Digital Information Technology and Foundations of Programming.
6.08 Florida Youth College (Post-Secondary Contract
Satisfactory Compliance
Provider)
The post-secondary provider, upon receiving the referral for services, shall assign a Florida
Youth College Career Navigator to each youth. Each youth shall attend an orientation session
to develop a career pathway plan. The career pathway plan shall include postsecondary
education options at a state or technical college or pre-apprenticeship/apprenticeship
programming that leads to an industry credential or academic credit. For youth transitioning
from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after
their release.
Each referral received by Florida Youth College from the education contract provider is
assigned a career navigator. The career navigator connects with the youth through the
residential contract provider to schedule an orientation session. During orientation, the youth
and career navigator develop a career pathway plan to include postsecondary courses and/or
enrollment in a state or technical college. The career navigator continues to assist youth on their
career pathway plan and have incremental follow-up sessions scheduled through the residential
contract provider. Two youth records were reviewed and there was no referral to Florida Youth
College; therefore, a career navigator was not assigned to either youth. An informal interview
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 67 of 68 (Revised September 2022)
with the Florida Scholar’s Academy (FSA) instructor explained post-secondary pathways are
individualized for each youth. Youth are offered several options during their time in FSA. Youth
are offered high school diplomas and general educational development (GED) testing while at
the facility. Students are connected to other resources by way of their juvenile probation officers
(JPO) and case managers and youth can earn certifications while at the program. FSA
instructors offer support to youth within the classroom to continue academic and credential
progress by means of referrals.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 68 of 68 (Revised September 2022)

report_type: QI Residential

program_name_raw: Cypress Creek Max Risk

rule: Indicator 3.14

excerpt: Suicide Prevention Training (Critical)

rating: Limited Compliance