summary: QI Residential - FY23-24 - 2 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Kissimmee Youth Academy
Youth Opportunity Investment, Inc.
(Contract Provider)
2330 New Beginnings Rd
Kissimmee, Florida 34744
Review Date(s): October 17-20, 2023
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:
Yvrose Sylvain, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Nicos Antonakos, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Rob Aguis, Career and Technical Education Deputy Director (Standard 1)
Christine Calvert, Office of Accountability and Program Support, Regional Supervisor
(Interviews and Standard 5)
Rosa Flores, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Cindy Jones, Office of Education, Deputy Education Director (Standard 2)
Rondarrell George, Office of Accountability and Program Support, Regional Monitor (Standard
5)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Standard 4 and
5)
Shakela Minns, Office of Accountability and Program Support, Regional Monitor (Standard 2
and 4)
Program Name: Kissimmee Youth Academy MQI Program Code: 1426/1468
Provider Name: Youth Opportunity Investments, LLC Contract Number: 10287
Location: Kissimmee County / Circuit 9 Number of Beds: 95
Review Date(s): October 17-20, 2023 Lead Reviewer Code: 125
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
2.20 Educational Access*
5.08 Contraband Procedure
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 70 (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 Satisfactory
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 70 (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
2.19 Career Education Satisfactory
2.20 Educational Access* Limited
2.21 Education Transition Plan 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 70 (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 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Non-Applicable
3.18 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 70 (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 70 (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 Satisfactory
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 Limited
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 and Inventory 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 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.21 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.22 Visitation and Communication Satisfactory
5.23 Recreation and Leisure Satisfactory
5.24 Search and Inspection of Controlled Observation Room Satisfactory
5.25 Controlled Observation Satisfactory
5.26 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 70 (Revised September 2022)
Program Overview
Kissimmee Youth Academy is a ninety-five-bed program, for fourteen- to twenty-one-year-old
males located in Kissimmee, Florida. The program is operated by Youth Opportunity
Investments, LLC, through a contract with the Department. The program provides services
including high-risk Substance Abuse Overlay Services, high-risk Behavioral/Mental Health
Overlay Services (BHOS/MHOS), maximum-risk BHOS/MHOS, and high-risk Borderline and
Developmentally Disabled Services. The program fosters each youth by providing delinquency
intervention, gender specific services, and restorative justice services. Additional treatment
services provided include individual, family, and group therapy. Program administration is
comprised of one facility administrator, three assistant facility administrators, one director of
case management, one human resource/business manager, one administrative assistant, one
health services administrator, one food services manager, and one clinical director/designated
mental health clinician authority (DMHCA). Case management services are provided by five
case managers and two transition service managers. Mental health staff at the program
includes one contracted psychiatrist, one DMHCA, one licensed therapist, six mental
health/substance abuse therapists, and one contracted behavior analyst. Medical services are
offered daily and are provided by one health services administrator, three registered nurses,
and a contracted designated health authority who is a licensed medical doctor. Educational
services are provided by the Osceola County School District. The layout of the program includes
one self-contained building with two wings separated by a common hallway which houses
medical, staff offices, staff break room, and the administrative area. The program has 128
security cameras providing coverage, and all were operational at the time of the annual
compliance review. At the time of the annual compliance review, the program had twenty-six
vacant positions which included thirteen safety and security specialist positions, three shift
supervisors, two therapists, two case managers, two registered nurses, one recreation therapist,
one physical plant worker, one food service staff, and one master control technician.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 70 (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 maintains a written policy and procedures to ensure all newly hired staff and
volunteers receive an initial background screening. The program had forty newly hired staff and
one volunteer since the last annual compliance review. A review of the staff records found each
of the forty received a background screening prior to contact with youth and confidential
records. Documentation reflected a criminal history report was reviewed and the Staff
Verification System (SVS) module was updated for each of the forty staff. None of the reviewed
records were applicable for obtaining an exemption prior to working with youth or for a break in
service. The program utilizes a pre-employment assessment tool for all direct care staff.
Reviewed documentation reflected each of the applicable newly hired staff received a passing
score on the pre-employment assessment tool prior to hire. A background screening was
completed for the new volunteer prior to contact with youth and the SVS module was updated.
There were no interns eligible for an initial background screening since the last annual
compliance review. The Annual Affidavit of Compliance with Level 2 Screening Standards was
submitted to the Department’s Background Screening Unit (BSU) on January 24, 2023, meeting
the annual requirement. The Osceola County School District, which provides teachers for the
program, submitted the Annual Affidavit of Compliance with Level 2 Screening Standards to the
BSU on January 17, 2023.
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 maintains a written policy and procedures to ensure all staff and volunteers
receive a background rescreening every five years from their initial date of hire. The program’s
administrator tracks each staff’s hire date and intern/volunteer start dates to determine when the
five-year rescreenings should be submitted. The program had two staff applicable for a five-year
rescreening since the last annual compliance review. Each staff’s rescreening was completed
and submitted to the Department’s Background Screening Unit prior to their anniversary date.
Each rescreening was completed at least ten business days prior to each staff’s five-year
anniversary. There were no volunteers or interns applicable for a five-year rescreening since the
last annual compliance review.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 70 (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 maintains a written policy and procedures ensuring an environment free of abuse
and neglect and in which youth and staff feel safe and secure. The policy reflects youth and
staff have unhindered access to reporting alleged abuse to the Florida Abuse Hotline. The
policy outlines the reporting procedures for staff to follow when a youth would like to make an
abuse call. Additionally, the program maintains an employee handbook which outlines the
program’s code of conduct. All staff are required to sign and acknowledge receipt of the
employee handbook and code of conduct which outlines the grievance policies and their
understanding of the program’s code of conduct. A review of nine staff records found each
record contained documentation of acknowledgement, receipt, and review of the program’s
code of conduct. Observations conducted during the annual compliance review week found
postings of the Florida Abuse Hotline and the Department’s Central Communications Center
(CCC) throughout the program. The program’s practice for when a youth requests to call the
Florida Abuse Hotline is to have the youth care worker contact the shift supervisor on the radio,
and then the shift supervisor takes the youth to place the call. The program completed the
Trauma Responsive and Caring Environment (TRACE) self-assessment for the Borderline
Developmental Disability and Developmental Disability program on May 8, 2023, and on June 8,
2023, for the Mental Health Overlay Services and Substance Abuse Treatment Overlay Service
programs. A review of all incidents since the last annual compliance review found there were
twelve incidents which involved complaints related to physical, psychological, or emotional
abuse, and each incident was closed as substantiated. The program had seventy reportable
incidents since the last annual compliance review, of which seven were reviewed. The Florida
Abuse Hotline and/or the CCC was notified as required for each reviewed incident. There were
no applicable cases for any potential human trafficking victims, children of sexual exploitation, or
labor trafficking reported at the time of the annual compliance review. Nine youth were
interviewed, and each reported never being stopped from reporting abuse to the Florida Abuse
Hotline or CCC and each youth knew where the telephone numbers were posted. Eight of the
nine youth reported staff are respectful when speaking with them and one reported some staff
are not respectful. All nine youth reported they have never exchanged personal contact
information with staff. Four youth reported never hearing staff use profanity when speaking to
youth, three reported occasionally, one reported once, and one reported often. All nine
interviewed youth reported feeling safe in the program. All nine interviewed staff explained the
process for allowing staff and youth to call the Florida Abuse Hotline or the CCC to report
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 70 (Revised September 2022)
suspected abuse. All interviewed staff reported they either knew or had access to the numbers
for the CCC and the Florida Abuse Hotline. All interviewed staff reported they never observed a
co-worker use profanity when speaking to youth and never observed a co-worker telling a youth
they could not make an abuse call. An interview with the facility administrator (FA) explained
staff alleged of abuse are removed from youth contact pending an investigation and, depending
on the severity of the incident, staff can be terminated on the first offense. The FA reported the
program completed the TRACE assessment and staff are trained on trauma responsive care.
The FA reported, when a youth requests to make an abuse call, the shift supervisor takes the
youth to go place the call.
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 maintains a written policy and procedures regarding abuse reporting, which is
following the Department’s criteria for reporting abuse. The program’s practice is to initiate an
internal investigation regarding the complaint and remove the staff involved from contact with
youth, when necessary. The program had twelve allegations related to physical, psychological,
or emotional abuse involving a staff since the last annual compliance review, of which seven
were reviewed. Reviewed documentation found management took immediate action regarding
the staff involved incidents by initiating an internal investigation in all incidents. In three
incidents, the staff failed to properly supervise youth and a written/oral reprimand was issued to
each staff involved. In one incident documentation supported the staff was no longer employed
at the program when the complaint of the allegation was reported. Documentation indicated one
staff was terminated based on the outcome of the internal investigation and the nature of the
incident. In one incident, documentation supported the staff received a coaching session. The
conclusion of the final incident documented there were four staff involved. Three of the four staff
violated policy, and a written/oral reprimand was issued to each staff involved. There was no
evidence to support the allegations against the fourth staff and no action was necessary. An
interview with the facility administrator (FA) reported there has been one staff terminated due to
allegations of abuse since the last annual compliance review. The FA explained all allegations
of abuse are reported to the Department’s Central Communications Center (CCC) within two
hours of the incident or becoming aware of the incident.
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 maintains a written policy and procedures regarding response to incidents in
accordance with Florida Administrative Code. The program had seventy reportable incidents
since the last annual compliance review. A review of seven incidents found five were reported to
the Department’s Central Communications Center (CCC) within two hours of the incident or staff
becoming aware of the incident. One incident was reported by a youth’s parent/guardian and
one incident was reported one month late. All seven incidents were documented in the
program’s logbook. A review of the program’s internal incident reports found there were no
additional incidents which should have been reported to the CCC and were not. The program
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 70 (Revised September 2022)
has experienced an increase in the number of reportable incidents to the CCC compared to the
last annual compliance review period. An informal interview with the program’s facility
administrator (FA) confirmed the program has a policy in reference to the CCC and ensures all
matters which require reporting are verbally reported within two hours of when the program
became aware of the incident. In addition, the FA stated the program received several transfer
youth from other programs, which suddenly increased the youth population, and lead to an
increase in reportable incidents to the CCC.
1.06 Protective Action Response (PAR) and Physical
Satisfactory Compliance
Intervention Rate
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 PAR Incident Report is completed and filed in accordance with the Florida
Administrative Code.
The program maintains a written policy and procedures regarding the utilization of physical
intervention techniques in accordance with Florida Administrative Code. The program had four
Protective Action Response (PAR)/Right Interactions (RI) incidents since the last annual
compliance review. There was documentation to support a monthly summary of PAR/RI Reports
was submitted to the Department each month since the last annual compliance review. A review
of the four PAR/RI Reports found all involved staff completed appropriate statements prior to the
end of their shift. The PAR/RI Reports were reviewed and processed within seventy-two hours
by all required parties. A PAR/RI medical review was conducted for each incident and
documentation supported each youth was seen by nursing staff for the post-PAR/RI medical
review. Documentation supported copies of the PAR/RI Reports were reviewed and placed in
the program’s centralized file within forty-eight hours of each approved incident. The program’s
PAR/RI Plan was approved by the Department’s Office of Talent, Leadership, and Culture on
January 27, 2023. The program experienced a decrease in the number of PAR/RI Reports
compared to the last annual compliance review period. The program’s PAR/RI rate during the
previous quarter was 0.62, which is below the statewide Residential PAR/RI rate of 1.35. Three
of the nine interviewed staff reported they never used PAR/RI, and six reported they used
PAR/RI and were able to explain the program's PAR/RI process and procedures. An interview
with the FA reported the staff complete a PAR/RI Report and submitted to the FA for review. In
addition, there is a follow-up mediation which is completed between the youth and staff.
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.
The program maintains a written policy and procedures regarding a pre-service training plan for
all new staff. The pre-service training is provided through a combination of instructor-led and
web-based courses. Nine staff training records were reviewed for pre-service certification
training. All nine reviewed training records documented each staff completed the certification
process within 180 days of hire. All nine staff training records showed documentation to support
each staff exceeded the required 120 hours of pre-service training. Completed trainings
included Protective Action Response (PAR)/Right Interactions (RI), first-aid, cardiopulmonary
resuscitation (CPR), automated external defibrillator (AED), professionalism and ethics, suicide
prevention, emergency procedures, child abuse reporting, Prison Rape Elimination Act (PREA),
and Facility or Program Operating Procedures prior to having any contact with youth. The
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 70 (Revised September 2022)
program’s contract outlined program specialist training and thirty-two hours of job specific
training for safety and security specialists. The program considers case managers,
operations managers, and assistant facility administrators (AFA) as direct care staff and
includes them for in the staff-to-youth ratio. All completed trainings were documented in the
Department’s Learning Management System (SkillPro) and were delivered by qualified trainers.
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 maintains a written policy and procedures regarding in-service training for all staff.
Nine staff training records were reviewed for in-service training. All nine reviewed staff training
records documented each staff exceeded the twenty-four hours of annual in-service training
requirements. All nine staff had current certifications in Protective Action Response (PAR)/Right
Interactions (RI). Each staff had certification in first-aid, automatic electronic defibrillator (AED),
and cardiopulmonary resuscitation (CPR). Each of the three applicable staff completed the eight
hours of management/supervisory training in the areas of coaching, leadership, and personal
accountability. The program has a training calendar which is updated as changes occur. All
trainings were delivered by qualified trainers and were documented in the Department’s
Learning Management System (SkillPro). The program maintains a written in-service training
plan which was submitted to the Department’s regional director on November 30, 2022.
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 maintains a written policy and procedures regarding the grievance process.
According to the program’s policy, procedures are in place to confirm each youth’s right to
grieve and ensure all youth are treated fairly, respectfully, without discrimination, and their rights
are protected. The program’s grievance procedures include informal, formal, and appeal phases
with a time frame of two days to provide feedback to the youth and to correct the grieved
situation or condition. The youth are also provided with the opportunity to file an alternative
informal request by utilizing a “Request to Speak” form as a first opportunity to voice an
objection and informally resolve a complaint. Grievance and “Request to Speak” forms were
available to youth as observed during the program tour. Reviewed documentation found there
were two grievances and several “Request to Speak” forms submitted by youth since the last
annual compliance review. A review of both formal grievances revealed the youth’s grievances
were resolved at the formal phase. Each grievance was addressed within the two-day time
frame. Nine pre-service staff training records and nine in-service training records were
reviewed. All eighteen training records documented each staff received the required training on
the program’s grievance process and procedures. During the annual compliance review, nine
youth and nine staff were interviewed. All nine youth were able to explain the grievance process
to include submission of a completed grievance form into the secured grievance box. Eight of
the nine interviewed youth reported being able to request assistance in completing a grievance
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 70 (Revised September 2022)
form if needed and one reported they never completed a grievance. All nine interviewed staff
were able to explain the grievance process. An interview with the facility administrator (FA)
reported the grievance process has three phases which consist of informal, formal, and appeal
phases.
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program has a written policy and procedures regarding delinquency interventions and
facilitator training. During the annual compliance review period, the program provided LifeSkills
Training (LST) and Trauma Focused-Cognitive Behavioral Therapy (TF-CBT) groups to youth. A
review of the program’s activity schedule and sign-in sheets confirmed youth were participating
in groups. The program had six group facilitators. All six facilitators had a master’s-level degree
or licensed mental health counselor credentials and were trained to facilitate groups. A review of
the program’s activity schedule verified all contractually required groups were provided as
scheduled. A review of the program’s activity schedule confirmed the program is providing
structured, planned programming, or activities at least sixty percent of the youth’s waking hours.
An interview with the facility administrator (FA) reported the program provides groups and all
youth participate in daily group sessions facilitated by a trained mental health professional. An
interview with the program’s clinical director verified staff’s education and work experience were
considered when determining staff delivery of delinquency intervention services.
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 maintains a written policy and procedures to address life skills training for youth.
The program provides life skills training through LifeSkills Training (LST) groups and incorporate
health and hygiene skills. The life skills groups specifically address communication,
interpersonal relationships and interactions, non-violent conflict resolution, anger management,
and critical thinking. A review of the program’s activity schedule confirmed the LST group is
provided to the youth once a week by the therapist. All staff conducting groups received formal
training and on-the-job training by a certified trainer to deliver the curriculum. A review of nine
youth case management records and group sign-in sheets indicated services were delivered, as
required. Nine interviewed youth reported they participated in life skills groups while at the
program. All nine interviewed youth reported they were able to demonstrate the skills during role
play activities in groups such as communicating better with peers, self-control, and how to say
no. An informal interview with the clinical director stated youth can practice skills in group role-
play activities, learn how to handle situations in a positive way, and how to interact better with
staff and other youth daily while at the program.
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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’s restorative justice programming includes Impact of Crime (IOC) groups, which is
a primary service. In addition, youth participate in reparation activities at the program. The
program administrators explained youth regularly participate in community service projects,
assist maintenance staff with cleaning of the program’s recreation yard, assemble hygiene
packages/kits for the local homeless shelter, and listen to guest speakers as part of their
restorative justice activities. The groups and activities are designed to assist youth in accepting
responsibility for harm they have caused by their past criminal actions, challenging them to
recognize and modify their irresponsible thinking such as denying, minimizing, rationalizing, and
blaming victims, and expose youth to victims’ perspectives through victim speakers. The
interviewed facility administrator (FA) reported restorative justice programming included youth
spot painting dormitory room doors, walls, and cleaning the program of debris. An interview with
the designated mental health clinician authority explained restorative justice is provided
throughout the week from different group projects or activities at the program. The program did
not have youth participating in restorative justice activities during the week of the annual
compliance review; therefore, an observation was not made. Eight of the nine interviewed youth
reported they participated in restorative justice groups/activities while at the program and one
reported they had not yet started.
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 written policy and procedures addressing youth alerts. The program enters
alerts into the Department’s Juvenile Justice Information System (JJIS) for youth requiring an
alert which may not have been entered prior to the youth’s admission. The program has an alert
board in the main conference room, which identifies each youth’s special alerts, escape risk,
and/or gang affiliation. The alert board also identifies youth placed on any type of mental health
alert. Reviewed documentation indicated the program’s internal alert report is reviewed daily
during shift briefings by the program's supervisory staff. Observations verified kitchen staff have
access to each youth’s diet and allergy alerts in the kitchen. Nine youth records were reviewed
for case management, medical, mental health, and substance abuse alerts. All applicable alerts
were accurately entered into JJIS. All internal and JJIS alerts were downgraded or discontinued
by a medical staff, the director of case management, and/or licensed mental health staff. Nine
staff were interviewed, and each reported they are informed of youth alerts during shift
meetings, a review of the program’s alert board, and a review of the medical binder. An
interview with the facility administrator (FA) reported all internal alerts are entered into JJIS by
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their specific departments and medical alerts are updated and provided to the shift supervisor
daily. The program’s FA stated youth alerts are reviewed daily during morning management
meetings and any change in medical alerts are emailed to all staff. The nursing interview
reported all nurses are responsible for updating the medical alert system.
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 has a written policy and procedures to ensure the management of all records are
consistent across operations and programs, the company philosophy, goals, objectives, and
the legal and contractual requirements. A review of nine youth healthcare, mental health and
substance abuse, and case management records showed each was marked “Confidential” and
each record documented the youth’s name, Department identification number (DJJID), the
youth’s date of birth, county of youth’s residence, date of admission, and committing offense.
Observations during the annual compliance review week showed all Individual Healthcare
Records, mental health and substance abuse records, and case management records were
secured in a locked room, which was not accessible to youth.
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 community advisory board which meets quarterly. Reviewed documentation
supported the program’s community advisory board meets at least quarterly; however,
participant attendance is continuously less than five people. The reviewed meeting minutes,
sign-in sheets, and agendas documented meetings occurred on December 21, 2022, March 31,
June 13, and September 20, 2023. Documentation also showed community advisory board
meetings are held in-person and utilizing a video conferencing software program for those
members who cannot attend in-person. The advisory board members currently consist of a
member from law enforcement, judiciary community member, interested community partners, a
community business member, a school board member, a victim advocate, a parent/guardian
whose child was previously involved in the juvenile justice system, and a faith-based community
member. A review of community advisory board agendas and meeting minutes documented the
program provides the board members with information regarding program updates, community
updates, and community service activities. An interview with the facility administrator (FA)
reported the program meetings are held quarterly. The program’s FA reported invitations are
sent to community members by mail and email with a calendar invite. A follow-up call for
confirmations is also made if a response is not given from the invites, which is a recruitment
effort to increase attendance. An advisory board member was called, however, the call was
unsuccessful with no answer or return call.
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1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program conducts ninety-day performance evaluations for newly hired staff and annual
evaluations for all staff thereafter. Nine staff personnel records were reviewed, of which five
contained an annual performance evaluation, and four contained a ninety-day performance
evaluation. The performance evaluations were specific to the applicable staff’s job description.
All nine reviewed performance evaluations found each staff’s evaluation was based on the
performance standards for their position. The evaluations rated the staff’s quality of work,
modeling of appropriate behavior, a positive reinforcement in a four-to-one ratio, and each
evaluation included ratings on the staff’s job-specific responsibilities. Nine staff were
interviewed, and six staff reported receiving an annual evaluation, three reported receiving a six-
month evaluation, and one staff also reported receiving a monthly evaluation. Four staff
reported communication amongst staff is very good, three reported good, and two reported fair.
An interview with the facility administrator (FA) reported staff are evaluated after their first ninety
days and annually, thereafter, on their job performance.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program’s contract is an older contract which did not clearly identify any special conditions
within the Memorandum of Negotiation (MON) with the exception of an increased budget. A
review of the program’s contract reflected certain conditions which were specific to the program
to include special visitations, religious offerings, resources for expectant fathers, and gas cards
for families. The program conducts special visitations and family sessions through zoom for
parents/guardians who are unable to visit the program. The program also partners with a
Christian based organization to come on-site twice a month to provide church services to the
youth. Additionally, when a youth is an expectant father, the program will assist the youth in
having an opportunity to view their child’s birth through video conferencing. Finally, the program
provided gas cards to parents/guardians who needed assistance with attending family day due
financial barriers since the last annual compliance review.
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1.18 Contract Specific Career and Technical Education
Satisfactory Compliance
Services
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), Special Conditions, or older contracts may not have them clearly identified as a
special condition. Career and technical education service instruction shall be provided so the
interests, aptitudes, and skills of the youth are developed, while building upon their existing
strengths, in a manner supportive of their employability goals which provide an occupational
advantage and workforce readiness in their community. These items may exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code.
The program maintains a written policy and procedures regarding contract specific career and
technical education (CTE) services. The program’s contract requires the program to provide
CTE services by the provider or directly by the local school district. The local school district, in
conjunction with the program, offer Entrepreneurship and Small Business and Agriculture
Associate certifications. The program is offering Occupational Safety and Health Administration
(OSHA) 10 and OSHA-30 certifications. The program has a plan to begin Florida Ready to Work
Soft Skills and is working with the school district to unblock the site to begin this work. The
program is successfully offering, and youth are earning certifications in, first-aid and
cardiopulmonary resuscitation (CPR) training as the pre-vocational and vocational services.
Youth certifications were reviewed, and the program is successfully offering two certifications
from the Career Source Master Credentials List, which include Entrepreneurship and Small
Business. The program is offering rapid credentials such as first-aid and CPR training to youth
as required. Throughout the annual compliance review period, eleven youth were taking CPR
and first-aid and each was certified, thirty-two were participating in the Agriculture Associates
certification and two earned their certification, fifty-five were participating in Entrepreneurship
and Small Business and seven earned certifications, four youth participated in OSHA-10 and
each earned certifications, and one participated in OSHA-30 and earned a certification. The
program implemented a designated time for CTE built into the education schedule Monday
through Friday. CTE is age appropriate for the youth in the program, appropriate for the abilities
and goals of the youth in the program, and appropriate for the length of stay and classification of
youth in the program. Participation in CTE was unable to be observed during the annual
compliance review week. Nine youth were interviewed and each youth reported daily and
weekly participation in these services. Youth are also participating in Project Anchor, in college
courses, or earning their high school equivalency diplomas (GED). The facility administrator
(FA) was interviewed and reported the program will offer Florida Ready to Work Soft Skills in
collaboration with the school district, Entrepreneurship and Small Business, basic first-aid,
OSHA-10, and OSHA-30.
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1.19 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 written policy and procedures which include data trend analysis
components. The program’s administration and management discussed research efforts to
enhance operations and contribute to the base knowledge of the Department’s practice. The
program’s quality assurance policy is designed to objectively and systematically monitor and
evaluate program outcomes, and ensure the program services are consistent and effective.
Youth Opportunity Investments, LLC has development processes, research, and analytics which
incorporate all of their programs. According to the program administrator, the program conducts
interviews with families and youth, tracks outcome measures, monitors incident reports,
conducts fidelity monitoring, tracks evidenced-based services, and performs quality
improvement audits. The program has several data collection reports, to include monthly
incident report trackers, monthly key performance indicator (KPI) data, and survey analysis
reports. Documentation showed data is shared through monthly monitoring and verification
meetings where the facility administration provides response and measures to address any
identified trends with the corporate team. The program staff are made aware of data trends
reports monthly during all staff meetings. The program’s facility administrator (FA) is responsible
for completing any follow-up needs identified on the data trends monthly reports and submitting
the required update to the corporate team. For example, if trends are identified on a particular
shift, the program’s FA can target those particular time frames for management to focus more
on those areas. Survey results also provide opportunities to target identified areas such as staff
morale or youth input.
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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 written policy and procedures regarding initial contact to the parent/guardian
and court notification after each youth’s admission. Nine youth case management records were
reviewed, and all contained documentation in the chronological notes indicating the
parent/guardian was contacted by telephone and informed of each youth’s arrival and program
information. Each of the nine youth case management records contained written notification to
the youth’s parent/guardian within twenty-four hours of the youth’s admission to the program.
Each of the reviewed case management records contained documentation verifying the
program notified the youth’s committing court and juvenile probation officer (JPO) on the day of
the youth’s admission or within five working days of the youth’s admission to the program.
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 written policy and procedures regarding youth orientation. Nine youth case
management records were reviewed. All nine youth case management records indicated the
program provided each youth with an orientation within twenty-four hours of admission. The
orientation included all required elements such as services available, the daily schedule,
expectations and responsibilities, the written behavior management system, which was
conspicuously posted and provided in the resident handbook, access to medical and mental
health services, access to the Florida Abuse Hotline, zero-tolerance policy regarding sexual
misconduct, special accommodations, the right to be free from sexual misconduct, and items
considered to be contraband. The orientation also included the performance planning process
involving the development of goals for each youth to achieve, dress code and hygiene practices,
procedures on visitation, mail, use of the telephone, expectations for release from the program,
community access, grievance procedures, emergency procedures, a program tour, living unit
assignment, treatment team, and medical topics. The program had one youth admission
scheduled during the annual compliance review week. Observations validated the program’s
admission and orientation process. Nine youth were interviewed, and all youth confirmed
receiving an orientation within twenty-four hours of admission. Each youth indicated the
orientation to the program included program rules, procedures, and schedules. Each youth was
able to explain the orientation process.
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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 written policy and procedures to address consent for youth who are
eighteen years of age or older. The policy requires the program to obtain written consent of any
eighteen-year-old youth prior to providing or discussing any information related to the youth’s
physical or mental health screenings, assessments, or treatments with the youth’s
parent/guardian. Three of the nine reviewed youth case management records were applicable
for the youth being eighteen years of age or older. Each of the three applicable records
contained the signed written consent of the eighteen-year-old youth obtained on the day the
youth turned eighteen.
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 written policy and procedures to address the classification process and
reassessment for activities. The program’s classification includes a review of physical
characteristics, age, maturity level, identified special needs including medical and mental health,
developmental, intellectual, and physical disabilities; history of violence, applicable gang
affiliation, criminal behavior, sexual aggression, vulnerability to victimization, and identified or
suspected medical, suicide, escape, or security risk. Safety and security risks are identified to
assist the staff in guiding the decision-making process determining each youth’s living unit
assignments, room assignment, and the staff assigned to the youth. Nine youth case
management records were reviewed. Each of the youth case management records contained a
completed Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) risk
assessment which was entered into the Department’s Juvenile Justice Information System
(JJIS) prior to each youth’s room assignment. Seven of the nine reviewed youth records
identified suspected risk factors. Three youth had a medical risk, one youth was an escape risk,
and seven youth had a security risk. Reassessments for classification were completed during
monthly treatment team meetings and prior to an increase in privileges and/or participation in
work projects. The facility administrator (FA) was interviewed and indicated all youth participate
in an admission classification meeting where the history, special needs, risk factors, sets of
alerts, and identified safety and security risks which will directly impact living room assignments
and group placement are reviewed.
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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 written policy and procedures regarding gang identification and notification
of law enforcement. Nine youth case management records were reviewed and three were
applicable for gang identification and notification to law enforcement. Each of the three
applicable youth case management records documented the program notified local law
enforcement and law enforcement in the youth’s home county. The documentation reviewed for
each applicable case management record indicated the program notified the education provider,
and the youth’s juvenile probation officer (JPO) regarding the youth’s gang involvement. A gang
alert was entered into the program’s internal alert system and the Department’s Juvenile Justice
Information System (JJIS) for each youth.
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 written policy and procedures regarding gang prevention and intervention
strategies. The program’s policy and procedures address providing program youth an
opportunity to develop plans to disaffiliate with criminal street gangs. Nine youth case
management records were reviewed, and three were applicable for gang affiliation/identification.
Each of the applicable case management records validated the youth were participating in gang
prevention and intervention activities. Each of the youth’s performance plans included relevant
goals and objectives relating to gang intervention strategies. A review of the sign-in sheets for
the annual compliance review period indicated each of the applicable youth were participating in
monthly gang groups as designated. Additionally, the program provides Impact of Crime (IOC)
groups to bring gang prevention and awareness to each youth in the program. The interviewed
facility administrator (FA) indicated the program’s gang intervention strategies include monthly
youth participation in gang intervention/prevention services using the Choices curriculum, and
youth are given assignments to complete. Additionally, the FA indicated, youth also participate
in the curriculum for IOC groups for prevention.
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 written policy and procedures to address the completion of the Residential
Assessment for Youth (RAY) and reassessments. The policy requires the completion of an
initial RAY within thirty days of admission to the program, the completion of a reassessment at
least ninety days after completion of the initial RAY, and at least every ninety days after each
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subsequent reassessment. Nine youth case management records were reviewed, and eight
records were applicable for RAYs and reassessments. One youth was not applicable as the
youth had not reached the thirty-day time frame from admission. Each of the eight applicable
records documented the initial RAY was completed within thirty days of admission. Each of the
eight applicable records had a RAY Reassessment completed. All of the applicable youth’s
reassessments were completed, meeting the required time frames. All RAYs and RAY
Reassessments were completed in the Department’s Juvenile Justice Information System (JJIS)
and documented in the youth’s case management record.
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 JJIS on the YNAS.
The program has a written policy and procedures to address the completion of a Youth Needs
Assessment Summary (YNAS) within thirty days of admission. Nine youth case management
records were reviewed, and seven youth records were applicable. One youth was not applicable
as the youth had not reached the thirty-day time frame from admission, and one youth was not
applicable as they were a transfer from another program and the YNAS was completed from the
other program. Each of the applicable records contained a YNAS which was completed within
thirty days of the youth’s admission to the program. Each YNAS 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.
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 written policy and procedures to address the development of the
performance plan, goals, and plan transmittal. The treatment teams are required to develop an
Individualized Performance Plan within thirty days of the youth’s admission to the program. Nine
youth case management records were reviewed, and eight records were applicable. One youth
was not applicable as the youth had not reached the thirty-day time frame from admission. Each
of the applicable records contained a performance plan completed by the program within thirty
days of the youth’s admission. All the performance plans were developed after the initial
assessment. Each performance plan was developed by the treatment team and all relevant
members participated during the development, including parents/guardians, the youth,
administrative representative, living unit representative, treatment staff, educational staff, and/or
the Department of Children and Families (DCF) counselor. The goals were individualized and
based on prioritized needs, reflecting the risk and protective factors identified during the initial
assessment. All performance plans contained target dates for completion of goals, youth
responsibility to accomplish goals, and the program’s responsibilities to assist the youth to
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achieve the goals. Each of the eight youth’s initial performance plans referenced the court-
ordered sanctions which were reasonably able to be completed in the program. Each of the
youth’s initial performance plans referenced the specific delinquency interventions based on the
Residential Assessment for Youth (RAY) results. Each of the performance plans included
transition goals for the youth to complete prior to release from the program. Each of the
performance plans included the top three criminogenic needs to be addressed. Each of the
performance plans were signed by the youth, treatment team leader, and all parties who had
significant responsibilities in goal completion. All of the applicable youth case management
records documented a transmittal letter and copy of the performance plan was sent to the
committing court, juvenile probation officer (JPO), and parent/guardian within ten working days
of the plan being completed. All of the eight applicable performance plans were mailed to each
parent/guardian with request to sign and return; however, there were no signed parent/guardian
signature pages returned. Reviewed documentation for the applicable youth in the care of DCF
indicated the performance plan was sent to the DCF caseworker. Nine youth were interviewed,
and each youth reported they were aware of their current performance plan goals and each
youth indicated they had a copy of their performance plan. Each of the youth reported they
participated in the development of their performance plan.
2.10 Performance Plan Revisions Satisfactory Compliance
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team.
The program has a written policy and procedures to address revisions to Individualized
Performance Plans, when determined necessary by the intervention and treatment team. The
policy requires revisions when new criminogenic needs are identified during the Residential
Assessment for Youth (RAY) Reassessments, when the youth demonstrate progress or lack of
progress toward completing a goal, or when new information is acquired or revealed. Nine youth
case management records were reviewed. Eight of the nine reviewed records were applicable
and contained a performance plan with revisions due to newly acquired information, the youth’s
progress towards completing goals, and/or lack of progress toward goal completion. One youth
record was not applicable for a RAY Reassessment because the youth was not in the program
for ninety days.
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 written policy and procedures to address the requirements for completion of
Performance Summaries every ninety days. Performance Summaries are due within ninety
days of the signing of the youth’s performance plan, or earlier, if requested by the committing
court. The policy further requires the treatment team to prepare a Performance Summary prior
to the youth’s release, discharge, or transfer from the program. The Performance Summary
provides information to the youth, parent/guardian, juvenile probation officer (JPO), and other
parties related to the status of each performance goal and describes the youth’s overall
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adjustment to and performance in the program. Nine youth case management records were
reviewed and eight were applicable for the completion of at least one Performance Summary
and transmittal. Each of the reviewed summaries were completed within ninety days of the
performance plan. Each of the eight reviewed summaries contained all the elements required
including the youth’s status on each goal, treatment progress, academic status, behavior, level
of motivation/readiness to change, interaction with peers, interaction with staff, adjustment to
the program, and positive/negative events. Each youth was given the opportunity to read and
add comments to their Performance Summaries. Each of the youth’s case management records
contained a signed form by the youth which stated the youth was provided a copy of their
Performance Summary. Each of the reviewed summaries were signed by the applicable
treatment team members, including the youth. Each of the applicable reviewed summaries were
filed in the youth’s case management record and were sent to the committing court, JPO, and
parent/guardian within ten working days of completion. Three applicable closed youth case
management records were reviewed for release summaries. Each of the reviewed records
contained a copy of the original summary sent at least forty-five days prior to the youth’s
anticipated release date, along with the Pre-Release Notification (PRN) to the JPO. Each
summary contained the justification for release. Each of the closed youth case management
records documented the program provided written notification to the parent/guardian of the
approval for release. All of the closed case management records retained a signed copy of the
Performance Summary. The program completed an Exit Residential Assessment for Youth
(RAY) for the exit assessment in each record. The Sexually Violent Predator Program (SVPP)
and victim notifications did not apply to the reviewed records. The program provided the
Performance Summary and transition plan to the JPO for each 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 written policy and procedures to address the inclusion of parents/guardians
in the case management process. Nine youth case management records were reviewed. Each
record documented the case manager sent an admission letter to the parent/guardian, which
included the dates/times for treatment team meetings. Each case management record
contained documentation to show the parent/guardian was involved in the assessment process
and participated in the development of the Individualized Performance Plan. A copy of the
performance plan was mailed to each parent/guardian with a request to sign and return the
signature page. There was documentation to show the parent/guardian was called for each
treatment team meeting. A treatment team meeting was observed during the annual compliance
review week. The director of case management contacted the parent/guardian of the youth, as
well as the youth’s juvenile probation officer (JPO), and were all able to participate in the
treatment team meeting along with all required staff. The youth’s status, goals, and progress
were discussed in the meeting. Nine youth were interviewed, and eight of the nine youth
reported their parents/guardians are involved in the case management process, treatment team
meetings, and therapy sessions. One youth reported their juvenile probation officer (JPO) and
Department of Children and Families (DCF) case manager were involved. An interview with the
facility administrator (FA) indicated the program encourages parental/guardian involvement with
the youth and family through the case management process, in which parent/guardians are
provided with the parent/youth handbook and are also notified of the youth’s informal and formal
treatment team meetings by mail and are invited by telephone. Additionally, the program sends
invitations to the youth’s parent/guardian or family for the program’s quarterly family day.
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2.13 Incorporation of Other Plans into Performance Plans Satisfactory Compliance
The youth’s performance plan shall reference or incorporate the youth’s treatment or care
plan.
The program has a written policy and procedures in place to ensure academic plans, treatment
plans, and Department of Children and Families (DCF) plans, if applicable, are included in the
youth’s performance plans. Nine youth case management records were reviewed. Each record
contained an Individualized Performance Plan. None of the reviewed case management records
were applicable for the incorporation of any other plans. The one youth applicable for DCF
placement did not have an additional plan requiring incorporation. The interviewed director of
case management indicated the program does not currently have any youth requiring an
incorporation of other plans. The program’s practice is to include education and mental health
treatment in the plans, and reviewed plans verified this practice.
2.14 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.
A program shall ensure the intervention and treatment team meets bi-weekly (formally and
informally) to review each youth’s performance, to include RAY Reassessment results,
progress on Individualized Performance Plan goals, positive and negative behaviors,
including behaviors resulting in physical interventions. If the youth has a treatment plan,
review their treatment plan progress.
The program has a written policy and procedures to address the provision of intervention and
treatment teams 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 meetings. The treatment teams are
required to meet every thirty days to formally review each youth’s performance, to include
Residential Assessment for Youth (RAY) Reassessment results, progress on Individualized
Performance Plan goals, and positive and negative behavior, including behavior which resulted
in physical interventions. The policy requires the case manager to conduct informal reviews of
each youth’s performance bi-weekly. The case manager meets with the youth during informal
reviews and incorporates input from treatment team members, as needed. The policy identifies
the case manager to be the treatment team leader. The program’s treatment team members
consist of the case manager/treatment team leader, youth, and representatives from program
administration, education, the youth’s living unit, mental health treatment, education, and
medical. The youth’s parent/guardian or the Department of Children and Families (DCF) case
worker, the transition case manager, and the juvenile probation officer (JPO) are included as
part of the treatment team, when applicable. Nine youth case management records were
reviewed. Each of the records documented formal treatment team reviews were held at least
every thirty days. Treatment team documentation included the youth’s name, date of review,
comments from treatment team members, progress in the program, progress of goals,
behaviors, skills, treatment progress, and RAY Reassessment results. All nine case
management records had documentation showing informal reviews were conducted bi-weekly.
Documentation of informal reviews included the youth’s name, date of review, comments from
treatment team members, progress in the program, progress of goals, behaviors, skills, RAY
Reassessment results, and treatment progress. Each of the reviewed records documented the
notification to the required participants of the treatment team meetings and who attended. If the
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parent/guardian and/or JPO did not participate in the treatment team meeting, there was
documentation to show attempts to contact the parent/guardian and JPO. All forms contained
signatures from required team members. During the annual compliance review week, a
treatment team meeting was observed, and observations confirmed all required participants
were present at the meeting. Nine interviewed youth reported the staff review each youth’s
performance on the performance plan, goals, behavior, and treatment progress. Each youth
indicated they felt they can demonstrate the skills learned in the program, and were able to
articulate their involvement during treatment team meetings.
2.15 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program has a written 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 (FA) or designee attended the
transition conference in each of the reviewed youth case management records. Each reviewed
record documented the youth’s juvenile probation officer (JPO), parent/guardian, education
staff, and any 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. Reviewed
documentation validated the treatment team leader obtained attendees’ dated signatures
representing their acknowledgement of the transition goals and accountability for completion. A
copy of each plan was mailed with a request for return with signature to the parent/guardian and
JPO. Each record confirmed the CRT meeting was conducted prior to the youth’s release and
both the youth and case manager participated in the CRT meeting.
2.16 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 written 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. Reviewed documentation revealed the applicable
exit portfolios included a copy of the transition plan, calendar with all dates, times, and locations
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of upcoming community appointments, Social Security card, birth certificate, State of Florida
identification card, educational or vocational certificates, educational record, school transcripts,
résumé, and sample employment applications. Two of the youth’s closed case management
records did not contain a state identification card due to the parent/guardian failing to provide
the required documents to the program. Two youth’s closed case management records did not
have a Social Security card and birth certificate due to the parents/guardians failing to provide
the required documents to obtain it. The program provided requests to obtain the documentation
for the youth. One of the applicable exit portfolios did not include an educational or vocational
certificates due to the youth not having earned any in the program. Reviewed documentation for
each record validated the youth’s exit portfolio was verified during the exit conference and the
exit portfolio was given to the youth upon release. Each record indicated the exit portfolio was
provided to the youth’s juvenile probation officer (JPO). Each youth record was applicable and
contained documentation evidencing the youth was provided with completed forms and clear
instruction as to how to obtain the information. Additionally, during the transition conference a
plan was put into place as to who would be responsible for working with the youth to obtain the
items.
2.17 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 written policy and procedures regarding an exit conference for each youth to
review the status of goals developed at the transition conference and to finalize the release
plan. Three closed youth case management records were reviewed and the exit conference for
each youth was conducted after the program notified the juvenile probation officer (JPO) of the
release and at least fourteen days prior to the youth’s release. Each exit conference included a
summary of pending transition goals, date of the conference, and signatures of all applicable
participants. A review of the Department’s Juvenile Justice Information System (JJIS) revealed
the date of admission and date of termination documented in the case management record for
each youth correlated with JJIS. Reviewed documentation for each record validated the status
of transition activities established at the transition conference were reviewed and updated
during the exit conference. For each reviewed record, all required and applicable members
participated in the exit conference. Each exit conference was held separately from the transition
and Community Re-Entry Team (CRT) meetings.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a formal process in place to promote constructive input by youth. The program
has the grievance process, “Request to Speak” forms, and the student council/youth advisory
council. The forms are maintained in the youth’s dormitories, along with the form drop box. The
youth can submit the form when seeking a discussion with a staff or when requesting any
needed item. Observations during the annual compliance week confirmed the forms were
located in the youth’s dormitories. The program’s “Town Hall” meetings and youth advisory
council meetings are held bi-weekly according to policy. These are facilitated by the assistant
facility administrator (AFA) and operations manager. The meetings include a discussion of
program issues and/or youth are given an opportunity to speak of any issues. Agendas and
sign-in sheets were observed of these meetings and validated the program’s practice. The
director of case management confirmed youth complete surveys on a quarterly basis. Surveys
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capture information concerning staffing, programmatic issues, and food at the program. Results
are passed to program administration for review. Reviewed documentation during the annual
compliance review week validated the program’s practice. Nine youth were interviewed, each
youth confirmed they are able to provide youth input at the program and each youth was able to
explain how they provide their input.
2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program has a policy and procedures regarding career education services. The program
provides a Type 3 vocational competency development program, which includes personal
accountability skills, behaviors, and employability skills which promote positive work ethics and
living standards. The facility administrator (FA) interview indicated the career opportunities
provided to the youth include Entrepreneurship and Small Business Career and Professional
Education (CAPE) certification coursework. Career education is provided by Osceola County
School District’s educational staff. The courses are all age appropriate and aligned with the
youth’s educational abilities and goals. Three closed youth case management records were
reviewed, and all records included sample completed employment applications, a résumé, and
documentation supporting the parent/guardian and juvenile probation officer (JPO) were made
aware of the youth’s vocational plan. One youth had a State of Florida Identification card (ID),
while the other two did not. There was documentation indicating the two youth would be
obtaining their ID cards upon release, with the assistance of a transition service provider, as
their parents/guardians did not provide the documentation required. One youth had information
on the local Career Source location while the other two did not; however, would be working with
a transition service provider, upon release. The transition service provider will be connecting the
youth with Career Source through their agency. This was verified in a discussion with case
management.
2.20 Educational Access (Critical) Limited Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a policy and procedures regarding educational access. The program
integrates education into the daily schedule in such a way to ensure the integrity of the required
minimum instruction time distributed over a twelve-month period. The district approved calendar
and daily school schedules were reviewed and it was determined the program incorporated the
required 250 days of instruction, with up to ten days used for teacher planning, and a minimum
of twenty-five hours of instruction weekly. The daily bell schedule includes five fifty-five-minute
and one fifty-minute class periods, which exceeds the required minimum of twenty-five hours of
instruction each week. Randomly selected logbook entries, including one day every month since
November 2022, as well as eight additional entries, showed deviations in adhering to the school
schedule. The deviations included anywhere from a few minutes to certain groups of youth
missing one or more class periods of instruction in a day on five separate occasions. These
results indicated the youth were not meeting the required twenty-five hours of instruction per
week. Video footage was reviewed for October 2, 6, and 10, 2023, and all three days exhibited
youth movement to and from school according to the school schedule, with little to no deviations
in the schedule. Nine interviewed youth indicated there were no interruptions during the school
day. An interview with the lead educator indicated the school schedule is followed daily.
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2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The program has a written policy and procedures regarding the Education Transition Plan.
Three closed youth records were reviewed, and all youth had an Education Transition Plan
developed upon entry based on each youth’s post-release goals. One youth entered the
program with a diploma; however, an Education Transition Plan was still initiated. All key
personnel related to transition activities were included and the plans were developed with the
youth, parents/guardians, program, education, and aftercare staff involved. The transition plans
placed specific monitoring responsibilities on individuals responsible for the reintegration and
coordination of the provision of support services upon the youth’s release. Each record
documented the youth’s case manager and parent/guardian were aware of the plan. Five of
nine interviewed youth indicated they were involved in the development of their Education
Transition Plans, while the other four responded they had completed school at the program and
did not require a post release education placement. When asked how well the youth thought the
program was preparing them for a high school equivalency diploma (GED), high school,
vocational school, employment, and/or college, all nine-youth responded they were being very
well, or well prepared. The Education Transition Plans are shared with staff during treatment
team and at multi-disciplinary meetings, according to the lead educator’s interview.
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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 maintains a written policy and procedures requiring a designated mental health
clinician authority (DMHCA) to work as a full-time staff who is on-site at least forty hours each
week. In addition, the program’s contract requires an additional full-time licensed mental health
professional to be on-site. The DMHCA is responsible for the coordination and implementation
of mental health and substance abuse services in the program. As part of the assigned
responsibilities, the DMHCA shall ensure consistent and appropriate mental health and
substance abuse services occur in addition to being on call twenty-four hours each day for
emergency consultation. The DMHCA is a licensed mental health counselor with a free and
clear license in the State of Florida with an expiration date of March 31, 2025. The DMHCA’s
license was displayed within the program, as required. The interviewed DMHCA verified the
program provides Behavioral Health Overlay Services, (BHOS), Borderline Developmental
Disability (BDD), Substance Abuse Treatment Overlay Services (SAOS), and Mental Health
Overlay Services (MHOS). Reviewed documentation and an interview with the DMHCA verified
the DMHCA was on-site weekly to ensure appropriate coordination and implementation of
mental health and substance abuse services provided to the youth, as required by the contract.
The program is licensed under Chapter 397 through the Department of Children and Families to
provide substance abuse services to adolescents. The reviewed license confirmed it was valid
with an expiration date of April 1, 2024. The newly promoted assistant regional clinical director
serves as the back-up DMHCA and second licensed mental health professional until the
assistant clinical director position is filled. The back-up DMHCA is a licensed mental health
counselor in the State of Florida with a free and clear license which expires on March 31, 2025.
The interviewed DMHCA confirmed their role in the coordination and implementation of mental
health and substance abuse services at the program. During the intake process, the DMHCA
gathers current information from youth and collateral information is reviewed to complete the
brief behavioral health status exam within five days. Each youth receives a comprehensive
assessment within thirty days of the intake, based on their current and past behavior, by
licensed or non-licensed mental health professionals, which is reviewed by the DMHCA or
designee. The DMHCA stated the program provides individual, family, and group clinical
services to the youth. The DMHCA communicates with the clinical staff during daily meetings
and weekly clinical supervision reviews.
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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 maintains a written policy and procedures to establish requirements for qualified
professionals in the delivery of mental health and substance abuse services. The program’s
designated mental health clinician authority (DMHCA) serves as the program’s supervisor for all
on-site clinical staff. A review of the program’s contract indicated an additional full-time licensed
mental health professional is required to be on-site. The assistant regional clinical director’s
license was free and clear in the State of Florida with an expiration date of March 31, 2025. The
assistant regional clinical director provides support and supervisory services to the DMHCA and
clinical staff and acts as the assistant clinical director until the position is filled. The program is
licensed under Chapter 397 by the Department of Children and Families to provide substance
abuse services to adolescents. The Chapter 397 license expires April 1, 2024. A review of
mental health licenses verified two therapists were registered mental health counselor interns,
and two therapists were registered clinical social worker interns. All four had active intern
registrations in the State of Florida. The psychologist is on-site for five hours every Friday. The
psychologist has a license which is free and clear in the State of Florida with an expiration date
of May 31, 2024.
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 maintains a written policy and procedures to establish requirements for qualified
professionals in the delivery of mental health and substance abuse services. The designated
mental health clinician authority (DMHCA) confirmed their responsibility for ensuring non-
licensed clinical staff are working under their supervision and performing services they are
qualified based on education, training, and experience. The program’s practice is to complete
group and/or individual clinical supervision for the eight non-licensed clinicians and the
recreation therapist. A review of clinical supervision logs since the last annual compliance
review verified clinical supervision was documented on the supervision logs and included all
elements on the Department’s Licensed Mental Health Professionals and Licensed/Certified
Substance Abuse Professionals Direct Supervision Log form. Documentation verified each non-
licensed clinical staff received clinical supervision for each week they provided services. The
program is licensed under Chapter 397 through the Department of Children and Families to
provide substance abuse services to adolescents. A review of the license reflected it was
displayed in the lobby with the program’s physical address listed. The reviewed license expires
on April 1, 2024. The program’s contract requires one DMHCA, one licensed assistant clinical
director, one recreation therapist, and eight non-licensed mental health clinicians. The
recreation therapist position has been vacant since September 2023, and there are two non-
licensed therapist positions vacant; however, one therapist position has an expected start date
of November 6, 2023. A review of the six non-licensed staff’s education documentation reflected
each held a master’s-level degree from an accredited university or college in the field of
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counseling, social work, psychology, or a related human services field. Each non-licensed staff
providing clinical services was employed by a service provider which was licensed under
Chapter 397. Each of the six non-licensed clinical staff received training in the administration of
the Assessment of Suicide Risk (ASR) or Crisis Assessments conducted on-site in the physical
presence of the licensed mental health professional. All training was documented on the
Department’s Non-Licensed Mental Health Clinical Staff Person’s Training in Assessment of
Suicide Risk form.
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 maintains a written policy and procedures which establish the system for gathering
important treatment and emergent needs information prior to each youth’s entry into the general
population. The program’s policy requires the staff to administer a mental health and substance
abuse screening, including a suicide risk screening, upon a youth’s admission to the program.
When indicated, referrals are made for further evaluation, assessment, and clinical services.
The program utilizes the Massachusetts Youth Screening Instrument, Second Version (MAYSI-
2) for initial screening. The policy dictates the screening shall be completed by the case
manager in a private/confidential manner with the youth on the day of admission. A review of
nine youth records reflected each youth was administered a MAYSI-2 on the day of admission.
The case manager completing the screening documented the review of available information to
include the commitment packet and other pertinent documents for existing mental health or
substance abuse problems, or history of human trafficking. Each reviewed MAYSI-2 was
completed by case management staff. Reviewed documentation verified each staff who
completed the MAYSI-2 was trained, and the MAYSI-2 was completed in the Department’s
Juvenile Justice Information System (JJIS). A review of nine youth records verified each MAYSI-
2 completed included the date, name of staff completing the MAYSI-2, was completed on the
day of admission, and was conducted in a confidential manner. Five youth MAYSI-2s indicated
a need for further assessment and four were overridden by the staff conducting the MAYSI-2
leading to a determination for further assessment; however, it is the program’s practice to refer
all youth for additional assessment regardless of the screening results. Each MAYSI-2
documented the need for further assessment. None of the reviewed MAYSI-2’s indicated an
assessment was needed due to the “suicide ideation” category; however, it is the program’s
practice to conduct an Assessment of Suicide Risk (ASR) to all youth upon admission to the
program. All nine youth records verified each youth was referred for an ASR and
comprehensive evaluation, and each included the reason for the referrals. The program’s facility
administrator (FA) is responsible for the implementation of the standardized admission/intake
mental health and substance abuse screening process. The reviewed policy confirmed the
process includes a review of commitment packet information, reports and records,
administration of the MAYSI-2 in JJIS by a qualified professional, and a referral of youth
identified by screenings as in need of further evaluation or immediate attention. The policy
outlines administration staff training and a standardized process for youth requiring immediate
attention and transfer to a Baker Act or Marchman Act receiving unit. The interviewed FA
reported, in addition to the mental health/substance abuse services provided by the program, a
contracted board-certified behavioral analyst provides additional services for youth as needed.
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3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program maintains a written policy and procedures to establish an assessment and
evaluation process to guide the development of each youth’s individualized treatment plan. The
program ensures the mental health and substance abuse needs of the youth are identified
through a comprehensive mental health and substance abuse evaluation process. Each youth
receives an in-depth assessment within the first thirty days of residential placement. All
assessments shall be completed by a licensed mental health professional or mental health
clinical staff working under the direct supervision of the licensed mental health professional. The
program’s practice is to incorporate the findings of the Massachusetts Youth Screening
Instrument, Second Version (MAYSI-2) and intake packet into each assessment. A review of
nine youth records verified each youth received a new mental health evaluation within thirty
calendar days of admission. The mental health evaluation included youth demographics, reason
for the evaluation, relevant background information, behavioral observations, Mental Status
Examinations, procedures administered, discussions of findings, diagnostic impressions
including the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
diagnosis, and recommendations. A review of nine youth records verified each youth received a
new substance abuse assessment within thirty days of admission. Each youth record included
the reason for the substance abuse assessment, all relevant background information,
behavioral observations, methods of assessment, patterns of alcohol and substance abuse,
impact of alcohol and substance abuse on major life areas, risk factors, clinical impression
including the DSM-5 diagnosis, and recommendations. All nine reviewed youth records
indicated the mental health/substance abuse assessment addressed the original referral
reasons.
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 maintains a written policy and procedures to establish an individualized treatment
planning process to guide service delivery. The program’s treatment planning focuses on the
provision of mental health and substance abuse interventions and treatment to reduce or
alleviate youth’s symptoms of mental disorder and/or substance abuse impairment. The
assigned intervention and treatment team shall assist in developing, reviewing, and updating
each youth’s initial and individualized plan. A review of nine youth records reflected an initial
treatment plan was developed within seven days of admission. Each reviewed initial plan was
documented on the program’s form and included all elements of the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form. Each initial plan was completed by a non-
licensed clinical staff and signed by the licensed designated mental health clinician authority
(DMHCA) within ten days of completion. Additionally, each initial plan was signed by all
treatment team members who participated in the development of the plan. Each plan was
signed by the youth, and documented juvenile probation officer (JPO) and parent/guardian
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participation by telephone. Each initial plan included the need for a psychiatric evaluation. The
program’s practice is to refer all youth for a new psychiatric evaluation regardless of medication
status. Two of the reviewed records indicated the youth were on psychotropic medications at
the time of the initial plan creation and the medication details were included in the plan. The
program completed an individualized treatment plan for each of the nine youth within thirty days
of admission. Each individualized plan was documented on the program’s form and included all
elements of the Department’s Individualized Mental Health/Substance Abuse Treatment Plan
form. Each individualized plan was completed by a non-licensed clinical staff and signed by the
DMHCA within ten days of completion. Each of the nine plans were signed by all treatment team
members who participated in the development of the plan. Each individualized plan documented
the participation of the assigned JPO and the parent/guardian by telephone. Two youth were
applicable for being on medication at the time of the individualized plan development and each
plan clearly listed the medication details and monitoring frequency. Nine records were reviewed,
and each verified the treatment plan reviews were conducted in thirty-day intervals. All
treatment plan reviews were documented on the program’s form which contained all elements
on the Department’s Individualized Mental Health/Substance Abuse Treatment Plan Review
form. Prescribed services included individual and group therapy for all nine youth, family therapy
for eight youth, psychiatric services, and medication management for four youth. The treatment
plan goals and objectives were individualized for each youth. A review of the program’s contract
confirmed the program was providing groups as required. The program’s primary service groups
include Skillstreaming the Adolescent which is a clinical mental health group and Seven
Challenges with is a clinical substance abuse group. The program is also currently providing
LifeSkills Training (LST), and Trauma Focused-Cognitive Behavioral Therapy (TF-CBT). A
review of video for three randomly chosen groups verified the sign-in sheets coincided with the
video. A review of sign-in sheets confirmed the program was providing groups as outlined in the
daily schedule. The program provides groups four to seven days each week, based on
individual youth needs as outlined in contract.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
The program maintains a written policy and procedures regarding discharge and transition
planning requirements for mental health and substance abuse treatment services. Discharge
and transition planning is a continual and perpetual process which culminates into the
development of a final mental health and substance abuse treatment summary. A review of nine
youth records reflected each youth was assigned a treatment team on the day of arrival to the
program. Reviewed treatment plan documentation and the treatment team assignment form for
each reviewed record confirmed the treatment teams were comprised of the youth, program
administration, residential living unit, education, medical staff, mental health and substance
abuse staff, and applicable parent/guardian. A review of the nine youth records reflected each
was applicable for a substance abuse diagnosis and treatment. The program is licensed through
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the Department of Children and Families under Chapter 397 to provide substance abuse
services to adolescents. A review of three closed records was conducted for discharge plans.
Each record contained an executed Authority for Evaluation and Treatment (AET) form or a
court order. Additionally, each youth record contained a signed Youth Consent for Substance
Abuse Treatment, and Youth Consent for Substance Abuse Treatment Records form. All
reviewed mental health or substance abuse treatment notes were documented on the program’s
form and included all the information on the Department’s Counseling/Therapy Progress Notes
form. Reviewed progress notes confirmed treatment services included individual psychotherapy
and psychosocial skills training. A review of treatment plans in comparison with progress notes
confirmed each youth received services as stipulated on their treatment plan. A review of three
youth discharge summaries indicated each was completed on the Department’s Mental
Health/Substance Abuse Treatment Discharge Summary form. None of the closed records were
applicable for the youth being released while on suicide alert/precautions. Each of the three
reviewed summaries documented the services needed for daily maintenance of the positive
improvement in behavioral, emotional, and social skills made by the youth during treatment.
Each reviewed discharge summary documented the telephone participation of the assigned
juvenile probation officer (JPO) and parent/guardian. Reviewed documentation verified the
program emailed a copy of the summary to each assigned JPO and provided a copy to the
youth and parent/guardian upon release.
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 written policy and procedures to establish a delivery protocol for
Behavioral Health Overlay Services, (BHOS), Borderline Developmental Disability (BDD),
Substance Abuse Treatment Overlay Services (SAOS), and Mental Health Overlay Services
(MHOS). The focus of substance abuse and mental health treatment is to target and
reduce/alleviate the youth’s symptoms of substance related disorder and/or mental disorder to
improve youth functioning within the program and ultimately the community. The program
provides substance abuse and mental health services through group therapy, individual therapy,
family therapy, and psychiatric services. A review of the program’s contract and an interview
with the designated mental health clinician authority (DMHCA) confirmed the program was
providing groups as required. The program’s primary service groups include Skillstreaming the
Adolescent which is a clinical mental health group and Seven Challenges which is a clinical
substance abuse group. The program is also currently providing LifeSkills Training (LST), and
Trauma Focused-Cognitive Behavioral Therapy (TF-CBT). Nine interviewed youth reported
participating in individual and family therapy services at the program. Nine interviewed staff
stated direct care staff do not facilitate any mental health or substance abuse groups. The
program provides substance abuse treatment services, which includes urinalysis drug testing.
Any positive tests are referred for an appropriate clinical intervention and sanctions. A review of
youth records, youth interviews, group sign-in sheets, and an interview with the DMHCA verified
the individual, group, and family therapy services are part of the youth’s treatment plan.
Documentation indicated therapeutic services are held at least five times a week. A review of
group sign-in sheets verified group therapy is limited to no more than fifteen participants. The
program has a Chapter 397 license through the Department of Children and Families to provide
substance abuse treatment services to adolescents. The license expires April 1, 2024. All metal
health clinicians working at the program were qualified to provide substance abuse treatment
and education services. The program has an agreement with a psychiatrist for the completion of
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psychiatric evaluations and medication management needs. A review of the clinical staff
schedules verified clinical staff were scheduled to be on-site seven days each week, as
required. A review of counselor caseloads verified the caseloads are limited to no more than ten
youth for substance abuse treatment services and to no more than sixteen youth for SAOS.
The program has a policy and procedures outlining developmental disability services. The
program provides individual, group, and/or family therapy to youth diagnosed with BDD or
requiring BHOS while in the program. The clinical staff are on-site daily to provide services to
the youth. In addition, youth with co-occurring disorders receive mental health and substance
abuse services. Reviewed documentation verified each youth received a developmental
evaluation. Youth diagnosed with BDD or requiring BHOS received an individualized treatment
plan based on the youth’s development evaluation results. A review of the program’s schedule,
group sign-in sheets, and youth records verified each youth received daily developmental and
psychosocial treatment and interventions. An interview with the facility administrator (FA)
verified the program has a contract with a behavior analyst to provide services to youth as
needed. An interview with the DMHCA verified clinical staff are on-site seven days a week. A
review of counselor caseloads verified caseloads are limited to no more than ten for BDD youth
and no more than sixteen for BHOS youth.
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 diagnosed DSM-
IV-TR or 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 maintains a written policy and procedures for the provision of psychiatric services.
The program’s contracted psychiatrist is responsible for psychiatric evaluations, consultation,
medication management, and medical supportive counseling. The program maintains an
agreement with a medical doctor for psychiatric services. The reviewed license showed it was
free and clear in the State of Florida with an expiration date of January 31, 2024. Reviewed
documentation confirmed the completion of psychiatric evaluations, medication reviews, and
treatment team participation. The program does not utilize a psychiatric advanced practice
registered nurse (APRN). The program did not utilize a back-up psychiatrist since the last
annual compliance review. The psychiatrist’s agreement and contract require weekly services
and a review of sign-in sheets and medication management documentation for the past twelve
months reflected the psychiatrist provided on-site services as required. The program does not
utilize telepsychiatry services. An interview with the psychiatrist, a review of the policy and
procedures, and a review of the agreement confirmed the psychiatrist is on call twenty-four
hours a day, seven days a week for emergency consultation. The psychiatrist provides initial
evaluations, medication management, and conducts all necessary follow-ups with the youth. An
interview with the designated mental health clinician authority (DMHCA) and the psychiatrist
confirmed they meet at least once every thirty days, or on an as needed basis. The psychiatrist
stated they meet with healthcare staff to review important medical issues pertaining to youth
receiving psychiatric services during treatment team every thirty days, or as needed. The
psychiatrist conducts face-to-face communication with the treatment team. A review of nine
youth records found three were applicable and received a diagnostic interview within fourteen
days of admission. The diagnostic psychiatric interview included the youth’s medical, mental
health, and substance abuse history, a mental health status examination, and the Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis for each youth. A
review of three youth treatment plans verified the plan was consistent with the DSM-5 diagnosis
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and included the treatment recommendations. A review of three applicable youth records
indicated each youth was prescribed psychotropic medication, which was related to the youth’s
diagnosis. Each diagnostic interview included target symptoms, initial treatment goals, potential
side effects, risk, and benefits of taking the medication, and the frequency of medication
management. The Initial Diagnostic Psychiatric Interview was documented on the Department’s
Clinical Psychotropic Progress Note (CPPN) which clearly identified as the Initial Diagnostic
Psychiatric Interview. Nine youth records were reviewed, three youth were admitted into the
program with psychotropic medication and one youth started taking psychotropic medication two
months after admission to the program. Each of the four applicable youth records documented
youth were seen for medication reviews by the psychiatrist at least once every thirty days. The
psychiatric evaluations were documented on the CPPN for each youth. The CPPN included the
youth’s identifying data, diagnosis, target symptoms of each medication, effect of prescribed
psychotropic medication on target symptoms, side effects of the medication, and the youth’s
adherence to the medication regime. In addition, each of the four CPPN’s included the youth’s
height, weight, and blood pressure. The psychiatrist signed and dated each of the four reviewed
CPPNs. Two of the four reviewed youth records were applicable for the monitoring of Tardive
Dyskinesia on a monthly basis as indicated in the CPPN. Documentation verified the
psychiatrist was monitoring for Tardive Dyskinesia on a monthly basis. The program’s policy
and contract does not allow the use of tele-psychiatry.
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 policy and procedures regarding the implementation of a Suicide
Prevention Plan. The plan shall provide guidelines for the identification, management, and
assessment of potentially suicidal youth. The program maintains a Suicide Prevention Plan
which was last signed and reviewed by the facility administrator on January 10, 2023. A review
of the plan reflected it included identification, assessment, staff training, suicide precautions,
levels of supervision, referral, communication, notification, documentation, immediate staff
response, and a review process. The review process for suicide attempts and mortality review
included circumstances surrounding the event, procedures relevant to the incident, relevant
training received by involved staff, pertinent medical and mental health services involving the
victim, possible precipitating factors, and recommendations.
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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 maintains a Suicide Prevention Plan which outlines the methods used for suicide
precautions which include observing, monitoring, and housing youth identified as a suicide risk.
A review of nine youth records indicated none were applicable for suicide risk. A review of three
additional records was conducted. Each of the three youth were identified as a suicide risk
through staff observations. All three applicable youth were placed on precautionary observation
status and assessed the same day. Each Assessment of Suicide Risk (ASR) was completed on
the Department’s ASR form by the designated mental health clinician authority (DMHCA). Each
youth was maintained on constant supervision upon immediate completion of the ASR or as a
result of the ASR. Documentation verified the parent/guardian and assigned juvenile probation
officer (JPO) were notified of the youth’s potential suicide risk. One youth record indicated a
Follow-Up ASR was completed on the Department’s Follow-Up ASR form. Upon the completion
of a Follow-Up ASR, suicide precautions could be discontinued for the applicable youth, and the
youth was stepped down to close supervision. The discontinuation of suicide precautions was
the result of a documented conference with the facility administrator, and mental health clinician
in each applicable record. Two of the three reviewed youth had an emergency Baker Act
proceeding. The two youth returned to the program following the off-site Baker Act proceedings
on precautionary observation, were reassessed upon return, and stepped down to close
supervision. All three youth were maintained on close supervision until it was determined
appropriate to step the youth down to standard supervision. A review of the Department’s
Juvenile Justice Information System reflected accurate alerts were initiated and updated as
required. A review of the program’s logbooks and assessments supported the administration
staff provided instructions regarding suicide precaution decisions. Logbooks documented the
placement and removal of precautionary observation and close supervision. Documentation
supported youth on suicide precautions were able to participate in activities with other program
youth in the specified safe housing areas. None of the three reviewed records indicated youth
were placed in secure observation. The program has not utilized secure observation since the
last annual compliance review. The program’s video is stored for thirty days. Only one of the
three youth was placed on precautionary observation within the last thirty days and could be
observed by video. The youth was on precautionary observation for approximately one hour and
the staff was monitoring the youth as required and documenting supervision on the
Precautionary Observation Log.
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3.12 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.
The program maintains a Suicide Prevention Plan which outlines levels of supervision and the
process for recording observations of youth on suicide precautions. A review of nine youth
records reflected none were applicable for suicide risk. A review of three additional records was
conducted. Each youth record contained documentation where a Suicide Precaution
Observation Log was maintained for the duration the youth was on precautions. Youth
behaviors were documented in real time and not exceeding thirty-minute intervals for each
youth. Each youth was applicable for warning sign observations, and notification to the mental
health clinician was clearly documented. Each of the reviewed logs were reviewed and signed
by the shift supervisor and mental health staff. Additionally, each log documented safe housing
requirements.
3.13 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 maintains a Suicide Prevention Plan which requires all staff with direct day-to-day
contact with youth to participate in suicide training. A review of nine pre-service and nine in-
service training records documented program staff completed the required six hours of suicide
training. The program has a total of two suicide kits which were located in each sub control. The
suicide kits are co-located with the program’s first-aid kits. The program is required to complete
one mock suicide drill for each shift at least quarterly. A review of suicide drill documentation for
the past twelve months reflected the program conducted a quarterly drill on each shift as
required. Reviewed drills consistently included the use of lifesaving measures to include the use
of cardiopulmonary resuscitation (CPR), suicide kits, first-aid kits, and the automated external
defibrillator (AED). The program’s practice is to review the drills during the monthly all staff
meetings. The interviewed facility administrator (FA) reported quarterly mental health and
suicide drills are conducted monthly on all shifts. Nine interviewed staff stated they would notify
mental health staff and conduct constant sight and sound supervision if a youth expressed
suicidal thoughts. Eight staff stated they would document supervision. Six staff stated they
would fill out a mental health referral form and one staff said they would search the youth and
their room for sharp objects. All nine staff knew the location of the suicide response kits. Each of
the nine staff stated suicide drills are conducted monthly.
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3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a written policy and procedures to outline operation procedures for crisis
intervention. The program’s Crisis Intervention Plan addresses mental health crisis intervention
services and Crisis Assessments. The Crisis Intervention Plan was signed and reviewed by the
facility administrator (FA) on January 10, 2023. A review of the plan verified it included
notification and alert systems, means of referrals, Crisis Assessment and follow-up,
communication, supervision, documentation, mental health supportive services, and review. The
plan states it shall be the responsibility of all staff to ensure crisis plans are implemented
immediately to afford youth with a maximum amount of safety and security.
3.15 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’s Crisis Intervention Plan addresses mental health crisis intervention services and
Crisis Assessments. A review of nine youth records indicated none were applicable for Crisis
Assessments. A review of three additional records was conducted. Two youth received a Crisis
Assessment after returning to the program from an off-site Baker Act and one youth was
emergency Baker Acted after a Crisis Assessment was conducted. Each of the reviewed youth
had a Crisis Assessment conducted based on the needs of the youth. Each Crisis Assessment
included the reason for the assessment, Mental Status Examination and interview,
determination of danger to self and/or others, initial clinical impressions, supervision
recommendations, treatment recommendations, recommendations for further evaluation, and
notification to the parent/guardian. All three Crisis Assessments were conducted by a licensed
mental health professional and a mental health alert was entered in the Department’s Juvenile
Justice Information System (JJIS). Each of the three reviewed Crisis Assessments indicated the
youth remained on alert until a follow-up Crisis Assessment was completed. An interview with
the DMHCA verified there were three youth who required a Baker Act during the annual
compliance review period. A review of three youth involved in an alleged Prison Rape
Elimination Act (PREA) event verified a Mental Health and Substance Abuse Referral Summary
was submitted for a Crisis Assessment. All three reviewed youth were offered on-going mental
health treatment services.
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3.16 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 maintains a written policy and procedures outlining the mental health and
substance abuse procedures for youth who are believed to be an imminent danger to
themselves or others because of mental illness or substance abuse impairment. The
Emergency Response Plan for Mental Health and Substance Abuse Emergencies requires
youth to receive the highest quality of care, safety, and management. The program’s
Emergency Response Plan was last signed and dated by the facility administrator (FA) on
January 10, 2023. A review of the plan validated it included immediate staff response,
notifications, communication, supervision, authorization to transport for emergency mental
health and substance abuse services, transport for emergency Baker Act, transport for
emergency Marchman Act, documentation, training, and review.
3.17 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program maintains a written policy and procedures regarding Baker and Marchman Acts. A
review of nine youth records found none were applicable for a Baker or Marchman Act. Three
additional youth records were reviewed which were applicable. Each of the three reviewed
records indicated staff observations determined the need for emergency care. Two of the three
reviewed records indicated staff submitted a mental health referral summary to clinical staff, and
the third youth record indicated the designated mental health clinician authority (DMHCA)
completed an Assessment of Suicide Risk (ASR). All three youth were placed on one-to-one
supervision and the mental health staff were involved. All three of the youth were Baker Acted
and transported off-site by law enforcement. Upon return to the program from the Baker Act,
each youth was placed on constant supervision. All three youth received a mental health referral
indicating a Mental Status Examination (MSE) was to be conducted. A Crisis Assessment was
completed for each youth by the DMHCA. Each youth was maintained on constant supervision
until an assessment was completed by the DMHCA which lowered the youth’s supervision level.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program maintains a written policy and procedures to establish a planning process
designed to identify areas which affect the youth and incorporate trauma responsive practices.
Within fourteen days of admission, the intervention and treatment team meet with each youth to
develop a Safety Plan. Safety planning is designed to identify stimuli which have positive and
negative effects on the youth. A review of nine youth records confirmed each contained a Safety
Plan. Each plan included warning signs, youth baseline behaviors, crisis recognition, jointly
developed coping strategies, youth preferred intervention strategies, and a debriefing process.
Each plan was completed within fourteen days of admission and incorporated recommendations
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from clinical assessments. Each plan was reviewed and updated at least every thirty days and
after significant behavioral or mental health events. All staff who have contact with the youth
reviewed the safety plans on a regular basis. The interviewed facility administrator (FA) reported
Safety Plans are located in the youth’s mental health records and on each sub control. The FA
reported all staff have access to the safety plans. Nine interviewed youth confirmed they
participated in the development of their Safety Plan. Nine interviewed staff reported Safety
Plans are accessible to staff and located in each sub control and in medical. Nine interviewed
staff reported youth Safety Plans are reviewed during shift briefing, during treatment team, and
all have access to the Safety Plans in sub control. Staff reported reviewing plans daily, weekly,
monthly, and as needed. The interviewed FA reported Safety Plans were updated monthly at
treatment team reviews.
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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 written policy and procedures which requires a contracted health authority to
provide on-site medical care to youth in the program. The program maintains a contract with a
State of Florida board-certified and licensed osteopathic physician (DO) who serves as the
designated health authority (DHA). The DHA has a clear and active license in the State of
Florida, expiring on March 31, 2024, with a specialty training in family practice. A review of the
Florida Department of Health records supported the DHA had no disciplinary cases and/or
public complaints on record. An advanced practice registered nurse (APRN) or physician’s
assistant (PA) is not utilized at the program. The DHA is available twenty-four hours a day,
seven days a week for acute medical concerns, emergency care, and coordination of off-site
care. The DHA is contracted to be on-site for two hours each week with no more than nine days
passing between on-site visits. A review of DHA sign-in sheets since the last annual compliance
review found the DHA was on-site for a minimum of two hours each week. The program has a
back-up DHA who is a licensed physician with a clear and active license in the State of Florida
expiring January 31,2024; however, the back-up DHA was not utilized during the annual
compliance review period. A review of the program’s policy confirmed it did not have any
conditional language included for either telemedicine or telehealth services. The interviewed
DHA reported their role in the program is to conduct all youth Comprehensive Physical
Assessments (CPAs), periodic evaluations, sick call follow-ups, if needed, review off-site visits,
and policy and procedures development. The DHA confirmed being on-site once weekly and on
call twenty-four hours each day, seven days a week.
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’s contract with the Department outlines the requirements for a health service
administrator (HSA) and four additional full time registered nurses (RNs). The program has one
HSA who is a RN and three full time RNs on-site. A review of the nursing schedule reflected the
HSA and RNs are all on-site weekly at a minimum of forty hours. The program provides on-site
nursing coverage seven days a week from 8:00 a.m. to 7:00 p.m. A review of licenses for the
HSA and the three nursing staff providing services at the program found each had a clear and
active RN license in the State of Florida, which expire July 31, 2024, and April 30, 2025. Two
additional licenses were reviewed for staff who are no longer with program; however, provided
services during the annual compliance review period, and it was found all had a clear and active
RN license in the State of Florida, two of which expire July 31, 2024, and one April 30, 2025.
The regional nurse is also on-site weekly to provide assistance. The regional nurse holds a
clear/active license which expires July 31, 2024. The program does not utilize a licensed
practical nurse (LPN). Reviewed documentation found the four RNs had current
cardiopulmonary resuscitation (CPR) certifications.
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4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has a written policy and procedures for all health-related procedures and protocols
utilized at the program. The designated health authority (DHA) is solely responsible for an
annual review of all health-related policies, procedures, and protocols. Reviewed policies and
procedures validated they were reviewed and signed by the DHA on August 23, 2022. The DHA
reviewed and signed all nursing protocols on August 23, 2022. The nursing staff signed a cover
page acknowledging their review of all procedures and treatment protocols on January 3 and 4,
2023, and May 1, 2023. The psychiatrist reviewed applicable policies on August 23, 2022. The
facility administrator and corporate staff signed on August 23, 2022. There were no noted
applicable policy changes during the annual compliance review period. The program staff
reported two new hires since the last annual compliance review. The program’s practice is to
provide new hires a comprehensive clinical orientation to healthcare services provided by the
health service administrator (HSA), and documentation supported this practice.
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 written policy and procedures to ensure the completion of the Authority for
Evaluation and Treatment form (AET) for all youth admitted into the program. The program
utilizes a separate form for youth eighteen years of age or older providing consent for release
for specific information as noted on the Release of Information Authorization for Youth Eighteen
Years of Age and Older form including to whom the information can be released and shared. A
review of nine youth Individual Healthcare Records (IHCRs) found seven contained a valid and
legible copy of an AET and the word, “Copy” was clearly stamped on each AET. Two of the nine
reviewed youth IHCRs were also applicable for the youth being eighteen years of age or older.
Documentation supported the youth signed a Release of Information Authorization Form for
Youth Eighteen Years of Age or Older form. Two youth were in the care of the Department of
Children and Families (DCF) and both youth’s IHCRs contained a valid court order authorizing
treatment at the program. The interviewed nurse reported they call the parent/guardian and
inform them they are mailing an acknowledgement for consent for the AET; however, AET’s for
youth eighteen years and older have a different consent form.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a written policy and procedures to inform the parent/guardian of significant
changes in youth’s condition and obtain consent when new medications and treatments are
prescribed. Nine youth Individual Healthcare Records (IHCRs) were reviewed for
parental/guardian notifications. Seven youth were applicable for consent from the youth’s
parent/guardian for all new medications, over-the-counter medications beyond those covered by
the Authority for Evaluation and Treatment (AET), or new psychotropic medications prior to
administration. All seven documented the program received consent from the youth’s
parent/guardian. Four of the seven reviewed IHCRs indicated the youth were taking prescribed
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psychotropic medications prior to admission into the program. All four youth were continued on
the same psychotropic medications with no change in dosage. There was documentation of a
staff witness for all telephone call attempts and conversations about psychotropic medications.
Two youth were in the care of the Department of Children and Families (DCF) and a court order
was found authorizing all medications and treatment and an additional court order authorized
the youth’s psychotropic medication prior to administration, as required. Each of the nine
reviewed IHCRs documented the program received and verified the youth’s vaccination records
on the date of admission. None of the youth were applicable for requiring new vaccinations or
requesting religious exemption. During an informal interview, the nurse confirmed the Florida
Shots website is reviewed and verified at the time of admission by the nurse and designated
health authority (DHA). The nurse also confirmed parents/guardians are notified by telephone to
obtain verbal consent, then page three of the Clinical Psychotropic Progress Note (CPPN) is
sent by mail.
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 written policy and procedures regarding healthcare screening for each youth
upon admission into the program. The program’s practice is to complete a rescreening and
complete the Department’s Facility Entry Physical Health Screening (FEPHS) form any time a
youth is admitted into the program or each time the physical custody of the youth changes with
subsequent return or readmission to the program. Nine youth Individual Healthcare Records
(IHCRs) were reviewed, and each contained a FEPHS form completed by a registered nurse
(RN) on the day of the youth’s admission. None of the FEPHS forms were completed by a direct
care staff. None of the youth were applicable for a change in custody. The nurse confirmed the
admission screening is completed by the nurse, and if there is a change in custody a new
FEPHS form is completed.
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 written policy and procedures to ensure each youth admitted into the
program receives a healthcare orientation. Nine youth Individual Healthcare Records (IHCRs)
were reviewed, and each contained documentation the youth was oriented to healthcare
services at the program upon admission. Each youth’s orientation included all required topics
which was documented on the Department’s Health Education form and an orientation sheet
which listed all reviewed topics and was signed and dated by the youth.
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4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a written policy and procedures to notify the designated health authority (DHA)
by telephone, email, or verbally, if on-site, of all youth admitted into the program identified with
chronic health conditions or youth in need of emergency care. Nine youth Individual Healthcare
Records (IHCRs) were reviewed and three were applicable for a documented chronic condition
upon admission. Six youth were not applicable. The program’s practice is to notify the DHA and
psychiatrist of all youth intakes regardless of the youth being admitted with psychiatric
medications or not. Reviewed documentation found the DHA and psychiatrist were notified upon
admission for each of the nine youth regardless of the youth’s status. Notification of the required
parties was documented in each youth’s IHCR in the chronological progress notes. The nurse
confirmed the DHA is notified at the time of admission by the registered nurse (RN) and an
admission progress note is completed.
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 written policy and procedures to address the completion of the Health-
Related History (HRH) form prior to the completion of the Comprehensive Physical Assessment
(CPA) upon each youth’s admission to the program. Nine youth Individual Healthcare Records
(IHCRs) were reviewed, and each contained a HRH completed by a registered nurse (RN) on
the day of admission. Each reviewed HRH was completed prior to completion of the CPA as
evidenced by the date and signatures on both the HRH and CPA. Eight of nine HRHs were
reviewed by the designated health authority (DHA). This was evidenced by a checkbox on the
CPA, indicating the HRH was reviewed. One HRH was not signed by the nurse. An interview
with the nurse confirmed the practice of completing the HRH at time of admission by the
admitting RN.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a written policy and procedures ensuring the completion of a Comprehensive
Physical Assessment (CPA) on the Department’s standardized form for all youth admitted into
the program. Nine youth Individual Healthcare Records (IHCRs) were reviewed, and each
contained a new CPA completed by the designated health authority (DHA) within seven days of
admission on the Department’s form. All sections of the CPA were completed in full utilizing an
“O” and/or applicable “X” markings except for sections numbered nineteen through twenty-two,
as those sections were not applicable to the male program. All nine youth refused a part of the
exam, and the DHA noted “youth refused” on the form and had the youth initial the form
confirming their refusal. In addition, each youth’s IHCR included a signed refusal form
confirming refusal. The results of each youth’s Tuberculosis Skin Test (TST) were documented
on the CPA, the Department’s Infectious and Communicable Diseases (ICD) form, and on the
program’s TST/Purified Protein Derivative (PPD) form. Reviewed documentation confirmed the
Department’s Problem List was updated as needed. An interview with the program’s nurse
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confirmed the CPA is completed by the DHA within seven days of admission. The nurse also
reported a TST is completed yearly, and a chest x-ray may be ordered by the DHA if needed.
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 written policy and procedures for the completion of sexually transmitted
infections (STIs) and human immunodeficiency virus (HIV) testing for all youth admitted into the
program. The policy reflected HIV test results may only be disclosed to the youth and entities
approved by Florida Administrative Code. Nine youth Individual Healthcare Records (IHCRs)
were reviewed, and each documented the youth was clinically screened for STIs. Each of the
youth were applicable for further evaluation and were referred to the designated health authority
(DHA). Each screening was signed and dated by the DHA on the same date testing was
performed. Testing, screening, clinical evaluations, and diagnoses were documented
accordingly on the Department’s Infectious and Communicable Diseases (ICD) form, excluding
HIV results. Each youth’s ICD form was filed within the lab section of the IHCR. None of the
reviewed youth were applicable for being out of the Department’s physical custody or presenting
with symptoms requiring a rescreen. All nine records contained documentation each youth was
offered testing and counseling for HIV. Four youth consented to receive counseling and testing
by signing the Department’s HIV Antibody Test Youth Consent form. Five youth checked the “I
do not consent” box on the Department’s HIV Antibody Test Youth Consent form. Three youth
received pre-counseling, testing, and post-counseling services. One youth later refused to move
forward with testing. A review of each applicable youth’s Health Education form found each
youth’s pre-test and post-test counseling was documented. The nurse reported the program
utilizes a local medical provider to provide pre- and post-test counseling. An interview with the
nurse in comparison to observations found the nurse utilizes the HIV Logbook to track the HIV
process for each applicable youth. Reviewed documentation confirmed the youth results were
filed in a confidential manner in a sealed envelope marked “Confidential” and included a
documented review by a practitioner on the sealed envelope. Nine youth were interviewed and
reported they can request a HIV test if needed. The nurse reported youth are screened for STIs
during admission following the youth’s consent. The nurse reported the youth can also request a
HIV test by providing consent.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a written policy and procedures ensuring all youth shall be able to make sick
call requests and have their complaints treated appropriately through the sick call system. The
program maintains approved treatment protocols appropriate to the level of the provider
conducting sick call. Sick call hours are conducted Monday through Friday at 8:30 a.m. and 2:30
p.m. and on Saturdays and Sundays at 8:30 a.m. The sick call hours are posted in various
areas of the program. Observations made during the tour found Sick Call Request forms located
on the living module. A locked sick call box was observed on both wings of the program located
by master control. The program’s practice is to check the boxes randomly throughout the day. A
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review of the program’s contract and the activity schedule found the program is following the
sick call hours. The program also provides a Non-Healthcare Medical and Emergency Protocol
Guide for staff to utilize when nursing staff are not on-site. The program currently has identified
and trained staff on the sick call process. Nine youth Individual Healthcare Records (IHCRs)
were reviewed for the sick call process. Five youth were applicable for submitting a sick call.
Each IHCR contained a Sick Call Request form completed by the youth and the program’s
registered nurse (RN). No sick calls were applicable for a youth presenting with similar
complaints three or more times within a two-week period. All Sick Call Request forms were filed
within the IHCRs in the progress notes section. None of the youth were applicable for being in
restricted housing. The program does not utilize restricted housing of any kind. Each form
documented the required elements. Each of the sick calls were documented on the Sick Call
Index and Sick Call Log, as required. The program did not have a sick call event during the
annual compliance review week; therefore, a sick call could not be observed. Nine staff reported
sick calls are reviewed and conducted by the nurse. Nine youth were interviewed regarding the
sick call process. Seven youth reported they can see a nurse within one day of submitting a sick
call. Two youth reported they are seen immediately. During an informal interview, the nurse
reported only the RN conducts sick call in the medical examination room located inside of the
clinic. The nurse confirmed the hours sick call is scheduled at the program.
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 written policy and procedures regarding the delivery of episodic and
emergency care. Nine youth Individual Healthcare Records (IHCRs) were reviewed and six
were applicable for episodic care encounters. Each of the episodic care events were rendered
by a registered nurse (RN) and documented in subjective, objective, assessment, and plan
(SOAP) format. None of the episodic or first-aid care was provided by non-healthcare staff.
None of the applicable youth were sent off-site for emergency care. Each applicable youth
episodic care events were documented in the chronological progress notes and tracked on the
Episodic Care Log. The program has five first-aid kits located in east sub-control, west sub-
control one, and the kitchen. Two first-aid-kits are for the two vans, which are kept in master
control. The program has a specific content list for each first-aid kit. The list is maintained in
each first-aid kit and has each item noted with an expiration date. The first-aid kits were
checked monthly by the RN to ensure they are secure and stocked properly. Three first-aid kits
were observed, and each contained the required items. The program has one automated
external defibrillator (AED) located in the staff break room. The AED provides audio instructions
on step-by-step procedures. Written AED procedures are maintained just above the box where
the AED is mounted on the wall. An observation of the AED in comparison with an informal
interview with the nursing staff confirmed the AED had a blinking green light which indicated the
device was functioning adequately. Reviewed documentation confirmed the AED batteries
expire on December 30, 2023, and the pads expire on October 31, 2023. The nurse reported
the new pads have been ordered to replace the pads which will expire in October. The batteries
were last changed on July 30, 2021, and the pads were last changed on August 1, 2021.
Reviewed documentation since the last annual compliance review confirmed the nurse checks
the AED weekly. A review of nine staff training records found each reviewed non-healthcare
staff who had direct contact with youth maintained current certifications in first-aid and
cardiopulmonary resuscitation (CPR) with AED. In addition, authorized direct care staff were
appropriately trained on the administration of the epinephrine auto-injector. A review of the
program’s mock emergency medical drills reflected a drill was conducted on all three shifts
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monthly since the last annual compliance review. An interview with the nurse confirmed the
program’s practice. Emergency medical drills included the demonstration of CPR and AED at a
minimum annually. The emergency medical drills consisted of both announced and
unannounced type drills conducted at least quarterly on each shift. Each drill replicated a
medical scenario, and the drill forms included all required elements. Emergency contact
telephone numbers are located in areas which are not accessible to youth. Observations made
throughout the program during the tour found postings informing staff of their right and
responsibility to call 9-1-1. The program did not have any episodic care events to observe
during the week of the annual compliance review. The program has a written policy and
procedure which steps out the use, access, and inventory of NARCAN®. The nurse secures the
NARCAN® in the locked medical cart. The nurse reported NARCAN® is inventoried weekly by
the RN. The nurse reported all RNs are trained and identified program staff who have been
trained on how and when to use NARCAN®. Nine staff were interviewed, and each reported
they are allowed to call 9-1-1. Nine youth were interviewed, and each reported they are able to
see a dentist or doctor if needed.
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 written policy and procedures to provide timely referrals, coordination, and
documentation of medical services to off-site health providers for youth with emergent or non-
emergent needs. Nine youth Individual Healthcare Records (IHCRs) found three youth
applicable for off-site care to the dentist office. Reviewed documentation supported the
parent/guardian was notified. The program reported not having any emergency off-site care
since the last annual compliance review. Each of the three applicable IHCRs had a Summary of
Off-Site Care Consultation Report form which was filed in the IHCR with any applicable
additional documents. The designated health authority (DHA) reviewed and signed all forms as
required. Two of the three applicable youth required follow-up care, and each received a follow-
up. The nurse reported all forms relating to off-site care findings, instructions, and information
are placed in the weekly logbook for review by the health service administrator. The DHA is also
notified of all hospital orders, and they are faxed to the pharmacy, if needed. Additionally, the
nurse reported nursing staff track follow-up testing, referrals, and appointments by utilizing a
calendar and the DHA’s logbook.
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 written policy and procedures ensuring youth who have been identified with
a chronic illness or who experience changes in condition or treatment regimen receive regularly
scheduled evaluations with the required follow-ups. Nine youth Individual Healthcare Records
(IHCRs) were reviewed and three were applicable for a chronic condition documented on their
Facility Entry Physical Health Screening (FEPHS) form during admission. Two additional youth
were identified with a chronic condition after being admitted into the program. None of the youth
were identified as having a communicable disease. Three youth were taking medication on an
on-going basis. None of the youth were undergoing treatment for a physical health condition
which included a body mass index greater than thirty. Each youth was classified with the
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appropriate Medical Grade. Each applicable youth was placed on the chronic illness list and
periodic evaluations were conducted every ninety days. Progress notes were reviewed for
documentation of each applicable youth’s completed periodic evaluation, which confirmed they
were conducted prior to renewing any medication which was expired. None of the youth were
applicable for taking anti-tuberculosis medications. None of the youth were applicable for
receiving off-site care for their condition. There was no indication of lapses in care or missed
periodic evaluations in each of the reviewed records. The Department’s Problem List for each
youth was updated in accordance with policy. The facility administrator (FA) was interviewed
and reported administration meets weekly with the medical department to review youth medical
issues. The FA also reported the medical department sends daily emails with youth alerts to
ensure all staff are made aware. The designated health authority (DHA) reported evaluations
are tracked and conducted every ninety days, or less, if needed. An informal interview with the
nurse also confirmed the process for the completion of periodic evaluations.
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 written policy and procedures which outline the process of how medications
are to be received, stored, inventoried, and administered in a safe and effective manner. A
review of nine youth Individual Healthcare Records (IHCRs) indicated five youth were admitted
with medication. All five youth Facility Entry Physical Health Screening (FEPHS) forms
documented the youth were admitted to the program with medications. Each prescription
verification was documented on the chronological progress note utilizing the Prescription
Medication Verification Checklist form. Reviewed documentation confirmed the designated
health authority (DHA) was notified. There were no instances when a youth’s medication could
not be verified and had to be returned to the youth’s parent/guardian. Reviewed documentation
supported all medications had a current, valid order, and were given pursuant to a current
practitioner’s order. When applicable, the psychiatrist conducted the youth’s initial diagnostic
psychiatric interview within fourteen days of admission. The program utilizes a pre-printed
Medication Administration Record (MAR) to document all medication and treatment. Each of the
reviewed MARs met all requirements outlined within Florida Administrative Code. The nursing
staff documented side-effect monitoring at a minimum of weekly on each MAR. There were no
instances where trained non-healthcare staff assisted in the delivery of medications. There were
no undocumented explanations for a lapse or errors in medication administration. Three of the
five youth were applicable for having refused medication at some point during the annual
compliance review period. Refusals were found notated on each applicable MAR and
subsequently youth signed or refused to sign the refusal of treatment form, as required. Each
reviewed MAR documented all required elements. When applicable, youth received medication
monitoring every thirty days as required. There was no indication of any type of standing orders
for psychotropic medications. There were no indications of any emergency treatment orders for
psychotropic medications. There was no indication of any pro re nata (PRN) orders for
psychotropic medications. The RN administered the medication as required and did not pre-
pour any of the medications. Nine youth were interviewed. Four youth reported the nurse
provides medication. Five youth reported not taking medication. Nine staff were interviewed
regarding the medication process. Each staff reported the nurse provides medication. During an
interview, the nurse reported only the nurses verify prescriptions admitted with the youth. The
nurse also reported the program has identified and trained staff to provide medication in the
event the nurse is not on-site. One medication pass was observed during the annual
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compliance review week with no noted issues. The youth was escorted to medical by direct care
staff. The Six Rights of Medication Administration were verified by the RN.
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 written policy and procedures to ensure medical equipment classified as
sharps/medications are secure and inventoried utilizing a routine perpetual inventory. An
observation of the medical cart found all medications were stored in the locked cart which is
kept in the locked medical office behind a locked door. All non-controlled medications were
stored in a separate, secure, locked medication cart. Narcotics and other controlled medications
are securely stored and double locked within the medication cart. The medication cart was
observed to be clean and organized, with stock items separate from youth specific medications.
Observations found all medications were securely stored in the medical clinic inaccessible to
youth. There was one medication requiring refrigeration during the annual compliance review
week which was observed in the refrigerator. The program’s practice is for over-the-counter
(OTC) medications to be inventoried using a perpetual inventory daily and verified weekly, and
reviewed documentation confirmed the practice. Perpetual inventories with running balances
are maintained on all controlled substances with a shift-to-shift inventory conducted by the
registered nurses. Syringes and sharps are counted through a perpetual inventory and are
verified weekly. During the week of the annual compliance review, three OTC medications were
reviewed, and the inventories were accurate. Three sharps were reviewed, and inventories were
accurate. Three narcotic or controlled medications were reviewed and found the inventories
were accurate. An interview with the nurse verified the program’s inventory and disposal of
expired medication process. The nurse advised unused medication is returned to an approved
pharmacy for credit. The nurse also was able to explain the program’s process for inventory
discrepancies in its entirety.
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 written policy and procedures for infection control which include an exposure
control plan which is written in accordance with Occupational Safety and Health Administration
(OSHA) and the Centers for Disease Control and Prevention (CDC) guidelines. The Infection
Control Policy was last reviewed and signed by the designated health authority (DHA) on
September 19, 2023, and the facility administrator (FA) on September 19, 2023. The plan also
included common infectious diseases of childhood, self-limiting, episodic contagious illnesses,
viral or bacterial infectious diseases, tuberculosis, Hepatitis A, B, and C, human
immunodeficiency virus (HIV), infectious diseases caused by blood-borne pathogens, other
outbreaks or epidemics caused by any other infectious agent, outbreaks of lice or scabies,
Methicillin-Resistant Staphylococcus Aureus (MRSA) and other anti-biotic resistant micro-
organisms, food-borne illnesses, bio-terrorist agents, and chemical exposures. The program
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maintains procedures for staff to adhere to universal precautions and the program provides staff
with the opportunity for Hepatitis B immunizations and access to protective equipment. The
Exposure Control Plan was written in accordance with OSHA standards and was last reviewed
and signed by the DHA on September 19, 2023, and the FA on September 19, 2023. The
program has a process for needle stick post-exposure evaluation which includes the
establishment of a separate file, maintained for youth and staff who have experienced a
facility/occupational exposure. There were no instances in which more than ten percent of youth
required hospitalization or quarantine during the annual compliance review period.
The nurse reported the program has not had any instances which required notification to the
local county health department, CDC, and/or the Department’s Central Communications Center
(CCC). In addition, the nurse reported nursing staff conduct infection control training for program
staff and youth. The nurse confirmed the Exposure Control Plan is in the medical department
and staff have access to protective equipment and Hepatitis B immunizations if needed.
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 written policy and procedures to address youth supervision and requiring all
program staff to promote safety and security by maintaining active supervision of youth to
include interacting positively with youth, engaging youth in a full schedule of constructive
activities, closely observing behavior of youth, and consistently applying the program’s behavior
management system (BMS). The program has a daily youth activity schedule which was posted
throughout the program. The program staff are required to account for the whereabouts of youth
under their supervision and ensure staff-to-youth ratios are in compliance with contract
requirements. The program’s contract requires staff-to-youth ratios to be one-to-eight during
awake hours and one-to-ten during sleep hours. The ratio for off-site activities, transportation,
and visitation is one staff to five youth. Observations of staff supervision during the annual
compliance review week included classroom activities, line movement, school breaks, youth
head counts, mental health groups, and outdoor/indoor recreation activities. The observations
ensured staff-to-youth ratios were maintained, as required. Informal interviews with three staff
while on the modules were conducted, asking staff how many youth they were supervising, and
each staff immediately knew the number of youth they were supervising. Observed staff and
youth were appropriately attired. Observations of interactions between program staff and youth
reflected the interactions were positive and consistent with the program’s BMS. Nine staff were
interviewed, and each staff indicated if there were any discrepancies in the youth count a code
yellow would be called, the staff would stop all movement, secure all youth, conduct an
emergency count, and conduct a search of the program until the missing youth is located.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program has a written policy and procedures addressing the implementation and training of
the program’s behavior management system (BMS) which has not changed since the last
annual compliance review. The program’s BMS is designed to maintain order and security
fostering compliance with the program rules teaching youth alternative pro-social methods of
dealing with problems using both rewards and a system of progressive discipline. It promotes
safety, respect, fairness and protection of rights within the community, provides for constructive
discipline and a system of positive and negative logical consequences to encourage youth in
meeting expectations for behavior, promotes positive reinforcement and recognition for
accomplishments, positive behaviors, at a minimum ratio of four-to-one positive to negative
consequences, promotes socially acceptable means for youth to meet their needs, and includes
processes which address the needs of and cognitive capacity of youth. The BMS promotes
dialogue and peaceful conflict resolution, minimizes the separation of youth from the general
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population, and assures consistent implementation and equitable treatment through oversight
and training. 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. 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 consequences
when redirecting the youth, as indicated in the program’s policy. Nine youth were interviewed,
and each stated the consequences included level freezes, early bedtimes, and confinement.
One youth stated if youth get into a fight, youth can be placed in controlled observation, and
depending on your behavior, a treatment team will be set to explain their side of the story. Each
youth was interviewed about the rewards used in the program and all stated youth can earn
nightly incentives and canteen. All nine interviewed youth were able to explain the difference
between each level and how to move from level to level. Each youth stated staff use rewards
the same. Eight youth also stated the BMS is good, and one youth stated it was poor. The
interview information was relayed to the program. Nine interviewed staff explained the BMS
consists of a level system where youth earn points, rewards, and consequences which are
based on the youth’s behavior. Three staff stated the BMS is in the youth handbook. Nine
interviewed staff stated youth can earn points to receive nightly incentives, and canteen. Each
staff stated the program uses a model called “Gotcha” where youth can earn food and rewards
on Mondays. “Gotchas” are used when youth are observed displaying positive behaviors.
Additionally, the program youth attend award ceremonies, name drawings for a meal reward,
nightly incentives, Mega Monday, and Phat Fridays. Each staff stated nothing can be taken
away from the youth as a consequence; however, youth with infractions cannot participate in the
incentives. An interview with the facility administrator (FA) indicated the program uses the
iChoose BMS, which is focused on modeling, coaching, and incentivizing pro-social healthy
behaviors which consists of a point system. The youth earn points based on behaviors and
points are added by day to total up to 200. These points are used to purchase canteen. The
youth can either earn or fail to earn their points to "make their day". As the youth earn their
points, it progresses the youth to level up in the program.
5.03 Use of Room Restriction Non-applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, provide constructive discipline and a system of positive and negative consequences
to encourage youth to meet expectations for behavior, provide opportunities for positive
reinforcement and recognition for accomplishments and positive behaviors, promote dialogue
and peaceful conflict resolution, and minimize separation of youth from the general
population.
Supervisors shall monitor staff implementation of the BMS and ensure the use of rewards and
consequences are administered fairly and consistently in application among all staff.
The program’s policy, procedures, and practice confirm the program does not use room
restriction; therefore, this indicator is rated non-applicable.
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5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a written policy and procedures in place to conduct and document ten-minute
checks during sleep hours or at other times, such as during an illness or room restriction. The
program has a total of 128 video cameras capable of recording thirty-days of video footage.
During the annual compliance review week, all cameras were operational. Prior to conducting
checks, staff are situated where they are able to see any movement within the dormitory. Staff
are required to conduct room checks every ten-minutes and document the time of the check on
the Ten-Minute Check Log when youth are sleeping. A review of twelve separate video footage
samples of ten-minute checks from each program living module and log sheets reflected there
were no discrepancies. Documentation confirmed staff who complete the checks initial or sign
the check sheet. Nine interviewed staff stated room checks were conducted every ten minutes
when a youth was placed in their room for sleeping or non-punishment reasons.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program has a written policy and procedures to ensure youth are always accounted for
through a system of physically counting youth at various times throughout each day. The
program’s policy indicates counts are conducted during power outages, escapes, riots, or any
other disruptions which may occur. Head counts shall be conducted at the beginning of each
shift, after outdoor activities, during emergency situations such as riots, and during drills, which
may be actual or simulated. A review of the logbooks for the last twelve months verified the
program documented counts at the beginning of each shift, after each outdoor activity, and
during emergencies. In addition, the program logbooks included documentation of new
admissions, releases, transfers, and youth temporarily away from the program. Observations
made during the annual compliance review week verified the program’s practice includes
conducting youth counts before movement to school. Nine interviewed staff explained youth
counts are conducted every hour, during drills, informal counts throughout the day, and after
every movement.
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5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has a written policy and procedures to ensure the maintenance of a chronological
record of events, incidents, and activities in a central logbook. The program maintains a master
control bound logbook with numbered pages for each month. Reviewed logbooks did not have
any loose pages and were not falling apart. Observations and a review of logbooks since the
last annual compliance review found logbook entries were documented in ink with no erasures
or white-out areas. Errors were typically struck through with a single line, dated, and initialed by
the staff correcting the error. Reviewed documentation of randomly selected days within the
logbooks reflected each entry included the date and time of the event, the names of the staff
and youth involved, as well as a brief description, the name, and signature of the staff making
the entry. Logbooks included entries for emergency situations, population counts, law
enforcement access to youth, perimeter checks, and youth movement. Reviewed logbooks
reflected recreation was conducted each day as required. The program ensures direct care
staff, including each supervisor, are briefed when coming on duty. Each staff signs the shift
briefing sign-in sheet to acknowledge receiving the information. Reviewed logbooks reflected
the program consistently documented internal incidents reported to the Florida Abuse Hotline
and/or the Department’s Central Communications Center (CCC).
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a written policy and procedures for key control and security which include
assignment, inventory, tracking, replacement of damaged keys, and storage of keys. The
assistant facility administrator (AFA) has overall responsibility for key control management
which includes replacing damaged keys. Observations made throughout the annual compliance
review week found all staff and visitors surrendered their personal keys upon entering the
program. Staff and visitor’s personal keys are collected upon entering the program and stored in
a secured key box located in master control. Upon entering the program, staff sign the key
logbook, enter the date, key ring number, and time the key was signed out. When leaving the
program, staff enter the time in and sign the key logbook indicating the key was returned. A
review of the key logbook verified this practice. The program has a list of staff who are assigned
permanent keys. Permanent keys are issued, and staff sign an acknowledgment form indicating
a key identification number and the number of keys issued. All key rings are tagged to record
the ring number, keys assigned, and number of keys on the ring. A review of three staff and
their permanently assigned keys during the annual compliance review week verified keys
matched the permanent key log. In the event of misplaced or lost keys, the immediate
supervisor, facility administrator (FA), and assistant facility administrator (AFA) shall be notified.
Staff shall indicate which keys were lost, when the loss was discovered, and any circumstances
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surrounding the loss. A written incident report shall be submitted as soon as possible to the FA
and AFA. A review of the Department’s Central Communications Center (CCC) reports verified
there were no instances of a staff losing their program keys since the last annual compliance
review. Nine staff were interviewed, and each was knowledgeable of the key control process.
The master control operator reported staff turn in their personal key and they receive assigned
keys. The operator stated staff sign-in and out assigned keys prior to and following each
assigned shift. The operator checks the key cabinet area and log before the beginning of the
shift to ensure all keys have been appropriately signed for and returned at the end of the
previous shift.
5.08 Contraband Procedures Limited Compliance
The program’s policy must address illegal contraband and prohibited items.
A program shall delineate items and materials considered contraband when found in the
possession of youth, the list must include: sharps, escape paraphernalia, tobacco products,
lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food or
clothing, any intoxicating beverage or any beverage which causes or may cause an
intoxicating effect, any controlled substance, any prescription or non-prescription drug which
has a hypnotic, stimulating, or depressing effect, any firearm or weapon of any kind or any
explosive substance, non-facility issued electronic equipment or devices to include
smartwatches, metals, personal non-facility issued cellular devices, unauthorized currency or
coin(s), and non-facility issued keys. The program shall provide youth with the list of
contraband items and materials and inform the youth of the consequences if found with
contraband. The program shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, and both staff and youth.
The program shall document the confiscation of any illegal contraband and the manner of
disposition. The program shall keep a copy of the documentation in the youth’s case record. If
a confiscated item is not illegal or prohibited, the program director or designee has the
discretion to discard of the item, return it to its original owner, mail it to the youth's home, or
return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a written policy and procedures to ensure the safety and security of
youth, staff, the program, and the public through effective search practices which include
detection and removal of contraband. The program staff, visitors, and youth are prohibited from
introducing any item into the secure area without authorization from the facility administrator
(FA) or designee. The introduction, removal, or possession of certain unlawful articles and
associated penalties are outlined in Florida Statutes. The policy outlines the program
responsibilities, standards for searches of youth, and program searches. Program searches
include youth rooms, common areas, and the program perimeter. All authorized items are
outlined in policy and the youth handbook. A review of the policy and youth handbook confirmed
prohibited items included 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 any keys not issued by the
program. The policy and handbook outline the consequences for youth found with contraband,
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which is also outlined in the behavior management system. Additionally, reviewed
documentation included the procedures for searching incoming and outgoing mail. The policy
dictates all illegal contraband will be surrendered to law enforcement, and unlawful activity will
be reported to law enforcement. A review of the weekly room search logs verified the program
documented room searches at varied times at least once each week. Unauthorized items were
collected and disposed of according to the logs. Items included pens, extra clothing, video
games, and extra food. Informally interviewed staff reported the supervisors conduct room
searches. Common area searches and perimeter searches were documented at least daily on
each shift within the program’s logbook. A review of the Department’s Central Communications
Center reports since the last annual compliance review indicated the program had six separate
incident reports involving illegal contraband since the last annual compliance review.
Contraband items referenced within the incidents included marijuana, a cellular device, and an
item perceived to be a homemade weapon. At the time of the annual compliance review, the
program had a major deficiency for contraband. The Outcome Based Corrective Action Plan
and the steps associated with the plan were scheduled for an anticipated correction date of
November 6, 2023. The interviewed FA reported any contraband which is illegal is turned over
to the local sheriff’s office. Additionally, any contraband which is not illegal is secured in the FA's
office, dated, and photographed until the investigation is complete. The contraband is then
disposed of off-site.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a written policy and procedures to ensure searches, and full body visual
searches, are conducted according to Florida Administrative Code at the time of admission,
after off-campus activities, and visitation. Parents/guardians are notified of searches during
visitation by way of the parent/guardian intake letter, which is sent at the time of each youth’s
admission. Youth are searched before all movement, during a new admission, readmission,
returning from visitation, returning from off-campus activities and/or appointments, when
suspected of contraband, or determined to be a security risk. Observations made throughout the
annual compliance review week validated youth are provided instructions regarding the search,
searches were conducted by staff of the same gender as the youth, were conducted in a
manner as not to degrade the youth, and were based on the Protective Action Response
(PAR)/Right Interactions (RI) training manual. Searches observed during the annual compliance
review week verified youth were searched before going to school and coming back from school,
after using the restroom, and after the graduation activity. There were observations of searches
made for a transport and a new admission during the annual compliance review week. There
was no observation made for visitation searches, as there were none available during the
annual compliance review week. Nine staff were interviewed, each staff was able to explain
when and how youth are searched. Nine youth were interviewed, and all indicated searches
occur after outdoor activities, when returning from off-site activities, and after every movement.
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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 a written policy and procedures to ensure vehicles used to transport youth are
properly maintained and in working order. 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 seatbelts, a seatbelt cutter, a window punch, a fire extinguisher, and an
approved first-aid kit. Youth and staff wear seatbelts during transports, and youth are not
attached to any part of the vehicle by any means other than the proper use of a seatbelt. During
the annual compliance review week, the program was using one van to transport youth;
however, they received a new vehicle during the annual compliance review week, which had not
yet been used to transport youth. Reviewed documentation verified each vehicle received an
annual safety inspection and was maintained by a certified automobile mechanic. The
program’s vehicle used to transport youth was inspected during the annual compliance review
week and verified all seatbelts were working, and the passenger doors could not be opened
from the inside. The inspection verified the van was locked when not in use. The inspected van
included a fire extinguisher, seatbelt cutter, first-aid kit, and window punch. A check of ten
vehicles in the program parking lot verified all vehicles were locked. Nine youth were
interviewed, and eight of the nine youth stated they had their seatbelts on with the handcuffs
and leg shackles during transports; three youth stated they have never been on a transport.
Nine staff interviews were conducted, and eight of the nine stated youth are handcuffed, wear
leg shackles, and wear seatbelts during transports. One staff stated youth are secured with a
seatbelt during transports.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a written policy and procedures to ensure the safety and security of youth and
the community when youth are transported outside of the program. Reviewed documentation
verified all approved drivers had a valid driver’s license. The program assigns a ratio of one staff
to five youth during transport, not including the driver. The program provides secure
transportation for high-risk and secure maximum-risk youth determined to be at greater risk. A
transport was observed and confirmed the staff-to-youth ratio was within the contract
requirements during the week of the annual compliance review. Nine staff were interviewed, and
all verified they use a company cellular telephone during transports. Each of the nine
interviewed staff stated the safety equipment in the transport vehicles included a first-aid kit,
window punch, seatbelt cutter, and a fire extinguisher. Each staff confirmed they are not allowed
to use personal vehicles to transport youth. Each interviewed staff indicated the transport
vehicles are searched for contraband prior to and after each use. Each interviewed staff stated
they would contact 9-1-1 and/or contact the program if an emergency arises during vehicle
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transport. All interviewed staff indicated the transportation ratio is one staff to five youth, not
including the driver. Nine interviewed youth stated they never saw anyone place contraband in a
transport vehicle and they feel staff are driving transport vehicles safely.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures requiring a safe and secure physical plant, grounds,
and perimeter to be maintained and for weekly safety and security audits to be conducted. The
facility administrator (FA), assistant facility administrator (AFA), and the program’s management
team are responsible for conducting weekly safety and security audits and submitting the audits
to the Department. Reviewed documentation confirmed weekly safety and security audits were
conducted and any identified deficiencies were documented on the reports including the status
and due date of any needed corrective action and were added to the program’s tracker. A
review of the program’s Preventative Maintenance Checklist forms for the past twelve months
indicated inspections were completed, as required, and documented deficiencies and repair
updates. An interview with the FA indicated the program completes a key performance indicator
(KPI) report based on the reported information from each morning meeting. This information is
totaled each month and compared to the previous month. A meeting with the management team
is conducted to plan how to reduce deficiencies. Internal reviews are completed by corporate
staff to verify deficiencies are being reduced.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a written policy and procedures for a tool management system which ensures
youth do not use tools or equipment as weapons or for security breaches. The reviewed policy
addresses the issuance, inventory, and control of equipment and tools. A review of inventory
logs and the tool storage room verified tools are securely stored when not in use, easily marked
for identification, and inventoried prior to and following work activities. All sharp edged and
pointed tools are inventoried daily when in use, including kitchen tools. There is a monthly
inventory of tools which do not have sharp edges or points. Prohibited tools at the program
include machetes, bowie knives, and other long bladed knives. If a tool is broken or inoperable,
the maintenance manager is responsible for replacing the broken tool. A review of the inventory
used to document issuance and return of tools found no discrepancies. If a tool is missing while
youth is in the area, staff will notify administration, the program will stop all youth movement, a
tag is placed on the shadow board, and the program will be searched until the tool is found. A
review of the Department’s Central Communications Center (CCC) reports verified there were
no instances of missing/lost tools since the last annual compliance review.
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5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a written policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries. The program’s policy and procedures included
supervision requirements, issuing tools to youth and staff, and activities involving tools. The
ratio is one staff for every five youth during tool use. Observations of youth in the living quarters
using a broom and dustpan confirmed staff-to-youth ratios were in compliance during the annual
compliance review week. A review of the program’s procedures and documentation verified staff
are required to complete a sign-out and sign-in log when Class B tools are taken and are
returned to the designated storage room. Reviewed documentation confirmed youth were
trained on the intended and safe use of Class B tools. Nine youth case management records
were reviewed, and risk assessments were completed prior to youth tool use. Nine youth were
interviewed, and eight stated they use mops and brooms. Five of out the nine also stated they
use a scrub brush. Nine staff were interviewed, and each stated youth can use brooms, mops,
and scrub brushes.
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 written policy and procedures establishing guidelines for outside contractors
who come on-site to complete repairs. When a contractor or vendor enters the program, they
sign the Outside Contractor On-Site Work Project Log which lists unauthorized items. A review
of the work project logs since the last annual compliance review verified the contractors signed
the log confirming notification of what items are considered unauthorized. If any unauthorized
items are needed by the contractor while in the program, approval is obtained by the facility
administrator (FA) or designee. Any tools required to be used within the program are inventoried
and recorded on the contractor’s agreement form before and after the repair is completed. A
reviewed of three project invoices showed the vendors signed contractor agreements and an
inventory of tools was completed and documented. An informal interview with the assistant
facility administrator (AFA) indicated when contractors are on-site, youth are not allowed near
the work area. The program’s practice is to assign a staff to the contractor to ensure the work is
being completed and all tools are secured.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program has a written policy and procedures to ensure fire safety and evacuation drills are
conducted, and youth and staff are prepared for immediate implementation or mobilization in the
event of an emergency or disaster. The Continuity of Operations Plan (COOP) requires the
program to conduct unannounced fire drills quarterly for each shift. Reviewed documentation
validated fire drills were conducted for all shifts as required. The program additionally conducted
monthly emergency drills on each shift ensuring disturbances, escapes, bomb threats, chemical
spills, medical situations, and severe weather were covered on a rotating basis. Drill
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documentation included the type of drill, date and time, participants, a brief scenario description,
deficiencies identified during the drill, and applicable corrective actions. The fire evacuation
routes are posted throughout the program. All twenty-four of the program’s fire extinguishers
were inspected annually. Nine staff were interviewed, and each reported they participated in fire
drills and escape drills. Eight reported they participated in weather drills. Six reported major
disturbance and bomb threat drills, and six reported they participated in suicide drills during the
previous twelve months. All nine interviewed youth stated they participated in fire drills and have
been instructed on what to do in the event of a fire. An interview conducted with the facility
administrator confirmed the program conducts monthly fire and COOP drills on all shifts.
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 department approved Disaster and Continuity of Operations Plan (COOP)
available for all staff to review. The facility administrator (FA) was interviewed and indicated the
COOP is available to all staff and is located in the conference room, master control, and the
main office. The plan was reviewed, updated, and approved by the Department on February 16,
2023. The COOP provides basic care and custody of youth in the event of an emergency of
disaster, addresses phases of a disaster plan, and emergency management including
preparedness, response, and recovery. The COOP addresses emergencies including fire
prevention, bomb threats, evacuations, chemical spills, severe weather, and terrorist attacks. A
review of the plan indicated alternative housing has been identified should the program require
evacuation due to an emergency or disaster. Reviewed documentation confirmed the program
maintains critical identifying information in hard copy binders including case management,
mental health, and medical. The program’s hard copy records are easily accessible and mobile
in the event of an emergency resulting in the program relocating quickly or in the event needed
information cannot be accessed electronically for all youth in the program. A review of nine
youth case management records confirmed each contained the youth’s name, a photograph,
Department identification number, admission date, date of birth, gender and race, overall health
status, address, and parent/guardian contact information which included name, address,
telephone number of the person with whom the youth resides and their relationship to the youth,
and person(s) to notify in case of an emergency. In addition, the records contained the youth’s
assigned juvenile probation officer (JPO), committing judge, state attorney, public defender, and
victim notification contact information. The facility administrator (FA) also reported fire drills,
COOP drills, suicide drills, and medical drills are completed on all shifts.
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5.18 Storage and Inventory of Flammable, Poisonous, and
Satisfactory Compliance
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 program has a written policy and procedures to ensure strict control of the procurement,
storage, and inventory of all flammables, toxic, poisonous, and caustic materials. The program’s
assistant facility administrator (AFA) and maintenance manager maintain a monitor system to
ensure compliance with flammable, poisonous, and toxic items. All flammable, poisonous, and
toxic items such as bleach, gas, cleaners, pesticides, and antifreeze were secured in the
outside storage area where youth do not have access. A review of the flammable, poisonous,
and toxic items and inventories verified the items were securely stored and inventories were
accurate. The program maintains a list of all staff who are authorized to handle the materials
which includes the facility administrator (FA), maintenance manager, AFA, and shift supervisor.
A Safety Data Sheet (SDS) binder is located inside the storage area with a picture of each
material corresponding to the SDS. The program maintains chemicals used daily in a locked
storage area inside the program and outside. The program has a Chemical Daily Usage Log to
track all toxic materials when in use by authorized staff. Observations of the storage area
indicated it is clearly marked hazardous chemicals, securely locked, and has a posted list of
authorized staff.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a written policy and procedures prohibiting youth from handling any
flammable, poisonous, and/or toxic items or materials. Program youth are strictly prohibited to
use, handle, or clean dangerous or hazardous chemicals, respond to chemical spills or clean,
handle, or dispose of any other person’s biohazardous material, bodily fluids, or human waste.
Youth are strictly prohibited from the maintenance area where toxic items and chemicals are
stored. Nine youth were interviewed and four out of the nine stated they have used chemicals or
cleaning products. Three youth stated they used paint to paint the rooms and one youth stated
they used bleach, laundry soap, and toilet cleaner. The information was relayed to the program.
Observations of youth during daily cleaning activities using a broom and dustpan were
completed during the annual compliance review week.
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5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program has a written policy and procedures for the disposal of flammable, toxic, caustic,
and poisonous items. The program’s maintenance manager and assistant facility administrator
(AFA) are responsible for disposing of unused flammable, poisonous, and/or toxic materials to a
local household hazardous waste drop off-site, when needed. The program has a list of
positions, titles, or functions authorized to dispose of these items. Reviewed documents
confirmed the program’s disposal procedures of chemicals were created in accordance with
Occupational Safety and Health Administration (OSHA) standards. All hazardous chemicals
which are no longer used or are outdated are disposed of by returning them back to the vendor
or sending the chemical to the hazardous waste center in accordance with the Safety Data
Sheets (SDS). The program maintains a SDS Log to track the disposal of such items. A review
of the Disposal Logs indicated the program did not have any chemicals disposed of since the
last annual compliance review. In an informal interview, the assistant facility administrator (AFA)
stated the program only purchases what is used and has not disposed of any items. If there are
any chemicals in need of disposal, the maintenance staff fill out the Disposal Log and drop off
the chemicals at the bio-hazardous waste station. All liquid waste from work details is disposed
by pouring the liquid in plumbing drains. Kitchen liquid waste, except for grease, is disposed in
the kitchen drain. Grease is placed in a separate container for disposal. The program has a
procedure in place in the event of a chemical spill. If a chemical spill occurs, the shift supervisor
and maintenance staff are notified, the staff shut down the air handlers and ventilation systems,
and closes all windows and doors. The program uses a local disposal company to dispose of
the grease in the grease trap every quarter.
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5.21 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.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a written policy and procedures to ensure youth are provided the opportunity
to receive visitation and communication with approved family members. The program’s policy
provides each youth opportunities to promote communication and engagement which fosters
family reunification and community connections. The program assists youth and families in
maintaining connections in a visitation environment which provides monitoring, control of
movement, and security practices to ensure visitor, youth, staff, and program safety. The
program also maintains a list of approved visitors; however, attorneys, representatives of the
court, juvenile probation officers, other agency representatives, and clergy are authorized to visit
at any time. Searches of visitors will be conducted upon entry and all youth shall be searched
following visitation sessions. During admission, each youth is provided with the program’s
visitation, telephone, and mail policies and guidelines. The program’s visitation policy indicated
consideration for requests of alternative visitation arrangements with parents/guardians, if
needed. Visitation is held two days a week on Saturdays and Sundays from 1:00 p.m. to 4:00
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Office of Accountability and Program Support Page 67 of 70 (Revised September 2022)
p.m. Youth can write letters or call by telephone at least once a week to approved family
members. A review of the logbooks and visitation sign-in sheets verified the program allows
visitation for approved family members. A review of the telephone chronological notes verified
youth have consistent telephone communication with family members. None of the reviewed
youth had a history of human trafficking. According to the facility administrator (FA) all incoming
and outgoing mail is checked for contraband and then given to the youth. The program posted a
visitation schedule and rules at the visitor’s entrance of the program, and rules are provided to
the visitors upon entry to ensure awareness of visitation guidelines. Nine youth were
interviewed, and each stated they took a tour of the program and received the youth handbook
with all the rules and policy. Nine staff were interviewed; one staff stated all services for
translations are through American Sign Language. Eight staff stated they will use interpreters
from the services line, and they have staff to translate.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a written policy and procedures to ensure each youth has a variety of
recreation and leisure activities. The program promotes the active participation of youth through
opportunities to make choices, assume meaningful roles, including team membership and
leadership roles, and give input into the rules and operation of the residential community. Staff
work with the youth to plan activities to expose youth to a variety of recreation and leisure
choices, exploration of interests, constructive use of leisure time, social and cognitive skill
development, as well as to promote creativity, teamwork, healthy competition, mental
stimulation, and physical fitness. Staff provide the youth with varying degrees of mental and
physical exertion throughout the day such as board games, creative arts, sports, and physical
fitness activities. Youth are provided with at least one hour of large muscle activity daily. An
informal interview with the facility administrator (FA) reported the recreation therapist position
became vacant in the month of September 2023; however, the youth are still receiving services.
Nine youth performance plans were reviewed, and each plan included a recreation goal.
Reviewed documentation of the logbook and daily activities schedule confirmed the program
has a range of supervised and structured indoor and outdoor recreation and leisure activities for
the youth for at least one hour daily. Nine staff were interviewed, each stated the program
provided basketball, football, card games, puzzle activities, basketball, and kickball. Nine youth
were interviewed, and each youth indicated the program allows the opportunity to exercise, play
outside, or inside depending on the weather. Each youth stated they participate in basketball,
football, board games, and television.
5.24 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 maintains a policy and procedures to ensure youth searches and room inspections
are conducted prior to placing a youth in a controlled observation room. A review of
documentation for five youth who were placed in a controlled observation room was completed.
Reviewed documentation confirmed each room, and each youth was searched prior being
placed in the room. Observation of rooms verified they were a minimum of thirty-five
unencumbered square feet, had a metal door with a shatter-resistant window, vents were not
easily accessible and covered with small mesh or a metal plate, recessed light fixtures covered
with shatter-resistant material, and no electrical outlets or electrical switches were outside
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 68 of 70 (Revised September 2022)
sleeping rooms. The program utilizes a controlled observation checklist which documents both
the room and youth searches.
5.25 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy and procedures address controlled observation, which may be used as an
immediate short-term crisis management strategy when a youth’s aggressive, violent, or
potentially dangerous behavior substantially threatens the physical safety of others,
compromises program security, and when non-physical interventions would not be effective.
Controlled observation shall not be used as a form of punishment or discipline. Youth
demonstrating acute psychological distress shall not be placed in controlled observation. The
facility administrator shall ensure all use of controlled observation is implemented only as
authorized and in accordance with policy. All program staff shall be sufficiently trained in both
use and documentation of controlled observation. The program had a total of eleven controlled
observation placements since the last annual compliance review. A review of documentation for
five youth who were placed on controlled observation was completed. None of the youth
exhibited behaviors indicative of mental health crisis or suicide; however, each youth exhibited
active aggression, violent behavior if continued, was physically out of control, and less
restrictive methods would be ineffective or inappropriate. Each of the five controlled observation
placements were authorized by a supervisor. Each controlled observation was authorized due to
at least one qualifying criteria. The staff discussed with each youth the reasons for their
placement and the expected behavior for removal from placement. A health status checklist was
completed for all five reviewed youth. None of the five youth were in controlled observation for
more than two hours; therefore, did not require an extension.
5.26 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 written policy and procedures address controlled observation safety checks and
release procedures. The policy states the program shall conduct safety checks for youth on
controlled observation and the facility administrator or designee shall approve a release when it
is determined, based on the youth’s behavior and if the youth is no longer an imminent threat to
themself or others. A review of five controlled observation safety checks and release procedures
confirmed staff making placements completed the first page of the controlled observation report
and submitted the form to a supervisor. Staff conducted and documented safety checks at least
every fifteen minutes and observed the youth’s behavior. The facility administrator or designated
supervisory staff, approved each of the youth’s release from controlled observation, which was
based on behavior and whether the youth was no longer an imminent threat to themself or
others. Each of the five youth required an internal alert upon placement and release from
controlled observation. The controlled observation report, Health Status Checklist, and
controlled observation safety check forms were maintained in an administrative file for each
youth and maintained in each youth’s individual management record. The facility administrator
(FA) reviewed and approved the controlled observation report for all five youth within twenty-
four hours of each of the nine youth’s release from controlled observation, which is within the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 69 of 70 (Revised September 2022)
required fourteen days. Reviewed documents confirmed the program’s policy and procedures
address staff designations for controlled observation. Nine youth were interviewed, and two of
the nine youth indicated they had been sent to their room for getting in trouble. Each youth
stated staff did checks while they were in their room.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 70 of 70 (Revised September 2022)

report_type: QI Residential

program_name_raw: Kissimmee Youth Academy - BDD/DD

rule: Indicator 2.20

excerpt: Educational Access (Critical)

rating: Limited Compliance

rule: Indicator 5.08

excerpt: Contraband Procedures