summary: QI Residential - FY23-24 - 10 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Alachua Academy
Wayne Halfway House
(Contract Provider)
3430 NE 39th Ave
Gainesville, Florida 32609
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:
Meghan Thrasher, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Janise Best, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Patrick Brock, Office of Education, Northeast Education Coordinator (Standard 2)
Renette Crosby, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Tara Gilligan, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Kristine Harshaw, Office of Accountability and Program Support, Co-Lead Reviewer (Standard 1
and Interviews)
Lea Herring, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Cindy Jones, Office of Education, Northeast Education Coordinator (Standard 2)
Benjamin Marrufo, Office of Accountability and Program Support, Technical Assistance
Specialist (Standard 2)
Program Name: Alachua Academy MQI Program Code: 1165
Provider Name: Wayne Halfway House Contract Number: 10189
Location: Alachua County / Circuit 8 Number of Beds: 28
Review Date(s): September 26-29, 2023 Lead Reviewer Code: 203
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
2.03 Written Consent of Youth Eighteen or Older
2.07 Residential Assessment for Youth (RAY)
2.09 Performance Plan Development, Goals and Transmittal *
2.20 Educational Access*
2.21 Education Transition Plan
3.08 Specialized Treatment Services*
3.12 Suicide Precaution Observation Logs *
5.13 Tool Inventory and Management
5.15 Outside Contractors
5.18 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 72 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 72 (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 Limited
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) Limited
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Limited
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
2.19 Career Education Satisfactory
2.20 Educational Access* Limited
2.21 Education Transition Plan Limited
* 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 72 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Limited
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Suicide Precaution Observation Logs * Limited
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Satisfactory
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 72 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 72 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Limited
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Limited
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 Limited
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.21 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.22 Visitation and Communication Satisfactory
5.23 Recreation and Leisure Satisfactory
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
5.25 Controlled Observation Non-Applicable
5.26 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 72 (Revised September 2022)
Program Overview
Alachua Academy is a twenty-eight bed program, for twelve to eighteen year old females,
located in Gainesville, Florida. The program is operated by Wayne Halfway House, through a
contract with the Department. The program provides Substance Abuse Treatment Overlay
Services (SAOS). In addition, the program fosters each youth by providing VOICES: A Program
of Self-Exploration and Empowerment groups, Teen Relationship Workbook, Seeking Safety,
Skillstreaming the Adolescent, Impact of Crime (IOC), Living in Balance, and Female Healthy
Relationships. Additional treatment services provided include family, individual, group, and
recreational therapy. Program administration is comprised of a facility administrator, assistant
facility administrator, three shift supervisors, director of nursing, lead teacher, human resources,
and facility maintenance manager. Case management services are provided by two case
managers and a recreation therapist. Mental health staff at the program includes a clinical
director, who is a licensed mental health counselor, and a contracted psychiatrist. Medical
services are offered 8:00 a.m. to 6:00 p.m. and are provided by a contracted medical doctor
(MD) who also serves as the designated health authority (DHA), a director of nursing, and two
part-time nurses. Educational services are provided by the Alachua County School Board. The
layout of the program includes the main building comprised of the main gathering area,
dormitory, therapist offices, kitchen and dining area, a multi-purpose room, and the case
managers’ office. Two separate buildings are used for education and training classes and as the
teacher offices maintained by the Alachua County School Board. There is also a utilities and
storage building. The program has thirty-eight operating security cameras providing coverage.
At the time of the annual compliance review, the program had six vacant positions to include
three youth care workers, two therapists, and one transition case manager. The program only
had three youth applicable for admission following their start-up monitoring; therefore, only three
youth records were able to be reviewed for the annual compliance review period. Five youth
were interviewed based on the program’s census at the time of the annual compliance review.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 72 (Revised September 2023)
Strengths and Innovative Approaches
• The program has recently started yoga and meditation classes to assist the youth with
mindfulness and enhance coping skills.
• The program allows the youth to release balloons on significant dates of a loved one’s
passing, such as the loved one’s birthday or the anniversary of the loved one’s passing.
The balloon program was implemented as an additional form of grief therapy.
• The program encourages youth to release their frustrations and concerns in a
confidential manner, while also allowing the youth the opportunity to practice coping and
assertive communication skills by placing a message conveying their plight in a box next
to the clinical director’s office.
• The program invites guest speakers to speak to the youth. Recently a speaker from the
University of Florida’s law school came to the program to engage the youth in
discussion.
• The program regularly partners with the University of Florida to offer additional training to
the youth.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 72 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
A review of the program’s staff roster found twelve staff were hired and no new volunteers
began since the new provider took over the contract for this program. A background screening
was completed for each staff prior to contact with youth and access to confidential youth
records. A criminal history report was reviewed for each staff. Each staff received an eligible
rating on the background screening and did not require an exemption. A pre-employment
assessment tool was administered to the direct care staff and each staff received a passing
score. The program added each staff to their Clearinghouse employment roster. An Annual
Affidavit of Compliance with Level 2 Screening Standards was completed and sent to the
Department’s Background Screening Unit (BSU) on January 31, 2023. The teachers who are
employed by the Alachua County School Board received an Annual Affidavit of Compliance with
Level 2 Screening Standards on October 6, 2023. There was documentation of the program
reviewing the Department’s Central Communications Center (CCC) Person Involvement History
Report, the Staff Verification System (SVS) module, and the Florida Department of Law
Enforcement (FDLE) Automated Training Management System (ATMS) results for each staff.
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 two staff eligible for a five-year rescreening during the annual compliance review
period. Both staff had a five-year rescreening requested by the Clearinghouse Prints Expiration
Date and no later than ten days prior to the staff’s five-year anniversary date.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 72 (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 of physical,
psychological, and emotional safety. All staff, volunteers, interns, and contracted staff who have
knowledge, or reasonable cause to suspect a youth is being abused or neglected are to report
the information to the Florida Abuse Hotline or the Department’s Central Communications
Center (CCC), if the youth is eighteen years or older. All allegations are reviewed by the facility
administrator (FA). A review of five staff personnel records revealed staff sign and adhere to a
code of conduct. Since the last annual compliance review the program had a total of five alleged
incidents related to physical, psychological, or emotional abuse reported to the CCC. All of the
cases were closed as inconclusive or unsubstantiated. A tour of the program found the Florida
Abuse Hotline and CCC numbers posted throughout the facility. The program completed a
Trauma Responsive and Caring Environment (TRACE) self-assessment on June 8, 2023.
Five interviewed staff reported all youth are allowed to call the Florida Abuse Hotline to report
abuse. The FA and supervisor on duty are notified of the request to call the Florida Abuse
Hotline. The staff then dials the number and allows the youth to speak. Staff are also allowed to
call if needed. All five interviewed staff revealed they have not observed a coworker telling a
youth they could not call the Florida Abuse Hotline. Three of the five interviewed staff reported
they have observed a coworker using profanity while interacting with youth, but not directing it
towards youth; however, no threats, intimidation, or humiliation when interacting with youth. The
remaining two staff denied witnessing any forms of profanity used in the youths’ presence or
any type of threats, intimidation, or humiliation when interacting with youth. All of the interviewed
staff knew the number to the Florida Abuse Hotline and/or where to find it. Each of the staff
stated it is posted throughout the facility. Four of five interviewed youth indicated they felt safe
stating reasons such as they feel protected, and the staff make them feel safe. All five youth
denied having access to the Florida Abuse Hotline be impeded. All five youth indicated they
have heard staff use profanity in the presence of other youth. One youth reported the assistant
facility administrator (AFA) calls youth names and another youth reported the youth care
workers (YCWs) body shame them and talk openly about youth’s issues. The information
provided by the youth and staff regarding profanity and taunting was reported to the FA and
regional compliance representative, to which they stated an all-staff training would take place
along with coaching notes to rectify this behavior. The FA verified all staff receive both pre-
service and in-service training regarding right interactions with youth who have experienced
trauma, further indicating the program’s policies implement practices which endorse the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 72 (Revised September 2022)
emotional well-being of all youth served by this program. All youth have safety plans which are
reviewed regularly. The FA stated all youth are provided the Florida Abuse Hotline and CCC
contact information during orientation to the program, under the external reporting section
located in their student handbook. This information is explained by the youth's case manager
during this process. Whenever a youth needs to make a report, they request to make a call,
staff immediately notify their supervisor, and the supervisor arranges for use of the phone to
make the abuse call. If the report is accepted, staff then make a call to the CCC. Staff are also
able to make the call, as they are mandatory reporters, and, if possible, youth involved shall be
made part of the call.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program has a policy and procedures regarding management response to allegations of
abuse. During the annual compliance review period the program had five unsubstantiated
incidents of physical, psychological, or emotional abuse ; however, they were reported to the
Department’s Central Communications Center (CCC) and, after investigation, required
immediate action on behalf of management. In all five instances, there was evidence
management took immediate action to address the allegations of physical, psychological, and
emotional abuse. Documentation was reviewed identifying applicable corrective action taken by
management for follow up to the allegations. According to the facility administrator (FA) and
reviewed documentation, two staff received disciplinary action and the remaining staff received
re-training. The FA reported they are responsible for ensuring training is provided to all staff,
and they review all accepted Florida Abuse Hotline contacts for further disciplinary action
towards staff, volunteers, and/or contracted personnel. The FA will contact the regional director
to report the incident to consult if any further action is needed, provide a resolution, and
complete an Administrative Notification of the CCC Reportable Incident for submission to the
provider's senior leadership team.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program has a policy and procedures in place to ensure the Department’s Central
Communications Center (CCC) is notified within two hours of the incident occurring, or within
two hours of any program staff becoming aware of the reportable incident. The program had a
total of twenty-two reports to the CCC during the annual compliance review period. Five reports
were selected for review. All of the incidents were reported within the required two-hour time
frame. Each of the incidents were documented in the logbook, with the exception of two which
were not reported by the program, and one the program failed to document. One of the calls
was closed as substantiated for improper conduct, improper supervision, and use of force by a
staff against a youth. A review of the program’s internal incidents and grievances found there
were no additional incidents which should have been reported to the CCC and were not. The
program has experienced an increase in the number of reportable CCC incidents. The facility
administrator (FA) revealed, during the annual compliance review period the program’s majority
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 72 (Revised September 2022)
of calls were due to youth Baker Acts. During the last annual compliance review period, the
program had not had any Baker Acts.
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 to document the use of physical intervention
in accordance with the Florida Administrative Code. The program had a total of eleven
Protective Action Response Right Interactions model (PAR/RI) incidents during the annual
compliance review period. Five reports were reviewed. All of the reports were completed by the
end of the staff’s workday and included statements from all staff involved. Mechanical restraints
were not used for any of the reported incidents. None of the PAR/RI incidents resulted in injury
to youth or staff; therefore, no PAR/RI medical reviews were conducted. Each of the five reports
were reviewed by a PAR/RI certified instructor/supervisory staff. There was documentation each
PAR/RI incident report was reviewed by the facility administrator (FA), or designee within
seventy-two hours of the incident and a copy of the report was placed in the program’s
centralized file within forty-eight hours of approval. The program’s PAR/RI Plan was updated
January 9, 2023. It was sent to the Department for approval on January 10, 2023; however, was
not approved by the Department’s Residential regional director until September 28, 2023. There
was no increase in the number of PAR/RI incidents since the last annual compliance review.
The program’s PAR/RI rate during the annual compliance review period was 1.46, which is
above the statewide Residential PAR/RI rate of 1.35. The facility administrator (FA) reported a
PAR/RI Report is completed any time a Level 2 or higher restraint is utilized on a youth. All
completed reports are submitted to the shift supervisor for review. The shift supervisor shall
review all completed PAR/RI Reports and incident reports prior to the end of the shift, and
ensure staff complete all required documentation prior to leaving their assigned shift. All
reviewed reports shall be submitted to the assistant facility administrator (AFA) for review. All
meetings held regarding the use of PAR/RI are documented in the facility logbook and are
communicated to the next shift either in a shift briefing, meeting, or by the outgoing shift
supervisor informing the incoming shift supervisor who shall inform their shift staff. Master
control staff document all use of PAR/RI in the master control logbook. The AFA or designee
forwards all PAR/RI reports, Mechanical Restraint Supervision Log(s), if applicable, camera
footage, and other related documentation to the FA, as soon as possible for an additional
review. The FA then completes a review of all uses of physical intervention and mechanical
restraints following each incident within twenty-four hours. Reviews include the incident report,
PAR/RI Report, supplemental statements, camera footage if available, Mechanical Restraint
Supervision Log, if applicable, and other related information. The FA will also review all uses of
PAR/RI and incident reports in management team meetings. Five staff were interviewed, two
indicated they have only used verbal techniques with youth, and three denied having ever used
a PAR/RI maneuver.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 72 (Revised September 2022)
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring.
The program has a policy and procedures addressing pre-service training requirements for new
staff during the initial 180 days of employment. All program instructors are qualified to deliver
the trainings provided. Staff who are considered to be direct care staff and are counted in the
staff-to-youth ratio are youth care workers and supervisors or administrators, provided they are
not conducting their regular duties while being included in ratio. Five staff records were
reviewed. Each newly hired staff are all within the first 180 days of employment; therefore, each
had not yet completed the required 120 hours of pre-service training. All reviewed staff records
documented completion of the essential skills trainings of cardiopulmonary resuscitation (CPR),
first-aid, automated external defibrillator (AED), forty hours of Protective Action Response Right
Interactions model (PAR/RI), professionalism and ethics including standards of conduct, facility
or program operating procedures, suicide awareness and prevention, emergency procedures,
child abuse reporting, and Prison Rape Elimination Act (PREA) within ninety days of hire and
prior to contact with youth. Four of the five staff were missing active shooter preparedness, and
three of the five staff did not complete adolescent development and behavior, balanced
approach to restorative justice, and the Department’s Central Communications Center/Incident
Reporting trainings. Four of the five staff have not had motivational interviewing and stress
management trainings. Online trainings were recorded in the Department’s Learning
Management System (SkillPro), but the program’s instructor-led trainings were not. The
instructor-led trainings have been entered in SkillPro since the annual compliance review week
for one staff, the remining four staff no longer work at the program.
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a policy and procedures addressing annual in-service training. Staff in-service
training records were not-applicable to be reviewed this annual compliance review because the
new provider took over after the in-service trainings for this annual compliance review period
were due to be completed. The program has an annual in-service training calendar, which is
updated as changes occur.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures in place including the training requirements of the
grievance process. A review of five pre-service and five in-service training records found each of
the staff received training on the grievance process. A review of the policy revealed the
program’s grievance process has three phases including informal, formal, and appeal. The
Florida Department of Juvenile Justice Residential Annual Compliance Report
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facility administrator (FA) revealed the policy states youth are explained the grievance process
during their program orientation. When a youth feels they are being treated unfairly or their
rights have been violated, the youth should first speak to the staff or peer they are having a
problem with or utilize the Request to Talk Form at the time the grieved situation occurs, and try
to work out the situation informally. Request to Talk forms should be placed in the Request to
Talk box located in the common area, which is checked by the assistant facility administrator
(AFA) or FA. If the problem cannot be solved at the informal phase, the youth can then submit a
written grievance and place it in the grievance box in the common area. The grievance box is
checked daily and grievances are logged in, to ensure time frames are followed. The grievances
are given immediately to the supervisory staff who needs to address the grievance. The next
level supervisor and/or shift supervisor who reviewed and investigated the youth’s grievance
then renders a written decision within four days of receiving the grievance. This decision and
any actions to be taken will be reviewed with the youth. The individual addressing the grievance
should be the direct supervisor of the staff the grievance is written on, if not, it shall be the next
level supervisor, for example shift supervisor of a direct care staff, who addresses the
grievance. If the supervisor is not available within the time frames specified, the AFA shall
address the issues within the time frames indicated. If the grievance is against a youth, the shift
supervisor shall become the first phase to address the grievance. If the youth is not satisfied
with the supervisor phase, the grievance will be forwarded to the assistant director and/or next
level supervisor. The grievance will be reviewed, and a written response will be provided and
discussed with the youth within twenty-four hours of receiving the grievance from the
supervisory phase. If the problem is still not resolved, the youth may request review by the FA.
The FA will provide the youth with a decision in writing within forty-eight hours of receiving the
grievance from the AFA. In most cases, decisions reached at this level will be considered final.
Time frames for responding to a youth’s grievance at the executive management level, including
the AFA, the FA, and other administrative staff, vary due to the staff not being on-site. Typically,
the grievance process will be completed at the FA’s level within seven days of receiving the
initial grievance from the grievance box. Five youth were interviewed, and two youth indicated
grievance forms are available throughout the program, and there are time frames associated
with the process. One youth reported grievances do not get addressed. Four were able to
articulate knowledge of the grievance process, and one stated the staff only check the box
weekly. These concerns were brought to the attention of the FA who stated the grievances are
checked almost daily and all grievances are responded to in the required time frames. Five staff
were interviewed and all five knew grievance forms were placed throughout the program. Four
reported youth are able to request help in filling a grievance form out, if needed, each stage has
time frames, and the FA reviews them. Two staff indicated the process has three phases, and
the supervisor also reviews the grievances. The program had one grievance during the annual
compliance review period, which was resolved during the formal phase in the required time
frame. The one filed grievance was made the week prior to the annual compliance review.
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program has a policy and procedures in place to implement interventions to youth in the
program. The interventions include evidence-based practices, promising practices, or a practice
with demonstrated effectiveness and any other delinquency interventions and treatment
services approved by the Department. The program facilitated groups including Seeking Safety,
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Teen Relationships Workbook, VOICES: A Program of Self-Exploration and Empowerment,
Skillstreaming the Adolescent, Impact of Crime (IOC), Living in Balance, and Female Healthy
Relationships. The facility administrator (FA) revealed the program has one staff qualified to
facilitate the non-primary groups; the designated mental health clinician authority (DMHCA) who
is a licensed mental health counselor (LMHC). The DMHCA’s education and work experience
were considered by the program when determining staff delivery of delinquency intervention
services. A review of the activity schedule, logbook, and three selected dates of video revealed
youth are not in groups as required. A review of sign-in sheets since the new provider took over
the contract revealed all groups were not conducted as required. VOICES: A Program of Self-
Exploration and Empowerment had no facilitator listed for one group and in one week group
was not held. In the month of August, the Teen Relationships Workbook group was only held
once, when the requirement indicates weekly, and one session was not held in June. Seeking
Safety had no facilitator listed in August for one session. Video review and sign-in sheets
revealed groups, including one VOICES group and four for Skillstreaming the Adolescent, were
not always being conducted for the required one-hour, and group sizes consisted of the entire
youth population at the program. The program indicated on the selected days of video review
where youth had not been in group the required amount of time, was due to the incorporation of
outside time as part of the therapy and the youth were outside continuing the session, where the
DMHCA engaged them in how they can utilize skills they have been taught. A review of the
activity schedule indicated the program is providing structured, planned programming, or
activities at least sixty percent of the youth’s awake hours. Additionally, due to the therapist
vacancies, the DMHCA has been leading all groups, and as a result the entire youth population
participates in each session. The DMHCA reported all youth are selected by the Department to
be in this Substance Abuse Overlay Treatment Services (SAOS) program. Substance abuse
and mental health groups are provided daily, individual and family sessions are provided once a
month or more, if needed. The FA indicated curricula include but are not limited to, Thinking for
Change (T4C), Impact of Crime, Cognitive Behavioral Group Therapy, Cannabis Youth
Treatment (CYT), and Anger Management. The treatment services provided by the program
target each youth’s criminogenic needs, behaviors, and attitudes. Delinquency staff who
implement these evidence-based curricula are well trained and are evaluated to ensure fidelity.
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 in place to provide youth with training in social skills,
planning skills, emotion management, positive alternatives to aggressive behavior, skills for
responding effectively to stress, and life skills. Social and life skills are addressed in problem
solving groups and educational groups. The delinquency intervention used by the program is
Skillstreaming the Adolescent which is a practice with demonstrated effectiveness as identified
on the Department’s website. The life skills provided by the program addressed communication,
interpersonal relationships and interactions, non-violent conflict resolution, anger management,
and critical thinking including problem-solving and decision making, and were provided to
address the program’s targeted gender group. A review of the activity schedule reflected youth
therapy groups were included on the schedule, but the type of group was not recorded. A review
of sign-in sheets, agendas, and photographs of groups confirmed life and social skills were
provided to youth, as required. The facility administrator (FA) revealed in addition to life skill
intervention services the youth learn gender-specific sex education, health and hygiene
education, relationship building, communication skills, parenting, domestic violence and
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violence prevention, improving self-esteem, cardiopulmonary resuscitation (CPR), and first-aid.
All five interviewed youth revealed they are certified in first-aid and CPR, and have participated
in groups for Impact of Crime and balancing budgets. The designated mental health clinician
authority (DMHCA) revealed life skills development and training is covered during Skillstreaming
the Adolescent and Teen Relationships mental health groups. The program also brings in guest
speakers, such as representatives from the University of Florida who come in and teach
different skills and media literacy, Teen Dating by Peaceful Paths, and financial literacy.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program provides activities and instruction 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. According to the program’s contract, the program utilizes
Impact of Crime (IOC). IOC is designed to teach youth about the impact of crime on victims,
their families, and their communities. A review of sign-in sheets revealed the youth are
participating in IOC as required. A review of the program’s activity schedule showed groups
have a designated time twice a week. The youth are active in the community through
partnerships with local non-profit organizations. The program has participated in community
projects, such as making cards for other youth involved with a local charity and creating a
memory garden. The facility administrator (FA) revealed the program teaches youth to make
reparation to the communities through the community service work programs. The IOC groups
are theme-centered, focusing upon identifying problems and helping youth gain insight for
acquiring pro-social behaviors and attitudes. The groups are designed to assist youth in
understanding the harmful consequences of their criminal behavior. The program provides a
system to measure the youths’ progress in problem solving and social skills through paperwork
assignments, in-group presentations, and level of participation. The designated mental health
clinician authority (DMHCA) confirmed IOC is conducted in the program twice weekly. All five
interviewed youth confirmed they participated in IOC and in these groups, they practice
communication, coping, and anger management skills. Two of the five interviewed youth stated
they have opportunities to practice new skills learned in groups.
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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 addressing alerts, including the program’s internal
alert system being updated on a continual basis, and all staff having access to alerts. A review
of five youth records was conducted. All of the youth had matching alerts placed in the
program’s internal alert system and the Department’s Juvenile Justice Information System
(JJIS). Each of the alerts were removed or downgraded by medical or mental health staff, as
required. Each applicable alert was documented in the program’s logbook. According to the
facility administrator (FA), upon entry to the program all youth alerts are documented and
evaluated, as needed. Any discrepancies will be documented, and all youth with Medical
Grades of two to five shall be placed on the program’s medical alert system. Open internal
alerts will also be posted on the alert board in a prominent location available to staff identifying
which youth are on the specific alerts. All alerts are documented in the alerts binder, which is
accessible to all staff and may be reviewed by staff at any time. The alerts binder is located in
master control. A current listing of youth on suicide risk alert or mental health alert in JJIS is
maintained and provided to direct care and clinical staff on a daily basis. This is done at shift
briefings conducted by the shift supervisor before each shift in accordance with Administrative
Rule. It is the responsibility of the FA, clinical director, case managers, nurses, and shift
supervisors to ensure compliance with the policy. Any staff, direct care staff, case manager,
clinicians, or nurse may place a youth on alert status if they meet criteria for inclusion in the
program’s alert system. Nursing staff further verified the registered nurse (RN) updates the
medical alert system. Five staff were interviewed and were able to articulate where they are
able to see any open alerts youth may have, to include the alert board, logbook, information
being passed down from supervisors, master control, through medical and mental health staff,
briefings, and through email.
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 official case records, labeled “Confidential” for each youth, which consist
of three separate records including a case management record, a mental health record, and an
Individual Healthcare Record. Each of the youth records contained the youth’s name,
Department identification number (DJJID), date of birth, county of residence, and committing
offense. The case management records also contain sections labeled as legal information,
demographics and chronological information, correspondence, case management and
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treatment team activities, and miscellaneous. When not in use each of the youth records were
secured in a clearly identifiable, locked cabinet labeled “Confidential.”
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
support group or advisory board meeting at least every ninety to 120 days. There was
documentation of the facility administrator (FA) soliciting active involvement from a law
enforcement representative, judiciary community, community partners, business community,
school board or district, faith community, and the LGBTQIA+ community, when possible. There
was also evidence of the FA recruiting a victim or victim advocate, and a parent/guardian whose
child was previously involved in the juvenile justice system. A review of the meeting agendas
and minutes revealed meetings were held, as required. The program reported no advisory
board meetings were scheduled between January and May 2023, due to the new provider
taking over the program. The purpose and duties of the advisory board is to help keep the
program in touch with the local community and allow the local community to better understand
the goals, objectives, and purpose of the program, as well as foster involvement with special
projects. Several board members were contacted during the annual compliance review week.
None of the messages were returned; therefore, no interview could be conducted.
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 in place to ensure it has a system for evaluating staff,
at least annually, based on established performance standards. Three position descriptions
were reviewed, and staff’s performance standards were clearly identified. A sample of
performance evaluations for five staff was reviewed to ensure evaluations were completed, as
outlined in policy. The program’s contract was reviewed and all specific contractually required
positions were maintained and performed, as outlined in the contract, with the exceptions of the
two vacant therapist and one vacant transitional case manager positions. The facility
administrator (FA) revealed the program has experienced turnover primarily in clinical, case
management, and direct care. The FA indicated direct care staff who have remained with the
program a year prior to June 2023 with no disciplinary actions on their record were rewarded
with a retention bonus in August 2023. The program also recognizes great performance through
monthly employee recognition checks valuing fifty dollars to three outstanding employees
outside the leadership team; these are announced during monthly all staff meetings. The FA
and administrative team review data, such as the Trauma Response and Caring Environment
(TRACE) survey, to determine which areas are strengths and needing to be improved to drive
policies and practices. The FA explained the program’s procedure includes weekly management
meetings to discuss and provide information, share opinions, talk about problem-solving
options, review feedback from staff, and implement new ideas from staff and youth to enhance
services at the program. Department heads conduct monthly meetings to keep staff informed
and to give them opportunities to provide input and feedback pertaining to the operation of the
program. Management conducts monthly meetings to reduce turnover and share ideas to create
a high morale amongst staff. All meetings have agendas and minutes documented. TRACE
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assessment surveys are completed annually in accordance with the Department’s policies. The
program includes information obtained from youth and parent/guardian surveys, in addition to
reports published annually by the Department in their program planning and assessment
process. The FA indicated a staff’s competency will be evaluated according to the individual’s
job description. This evaluation may include other areas of professional and personal
development, as necessary. All employees receive monthly coaching from their supervisor to
ensure competency and attend to individual training needs or areas for development. All staff
receive formal competency evaluations at the completion of their ninety-day probation period,
and on an annual basis thereafter. Both the supervisor and the staff will have an opportunity to
make comments about these evaluations and will sign them. Five staff were interviewed and
three revealed communication amongst staff at the program is good. Two staff revealed
communication amongst staff was fair. Three staff revealed a formal evaluation of their
performance based on the performance standards is conducted annually, while the remaining
two staff had not had one yet due to being newly hired.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program’s special contract conditions include, providing youth with substance abuse issues
the opportunity to participate in Alcoholics Anonymous (AA) and/or Narcotics Anonymous (NA)
while in the program, hosting guest speakers for education topics, providing regular faith-based
opportunities, providing additional opportunities for youth to obtain community service hours,
transportation assistance for discharged youth, and in-home assessments for youth after
release. Reviewed documentation confirmed the program has made several attempts to begin
on-site AA and NA meetings for youth, with no response from the providers for the meetings.
The program provided photos, sign in sheets, and agendas reflecting guest speakers have
provided training and education to the youth at the program, to include Peaceful Paths Domestic
Violence Services and Gainesville Child Advocacy Center. Faith-based opportunities are
available to the youth through Evangel Temple of Jacksonville, who conducts monthly church
services, provides motivational guest speakers, and gives the youth an opportunity to participate
in the church choir. Youth have many opportunities for completing community service during
their time at the program by doing chores and participating in group service activities. During the
annual compliance review period, there had been no youth needing financial assistance to
return home; however, the program provides financial assistance for families to attend visitation
and family days. A transition specialist is required to conduct in-home assessments for youth
within a seventy-five mile radius, and request assistance from juvenile probation officers for
youth outside of seventy-five miles. Five youth were interviewed. Each reported having attended
several sessions with guest speakers and attended church services. Each of the five youth were
able to discuss the community service opportunities available to them at the program.
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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 career and technical education services be provided to youth,
including Career and Technical Education (CTE) Services, Florida Ready to Work Soft Skills
Credential interactive training program, Occupational Safety and Health Administration (OSHA)
ten-hour training course, and first-aid/cardiopulmonary resuscitation (CPR) training. At the time
of the annual compliance review week, the program had trained all of the youth in CPR and first-
aid. The education department had just begun CTE services, Florida Ready to Work, and OSHA
training the month prior to the annual compliance review week. The program has also begun
providing ServSafe training, and one youth had earned their certification. All staff facilitating
trainings are qualified to deliver the training. The career and technical education program is
appropriate for the age, abilities, goals, the length of stay, and classification of the youth in the
program. An interview with the facility administrator reflected they are aware of the CTE
services required by the provider’s contract.
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 includes the review and analysis of data in decision-making practices and shares
the data among administrators and staff to proactively make policy, practice, and programming
changes designed to foster system and program improvement. The program has a practice to
track and capture data such as releases, youth demographics, average length of stay,
population, and recidivism. The program uses this information, as well as the youth point
sheets, to drive practices, policy changes, and policy implementation. According to the facility
administrator (FA), recently a change was made to the behavior management system (BMS)
based off data regarding the number of intakes versus discharge. The program shares this
information with staff during their monthly all-staff meetings., At this meeting all data driven
information is relayed to staff including the Trauma Response and Caring Environment
(TRACE) assessment information and any necessary training. The program shares information
on data trends with their contract provider weekly, as well as discusses staff turnover and status
of vacancies. Stakeholders are informed quarterly at the advisory board meeting. The FA
reported the program utilizes the data they collect to revamp policies, conduct refresher
trainings, and any additional trainings as needed, as well as address any other issues, as
needed.
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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 regarding the notification of each youth’s
parent/guardian and committing court of the youth’s admission to the program. Three case
management records were reviewed. All three records confirmed the program notified the
youth’s parent/guardian, by telephone, within twenty-four hours of admission. All three case
management records indicated the program notified the parent/guardian, in writing, within forty-
eight hours of admission. All three records included documentation to support the youth’s
committing court and juvenile probation officer (JPO) were notified within five working days of
the youth’s admission to the program.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures to provide each youth an orientation to the program
on the day of admission. Three youth case management records were reviewed. Two of the
three reviewed records indicated the program provided each youth with an orientation within
twenty-four hours of admission. One youth’s orientation checklist only had the case manager’s
signature and not the youth’s signature. Orientation included all required elements such as
services available, the daily schedule, expectations and responsibilities, the written behavior
management system conspicuously posted and provided in the youth handbook, access to
medical and mental health services, access to the Florida Abuse Hotline, zero-tolerance policy
regarding sexual misconduct, special accommodations, right to be free from sexual misconduct,
and items considered contraband. Also included in the orientation is the performance planning
process involving the development of goals for each youth to achieve, dress code and hygiene
practices, procedures on visitation, mail, use of the telephone, expectations for release from the
program, community access, grievance procedures, emergency procedures, a facility tour, living
unit assignment, and treatment team and medical topics as outlines in Chapter 63M-2. There
were no admissions during the week of the annual compliance review to observe. Five youth
were interviewed. Each youth reported they received an orientation within twenty-four hours of
admission into the program. The youth stated during the program’s orientation process they are
provided with a handbook and orientation package which involves program rules, procedures,
and information regarding how the program works.
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2.03 Written Consent of Youth Eighteen Years or Older Limited Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a policy and procedures for obtaining consent from youth eighteen years of
age or older. All three reviewed records were not applicable for youth eighteen years of age or
older. The program provided one additional record for review. The one record did not contain
documentation, signed by the youth, giving consent to release information regarding physical or
mental health screenings, assessments, or treatments to their parent/guardian; however, there
was documented contact with the parent/guardian. The program corrected the issue by having
the youth sign a written consent form and by providing a corrective action plan stating the
program will implement a clinical tracker which will contain key dates with one of the key dates
being the youth’s eighteenth birthday. The clinical tracker will be reviewed weekly by the clinical
director with the case management staff. The week prior to the youth’s eighteenth birthday, the
case management staff will be reminded of the need to complete the written consent document
with the youth on the youth’s birthday or the next business day after the youth’s birthday.
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 regarding classification factors and procedures, as
well as reassessments for activities. The program has a system in place used for the purpose of
classifying youth. Classification forms include physical characteristics of the youth, the youth’s
age and maturity level, identified special needs, history of violence, gang affiliation, criminal
behavior, sexual aggression or vulnerability to victimization, the youth’s perception of
vulnerability, any history of potential or verified human trafficking, and level of risk to include
suicide, medical, escape, and security, and any other suspected risk factors. Three youth case
management records were reviewed. Each of the three reviewed youth records contained
documentation indicating the youth were initially classified on the date of admission based on
the classification criteria on the classification forms. A new Vulnerability to Victimization and
Sexually Aggressive Behavior (VSAB) was completed and entered into the Department’s
Juvenile Justice Information System (JJIS) prior to youth’s room assignment in all three records.
All case management records contained documentation indicating each youth was classified for
the purposes of assignment to a living area, sleeping room, group, and case manager. All youth
identified with risk factors were entered into JJIS. All records reviewed were found to contain
monthly reassessments for each of the youth to increase the youth’s privileges or freedom of
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movement, participation in work projects or other activities involving tools or instruments, or
participation in off-campus activities. Three youth participated in work projects or other activities
involving tools or other instruments, and all three youth participated in off-campus activities. An
interview with the facility administrator confirmed the practice and procedures used by the
program to classify youth to determine the most appropriate group placement and sleeping
arrangements and to increase staff awareness of classification issues. The program’s policy and
procedures clearly outline the classification process and include a classification system which
promotes safety and security, as well as effective delivery of treatment services, based on the
determination of each youth’s individual needs and risk factors, which addresses, at a minimum,
items outlined in Florida Administrative Code. Throughout the youth's commitment, the
treatment team will reassess and reclassify youth, 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.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a policy and procedures for gang identification and notification to law
enforcement. None of the three reviewed records were applicable for gang identification. The
program did not have any applicable records for review. The program’s policy and procedures
state the local law enforcement will be notified if a youth is a suspected gang member or
affiliate. Prior to the annual compliance review team’s seven-day notice, local law enforcement
and law enforcement in the youth’s home county will be notified by the program of the youth’s
gang involvement. Gang alerts will be entered into the internal alert system and the
Department’s Juvenile Justice Information System (JJIS) upon identification. Information on the
youth’s gang status will be shared with the local school district providing services at the
residential program and the youth’s juvenile probation officer (JPO).
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 for intervention strategies when youth are identified
as a criminal street gang member, are affiliated with any criminal street gang, or are at high-risk
for gang involvement. None of the three records reviewed were applicable for gang
identification. The program did not have any youth who were identified as a gang member, an
affiliate of a gang, or at high risk for gang involvement. The program uses the ARISE curriculum
and Impact of Crime (IOC) for prevention and intervention awareness efforts provided to the
youth at the program. The ARISE gang prevention curriculum is the intervention and prevention
strategy implemented at the program to help reduce the risk factors leading to gang
membership. Topics included in this curriculum are reasons for avoiding gang membership,
essential guidance for managing anger and conflict, reasons for developing positive self-
esteem, practical steps for building a solid future and the skills needed for finding and keeping a
job, becoming aware of the dangerous consequences of gang member relationships, life skills
necessary for avoiding violence and bad behavior on the streets and at home, and developing
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important interpersonal skills which can last a lifetime. The program keeps sign-in sheets in the
ARISE gang prevention binder to confirm the groups were delivered as designed. Impact of
Crime is used as a supplement to the ARISE gang prevention curriculum. Impact of Crime
topics include victim impacts and restorative justice, owning one’s actions, introduction to harm,
consequences of making decisions, the ripple effect of crime, managing conflict, and the road to
reparation. The program keeps the Impact of Crime sign in sheets in a binder labeled Impact of
Crime. An interview with the facility administrator confirmed the gang intervention and
prevention strategies utilized at the program is the ARISE gang prevention curriculum which
consists of youth gang prevention strategies, similar to a life skills curriculum which helps
reduce the risk factors leading to gang membership and Impact of Crime as a component of the
gang awareness/prevention strategy.
2.07 Residential Assessment for Youth (RAY) Assessments and
Limited Compliance
Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
The program has a policy and procedures to assess each youth using the Residential
Assessment for Youth (RAY) within thirty days of admission, as well as a RAY Reassessment
every ninety days thereafter. Three youth case management records were reviewed. Two of the
three reviewed youth records contained an initial RAY assessment completed within thirty days
of the youth’s admission to the program. One of the three youth records show the initial RAY
assessment was completed ten days late. Each RAY assessment was appropriately maintained
on the Department’s Juvenile Justice Information System (JJIS). Each of the three reviewed
records did not contain documentation showing a RAY Reassessment completed each ninety
days after the initial RAY assessment. One youth’s RAY Reassessment was seven days late. A
second youth’s RAY Reassessment was 104 days late. The third youth’s RAY Reassessment
was ninety-nine days late. It could not be determined if the three youth records were applicable
for updates on the reassessments by the intervention and treatment team to effectively manage
the youth’s case in addition to the ninety-day updates, since all three youth did not have a RAY
Reassessment completed at the time of the annual compliance review. The program’s policy
and procedures stated all reassessment documentation is maintained in the youth’s official case
record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in JJIS on the YNAS.
The program has a policy and procedures for the completion of a Youth Needs Assessment
Summary (YNAS) on each youth within thirty days of admission. Three youth case management
records were reviewed. Two of the three records contained a YNAS completed within thirty days
of admission. One youth’s record documented the YNAS was completed 114 days late. The
YNAS was documented in the Department’s Juvenile Justice Information System (JJIS) in all
three of the records reviewed.
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2.09 Performance Plan Development, Goals, and Transmittal
Limited 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 regarding the development of performance plans.
Three case management records were reviewed for the development of performance plans.
Two of the three records documented the youth’s performance plan was developed within thirty
days of admission to the program. One of the three records documented the youth’s
performance plan was completed seventeen days late. All performance plans were completed
after the initial assessment with the intervention and treatment leader, youth, administration
representative, living unit representative, treatment staff, education staff, and parent/guardian.
One plan was applicable for the presence of the youth’s Department of Children and Families
(DCF) caseworker. Records indicated the DCF caseworker was not present for the development
of the individualized performance plan. There was documentation of an attempt to contact DCF.
The remaining two records documented the parent/guardian participated by telephone. The
program had documentation the two initial performance plans and signature sheets were mailed
to the parent/guardian; however, none of the signature sheets were returned. All three reviewed
records documented the performance plans included goals individualized for each youth based
upon the prioritized needs reflecting the risk and protective factors identified during the initial
assessment process, the youth’s responsibilities to accomplish goals, program staff
responsibilities to enable youth to complete the goals, and target dates for goal completion.
None of the three performance plans target court-ordered sanctions which could be reasonably
initiated/completed while in the program. One applicable performance plan contained transition
activities targeted for the last sixty days of the youth’s anticipated stay. All three of the
performance plans included all the youth’s top three criminogenic needs. Two of the three
records documented specific delinquency interventions which were based on the youth’s top
three criminogenic needs. One of the three reviewed plans did not document specific
delinquency interventions which were based on results from the Residential Assessment for
Youth (RAY). All three of the youth’s records documented measurable outcomes which will
decrease the youth’s criminogenic risk factors and promote strengths, skills, and supports to
reduce the likelihood of the youth reoffending. There was documentation in one of the three
records showing the program sent the performance plans to the youth’s committing judge,
juvenile probation officer (JPO), parent/guardian, and DCF, when applicable, within ten working
days of completion. Two of the three records did not contain written documentation showing the
performance plan was sent to the committing court or JPO. One of the three records was
applicable to send the performance plan to the DCF counselor. The one applicable youth record
did not contain written documentation the performance plan was sent to the DCF counselor.
Five youth were interviewed, and all confirmed they participated in the development of their
current performance plan, were aware of their current performance goals, and had a copy of
their performance plan.
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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 to address revisions to performance plans. A review
of three youth case management records determined the program revised and updated
performance plans monthly during treatment team meetings. Performance plan revisions were
completed based on newly acquired information or the youth demonstrating progress or lack of
progress towards goals. It is unknown if the youth’s performance plan revisions were completed
due to the youth’s Residential Assessment for Youth (RAY) Reassessment results since none of
the three youth had a RAY Reassessment completed. One of the three youth records were
applicable for transition activities. The one applicable record did not show revisions to the
individualized performance plan were being made to facilitate transition activities during the last
sixty days of the youth’s stay.
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 for the completion of Performance Summaries and
transmittals. Three open youth case management records were reviewed and found no initial
Performance Summaries were completed within ninety days following the signing of the
performance plans in all three open records. At the time of the annual compliance review, none
of the Performance Summaries had been completed and were 100, nine, and thirty-nine days
late. Components of the summaries were unable to be verified since none of them were
completed. Three closed youth records were reviewed for Release Summaries. Each of the
closed records contained documentation indicating the original summary was sent with the Pre-
Release Notification (PRN) to the youth’s assigned JPO. There was documentation in two
youth’s closed records indicating the PRN was sent at least forty-five days prior to each youth’s
anticipated release date. The PRN was sent twelve days late for the remaining youth. All three
closed youth records had a signed copy maintained in each youth’s record. Upon the court’s
approval of the PRN, two of the closed youth’s records documented the program provided
written notification to the youth’s parent/guardian advising of the youth’s anticipated release, the
remaining record did not contain documentation confirming the notification was sent to the
youth’s parent/guardian. Two of the three closed records had a completed Residential
Assessment for Youth (RAY) Exit Assessment, the remaining did not. None of the three closed
records were applicable for victim notification.
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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 encourage and facilitate involvement of the youth’s
parent/guardian in the case management process. The program invites the youth’s
parent/guardian to participate in the assessment process, development of the youth’s
performance plan, progress reviews, advanced notice of formal treatment team meeting dates
and times, and transition planning. If unable to attend, the program gives the parent/guardian
the opportunity to participate by telephone/video conference or provide written input prior to the
meeting. There were no treatment team meetings held during the week of the annual
compliance review; therefore, observations could not be completed. An interview with the facility
administrator (FA) revealed the case manager invites the youth’s parent/guardian to participate
in intervention and treatment team meetings for the purpose of developing the youth’s
Individualized Performance Plan, conducting formal performance reviews of the youth’s
progress in the program, and planning for the youth’s transition to the community upon release.
Five youth were interviewed, and each youth confirmed parents/guardians are involved in case
management through telephone calls made by the case manager and during visitation.
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 for the incorporation of other plans such as
academic, medical, and treatment plans into performance plans. Three youth case management
records were reviewed for incorporation of other plans into performance plans. All three
performance plans incorporated all other plans, including academic and treatments plans, into
the performance plan. One youth was applicable for Department of Children and Families (DCF)
involvement but did not incorporate a DCF care plan. None of the reviewed records required
Agency for Persons with Disabilities (APD) involvement.
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 policy and procedures identifying members of the treatment team and
detailing treatment team participation. A review of three youth case management records
indicated treatment teams were composed of a treatment team leader, youth, administrative
representative, living unit representative, treatment staff, educational staff, juvenile probation
officer (JPO), parent/guardian, medical staff, and recreational therapist. The gang prevention
specialist, transition services manager, Department of Children and Families (DCF), and
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trafficking-specific service provider are included when applicable. Documentation showed
members of the treatment team from the program either attended treatment team meetings or
provided written input for the treatment team meetings. Documentation showed the program
called parent(s)/guardian(s) and JPOs to participate in treatment team meetings. The three
reviewed youth had a total of thirteen formal treatment teams during the annual compliance
review period, all thirteen of which included all required parties. The program has a written
policy and procedures requiring the intervention and treatment team to meet every thirty days
(formally and informally) to review each youth’s performance. Three youth case management
records were reviewed. Two of the three records documented formal treatment team meetings
were held every thirty days, as required. The remaining youth had a formal treatment team
meeting 135 days late. Treatment team meeting documentation included the youth’s name, date
of review, meeting attendees, comments from treatment team members, a brief synopsis of the
youth’s progress, performance plan revisions, progress on performance plan goals, positive and
negative behaviors, behaviors resulting in physical interventions, treatment progress, and
documentation the youth were provided an opportunity to demonstrate skills acquired. None of
the youth’s treatment team documentation included Residential Assessment for Youth (RAY)
results. Formal treatment team documentation was maintained in all three youth case
management records. One of three records contained documentation indicating the intervention
and treatment team met bi-weekly. The remaining two records indicated an informal review was
held 121 days late for one youth and sixty-four days late for the other. The informal treatment
team reviews included the youth’s name, date of review, meeting attendees, comments from
treatment team members, a brief synopsis of the youth’s, performance plan revisions, progress
on performance goals, positive and negative behaviors, behaviors resulting in physical
intervention, treatment progress, and an opportunity for the youth to demonstrate skills acquired
in the program. None of the records included RAY results in the informal treatment team
documentation.
There were no treatment team meetings during the week of the annual compliance review;
therefore, observations were not completed. A review of treatment team documentation showed
members actively participated in the meeting by providing information regarding the youth’s
progress on performance plan goals, positive and negative behaviors, behaviors resulting in
physical interventions, and treatment progress. A review of treatment plans provided information
on the youth’s anticipated release date. All five interviewed youth confirmed staff review their
performance to include progress on performance plan goals, positive and negative behaviors
and treatment progress. Four of the five youth also reported they are given an opportunity
during treatment team meetings to demonstrate skills learned in the program by having an
opportunity to communicate with staff during treatment team, provide input on progress in the
program and education, and express themselves in a positive manner. One youth stated they
were not given an opportunity to demonstrate skills learned. The youth did not give any
additional explanation.
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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.
A review of the three closed records showed a transition conference was held at least sixty days
prior to the youth’s targeted release dates in all three records. The intervention and treatment
team members during the conference included the youth, treatment team leader, executive
director (ED) or designee, juvenile probation officer (JPO), the youth’s parent/guardian, human
trafficking services provider (if applicable), and other pertinent parties, with the exception of
education staff who attended for two of the three youth. All three reviewed records showed the
youth participated in a transition conference. All three records showed transition activities on the
youth’s performance plan, which were revised when necessary to identify additional transition
activities and target completion dates. The transition conference participants identified the
person responsible for completion of transition activities, and the treatment team leader
obtained attendees’ dated signatures, representing their acknowledgement of the transition
goals and accountability for completion. In one of the three records, a copy of the plan was not
sent with a request for return with signature to anyone not in attendance who had a
responsibility for completion of transition goals. The remaining two records showed a copy of
the plan was sent with a request for return with signatures to anyone not in attendance. The
plans were transmitted electronically and by mail to the JPO and/or the Department of Children
and Families (DCF) counselor when applicable, but the return email acknowledgement receipt
and United Stated Postal Service receipt were not printed and filed with the plan. The program
held a Community Re-Entry Team meeting prior to each youth’s release with the youth and
case manager. Two of the records contained evidence of an invitation to participate in the
meeting, however, one did not contain this documentation.
2.16 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
None of the three open records reviewed were applicable for transition services; therefore, the
program provided three closed youth records. All three records documented the exit portfolio
was discussed and initiated during the youth’s transition conference. One of three applicable
portfolios included a state-issued identification (ID) card. One of the remaining two youth was
fourteen years of age and not applicable for an ID. All three closed records included a copy of
the youth’s transition plan and calendar with all dates, times, and locations of upcoming
appointments. Two of the three applicable youth had a Social Security card and a birth
certificate. An informal interview with the case manager determined the program does request
the birth certificate and Social Security card from all of the parents/guardians in order to obtain a
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youth ID; however, the documents are rarely provided. Two of the three portfolios included
educational and/or vocational certificates earned in the program, educational
records/documents, and school transcripts. One of the three closed records did not contain a
copy of the youth’s school transcripts. All three applicable records included a résumé and
completed sample job applications. The youths’ exit portfolios were verified during the exit
conference in all three records. There was documentation indicating the exit portfolio was given
to the youth upon release or the program forwarded the exit portfolio information to the juvenile
probation officer.
2.17 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
Three closed records were reviewed for the Exit Conference and each Exit Conference
occurred after the program notified the youth’s juvenile probation officer (JPO) of the youth’s
release, was separate from the transition conference, and at least fourteen days prior to the
release. Each youth’s Exit Conference documentation included all required information, and the
status of transition activities was finalized. Each youth’s release date in the Department’s
Juvenile Justice Information System (JJIS) correlated with the youth’s actual release date. All
required parties attended the Exit Conference for all three youth with the exception of the
education provider for one youth.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures to promote constructive input by the youth. The
program’s policy allows the youth to give feedback on a daily, weekly, and monthly basis. Some
of which include a request for service form, the grievance and request to talk system, and
monthly town hall meetings. Staff ensure the grievance, request to talk, and request for service
forms are available at all times. The facility administrator (FA) and/or designee checks the
appropriate boxes routinely to address immediate issues. Monthly town halls are conducted with
all the youth along with the youth care workers (YCWs), supervisors, and FA and/or designee.
The annual Trauma Responsive and Caring Environment (TRACE) survey, youth exit survey,
and daily clap up are used. The program provided advisory board minutes and grievance forms
to document the program’s efforts to solicit input from the youth. All monthly town hall meetings,
annual TRACE surveys, and youth exit surveys were completed in a timely manner. The FA
was interviewed and provided the program’s policy and procedures for youth input.
2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program has a policy and procedures to provide for career education based on age and
educational abilities of the youth in the program. The program provides Type 2 career education
development. The interview with the lead educator indicated this includes career learning
strategies such as soft vocational skills and ServSafe food handling and training certification.
Naviance (college and career software) is also used to assist with career planning. An interview
with the facility administrator indicated the program provides career education programming
which is appropriate based on the youth’s age, assessed educational abilities, and goals of the
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youth. Three closed youth records were reviewed and included a completed employment
application, a résumé, and an appointment with Career Source Center along with appropriate
documents essential to obtaining employment. Documentation indicating the youth's
parent/guardian and juvenile probation officer (JPO) were aware of the vocational plan for the
youth was contained in each record. Two out of the three records reviewed did not have a State
of Florida identification card (ID), while the other youth had the required documentation. One of
the two youth without an ID was fourteen years of age; therefore, was not applicable.
2.20 Educational Access (Critical) Limited Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a policy and procedures to provide educational access. The program provides
education services through the Alachua County School Board in compliance with a 250-day
calendar, which is distributed over twelve months, includes ten days for teacher training and
planning, and is approved by the district. A review of the daily school schedule revealed the
program provided four seventy-five minute class periods from 8:30 a.m. to 2:30 p.m., with a
forty-minute lunch break daily, fulfilling the weekly requirement of twenty-five hours of
instructional time. The interview with the lead educator indicated the school schedule is adhered
to. Five youth were interviewed and four reported there is little to no interruption to the school
day. One youth said there were interruptions, as they get called out from class two to three
times a week to see the nurse, therapist, or case manager. A review of five randomly selected
logbook reviews from April 19, April 20, May 3, May 18, and August 7, 2023, showed the youth
were not attending school according to the daily bell schedule. Youth were either arriving to
education late or being dismissed early. The issue appeared to be due to the teachers arriving
late and leaving early. Further review of logbook entries and video footage, for three days in
September 2023, verified this same finding. During the days of the video review, the youth were
missing twenty-one and twenty-two minutes of school on two of those days, falling short of the
required school time. All reviewed days showed the youth were not participating in school as
scheduled, arriving late at the beginning of the day and returning late after lunch, which then
resulted in the youth not receiving their twenty-five hours of required instruction each week.
2.21 Education Transition Plan Limited 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 education transition plan to be
developed upon each youth’s admission. Three closed youth case management records were
reviewed. None of the three youth records included the specified education transition plan. The
lead educator stated she has a similar process developed which addresses the continuation of
the student’s education and employment, but she does not complete the actual transition plan.
Although none of the youth had an education transition plan, it was confirmed the youth were
still receiving services, as required. Each of the three records contained an exit plan indicating
the case manager, parent/guardian, and youth were all aware of the plan. Included in each
record was an Electronic Educational Exit Plan (EEEP), which identified the next educational
placement information and input from the post-release school district representative. Three of
five interviewed youth reported they participated in the development of their education transition
plan while two youth said they did not participate. Three out of the five youth reported the
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program was preparing them very well or well when it came to high school, high school
equivalency diploma (GED), vocational school, employment, and/or college. The responses
from the two youth who indicated they were not involved in developing a transition plan included
the principal does not come to school when needed, feels like they do not learn anything, and
will fall behind when they return to regular school.
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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 designated mental health clinician authority (DMHCA) is a licensed mental health counselor
under Chapter 491. The DMHCA has a clear and active license in the State of Florida which
expires March 31, 2025. At a minimum, the DMHCA is on-site for forty hours a week to ensure
appropriate coordination and implementation of mental health and substance abuse services
were taking place and is available as needed on evenings and weekends. A copy of the license
and position description were reviewed, with no issues noted. Back-up for the DMHCA includes
one regional DMHCA from the same provider. The back-up DMHCA is licensed under Chapter
491, with a clear and active license in the State of Florida which expires March 31, 2025. An
interview with the DMHCA confirmed they are responsible for ensuring mental health and
substance abuse services are delivered to all the youth in the program. The DMHCA oversees
substance and mental health groups, individual therapy sessions, and group therapy sessions.
The DMHCA indicated communication is provided on a daily basis to clinical staff.
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’s policy, procedures, or contract does not require any other licensed clinical staff
other than the individual serving as the designated mental health clinician authority (DMHCA).
The DMHCA is the licensed mental health professional and staffing is in accordance with the
current contract. A copy of the DMHCA license was available on-site and expires March 31,
2025.
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 designated mental health clinician authority (DMHCA) assures the non-licensed clinical
staff working under their supervision are performing services they are qualified to provide based
on education, training, and experience. The reviewed documentation reflected the previous non-
licensed mental health clinical staff working under the direct supervision of a licensed mental
health professional received a minimum of one hour a week of on-site, face-to-face direct
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supervision by a licensed mental health professional for the purpose of overseeing and directing
the mental health services provided in the program during the annual compliance review period.
Direct supervision is documented on a form including all the elements of the Department’s
Licensed Professionals Direct Supervision Log. The program had two non-licensed mental
health staff employed during the annual compliance review period who were employed in
accordance with the current contact. The positions became vacant in June 2023. The program
had two staff hired, screened, and trained in August 2023. One staff did not report for their first
day of work, and the second did not return from lunch break on the first day. At the time of the
annual compliance review both positions were still vacant.
The program previously had two non-licensed mental health clinical staff applicable for review
during the annual compliance review period, and both hold a master’s-level degree from an
accredited university or college necessary, in accordance with the current contract. The
program is licensed under Chapter 397 and all non-licensed substance abuse clinical staff are
working under the direct supervision of a qualified professional as required. The program’s
Chapter 397 license expires on May 9, 2024. All non-licensed mental health clinical staff who
conducted Assessments of Suicide Risk (ASRs) completed twenty hours of training and
supervised experience in assessing suicide risk, mental health crisis intervention, and
emergency mental health services. The training included administration of ASRs or Crisis
Assessments conducted on-site in the physical presence of a licensed mental health
professional which were documented on the Department’s Non-Licensed Mental Health Clinical
Staff Person’s Training in Assessment of Suicide Risk form. All non-licensed substance abuse
clinical staff who provided substance abuse services completed training in accordance with
administrative rule.
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.
Three youth mental health and substance abuse treatment records were reviewed for mental
health and substance abuse admission screenings. All three youth had a Massachusetts Youth
Screening Instrument, Second Version (MAYSI-2) completed upon admission to the program.
The screener reviewed available information to include the commitment packet, and reports
and/or records for existing documentation of mental health or substance abuse problems or
history of human trafficking. A MAYSI-2 was completed for each of the three youth by a trained
staff. The screenings were administered on the day of admission in the Department’s Juvenile
Justice Information System (JJIS) in a confidential manner.
All of the MAYSI-2 screenings were completed in full. All three screenings indicated further
assessment was required, and a referral was made for further evaluation or immediate attention
in all three records reviewed. All youth are referred for an Assessment of Suicide Risk (ASR)
during intake, as such, all three youth were referred for an ASR. When the MAYSI-2 or other
admission information indicated the need for an assessment, crisis intervention, or emergency
services, the facility administrator or designee was notified, and a referral made to alert the
designated mental health clinician authority (DMHCA) in all three records reviewed. The facility
administrator (FA) ensures an ASR was conducted within twenty-four hours when the MAYSI-2
category “suicide ideation” indicated further assessment was needed or other information
obtained at intake/admission suggested potential suicide risk. All three records showed the
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youth was referred for an ASR, as part of the intake process, and the referral documented the
reason for the referral.
The facility is responsible for developing written facility operating procedures for the
implementation of a standardized admission/intake mental health and substance abuse
screening process. The program’s policy outlines a standardized screening process which
includes review of commitment packet information, reports, and records, administration of the
MAYSI-2 on JJIS or Clinical Mental Health Screening by a licensed mental health professional
and Clinical Substance Abuse Screening by a qualified professional, and referral of juvenile
offenders identified by screenings as in need of further evaluation or immediate attention and
staff training in mental health and substance abuse issues and administration of the MAYSI-2.
The policy also includes a standardized process for referral of youth identified as in need of
further mental health and/or substance abuse evaluation to an appropriate service
provider/professional or, when immediate attention is needed, to a hospital, Baker Act, or
Marchman Act receiving facility.
An interview with the FA confirmed the program’s policy regarding the screening process to
identify youth at risk for mental health and substance abuse problems and suicide.
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.
Three youth records were reviewed for mental health and substance abuse (MHSA)
assessments/evaluations. The program completed a new combined MHSA evaluation within
thirty calendar days of admission for all three applicable youth. One of the three assessments
was completed by a non-licensed mental health clinical staff, and both assessments were
reviewed and signed by a licensed mental health professional within ten calendar days after the
evaluation was conducted. All three applicable evaluations included identifying data, reason for
the evaluation, relevant background including home environment and family functioning, history
of physical abuse, sexual abuse, neglect, witnessing violence and other forms of trauma,
behavioral functioning, physical health, mental health, and substance abuse history, and
education functioning. The evaluations also included behavioral observations, Mental Status
Examinations, procedures administered and method of assessment, discussion of findings,
patterns of alcohol and other drug use, impact of substance use on major life areas, risk factors
for substance abuse, diagnostic impressions/formulation including a Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition diagnosis, and recommendations.
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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.
Three youth records were reviewed for mental health and substance abuse treatment. In two of
three records, the initial treatment plan was developed within seven days of the initiation of
treatment. The remaining record was developed fourteen days late. Two of three initial mental
health treatment plans were documented on an initial treatment plan which included all
elements of the required form. The remaining record was incorrectly completed on the
individualized treatment plan instead of the initial treatment plan. The initial treatment plan was
signed by the mental health or substance abuse clinical staff completing the form. All three initial
treatment plans were completed by a non-licensed mental health clinical staff and were signed
by the licensed clinical supervisor, within ten days of completion. The plans were also signed by
all treatment team members who participated in the development of the plan, and the youth.
Plans were mailed to all three parents/guardians for signature and a request to return to the
program. Initial treatment plans included the youth’s psychiatric needs (when applicable),
including medication and frequency of monitoring by the psychiatrist.
Three records were reviewed for individualized treatment plans. One of three plans was
developed for the youth within thirty days of admission. The remaining two plans were
developed one and thirty-nine days late. All three individualized treatment plans were developed
on the Department’s Individualized Mental Health/Substance Abuse Treatment Plan form. All
three records showed the individualized treatment plan was signed by the mental health or
substance abuse clinical staff completing the plan. One of three plans was completed by a non-
licensed staff, and was reviewed and signed by the licensed supervisor, within ten days of
completion. One of three individualized treatment plans was signed by all treatment team
members who participated in development of the plan, the youth, and parent/guardian (as
allowed). The two remaining plans had all the required member signatures with the exception of
the parents/guardians, with no indication the program attempted to obtain the parent/guardian
signature. All three records were applicable to psychiatric services. All three individualized
treatment plans included psychiatric services, including psychotropic medication (when
applicable) and frequency of monitoring by the psychiatrist for all youth who received
psychotropic medication. All individualized treatment plan reviews were completed on the
Department’s Individualized Mental Health/Substance Abuse Treatment Plan Review
form. Fourteen treatment plan reviews were reviewed for the three records. Three of the reviews
were one day late. The program was completing plans on the same day each month and failed
to account for the months with thirty-one days. The facility administrator put corrective action in
place to ensure the plans are being completed within thirty days, and not monthly. One plan was
two days late and one plan was missing for the month of August. All three youth plans included
prescribed services which included individual, group, and family therapy. Two of three plans
included psychiatric service requirements. One plan was missing psychiatric service
requirements. Goals and objectives were individualized for each youth. A comparison of video
to the logbooks and sign-in sheets verifying the facilitation of groups was conducted and found
all groups were held for the required group time/length.
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3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
Three open and three closed youth records were reviewed for treatment and discharge
planning. All three open youth records showed each youth was assigned a treatment team upon
arrival to the program. A review of treatment team documentation showed the youth, facility
administrator, residential living unit representative, medical staff, mental health and substance
abuse staff, and parent/guardians were in attendance for treatment team reviews. Education
and vocational staff provided written input for the treatment team regarding the youth’s
progress.
Three closed youth records were reviewed for discharge planning. All three youth were
determined to be in need of substance abuse treatment and received individual, group, and/or
family counseling provided by a licensed qualified professional, or a non-licensed substance
abuse clinical staff in accordance with the youth’s initial or individualized substance abuse
treatment plan. All three youth who received mental health treatment had a properly executed
Authority for Evaluation and Treatment (AET) form. All three youth receiving substance abuse
treatment provided consent through a signed Youth Consent for Substance Abuse Treatment.
All three youth signed a Youth Consent for Release of Substance Abuse Treatment
Records form. Mental health treatment notes or substance abuse treatment notes were
documented on a form which contains all of the information in the required form, in all three
records reviewed. Mental health and substance abuse group therapy included individual
psychotherapy or one-to-one counseling between a youth with a diagnosed mental health
disorder and a mental health clinical staff professional in all three records reviewed.
Psychosocial skills training included therapeutic activities designed to address specific skill
deficits or maladaptive behaviors and promote skill development and improved functioning of
youth with mental disorders and addressed the specific symptoms or maladaptive behaviors
identified in the youth’s treatment plan in all three records reviewed. A review of progress notes
determined youth received services as stipulated on the treatment plan in all three records
reviewed. The discharge plan was documented on the Department’s Mental Health/Substance
Abuse Treatment Discharge Summary form in all three records reviewed. None of the reviewed
youth were released while on suicide alert. The Mental Health/Substance Abuse Treatment
Discharge Summary form documented the services needed for daily maintenance of the
positive improvement in behavioral, emotional, and social skills made by the youth during
treatment in all three records reviewed. A review of documentation reflected the discharge plan
was discussed with the youth, parent/guardian (when allowed), and juvenile probation officer
(JPO) during the exit conference, in all three records reviewed. A copy of the Mental
Health/Substance Abuse Treatment Discharge Summary was provided to the youth, JPO, and
to the parent/guardian (as allowed), in all three records.
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3.08 Specialized Treatment Services (Critical) Limited Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program provides individual, group, and family counseling at least seven times a week to
each youth as part of the individualized treatment plan. Therapeutic activities (psychosocial
skills training, psychoeducation, and supportive counseling) are provided by mental health
clinical staff six days a week, as the program only had one licensed mental health clinical staff
at the time of the annual compliance review. The one licensed staff is at the program six days a
week, and on call twenty-four hours a day, seven days a week, as needed. A trained and
qualified staff provides services based on their training and qualifications on the remaining day.
Youth with co-occurring substance abuse disorders receive substance abuse services. The
program arranges for a psychologist on staff to provide services. The counselor caseloads are
limited to sixteen, by contract, however, the program has one licensed mental health counselor
(LMHC) employed at this time, who is currently providing all services for the program. Group
therapy was over the limit of ten youth because only one LMHC was providing services. The
program’s LMHC is also providing substance abuse groups. The LMHC is qualified to provide
substance abuse education.
The program provides urinalysis drug testing, with positive tests followed by appropriate clinical
intervention and sanctions (including drug screening upon the youth’s initial intake into the
program). The program provides individual, group, and family therapy as part of each youth’s
treatment plan. Each youth receives individual, group, or family therapy at least five times a
week. Group therapy could not be limited to no more than fifteen participants because only one
LMHC was providing services. Each youth receives daily therapeutic activities such as
substance abuse education, relapse prevention, substance refusal skills, and coping skills.
Youth with co-occurring mental health disorders receive mental health treatment. The program
is licensed under Chapter 397, and a “qualified professional” is on-site at least five days a week.
A licensed psychiatrist provides psychiatric evaluations and medication management and
participates in treatment planning. Substance abuse clinical staff are on-site six days a week,
and available twenty-four hours a day, seven days a week. The program has vacancies for
licensed staff and has one staff performing all required duties. Counselor caseloads are limited
to no more than ten youth for substance abuse treatment services or sixteen youth for
substance abuse treatment overlay services.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.***
Psychiatric services are provided by a psychiatrist licensed under Chapter 458 with a clear and
active license in the State of Florida, expiring on January 31, 2024, and meeting the
requirements in Florida Administrative Code. The psychiatrist is available for emergency
consultation twenty-four hours a day, seven days a week. The psychiatrist or psychiatric
advanced practice registered nurse (APRN) providing psychiatric services briefs a
representative of the treatment team regarding the psychiatric status of each youth receiving
psychiatric services who is scheduled for treatment team review through face-to-face interaction
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or telephonic communication with the representative or treatment team. If a psychiatric APRN is
utilized, the position is a designee for clinical responsibilities only. The program’s two psychiatric
APRNs both hold a clear and active license in the State of Florida, with both licenses expiring
on July 31, 2024. Both psychiatric APRN’s education, experience, and certification/licensure is
in psychiatry/mental health, as stated on the Department of Health website. If the psychiatric
APRN provides psychiatric services, the psychiatric APRN has a Collaborative Practice
Protocol in place with the psychiatrist. There was a review of the Collaborative Practice Protocol
with the APRN to verify a copy is maintained on-site and specifies to be with the psychiatrist on-
site. A review of sign-in/out logs confirmed visits during the annual compliance review period
were conducted as required by the contract or agreement. A review of documentation confirmed
the psychiatrist actively participates in, manages, and supervises psychotropic medication
services in the program. A review of documentation showed duties were delegated to the
psychiatric APRN, the psychiatrist provided bi-weekly on-site supervision of the APRN’s
medication management services and was available to evaluate and monitor youth as needed,
and the psychiatrist was available to the APRN by telephone or by another communication
device when not physically available on the premises. The program’s contract does not include
tele-psychiatry.
An interview with the psychiatrist confirmed the psychiatrist completed evaluations on every
youth entering the program and medication management is provided monthly to youth on
psychotropic medications. The psychiatrist confirmed they are on-site every other week to
provide psychiatric services and psychotropic medication management. The psychiatrist meets
with the designated mental health clinician authority (DMHCA) every time they are on-site, and
is on-call twenty-four hours a day, seven days a week if needed by the medical staff to discuss
the youth needs, psychiatric services, and any important medical issues/concerns, and provides
face-to-face communication with the treatment team. The psychiatrist had no concerns
regarding mental health or substance abuse services at the program. An interview with the
DMHCA confirmed they meet with the psychiatrist at least monthly to discuss youth receiving
psychiatric services.
Three youth records were reviewed for psychiatric services. All three youth were admitted to the
program on psychotropic medications and were referred for a psychiatric interview as part of the
intake process. All three youth received a psychiatric interview within fourteen days of
admission as required. Each of the Initial Diagnostic Psychiatric Interviews included the youth’s
medical, mental health, and substance abuse history, Mental Status Examination, Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition diagnosis, which was consistent with
the treatment plan, and treatment recommendations. Each of the three Initial Diagnostic
Psychiatric Interviews indicated the youth needed to be prescribed medications and an
explanation of the need for psychotropic medications related to the youth’s diagnosis, target
symptoms, initial treatment goals, potential side effects, risks and health benefits of taking the
medication, and frequency of medication monitoring/management was also included. The Initial
Diagnostic Psychiatric Interview was documented on a form developed by the program which
contains all the information included on the Department’s Clinical Psychotropic Progress Note
(CPPN) and the CPPN clearly identified the form as the Initial Psychiatric Assessment, in all
three records. When the psychiatric evaluation resulted in the prescription of psychotropic
medication or changes to the youth’s existing psychotropic medication, page three of the CPPN
was completed, regardless of the form used to document the evaluation. When psychotropic
medications were prescribed/dispensed/administered by the psychiatrist or psychiatric APRN,
identifying data, diagnosis, target symptoms of each medication, evaluation, and description of
effect of prescribed medication on target symptoms were documented in all four applicable
records. Prescribed psychotropic medication, including the name, dosage and quantity of the
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medication, normal dosage range, ordered dosage, frequency and route of administration,
reasons for changes in medication and/or dosage were also documented in all three records
reviewed. Side effects, adherence to the medication regimen, heigh, weight, blood pressure,
most recent serum drug levels or laboratory findings, as appropriate, telephone contact with the
youth’s parent/guardian to discuss medication, signature of the psychiatrist or psychiatric APRN,
date of signature, and Tardive Dyskinesia monitoring were also recorded in all three records.
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 policy and procedures regarding suicide prevention services to include a
written plan detailing suicide prevention procedures. The plan includes identification and
assessment of youth at-risk of suicide, six hours of staff training annually, suicide precautions,
levels of supervision including one-to-one supervision, constant supervision, and close
supervision, drills for all staff on each shift, referrals, communication, notification,
documentation, immediate staff response, and a review process. The review process for suicide
attempts and mortality includes the circumstances surrounding the event, facility procedures
relevant to the incident, relevant training received by staff, pertinent medical and mental health
services involving the victim, possible precipitating factors, and recommendations, if any, for
changes in policy, training, physical plant, medical or mental health services, and/or operation
procedures. The Suicide Prevention Plan is reviewed annually and was last reviewed January 4,
2023, by the designated mental health clinician authority (DMHCA), psychiatrist, and facility
administrator (FA).
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.
Three youth records were reviewed for suicide prevention services. One youth was applicable
for having three separate instances of precautionary observation (PO). All three instances were
reviewed. It is program policy to have all youth placed on PO during their admission screenings,
until they are seen by mental health staff. The youth was determined to be at risk during the
admission screening as required by policy, and twice through staff observation. For all three
instances, the youth had an Assessment of Suicide Risk (ASR) completed on the Department’s
ASR form within twenty-four hours of screening/concerns. The youth was placed on constant
supervision in all three instances. The program does not require the parent or juvenile probation
officer (JPO) to be notified if the youth is placed on PO during their admission screening and
then cleared by the ASR; therefore, parent/guardian notification was applicable for two of the
three instances of PO. There was no indication the parent/guardian was notified of the youth’s
potential suicide risk on the ASR in either of the two applicable instances. There was
documentation the JPO was notified in both instances. Mental health staff provided supportive
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services in all three instances. A follow-up ASR was completed prior to removal of the youth
from PO in two applicable instances. Both follow-up ASRs were documented on the
Department’s Follow-Up ASR form. The youth was maintained on suicide precautions and
constant supervision until the initial ASR or Follow-Up ASR indicated suicide precautions could
be discontinued in all three instances. When the youth’s initial ASR or Follow-Up ASR indicated
suicide precautions could be discontinued, the youth was stepped down to close supervision
prior to transition to normal routine and standard supervision in all three instances. Close
supervision was maintained until it was determined no longer necessary by the designated
mental health clinician authority (DMHCA) or licensed mental health professional (LMHP) in all
three instances reviewed. Discontinuation of close supervision was documented in the youth’s
mental health/substance abuse (MH/SA) record by a mental health clinical staff and there was
documentation of a conference held by the facility administrator (FA) and LMHP to reduce level
of supervision in all three instances. Documentation confirmed the actual date/time the licensed
mental health professional conferred with the FA on the ASR in the date/time sections. None of
the instances found the youth to be in crisis. An alert in the Department’s Juvenile Justice
Information System (JJIS) was entered in one of three instances. The one applicable alert was
accurately closed following the recommendations of the ASR. The program had an internal alert
system where the suicide alerts were documented for all three instances. There was no
evidence in the facility logbook, but there was documentation on the suicide risk assessment
indicating administration or supervisory staff provided instructions related to the suicide risk
assessment findings and suicide precaution decisions. While on PO, the “at-risk” youth was
allowed to participate in select activities with other youth in designated safe housing/observation
areas of the facility in all three instances.
There were no youth who had been placed on PO in the last thirty days, as such, no video was
able to be viewed for PO.
3.12 Suicide Precaution Observation Logs (Critical) Limited 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.
Three youth records were reviewed for Suicide Precaution Observation Logs. One of the three
youth records showed three separate instances of suicide precaution. All three instances were
reviewed. The Suicide Precaution Observation Logs were maintained for two of the three
instances, for the duration the youth was suicide precaution. In the remaining instance, the
youth was on precautionary observation from May 27 through May 31, 2023. The precautionary
observation (PO) logs were maintained for May 27through 28; however, no other logs were
found for the remaining days of May 29 through 31. the appropriate level of supervision and
observations of the youth’s behavior documented in real time and not exceeding thirty-minute
intervals in all three instances. In the PO logs available for review, notification of the facility
administrator (FA) or designee and mental health clinical staff was documented on the Suicide
Precaution Observation Log. All the reviewed PO logs were signed by each shift supervisor,
reviewed and signed by mental health clinical staff, and documented safe housing
requirements.
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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.
Five pre-service and five in-service staff training records were reviewed for suicide prevention
training. All ten staff completed two hours of training in the Department’s Learning Management
System (SkillPro) and four hours of instructor-led suicide prevention training. Training included
mock suicide drills held no less than quarterly on each shift, for all staff who come in contact
with youth including kitchen and maintenance staff. The program has three suicide response
kits which include a knife-for-life, wire cutters, and needle nose pliers. Suicide response kits are
co-located with first-aid kits; located in master control, on the medical cart, and in the laundry
room. All mock mental health drills in response to a suicide attempt and/or incident of serious
self-injury were simulated, and no youth were used in the simulations. The program provided
semi-annual training on emergency response procedures which included mock training in
emergency response to a suicide attempt or incident of serious self-inflicted injury, as confirmed
by a review of drills and an interview with the facility administrator (FA). Staff who were not
present during a quarterly drill had the opportunity to review each drill scenario and procedures
in an effort to understand the process and receive the necessary training to respond to an
incident of a suicide attempt or incident of serious self-inflicted injury in the facility.
Five staff were interviewed, and all indicated they are required to notify mental health and
provide constant sight and sound of a youth who expresses suicidal thoughts. When asked
where suicide response kits are located in the facility, four staff stated they are in maser control,
one stated they are in medical, two stated they are located on the dorm, one stated they are
located in the laundry room, and one staff indicated they did not know where the kits were
located. The FA was informed one of the staff did not know the location of the suicide response
kits, and the FA will be completing an in-service training on suicide response kits and drills for
all staff. Five staff indicated medical emergency drills and suicide drills are conducted monthly
on their shift.
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 policy and procedures regarding mental health crisis intervention services
which includes written crisis intervention procedures. The crisis intervention plan includes a
notification and alert system, a means of referral including youth self-referral, communication,
supervision, documentation, and review.
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3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a written crisis intervention plan which includes a process for implementation
of a Crisis Assessment form. The form includes the reason for the assessment, Mental Status
Examination and interview, determination of danger to self and/or others, initial clinical
impressions, supervision, treatment, follow-up recommendations, and notification to the
parent/guardian of follow-up treatment. The program had no youth applicable for Crisis
Assessment during the annual compliance review period.
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, transport for emergency mental
health evaluation and treatment under Baker Act, transport for emergency substance abuse
assessment and treatment under Marchman Act, documentation, training, and review.
3.17 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
Three youth records were reviewed for Baker and Marchman Acts. None of the records were
applicable, as such, the program provided three additional records for review. When a youth
was determined to be in need of emergency care, the staff entered a mental health alert, placed
the youth on precautionary observation (PO), and referred the youth for placement under Baker
Act in all three records. The notification was made by the program’s licensed mental health
professional (LMHP). The youth was placed on one-to-one supervision, with mental health
involvement, at the time of discovery in all three records. All three youth were taken out of the
program and transported by law enforcement, which was authorized by the program’s facility
administrator (FA). Upon return to the program from a Baker Act, the youth was placed on
constant supervision in all three records. A mental health referral was completed indicating a
Mental Status Examination (MSE) to be conducted for all three records. An Assessment of
Suicide Risk was completed by a LMHP. All three youth were maintained on a minimum of
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constant supervision until properly transitioned to a lower level of supervision. The youth’s
supervision level was not lowered until an appropriate assessment was conducted and the
LMHP conferred with the FA or designee in all three records.
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.
Three youth records were reviewed, and documentation showed all youth had a safety plan
which included warning signs, the youth’s baseline behaviors, crisis recognition, intervention
strategies preferred by the youth, and a debriefing process. All three records included jointly
developed coping strategies. The safety plan was completed within fourteen days of admission
in all three records reviewed. One of the records indicated the plan was jointly prepared with the
youth parent/guardian and clinical staff. One of the records was missing any indication of
parent/guardian participation but included all other applicable parties. Two of three safety plans
incorporated recommendations from previous or current clinical assessments or screening
instruments and trauma responsive practices. One plan did not include recommendations from
previous assessments and the other plan was missing the page which included information
regarding previous assessments or screening instruments. The plans were reviewed and
updated as necessary following any significant behavioral or mental health event identified by
the youth’s intervention and treatment team. A review of sixteen safety plan updates showed
one plan was nine days late. The remaining plans were all updated every thirty days. Safety
plans are reviewed by staff who have contact with the youth. The plans are maintained in
master control.
Five youth were interviewed, and all confirmed they contributed to their safety plan. Five staff
were interviewed, and confirmed the safety plans are located in master control and they can
access them when needed. The facility administrator confirmed plans must be updated every
thirty days or following any significant behavioral or mental health event identified by the youth’s
intervention and treatment team.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program’s designated health authority (DHA) is a licensed physician who holds an
unrestricted license and meets all requirements for independent and unsupervised practice in
the State of Florida. The DHA license expires on January 31, 2024. The DHA’s specialty training
is in family practice with experience in adolescent health. The DHA does not have any
disciplinary cases or public health complaints on record. According to the contract, the DHA is
required to be on-site weekly for a minimum of two hours. A review of the sign-in sheets for the
annual compliance review period indicated the DHA was on-site, as required. If the DHA has a
scheduled absence, the program has an agreement with another licensed physician to provide
medical care to the youth. The back-up licensed physician holds a clear and active unrestricted
license, which expires on January 31, 2024, and meets all requirements for independent and
unsupervised practice in the State of Florida. The back-up physician did not provide services to
the youth during the annual compliance review period. The DHA reviewed facility procedures as
documented by signature and date. There was no inclusion of tele-medicine in the facility’s
contract. The DHA was interviewed, and their responsibilities include completing comprehensive
physical assessments, monitoring chronic conditions, youth sick call, and policy and procedure
development. The DHA performs any on-site services needed by the program weekly for two
hours and is available by phone.
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 three registered nurses (RNs), one full-time and two part-time, and one of the
RNs serves as the health services administrator (HSA). A review of each RN’s license
credentials reflected each of the nurses have a clear and active license, in the State of Florida,
according to the Florida Department of Health Medical Quality Assurance website. Two of the
licenses are valid through April 2024, and one valid through April 2025. In addition, each of the
RNs have current cardiopulmonary resuscitation (CPR) certifications. The required on-site hours
according to the contract are seven days a week for a total of sixty-six hours. The nursing staff
has been in compliance with the contractual requirements throughout the annual compliance
review period.
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4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has a policy and procedures for all health-related protocols utilized at the program.
The designated health authority (DHA) and facility administrator (FA) signed and dated all
treatment protocols. The DHA, and FA reviewed and signed protocols and facility operating
procedures (FOPs) on January 4, and May 24, 2023. FOPs and protocols related to psychiatric
services and psychotropic medication management are developed and reviewed by the
program’s psychiatrist. The psychiatrist reviewed and signed the psychiatric protocols on
January 11, 2023. The nursing protocols were signed by the nursing staff on January 4, 2023.
There were no new policies or changes in policy made during the annual compliance review
period. An annual review of all FOPs and protocols confirmed they were signed by the
respective individuals from each discipline on January 4, 2023, signifying their understanding of
the FOPs and any new health-related Department policies. All newly hired medical staff
received a comprehensive clinical orientation to the Department’s healthcare policies and
procedures conducted by the registered nurse (RN). The DHA had written and authorized
approval of treatment protocols and standing procedures which were not delegated to any other
person.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a policy and procedures ensuring the completion of the Authority for
Evaluation and Treatment (AET) authorizing treatment of youth in the program’s custody. A
review of three youth Individual Healthcare Records (IHCRs) found three were applicable for the
AET forms. Three of the youth had a parent/guardian signed AET form filed in the record with
the word “Copy” legibly stamped on it. The AET is valid for as long as the youth is in the
program or until the youth’s eighteenth birthday. None of the three applicable youth were
eighteen years of age or older and one of the youth was in the care of the Department of
Children and Families (DCF). An interview with the registered nurse confirmed the youth arrive
to the program with a signed AET by the parent/guardian and if the youth is in DCF care then a
court order is obtained.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures to ensure the parent/guardian is notified of any
changes in the youth’s condition and to document informed consent for youth healthcare. A
review of three youth Individual Healthcare Records (IHCRs) found all were applicable for
parental notifications for over-the-counter (OTC) medications beyond those covered by the
Authority for Evaluation and Treatment. Two of the applicable IHCRs included documentation of
attempted contact to the parent/guardian in the progress notes when a new medication was
ordered, one youth was not on any medications. Three applicable IHCRs contained written
notifications documented on the Department’s Parental Notification of Health-Related Care:
General or Parental Notification of Health-Related Care: Medications forms. Two of the youth
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were taking prescribed psychotropic medications. Two of the youth were applicable for a new
psychotropic medication, change in dosage, or discontinuation of medication which was
documented on page three of the Department’s Clinical Psychotropic Progress Note (CPPN)
form and notification to the parent/guardian was witnessed as required. One youth was in the
care of the Department of Children and Families (DCF). In all three IHCRs, vaccinations were
verified within thirty days of each youth’s admission. An interview with the registered nurse (RN)
confirmed parental notifications are made verbally and are followed by a written notification for
all medications and treatments. Immunization records are obtained from Florida Shots within
thirty days of admission.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a policy and procedures regarding youth healthcare admission screening and
rescreening each time the physical custody of the youth changes. Three youth Individual
Healthcare Records (IHCR) were reviewed for a Facility Entry Physical Health Screening
(FEPHS) form. All three FEPHS forms were completed by the registered nurse (RN) on the date
of each youth’s admission. None of the youth were out of the physical custody of the
Department. The interview with the RN confirmed the RNs complete the FEHPS forms upon
arrival to the program.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy and procedures ensuring all youth admitted to the program are
provided an orientation to healthcare services. A review of three youth Individual Healthcare
Records (IHCRs) confirmed all youth were provided a general care orientation upon admission
to the program. The Health Education form in all five IHCRs included access to medical care,
sick call, what constitutes an “emergency,” medication process, right to refuse care, and what to
do in the case of a sexual assault or attempted sexual assault, the role of non-disciplinary health
care providers, and Standard Universal Precautions, which were discussed with the youth as
evidenced by their signature.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a policy and procedures to notify the designated health authority (DHA) or
designee, by telephone or verbally, of each youth’s arrival at the program and provide
immediate notification when any youth admitted to the program require emergency care. The
program’s practice is to notify the DHA of all youth admissions, including youth with chronic
conditions, medical concerns, or any youth admitted on psychotropic medications. Three youth
Individual Healthcare Records (IHCRs) were reviewed. One of the youth were admitted with a
known or suspected chronic condition or required a referral to the DHA. None of the youth were
identified as in need of an emergency response upon admission. All records documented the
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DHA notification in each youth’s Chronological Progress Notes and the Chronic Conditions Log
was updated after the notification. Two youth were applicable for taking psychotropic medication
upon admission, and documented notification to the psychiatrist. According to an interview with
the registered nurse (RN), the DHA is notified of all new admissions and any chronic conditions,
on the day of admission, and all youth are added to the DHA appointment list and medical
tracker.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a policy and procedures ensuring the Department’s Health-Related History
(HRH) form is completed prior to the Comprehensive Physical Assessment (CPA) and
healthcare needs are identified. A review of three youth Individual Healthcare Records (IHCRs)
found each HRH was completed on the day of the admission. All three IHCRs indicated the
HRH form was completed prior to the CPA as indicated by the date and signatures. In all
IHCRs, the designated health authority (DHA) reviewed the HRH form as evidenced by a
checkbox on the CPA and a focused note in the admission documentation. An interview with the
registered nurse (RN) confirmed a new HRH is completed on the day of admission for all new
youth by the RN.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a policy and procedures ensuring the acute and chronic healthcare needs of
the youth are addressed by completing a Comprehensive Physical Assessment (CPA) within
seven days of youth admission. A review of three Individual Healthcare Records (IHCRs)
confirmed the program utilized the Department’s CPA form. All CPAs were completed by the
designated health authority (DHA) within seven days of each youth’s admission to the program.
All three had the youth’s Medical Grade documented on the CPA. The program completes a
new CPA for all youth, no prior CPAs were utilized. All sections of the CPAs were completed in
full utilizing “O” or “X” markings. All three youth refused the genital exam which was
documented as “youth refused” on each CPA. All youth signed a refusal form which reflected
the refused portion on each CPA. The CPA in all three records included documentation of the
most recent verified Tuberculosis Skin Test (TST) which was administered within the last year to
determine exposure to tuberculosis (TB). The results of the TST were documented on each
youth’s CPA and matched the documentation on the Department’s Infectious and
Communicable Disease (ICD) forms. The Department’s Problem List was updated for each
youth, when applicable. An interview with the registered nurse (RN) confirmed a new CPA is
completed within seven days of arrival and renewed yearly.
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4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures to ensure all youth admitted to the program are
screened, evaluated, and treated, if applicable, for sexually transmitted infections (STIs) and
human immunodeficiency virus (HIV). The designated health authority (DHA) determines, based
on the youth’s risk factors, screening tool, and evaluation, whether to order testing for STIs. A
review of three Individual Healthcare Records (IHCRs) found all youth were clinically screened
and evaluated for STIs on the date of admission. One IHCR was applicable for further
evaluation and referred to the DHA, which was documented on the Department’s STI form. All
testing, screening, clinical evaluations, and diagnoses were documented on the Department’s
Infectious and Communicable Diseases (ICD) forms, excluding the HIV results, and were filed in
the lab section of the IHCR. None of the youth were out of the Department’s physical custody;
therefore, a rescreening was not applicable. All three youth were offered pre/post-test
counseling, testing, and referral for treatment for HIV. Two of three youth consented to receive
an HIV test, which was documented in each IHCR. The HIV results were filed confidentially in a
sealed envelope marked “Confidential” in each applicable record. The program’s policy ensures
the youth’s HIV test results are only disclosed to the youth’s legally authorized representative,
healthcare providers during treatment, the Department of Health for purposes of reporting,
health facility staff committees conducting facility monitoring, medical personnel who have been
subject to significant exposure, and healthcare facility personnel or agents for healthcare
providers who have a need to know during patient care. Pre and post-test counseling services
are provided by the DHA. Five youth were interviewed all indicated they can request testing. An
interview with the registered nurse (RN) confirmed all youth are screened at admission and
results are provided to the DHA. STI results are filed in the lab section of each youth’s record.
Testing documentation is entered on ICD forms. Results of HIV testing are placed in a sealed
envelope marked “Confidential” and placed under the lab section of the youth’s record.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a policy and procedures addressing the program’s sick call process. None of
the youth presented with a similar sick call complaint three or more times within a two-week
period. The three youth had a sick call request addressed by the registered nurse (RN). Each of
the Sick Call Request forms were filed in each youth’s Individual Healthcare Record (IHCR) in
reverse chronological order. None of the youth were in restricted housing of any kind. The sick
call request forms and progress notes were documented in accordance with Florida
Administrative Code, including vital signs, treatment, education, and follow-up plans. Each of
the sick call events were documented on the Sick Call Index and on the program’s Sick Call
Referral Log. All the dates listed on the Sick Call Index corresponded to the completed Sick Call
Request forms located in each youth’s IHCR. Sick call occurs seven days a week twice a day.
Sick call hours are posted on the medical office door and common area. Sick call forms are
located on the living units and the common area. Only licensed nurses conduct sick call, and
when a licensed nurse is not on-site the shift supervisor is to review all requests as soon as
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possible and within four hours of the request being submitted. An exam table and equipment are
used to perform sick call. Five interviewed staff advised the nurse reviews and conducts sick
call. Five youth were interviewed and five advised they are seen within one day. An interview
with the nurse advised youth must complete a Sick Call Request form then place it inside a
locked "sick call" box. The sick call boxes are checked twice daily by medical personnel.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a policy and procedures to ensure the youth have access to episodic and first-
aid care. A review of three youth Individual Healthcare Records (IHCRs) found two youth
required on-site episodic care. In both IHCR’s, the on-site care was provided by a licensed
healthcare staff and documented including the problem-oriented subjective, objective,
assessment, and plan (SOAP) elements. The program has a total of nine first-aid kits located in
designated areas throughout the program. The kits are in the laundry room, kitchen, master
control, school office, multi-purpose room, classroom one, classroom two, and two for transport.
The program has a process for ensuring contents of the first-aid kits are maintained and stored
in accordance with guidelines to prevent expiration or deterioration. An observation of three first-
aid kits confirmed the kits were fully stocked with designated health authority (DHA) approved
contents. The nurse monitors the first-aid kits weekly and checks for expired contents, which is
documented on the first-aid kits logs. The program has one automated external defibrillator
(AED) located in master control. The AED procedures are located with the AED. The AED
battery and pads are checked by the registered nurse (RN) once a month. Documentation
confirmed the RN monitored the AEDs as required. The RN checked the expiration dates of the
AED and conducted a self-test in front of the annual compliance review team, and no issues
were noted. The battery of the AED was last changed in January 2023 and expire in December
2027. The AED pads were changed November 2022 and expire in April 2024. A review of the
emergency drills confirmed the program conducted an emergency drill including
cardiopulmonary resuscitation (CPR)/AED annually, and other announced or unannounced
emergency medical drills at least quarterly on each shift. The emergency medical drills
simulated an episodic care event which called for immediate first-aid, administration of CPR
techniques, and the initiation of emergency procedures to follow when a life-threatening
emergency does occur. The program ensured all staff with direct youth contact had the
opportunity to participate in at least one man-down emergency drill annually. The program had a
list of emergency numbers which were inaccessible to youth. The emergency numbers are
posted in master control. A review of ten training records confirmed all staff were trained in
episodic, first-aid, and emergency care, and the administration of the epinephrine auto-injector.
The program has a facility operating procedure (FOP) regarding Narcan. The policy states
Naloxone (Narcan) nasal spray is to be given right away and does not take the place of
emergency medical care. Get emergency medical help right away after giving the first dose of
Naloxone nasal spray, even if the person wakes up. Naloxone nasal spray is safe and effective
in children for known or suspected opioid overdose. Naloxone nasal spray is used to temporarily
reverse the effects of opioid medicines. The medicine in Naloxone has no effect in people who
are not taking opioid medicines. Training must be conducted with all staff at new hire and
annually thereafter by the RN as directed by the DHA. Narcan is stored in medical and
inventoried along with other medication. All staff are trained on the use of Narcan. Five
interviewed staff confirmed they could call 9-1-1 in the event of an emergency. Five youth were
interviewed, and confirmed they can see a doctor if needed. The RN advised episodic care is
provided by the RN. A note is placed in the youth record and a twenty-four hour follow up is
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conducted by the RN. If episodic care is provided by non-healthcare staff, the Department’s
Report of On-Site Health Care by Non-Health Care Staff form is used and followed-up within
twenty-four hours by the RN.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a policy and procedures to ensure for timely referrals and coordination of
medical services to an off-site healthcare provider. A review of three Individual Healthcare
Records (IHCRs) found two were applicable for off-site care. In both applicable IHCRs, there
was an indication the youth required off-site first-aid or emergency care, which was documented
on the Episodic Care Log. The Department’s Summary of Off-Site Care Consultation Report
form was utilized and filed in each youth’s IHCR. Both IHCRs had documentation of the
parent/guardian notification efforts. Both youth were applicable for discharge documentation,
and each had the applicable documents filed in the IHCR. The DHA reviewed and signed all off-
site care findings, instructions, and information in both IHCRs. Both youth required follow-up
testing, referrals, or appointments. There was evidence indicating the referrals were tracked and
youth received appropriate follow-up care as documented in each IHCR. The registered nurse
(RN) confirmed the youth are tracked utilizing the episodic log and calendar.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a policy and procedures to ensure any youth admitted to the program who
have chronic conditions receive regularly scheduled evaluations and as-needed follow-up care.
A review of three youth Individual Healthcare Records (IHCRs) found one was identified on the
Department’s Facility Entry Physical Health Screening (FEPHS) form with a chronic condition at
admission. None of the youth were identified as having a communicable disease. None of the
youth were taking prescribed medication on an on-going basis. One youth was undergoing
treatment for a physical health condition. One youth was classified with a Medical Grade of two
to four, was placed on the program’s Chronic Illness List and received periodic evaluations at
least every ninety days. None of the youth were applicable for taking anti-tuberculosis
medications. None of the youth had an evaluation conducted off-site. There was no evidence of
any lapses in care or missed periodic evaluations. Periodic evaluations were conducted prior to
renewing any prescription medication which expired. The Department’s Problem List was
updated for each youth. An interview with the facility administrator (FA) confirmed meetings with
healthcare staff are held a minimum of weekly. Any issues are relayed daily between the FA
and healthcare staff. The designated health authority (DHA) interview confirmed a log is kept of
youth with chronic conditions and the date seen, to schedule the next follow-up. The nurse
confirmed all youth with chronic conditions are seen every ninety days. It is monitored by the
registered nurse on the medical tracker.
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4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program has a policy and procedures to ensure the accurate and safe administration of
youth medications. A review of three youth Facility Entry Physical Health Screening (FEPHS)
forms found two youth were taking medication at the time of admission, and each received an
Initial Diagnostic Psychiatric Interview with the psychiatrist within fourteen days of admission.
Each of the youth medications were verified prior to the youth being admitted into the program,
and the prescription notification was documented in each youth’s Chronological Progress Notes.
The designated health authority (DHA) and, when applicable, the psychiatrist was contacted to
obtain an order to resume the specified medications prescribed prior to admission for each
youth. A review of the three youth IHCRs found two youth were applicable for current
medications to be continued, discontinued, changed, or for new medications to be ordered.
Each of the two applicable youth IHCRs included a Practitioner Order form indicating the DHA,
or psychiatrist, ordered the prescription for the youth. None of the youth were in restricted
housing of any kind. Two of the youth were applicable for over-the-counter (OTC) medications,
which were administered according to approved protocols. The Department Medication
Administration Record (MAR) was used to document all medications and treatments for all
reviewed IHCRs. The MAR clearly indicated medication start and stop dates. In all applicable
IHCRs, the staff initialed each administered medication entry. There were no undocumented
explanations for lapses or errors in medication administration for any of the reviewed IHCRs.
The registered nurse (RN) documented side-effects monitoring weekly on each MAR for both
applicable IHCRs. Each MAR contained all required elements. Each youth initialed each
provided medication entry. There were no indications of lapses or errors in medication
administration. One youth had refusals, which were clearly documented on the MAR. None of
the youth were applicable for psychotropic medication subsequent to admission. None of the
youth required parenteral medication. The DHA and/or psychiatrist were notified upon each
applicable youth’s admission. There were no standing orders for psychotropic medications,
emergency treatment orders for psychotropic medication, or any pro re nata (PRN) orders for
psychotropic medications. A medication pass was observed. The youth were escorted by the
youth care worker and approached the nurse individually. The medical provider identified
themself and confirmed the reason youth was present. The medical provider prepared the
medication and verified each youth’s allergies and alert status. The medical provider and youth
initialed each MAR, and the medical provider observed each youth to ensure the medication
was swallowed. The Six Rights of Medication Delivery/Administration was maintained. All OTC
medication administrations were documented, and no prescription medications were pre-poured
from their original packaging and placed in another container for subsequent administration.
Non-healthcare staff were trained in medication provision, however, none provided medications
to youth throughout the annual compliance review period. Five youth were interviewed, and
confirmed a nurse provides medication. All could explain the process. Five staff were
interviewed and advised a nurse provides the medication. An interview with the nurse confirmed
the nurse provides mediation three times a day. All youth medications are reviewed upon
admission and listed on the prescription medication form. All medications must have an intact
pharmacy label with the youth’s name and pertinent information.
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4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a policy and procedures to ensure medical equipment classified as sharps
and medications are secure and inventoried utilizing a routine perpetual inventory. A review of
the medical equipment classified as sharps confirmed the items were securely stored and
inventoried utilizing a routine perpetual inventory with a descending count. All medications were
identified and secured in a locked medication cart designated for storage of medications. The
medication cart was secured, clean, and organized with stock items separate from youth-
specific medications. The program had no controlled medication on-site during the annual
compliance review week. All medications were stored in a separate, secured area, inaccessible
to the youth. Narcotics and other controlled medications are stored behind two locks,
refrigerated medication was stored in a secured refrigerator only used for medication. The
program has a process for the destruction and disposal of medications. Medications in a bubble
pack are sent back to the pharmacy. Controlled substances are disposed of in a pharmacy
approved liquid when the consultant pharmacist is on-site along with two nurses. The program
conducts a perpetual and weekly inventory of all sharps and stock over-the-counter (OTC)
medications which did not indicate any discrepancies. The nursing staff maintain a shift-to-shift
inventory of all controlled substances, in the event a youth is prescribed a controlled substance
and documented this on the youth’s Individualized Controlled Medication Inventory Record. The
number of pills, tablets, or dosages remaining were documented on the youth’s Individualized
Controlled Medication Inventory Record after each administered dosage when controlled
medications were on-site.
Seven supervisory level staff were trained in the delivery and oversight of medication self-
administration. The training was provided by a registered nurse (RN). During the annual
compliance review week observations were conducted of inventory counts of three OTC
medications and three sharps. All inventories were correct with no discrepancies. The registered
nurse (RN) reported if there is a daily controlled substance inventory discrepancy, the health
services administrator (HSA), designated health authority (DHA), and facility administrator (FA)
shall be notified immediately. The program shall report and investigate unexplained losses of
controlled substances and report as required by Florida Administrative Code. The interview with
the nurse confirmed all controlled medications are kept in the medication cart and are double
locked.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a policy and procedures regarding Infection Control and an Exposure Control
Plan. The Infection Control and Exposure Control Plan is reviewed and signed annually and was
reviewed and signed by the designated health authority on January 11, 2023, and the facility
administrator (FA) on January 4, 2023. The program’s infection control procedures include
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prevention, containment, treatment, and reporting requirements related to infectious diseases,
according to Occupational Safety and Health Administration (OSHA) federal regulations and the
Centers for Disease Control and Prevention (CDC) guidelines. The plan addresses common
infectious diseases of childhood, self-limiting, episodic contagious illnesses, viral and bacterial
infectious diseases, tuberculosis, Hepatitis A, B, and C, human immunodeficiency virus (HIV)
infectious diseases caused by blood-borne pathogens, other outbreaks or epidemics caused by
any other infectious agent, outbreaks of lice or scabies, Methicillin-Resistant Staphylococcus
Aureus (MRSA) and other antibiotic resistant micro-organisms, food-borne illnesses, bio-
terrorist agents, and chemical exposures. The program’s Exposure Control and Infection Control
Plan is written in accordance with the OSHA standards. The program offers Hepatitis B
immunizations to staff. Staff have access to personal protective equipment. The program has a
comprehensive process for needle stick post-exposure evaluation. Any exposure incident will be
immediately reported to the FA through the chain of command. Private sector employees under
contract with the Department will complete the Log of Work-related Injuries and Illnesses
(OSHA 300) or their private insurance carrier’s first report of injury. Subsequently, the exposed
individual and their supervisor will evaluate the situation and provide suggested preventative
measures and corrective actions. The program has a separate file containing all documents of
youth and staff who have experienced a program or occupational exposure. The program’s
Exposure Control Plan was written in accordance with OSHA standards and is in the
breakroom, master control, and the medical department. There were no instances where the
program had three or more cases of any reportable infectious diseases which needed to be
reported to the local county health department or the CDC, and no instances involving the
quarantining of at least ten percent of the total population. An interview with the FA confirmed
the program maintains an Exposure Control Plan, and it is located in master control and the
medical office. The exposure and infection control procedures shall follow guidelines and
recommendation of the CDC. An interview with the nurse confirmed exposure control training is
provided by the registered nurse.
4.19 Prenatal Care/Education Satisfactory Compliance
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
The program had one pregnant youth since the last annual compliance review. There was
documentation prenatal physical and psychological care began immediately upon determination
the youth was pregnant, continued until discharge/transfer, and through post-partum. There was
evidence of the designated health authority (DHA) providing routine, focused medical
evaluations of the youth’s pregnancy every thirty days, or sooner if ordered. The youth was
placed on the internal alert system for sleeping arrangements, vital nutrition, and health
awareness for staff. The youth did not have documented complaints of issues. The youth
received nutritious food in appropriate quantities and was monitored routinely concerning the
youth’s nutrition and weight status. There was documentation of the youth receiving prenatal
and/or postnatal care at recommended intervals. The youth were provided education related to
alcohol and drug use, smoking, nutrition, sexually transmitted infections (STIs), contraception,
prenatal care, birthing process, post-partum care, basic baby care, child/infant development,
and parenting skills. All the education was documented in the Individual Healthcare Record
(IHCR) on the Health Education form. A review of five in-service training records found a
licensed nurse provided education on girl’s healthcare and prenatal care to staff. The registered
nurse (RN) indicated pregnant youth are seen monthly by the DHA. A local hospital provides
prenatal care, and the program provides monthly prenatal education. Pregnant youth are seen
daily at the medication cart and weekly in medical to assess vitals. Pregnant youth receive
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education on signs of miscarriage, prenatal exams, diet/nutrition, bodily changes through each
phase, safe exercises, activities to avoid, stress management, gestational diabetes,
contractions versus Braxton Hicks, family planning, and post-pregnancy birth control.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures in place requiring all program staff to maintain active
supervision of constructive activities, closely observing behavior of youth and changes in
behavior, and consistently applying the program’s behavior management system (BMS). The
policy states all program staff should always account for the whereabouts of youth under their
supervision. Informal interviews with three random staff revealed each staff knew how many
youth they were supervising. The program’s staff-to-youth ratio was observed and was found
compliant with contract requirements. The program’s contract requires staff-to-youth ratios of
one-to-eight during daytime activities, one-to-twelve during the nighttime hours, and one staff to
five youth during off-campus trips. The program has a daily schedule available to youth which is
posted in the youth dormitory. During observations, twenty-four of twenty-five youth were
engaged in the full schedule of activities. One youth who had graduated the education program
was not involved in classroom activities. A review of the video showed staff observed youth
while they are in their sleeping rooms.
During the four days of the annual compliance review week, staff were observed actively
supervising youth during school, recreation, meals, breaks, medication pass, and line
movements. Each of the four days, staff were observed to be in the required ratio, interacting
positively with you, and positioned to maintain constant sight and sound supervision. Youth
were observed during line movement with their hands behind their backs. During meals one
youth was observed at each table. Five interviewed staff revealed if a youth count cannot be
reconciled master control is contacted, an emergency count is conducted, and all movement is
stopped. A search for the youth is conducted until the youth is found.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program has a detailed written description of the collaborative behavior management
system (BMS) which was created by all appropriate parties at the start of the contract. The
written description is posted in areas accessible to youth and provided in the youth handbook to
allow easy access for youth, including rules governing conduct and positive and negative
consequences for behavior including while in the classroom. The school does not have an
agreement with the program relating to the BMS; however, documentation reflected the school
does log youth’s behavior while in the classroom. Three staff position descriptions were
reviewed, and each contained implementation of the BMS. Three staff records were reviewed,
and confirmed each staff received training the int program’s BMS. Five youth case management
records were reviewed and confirmed each youth’s orientation included a review of the
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program’s BMS. A tour of the program found the BMS was posted on the youth dorms and the
main hallway near the common area. The BMS is documented in the youth handbook, to
include the rules governing conduct, and positive and negative consequences. A review of the
BMS found it included promoting safety, respect and fairness, promoting and protecting youth
rights, positive and negative consequences, constructive disciplinary actions/non-punitive,
opportunities for positive reinforcement, recognition of accomplishment and positive behaviors
at a four to one ratio, promoting socially acceptable means for youth to meet their needs,
process for explaining to youth the reasons for any sanctions imposed, youth having the
opportunity to explain his/her behavior, opportunities for staff and youth to discuss the impact of
behavior on others, reasonable reparations for harm caused to others, discussions of alternate
behaviors, promoting positive dialogue and peaceful conflict resolution, and separation of youth
from population is minimized. The BMS appropriately did not include increased length of stay,
denial of a youth’s basic rights, promotion of group discipline, punishment of youth by other
youth, or disciplinary confinement. All youth participate in an award ceremony on the last Friday
of each month. During the ceremony, the youth receive awards for room of the month, youth of
the month, most improved of the month, student of the month, and point store rewards. Some
incentives include outside food and off campus trips. Staff and youth interactions were observed
and confirmed adherence to the listed elements of the BMS, and negative consequences were
in direct relation to the severity of the inappropriate behavior. The BMS includes a process
where staff explain any consequences to youth, you are allowed to explain their behavior, the
staff and youth discuss the impact of the behavior on others, and discuss alternative acceptable
behaviors.
Four of five interviewed staff revealed they have received training in the BMS. One staff stated
has not received training on the new BMS. All five staff revealed the BMS consists of a point
and level system. Four of five indicated the BMS has rewards and consequences. The five staff
reported the BMS is posted throughout the program, included in the youth handbook, and
provided to youth during orientation to the program. Staff revealed rewards include point store,
snacks, raffles, awards, outings, church choir, and stickers. Four of five staff reported things can
be taken away from youth as consequence. All five staff reported the youth is informed of the
consequences through an emergency treatment team. All five reported supervisors provide
feedback to the staff regarding the implementation of the BMS. Four of five youth interviews
revealed youth can receive additional days/“catch time” in the program as consequence, which
was discussed with the program. One youth reported the incident is discussed, a consequence
is decided, youth sign a document, and get the consequence. Three of five youth reported they
are rewarded through a point store, the other two reported they are not rewarded. All five youth
reported the process in which to advance in levels to complete the program. All five youth
reported they are not allowed to punish other youth. Three of five youth reported staff use
rewards consistently, and two said “no”; there are no rewards. Two youth reported the BMS is
good, two said fair, and one youth reported the BMS is poor. The facility administrator (FA) was
interviewed and reported the BMS is a point and level system, with rewards and consequences.
It shall be the responsibility of the FA to implement the BMS and to monitor the culture of the
program. The assistant facility administrator oversees the daily implementation of the BMS.
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5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, provide constructive discipline and a system of positive and negative consequences
to encourage youth to meet expectations for behavior, provide opportunities for positive
reinforcement and recognition for accomplishments and positive behaviors, promote dialogue
and peaceful conflict resolution, and minimize separation of youth from the general
population.
Supervisors shall monitor staff implementation of the BMS and ensure the use of rewards and
consequences are administered fairly and consistently in application among all staff.
The program’s policy, procedures, and practice confirm the program does not use room
restriction; therefore, this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a policy and procedures in place to conduct ten- minute checks while the
youth are in their sleeping rooms. The program’s policy states staff conduct the observations in
a manner to ensure the safety and security of each youth and shall document real time
observations manually. The program has a total of thirty-eight video cameras capable of storing
thirty days of video recording. All cameras were operational at the time of the annual
compliance review week. The staff are required to conduct room checks every ten minutes and
document the time of the check on the ten-minute check log when youth are sleeping. A review
of ten-minute check logs in comparison with video revealed checks are conducted every eight
minutes. Three randomly selected dates were reviewed to verify checks were being conducted
as required. On each of the three reviewed days all checks were observed to be conducted in
real time, and staff observed youth for safety. The executive director revealed they review ten-
minute checks, and cameras have recording capabilities of thirty days. Five interviewed staff
revealed checks are completed every eight minutes when youth are placed in their rooms for
sleeping or non-punishment reasons.
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5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program has a policy and procedures in place to ensure youth are always accounted for
through a system of physically counting youth at various times throughout each day. Program
policy indicates counts are conducted during power outages, escapes, riots, or any other
disruptions which may occur. The policy states the facility administrator (FA) tracks daily census
information to include census counts, new admissions, releases, direct discharge transfers, and
youth temporarily away from the program. A review of one date a month throughout the annual
compliance review period in the facility logbook validated head counts and movements were
conducted at the beginning of each shift, after outdoor activities, during emergency situations,
and during actual and simulated drills. During the annual compliance review week counts were
observed during movements from the classroom to the youth dorm for breaks and back to the
classroom. During the annual compliance review week, each of the five interviewed staff were
able to correctly state the daily youth census.
A review of the logbook during the annual compliance review period revealed the counts at the
beginning of each shift, after each outdoor activity, during emergency situations, total daily
census counts, head counts, youth movements, new admissions, releases, or direct discharges,
transfers, and youth temporarily away from the program were documented. On August 29,
2023, twenty-five youth and fourteen staff were evacuated to another program due to hurricane
Idalia. All youth and staff returned to the facility on August 31, 2023. Five interviewed staff
revealed formal counts are conducted every hour, and during every movement throughout the
day. Random counts are also conducted throughout the day. The five staff revealed emergency
counts are conducted after any type of emergency or drill. Several observations of youth
movement were completed during the annual review for which a head count was completed
prior to any movement.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has a policy and procedures to ensure the maintenance of a chronological record
of events, incidents, and other activities in a central logbook. The program maintains a bound
logbook named the shift report logbook with numbered pages. During the review of logbooks
during the annual compliance review week, there were pages observed to be unattached and
stapled back into the logbook. No pages were missing. Numerous mistakes were scribbled
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through using ink pen. A review of logbooks revealed six entries which were scribbled through,
not utilizing just one line strike through, and staff initials were not provided on errors. There were
no erasures or white out areas. All entries included the dates and times of the events, with the
names of the staff and youth involved, brief descriptions of the events, and the names and
signatures of the staff making the entries. The logbook indicated recreation was conducted, as
scheduled. A review of the logbooks found the program documented the 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 facility including the
names of the staff, youth involved, and the destination, removal of any youth from the
mainstream population, and admission and releases including the name, date, and time of
anticipated arrival or departure and mode of transportation. Pertinent information from the
logbook is reviewed during shift briefing and staff document their review. There was
documentation of the program recording reports made to the Department’s Central
Communication Center (CCC).
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a written policy and procedures in place for key control and security which
includes assignment, inventory, tracking, and storage of keys. The policy also includes
procedures addressing missing or lost keys and reporting and replacement of damaged keys.
During observations made throughout the annual compliance review week, all staff and visitors
surrendered their personal keys to master control upon entering the program. Keys were then
stored in a locked cabinet in master control. Program keys are in a locked box in master control.
When entering the program, staff sign the key logbook, write the date, key ring number, and
time the keys were taken. When leaving the program, staff write the time and sign the key
logbook indicating the keys were returned. A review of key logbooks for the annual compliance
review period verified this practice. The program has a list of staff who are assigned permanent
keys authorized by the facility administrator (FA). Permanent keys are issued, and staff signed
an acknowledgment form indicating a key identification number and the number of keys on the
ring. If keys are damaged or need to be replaced it is reported to the shift supervisor and a
maintenance request form is completed. The damaged keys are given to the maintenance
manager and the staff are given new keys. There were not any incidents reported to the
Department’s Central Communications Center (CCC) or Program Monitoring and Management
(PMM) deficiencies related to key control concerns. Informal interviews were conducted with the
master control operator and the human resources personnel, and both were able to explain the
process for restricting usage of keys such as medical, youth and staff records, and youth
property locker keys. Each of the three informally interviewed staff knew how many keys were
on their personal key ring and the function of each key. Their responses were compared to the
key inventory and there were no discrepancies. Five staff were interviewed, and each were able
to explain the key control process.
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5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items.
A program shall delineate items and materials considered contraband when found in the
possession of youth, the list must include: sharps, escape paraphernalia, tobacco products,
lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food or
clothing, any intoxicating beverage or any beverage which causes or may cause an
intoxicating effect, any controlled substance, any prescription or non-prescription drug which
has a hypnotic, stimulating, or depressing effect, any firearm or weapon of any kind or any
explosive substance, non-facility issued electronic equipment or devices to include
smartwatches, metals, personal non-facility issued cellular devices, unauthorized currency or
coin(s), and non-facility issued keys. The program shall provide youth with the list of
contraband items and materials and inform the youth of the consequences if found with
contraband. The program shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, and both staff and youth.
The program shall document the confiscation of any illegal contraband and the manner of
disposition. The program shall keep a copy of the documentation in the youth’s case record. If
a confiscated item is not illegal or prohibited, the program director or designee has the
discretion to discard of the item, return it to its original owner, mail it to the youth's home, or
return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a policy and procedures in place to identify items considered to be illegal
contraband and prohibited items, which included all of the required items. During orientation all
youth are provided a list of contraband items within the youth handbook and informed of the
consequences if found with contraband by the youth handbook. The searches conducted to
ensure contraband does not enter the program include search of the physical plant, search of
the facility grounds, search of the youth, search of incoming mail (in presence of youth or youth
representative), and searching of outgoing mail. The searching of youth mail is documented on
the mail log. A review of the logbook revealed searches are conducted.
An interview with the facility administrator (FA) revealed during the annual compliance review
period the program had one incident of contraband being found in the program. The search was
not documented in the logbook; however, the report to the Department’s Central
Communications Center (CCC) was documented. Additionally, a copy of the report was not
located in the youth record. The FA revealed the program holds scheduled and unscheduled
searches of the youth as well as youth possessions, the unit, and all other program areas, to
deter the possession of contraband and/or unauthorized items. Searches are conducted as a
means to enhance safety within the program and control the introduction of contraband. All
searches avoid using unnecessary force, embarrassment, or indignity to those being searched.
Searches take place no more frequently than necessary to control contraband or to ensure
safety.
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5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a policy and procedures to ensure searches and full body visual searches are
conducted according to Florida Administrative Code at the time of admission, before and after
off-campus activities, visitation, and randomly. All parents/guardians are notified of searches
during visitation by way of the parent/guardian intake letter, which is sent at the time of each
youth’s admission. All youth are searched before all movement, during a new admission,
returning from visitation, returning from off campus activities or appointments, when there is a
suspicion of contraband, or when a youth is identified as a security risk. During observations
made throughout the week of annual compliance review, youth were seen searched by staff of
the same gender and in a manner where the youth would not feel degraded. There were no
transports, admissions, visitation, or off-campus activities during the annual compliance review
week to observe. The facility administrator (FA) was interviewed and stated searches are
conducted before youth leave for any transport and when the youth return, during admission,
and before and after visitation by a staff of the same gender. Youth were observed being
searched before and after education. All searches observed were conducted as required and in
accordance with the Protective Action Response Right Interactions model (PAR/RI) training
manual. Five interviewed staff revealed searches are conducted anytime there is youth
movement such as from the classroom, restroom, dining hall, common area, recreational
activities, transportation, and visitation. Four of five interviewed youth revealed searches are
conducted when returning from off campus, after outdoor activities, when items are missing,
after visitation, and after mealtime.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has a written policy and procedures to ensure vehicles used to transport youth are
properly maintained and in working condition. The program has two vans which are used to
transport youth. Both vans received an annual safety inspection. Both vans were observed
during the annual compliance review week and neither van was required to have a safety
screen separating the front seat from the rear passenger’s compartment as the program is a
non-secure program. Both vans had the appropriate number of operational seatbelts. The
passenger door could not open from the inside. Both vans included a fire extinguisher, seatbelt
cutter, first-aid kit, and window punch. Three staff vehicles and both facility vehicles were
checked to ensure the vehicles were locked when not in use. Five interviewed youth stated they
are secured in the transport vehicle by seatbelts. Five interviewed staff stated youth are secured
by seatbelts.
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5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a policy and procedures in place to ensure the safety and security of youth
and the community when youth are transported away from the program. The program assigns a
ratio of two staff to five youth on transports. During the annual compliance review week, there
were no transports to be observed. An informal interview with human resources revealed all
staff must possess a valid driver’s license to be employed at the facility. A review of four staff
records revealed each staff had a valid driver’s license. Five interviewed staff stated the staff
are given a program transport telephone and radio for each transport. The staff revealed
transport vehicles have first-aid kits, a toolbox, window punch, and fire extinguishers. Each staff
revealed they are not allowed to use their personal vehicles to transport youth. The staff
revealed the transport vehicles are searched for contraband prior to and after each use. If there
is an emergency during a transport the five interviewed staff stated, they will contact the facility
and 9-1-1 for further instructions. The staff revealed the staff-to-youth ratio during transports is
two staff to five youth. Five interviewed staff revealed they had never seen anyone place
contraband in a transport vehicle. Five interviewed youth stated they felt staff are driving
transport vehicles safely. Two of five youth interviewed stated they brought contraband onto the
transport vehicles. In both incidents, the youth reported bringing pens onto the transport vehicle.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures outlining the audit/inspection process to include who
is responsible for conducting the weekly security audits and safety inspections, the development
and implementation of corrective actions warranted as a result of safety and security
deficiencies found during any internal or external review, audit, or inspection, and internal
system to verify the deficiencies are corrected and existing systems are improved or new
systems are instituted as needed to maintain compliance. The facility administrator (FA) is
responsible for conducting the weekly security audits and safety inspections. If deficiencies
occur the FA consults with the facility maintenance manager and leadership team during
management meetings and informal conversation. The documentation for the time frame from
August 23, 2023, through September 8, 2023 was missing due to the hurricane evacuation of
the youth and staff. There was documentation of weekly safety and security audits being
conducted every other week during the annual compliance review period. The program’s
Preventive Maintenance Checklist was reviewed to ensure maintenance schedules and repairs
were conducted as outlined in Florida Administrative Code. The FA revealed it is the
responsibility of the FA and/or designee to ensure all aspects of the facility are safe and secure
for youth, staff, and visitors. The safety and security audit tool is completed on a weekly basis
and filed in the FA office. Any deficiencies will be noted on the safety and security audit tool for
review by the FA. A corrective action plan will be developed for all deficiencies noted on the
safety and security audit tool. The corrective action plan will be documented on the safety and
security audit tool document. The FA will follow–up on a weekly basis to ensure the corrective
action plan is followed thoroughly to correct the deficiency. Once the deficiency is corrected the
FA will approve the deficiency to be removed from the safety and security audit document.
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5.13 Tool Inventory and Management Limited Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a tool management system ensuring youth do not use tools or equipment as
weapons or for security breaches. The policy on tools addresses the issuance, inventory, and
control of equipment. A tour of the facility found all tools were securely stored when not in use
and marked for easy identification. The tool inventory logbook in the maintenance office was
reviewed. Four of the six tools reviewed were not properly recorded in the tool inventory
logbook. Due to not being properly recorded, it was unclear if the tools are properly checked out
and returned daily. A review of the tool inventory logbook in the laundry room revealed the tools
are inventoried daily. The tool inventory logbook in the kitchen revealed missing or incomplete
documentation for the months of February, June, July, and August. All log sheets were not
signed by the supervisor or designee. The program maintains a locked box in the kitchen office
which contains four knifes, two pitch forks, and a pizza cutter. The items are labeled and
identified; however, there was no record of the items being checked in or out on an inventory log
sheet. Machetes, bowie knives, or other long blade knives are prohibited. If a tool is broken or
non-operational, the maintenance manager is responsible for replacing the broken tool. If a tool
is missing, staff will notify administration, the program will stop all youth movement, a red tag is
placed on the shadow board, and the program will be searched until the tool is found.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a policy and procedures which includes supervision requirements when using
tools, issuing tools to youth and staff, an assessment to determine a youth’s risk to self and
others, established ratios, tool distribution, collection, and search criteria during work projects.
During activities involving tool use, there is a one staff to five youth ratio. The program does not
utilize disciplinary work projects. The facility administrator reported youth never use tools while
at the program. Five interviewed youth stated they only use mops and brooms. Five interviewed
staff revealed youth use mops and brooms. Youth were observed on video using brooms and
mops to clean the cafeteria area. A review of risks assessments revealed youth can use
cleaning tools such as brooms and mops.
5.15 Outside Contractors Limited Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures establishing guidelines for outside contractors which
includes information regarding tool control and restrictions. The program’s policy states, it is the
maintenance manager and facility administrator’s (FA) responsibility to monitor use of all tools
and equipment in the facility. When a repair person or other worker comes on-site from the
outside community with the tools of their trade, program staff alert them to the potential danger
of tools used on grounds and request them to limit the tools used to only those necessary to
complete the job, check tools when they arrive and leave, keep close track of tools while
working on-site, and immediately notify program staff if any tool is missing. When a contractor
arrives at the program, the contractor signs the visitor sign-in log and is provided a contract
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agreement form confirming notification of what, if any, items are considered unauthorized items
and are needed by the contractor. After review of the agreement form, the contractor signs the
form confirming notification of what items are unauthorized. If any unauthorized items are
needed by the contractor while in the program, approval is obtained by the FA or designee. A
review of the sign-in sheets, the contractor’s agreement forms, and five work invoices verified
the contractors were on-site on the same date the documents were signed. Staff entered “tool
bag” as a description of what was being brought into the facility in one scenario. It is unclear if
anything unauthorized was brought into the facility or left at the facility. Inventory of the
contractor’s tool bag was incomplete upon entrance and exit.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program has a policy and procedures in place ensuring youth and staff are prepared for
immediate implementation or mobilization in the event of an emergency or disaster by
conducting fire, safety, and evacuation drills. The program conducts fire, safety, and evacuation
drills monthly. A review of drill documentation revealed the program conducted at least one
monthly drill for the annual compliance review period on each shift covering monthly Continuity
of Operations Plan (COOP) drills. The documentation for all of the drills contained the type of
drill, date and time, participants, brief scenario, and findings and recommendations. A tour of the
facility revealed fire evacuation route and egress plans were posted throughout the facility. The
program has a total of five fire extinguishers which were last inspected September 2023. The
FA revealed the program conducts practice events or drills at least semi-annually for emergency
or disaster situations including riots and other major disturbances, hurricane/evacuation drills,
fire drills, hostage situations, escape drills, bomb threats, chemical spills, flooding, and terrorist
threats/acts. Five interviewed youth revealed they had been instructed on what to do in case of
a fire. Four youth stated drills are conducted twice a month. One youth stated drills are
conducted monthly. Five interviewed staff stated they participated in fire drills, escape drills,
medical/suicide, major disturbance, bomb threat, and flooding drills.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program has a Disaster and Continuity of Operations Plan (COOP) approved by the
Department readily available for all staff to review. The plan was reviewed and updated on
February 13, 2023, and approved by the department on February 15, 2023. A review of the plan
revealed it addresses alternative relocation sites approved by the applicable department
regional director/designee. The facility administrator (FA) revealed the disaster/COOP plan is
available to staff for access. Additionally, the COOP plan is inclusive of the disaster plan. The
plan is located in the FA office, master control, and training officer's office. Emergency
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equipment and supplies include first-aid kits, blankets, flares, water, food, medications, cell
phones, clothing, flashlights, batteries, fire safety equipment, and laptop computers. The
supplies are located in the attic of the facility.
The COOP included procedures for fire/fire prevention/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 has separate records or
one administrative hard-copy file for each youth. The records are secured in locked boxes and
taken with the program staff in the event of an evacuation. Each of the records contained the
youth’s full name, Department identification number, admission date, date of birth, gender,
name, address, and telephone numbers for parent/guardian, name, address, and phone number
of the person with whom the youth resides and their relationship to the youth, person(s) to notify
in case of an emergency (and contact information), juvenile probation officer’s (JPO) name,
circuit/unit, and contact information, names of committing judge, state attorney, and public
defender (or attorney of record) with contact information on each, committing offense and
judicial circuit where the offense occurred, notation of whether or not the judge retains
jurisdiction, victim notification contact information if notification is required, physical description
of youth to include height, weight, eyes and hair color, and any identifying marks, overall health
status, personal physician, and photograph of the youth.
5.18 Storage and Inventory of Flammable, Poisonous, and
Limited Compliance
Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items.
The program has a policy and procedures in place to ensure strict control of flammable,
poisonous, and toxic items used. All chemicals entering the facility are approved and maintained
in a safe and secure manner. It is the responsibility of the maintenance manager, under the
supervision of the assistant facility administrator (AFA) and facility administrator (FA), to
maintain a monitoring system to ensure overall compliance with the flammable, poisonous, and
toxic chemicals. Flammable, poisonous, and toxic items and materials were found to be
securely stored. Toxic and flammable items are usually stored outside the program in locked
storage cabinets labeled hazardous materials, inaccessible to youth. During the annual
compliance review week, the program did not have any flammable, poisonous, or toxic items on
site. Supervisors, the FA, and the maintenance manager are authorized to handle these items.
An informal interview with the maintenance staff revealed the program has a process to
inventory all items and to maintain applicable Safety Data Sheets (SDS) for each item. A SDS
binder is located inside the laundry room and kitchen for each material corresponding to the
SDS. The laundry room inventories were compared to the actual items at the program and there
were no missing or additional items on the inventory. The chemical inventory logbook located in
the kitchen was missing documentation for months June, July, and August. One log sheet was
completed until the seventh day of one month, however, the month was not provided on the
form. No forms were signed by the supervisor or designee. The maintenance manager is
responsible for maintaining inventories for all hazardous items in the facility. Items identified as
such are to only be drawn by an authorized person to include the maintenance manager, FA,
AFA, shift leader, and the cook. Youth are not allowed to handle these items and they do not
have access where these items are being used and/or stored. Cleaning chemicals are stored in
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locked areas within the program. A SDS binder is located inside the closet with a picture of each
material corresponding to the SDS.
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’s policy states youth are not allowed to handle flammable, poisonous, or toxic
items and materials and do not have access where these items are being used and stored.
Youth are not permitted to clean, handle, or dispose of any other person's bio-hazardous
material, bodily fluids, or human waste. Youth were observed during daily cleaning activities and
the youth were only using brooms and mops under the supervision of staff. Five youth were
interviewed, and one youth stated they use bleach explaining staff hold the bleach for the mop
water. Four youth stated they do not use any chemicals/cleaning products.
5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program has a policy and procedures in place to ensure the strict control and disposal of
flammable, poisonous, and toxic items. The program’s policy states, liquid waste not resulting
from work details (dirty mops water or unused beverages) is disposed of in the drain of the
cleaning supply closet. Kitchen liquid waste, except for grease, is disposed of in the kitchen
drain. Grease is placed in a separate container for disposal. An interview with the maintenance
staff and facility administrator (FA) revealed the program has not had a chemical spill since the
last annual compliance review. The program’s policy states in the case of a chemical spill, the
shift supervisor is to immediately be notified, the supervisor will then direct the shutdown of all
air handlers and ventilation systems and close all windows and doors at the direction of the FA
or designee, and lastly assistance from outside the facility is contacted, if it be necessary and
consistent with emergency procedures. The program’s disposal practices were in accordance
with Occupational Safety and Health Administration (OSHA) standards and conducted
according to policy.
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5.21 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity.
Programs allowing youth to participate in water related activities shall have a water safety
plan addressing, at a minimum, safety issues, emergency procedures, and the rules to be
followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures in place which allows visitation and communication
for youth while in the program. The policy states youth may receive approved visitors except
where there is documented evidence the visitor poses a threat to the safety and security of the
program. Weekly, youth will be allowed to place a ten-minute phone call to their
parent/guardian. Extra phone call time can be earned. Youth can receive unlimited mail from
their parent/guardian and other individuals listed on their correspondence authorization list.
Visitation time is scheduled for Saturdays from 1:00 p.m. until 3:00 p.m. The youth in the
program are given the opportunity to communicate with family members by mail and telephone.
As an alternative measure, online video conferencing is used to provide visitation for youth. For
youth with a history of human trafficking, the Human Trafficking Service Coordinator Assignment
forms are sent to the youth's juvenile probation officer (JPO) concerning the situation. The form
is sent back to the program to let them know if everyone is clear. Incoming and outgoing mail is
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searched in the presence of the youth. The program has two staff who speak Spanish to assist
with parents/guardians who do not speak English.
Five interviewed youth revealed youth can call their parent/guardian or send a letter. Three
youth revealed the program has a translator in place for youth whose primary language is not
English. Two youth indicated they did not know there was a translator available. One youth
revealed there are staff that speak Spanish. Four of five interviewed staff revealed the program
has a translator in place for youth whose primary language is not English. One staff indicated
there are staff who speak Spanish. The facility administrator interview revealed the program
utilizes a telephone translation service. The program also has bilingual staff to provide services.
The designated mental health clinical authority (DMHCA) indicated they are bilingual. The
program also uses an online translation service and the translation line when in need of
additional support.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a policy and procedures in place which provide a variety of recreation and
leisure activities to the youth. The activity schedule documents a range of supervised and
structured indoor and outdoor recreation and leisure activities for at least one hour daily.
Outdoor activities provide large muscle engagement. A review of the logbook indicated
recreation was completed as scheduled. During the annual compliance review week, youth
were observed outside playing kickball, cards, and checkers. It is the facilities goal to provide
activities which promote social and cognitive skill development, creativity, teamwork, healthy
completion, mental stimulation, and physical fitness. Five interviewed youth revealed they are
allowed at least an hour daily to exercise, play outside, or down time to read books, or play a
board game. Five interviewed staff revealed youth are provided one hour daily for indoor and
outdoor activities.
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
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5.26 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
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report_type: QI Residential

program_name_raw: Alachua Academy

rule: Indicator 2.03

rating: Limited Compliance

rule: Indicator 2.07

rule: Indicator 2.09

rule: Indicator 2.20

excerpt: Educational Access (Critical)

rule: Indicator 2.21

excerpt: Education Transition Plan

rule: Indicator 3.08

rule: Indicator 3.12

rule: Indicator 5.13

excerpt: Tool Inventory and Management

rule: Indicator 5.15

excerpt: Outside Contractors

rule: Indicator 5.18