state: FL

summary: QI Residential - FY23-24 - 1 finding

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Fort Myers Academy
TrueCore Behavioral Solutions, LLC
(Contract Provider)
2515 Ortiz Ave
Fort Myers, Florida 33905
Review Date(s): February 6-9, 2024
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Rosa Flores, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Rob Aguis, Career and Technical Education Deputy Director (Standard 1)
Nicos Antonakos, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Paula Friedrich, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Rondarrell George, Office of Accountability and Program Support, Regional Monitor (Standard
5)
Evan Hald, Office of Education, Southwest Region Education Coordinator (Standard 2)
Sharon Wong, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Program Name: Fort Myers Academy MQI Program Code: 1494
Provider Name: TrueCore Behavioral Solutions, LLC Contract Number: 10694
Location: Fort Myers County / Circuit 20 Number of Beds: 28
Review Date(s): February 6-9, 2024 Lead Reviewer Code: 182
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
3.08 Specialized Treatment Services*
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 78 (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 78 (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* Satisfactory
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 78 (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* Limited
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 78 (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 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 7 of 78 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage 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 Non-Applicable
5.25 Controlled Observation 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 8 of 78 (Revised September 2022)
Program Overview
Fort Myers Academy is a twenty-eight-bed program, for thirteen to eighteen-year-old females,
located in Fort Myers, Florida. The program is operated by TrueCore Behavioral Solutions,
LLC., through a contract with the Department. The program provides Intensive Mental Health
(IMH) Treatment Services. Additional treatment services provided include group, family, and
individual therapy. In addition, the program fosters each youth by providing youth with mental
health treatment groups which include Moral Reconation Therapy (MRT), Dialectical Behavioral
Therapy (DBT), Skillstreaming the Adolescent, Impact of Crime (IOC), group process therapy,
trauma groups, anger management groups, conflict resolution, clinical education group forums,
and/or other psycho-educational training groups. Program administration is comprised of a
facility administrator, assistant facility administrator (AFA), administrative assistant, and a
human resources manager. Case management services are provided by a director of case
management, three case managers, and a transitional services manager. Mental health staff at
the program include a director of clinical services, one full-time licensed therapist, one pro re
nata (PRN) licensed therapist, two non-licensed therapists, one recreation therapist, two
certified behavioral analysts, one psychologist, and one contracted psychiatrist. The program is
licensed under Chapter 397 through the Department of Children and Families to provide
substance abuse services to adolescents. Medical services are offered 7:00 a.m. through 7:30
p.m. daily and are provided by the regional health services administrator (HSA), who is a
registered nurse (RN), and one full-time regional RN, one pro re nata (PRN) RN, one licensed
practical nurse (LPN), and one contracted medical doctor. Educational services are provided by
the Lee County School District. The program has thirty-seven security cameras providing
coverage with the capability to store video for up to thirty-days. All cameras were operational at
the time of the annual compliance review. The layout of the program includes the administrative
office, a master control office, lobby, a kitchen with an attached cafeteria, two classrooms, a
multipurpose room, and a youth living unit. All meals are prepared on-site. At the time of the
annual compliance review, the program had fifteen vacant positions including six youth care
worker I’s, one youth care worker II, two youth care workers III’s, one shift supervisor, one RN,
one AFA, one HSA, one staff development specialist, and one dietary associate.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 78 (Revised September 2022)
Strengths and Innovative Approaches
• The program is partnering with the community animal shelter and soup kitchens, in order to
allow the youth to assist the local dog shelter and have an ongoing volunteer process.
• The program has a gardening initiative which is designed to engage young individuals in the art
and science of horticulture. Through hands-on experience and mentorship participants will learn
about plant care, sustainable gardening practices, and the importance of environmental
stewardship. The program not only equips them with valuable skills but also instills a sense of
responsibility and connection to nature. An additional opportunity is available for the elegance
level youth who have their own garden. The program recognizes the importance of providing a
serene environment for youth who seek moments of tranquility and introspection. The elegance
level space is currently being designed to be a haven, where young individuals can unwind,
meditate, read, or engage in creative activities. This space is curated to promote relaxation,
mindfulness, and personal growth.
• For youth who are parents or expecting parents, we offer specialized parenting classes and
support services. The program provides sessions which cover a range of topics including
prenatal care, child development, positive parenting techniques, and navigating the challenges
of parenthood at a young age.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 78 (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,
volunteers, and interns receive an initial background screening prior to unsupervised contact
with youth. The program had forty-three new staff hired during the annual compliance review
period. All forty-three records reflected an eligible background screening from the Agency for
Healthcare Administration (AHCA) Clearinghouse through the Department’s Background
Screening Unit (BSU) were received prior to contact with youth or access to confidential
records. There were no staff screenings which required an exemption prior to working with
youth. In all reviewed staff records, background screenings were completed prior to the date of
hire, criminal histories were reviewed, and each new direct care staff completed a pre-
employment assessment tool. Each of the applicable forty direct care staff received a passing
score on the pre-employment assessment tool. Each of the new staff were placed into pre-
service training. Reviewed documentation confirmed the program reviewed the Department’s
Central Communications Center (CCC) Person Involvement History Report, the Staff
Verification System (SVS), and the Florida Department of Law Enforcement (FDLE) results for
each new staff prior to hiring. The program reported there were two applicable volunteers since
the last annual compliance review, and initial background screenings were completed and
reviewed with no discrepancies. The Annual Affidavit of Compliance with Level 2 Screening
Standards was signed and submitted to the BSU on December 6, 2023, meeting the annual
requirement. The Annual Affidavit of Compliance with Level 2 Screening Standards for
education staff was completed and sent on December 6, 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 has a written policy and procedures to ensure all staff, volunteers, and interns
receive a background rescreening every five years from the initial hire date. The program’s
policy is to submit information to the Department’s Background Screening Unit
(BSU)/Clearinghouse at least ten days prior to the staff’s anniversary date. The program did not
have any applicable staff requiring five-year background rescreening during the annual
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 78 (Revised September 2022)
compliance review period. There were no volunteers, interns, or contracted workers applicable
for a rescreening during the annual compliance review period.
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
 The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
 All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
 Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
 The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
 A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program maintains a written policy and procedures to ensure the addressing of each
youth’s rights, staff rights, and others to feel safe and secure in an abuse-free environment. The
program’s policy outlines the reporting procedures for all staff to follow when a youth requests to
report abuse. The policy and procedures for abuse reporting mandates any staff who has
knowledge of, or has a reasonable suspicion a youth has been, is being, or is in danger of being
abused, to immediately report the allegation to the Florida Abuse Hotline (for youth under the
age of eighteen), or the Department’s Central Communications Center (CCC) (for youth
eighteen years of age or older). Staff are required to sign the manual acknowledgment form
indicating they reviewed the required information. Five reviewed staff personnel records
reflected each staff reviewed the program’s code of conduct and signed the acknowledgement
form. The Florida Abuse Hotline and the CCC telephone numbers were observed to be posted
throughout the program. A telephone located in the main hallway of the living area is designated
for youth to contact the Florida Abuse Hotline or the CCC, if youth feel they have been abused
or neglected. An interview with the facility administrator (FA) indicated staff are all mandated
reporters and can contact the Florida Abuse Hotline at any time. Staff must notify the shift
supervisor and the FA if a youth requests access to the Florida Abuse Hotline or the CCC, as
appropriate. Youth can freely and/or privately contact the Florida Abuse Hotline or the CCC
operator. The program had a total of fifty-two incidents reported to the CCC. The program had
three incident reports alleging physical, psychological and/or emotional abuse toward a youth
since the last annual compliance review, there were no incidents against staff. Two incidents
were substantiated, and one incident was found to be inconclusive at the time of the annual
compliance review. There were no Prison Rape Elimination Act (PREA) investigations and no
investigations with the Department’s Office of the Inspector General (OIG) pending at the time
of the annual compliance review. There were no applicable cases for any potential human
trafficking victims, children of sexual exploitation, or labor trafficking reported. The program
completed a Trauma Responsive and Caring Environment (TRACE) self-assessment on April
26, 2023. Five youth were interviewed, each indicated they feel safe in the program, and stated
they have never been stopped from reporting abuse to the Florida Abuse Hotline and/or from
contacting the CCC. Five interviewed youth indicated staff are respectful when talking to them.
Three youth indicated they have never heard staff use profanity, one youth indicated they have
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 78 (Revised September 2022)
occasionally, and one youth said often. Five interviewed youth denied having been asked to, or
exchanged emails, telephone numbers, or social media information with any staff. Five staff
were interviewed, and each staff explained the process for allowing staff and youth to call the
Florida Abuse Hotline or the CCC to report suspected abuse. Five staff were interviewed, and
each stated they have never heard a coworker use profanity when speaking to a youth and
never observed a coworker telling a youth they could not make an abuse call. Each staff was
able to explain where the telephone number for the Florida Abuse Hotline and CCC was
located. An interview with the FA reported the program’s staff general standards of code of
conduct is outlined within the staff handbook and addresses physical abuse, threats, and
profanity towards youth. The severity of the penalty depends on the frequency and nature of a
particular offense. These examples of rule infractions or misconduct may result in disciplinary
action, including termination.
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 to ensure the program takes immediate
action to address incidents of physical, psychological, and emotional abuse. The program’s
administration manages youth and staff needs and provides directions to each on how to
access the Florida Abuse Hotline. The program had three incident reports alleging physical,
psychological and/or emotional abuse toward a youth since the last annual compliance review.
Two incidents were substantiated, and one incident was found to be inconclusive at the time of
the annual compliance review. A review of the incident reports indicated the facility administrator
(FA) took immediate action to address the concerns by removing the staff from youth contact
until a determination was made. An interview with the FA indicated the program’s management
response to allegations of abuse is for all staff, volunteers, interns, or contracted staff to
immediately report any allegations or suspicion of an incident of abuse or harassment which has
occurred in the program to the Florida Abuse Hotline and/or the Department’s Central
Communications Center, for youth eighteen years of age or older. Additionally, management will
investigate if the allegation is against staff and take necessary precautions to prevent further
incident or allegations. Upon completion of the investigation, disciplinary action will be issued
following the program’s progressive disciplinary system, which could lead up to termination of
employment.
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 to ensure program-related occurrences
which place at-risk, or have the potential to place at-risk, the health, safety, or welfare of the
public, youth, staff, visitors, the security of the program, or the reputation of the program are
reported to the Department’s Central Communications Center (CCC) and handled appropriately
and in a timely fashion. The program staff notify the supervisor and complete an internal
incident form. A review of the incident is then completed by the supervisor with staff during
debriefing. The incident is reviewed by management to assess if all protocols were followed or if
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 78 (Revised September 2022)
there is an additional investigation needed. The program maintains a separate file of all incident
reports and has a system in place for tracking all incidents. The program had fifty-two incidents
reported to the CCC during the annual compliance review period. A review of five CCC reports
confirmed each incident had the incident date, time, and CCC number, with the time the
program became aware of the incident. Each incident was reported to the CCC within the
required two-hour time frame and documented in the program’s incident report logbook and shift
reports, as required. There were no incidents which were reported late. A review of the
program’s internal incident reports and youth grievances reflected no additional incidents which
should have been reported to the CCC. An interview with the facility administrator (FA) indicated
the incident reporting process is to notify the CCC and/or the Florida Abuse Hotline within two
hours of the reportable incident or learning of the incident. When the FA/designee is notified of
any incident, it is determined if the incident is CCC reportable by review of the Department’s
CCC reportable incidents criteria. The FA/designee shall obtain necessary information and
contact the CCC within the two-hour time frame and updates are made as necessary. Youth
eighteen years of age or older are permitted to contact the CCC upon request to report incidents
of abuse or neglect. The FA/administrative duty officer are primarily the reporting staff; however,
any staff can make a CCC report. For abuse reporting, all staff are mandated reporters and can
contact the Florida Abuse Hotline at any time. Youth who request to contact the Florida Abuse
Hotline are provided with the opportunity to do so immediately upon request. Management
ensures staff are knowledgeable in the procedures for contacting the Florida Abuse Hotline and
the CCC. Incidents are reviewed with staff during meetings and are notified if there are any
changes to the facility operating procedures (FOPs). Additionally, staff receive training during
pre-service and annual trainings on incident reporting.
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 policy and procedures to ensure the proper use of Protective Action
Response (PAR)/Right Interactions (RI) techniques by staff. The program submitted all PAR/RI
incident data to the Department on or before the fifteenth of every month during the annual
compliance review period. The program’s PAR/RI training plan was submitted to the
Department’s Office of Talent, Leadership, and Culture on January 9, 2023. The program had
twenty incidents of utilizing PAR/RI during the annual compliance review period. Five PAR/RI
Reports were reviewed, and all reports were completed by the end of the staff’s shift and
included statements from all staff involved. Mechanical restraints were not utilized in any of the
PAR/RI incidents. One of the five PAR/RI Reports indicated the need for medical attention, a
PAR/RI medical review was conducted, and the incident was reported to the Department’s
Central Communications Center (CCC), as required. None of the reports resulted in an
allegation of abuse. All five reports reflected a review by a PAR/RI certified
instructor/supervisory staff, and post-PAR/RI interviews were completed with the youth involved
within thirty minutes of the incident. The program’s practice confirmed a post-PAR/RI interview
was conducted with each youth by the facility administrator (FA) or designee to assess the need
for further medical review. All five reports were reviewed by the administrator or designee within
seventy-two hours of the incident. The program did not have any PAR/RI incidents or a previous
annual compliance review for comparison, as this review was the programs first annual
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 78 (Revised September 2022)
compliance review. The program’s PAR/RI rate during the previous quarter was 4.50, which is
higher than the statewide Residential PAR/RI rate of 1.82. An interview with the FA confirmed
PAR/RI incidents are tracked utilizing the incident report tracker to determine the trends and
factors, such as excessive force, level of response, and correlation for types of incidents. The
PAR/RI Reports are reviewed and discussed during the morning management meetings. Five
pre-service and one applicable in-service training record were reviewed, and indicated all staff
received PAR/RI training. In an interview with five staff, four staff explained the program’s policy
and procedures and indicated having utilized PAR/RI techniques, and one staff reported they
have not used PAR/RI.
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 has a written policy and procedures ensuring all newly hired staff are sufficiently
prepared to satisfy pre-service training requirements. According to the program’s policy and
procedures, staff must complete a minimum of 120 hours of required training within the first 180
days of their hire date. Training documentation was available for review within the Department’s
Learning Management System (SkillPro). An informal interview was conducted with the facility
administrator (FA) confirming all youth care workers are Protective Action Response
(PAR)/Right Interactions (RI) certified prior to providing direct care to the youth. These staff are
included in the program’s staff-to-youth ratio. Each supervisor, assistant facility administrator
(AFA), case management staff, kitchen staff, maintenance staff, and mental health staff are
PAR/RI certified and qualified to supervise all youth in special circumstances. Pre-service
training is provided through a combination of instructor-led, web-based courses, and on-the-job
training. Five staff training records were reviewed for pre-service training. A review of five staff
pre-service training records verified all five staff exceeded the required pre-service training
requirements within 180-days of employment to include cardiopulmonary resuscitation (CPR),
first-aid, automated external defibrillator (AED), PAR/RI, ethics, suicide prevention, facility
operating procedures, emergency procedures, child abuse reporting, Prison Rape Elimination
Act (PREA), human trafficking, active shooter preparedness, adolescent development and
behavior, balanced approach to restorative justice, the Department’s Central Communications
Center incident reporting, civil rights, communication, confidentiality/Health Insurance Portability
and Accountability Act (HIPAA), diversity, the Department of Juvenile Justice (DJJ) history, as
well as individualized job specific training. Additional trainings included Equal Employment
Opportunity, gang awareness, infection control/bloodborne pathogens, information security
awareness, the Department’s Juvenile Justice Information System, mental health and
substance abuse, Motivational Interviewing (MI), quality report writing, safety, security, and
supervision of youth, sexual harassment, standards of conduct, trauma responsive practices,
and addressing workplace dilemmas one on one. Documentation confirmed all trainings were
delivered by qualified trainers and documented in SkillPro. The program’s pre-service training
plan was approved by the Department on December 30, 2022.
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1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a written policy and procedures ensuring all staff maintain the necessary
training to meet the needs of the program and youth in their care. The program’s in-service
training plan was submitted to and approved by the Department’s Office of Talent, Leadership,
and Culture on December 30, 2022. An informal interview with the facility administrator (FA)
reported all youth care workers are Protective Action Response (PAR)/Right Interactions (RI)
certified and included in the program’s staff-to-youth ratio. The program only had one applicable
staff for in-service training, and the training record was reviewed for in-service training. The
training record documented the staff exceeded the hours for the in-service training
requirements, which included active shooter preparedness, cardiopulmonary resuscitation
(CPR), first-aid, automated external defibrillator (AED), human trafficking, information security
awareness, professionalism, interpersonal communication, PAR/RI certification update, sexual
harassment, trauma responsive practices, suicide prevention, and Prison Rape Elimination Act
(PREA). The staff had current certifications in first-aid, CPR, AED, and PAR/RI. The staff
completed training in professionalism and ethics, including standards of conduct, infection
control, emergency response, blood borne pathogens, and exposure control plan. The reviewed
record further verified completion of training in mental health and substance abuse.
Documentation confirmed all trainings were delivered by qualified trainers and documented in
the Department’s Learning Management System (SkillPro). The list of in-service trainings which
included course names, descriptions, objectives, and training hours for any instructor-led
training based on the above topics was approved by the Department’s regional director on
December 30, 2022. The program has an annual in-service training calendar, which is updated
as changes occur.
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 to ensure the grievance process is
outlined for the youth to formally file complaints regarding conditions, treatment, services, and
the actions of program staff and other youth which are in violation of the youth’s rights. Staff are
trained on the grievance process as a part of the program’s pre-service training plan. A review
of five staff pre-service training records confirmed each completed grievance training. The policy
ensures complaints are reviewed in a fair and expeditious manner and are resolved in the best
interest of the youth, the program, and the Department. The program’s grievance process
includes informal, formal, and appeal phases for youth to submit a grievance. In the informal
phase, when the youth have concerns, they are encouraged to make all efforts to reach a
resolution for the complaint. The youth may present an informal grievance to any staff and all
staff shall make every reasonable effort to discuss the youth’s concerns or complaints and
assist the youth in resolving the issue. The formal and appeal phases include the documented
intervention of administrative staff. Youth are informed of the grievance process at the time of
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admission. According to the policy and procedures, the program has seventy-two hours to
handle informal and formal grievances. All youth have access to the grievance forms, as they
are available to youth and are located in the day living area. The program had twenty-one
grievances filed during the annual compliance review period. A review of a sample of five
grievances confirmed the program’s grievance practice. Two of the five reviewed grievances
went to the appeal phase. The two grievances were completed as required, meeting required
time frames. Five youth were interviewed and confirmed grievance forms are placed throughout
the program. Each youth stated they can request assistance to complete a grievance form and
were knowledgeable in the grievance process. Five staff were interviewed and each staff stated
grievance forms are placed throughout the program, youth can request assistance in completing
the form, and a supervisor reviews each grievance. The interviewed facility administrator (FA)
was knowledgeable and able to summarize the informal, formal, and appeal grievance
processes.
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 who’s 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 to ensure delinquency interventions and
facilitator training. A review of the contract indicated the program is required to conduct Impact
of Crime (IOC), Moral Reconation Therapy, and Skillstreaming the Adolescent groups, each of
which was provided by trained therapists or case managers. All remaining groups provided were
either identified as primary services or clinical groups. A review of training documentation found
ten staff facilitated and were trained to deliver the curricula. The program’s case managers are
trained to facilitate the IOC restorative justice group. A review of five youth records found all to
be participating in IOC. A review of the activity schedule indicated the youth are provided with
structured, planned programming, or activities for at least sixty percent of awake hours. The
program has Dialectical Behavior Therapy (DBT) for mental health and substance abuse group
and trauma focused Cognitive Behavioral Therapy (CBT) to provide based on identified needs.
A review of the program’s activity schedule, the group sign-in sheets, and documentation,
supported groups were being conducted. Documentation revealed all groups were provided as
outlined in the contract. At the time of the annual compliance review, reviewed documentation
confirmed only licensed therapists provide substance abuse treatment. An interview with the
facility administrator (FA) confirmed these intervention models and services are provided to
address the needs of all youth entering the program. An interview with the designated mental
health clinician authority (DMHCA) revealed the program provides implementation to
interventions to address the needs of the youth through trainings for groups being facilitated.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a written policy and procedures which emphasizes social and life skills training
for youth. The program identifies youth in need of services by reviewing the risk and
criminogenic needs. The program’s delinquency interventions used for life skills training include
Skillstreaming the Adolescent, Moral Reconation Therapy (MRT), and Dialectical Behavioral
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Therapy (DBT). Interventions are evidence-based, a promising practice, or practice with
demonstrated effectiveness. Each youth’s time is spent in structured, therapeutic activities,
devoted to the delivery of treatment services targeted to address identified risk, criminogenic
behaviors, and treatment needs. The program provided life and social skills intervention
services addressing communication, interpersonal relationships and interactions, non-verbal
conflict resolution, anger management, and critical thinking, which includes problem-solving and
decision making. The program addresses the needs of the program’s targeted gender group to
include health, hygiene, the physical environment, life and social skills training, and leisure and
recreational activities in a group setting. A review of the program’s activity schedule, handouts,
and group sign-in sheets verified groups were held, as required. Five youth were asked what
group/activities they participate in at the program, four youth indicated they participate in IOC
and MRT, and one youth indicated at the time of the interview, they have only participated in
vocational training. An interview with the designated mental health clinician authority (DMHCA)
confirmed youth life skills groups are provided through Skillstreaming the Adolescent and DBT.
The DMHCA added youth are provided an opportunity to practice these skills during groups,
school, recreation, and/or during leisure activities. The interviewed facility administrator (FA)
confirmed youth attend and participate in mental health, and delinquency groups at least five
days a week. Additionally, the FA indicated mental health groups are facilitated by trained
licensed therapists and delinquency groups are facilitated by case management staff twice a
week.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program provides the Impact of Crime (IOC) curriculum which addresses restorative justice
awareness for youth and helps them develop empathy for crime victims and survivors, while
increasing personal accountability for criminal actions and harm to others. The IOC curriculum is
designed to assist youth to accept responsibility for the harm caused by past criminal actions.
The restorative justice activities or instruction is designed to assist youth to accept 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 teach youth about the impact of crime on victims, their families, and their
communities. The programming is known to provide opportunities for youth to plan and
participate in reparation activities intended to restore victims and communities, such as
restitution activities and community service projects. The IOC curriculum is facilitated by the
case managers of the program. The program’s activity schedule addresses group times. A
review of the group sign-in sheets and topics confirmed groups were being conducted as
scheduled, with no issues. In addition to the IOC curriculum, the program also affords youth
opportunities to complete community service hours on-site, complete apology letters to victims,
participate in the program’s garden projects, and participate with collecting and the making of
hygiene and snack bags for the homeless. Additionally, the program is working on a partnership
to assist with the local animal shelter and the local community food bank. An observation of an
IOC group was completed through video surveillance during the annual compliance review
week, which matched the program’s activity schedule and required time frames. In an interview
with five youth, three youth confirmed they are currently participating in IOC as their restorative
justice group and two youth indicated they are participating in other groups. Each of the five
interviewed youth indicated they have learned a new skill and have practiced the skill outside of
the group. The interviewed facility administrator (FA) indicated youth entering the program
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participate in IOC restorative justice groups and work on projects to help them understand the
impact they have on their communities, their families, and themselves. Additionally, each youth
is provided with the opportunity to participate in community service projects within the program,
as well as in the community. The interviewed designated mental health clinician authority
(DMHCA) confirmed the program provides restorative justice IOC group to youth, twice a week,
which is facilitated by a trained case manager.
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 maintains a written policy and procedures to ensure security, medical and mental
health alerts, the use of an internal alert system, and entering alerts into the Department’s
Juvenile Justice Information System (JJIS) are all documented properly. The policy explained
how alerts are identified, documented, updated, and communicated to staff. The alerts help staff
identify youth who pose a risk to security or safety including escape, assaultive or violent
behaviors, suicide risk, other mental health, as well as other concerns including food allergies
and special diets. A review of five youth case records revealed each youth presented with alert
risks and was placed on the alert system, as specified in the program’s written procedures.
Alerts are identified at the time of admission either through an interview with the youth and/or a
review of supporting documentation within the admission packet. Alerts are then entered in JJIS
and added to the program’s internal alert system. The observed internal alert lists were posted
in the kitchen, medical, and the training/break room which identified security and/or escape
risks, mental health and applicable suicide risks, medical alerts, and allergies. A review of
documentation and observations during the annual compliance review week confirmed the alert
board and alerts are logged in the logbook and discussed by the shift supervisor at each shift
briefing for oncoming staff. No discrepancies were identified when comparing the internal alert
system with JJIS alerts for the five applicable reviewed youth. An interview with the facility
administrator (FA) reported the program has an internal alert system which reflects all safety
and security alerts, in addition to all medical, dietary, and mental health alerts, which are
updated daily or as needed. Alerts are addressed during the program’s morning management
meetings and updates are provided to the staff in the daily shift briefing and logbook. The
interviewed nursing staff confirmed the registered nurse (RN) is responsible for updating the
medical alert system. Five interviewed staff reported they are informed of all youth alerts during
shift briefing meetings, morning management meetings, the alert board in the
training/conference room, logbook, and email communications.
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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 maintains a written policy and procedures to ensure the maintenance and storage
of Individual Healthcare Records (IHCRs), mental health and substance abuse records, and
case management records for each youth at the program. A review of five IHCRs, individual
case management records, and mental health/substance abuse records confirmed the records
were labeled and contained the youth’s name, Department identification number (DJJID), date
of birth, county of residence, and committing offense. A review of five youth records confirmed
they were in a secured area within a locked file cabinet, not accessible to youth. Each record
was organized with tabs dividing information into specific sections for legal information,
correspondence, documentation of case management activities, and was marked “Confidential.”
Each record included sections for demographic and chronological information, treatment team
activities, and miscellaneous.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a written policy and procedures to ensure the program establishes a
community advisory board which would meet at least every ninety to 120 days, and would serve
as a support to the program and a link to the community. The policy indicates the facility
administrator (FA), shall solicit active involvement of interested community partners. The
program provided a contact list of members identified for their community advisory board. The
advisory board list consisted of representatives of law enforcement agencies, judiciary, local
community business, faith-based member, and a local victim advocacy agency; however,
attempts for recruiting a school board member, a former program resident, and a
parent/guardian of a youth formerly involved in the juvenile justice system are ongoing. The
facility administrator (FA) is continuing to solicit and recruit members of the community, in order
to maintain a collaborative partnership with the Department and local stakeholders in the
community. The program provided documentation of recruitment letters and correspondence of
invitations and recruitment to interested community partners. The program maintains a
community advisory board binder; however, the program has not held any community advisory
meetings, because the member recruitment process is still ongoing and member confirmation is
still pending. An interview with the FA confirmed the recruitment efforts for the community
advisory board are still ongoing.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a written policy and procedures for evaluating staff, performance standards,
and the frequency of evaluations. The program’s policy indicates evaluations are to be
completed annually. A review of five staff position/job descriptions was conducted and
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determined each staff’s performance standards were clearly identified. A sample of performance
evaluations was reviewed and determined each was completed in accordance with the
program’s policy. Staff are evaluated at ninety-days for first year staff and annually for all
additional staff on their established performance standards. The performance standards
matched job descriptions for each staff position reviewed. An interview with the facility
administrator (FA) revealed the program has a system in place to address turnover and morale
issues. The FA Indicated the program has experienced turnover in each department during the
past year; however, the program has maintained focused on its current staff and has hosted a
number of activities such as spirit week, on-campus socials, staff potlucks, gift exchanges, and
staff awards to boost morale. The FA indicated staff are evaluated within the first ninety days of
their date of hire, and thereafter are evaluated annually. The FA stated staff are provided with
feedback and areas in need of improvement and the staff and the supervisor develop goals for
the year. An interview with five staff revealed two stated evaluations are conducted yearly and
every ninety days, two stated every six months, and one stated they have not yet been at the
program ninety days.
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 shall implement all items or services either negotiated or outlined in the contract,
Memorandum of Negotiation, and applicable Award Letter. These items typically exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code. The items
include life skill trainings, community service, staff pre-screening, art therapy, and gardening.
The program utilizes the BERKE Pre-Assessment to screen applicants before they are hired.
The program has created a butterfly garden, which allows the youth to plant fruits and
vegetables as well as flowers. Reviewed documentation and on-site interviews confirmed the
program youth participate in community service and community relationship building projects
through restorative justice programming. The contract also requires the health services
administrator (HSA)/registered nurse (RN), to be on-site for forty hours each week. The
reviewed sign-in/out logs during the annual compliance review period reflected the HSA was on-
site as required. Five youth were interviewed, and each youth stated they receive and actively
participate in the contracted condition services which are being provided. An interview with the
facility administrator (FA) confirmed all value-added items and negotiated items are provided as
required by the contract.
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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’s contract requires the program to provide career and technical education (CTE)
services by the provider or directly provided by the local school districtCTE 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. The local
school district, in conjunction with the program provide Florida Ready to Work, Soft Skills,
Occupational Safety and Health Administration (OSHA) ten-hour (10) course, cardiopulmonary
resuscitation (CPR), first-aid, and Entrepreneurship and Small Business, an industry certification
from the master credentials list. The Entrepreneurship and Small Business certification is
offered through a contract with an online certification company. Additionally, youth have the
opportunity to earn the Food Handler certification and Microsoft Information Technology
Professional certifications if interested and career ready, which they receive through Florida
Ready to Work training. CTE services are integrated with the daily academic school schedule,
and all youth are given the opportunity to participate throughout the day. The program’s
schedule indicates CTE services are offered Monday through Friday from 11:00 a.m. to 2:00
p.m., where youth have classroom support for OSHA 10 and Florida Ready to Work, and from
4:00 p.m. to 5:00 p.m., testing is available for Florida Ready to Work and for OSHA 10. CPR,
first-aid, and Entrepreneurship and Small Business are held on Tuesdays and Thursdays. At the
time of the annual compliance review, twenty-six youth had received CPR/first-aid training, and
three youth had received their CPR/first-aid certificate. Thirty youth received or are in progress
of receiving OSHA 10 training and seven youth received the OSHA 10 certification. Thirty youth
have been registered for the Florida Ready to Work training. There were thirteen youth currently
in progress for the Florida Ready to Work training, and there were no youth having earned the
Florida Ready to Work Soft Skills certificate. Twelve youth are enrolled in Entrepreneurship and
Small Business and there were no youth having received this certification. The informally
interviewed facility administrator (FA) confirmed the program provides the pre-vocational and
vocational services as required by the program’s contract. Services include OSHA 10, CPR,
first-aid, Florida Ready to Work, certificates for Entrepreneurship and Small Business,
interviewing, and résumé skills. Five youth were interviewed, and all youth indicated they
participate in the identified CTE services. When asked how often they participate, each youth
indicated they participate daily, and/or weekly. Additionally, one youth stated every day except
for Saturday and Sunday. One youth indicated they are participating in services, two youth
indicated they attend school, and two youth did not provide an answer.
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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 policy and procedures for reviewing and analyzing data trends to utilize in
decision-making practices. The program’s trend analysis and data-driven decision making is
strengthened through an internal database and dashboard system which allows for daily data
entry by every program. The information includes incident reports, intakes, releases, physical
interventions, grievances, behavior management milestones, transports, vocational
certifications, youth, staff, and family surveys. This daily process and outcome information is
aggregated into monthly totals, displayed in interactive dashboards specific to each program,
and provided back to corporate as well as program management for the purposes of tracking
trends and informing risk management. The program enters placement information in the
Department’s Juvenile Justice Information System (JJIS) and youth are tracked for post-
completion of services for recidivism. Results are first reviewed by the chief compliance officer,
regional, and program staff. If results require additional training or reinforcement, staff may be
provided with supplemental training or extra oversight to ensure compliance. Additionally,
through the Trauma Responsive and Caring Environment (TRACE) initiative, youth and staff are
surveyed annually. Data and surveys are evaluated for both protective trends as well as
forecasting trends which can impact compliance or programming. Results are analyzed and
guide the program’s action plans which affect all aspects of programming. The management
team dedicates time to using data to inform and educate staff, providers, and stakeholders on a
quarterly basis. The findings from trend data analyses are utilized to determine recruitment
strategies, positive morale approaches, to update the policy and procedures, to improve youth
supervision techniques, to review restorative justice programs, and to review individual and
family services. Information is shared with staff during monthly all staff meetings.
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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 maintains a written policy and procedures regarding initial contacts to
parents/guardians and court notification. A review of five youth case management record’s
documentation showed the program notified the parent/guardian by telephone within twenty-four
hours of admission. Each of the five reviewed records included documentation supporting the
program notified the parent/guardian, in writing, within forty-eight hours of the youth’s
admission. All five records had documentation indicating the juvenile probation officer (JPO),
court, and applicable post-residential counselor were notified in writing within five working days
of the youth’s admission.
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 maintains a written policy and procedures regarding youth orientation. A review of
five youth case management record’s documentation showed the program provided each youth
an orientation on the day of admission. Each reviewed record documented a signed receipt
acknowledging the youth received an orientation packet including a copy of the youth handbook.
The program’s orientation included services available, daily schedule, expectations and
responsibilities of the youth, written information on the program’s behavior management system,
information on how to access medical and mental health services, and how to access the
Florida Abuse Hotline or the Department’s Central Communications Center (CCC), if the youth
is over eighteen years of age. The youth orientation also includes information on the
performance plan process, dress code and hygiene requirements, procedures regarding
visitation, mail, and use of the telephone, anticipated length of stay, community access,
grievance procedures, emergency drills, physical design of the program, and assignment to a
living unit. Observations of a youth orientation were not conducted due to the program not
having an admission during the annual compliance review week. An interview with five youth
was conducted and each youth stated they received an orientation within twenty-four hours of
their admission. All five youth confirmed orientation to the program included program rules,
procedures, schedules, and other pertinent information.
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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 maintains a written policy and procedures outlining consent for youth eighteen
years of age or older, unless the youth is incapacitated and has a court-appointed guardian,
before providing or discussing with the parents/guardians any information related to the youth’s
physical or mental health screenings, assessments, or treatment. Five youth case management
records were reviewed, and two records were applicable. A review of the two case management
records confirmed each contained documentation signed by the youth allowing the release of
information regarding physical or mental health screening, assessment, and/or treatment with
their parents/guardians. The program did not have any other applicable records for review.
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 maintains a written policy and procedures outlining the classification process for
youth upon admission to the program and completion of reassessments. The classification
system is used for the purpose of assessing each youth admitted to a living unit, sleeping room,
and group. Youth are also 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. The procedure also requires all admitted youth to 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 program’s classification forms included the physical
characteristics of the youth, age, maturity level, identified special needs, history of violence,
gang affiliation, criminal behavior, sexual aggression or vulnerability to victimization, the youth’s
perception of vulnerability, any history of potential or verified human trafficking, suicide, medical,
escape, and/or security risks. A review of five youth case management record’s documentation
showed each record contained an admission classification form including all required elements
outlined by Florida Administrative Code. A review of the Department’s Juvenile Justice
Information System (JJIS) confirmed a new Vulnerability to Victimization and Sexually
Aggressive Behavior (VSAB) screening was completed for each youth. A review of JJIS alerts
and the programs internal alerts confirmed all five youth had a documented suicide and/or
medical risk. Additionally, one youth was identified with an escape risk, and one youth with a
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security risk factor. Each youth was classified for the purpose of assignment to a living area,
sleeping room, and group. The program maintains an alert board in the program’s conference
room, which is updated as needed. All five youth case management records included
documentation for reclassification of youth prior to engaging in certain activities. The program’s
policy is to complete a reassessment every ninety days; however, reassessments were
completed for three youth who were being considered for an increase in privileges, freedom of
movement, and/or participation in work projects. An interview with the facility administrator
stated youth living unit placement is based on alerts identified during the VSAB and admission
classification. Based on the alert, the youth would be assigned to a living unit to ensure their
safety and well-being.
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 maintains a written policy and procedures outlining gang identification and
notification to law enforcement. Five youth case management records were reviewed; however,
none were applicable. The program had one applicable youth for gang identification and
notification to law enforcement. There were no additional applicable youth with gang
identification during the annual compliance review period. Reviewed documentation for the
applicable record confirmed local law enforcement was notified of the suspected gang activity. A
review of the Department’s Juvenile Justice Information System (JJIS) indicated the gang alert
was entered. Information of the youth’s gang status was shared with the assigned juvenile
probation officer (JPO), education staff, and the youth’s applicable post-residential services
counselor.
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 maintains a written policy and procedures for 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’s policy and procedures addressed providing
youth an opportunity, if they so desire, to develop a plan to disaffiliate with a criminal street
gang. Five youth case management records were reviewed; however, none were applicable for
being gang affiliated. The program had one applicable youth for being identified as a gang
member, or affiliated. There were no other applicable youth with gang identification.
Documentation supported the applicable youth participated in gang prevention and intervention
strategies. The youth’s performance plan included goals and objectives related to gang
intervention strategies to be completed prior to release from the program. The program utilizes
the Impact of Crime (IOC) curriculum for prevention and intervention awareness efforts provided
to the youth at the program. Group sign-in sheets were reviewed and found the youth
participated in gang prevention and intervention activities. The interviewed facility administrator
(FA) stated upon the admission of the youth, a review of the youth’s history and/or alerts is
conducted to identify if a youth is gang affiliated. If a youth is identified as having gang
involvement/affiliation, the program will designate and add gang interventions and goals to the
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youths Individualized Performance Plan (IPP). Additionally, the FA indicated, youth are provided
with educational material in order to inform the youth on the various risks of being involved in
gang activity, throughout their stay at the program. The program maintains a gang binder which
contains the youth's goals, security threat, group questionnaire, and notifications made to law
enforcement.
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 maintains a written policy and procedures to assess each youth using the
Residential Assessment for Youth (RAY) within thirty days of admission, as well as a RAY
Reassessment every ninety days thereafter. Five youth case management records were
reviewed, and each contained an initial RAY completed within thirty days of the youth’s
admission to the program. Each RAY was appropriately maintained in the Department’s
Juvenile Justice Information System (JJIS). Five youth case management records were
reviewed, and four were applicable for RAY Reassessments and each was completed within
ninety days of the initial RAY. One record was not applicable for RAY Reassessments. The
program maintained all initial RAY and RAY Reassessment documentation in the youth’s official
case 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 maintains a written policy and procedures for the completion of a Youth Needs
Assessment Summary (YNAS) on each youth within thirty days of admission. A review of five
youth case management record’s documentation supported each youth’s YNAS was completed
within thirty days of admission and was documented in the Department’s Juvenile Justice
Information System (JJIS).
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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 maintains a written policy and procedures regarding the development of
performance plans, goals, and transmittals. A review of five youth case management records
documentation supported each youth’s Individualized Performance Plan (IPP) was developed
within thirty days of the youth’s admission and developed after the initial Residential
Assessment for Youth (RAY). Each IPP was completed after the initial assessment with the
intervention and treatment leader, youth, administration representative, living unit
representative, treatment staff, education staff, and parent/guardian. One plan was applicable
for the participation of the youth’s Department of Children and Families (DCF) caseworker, and
participation was validated. Documentation showed each of the completed IPPs were mailed to
the youth’s parent/guardian, and/or DCF caseworker requesting a signature; however, only one
was returned to the program at the time of the annual compliance review. Each of the youth
case management records documented the parent/guardian participated by telephone. Each
reviewed IPP included individualized goals for each youth based upon the prioritized needs
identified during the initial assessment reflecting the risk and protective factors identified during
the initial assessment process. Each IPP addressed the youth’s three top criminogenic needs,
based on the RAY results with measurable outcomes which will decrease the youth’s
criminogenic risk factors and promote strengths, skills, and supports to reduce the likelihood of
the youth reoffending. Each IPP outlined program staff responsibilities and target dates for goal
completion. Each IPP was sent to each youth’s committing court judge, juvenile probation officer
(JPO), parent/guardian, and applicable DCF counselor, within ten days of completion. Five
youth were interviewed and stated they participated in the development of their performance
plan. Each youth was knowledgeable with the goals listed on their performance plan and were
able to list some of their goals. Three youth indicated they received a copy of their performance
plan, and two youth indicated they did not receive a copy.
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 maintains a written policy and procedures outlining revisions to a youth’s
Individualized Performance Plan (IPP). Five youth case management records were reviewed,
four were applicable for revisions to the performance plans based on the Residential
Assessment for Youth (RAY) Reassessment, and newly acquired information. None of the five
records were applicable for youth demonstrating lack of progress toward completing a goal.
Three records were applicable and documented updates needed to facilitate transition activities
during the last sixty days of the youth’s stay.
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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 completion of Performance
Summaries and the transmittal of the summaries. Five reviewed youth case management
records indicated four were applicable for the completion of a ninety-day summary. All four youth
records indicated each had Performance Summaries completed within the required ninety-day
time frame. All summaries included reports on the youth’s status on each Individualized
Performance Plan (IPP) goal, youth’s overall treatment progress based on their treatment plan,
and the youth’s academic status, including performance and behaviors in school. In addition, the
youth’s behavior including the level of motivation and readiness for change, interactions with
peers and staff, overall behavior adjustment to the program, and the youth’s significant positive
and negative events. All four youth were provided the opportunity to review the performance
plan and add comments prior to signing and were provided a copy of the summary. Each
summary was filed in the youth’s case management record. All four Performance Summaries
were signed and dated by the treatment team leader, staff preparing the summary, program
director, and youth, except for one which was missing the facility administrator’s signature and
one which did not have the treatment team leader’s signature. All four summaries were sent
within ten working days to the committing court, youth’s juvenile probation officer, and
parent/guardian. Three release summaries were reviewed, and each included the original
summary, along with justification for release, and were sent with Pre-Release Notification (PRN)
to the youth’s juvenile probation officer (JPO). Each release summary and PRN were sent at
least ninety-days prior to the planned release. A signed copy of the PRN was retained in each
youth’s case management record. None of the reviewed case management records were
applicable for Victim Notification of Release letters to be mailed to the victims at least ten days
prior to the youth’s release.
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 maintains a written policy and procedures to provide parental/guardian
involvement in case management. A review of five youth case management record’s
documentation confirmed the program reached out to parents/guardians informing them of the
youth’s treatment team schedule for the duration of their stay in the program. Reviewed
documentation found each applicable youth’s case management record reflected the program
encouraged and facilitated involvement of the youth’s parents/guardian in case management
activities, to include the assessment process, development of the youth’s performance plan, and
monthly progress reviews. Documentation supported the program provided advanced notice of
formal treatment team meetings and transition planning. Documentation supported the program
reached out to the parents/guardians to facilitate involvement by hosting family days, inviting
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parents/guardians to participate in treatment team meetings, and through family therapy
sessions. An observation of a treatment team validated the program’s practice of telephone
parent/guardian participation. An interview with the facility administrator (FA) reported
parent/guardian engagement is encouraged through the duration of the youth's commitment.
Every attempt is made to ensure the parents/guardians are included in the admission process,
admission classification, youth needs assessment, and monthly youth treatment team meetings.
The parents/guardians are encouraged to provide feedback regarding the youth's treatment.
Youth are provided a weekly phone call with their parent/guardian as well. Five interviewed
youth reported their parent/guardian was involved with case management activities.
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 maintains a written policy and procedures for the intervention and treatment team
to reference and/or incorporate other treatment plans into the youth’s Individualized
Performance Plan (IPP). A review of five youth case management record’s documentation
supported each youth’s IPP incorporated the youth’s education plan. Each youth record had
separate mental health/substance abuse treatment plans, all of which were referenced in the
performance plans. One youth was involved with the Department of Children and Families
(DCF) and the youth’s DCF plan was incorporated into the IPP.
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 maintains a written policy and procedures addressing formal and informal
treatment team meetings. Five youth case management records were reviewed for formal and
informal treatment team meetings. Each reviewed record documented formal treatment team
reviews were conducted at least once every thirty days. Each record reviewed for informal
treatment team reviews reflected they were conducted at least once within thirty-days for all
each youth reviewed. Each record reviewed for informal treatment team reviews, and
documentation supported informal treatment team meetings were held biweekly, to review youth
performance, progress on their individual performance plan goals, behavior, and individual
treatment plan. The program utilized a performance plan review form which included the youth’s
name, date of review, comments from treatment team members, brief synopsis of youth
progress, positive and negative behaviors, and any Residential Assessment of Youth (RAY)
revisions. Reviewed documentation confirmed treatment team meeting attendees included the
youth, case management staff who act as the treatment team leader, clinical staff, education,
and a program administration representative. Each youth’s juvenile probation officer,
parent(s)/guardian(s), and other pertinent parties were invited to participate in person, by
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telephone, and/or provide written input. Each formal treatment team review included comments
from treatment team members, brief synopsis of the youth’s progress in the program,
performance plan revisions, progress on performance plan goals, positive and negative
behaviors, behaviors resulting in physical interventions, treatment progress, and RAY
Reassessment results. Each youth was provided an opportunity to demonstrate skills acquired
in the program and all formal treatment team meetings were documented in the youth’s record.
Five youth were interviewed one youth stated anger management was discussed in their
treatment team meetings, two youth stated they were given the opportunity to read their goals,
and two reported they could talk about their feelings and progress in the program. All five youth
stated they have the opportunity demonstrate their skills. An observation of a formal treatment
team meeting was conducted during the annual compliance review week and verified the
participants. The education staff provided written input. All present treatment team members
reviewed the performance goals, positive and negative behaviors, RAY Reassessment results,
and treatment progress with the youth.
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 maintains a written policy and procedures to ensure the intervention and treatment
team is planning for each youth’s successful transition to the community upon release from the
program. The policy outlines the process for transition planning, conferences, and Community
Re-Entry Team (CRT) meetings. A review of three closed youth case management records
documented each youth had a transition conference at least sixty days prior to the youth’s
targeted release date. Transition conference documentation reflected the youth, treatment team
leader, facility administrator or designee, and other applicable team members were in
attendance. Notification documentation supported the youth’s juvenile probation officer (JPO)
and parent/guardian, were encouraged to participate. There were no youth who had additional
activities and no youth were applicable for the attendance of a human trafficking specific service
provider. Transition documents supported the conference included a review of transition
activities, necessary performance plan revisions, target completion dates, and persons
responsible for transition activities. Transition conference documentation contained
acknowledgement of transition goals and responsibilities of members through signatures of
participants. A copy of each transition plan was sent to the assigned JPO and any members
sharing responsibility of plan completion. When applicable, the records documented
acknowledgements of plan receipt. Each of the reviewed three closed records documented a
CRT invitation was sent and a meeting was held prior to the youth’s release.
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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 maintains a written policy and procedures outlining the requirements of the exit
portfolio. A review of three closed youth case management record’s documentation showed
each youth’s exit portfolio was discussed during the transition conference. One of the three exit
portfolios contained a state-issued identification card, and two did not due to their age. Each
contained a copy of the youth’s transition plan and a calendar of upcoming appointments. Two
had a Social Security card and one did not. Reviewed documentation supported attempts were
made to retrieve the document. All three records had a birth certificate, educational/vocational
certificates earned at the program, school transcripts, a sample employment application, and
two of the three youth had a résumé. Documentation supported each youth’s exit portfolio was
verified during the exit conference, and documentation indicated the exit portfolio was given to
the youth upon release and forwarded to the youth’s juvenile probation officer (JPO). The
program’s contract did not include any additional requirements for the exit portfolio.
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 maintains a written policy and procedures to address the requirements for each
youth’s exit conference. Three closed youth case management records were reviewed. There
was documentation each youth’s exit conference was conducted after the program notified the
youth’s juvenile probation officer (JPO) of the youth’s pending release and at least fourteen
days prior to the youth’s release date. The conference documentation included a summary of
pending transition goals and the date. Each record had documentation to confirm the treatment
team leader, parent/guardian, education representative, therapist, JPO, youth, and other
pertinent parties participated during the exit conference. Each record had documentation
reflecting the status of transition activities and finalized plans for the youth’s release. The date of
admission and date of release correlated with the Department’s Juvenile Justice Information
System (JJIS) in each record. There was documentation in each youth record the exit
conference was held separately from the transition conference and Community Re-Entry Team
(CRT) meeting.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a formal process for the promotion of constructive input of youth. The program
encourages youth input through a food satisfaction survey, the Trauma Responsive and Caring
Environment (TRACE) assessment, and youth surveys. The program holds meetings which are
conducted on a monthly basis. A review of logbooks verified the program was conducting
monthly meetings with all program youth as scheduled. An interview with the facility
administrator (FA), reported youth can provide input by way of a “My Voice Matters” form,
grievance form, and during daily meetings. On a monthly basis, a community circle is also held
for youth to be able to express issues, concerns, and positive and negative feedback. In
addition, the youth advisory board is in effect for the youth to provide input. The board meets bi-
weekly, and any suggestions or input is provided to the FA for review and approval. The youth
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facilitate their own formal treatment teams and provide input on the program, grievances, sick
calls, abuse access, and medical questions. Five interviewed youth indicated youth are able to
provide input about what happens in the program. Three youth indicated during daily meetings,
one youth stated by talking with staff or a supervisor, two youth stated they are able to fill out a
“My Voice Matters” form, and one youth indicated they can provide input during the youth
advisory meetings.
2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program maintains a written policy and procedures to ensure the instruction of a career
education curriculum which provides youth program content and an orientation to the broad
scope of career choices based upon personal abilities, aptitudes, and interests. The program of
study, which is conducted and directly supervised by the Lee County School District, is identified
as a Type 2 career education program. The course programming includes instruction of
interpersonal skills, communication skills, and decision-making skills. This program, which is
age appropriate for the youth, is also suitable to their current educational level as well as to their
length of stay within the program. Three closed records were reviewed. Two of the three closed
records contained résumés, and all three records contained samples of completed employment
applications. One of the three closed records contained a copy of a valid Florida identification
card for the youth, with the other two youth not having an identification card available due to
their younger age. All three records contained documentation the parent/guardian and juvenile
probation officer (JPO) were aware of the vocational plan for the youth, as well as evidence the
case manager and parent/guardian were aware of the plan, documents, and post-release
discharge plans. All three closed records contained appropriate documents essential to
obtaining employment, along with documentation indicating the local Career Source Center
information. Career and Professional Education (CAPE) courses are not provided at this
program due to the youth not staying in the program for the minimum time of nine months. An
interview with the facility administrator (FA) indicated youth are provided with career education
services to all youth, which includes certifications, training, and general education about the
process of applying for and maintaining employment. The interviewed lead teacher stated youth
are assigned to their academic classes by the youth’s assigned guidance counselors and
placed in their appropriate grade level and courses.
2.20 Educational Access (Critical) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program maintains a written policy and procedures which address educational access. The
program’s education program is directly managed and supervised by the Lee County School
District. A review of the school calendar and documentation indicated the academic calendar for
the program provided 250 days of instruction which included ten days set aside for teacher
planning or professional development during the calendar year, and each calendar week
contained a minimum of twenty-five hours of classroom education. Youth are able to receive
credits for the education and training experience while in the program. A review of the program’s
daily academic schedule indicated the youth attend school for a minimum of 300 minutes each
instructional day, for a total of at least twenty-five hours of classroom education each week. A
review of three randomly chosen days in the program’s logbook reflected classes were held in
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accordance with the program’s schedule with minimal interruptions. A review of three randomly
selected school days of video along with the corresponding days in the logbook was conducted
and each showed school starting on time and ending on time. The interviewed lead educator
indicated school takes place as scheduled with minimal interference, and confirmed youth take
part in the various career education offerings at the program. Five interviewed youth reported no
interruptions during school hours.
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 maintains a written policy and procedures providing for an individualized transition
plan (ITP) to be developed upon admission. The educational transition plan is developed with
input from the youth, lead teacher, and program staff. The identified services addressed the
youth’s reintegration back to their home community, the recommended academic placement
upon the youth’s release, as well as the specific monitoring responsibilities by individuals who
were assigned responsibilities for the coordination and the provision of support services for the
youth upon return to their home community. Each plan addresses key services and monitoring
responsibilities by individuals essential to the plan’s creation. A review of three closed youth
case management records confirmed each youth had an ITP in place at the time of their release
from the program. Two of the three closed records contained documentation confirming the
participation in the creation of the education transition plans from the youth, the parent/guardian
of the youth, the youth’s juvenile probation officer (JPO), a representative from the program’s
educational component, a transitional representative, as well as a representative of the youth’s
home school district. One record did not document a representative from the program’s
educational component. The transition plans are solely based upon the youth’s individual
assessed needs, performance, as well as their post release goals whether they be a
continuation of their education or employment. Furthermore, each plan listed key monitoring
responsibilities and were acknowledged by individuals who were responsible for the re-
integration and coordination of the provision of support services for the youth upon release from
the program. The transition plans addressed the services and interventions provided to each
youth which were based on their individual needs and performance while in the program. The
interviewed lead educator confirmed the program’s ITP process. Five youth were interviewed
and four reported they were involved in the development of their ITP, and one youth reported
they were not. When asked how well the youth think the program is preparing them for high
school, the high school equivalency diploma (GED), vocational school, employment, and/or
college, three youth indicated very well, one youth stated well, and one youth stated not well.
The youth’s concerns were shared with the program during the annual compliance review.
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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 ensures consistent and appropriate mental health and substance
abuse services are provided in addition to being on call twenty-four hours each day for
emergency consultation. The DMHCA is a licensed mental health counselor (LMHC) 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 program’s contract
stipulates the program provides Intensive Mental Health (IMH) Treatment Services. Reviewed
documentation and an interview with the DMHCA verified the DMHCA was on-site weekly to
ensure the 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
September 6, 2024. The DMHCA stated the second LMHC serves as the back-up DMHCA as
needed. The back-up DMHCA is a LMHC in the State of Florida with a free and clear license
which expires on March 31, 2025. The interviewed DMHCA stated they oversee all clinical
services for the youth at the program. The DMHCA ensures all youth are assigned a therapist to
complete their needed treatment services. The DMHCA oversees all group, individual, and
family services and provides ongoing supervision and support to therapists to enhance
therapeutic service delivery. All documentation is reviewed and approved to ensure youth
clinical needs are being addressed. The DMHCA is also providing all training and oversight for
the suicide prevention and crisis intervention plans. The DMHCA assists with group and
individual sessions as needed. The DMHCA also provides supportive counseling and crisis
intervention to youth in need. The DMHCA meets with the therapists for clinical supervision on a
weekly basis. The therapists and the DMHCA communicate on a regular basis by face-to-face
conversations, telephone, text, and emails.
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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. The DMHCA ensures licensed clinical staff are performing services they are
qualified to provide based on education, training, and experience in accordance with the job
descriptions, and an informal interview with the regional compliance manager verified the
practice. The program’s contract requires one additional licensed mental health professional to
be on-site. The program has one full time licensed clinical social worker (LCSW) who holds a
free and clear license in the State of Florida with an expiration date of March 31, 2025. In
addition, the program has one pro re nata (PRN) LCSW with a flexible schedule. Copies of all
licenses were available and displayed on-site. A review of mental health licenses which included
the LCSW, the psychiatrist, and clinical psychologist verified each had a license which is free
and clear in the State of Florida. The program has a contract with a clinical psychiatrist. The
program is licensed under Chapter 397 through the Department of Children and Families to
provide substance abuse services to adolescents. The license was displayed in the lobby with
the program’s physical address listed and had an expiration date of September 6, 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 interviewed
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 to based on education, training, and experience. The program’s practice is to complete
group and/or individual clinical supervision for the two non-licensed clinicians. A review of
clinical supervision logs during the annual compliance review period verified clinical supervision
was documented on the program’s 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 the non-licensed clinical staff
received clinical supervision for each week they provided services. The non-licensed clinical
staff were in accordance with the contract and the staff were on-site for forty hours each week.
The program is licensed under Chapter 397 through the Department of Children and Families to
provide substance abuse services to adolescents. The license was displayed in the lobby with
the program’s physical address listed and had an expiration date of September 6, 2024. The
program’s contract requires one DMHCA, one licensed mental health professional, one
recreation therapist, two behavioral analysists, and two master’s-level therapists. The program
has a contract to utilize the behavior analyst’s services. A review of the recreation therapist’s
credentials, the program’s staffing roster, program schedule, and services provided to youth
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ensured the contract requirements were met. A review of the two non-licensed staff’s education
documentation reflected each clinical staff held a master’s-level degree from an accredited
university or college in the field of counseling, social work, psychology, or a related human
services field. The non-licensed staff providing clinical services are employed by a service
provider which was licensed under Chapter 397. The non-licensed clinical staff received training
in the administration of the Assessment of Suicide Risk (ASR) and 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 clinical staff
in a confidential manner with the youth on the day of admission. A review of five youth records
reflected each youth was administered a MAYSI-2 on the day of admission. The clinical staff
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. 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 five youth records verified each
completed MAYSI-2 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. It is the program’s practice to refer all youth for
additional assessments regardless of the screening results. None of the reviewed MAYSI-2s
documented the need for a crisis intervention, or emergency services. None of the reviewed
MAYSI-2s 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) for all
youth upon admission to the program. All five youth records verified each youth was referred for
an ASR and comprehensive evaluation, and each included the reason for the referrals. In
addition to the MAYSI-2 and ASR, the program utilizes the Trauma Symptom Checklist for
Children (TSCC), Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB), and
Structured Assessment of Violence Risk in Youth (SAVRY) to evaluate youth. 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
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reported the clinical staff utilize the MAYSI-2 to identify youth for mental health and substance
abuse problems and suicidal ideation.
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
reviewed assessments were 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 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 five 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 five youth records verified each youth received a
new substance abuse assessment within thirty days of admission and consent was obtained
from each youth record. Clinical staff obtained consent for substance abuse services for all five
reviewed youth records. Each applicable 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 five reviewed youth records indicated the mental health/substance abuse
assessment addressed the original referral reasons. In a formal interview, the designated
mental health clinician authority (DMHCA) stated every youth admitted into the program
undergoes a series of screening processes which include a records review of the youth's
previous records, evaluations, assessments, and a review of the Department’s Juvenile Justice
Information System (JJIS) alerts the youth received prior to the admission. Upon completion of a
thorough records review, the therapist conducts an admission interview with the youth and
completes the MAYSI-2, Assessment of Suicide Risk (ASR), and a Vulnerability to Victimization
and Sexually Aggressive Behavior (VSAB), along with any other assessments needed based on
the results of the MAYSI-2. The final stage of the admission process includes an admission
classification meeting which includes the therapist, case manager, nurse, administrator, living
unit representative, and the youth. Within the meeting, the findings of the records review,
MAYSI-2, ASR, VSAB, and the initial interview are reviewed. Based upon this information, the
classification team identifies needs for referrals. The therapist completes a referral for
comprehensive mental health and substance abuse evaluation and psychiatric evaluation upon
admission. All youth admitted to the program are referred to the psychiatrist for a psychiatric
evaluation. All youth meet with a therapist and complete a comprehensive mental health and
substance abuse evaluation along with an individualized treatment plan within thirty days of
admission. Following the admission process, if a youth exhibits behaviors or other needs which
require further evaluations, the assigned therapist or observing staff initiate a referral for
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assessment and documents the referral on the Mental Health Substance Abuse Referral
Summary form.
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 assists in developing, reviewing, and updating each
youth’s initial and individualized plan. A review of five 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 licensed
clinical staff and signed by the designated mental health clinician authority (DMHCA) within ten
days of completion. Each initial plan was signed by all treatment team members who
participated in the development of the plan with the exception of one plan which was missing
the signatures of the director of case management (DCM) and the shift supervisor and another
plan which indicated the case manager and living unit representative did not participate in the
development of the plan. Each plan was signed by the youth and documented juvenile probation
officer (JPO) and parent/guardian 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. Three 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 youth within thirty days of admission. Each applicable 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 applicable individualized plan was
completed by a licensed clinical staff and signed by the DMHCA within ten days of completion.
Each of the 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. Three youth were applicable for being on
medication at the time of the individualized plan development and the plan clearly listed the
medication details and monitoring frequency. Five records were reviewed, and four were
applicable for individualized treatment plan reviews, one youth was not in the program long
enough for individual treatment plan reviews. All four reviewed treatment plan reviews were
conducted in thirty-day intervals with the exception of one monthly review which was five days
late. 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, family therapy,
psychiatric services as needed for five youth, and medication management for three youth. The
treatment plan goals and objectives were individualized for each youth. A review of the
program’s contract and interview with the DMHCA verified the program conducts Moral
Reconation Therapy, Skillstreaming the Adolescent, Dialectical Behavior Therapy (DBT), and
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process groups. 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. The interviewed DMHCA stated
at a minimum, youth are provided weekly individual, monthly family, and daily group therapy to
include specialized mental health group services. If a youth has an identified substance abuse
treatment need, services are specified on the treatment plan and provided on a weekly basis by
a licensed mental health professional. Therapists are assigned to group therapy services which
are identified on the intervention service schedule maintained by the DMHCA. The therapists
document these services in daily progress notes and complete a summary of services and
progress weekly. These notes are provided to and reviewed by the DMHCA. Additionally, the
DMHCA monitors service trackers in order to ensure service delivery. The DMHCA co-signs
comprehensive evaluations, individualized treatment plans, and treatment plan reviews.
Licensed professionals complete the substance abuse portions of the individualized treatment
plans and treatment plan reviews. These items are tracked by the DMHCA to ensure
completion. Daily management meetings are conducted each weekday morning with the
management team to review documentation and program services, to include clinical services.
All non-licensed clinical staff participate in clinical supervision weekly facilitated by the DMHCA
in which clinical services are reviewed. As a part of the quality improvement process, both
regional staff and the DMHCA monitor youth records and complete fidelity checks to ensure
services are provided to the youth in accordance with the curriculum standard as well as with
their individualized treatment needs. The treatment team assists the primary therapist in
developing, reviewing, and updating the youth’s initial mental health/substance abuse treatment
plan as well as the individualized mental health/substance abuse treatment plan. The initial
mental health/substance abuse treatment plan is completed within twenty-four hours of the
youth’s arrival to the program, typically following the initial intake. Within thirty days of the
intake, the treatment plan development needs are also discussed and target areas for mental
health and substance abuse problems are identified. Each youth’s treatment plan is developed
according to the youth’s specified individual treatment needs and is based on the findings
indicated within the comprehensive mental health and comprehensive substance abuse
assessments. Based upon the identification of the youth’s individualized treatment needs,
multidisciplinary treatment staff collaboratively identify and develop specific goals and objectives
for inclusion within the youth’s individualized mental health and/or substance abuse treatment
plan. The assigned therapist, working under the direct supervision of the licensed professional,
is responsible for the preparation of the plan and the primary service provisions specified within
the individualized treatment plan. Ongoing reviews of the treatment plan occur on at least a bi-
weekly basis with formal revisions and modifications to the treatment plan occurring on a
monthly basis. Treatment plan goal modifications and status reviews are documented directly
onto the individualized mental health/substance abuse treatment plan and within treatment plan
reviews. Progress reporting is presented within the informal and formal treatment team reporting
by the assigned therapist. The treatment plan review shall assess the youth’s progress towards
specific treatment goals and objectives and shall assist in determining whether modifications to
the treatment plan are needed. The plan is reviewed, revised, and/or modified monthly based
upon input from the treatment team which include a multi-disciplinary team, the youth, juvenile
probation officer, and family.
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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 five
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, mental health and substance abuse staff, and applicable
parent/guardian. Medical and education staff do not attend the treatment team meetings;
however, they provide written input. A review of the five youth records reflected each was
applicable for a substance abuse diagnosis and treatment. The program is licensed through the
Department of Children and Families under Chapter 397 to provide substance abuse services to
adolescents. Each record contained an executed Authority for Evaluation and Treatment (AET)
form. Additionally, each youth record contained a signed Youth Consent for Substance Abuse
Treatment form, 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
closed records was conducted for discharge plans. 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.
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3.08 Specialized Treatment Services (Critical) Limited 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
Intensive Mental Health (IMH) Treatment Services and substance abuse services. 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 which include Moral
Reconation Therapy (MRT) three days weekly, Skillstreaming the Adolescent one day a week,
Dialectical Behavior Therapy (DBT) one day a week, Impact of Crime (IOC) two days a week,
and process group three days a week. The DMHCA verified the program provides group
counseling five days a week, individual counseling weekly, and family therapy bi-weekly.
Supportive counseling and crisis intervention are provided as needed. An interview with the
facility administrator (FA) verified the youth Safety Plans are updated every formal treatment
team meeting and after any incident of mental health crisis. A review of youth records, youth
interviews, group sign-in sheets, and an interview with the DMHCA verified the individual, group,
and family therapy are part of the youth’s treatment plan. Documentation indicated therapeutic
services are held at least five times a week. Five interviewed youth reported participating in
individual, family therapy services, and participating in groups at the program. Five interviewed
staff stated direct care staff do not facilitate any mental health or substance abuse groups. A
review of mental health treatment and substance abuse group sign-in sheets verified there were
no more than ten youth participating in the IMH groups. Reviewed documentation and an
interview with the DMHCA verified only licensed clinical staff facilitate substance abuse groups.
Documentation verified staff were qualified to provide substance abuse education. A review of
group sign-in sheets verified group therapy is limited to no more than fifteen participants in
substance abuse groups. All mental health clinicians working at the program were qualified to
provide substance abuse treatment and education services. The program provides substance
abuse treatment services, which includes urinalysis drug testing. Any positive tests are referred
for an appropriate clinical intervention and sanctions. The program has a Chapter 397 license
through the Department of Children and Families to provide substance abuse treatment
services to adolescents. 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 as required by contract. The
program has an agreement with a psychiatrist for the completion of psychiatric evaluations and
medication management needs. The program’s contract requires a psychologist to provide
services on-site weekly for two hours. A review of sign-in logs indicated the psychologist was
not on-site for sixteen weeks during the annual complianced review period. In addition, the
program sub-contracts behavior analyst’s services as needed. A consultation with the
Department’s Office of Health Services (OHS) verified the program did not meet the
requirement of the psychologist being on-site weekly to provide services.
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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 March 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 identified the back-up psychiatrist with a license which
was free and clear in the State of Florida with an expiration date of January 31, 2025; however,
the program did not utilize a back-up psychiatrist during the annual compliance review period.
The psychiatrist’s agreement and contract require weekly services and a review of sign-in
sheets and medication management documentation reflected the psychiatrist provided on-site
services or telepsychiatry services with prior approval. An interview with the psychiatrist verified
psychiatric services are provided weekly. 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 weekly. The psychiatrist stated they meet with healthcare staff to review important
medical issues pertaining to youth receiving psychiatric services during treatment team weekly
in person or telephonically. The psychiatrist conducts weekly face-to-face or telephonic
communication with the treatment team. It is the program’s practice for all youth admitted to the
program to be referred for a psychiatric interview. A review of five youth records found each
youth was referred for a psychiatric interview and three youth were applicable for entering the
program on psychotropic medication. The youth admitted to the program with psychotropic
medication received a psychiatric interview within fourteen days of admission. Five youth
records were reviewed, and each received a diagnostic psychiatric interview which 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. A review of five youth treatment plans verified the plan was consistent with the
DSM-5 diagnosis and included the treatment recommendations. The initial diagnostic
psychiatric interview was documented on the Department’s Clinical Psychotropic Progress Note
(CPPN) form which was clearly identified as the Initial Diagnostic Psychiatric Interview. 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. Five youth
records were reviewed, four youth were prescribed psychotropic medication after the initial
diagnostic interview, and one youth started taking psychotropic medication after being at the
program for several months. Four of the five applicable youth records documented youth were
seen for medication reviews by the psychiatrist at least once every thirty days, and one youth
had not been at the program for thirty days. The psychiatric evaluations were documented on
the Department’s CPPN form for each youth. The Department’s 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 reviewed CPPN’s included the
youth’s height, weight, and blood pressure. The psychiatrist signed and dated each of the five
reviewed CPPNs. Two of the five reviewed youth records were applicable for the monitoring of
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Tardive Dyskinesia on a monthly basis, as indicated in the CPPN. Documentation verified the
psychiatrist was monitoring for Tardive Dyskinesia on a monthly basis.
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 maintains 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 designated mental health clinician authority
(DMHCA) on January 12, 2024. 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.
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 written Suicide Prevention Plan which outlines the methods used for
suicide precautions which include observing, monitoring, and housing youth identified as a
suicide risk. It is the program’s practice to conduct an Assessment of Suicide Risk (ASR) for all
youth admitted to the program. A review of five youth records found each received an ASR upon
admission to the program. Each reviewed ASR included the precautionary observation (PO)
date, ASR referral date, and was completed on the Department’s ASR form. All five records
included the level of supervision. Two youth were identified as being a suicide risk after staff
observations and were placed on PO. One youth was placed on PO several times after
admission to the program. Two separate instances of the same youth were reviewed, and a
second applicable youth was reviewed. All three applicable events documented the youth were
placed on PO status and assessed utilizing the ASR which was completed on the Department’s
ASR form by the designated mental health clinician authority (DMHCA) within twenty-four hours.
Documentation verified the parent/guardian and assigned juvenile probation officer (JPO) were
notified of the youth’s potential suicide risk. One youth was stepped down to standard
supervision after the DMHCA completed the ASR. Two youth records 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 were stepped to close supervision. The discontinuation of suicide precautions was the
result of a documented conference with the facility administrator (FA), and mental health
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clinician in each applicable record. All three youth records verified youth were maintained on
close supervision until it was determined appropriate to step the youth to standard supervision.
A review of the Department’s Juvenile Justice Information System (JJIS) reflected accurate
alerts were entered 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 PO 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 during the annual compliance review period. The program’s video is
stored for thirty days. An interview with the regional compliance manager verified there were no
youth placed on precautionary observation within the last thirty days; therefore, none could not
be observed by video.
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 written Suicide Prevention Plan which outlines levels of supervision
and the process for recording observations of youth on suicide precautions. A review of five
youth records was conducted and indicated two youth were applicable for suicide precautions;
therefore, an additional record was requested and reviewed. The review of the three youth
records identified each youth as being a suicide risk after staff observations and confirmed they
were placed on precautionary observation (PO). One youth was placed on PO several times
after admission to the program. Each youth record contained documentation where a Suicide
Precautions Observation Log form was maintained for the duration of when the youth was
placed on suicide precautionary observation. Youth behaviors were documented in real time
and did not exceed the thirty-minute intervals for each youth. Each youth was applicable for
warning sign observations, and notification to the mental health clinicians were 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 written Suicide Prevention Plan which requires all staff with direct day-
to-day contact with youth to participate in suicide training. A review of five pre-service and one
in-service training record documented program staff completed the required six hours of suicide
training. The program has a total of two suicide kits which were located in master control and
the laundry room near medical. 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 during the annual compliance review period 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. Staff who did not participate
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in a quarterly drill have the opportunity to review each drill scenario and procedures in an effort
to understand the process and receive the necessary training to respond to an incident of a
suicide attempt, or serious self-inflicted injury. The interviewed facility administrator (FA)
reported the licensed clinician completes mock mental health and suicide prevention drills
across all shifts, ensuring all staff participate in at minimum of one drill on a quarterly basis.
Each drill is reviewed monthly during the general staff meeting with all staff. Five staff were
interviewed and all stated they would conduct constant sight and sound supervision and notify
mental health staff if a youth expressed suicidal thoughts. Three stated they would document
supervision, and four stated they would search the youth and room for sharp objects. Five staff
stated suicide response kits are located in master control, two staff stated in the laundry room,
one staff stated in medical, and one stated in the youth living units. Each of the five staff stated
medical/suicide drills are conducted monthly.
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
designated mental health clinician authority (DMHCA) on January 12, 2024. A review of the plan
confirmed 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 five youth records found none were applicable for a Crisis
Assessment. An informal interview with the regional compliance manager verified there were no
youth applicable for a Crisis Assessment during the annual compliance review period.
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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 in 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 signed and reviewed by the designated mental health clinician
authority (DMHCA) on January 12, 2024. 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) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
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 five 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
from clinical assessments. Each plan was reviewed and updated at least every thirty days, with
the exception of one youth’s plan which was updated five days late and after significant
behavioral or mental health events. According to the program’s policy, the Safety Plans are
reviewed during the monthly all staff meetings. Safety Plans are accessible to all staff and are
located in master control, the conference room, and in each youth’s mental health record. The
interviewed facility administrator (FA) reported the Safety Plans are updated every formal
treatment team meeting and after any incident of mental health crisis. Five interviewed youth
confirmed they participated in the development of their Safety Plan. Four interviewed staff
stated Safety Plans are located in master control, one staff stated they were located in clinical,
and one staff stated the conference room. Staff stated plans are reviewed during shift briefings,
treatment team meetings, or clinical staff inform them of any changes. Three staff stated they
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review the plans daily, one staff stated about a month ago, and one staff saw one a couple of
weeks ago during new hire training.
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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 maintains a written policy and procedures which require a contracted health
authority to provide on-site medical services to youth in the program. The program maintains an
independent contractor agreement with a State of Florida physician to serve as the designated
health authority (DHA). The DHA has a clear and active license in the State of Florida, which
expires on January 31, 2025, with specialty training in pediatrics. A review of the Florida
Department of Health documentation showed the DHA had no current disciplinary cases and/or
public complaints on record. The DHA is required by contract to be on-site for a minimum of two
hours each week. A review of sign-in sheets maintained for the annual compliance review
period showed the DHA was on-site as required each week of the annual compliance review
period. The program has a back-up DHA who has a clear and active license in the State of
Florida expiring on January 31, 2025. An interview with the regional health services
administrator (HSA) stated the back-up DHA was not utilized during the annual compliance
review period. The program does not utilize an advanced practice registered nurse (APRN) or
physician’s assistant (PA). A review of the program’s contract and policy and procedures
indicated there was no inclusion or approval from the Department’s Office of Health Services for
tele-medicine/tele-health services other than for telepsychiatry. An interview with the DHA
stated their role in the program is to complete Comprehensive Physical Assessments (CPAs),
conduct periodic evaluations, sick call, and policy and procedure development. The youth with
chronic problems are to be seen every sixty days and an internal calendar is utilized to track the
periodic evaluations. The DHA confirmed being on-site weekly and being available by phone
twenty-four hours a day, seven days each 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 maintains a written policy and procedures for all health-related procedures and
protocols utilized. The program provides on-site medical coverage seven days a week from 7:00
a.m. to 7:30 p.m. The program is to have two registered nurses (RNs), and one licensed
practical nurse (LPN). One of the RNs is to serve as the program’s health services administrator
(HSA). At the time of the annual compliance review the program had one full-time LPN position
filled and two corporate regional HSAs were providing nursing coverage. The program’s HSA
position became vacant on January 22, 2024, and the full-time RN transferred from full-time to
pro re nata (PRN) on February 5, 2024. A review of the program’s February 2024 nursing
schedule showed at least one of the two corporate regional HSAs work each weekday to
provide clinical supervision and medical services from 7:00 a.m. to 3:30 p.m. or from 7:00 a.m.
to 7:30 p.m. Either two or three nurses are scheduled for overlapping weekday shifts from 7:00
a.m. to 7:30 p.m. The PRN nurse is scheduled to work on Saturdays and the LPN is scheduled
to work on Sundays, both from 7:00 a.m. to 7:30 p.m. Due to the vacancies, the posted daily
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schedule, which has morning medication pass set to occur from 6:00 a.m. to 6:45 a.m., has
been slightly altered in practice to accommodate the temporary schedule of nurses providing
coverage at the program from 7:00 a.m. to 7:30 p.m. A review of licenses for the current nursing
staff providing services at the program found each had a clear and active license in the State of
Florida. Reviewed documentation found each nurse held a current certification in
cardiopulmonary resuscitation (CPR). An interview with the corporate regional HSA indicated
the program recently hired a nurse who was completing orientation training during the week of
the annual compliance review with an anticipated start date of February 19, 2024.
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 medical facility operating procedures (FOPs) for all health-related procedures
and protocols utilized. The program’s designated health authority (DHA) conducts an annual
review of all health-related policies, procedures, and protocols. Reviewed documentation
showed the DHA reviewed, signed, and dated the FOPs on September 20, 2023, the facility
administrator signed on September 25, 2023, and the psychiatrist signed on January 12, 2024.
The DHA reviewed and signed all nursing protocols on August 11, 2023. The nursing staff
signed a cover page acknowledging their review of all FOPs and treatment protocols on August
23 and December 4, 2023. There was documentation both the registered nurse (RN) and
licensed practical nurse (LPN) hired in 2023 received a comprehensive clinical orientation.
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 maintains a written policy and procedures requiring the completion of the Authority
for Evaluation and Treatment (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 of
specific information as noted on the Release of Information Authorization for Youth Eighteen
Years of Age and Older form and to whom the information can be released and shared. A
review of five youth Individual Healthcare Record’s (IHCR’s) documentation showed three youth
had a valid AET and the word “Copy” was stamped on each youth’s AET. Each of the three AET
forms were signed by the youth’s parent/guardian. There was documentation each AET was
signed by a Department representative. There were two youth applicable for being in the care of
the Department of Children and Families (DCF) and a court order authorizing all treatment and
procedures was filed in the two applicable IHCRs. An interview with nursing staff stated new
admissions are discussed with the case management staff prior to the youth’s arrival, and if
needed the juvenile probation officer (JPO) would be contacted through case management to
obtain a new AET. Any youth aged eighteen years or older at the time of intake, or upon turning
eighteen, will fill out a release of information form to consent to the release of medical
information.
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4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program maintains a written policy and procedures requiring notification to the
parent/guardian of significant changes in the youth’s condition and to obtain consent when new
medications and treatments are prescribed. A review of five youth Individual Healthcare
Record’s (IHCR’s) documentation showed a consent was provided by the parent/guardian of
four youth applicable for over-the-counter (OTC) medications beyond those covered by the
Authority for Evaluation and Treatment (AET). Four of the five youth were applicable for taking
psychotropic medications. Documentation showed in all four applicable records a staff
witnessed all telephone calls whenever a new psychotropic medication was prescribed or
discontinued, or changes were made requiring parental/guardian verbal consent. Two of the five
youth were applicable for being in the care of the Department of Children and Families (DCF)
and the respective IHCRs included a court order. Each of the five 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 a religious
exemption. An interview with the regional health services administrator (HSA) stated verbal
consent is obtained for any OTC medication which is not listed on the signed AET, for new
prescriptions, significant dosage changes, or discontinuation of a medication. Medical staff will
then follow-up by mailing a written parental/guardian notification.
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 maintains a written policy and procedures regarding healthcare screening for each
youth upon admission into the program. A review of five youth Individual Healthcare Record’s
(IHCR’s) documentation showed each youth received a Facility Entry Physical Health Screening
(FEPHS) upon admission, by the program’s nurses. One of the five youth was applicable for a
change in physical custody and reviewed documentation validated the youth was rescreened
upon readmission to the program on August 6, 2023. An interview with the regional health
services administrator (HSA) stated newly admitted youth are seen by medical staff immediately
following the initial search. The nurse stated new intakes are discussed prior to admission in
collaboration with the administration team. The nurse also confirmed all admission screenings
are completed by medical staff on-site at the time of each youth’s admission.
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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 maintains a written policy and procedures requiring each youth admitted into the
program to receive a healthcare orientation. A review of documentation in five youth Individual
Healthcare Records (IHCRs) confirmed each youth received an orientation to healthcare
services at the program upon admission. Each youth’s orientation included topics such as
access to medical care, sick call process, emergency situations, medication process, the right to
refuse care, what to do in case of sexual assault or attempted sexual assault, the non-
disciplinary role of healthcare staff, and standard universal precautions. All topics were
documented on the Health Education form, and each was signed and dated by the youth.
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 maintains a written policy and procedures to notify the designated health authority
(DHA) by telephone, text message, or verbally, if on-site, of all youth admitted into the program
identified with chronic health conditions or youth in need of emergency care. A review of five
youth Individual Healthcare Records (IHCRs) reflected four youth were applicable for having a
known or suspected chronic condition. Documentation showed the DHA was notified within
twelve hours of admission of all five youth, regardless of chronic condition status. Two of the
five youth were taking psychotropic medication upon admission, and there was documentation
the psychiatrist was notified in each instance. An interview with the regional health services
administrator (HSA) confirmed the nurse contacts the DHA upon each youth’s admission to the
program to obtain admission orders.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program maintains 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. A review of documentation in five youth
Individual Healthcare Records (IHCRs) showed a HRH was completed within the required
seven days of admission, and prior to each youth’s CPA. Documentation showed the
designated health authority (DHA) reviewed the HRH form in each of the five records. An
interview with the regional health services administrator (HSA) stated the HRH is completed by
the nurse during the initial nursing assessment.
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4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program maintains a written policy and procedures ensuring each youth admitted shall
receive and/or shall have on record a current Comprehensive Physical Assessment (CPA) and
Health-Related History (HRH) form no later than seven calendar days after admission into the
program. A review of documentation in five youth Individual Healthcare Records (IHCRs)
showed each youth had a new CPA completed by the designated health authority (DHA) within
seven days of admission, using the Department’s form and each youth’s Medical Grade was
documented on the CPA. There was no sign of any missing/incomplete elements on the
reviewed forms. Documentation indicated none of the five youth refused any part of the
examination; however, four records documented the clinician deferred a gynecological
examination due to the youth having no symptoms. One youth record indicated the
gynecological examination was deferred by the clinician but did not indicate the basis upon
which the deferral was made. Each youth’s CPA documented the deferral. All sections of the
CPA were completed in full utilizing an “O” and/or applicable “X” markings. Documentation
confirmed the results of each youth’s Tuberculosis Skin Test (TST) were documented on the
CPA, the Department’s Infectious and Communicable Disease (ICD) form, and on the program’s
TST/Purified Protein Derivative (PPD) form. An interview with the regional health services
administrator (HSA) confirmed the CPA is completed by the DHA annually and gynecological
examinations are not routinely completed. The nurse stated youth are screened for tuberculosis
annually.
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 maintains a written policy and procedures requiring all admitted youth to be
clinically screened and medically evaluated for sexually transmitted infections (STIs) and human
immunodeficiency virus (HIV). A review of five youth Individual Healthcare Record’s (IHCR’s)
documentation showed each youth was clinically screened and evaluated for STIs. Four of the
five youth were referred for further evaluation and referred to the designated health authority
(DHA). Documentation showed the four youth received a referral for testing and testing was
provided. Each youth’s testing, screening results, clinical evaluations, and diagnosis was
showed to be documented on the Department’s Infectious and Communicable Disease (ICD)
form. All five youth IHCRs documented each youth was offered counseling and testing for HIV.
Four of the five youth declined consent for testing. There was a signed consent from the one
youth who consented to testing. The laboratory section of the youth’s IHCR included a sealed
envelope marked “Confidential”, the outside of which was initialed and dated by the DHA to
indicate their review. The youth’s IHCR documented pre- and post-test counseling was
conducted. An interview with the regional health services administrator (HSA) indicated the DHA
provides the pre- and post-test counseling. The youth’s confidentiality was protected and there
was no indication the results were documented in the program alerts. The program maintains a
written policy and procedures ensuring all youth at risk for HIV infection are offered counseling,
testing, education, prevention counseling, and a referral for medical treatment. The program’s
policy confirmed the practice. Five youth were interviewed, and each stated they can request a
HIV test at the program. The interviewed regional HSA stated all youth admitted to the program
are screened for possible STIs by completing the Sexually Transmitted Infections Screening
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form. If a youth screening indicates a need for further evaluation the youth will be referred to the
DHA to receive a physician order for testing. When all youth testing has been provided and
results are received, the youth results are stored in the IHCR in the laboratory section of the
record.
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 maintains a written policy and procedures to allow all youth to submit sick call
requests and have medical complaints treated appropriately through the sick call system. The
program's policy indicated there was nursing staff on-site “twenty-four hours a day/seven days a
week" which was not accurate; therefore, the program’s policy was revised, approved, and
signed during the week of the annual compliance review to reflect the program’s actual practice.
Sick call hours were posted on the medical clinic door. The program’s sick call is conducted
twice daily; Monday through Friday from 11:30 a.m. to 12:20 p.m. and 3:05 p.m. to 3:15 p.m.
and weekends from 12:30 p.m. to1:00 p.m. and 4:20 p.m. to 5:30 p.m. Sick call forms were
observed in the dayroom hallway in a wall-mounted slot which is accessible by youth. A locked
sick call deposit box was wall-mounted in the dayroom hall adjacent to the sick call forms. A
review of five youth Individual Healthcare Records (IHCRs) reflected none of the five reviewed
youth were applicable for presenting with a similar sick call complaint three or more times within
a two-week period. All five reviewed youth were applicable for having submitted at least one
sick call request form. One youth was applicable for a licensed practical nurse (LPN) having
conducted the sick call and documentation validated the sick call was reviewed by the
program’s registered nurse (RN). All sick calls were documented on the Department’s Sick Call
Index and Sick Call Referral Log, and filed within each youth’s IHCR in reverse chronological
order. No youth were applicable for having been in restricted housing as the program does not
utilize restricted housing of any kind. An observation of one sick call was conducted during the
week of the annual compliance review. The youth was escorted to sick call by a male direct care
staff who remained in the hallway to allow privacy while the regional health services
administrator (HSA) examined the youth. The nurse stated youth may submit a sick call at any
time by placing a request form in the sick call box and youth are to be seen within twenty-four
hours. Five staff were interviewed, and each stated the nurse reviews and conducts sick calls.
Five youth were interviewed, and each youth stated they can see the nurse within one day when
a sick call request is made. The program’s policy did not address sick call requests submitted
after healthcare staff depart the program at 7:30 p.m. and did not include procedures for
supervisors to review submitted requests within four hours of submission, as required. The
program revised their policy and procedures to add procedures for shift supervisory review and
determination of sick call requests submitted when licensed healthcare staff are not on-site. The
revised policy was approved and signed by the designated health authority (DHA) and facility
administrator (FA) during the week of the annual compliance review.
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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 maintains a written policy and procedures to address the provision of episodic and
emergency care. A review of five youth Individual Healthcare Records (IHCRs) reflected all five
youth were applicable for episodic care encounters. Each of the five reviewed episodic care
events were conducted by a nurse and documented in subjective, objective, assessment, and
plan (SOAP) form. None of the episodic or first-aid care was provided by non-healthcare staff.
Each applicable youth’s episodic care event was documented in the chronological progress
notes and tracked on the Episodic Care Log. The program has ten first-aid kits located in areas
throughout the program including maintenance, each of the two classrooms, case management,
each of two transport vans, master control, the medical clinic, dry storage, and the laundry
room. Two first-aid kits are maintained for use in the program’s two transportation vans. The
program has a prescribed contents list for each first-aid kit. Program staff are to check the first-
aid kits daily to ensure the kits are sealed. If the kit is not sealed, the staff is to bring the first-aid
kit to the healthcare staff, as soon as reasonably possible. Reviewed documentation indicated
the nurse also checks the first-aid kits weekly. An observation of one first-aid kit was conducted
and the kit contained all of the required items. The program had two automated external
defibrillators (AEDs) located in master control and the laundry room. The AED procedures are
located within the AED case and each AED provides audible instructions. Reviewed
documentation validated the AED is checked by the nursing staff once a month. Reviewed
documentation confirmed the AED batteries and the pads expire in December 2024. The
batteries were last changed on April 6, 2020, and pads were last changed on March 12, 2023.
An observation of a self-test of the AED showed the AED was operating correctly and there
were no issues. The program operated with two twelve-hour shifts until September 2023, when
three eight-hour shifts were instituted. A review of the program’s mock emergency medical drills
documentation showed a drill was conducted on each shift monthly during the annual
compliance review period. Emergency medical drills included the demonstration of
cardiopulmonary resuscitation (CPR) and AED at a minimum annually. The emergency medical
drills consisted of both announced and unannounced drills and were conducted on each shift as
required. A review of five pre-service and one in-service staff training record confirmed all six
staff had current CPR/first-aid and AED certifications. The program has a list of emergency
numbers posted in master control and the medical clinic, accessible to non-licensed and
licensed staff. Emergency phone numbers were inaccessible to youth. No episodic care events
took place during the week of the annual compliance review; therefore, none were observed.
The program has a written policy and procedures which detailed the use, access, and inventory
of NARCAN®, which is stored in the locked medical cart. The nurse reported all medical staff
and three identified program staff have been trained on how and when to use NARCAN®. The
nurse stated a perpetual inventory is maintained for NARCAN® which is inventoried when
conducting the medication count along with all other medications. An interview with five staff
confirmed each staff is personally allowed to call 9-1-1 if a youth had a medical emergency. Five
interviewed youth each stated they can see the dentist and the doctor if needed.
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4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program maintains a written policy and procedures for the provision of off-site emergency
and non-emergency referrals for medical care and treatment. A review of five youth Individual
Healthcare Records (IHCRs) reflected none were applicable for receiving off-site care;
therefore, three applicable records were requested for review. One youth was applicable for
having emergency care documented on the Episodic Care Log. Two youth were taken off-site
for podiatry or dental appointments. Documentation showed the two youth’s parent/guardian
was notified of the youth’s off-site care event and one youth was over the age of eighteen. Each
of the three reviewed youth records had a Summary of Off-Site Care Consultation Report form
which was filed in the IHCR with any applicable discharge and other additional documents. The
designated health authority (DHA) reviewed and signed all forms as required. Two of the three
applicable youth required a follow-up appointment, and documentation showed each youth
received the follow-up appointment in a timely manner. An interview with the regional health
services administrator (HSA) stated the DHA signs off on all off-site summary forms which are
flagged in the youth’s record after they return from the off-site visit, and if a follow-up
appointment is needed the nurse documents the appointment on the nursing calendar/medical
tracker.
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 maintains a written policy and procedures requiring youth who have chronic
illnesses to receive regularly scheduled evaluations with required follow-up. A review of five
youth Individual Healthcare Records (IHCRs) reflected three youth were applicable for having a
chronic condition upon admission, one additional youth was diagnosed subsequent to
admission. There were no youth documented as having a communicable disease. One youth
was taking medication on an ongoing basis. All applicable youth were undergoing treatment for
a physical health condition. Each youth is to be placed on the chronic illness list and periodic
evaluations are conducted when applicable, at least every ninety days. The program maintains a
tracking log for youth with chronic conditions and evaluation dates. The tracking log indicated
each youth’s next scheduled appointment. No youth were applicable for taking anti-tuberculosis
medications. Periodic evaluations were conducted prior to a prescription renewal, change, or
expiration, when applicable. None of the reviewed youth were applicable for an off-site
evaluation. The four applicable records had a total of ten required periodic evaluations. There
were no documented lapses in care or missed periodic evaluations in three of the four reviewed
records. One reviewed record had one periodic evaluation conducted three days late in January
2024. The Department’s Problem List for each youth was updated in accordance with policy. An
interview with the facility administrator (FA) stated medical issues and medications are
discussed during monthly meetings with the healthcare staff, and any time as needed
throughout the month. An interview with the nursing staff and the designated health authority
(DHA) confirmed the process for the completion of periodic evaluations.
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4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program maintains 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 five youth Individual Healthcare Records (IHCRs) reflected three youth
were applicable for being on medication prior to admission. Medication was verified prior to the
admission for each of the three-youth utilizing the Prescription Medication Verification Checklist
form. Each reviewed youth prescription verification was documented in the chronological
progress notes. Each IHCR documented the designated health authority (DHA) and, when
applicable, the psychiatrist were contacted to obtain orders to resume medications. Each
medication had a current, valid order, and were administered pursuant to a current order. Each
youth had a Practitioner Order form filed in their IHCR for continued medication or new
medication. Documentation showed each youth had a standard Department Medication
Administration Record (MAR) to document all medication and treatment. A review of the MAR
for all three youth reflected no instances where a non-healthcare staff assisted in the delivery of
medication. Reviewed documentation in each record demonstrated medical staff initialed each
medication entry, along with documented side-effect monitoring at each medication
administration. Two of the three records were applicable for at least one youth refusal of
medication. In each instance, there was clear documentation on the MAR along with a signed
Refusal of Treatment form. Each reviewed MAR documented all required elements. None of the
reviewed youth were applicable for parenteral medication. Documentation showed youth
received an initial diagnostic psychiatric interview within fourteen days of admission, as
required. All three youth received medication monitoring every thirty days as required. There
was no sign of any type of standing order, emergency treatment orders, or any pro re nata
(PRN) orders for psychotropic medications. One medication pass was observed during the
annual compliance review week with no noted issues. Each youth was escorted to medical by
direct care staff. The Six Rights of Medication Administration were verified by the nurse. The
nurse administered the medication as required and did not pre-pour any of the medications.
Five youth were interviewed, and four stated the nurse gives medication while one youth stated
they do not take medication. Five staff were interviewed, and each staff stated the nurse
dispenses medication and one staff stated the shift supervisor is trained to administer
medication. An interview with the regional health services administrator (HSA) confirmed the
process for nursing staff verifying youth medications.
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 maintains a written policy and procedures regarding the requirements for the
storage and inventory of medications and sharps ensuring all medication is inaccessible to
youth at the program. The program has a list of trained non-healthcare medical staff who are
trained in the delivery and oversight of over-the-counter (OTC) medication, when nursing staff
are not on-site. Observations of the medication cart showed it was clean and organized, with
stock items separate from youth specific medications. An observation of the medication cart
found all medications were stored in the locked cart which is kept in the locked medical office.
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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. Observations found all medications were securely stored in the medical clinic
inaccessible to youth. The program had no medication requiring refrigeration during the annual
compliance review week; however, the program has a refrigerator which is used only for
medication, if needed. A review of documentation showed the program’s OTC medications are
inventoried using a perpetual inventory daily. An interview with the regional health services
administrator (HSA) confirmed the program’s practice. Perpetual inventories with running
balances are maintained on all controlled substances with a shift-to-shift inventory conducted by
the nurses. Syringes and sharps are counted through a perpetual inventory and are verified
weekly. An observation of counts was conducted with the regional HSA during the annual
compliance review week. The program had one youth prescribed one controlled medication and
the reviewed inventory was accurate. A review of three OTC medications was conducted which
validated the inventories were accurate. Three sharps were reviewed, and inventories were
accurate. An interview with the regional has stated the program’s practice is for medication to be
sent to the pharmacy for disposal, while Class II medications are destroyed on-site with the
pharmacist, when applicable.
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 to 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 maintains a written policy and procedures for infection control which includes an
Exposure Control Plan and is written in accordance with Occupational Safety and Health
Administration (OSHA) and the Centers for Disease Control and Prevention (CDC) guidelines.
The policy for infection control was signed by the facility administrator (FA) on September 25,
2023, and the designated health authority (DHA) on January 31, 2024. The plan 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 antibiotic resistant micro-organisms, food-borne
illnesses, bio-terrorist agents, and chemical exposures. The program also has Hepatitis B
immunizations available to staff along with access to protective equipment. An interview with the
program’s compliance manager confirmed there were no instances where the local county
health department, CDC, and/or the Department’s Central Communications Center (CCC)
needed to be notified of any infection’s disease; however, the program has a separate file
containing documents for youth and staff who have experienced an occupational exposure. The
plan includes a process for needle stick post-exposure evaluation. There were no instances
involving quarantining or hospitalization during the annual compliance review period. An
interview with the FA stated the infection control and exposure plans are located in the FA’s
office and the medical clinic and are reviewed twice a year. An interview with the regional health
services administrator (HSA) stated infection control and exposure control training for staff is
conducted by the program’s HSA, and the training for youth is provided during the admission
process.
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4.19 Prenatal Care/Education Satisfactory Compliance
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
The program maintains a written policy and procedures to ensure the provision of prenatal care
to all pregnant youth. Health education is to be provided to both youth and staff. A review of five
Individual Healthcare Records (IHCRs) found none of the youth were pregnant at the time of the
annual compliance review. The program indicated they have not had any pregnant youth during
the annual compliance review period. A review of training sign-in sheets indicated non-
healthcare staff involved in the supervision or treatment of pregnant youth received in-service
education on girl’s healthcare, teen pregnancy, and pregnancy complications annually. This
training was last provided on December 19, 2023, by the health services administrator (HSA). A
review of the training curriculum indicated the in-service training included observation and
monitoring of emergency care needs/symptoms of possible miscarriage. The program maintains
nursing protocols and treatment plans for pregnant youth. An interview with the regional HSA
indicated services provided to pregnant youth, when applicable, include various health
education topics including alcohol and drug use, smoking, nutrition, sexually transmitted
diseases, contraceptive use, prenatal care, birthing process, post-partum care, basic baby care,
child/infant development, parenting skills, shaken baby syndrome, anger management, time
management, and after care planning. Pregnant youth are to receive a special diet and weekly
checkups for weight and nutritional status updates. Nursing staff indicated, with verbal consent,
youth are tested for pregnancy upon admission.
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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 addressing youth supervision and requiring all
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’s daily activity schedule was posted in the program’s
day room, within the youth’s living unit, and available to all youth. The program’s contract
requires the staff-to-youth ratio be one-to-eight during sleep hours, one-to-five for off-site
activities, and one-to-six during awake hours. 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. Observations of staff supervision during the annual compliance
review week included classroom activities, line movement, youth searches, school breaks,
youth head counts, transportation, groups, outdoor/indoor recreation, and leisure activities.
Activities observed during the annual compliance review consisted of supervision of youth
during school hours, youth in the dining area, recreational activities, and youth movement
through the program. Each staff was observed to be positioned to ensure proper supervision
and to ensure there were no physical obstructions in their view of the youth. Each youth was
observed to be actively involved in their daily education during the annual compliance review
week. Informal interviews with three staff while in the classrooms were conducted. Each staff
was immediately able to report the accurate number of youth they were supervising. Observed
staff and youth were appropriately attired, and staff interactions were observed to be positive
and consistent with the program’s BMS. Five staff were interviewed, and four staff were
knowledgeable of the program’s procedure for when youth counts cannot be reconciled. One
case manager reported they did not conduct counts.
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). The program’s BMS is called the positive
performance system (PPS). The program’s policy outlines the implementation of the PPS,
including a contingency management system of rewards, privileges, consequences to
encourage youth to fulfill the program’s expectations, compliance with program rules, teach the
youth alternative, pro-social means of meeting their needs, and encourage self-managed,
independent behavior, including dealing effectively with challenging and stressful situations. It is
based upon the principles of Social Learning Theory; a behavioral theory which is based on the
belief most human behavior is learned observationally through modeling. The program’s policy
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Office of Accountability and Program Support Page 60 of 78 (Revised September 2022)
outlines the implementation of the PPS, which is designed to maintain order and security,
promote safety, respect, fairness, protection of rights within the program, foster compliance with
the program rules, teach youth alternative social methods of dealing with problems, and to
provide positive reinforcement and recognition for accomplishments. The policy and procedures
include a protocol where staff are provided feedback regarding the implementation of the BMS.
The program maintains a BMS staff manual and a youth handbook outlining program
expectations and norms. The BMS is designed to enhance youth treatment, to increase healthy
pro-social behavior using positive reinforcement, and to decrease unhealthy behaviors through
natural consequences. Observations made confirmed the BMS was posted throughout the
program. The program maintains a weekly/monthly incentive calendar of BMS activities and
rewards. Each youth begins the program at the orientation level and can earn points to be
progressively promoted to each of the higher levels. Positive and negative behaviors are
identified throughout each day and incentives are in place to encourage youth to improve their
behavioral choices. Special treatment team meetings are conducted when serious infractions of
the BMS occur. The program’s policy and procedures were revised and signed by the facility
administrator (FA) on January 29, 2024. The program has an agreement with the Lee County
School District related to the BMS/positive performance system (PPS). The program’s policy
addresses the training and documentation provided and indicated the teachers were trained, by
the FA and/or the designee, on March 1, 2023. The BMS/PPS training is provided to staff during
pre-service training. A review of five staff pre-service training records confirmed each was
trained on the BMS/PPS. A review of the program’s youth handbook reflected an overview of
the BMS was included. The program’s written BMS/PPS is compiled of a series of levels, which
was confirmed through an interview with the FA. A review of five youth case management
records confirmed the youth’s orientation included a review of the program’s BMS. A review of
five youth case management records supported the program was utilizing individual behavior
plans as outlined in the BMS. The program’s BMS did not include increased length of stay,
denial of youth basic rights, promotion of group punishment, punishment of youth by other
youth, and/or disciplinary confinement. Observations made during the annual compliance review
week confirmed program staff adhered to the implementation of the BMS when interacting with
youth throughout each day. The youth complete each level by earning daily points to earn a
positive day in the program. Earning positive days allows youth to also participate in nightly
incentive. If a youth has a behavioral infraction, they will not earn points for a task, after so
many deducted points they will not earn enough points to make their positive day which hinders
their progression in the level. Additionally, youth can earn a special treatment team referral for
more serious behavioral violations. The youth will meet with her treatment team to provide
feedback and share input on the situation and together will determine an appropriate
consequence. Five interviewed staff reported receiving training on the BMS. Each staff reported
the program utilizes a point and level system with rewards and consequences and four staff
indicated the BMS is included in the youth’s handbook and orientation process. Additionally,
each staff indicated the BMS is posted throughout the program. Two of five interviewed staff
reported things can be taken away from youth as a consequence and three staff reported levels,
transition, or privileges cannot be taken away. Staff reported rewards provided as part of the
BMS include shopping at the canteen store, receiving snacks, food, and/or other special
activities. Staff indicated the program provides ongoing training related to the PPS as needed
and appropriate, during monthly all staff meetings. Five youth were interviewed and explained
the consequences used in the program include level freezes, special treatment team meetings,
and incentive privilege suspension. Five youth were interviewed, and each reported youth are
rewarded with incentives, snacks, meals, or other activities. Five of the interviewed youth were
knowledgeable and able to explain the difference between each level and how to move level to
level. All youth interviewed denied being able to punish other youth. Four of the five interviewed
youth reported staff are consistent with rewards and consequences; however, one youth
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indicated some staff do and some staff do not. One of the five interviewed youth indicated they
felt the BMS was fair, two youth indicated it was good, and two indicated it was very good.
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.
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. The program has a total
of thirty-seven video surveillance cameras from which video recordings are maintained for at
least thirty days. During the annual compliance review week, all cameras were operational. 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. Checks are documented on the program’s
ten-minute check logs with the time of each check noted in real time along with the initials of the
staff conducting each check. A review of nine separate video footage samples of ten-minute
checks and ten-minute check logs documented by staff reflected there were no discrepancies.
An interview with the facility administrator (FA) and observations confirmed all the cameras,
were functional during the week of the annual compliance review. Five staff were interviewed,
and two indicated room checks were completed every ten-minutes, and three staff indicated
room checks are conducted every seven to eight minutes.
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Office of Accountability and Program Support Page 62 of 78 (Revised September 2022)
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 shall conduct at least six formal counts and ongoing informal counts within each
twenty-four-hour period. All formal and emergency counts shall be reported to the master
control operator by radio or telephone and shall be documented in the program’s logbook.
Master control maintains a running count to ensure all youth are properly accounted for,
whether on or off program grounds. Documentation of all counts is maintained for a minimum of
one year. The program utilizes the logbook to document the youth counts and movements
conducted throughout the day. Counts are conducted at the beginning of each shift, after
outdoor activities, and in emergency situations. The program also documents and tracks youth
intakes, releases, and all movements outside of the program. The program utilizes an alert
board located in the program’s conference room for tracking of the daily counts of all youth in
and out of the program. Observations conducted during the annual compliance review week and
a review of program logbooks for the annual compliance review period confirmed the youth daily
census counts, head counts, and youth movements were documented at the beginning of each
shift and after each outdoor activity. In addition, the program logbooks included documentation
of new admissions, releases, transfers, and youth temporarily away from the program.
Observations conducted during the annual compliance week confirmed staff were aware of all
youth whereabouts and were able to provide the proper counts to the annual compliance review
team member. Five staff were interviewed and four staff were able to explain when counts and
when emergency counts are conducted. One staff stated they were not sure because they are a
case manager and not a direct care staff. Each staff was able to report the daily youth census.
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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 requiring a chronological record of routine
events, incidents, activities, and emergency situations in a logbook in accordance with Florida
Administrative Code. A review of the program logbooks confirmed they were bound with
numbered pages. Observations and a review of logbooks for the annual compliance review
period found logbook entries were documented in ink with no erasures or white-out areas and
none of the reviewed logbooks were destroyed. Errors were typically struck through with a
single line, dated, and initialed by the staff correcting the error. The logbook included
documentation of incidents, counts, perimeter checks, youth transports, emergency situations,
admissions, releases, movements, education, recreation, and calls to the Florida Abuse Hotline
and the Department’s Central Communications Center (CCC). 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, a brief description of the event, and the
name and signature of the staff making the entry. The program utilizes shift reports to
summarize the events, incidents, and activities documented in the program’s logbook and to
brief all incoming staff. A review of the logbooks and shift reports demonstrated incoming staff
sign and date the shift logbook to document they have reviewed or been verbally briefed about
its contents. The activity schedule and logbook also documented minimal interference of
educational instruction and recreation. The logbook reflected youth arrived and departed school
on time.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program maintains a written policy and procedures for key control and security which
includes the assignment, inventory, tracking, storage, replacement of damaged keys, and
accountability of all keys used in the program. The facility administrator (FA) and physical plant
manager have overall responsibility for key control management. Responsibilities include
maintaining the key inventory, issuance of duplicate keys, replacement of damaged or broken
keys, and quarterly inventory of the overall key control procedure. The key control system
requires simple and efficient daily checks of all keys used in the program. Program keys shall be
recorded and stored for proper accountability. Unauthorized possession, alteration, marking,
duplication, manufacture, or impression making of keys is strictly prohibited unless authorized
by the FA and may result in disciplinary action and/or referral to local law enforcement agencies.
The FA must authorize, in advance, changes which affect the inventory in any way. All program
keys are maintained within the master control area, which is located at the entrance of the
program. Keys are maintained inside a locked cabinet within the master control room, and are
only accessible by the master control staff, supervisors, and administration. All restricted keys
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are housed within a central key cabinet, which remains locked when not in use. All key rings are
tagged to record the ring number, keys assigned, and number of keys on the ring. A review of
the inventory confirmed it matched the key rings in use. Each set of keys has an assigned key
hook and tracking number. In order to provide strict accountability of program keys, master
control operators, supervisors, or designees are responsible for the inventory, issuance,
inspection, return, and documentation of active keys. Key control logs documented the issuance
and return of keys on a consistent basis. Staff sign-out the program keys at the start of the shift
and sign-in the program keys at the end of their shift. The program maintains all restricted keys,
and visitor keys separate from each other. 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. Permanent issued keys are
assigned to the FA, assistant facility administrator (AFA), and physical plant manager.
Observations made throughout the annual compliance review week found all staff surrendered
their personal keys upon entering the program and keys were stored within the master control
office. A review of three staff and their assigned keys during the annual compliance review week
verified keys matched the key log. All observations during the annual compliance review week
found personal keys were secured and staff were aware of program keys in their possession. A
review of the Department’s Central Communications Center (CCC) reports verified there were
no instances of a staff losing their program keys during the annual compliance review period. An
informal interview with the master control operator confirmed each set of keys has an assigned
key hook and tracking number and indicated in order to provide accountability of program keys,
only supervisors, master control, FA, or designees are responsible for the inventory, issuance,
inspection, return and documentation of active keys. Additionally, master control staff indicated
the process for reporting or replacing lost or damaged keys is to immediately notify the FA. In
the event the key is damaged or broken, the broken or damaged key, including the key ring,
shall be returned to the central lock box and a new set will be issued. An informal interview with
a supervisory staff and direct care staff confirmed the process for restricting usage of keys.
Restricted keys may only be issued with prior approval from the shift supervisor or above.
Restricted keys are stored and secured in the restricted key box located within master control.
All restricted keys are clearly separated from all other active keys. Five interviewed staff
confirmed they had knowledge of key control policies and procedures. Each staff reported keys
are given to master control upon entry to the program, personal keys are securely stored, and
each staff signs the key log.
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5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items.
A program shall delineate items and materials considered contraband when found in the
possession of youth, the list must include: sharps, escape paraphernalia, tobacco products,
lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food or
clothing, any intoxicating beverage or any beverage which causes or may cause an
intoxicating effect, any controlled substance, any prescription or non-prescription drug which
has a hypnotic, stimulating, or depressing effect, any firearm or weapon of any kind or any
explosive substance, non-facility issued electronic equipment or devices to include
smartwatches, metals, personal non-facility issued cellular devices, unauthorized currency or
coin(s), and non-facility issued keys. The program shall provide youth with the list of
contraband items and materials and inform the youth of the consequences if found with
contraband. The program shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, and both staff and youth.
The program shall document the confiscation of any illegal contraband and the manner of
disposition. The program shall keep a copy of the documentation in the youth’s case record. If
a confiscated item is not illegal or prohibited, the program director or designee has the
discretion to discard of the item, return it to its original owner, mail it to the youth's home, or
return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a 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’s policy specifies items and materials defined as
contraband and unauthorized items, which are also detailed in the program’s youth handbook,
are never allowed to be in a youth’s possession. The policy states staff are prohibited from
introducing any item deemed as contraband inside the program and are obligated to assist in
the prevention, detection, and removal of contraband/unauthorized items from within the
program’s boundaries. Any youth found in possession of contraband or unauthorized items will
be subject to disciplinary action through the programs positive performance system/behavior
management system (PPS/BMS) and/or possible legal consequences. The youth’s assigned
case manager will review items considered to be unauthorized or contraband, the
consequences of having those items with the youth on their day of admission to the program,
and will ensure the youth signs the orientation checklist, verifying the unauthorized/contraband
items were reviewed. Additionally, the assigned case manager will mail an admission/welcome
letter to the parent/guardian advising of the consequences of bringing unauthorized items or
contraband into the program. A review of the policy and the youth handbook confirmed the
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-program
issued electronic equipment or devices to include smartwatches, metals, personal non-program
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,
which is also outlined in the BMS. The policy outlines the program’s responsibilities, standards
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for searches of youth, and program searches. Program searches include youth rooms, common
areas, and the program perimeter. A review of the contraband logs found contraband searches
were conducted on a weekly basis on each shift during the annual compliance review period.
Unannounced random youth searches are conducted, as well as searches of common areas
prior to and after use by youth. The program’s perimeter security is checked on each shift.
Searches and search findings are documented in the program’s logbook. Observations of daily
youth searches during the annual compliance review week included searches during line
movements to and from educational classes, meals, breaks, transportations, and other
movements within the program, and validated the program’s practice. A review of the
Department’s Central Communications Center (CCC) incidents related to contraband, indicated
there were no contraband incidents during the annual compliance review period. An interview
with the facility administrator (FA) indicated upon entry into the program, staff and visitors are
searched in an effort to prevent contraband from entering the program. All visitors/staff are
notified of Florida Administrative Code as it is posted at the entrance doors of the program. In
addition, a list of items identified as contraband are noted within the program’s parent/youth
handbook and the staff handbook. All staff are required to remove shoes and jackets upon entry
to the program, and bags are searched upon entry to the program. Weekly room and common
area searches are completed, and findings are documented on the search log. Any
unauthorized item/illegal contraband is documented on the log and disposed of properly. Any
findings of illegal contraband require notification/reporting to the CCC. Four of five interviewed
staff were able to explain the program’s process for youth room searches and one staff
indicated having never participated in a room search.
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 no contraband is being introduced
into the program. The program’s practice is to search youth after school, group, outdoor
recreation, visitation, work detail, transports, and meals. Reviewed documentation confirmed
youth searches were done during youth movement, transports, admissions, visitation, and off-
campus activities. There was one observation of a search made for a transport during the
annual compliance review week. During the annual compliance review week, the program did
not have any visitations or off-site activities available for observation; therefore, no observations
of searches were conducted during any of these events. Observations during the annual
compliance review week included of searches conducted before and after line movements, to
and from educational classes, meals, and breaks which validated the program’s practice.
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. The program
did not have any admissions or releases during the annual compliance review week. Five staff
were interviewed, and each of the staff were knowledgeable of the program’s policy regarding
the search procedures. One staff reported they never participated in searches. Five youth were
interviewed and indicated searches are conducted after every movement, three reported after
returning form off campus, and four reported after outdoor activities, visitation, and meals.
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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 requiring the program vehicles to be properly
maintained, contain safety and emergency equipment, and be operated in a safe manner. The
program ensures any vehicle used by the program to transport youth is properly maintained and
documentation regarding the use of each vehicle is kept. 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. At the time of the annual compliance review, the
program had two operable vans used to transport youth. Each vehicle had a completed
inspection during the annual compliance review period on January 31, and February 5, 2024.
Both transportation vans were equipped with a safety screen. Each vehicle was equipped with a
fire extinguisher, seatbelt cutters, a window punch, and operable seatbelts for each passenger.
The vehicle first-aid kits are stored in the master control office and are checked out each time a
vehicle is in use. The program maintains a transportation vehicle inspection log which contains
the documentation of the completed weekly vehicle inspections. A random check of ten
personal vehicles and the program’s transportation vehicles was conducted during the annual
compliance review week and each vehicle was found to be locked when not in use. An
observation of a transport was conducted during the week of the annual compliance review with
no noted issues. Five youth were interviewed and indicated during transports youth are secured
within the vehicle with seatbelts, handcuffs, and shackles, and one youth indicated they have
not been transported in the program’s vehicles. Five staff were interviewed, and each indicated
during transports youth are secured within the vehicle with seatbelts, handcuffs, and
shackles/leg cuffs.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a policy and procedures to ensure the appropriate staff-to-youth ratio is
maintained while youth are transported off program grounds to ensure the safety and security of
youth and the community during transport. The program’s policy requires staff assigned to
provide secure transportation to be adequately trained and aware of security procedures before
being assigned transportation duties. Staff shall use proper safeguards at all times. Youth
transported in a vehicle which does not have a safety screen shall be restrained and at least two
staff, including the driver, shall supervise the youth; however, youth classified as high risk or in
controlled observation status shall only be transported in a caged vehicle with working
communication equipment and supervised by two staff, including the driver. Staffing in both
caged and uncaged vehicles shall be based on the ratio of one staff to five youth. All restraint
equipment used in transporting youth shall be double-locked. Youth shall never be restrained to
stationary objects or furniture. Staff and youth shall wear seatbelts at all times during transport.
Release or discharge youth may not be transported by common carrier unless staff accompany
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them and or arrangements have been made with the Department to ensure appropriate security
measures are in place. Vehicles used to transport youth shall be locked when not in use. The
physical plant manager shall conduct weekly inspections of the vehicles. All vehicles used to
transport youth shall have an annual safety inspection and any safety deficiencies found shall
be repaired. The program has an approved transport list which is updated monthly to ensure
staff driver’s licenses are valid. The approved driver’s list is located within the administration
office. The program’s transport ratio is one staff to five youth, not including the driver.
Observations were conducted of the vehicles, and they appeared to be maintained and in
working order. An observation of a transport was conducted during the week of the annual
compliance review and confirmed the staff rode in the back with the youth, the staff-to-youth
ratio was within the contract requirements, youth were secured, were wearing seatbelts, and
staff had all required equipment including a program issued telephone. Five youth were
interviewed, and each stated they felt safe while being transported and have not seen any staff
place contraband in a transport vehicle. Five staff were interviewed, and each staff indicated
they utilize the program’s cellular telephone or communication device when transporting youth.
Four staff indicated the safety equipment in the transport vehicles consists of a first-aid kit, fire
extinguisher, and a window punch, and one staff indicated they do not conduct transports. All
staff reported transport vehicles are searched for contraband prior to and after each use, and
they are not allowed to use personal vehicles to transport youth. Five staff indicated the
emergency response process consists of notifying the program, the facility administrator (FA),
and/or the assistant facility administrator (AFA), and two staff indicated calling emergency
services (9-1-1) or law enforcement. Four staff were knowledgeable in the program’s ratio policy
during transports and one staff stated they have never conducted a transport.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a written policy and procedures to ensure a safe and secure physical
plant, grounds, and perimeter are maintained, and for weekly safety and security audits to be
conducted. The program has developed a policy and procedures outlining the audit/inspection
process. The facility administrator (FA) and the physical plant manager are responsible for
ensuring weekly safety and security audits are conducted, reviewed, and submitted to the
Department, and to ensure verification of all deficiencies, corrections, and implementations are
in compliance. The weekly safety and security audits include the inspection of the program
cameras, radios, keys, locks and doors, vehicles, and living areas to include youth rooms and
bathrooms. The program maintains the weekly safety audits in a binder. A review of the
program’s Preventive Maintenance Checklist and Safety Inspection Logs during the annual
compliance period, confirmed the physical plant manager conducts weekly safety/security
inspections. All findings are documented on the Weekly Safety Inspection Reports. The policy
includes the development and implementation of corrective action warranted as a result of
safety and security deficiencies found during any internal or external review, audit, or inspection.
All deficiencies are tracked, and efforts are made to correct any deficiencies noted. A review of
the weekly inspection reports during the annual compliance review period reflected there were
no inspections missing or any discrepancies. The program’s Preventive Maintenance Checklist
was reviewed to ensure maintenance schedules and repairs were conducted in accordance with
contract language, with no exceptions. All reviewed documentation was signed by the FA. The
program has documentation of ongoing efforts for any repairs. An interview with the FA
confirmed the program’s plant manager and administrator complete weekly safety/security
inspections. Findings are documented on the weekly report and provided to the FA for review.
The report will detail identification of the issue and track the correction of the deficiencies. All
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efforts are made to correct deficiencies in a timely manner, depending on the severity of the
issue.
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 to address the proper identification, control,
and management of tools to ensure youth do not use tools or equipment as weapons or security
breaches. The reviewed policy requires all tools, including tools used in vocational classes, and
kitchen utensils to be properly controlled and secured, to minimize the possibility of tools and
kitchen utensils being used as weapons or to assist in escape attempts. The facility
administrator (FA) shall also ensure prohibited tools are not brought into or stored in the
program. All violations shall be immediately reported to the FA or designee, who shall ensure
appropriate corrective actions are taken. Private contractors shall receive written instructions
detailing their responsibilities regarding tool management and contraband and confine their
work to the authorized area of work, performing the work with proper security and safety
precautions. In addition, upon leaving, these contracted individuals shall not leave tools at the
program. The policy prohibits specific tools including machetes, bowie knives, and long blade
knives. The program has a policy and procedures for missing/lost tools and for tools requiring
disposal. The program has identified the physical plant manager as the program’s tool control
manager. The policy classifies tools into two categories, Class A tools and Class B tools. Class
A tools are hazardous with sharp edges or points with a high potential to be used as a weapon
to inflict serious bodily harm such as knives, hammers, screw drivers, and electric drills. Class B
tools do not have sharp edges or points, such as brooms, mops, and scrub brushes. 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. Class A
tools are secured in the maintenance shed and are inventoried daily when in use. Observations
found the maintenance office to be organized, and clean. All tools were observed to be
maintained in a secured location. All Class A tools were stored on the maintenance office walls
with a photo of the tool and a number to identify the tool was stored in the proper place. A
review of ten randomly selected Class A tools showed each tool was labeled and securely
stored and in the correct location. All Class A tools were in good repair and accounted for. All
Class A tools are inventoried daily by the physical plant manager except on days when tools are
not utilized. The program has a sign-in and sign-out log for Class A and Class B tools. The
informally interviewed physical plant manager confirmed all tools are signed in and out when
used. Class B tools, including mops, brooms, and buckets are maintained in a locked closet
which is inaccessible to the youth. Class B tools are inventoried daily by program staff. A review
of Class B storage reflected inventories were accurate and tools were secured when not in use.
A review of the inventory sheets validated the program’s practice. All tools were properly
identified and inventoried during the annual compliance review period. In an informal interview,
the program’s physical plant manager was able to explain the policy and procedures to follow if
tools are missing or damaged. The plant manager reported there have been no instances of
missing or lost tools during the annual compliance review period. The plant manager also
reported the program has not had any instances of broken tools which required disposal or
replacement during the annual compliance review period. A review of five pre-service training
records indicated all staff were trained on the safe use of tools. 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 to themselves, other youth, and staff. All youth are
assessed prior to accessing tools to determine if the youth is a risk to the public, staff, other
youth, or the youth themselves, and if the youth should be allowed to participate in training or
work projects involving the use of tools. Any youth who is prohibited from using tools, based on
risk assessment results, shall be restricted from being in the area where a work project or
activity is being conducted. The program’s policy and procedures included supervision
requirements, issuing tools to youth and staff, and activities involving tools. Class B tools which
include mops, brooms, toilet brushes, and scrub brushes are inventoried daily by staff to ensure
each tool is accounted for. A review of the Class B Tool Inventory Log sheets confirmed the
program’s practice. Five youth case management records were reviewed, and all indicated
youth have been trained on the proper usage of tools. A signed acknowledgement form is filed
in each youth’s case management record. The program staff-to-youth ratio during Class B tool
use is one staff to five youth. The informally interviewed facility administrator (FA) confirmed the
youth are allowed to use Class B tools, and indicated youth are only allowed to use them during
chores. During the annual compliance review week, there were no cleaning, chores, or work
projects which involved youth and the use of tools; therefore, no youth were observed handling
tools. Five youth were interviewed and three reported they are allowed to use a mop and
brooms. Two youth reported they are allowed to use a sponge when cleaning. Five staff were
interviewed, and four confirmed youth are allowed to use a mop and brooms. One staff
indicated youth are allowed to use a scrub brush.
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. Contractors are required to sign the visitor log upon entry
and are provided a contract agreement form which indicates a list of unauthorized items. The
physical plant manager or designee inspects all tools upon the arrival of outside contractors and
is responsible for providing approval if such tools are required. The outside contractor
completes the program’s “Outside Contractor” form upon entrance to the program, where they
list what tools are needed to complete the work order. The physical plant manager will review
the form and sign once the tools are inventoried and approved. If any unauthorized items are
needed by the contractor while in the program, approval is obtained by the facility administrator
(FA) or designee. Upon exiting the program, the “Outside Contractor” form is reviewed, all tools
are verified, then the form is signed. 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 review of the sign-in sheet, the contractor’s agreement forms, and three randomly
chosen work invoices verified the contractors were on-site on the same date the documents
were signed.
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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 program has a written Continuity of Operations Plan
(COOP) which was approved by the Department on January 29, 2024. A tour of the program
during the annual compliance review week found fire evacuation routes and egress plans were
posted throughout. The program has a total of eleven fire extinguishers and reviewed
documentation confirmed the annual inspection was completed in August 2023. The COOP
requires the program to conduct unannounced fire drills quarterly for each shift. A review of
documentation since the start-up monitoring in June 2023 confirmed fire drills were conducted
on each of the shifts on a monthly basis. Additionally, the program conducted emergency drills
which include severe weather, hurricane, and disturbance/riot drills at least on a quarterly basis.
Documentation for all drills contained the type of drill, date and time, participants, brief scenario,
findings, and recommendations. The program reviews each drill and debriefs staff on how well
drills were conducted during the monthly all staff meetings. An interview with the facility
administrator (FA) indicated COOP drills are completed on a monthly basis, across each shift.
These drills include disturbances, riots, threats, severe weather, evacuation, escape, and others
required by Florida Administrative Code. In addition, fire drills are conducted on a monthly basis.
Each drill is reviewed monthly in the general staff meeting. Five interviewed youth reported they
participate in fire drills and have been instructed on what to do in the case of a fire. Each youth
indicated drills are conducted at least once a month. Five interviewed staff indicated they have
participated in at least one COOP and/or mental health drill which included either weather,
major disturbance, or fire drills.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program has a written policy and procedures requiring the development of a Continuity of
Operations Plan (COOP) which is updated as necessary and maintained a COOP in compliance
with state law and Department policy. A review of the COOP validated the plan was submitted
and approved by the Department on January 29, 2024, and provides for basic care and custody
of youth in the event of an emergency or disaster. The COOP is located in the facility
administrator’s (FA’s) office and staff conference room and is readily available to staff. The
COOP addresses phases of a disaster plan as well as emergency management including
preparedness, response, and recovery. The COOP addressed emergencies including fire
prevention and evacuation, severe weather, major disturbances, bomb threats, hostage
situations, chemical spills, flooding, terrorist threats or acts, staff roles and responsibilities, any
equipment and supplies needed, information about youth which may be needed, alternative
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housing arrangements, provisions for continuity of care and custody of youth, and provisions for
public protection. The COOP details alternative housing plans in case the program is required to
vacate due to an emergency or disaster. The interviewed FA indicated all staff have access to
the program’s COOP and the plan is located in the FA’s office and staff duty station. The
program has the necessary supplies readily available in an office in case of an emergency
evacuation. Each youth has their own personal bin in their room in case of emergency
situations. The program also maintains an administrative hard copy for each youth in case of
emergency. 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 five 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 the 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.
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 addressing storage and inventory, to ensure
all youth and staff are safe from the effects of the unauthorized use of flammable, poisonous,
toxic, and caustic materials. The program’s policies required all flammable, poisonous, toxic,
and caustic materials to be inaccessible to youth, and indicated no youth shall be permitted to
use, handle, or access these items. Whenever possible, the least hazardous substance shall be
procured and used in the program. The physical plant manager shall maintain an ongoing and
regularly updated perpetual inventory of all flammable, poisonous, toxic, and caustic materials
procured and used in the program. The facility administrator (FA), in consultation with the
physical plant manager, has designated certain staff to draw and utilize flammable, poisonous,
toxic, and caustic materials from the inventory to include the FA, assistant facility administrator
(AFA), physical plant manager, shift supervisors, and direct care workers. Staff not authorized
shall not draw, nor use, any flammable, poisonous, toxic, and caustic materials. All flammable,
poisonous, toxic, and caustic materials shall be securely stored in areas inaccessible to youth
when not in use. The program’s physical plant manager maintains a daily tracking system to
ensure compliance with flammable, poisonous, and toxic items. The program’s flammable,
poisonous, and toxic materials are stored in an outside shed in the physical plant manager’s
office. A review of ten flammable, poisonous, and toxic items verified the items were securely
stored and inventoried. A copy of each current Safety Data Sheet (SDS) is maintained in the
physical plant manager’s office for each substance. A complete chemical inventory is completed
daily and documented on the monthly chemical inventory sheet. A tour of the program and
observations found the program stores all toxic items and poisonous materials in the storage
shed in the physical plant manager’s office and other cleaning agents are stored within a secure
locked cabinet in the kitchen office area, inaccessible to youth. A review of five separate
cleaning chemicals was completed, and all inventories were accurate. All inventory forms, sign-
in and sign-out forms, and SDSs were accurate to the chemicals maintained. The program also
stores cleaning supplies in a locked storage closet, along with the Class B tools. The storage
room is locked at all times and can only be accessed by the physical plant manager,
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supervisors, and administration or authorized personnel. The items maintained in the storage
room are inventoried and have an accompanying SDS located in the binder, as well as a
perpetual inventory for staff to sign-in and sign-out items with each use.
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. The 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.
Observations confirmed all chemicals were maintained in the outside shed, and youth do not
have access to areas where items are being stored. Youth do not have access to these items
and are supervised by staff during any cleaning. During the annual compliance review week,
there were no observations of youth cleaning and/or using any chemicals. Five youth were
interviewed, and each reported not using any chemicals/cleaning products.
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 policy and procedures for the disposal of flammable, toxic, caustic, and
poisonous items. The program’s policy requires adherence to procedures in accordance with
Occupational Safety and Health Administration (OSHA) federal regulations. The policy prohibits
chemicals from being poured on the ground or being disposed of by any method other than
what is outlined by the biohazard guidelines. The program reported liquid waste, including dirty
mop water and unused beverages, is disposed of in the kitchen or mop storage plumbing
drains. The program’s physical plant manager, facility administrator (FA), assistant facility
administrator (AFA), and other authorized staff are the only staff authorized to handle
flammable, poisonous, and toxic items. Reviewed documents confirmed the program’s disposal
procedures of chemicals were created in accordance with OSHA standards. Used kitchen
grease and waste is stored in a container outside the kitchen area. The program has a contract
with the local solid waste management department to dispose of used kitchen grease and
waste. Reviewed invoices validated the program’s practice. The program maintains strict
procedures regarding chemical spills. All spills are reported immediately to the shift supervisor
who immediately assesses the emergency, ordering an evacuation of the spill area as
necessary, and determines whether to contact outside assistance to help control the spill. The
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physical plant manager reported the program has not had a chemical spill during the annual
compliance review period. The program’s physical plant manager was interviewed on the proper
procedures of disposing chemicals and stated all items for disposal are collected by the local
county waste disposal department. Additionally, the physical plant manager indicated the
program has not needed to dispose of any chemicals. A review of the disposal logs confirmed
the program did not have any chemicals disposed of during the annual compliance review
period. An interview with the FA validated the program’s practice.
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.
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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 in place allowing youth to have visitation and
communication with family members while in the program. The program’s policy provided each
youth assistance in maintaining and strengthening positive family and community ties in an
environment which unobtrusively monitors and controls the movement of visitors within the
program. The program maintains a list of approved visitors. Youth have the right to visitations,
for which the program maintains a list of approved visitors; however, attorneys, representatives
of the court, juvenile probation officers (JPOs), other agency representatives, Department of
Children and Families (DCF), and clergy are authorized to visit at any time. Staff shall address
visitors to the program in a courteous, polite, and helpful manner. All youth shall be frisk
searched after visitation and will be subject to a full body visual search if there is a reasonable
suspicion to believe the youth possesses contraband or there has been contact during visitation.
Searches of visitors will be conducted upon entry. The program’s visitation policy indicated
consideration for requests of alternative visitation arrangements with parents/guardians, if
needed. Youth are informed about visitation upon their admission to the program during the
orientation process. The visitation and communication procedures are covered in the youth
handbook, parent/guardian handbook, and addressed on the orientation checklist. Designated
days and times are in place to ensure all youth have the opportunity to have visitors. Visitation is
permitted on Saturdays and Sundays from 2:00 p.m. to 4:00 p.m. Visitation shall be on the
program’s scheduled days with multiple offered sessions as designated by the program.
Sessions shall be initiated to accommodate ample visitation opportunities for the number of
youth in the program. Youth are given opportunities to communicate with their family in person,
by telephone, and by mail. The program requests clarification from the assigned JPO, from the
youth’s parent/guardian, and other family members to verify if youth are not under current or
past investigation for human trafficking-related charges for youth with a history of human
trafficking. Youth are provided with writing materials and stamped self-addressed envelopes to
send letters to approved family members. The program maintains a correspondence log for
each youth which documents incoming and outgoing mail, which is inspected by case
managers. The correspondence logs are maintained in each youth’s case management record.
Youth are permitted weekly telephone calls. Each youth’s use of the telephone is documented in
each youth’s case management record chronological and telephone log. A review of the
logbooks, visitation sign-in logs, and outgoing and incoming mail logs verified the program
allows visitation and mail from approved family members. The program maintains a list of
interpreters, and utilizes the language line, as a third-party language service entity as needed
for youth with a language barrier. Five youth were interviewed, and each confirmed they are
able to call and/or send letters to their parent(s)/guardian(s). Three interviewed youth indicated
the program utilized a translation system. Two youth did not know if the program utilized a
language translation system. An interview with the facility administrator (FA), indicated the
program will provide support if the family or youth request a Spanish speaking staff, and staff
will assist the youth and parent/guardian. Five staff were interviewed and four staff indicated the
program utilizes a translator service or a bilingual staff for interpretation, and one staff was not
sure what was utilized.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 76 of 78 (Revised September 2022)
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. A review of the staff roster confirmed the program has a
recreation therapist, who meets all requirements for the position. The program’s recreation
calendar ensures youth participate in outdoor recreation activities daily. Additionally, there’s a
calendar of alternative activities planned in case of indoor recreation. A review of the program’s
schedule found large muscle activities are scheduled for at least one hour daily. All activities
promote social and cognitive skill development, creativity, teamwork, healthy competition,
mental stimulation, and physical fitness. The program takes precautionary measures to prevent
over-exertion, heat stress, dehydration, frostbite, hypothermia, and exacerbation of existing
illness or physical injury. The program’s activity schedule is displayed throughout the living units
and common areas of the building. Five youth case management records were reviewed, and it
was found the recreational therapy goals were included in each youth’s individualized treatment
plan. A review 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. Observations made throughout the annual compliance review week
validated youth are provided with at least one hour of indoor or outdoor recreation and leisure
time. Five staff were interviewed and each staff indicated the program provides youth with at
least one hour of recreation each day. Four staff indicated the outdoor activities consist of
basketball, football, soccer, and/or other sports, and one staff indicated youth get an hour of
activities, such as board games, or other indoor activities. Each staff indicated the indoor
activities consist of board games, indoor games, and movies. Five youth were interviewed, and
each youth indicated the program allows youth the opportunity to exercise, play outside, or
inside depending on the weather. Two youth further indicated they are allowed to participate in
basketball, football, or exercise.
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 77 of 78 (Revised September 2022)
5.26 Controlled Observation Safety Checks Release Procedures Non-Applicable
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’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 78 of 78 (Revised September 2022)

source: DJJ

report_type: QI Residential

program_name_raw: Fort Myers Youth Academy

rule: Indicator 3.08

rating: Limited Compliance