summary: QI Residential - FY24-25

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Tampa Residential Facility
TrueCore Behavioral Solutions, LLC.
(Contract Provider)
9508 East Columbus Drive
Tampa, Florida 33619
Review Date(s): November 19, 2024 - November 22, 2024
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:
Heather Molinario, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Marvin Bliss, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Aliyah Farley, Department of Juvenile Justice Detention Services, Training Coordinator
(Standard 5)
Cheryl Francis, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Gus Mazorra, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Luis Rodriguez, Office of Accountability and Program Support, Regional Monitor (Standard 1)
Justin Terziu, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Sandra Thompson, Office of Accountability and Program Support, Regional Monitor (Standard
4)
Jennifer Tummino, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Bonita Williams, Office of Accountability and Program Support, Regional Monitor (Co-lead)
Program Name: Tampa Residential Facility MQI Program Code: 1281
Provider Name: TrueCore Behavioral Solutions, LLC Contract Number: 10829
Location: : Hillsborough County / Circuit 13 Number of Beds: 72
Review Date(s): November 19, 2024 - November 22, 2024 Lead Reviewer Code: 197
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
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 60 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Indicator Ratings
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 Satisfactory
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 Contract Specific Career and Technical Education Services Satisfactory
1.19 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 60 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Indicator Ratings
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 Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 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 60 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
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* Satisfactory
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* Satisfactory
3.13 Suicide Precaution Observation Logs * Satisfactory
3.14 Suicide Prevention Training * Satisfactory
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 * Satisfactory
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 60 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Indicator Ratings
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 60 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
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 60 (Revised September 2022)
Program Overview
The Tampa Residential Facility is a seventy-two bed program, for fourteen to eighteen-year-old
males, located in Tampa, Florida. The program is operated by TrueCore Behavioral Solutions,
LLC., through a contract with the Department. The program provides services including
comprehensive mental health and substance abuse services, or medically complex services. In
addition, the program fosters each youth by providing Aggression Replacement Training,
Cannabis Youth Treatment, Impact of Crime, Skillstreaming for the Adolescent, A New
Direction, The Relapse Prevention Program, The Adolescent Coping with Depression,
Dialectical behavior therapy Skills, Passport Program, Coping with Stress, A Cognitive
Behavioral Therapy Workbook for Teens with Trauma, and Essentials Art Therapy with a
Cognitive Behavioral Therapy Art Activity Book. Additional treatment services included group,
family, and individual therapy, as well as animal and recreational therapy. Program
administration is comprised of a facility administrator, two assistant facility administrators, an
administrative assistant, human resource generalist, and a staff development specialist. Case
management services are provided by a director of case management, four case managers,
and two transitional services managers. Mental health staff at the program include the director
of clinical services, one assistant director of clinical services, three licensed therapists, five non-
licensed therapists, two recreation therapists, one certified behavioral analyst who is contracted,
a file clerk, one contracted psychologist, and one contracted psychiatrist. Medical services are
offered 6:00 a.m. through 10:00 p.m. daily and are provided by a health services administrator,
who is a registered nurse (RN), three full-time RNs, and one contracted medical doctor.
Educational services are provided by the Florida Scholar’s Academy through Florida Virtual
School. The layout of the program includes an administrative building, a kitchen with an
attached cafeteria, classrooms, and three youth living unit buildings. The program has 138
security cameras with 127 operationally providing coverage; the new classroom portables are
not in use and not online at this time. At the time of the annual compliance review, the program
had twelve and one-half vacant positions including two case managers, one RN, one half/part-
time medical clerk, one shift supervisor, one youth care worker II, five youth care worker Is, one
physical plant worker, and one dietary staff.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 60 (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 to ensure all staff, volunteers, mentors, interns, and
contracted staff complete a background screening and are determined to be eligible. The
program also has a policy to ensure all volunteers, mentors, and interns who work with youth
less than ten hours a month are under the sight and sound supervision of a qualified staff. The
Annual Affidavit of Compliance with Level 2 Screening Standards was completed and sent to
the Department’s Background Screening Unit on December 1, 2023, prior to the January 31
deadline. The teachers who provided services under the county school board also submitted an
Annual Affidavit on the same date. The program had twenty-five newly hired staff and six new
volunteers during this annual compliance review period. All thirty-one background screenings,
which included a criminal history review, received an eligible rating prior to the date of hire;
therefore, no exceptions were needed. None of the thirty-one staff nor volunteers had a break in
service. All twenty-five new staff records contained a signed contraband attestation form; the six
volunteers signed the visitor log, containing a contraband statement, upon each entry into the
facility. Thirteen of twenty-five newly hired staff were required to complete a pre-employment
assessment tool; the remaining twelve staff were hired for positions which do not require this
assessment. Three of the thirteen eligible staff were required to complete an additional
assessment interview as a result of a low score on the pre-employment assessment; the
remaining nine eligible staff achieved passing scores. Each new staff and volunteer was added
to the program’s Clearinghouse employee roster. None of the thirty-one were prior Department
staff nor hired by another contracted provider.
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 to ensure all staff receive a five-year
rescreening/renewal prior to the expiration of the current screening. The program had five staff
applicable for five-year rescreening. Each staff was submitted for a rescreening at least ten
business days prior to the five-year anniversary/expiration.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 60 (Revised September 2022)
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 create an environment free of abuse or
harassment, to include the program’s steps for reporting abuse. There were five physical abuse
allegations made against staff during this annual compliance review period. None of the five
complaints were substantiated. Three were called into the Florida Abuse Hotline and all five
were reported to the Department’s Central Communications Center (CCC); the remaining two
events were not reported to the Florida Abuse Hotline as both youth were eighteen years old.
Nine staff records were reviewed for the signed code of conduct verification, which confirmed
each staff signed the code of conduct. The Florida Abuse Hotline and the CCC telephone
numbers are posted throughout the facility for quick reference for youth and staff. The program
conducted the last Trauma Responsive and Caring Environment self-assessment on February
27, 2024. Nine staff were interviewed, and each confirmed the supervisor is notified and the
youth is able to make a call when a youth requests to report abuse. Additionally, four staff
indicated the facility administrator (FA) is notified and three staff noted staff can also call to
report abuse. Nine youth were interviewed, and each reported feeling safe, had never needed to
report abuse, never had exchanged personal contact information with staff, and each youth was
able to identify where the Florida Abuse Hotline and the CCC numbers are located within the
facility. Eight of nine youth reported staff are respectful to youth and have never been heard
cursing at the youth; the remaining youth stated staff are sometimes respectful and have
occasionally cursed at youth. The FA outlined the staff code of conduct requirements, the
consequences for prohibited behaviors, and confirmed the incident reporting process. The FA
stated the program utilizes the trauma assessment results and they provided the program’s
methods to ensure youth have access and know where to locate the numbers for the Florida
Abuse Hotline and the CCC.
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 to ensure all allegations of abuse are reviewed and
handled according to the findings. Five incidents of allegations of abuse against staff were
reviewed, and in each incident management took immediate action to begin the review process
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 60 (Revised September 2022)
as confirmed by the documentation reviewed. The program did not have any verified allegations
during this annual compliance review period. The facility administrator (FA) confirmed no
allegations were affirmed and explained the management response process to allegations of
abuse.
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 to ensure all reportable incidents are reported to the
Department’s Central Communications Center (CCC) within the required two-hour time frame.
The program had twenty-one reportable incidents during this annual compliance review period:
a reduction from the previous year of thirty reportable incidents. Five incidents were reviewed,
and each was found to have meet the reporting deadline to the CCC. Four of five incidents were
located in the master control logbooks; the remaining incident was a third-party late report and
would not be required to be in the logbook. No additional incidents were located during the
annual compliance review.
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 to ensure all use of force is reviewed and monitored,
to include incidents where Right Interactions (RI) techniques were utilized. The program had
four RI incidents during the annual compliance review period; a reduction from last year’s ten.
All four incidents were reviewed. Each incident process contained each requirement as
evidenced by documentation. Each report was timely and completed in its entirety. Monthly
summaries are maintained and sent to the regional office. The program’s RI plan was last
updated on February 3, 2023. The program’s RI rate during the previous quarter was 0.16,
which is below the statewide Residential RI rate of 1.76. The facility administrator confirmed the
program’s monitoring of RI incidents and use of force within the facility. All nine interviewed staff
confirmed they utilized RI techniques and were able to explain the basic steps needed to be
completed after an RI incident.
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 to ensure all newly hired staff complete all required
training within the first 180 days of employment. The program did submit a pre-service training
plan prior to implementation, and the plan was approved by the highest ranking official at the
program, the assistant secretary of the Department’s Office of Residential Services, and the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 60 (Revised September 2022)
director of the Department’s Office of Talent, Leadership, and Culture, as evidenced by their
signatures. All the instructors who provided training had the qualifications required to deliver the
training. All nine reviewed pre-service staff training records achieved more than the required
120 hours of training within their initial 180 days of employment; however, due to the
Department-wide system outages, not all the trainings have been entered and updated in the
Department’s Learning Management System (SkillPro).
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 to ensure all staff complete the required annual
training. The program did submit an in-service training plan prior to implementation, and the
plan was approved by the highest ranking official at the program, the assistant secretary of the
Department’s Office of Residential Services, and the director of the Department’s Office of
Talent, Leadership, and Culture, as evidenced by their signatures. All the instructors who
provided training had the required qualifications to deliver the training. All nine reviewed in-
service staff training records, including three supervisors, achieved more than the required
annual twenty-four hours. The three supervisors also completed more than the required eight
hours of annual training. All trainings were located in the Department’s Learning Management
System (SkillPro).
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 for youth to voice concerns and have a say in what
happens within the program. There are three phases to the program’s grievance process;
informal, formal, and appeal. Staff are the first line of assistance for a youth to state a grievance,
and the youth can either place a “Let’s Talk” request in or approach staff at the appropriate time.
The program’s practice did correlate with the process. The program did not have any formal
grievances during this annual compliance review period. The interviews with the youth, staff,
and facility administrator confirmed each youth and staff was able to outline the program’s
grievance process. Nine interviewed youth confirmed they knew youth could ask for assistance
in filing a grievance.
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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 60 (Revised September 2022)
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 which emphasize social and life skills training for
youth. These skill and intervention services address communication, interpersonal relationships,
non-violent conflict resolution, anger management, and critical thinking. Staff are required to
reinforce and model appropriate social skills. The program’s delinquency interventions used for
life skills training include Overcoming Obstacles, Positive Performance System, and Health
Education. The program’s clinical staff provide medical education to all youth. Interventions are
evidence-based, a promising practice, or a practice with demonstrated effectiveness. A review
of the program’s activity schedule identified periods for groups reflecting life skills education.
Samples of sign-in sheets, family surveys, and group topics were reviewed and confirmed
groups were being conducted with no issues. Nine youth were interviewed, and three youth
indicated they participate in substance abuse groups, four indicated they participate in mental
health groups, one youth indicated they participate in anger management groups, and one
youth indicated they did not know the names of the groups they participate in. The designated
mental health clinician authority (DMHCA) indicated the youth can practice skills through their
daily use of the Positive Performance System and how they navigate advancement through the
level system. The DMHCA also indicated youth participate in daily meetings where they are
provided an opportunity to appropriately air their grievance issues, demonstrate their leadership
skills, and present for their levels where they are encouraged to recognize and address their
strengths and weaknesses or areas in need of improvement. The facility administrator indicated
the Positive Performance System, living environment, clothing, and youth’s chosen pronouns
are honored to help target the needs of a targeted gender group.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
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.
The program provides “Who Am I”, community car wash, community bake sales, community
garden, restorative justice potluck, volunteer at a local agency, apology letters, community trash
clean up, feeding Tampa Bay homeless, restorative justice music studio, performance art
concerts, and runs through downtown Tampa for restorative justice and awareness programs.
These programs are held during the week and two to three times a month. Impact of Crime
(IOC) is designated as a primary service. Logbook documentation was reviewed and indicated
these groups were taking place. Observations of youth participating in practice for a
performance art concert were made. The facility administrator (FA) was interviewed and
indicated youth write letters to victims, conduct community service work hours, and have guest
speakers for restorative justice awareness. Nine youth were interviewed and five youth stated
they take IOC, three youth said they did not take IOC, and one youth was unsure if they took
IOC. An informal interview with the regional compliance manager confirmed all youth admitted
to the program take IOC.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 60 (Revised September 2022)
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 for maintaining an internal alert system. Staff can
access alerts through the alert boards in the conference room, from the master control logbook
and shift reports, as well as through the intake process, shift briefings, and observations. A total
of seventy-two alerts were reviewed within the nine youth records. All nine reviewed youth
records contained alert risks, and these alerts were documented as outlined in the program’s
policy. Each reviewed alert was entered, closed if appropriate, and documented by the
appropriate staff. The facility administrator interview confirmed the program’s policy and
procedures for alert information entry and sharing. The nursing interview results confirmed the
nurse is responsible for creating, updating, and closing medical related alerts. Nine interviewed
staff were able to identify locations to access youth alerts.
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 Management Record
The program separates the youth records into an individual management record, an Individual
Healthcare Record, and a mental health record. All youth records are marked ‘Confidential.’ All
records are maintained in locked cabinets within the responsible program area’s office. No
records were observed to be accessible to youth. Office area doors are also marked
‘Confidential’. A review of nine individual management records found each record had a label
which included the youth’s name, Department identification number, date of birth, county of
residence, and committing offense. Each record included legal information, demographic and
chronological information, correspondence, case management and treatment team activities,
and miscellaneous.
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.
The program has a joint community advisory board (CAB) which is scheduled to meet on a
quarterly basis. A review of the CAB binder found the last quarterly advisory board meeting was
held on November 11, 2024. CAB meetings are held in person and utilize a video conferencing
software program for those members who cannot attend in person. A review of the list of
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attendees, the board roster, and letters from the program found the facility administrator (FA)
has solicited involvement from a law enforcement representative, a judiciary community
representative, other community partners, a business community representative, a school board
or district representative, a faith community representative, and a LGBTQIA+ community
representative. A review of letters in the CAB binder confirmed the FA recruited a victim, victim
advocate, and a parent/guardian whose child was previously involved in the juvenile justice
system. A review of documentation reflected a representative from each category was a
member of the CAB or had been invited to join. An interview was conducted with the FA who
confirmed meetings are held quarterly. The FA maintains the CAB requirements. CAB meetings
are held quarterly and include a review of an agenda detailing program updates and CAB
member updates. Following each meeting, meeting minutes are shared with all board members
to inform those who may not have been present. Recruitment letters are mailed out periodically
to solicit new membership and ensure each position on the board is properly represented. All
positions are filled except for a judiciary representative. The interviewed board member stated
they have served on the board for several years and has been attending the meetings.
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 indicates evaluations are completed annually. A
review of seven position descriptions was conducted and determined each staff member’s
performance standards were clearly identified. A sample of performance evaluations were
reviewed and determined to be completed consistent with the program’s policy. Staff are
evaluated on their established performance standards at the ninety-day mark for their first year
and annually thereafter. The performance standards matched job descriptions for each staff
position reviewed. The facility administrator (FA) was interviewed and stated staff turnover has
been an issue; however, some of it is due to hours, pay, mandate system, and not necessarily
the job itself. The FA stated they work to provide a safe environment for staff where they feel
supported and assist in reducing stress levels which could arise from this line of work. There are
incentives put in place, staff events, staff outings, and other team building activities. There are
meetings held in which staff can provide ideas to assist with morale. Ninety-day
evaluations/yearly evaluations and coaching's are conducted as required. The program
conducts hiring events to hire new staff and reduce burnout. The program hosts job fairs once a
month. Nine staff were interviewed and five staff reported they receive performance evaluations
annually, three stated every six months, and one stated they have just transferred to the
program, and it depends if a staff has issues, then it can be quarterly.
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 has several additional services and items within the contract which shall be
available and/or provided to the youth. The program utilizes a telephone application to assist
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with lodging for families who need assistance to see the youth; however, no family has
requested this service during this annual compliance review period. Additionally, the program
has been able to maintain ongoing medication delivery to the youth through licensed staff only.
The program has had 128 youth served this annual compliance review period under the current
contract. Each youth has been served or offered specialized items including the two transition
services managers, three meals and three quality snacks daily, seasonally appropriate clothing,
in good repair, and laundry is completed regularly, the facility is maintained and safe, positive
interactions with youth were observed, therapeutic artwork was observed which promotes
creativity, monthly events/activities are scheduled to promote positive development of family
relationships, faith-based services are offered regularly, and youth can always request specific
religious items needed, the nursing staff have a monthly health topic and education for the
youth. The facility administrator interview specified several of these special conditions are being
provided.
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 program’s trend analysis and data-driven decision are
strengthened through an internal database called LAURIS which allows for daily data entry by
every program. This daily process and outcome information are 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,
such as the monthly Key Performance Indicators (KPIs) tracking, including monthly admissions,
incidents, youth assaults and fights, youth restraints, family contacts, treatment services for all
groups, individual and family sessions, treatment teams, positive youth services for community
service hours and advisory boards, staff vacancies, and the Trauma Responsive and Caring
Environment (TRACE) self-assessment. The program shares the KPI trends in monthly staff
meetings and postings where the data trends are easily accessible by staff, educators, and
stakeholders. Information is discussed in daily meetings with administrative staff. Staff are
updated monthly in all staff meetings, quarterly advisory board meetings, and monthly corporate
senior management meetings. The findings from trend data analyses are utilized to determine
recruitment strategies, positive morale approaches, update the policy and procedures, youth
supervision techniques, restorative justice programs, and individual and family services.
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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 with the parent/guardian
and court notifications. Nine youth case management records were reviewed, and seven of nine
records contained documentation the parent/guardian was contacted by telephone on the day of
admission. One youth record included the attempted contact with the parent/guardian and the
remaining youth record was not applicable because the record indicated the youth had no
contact with their biological family. Eight of nine records indicated parents/guardians were
mailed an admission letter on the day of admission which spoke about length of stay, visitation,
and the performance planning process. The remaining record included a letter to the
Department of Children and Families (DCF). All nine 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 the 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. Nine youth case
management records were reviewed. All nine youth received an orientation within twenty-four
hours of being admitted to the program. All nine 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, 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 related information. A youth orientation was not
observed during the week of the annual compliance review because there were no admissions.
Nine youth were interviewed, and all youth confirmed they received orientation to the program
within twenty-four hours of arrival. Seven of nine youth were able to articulate information
provided during the orientation process and the remaining two youth could not remember due to
their length of stay.
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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
parents/guardians, which is contained within the orientation policy. Nine 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. Four of the nine records reviewed were applicable as the
remaining five youth were under the age of eighteen. All four records contained an 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. Nine youth case management records were reviewed
regarding classification. Each of the nine 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 aggressiveness,
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) screening, medical
needs, and suicide, escape, and security risks. Each youth is assigned a room based on the
results of the youth classification procedures, and may be reclassified if there are any changes
in behavior or status. All nine case management records contained a classification form
completed on the day of the youth’s admission to the program which addressed all
requirements. In all 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 nine youth were identified with a suicide risk or escape
risk, seven of nine youth were identified with a medical risk, four of nine youth were identified
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with other risks, and three of nine youth were identified with a security risk. A review of the
Department’s Juvenile Justice Information System (JJIS) Alert List for any issues affecting
classification was completed for all nine 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
subsequent to the classification process were immediately entered into the program’s internal
alert system and JJIS for all nine youth. Three of the nine youth were applicable for
reclassification and all received an increase in privileges or freedom of movement and two of
the three youth records included participation in work projects and off-campus activities. The
program’s policy is to complete a Residential Assessment of Youth Reassessment every ninety
days, while the youth is in the program, to include collateral sources such as treatment team
meetings, checklists, or rating sheets for specified domains by staff to provide input. The facility
administrator interview indicated factors such as mental health status, physical health status,
cognitive performance, age, and prior victimization are considered during the admission
classification process and if there are hits on the VSAB form.
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. Nine youth case management records were reviewed; however,
only two of the youth in the sample size were applicable for gang affiliation or membership. The
program was able to provide one additional record for review of gang identification and
notification. All three identified youth were confirmed in the Department’s Juvenile Justice
Information System (JJIS) as well as the program’s internal alert system with gang alerts. A
review of the three applicable youth records established each contained a security threat
questionnaire which was completed at the time of admission to the program in order to gauge
the level of gang involvement. Documentation demonstrated the program ensured timely
notification to law enforcement, the educational provider, the youth’s juvenile probation officer
(JPO), and the youth’s post-residential counselor, if applicable. 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 Impact
of Crime, a primary service, as part of their gang prevention and intervention strategies. Nine
youth case management records were reviewed; however, only two of the youth in the sample
size were applicable for gang affiliation or membership. The program was able to provide one
additional record for review of gang identification and notification. A review of the three records
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confirmed each youth was identified as a gang member or affiliated gang member. Two of three
youth had a gang goal listed on their Individualized Performance Plan (IPP); however, the
remaining youth had recently arrived at the program and the IPP had not yet been completed. A
review of the program’s gang binder found the two applicable youth participated in monthly gang
intervention sessions with their assigned case manager as evidenced by observed sign-in
sheets. The program’s policy as well the facility administrator’s interview both indicate a youth
are provided the opportunity to disaffiliate from their identified criminal street gang should they
choose to.
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. Nine youth case
management records were reviewed, and all contained an initial RAY completed within thirty
days of admission. All nine initial RAYs were maintained in the Department’s Juvenile Justice
Information System (JJIS). Each youth also had a copy of their RAY Overview Report filed
within their individual case management record. Three of nine youth were applicable for RAY
Reassessments. The three reviewed case management records contained a total of eleven
RAY Reassessments, which were all completed at least every ninety-days, as required.
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
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. Nine youth case
management records were reviewed, and all contained a YNAS, which was completed within
thirty days of admission and was documented in the Department’s Juvenile Justice Information
System (JJIS).
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.
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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 parent/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/feedback from the
intervention and treatment team, is utilized by the assigned case manager to create the
performance plan. In addition, information provided by the parent/guardian on the Parent Input
form sent at admission is incorporated into the performance plan. Nine youth case management
records were reviewed. Eight of nine records contained documentation of the Individualized
Performance Plan (IPP) being developed within thirty days of admission, following the youth’s
initial needs assessment and 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 treatment team leader, youth,
program administration, living unit representative, mental health treatment staff, education staff,
and medical staff. The remaining youth was not applicable because they had not been at the
program for thirty days yet. Two of nine case management records were applicable for and
included the Department of Children and Families (DCF) caseworker or Agency for Persons
with Disabilities waiver support coordinator; the remaining seven records were not applicable.
Six records contained documentation sent to the parent/guardian from the assigned case
manager requesting they review and sign the signature sheet and return it in the self-addressed
envelope provided by the program; however, none of the reviewed case management records
contained an IPP signature sheet signed by the youth’s parent/guardian. All eight performance
plans contained applicable individualized goals based on the prioritized needs of the youth, the
top three criminogenic needs, delinquency interventions, and court-ordered sanctions. 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/end date. Documentation confirmed
for the eight applicable youth, upon development of the performance plan, and after signature
by required parties, a transmittal letter and a copy of the plan were mailed to the committing
court, juvenile probation officer, parent/guardian, and DCF counselor, as applicable. In the eight
youth case management records, transmittal letters were distributed to these parties within ten
working days. All nine 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 in place to ensure the performance plan reviews are
completed monthly. Eight of nine reviewed case management records included documentation
of performance plan revisions occurring due to newly acquired information and demonstrated
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progress towards goal completion; the remaining youth has been at the program less than thirty
days. Five youth records indicated revisions were necessary following the Residential
Assessment for Youth (RAY) Reassessment results and two were revised because of youth’s
lack of progress towards completing a goal. Three youth records included revisions to the
performance plan to include facilitation of transition activities during the last sixty days of the
youth’s stay. Each performance plan referenced all other applicable plans including academic
and treatment plans. One of nine youth records reviewed had a behavior support plan through
the Department of Children and Families.
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 in place to ensure Performance Summaries are
completed within the required time frame of ninety days from the completion and signing of the
initial performance plan. Three of the nine reviewed case management records contained
documentation of the completed Performance Summaries within the required time frame; the
remaining six records were not applicable. All reviewed Performance Summaries included the
youth’s status on performance plan goals, youth’s treatment progress, academic status, youth’s
behavior, level of motivation/readiness for change, interaction with peers, interaction with staff,
overall behavior adjustment to the program, and significant positive and negative events. The
three applicable reviewed records indicated each youth was allowed to read and add comments
to the Performance Summary prior to signing. All original Performance Summaries were
maintained in each youth’s case management record. The documentation is maintained in each
record to include the signatures of the treatment team leader, staff member preparing the
Performance Summary, facility administrator, and youth. All three applicable reviewed case
management records contained documentation of the Performance Summary being transmitted
to the committing court, juvenile probation officer, youth, parent/guardian, and Department of
Children and Families, if applicable, within ten working days of completion. A review of three
closed records was conducted, and all three records contained a release summary. Each closed
record contained a signed copy of a Pre-Release Notification (PRN) which met the required time
frames for submission and approval. Upon approval of the PRN, each record confirmed the
program made notification to each parent/guardian of the pending discharge, and a completed
exit Residential Assessment for Youth.
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 in place to ensure the parents/guardians are involved
in the case management process for the youth. Nine reviewed case management records
indicated the parents/guardians were involved in the assessment process, development of the
youth’s performance plan, progress reviews, and treatment team meetings. All nine reviewed
case management records contained documentation of the program’s requests for the
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parent/guardian involvement in all treatment team meetings. A treatment team was observed
during the annual compliance review week; no parent/guardian participation was required as the
youth was eighteen years old. The facility administrator was interviewed and advised starting
from admission, all parents/guardians are encouraged and invited to participate in meetings and
provide input during planning. The program provides weekend visitation on a consistent basis,
and the case managers and therapists encourage parents/guardians to visit whenever they
speak to the parents/guardians to provide treatment updates. Nine youth were interviewed, and
all indicated their parent/guardian is involved in their case management through telephone,
treatment teams, and/or visitation.
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 in place to ensure representatives from the program’s
administration and residential living unit, education, and others responsible for overseeing the
provision of intervention and treatment services are included in the treatment team. Six of the
nine reviewed youth case management records were applicable for formal treatment team
meetings, and each contained documentation showing formal treatment team reviews indicated
people present at the treatment team meetings included the treatment team leader, youth, living
unit representative, treatment staff, medical, transitional service managers, recreation
therapists, and education staff. All of the applicable youth’s juvenile probation officers and
parents/guardians or Department of Children and Families (DCF) counselor if applicable, were
contacted by telephone, and were present in the formal treatment team meetings. Eight of nine
youth case management records were reviewed were applicable for informal treatment team
meetings, and each contained documentation showing treatment team reviews indicated people
present at the treatment team meetings included the treatment team leader, youth, living unit
representative, treatment staff, and education staff. The juvenile probation officer and
parent/guardian or DCF counselor, if applicable, were contacted by telephone. A treatment team
was observed during the annual compliance review week, and all required treatment team
members were present in person or by telephone. Nine youth were interviewed, and each youth
confirmed staff have discussed their performance and progress on plan goals. Six of the nine
youth confirmed they were able to demonstrate the skills they have learned during the treatment
team meeting; the remaining three youth have not yet had a formal treatment team meeting.
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.
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Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program has a policy and procedures addressing transition planning, conferences, and
Community Re-Entry Team (CRT) meetings. Three closed youth case management records
were reviewed and a transition conference for each youth was held at least sixty-days prior to
the targeted release date. All required and applicable treatment team members including the
youth, treatment team leader, and the facility administrator or designee attended the transition
conference in all the reviewed youth case management records. Each reviewed record
documented the youth’s juvenile probation officer (JPO), parent/guardian, education staff, and
other pertinent parties were invited to attend the transition conference and all required parties
participated either in person or by telephone. 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. Each reviewed record
contained documentation to validate the treatment team leader obtained attendees’ dated
signatures representing their acknowledgement of the transition goals and accountability for
completion; and a copy of each plan was mailed with a request for return with signature to the
parent/guardian and JPO. Each record indicated the CRT meeting was conducted prior to the
youth’s release and the youth and case manager participated in the CRT meeting.
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 addressing the assembly of an exit portfolio to assist
each youth once they are released back into the community. Three closed youth case
management records were reviewed and the exit portfolio for each youth was initiated and
discussed during the transition conference. A review of documentation revealed the exit portfolio
for each youth included a copy of the transition plan. Each reviewed record contained
documentation showing a request was made to obtain the Social Security card from the
parent/guardian; however, none were received. Two of the three exit portfolios included a State
of Florida identification card, and the remaining record included a birth certificate. The two
records without the birth certificates did contain case notes which indicated each was requested
from the parent/guardian. Each exit portfolio contained all other required information, and the
exit portfolio was given to the youth at discharge. Each record indicated the exit portfolio was
provided to the youth’s juvenile probation officer.
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 the exit conference is completed as
required. Three closed youth case management records were reviewed. Each record confirmed
the exit conference was held at least fourteen days prior to discharge with the attendees, and
the required transition documentation located in each record.
2.17 Youth Input Satisfactory Compliance
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The program has a formal process to promote constructive input by youth.
The program has a policy and procedures to ensure the youth are able to provide input at the
program. The program offers a variety of ways for the youth to amplify their voices as it relates
to treatment and programming; youth are surveyed at least quarterly, within the positive
performance system, youth are provided opportunities to demonstrate their new leadership skills
in a pro-social manner by representing their peers on the youth advisory board, every day youth
participate in daily meetings to process the day and prepare for the evening, and youth can
submit "Let's Talk" forms as informal communication to work out minor conflicts before they
escalate. The reviewed documentation confirmed these activities are taking place as scheduled
to resolve youth needs in a timely manner, as evidenced by no formal grievances made during
the annual compliance review period. Nine youth were interviewed and three youth stated they
could talk to the recreation therapist; three youth stated they could talk with a supervisor or
administration; two youth reported they utilize the youth advisory board; and the remaining
youth did not know. The facility administrator interview confirmed the program utilizes the Let’s
Talk form, youth advisory board meetings, and community/dormitory meetings.
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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 full-time licensed marriage and family therapist (LMFT) who serves as the
designated mental health clinician authority (DMHCA) and as the clinical director. A review of
the DMHCA’s license found it to be clear and active, with an expiration date of March 31, 2025.
The DMHCA is on-site as required by contract, at least forty hours a week, for a sufficient
amount of time to ensure appropriate coordination and implementation of mental health and
substance abuse services were taking place. The DMHCA is also available twenty-four hours a
day, seven days a week in the event of a mental health or substance abuse emergency. In the
absence of the DMHCA, the program will utilize the assistant DMHCA, who is a licensed mental
health counselor (LMHC). A review of their license found it was clear and active, with an
expiration date of March 31, 2025. The program previously utilized a LMHC who served as the
DMHCA during the annual compliance review period. A review of their license found it was clear
and active, with an expiration date of March 31, 2025. The DMHCA interview indicated they
maintain a caseload as needed and conduct individual and family therapy sessions.
Additionally, the DMHCA provides coverage for group therapy and other assessments as
needed and ensures the treatment programming at the program complies with all requirements
outlined in the program’s contract.
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 stating the designated mental health clinician
authority (DMHCA) is responsible for ensuring mental health and substance abuse services are
provided by individuals with appropriate qualifications. The clinical supervisor ensures clinical
staff working under their supervision are performing services the staff are qualified to provide
based on education, training, and experience based on review of their job description and an
informal interview with the DMHCA. The licensed mental health and substance abuse clinical
staff all possess adequate education and training to perform the duties which they are assigned
and meet all applicable licensing or certification requirements for their respective disciplines and
Florida Administrative Code. The program has three licensed staff including the DMHCA, the
assistant DMHCA, and a licensed therapist. Each licensed staff has a current license which
expires March 31, 2025. All licensed staff had their license posted in their offices and made
available to the annual compliance review team. The program is licensed under Chapter 397
with the Department of Children and Families to provide substance abuse services for
outpatient treatment. The license is displayed in the lobby of the facility. Substance abuse
services are provided by mental staff within the program under the supervision of the DMHCA.
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During the annual compliance review period, the program had a total of three licensed
therapists who were all properly licensed to provide services.
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.
The program has a policy and procedures to ensure mental health and substance abuse staff
have the appropriate qualifications. The program has five full-time non-licensed clinicians who
provide services to youth in the program. Each of the non-licensed clinicians hold a master’s
degree in a related field of study. A review of the Department’s Licensed Mental Health
Professionals and Licensed/Certified Substance Abuse Professionals Direct Supervision Log for
the annual compliance review period confirmed all non-licensed mental health clinical staff were
provided with at least one hour of on-site face-to-face direct supervision by the designated
mental health clinician authority (DMHCA), or their back-up, each week they worked, with no
exceptions. The documentation confirmed the program has a Chapter 397 license which was
located in the program lobby and expires on September 6, 2025. Each of the non-licensed
mental health clinical staff completed the training, which allows them to conduct Assessments of
Suicide Risk (ASRs) and prepare them for approval by a licensed clinician. There were no
periods of vacancy with non-licensed clinician positions during the annual compliance review
period.
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 for the implementation of a standardized
admission/intake mental health and substance abuse screening process which includes a
review of commitment packet information, reports, and records, administration of the
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) on the Department’s
Juvenile Justice Information System (JJIS), and a referral process for youth identified by
screenings as in need of further evaluation or immediate attention. The policy and procedures
also included staff training in mental health and substance issues, administration of the MAYSI-
2, and a standardized process for referral of youth identified in need of further mental health
and/or substance abuse evaluation to an appropriate service provider/professional or, when
immediate attention is needed, to a hospital or Baker Act or Marchman Act receiving facility. All
nine reviewed youth mental health records had a MAYSI-2 completed upon admission. All
available information in each record was reviewed, which included the commitment packet,
reports, and records for existing documentation of mental health or substance abuse problems,
or history of human trafficking. A review of the Department’s Learning Management System
(SkillPro) was conducted and verified appropriate MAYSI-2 training was completed by staff
conducting the MAYSI-2. The designated mental health clinician authority (DMHCA) reviewed
all nine MAYSI-2s and indicated if the youth needed further assessments or a referral. Eight of
the nine screenings indicated further assessment was required; the remaining record did not
need a referral. All eight applicable records contained a referral for further evaluation. All eight
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applicable youth received an Assessment of Suicide Risk (ASR) and were referred for
assessment. All eight ASRs were conducted within twenty-four hours of the referral. The
program director and DMHCA signed off on all ASRs within twenty-four hours when the MAYSI-
2 category suicide ideation indicated further assessment was needed or other information
obtained at intake/admission suggested potential suicide risk. The staff who made the referral in
all nine reviewed records documented consultation with the DMHCA on the assessment. The
program director was interviewed and reported the youth are screened using the MAYSI-2 and
ASR.
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 explaining how they will complete a new
Comprehensive Mental Health and Substance Abuse Evaluation. Eight of nine youth received a
new Comprehensive Mental Health and Substance Abuse Evaluation within thirty calendar days
of admission; the remaining youth was not applicable due to not being at the program for thirty
days. Three of the eight assessments were completed by a non-licensed clinician and reviewed
within ten calendar days after the evaluation was conducted by a licensed clinical staff. Five of
eight assessments were completed by a licensed clinician. Each reviewed assessment included
the reason for the assessment, identifying information, relevant background information, family
history, history of abuse/neglect/trauma, behavioral observations, methods of assessment,
patterns and impact of alcohol and other drug abuse, mental health, mental status
examinations, substance abuse history and treatment, diagnostic impression/formulation,
summary of clinical impressions, treatment recommendations, and addressed the youth’s
original referral reason.
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 in place outlining the program’s mental health and
substance abuse services. Nine youth mental health records were reviewed for mental health
and substance abuse treatment. All nine youth mental health records included documentation
an initial treatment plan was developed within seven days of initiation of treatment. All nine initial
mental health treatment plans were documented on a form which included all elements of the
Department’s Mental Health/Substance Abuse Treatment Plan form. The initial treatment plan
was signed by the mental health clinical or substance abuse clinical staff. All nine records
included documentation the initial treatment plan was completed by a licensed mental health
clinical staff. All nine treatment plans were signed by all treatment team members who
participated in the development of the plan, the youth, and parents/guardians. All nine youth
treatment plans were mailed to the parents/guardians the day the plans were signed by the
treatment team. Each reviewed initial treatment plan to included the youth’s psychiatric needs.
All nine individualized treatment plans were developed for the youth within thirty days of
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admission. All nine treatment plans were developed on forms which contained all elements of
the Department’s Individualized Mental Health/Substance Abuse Treatment Plan form. All
contained signatures of the treatment team and three were not applicable for a parent/guardian
signature due to being eighteen. Six of nine youth mental health records included
documentation of the treatment team reviews being conducted every thirty days. Three of nine
youth were not applicable for a treatment team review due to not being in the program at least
sixty days. All nine treatment plans included documentation of the prescribed services to include
individual, group, family, and psychiatric services. All services were individualized for each
youth. A review of three days of group sign-in sheets from each of the six dorms for a total of
twelve and video observations indicated all groups were conducted for a minimum of fifty
minutes each, during the time as designated on the group schedule, with no more than ten
youth, and by a qualified facilitator.
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.
Nine youth mental health and substance abuse records were reviewed for mental health and
substance abuse treatment. Each of the reviewed youth records confirmed assignment to a
treatment team upon admission to the program. The multidisciplinary treatment team members
included the youth, program administration, living unit staff, education staff, medical staff,
mental health staff, and when possible, the youth’s parent/guardian. Five of the nine reviewed
youth records were applicable for substance abuse treatment. Substance abuse services
consisted of individual, group, and/or family counseling, which were provided by licensed clinical
staff. All nine reviewed records were in receipt of mental health treatment services and had a
properly signed Authority for Evaluation and Treatment (AET) form on record. Each reviewed
youth record included a documented diagnosis. All five applicable youth records contained a
signed Youth Consent for Substance Abuse Treatment form and Youth Consent for Release of
Substance Abuse Treatment Records form. When necessary, mental health treatment and
substance abuse treatment notes were documented on the provider’s form, which contained all
the information required. Each of the reviewed youth records confirmed youth were involved in
individual psychotherapy, counseling, or were engaged in psychosocial skills training.
Three closed youth records were reviewed for treatment and discharge planning. All three
discharge plans were documented on the Department’s Mental Health/Substance Abuse
Treatment Discharge Summary forms. None of the three youth were released while on suicide
risk alert/suicide precautions. In all three records reviewed, documentation reflected the
discharge plan was discussed with the youth, parent/guardian when allowed, and juvenile
probation officer (JPO) during the exit conference. Copies of all three Mental Health/Substance
Abuse Treatment Discharge Summary forms were provided to the youth, JPO, and to the
parent/guardian.
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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 maintains a policy and procedures to establish a delivery protocol for Substance
Abuse Treatment Overlay Services (SAOS) and Mental Health Overlay Services (MHOS).
Substance abuse and mental health treatment are provided on-site through the provision of
SAOS/MHOS. The policy indicated therapy models utilized are Aggression Replacement
Training, Cannabis Youth Treatment, Impact of Crime, Skillstreaming the Adolescent, and A
New Direction. Nine interviewed youth reported participating in individual, group, and family
therapy services at the program. Nine interviewed staff reported only mental health clinicians
facilitate mental health and substance abuse groups. The facility administrator interview
indicated the program provides MHOS and SAHOS services. The program offers MHOS/SAOS
group therapy services four days a week, individual sessions are held bi-weekly, family sessions
monthly, and the psychiatrist provides services at least once every fourteen days. The
program’s designated mental health clinician authority (DMHCA) is on-site forty hours a week
and licensed clinical staff are on-site a minimum of five days a week. MHOS groups have no
more than ten youth to one counselor, and SAOS groups have no more than fifteen youth to
one counselor.
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 contract with a licensed physician, a medical doctor (MD), to provide
psychiatric services. The MD is certified by the American Board of Child and Adolescent
Psychiatry. The MD’s license is clear and active, with an expiration date of January 31, 2026.
The psychiatrist is available for emergency consultation twenty-four hours a day, seven days a
week. A briefing is provided by the psychiatrist to program staff for youth receiving psychiatric
services, and the recommendations are included within the youth’s individualized treatment
plan. A review of psychiatric logs confirmed the psychiatrist was available and provided services
through the annual compliance review period; with the exception of October 7, 2024, through
October 12, 2024, due to a hurricane. The program has a MD with a clear and active license,
expiring on March 31, 2025, who serves as the back-up for the psychiatrist; however, the back-
up was not utilized during the annual compliance review period. The psychiatrist interview
confirmed services are provided at least bi-weekly. These services include monthly medication
reviews, evaluations, and consultations. The psychiatrist meets weekly with the clinical staff and
reviews youth refusals. The DMHCA interview confirmed the results of the psychiatrist’s
interview responses. A review of nine youth mental health and substance abuse records
indicated four youth were applicable for psychiatric services. All four applicable youth records
contained documentation of admission with psychotropic medication and were referred for a
psychiatric interview. The review of youth records indicated each of the four youth were seen by
the psychiatrist within the required time frame. All four Initial Psychiatric Diagnostic Interviews
were completed using the program’s Initial Psychiatric Evaluation form, which included the
youth’s medical, mental health and substance abuse history, Mental Status Examination,
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and treatment
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recommendations. Each was clearly identified as an “Initial Diagnostic Psychiatric Interview”
which was documented on the Department’s required Clinical Psychotropic Progress Note
(CPPN). Each reviewed CPPN contained all of the required elements. All required monthly
reviews were conducted and documented on the required form. The diagnosis for each youth
was confirmed and consistent with every treatment plan. Tele-psychiatry services were not
utilized during the annual compliance review period.
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 written suicide prevention plan, which includes 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 includes circumstances surrounding the event, facility procedures
relevant to the incident, all relevant training received by involved staff, pertinent medical and
mental health services involving the victim, possible precipitating factors, and recommendations.
The plan was reviewed by the facility administrator on December 18, 2023.
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.
The program has a suicide prevention plan for supervising, observing, monitoring, and housing
youth identified through screenings, available information, or staff observations of having suicide
risk factors. A review of nine youth mental health and substance abuse records was conducted
and found three youth records were applicable. Each of the three applicable youth were placed
on constant supervision. One youth was documented with a self-report feeling of possible self-
harm, one youth was identified by staff observations, and one youth had self-reporting and staff
observations documented. The Assessment of Suicide Risk (ASR) referral was created for each
of the reviewed youth records. The ASR was completed using the Department’s form. One
youth was immediately stepped down to standard supervision upon completion of the ASR. The
second youth remained on constant supervision until the next day, and the third youth remained
on constant for an additional day. All three ASRs were completed by a licensed clinician.
Supervision for each youth was documented on a Suicide Precautions Observation Log. These
forms were completed in their entirety, to include the identification of safe housing areas. Each
ASR contained documentation of notifications made to the youth’s parent/guardian and their
assigned juvenile probation officer, regarding the youth’s status. Two youth were applicable for
Follow-Up ASRs which were completed as required. The Department’s Juvenile Justice
Information System (JJIS) suicide alerts were initiated for all three youth placed on suicide
precautions and were closed following the recommendations of the ASR. The review of logbook
documentation found no discrepancies. Each youth was allowed to participate in select activities
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with other youth in designated safe housing/observation areas of the facility. There were no
youth placed on precautionary observation for the thirty days leading up to the annual
compliance review; therefore, video observations could not be conducted.
3.12 Secure Observation (Critical) Non-Applicable
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.
One of nine reviewed youth mental health and substance abuse records confirmed the youth
was placed on suicide precautionary observation. Two additional youth mental health and
substance abuse records were provided for review. All Suicide Precautions Observation Logs
were maintained for the duration each youth was on suicide precautions, and the staff
documented each youth’s behavior in real time at intervals which did not exceed thirty minutes
on the required Department forms. None of the reviewed records were applicable for
documented warning signs, or notifications made to the designated mental health clinician
authority nor the facility administrator/designee. Each Suicide Precautions Observation Log was
reviewed and signed by mental health clinical staff and documented safe housing requirements.
3.14 Suicide Prevention Training (Critical) Satisfactory 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 to ensure all staff receive suicide prevention training.
All eighteen staff received the internal mental health and substance abuse training as
documented on the staff individual training plans. The program had four suicide response kits;
one in master control and one in each of the three unit sub control rooms, which were all co-
located with first-aid kits. The program ran three shifts from November 2023 to April 2024, and
then switched to two shifts in May 2024. The program did provide semi-annual training on
emergency response procedures and provided staff who were not present during a quarterly
drill the opportunity to review each drill scenario and procedures. A video review of a mock drill
was completed; however, the staff were observed to be discussing the drill, not simulating the
drill. The program held another drill during the annual compliance review week, which was
observed to be simulated. The facility administrator interview reiterated the program’s policy and
indicated the program provides training or mock suicide drills for staff, including emergency
response to suicide attempts or self-inflicted injury monthly. Eight of nine staff interviews
indicated medical emergency and suicide drills are conducted on each shift monthly, and the
remaining staff stated mental health drills were held weekly.
3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
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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 Comprehensive Mental Health Crisis Intervention Plan. The plan ensures
the program responds 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 program. The plan
contains all the required elements which includes a notification and alert system, means of
referral including youth self-referral, communication, supervision, and documentation and review
of the crisis.
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 written crisis intervention plan which includes notification and alert system,
means of referral, including youth self-referral, communication, supervision, documentation, and
review. The program did not have any youth in need of a Crisis Assessment during the annual
compliance review period.
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 which
addresses mental health and substance abuse emergency care. The plan contains all the
required elements outlined in the Florida Administrative Code and includes the immediate staff
response, notifications, communication, supervision, authorization to transport for emergency
mental health or substance abuse services, transport for emergency mental health evaluation
and treatment, transport for emergency substance abuse assessment and treatment,
documentation, staff training, and a review process for each incident.
3.18 Baker and Marchman Acts (Critical) Satisfactory Compliance
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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.
Nine youth mental health records were reviewed for Baker and Marchman Acts. None of the
records were applicable; the program provided one additional record which was applicable for
review. The program did not have any other applicable records during the annual compliance
review period. When the applicable youth was determined to be in need of emergency care, the
staff entered a mental health alert, placed the youth on precautionary observation, and referred
the youth for placement under Baker Act. The notification was made by the program’s
designated mental health clinician authority (DMHCA). The youth was placed on one-to-one
supervision with mental health involvement, the youth was taken out of the program and
transported by law enforcement, which was authorized by the program’s facility administrator
(FA). Upon return to the program from the Baker Act, the youth was placed on constant
supervision. A mental health referral was completed indicating a Mental Status Examination to
be conducted for the youth. An Assessment of Suicide Risk was completed by the DMHCA. The
youth was maintained on a minimum of constant supervision until properly transitioned to a
lower level of supervision. The youth’s supervision level was not lowered until an appropriate
assessment was conducted and the DMHCA conferred with the FA or designee.
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.
Nine youth mental health and substance abuse records were reviewed for safety planning. The
program had documentation of on-going safety planning for each youth. All plans were
completed within fourteen days of admission. Eight of nine plans were developed with the youth,
parent/guardian, and program’s clinical staff; and the remaining reviewed record was non-
applicable for joint preparation with parent/guardian as the youth was eighteen years old. Each
plan incorporated recommendations from previous or current clinical assessment or screening
instruments and incorporated trauma responsive practices. Each of the plans highlighted the
youth’s warning signs, behavior, crisis recognition, and coping and intervention strategies. Eight
of nine plans were reviewed and updated as necessary at least every thirty days and signed by
each staff who had contact with the youth; the remaining plan had not yet required a thirty-day
review. All nine interviewed youth reported they were involved in the development of their safety
plan. Safety plans are located in the sub control rooms on the dormitories and can be reviewed
by staff at any time. An interview with the facility administrator indicated safety plans are
updated monthly or during any significant change of event.
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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 has a policy and procedures which require a designated health authority (DHA) to
be clinically responsible for the medical care of all youth at the program. The DHA is a licensed
physician, who is a licensed internist with experience in adolescent health, with a clear and
active license expiring on January 31, 2025. The program does not utilize a physician assistant
or an advanced practice registered nurse. The DHA is contractually required to be on-site four
hours each week. A review of the DHA sign-in and sign-out logs revealed the DHA was on-site
four hours each week, except for September 26, 2024, October 7, 2024, and October 10, 2024,
all which were days youth were not seen due to hurricanes and program evacuations. The DHA
has a back-up, also with a clear and active license expiring on January 31, 2026. The back-up
DHA was not used during the annual compliance review period. Telemedicine or telehealth was
not utilized during the annual compliance review period. The DHA was interviewed and advised
he sees youth for initial Comprehensive Physical Assessments, periodic evaluations, and sick
call referrals as needed. The DHA is on-site two days each week. The DHA said they
communicate with staff regularly by telephone or in person when on-site. The DHA also advised
there is a communication folder in the medical office which is used to pass information. The
DHA is available by telephone when not on-site. The DHA provides all clinical services and
does not use a designee. All pertinent youth medical information is placed in a folder by medical
staff for the DHA to review when on-site. The DHA meets with medical staff to discuss any
concerns or new developments.
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 a policy and procedures which require a designated health authority (DHA) to
be clinically responsible for all healthcare services provided to youth at the program. Daily
clinical care is to be performed by licensed medical staff according to developed and authorized
protocols. The program uses registered nurses (RNs) to provide on-site nursing coverage. A
review was conducted of all the RN’s license credentials, and all had clear and active licenses.
In addition, all RNs had current cardiopulmonary resuscitation certificates. The contract requires
for nursing services to be provided for a total of 200 hours each week. This is accomplished by
having nursing coverage for a minimum of twelve hours each day, seven days a week. The
health services administrator works forty hours each week and four RNs work a total of 160
hours each week to provide the required coverage. The program provides on-site nursing
coverage seven days a week from 6:00 a.m. to 10:00 p.m.
4.03 Facility Operating Procedures Satisfactory Compliance
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The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has facility operating procedures (FOPs) for all health-related procedures and
protocols utilized. The program’s designated health authority (DHA) and the facility administrator
conducted an annual review of all respective treatment FOPs on December 14, 2023. Nursing
staff reviewed, signed, and dated the cover page for all FOPs, healthcare protocols, and other
procedures on December 14, 2023, and on June 10, 2024. New policies or changes in policies
made during the year were reviewed, signed, and dated by each nurse on the individual policy
changes on a signature page added with the specific policy listed, date of revision, and
signatures. All newly employed healthcare staff received a comprehensive clinical orientation to
the Department’s healthcare policies and procedures which was given by a registered nurse.
The approval of treatment protocols 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 which require the completion of the Authority for
Evaluation and Treatment (AET) for all youth admitted into the program. Nine youth Individual
Healthcare Records (IHCRs) were reviewed, and seven contained an AET which was signed on
the day of admission. The remaining two were youth who were in the custody of the Department
of Children and Families (DCF), and these IHCRs contained a court order. The AET forms were
signed by the parent/guardian and a Department representative for the seven youth who were
not under the custody of DCF prior to admission. All the AETs were valid. Four of the nine youth
were over the age of eighteen, and all IHCRs contained a documented release of information.
The nurse supervisor was interviewed and advised the nurses review all projected intakes in the
Department's Juvenile Justice Information System and validate all AETs. New admissions are
discussed with case management prior to youth arrival. If needed, the juvenile probation officer
will be contacted to obtain a new AET. The nurse supervisor also said if a youth is over the age
of eighteen upon arrival, nursing staff will have the youth sign a release of information at
admission.
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 maintains a policy and procedures which require the parent/guardian to be
informed of significant changes in the condition of any youth and to obtain consent when new
medications and treatments are prescribed. Nine youth Individual Healthcare Records (IHCRs)
were reviewed, and one contained documentation of parental/guardian notification and consent
for over-the-counter (OTC) medications beyond the Authority for Evaluation and Treatment
(AET). The remaining eight youth did not have OTC medications beyond those covered by the
AET. Two of nine youth had new medication ordered at admission, and both IHCRs contained
documentation of parental/guardian notification in the progress notes. Six of nine IHCRs
contained documentation which confirmed written notifications were sent utilizing the
Department’s Parental Notification of Health-Related Care: General or Parental Notification of
Health-Related Care: Medications forms. The remaining three youth were over the age of
eighteen at admission and did not require this form. Four of nine youth were taking psychotropic
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medication at the time of admission and documentation was contained in the IHCRs which
confirmed staff witnessed all telephone conversations with the parent/guardian for two of the
youth. The third youth was over the age of eighteen at admission, and this was not required.
None of the youth were applicable for a new psychotropic medication being prescribed,
discontinued, or the drug dosage being significantly changed. Two of the nine youth were in the
custody of the Department of Children and Families prior to admission, and both contained a
court order which authorized all treatments and procedures. All nine IHCRs contained
documentation which confirmed vaccinations were verified within thirty days of admission. None
of the youth had a Religious Exemption from Immunization form and none had a refusal to
consent for immunizations due to medical reasons. The nurse supervisor was interviewed and
said parental/guardian notifications are required for doctor visits, off-site visits, and when new
medications are prescribed and started. Parental/guardian notification is written within twenty-
four hours and verbal consent is made as soon as possible, after an order has been written by
the physician. If a youth requires emergency medical services, all attempts are made to verbally
contact a parent/guardian before the youth departs the program. Parental/guardian notification
is also made upon the return of the youth to the program, followed by written notification. When
psychotropic medications are started, discontinued, or changed, a witnessed verbal consent it
obtained, followed by written documentation, which is mailed. Medical records are reviewed by
the health services administrator when the notification for admission is received. Immunization
records are obtained from the Department's Juvenile Justice Information System or the Florida
Shots website. If no record is available, the parent/guardian is contacted, and a copy of the
immunization record is obtained.
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 which ensure all youth are screened upon admission
for healthcare concerns which may require further assessment and referral by healthcare staff.
Nine youth Individual Healthcare Records were reviewed, and all nine youth were screened with
the Facility Entry Physical Health Screening form upon admission. All nine youth were screened
by a registered nurse and there was no change in physical custody for any of the nine youth,
greater than a twenty-four-hour period.
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 which ensure all youth are oriented to the general
process of healthcare and delivery of services at the program. All nine reviewed youth Individual
Healthcare Records (IHCRs) contained documentation which confirmed each youth received a
general healthcare orientation upon admission. All the required topics, including, but not limited
to access to medical care, sick call, right to refuse care, and universal precautions were
reviewed by all youth during the orientation process. Youth sign their orientation sheets to
acknowledge they received orientation to healthcare services. A review of the program’s
contract determined Health Education is documented upon admission and conducted monthly
thereafter. Health education covered seatbelt usage, alcohol and drug related problems,
sexually transmitted diseases and infections, tobacco products including smoking cessation,
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dental hygiene and care, basic personal hygiene, immunizations, prevention of sexual and
physical violence, nutrition, physical fitness, breast and testicular self-examinations, parenting
skills, and prenatal, postpartum, and parenting education.
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 which ensure the designated health authority (DHA)
or designee is notified when an admitted youth requires emergency medication intervention or
routine notification according to Department requirements. Nine youth Individual Healthcare
Records (IHCRs) were reviewed, and five youth were known to have a chronic condition,
warranting a referral the physician; however, none of the nine youth were identified as in-need
of emergency care upon admission. Four of the nine reviewed youth were taking psychotropic
medication upon admission and the psychiatrist was notified. According to the nursing
supervisor in an interview, the DHA is notified verbally if on-site or by telephone regarding all
youth history and chronic conditions once the initial assessment is completed. Notifications are
documented in the youth IHCRs and admission orders.
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 which ensure the standard Health-Related History
(HRH) form is used for all youth admitted into the physical custody of a Department facility. Nine
youth Individual Healthcare Records were reviewed, and all had a completed HRH form within
seven calendar days of admission. All nine HRH forms were updated/completed prior to the
Comprehensive Physical Assessment and were signed and dated. All nine HRH forms had
been reviewed by the physician and the focused note regarding the review was documented.
The nurse supervisor interview indicated the nursing staff are responsible for completing the
HRH form of youth upon admission to the program.
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 maintains a policy and procedures which require each youth admitted to receive
and/or have on record a current Comprehensive Physical Assessment (CPA). Nine youth
Individual Healthcare Records were reviewed, and all contained a new CPA form which was
completed by the designated health authority (DHA). Eight of the nine were completed within
seven days of admission. The ninth was three days late due to an evacuation for a hurricane.
The Medical Grade was documented on the CPA for each youth. There were no missing or
incomplete elements on any of the reviewed CPAs. All sections of the CPA were completed by
using an “O” or “X” as appropriate on each box. One of nine youth refused a part of the
examination, and the program did not have the youth sign a refusal form and did not update the
problem list, as required. All nine youth had at least one verified Tuberculosis Skin Test (TST)
completed and documented within a year of their admission and the results were documented
on their CPA and on their Infectious and Communicable Disease form. Each of the test results
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matched on both forms. The nurse supervisor was interviewed and said the DHA completes a
new CPA on each youth annually. The nurse also said the Department's Juvenile Justice
Information System records are reviewed for TST status prior to admission and upon arrival. A
tuberculosis screening is completed by the nurse during the initial nursing assessment;
thereafter, a medical tracker is maintained to monitor TST due dates. Documentation is located
on the Facility Entry Physical Health Screening form.
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 entering the program are
evaluated and treated for sexually transmitted infections (STIs) and human immunodeficiency
virus (HIV). Nine youth Individual Healthcare Records (IHCRs) were reviewed, and all admitted
to being sexually active and were clinically screened for STIs. Six of nine required further
evaluation, and they were referred to the designated health authority (DHA). This referral was
documented on the STI screening tool for all six applicable youth. Three of six youth had testing
ordered and performed. All six youth had the testing, screening results, clinical evaluations, and
diagnosis documented on the Infectious and Communicable Diseases form. None of the
sexually active youth were out of the Department’s physical custody; therefore, a rescreen was
not required. Documentation was filed in each IHCR confirming each youth was offered
counseling, testing, and if indicated, treatment/referral for HIV. Two of nine youth consented to
have HIV testing conducted. The remaining seven did not consent. In all nine, documented
consent and refusals were noted. The HIV results for both youth were filed confidentially in a
sealed envelope marked “Confidential”, as required. One of the two envelopes contained proof
of a review by the DHA documented on the sealed envelope. The other envelope was not
marked as reviewed by the DHA. Both applicable IHCRs contained documentation of pre/post-
test counseling offered to each youth. In both instances, the youth’s confidentiality was
protected by not including the youth’s HIV status and any other STI diagnosis on the program’s
internal alert system. The program has a policy and procedures reflecting HIV test results are
only disclosed to the youth, the youth’s legally authorized representative, healthcare providers
during the course of consultation, diagnosis, or treatment, the Department of Health for
purposes of reporting and control of spread of disease, health facility staff committees
conducting program monitoring, evaluation, and service reviews, medical staff who may have
been subject to a significant exposure, and healthcare facility staff or agents for the healthcare
provider who have a need to know in the course of patient care activities or administrative
operations. HIV pre and post-test counseling is provided by an outside provider, who has an
active and valid license with an expiration date of April 3, 2025. Nine youth were interviewed,
and all said they could take a HIV test whenever they want. The nurse supervisor was
interviewed, and advised youth are interviewed during the initial nursing assessment to obtain
their history. All youth are screened for STI, regardless of their risk. If the screening indicates a
need for further evaluation, youth will be referred off-site. The STI screening and lab results are
filed in the youth IHCR. Youth can be rescreened at any time they request. HIV testing results
are sealed, marked confidential, and filed in the IHCR. The results are given to youth when they
are discharged. Youth are asked if they want HIV testing during intake, and this is logged in
their assessment. The process is documented on the nursing notes and educational log.
4.12 Sick Call Process Satisfactory Compliance
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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 maintains a policy and procedures which require all youth in the program to be
able to submit sick call requests and have complaints treated appropriately through the sick call
system. The program is required to respond appropriately, in a timely manner, and document all
sick call encounters. Nine Individual Healthcare Records (IHCRs) were reviewed, and two were
applicable for having requested sick call; therefore, the program provided an additional IHCR for
review. None of the three applicable youth presented with a similar sick call complaint three or
more times within a two-week period. In all three IHCRs reviewed, youth completed a Sick Call
Request form, and the nurse completed the form as well. All sick calls are conducted by a
registered nurse (RN). The Sick Call Request forms were filed in each IHCR, in reverse
chronological order. None of the youth at the program were in restricted housing; therefore,
medical staff did not have to conduct daily rounds and question youth for sick call or other
health complaints. Sick call forms and progress reports included vital signs, treatment,
education, and follow-up plans. All sick calls were documented on the Sick Call Index as well as
the program’s Sick Call Referral Log. The dates listed on the Sick Call Index matched the dates
on the completed Sick Call forms reviewed. A review of the daily schedule confirmed sick call
was conducted Monday through Friday from 10:10 a.m. through 10:25 a.m., from 12:30 p.m.
through 1:05 p.m., and from 6:15 p.m. through 7:00 p.m. Sick call is also conducted on Saturday
and Sunday from 6:00 p.m. through 7:00 p.m. The sick call hours are posted on the nurses’
door and the activity schedule. The program has a policy and procedures in place for when
there is not a licensed nurse on-site, whereby the shift supervisor reviews all sick call requests
as soon as possible and within four hours after the request is submitted. Each housing unit has
a sick call box in the dayroom which contains sick call forms, as well as a locked box where
youth can submit completed sick call forms. The nurses’ office has an exam table and
equipment used to perform sick call. Nine youth were interviewed, and one said they are seen
for sick call immediately after submitting a request, seven said within one day, and one said it
takes more than three days to be seen. The nurse supervisor was interviewed and said youth
can submit sick call anytime by completing the form and placing it in the sick call box. The box is
checked at regular intervals by nursing staff, not to exceed two hours. Youth are assessed
within twenty-four hours. Sick call is conducted by nursing staff in the medical clinic, three times
a day during the week, and once daily on the weekend. If youth present for sick call three times
within fourteen days, or if the treatment protocol seems to be ineffective, the youth is scheduled
to see the doctor. There were no sick calls to observe during the annual compliance review
week while the team was on-site.
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 requiring a comprehensive process for the provision
of episodic care and first-aid care. Nine youth Individual Healthcare Records were reviewed and
three were applicable for episodic care. Each of the three events were documented in the
required subjective, objective, assessment, and plan format. The program’s episodic and
emergency care procedures were reviewed and found to be current. The program maintains
first-aid kits in each housing unit, master control, and in the transport vehicle. The first-aid kits
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are checked weekly by nursing staff and replenished as needed, or monthly. Documentation
was provided which confirmed the first-aid kits are monitored, as required. The program has
four automated external defibrillators (AEDs), located in each of the housing units and in master
control. Instructions are located inside each of the AED cases. Nursing staff conduct weekly
checks of the AEDs to ensure the AED batteries and pads are operable. The green light was
flashing on each AED during the annual compliance review week, indicating they were
operating properly. The batteries were last changed on the AED in master control June 28,
2024, and Alpha, Bravo, and Charlie dorms February 2021. The AED batteries expire on June
28, 2026, in master control, and Alpha, Bravo, and Charlie on February 8, 2025. A list of
emergency numbers, including the Poison Information Control Center, is posted and accessible
for non-licensed and licensed staff in the medical office, and inaccessible to youth. Supervisory
direct care staff have been trained by a registered nurse on the administration of the
epinephrine auto-injector. Eighteen staff training records were reviewed, and all met the annual
requirements for having taken episodic, first-aid, and emergency care training. Emergency
medical drills were reviewed from the time of the last annual compliance review. All shifts
conducted a minimum of one emergency medical drill monthly, which exceeds the requirement
of quarterly drills. Twenty-three staff were reviewed for participation in drills. Four of the twenty-
three applicable staff did not participate in a drill involving cardiopulmonary resuscitation (CPR).
A video review confirmed drills were simulated. All of the drills simulated 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 occurs. The program
maintains documentation for medical drills in a binder. There were no episodic events during the
review; therefore, an observation of episodic events was not conducted. The program stores
Narcan in the medical department. Only medical staff and supervisory staff are trained to use
Narcan. Nursing staff inventory Narcan weekly. Nine staff were interviewed, and all said they
could call 9-1-1 in the event of a medical emergency. Nine youth were interviewed, and all said
they could see a doctor or dentist when they need to. The nurse supervisor was interviewed and
was able to identify where the first-aid kits are located. The nurse also described the process for
documenting episodic care, to include notifications needed. The nurse supervisor also was
aware of where the AEDs are stored.
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.
The program has a policy and procedures which require them to provide timely referrals and
coordination of medical services to an off-site healthcare provider for emergent and non-
emergent incidents. Nine youth Individual Healthcare Records (IHCRs) were reviewed, and only
one was applicable for off-site first-aid or emergency care; therefore, the program provided two
additional applicable IHCRs requiring off-site care. In all three reviewed IHCRs, the Summary of
Off-Site Care Consultation Report form was utilized and filed; the off-site care was documented
on the Episodic Care log; parental/guardian notification efforts were made; and the discharge
instructions and other applicable documents were maintained. All three applicable IHCRs also
contained documentation supporting the designated health authority (DHA) reviewed and
signed all off-site care findings, instructions, and information. All three youth required follow-up
appointments, and these were tracked to ensure each youth received the follow-up care as
needed. The nurse supervisor was interviewed and advised the episodic log is used to track
youth who are sent off-site for first-aid or emergency needs. A copy of the off-site care findings,
instructions, and information are reviewed and discussed with the DHA. The DHA then gives
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orders for any follow-up. All instructions and information for the DHA to review are kept in a
DHA folder for weekly reviews and anything else needing to be flagged for the next on-site visit.
Medical logs and trackers are kept in a binder to 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 youth who have been identified with a
chronic illness receive regularly scheduled evaluations and follow-up treatment, as needed.
Periodic evaluations are scheduled to ensure the youth requiring ongoing treatment and any
youth who have experienced changes in condition or treatment regimen can be adequately
monitored. Nine youth Individual Healthcare Records were reviewed, and six were identified
with a chronic condition as documented on the Facility Entry Physical Health Screening form.
After admission one additional youth was identified with a chronic condition. None of the youth
were identified as having a communicable disease. Four of seven applicable youth were taking
prescribed medication on an ongoing basis; the remaining three did not take the medication
continuously. Six of seven applicable youth were undergoing treatment for a physical health
condition; the remaining youth did not have a monitored physical health issue. All seven youth
were classified with a Medical Grade two through four, or a Medical Grade five for youth also
taking psychotropic medications. All seven youth were placed on the program’s Chronic Illness
List. A review of progress notes confirmed four of the seven youth received periodic evaluations
at least every ninety-days. The remaining three youth had not been in the program for ninety
days at the time of the annual compliance review. The program maintains a tracking log for
youth with chronic conditions and evaluation dates. The tracking log indicated each youth’s next
scheduled appointment. None of the youth were taking anti-tuberculosis medication. None of
the youth required an evaluation to be completed prior to a prescription renewal, change, or
expiration. None of the youth reviewed were applicable for an off-site evaluation. There were no
indications of lapses in care or missed periodic evaluations in any of the reviewed records. The
Department’s Problem List for each youth was updated as required. The facility administrator
(FA) was interviewed and advised the nurse supervisor informs the FA of any youth with chronic
conditions, and this information is disseminated as needed. Daily meetings are conducted with
the nurse supervisor to discuss medical concerns, issues, and appointments. The designated
health authority was interviewed and advised periodic evaluations for youth with chronic
conditions are conducted every sixty days. A tracker system is in place to ensure periodic
evaluations are conducted on time. The nurse supervisor was interviewed and advised the
medical tracker is used to monitor youth with chronic conditions.
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.
The program has a policy and procedures which require for all medication to be received,
stored, inventoried, and provided in a safe and effective manner. This includes ensuring medical
staff verify any medications arriving with a newly admitted youth and the continuance of all
currently prescribed medications. Nine youth Individual Healthcare Records (IHCRs) were
reviewed, and eight youth were admitted on prescribed medications. Documentation confirmed
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all medications were verified prior to being admitted into the program and this verification was
included in the Chronological Progress Note and by utilizing the Prescription Medication
Verification Checklist form. The designated health authority (DHA) was contacted to obtain the
order to resume the specified medications prescribed prior to admission for all applicable youth.
All medications for each of the youth had a current, valid order. Each time a medication was
continued, discontinued, changed, or a new one was ordered, the DHA placed an order on the
Practitioner Order form. None of the youth were in restricted housing during the annual
compliance review period. One youth was applicable for over-the-counter (OTC) medications
not listed on the Authority for Evaluation and Treatment form, and these medications were
administered according to approved protocols. The program utilizes a standard Medication
Administration Record (MAR) to document all medication and treatment. Each of the reviewed
MARs clearly indicated the medication start and stop dates, as required. The nursing staff
documented side-effect monitoring at a minimum of weekly on each MAR. There were no
occurrences where trained non-healthcare staff assisted in the delivery of medications for any of
the youth reviewed. There were no undocumented explanations for a lapse or errors in
medication administration. Nursing staff documented weekly side-effect monitoring on all the
MARs reviewed. None of the reviewed youth had any instance where they refused medication.
All the MARs contained the youth’s name, Department identification number, date of birth,
allergies, precautions, Medical Grade, medical alerts, and a current picture of the youth. There
were no youth in need of parenteral medication during the annual compliance review period.
Four of the reviewed youth were taking psychotropic medication upon admission, and the DHA
and psychiatrist were notified the day of admission. The remaining five youth were not
applicable. The psychiatrist conducted an Initial Diagnostic Psychiatric Interview with the
applicable youth within fourteen days of admission. Two of three applicable youth received
medication monitoring/reviews every thirty days, as required. The third youth had not been in
the program for thirty days at the time of the annual compliance review. There were no standing
orders for psychotropic medications, no emergency treatment orders for psychotropic
medications, or pro re nata orders for psychotropic medications. Medication pass was observed
for four youth during the annual compliance review week. Each youth was escorted to
medication pass by direct care staff and approached the medication window individually.
Nursing staff identified themselves and stated why the youth was present. The same nursing
staff prepared and administered the medication. The nurse verified each youth’s allergy and
alert status prior to administering the medication. The nurse initialed the MAR for each youth.
Since there were no refusals, none of the reviewed youth had to initial the MAR. There were no
OTC medications administered during medication pass. The nurse verified the Six Rights of
Medication Administration for each youth. No medications were observed to be pre-poured.
Nine youth were interviewed, and five youth said the nurse gives them medication. Four said
they do not take medication. The nurse supervisor was interviewed and explained medications
are procured through a local pharmacy. The program uses a psychiatrist on-site eight hours
weekly.
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 requiring any medical equipment classified as sharps,
as well as stock medications, to 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. During the annual compliance review week, a tour was conducted of the medical
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area. All medical equipment classified as sharps were found secured and inventoried, with a
perpetual inventory descending count as each sharp was utilized and disposed of. All
medications were identified and secured in the locked medication cart and locked medical
cabinet area designated for storage of medications. The medication cart was clean and
organized, with stock items separate from youth-specific medications. All controlled substances
had a perpetual inventory and were stored separately from other medications. All medications
were stored in a separate, secured area, inaccessible to youth. Narcotics and other controlled
medications were securely stored in a locked box located within the medication cart, maintaining
these medications behind two locks. The program has a secured refrigerator, exclusively
designated for medications requiring refrigeration; however, there were no medications on-hand
requiring refrigeration at the time of the annual compliance review. Any medication needing to
be destroyed and disposed or returned if expired or discontinued is collected by the pharmacist
on regularly scheduled visits. A review of inventory forms confirmed perpetual and weekly
inventories of all sharps and stock over-the-counter (OTC) medications were completed as
required. In accordance with the Board of Pharmacy regulatory requirements, a shift-to-shift
inventory count of all controlled substances was documented on any applicable youth’s
Individualized Controlled Medication Inventory Record. Three supervisory direct care staff
training records were reviewed, and all supervisory-level, non-healthcare staff were trained in
the delivery and oversight of medication self-administration. This training was conducted by a
registered nurse. A random inventory of three controlled medications, three OTC medications,
and three sharps was conducted and compared with the numbers listed on the inventory forms.
All inventoried items matched the numbers listed on the inventory forms. In the event the
program has any inventory discrepancy, the reporting criteria is to immediately notify the facility
administrator (FA) and the nurse supervisor, restrict youth movement, and search for the
missing item. The nurse supervisor was interviewed and advised medications are disposed of
by the pharmacist and controlled substances are kept in a medication cart, locked separately
from the other medications, and are counted twice each day. The pharmacist consultant is on-
site monthly to complete monthly, quarterly, and yearly reviews and to ensure there are no
complaints or issues with the pharmacy and ensure they are complying with regulations. The
reviews include the medical staff, FA, designated health authority, psychiatrist, and pharmacist
consultant.
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 requiring them to implement infection control
procedures which include prevention, containment, treatment, and reporting requirements
related to infectious diseases, in accordance with Occupational Safety and Health
Administration (OSHA) federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan must include pre-service and in-service
training for all staff. Education for youth regarding infection control shall also be provided during
admission and subsequently when the need is identified. The program’s infection control
procedures were reviewed by the designated health authority (DHA) on December 14, 2023,
and by the facility administrator (FA) and compliance officer on December 18, 2023. The
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infection control procedures included common infectious childhood diseases, self-limiting
episodic contagious illnesses, viral of bacterial infectious diseases, tuberculosis, Hepatitis A, B,
and C, human immunodeficiency virus caused by bloodborne pathogens, other outbreaks or
epidemics caused by any other infectious agent, outbreaks of pediculosis and/or scabies,
Methicillin-Resistant Staphylococcus Aureus and other emerging antibiotic-resistant micro-
organisms, foodborne illnesses, bio-terrorist agents, and chemical exposures. The program
provides staff with the opportunity for Hepatitis B immunizations and staff have access to
personal protective equipment. During the annual compliance review period, there were no
instances where the local county health department, CDC, and/or the Department’s Central
Communications Center (CCC) needed to be notified of an infectious disease. The program’s
exposure control plan is written in accordance with OSHA standards and was last reviewed by
the FA on December 18, 2023. The program’s process for needle stick post-exposure
evaluation is to establish how the exposure occurred, identify the source, obtain consent for
testing blood to determine if infected document source of blood test results, obtain consent to
collect the exposed staff’s blood, provide medical examination/treatment through workman
compensation, offer post-exposure vaccinations, and provide the staff a copy of the healthcare
professional’s opinion. The FA was interviewed and advised the exposure control plan is located
in the FA’s and medical offices. The nurse supervisor was interviewed and advised she has a
copy of the exposure control plan. The nurse supervisor also advised healthcare staff to
complete training bi-annually at the program for youth and staff. The nurse supervisor explained
the youth follow an education calendar, where they receive infection control training. Staff
receive exposure control training in addition to infection control training.
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 stating how they will maintain active supervision of
youth at all times. Observations of staff during the annual compliance review week found staff
supervising youth appropriately and positive interactions during all observed activities.
According to the policy and procedures provided to the annual compliance review team, staff-to-
youth ratios are one staff to eight youth during awake hours, one staff to twelve youth during
sleep hours, and one staff to five youth for off-site activities. Observed activities made during the
four-day annual compliance review were supervision of youth during school hours, recreation,
education, and youth movement through the facility. The daily schedules were posted in the
dorms and cafeteria. At no time during the annual compliance review week were youth
observed wandering freely about the program. Three staff were informally interviewed about
how many youth were under their supervision and all three staff were aware of the total number
of youth in their care. Observations found the counts were conducted at scheduled and
unscheduled times. Nine staff were interviewed and all staff indicated the count is reconducted
and all movement is ceased when a count cannot be reconciled. The program maintains active
supervision through proper ratio and sight and sound observation. The daily schedule was
posted and available for youth in each dormitory. Youth were observed to be engaged in
activities throughout the annual compliance review week.
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 maintains a policy and procedures addressing the implementation and training of
the program’s behavior management system (BMS). The program’s BMS was developed with
program administration and other appropriate program staff, and staff can provide feedback on
the implementation of the BMS. The program and educational staff have an agreement to utilize
the BMS, and educational staff are trained on the system. The program’s BMS includes all of
the required elements, and was developed to exclude denial of basic rights, group discipline,
youth punishing each other, and improper isolation. Youth learn about the BMS during the
orientation process. Each youth is provided a program handbook which describes the BMS. A
review of the youth handbook indicated the BMS is included and clearly written. In addition, the
parent/guardian handbook includes a description of the BMS. A review of nine youth case
management records indicated each youth participated in orientation upon arrival to the
program and received a copy of the youth handbook. Nine staff pre-service training records
were reviewed, and all staff were trained in the program’s BMS system. Observations found the
BMS was posted throughout the program. Observations of staff and youth interactions verified
staff were adhering to the BMS by utilizing a ratio of four-to-one positive to negative
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consequences when redirecting the youth as indicated in the program’s policy. Nine youth were
interviewed, and each stated the consequences included write ups, level freezes, level drop or
level freeze, and earning zero points which affects the daily and weekly incentives. Nine youth
were interviewed about the rewards used in the program and all stated youth can earn daily
incentives, canteen, off campus activities, extra points, extra telephone calls, and pizza parties.
All nine interviewed youth were able to explain the difference between each level and how to
move from level to level and stated staff are consistent. Nine staff were interviewed and each
staff was able to explain the BMS to include rewards, restricted punishments, and
communication with youth regarding behavior choices. The facility administrator (FA) was
interviewed and was able to explain the program’s BMS, how rewards were
monitored/consistency of implementing the BMS, and how the consequence/punishment was
monitored.
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, procedures, or contract states the program does not use restricted
housing, to include confinement, room restriction, or secure observation; therefore, this indicator
is rated non-applicable.
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 outlining the process of conducting ten-minute
checks when youth are secured in the rooms. The program has a total of 138 cameras and of
those 127 were operational at the time of the annual compliance review. The non-operational
cameras were facing the new school portables which were not being utilized at the time. The
camera system stores up to thirty days of recordings. A review of logs and video observations
confirmed checks were documented in real time and initialed by the staff conducting the check.
During video observations, it was confirmed staff conducted checks at least every five minutes
by using a flashlight to look inside each room occupied by a youth. The ten-minute check logs
matched the video observations and confirmed the checks were conducted as required. During
interviews with nine staff, eight reported room checks are conducted every five minutes and one
staff reported every six 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.
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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 maintains a policy and procedures which address population census, counts, and
tracking of youth. The program’s policy indicates headcounts will be conducted at a minimum of
once at the beginning of each shift, during any emergency situation, prior to and after each use
of a vehicle, and before and after each movement. The program utilizes the master control
logbook to document youth counts and movements. Logbooks were reviewed from January
2024 to October 2024. The logbook is utilized to maintain a chronological record of events as
they occur. The program headcounts are conducted by the shift supervisor at the beginning of
each shift to verify accuracy and document counts in the program’s logbook. Counts are
conducted at the beginning of the shift, after outdoor activities, and during emergencies. The
logbook also tracks youth intakes, releases, transfers, and youth temporarily away from the
program. An informal youth count was observed following an incident within a dormitory during
the annual compliance review week. Nine staff were interviewed, and each staff was aware of
the count procedures as required by the program’s policy. Staff were aware of all youth
whereabouts and were able to provide the proper counts to the annual compliance review team
members during the week. Nine staff were interviewed, and each was aware of count
procedures, as required by program policy, including what to do in the case of an unsuccessful
count.
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 maintains a policy and procedures addressing logbook entries. The program
maintains a chronological record of events, incidents, and activities in a logbook in accordance
with the program’s policy. The logbooks utilized by the program over the past twelve months
were reviewed. Each reviewed logbook was bound with numbered pages and entries were
made in ink with no white-outs or logbook entries being removed or missing. Logbook entries
included movement to and from school and interruptions if any occurred. At the time of the
annual compliance review, the youth were moving to classes. Youth were in the classrooms and
the dining hall since class is conducted in the dining room due to the new portables being
inoperable at this time. The teachers moved to the different classrooms youth were in. The
program documented all applicable events in the logbooks during the annual compliance review
period to include emergency situations, special instructions for supervision and monitoring of
youth, population counts at the beginning and end of each shift, any other population counts
conducted during a shift, perimeter security checks and other security checks conducted by
direct care staff, transports away from the program, including the names of the staff and youth
involved, and the destination, requests by law enforcement to access any youth, removal of any
youth from the mainstream population, admission and releases, including the name, date, and
time of anticipated arrival or departure and mode of transportation, and information relating to
escapes or attempted escape incidents. There were no incidents including the use of
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mechanical restraints as they are not utilized at this program. On-coming staff members
participated in a shift briefing and signed the shift report acknowledging they are aware of all
information from the last shift and any changes about the youth. Each reviewed logbook entry
was legible and included the time and date of the entry, printed name, and the signature of the
staff member making the entry. All reviewed Department Central Communications Center
reportable incidents were noted in the logbook.
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 maintains a policy and procedures to ensure key control and security which
includes assignment, inventory, tracking, and storage of keys. Observations made indicated the
program has a system in place for the usage of keys at the program. A review of the program’s
policy and procedures on key control determined it includes the control and use of keys
including key assignment and usage, 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’s staff turn in their personal keys and receive a
program key. This key is updated in the logbook to reflect the key with the tag number given to
staff. The program staff sign a permanent key assignment acknowledgment form to receive the
keys, and proper procedures for controlled keys. Keys are stored in secured boxes marked
active key box, restricted key box, permanent key box, and emergency key box in master
control. The key control process was observed during the annual compliance review week and
was conducted appropriately. Visitor keys are exchanged with a numbered chip. Three random
staff were requested to present their keys, which were compared with the key control log and
the inventory to ensure the keys were correct. All three were correct and master control had
signed their keys out. All three staff were aware of the key functions. An interview with nine staff
confirmed there weren’t any youth at the program with access to the program keys, and each
staff was able to state what procedures must be followed regarding lost or damaged keys. A
review of the Department’s Central Communications Center (CCC) reports was conducted. One
deficiency regarding key control was identified and corrected during the annual compliance
review period.
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
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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 system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, program grounds, and youth, which
is clearly explained in the program’s policy and procedures, and youth handbook. The policy
also states any staff who is found in possession of contraband in a program will be subject to
disciplinary action up to, and including, dismissal, as well as procedures regarding notification of
law enforcement for items considered illegal as defined in Florida Statutes. The program’s policy
and procedures and the youth handbook define items and materials considered contraband
when found in the possession of youth, provides youth with a list of contraband which meets the
requirements, and informs youth of the consequences if found with contraband. The prohibited
list includes personal cellular telephones and/or equipment and/or electronic devices capable of
taking pictures and/or audio/video recordings. The list also includes unauthorized articles of
clothing and food, controlled substances, prescription or non-prescription drugs, and any firearm
or explosive device. The visitors log contains a contraband attestation statement and thirty-one
newly hired staff had a completed attestation form in their personnel record. Staff interviews
were conducted, and all nine interviewed staff were able to explain the contraband procedures.
The contraband notice is posted, and states law enforcement will be contacted for anyone
bringing in contraband and a criminal report will be filed. This practice was confirmed through an
interview with facility administrator who recited the program’s policy. The policy stated law
enforcement shall be contacted if any found item would be considered illegal, as defined in state
law, or if there is evidence of unlawful activity. According to the policy and procedures all
searches, as well as the findings and disposition of contraband/unauthorized items, shall be
documented. The facility administrator (FA) shall determine the method of disposition of
contraband and unauthorized items which are not illegal. Such contraband and unauthorized
items may be discarded, returned to the original owner, mailed to the youth’s home, or stored
and returned to the youth upon release. Any usable contraband or unauthorized items,
excluding weapons or illegal materials, not able to be returned or turned over to law
enforcement may be donated to any established charity. All program staff, visitors, vendors, and
contracted providers shall be searched prior to entering the program. Any program or education
program staff who refuses to be searched will be denied entry into the program and may be
subject to disciplinary action. Any staff found in possession of contraband will be subject to
disciplinary action up to and including dismissal. All items carried by program and education
program staff are subject to a search when entering and leaving the facility. There were no
incident reports for contraband during the annual compliance review period. Nine staff were
interviewed and each staff was able to identify search frequency and locations/persons. The FA
was interviewed and confirmed the program’s procedures for handling and disposing of
contraband.
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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 maintains a policy and procedures addressing searches and full body visual
searches. The program conducts searches as a method to prevent the introduction of
contraband and unauthorized items into the facility. The policy indicates searches of youth are
conducted after off-site transports, after visitation, before moving youth from an outside area
into the building, prior to moving youth from the building to an outside area, as well as moving
from one building to another. The program conducted one off-site transport during the week of
the annual compliance review. The review team observed properly conducted searches and a
full visual search after the transport. The review team also observed several youth searches
during the week of the annual compliance review. Searches were conducted with each
movement of youth from each area of the building such as the classroom, groups, and dorms.
Search procedures and expectations were properly explained to all youth before searches were
conducted. Searches were conducted by staff of the same gender as the youth, while a second
staff member assisted with supervision. Searches were thorough and done in a manner which
did not degrade the youth. All searches were documented in the program’s logbook. During the
annual compliance review week, f frisk searches of youth were observed in the classroom
before movement. One staff member conducting the frisk searches was the same gender as the
youth. Each observed frisk search was conducted properly according to policy. Video review of
vistor and staff searches was conducted, and each observed search was conducted as required
and thorough of the visitor/staff and any personal items entering the facility with them. Youth
and staff interviews revealed all parties were aware of proper search procedures and when the
searches take place. Nine youth were interviewed, and each confirmed searches are conducted
any time they move from one area of the program to another. Nine staff interviews confirmed
searches are conducted on the youth as required by policy.
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 for managing vehicles and maintenance.
The program utilizes two vehicles for youth transport, with one vehicle observed during the
annual compliance review week. The second vehicle was not observed, as it was being used at
another program run by the same provider. Documentation confirmed the vehicle used for youth
transport underwent its annual safety inspection, with no deficiencies identified. All required
maintenance records were properly documented. The vehicle was secured at all times when not
in use. It was equipped with a fire extinguisher, the appropriate number of seatbelts, and a
safety screen. The door to the youth passenger area cannot be opened from the inside,
ensuring youth safety during transport. An approved first-aid kit is checked out of master control
with the vehicle keys for each transport. Additionally, a seatbelt cutter and window punch tool
are attached to the vehicle key ring. Youth are secured in the vehicle solely by proper use of
seatbelts as confirmed by an informal interview with staff. A review of fifteen randomly selected
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program and personal vehicles was conducted during the annual compliance review week, and
all were found to be locked when not in use.
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 maintains a policy and procedures addressing the transportation of youth, outlining
staff to youth ratio during transports as one to five; however, if there are five or less youth, a
minimum of two staff are needed to perform all transports. The program has an approved
transport list which is updated monthly to ensure staff driver’s licenses are valid. This approved
driver’s list is located in master control. The annual compliance review team was able to
observe a transport and staff followed procedures. Nine staff interviews confirmed they are
issued a cellular telephone and two added a program radio is taken on transports as well. Each
interviewed staff confirmed they do not conduct transports in personal vehicles, and transport
vehicles are checked before and after transports. All nine staff were able to accurately describe
what safety equipment is required for all transports. All staff were able to describe the process
required in case of an emergency. The facility administrator interview stated the program is a
moderate-high risk/secure program and does have the required safety screen in the vehicles
which transport youth. Nine youth were interviewed and none of the youth stated seeing staff
place contraband inside the vehicle, and all nine youth stated they were never handcuffed to
any part of the vehicle during transport.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a policy and procedures to ensure a safe and secure physical plant,
grounds, and perimeter are maintained, and for weekly safety and security audits to be
conducted. The program has developed a policy and procedures outlining the audit/inspection
process. The policy includes the development and implementation of corrective action
warranted because of safety and security deficiencies found during any internal or external
review, audit, or inspection; however, at the time of the annual compliance review the program
did not have any corrective actions warranted. The program has an internal system to verify the
deficiencies are corrected and existing systems are improved, or new systems are instituted as
needed to maintain compliance. Weekly safety and security audits were completed during the
annual compliance review period with no concerns or issues. The program’s weekly safety and
security audits were reviewed to ensure maintenance schedules and repairs were conducted in
accordance with contract language, with no exceptions. A review of documentation confirmed all
findings were documented and reviewed on the weekly safety inspection report. Weekly safety
and security audits are conducted by the physical plant manager or designee and documented
on the Safety and Security Audit Inspection form. Any deficiencies are addressed on the form
and a work order is submitted to the appropriate staff for corrections. An interview with the
facility administrator confirmed the program policy for identifying safety and security
deficiencies.
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.
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The program maintains a policy and procedures to address tool inventory and management.
The policy addresses the issuance, inventory, and control of equipment and tools. The policy
classifies tools into two categories; Class A tools and Class B tools. Class A tools are
hazardous with sharp edges or points and with a high potential to be used as a weapon to inflict
serious bodily harm such as knives, hammers, screwdrivers, and electric drills; however,
machetes, bowie knives, and other long blade knives are prohibited. Class B tools do not have
sharp edges or points such as brooms, mops, and scrub brushes. All tools are inventoried prior
to being issued for work, and again following the completion of work activities. Inventory of all
Class A tools is conducted daily, with the exception of days tools are not utilized; and a monthly
inventory is conducted of all Class B tools. Youth only have access to Class B tools which are
brooms, mops, and scrub brushes. The program has identified the physical plant manager as
the program’s tool control manager. The on-site physical plant manager is completing all
maintenance requirements on a weekly basis. The kitchen maintains Class A tools and they are
inventoried when signed in and out as well as at the beginning and end of each shift. Kitchen
tools are secured within a locked cabinet. A review of the inventory found them to be accurate.
All Class A tools are secured with the outside plant manager and are brought in when on-site.
The plant manager stated there were no tools which were damaged or out of use. When a tool
is lost/missing, the program stops youth movement to conduct a thorough search of the area
and all notifications are made as required. When a tool is dysfunctional and needs to be
replaced or disposed of, the program places a tag on the shadow board where the item is
assigned to be stored, the facility administrator (FA) is notified, and documentation is placed on
the tool inventory and audit forms. The broken tool is then disassembled and disposed of in a
trash receptacle away from the facility grounds, and a replacement form is completed after the
FA’s approval. An observation of ten Class A tools, six from the maintenance shed and four
from the kitchen, was conducted. Each observed tool was secured, inventoried accurately, and
had markings for easy identification.
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 maintains a policy and procedures addressing youth tool handling and
supervision. The policy outlines proper procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries to youth and staff. The program completes Risk
Assessments which determine each youth’s risk to self and others during treatment teams. Nine
youth case management records were reviewed, and each had been given instructions on
Class B tools use. Each reviewed record had a risk assessment tool which would be utilized if
youth were able to use Class A tools. The staff to youth ratio during vocational training is one to
five. Youth interviews confirmed youth are only allowed to use a scrub brush, mop, broom, and
dustpan. Staff interviews revealed youth are allowed to use Class B tools after the orientation
training.
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 outlining the process of outside contractors entering
the facility. A review of sign-in sheets since the last annual compliance review confirmed the
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outside contractors filled out a form which included all required elements/guidelines. A review of
three outside vendor sign-in sheets and invoices confirmed the program staff and outside
vendor inventoried the tools or other equipment when the vendor arrived and left the facility. The
program’s policy and procedures outline who is responsible for providing approval/permissions if
personal cellular telephones and/or equipment/electronic devices are needed on-site.
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 maintains a policy and procedures to address fire, safety, and evacuation drills.
The program conducts fire, safety, riot, disturbance, Continuity of Operations Plan (COOP), and
evacuation drills to ensure youth and staff are prepared for immediate implementation or
mobilization in the event of an emergency or disaster. Drills are consistent with the program’s
COOP. The program went to two shifts as of April 2024. Twenty-three drills were reviewed. All
drills were properly documented in the program’s logbook and documented on the program’s
designated drill form. Each drill form except for one on October 16, 2024, contained the type of
drill, a description of the drill, the date the drill was conducted, the time of the drill, and
participants’ signatures. On October 16, 2024, the fire drill report wasn't filled out, missing check
marks for the Pre-Drill Assessment, Evacuation, and Assessment. The review of drills revealed
various drills were conducted from January 2024 through October 2024. A total of twenty-three
drills were reviewed. At least one fire drill was conducted for each shift each month and two
COOP drills were conducted for each. Fire evacuation routes and egress plans were posted
throughout the program. All fire extinguishers were inspected on an annual basis. An interview
with the facility administrator recited the program’s policy for drills. All nine staff interviews
confirmed staff have participated in fire, weather, bomb threat, mental health/suicide, and
medical drills. All nine youth stated they have participated in monthly fire drills.
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.
The program has a policy and procedures addressing the Continuity of Operations Plan
(COOP). The policy states the COOP is located in master control, facility administrator’s office,
and assistant facility administrator’s office. The plan addresses alternative housing plans
approved by the applicable Department regional director/designee. The COOP was last
approved on May 17, 2024. The COOP addresses fire prevention and evacuation, severe
weather, disturbances or riots, bomb threats, hostage situations, chemical spills, flooding,
terrorist threats or acts, staff roles and responsibilities, any equipment and supplies needed,
information about youth which may be needed, alternative housing arrangements, provisions for
continuity of care and custody of youth, and provisions for public protection. The program
conducts COOP drills on each shift. The drill documentation included type of drill, date and time
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 55 of 60 (Revised September 2022)
of the drill, participants, brief scenario and findings/recommendations, and pictures. The drills
included escape, missing tools, fire, evacuation due to severe weather, lightning, riot, active
shooter, and chemicals. The program has food and necessary supplies readily available at the
program in case of an emergency evacuation. The program maintains an administrative hard
copy of youth records in case of emergency with all required information, which is located in the
case management office, master control, and medical; to include committing court personnel,
committing offense(s), jurisdiction, youth demographics, youth photograph, and important
medical information/alerts. The facility administrator recited the program’s policy for the
disaster/COOP.
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 maintains a policy and procedures addressing storage and inventory of flammable,
poisonous, and toxic items and materials. The program’s flammable, poisonous, and toxic
materials are stored on-site in the chemical closet which is maintained by the physical plant
manager. The program maintains proper inventory of these items. The program’s plant manager
is the only individual authorized to handle or dispose of flammable, poisonous, and toxic items
which are brought in from another facility or purchased as needed. A binder is stored in the
cleaning supplies closet containing the Safety Data Sheets (SDSs) for the items located in the
cabinet as well as cleaning supplies. The cleaning supplies closet is locked at all times and can
only be accessed by staff, who sign these items in and out with each use. The facility
administrator was interviewed regarding chemical disposal and indicated most items are used in
their entirety; however, proper disposal is completed by the plant manager if needed.
Flammable, poisonous, and toxic items are always secured and inaccessible to youth. There
are inventories maintained for these items, and the program maintains a list of authorized staff
who are permitted to handle these items. The program has a policy and procedures to ensure
all flammable, toxic, caustic, and poisonous items are disposed of properly. The program’s
physical plant manager is designated to work with the facility administrator (FA) to follow federal
and state laws, to include Occupational Safety and Health Administration (OHSA) standards, in
the disposal of these items. Hazardous waste from the program is disposed of through a bio-
hazardous waste contractor; however, there were no incidents of disposal during the annual
compliance review period. The informal interview with the physical plant staff confirmed the
program’s policy and procedures for hazardous waste. There was no disposal or storage of
hazardous liquid waste during this annual compliance review period. Kitchen liquid waste,
except grease, was disposed of in the kitchen. The grease was placed in a separate container
for disposal. Liquid waste from cleaning or left over beverages was disposed of through
plumbing drains. The program’s policy and procedures for chemical spills included notification to
master control, the shutdown of all affected air handlers and ventilation systems, the closing of
all windows and doors, and proper emergency procedures to be followed. The FA interview
confirmed the program’s disposal practices. An observation of the storage, inventory, and SDSs
was conducted for ten substances. All ten items were found in the designated storage area, with
an accurate inventory, and with the availability of the appropriate SDS.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 56 of 60 (Revised September 2022)
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 maintains a policy and procedures addressing youth handling and supervision of
flammable, poisonous, and toxic materials. The policy prohibits youth from using such items.
Youth do not have access to these items and are supervised by staff during daily cleaning.
Youth were not observed participating in facility clean-up during the week of the annual
compliance review. Nine youth were interviewed, and they all stated they do not use any
chemicals or cleaning products; nor do youth clean, handle, or dispose of any person’s bio-
hazardous materials, bodily fluids, or human waste.
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
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
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 57 of 60 (Revised September 2022)
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 regularly scheduled weekly visitation included within the program’s posted
daily activity schedule. There is a policy and procedures for youth to send and receive mail and
telephone calls. A review of the program’s visitation, telephone, and mail logs was conducted. It
was observed the program does hold visitation as scheduled; providing the ability and time for
youth to create correspondence and place telephone calls. The program has visitation on
Saturdays from 1:30 p.m. through 3:30 p.m.; additionally, the program has a back-up visitation
day scheduled every Sunday during the same hours. The program does have a policy and
procedures to create alternative visitation arrangements if necessary. Youth are encouraged to
utilize their free time to correspond with their family through written letters. Telephone calls are
based on a schedule within the housing units; youth can earn more time/calls with their family
through positive behavior choices. The director of case management confirmed the program’s
procedures for taking additional steps to verify all contacts with the assigned juvenile probation
officer for youth identified with a history of human trafficking. Mail is searched through the case
manager. The program utilizes a third-party language service when needed. Nine youth were
interviewed and eight confirmed their ability to write or call their parent/guardian; the remaining
youth is in the care of the Department of Children and Families and does not choose to
communicate with their family. The facility administrator’s interview confirmed the program has a
language service in order to ensure communication with all families.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a policy and procedures stating recreation activities shall be provided for a
minimum of one hour a day. The youth have a variety of recreation and leisure activities. The
program’s schedule has structured indoor and outdoor recreation and leisure activities which
include a large muscle activity for a minimum of one hour each day. A review of the program’s
logbooks since January 2024 indicated recreation was conducted as scheduled. The program
activities promote social and cognitive skill development, creativity, teamwork, healthy
competition, mental stimulation, and physical fitness. Recreational activities were observed
during the annual compliance review week and the program was observed taking precautionary
measures to prevent overexertion, heat stress, dehydration, frostbite, hypothermia, and
exacerbation of existing illness or physical injury. The program’s contract required a recreation
therapist, and each of the nine reviewed youth performance plans included recreational therapy
goals. The recreational therapist is on-site five days a week. Nine interviewed youth stated the
program allows the opportunity to exercise, play outside, read a book, play a board game, play
sports, or complete physical fitness activities. Nine youth also stated physical activities are
provided for at least one hour a day. Nine staff were interviewed and confirmed recreation was
occurring and included activities such as football, basketball, arts and crafts, board games, and
playing video games.
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Office of Accountability and Program Support Page 58 of 60 (Revised September 2022)
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 to ensure safety checks for youth on controlled
observation. A tour of the facility was completed, during which the controlled observation room
was viewed. The room used for controlled observation had a metal door with a shatter-resistant
window, was at least thirty-five unencumbered square feet, with properly covered vents and
lighting, an approved fire-retardant mattress, no electrical outlets, and the electrical switches
were located outside the sleeping room. The program placed a youth on controlled observation
one time during the annual compliance review period. The controlled observation report was
reviewed, and confirmed staff documented an inspection of the room and a same gender staff
searched the youth before the youth was placed in the 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 regarding controlled observation. The program
placed one youth on controlled observation during the annual compliance review period. The
controlled observation report was reviewed and included documentation the supervisory or
higher-level staff authorized placement. The youth in this incident was exhibiting behaviors
indicative of a mental health crisis or suicide, displaying active aggression, violent behavior, and
being physically out-of-control. Documentation reflected evidence staff needed to quickly gain
control and order for program safety and security. Staff advised the youth of the reason for
placement in controlled observation and the expected behavior for removal. A healthcare
professional or staff of the same gender as the youth completed the Health Status Checklist.
This youth did not require an extension which is required if placed for over the initial two hours,
as the youth was only in this status for under an hour and thirty-three minutes.
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 a policy and procedures to maintain controlled observation safety checks and
releases, including staff designations for controlled observation. The program had a single
controlled observation incident during the annual compliance review period. The controlled
observation report was reviewed and the staff making the placement completed the first page of
the controlled observation report and submitted it to a supervisor. Staff documented safety
checks at least once every fifteen minutes, along with observations of the behavior of the youth,
on the Controlled Observation Safety Checks form. The facility administrator (FA) or supervisor
who had delegated authority, gave written approval before the youth was released from
controlled observation. The controlled observation report, Health Status Checklist, and
controlled observation safety checks were maintained in an administrative record and in the
case management record of the youth. The FA or designee reviewed and approved the
controlled observation report within fourteen days of the youth’s release from controlled
observation.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 59 of 60 (Revised September 2022)
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 60 of 60 (Revised September 2022)

report_type: QI Residential