summary: QI Residential - FY23-24 - 1 finding

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Columbus Youth Academy
TrueCore Behavioral Solutions, LLC.
(Contract Provider)
9502 E Columbus Dr
Tampa, Florida 33619
Review Date(s): September 26-29, 2023
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Alexis Sapp, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Rob Aguis, Office of Educational Services, Director of Postsecondary and Workforce Education
(Standard 1)
Marvin Bliss, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Kara Brown, Office of Accountability and Program Support, Deputy Regional Supervisor
(Standard 4)
Cindy Jones, Office of Educational Services, Deputy Director of Education (Standard 2)
Tamara Mahl-Adkins, Office of Accountability and Program Support, Regional Monitor
(Standard 3)
Paul Sheffer, Circuit 12 Probation, Operations Coordinator (Standard 2)
Bonita Williams, Office of Accountability and Program Support, Regional Monitor (Standard 1)
Program Name: Columbus Youth Academy MQI Program Code: 1442
Provider Name: TrueCore Behavioral Solutions, LLC. Contract Number: 10476
Location: Hillsborough County / Circuit 13 Number of Beds: 50
Review Date(s): September 26-29, 2023 Lead Reviewer Code: 207
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
5.01 Youth Supervision *
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 69 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Youth Input Satisfactory
1.16 Advisory Board Satisfactory
1.17 Staff Performance Satisfactory
1.18 Recreation and Leisure Activities Satisfactory
1.19 Special Contract Conditions Satisfactory
1.20 Contract Specific Career and Technical Education Services Satisfactory
1.21 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 69 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
2.19 Career Education Satisfactory
2.20 Educational Access* Satisfactory
2.21 Education Transition Plan Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 69 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Non-Applicable
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 69 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 69 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
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 Satisfactory
5.25 Controlled Observation Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 69 (Revised September 2022)
Program Overview
The Columbus Youth Academy is a fifty bed program, for thirteen to eighteen year old males,
located in Tampa, Florida. The program is operated by TrueCore Behavioral Solutions, LLC.,
through a contract with the Department. The program provides services including Mental Health
Overlay Services (MHOS) and Substance Abuse Treatment Overlay Services (SAOS)
with a specialized emphasis on juvenile sexual offender (JSO) treatment services. In addition,
the program fosters each youth by providing Pathways, Skillstreaming the Adolescent,
Passport, Living in Balance, Coping with Depression, Coping with Stress: A Cognitive
Behavioral Therapy (CBT) Guide for Teens with Trauma, and Life Skills Training. Additional
treatment services provided include family/individual therapy, group therapy, and recreational
therapy. Program administration is comprised of a facility administrator (FA), assistant facility
administrator (AFA), designated mental health clinician authority (DMHCA), designated health
authority (DHA), director of nursing, director of case management, and a community liaison.
Case management services are provided by the director of case management, four case
managers, one transitional case manager, and one recreational therapist. Mental health staff at
the program include the clinical director, a licensed mental health counselor (LMHC) who serves
as the DMHCA, and five additional LMHCs. Medical services are offered Sunday to Saturday
from 7:00 a.m. to 5:00 p.m. and are provided by three full-time registered nurses (RNs), and one
RN providing services pro re nata (PRN). Educational services are provided by the Hillsborough
County School Board. The layout of the program includes one building, which consists of
administration, master control, three youth dormitories, three group rooms, three classrooms, a
kitchen area, and a game room. The program has sixty-seven operating security cameras
providing coverage. At the time of the annual compliance review, the program had ten vacant
positions; four youth care worker (YCW) Is, two YCW IIs, one master control, one shift
supervisor, and two licensed therapists.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 69 (Revised September 2022)
Strengths and Innovative Approaches
• The program held an art display and auction. Youth were provided painting materials
and created paintings using ideas from books and school magazines. The paintings act
as a creative emotional outlet for the youth and will be sent to Tallahassee for auction
upon completion.
• Ten youth and two staff were given the opportunity to attend a professional baseball
game. Youth earned the opportunity as an incentive for positive behavior and completion
of treatment work. Youth were able to use this experience to practice life and social skills
learned in the program.
• The program’s aquaponics group attended a community service outing to a tropical plant
nursery and fish farm. Youth had the opportunity to learn about the aquaponics process
and assist with transplanting plants on the farm.
• The program hosted a Super Bowl watch party for the youth as an incentive. Youth were
given snacks and dessert, and were able to practice their social skills among their peers.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 69 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures requiring all staff, volunteers, and contracted staff to
be background screened prior to contact with youth and youth records. The program did not
have any volunteers or interns who interacted with youth on an intermittent basis for less than
ten hours a month. The program had fourteen new staff during the annual compliance review
period, and each new staff received a background screening prior to hire. The program had
thirteen new volunteers during the annual compliance review period, and all had a background
screen completed prior to contact with youth and confidential records. A criminal history report
was reviewed for each staff and volunteer, and all staff and volunteers were added to the
Clearinghouse employment roster. None of the staff or volunteers required an exemption prior
to working with youth. A pre-employment assessment tool was administered to the direct care
staff hired and each staff received a passing score. An Annual Affidavit of Compliance with
Level 2 Screening Standards was completed on September 20, 2023 and sent to the
Department’s Background Screening Unit on September 26, 2023. The teachers who are paid
by the school board received their annual screening September 20, 2023. This is after the
annual deadline of January 31st; however, the provider did not acquire the program until
January 31, 2023.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a policy and procedures in place requiring all staff and volunteers to receive a
background rescreening every five years from their hire date. A review of the staff roster found
there were six staff applicable for a five-year rescreening during the annual compliance review
period. All of the five year rescreenings were completed on time and submitted to the
Clearinghouse at least ten business days prior to the five year anniversary date.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 69 (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 in place to promote an environment in which youth,
staff, and others feel safe, secure, and not threatened by any form of abuse or harassment.
According to the program’s policy, all staff shall immediately report any knowledge or suspicion
regarding an incident of abuse or sexual harassment which has occurred in the program. They
are also required to report any retaliation against youth or other staff who reported an incident,
and any staff neglect or violation of responsibilities which may have contributed to an incident or
retaliation. Potential abuse must be reported to the Florida Abuse Hotline. In addition to
reporting to the Florida Abuse Hotline, the program shall ensure notification is made to the
provider’s corporate management team by the incident reporting email group. The telephone
numbers for the Florida Abuse Hotline and the Department’s Central Communications Center
(CCC) are posted throughout the program. Staff adhere to a code of conduct, which is agreed
to, signed, and documented in each staff’s personnel record. A review of seven staff personnel
records found each of the staff signed a code of conduct. The program completed a Trauma
Responsive and Caring Environment (TRACE) self-assessment on February 20, 2023. The
program had two incidents of alleged staff abuse during the annual compliance review period.
One of the incidents was not substantiated, and the remaining incident was substantiated. None
of the incidents included a potential human trafficking victim, commercial sexual exploitation, or
labor trafficking.
Seven youth were interviewed, and all reported they feel safe at the program, the telephone
number for the Florida Abuse Hotline is posted throughout the program, and they have never
called the Florida Abuse Hotline. Six youth reported staff are respectful when speaking to youth,
and the remaining youth reported the floor staff are a little rude; however, administration is
respectful. Six youth reported they have never heard staff use curse words. The remaining
youth reported they occasionally have heard staff use curse words. The youth reported this was
never directed at the youth and was an accident. All youth reported they have never exchanged
emails, telephone numbers, social media, or contact information with a staff member. Seven
staff were interviewed. All staff reported staff are allowed to call the Florida Abuse Hotline, and
youth are not denied abuse calls. Six staff reported they notify the supervisor or program
director when youth call the Florida Abuse Hotline or CCC. One staff reported the supervisor
makes the call. All seven staff reported they have never observed a coworker using profanity,
threats, or humiliation when speaking to the youth, and they know where to find the telephone
number for the Florida Abuse Hotline. The facility administrator (FA) was interviewed and
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Office of Accountability and Program Support Page 12 of 69 (Revised September 2022)
reported the staff code of conduct specifies what actions will be taken in the event a staff
violates a policy. Disciplinary action shall be administered using progressive discipline; however,
infractions which are critical can result in immediate termination. If abuse, threats, or profanity
are used toward a youth an internal investigation will be initiated by the program, appropriate
notifications will be made, and the staff member will be placed on suspension pending the
results of the investigation. If allegations are verified those actions would constitute termination
of the employee. The program has a dedicated champions team which drives their TRACE
initiatives. They have completed their self-assessment, surveys, and action plan. Through their
targeted interventions they focus on sustaining a physically and emotionally safe environment.
Trauma responsive practices are embedded in policies and practice. From the moment a youth
enters the program they are immersed in a culture which is trauma responsive. All staff are
obligated by law to report allegations of abuse. All youth within the program have unimpeded
access to contact the Florida Abuse Hotline. After an allegation of a reportable incident, the FA
and/or designee are immediately notified. The CCC is notified within the required two-hour time
frame for all reportable incidents. Staff are made aware of Florida Abuse Hotline/CCC reporting
procedures during new hire training, in-service trainings, and during general staff meetings. All
youth are made aware of the Florida Abuse Hotline/CCC during the orientation process. Youth
also receive a resident handbook which contains information regarding the Florida Abuse
Hotline/CCC. Florida Abuse Hotline/CCC postings are posted throughout the program in areas
accessible to youth and staff.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program has a policy and procedures ensuring management takes immediate action to
address incidents of physical, psychological, and emotional abuse. A review of the two incidents
since the last annual compliance review found each involved a complaint against staff for
physical abuse. Reviewed documentation found management took immediate action to address
each incident. In both incidents, staff were immediately placed on no youth contact. One
incident was substantiated, and the staff was terminated. The remaining incident resulted in a
program review; however, was not substantiated. The facility administrator (FA) was interviewed
and reported all youth have access to grievance forms on their dormitories and can submit them
in the grievance boxes. The first phase of the process is the youth filling out the grievance, the
second phase is the youth meeting with the program grievance officer. The final phase includes
a review by the assistant facility administrator (AFA) or a meeting with the youth and an
administrator if the youth is not satisfied with the resolution proposed by the grievance officer.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program maintains a policy and procedures to ensure the Department’s Central
Communications Center (CCC) is notified within two hours of an incident occurring, or within two
hours of any program staff becoming aware of a reportable incident. Five incidents were
reported during the annual compliance review period, and all five were reviewed. Each incident
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Office of Accountability and Program Support Page 13 of 69 (Revised September 2022)
was reported within the required two-hour time frame and was documented in the logbook.
There were no incidents during the annual compliance review period which should have been
reported to the CCC and were not. Due to the program changing providers this year, the
number of CCC reports from the last annual compliance review period cannot be compared to
the number of CCC reports from this annual compliance review period.
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 has a policy and procedures in place requiring a Protective Action Response Right
Interactions model (PAR/RI) Report to be completed any time staff uses a physical intervention
technique. There were four PAR/RI incidents during the annual compliance review period. All
four PAR/RI Reports were completed by the end of the staff’s workday and included statements
from all staff involved. All four reports were reviewed by a supervisor and PAR/RI instructor and
reviewed by the facility administrator (FA) or designee within seventy-two hours of the incident.
A copy of all four PAR/RI Reports were placed in the program’s centralized file within forty-eight
hours of approval by the FA. None of the PAR/RI incidents were applicable for completion of the
Mechanical Restraint Supervision Log, Department’s Central Communications Center (CCC)
notification due to injury, Florida Abuse Hotline contact, or a PAR/RI medical review. Monthly
summaries of PAR/RI incidents were maintained by the program and submitted to the
Department by the fifteenth of each month. The program’s PAR/RI plan was updated on
January 6, 2023, before the provider acquired the program. The PAR/RI plan was approved by
the Department on January 9, 2023. The number of PAR/RI Reports from the annual
compliance review period cannot be compared to the number of PAR/RI Reports in the prior
annual compliance review period due to a new provider acquiring the program. The program’s
PAR/RI rate at the time of the annual compliance review was 0.11, which is below the statewide
Residential PAR/RI rate of 1.35. The facility administrator (FA) was interviewed and reported the
program continuously places an emphasis on utilizing verbal de-escalation techniques when
dealing with escalated situations/incidents. Physical intervention is always used as a last resort.
All PAR/RI related incidents are reviewed by the assistant facility administrator (AFA) and/or the
FA. A PAR/RI review committee is held following each PAR/RI incident. The staff and youth
involved in the incident along with members of the treatment team are present at the meeting.
The purpose of the meeting is to process incidents with youth in attempt to avoid future PAR/RI
related incidents with the youth. Seven staff were interviewed. Five staff reported they have
never used PAR/RI. The remaining two staff reported using PAR/RI, one in April 2023, and one
a long time ago.
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.
Seven staff were reviewed for pre-service training requirements. Due to the change in service
provider, none of the applicable staff had been employed for a sufficient period of time to
complete their initial 180 days of employment. Four reviewed staff had completed all pre-service
training requirements and were not missing any required trainings. The remaining three staff
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were not yet completed with the required trainings; however, were making progress on
completing them and remained out of contact with youth and confidential records. Completed
trainings were documented in the Department’s Learning Management System (SkillPro). All
instructors were qualified to deliver training 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.
Due to the change in service provider at the program, none of the staff were applicable for
review for in-service training. All instructors were qualified to deliver the trainings provided. The
list of in-service trainings was approved on December 30, 2022. This is after the deadline of
December 1, 2022; however, the provider did not acquire the program until January 31,2023.
The program has an annual in-service training plan 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 include the training requirements for the
grievance process. The program has a grievance process which includes an informal phase, a
formal phase, and an appeal phase. The informal phase includes encouraging the youth to
resolve questions, disputes, and complaints through informal communication with program staff
and use of a conference request form. Documentation correlated the program’s practice with
their process. The program had three grievances during the annual compliance review period,
and all three were reviewed. The program maintained copies of each grievance. Seven youth
were interviewed. Three youth reported they have never filed a grievance and are unaware of
the process. Three youth were able to describe the grievance process. The remaining youth
reported they have never filed a grievance, so they do not know the entire process; however,
they know how to submit a grievance if needed. All seven youth reported they are able to ask
for help with filling out a grievance if needed. Seven staff were interviewed, and all were able to
describe the program's grievance process. The facility administrator (FA) was interviewed and
reported all youth have access to grievance forms on their dormitories and have the ability to
submit them in the grievance boxes in the program. The first phase of the process is the youth
filling out the grievance and the second phase is the youth meeting with the facility grievance
officer. The final phase includes a review by the assistant facility administrator (AFA) or a
meeting with the youth and an administrator if the youth is not satisfied with the resolution
proposed by the grievance officer.
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Office of Accountability and Program Support Page 15 of 69 (Revised September 2022)
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 contractually required services, which were not primary services, revealed the
program is providing delinquency interventions as required. The program provides Thinking for
Change as the only non-primary service. The staff assigned to facilitate these curriculums were
reviewed for education and experience. All assigned staff have the required years of experience
and education to facilitate these groups. The assigned staff training records were reviewed and
trainings within the specified curricula were confirmed for all five applicable staff. A review of the
program’s posted activity schedule confirmed the program was providing structured programing
and activities at least eighty percent of youth awake hours, as required in the program’s
contract, and groups are being provided as outlined on the program’s daily schedule. The facility
administrator (FA) was interviewed and reported the program utilizes Pathways, Thinking for
Change, and Impact of Crime as evidence-based delinquency intervention groups. These
groups are held with fidelity and monitored for quality assurance and fidelity to demonstrate
effectiveness with the youth as they graduate from the group and earn their release from the
program. The designated mental health clinician authority (DMHCA) was interviewed and
reported the program licensed clinicians provide individual, group, and family therapy to the
youth. All program clinicians are licensed. Since there is no correct mix of learning styles, nor
are youth learning styles fixed, clinical services at the program are geared toward male
adolescents, and utilize several modes of delivery to increase the prospects youth will respond
positively to services. Written clinical material is read aloud during each therapy group and
helps youth whose dominant style of learning is reading or listening. Role playing is performed
in groups to involve youth whose learning style is most productive when they are socially,
emotionally, and physically involved in a task. Written material is infrequently utilized in therapy
groups due to the problems many of the youth have with writing. When written material is used
in a clinical setting, youth who have difficulty with writing may pair up with fellow group
participants to complete the assignment. For these same youth, written treatment plan
objectives are converted to learning experiences which are completed using verbal skills. Since
some youth learn best in a solitary manner, clinical material is often dispensed to them to
complete on their own and reviewed with their therapists during their individual sessions. Lastly,
specific curriculums are chosen for their effectiveness with reducing criminogenic risk factors.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures which emphasize social and life skills training for
youth. The life skill intervention provided is Thinking for Change which is an intervention which
is an evidence-based, promising practice, or a practice with demonstrated effectiveness. The
program’s life and social skills intervention services address communication, interpersonal
relationships and interactions, non-violent conflict resolution, anger management, and critical
thinking. A review of the program’s activity schedule and group sign-in sheets indicated groups
were held as scheduled. In addition to the life and social skills curriculum, the program is
incorporating additional life skills for the youth, including the behavior management system
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(BMS) of the program. The program’s BMS is based on social skills training and utilizing what
the youth are taught in daily practice. Seven youth were interviewed. Five youth indicated they
participate in Pathways, one youth reported participating in life skills, and the remaining youth
was unable to remember the groups they participate in. Five youth reported they are unsure
what gender specific groups they participate in, and the remaining two reported all the groups
are gender specific since there are only males in the program. The facility administrator (FA)
was interviewed and reported all youth in the program participate in Thinking for Change
groups among other mental health and substance abuse groups. From the moment a youth is
admitted to the time they transition home, the staff address them with dignity and role model
expectations. All youth receive orientation, treatment planning, family therapy, and more which
target their specific juvenile sexual offender (JSO) needs. As a male population they also
receive health education targeting their gender group. All curriculums are chosen specifically to
address their gender and needs. Staff are trained to treat all with dignity and respect. The
designated mental health clinician authority (DMHCA) was interviewed and reported youth at
the program are offered daily opportunities to utilize the skills they have learned in the group
settings. Youth are able to practice role playing opportunities in the group setting to help them
improve upon their skills so they have better success when it comes to "real world" uses. The
youth are provided with an opportunity to utilize communication skills when participating in level
up procedures, treatment team meetings, and daily interactions with both staff and peers. The
youth can also utilize the skills they have learned when talking with guest speakers, during any
outings within the community, and when corresponding with their families by telephone or face-
to-face visits.
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 has a policy and procedures ensuring the program provides activities and
instructions intended to increase youth awareness of, and empathy for, crime victims and
survivors, and increase personal accountability for youths’ criminal actions and harm to others.
The program provides Impact of Crime (IOC) for restorative justice, which is a primary service;
therefore, this group is not applicable for review. Thinking for Change, a promising practice, is
also provided as a restorative justice intervention to all youth in the program. Sign-in sheets
were reviewed and confirmed Thinking for Change is provided according to the program’s
activity schedule. In addition to the restorative justice groups, the program incorporated
additional restorative justice activities to include community service through assisting with food
delivery, assisting staff with horticulture, monthly therapy dog visits, and family day at the
program. Restorative justice activities were unable to be observed during the annual compliance
review week. The facility administrator (FA) was interviewed and reported the program provides
community service projects as restorative justice activities. Additionally, the youth are working in
the aquaponics victim impact garden as restorative justice. Youth have participated in
restorative justice projects such as park cleanup, feeding the homeless, and a toy drive with
donations going to youth in the Department of Children and Families (DCF) care. The program
offers all youth the opportunity to participate in off-campus community service projects to
include assisting at an aquaponics farm and feeding the homeless. Youth intend to restore
victims and communities by providing assistance to community programs in need of volunteers.
Youth want to help rebuild the community through maintaining community areas and donating
time to community institutions in need. The designated mental health clinician authority
(DMHCA) was interviewed and reported the program provides IOC and Thinking for Change as
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restorative justice groups, and Skillstreaming the Adolescent as a life skills group. Seven youth
were interviewed. Five youth reported participating in IOC, four youth reported completing
community service hours, one youth reported participating in aquaponics, and the remaining
youth reported they do not know what restorative justice groups or activities are.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures which outline how alerts are identified, documented,
updated, and communicated to staff. The program’s policy requires any alerts be entered into
the Department’s Juvenile Justice Information System (JJIS), and notated on the alert
communication board in the facility administrator’s (FAs) office, and on the shift report form. The
program logbook is used to notate suicide/mental health alerts within the program and
instructions for staff. Seven youth records were reviewed, and forty-four alerts were reviewed
from the seven records. Four alerts were in JJIS; however, not on the program’s internal alert
board. The program added the alerts to the alert board while the annual compliance review
team was on-site. The remaining alerts were all consistent between JJIS alerts and the internal
alerts. The FA was interviewed and reported the program management team meets daily to
discuss medical issues and the director of nursing or a medical representative is present at the
meetings. Furthermore, on a weekly basis, the designated health authority (DHA) debriefs with
the FA and director of nursing prior to exiting the program to provide any updates pertaining to
the wellbeing and medical condition of the youth. A confidential alert board is available in the FA
office for staff to review during shift briefings. Alert logs/board are also maintained in master
control and dietary. The clinical director, director of case management, and director of nursing
are responsible for entering and closing out JJIS alerts. Alerts are reviewed during daily
management meetings. The health services administrator (HSA) was interviewed and reported
all registered nurses (RNs) are responsible for updating alerts. Seven staff were interviewed,
and all were able to describe how they are notified of youth alerts.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program maintains an Individual Healthcare Record, and a separate individual
management record. The individual management records contained the youth’s name,
Department identification number, date of birth, county of residence, and committing offense.
The individual management records contained sections labeled legal information, demographics
and chronological information, correspondence, case management and treatment team
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activities, and miscellaneous. All youth records were labeled confidential and secured in a
locked file cabinet.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a policy and procedures in place to ensure the program has a community
advisory board meeting at least every ninety to 120 days. Sign in sheets were reviewed for the
advisory board meetings, and documentation confirmed board meetings were held every ninety
to 120 days as required. A review of the list of attendees, the board roster, and letters from the
program found the facility administrator (FA) solicited involvement from all required parties. No
meetings were applicable for re-scheduling or for being held virtually. The FA was interviewed
and reported community advisory board meetings are held on a quarterly basis. Meetings are
scheduled on Thursdays and the start time is either 10:30 a.m. or 11:00 a.m. The FA and
community liaison solicit active involvement of interested community partners including, but not
limited to, representatives from law enforcement, the judiciary, the school board or district, the
business community, faith community, victim, victim advocate, or other victim services
community representative, and a parent whose child was previously involved in the juvenile
justice system. The program makes continuous efforts through email correspondence and
telephone correspondence to invite all members to the quarterly meetings. The annual
compliance review team was unable to interview a community advisory board team member.
The annual compliance review team attempted to contact two members of the board by
telephone and left messages.
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 to ensure staff are evaluated, at least annually, based
on established performance standards. Three position descriptions were reviewed, and staff
performance standards were clearly identified in each. Performance evaluations were reviewed
for seven staff, and each was completed as outlined in the program’s policy, and the
performance standards for each evaluation matched the job description for each staff. The
program’s contractual key positions were reviewed, and all were maintained by the program.
The facility administrator (FA) was interviewed and reported the program has experienced slight
turnover; however, no problems with staff morale. Vacancies are continuing to be filled for direct
care and key and/or critical personnel. Staff incentives are continuously being given to the staff
to show the appreciation and commitment they display every day working with troubled youth.
Additionally, staff surveys are completed on a quarterly basis to gauge staff morale and gather
feedback from the staff to better the workplace. Annual evaluations are completed for all staff
employed with the program for the year. Each department head and/or supervisor is responsible
for completing the evaluation for each of their subordinates. Evaluations are reviewed and
discussed with each staff individually. A copy of the evaluation is maintained in the staff’s
personnel file. All staff who facilitate a delinquency intervention group receive a rating on their
evaluation. Seven staff were interviewed. One staff reported communication between staff is
very good, four staff reported communication is good, and the remaining two staff reported the
communication between staff is fair. Five staff reported getting yearly evaluations, one staff
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reported getting an evaluation every six months, and the remaining staff reported they have not
had an evaluation since the new contract.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program has several contract requirements detailing services to be provided to youth while
in the program. Each service is to prepare youth for transitioning back in the community. The
program had documentation, which includes sign-in sheets and youth worksheets, indicating
youth were receiving services. The program provides discharge policies and transition services,
self-sufficiency planning, health education, and video surveillance systems with remote live
feed. During the annual compliance review week, the video surveillance was observed to be in
the process of being installed. In addition, the program was to offer Alcoholics Anonymous
(AA)/Narcotics Anonymous (NA); however, the program offered the first AA/NA service on
September 22, 2023, after the program received their seven day notification of the annual
compliance review. The program indicated they had not offered the service since April 2023
because the youth were not interested in participating. The program provided community
involvement involving outside providers. The youth participated in the canine program at least
once a month. The program provides monthly health education classes for youth. There is
documentation to confirm current youth and youth released from the program participate in their
discharge and transition planning, such as a relapse prevention plan. Three closed youth
records were reviewed for post-release youth with required contacts to be made by the
transition services manager (TSM). Contacts were not made by the TSM, instead they were
done by the program’s community liaison; however, the contacts were made as required in each
of the three closed case management records. The facility administrator (FA) was interviewed
and reported the program has a transition dormitory and focuses on the youth’s self-sufficiency
with targeted interventions identified through the admission assessments and transitional goals.
Seven youth were interviewed. Five youth reported participating in Impact of Crime, four youth
reported participating in Pathways, three youth reported participating in coping with stress, and
one youth reported they do not know the groups they participate in.
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1.18 Contract Specific Career and Technical Education
Satisfactory Compliance
Services
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), Special Conditions, or older contracts may not have them clearly identified as a
special condition. Career and technical education service instruction shall be provided so the
interests, aptitudes, and skills of the youth are developed, while building upon their existing
strengths, in a manner supportive of their employability goals which provide an occupational
advantage and workforce readiness in their community. These items may exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code.
The program’s contract requires the program to provide career and technical education (CTE)
services by the provider or directly by the local school district. The local school district in
conjunction with the program offer Occupational Safety and Health Administration (OSHA),
Food Handling (ServSafe), Microsoft Office Applications, Florida Ready to Work Soft Skills, first-
aid, and cardiopulmonary resuscitation (CPR) training as the pre-vocational and vocational
services. Youth certifications were reviewed and supported the program is providing Florida
Ready to Work Soft Skills, first-aid, and CPR training to youth as required. Documentation
reflected the program was not providing ServSafe; however, was providing the youth a different
food handling course. The program has not initiated OSHA training with the youth yet; however,
the program provided documentation to indicate they will be initiating the training as required
with the youth in October 2023. The program has not had any youth complete Microsoft Office
Applications; however, the program provided refusal sheets signed by the youth to indicate the
service was not provided due to a lack of youth interest in the certification. The program also
provided documentation to show they have the ability to offer the certification if any youth are
interested in completing it. The program does not have a designated time for CTE built into the
education schedule, and indicated it is offered throughout the day depending on the needs of
the youth. CTE is provided by the program’s community liaison and the teachers. CTE is age
appropriate for the youth in the program, appropriate for the abilities and goals of the youth in
the program, and appropriate for the length of stay and classification of youth in the program.
Participation in CTE was unable to be observed during the annual compliance review week.
Seven youth were interviewed and six reported participating in pre-employment skills, two youth
reported participating in safe food handling, and two youth reported participating in photography.
One youth reported these services occur daily, three youth reported these services occur when
the youth are in school, one youth indicated these services occur once a week, one youth
indicated these services occur twice a week, and the remaining youth reported these services
occur every day the youth are in groups. The facility administrator (FA) was interviewed and
reported the program offers Florida Ready to Work, Soft Skills, Safe Staff, ServSafe, basic first-
aid, CPR, and Microsoft Office certifications.
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1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has practices in place to collect information about the program and share this
information with their staff and administration monthly. The program utilizes daily management
meetings, the Department’s Juvenile Justice Information System (JJIS), staff and youth surveys,
and electronic records system to gather and share information with staff and administration.
There is documentation of daily management meetings, monthly staff meetings, youth and staff
surveys, and the use of the internal dashboard. The internal dashboard includes information
from operations, mental health, health services, support services, and human resources. The
electronic records system allows the program to pull reports on demographics, trends, and/or
additional items. The daily management meetings and monthly staff meeting’s minutes include
the same information as previously mentioned. The program provides the collected information
to providers and stakeholders through their community advisory board meetings, daily
management meetings, and monthly staff meetings. With the collected information, the program
reviews and determines how information can be modified or added to their practices as well as
allowing staff to be better prepared when caring for youth in the program.
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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 ensuring each youth’s parent/guardian is contacted
by telephone within twenty-four hours, and in writing within forty-eight hours of the youth’s
admission to the program. The policy and procedures also require the case manager to notify
the youth’s committing court, assigned juvenile probation officer (JPO), and post-residential
counselor (if applicable) within five working days of the youth’s admission. A review of seven
youth case management records determined each youth’s parent/guardian was contacted by
telephone within twenty-four hours of admission, and each record contained documentation
confirming the youth’s parent/guardian was notified in writing within forty-eight hours of
admission. All seven records had documentation indicating the JPO, committing court, and post-
residential counselor (if applicable) were notified of the youth’s admission. All notifications were
sent the same day as the youth’s admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures in place to ensure on the day of a youth’s admission,
the youth will be oriented on the program’s rules, procedures, schedule, and services. The
policy indicates this will be initiated within two hours of the youth’s admission by the transition
services manager (TSM). The program uses a checklist during the process to ensure all
required elements are addressed. Additionally, they provide a youth handbook detailing all the
required elements. Each youth’s parent/guardian is mailed a parent handbook covering all
required elements. Seven youth case management records were reviewed, and each contained
an Orientation Checklist form signed by each youth confirming completion of an orientation,
which covered all required elements. During the annual compliance review week, there was an
admission. Observations of the orientation process confirmed the completion of the orientation
process, which included a review of the youth handbook and completion of the Orientation
Checklist. Seven youth interviews indicated an orientation was provided within twenty-four hours
of admission which reviewed program rules, how to progress through the program, and who
program staff are.
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2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a policy and procedures in place to obtain written consent of any youth
eighteen years of age or older to obtain approval for release of their confidential information to a
parent/guardian. Seven youth case management records were reviewed, and two were
applicable for written consent. One additional applicable record was provided for review. All
three applicable youth records included a signed consent form completed by each youth.
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 on the utilization of a classification system which
promotes the safety and security, as well as the effective delivery of treatment services. The
initial classification of youth is used for the purposes of assigning each newly admitted youth to
a living unit, sleeping room, and assignment of a case manager and therapist. A review of seven
youth case management records found each youth’s admission classification was completed on
the day of their admission to the program. The admission classification forms contained all
required elements. Each classification form also included a review of each youth’s possible risks
including suicide, mental health, medical, and escape risks. Each youth is also screened for any
other specific information, which may indicate heightened needs for supervision, additional
safety precautions, or separation from certain other youth. The program’s policy and procedures
also require the youth to be screened for vulnerability to victimization and sexually aggressive
behavior prior to receiving a room assignment. All seven records documented a Victimization
and Sexually Aggressive Behavior (VSAB) form was completed in the Department’s Juvenile
Justice Information System (JJIS) prior to assigning the youth to a room. Seven youth case
management records were reviewed, and each record contained an admission classification
form completed with all required elements. Three of the seven reviewed records revealed
documentation of newly identified or suspected risk factors. Each youth had these alerts entered
into JJIS and in the program’s internal alert system. The program utilizes a risk assessment
form to conduct reassessments for all youth in the program. None of the reviewed youth were
applicable for a reassessment for activities with the program. Three applicable records were
provided for review. A review of the three youth’s risk assessments confirmed each contained
input for an increase in program privileges. Each of the risk assessments were completed to
allow participation in an off-campus activity. The interview of the facility administrator confirmed
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mental health status, physical health status, cognitive performance, age, and prior victimization
are considered when assigning youth to a living unit and sleeping room during admission
classification.
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 in place addressing gang identification and
notification with appropriate agencies. Seven youth case management records were reviewed,
and one was applicable for suspected gang activity. The program had one additional applicable
youth during the annual compliance review period. The two applicable case management
records indicated upon identification, local law enforcement and the youth’s home county law
enforcement were notified of youth’s suspected gang activity. The educational provider and
youth’s assigned juvenile probation officer were each notified of the suspected gang activity.
Both youth had an appropriate alert entered into the Department’s Juvenile Justice Information
System (JJIS).
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 to ensure youth identified as gang-related are
provided gang prevention and intervention activities. Seven youth case management records
were reviewed, and one was applicable for suspected gang activity. The program had one
additional applicable youth during the annual compliance review period. The two applicable
reviewed youth case management records reflected the program incorporated a gang goal in
each youth’s Individualized Performance Plan (IPP) addressing the need for gang awareness
and intervention services. The program has a gang binder which maintains all documented
information and program activities completed with gang identified youth. The program utilizes
the GANGS: 50+ Stories of Fractured Lives curriculum as the selected gang prevention and
awareness curriculum. The case management director indicated they also provide a lesson
about the Racketeer Influenced and Corrupt Organizations (RICO) Act to let these youth know
about additional legal consequences they could face if they stay involved in a gang. The facility
administrator indicated they use the GANGS: 50+ Stories of Fractured Lives curriculum as their
gang intervention for identified youth. The gang binder included all packets completed by the
identified youth and notifications made to local law enforcement and the youth’s home county
law enforcement, as well as the youth’s educational provider and juvenile probation officer.
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2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a policy and procedures ensuring each youth receives a Residential
Assessment for Youth (RAY) within thirty days of admission. The program is to maintain all
documentation of the initial RAY in the Department’s Juvenile Justice Information System
(JJIS). The program is to maintain documentation of RAY Reassessments in the youth’s record.
A review of seven youth case management records found each youth had a RAY completed in
JJIS within thirty days of admission. The program’s policy also requires each youth to receive a
RAY Reassessment within ninety days of the initial RAY, or when deemed necessary by the
intervention and multidisciplinary treatment team. All seven reviewed records were applicable
for the completion of at least one ninety-day reassessment, and each was completed as
required, with one exception. One RAY reassessment was completed one day late. All RAY
Reassessments were maintained in the youth’s record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in JJIS on the YNAS.
The program has a policy and procedures ensuring a Youth Needs Assessment Summary
(YNAS) is completed within thirty days of each youth’s admission to the program. A review of
seven youth case management records determined each youth had a YNAS completed within
thirty-days of admission. Each YNAS was documented in the Department’s Juvenile Justice
Information System (JJIS), as required.
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2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
The program has a policy and procedures addressing the development of performance plans,
goals, and transmittal. Seven reviewed case management records found each youth’s
performance plan was developed within thirty days of admission to the program. All seven
performance plans were developed after the initial assessments were completed. Each
performance plan was signed by the youth, intervention and treatment team leader, and all
parties who had significant responsibilities in goal completion. All reviewed records had
documentation indicating the performance plans were mailed to each youth’s parents/guardians.
All seven performance plans contained the youth individualized goals and were based upon the
prioritized needs reflecting the risk and protective factors identified during the initial assessment
process. Five of the seven plans addressed the youth’s top three criminogenic needs. The
remaining two youth records contained documentation reflecting why the program addressed
other criminogenic needs instead. All performance plan goals were set to provide measurable
outcomes which will decrease the youth’s criminogenic risk factors and promote strengths,
skills, and supports to reduce the likelihood of the youth to reoffend. Each of the plans identified
program staff and youth responsibilities to accomplishing each of the goals, as well as target
completion dates. All seven records contained documentation indicating copies of the plans
were sent to the youth’s committing court, juvenile probation officer (JPO), and parent/guardian
within ten days of completion. One youth was involved with the Department of Children and
Families (DCF) and the reviewed documentation reflected their DCF plan being sent to their
assigned DCF caseworker. Interviews with seven youth indicated each participated in the
development of their performance plan and each knew at least one of their assigned goals.
2.10 Performance Plan Revisions Satisfactory Compliance
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team.
The program has a policy and procedures regarding performance plan revisions. Performance
plan revisions are completed when deemed necessary by the intervention and multidisciplinary
treatment team. Seven case management records were reviewed, and six were applicable for a
revision based upon progress towards completion of a goal and revisions to the performance
plan were made as required. One had revisions done based on lack of progress on their plan
and another had a revision based on Residential Assessment for Youth (RAY) Reassessment
results. One of the plans also had a revision due to newly acquired information.
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2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program has a policy and procedures which addresses the completion of performance and
release summaries. All seven youth were applicable for completion of a Performance Summary.
Six of seven reviewed records documented completion of a Performance Summary every
ninety-days. The remaining record reflected the initial Performance Summary was completed
two days late. The completed summaries contained the status of each youth’s performance plan
goals, the overall treatment progress, the youth’s academic progress, behavior, readiness to
change, interactions with peers and staff, behavior adjustment to the program, positive and
negative events, and if applicable, justification for release. The reviewed records revealed the
youth were afforded the opportunity to read and add comments prior to signing the summary.
Each record contained documentation reflecting the youth were provided with a copy of their
Performance Summary once this was sent to all parties. The original Performance Summary
was maintained in each of the seven reviewed youth case management records and contained
all required signatures. A review of three closed youth case management records found release
summaries were completed, as required. Each of the three records had documentation
indicating the parent/guardian was provided written notification of the youth’s planned release
once approved by the court. All three records included a Residential Assessment for Youth
(RAY) Exit Assessment. One active youth in the original sample was applicable for the Sexually
Violent Predator Program (SVPP). Two additional records were provided for review. The
juvenile probation officer (JPO) was sent the Residential Program Notification Checklist, and
they included the performance plan, summary of the youth’s adjustment to the program,
physical health summary, and any psychological/psychiatric reports for the youth as well. The
program provided the JPO with the SVPP eligibility form/notification checklist in each of the
records. This form and supporting documentation are required to be sent at least 240 days prior
to the youth’s anticipated date of release. One packet was completed on time, as required. One
youth’s packet was originally sent thirty-five days late, however, the release date of this youth
was moved back which then made the transmittal of the packet on-time. The third youth’s
packet was submitted 149 days late. There was no evidence found to indicate this was going to
cause a hindrance to the release for any of these youth. Each of the three closed youth case
management records were applicable for victim notifications, and all had a copy of the mailed
Victim Notification of Release letter to the victim at least ten days prior to the youth’s release.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures to address facilitation, involvement, and
encouragement of participation of the youth’s parent/guardian in case management services.
The program encourages each youth’s parent/guardian to participate in the youth’s case
management and treatment services. Upon admission, each youth’s parent/guardian is mailed a
letter which includes information about the services offered at the program. Included in the letter
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are the dates and times of the youth’s treatment team meetings. Parents/guardians are
encouraged to participate in person; however, if this cannot be arranged, parents/guardians
may participate by telephone. A review of seven youth case management records determined
each youth’s parent/guardian was sent an admission letter no later than the day after the
youth’s admission. This included information about the initial assessment meetings set for the
youth. Each of the records contained documentation indicating the youth’s parent/guardian was
involved in the youth’s assessment process, participated in the development of the youth’s
performance plan, received progress reviews, and participated in formal treatment team
meetings, when available. A treatment team meeting was observed during the annual
compliance review week. The parents/guardians of the youth participated in the treatment team
in-person. The parents/guardians were active participants in the treatment team meeting and
were made aware of upcoming meetings associated with their child. The facility administrator
(FA) stated parent/guardian engagement is encouraged throughout the duration of each youth's
commitment. They indicated the families are contacted upon the arrival of the youth and are
invited to attend all treatment team meetings either by telephone or in-person. The FA stated
the parents/guardians also receive written communication about the youth’s progress and are
also invited to participate in therapy sessions with the youth. All seven youth interviews
indicated their parents/guardians participated in case management services by telephone or in-
person. Each youth also mentioned participation by their parent/guardian in family sessions and
at family days held by the program.
2.13 Incorporation of Other Plans into Performance Plans Satisfactory Compliance
The youth’s performance plan shall reference or incorporate the youth’s treatment or care
plan.
The program has a policy and procedures to address incorporation of other existing plans into
each youth’s treatment and Individualized Performance Plan (IPP). Seven youth case
management records were reviewed for incorporation of other plans into the youth’s IPP. Each
of the youth’s IPPs incorporated additional plans including the youth’s academic and mental
health treatment plans. One of the reviewed youth was applicable for a Department of Children
and Families care plan, and this plan was found to be incorporated into their IPP.
2.14 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
A program shall ensure the intervention and treatment team meets bi-weekly (formally and
informally) to review each youth’s performance, to include RAY Reassessment results,
progress on Individualized Performance Plan goals, positive and negative behaviors,
including behaviors resulting in physical interventions. If the youth has a treatment plan,
review their treatment plan progress.
The program has a written policy and procedures regarding performance reviews which
establish the treatment team and its members. It also defines the process for treatment team
reviews and the information which shall be reviewed. A review of seven youth case
management records confirmed each youth had a formal treatment team meeting which was
held at least every thirty days. The program holds treatment team meetings on Wednesdays,
and these are scheduled/held every twenty-eight days for each youth. The treatment teams are
comprised of the youth, case manager, a representative from education, a mental health
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therapist, the youth’s parent/guardian, assigned juvenile probation officer (JPO), medical staff, a
representative from the living unit, and a representative from the program’s administration. If
staff from education, the medical department, or living unit are unable to attend they can provide
a written progress report to be shared with the treatment team. If the parent/guardian was
unable to participate, the program documented the reason why on the treatment team form. The
reviewed documentation reflected all treatment team members participated, or provided written
input, in all except for four reviewed records out of thirty-nine formal treatment team meetings.
The review found a member of administration failed to attend three of the reviewed treatment
teams and a living unit representative did not attend or provide written input for one meeting.
Documentation for each of the formal and informal treatment team review meetings included the
youth’s name, date of review, comments from treatment team members, a brief synopsis of the
youth’s progress, performance plan revisions, positive and negative behaviors, behaviors
resulting in physical interventions, treatment progress, and Residential Assessment for Youth
(RAY) Reassessment results. All information was included in each formal treatment team
review; however, the RAY Reassessment results were not addressed for three of the youth
during the reviewed meetings. A review was also conducted for the informal treatment team
meetings for seven youth. The reviewed documentation confirmed these meetings were held at
least every thirty days, with one exception. One informal treatment team meeting was
conducted five days late. Each of these meetings were attended by the case manager and
youth. Written progress updates were provided when applicable. The reviewed documentation
revealed the informal treatment reviews included a brief synopsis of the youth’s progress in the
program, any performance plan revisions, progress on their performance plan goals, positive or
negative behaviors exhibited during the review period, and any behaviors which resulted in
physical interventions. The youth was also allowed to share skills they acquired, and treatment
progress and RAY Reassessment results were reviewed, when applicable. The reviewed
documentation in each of the seven youth case management records reflected the youth’s JPO
and parent/guardian were invited to participate in each scheduled treatment team meeting. A
treatment team meeting was observed during the annual compliance review week. All treatment
team members were present. They conducted a thorough review of the youth’s progress in the
program, and the youth was able to share the skills they had recently learned. The youth’s
parents/guardians were present at this meeting. Interviews were conducted with seven youth.
Each of the youth indicated the treatment team reviews the progress on their performance plan
goals, positive and negative behaviors, and their treatment progress. They also indicated they
are given the opportunity to share the skills they have learned during these meetings.
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2.15 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program has a policy and procedures which address planning for the youth’s successful
transition to the community upon release from the program. This includes planning for transition
meetings and participation in the Community Re-Entry Team (CRT) meetings. A review of three
closed youth case management records found each youth had a transition conference held at
least sixty days prior to their targeted release date. Each record documented the youth’s
juvenile probation officer (JPO), parent/guardian, education staff, and any other additional
pertinent parties were invited and encouraged to participate in the youth’s transition conference.
Each transition conference included a review of transition activities on the youth’s performance
plan, targeted completion dates, persons responsible for completion, and other pertinent
transition activities. Reviewed documentation validated the treatment team leader obtained
attendees’ dated signatures representing their acknowledgement of the transition goals and
accountability for completion for all three youth. A copy of each plan was mailed with a request
for return with signature to the parent/guardian and JPO. All three records documented a CRT
meeting was conducted prior to the youth’s release. Each of the records contained an email
invitation, inviting the program’s case manager and youth to participate in the meeting.
Documentation in each of the records indicated the youth, case manager, and transition
services manager participated in the CRT meeting.
2.16 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures addressing the assembly of an exit portfolio to assist
each youth once they are released back into the community. Three closed youth case
management records were reviewed, however, two of the youth in the sample were fourteen at
the time of release, so two additional records were reviewed to capture all requirements. Five
total closed records were reviewed. The reviewed documentation and the exit portfolio for each
youth was initiated and discussed during the transition conference. Reviewed documentation
revealed the exit portfolio for each youth included a copy of the youth’s transition plan, calendar
with all dates, times, and locations of upcoming community appointments, educational record,
and school transcripts. All five exit portfolios included educational or vocational certificates
earned in the program. Two records were not applicable for the exit portfolio containing a copy
of the youth’s birth certificate, résumé, employment application, Social Security card, or state-
issued identification card due to the youth being fourteen years of age. The three applicable
records included a copy of their birth certificate, a résumé, and a completed sample
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employment application. One of the three applicable records had a Social Security card and
state-issued identification (ID) card. The records revealed the additional two youth who were
over fifteen years old already had a state-issued ID. This information was not provided to the
program after multiple requests were made. Reviewed documentation for each record validated
the youth’s exit portfolio was verified during the exit conference and the completed exit portfolio
was given to the youth upon release. Each record indicated the exit portfolio was provided to the
youth’s juvenile probation officer (JPO).
2.17 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a policy and procedures to address the requirements for conducting exit
conferences. Three closed youth case management records were reviewed for exit
conferences. Reviewed documentation indicated the exit conferences were conducted after the
program notified the youth’s juvenile probation officer (JPO) of the youth’s pending release and
at least fourteen days prior to the youth’s release date. The exit conference documentation in
each of the records contained the date, participant’s signatures, or names, if participating by
telephone, and a summary of pending transition goals. All records documented the exit
conference was conducted separately from the transition conference and Community Re-Entry
Team meetings.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has formal processes to promote input from youth. A review of meeting sign-in
sheets and agendas found evidence the program hosts weekly community meetings and
monthly Youth Advisory Board (YAB) meetings. The program provides Conference Request
forms to allow youth to share ideas, needs, or concerns. The forms are available on the living
units. Youth may complete and submit the Conference Request forms to staff in order to speak
with designated staff and administration concerning issues they may have. In addition, the
program conducts regular surveys for youth and parents/guardians. The FA indicated the
program utilizes a formal process where youth can solicit input on a Conference Request form.
This form is readily available to the youth, and they can submit the forms at any time. Youth also
have community meetings and YAB meetings, at which time they are able to solicit input and
ideas to better the residential community. Youth also complete surveys which assist the
program with innovative ideas to better the program and residential community. Reviewed
documentation confirmed the program conducts weekly community meetings. Community
meetings are held on each dormitory by the treatment team and all youth every Wednesday.
During this meeting, youth are able to express issues, concerns, and positive
information/feedback to the program representatives. Each dormitory has leaders, which are
titled mayor and assistant mayor. They represent their dormitories on the YAB. The YAB
representatives are responsible for taking notes during the community meeting. The YAB meets
monthly with the assistant facility administrator (AFA) and the transition services manager
(TSM), as confirmed by a review of meeting minutes. The dormitory representatives bring
community issues, concerns, and ideas to the meetings, and then the staff discuss these
concerns for the upcoming monthly meeting or create immediate solutions for problems. Seven
youth were interviewed, and all reported they are able to provide input about what happens at
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the program. Four youth reported they can do this through the Conference Request forms and
community meetings, and three youth reported they speak to staff about any issues.
2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program maintains a policy and procedures to provide for career education. The program
provides Type 2 career education programming, and vocational certificates are offered to all
youth. According to the lead educator’s interview, youth are administered a career assessment
upon entering the program. The certification programs offered include a food handling course,
Florida Ready to Work soft skills, and youth who qualify are provided services through
vocational rehabilitation. The certification information was provided through an interview with the
lead educator and confirmed by certifications included in a review of five closed case
management records. The facility administrator (FA) verified these offerings as well. Five closed
youth case management records were reviewed. Three of the five records contained a résumé,
completed job applications, and all five included documentation including the youth’s local
Career Source Center’s address and hours of operation. One youth had a State of Florida
driver’s license, and one had a State of Florida identification (ID) card, which was documented
in the record; however, there was no photocopy of the card. The remaining three did not have
an ID, as they were not required due to their age.
2.20 Educational Access (Critical) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program maintains a policy and procedures to provide for educational access for the youth.
The program integrates education into the daily schedule in such a way to ensure the integrity of
the required instruction is distributed over 250 days. This year-long schedule included ten days
of teacher training and planning. A review of the daily education schedule, provided by the lead
educator, revealed youth are being provided with a minimum of twenty-five hours of instruction
each week. The 250-day calendar and the daily school schedule are approved by the
Hillsborough County School district, who also oversees the academic schedules for the youth.
Courses are provided and youth can earn credit as appropriate upon course completions. The
lead educator interview indicated the school schedule is adhered to with no deviations. Seven
youth were interviewed, and each youth indicated there were no interruptions during the school
day. A review of six randomly selected days of the program’s logbook, covering March, May,
July, and August 2023, documented the youth were attending school according to the daily
schedule. Video verification for three days in September of 2023 recorded the youth following
the daily school schedule.
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2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The program maintains a policy and procedures requiring an educational transition plan to be
developed, upon the youth’s admission into the program. Five closed youth case management
records were reviewed and confirmed the program’s instructional staff and the youth completed
an education transition plan, upon admission. The plans included services and interventions
based on each youth’s assessed educational needs, post-release education plans,
recommended post-release placement, and specific monitoring responsibilities for individuals
responsible for the reintegration and coordination of the provision of support services. The
development of the plan and subsequent plans, such as the youth’s transition plan and
Electronic Educational Exit Plan (EEEP), incorporated key members including the youth,
parent/guardian, education representative, and school district personnel responsible for
providing guidance services. Seven youth were interviewed, as well as the lead educator, and
all indicated the plans were collaboratively developed upon the youth’s entry into the program.
According to the interview results, six of the seven youth felt they were being very well or well
prepared for continuing their education or gaining employment, while one responded not well
due to being a graduate.
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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’s clinical director (CD) is a licensed clinical social worker with an active license
expiring March 31, 2025. The CD is a full-time staff working forty hours a week on-site with a
juvenile sex offender certification. The CD is responsible for the coordination and
implementation of mental health/substance abuse services. The assistant CD acts as the back-
up when required. The assistant CD is a licensed mental health counselor with an active license
expiring March 31, 2025. The CD interview indicated the role of the CD is to provide ongoing
supervision and both formal and informal assistance to all staff. The CD ensures the services
are being implemented, conducts fidelity checks of group services, conducts chart audits, and
reviews the weekly progress notes. The CD conducts monthly treatment plan reviews to ensure
the clinical team is working on identified goals with the youth. The CD also provides annual
training to all staff pertaining to suicide training, effective communication, Prison Rape
Elimination Act (PREA) needs, and how to work with traumatized youth. The CD meets daily
with the management team to ensure all departments are working together to address any
needs as they arise or help prevent any potential complications.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has three licensed clinical social workers, and two licensed mental health
counselors, all maintaining their juvenile sex offender certification, as contractually required. All
five licenses were active and expire March 31, 2025. Each of the licenses were posted on-site.
The clinical director ensures all the licensed clinical staff working under her supervision are
performing services they are qualified to provide based on education, training, and experience.
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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 does not have any contractual obligation to retain non-licensed clinical staff. The
program has a recreational therapist, as contractually required, who has a bachelor’s degree in
sport and recreation management with more than one year of experience. The recreational
therapist facilitates structured and organized physical activities to restore motor, social and
cognitive functioning, builds confidence, develops coping skills, and promotes wellness and pro-
social activities. The recreational therapist reports to the clinical director and works closely with
the therapists to integrate physical and mental health wellness goals into each youth's
individualized treatment plans.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program has a policy and procedures addressing a standardized process for screening and
referral of youth identified as in need of further mental health and/or substance abuse
evaluation, staff training in mental health and substance abuse issues, as well as administration
of the Massachusetts Youth Screening Instrument, Second Version (MAYSI-2). The program’s
policy states all newly admitted youth receive an Assessment of Suicide Risk (ASR) and
comprehensive evaluation, no matter the risk factors. In all seven mental health and substance
abuse records reviewed the screener reviewed all available information, including the
commitment packet, and reports and/or records for existing documentation of mental health or
substance abuse problems or a history of human trafficking. All seven youth were screened with
the MAYSI-2 in the Department’s Juvenile Justice Information System (JJIS) on the day of
admission in a confidential manner by one of the trained therapists. All MAYSI-2 screenings
were completed in full, indicating further assessment was required with a referral being
completed to alert the clinical director and the facility administrator (FA)/designee. All seven
referrals indicated a need for a comprehensive evaluation and two for an ASR; all documented
the reason for the referral. The FA interview indicated a classification meeting is conducted for
all youth on the day of admission as a part of the intake process. The intake process includes a
review of the findings of the MAYSI-2 screening, records review, Vulnerability to Victimization
and Sexually Aggressive Behavior (VSAB), ASR, and the initial interview. The classification
team identifies needs for comprehensive evaluations, placement on precautionary observation
when indicated, and mental health/substance abuse alert status. Any time when behavior
warrants, program staff or the treatment team may complete a Mental Health/Substance Abuse
Referral form requesting a comprehensive evaluation to be conducted, which is forwarded to the
therapist. The comprehensive evaluation is completed within thirty days of referral.
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3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
All seven mental health and substance abuse records maintained a new combined mental
health and substance abuse evaluation which was completed within thirty days of admission by
a licensed clinical staff. All seven youth provided consent for substance abuse services. The
seven combined mental health and substance abuse evaluations included identifying
information, reason for evaluation, relevant background information, mental status examination,
interview/procedures administered, and diagnostic/clinical impression with Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) diagnosis where applicable, as
well as 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,
discussion of findings 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.
In all seven reviewed mental health and substance abuse records an initial treatment plan was
developed within seven days of treatment initiation on a form which contained all elements of
the Department’s Initial Mental Health/Substance Abuse Treatment Plan form. All seven initial
treatment plans were signed by the licensed clinical staff completing the form, as well as all by
treatment team members who participated in the development of the plan, each youth, and
parent/guardian, where applicable. Three of seven the initial treatment plans included each
youth’s psychiatric needs, as well as medication and frequency of monitoring by the psychiatrist.
The remaining four youth did not take psychotropic medications. In all seven mental health and
substance abuse records an individualized treatment plan was developed within thirty days of
admission on a form which contained all elements of the Department’s Individualized Mental
Health/Substance Abuse Treatment Plan form. All seven individualized treatment plans were
signed by the licensed clinical staff completing the form, as well as all treatment team members
who participated in the development of the plan, and each youth. In three of seven the
parent/guardian participated telephonically; however, did not sign the plan. Each record
contained a letter which was sent to the parent/guardian with the plan to return with signature.
Three of seven youth received psychotropic medications and the individualized treatment plan
included psychiatric services, as well as psychotropic medication and frequency of monitoring
by the psychiatrist. In all seven records the individualized treatment plan reviews were
completed on a form which contained all elements of the Department’s Individualized Mental
Health/Substance Abuse Treatment Plan Review form. In six of seven, the individualized
treatment plan reviews were conducted every thirty days; the remaining one record had one of
six reviews missing. In all seven the goals and objectives were individualized for each youth.
Video and logbook review of three random dates, during the annual compliance review period,
indicated the juvenile sex offender, Pathways, and mental health groups were conducted for the
required amount of time according to the schedule. A review of group sign-in sheets for the
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annual compliance review period indicated Adolescents Coping with Depression, Coping with
Stress/Trauma, and Living in Balance were provided according to the schedule for the required
amount of time. Life Skills Training was provided according to the schedule and for the required
amount of time in 255 of 264 groups; in the remaining nine groups there was no time noted on
the sign-in sheet. A review of the Skillstreaming the Adolescent group sign-in sheets indicated
two of 152 groups were conducted at the same time by the same therapist with ten youth each
participating in the group.
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.
In all seven mental health and substance abuse records each youth was assigned to a
treatment team upon admission. A review of treatment team documentation indicated in four of
seven reviewed records all required treatment team members participated in treatment team
meetings. In one of the remaining three records program administration did not participate in
one treatment team. In one of the remaining two records the residential living unit did not
participate in one treatment team and in one record education staff did not participate/provide
input in one treatment team meeting. In three of seven records each youth was determined to
need substance abuse treatment, which included individual, group, and/or family counseling
provided by a licensed qualified professional in accordance with each youth’s initial or
individualized substance abuse treatment plan. All seven records contained a signed
Department’s Youth Consent for Substance Abuse Treatment and a Youth Consent for Release
of Substance Abuse Treatment Records form. In four of seven an Authority for Evaluation and
Treatment was maintained in each record. Two of the three remaining youth were eighteen
years old. The one remaining youth had a court order allowing for mental health and medical
care. In all seven records the mental health and substance abuse treatment notes were
documented on a form which contained all elements of the Department’s Counseling/Therapy
Progress Notes form. All seven youth received individual counseling and psychosocial skills
training. Five of seven the progress notes determined youth received services as stipulated on
each treatment plan. In the remaining two records two individual counseling sessions each were
not documented, as well as one of the two missing one group session and no monthly
counseling sessions or barriers documented for four months. In all three closed mental health
and substance abuse records the discharge plan was documented on the Department’s Mental
Health/Substance Abuse Treatment Discharge Summary form and included the services
needed for daily maintenance of the positive improvement in behavioral, emotional, and social
skills made by each youth during treatment. In all three the discharge plan was discussed with
each youth, parent/guardian, where applicable, and the juvenile probation officer during the exit
conference, as well as a copy of the plan provided. None of the youth were released while on
suicide alert/precautions.
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3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program’s clinical groups according to the contract are Pathways: A guided workbook for
youth beginning treatment, Adolescent Coping with Depression, Skillstreaming the Adolescent,
Life Skills Training, Living in Balance, and Coping with Stress/Trauma. The program provides
individual, group, or family therapy seven days a week to each youth as part of the
individualized treatment plan. All daily therapeutic activities are provided by licensed clinical
staff and youth with co-occurring mental health and substance abuse disorders receive both
treatment services. The program is not contractually obligated to provide a psychologist. All
counselor caseloads were limited to no more than ten youth. All mental health therapy groups
had no more than ten youth, and all substance abuse groups no more than fifteen, other than
one group for one day, which had twenty youth. The program does not have a Chapter 397
license; all therapists are licensed clinicians who had sex offender training and provide on-site
coverage seven days a week for more than forty hours a week. A licensed psychiatrist provides
psychiatric evaluations and medication management, as well as participates in treatment
planning. The program does not provide urinalysis drug testing upon each youth’s initial intake
into the program, they conduct drug screens only if a youth was on a home pass or in court. The
program’s updated policy and procedures indicate drug screens are conducted upon a youth’s
return from court, home pass, or other activities where there is an approved break in custody.
The prior facility operating procedure (FOP) indicated youth are to be drug screened during the
admission process. The FOP was updated during the annual compliance review week when the
error in the FOP was discovered. The program provides sex offender/mental health/substance
abuse evaluations, sex offender treatment planning, juvenile sex offender therapy, and crisis
interventions. All seven staff interviews indicated they or other direct care staff do not facilitate
any mental health or substance abuse groups. Six of seven youth interviews indicated they
participate in family and/or individual counseling from bi-weekly to monthly. The remaining one
stated they do not participate. The clinical director interview indicated there are several mental
health and substance abuse treatment services provided at the program. The youth are
provided with individual, group, and family therapy, as well as treatment goals addressing both
mental health and substance abuse needs. The program offers behavior management services,
medication management, skills training, and life skills training. All youth receive a treatment plan
with goals and objectives addressing needs which are identified through a records review,
interviews with youth and parent/guardian, juvenile probation officer, as well as through
behavioral observations.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.***
The program has a psychiatrist with a clear and active license expiring on January 31, 2024,
providing psychiatric services, actively participating in, managing, and supervising psychotropic
medication services in the program. The psychiatrist is available for emergency consultation
twenty-four hours a day, seven days a week and briefs a representative of the treatment team
regarding the psychiatric status of each youth receiving psychiatric services who is scheduled
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for treatment team reviews. The psychiatrist’s evaluation and recommendations for each of the
three applicable youth records reviewed were incorporated into the evaluations of each youth
and each youth’s Individualized Mental Health/Substance Abuse Treatment Plan. The program
does not have a psychiatric advanced practice registered nurse. A review of the sign-in and out
logs confirmed the psychiatrist was on-site at least two hours weekly since the last annual
compliance review. In three of seven mental health and substance abuse records each youth
entered the program on psychotropic medication. All seven youth received an initial psychiatric
interview/evaluation within fourteen days of admission on the Department’s Clinical
Psychotropic Progress Note (CPPN) form, including page three. The interview/evaluation was
named as the Initial Diagnostic Psychiatric Evaluation and contained history, Mental Status
Examination, treatment recommendations, and Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5) diagnosis. The DMS-5 diagnosis was documented and
consistent with each youth’s treatment plan, other than two youth, who did not have a DSM-5
diagnosis. In the three applicable youth prescribed medications, target symptoms, explanation
of the need for psychotropic medication related to diagnosis, initial treatment goals, potential
side effects, risk and benefits of taking the medication, and frequency of medication monitoring
were also documented. In the three applicable records each youth received a medication review
by the psychiatrist every thirty days, documented on the Department’s CPPN, containing
identifying data, diagnosis, target symptoms of each medication, and the evaluation and
description of effect of prescribed medication on target symptom. The form also contained
prescribed psychotropic medications, side effects, youth adherence to the medication regime,
weight, blood pressure, signature of the psychiatrist and date, as well as Tardive Dyskinesia,
where indicated. The program did not utilize tele-psychiatry. The psychiatrist interview indicated
being on-site weekly to work with the mental health team, as well as with nursing staff and
therapists to adjust care and procedures as needed to ensure comprehensive evaluations and
appropriate treatment is completed. The psychiatrist evaluates every new patient, diagnoses,
and treats psychiatric disorders with medications and other modalities. Youth not already in
psychiatric care are referred and seen promptly. When a youth refuses medication the nursing
staff document the refusal, and contact the psychiatrist if the youth refuses medication three
times in a row. The psychiatrist indicated meeting with the clinical director (CD) weekly during
medication management and with the facility administrator frequently, and as needed. The CD
interview indicated the clinical and case management team meet with the psychiatrist on a
weekly basis for one hour for medication management meetings. Case managers, clinical staff,
and the CD also meet with the psychiatrist informally as needed for any additional input or
feedback.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a suicide prevention plan including identification and assessment of youth at
risk of suicide, staff training, suicide precautions, levels of supervision, referral, communication,
notification, documentation, immediate staff response, and review process. The program’s
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. The suicide prevention plan was reviewed annually as required,
on January 31, 2023, by the facility administrator (FA), the clinical director, and the chief
compliance officer.
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3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors.
Any youth exhibiting suicide risk behaviors shall be placed on suicide precautions
(precautionary observation or secure observation), and a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations shall be placed on suicide precautions and receive an
Assessment of Suicide Risk.
In all seven reviewed mental health and substance abuse records each youth was identified on
the day of admission to be at risk and received an Assessment of Suicide Risk (ASR) during the
intake process, which was documented on the Department’s ASR form and completed by a
licensed clinical staff. All seven youth were stepped down to standard supervision after
completion of the ASR. One of the seven youth had been on precautionary observation (PO)
prior to admission and the Department’s Juvenile Justice Information System (JJIS) alert was
updated and closed, as well as evidence in the logbook administration/designee provided
instructions related to the ASR findings and suicide precaution decisions. In five of the seven
records the parent/guardian and juvenile probation (JPO) were notified of each youth receiving
an ASR. In the remaining two records, each youth was over eighteen years old, and no
parent/guardian notification was required; the JPO was contacted. Three examples of youth
receiving a follow-up ASR were requested. The program provided two youth records with three
events. In the three events each youth self-reported and was identified to be at risk, a referral
was made, and an ASR was completed immediately on the Department’s ASR form by a
licensed clinical staff. Each youth was maintained on PO, mental health staff provided
supportive services, and each youth received a follow-up ASR on the Department’s Follow-Up
ASR form prior to removal from PO. One youth was under eighteen years old, and the
parent/guardian and JPO were notified of the youth’s potential suicide risk, which was
documented on the ASR. The remaining youth was over eighteen years old, and no
parent/guardian notification was required; the JPO was contacted. In the three events a follow-
up ASR indicated suicide precautions could be discontinued, each youth was stepped down to
close supervision prior to transition to normal routine and standard supervision. Close
supervision was maintained until it was determined no longer necessary by the clinical
director/licensed mental health professional, and this was documented in accordance with the
program’s suicide prevention plan in each youth’s mental health and substance abuse record. A
conference between the facility administrator and licensed mental health professional to reduce
the level of supervision was documented on the ASR with date and time. In all three events a
JJIS alert was initiated and then closed appropriately, as well as an entry made in the logbook
by administration/designee providing instructions related to the ASR/Follow-Up ASR findings,
suicide precaution decisions, and discontinuation of close supervision. While on PO each “at-
risk” youth was allowed to participate in select activities with other youth in designated safe
housing/observation areas of the program. The program does not utilize secure observation.
During the annual compliance review week, maintenance was being conducted on the
program’s camera system and only limited footage was available, which did not include PO;
therefore, video observation of PO could not be reviewed. Six of seven staff interviews indicated
if a youth expresses suicidal thoughts, direct care staff are responsible to notify mental health,
five said document supervision and provide constant sight and sound, four indicated notify the
supervisor, two stated search room and youth for sharp objects, and one said to make a
referral.
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3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
One of seven mental health and substance abuse records were applicable for being placed on
suicide precautions. Two more records were requested. In all three applicable records the
Suicide Precaution Observation Logs were maintained for the duration each youth was on
suicide precaution safe housing requirements were documented. Each Suicide Precaution
Observation Log documented the appropriate level of supervision and observations of each
youth’s behavior in real time, not exceeding thirty-minute intervals, and each log was reviewed
and signed by each shift supervisor and mental health clinical staff. In two records warning
signs were observed and the facility administrator/designee and mental health clinical staff were
notified, which was documented on the Suicide Precaution Observation Log.
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.
Four of seven pre-service training records indicated the staff had completed suicide prevention
training. The remaining three staff were still in the first 180 days of employment. The program
has five suicide response kits co-located with first-aid kits, one each in all three dormitories, the
clinic, and master control. All suicide response kits contain a knife-for-life, a needle nose plier,
and wire cutters. The program conducts mock suicide drills at least quarterly on each shift, for
all staff who come in contact with youth, including kitchen and maintenance staff. Each mock
mental health drill was in response to a suicide attempt and/or incident of simulated serious self-
injury, without the use of program youth, and occurred at least semi-annually utilizing cardio-
pulmonary resuscitation as part of the training. Staff who were not present during a quarterly
drill had the opportunity to review each drill scenario and procedures. The facility administrator
interview indicated the program conducts monthly Continuity Of Operations Plan, fire, medical,
and mental health/suicide drills on all three shifts. All seven staff interviews indicated the suicide
response kits are maintained in master control and each module. Six of seven stated medical
emergency and suicide drills are conducted monthly on each shift, one stated three times a
month.
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 a written crisis intervention plan addressing communication, supervision,
documentation, review, notification, and alert system, as well as means of referral, including
youth self-referral.
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Office of Accountability and Program Support Page 42 of 69 (Revised September 2022)
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.
None of the seven mental health and substance abuse records reviewed were applicable for a
Crisis Assessment. Three examples of Crisis Assessments were requested; however, the
program only had one since the last annual compliance review. In the one applicable record the
Crisis Assessment was conducted immediately by a licensed clinical staff and included reason
for assessment, Mental Status Examination and interview, determination of danger to self and
others, initial clinical impression, as well as supervision recommendations, treatment
recommendations, recommendations for follow-up, and notification to parent/guardian of follow-
up treatment. The recommendation of the Crisis Assessment was to step the youth to standard
supervision. The youth was an alleged victim in a Prison Rape Elimination Act event and was
offered ongoing mental health treatment services. The program was unable to provide the
Mental Health and Substance Abuse Referral Summary.
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 a written emergency mental health and substance abuse plan which includes
immediate staff response, notifications, communication, supervision, authorization to transport
for emergency mental health or substance abuse services, including Baker Act and Marchman
Act, as well as documentation, training, and review.
3.17 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker Act or Marchman Act procedures during the annual
compliance review period; therefore, this indicator is rated non-applicable.
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Office of Accountability and Program Support Page 43 of 69 (Revised September 2022)
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
All seven mental health and substance abuse records contained a safety plan completed within
fourteen days of admission, including warning signs, youth baseline behaviors, crisis
recognition, jointly developed coping strategies, intervention strategies preferred by the youth,
debriefing process, trauma responsive practices, and any recommendations from previous or
current clinical assessments or screening instruments. Each safety plan was jointly prepared by
the youth and clinical staff, and two of the seven also included the parent/guardian. In six of
seven records the plan was reviewed and updated as necessary at least every thirty days. In
the remaining one record one of the thirty-day reviews was seven days late. The safety plans
are maintained in each youth record, as well as master control. Staff sign the shift briefing form
acknowledging review of the safety plans. All seven staff interviews indicated the youth safety
plans are located in master control; one also mentioned the modules. Six said the plans can be
reviewed anytime and one said the plans are usually maintained by the therapist to review if
needed. The staff stated varying time frames when they had reviewed the safety plans last
including yesterday, this week, one week ago, one month ago, over a month ago, and it has
been a minute. All seven youth interviews indicated participating in the safety plan creation; five
stating with the therapist, case manager, and treatment team. The facility administrator interview
indicated the safety plans are updated monthly at a minimum, as well as when a significant
situation occurs.
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Office of Accountability and Program Support Page 44 of 69 (Revised September 2022)
Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a policy and procedures stating the designated health authority (DHA) shall be
clinically responsible for the medical care of all youth at the program. The program’s DHA is a
licensed physician who holds a clear and active license with an expiration date of January 31,
2025. The physician’s specialty training is in internal medicine. The DHA does not have any
disciplinary cases or public complaints on record. The program does not utilize a physician’s
assistant or advanced practice registered nurse. Reviewed sign-in/out logs since the last annual
compliance review confirmed the DHA was on-site for two hours each week, as required by
contract. The program has a back-up physician in the event of the DHA’s absence who holds a
clear and active license with an expiration date of January 31, 2024; however, the DHA has not
been absent since the current provider took over the contract. A review of the program’s
contract and DHA’s contract found the program does not utilize telemedicine or telehealth for
medical services. The DHA was interviewed and indicated they see youth for initial intake
physical exams, periodic evaluations, sick calls, and referrals to specialists, as needed. The
DHA stated all items needing review are placed in a folder for their review. The DHA indicated
medical staff inform them of any new medical developments involving youth and they meet with
medical staff quarterly. The DHA reports being available by telephone or through an answering
service when not on-site.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has a policy and procedures indicating the designated health authority is clinically
responsible for all healthcare services provided to youth at the program. Daily clinical care shall
be performed by licensed medical staff, according to developed and authorized protocols. The
program’s contract indicates they will have a full-time health services administrator (HSA) and
two full-time registered nurses (RNs). Nursing staff are required to be on-site for ten hours,
seven days a week, for a total of 120 hours a week. The program has nursing staff on-site
seven days a week from 7:00 a.m. to 5:00 p.m. At the time of the annual compliance review, the
HSA and one full-time RN were scheduled four days a week, and the remaining RN was
scheduled three days a week, for a total of 110 scheduled hours each week. During the annual
compliance review, the nursing schedule was updated to reflect the HSA and both RNs working
forty hours a week, for a total of 120 hours weekly. The program also employs one pro re nata
(PRN) RN, who works as needed. The program does not utilize any licensed practical nurses. A
review of nursing licensure credentials on the Florida Department of Health Medical Quality
Assurance website confirmed each of the RN’s licenses were clear and active. The HSA’s
license expires on April 30, 2023, both full-time RN’s and the PRN RN’s licenses expire on July
31, 2024. Each nurse has a current cardiopulmonary resuscitation certification card.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 45 of 69 (Revised September 2022)
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 facility operating procedures (FOPs) for all health-related procedures and
protocols utilized at the program. The medical FOPs were signed by the designated health
authority (DHA) and the facility administrator (FA) on January 31, 2023. The psychiatrist signed
the FOPs on February 7, 2023. A cover page indicating all FOPs and nursing protocols were
reviewed was signed by the program’s health services administrator and pro re nata (PRN)
registered nurse (RN) on February 1, 2023, and by one full-time RN on February 3, 2023. The
remaining full-time RN’s first day at the program was during the annual compliance review
week; therefore, they had not yet reviewed and signed. Some of the medical FOPs were revised
on August 31, 2023. Each revised FOP was signed by the DHA and FA, and a signature page,
with the specific policies and date of revision, was signed by nursing staff following the
revisions. The program had one newly hired nursing staff since the current provider took over
the contract. The newly hired nurse was still in training at the time of the annual compliance
review. Approval of treatment protocols and standing procedures were written and authorized by
the DHA and 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 specific treatment for youth in the custody of the
Department. Seven youth Individual Healthcare Records (IHCRs) were reviewed. Four IHCRs
contained a valid AET form. Each AET was a copy and was stamped with the word “copy.” Each
AET was signed by a parent/guardian and a Department representative; however, one of the
four did not have a date on it. Two youth were eighteen years of age, and both had a
documented release of information in their IHCR. The remaining youth was in the care of the
Department of Children and Families where there had been a termination of parental rights. The
youth’s IHCR included a court order authorizing all treatment and procedures. During an
interview with the health services administrator, it was stated nursing staff review all intakes in
the Department’s Juvenile Justice Information System to validate the AET. If needed, case
management staff would contact the youth’s assigned juvenile probation officer to obtain a new
AET. Youth who are eighteen years of age or older sign a release of information, which is
placed in their IHCR.
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 informed of
significant changes in the youth’s condition and to obtain consent when new medications and
treatments are prescribed. Seven youth Individual Healthcare Records (IHCRs) were reviewed;
however, only five were applicable for parent/guardian notification, as the remaining two youth
were eighteen years of age at the time of admission. Three youth IHCRs were applicable for
parental notifications for over-the-counter (OTC) medications beyond those covered by the
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Authority for Evaluation and Treatment (AET). All three IHCRs contained documentation of
parent/guardian notification and consent for each OTC medication. New medication was
ordered for four of the five applicable youth. Documentation of notification to the parent/guardian
for each new medication was in each youth’s IHCR. All written notifications were sent utilizing
the correct forms. Three youth were taking psychotropic medications. Only one youth had a new
psychotropic medication prescribed, discontinued, or had the dosage significantly changed.
Documentation in the one IHCR found parent/guardian verbal consent was documented on
page three of the Clinical Psychotropic Progress Note (CPPN). The one applicable CPPN
included a progress note signed by a witness, indicating staff witnessed telephone call attempts
or conversations regarding the psychotropic medication. One youth was in the care of the
Department of Children and Families where there had been a termination of parental rights. The
youth’s IHCR included a court order authorizing all treatment. All seven reviewed youth had
their vaccinations verified within thirty days of admission. None of the reviewed youth received a
vaccination at the program; however, parent/guardian consent was attempted for one youth.
None of the reviewed youth required an exemption for a vaccination. An interview with the
health services administrator (HSA) found parent/guardian consent is obtained for any OTC not
approved by the AET, new prescriptions, when a dosage is significantly changed, or when
medication is discontinued. Parent/guardian notifications are completed for all off-site care.
Verbal consent is obtained as soon as possible, and written notifications are made within
twenty-four hours. The HSA indicated if a youth goes to the emergency room, they attempt to
make verbal notification to the parent/guardian prior to the visit and again when the youth
returns. Written notification is completed after return from the emergency visit. The program
obtains immunization records from Florida Shots. The records are reviewed as soon as possible
and always prior to completion of the Comprehensive Physical Assessment. The HSA stated if a
parent/guardian is requesting youth exemption from an immunization, they must obtain the
appropriate form and submit it to the Department of Health. The program will also receive a
copy of the form to file in the youth’s IHCR.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program maintains a policy and procedures which ensure youth are screened upon
admission for healthcare concerns which may require a referral for further assessment by
healthcare staff. Seven youth Individual Healthcare Records (IHCRs) were reviewed for
completion of the Department’s Facility Entry Physical Health Screening (FEPHS) form. Each
youth’s IHCR contained a FEPHS form completed by a registered nurse (RN) on the day of their
admission. The program did not have any youth with a change in physical custody for greater
than twenty-four hours. An interview with the health services administrator (HSA) found each
youth is seen by a RN upon admission. This typically takes place within ten to fifteen minutes of
admission, following the initial search. If there is a change in custody, a new FEPHS form is
completed upon the youth’s return to the program. The HSA stated if a FEPHS form were to be
completed by direct care staff, nursing staff would conduct a review within twenty-four hours.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 47 of 69 (Revised September 2022)
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program maintains a policy and procedures to ensure all youth are oriented to the general
process of healthcare delivery services at the program. Seven youth Individual Healthcare
Records (IHCRs) were reviewed for healthcare orientation. Each youth received a general care
orientation on the day of admission. The program’s healthcare orientation included all required
topics including access to medical care, sick call, what constitutes an “emergency” and when to
notify staff, medication process to include side-effect monitoring, the right to refuse care and
how it is documented, what to do in the event of sexual assault or attempted sexual assault, the
non-disciplinary role of healthcare providers, and Standard Universal Precautions. Each youth’s
IHCR included a signed Health Care Services Orientation form and a signed acknowledgment
stating they reviewed and understood the Health Education Packet.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program maintains a policy and procedures to ensure the designated health authority
(DHA) is notified when a youth admitted requires emergency care or routine notification in
accordance with the Department’s requirements. The program’s practice is to notify the DHA of
each admission. Seven youth Individual Healthcare Records (IHCRs) were reviewed. Four
reviewed youth had a known or suspected chronic condition upon admission. None of the
reviewed youth were identified as in-need of an emergency response upon admission. Each
youth’s IHCR contained documentation of notification being made to the DHA within twelve
hours of admission. Two youth were taking psychotropic medication when admitted to the
program. Both IHCRs included documentation of the psychiatrist being notified. During an
interview, the health services administrator (HSA) stated they learn of new admissions from
case management. Once a youth is admitted, the admitting nurse notifies the DHA by telephone
and informs them of the youth’s history and any chronic conditions. The HSA indicated all DHA
notifications are made the day of admission.
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 to ensure the standard Department’s Health-Related
History (HRH) form is used for all youth admitted into their physical custody. Seven youth
Individual Healthcare Records (IHCRs) were reviewed for completion of a HRH form. A new
HRH form was completed within seven calendar days of admission for each youth. Each
reviewed HRH form was completed prior to the Comprehensive Physical Assessment and
reviewed by the designated health authority. The health services administrator stated nursing
staff complete the HRH form during the initial nursing assessment. HRH forms are completed
annually, as needed, or anytime there is a significant medical event or change.
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4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program maintains a policy and procedures ensuring the standardized Comprehensive
Physical Assessment (CPA) form is used for all youth admitted into the program. A review of
seven youth Individual Healthcare Records (IHCRs) found a new CPA form was completed by
the designated health authority (DHA), on the Department’s CPA form, within seven days of
admission for each youth. Each youth’s Medical Grade was documented on their CPA. Three
youth were identified as Medical Grade two, one youth was identified as Medical Grade four,
and three youth were identified as Medical Grade five. All sections of each CPA were marked
with an “O” or an “X.” Those sections marked with an “X” had comments by the DHA in the
comments section of the form for each youth. One youth refused a portion of the exam. The
youth’s IHCR included a signed refusal form reflecting the refused portion and was dated the
date of the exam. The Department’s Problem List was updated, as required, for each youth. All
seven youth had at least one verified Tuberculosis Skin Test (TST) completed and documented
within a year of admission. Each youth’s results were documented on their CPA and r Infectious
Communicable Disease form, and each youth’s test results matched on both forms. An
interview with the health services administrator (HSA) found CPAs are conducted within seven
days of admission and annually thereafter. The HSA indicated they review the Department’s
Juvenile Justice Information System for TST status prior to admission. A tuberculosis screening
is completed during the initial nursing assessment and a medical tracker is maintained to
monitor for TST due dates.
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 ensuring all youth are evaluated and treated, if
necessary, for sexually transmitted infections (STIs). Seven youth Individual Healthcare
Records (IHCRs) were reviewed. Each youth’s IHCR contained documentation showing they
were screened and evaluated for STIs on the day of admission. Further evaluation was only
required for one youth. The one youth was referred to the designated health authority (DHA)
and the referral was documented on their STI form. Testing was ordered and performed for the
youth. The youth’s IHCR included documentation of testing, screening results, clinical
evaluations, and diagnoses on the Department’s Infectious and Communicable Disease (ICD)
form. None of the reviewed youth required a rescreen. Consent forms in all seven reviewed
IHCRs reflected each youth was offered counseling, testing, and if indicated, treatment/referral
for human immunodeficiency virus (HIV). Four of the seven reviewed youth refused HIV testing
and a refusal was documented. Three youth consented to testing. All three youth received HIV
testing and consent was documented for each. Each youth’s results were located in their IHCR
in a sealed envelope marked “confidential,” consistent with Florida Administrative Code. All
three envelopes were signed by the DHA, indicating their review. Documentation of pre-test and
post-test counseling was maintained in each youth’s Health Education Record. Each youth’s
confidentiality was protected, as their HIV statuses were not included on the program’s internal
alert system. The program’s policy and procedures indicate youth HIV test results are only
disclosed to entities as outlined Florida Administrative Code. The program has a provider with a
500/501 certification by the Department of Health who provides their HIV testing and pre-test
and post-test counseling services. Seven interviewed youth stated they can ask for a HIV test.
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The health services administrator (HSA) was interviewed and stated every youth is screened for
STIs, regardless of their risk. Youth are referred for off-site evaluation if needed. The HSA
indicated STI screening results are documented on the ICD form and lab results are filed in the
IHCR. The HSA confirmed each youth is offered HIV testing and stated a log is maintained for
youth who have requested testing. The HSA stated pre and post-test counseling is documented
on each youth’s Health Education Record and results are kept in a sealed, “confidential”
envelope, which is initialed by the DHA.
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 to ensure all youth can submit sick call requests and
have their complaints treated appropriately through the program’s sick call system. Seven
Individual Healthcare Records (IHCRs) were reviewed, and five were applicable for sick calls.
None of the five applicable youth presented with a similar sick call complaint three or more
times within a two-week period. There was a total of thirteen sick calls documented for the five
applicable youth. Each Sick Call Request form was completed by the youth requesting a sick
call and the nurse conducting the sick call. Reviewed documentation found each sick call was
completed by a registered nurse (RN). Each youth’s Sick Call Request forms were filed in their
IHCR in reverse chronological order. Each Sick Call Request form was documented in
accordance with Florida Administrative Code. Each youth’s sick calls were documented on their
Sick Call Index in their IHCR. Each sick call was documented on the program’s Sick Call
Referral Log. All dates listed on the Sick Call Indexes corresponded to the completed Sick Call
Request forms located in the IHCRs. None of the youth were in restricted housing. A review of
the daily schedule, posted schedule, and nurse interview found sick call is held daily from 11:00
a.m. to 2:00 p.m., which exceeds the contract requirement of two times a day from 6:45 a.m. to
7:30 a.m. and 3:35 p.m. to 3:45 p.m. on the weekdays and from 9:45 a.m. to 10:00 a.m. and
4:30 p.m. to 5:30 p.m. on the weekend. Sick call hours are posted outside of the medical clinic.
An exam table is located in the medical clinic to utilize during sick calls. Sick Call Request forms
are available to youth on the living units. Completed forms are submitted by youth into a box in
the living units. If there are no nursing staff on-site, the program’s policy indicates Sick Call
Request forms should be turned in to the shift supervisor promptly; however, no longer than two
hours after being submitted. Seven interviewed staff stated nursing staff review, respond to, and
conduct sick calls. Seven youth were interviewed. Two youth stated they see a nurse
immediately and five youth stated they see a nurse within one day when a sick call is requested.
A sick call was not observed, as no sick calls took place during the annual compliance review
week.
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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 showing they have a comprehensive process for the
provision of episodic care and first-aid care. Seven youth Individual Healthcare Records
(IHCRs) were reviewed and two were applicable for episodic care. An additional IHCR was
requested. A total of three episodic care or first-aid care events were reviewed for the three
youth. On-site care was provided by licensed healthcare staff for each event. Each event was
documented in the required subjective, objective, assessment, and plan (SOAP) format. All
three events were documented on the Episodic Care Log. An interview with the health services
administrator (HSA) confirmed episodic care is documented in nursing progress notes and on
the Episodic Care Log. The HSA stated if non-healthcare staff provide episodic or first-aid care,
it is documented on the Department’s Report of On-Site Health Care by Non-Health Care Staff
form to notify nursing staff to assess the youth. An episodic care event was not observed, as
one did not take place during the annual compliance review week. Seven interviewed staff
stated they can call 9-1-1 if needed. Seven interviewed youth indicated they can see a dentist or
doctor, if needed. The program maintains nine first-aid kits. The kits are kept in the kitchen,
maintenance office, front office, master control, two for transport, and in the closet on each of
the three living units. Expiration dates are listed on the back of the first-aid kits and items are
switched out as needed. Three first-aid kits were checked. Each first-aid kit was fully stocked
with designated health authority (DHA) approved items. A review of documentation since the
provider took over the contract found first-aid kits were inspected weekly by healthcare staff, as
required. An interview with the HSA confirmed the number and location of the first-aid kits. The
program has one automated external defibrillator (AED), which is located in master control.
Instructions are located in a binder in master control. Reviewed documentation confirmed on-
site healthcare staff check to ensure the AED batteries and pads are operable. The green light
was flashing on the AED during the annual compliance review week and no issues were noted.
The batteries were last changed on June 21, 2023 and expire on June 21, 2028. The pads were
last changed on July 25, 2023 and expire on December 15, 2025. An interview with the HSA
confirmed the location of and expiration dates for the AED. A review of emergency drill
documentation, since the provider took over the contract on January 31, 2023, found the
program has conducted drills, which simulate an episodic care event which calls for immediate
first-aid and/or administration of cardiopulmonary resuscitation (CPR) techniques and the
initiation of the emergency procedures to follow when a life-threatening emergency occurs,
monthly on each shift. A review of drill documentation found direct care staff participated in a
drill or participated in a review of a drill including the use of CPR; and staff had the opportunity
to participate in at least one emergency drill annually. The program has a list of emergency
numbers inaccessible to youth, including the Poison Information Control Center, which is
located in administration and in the desk in the medical clinic. A review of training sign-in sheets
found all twelve direct-care staff, who are trained to assist in the administration of medication,
were trained by a RN on the administration of the epinephrine auto-injector. A review of seven
pre-service staff training records found five staff were trained in episodic, first-aid, and
emergency care. The remaining two staff were still within their initial 180 days of hire. No in-
service staff training records were reviewed as the provider just took over the contract this
calendar year. The program has a policy on the use, access, and inventory of Narcan. The
policy indicated Narcan is kept in the medication cart in the medical clinic with the epinephrine
auto-injector. The program is to carry at least one dose of Narcan for emergency purposes, a
perpetual/daily inventory must be maintained, and the Narcan must be stored at room
temperature away from light. The program has two doses of Narcan in the medical cart and two
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more in a locked cabinet with the overflow medication. Only nursing staff and staff trained to
assist in the administration of medication have access to the Narcan. Training on when and how
to use Narcan is included in the medication administration training. The program inventories
Narcan on their medication inventory documentation. An interview with the HSA confirmed
emergency numbers are posted in administration, medical, and master control. The HSA stated
medical drills are done monthly on each shift. The HSA stated nursing staff follow a drill
calendar and plan drills accordingly. The drill calendar has various drills which incorporate CPR
at least quarterly throughout the year.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program maintains a policy and procedures ensuring the program provides for timely
referrals and coordination of medical services to off-site healthcare providers. Three of seven
reviewed Individual Healthcare Records (IHCRs) were applicable for off-site care. A total of
sixteen off-site care events were reviewed for the three youth. The Department’s Summary of
Off-Site Care Consultation Report form was utilized for fifteen of the sixteen off-site care events.
The program was unable to locate the form for the remaining event. None of the off-site care
events were for emergency care; therefore, documentation on the Episodic Care Log was not
applicable. Only one youth was applicable for parent/guardian notification, as the remaining two
youth were eighteen years of age or older at the time of the events. Documentation of
parent/guardian notification was located for the one youth’s off-site care event. The designated
health authority (DHA) reviewed all off-site care findings, instructions, and information and
initialed the Summary of Off-Site Care Consultation Report form acknowledging his review for
all, except one event. There was a progress note indicating the DHA review for the remaining
event; however, the form was not initialed. The DHA initialed and dated the form during the
annual compliance review week. Two youth required follow-up care. Evidence indicating both
youth received appropriate follow-up care was provided. During an interview, the health services
administrator (HSA) indicated youth who are sent off-site for emergency needs are tracked on
the Episodic Care Log. All orders are reviewed by nursing staff and the DHA when the youth
returns. The HSA stated all follow-up appointments are tracked on their healthcare tracker.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a policy and procedures to ensure youth who have chronic conditions receive
regularly scheduled evaluations and necessary follow-up. Seven youth Individual Healthcare
Records (IHCRs) were reviewed. Four of the youth were applicable for chronic conditions. All
four reviewed youth were identified on the Department’s Facility Entry Physical Health
Screening (FEPHS) form as having a chronic condition. None of the reviewed youth had a
communicable disease. One youth was taking prescribed medication on an ongoing basis. All
four youth had an identified chronic health condition, were undergoing treatment for a physical
health condition, and were classified with a Medical Grade two through four, or a Medical Grade
five for youth also taking psychotropic medications. Each youth was placed on the program’s
Chronic Illness List. A review of progress notes found each youth received periodic evaluations
at least every ninety-days. There were no youth at the program who were taking anti-
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tuberculosis medication. All periodic evaluations were conducted on-site, prior to renewing any
prescription medications which expired. There were no instances of lapses in care or missed
periodic evaluations for any youth. The Department’s Problem List was updated, as required, for
three youth. The remaining youth’s Problem List was not updated to reflect one of their chronic
conditions. The program’s facility administrator (FA) was interviewed and stated program
management, including healthcare staff, meet daily to discuss medical issues. The FA indicated
they also meet with the health services administrator (HSA) and the designated health authority
(DHA) weekly for the DHA to provide any updates pertaining to the wellbeing and medical
conditions of the youth. The DHA was interviewed and stated periodic evaluations are done
every two months. The DHA stated they ensure the periodic evaluations are completed by
utilizing a tracking system. The HSA was interviewed and stated youth with chronic conditions
are placed on the medical tracker for monitoring and tracking of due dates.
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 indicating they shall receive, store, inventory, and
provide medication in a safe and effective manner which shall be demonstrated by observation,
as well as review of documentation of procedures and processes. Seven youth Individual
Healthcare Records (IHCRs) were reviewed. Four youth were identified on the Department’s
Facility Entry Physical Health Screening (FEPHS) form and in the chronological progress notes
as admitted to the program with medication. Documentation found each youth’s medications
were verified prior to being admitted into the program. The designated health authority (DHA)
and/or psychiatrist was contacted to obtain an order to resume the medication prescribed prior
to admission for all four youth. Two additional reviewed youth were prescribed medication after
their admission. All medications for all six youth were observed to have a current, valid order,
and were given pursuant to a current prescription. Each time a medication was continued,
discontinued, changed, or a new one was ordered, the DHA placed an order on a Practitioner
Order form. None of the youth were in restricted housing. Five youth were applicable for OTC
medications not listed on the Authority for Evaluation and Treatment form. All OTC medications
were administered in accordance with approved protocols or practitioner’s order. The program
utilizes a preprinted pharmacy Medication Administration Record (MAR), which includes all
required elements. A review of MARs found staff initialed each administered medication and
side-effect monitoring was documented at least weekly for each youth. There were no
undocumented explanations for lapses or errors in medication administration. Non-healthcare
staff did not assist in the administration of medication for any of the reviewed youth. None of the
reviewed youth refused any medication. One reviewed youth required parenteral medication
and their medication was administered by licensed staff. Three youth were prescribed
psychotropic medication upon admission, and the DHA and psychiatrist were notified the day of
admission for each. The psychiatrist conducted an Initial Diagnostic Psychiatric Interview with
each youth within fourteen days of admission. All three youth received a medication
monitoring/review every thirty days, as required. None of the reviewed youth were prescribed
psychotropic medications after admission. There were no standing orders, emergency treatment
orders, or pro re nata orders for psychotropic medications. Medication pass was observed for
three youth during the annual compliance review week. Medication delivery was the sole
responsibility of the nurse during the time of administration. Each youth was escorted to
medication pass by direct care staff and each youth approached the nurse administering
medication individually. The nurse reviewed each youth’s MAR to verify the Six Rights of
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Medication Delivery/Administration. The same staff prepared and administered each medication
and none of the medications were pre-poured from their original packaging nor placed in
another container for subsequent administration. One youth’s medication was a pill. The youth
took their medication and then did a mouth sweep and coughed. The remaining two youth had
parenteral medications. Both youth took their medication and the nurse ensured the sharps
were disposed of properly. The staff initialed the MAR for each administration. Seven youth
were interviewed. Five youth stated a nurse dispenses their medication and two youth stated
they do not take medication. Two of the youth explained the process for receiving medication.
The two youth indicated they are asked their name, date of birth, and what medications they
take. After taking their medication they sweep their mouth. Seven interviewed staff stated
nursing staff dispense medication. Six staff indicated a supervisor can also dispense medication
and one staff indicated trained staff can dispense medication. The health services administrator
(HSA) was interviewed and stated medications are verified through the parent/guardian, youth,
and with the records sent from detention. The HSA indicated the program utilizes a preprinted
pharmacy MAR. The HSA stated they train non-licensed staff who are able to assist in the
delivery of medication. The HSA stated medication pass is held daily at 8:00 a.m., 12:00 p.m.,
4:00 p.m., and 8:00 p.m.
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 stating 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’s sharps are secured in a locked cabinet in the medical clinic. A
review of sharps inventories since the provider acquired the contract on January 31, 2023 found
weekly inventories are conducted by healthcare staff. The program also utilizes a perpetual
inventory for sharps, such as syringes and items which are used daily, which is completed as
the items are utilized and disposed of. All medications were identified and secured in a locked
area designated for storage of medications in the medical clinic. Medications are kept in the
locked medication cart, with all overflow medications stored in a locked cabinet in the medical
clinic. The medication cart was found to be organized with stock items separate from youth
specific medications and all injectable, topical, drops, and liquids separated. There is a locked
drawer within the locked medication cart for controlled substances. Nursing staff document a
shift-to-shift inventory count of each controlled medication, as well as a count each time a dose
is administered. The program has a dedicated refrigerator for medication requiring refrigeration
only. A review of over-the-counter (OTC) inventories since the provider acquired the contract
found a perpetual inventory is done whenever an OTC medication is utilized, and weekly
inventories are conducted by healthcare staff. All discontinued medications are quarantined.
The program’s quarantine process is to complete a Quarantine form, utilize a label which is
provided by the pharmacy, and ship the medication back to the pharmacy. The program utilizes
a Quarantine Tracking Log to keep track of any medication they send back to the pharmacy. All
controlled medications which have been discontinued and need to be destroyed are destroyed
on-site with the pharmacist and a nurse. Twelve staff training records were reviewed for non-
healthcare staff who may assist in delivery and oversight of medication self-administration. Each
staff received training, delivered by a registered nurse (RN), on medication administration. The
health services administrator (HSA) was observed counting three controlled medications, three
OTC medications, and three sharps. All counts matched the ending inventory numbers. The
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HSA stated if there were to be an inventory discrepancy, they would check to ensure none of
the non-licensed staff assisted in medication administration and forgot to write it on the
perpetual inventory. They would then attempt to locate the medication or sharp and report the
missing item to regional staff. The HSA was interviewed and confirmed the program’s inventory
process, as well as medication destruction process. The HSA indicated the program has a
consultant pharmacist, who comes on-site monthly to conduct medication inventories, inspect
the medication cart, and complete controlled medication destruction.
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 implemented infection control procedures which include prevention,
containment, treatment, and reporting requirements related to infectious diseases, as according
to Occupational Safety and Health Administration (OSHA) federal regulations and the Center for
Disease Control and Prevention (CDC) guidelines. The program’s Infection Control Plan and
Exposure Control Plan were reviewed and signed by the designated health authority, facility
administrator (FA), and chief compliance officer on January 31, 2023. The program’s Infection
Control Plan includes all required topics. Hepatitis B immunizations are available for all staff and
staff have access to protective equipment, as needed. There were no instances in which the
local county health department, CDC, and/or the Department’s Central Communications Center
(CCC) should have been notified of an infectious disease. There have been no facility or
occupational exposures since the provider acquired the program; however, the program will
maintain a separate file containing all documents for youth and staff who have experienced a
facility/occupational exposure, as necessary. The program’s Exposure Control Plan was found
to be written in accordance with OSHA standards and is available to all staff. The program has a
comprehensive process for needle stick post-exposure evaluation. Exposure must be reported
to the FA immediately and evaluation must be made available immediately. The evaluation
process is outlined in the program’s Exposure Control Plan. There were no cases of a
reportable infectious disease which needed to be reported to the local county health department
and/or CDC or an instance involving the quarantining or hospitalization of at least ten percent of
the total population of youth or staff, or six individuals. The FA was interviewed and stated the
Exposure Control Plan is located in the FA’s office and in the medical clinic and is reviewed with
new hires and with all staff on a yearly basis. An interview with the health services administrator
(HSA) confirmed the Exposure Control Plan is located in the medical clinic. The HSA stated a
nursing staff conducts exposure control and infection control training for new staff and for all
other staff bi-annually.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) 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.
Due to an open Outcome Base Corrective Action Plan (OBCAP), indicator 5.01 youth
supervision is rated limited compliance. The program recently had a youth escape as a result of
inadequate staff supervision, which resulted in the OBCAP. The program has a policy and
procedures stating how the program shall maintain active supervision of youth 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, were
supervision of youth during school hours, in the dining area, education, recreation, and youth
movement through the program. The daily schedules were posted in the dormitories and
cafeteria. At no time during the annual compliance review week were youth observed wandering
freely about the program. Each of the seven interviewed staff confirmed their understanding of
the procedures when there is a discrepancy with the count. Seven staff indicated 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. Informal interviews with ten staff found they were aware of the number of youth
under their supervision immediately without having to stop and count.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program has policy and procedure to address the behavior management system (BMS) or
positive performance system (PPS). The PPS fosters accountability for behavior and
compliance with the residential community’s rules and expectations. The PPS was observed to
be posted on the dormitories. The PPS is clearly explained in the resident handbook, which is
accessible to youth and a copy provided to the youth upon intake. The program’s PPS details
the rules and the positive and negative consequences for actions. Seven pre-service training
records and seven in-service training records were reviewed and indicated all staff training
records contained PPS training. All seven interviewed staff confirmed training and
understanding of the PPS. All seven staff stated the PPS is a point system to earn rewards and
levels. Staff stated the PPS levels and points earned are updated daily and the information is
posted on the dormitories. The program uses an excel spreadsheet which consists of each
youth by dormitory, daily behavior, phase levels, and daily and weekly points earned. There are
four phase levels youth must apply for and achieve to complete the program. Each phase level
has a phase packet youth must complete to show what skills they have learned and how they
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were able to display these skills. Each phase level has a required number of days the youth
must meet in order to complete the level and phase packet. The treatment teams meet to review
the youth behavioral infractions, earned points, and consequences which are administered
through the PPS system as a result of program rule violations by the youth. The orientation
checklist documents the PPS is reviewed with the youth. All seven reviewed youth case
management records contained a complete orientation checklist. The PPS promotes youth
rights, positive and negative consequences, constructive disciplinary action, opportunities for
reinforcement, positive dialogue, and peaceful resolutions, as well as provides youth with pro-
social acceptable alternative behavior, and maintains order and security. Youth have an
opportunity to explain their behavior during treatment teams and special treatment teams. The
PPS is connected to each youth’s individual performance and treatment plan goals. The PPS
includes a variety of rewards including daily snacks, meals, canteen, fun days, movies, verbal
praise, and special privilege activities. The facility administrator stated the program maintains a
spreadsheet which is monitored daily and updated on a weekly basis. It displays the daily
behavior write-ups, if any, on all youth which shows whether the youth gained or lost a particular
day. The positive reward for earning days consists of; caught being good canteen points
(twenty-five points), weekly Monday/Thursday incentive, weekly canteen (Friday’s only),
monthly meal day, Monthly Movie Night, Dormitory of the Month, Monthly Community Service
Outings, and Special events. The phase level three and four residents could earn a privilege
telephone call in addition to the weekly telephone call. The consequence within the PPS
program is losing the ability to attend and/or earn one of the above listed positive rewards.
Seven interviewed youth indicated they receive prompts from staff prior to receiving a write-up
for their actions and youth can earn a minor, moderate, or major rule violation for their negative
behaviors or points for positive behaviors. All seven youth stated they earn snacks or meals,
recreation time, canteen, television time, daily incentives, weekly incentives, and monthly
incentives for positive behaviors.
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, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
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5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has sixty-seven operational cameras. At the time of the annual compliance review
the digital recording devices were being replaced. All cameras were operational at the time of
the annual compliance review. The video coverage is stored for thirty days. The program’s
practice is to conduct checks of youth in their rooms every eight to ten minutes. Ten-minute
check sheets were reviewed for three dormitories finding no more than ten minutes passed
without the staff actively observing each youth. Video review of three dormitories for two shifts
at thirty-minute intervals found no more than ten minutes passed without staff actively observing
youth. Seven staff were interviewed; five staff indicated they walk to each room and make a
visual skin check, two staff indicated checks are conducted every eight minutes with one of the
two staff stating checks are documented on the accountability sheet. All seven interviewed staff
stated ten-minute checks are completed every eight minutes.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program maintains a policy and procedures which address population census, counts, and
tracking of youth. The program’s policy indicates headcounts will occur and shall be
documented at a minimum of every thirty minutes with formal counts being conducted at the top
of the hour and informal counts being completed at the half hour. The program utilizes the
master control logbook to document youth counts and movements. The logbook is utilized to
maintain a chronological record of events as they occur. The program headcounts are
conducted by the shift supervisor at the beginning of each shift to verify accuracy and document
counts in the program’s logbook, then every hour. Counts are conducted at the beginning of
shifts, after outdoor activities, every youth movement, and emergency situations. The logbook
also tracks youth intakes, releases, and movements outside of the program. The program
utilizes alert boards to track the daily count of all youth in and out of the program. Three informal
interviews were conducted, and all three staff were aware of all youth whereabouts and were
able to provide the proper counts to the annual compliance review team members during the
review week. Seven interviewed staff were aware of count procedures, as required by program
policy, including what to do in the case of an unsuccessful count.
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5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a policy and procedures addressing logbook entries. The program
maintains a chronological record of events, incidents, and activities in a logbook in accordance
with Florida Administrative Code. Logbooks utilized by the program during the last ten months
were reviewed. Each reviewed logbook is bound with numbered pages and entries were made
in ink with no white-outs or logbook entries being removed or missing. Logbook entries included
emergency situations, incidents, including the use of mechanical restraints which are not
applicable at this program, special instructions for supervision and monitoring of youth,
population counts at the beginning and end of each shift, any other population counts conducted
during a shift, perimeter security checks and other security checks conducted by direct care
staff, transports away from the program, including the names of the staff and youth involved,
and the destination, requests by law enforcement to access any youth, removal of any youth
from the mainstream population, such as when a youth is placed on room restriction or
controlled observation, admission and releases, including the name, date, and time of
anticipated arrival or departure and mode of transportation, and information relating to escapes
or attempted escape incidents. Oncoming staff members participate in a shift briefing and sign
the logbook acknowledging they are aware of all information from the last two shifts and alert
changes. Each reviewed logbook entry was legible and included the time and date of the entry,
printed name, and the signature of the staff member making the entry. Samples of reported the
Department’s Central Communications Center (CCC) incidents which occurred during the
annual compliance review period were reviewed. All reviewed CCC incidents were noted in the
logbook.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures to address key control. The policy and procedures
addressed distribution, tracking, storage, and overall control and security of keys. A review of
the inventory matched the key rings in use. Personal keys are kept in a secure lock box within
the administrative office, which is not accessible to youth, staff receive a chit and turn it into
master control for their assigned program keys. Each set of keys has an assigned key hook.
Keys are assigned to staff according to their department. Restricted keys, temporary keys, and
visitor keys are all kept separate from each other. There were no reports of a broken or
damaged key. There were no incidents of lost keys, which was verified by the review of internal
incident reports and the Department’s Central Communications Center (CCC) reports. A
random check of three staff key rings confirmed the keys matched the inventory. The physical
plant manager is responsible for replacing broken or damaged keys. Informal interviews with
staff confirmed staff’s knowledge of the key rings and assigned keys. All observations during the
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annual compliance review week found personal keys were secured and staff were aware of
program keys in their possession. Key control logs documented the issuance and return of keys
on a consistent basis. All seven interviewed staff confirmed they had knowledge of the
implementation of key control policies and procedures. Additionally, staff reported if keys were
damaged, they would notify their supervisor and submit a maintenance request. An informal
interview with the shift supervisor indicated assigned keys are only assigned by the facility
administrator, restricted keys are kept apart from non-restricted keys, and only assigned staff
can access restricted keys. The shift supervisor tracks keys as they are signed out and back in
by staff prior to receiving their personal keys.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items.
A program shall delineate items and materials considered contraband when found in the
possession of youth, the list must include: sharps, escape paraphernalia, tobacco products,
lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food or
clothing, any intoxicating beverage or any beverage which causes or may cause an
intoxicating effect, any controlled substance, any prescription or non-prescription drug which
has a hypnotic, stimulating, or depressing effect, any firearm or weapon of any kind or any
explosive substance, non-facility issued electronic equipment or devices to include
smartwatches, metals, personal non-facility issued cellular devices, unauthorized currency or
coin(s), and non-facility issued keys. The program shall provide youth with the list of
contraband items and materials and inform the youth of the consequences if found with
contraband. The program shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, and both staff and youth.
The program shall document the confiscation of any illegal contraband and the manner of
disposition. The program shall keep a copy of the documentation in the youth’s case record. If
a confiscated item is not illegal or prohibited, the program director or designee has the
discretion to discard of the item, return it to its original owner, mail it to the youth's home, or
return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, program grounds, and youth, which
is clearly explained in the program’s policy and procedures, and resident handbook. The policy
also states any staff who is found in possession of contraband in the program will be subject to
disciplinary action up to, and including, dismissal, as well as procedures regarding notification of
law enforcement for items considered illegal as defined in Florida Statutes. The program’s policy
and procedures and the youth handbook define items and materials considered contraband
when found in the possession of youth, provides youth with the required list of prohibited
contraband, and informs youth of the consequences if found with contraband. The prohibited list
includes personal cellular telephones and/or equipment and/or electronic devices capable of
taking pictures and/or audio/video recordings, which are prohibited in the secure area. The list
also includes unauthorized articles of clothing and food, controlled substances, prescriptions or
non-prescription drugs, and any firearm or explosive device. The contraband notice is posted on
the front of the building and states law enforcement will be contacted for anyone bringing in
contraband and a criminal report will be filed. This practice was confirmed through an interview
with the facility administrator (FA). The FA stated law enforcement shall be contacted if any
found item would be considered illegal, as defined in state law, or if there is evidence of unlawful
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activity. According to policy and procedures all searches, as well as the findings and disposition
of contraband/unauthorized items, shall be documented. The FA shall determine the method of
disposition of contraband and unauthorized items which are not illegal. Such contraband and
unauthorized items may be discarded, returned to the original owner, mailed to the youth’s
home, or stored and returned to the youth upon his or her release. Any usable contraband or
unauthorized items, excluding weapons or illegal materials, not able to be returned or turned
over to law enforcement may be donated to any established charity. Under no circumstances
may a staff be allowed to retain possession of any contraband found in the program. All
program staff, visitors, vendors, and contracted providers shall be searched prior to entering the
program. Any program or education program staff who refuse to be searched will be denied
entry into the program and may be subject to disciplinary action. Any staff found in possession
of contraband will be subject to disciplinary action up to and including dismissal. All items
carried by program and education program staff are subject to search when entering and
leaving the program.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a policy and procedures addressing searches and full body visual
searches. The program conducts searches as a method to prevent the introduction of
contraband and unauthorized items into the program. The policy indicates searches of youth are
conducted after off-site transports, after visitation, before moving youth from an outside area
into the building, and prior to moving youth from the building to an outside area, as well as
moving from one area of the building to another. The program conducted one off-site transport
during the week of the annual compliance review. The annual compliance review team
observed a properly conducted search and full visual search before and after the transport. The
annual compliance review team also observed several youth searches during the week of the
annual compliance review. Searches were conducted with each movement of youth from each
area of the building such as the classroom, groups, and dormitory. Search procedures and
expectations were properly explained to all youth before searches were conducted. Searches
were conducted by staff of the same gender as the youth, while a second and third staff
assisted with supervision. Searches were thorough and done in a manner which did not
degrade the youth. All searches were documented in the program’s logbook. Observed
searches of youth were conducted in the classroom. Both staff conducting the searches were
the same gender as the youth. Each observed search was conducted properly according to
policy. Youth and staff interviews revealed all parties were aware of proper search procedures
and when the searches take place. Three interviewed staff stated youth are searched after
every movement. One of the seven interviewed staff stated youth are searched after all
movements or if a youth is accused of taking items from mental health, one interviewed staff
stated youth searches are conducted after all movement and a male staff pats down the youth.
One interviewed staff stated searches are conducted after all movements, with youth being
asked to line up so staff can pat them down and youth are asked to remove their shoes. One
interviewed staff stated after every large movement such as school, recreation, medication
pass, and therapy sessions. This same interviewed staff stated youth are searched following
visitation or a youth’s return from an off-campus activity. Seven interviewed youth stated
searches are conducted after every movement. One youth stated youth are searched when
returning from off campus, one stated after outdoor activities, one stated after visitation and five
stated after meals.
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5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a policy and procedures addressing vehicles and maintenance. The
program utilizes two vehicles for youth transports. Both of the vans passed inspections this
annual compliance review period. The vehicles are also inspected weekly by the plant manager.
Results of weekly inspections are documented and stored in the program’s vehicle maintenance
log/binder. A member of the annual compliance review team inspected the vehicles, and all
required equipment was observed, which included a seatbelt cutter, window punch, and fire
extinguisher. The first-aid kits are not stored in the van to preserve the items inside of the kit.
Staff check out a first-aid kit prior to a transport and returns the kit to the program upon return.
All seatbelts in both vans were in proper working condition. The vehicle also had a safety screen
separating the youth from the driver. A random check of personal vehicles and both vans was
conducted during the annual compliance review week and all were found to be locked. There
was one transport to observe during the annual compliance review week and staff followed the
program’s procedure. Three of seven interviewed youth stated they have not participated in a
transport and four stated they are secured as required with a seatbelt, handcuffs, and shackles.
Seven interviewed staff indicated youth are secured in the vehicle with a seatbelt, handcuff, and
shackles during 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 addressing transportation of youth, outlining
staff to youth ratio during transports as one to five; however, if there are five or less youth, a
minimum of two staff are needed to perform all transports. The program’s transport vehicles
were inspected by an annual compliance review team member and the vehicles were found to
be in working order. The program has an approved transport list which is updated monthly to
ensure staff driver’s licenses are valid. The approved driver’s list is located in the administrative
area. An annual compliance review team member observed the program transporter conduct a
routine check of all personal vehicles in the parking lot including the program’s transport
vehicles. All vehicles were found locked and secured. The annual compliance review team was
able to observe a transport during the annual compliance review week and staff followed
procedures. Staff interviews confirmed they are issued a cellular telephone and three added a
program radio is taken on transports as well. Staff do not conduct transports in personal
vehicles, and vehicles are checked before and after transports. All seven staff were able to
accurately describe what safety equipment is required for all transports. All seven staff were
able to describe the process required in case of an emergency. All seven staff knew the ratio of
staff to youth during a transport. One of seven youth stated seeing staff place contraband inside
the vehicle, however, this youth’s only documented transport occurred when the youth arrived at
the facility. four of the seven youth stated they feel safe while being transported, and three
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stated they did not feel safe while being transported, however, these youth had not been on any
additional transports other than being brought to the program.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The policy and procedures designate the physical plant manager as the person responsible for
conducting the weekly safety and security audits. The weekly safety audits are kept in a binder,
which was reviewed weekly during the safety committee meeting held on Fridays. The
committee consists of the facility administrator (FA), assistant facility administrator (AFA), and
the physical plant manager. Findings are discussed and a corrective action plan is implemented
to fix any deficiency noted. During the annual compliance review period, there were no
inspections missing. The forms documented safety and maintenance repairs needed and the
date and time the repairs were completed, or due to be completed. All forms were reviewed and
signed by the FA. The forms cover radios, cameras, keys, telephones, mechanical restraints,
the generator, flashlights, fire safety equipment, alarms, ensuring no anchor points, youth
rooms, recreation area, grounds, corrective action needed, and corrective action completed.
The interview completed by the FA confirmed the weekly safety audits are conducted in
accordance with program policy and procedures.
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 address tool inventory and management.
The policy addresses the issuance, inventory, and control of equipment and tools. The program
has identified their plant manager as the program’s tool control manager. The policy classifies
tools into two categories as class A tools and class B tools. Class A tools are hazardous with
sharp edges or points and with a high potential to be used as a weapon to inflict serious bodily
harm such as knives, hammers, screw drivers, and electric drills. Class B tools do not have
sharp edges or points such as brooms, mops, and scrub brushes. All tools are secured behind a
locked door and are placed on a board within a shadow and a photo of the tool to identify proper
placement. Class A tools are secured in the plant manager’s office. Upon observation, the plant
manager’s office was neat, clean, and organized. All class A tools were neatly stored on the
walls with a photo and shadow of the tool to identify the tool belonged in the proper place. All
class A tools were in good repair and accounted for. All of the program’s class A tools are
inventoried daily by the plant manager except on days when the maintenance office is not
accessed and during the weekends and holidays. Class B tools are inventoried daily by program
staff. All program tools are signed out by staff before use and signed back in once they are
returned to their proper location. All tools were properly identified during inspection by the
annual compliance reviewer. Pre-service training records indicated all staff were trained on the
safe use of tools. During an interview, the program’s plant manager was aware of the proper
procedures to follow if tools are missing or damaged, in accordance with the program’s policy
and procedures. The plant manager stated there were no tools which were damaged or out of
use during the annual compliance review week.
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5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a policy and procedures addressing youth tool handling and
supervision. The policy outlines proper procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries to youth and staff. The program completes Risk
Assessments which determine youth risk to self and others and are completed during treatment
teams. Seven youth case management records were reviewed, and all records indicated youth
have been trained on the proper usage of tools during their orientation process. Youth signed an
acknowledgement of tool training during the orientation process. The signed acknowledgement
form is filed in each youth’s record. Seven interviewed youth confirmed youth are only allowed
to use a scrub brush, mops, and brooms, one youth stated they can use a rake. Three of the
seven interviewed staff indicated youth can use a scrub brush, six stated youth can use a mop
and a broom, and one interviewed staff stated youth do not use tools.
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 maintains a policy and procedures which address outside contractors. The
program has established guidelines for outside contractors which includes information regarding
tool control and restrictions. The program has a form to be signed by outside contractors which
addresses how tools will be checked upon arrival to and departure from the program,
restrictions for youth access to work areas, immediate reporting of missing tools, and restriction
of personal cellular telephones and/or equipment capable of taking pictures and/or recording
audio/video in secure areas. The form also requires contractors to list each tool brought into the
program. This list is reviewed by the plant manager or designee before the contractor has
access to a secure area. This list is again reviewed before the contractor exits the program. The
contractor’s failure to sign this form prohibits access to work within the program. Outside
contractors are escorted and supervised by the plant manager or designee any time they are
within the program. The review team was able to observe this process during the annual
compliance review week and found they met the requirements of the program’s policy and
procedures. Program invoices were cross checked to ensure outside contractor agreements
were signed on the date of service. All invoices and contractor agreements matched and there
were no discrepancies found.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program maintains a policy and procedures to address fire, safety, and evacuation drills.
The program conducts fire, safety, riot, disturbance, Continuity of Operations Plan (COOP), and
evacuation drills to ensure youth and staff are prepared for immediate implementation or
mobilization in the event of an emergency or disaster. Drills are consistent with the program’s
COOP. All drills were properly documented in the program’s logbook and documented on the
program’s designated drill form. Each drill form contained the type of drill, a description of the
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drill, the date the drill was conducted, the time of the drill, and participants’ signatures. A review
of drills revealed fifty various drills were conducted over the annual compliance review period. At
least one fire and COOP drill was conducted for each shift each month. Fire evacuation routes
and egress plans were posted throughout the program. All fire extinguishers were inspected on
an annual basis. An interview with the facility administrator verified fire drills are conducted
monthly on all shifts. COOP drills are completed monthly. Seven interviewed staff indicated they
participated in a weather drill, two staff participated in a bomb threat drill, one staff participated
in a hostage drill, five staff participated in an escape drill, six participated in a fire drill, and five
stated they have participated in a suicide drill. Three of the seven staff stated they participated
in a medical drill. Three of the seven interviewed youth stated they have been instructed on
what to do in case of a fire and four stated they have not.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program has policy and procedures addressing the Continuity of Operations Plan (COOP).
The policy states the COOP is located in the facility administrator’s (FA) office and master
control. The plan addresses alternative housing plans approved by the applicable Department
regional director/designee. The COOP was last approved on February 14, 2023, with the new
COOP being submitted to the Department on February 14, 2023. The COOP addresses fire
prevention and evacuation, severe weather, disturbances or riots, bomb threats, hostage
situations, chemical spills, flooding, terrorist threats or acts, staff roles and responsibilities, any
equipment and supplies needed, information about youth which may be needed, alternative
housing arrangements, provisions for continuity of care and custody of youth, and provisions for
public protection. The program conducts COOP drills on each shift. The drill documentation
included type of drill, date and time of the drill, participants, brief scenario and
findings/recommendations, and pictures. The drills included escape, missing tools, fire,
evacuation due to severe weather, lightning, riot, active gunman, and chemical. The program
has food and necessary supplies readily available in case of emergency evacuation. The
program maintains an administrative hard-copy of the youth’s Department’s Juvenile Justice
Information System (JJIS) face sheet and program admission card, in case of an emergency,
with all required information which is located in the director of case management office. The FA
reported the COOP is located in the FA’s office and master control.
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 maintains a policy and procedures addressing storage and inventory of flammable,
poisonous, and toxic items and materials. The program’s flammable, poisonous, and toxic
materials are stored in a flame-resistant cabinet. The program maintains proper inventory of
these items. The program’s physical plant manager is the only individual authorized to handle
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flammable, poisonous, and toxic items. A binder is stored in the flame-resistant cabinet
containing the Safety Data Sheets (SDSs) for the items located in the cabinet. The program also
stores cleaning supplies in a locked storage room. The storage room is locked at all times and
can only be accessed by the physical plant manager, supervisors, and the facility administrator
(FA). The items in this storage room are inventoried and have an accompanying SDS located in
a binder. Staff sign these items in and out with each use. The program had 100 chemicals on
site, ten of which were reviewed and compared with the program’s perpetual inventory. The
inventory was accurate for each reviewed item and the SDS for the items were located with the
inventory items.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a policy and procedures addressing youth handling and supervision of
flammable, poisonous, and toxic materials. The policy prohibits youth using those items and
materials. Flammable, poisonous, and toxic materials are stored in a storage locker located in
the maintenance area. Youth do not have access to these items and are supervised by staff
during daily cleaning. Youth were observed participating in program clean-up during the week of
the annual compliance review and none were observed to be handling flammable, poisonous,
and toxic materials. Staff were observed spraying the needed chemical for the youth. Six of the
seven interviewed youth indicated youth do not use any chemicals and one of the seven
indicated he used laundry soap.
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 addressing disposal of all flammables, toxic,
caustic, and poisonous items. The policy prohibits chemicals from being poured on the ground
or being disposed of by any method other than what is outlined by the biohazard guidelines. The
program’s physical plant manager is the only individual authorized to handle flammable,
poisonous, and toxic items. The program’s physical plant manager was interviewed regarding
the proper procedures of disposing chemicals and stated all items for disposal are collected by
the local county waste disposal. The physical plant manager further stated the program has not
needed to dispose of any chemicals since the last annual compliance review. An interview with
the facility administrator (FA) validated this practice. Kitchen liquid waste which cannot be
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disposed of by pouring it down the sink, and grease, is picked up by a contracted provider and
stored outside the building in a separate container.
5.21 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity.
Programs allowing youth to participate in water related activities shall have a water safety
plan addressing, at a minimum, safety issues, emergency procedures, and the rules to be
followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures to allow visitation and communication for youth while
in the program. The visitation procedures are posted at the front door and on the wall in the
lobby. The visitation and communication procedures are covered in the resident handbook,
parent handbook, and addressed on the orientation checklist. The program utilizes staff
translators or an online translation site with live translators if necessary. All seven youth
interviews indicated they can make weekly calls to the parents/guardians, as well as send
letters. Three of the seven youth stated if translation is needed, staff can translate for them, one
of the youth stated someone can translate for them; however, did not specify who. One of the
seven youth stated other youth translate for them, one stated they are not sure who translates
for them, and one stated they had not seen any staff translating for youth. The visitation
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 67 of 69 (Revised September 2022)
schedule was posted throughout the program. Visitation documentation indicated visitation is
being offered on the weekends as required by policy. The visitation, telephone, and
correspondence logs were reviewed. The logs showed youth have contact with only approved
persons. Incoming and outgoing mail is given to the youth’s case manager and searched by the
case manager with the youth present. Incoming mail is then given to the youth and outgoing
mail is placed in the outgoing mailbox in master control. All incoming and outgoing mail is
recorded in the correspondence logs. There were no youth applicable for a history of human
trafficking; therefore, the program is not required to request clarification from youth’s juvenile
probation officer (JPO) about any parent/guardian past or current human trafficking investigation
involvement. Six of the seven interviewed staff indicated staff can translate for youth, four of the
staff indicated staff can translate Spanish, two stated education staff can assist with
translations, and one of the seven staff indicated they did not know.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program provides a variety of recreational and leisure activities to include basic physical
fitness, team and individual sports, art, leadership, and teambuilding activities. The program has
a posted activity schedule. The program has a policy and procedures which provide activities
based on the developmental levels and needs of the youth in the program. Activities include a
choice of leisure and recreation options. Youth are encouraged by staff to participate in an
activity. Youth were observed during the annual compliance review week to be engaged in
constructive use of leisure time. Observations of activities found the activities promote social
and cognitive skill development, creativity, teamwork, healthy competition, mental stimulation,
and physical fitness. The program takes precautionary measures to prevent over-exertion, heat
stress, dehydration, frostbite, hypothermia, and exacerbation of existing illness or physical
injury, some of which is documented in the logbook (outside temperatures and conditions,
physical plant issues). The program currently has a recreational therapist who meets the
contract requirements. A review of seven youth case management records demonstrated the
therapeutic activities provided are part of each youth’s performance and/or treatment plan. The
program has a formal process to promote constructive input by youth. Seven youth were
interviewed. Each of the youth agreed there are physical activities and leisure activities provided
for at least one hour a day. Youth described some of the activities to include flag football,
basketball, pickleball, volleyball, video games, corn hole, four square, and jogging/walking. Each
of the seven youth affirmed they are provided with varying degree of mental and physical
exertion throughout the day. Seven staff were interviewed, and each was able to provide an
example of what types of indoor and outdoor activities are provided to the youth.
5.24 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy and procedures address their practice for the search and inspection of
controlled observation rooms. A review of documentation indicated the program has not used
controlled observations since January 2023 to present.
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Office of Accountability and Program Support Page 68 of 69 (Revised September 2022)
5.25 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy and procedure address their practice for controlled observation. A review
of documentation indicated the program has not used controlled observations since January
2023 to present. Six of the seven interviewed youth stated they had not been sent to their room
for getting in trouble, one of the seven interviewed youth stated they had been sent to their room
for getting in trouble.
5.26 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy and procedures address controlled observation safety checks and release
procedures. A review of documentation indicated the program has not used controlled
observations since January 2023 to present.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 69 of 69 (Revised September 2022)

report_type: QI Residential

program_name_raw: Columbus Youth Academy

rule: Indicator 5.01

excerpt: Youth Supervision (CRITICAL)

rating: Limited Compliance