summary: QI Residential - FY23-24 - 2 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Deep Creek Youth Academy- Borderline Developmentally Disabled
(BDD)/Developmentally Disabled (DD), Intensive Mental Health,
Comprehensive Mental Health, Intensive Medical
Youth Opportunity Investments
(Contract Provider)
765 E Saint Johns Avenue
Hastings, Florida 32145
Review Date(s): March 26-29, 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:
Kamille Payne, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Cionna Allen, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Jeff Campbell, Office of Education, Northeast Education Coordinator (Standard 2)
Renette Crosby, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Jessica Gibson, Office of Accountability and Program Support, Regional Monitor (Standard 3)
LeAnn Gruentzel, Office of Accountability and Program Support, Deputy Regional Supervisor
(Standard 2)
Kristine Harshaw, Office of Accountability and Program Support, Regional Monitor (Standard 5,
Interviews)
Miguel Roca, AMIkids Jacksonville, Behavior Interventionist (Standard 5)
Desiree Taylor, Office of Accountability and Program Support, Deputy Bureau Chief (Interviews)
Program Name: Deep Creek Youth Academy MQI Program Code: 1486
Provider Name: Youth Opportunity Investments, LLC Contract Number: 10677
Location: St. Johns County / Circuit 7 Number of Beds: 77
Review Date(s): March 26-29, 2024 Lead Reviewer Code: 161
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
Failed
Limited Ratings
Ratings
1.13 Internal Alerts
System and Alerts
(JJIS)*
5.01 Youth
Supervision *
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 63 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training 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)* Limited
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 63 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions 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 63 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Satisfactory
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 63 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 63 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Limited
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
5.26 Controlled Observation Safety Checks and Release Procedures 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 63 (Revised September 2022)
Program Overview
The Deep Creek Youth Academy is a seventy-seven bed program, for twelve to nineteen year
old males, located in Hastings, Florida. The program is operated by Youth Opportunity
Investments, LLC, through a contract with the Department. The program provides services
including Borderline Developmentally Disabled (BDD), Developmentally Disabled (DD),
Intensive Mental Health (IMH), Comprehensive Mental Health (CMH), and Intensive Medical
beds. In addition, the program fosters each youth by providing Skillstreaming the Adolescent,
Moral Reconation Therapy, Living in Balance, and Impact of Crime. Additional treatment
services provided include individual and family therapy, animal assisted therapy, and
recreational therapy. Program administration is comprised of a facility administrator and two
assistant facility administrators. Case management services are provided by a director of case
management, three transition services managers, and six case managers. Mental health staff at
the program includes a designated mental health clinician authority (DMHCA) who is a licensed
psychologist, two assistant clinical directors, one licensed therapist, and nine non-licensed
therapists. Medical services are offered twenty-four hours a day and are provided by a
designated health authority (DHA), psychiatrist, health services administrator (HSA), and four
registered nurses. Educational services are provided by TrueCore Behavioral Solutions through
an agreement with the St. Johns County School Board. The layout of the program includes one
main building which houses administration, master control, education, medical, kitchen and
dining areas, and a multi-purpose space, and two buildings housing a total of four youth
modules. The program has 166 operating security cameras providing coverage. There were
thirteen cameras not operational at the time of the annual compliance review; however, each
area covered by a non-operational camera was covered by another program camera at a
different angle. At the time of the annual compliance review, the program had twenty-six vacant
positions; one licensed therapist, three non-licensed therapists, one recreational therapist, one
nurse, two case managers, four supervisors, one master control, two transporters, and eleven
safety and security specialists.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 63 (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.
A review of the staff roster found fifty-five staff were hired during the annual compliance review
period. Each staff received a clear and eligible background screening in the Clearinghouse
system and their criminal history reports were reviewed prior to contact with youth or
confidential youth records. None of the staff required an exemption. None of the staff were
applicable for a break in service and five staff were applicable for being hired from another
provider. Each of the five applicable staff had a new background screening completed as
required. Each applicable staff was administered a pre-employment assessment tool and a
passing score was obtained and documented in their personnel records. Fifty-one of fifty-five
staff were added to the program’s roster in Clearinghouse, the remaining four staff were added
during the annual compliance review week. After hire, one staff received disqualifying charges
and was removed from youth contact. The charges were dropped and the paperwork was
submitted to the Department’s Residential Services. The staff returned to the floor; however, the
paperwork was not submitted to the Department’s Background Screening Unit (BSU). The
staff’s eligibility in Clearinghouse was changed to ineligible, which was not discovered until the
annual compliance review week at which time the Department’s Central Communications
Center (CCC) was contacted. Following discussion with the Department’s Residential Services
and BSU it was determined the staff should have been eligible to work the floor and a new
background screening was initiated and received as eligible while the annual compliance review
team was on-site. The program did not have any volunteers, mentors, contract staff, or interns
who required a background screening. The Annual Affidavit of Compliance with Level 2
Screening Standards was submitted for the program on January 19, 2024 and for the teachers
who are provided by TrueCore Behavioral Solutions through a contract with the St. Johns
County School Board on January 18, 2024.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a policy and procedures to ensure all staff are administered background
rescreenings every five years of employment. A review of the staff roster found no staff were
eligible for a five-year background rescreening.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 63 (Revised September 2022)
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
 The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
 All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
 Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
 The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
 A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures to ensure an abuse-free environment which outline
the staff code of conduct, which they are required to sign upon hire, in addition to the program’s
abuse reporting procedures. The abuse reporting procedures indicate youth shall have
unhindered access to the Florida Abuse Hotline and the staff are to notify the supervisor, who
will notify the facility administrator, and immediately allow the youth to make the call. Ten
personnel records were reviewed and confirmed the staff signed their code of conduct upon
hire. A program tour confirmed the program has postings for the Florida Abuse Hotline and
Department’s Central Communications Center (CCC) throughout the program in areas
accessible to youth. The program last completed a Trauma Responsive and Caring
Environment (TRACE) self-assessment in April 2023. The program had nine incidents of alleged
abuse during the annual compliance review period, five of which were reviewed and one of
which was substantiated. Each of the five reviewed incidents was reported to the CCC and
Florida Abuse Hotline. None of the reviewed incidents involved allegations of human trafficking
or exploitation. An interview with the facility administrator confirmed the program follows the
abuse reporting procedures and ensure youth have unhindered access to the Florida Abuse
Hotline. Three youth were interviewed and confirmed they have never been stopped from
reporting abuse and know where the Florida Abuse Hotline number is posted. Two of the three
youth reported feeling safe in the program, one youth reported staff are trying to press charges
on the youth; however, the youth then made self-harm statements. The youth was offered and
declined an abuse call and the program staff were notified and provided mental health services
to the youth. Two of three youth reported staff use profanity at youth and are not respectful to
youth. None of the youth had ever exchanged contact or social media information with staff.
Three staff were interviewed and each reported in the event a youth wants to report an
allegation of abuse they are allowed to make a call or allow the youth to call the Florida Abuse
Hotline. Two of the three reported they would call the supervisor and allow the supervisor to
make the call. One of three would also call the facility administrator. Each staff reported they
have never witnessed another staff deny a youth the opportunity to call the Florida Abuse
Hotline or use threats, profanity, or intimidation when speaking with youth. Each staff knows
where the Florida Abuse Hotline number is posted. Results of the interviews were shared with
the program who responded any staff found to use profanity toward youth would be written up in
accordance with the program’s code of conduct.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 63 (Revised September 2022)
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 had nine allegations of abuse against staff reported the Florida Abuse Hotline and
Department’s Central Communications Center (CCC) during the annual compliance review
period, five of which were reviewed. Incident reports were provided which confirmed the
program took immediate action and placed staff on no youth contact pending the investigation
into each incident. Corrective action was taken based upon the results of the investigations and
one incident was founded which resulted in the termination of the staff. The facility administrator
confirmed the program takes immediate action and places staff accused of abuse on no youth
contact pending an investigation.
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 had seventy-two incidents reported to the Department’s Central Communications
Center (CCC) during the annual compliance review period, seven of which were reviewed. Each
reviewed incident was called into the CCC within two hours of the incident occurring or
discovery of the incident and was found in the program’s master control logbook. There were no
additional incidents found which should have been reported to the CCC and were not. The
program had an increase in reports from the previous annual compliance review period and
reported the increase was due to the increase in bed capacity and thirty-five incidents were
medical incidents, of which eleven were in regard to one youth’s chronic condition.
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 had seven Protective Action Response Right Interactions model (PAR/RI)
incidents during the annual compliance review period, five of which were reviewed. Each
reviewed PAR/RI incident report was completed with statements from all staff before the end of
the staff’s workday. Each PAR/RI included documentation a post-PAR/RI interview and PAR/RI
medical review were completed and the PAR/RI was reviewed by all required parties. One of
the PARs/RIs resulted in an injury to the youth and the incident was reported to the Florida
Abuse Hotline and the Department’s Central Communications Center (CCC). None of the
incidents involved the youth of mechanical restraints. Each PAR/RI Report was placed in a
centralized record and the program submitted their monthly PAR/RI Reports to the Department
as required. The program’s PAR/RI plan was last updated and submitted to the Department on
November 6, 2023 and approved by the Department on November 28, 2023. The program’s
PAR/RI rate during the previous quarter was 0.43, which is below the statewide Residential
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 63 (Revised September 2022)
PAR/RI rate of 1.76. The program experienced an increase in PAR/RI incidents since the last
annual compliance review period and the program reported this was due to an increase in the
program’s census and transfer of youth into the program. The facility administrator was
interviewed and reported the PAR/RI matrix should be used and physical intervention should be
used when all alternatives have been exhausted. One of the three interviewed staff reported
they have utilized PAR/RI and the one applicable staff reported they attempted to verbally de-
escalate the youth prior to utilizing 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.
Five staff records were reviewed for pre-service training requirements. Each of the five staff
completed an excess of 120 hours of training in the first 180 days of hire. Each staff completed
all essential skills training prior to contact with youth and all additional required training to be
certified within 180 days of hire. All training was documented in the Department’s Learning
Management System (SkillPro). None of the staff were applicable for re-certification training of
staff who were separated from employment. All staff who could be responsible for the
supervision of youth received the required training. All instructors were qualified to deliver
trainings provided.
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.
Five staff records were reviewed for in-service training requirements. Each staff completed an
excess of the required twenty-four hours of annual in-service training, which included training in
all required topics. Each staff maintained required certifications. Two staff were applicable for
supervisory training and one staff completed ten hours of supervisor training in coaching,
leadership, and personal accountability. The remaining staff completed six of the required eight
hours of supervisory training. All training was documented in the Department’s Learning
Management System (SkillPro). All instructors were qualified to deliver trainings provided. The
program has an in-service training plan which was approved by the Department on December
23, 2023, and an 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 has a policy and procedures which outline the grievance process and required
staff training. The program’s grievance process includes informal, formal, and appeal phases
and associated timelines. All grievances are reviewed at morning management meetings and
assigned to administrative staff for response. A review of the program’s grievance
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 63 (Revised September 2022)
documentation confirmed the program maintains grievances for the past twelve months, which
included eight grievances across all program youth for the annual compliance review period.
Five of the grievances were reviewed and four of the five grievances were responded to within
the required time frame, one grievance was responded to four days late. Each grievance was
resolved during the formal phase. Six youth were interviewed, three youth from each side of the
program. Five of the six youth knew the grievance process included completion of grievance
forms, the remaining youth had not needed to complete a grievance. Each of the six youth
reported they could ask for assistance in completing a grievance. Six staff were interviewed,
three representing each side of the program. Each of the six staff reported the forms are posted
on the dorms, five staff reported the supervisor reviews grievances, four staff reported youth can
request assistance in completing the forms, and two staff indicated there were time frames
associated with the grievance process.
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
A review of the program’s contract found all groups provided are either clinical or primary
services; therefore, delinquency intervention groups were not reviewed as part of the annual
compliance review. The program’s activity and group schedules confirmed groups are being
offered as required and in accordance with the program’s contract. The activity schedule
reflected youth are engaged in structured activities more than sixty percent of their awake
hours. The facility administrator was interviewed and reported the program provides Moral
Reconation Therapy, Impact of Crime, Skillstreaming the Adolescent, and Living in Balance. All
groups are provided by trained therapists or case managers. The designated mental health
clinician authority (DMHCA) was interviewed and confirmed the groups offered by the program
and indicated the clinical director provides supervision to therapists and conducts fidelity
monitoring of interventions.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures which outline life skills training shall be provided to all
youth and youth are assigned to life skills groups based on the specialized services they
receive. The program provides Skillstreaming the Adolescent as a life skills curriculum which is
a practice with demonstrated effectiveness. Skillstreaming the Adolescent is a primary service
for all youth components with the exception of the Intensive Mental Health (IMH) youth. The
Skillstreaming the Adolescent group addresses all required topics and is facilitated by trained
clinical staff. A review of group sign-in sheets verified the program is providing the group as
required for the IMH youth. The group is monitored by the Department’s Office of Technical
Assistance for the remaining youth components. In addition to Skillstreaming the Adolescent,
the program reported they offer Barbershop Talks for youth in which they invite community
partners to speak with youth in an informal barbershop setting to discuss different life skills
topics, utilize assessment tools to determine skills the youth need assistance with, and include
independent living goals on the treatment plans. The facility administrator was interviewed and
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 63 (Revised September 2022)
verified youth participate in groups facilitated by trained clinicians and Barbershop Talks. The
designated mental health clinician authority (DMHCA) was interviewed and reported youth are
able to practice skills learned throughout the day. Three youth were interviewed and each
reported they are given the opportunity to practice skills. Two of the three youth also reported
they complete substance abuse and Moral Reconantion Therapy (MRT) groups and one youth
reported they are given life skills packets.
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 offers Impact of Crime (IOC) groups for all youth which is a primary service for all
program components. The program facilitated restorative justice projects as a part of the Impact
of Crime groups, such as cleaning up the facility, victim letters, and picking up trash. The
program’s contract did not require additional restorative justice programming and the program
reported no additional restorative justice activities. Observations of restorative justice activities
were unable to be conducted during the annual compliance review week. The facility
administrator was interviewed and reported the youth participate in IOC and a restorative justice
project at the end of the group. The designated mental health clinician authority (DMHCA)
reported IOC is offered four times a week. Three youth were interviewed and each youth
verified they participated in IOC.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Limited Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures regarding the alert process which outline alerts shall
be consistent in the internal alert system and the Department’s Juvenile Justice Information
System (JJIS) and only authorized staff shall update or close applicable alerts. The program
utilizes an alert board in the staff break room to track all internal alerts. Five youth records were
reviewed with twelve applicable alerts between them. Five of the twelve alerts were entered in
JJIS two, five, nine, thirty-one, and thirty-five days late, four of which were suicide risk alerts and
one was a medication alert. One of the twelve alerts was not found on the internal alert board.
One alert was on the alert board and not JJIS; however, the program reported this was an error
on the alert board. One of the five applicable alerts was not found in the program’s logbook.
Only authorized staff entered, downgraded, and closed alerts. The nurse was interviewed and
reported nurses update medical alerts as changes are made and they are reviewed weekly. The
facility administrator was interviewed and reported alerts are reviewed at the morning
management meetings. The facility administrator verified the program utilizes an alert board and
all alerts should be reflected on the alert board, in JJIS, and in the logbook. Three staff were
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reviewed and each reported learning of alerts in a different manner, one reported they learn of
alerts through mental health and medical, one reported through the case manager or master
control, and the remaining staff utilized the alert board. Each staff reported communication is
good at the program.
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 separate individual management records, mental health records, and
Individual Healthcare Records. Five youth records were reviewed and each record is labeled
confidential and maintained in locked cabinets and offices marked as confidential. Each
individual management record includes all required information and is separated into required
sections.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program operates a Community Advisory Board which included representatives from all
required community partners. A review of sign-in sheets and meeting minutes confirmed
meetings were held hybrid in-person and by video conferencing at least quarterly during the
annual compliance review period. The facility administrator was interviewed and verified
meetings are held quarterly with all required parties and invitations are sent to solicit active
involvement from board members. A board member was interviewed and reported they work
with youth who have been discharged from the program and are over the age of eighteen. The
board member utilizes their role on the board to update the board on the youth and seek out
opportunities for the youth.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures which outline performance evaluations will be
conducted ninety days after hire and annually thereafter. Position descriptions for four different
position types were reviewed and compared with the ten staff records reviewed and confirmed
staff were evaluated based on established performance standards. A review of the program’s
staff roster and contract confirmed all required positions were maintained with the exception of
three non-licensed therapists, which were added positions with the addition of two program
components, and one licensed therapist which has been vacant five months. The program
reported this position is being covered by the state clinical director. The facility administrator
was interviewed and reported turnover has decreased and the program’s staff morale
committee has implemented multiple initiatives to improve morale and recognize staff
performance. Three staff were interviewed and each reported they receive performance
evaluations every six months.
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1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program’s contract was reviewed for contract-specific requirements. Documentation
confirmed the program is providing each of the fifteen contract-required activities. The program
has agreements, sign-in sheets, and picture documentation of activities with Friends In Blue
through the St. Johns Sheriff’s Office, mentoring through Compassion St. Augustine, animal
assisted programming through the Hands and Feet Foundation, and First Coast Technical. The
program maintains spaces for youth to utilize as part of their behavior management system
including an enhanced basketball court, arcade, barbershop, diverse media center and music
studio. The nurses taught two classes with an infant simulator to instruct youth in caring for an
infant. Youth are provided required clothing, salad bowls with their meals, opportunities to
receive the iHope patch for fitness achievement, and input through the youth advisory board.
The program provided documentation they have leases for four passenger vans, exceeding the
contract requirement of three. A review of the program’s staff roster confirmed they have a
medical clerk and a physical plant worker with certifications in heating, ventilation, and air
conditioning (HVAC). The program utilizes recruitment and retention efforts confirmed through
their staff handbook. The facility administrator confirmed the contract-specific opportunities
offered to youth. Three youth were interviewed and none of the youth reported participating in
contract-specific activities; however, sign-in sheets, pictures, and agreements confirmed the
program is providing the activities as required.
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.
A review of youth records, certificates, sign-in sheets, and the program’s contract confirmed the
program is providing all required career and technical education (CTE) certifications. During the
annual compliance review period twenty-four youth received their Florida Ready to Work soft
Skills certification through online training. Certified program staff facilitated training in which 110
youth achieved their certification in first-aid/cardiopulmonary resuscitation (CPR). The Core
Group was utilized for 136 youth to complete their Occupational Safety and Health
Administration (OSHA)-10 certification. Seventy-two youth completed ServSafe through trained
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SafeStaff facilitators. Sixteen youth completed Self Advocacy through EmployU. Seventeen
earned certifications through C-Tech programming which is facilitated by the program’s physical
plant manager who is certified to facilitate the training. An additional five youth are currently
enrolled. Thirteen youth completed Express Yourself training in the music studio, facilitated by
the vocational instructor. One youth completed Integrative Behavioral Health through a referral
with vocational rehabilitation services. The program reported vocational services are completed
during youth leisure time or during the school day for EmployU and Florida Ready to Work
courses. The facility administrator confirmed the program’s CTE services. Three youth were
interviewed and none of the youth reported participating in the CTE services; however, sign-in
sheets and certifications confirmed the program is providing the CTE activities as required.
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’s quality assurance program includes data collection, review and internal fidelity
monitoring and verification processes which address all components of the program including
but not limited to management accountability, living and treatment environment, case
management, delinquency interventions, mental health and substance abuse services, safety
and security, and health care services. Within these respective areas, routine reviews and
evaluations of youth care and services, client records, staff development, facility safety and
maintenance are conducted. Fidelity monitoring, peer review, and utilization reviews are also
completed. The program uses reporting systems to track key performance data and ensures the
timely review and communication of system data with program and corporate leadership teams
as well as the Department. Data collection includes daily management meeting reports, monthly
incident reports, corporate leadership data review, and monthly key performance indictor (KPI)
data. The data is utilized to make decisions within the program and improve performance in the
KPI data and performance standards.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures in order to provide proper initial contact to youth, their
parent/guardian, and committing court upon admission. This process includes initial contacts to
the youth’s parent/guardian within twenty-four hours of admission, and in writing within forty-
eight hours of admission to the youth’s parent/guardian, committing court, juvenile probation
officer (JPO), and if applicable, the post-residential services counselor. A review of five youth
records found the program notified each youth’s parent/guardian by telephone and sent
notifications to the parent/guardian, court, and JPO within the required time frames.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures to provide youth an orientation the day of the youth’s
admission. A review of five records found the program provided each youth an orientation on
the day of admission which included the services available, daily schedule, expectations and
responsibilities of youth, written behavioral management system, availability and access to
medical, mental health and substance abuse services, access to the Florida Abuse Hotline or
Department’s Central Communications Center if the youth is eighteen or older, the program’s
zero-tolerance policy regarding sexual misconduct and how to report, and special
accommodations for youth with limited reading skills or who are visually impaired, deaf, or
otherwise disabled. The orientation also included performance planning process involving
achievable development of goals for each youth, dress code, hygiene practices, visitation, mail,
use of telephone, expectations for release from the program, community access, grievance
procedures, emergency procedures, facility tour, a general layout of facility, assignment to a
living unit, treatment team, and if applicable, assignment to staff advisor or youth group. A
review of five youth records documented a signed form acknowledging the youth received an
orientation packet, including a copy of the youth handbook. A youth orientation was unable to be
observed since no intakes were scheduled during the annual compliance review week.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a policy and procedures for obtaining written consent of any youth eighteen
years of age or older. A review of five records found two youth were applicable for written
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consent of youth over the age of eighteen. An additional record was requested and provided for
review. All three applicable youth records contained consent forms signed by the youth allowing
the program to share with the parent/guardian any information related to the youth’s physical or
mental health screenings, assessments, or treatment. Three interviewed youth stated their
orientation began within twenty-four hours of admission to the program which included program
rules, procedures, and schedule, and each was able to explain the orientation process.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
The program has a policy and procedures for classifying youth by using a classification system
to promote safety and security, as well as effective treatment services based on each youth’s
needs and risk factors. The factors include physical characteristics of the youth, age, maturity
level, special needs, history of violence, gang affiliation, criminal behavior, sexual aggression or
vulnerability to victimization, youth perception of vulnerability, youth history of potential or
verified human trafficking, suicide risk, medical risk, escape risk, and/or suicide risk. Five youth
records were reviewed. Four out of five youth had an initial classification form completed on the
same day as admission notating each youth’s risks, review of alerts or newly identified risks
entered into the Department’s Juvenile Justice Information System, and assignment of the
youth’s living unity, room, youth group, or staff advisor. One youth’s initial classification form
was incomplete and did not notate risk factors, review of alerts, or assignments. The program’s
policy provides classification reassessments when warranted to consider an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments can be potential weapons, and participation in off-campus activities. Three
out of five youth records reviewed included a reassessment to increase privileges or freedom of
movement and two were for participation in work activities or additional activities. An interview
with the facility administrator verified reclassification, if warranted, is based on changes in
youth’s supervision, alerts, behavioral concerns, and relevant information to treatment team,
ensuring the safety and security of youth and the program. The interviewed facility administrator
was able to provide the program’s classification system policy relating to room assignment.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a policy and procedures for addressing gang identification which include
notifying law enforcement. The program evaluates each youth during intake for suspected gang
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involvement. Five youth records were reviewed and two were applicable for gang identification
and notification of law enforcement. One additional record was reviewed for gang identification
notification. In each of the three applicable records local law enforcement was notified of
suspected gang affiliation prior to the seven-day notification. All three youth were identified as
having gang involvement prior to admission to the program by their juvenile probation officer
(JPO), who entered the alert into the Department’s Juvenile Justice Information System (JJIS)
as well as notified the home county law enforcement. The program shares the gang status with
the youth’s education provider.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures implementing gang prevention and intervention
strategies to youth who are identified as or are a suspected gang member. Five youth records
were reviewed and two were applicable for gang prevention and intervention activities. One
additional record was reviewed. Documentation of sign-in sheets confirmed each youth’s
participation in gang prevention and intervention of Gang Resistance and Drug Education
(G.R.A.D.E.). Each youth performance plan included relevant goals and objectives to be
completed prior to release. The program provides gang prevention/awareness efforts to youth at
the program by refraining from using any form of representation of gangs including but not
limited to gang signs, graffiti, gang language, and/or any other form of gang representation. The
program provides youth an opportunity, if they desire, to develop a plan to disaffiliate with gang.
The interviewed facility administrator stated the program facilitates monthly gang intervention
groups.
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.
For the five youth records reviewed, each completed a Residential Assessment for Youth (RAY)
within thirty days of the youth’s admission to the program. All initial RAY assessments were
completed and maintained in the Department’s Juvenile Justice Information System (JJIS).
Reassessments were completed every ninety-days as required as well as maintained in all five
reviewed records.
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.
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Five youth records were reviewed for a Youth Needs Assessment Summary (YNAS). All five
YNASs were completed within thirty days of the youth’s admission to the program. Reviewed
documentation supported each YNAS was documented in the Department’s Juvenile Justice
Information System (JJIS).
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
Five youth records were reviewed for Individualized Performance Plan (IPP) development. All
five records contained an IPP completed within thirty days of the youth’s admission to the
program and after the initial Residential Assessment for Youth (RAY) and Youth Needs
Assessment Summary (YNAS). Each IPP was developed and signed by the treatment leader,
youth, administrative representative, living unit representative, treatment staff, education,
Department of Children and Families (DCF) caseworker, if applicable, and all parties who have
significant responsibility in goal completion. Reviewed records confirmed a copy of the IPP was
sent to each of the youth’s parent/guardian along with a signature page to return in the
addressed stamped envelope. Three youth parents/guardians signed and returned the signature
sheet which was maintained with the IPP. The five youth IPPs documented the youth’s top three
criminogenic needs and individualized goals based upon the prioritized needs reflecting the risk
and protective factors identified in assessment process. Each IPP included specific delinquency
interventions with measurable outcomes to decrease youth’s criminogenic risk factors and
promote strengths, skills, and support to reduce the likelihood of the youth reoffending. All five
youth IPPs included court-ordered sanctions, which can be initiated and/or completed while the
youth is in the program, transition activities for the last sixty days of the youth’s stay, youth’s
responsibilities to accomplish goals, program staff responsibilities to enable youth to complete
goals, and target goal completion date. The five youth records documented a transmittal letter
and a copy of the plan was sent to the committing court, parent/guardian or DCF caseworker,
and juvenile probation officer (JPO) within ten working days of the IPP being completed. Three
interviewed youth advised they contributed in the development of their IPP and were provided a
copy. One youth was able to articulate their current goals, one youth stated they did not know
their goals, and one youth stated goals were finished and did not remember them.
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.
Five youth records were reviewed for Individualized Performance Plan (IPP) revisions. Two
IPPs were revised by the treatment team based on the Residential Assessment for Youth (RAY)
Reassessment results. All youth demonstrated progress towards completion of goals which was
reflected on the IPP revisions. Two IPP revisions were based on the lack of progress toward
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completing goals. Two of the five reviewed records were applicable for youth in transition.
Documentation showed each applicable IPP was revised to facilitate transition activities during
the last sixty days of the youth’s stay in the program.
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.
Five reviewed youth records documented Performance Summaries were completed within the
required ninety-day time frame following the signing of the Individualized Performance Plan
(IPP) as well as every ninety-days thereafter. All youth summaries included the status on each
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, interactions with peers and staff, overall behavior adjustment to the program, level of
motivation and readiness for change, and positive and negative events were included in the
Performance Summary. Reviewed Performance Summaries supported each youth was
provided the opportunity to review and add comments prior to signing and received a copy.
Reviewed documentation supported each completed summary was signed by the treatment
team leader, facility administrator or designee, and the youth and the original was filed in each
applicable youth record. All Performance Summaries were sent to the youth’s committing court,
juvenile probation officer (JPO), and parent/guardian within ten working days with the exception
of one summary not being sent to the committed court. A review of three closed youth records
supported an original release summary, along with justification for release and Pre-Release
Notification (PRN), was sent to each youth’s assigned JPO. All three release summaries and
PRNs were sent at least forty-five days prior to the planned release date and a signed copy was
retained in the youth’s closed record. One youth record documented the court objected the
release twice. The youth was required to appear in court several times before the judge
approved the release, therefore, the PRN was signed right before release. Reviewed
documentation in each closed record verified, once each PRN was approved, the program
provided written notification to the youth’s parent/guardian regarding the planned release and
completed an Exit Residential Assessment for Youth (RAY). The reviewed program was not an
identified sexually violent predator program (SVPP). None of the closed records were applicable
for a Victim Notification of Release letter.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures which address the encouragement of parent/guardian
involvement in the case management process. Five reviewed records verified the program
encouraged and facilitated the involvement of each youth’s parent/guardian in the assessment
process, performance planning and development, progress reviews, and transition planning.
The program provides all parents/guardians advanced notice of the scheduled formal treatment
team meetings and conferences with dates and times. Each letter also indicates if the
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parent/guardian cannot attend by telephone or video conference on the day of the meeting, they
may participate by providing verbal or written input prior to the meeting. Parents/guardians
participate in the youth case management services through treatment team meetings, weekly
telephone calls, visitation, and family therapy. An interview with the facility administrator
confirmed parental/guardian involvement in the case management process is encouraged
through emails, visitation, letters and weekly phone calls. Two of three interviewed youth stated
parents/guardians are involved with their case management through participation in treatment
team meetings, family sessions, and weekly calls. One youth is involved with the Department of
Children and Families (DCF) and documentation confirmed the caseworker is involved.
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 policy and procedures indicating the Individualized Performance Plan
(IPP) shall reference or incorporate each youth’s treatment or care plan. Five reviewed youth
records revealed each youth had a separate treatment and academic plan and their IPP
contained documentation of incorporation of the plans. One youth was applicable for having a
plan from an outside agency. The youth had a case plan through the Department of Children
and Families (DCF) which was coordinated on the IPP for related issues.
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.
Five youth records were reviewed for treatment team meetings. Each record documented formal
treatment team reviews were conducted at least once every thirty days. Informal reviews were
documented as held bi-weekly in each record. The program utilized a Performance Plan Review
form for both the formal and informal treatment team meetings which included the youth’s name,
date of review, meeting attendees, comments from treatment team members, youth’s progress,
the progress of each youth’s goals, positive and negative behaviors, physical interventions,
treatment progress, and Residential Assessment for Youth (RAY) Reassessment results. Youth
are provided the opportunity to demonstrate skills acquired in the program. Reviewed
documentation confirmed formal treatment team meeting attendees consisted of the youth, case
management staff who act as the treatment team leader, clinical staff, education, living unit
representative, and a program administration representative for each of the five youth. All staff
gave relevant input on the youth. Each youth’s juvenile probation officer (JPO) and
parent/guardian were invited to participate in person, by telephone/video conference, and/or
provide written input. Reviewed documentation of signed forms confirmed informal treatment
team meeting attendees consisted of the youth and case management staff, with relevant
information being provided by treatment team members. An observation of treatment team was
not conducted as there were no treatment teams during the week of the annual compliance
review. Three interviewed youth stated they are given an opportunity to demonstrate the skills
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they have learned in the program and staff review performance, including progress on goals,
positive and negative behavior, and treatment progress.
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.
Three closed youth records were reviewed regarding transition planning, conferences, and
Community Re-Entry Team (CRT) meetings. Documentation showed all required treatment
team members, youth, parent/guardian, education staff, and juvenile probation officer (JPO)
were invited and participated in the transition conference held at least sixty days prior to the
youth’s targeted release date in two of the three closed case records. One closed record
documented two transition conferences were completed since the committing judge continued
to deny release, however, neither was held sixty-days prior to release. The youth was required
to appear in court several times before judge approved the release, which was not until right
before release, therefore, a new transition conference could not be held. All three closed youth
records documented the transition conferences were conducted and documented on the
Transition Conference form which included attendees and signature acknowledging the
transition goals and accountability of completion. During the transition conference, participants
reviewed the transition activities outlined on each youth’s Individualized Performance Plan (IPP)
or revised IPP, additional identified transition activities, target completion dates, and each
person’s responsibility for goal completion. Each youth record contained documentation a copy
of the transition plan was sent with a request to return signature sheet to anyone not in
attendance who had a responsibility for completion of transition goals, as well as documentation
a copy of the plan was sent electronically to the JPO and Department of Children and Families
counselor, when applicable. Documentation in all three closed records supported the program
received an invitation to the CRT meetings. Reviewed documentation supported the program,
youth, and parent/guardian participated in the CRT meetings.
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 policy and procedures for the assembly of the exit portfolio for each
youth to assist them once released back into the community. Exit portfolios are to include a
state-issued identification card, Social Security card, birth certificate, all educational
documentation, school transcripts, résumé, sample employment applications,
educational/vocational certificates earned in the program, along with a calendar of upcoming
appointments. Two of the three closed youth records reviewed confirmed the youth had a
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completed exit portfolio with all required elements as outlined in the policy. One youth record
contained all required elements except for completed sample application, the state-issued
identification card, Social Security card, and birth certificate. Documentation showed the
parent/guardian was sent a notification letter, was notified during treatment team, and the
transition conference requesting the needed Social Security card and birth certificate to obtain
the identification card, however, the program never received the needed items. The program
also documented the youth refused to complete sample applications, for the youth felt there was
not a need to. All three closed youth records indicated the exit portfolio was discussed and
initiated during the transition conference and verified during the exit conference. Documentation
supported the exit portfolio was completed and given to each youth upon release.
Documentation showed the program forwarded each youth’s juvenile probation officer (JPO) a
copy of the exit portfolio. The program’s contract included two additional requirements of an i-
Home Experience Exit Portfolio for each youth and weekly follow-up checks for a month after
release. The program provides each youth with an i-Home Experience Exit Portfolio binder at
admission to capture all requirements and accomplishments while in the program. Observations
confirmed all youth are provided with a binder to transition home with once released.
Documentation confirmed the transition specialist or case manager conducted post-release
follow-ups with each youth on a weekly basis for thirty days after release.
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.
Three closed youth records were reviewed for completion of the exit conference. Reviewed
documentation found each exit conference was conducted at least fourteen days prior to the
youth’s release and after notifying the juvenile probation officer (JPO) of the youth’s release.
Reviewed documentation supported the youth, case manager who also acted as the treatment
team leader, the facility administrator or designee, educational staff, mental health staff, and
medical staff all participated and signed the exit conference, with the parent/guardian and JPO
participating by telephone. Transition activities and target dates were reviewed and finalized
during the exit conference. Documentation showed a copy of the exit conference was
electronically sent to each JPO and mailed to each parent/guardian. All exit conferences were
separate from the transition and Community Re-Entry Team meetings. All three of the closed
youth records showed the date of admission and release coincided with the dates entered in the
Department’s Juvenile Justice Information System (JJIS).
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The programs formal process promoted constructive input by youth through weekly house
meetings and the youth advisory board to represent youth, as well as written program and youth
concerns through Speak-Out forms, Trauma Responsive and Caring Environment (TRACE)
assessment, and quarterly and exit surveys. Documentation confirmed the program completed
quarterly and exit youth surveys and the TRACE assessment to gather input information. A
review of Speak-Out forms, weekly house meetings, and bi-weekly youth advisory board
meetings verified the program’s process to promote input from youth, with the exception of two
weeks of weekly house meetings in May, which could not be verified through sign-in sheets.
Three interviewed youth reported they provide input about what happens at the facility through
speak-outs. The facility administrator confirmed the program’s policy.
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2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program has a policy and procedures to provide career education based on age and
appropriateness for the educational abilities of the youth in the program. The program provides
Type 2 career education development. An interview with the facility administrator and lead
educator indicated the program provides career education services through Employ-U, Florida
Ready to Work, C-Tech, and Upper Iowa University. They also provide certifications in first-
aid/cardiopulmonary resuscitation (CPR)/automated external defibrillator (AED), Occupational
Safety and Health Administration (OSHA)-10, and ServSafe. Three youth case management
records were reviewed Two records included a completed employment application, and one
record was missing the job application as the youth declined to complete it due to already
having a job. All three records included a résumé, and contact information with Career Source
Center. There was documentation in all three records indicating the youth's parent/guardian and
juvenile probation officer (JPO) were aware of the vocational plan for the youth. Two of the
reviewed youth records had a Department of Highway Safety and Motor Vehicles state-issued
identification card (ID). In one record the parent/guardian refused to provide the required
documents to obtain a State ID. All three records contained certifications in ServSafe and first-
aid/CPR.
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 has a policy and procedures to provide educational access. The center provides
education services through TrueCore Behavioral Solutions and the 250-day calendar,
distributed over twelve months, includes ten days used for teacher training and planning. A
review of the daily school schedule revealed the center provides six fifty-minute classes fulfilling
the weekly requirement of twenty-five hours of instructional time. The interview with the lead
teacher indicated all the youth receive credit for a course completed. The lead teacher also
reported the school schedule is adhered to. Three youth were interviewed, and two reported
there were no interruptions in school, one reported there were interruptions due to kids fighting.
The Department’s Office of Education noted an issue with the educational access due to the
school provider having teacher vacancies. This issue was addressed through the Department’s
Office of Education, the program, and the school provider; therefore, all reviewed logbook and
video samples were after the issue was corrected on March 1, 2024. A review of seven
randomly selected days in the logbook indicated education classes started on time on two days.
The other days showed classes started two to eighteen minutes late. On those days the school
day was extended. It should be noted the logbook entries in all the days reviewed were missing
documentation of class movement throughout the school day. Observations of the program
video on three days indicated school started and ended on time and classes followed the school
schedule.
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.
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The program has a policy and procedures requiring an Education Transition Plan to be
developed upon each youth’s admission. Three closed youth case management records were
reviewed. All three youth records included an individual Education Transition Plan developed
upon entry, including the youth’s post-release goals, meeting the required elements. Each of the
three records contained an Exit Plan indicating the case manager, parent/guardian, and youth
were all aware of the plan. Included in each record was an Electronic Educational Exit Plan
(EEEP) which identified the next educational placement information and input from the post-
release school district representative. Three interviewed youth reported they participated in the
planning of their Education Transition Plan. Two of the three interviewed youth reported the
program was preparing them well when it came to high school, high school equivalency diploma
(GED), vocational school, employment, and/or college. One youth reported not being well due to
doing lower-grade work.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program has a designated mental health clinical authority (DMHCA) who is a psychologist
with a clear and active license with an expiration date of May 31, 2024, as required by the
program’s contract. A review of the position description confirmed the DMHCA is a full-time staff
who works at least forty-hours a week and is responsible for the coordination and
implementation of clinical services at the program. The program utilizes a back-up DMHCA who
is the assistant clinical director (ACD). The back-up DMHCA is a licensed mental health
counselor (LMHC) with a clear and active license in the State of Florida which expires March 31,
2025.
The DMHCA was interviewed and confirmed they provide clinical supervision for non-licensed
mental health professionals, provides weekly group schedule, and monthly fidelity and
feedback. The DMHCA submits monthly service calendars of scheduled individual and family
sessions to the clinical director or designee. During the intake process, the licensed mental
health professional (LMHP) gathers current information from the youth and within the first five
days of admission. The LMHP also confirms youth reports by referring to collateral information
obtained in the Department’s Juvenile Justice Information System and completes the Brief
Behavioral Health Status Exam. The LMHP completes and/or reviews all Assessments of
Suicide Risk (ASRs). The LMHP also provides any group therapy, individual/family therapy, and
any needed clinical service in the absence of a therapist.
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 policy and procedures ensuring mental health and substance abuse
services are provided by individuals with appropriate qualifications. The clinical supervisor
ensures the licensed clinical staff working under their supervision are performing services they
are qualified to provide based on education, training, and experience, which was determined by
a review of job descriptions and an informal interview with the designated mental health clinician
authority (DMHCA). The licensed mental health and substance abuse clinical staffing is in
accordance with the current contract and Florida Administrative Code. Copies of the licenses
were available on-site. Licenses of all licensed mental health professionals and licensed
qualified professionals employed at the program during the annual compliance review period
were reviewed and found to be clear and active. The program’s contract requires two assistant
clinical directors and one additional licensed therapist. A review of the staff roster and licenses
found the program had two assistant clinical directors; however, the licensed therapist position
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has been vacant since October 3, 2023. The provider’s director of mental health is currently
assigned to the program providing coverage.
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 policy and procedures ensuring mental health and substance abuse
services are provided by individuals with appropriate qualifications. The clinical supervisor
assures the non-licensed clinical staff working under their supervision are performing services
they are qualified to provide based on education, training, and experience based on a review of
job descriptions and an informal interview with the designated mental health clinician authority
(DMHCA). The program had seven non-licensed master’s-level clinical staff at the time of the
annual compliance review. The program had three vacancies for therapist positions which were
open for twenty-eight, fifty, and eighty-one days. During the annual compliance review period,
the program had six additional non-licensed master’s-level clinicians who provided services but
were no longer with the program. A review of the clinician’s credentials found each was qualified
to provide services based on their education, training, experience, and the contractual
requirements. The reviewed documentation reflected each non-licensed mental health clinical
staff working under the direct supervision of a licensed mental health professional received a
minimum of one hour a week of on-site, face-to-face direct supervision by a licensed mental
health professional for the purpose of overseeing and directing the mental health services
provided in the program during the annual compliance review period, as required. Direct
supervision was recorded on a form which included all elements of the Department’s Licensed
Mental Health Professionals and Licensed/Certified Substance Abuse Professionals Direct
Supervision Log form. During the annual compliance review period, the program had six
additional non-licensed master’s-level clinicians who resigned. A review of the clinician’s
credentials found each was qualified to provide services based on their education, training,
experience, and contractual requirements. The program has a Chapter 397 license which
expires April 1, 2025. The program’s staffing roster was reviewed and showed the program
employs two recreational therapists. Both recreational therapist’s credentials, schedule, and
services provided to youth were reviewed and requirements were met as outlined in the
contract. The non-licensed mental health and substance abuse clinical staffing is in accordance
with the current contract to include the number of hours.
All seven non-licensed mental health clinical staff hold a master’s-level degree from an
accredited university or college in the field of counseling, social work, psychology, or related
human services field. The non-licensed substance abuse clinical staff provide substance abuse
services in the program which is licensed under Chapter 397, Florida Statute. All seven
currently employed non-licensed mental health clinical staff who conducted Assessments of
Suicide Risk completed twenty hours of training and supervised experience in assessing suicide
risk, mental health crisis intervention, and emergency mental health services, as required. A
review of the six non-licensed staff no longer employed at the program also completed twenty-
hours of training and supervised experience in assessing suicide risk, mental health crisis
intervention, and emergency mental health services, as required. The non-licensed mental
health and substance abuse clinical staffing is in accordance with the current contract to include
the number of hours.
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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 policy and procedures for mental health and substance abuse
admission screenings. The policy was reviewed and included a standardized screening process
which addresses a review of commitment packet information, reports and records,
administration of the Massachusetts Youth Screening Instrument, Second Version (MAYSI-2),
clinical screening completed by a “qualified professional”, referrals which indicate the need for
further evaluation or immediate attention, staff training in mental health, substance abuse
issues, and a standardized process for referral of youth identified as in need of further mental
health and/or substance abuse evaluation to an appropriate service provider/professional, or
when immediate attention is needed, to a hospital, Baker Act, or Marchman Act facility. Five
youth mental health records were reviewed. All five records included documentation of the
MAYSI-2 and a clinical screening. All five records included documentation the screener
reviewed all available information to include the commitment packet, reports, and records for
existing documentation of mental health or substance abuse problems. All five screenings were
completed in the Department’s Juvenile Justice Information System (JJIS) on the day of
admission by a trained staff. All MAYSI-2s were completed in full. Four of the five MAYSI-2s
indicated further assessment was required and a referral was completed. Two of the five youth
were applicable for a referral for further evaluation for mental health, substance abuse, and/or
was a suicide risk. Both youth had referrals completed for the appropriate evaluation. The
program director ensured an Assessment of Suicide Risk (ASR) was conducted within twenty-
four hours due to the program completing an ASR upon admission for all youth at the program.
Based upon the MAYSI-2 results, two youth were applicable for an ASR, and one youth was
applicable for a comprehensive evaluation.
The facility administrator reported the screening process to identify youth at risk for mental
health and/or substance abuse problems and suicide is completed through the MAYSI-2, ASR,
Substance Abuse Subtle Screening Inventory (SASSI), Childhood Trauma Questionnaire
(CTQ), and the Strengths, Needs, Attitudes, Preferences (SNAP) Assessment.
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 policy and procedures for providing mental health and substance
abuse assessments and evaluations to youth in the program. The procedures state each youth
admitted to the program is assessed over the first thirty days of placement in the program. Five
youth mental health records were reviewed. All five records included documentation the
program completed a combined mental health and substance abuse evaluation for the youth. All
five evaluations were new and not updated. All five evaluations were completed within thirty
calendar days of admission. Two of the five mental health/substance abuse evaluations were
completed by a non-licensed mental health staff and there was evidence both were reviewed
and signed by a licensed qualified professional within ten calendar days of the evaluation being
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conducted. All five evaluations included identifying information, reason for evaluation, relevant
background information which includes home environment, family functioning, sexual abuse,
neglect, witnessing violence, trauma, behavioral functioning, physical health, mental health,
substance abuse history, and education functioning, behavioral observations, Mental Status
Examination, interview or procedures, discussion of findings, Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition (DSM-5) diagnosis, and recommendations.
All five youth records included documentation of the youth receiving a new substance abuse
assessment. All five records included documentation a consent was completed for substance
abuse services. All five assessments were completed within the first thirty calendar days of
admission. All five substance abuse assessments included the reason for assessment, relevant
background information which includes home environment, family functioning, history of
physical abuse, sexual abuse, neglect, witnessing violence, trauma, behavioral functioning,
physical health, mental health, substance abuse history, and education functioning. The
substance abuse assessment also included behavioral observations, methods of assessment,
patterns of alcohol and other drug abuse, impact of alcohol and other drug abuse on major life
areas, risk factors of continued alcohol and other drug abuse, clinical impression including
DSM-5 diagnoses, and recommendations.
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.
All five youth records included documentation an initial treatment plan was developed within
seven days of the initiation of treatment. All five initial mental health treatment plans included all
required elements. All five initial treatment plans were developed within seven days of the onset
of treatment. All five initial treatment plans were signed by the clinical staff, licensed clinical
supervisor, all treatment team members who participated in the development of the plan, and
the youth. Two of the five initial treatment plans did not have parent/guardian signatures, but the
parents/guardians did participate by telephone as evidenced by notes on the treatment plans.
One initial treatment plan did not have a signature of the psychiatrist, but psychiatry input was
included on the treatment plan. All five plans included the youth’s psychiatric needs, medication,
and frequency of monitoring by the psychiatrist.
All five youth mental health records included documentation their individualized treatment plans
were developed within thirty days of admission. All five individualized treatment plans were
developed on a form which contained all of the required elements. All five individualized
treatment plans were signed by the clinical staff and the licensed supervisor within ten days of
completion. All five individualized treatment plans were signed by all treatment team members
and the youth. Three of the five plans did not have parent/guardian signatures. Four of the five
individualized treatment plans included psychiatric services, which included medication and
frequency of monitoring by the psychiatrist. One youth was not placed on medication. All five
individualized treatment plan reviews were completed on a form which contained all required
elements. Four of the five youth records included documentation the treatment plan reviews
were completed every thirty days. One treatment plan review was completed twenty-four days
late. All five treatment plans included documentation of the prescribed services to include
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individual, group, family, and psychiatric services as applicable. All services were individualized
for each youth. A review of video for three random days revealed groups were being held, as
required.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
The program has a written policy and procedures for mental health, substance abuse, transition,
and discharge planning. Five youth mental health records were reviewed for treatment and
discharge planning. All five youth records indicated the youth were assigned a treatment team
upon arrival at the program. A review of documentation revealed the treatment team included
the youth, program administration, residential living unit, education, medical staff, and clinical
staff. Three of the five records included documentation of parent/guardian participation. Four of
the five youth records included documentation the youth received substance abuse treatment
through individual, group, and/or family counseling provided by a licensed qualified professional,
or a non-licensed substance abuse clinical staff in accordance with the youth’s initial or
individualized treatment plan. All five youth records included a properly executed Authority of
Evaluation (AET) form. All five youth provided consent for substance abuse treatment as
evidenced in their records. All five youth records included documentation the clinical treatment
notes were completed on the Department’s Counseling/Therapy Progress Notes form.
All five youth mental health records included documentation of mental health and group therapy
including individual psychotherapy and psychosocial skills training designed to address specific
skill deficits or maladaptive behaviors and promote skill development and improved functioning
of youth with mental disorders. All progress notes were reviewed and revealed they include
documentation the youth received services as stipulated on the treatment plan. Three closed
youth mental health records were reviewed for discharge planning. All three closed records
included the discharge plan documented the Department’s Mental Health and Substance Abuse
Treatment Discharge Summary form. None of the youth were released while on suicide alert or
precautions. All three treatment discharge summaries documented the services needed for daily
maintenance of the positive improvement in behavioral, emotional, and social skills made by the
youth during treatment. All three records included documentation the discharge plan was
discussed with the youth, parent/guardian, and juvenile probation officer (JPO) during the exit
conference. All three youth received a copy of their discharge summaries, along with the
parents/guardians and JPOs.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
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The program provides services for youth with borderline developmental disabilities (BDD) and
youth with developmental disabilities (DD), Intensive Mental Health (IMH), and Comprehensive
Mental Health (CMH). The program maintains a written policy and procedures for establishing
service delivery protocols for specialized treatment services. The program’s required clinical
groups according to the contract include Moral Reconation Therapy, Skillstreaming the
Adolescent, and Living in Balance. For youth identified with BDD/DD, there was documentation
in the youth mental health records of each youth receiving a development evaluation. All youth
records also included documentation the youth received disability treatment planning. All
treatment plans reviewed were individualized, based upon the youth’s developmental evaluation
results. All youth receive daily developmental and psychosocial treatment and interventions,
along with therapeutic activities. If the youth have co-occurring disorders, they receive mental
health and substance abuse services. A psychologist, who serves as the developmental
specialist, is on-site as required by contract. A mental health clinician is on-site seven days each
week. The therapist ratio is one staff (clinician) to twelve youth.
The program provides services for youth with CMH and IMH, to include dual diagnoses. The
program provides mental health and substance abuse evaluations to all youth. If the youth are
applicable, they receive mental health and substance abuse treatment planning. The youth
receive daily individual therapy, family therapy, daily support activities, substance abuse
therapeutic activities, mental health crisis interventions on a daily basis, and on-site psychiatric
services. The program maintains a full-time licensed psychiatrist five days a week for forty
hours, mental health clinical staff on-site seven days a week, a psychologist on-site forty hours
a week to provide psychological evaluations and services within the program and for emergency
consultation services, and a registered nurse on-site daily for each shift to ensure appropriate
administration of medication.
Three interviewed youth reported they receive individual counseling weekly. One youth reported
getting family counseling once a month. Three interviewed staff reported direct care staff do not
facilitate any mental health or substance abuse groups. The designated mental health clinical
authority (DMHCA) reported substance abuse treatment overlay services, comprehensive
services for major disorders, BDD/DD treatment services, IMH treatment services, and mental
health overlay services are provided. The facility administrator reported the program provides
treatment services on-site through the provision of IMH, BDD, DD, CMH, or medically complex
overlay services. The facility administrator reported all program youth shall be pre-screened and
placed based upon identified treatment needs. The youth are provided group, individual, and
family sessions.
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.***
Psychiatric services are provided by two psychiatrists who both possess a clear and active
license in the State of Florida, both expiring January 31, 2026. The psychiatrists are available
for emergency consultation twenty-four hours a day, seven days a week. The psychiatrists
providing psychiatric services brief a representative of the treatment team regarding the
psychiatric status of each youth receiving psychiatric services who is scheduled for treatment
team review. The psychiatrists’ evaluations and recommendations for the youth are
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incorporated into the mental health clinical staff’s evaluations of the youth and the youth’s
individualized mental health or substance abuse treatment plan. A review of sign-in/out logs
confirmed visits during the annual compliance review period were conducted as required by the
contract for both psychiatrists. The psychiatrists actively participate in, manage, and supervise
psychotropic medication services in the program. The program did not use a back-up
psychiatrist during the annual compliance review period. An interview with one of the
psychiatrists confirmed their role at the program is to perform initial psychiatric evaluations and
provide diagnoses for youth within thirty days of arrival or within two weeks of arrival if the youth
is on medication at the time of admission. Collateral information is obtained with informed
consent, when necessary, from the parent/guardian or adult youth for any new medication or for
any significant change in dosage. If medications have adverse side effects, non-compliance, or
are no longer necessary, the psychiatrist will attempt to inform/discuss with the parent/guardian
prior to discontinuation when possible. Youth on medications are seen by appointment at least
monthly, and more often than monthly when clinically indicated. The psychiatrist also confirmed
they perform diagnostic evaluation services, psychiatric care and treatment, provide
consultation, and approve treatment plans. Medication management is provided for youth who
arrive to the program on medication or are placed on medication. The psychiatrists also provide
in-service training when designated by the facility administrator or clinical director. The
psychiatrists meet with the clinical director at least weekly and attend a clinical staff meeting
with the entire clinical staff and clinical director bi-weekly or monthly. Formalized procedures are
in place with the healthcare staff to review the important medical issues pertaining to youth at
the program receiving psychiatric services. The psychiatrists communicate face-to-face with
therapists at least once on each clinical day and are available twenty-four hours a day, seven
days a week by phone when requested. The psychiatrist did not have any concerns with mental
health or substance abuse services at the program during the annual compliance review. An
interview with the designated mental health clinician authority (DMHCA) determined the
licensed mental health professional meets with the psychiatrists two times a week.
Five youth mental health records were reviewed for psychiatric services. Three of the five youth
records included documentation the youth entered the program on psychotropic medication.
Although only three youth entered the program on psychotropic medications, all five youth
received a psychiatric diagnostic interview within fourteen days. All of the initial diagnostic
interviews included the medical, mental health, and substance abuse history, Mental Status
Examination, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
diagnoses, prescribed medications, explanation of the need for psychotropic medications
related to diagnoses, target symptoms, initial treatment goals, potential side effects, risks and
benefits of taking the medication, and frequency of mediation monitoring and management. All
the reviewed diagnoses are consistent with the youth’s treatment plans and treatment
recommendations. All diagnostic interviews were documented on the Department’s Clinical
Psychotropic Progress Note (CPPN). The CPPN was clearly identified as an “Initial Diagnostic
Psychiatric Interview” for all five youth. Four of the five youth were placed on psychotropic
medications based upon the initial psychiatric interview. All four youth received medication
reviews for the duration of the time on medications. One youth was removed from medications
in October 2023. The four applicable youth records included the identifying data, diagnosis,
target symptoms of each medication, evaluation and description of effect of prescribed
mediation on target symptoms, the name, dosage, quantity, normal dosage range, ordered
dosage, frequency and route of administration, and reasons for changes in medication and/or
dosage. All four records also included documentation of the possible side effects of the
prescribed psychotropic medications, youth adherence to the medication regime, height, weight,
blood pressure, most recent serum drug levels, parent/guardian contact or attempted contact,
signature of the psychiatrist, and date of signatures. All four records included documentation the
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psychiatrist and the nursing staff have documented monitoring for Tardive Dyskinesia on a
monthly basis which is documented on the CPPN. The program does not utilize tele-psychiatry.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a written plan detailing suicide prevention procedures. The plan includes
identification and assessment of youth at-risk of suicide, staff training of six hours annually
including two hours of web-based and four hours of instructor-led training, drills for all staff on
each shift, suicide precautions, levels of supervision including one-to-one supervision, constant
supervision, and close supervision, referrals, communication, notification, documentation,
immediate staff response, and a review process. The review process for suicide attempts and
mortality review includes circumstances surrounding the event, facility procedures relevant to
the incident, all relevant training received by involved staff, pertinent medical and mental health
services involving the victim, possible precipitating factors, and recommendations, if any, for
changes in policy, training, physical plant, medical or mental health services, and/or operational
procedures. The Suicide Prevention Plan is reviewed annually and was last reviewed March 25,
2024, by the designated mental health clinician authority (DMHCA), facility administrator, and
corporate staff.
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 policy and procedures for the Suicide Prevention Plan and
services. Two of the five youth records were applicable for suicide prevention services. An
additional record was provided for review. Two youth were determined to be at-risk during
admission and one youth was referred by staff. All three assessments were completed on the
Department’s Assessment of Suicide Risk (ASR) form. All three youth were placed on
precautionary observation (PO) based upon the results of the ASR. The parents/guardians and
assigned juvenile probation officer (JPO) were notified of each youth’s potential suicide risk, and
mental health staff provided supportive services. All three youth received a Follow-Up ASR prior
to being removed from PO and it was documented on the Department’s Follow-Up ASR form.
All three youth were maintained on constant supervision for suicide precautions until the Follow-
Up ASR was completed. All three youth were stepped down to close supervision prior to
transition to normal routine and standard supervision. Close supervision was maintained for all
three youth until it was determined no longer necessary by the designated mental health
clinician authority (DMHCA) or licensed mental health professional. All documentation regarding
the discontinuation of close supervision was documented by mental health staff and maintained
in the youth’s mental health record. All three youth records included documentation a
conference was held by the program director and licensed mental health professional to reduce
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the level of supervision. A review of the documentation revealed the discontinuation of close
supervision was documented in accordance with the program’s suicide prevention plan. There
was an alert initiated in the Department’s Juvenile Justice Information System (JJIS) when the
youth was placed on suicide precautions and each alert was accurately closed following the
recommendations of the Follow-Up ASRs. One out of the three suicide risks and POs were
documented in the program’s logbook. Two of the initial placements on suicide precautions
were not documented. One youth was able to participate in select activities with other youth in
designated safe housing/observation areas of the program. All three youth mental health
records included documentation the ASRs were completed within twenty-four hours of concerns
or screening. The ASRs were completed by a licensed staff. There was documentation the
facility administrator or designee documented discontinuation of close supervision in the
program logbook for all three youth reviewed. The actual date and time the clinician conferred
with the facility administrator or designee and licensed mental health professional was
documented on all ASRs reviewed. All three youth had an ASR completed immediately when
the youth was in crisis.
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 policy and procedures for Suicide Precaution Observation
Logs. Three youth mental health records were reviewed for PO logs. All three youth records
included documentation the logs were maintained for the duration each youth was on suicide
precautions. The appropriate level of supervision and observations of the youth’s behavior was
documented in real-time and did not exceed thirty minutes for the three youth reviewed. One
youth record was applicable for warning sign documentation. The youth’s record included
documentation of the facility administrator or designee and mental health clinical staff being
notified and documented on the logs. All three youth records included documentation the logs
were reviewed and signed by each shift supervisor and mental health clinical staff. All of the
logs included documentation of 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 policy and procedures for suicide prevention training for staff. Twenty
staff training records (ten pre-service and ten in-service) were reviewed for suicide prevention
training. All twenty staff received suicide prevention training. The program maintains three
suicide kits in the program. All suicide kits are located on the youth living modules. Two dorms
have suicide kits co-located with first-aid kits. One dorm only has suicide kits. Mock suicide drill
documentation was reviewed. The program is conducting suicide drills, at least once a quarter
on each shift for all staff who come in contact with the youth. The program conducted mock
suicide drills each month for each shift during the annual compliance review period. All mock
mental health drills included a suicide attempt or serious self-injury. No youth were used during
the mental health drills. After each drill, the program provided training on the emergency
response procedures. The program documented on each drill form “areas of improvement”. This
information was then reviewed with the staff who participated in the drill and during all staff
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meetings, as documented on the reviewed drill forms. If there were staff who were not present
during a quarterly drill, they did have an opportunity to review the 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 incident of serious self-inflicted injury in the program. The facility
administrator reported they maintain a monthly drill calendar which includes mental health drills
and responses to suicide attempts. A review of each drill is also completed during the monthly
all-staff meetings. Three staff reported staff are to notify mental health staff and the youth is to
be put on constant sight and sound supervision when a youth expresses suicidal thoughts. Two
staff reported the staff document the supervision. One staff additionally reported the staff talk
with the youth and go over coping skills. Two staff reported the suicide kits are in medical and
all three staff reported the kits are on each of the dorms. All three staff reported medical
emergency and suicide drills are conducted on a monthly basis. One staff went on to state, drills
may be conducted twice a month or more.
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 has an integrated mental health crisis intervention and emergency mental health
and substance abuse services plan which includes a notification and alert system, means of
referral including youth self-referral, communication, supervision, documentation, and review.
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 maintains a policy and procedures for crisis intervention and a crisis intervention
plan. Five youth records were reviewed. One of the five youth were applicable for Crisis
Assessments. One additional record was provided for review. There were no other youth
applicable for Crisis Assessments during the annual compliance review period. Both Crisis
Assessments were conducted within twenty-four hours based on the needs of the youth. Both
youth records included documentation the Crisis Assessments included the reason for
assessment, Mental Status Examination and interview, determination of danger to self or others,
initial clinical impressions, supervision recommendations, treatment recommendations, follow-
up/further evaluation recommendations, and notification to parents/guardians of follow-up
treatment. The Crisis Assessments were conducted by a licensed mental health professional. A
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mental health alert was entered into the Department’s Juvenile Justice Information System
(JJIS) when the youth was placed on precautions after completion of a Crisis Assessment. Both
youth’s assessments determined they posed a safety and security risk. Both youth remained on
alert until a Follow-Up Crisis Assessment was completed. Both youth were placed on constant
supervision and this was documented on the Department’s Mental Health Alert Observation
Log. One youth was applicable for off-site care. Upon the youth’s return from off-site, the youth
was placed on constant supervision until a mental health clinical staff reviewed the off-site
assessment documents and provided a Follow-Up Crisis Assessment.
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 has an integrated mental health crisis intervention and emergency mental health
and substance abuse services plan which includes immediate staff response, notifications,
communication, supervision, authorization to transport for emergency mental health and
substance abuse services, transport for emergency mental health evaluation and treatment
under Chapter 394 Baker Act, transport for emergency substance abuse assessment and
treatment under Chapter 397 Marchman Act, documentation, training, and review.
3.17 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program maintains a written policy and procedures for an emergency response plan, which
outlines procedures for emergency mental health services, substance abuse services, Baker
Acts, and Marchman Acts. Five youth mental health records were reviewed and none of the
youth were applicable for Baker or Marchman Acts. The program provided one additional record
for review. No other youth were applicable during the annual compliance review period. The
youth record contained documentation which indicated a youth was determined to be in need of
emergency care based upon completion of a Crisis Assessment. It was also documented the
staff notified mental health staff, a Crisis Assessment was completed, and an involuntary
examination was completed by the psychiatrist. The youth was placed on constant supervision
and was on constant supervision at the time of the Baker Act. There was documentation in the
youth record mental health staff were involved during the process. The youth was taken out of
the program and transported by a county sheriff’s deputy. This transport was authorized by the
psychiatrist. When the youth returned from the Baker Act, documentation showed the youth was
placed on constant supervision and a mental health referral was completed requesting a Mental
Status Examination be conducted. A Crisis Assessment was completed by a licensed mental
health professional. The youth was maintained on a minimum of constant supervision until
properly transitioned to a lower level of supervision. The youth’s supervision was maintained
until an appropriate assessment was conducted and mental health staff conferred with the
facility administrator.
3.18 Safety Planning Process for Youth Satisfactory Compliance
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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 policy and procedures for the safety planning processes for the youth
admitted to the program. Five youth mental health records were reviewed. All five safety plans
included warning signs which indicated when a youth’s behavior is escalating, youth’s baseline
behavior, crisis recognition, jointly developed coping strategies, to include people and healthy
environments as defined by the youth, intervention strategies preferred by the youth, and
debriefing procedures. All five initial safety plans were completed within fourteen days of
admission. The safety plans were jointly prepared by the youth, parents/guardians, and clinical
staff. One of the five youth records indicated the parents/guardians did not participate; however,
there was documentation the program attempted to contact the parents/guardians. All other
youth records included documentation all parties participated in the development of the safety
plans. All five safety plans incorporated recommendations from the current clinical assessments
and screening instruments, and incorporated trauma responsive practices. All youth records
included documentation the safety plans were reviewed and updated, as necessary, at least
every thirty days. Two of the five youth records included documentation the safety plans were
updated following any significant behavioral or mental health event identified by the youth’s
intervention and treatment team. The remaining three youth were not applicable for updates
based on significant incidents. Each reviewed plan included documentation of being reviewed
by staff who have contact with the youth. The safety plans are maintained in the youth mental
health records, staff break room, dorms, supervisor’s office, and case manager’s offices. Three
youth were interviewed and reported they all contributed to their safety plans. Three interviewed
staff reported safety plans are located in the staff break rooms, all youth dorms, supervisor’s
office, case manager’s office, and behaviors of the youth can also be found on the alert board.
The staff reported they can review safety plans at any time, during briefings and debriefings
every morning, during formal and informal treatment team meetings, and for any additional
information on the youth. One staff reported reviewing safety plans a month ago for new
intakes, one reported reviewing them thirty minutes ago, and one reported reviewing them last
week. The facility administrator reported the safety plans are updated during each treatment
team as needed.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program’s designated health authority (DHA) is a licensed physician who holds an
unrestricted license and meets all requirements for independent and unsupervised practice in
Florida. The DHA license expires on March 31, 2024. The DHA’s specialty training is in family
practice with experience in adolescent health. The DHA does not have any disciplinary cases or
public health complaints on record. According to the contract, the DHA is required to be on-site
one hour each day five days a week. A review of the sign-in sheets for the annual compliance
review period indicated the DHA was on-site, as required. If the DHA has a scheduled absence,
the program has an agreement with another licensed physician to provide medical care to the
youth. The back-up licensed physician holds a clear and active unrestricted license, which
expires on January 31, 2026, and meets all requirements for independent and unsupervised
practice in the State of Florida. The back-up physician was not utilized during the annual
compliance review period. The DHA reviewed facility procedures as documented by signature
and date. There was no inclusion of telemedicine in the facility’s contract. The DHA was
interviewed, and confirmed their responsibilities include performing Comprehensive Physical
Assessments upon intake, review health-related history, chart review, lab review, provides
medical care, and reviews policy and procedures.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has two licensed practical nurses (LPNs) and five registered nurses (RNs), one of
the RNs serves as the health services administrator (HSA). A review of each RN’s license
credentials reflected each of the nurses have a clear and active license, in the State of Florida,
according to the Florida Department of Health Medical Quality Assurance website. In addition,
each of the LPNs and RNs had current cardiopulmonary resuscitation (CPR) certifications. The
required on-site hours according to the contract are seven days a week for a total of 220 hours.
The nursing staff was in compliance with the contractual requirements and nursing coverage is
provided twenty-four hours a day as required by the program’s contract.
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has a policy and procedures for all health-related protocols utilized at the program.
The designated health authority (DHA) and facility administrator (FA) signed and dated all
treatment protocols. The DHA and FA reviewed and signed protocols and facility operating
procedures (FOPs) on January 19, 2024. FOPs and protocols related to psychiatric services
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and psychotropic medication management are developed and reviewed by the program’s
psychiatrist. The psychiatrist reviewed and signed the psychiatric protocols on January 19,
2024. The nursing protocols were signed by the nursing staff on January 26, 2024. There were
no new policies or changes in policy made during the annual compliance review period. An
annual review of all FOPs and protocols was conducted by the respective individuals from each
discipline on February 6, 2024, with a signature signifying their understanding of the FOPs and
any new health-related Department policies. All newly hired medical staff receive a
comprehensive clinical orientation to the Department’s healthcare policies and procedures
conducted by the registered nurse (RN). The DHA had written and authorized approval of
treatment protocols and standing procedures which were not delegated to any other person.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a policy and procedures ensuring the completion of the Authority for
Evaluation and Treatment (AET) authorizing treatment of youth in the program’s custody. A
review of five youth Individual Healthcare Records (IHCRs) found two were applicable for the
AET forms. Two of the youth had a signed AET form filed in the record with the word “Copy”
legibly stamped on it. The AET is valid for as long as the youth is in the program or until the
youth’s eighteenth birthday. Two of the five were eighteen years of age and had a documented
release of information. One youth was in the care of the Department of Children and Families
(DCF), and a court order was included in the IHCR authorizing all treatment and procedures. An
interview with the registered nurse (RN) advised if the AET is not included, contact is made with
the juvenile probation officer (JPO) to obtain it. Once a youth turns eighteen, a release of
information is completed.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures to ensure the parent/guardian is notified of any
changes in the youth’s condition and to document informed consent for youth healthcare. A
review of five youth Individual Healthcare Records (IHCRs) found three were applicable for
parental/guardian notifications for over-the-counter (OTC) medications beyond those covered by
the Authority for Evaluation and Treatment (AET). Two of the IHCRs had consent provided by
the parent/guardian. One of the applicable IHCRs included documentation of attempted contact
to the parent/guardian in the progress notes when a new medication was ordered. Three
applicable IHCRs contained written notifications documented on the Department’s Parental
Notification of Health-Related Care: General or Parental Notification of Health-Related Care:
Medications forms, two of the youth were eighteen. Three of the youth were taking prescribed
psychotropic medications. Two of the youth were applicable for a new psychotropic medication,
change in dosage, or discontinuation of medication which was documented on page three of the
Department’s Clinical Psychotropic Progress Note (CPPN) form. A staff witness for telephone
call attempts was documented in both applicable IHCRs. One youth was in the care of the
Department of Children and Families (DCF), and a court order was included in the IHCR
authorizing all treatment and procedures. In all five IHCRs, the youth vaccinations were verified
within thirty days of the youth’s admission. An interview with the registered nurse (RN)
confirmed verbal consent is required when youth are starting a new medication, witnessed by
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another nurse. Parental/guardian notification is sent as well. Written consent is required for any
invasive dental procedures, surgeries, and vaccines. Parental/guardian notifications and verbal
notifications are also made when a youth has a psychiatric medication change, is seen by an
off-site provider, or has imaging completed. The RN reported a parental/guardian notification
and a copy of the CPPN, page three are mailed to the parent/guardian with any change to
psychotropic medications and the psychiatrist contacts the parent/guardian for verbal consent
and documents.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a policy and procedures regarding youth healthcare admission screening and
rescreening each time the physical custody of the youth changes. Five youth Individual
Healthcare Records (IHCRs) were reviewed for a Facility Entry Physical Health Screening
(FEPHS) form. All five FEPHS forms were completed by the registered nurse (RN) on the date
of the youth’s admission. None of the youth were out of the physical custody of the Department.
An interview with the RN advised notification is received by email when a youth is admitted to
the program. A nurse completes the FEPHS on the day of admission.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy and procedures ensuring all youth admitted to the program are
provided an orientation to healthcare services. A review of five youth Individual Healthcare
Records (IHCRs) confirmed all youth were provided a general care orientation upon admission
to the program. The Health Education form in all five IHCRs included access to medical care,
sick call, what constitutes an “emergency,” medication process to included side effect
monitoring, right to refuse care and how it is documented, what to do in the case of a sexual
assault or attempted sexual assault, the role of non-disciplinary healthcare providers, and
Standard Universal Precautions were discussed with the youth as evidenced by their signature
documented on the Health Education form in the youth’s IHCR.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a policy and procedures to notify the designated health authority (DHA) or
designee, by telephone or verbally, of each youth’s arrival at the program and provide
immediate notification when any youth admitted to the program requires emergency care. The
program’s practice is to notify the DHA of all youth admissions including youth with chronic
conditions, medical concerns, or any youth admitted on psychotropic medications. Five youth
Individual Healthcare Records (IHCRs) were reviewed, three of the youth were admitted with a
known or suspected chronic condition or required a referral to the DHA. None of the youth were
identified as in need of an emergency response upon admission. All records documented the
DHA notification in the youth’s Chronological Progress Notes and the Chronic Conditions Log
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was updated after the notification. Three youth were applicable for taking psychotropic
medication upon admission, and notification to the psychiatrist was documented. According to
an interview with the registered nurse (RN), the DHA is notified by phone or on-site upon
completion of intake.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a policy and procedures ensuring the Department’s Health-Related History
(HRH) form is completed prior to the Comprehensive Physical Assessment (CPA) and
healthcare needs are identified. A review of five youth Individual Healthcare Records (IHCRs)
found each HRH was completed on the day of the admission. All five IHCRs indicated the HRH
form was completed prior to the CPA to include the date and signatures. In all IHCRs, the
designated health authority (DHA) reviewed the HRH form as evidenced by a checkbox on the
CPA and a focused note in the admission documentation. An interview with the registered nurse
(RN) confirmed the HRH is completed upon intake. It is reviewed annually as well and updated
when necessary.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a policy and procedures ensuring the acute and chronic healthcare needs of
the youth are addressed by completing a Comprehensive Physical Assessment (CPA) within
seven days of youth admission. A review of five Individual Healthcare Records (IHCRs)
confirmed the program utilized the Department’s CPA form. All CPAs were completed by the
designated health authority (DHA) within seven days of the youth’s admission to the program.
All five had the youth’s Medical Grades documented on the CPA. The program completes a new
CPA for all youth, no prior CPAs were utilized. All sections of the CPA were completed in full
utilizing “O” or “X” markings. All five youth refused the genital exam which was documented as
“youth refused” on each CPA in the IHCRs, all five youth signed a refusal form which reflected
the refused portion on the CPA. The CPA in all five records included documentation of the most
recent verified Tuberculosis Skin Test (TST), which was administered within the last year to
determine exposure to tuberculosis (TB). The results of the TST were documented on each
youth’s CPA and matched the documentation on the Department’s Infectious and
Communicable Disease (ICD) forms. The Department’s Problem List was updated for each
youth, when applicable. An interview with the registered nurse (RN) confirmed a CPA is
completed upon admission and annually thereafter. The youth are screened for TB yearly.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures to ensure all youth admitted to the program are
screened, evaluated, and treated, if applicable, for sexually transmitted infections (STIs) and
human immunodeficiency virus (HIV). The designated health authority (DHA) determines, based
on the youth’s risk factors, screening tool, and evaluation, whether to order testing for STIs. A
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review of five Individual Healthcare Records (IHCRs) found all youth were clinically screened
and evaluated for STIs on the date of admission. All five of the IHCRs were applicable for
further evaluation or referred to the DHA, which was documented on the Department’s Sexually
Transmitted Infections form. All testing, screening, clinical evaluations, and diagnoses were
documented on the Department’s Infectious and Communicable Diseases (ICD) forms,
excluding the HIV results, and were filed in the lab section of the IHCR. None of the youth were
out of the Department’s physical custody; therefore, a rescreening was not applicable. All five
youth were offered pre/post-test counseling, testing, and referral for treatment for HIV. Two
youth consented to receive a HIV test and had documented consent from the youth. The HIV
results were filed confidentially in a sealed envelope marked “Confidential”. Each of the
envelopes were signed by the DHA indicating their review. Pre/post-test counseling was
documented on the Individual Health Education Record in each applicable record. The youth’s
confidentiality was protected by not including the youth’s HIV status on the program’s internal
alert system. The program’s policy ensures the youth’s HIV test results are only disclosed to the
youth’s legally authorized representative, healthcare providers during treatment, the Department
of Health for purposes of reporting, health facility staff committees conducting facility monitoring,
medical personnel who have been subject to significant exposure, and healthcare facility
personnel or agents for healthcare provider who have a need to know during patient care. Pre
and post-test counseling services are provided by the DHA. Three youth were interviewed and
all three advised they can request testing. An interview with the registered nurse (RN) confirmed
youth provide a urine sample upon admission and if requested later for STI testing. Results are
documented on the ICD form and the Health Education Record is updated.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a policy and procedures addressing the program’s sick call process. None of
the youth presented with a similar sick call complaint three or more times within a two-week
period. Three of five youth had a sick call request, addressed by the registered nurse (RN).
Each of the Sick Call Request forms were filed in each youth’s Individual Healthcare Record
(IHCR) in reverse chronological order. None of the youth were in restricted housing of any kind.
The Sick Call Request forms and progress notes were documented in accordance with Florida
Administrative Code, including vital signs, treatment, education, and follow-up plans. Each of
the sick call events were documented on the Sick Call Index and on the program’s Sick Call
Referral Log. All the dates listed on the Sick Call Index corresponded to the completed Sick Call
Request forms located in the youth IHCRs. Sick call occurs seven days a week, twice a day.
Sick call hours are posted on the medical office door, in the education area, and dorms. Sick
call forms are located on each dorm. An exam table and equipment are used to perform sick
call. Sick call was not observed during annual compliance review as none occurred. Three
interviewed staff advised the nurse reviews and conducts sick call. Three youth were
interviewed and all advised they can see a doctor or dentist if needed. Two youth advised being
seen within one day for sick call, and one youth advised within three days. the facility
administrator indicated the youth will be re-educated on the process for sick call to ensure youth
are seen within twenty-four hours. The nurse advised youth are seen for sick call, and the visit is
documented and placed on the list to see the designated health authority (DHA). The program
provides twenty-four-hour medical care.
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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 has a policy and procedures to ensure the youth have access to episodic and first-
aid care. A review of five youth Individual Healthcare Records (IHCRs) found five youth required
on-site episodic care. In all five IHCRs, the on-site care was provided by a licensed healthcare
staff documented including the problem-oriented, subjective, objective, assessment, and plan
(SOAP) elements. The program has a total of ten first-aid kits located in designated areas
throughout the program. The kits are in the kitchen, maintenance, alpha, bravo, charlie, delta
(dorms), multipurpose room, and four for transport. The program has a process for ensuring
contents of the first-aid kits are maintained and stored in accordance with guidelines to prevent
expiration or deterioration. An observation of three first-aid kits confirmed the kits were fully
stocked with designated health authority (DHA) approved contents. The nurse monitors the first-
aid kits weekly and checks for expired contents, which is documented on the first-aid kits logs.
The program has two automated external defibrillators (AEDs) located in medical and charlie
dorm. The AED procedures are located with the AEDs. The AED batteries and pads are
checked by the registered nurse (RN) once a month. Documentation confirmed the RN
monitored the AEDs as required. The RN checked the expiration dates of the AEDs in the
presence of the Monitoring and Quality Improvement regional monitor. The nurse conducted a
self-test of the AEDs in front of the regional monitor. The batteries of the AED were last
changed in July 2023 and expire in March 2027. The AED pads were changed December 2023
and expire in February 2029. A review of the emergency drills confirmed the program conducted
an emergency drill to include cardiopulmonary resuscitation (CPR)/AED annually. The
emergency medical drills simulated an episodic care event which called for immediate first-aid
and/or administration of CPR techniques, and the initiation of emergency procedures to follow
when a life-threatening emergency does occur. The program had a list of emergency numbers
which were inaccessible to youth. The emergency numbers are posted in master control,
medical, and administration. A review of ten training records confirmed all staff were trained in
episodic, first-aid, and emergency care, and the administration of the epinephrine auto-injector.
The program has a facility operating procedure (FOP) regarding Narcan. The policy states all
newly employed staff and admitted youth shall receive education on recognizing and treating
symptoms of opioid overdose. Training will include risk factors for overdose, strategies to
prevent overdose deaths, overdose recognition and response, and administration of Narcan.
The training and prevention plan also includes emergency response procedures. Narcan is
stored in medical and inventoried along with other medication. Supervisors are trained on the
use of Narcan. Three interviewed staff confirmed they could call 9-1-1 in the event of an
emergency. Three youth were interviewed and all confirmed they can see a doctor if needed.
The RN advised episodic care is documented on an episodic note and in the episodic logbook.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a policy and procedures to ensure for timely referrals and coordination of
medical services to an off-site healthcare provider. A review of five Individual Healthcare
Records (IHCRs) found all were applicable for off-site care. In all five IHCRs, there was an
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indication the youth required off-site first-aid or emergency care. The Department’s Summary of
Off-Site Care Consultation Report form was utilized and filed in the youth’s IHCR. Two IHCRs
had documentation of the parent/guardian notification efforts, one youth was in the custody of
the Department of Children and Families (DCF), who was notified, and two youth are eighteen
and did not require parent/guardian notification. Four youth were applicable for discharge
documentation, and each had the applicable documents filed in the IHCR. The DHA reviewed
and signed all off-site care findings, instructions, and information in each of the four IHCRs.
Three of the youth required follow-up testing, referrals, or appointments. The IHCRs had
documentation the referrals were tracked, and the youth received appropriate and timely follow-
up care. The registered nurse (RN) confirmed all completed off-site care forms are flagged for
DHA review, and youth are tracked utilizing a medical tracking log and a white board within the
medical area.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a policy and procedures to ensure any youth admitted to the program who
have chronic conditions receive regularly scheduled evaluations and any as-needed follow-up
care. A review of five youth Individual Healthcare Records (IHCRs) found three were identified
on the Department’s Facility Entry Physical Health Screening (FEPHS) form with a current
chronic condition at admission. None of the youth were identified as having a communicable
disease. Two of the youth were taking prescribed medication on an on-going basis. One youth
was undergoing treatment for a physical health condition. All three youth were classified with a
Medical Grade of two to four, were placed on the program’s Chronic Illness List, and received
periodic evaluations at least every ninety days. None of the youth were applicable for taking
anti-tuberculosis medications. One youth had an evaluation conducted off-site, and the
evaluation was documented on the Summary of Off-Site Care form and filed in the IHCR. There
was no evidence of any lapses in care or missed periodic evaluations. The Department’s
Problem List was updated for each youth. An interview with the facility administrator (FA)
advised meetings with healthcare staff are held daily. The program meets daily with medical
staff to discuss all medical issues pertaining to youth. The designated health authority (DHA)
interview confirmed youth with chronic conditions are seen every ninety days and tracked with a
chronic tracker at the program. The nurse confirmed the appointment dates are kept on a
medical tracker and on a calendar in the DHA binder.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program has a policy and procedures to ensure the accurate and safe administration of
youth medications. A review of five youth Facility Entry Physical Health Screening (FEPHS)
forms found five youth were taking medication at the time of admission. Each of the youth
medications were verified prior to the youth being admitted into the program, and the
prescription notification was documented in the youth’s Chronological Progress Notes. The
designated health authority (DHA) and, when applicable, the psychiatrist was contacted to
obtain an order to resume the specified medications prescribed prior to admission for each
youth. Each of the five reviewed youth Individual Healthcare Records (IHCRs) documented the
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youth received medication while in the program and all medications were continued,
discontinued, changed, or new medications ordered utilizing the Practitioner Order form. Each
medication had a current and valid prescription or order. None of the youth were in restricted
housing of any kind. Two of five youth were applicable for over-the-counter (OTC) medications,
which were administered according to approved protocols. The Department Medication
Administration Record (MAR) was used to document all medications and treatments for all
reviewed IHCRs. The MAR clearly indicated medication start and stop dates of the youth’s
medications. In all applicable IHCRs, the staff initialed each administered medication entry.
There were no undocumented explanations for lapses or errors in medication administration for
any of the reviewed IHCRs. The registered nurse (RN) documented side-effects monitoring
weekly on the MAR for all five reviewed IHCRs. There were no medications administered by
non-healthcare staff. The MAR contains all required elements. There were no indications of
lapses or errors in medication administration. Three youth had refusals, which were clearly
documented on the MAR. Each of the five youth were admitted to the program on psychotropic
medications and the psychiatrist was notified. Each youth received a psychiatric evaluation
within fourteen days. None of the youth were applicable for psychotropic medication subsequent
to admission. There were no standing orders for psychotropic medications, emergency
treatment orders for psychotropic medication, or any pro-re-nata (PRN) orders for psychotropic
medications. A medication pass was observed. The youth were escorted by the direct care staff
and approached the nurse individually. The medical provider identified themself and confirmed
the reason the youth was present. The medical provider prepared the medication and verified
the youth’s allergies and alert status. The medical provider and youth initialed the MAR, and the
medical provider observed to ensure the medication was swallowed. The Six Rights of
Medication Delivery/Administration were maintained for each youth. Three youth were
interviewed, and all advised a nurse provides medication and could explain the process. Three
staff were interviewed all advised a nurse provides the medication. An interview with the nurse
confirmed the pharmacy utilized, and advised two nurses destroy all medications except
controlled medication, which is destroyed by one RN and a pharmacy inspector.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a policy and procedures to ensure medical equipment classified as
sharps/medications are secure and inventoried utilizing a routine perpetual inventory. A review
of the medical equipment classified as sharps confirmed the items were securely stored and
inventoried utilizing a routine perpetual inventory descending count. All medications were
identified and secured in a locked medication cart designated for storage of medications. The
medication cart was secured, clean, and organized with stock items separate from youth-
specific medications. All medications were stored in a separate, secured area, inaccessible to
the youth. Narcotics and other controlled medications were stored behind two locks, refrigerated
medication was stored in a secured refrigerator only used for medication. The program has a
process for the destruction and disposal of medications. Two nurses destroy all medication
except controlled medication which is destroyed by one registered nurse (RN) and a pharmacy
inspector. The program conducts a perpetual and weekly inventory of all sharps and stock over-
the-counter (OTC) medications which did not indicate any discrepancies. The nursing staff
maintain a shift-to-shift inventory of all controlled substances, in the event a youth is prescribed
a controlled substance, and documented this on the youth’s Individualized Controlled
Medication Inventory Record. The number of pills, tablets, or dosages remaining were
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documented on the youth’s Individualized Controlled Medication Inventory Record after each
administered dosage. Six supervisory level staff were trained in the delivery and oversight of
medication self-administration. The training was provided by the RN. Observations were
conducted of inventory counts of three controlled medications, three OTC medications, and
three sharps. All inventories were correct with no discrepancies. The RN reported if there is a
discrepancy in the count, the health services administrator (HSA), designated health authority
(DHA), and facility administrator (FA) shall be notified immediately, and a call to the
Department’s Central Communications Center (CCC) will be placed. The interview with the
nurse confirmed medications are secured behind two locks and inventoried weekly and
perpetually.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a policy and procedures related to an Infection Control and Exposure Control
Plan. The Infection Control and Exposure Control Plan is signed annually and was reviewed and
signed by the designated health authority (DHA) on February 2, 2023, and facility administrator
(FA) on February 2, 2023. The program’s infection control procedures include prevention,
containment, treatment, and reporting requirements related to infectious diseases, as according
to Occupational Safety and Health Administration (OSHA) federal regulations and the Centers
for Disease Control and Prevention (CDC) guidelines. The plan addresses common infectious
diseases of childhood, self-limiting, episodic contagious illnesses, viral and 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 offers Hepatitis B immunizations to staff. Staff
have access to personal protective equipment. The program has a comprehensive process for
needle stick post-exposure evaluation. The program has a separate file containing all
documents of youth and staff who have experienced a program or occupational exposure. An
interview with the FA confirmed the plan is located in the staff station. An interview with the
nurse confirmed exposure control training is provided by the registered nurse (RN).
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program therefore is indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Limited Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures stating how the program shall maintain active
supervision of youth at all times. Active supervision is described as interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of youth
and changes in behavior, and consistently applying the behavior management system.
Additionally, program staff shall be able to account for the whereabouts of youth under their
supervision at all times. Observations of staff during the annual compliance review week found
staff supervising youth appropriately during all observed activities. According to the policy and
procedures provided to the annual compliance review team, staff-to-youth ratios are one staff to
eight youth during awake hours, one staff to ten youth during sleep hours, and one staff to five
youth for off-site activities. Observed activities made during the four-day annual compliance
review week were supervision of youth during school hours, in the dining area, recreation,
supervised cleaning activity, and youth movement through the program. The daily schedules
were posted in the dormitories, common areas, and cafeteria. Youth were observed to be
supervised at all times during the annual compliance review week. Positive interactions were
observed between youth and staff. Youth were observed while they were in their sleeping
rooms. Three interviewed staff confirmed their understanding of the procedures when there is a
discrepancy with the count. Three staff indicated movement is stopped and the count is
reconducted until the count is reconciled. Observations found the counts were conducted at
scheduled and unscheduled times and the shift supervisor was able to give an accurate count
when asked.
During the annual compliance review period the program had an escape which resulted in an
outcome based corrective action plan (OBCAP) for youth supervision. As a result, this indicator
will be rated as limited compliance.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program maintains a policy and procedures addressing the implementation and training of
the program’s behavioral management system (BMS), which has not changed since the last
annual compliance review and contains all the required elements. The program utilizes the
iChoose System BMS which is a coordinated system of promoting, monitoring, recognizing, and
rewarding a youth’s progress. It is a program of incentives and consequences which promote
individualized skill building, appropriate behavior, and accountability. Staff use point cards to
monitor how well the youth are progressing in the program. Youth earn points daily for
complying with the program rules. At the end of each day, the points are totaled, and the youth
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are rewarded based on the number of points earned. Each youth enters the program on an
orientation level prior to starting the BMS and progresses their way up the four levels. Six
interviewed youth, three from each program, were able to explain how the level system of the
BMS works. A review of the BMS confirmed it is not used solely to increase a youth’s length of
stay, deny basic rights or services, promote the use of group punishment, allow youth to punish
other youth, or include disciplinary confinement. All three interviewed youth reported youth are
not allowed to punish other youth. Youth learn about the BMS during the orientation process.
Each youth is provided a program handbook which describes the BMS. A review of the youth
handbook indicated the BMS is included and clearly written. A review of five staff training
records indicated staff were trained on the BMS. Additionally, education staff are TrueCore
Behavioral Solutions staff, and each received BMS training by the regional training manager
within the last year. A review of five youth case management records indicated each youth
participated in orientation upon arrival to the program and received a copy of the youth
handbook. Observations found the BMS was posted throughout the program. Observations of
staff and youth interactions verified staff were adhering to the BMS by utilizing a ratio of four-to-
one positive to negative consequences when redirecting the youth as indicated in the program’s
policy. Three staff were interviewed, and all three reported they were trained in the BMS. Three
staff stated the BMS consists of a point system, with two of three reporting it includes rewards
and consequences, and one stating the BMS includes a level system. The interviewed staff
stated the BMS rewards youth with daily and weekly incentives including snacks, game nights,
pizza night, ice cream, off-site activities, and canteen. Each of the three interviewed staff stated
nothing can be taken away from a youth as a consequence, youth are informed of the
consequences of their behavior, and are able to explain the reason for their behavior. The three
interviewed staff reported the supervisors inform staff on how the BMS should be utilized and
provide feedback during shift briefings and after reviewing youth point cards. Three youth were
interviewed, and each youth stated the consequences included level freezes and early bedtime.
Three youth reported they receive daily and/or weekly incentives such as special meals, snacks,
reward parties, and canteen. Each youth was familiar with the program’s BMS level system and
each stated youth are not allowed to punish other youth. All three youth report staff use rewards
the same. One youth said the BMS is good, one said poor, and one said very poor. An interview
with the facility administrator (FA) confirmed the program utilizes the iChoose System BMS and
reiterated the program’s BMS policy.
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
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room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a policy and procedures 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 177
video cameras capable of storing thirty-days of video footage. During the annual compliance
review week, 166 of the cameras were operational. Prior to conducting checks, staff are
positioned where they are able to see any movement within the living unit. 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. The program’s practice is to complete checks at eight
minute intervals. A video review of ten-minute checks, including samples from each of the living
units, verified staff were conducting checks every eight minutes and documented the times
accurately on the Ten-Minute Check Log. In addition, the Ten-Minute Check Logs since the last
annual compliance review were reviewed. A sample of various days, times, and shifts indicated
the ten-minute checks were completed within the required frequencies. Three interviewed staff
verified room checks were conducted every eight to ten-minutes when a youth is placed in their
room for sleeping or non-punishment reasons. In a formal interview, the facility administrator
(FA) stated the program has 177 cameras with video recording storage capabilities for thirty-
days.
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 maintains a 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 conducts formal head counts each hour and after outdoor activities. The program’s
policy indicates counts are conducted during power outages, escapes, program disturbances, or
any other disruptions which may occur. A review of the policy and procedures and well as the
Continuity of Operations Plan (COOP) verified program staff must always account for the
whereabouts of the youth in the care and custody of the program. This includes the need for
continual head counts to be conducted minimally at the beginning of each shift, during any
emergency situations, and at regular intervals. A review of twelve randomly selected dates and
times in the program’s logbook since the last annual compliance review validated head counts
were conducted at the beginning of each shift, hourly, after outdoor activities, during emergency
situations such as program disturbances, and during actual and/or simulated drills. In addition,
the program logbooks included documentation of new admissions, releases, transfers, and
youth temporarily away from the program. Observations made during the annual compliance
review week indicated it is the program’s practice to conduct hourly youth counts and to
announce youth counts before all movement. Three interviewed staff explained formal counts
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are conducted every hour. Each staff stated emergency counts are conducted anytime a code is
called which includes escapes, if there is a discrepancy in the count, and during drills. During
the annual compliance review week, the youth census was eighty-six youth. Two of the three
interviewed staff knew the youth census during the annual compliance review week, one staff
stated eighty-four youth.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a policy and procedures to ensure the maintenance of a chronological
record of events, incidents, and activities in a central logbook. The program maintains a bound
logbook with numbered pages for each month. Observations and a review of logbooks since the
last annual compliance review found the back covers of some logbooks were missing or falling
off. The logbooks daily pages were limited in space, if additional entries were needed, a blank
entry page was stapled to the book to add additional information. A review of logbook entries
confirmed they were documented in ink with no erasures or white-out areas. Errors were
struck through with a single line, dated, and initialed by the staff correcting the error.
Reviewed documentation of randomly selected days within the logbooks reflected each entry
included the date and time of the event, the name of the staff and youth involved, as well as a
brief description, the name, and signature of the staff making the entry. Logbooks included
entries for emergency situations, population counts, law enforcement access to youth, perimeter
checks, and youth movement. In addition, admissions and releases were documented as well
as transports away from the program. A review of precautionary observations (POs) reflected
the start of the POs were not entered into the logbook, however, the step-down in supervision
was logged. A review of the activity schedule and logbook documentation verified there was
minimal interference of education instruction. Logbook entries for education included youth
movement to and from the classrooms and school start and end times. Logbook entries and
observations verified recreation was conducted as scheduled. A review of internal incidents
reported to the Florida Abuse Hotline and/or the Department’s Central Communications Center
(CCC) verified each was documented in the logbook. The program ensures direct care staff,
including each supervisor, are briefed when coming on duty. Each staff signs the shift briefing
section of the logbook to acknowledge receiving the information.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures for assignment, inventory, tracking, and storage of
program keys. Keys are bound on a tamper resistant ring which includes a brass-colored tag
with the number of keys and a tracking number. The facility administrator (FA) is responsible for
inventory and tracking of all program keys including issuance, verification activities, and tracking
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of keys including retrieval of keys from permanent staff. Shift supervisors with the assistance of
the master control operator are responsible for the inventory, issuance, and return of keys from
shift to shift. Observations verified program keys and staff personal keys are maintained in
master control in a secured cabinet with a lock. The program has a Daily Key Log to track keys.
The log indicates the name of staff and what type of key they are to be assigned according to
their position. The program maintains a master inventory list of program keys. A random check
of five different sets of program keys compared to the inventory list indicated the keys were
accounted for. The program identifies keys as active and restricted which are kept in a locked
drawer below the key cabinet in master control. Active keys are assigned to direct care staff
while restricted keys are designated for medical staff, kitchen staff, case managers, and
therapists. The program’s practice is when staff arrive at the program, personal keys are
collected by master control and placed in the key cabinet. Active program keys are given to staff
by master control who also document in the key logbook. A review of the key logs since the last
annual compliance review verified this practice. In addition, the program has a list of staff who
are assigned permanent keys. Permanent keys are issued, and staff sign an acknowledgment
form indicating the key identification number and the number of keys issued. A review of the
signed acknowledgment forms indicated each staff signed for the use of permanent keys. A
random check of three staff indicated they had program keys, knew the number of keys on the
key ring, and knew the function of each key. If a key becomes damaged, a Broken Key Report
is filled out which includes the date, reporting staff, key hook number, key number, description,
and attach the broken key with tape. The shift supervisor and key control manager sign the form
and the key is replaced. If the key is stuck in the lock, a Maintenance Work Order form is filled
out for maintenance staff to remove the broken key. A review of the Department’s Central
Communications Center (CCC) reports since the last annual compliance review indicated there
were no incidents related to key control. Three staff were interviewed, and each stated program
keys are assigned to staff and there is a daily tracking of keys. Two staff also reported staff and
visitor keys are given to master control upon entry, personal keys are securely stored, they are
to notify master control of missing keys, and the facility is searched when keys are missing. One
staff reported youth do not have access to keys, and the youth are searched when keys are
missing.
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
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return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a policy and procedures to identify materials considered to be
contraband, to prevent contraband from entering the program, and consequences when found
in the possession of youth in the program. The program has a system in place to prevent
contraband entering the facility which includes defining items/material considered contraband,
exemptions, providing youth with a list of contraband, informing youth of consequences if found
with contraband, and searches of the physical plant, program grounds, youth, and incoming and
outgoing mail. The facility visitor log and all ten sampled staff personnel records contained a
signed contraband attestation statement. All ten of the new hire staff records contained the
contraband attestation statement. The attestation statement addresses any staff who is found in
possession of contraband in a program will be subject to disciplinary action up to and including
dismissal as outlined in Florida Administrative Code. The policy also states law enforcement will
be contacted if any found item is considered illegal as defined in Florida Statutes, or if there is
evidence of any type of unlawful activity. The program clearly delineates those items considered
contraband and keeps a contraband log documenting the focus of the search, items found, and
the disposition of any items found. There were no incidents of illegal contraband turned over to
law enforcement or reported to the Department’s Central Communications Center (CCC) during
the annual compliance review period. The program logbooks, search and contraband logs, and
incident reports were reviewed to determine frequency and quality of searches and the results
of each search, and each was found to be in compliance with policy. In an interview the facility
administrator (FA) stated any suspicion of youth, staff, or visitor having contraband shall be
dealt with immediately to ensure the safety and security of the program. The FA reaffirmed the
program’s policy shall be followed, to include preserving evidence for law enforcement and
required outside reporting procedures. Three staff were interviewed and each reported weekly
contraband searches, done on a rotation and on random days, are completed for youth rooms.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a policy and procedures to ensure searches, including full body visual
searches, are conducted according to Florida Administrative Code at the time of admission,
after off-site activities, and visitation. Parents/guardians are notified of searches during
visitation by way of the parent/guardian intake letter, which is mailed at the time of each youth’s
admission. Youth are searched after school, group, outdoor recreation, and meals. Youth who
are a new admission, readmission, returning from visitation, returning from off-site activities
and/or appointments, suspected of contraband, or are a security risk are full body searched.
Observations made throughout the annual compliance review week validated youth are
provided instructions regarding the search, youth searches were conducted by staff of the same
gender as the youth, were conducted in a manner so as not to degrade the youth, and were
based on the Protective Action Response (PAR)/Right Interactions (RI) training manuals.
Searches observed during the annual compliance review week verified youth were searched
after every movement. Youth searches were observed following the use of cleaning tools,
verifying searches are conducted according to policy. Observed searches were completed
thoroughly and respectfully. Youth appeared to be comfortable and accustomed to the process.
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Three staff were interviewed, and each reported youth are searched after every movement by
same gender staff. Three youth were interviewed, and all indicated searches occur prior to all
movement from one location to another.
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 center maintains a policy and procedures for transportation, operation, and maintenance of
each vehicle used to transport youth. The center has a total of five vehicles of which four are
used to transport youth. Two of the vans are Department issued and three are provider-owned.
Each vehicle had an annual safety inspection conducted by a certified automobile mechanic.
Observations of the four program vehicles were conducted, the remaining vehicle is not used for
youth transports. Observations verified each vehicle was locked when not in use. The four youth
transport vehicles have the appropriate number of seatbelts, a safety screen, a seatbelt cutter, a
window punch, up-to-date fire extinguishers, and an assigned first-aid kit with approved items by
the designated health authority (DHA). First-aid kits are stored in master control until the vehicle
is in use. Weekly visual vehicle inspection checks are conducted on all vehicles as required and
documented on the preventative maintenance check sheets. The four observed vehicles had
working seatbelts and the passenger doors could not be opened from the inside. A random
check of five staff personal vehicles and five program vehicles during the annual compliance
review week found all the vehicles were locked and secured when not in use.
Three staff were interviewed, and each stated youth are secured in the vehicle with
handcuffs, leg shackles, and by wearing the seatbelt. Three youth were interviewed. Two youth
reported they are required to wear seatbelts and the third youth reported never being on a
transport.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a policy and procedures to ensure the safety and security of youth and
the community when youth are transported outside of the program. Reviewed documentation
verified all approved drivers had a valid driver’s license. The program assigns a ratio of one staff
to five youth during transport, not including the driver. The program provides secure
transportation for secure high and maximum-risk youth determined to be at greater risk. An
observation of a transport was unable to be conducted, as there were no off-site events or
appointments planned for the annual compliance review week. Logbook entries with names of
staff transporting youth reflected at least one staff of the same gender as the youth is on each
transport. Three staff were interviewed, and each staff confirmed they are not allowed to use
personal vehicles to transport youth. Three interviewed staff verified staff bring cellular
telephones during transports and two also stated two-way radios. Two interviewed staff stated
the safety equipment in the transport vehicles included a first-aid kit and a fire extinguisher. Staff
also reported each vehicle contains a logbook, wheel lock device, handcuff key, jack and spare
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tire, and a window punch. All three interviewed staff stated the transport vehicles are searched
for contraband prior to and after each use. Each of the three staff know what to do in case of an
emergency during a transport. The three staff reported a minimum of two staff are required for
transports. Three interviewed youth stated they are secured in the vehicle using seatbelts. Each
interviewed youth stated they never witnessed anyone placing contraband in a transport vehicle
and they indicated staff were driving transport vehicles safely.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a policy and procedures to ensure safety and security is maintained.
The policy addressed who is responsible for conducting weekly audits, procedures to implement
corrective actions for deficiencies, and an internal system to verify deficiencies are corrected.
Weekly safety and security audits are conducted by the maintenance manager or designee
and documented on the Safety and Security Audit Inspection form. Any deficiencies are
addressed on the form and a work order is submitted to the appropriate staff for corrections. In
addition, deficiencies are discussed during the morning management meeting. A review of the
safety and security inspection forms since the last annual compliance review indicated
inspections were completed, as required. The program’s Preventive Maintenance Checklist was
reviewed and ensured maintenance schedules and repairs were conducted as required. In a
formal interview, the facility administrator stated weekly safety and security inspections and
daily perimeter checks are conducted, and any deficiencies identified are discussed amongst
the management team and addressed, as necessary.
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 maintains a policy and procedures to have a tool management system which
ensure youth do not use tools or equipment as weapons or for security breaches. The policy
addresses the issuance, inventory, and control of equipment and tools. A review of inventory
logs and observations verified tools are securely stored when not in use, easily marked for
identification, inventoried prior to, and following work activities. All sharp edged and pointed
tools are inventoried daily when in use. A review of six unique tools in the maintenance area
and four unique tools in the bravo dorm verified the inventory matched the inventory list. The
maintenance staff are responsible for conducting the inventories and securely maintaining all
Class A tools and equipment. The maintenance staff complete a tool inventory list which
documents each tool in inventory. All maintenance tools were inaccessible to youth and were
observed to be secured in the maintenance area. Observations of the tool storage area found it
was organized and secure. Class B tools including mops, brooms, and buckets are maintained
in locked closets by each dormitory and in a locked closet in the kitchen area. The items are
used by staff and youth when performing daily cleanup activities. Staff are required to complete
a sign-out and sign-in log when items are taken and are returned to the designated storage
room. A review of five staff training records and five youth case management records indicated
staff and youth are trained in the safe use of Class B tools. Reviewed documentation verified
there were no instances of missing or lost tools since the last annual compliance review.
Prohibited tools at the program include machetes, bowie knives, and other long bladed knives.
According to the program policy, if a tool is broken or inoperable, the maintenance staff is
alerted and makes a notation on the inventory log. The maintenance manager is responsible for
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replacing the broken tool. If a tool is missing, staff shall notify administration, fill out an incident
report, document the incident in the logbook, place a tag on the shadow board, call the
Department’s Central Communications Center (CCC), and the program shall be searched until
the tool is found.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries. A review of the program’s procedures verified staff
are required to complete a sign-out and sign-in log when Class B tools are taken and are
returned to the designated storage room. A risk assessment is completed by the case
manager prior to youth using any tools. Five youth case management records were reviewed,
and each youth had a Youth Risk Assessment completed by the case manager. The
program’s staff-to-youth ratio during a work project is no less than one staff to five youth.
Program staff search youth after a work detail has been completed. An observation of youth
using a broom to sweep the common area of the dormitory verified the youth were properly
supervised while sweeping and searched before returning to regular activities. Three youth were
interviewed. All three youth stated they use mops and brooms, with one youth reporting they
use scrub brushes. Three staff were interviewed, and each stated youth are allowed to use
mops, brooms, and scrub brushes.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures establishing guidelines for outside contractors who
come on-site to complete repairs. The program's policy stipulates the facility administrator (FA)
is responsible for providing approval and permissions if a personal cellular telephone and/or
equipment/electronic devices capable of taking pictures and/or audio or video recordings,
including smart watches, are required. The program’s procedures specify tools are restricted to
only the
tools needed for the job, tools are checked upon arrival and departure, and youth are restricted
from the work area. When a contractor arrives on-site, they sign the Outside Contractor On-Site
Work Project Log which includes the vendor’s name, date, time in, a list of tools needed for
the job, the beginning quantity of tools and ending quantity of tools, staff name checking the
tools, and date and time out. The form states the vendor must report any lost tools to
administration immediately. A review of vendor sign-in sheets since the last annual compliance
review confirmed tools and other equipment were inventoried when the vendor arrived and
inventoried when they left. Three reviewed project invoices showed the date of the project
matched the vendor sign-in sheets. Outside vendors are accompanied by staff to the work area
and youth access is restricted from the work area. Staff must supervise vendors in the work
area where youth are located. An observation of vendors cutting the facility grass was
conducted and youth were restricted from the work area.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
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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’s Continuity of Operations Plan (COOP) addresses fire, safety, evacuation
emergency processes, and the frequency of conducting drills at random times and under varied
conditions. Reviewed documentation validated fire drills were conducted for all shifts each
month, as required. In addition, the program conducted emergency drills on each shift ensuring
fire, riot, severe weather, flooding, terrorist threats, chemical spills, medical situations, and
bomb threats were covered on a rotating basis. Drill documentation included the type of drill,
date and time, participants, a brief scenario description, deficiencies identified during the drill,
and applicable corrective actions. Observations of the program during the annual compliance
review week indicated there were thirty-eight annually inspected fire extinguishers, and egress
plans are posted throughout the program. Three interviewed staff all reported they have
participated in fire and escape drills since the last annual compliance review. In addition, two of
the three staff reported they have participated in weather, major disturbance, bomb threat,
hostage situation, chemical spill, flooding, and terrorism drills. Three youth were interviewed,
and two stated they have been instructed on what to do in the case of a fire, one youth stated
they have not participated in a fire drill. One interviewed youth stated fire drills were conducted
monthly and one youth reports there has only been one since he was admitted. An interview
with the facility administrator (FA) indicated the program maintains a drill calendar which
includes drills for fire prevention, mental health, medical emergencies, severe weather, bomb
threats, and hostage situations. Drills are conducted randomly, and on each shift, at least
monthly for fire and quarterly for the remaining 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 maintains a Department approved Continuity of Operations Plan (COOP) available
for all staff to review. The COOP was submitted on February 1, 2023, and approved by the
Department on February 21, 2023. The COOP provides for basic care and custody of youth in
the event of an emergency or disaster. The COOP also addresses phases of a disaster plan as
well as emergency management including preparedness, response, and recovery. The COOP
addresses emergencies including fire prevention, bomb threats, evacuations, chemical spills,
severe weather, and terrorist attacks. A review of the plan indicated alternative housing has
been identified should the program require an evacuation due to an emergency or disaster. The
program also has provisions of equipment and supplies maintained in the kitchen, the
maintenance building, and the assistant facility administrator’s (AFA) office to ensure a
continuous operation of services during emergency or disaster situations. In addition, the
program has a generator to provide continuous power from ten to fourteen days. The program
maintains identifying information on each youth in the program, and in the event the program
has to evacuate the youth record accompanies the youth to the temporary location. A review of
five youth records indicated each has the youth’s name, Department identification number,
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admission date, gender, race, contact information, emergency contact, assigned juvenile
probation officer (JPO), committing judge, victim information, physical description, health status,
and a photograph. The interviewed facility administrator (FA) reported the copy of the COOP is
maintained in master control and the FA’s office.
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 policy and procedures for the storage and inventory of flammable,
poisonous, and toxic materials. Toxic items are stored outside of the program in a locked shed.
Cleaning supplies are located in the locked closets by each dormitory and in a locked closet in
the kitchen area. A list of staff which includes the facility administrator (FA), assistant facility
administrators (AFAs), supervisors, and maintenance staff designates they are authorized to
handle flammable, poisonous, and toxic materials. All flammable, poisonous, and toxic materials
are stored according to type and use. A Safety Data Sheet (SDS) binder is located inside the
storage area with a picture of each material and a number corresponding to the SDS for each
chemical. A perpetual chemical inventory list is maintained, and the chemicals are checked
daily. A review of the inventory list verified this practice. The perpetual inventory form identifies
the chemical number, description, amount used, amount remaining, date chemical is used, and
initial of staff. Observations of the storage area indicated it is clearly marked hazardous
chemicals and securely locked. A review of five unique chemical inventories were compared to
the actual items in the storage areas and verified the inventory was correctly documented.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a policy and procedures prohibiting youth from handling any flammable,
poisonous, and/or toxic items or materials. Youth are not to clean, handle, or dispose of any
toxic chemicals, biohazardous bodily fluids, or human waste. Youth are strictly prohibited from
the maintenance area where toxic items and chemicals are stored. Three youth were
interviewed, and all three youth stated they did not handle any chemicals and/or cleaning
products. One youth reported the staff spray the chemicals and youth wipe the surfaces with a
towel. An observation of the youth sweeping the floor in the common area of the dormitory
verified no chemicals were used by the youth. A review of the program’s preventative
maintenance checklist verified maintenance schedules and repairs are being conducted, as
required.
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5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program maintains a policy and procedures to ensure all flammable, toxic, caustic, and
poisonous items are disposed of appropriately. The facility administrator (FA) or designee and
maintenance staff are responsible for the control and accountability of all caustic, toxic,
poisonous, flammable, or hazardous, fluids, substances, or chemicals used in the program. All
unused hazardous materials are kept in the locked storage shed located outside the program
and are disposed of according to the Safety Data Sheet (SDS). An interview with the FA
indicated disposal of hazardous chemicals is accomplished within parameters of state, local,
and federal laws. The maintenance staff is responsible for the safe and lawful disposal of these
items and only maintenance or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and solid waste are responsible for disposing of
hazardous items and toxic materials. The FA stated there were no chemicals disposed of during
the annual compliance review period. Used kitchen grease and waste is stored in a large
container outside the kitchen area and is disposed of by a local vendor. All liquid waste from
work details is disposed down plumbing drains. The program’s policy states all chemical spills
are reported to master control immediately and the shift supervisor. An evacuation of the
affected area is conducted and a determination by the FA whether to contact outside assistance
to contain the spill. Staff and youth are not allowed to return to the affected area until it has been
deemed safe by a qualified professional. An interview with the FA indicated disposal of
hazardous items and toxic substances or chemicals is completed by taking them to the local
transfer station.
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
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• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a policy and procedures for youth to have visitation and communication
with family members in order to reestablish family and community relationships. Youth are
informed of visitation upon admission during the orientation process. The program encourages
visitation from the parents/guardians by forwarding a welcome letter upon the youth’s admission
notifying the days and time of visitation, who is allowed to visit, and the corresponding rules of
visitation. A list of authorized visitors and correspondence is maintained in the youth’s case
management records and updated, as needed. A review of five youth case management
records verified each record contained an approved correspondence, visitation, and telephone
log. Visitation is held on Wednesdays from 2:00 p.m. through 4:00 p.m. and on Saturdays and
Sundays from 1:00 p.m. through 3:00 p.m. Special visitations are also provided for
parents/guardians who are unable to participate in the regularly scheduled visitation days. A
review of the program logbooks and visitation sign-in logs since the last annual compliance
review verified visitation and special visitation are conducted. Youth are also provided one
fifteen-minute telephone call each week, writing material, and a self-addressed and stamped
envelope to talk with and send letters to approved family members. A review of the mail logs
since the last annual compliance review showed the youth were receiving and sending mail to
approved family members. Youth can have unimpeded access with the courts, attorneys, their
juvenile probation officer (JPO), and/ or the Department of Children and Families case worker.
Three youth were interviewed, and each indicated they are given the opportunity to
communicate with family members by mail, telephone, and/or visitation. None of the youth were
aware of an interpreter for youth who do not speak English. Three interviewed staff stated the
program uses bilingual staff and/or interpreters to provide translation services if needed. An
interview with the facility administrator indicated the program utilizes translation services, if
needed.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a daily activity schedule which reflects the youth receive at least one hour of
recreation each day and additional time allotted for leisure activities. The program’s contract
requires two recreation therapists. Both recreation therapists have the required credentials
outlined in the program’s contract. The contract does not require special provisions for the
incorporation of recreation into the youth’s performance or treatment plans. The recreation
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therapist created monthly activity calendars which reflect the recreation and leisure
opportunities available to youth each day. A review of the activities confirmed they promote
social and cognitive skill development, creativity, teamwork, healthy competition, mental
stimulation, and physical fitness. Logbooks were reviewed for the annual compliance review
period and recreation was documented each day for at least one hour, as required. Recreation
was observed during the annual compliance review week at its scheduled time and staff were
found to be taking precautionary measures to ensure the health and safety of the youth. Three
youth were interviewed, and two of the three youth reported they have the opportunity to
exercise, play outside, or down time to read a book, or play a board game. One youth stated
they did not. Two out of three youth reported they do not get one hour of physical activities. One
youth reported they did. All three mentioned when they do go outside, they play basketball or do
other large muscle movement. Three staff were interviewed and reported youth receive
recreation as required which includes basketball, football, cards, video games, dodgeball,
kickball, exercises, movies, and board games.
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.
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.
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report_type: QI Residential

program_name_raw: Deep Creek Youth Academy - Intensive

rule: Indicator 1.13

rating: Limited Compliance

rule: Indicator 5.01

excerpt: Youth Supervision (CRITICAL)