state: FL

summary: QI Residential - FY24-25

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Juvenile Unit for Specialized Treatment (JUST) and Twin Oaks
Vocational Academy (TOVA) II
Twin Oaks Juvenile Development, Inc.
(Contract Provider)
29481 Liberty Wilderness Road
Sumatra, Florida 32335
Review Date(s): January 14 - 17, 2025
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:
Jessica Gibson, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Rebecca Smith, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Patrick Brock, North Central Education Coordinator, Office of Education (Standard 6)
Carlametress Harrell, Workforce Education Coordinator, Florida Youth College (Standard 6)
Kayshala Patterson, Office of Accountability and Program Support, Regional Monitor (Standard
3)
James K. Phillips, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Stephanie Solano, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Bradley Taylor, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Andre Watson, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Program Name: JUST/TOVA II MQI Program Code: 1086
Provider Name: Twin Oaks Development, Inc. Contract Number: 10696
Location: Liberty County / Circuit 2 Number of Beds: 44
Review Date(s): January 14-17, 2025 Lead Reviewer Code: 210
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, (5) Safety and Security, and (6) Educational
Services, which are included in the Residential Standards.
Overall Rating Summary
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 68 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Non-Applicable
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Non-Applicable
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 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 68 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions and Incorporation of Other Plans Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.14 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.15 Exit Portfolio Satisfactory
2.16 Exit Conference Satisfactory
2.17 Youth Input Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 68 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Secure Observation* Non-Applicable
3.13 Suicide Precaution Observation Logs * Satisfactory
3.14 Suicide Prevention Training * Satisfactory
3.15 Mental Health Crisis Intervention Services * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.18 Baker and Marchman Acts * Non-Applicable
3.19 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 68 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 68 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
5.24 Controlled Observation Non-Applicable
5.25 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 68 (Revised September 2022)
Standard 6: Educational Services
Residential Rating Profile
Standard 6 - Educational Services
6.01 Contract Specific CTE Services (Residential Contract) Satisfactory
6.02 Educational Access (Residential Contract) * Satisfactory
6.03 Educational Access (Education Contract) * Non-Applicable
6.04 Career Education (Education Contract) Satisfactory
6.05 Education Transition Plan (Education Contract) Non-Applicable
6.06 Qualified Intructional Personnel (Education Contract) Non-Applicable
6.07 Florida Youth College (Education Contract) Satisfactory
6.08 Florida Youth College (Post-Secondary Contract) 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 9 of 68 (Revised September 2022)
Program Overview
The Juvenile Unit for Specialist Treatment (JUST)/Twin Oaks Vocational Academy (TOVA) II is
a forty-four bed program, for ten- to seventeen-year-old males, located in Sumatra, Florida. The
program, comprised of two components, is operated by Twin Oaks Juvenile Development, Inc.,
through a contract with the Department. The program provides the following services: Boys and
Girls Club, and Department of Transportation. In addition, the program fosters each youth by
providing intensive mental health services to youth in the program, Impact of Crime (IOC)
curriculum, Skillstreaming the Adolescent, Trauma Affect Regulation: Guide for Education and
Therapy (TARGET), and Life Skills Training. Additional treatment services provided include
family therapy, individual therapy, intensive mental health services, Mental Health Overlay
Services (MHOS), group, and recreational therapy. Program administration is comprised of a
program director, assistant program director, director of operations, administrative assistant,
and shift supervisors. Case management services are provided by three case managers and a
transition case manager. Mental health staff at the program includes a licensed mental health
counselor who serves as the designated mental health clinician authority (DMHCA) and four
non-licensed master’s-level therapists. Medical services are provided by a medical doctor who
serves as the program’s designated health authority (DHA), one director of nursing (DON), and
three licensed registered nurses (RN). There is nursing staff on-site seven days a week.
Educational services are provided by Florida Virtual School (FLVS). The program is located in
the Apalachicola National Forest which spans 560,000 acres. The program’s administration
building is centrally located in the program and consists of administrative offices, case
managers offices, and mental health staff offices. Another building has the medical clinic and
dining tables for youth. Another portable on-site has two classrooms and a teacher’s office. The
program has an area in the back where vocational classes are located, and another structure on
the property where agriculture classes, including animal care and aquaponics are conducted.
The program has forty-six cameras. During the annual compliance review, it was discovered
video review could not be conducted. The program put in a work order and reported the outage
to the Department’s Central Communications Center (CCC) within the required timeframe.
When the cameras and hard drive were recovered, it was discovered video from the previous
few weeks could not be viewed. At the time of the annual compliance review, the program had
no vacant positions.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 68 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program maintains a policy and procedures for volunteers, mentors, and interns who work
with the youth less than ten hours a month requiring them to always be within sight and sound
supervision of certified staff at all times, all other staff, volunteers, mentors, and interns but have
a completed background screening. The Annual Affidavit of Compliance with Level 2 Screening
Standards was completed and sent to the Department’s Background Screening Unit (BSU) on
January 6, 2025. The program hired fifteen new staff during the annual compliance review
period. All fifteen staff had a background screening completed prior to contact with the youth
and access to confidential youth records. None of the staff had a criminal history report for
review; therefore, an exemption was not needed. One of the fifteen staff did have a break in
service as indicated in the Department’s Staff Verification System (SVS) and this staff received
a new background screening. A pre-employment assessment and passing scores were
completed by all fifteen staff. All reviewed staff had been added to the program’s Clearinghouse
employee roster. All of the new staff also had a signed contraband attestation form located in
their personnel records.
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.)
Five staff were eligible for a five-year rescreening. The five-year rescreenings were completed
every five years based upon the Clearinghouse Prints Expiration Date for all five staff. The
rescreenings were submitted to the Department’s Background Screening Unit (BSU) and
Clearinghouse at least ten business days prior to the five-year anniversary.
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.
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Office of Accountability and Program Support Page 11 of 68 (Revised September 2022)
▪ 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 did not have any incidents or substantiated incidents related to physical,
psychological, and/or emotional abuse during the annual compliance review period. Five staff
records were reviewed and all five included a signed Code of Conduct. The Florida Abuse
Hotline and the Department’s Central Communications Center (CCC) numbers were observed
to be posted throughout the program. The program’s steps to report abuse include calling the
Florida Abuse Hotline, notifying a supervisor, and then calling the CCC. The program completed
their Trauma Responsive and Caring Environment (TRACE) self-assessment on January 9,
2025. There was a meeting scheduled during the last quarter; however, it was canceled due to
a hurricane and State of Emergency. Five youth were interviewed and all reported they feel safe
at the program. All five youth also reported they have never been stopped from calling the
Florida Abuse Hotline and they all know where the number is located in the program. All five
youth reported staff are respectful when talking with other youth. One youth went on to say
some staff try to argue with the youth. Three youth reported never hearing staff curse, one said
occasionally, and one said often. Both youth went on to state they heard staff cursing when
talking with other staff. The program director was notified of the information. None of the youth
have exchanged contact information with staff at the program. Five staff were interviewed and
all were able to explain the process for allowing a youth to call the Florida Abuse Hotline or the
CCC when the youth requests to do so. None of the staff have heard anyone tell a youth they
could not call the Florida Abuse Hotline. None of the staff have heard other staff using profanity
while speaking with the youth. The program director was interviewed and included the policy
and procedures for the staff's Code of Conduct. The program director included all of the
information contained within the Code of Conduct used by the program. The program uses the
Adverse Childhood Experiences (ACE) Trauma Assessment and the Trauma Affect Regulation
Guide for Education Therapy (TARGET) curriculum with the youth. TARGET is utilized in a
group setting and during individual and/or family sessions. The program is located in the
wilderness and the staff are able to utilize their environment for calming strategies. The youth
are able to work or exercise to help them remain calm, productive, and motivated. The program
director included the program's policy and procedures in the interview for incident reporting and
how staff and youth are knowledgeable about contacting the Florida Abuse Hotline and CCC.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program had no allegations of physical, psychological, or emotional abuse in the program
during the annual compliance review period; therefore, this indicator is rated non-applicable.
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1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program had a total of thirteen incidents reported to the Department’s Central
Communications Center (CCC) during the annual compliance review period. Five of the fifteen
incidents were reviewed. Four of the five incidents were reported timely. One was reported
thirty-five minutes late; however, the incident was to be reported by the Florida Virtual School
(FLVS) staff. The program director was made aware of the incident, realized it had not been
reported, and then reported it to the CCC. Updated training will be completed by the director of
operations at the program. Four of the five incidents were documented within the program
logbook. The program was made aware of the missing logbook entry. The employee was
counseled on what entries are required for the program logbook.
1.06 Right Interactions (RI) and Physical Intervention Rate Non-Applicable
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. 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 RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
There have been no Right Interactions (RI) incidents during the annual compliance review
period; therefore, this indicator is rated non-applicable.
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. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
Program staff who are considered direct care staff and are counted in the staff-to-youth ratio
include the team leaders. All instructors were qualified in the curricula provided to the program
staff. The program submitted a pre-service training plan, which was provided for review. The
training plan was approved by the highest ranking official at the program, the assistant secretary
for Residential Services, and the director of the Department’s Office of Talent, Leadership, and
Culture (TLC). Five staff were reviewed for pre-service certification requirements. All five staff
completed more than the required 120 hours of training within the first 180 days of employment.
All five staff completed the essential skills trainings of Child Abuse Recognition, Reporting, and
Prevention, cardiopulmonary resuscitation (CPR), first-aid, automated external defibrillator
(AED), emergency procedures, program operating procedures, Prison Rape Elimination Act
(PREA), professionalism, interpersonal communication, ethics, and code of conduct, Right
Interactions (RI), and suicide awareness and prevention, prior to having contact with youth. The
following additional trainings were completed by all five staff: active shooter preparedness,
adolescent development and behavior, balanced approach to restorative justice, the
Department’s Central Communications Center (CCC) Incident Reporting, civil rights,
communication, Health Insurance Portability and Accountability Act (HIPPA), the Department of
Juvenile Justice Legacy/History, Equal Employment Opportunity, gang awareness, human
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trafficking intervention, infection control/bloodborne pathogens, information security awareness,
Juvenile Justice Information Systems, mental health and substance abuse, Motivational
Interviewing, quality report writing, safety, security, and supervision of youth, sexual
harassment, effective and respectful treatment of youth, and trauma responsive practices.
Additionally, job shadowing was completed by all five staff. All five staff completed the following
trainings as required by other Rules or manuals: grievance process, infection control, exposure
control plan, behavior management system, and intended use of safe tools. All five staff also
completed all required specialized services trainings. None of the newly hired staff were hired
as a supervisor; therefore, the supervisory trainings were not applicable. All pre-service
trainings were documented in the Department’s Learning Management System (SkillPro).
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
Five staff training records were reviewed for in-service training requirements. All five records
included documentation the staff completed all mandatory training topics, active shooter
preparedness, cardiopulmonary resuscitation (CPR), first-aid, automated external defibrillator
(AED), human trafficking, information security awareness, mental health and substance abuse,
Prison Rape Elimination Act (PREA), Right Interactions (RI), professionalism, interpersonal,
communication, and ethics, sexual harassment, suicide awareness and prevention, trauma
responsive practices, emergency response and emergency drills, infection control, bloodborne
pathogens, and exposure control plan during the annual compliance review period. All five staff
completed over the required twenty-four hours of training. All five staff also completed training
for mental health overlay services (MHOS), substance abuse treatment services, substance
abuse treatment overlay services, comprehensive services for major disorders, developmental
disabilities treatment services, and juvenile sex offenders. Two of the five staff were supervisory
staff and were reviewed for the completion of the required supervisory training. Both staff
completed eight additional hours of supervisory training during the annual compliance review
period. These trainings included coaching, leadership, and personal accountability. The
supervisory staff also completed medication administration for non-licensed staff training. All
instructors were qualified to provide the trainings. The program submitted and implemented an
annual in-service training calendar. The highest ranking official at the program, the assistant
secretary for Residential Services, and the director of the Department’s Office of Talent,
Leadership, and Culture (TLC) all signed the training plan.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program maintains a policy and procedures for the grievance process. The policy includes
the informal phase where the youth has the responsibility to contact the person involved and
talk about the matter in a calm and polite way. If this does not resolve the issue then it is
escalated to the formal phase. This phase includes the youth completing a grievance form and
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submits it to the supervisor on-duty. The supervisor then has forty-eight hours to address the
matter and provide written feedback to the youth. If it is not resolved at this point, it is escalated
to the appeal phase. During the appeal phase, the youth can choose to submit a written
grievance to the program director. The decision of the program director is considered final. The
informal phase includes the youth asks for a grievance form, writes out their grievance, and then
meet with the staff to attempt and resolve the issue. Based upon reviewed documentation, the
program completes the grievance process as described in their policy and procedures. The
program maintains grievance forms in a binder. Five youth were interviewed about the
grievance process in the program. All five were able to correctly summarize the grievance
process. Five staff were interviewed about the grievance process in the program. All five were
able to correctly summarize the grievance process. The program director was interviewed
regarding the program's grievance process. The program director listed the program's policy
and procedures which accurately describe the grievance process at the program. Two
grievances were provided for review. The program had no other grievances during the annual
compliance review period. Both grievances were able to be resolved during the informal phase.
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 offered one non-clinical, non-primary curriculum which is EQUIP. All additional
group curricula are either primary or clinical services. This information was provided by the
designated mental health clinician authority (DMHCA). EQUIP is not a curriculum based
program. It is designed to provide specific topics for youth to discuss in an open group. The
program utilizes EQUIP during the nightly “Pow-Wows” in the dorms. Fifteen staff have been
trained to provide the EQUIP topics. The program provided a slide show utilized by the DMHCA
who provides the training to direct care staff. All fifteen staff were appropriately trained prior to
providing the group topics to the youth. The staffs’ education and work experience were
considered by the program when determining who would facilitate the discussions. A review of
the group schedule confirmed groups were being held every day each week. The program’s
activity schedule was reviewed and consisted of structure, planned programming, and/or
activities at least sixty percent of the awake hours. The program director reported staff at the
program who facilitated groups during the annual compliance review period. The delinquency
intervention models listed by the program director included the behavior management system,
Impact of Crime, Skillstreaming the Adolescent, Life Skills Training, and Trauma Affect
Regulation Guide for Education Therapy (TARGET).
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program maintains a policy and procedures for delivery of life and social skills activity in the
program. The procedures include the goal of the programming which is to reduce risk factors
and increase protective factors which will enable our youth to become more productive citizens
and ultimately reduce recidivism. The procedures also include a description of services provided
at the program and program schedules to include all activities for the youth. The program
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provides life and social skills activities which include communication, interpersonal relationships
and interactions, non-violent conflict resolution, anger management, critical thinking, problem-
solving, and decision-making. The program also addresses the needs of the targeted gender
group through training in health and hygiene, physical environment, life and social skills training,
and leisure and recreational activities. The program provides EQUIP daily during Pow-Wow time
on each dorm in the evenings. This open group includes providing a topic to the youth to
discuss openly. Sign-in sheets were also provided for review. There were no discrepancies
noted for this meeting. The program also provides Life Skills Training, Skillstreaming the
Adolescent, Living in Balance, Trauma Affect Regulation Guide for Education Therapy
(TARGET), Impact of Crime, and Coping with Depression. All listed curricula are primary
services or are clinical services provided at the program. The youth also receive process groups
on a regular basis. Five youth were interviewed regarding life skills groups and activities. The
youth reported they participate in carpentry, aquaponics, mental health groups, coping with
anger, poor decision making groups, Impact of Crime (IOC), Life Skills Training, TARGET,
Occupational Safety and Health Administration (OSHA), and groups held in the morning, which
include self-control, mindfulness, and asking others for help as some topic examples. The
program director was interviewed regarding life and social skills groups and services. The
program director reported all youth are assigned groups based on treatment needs and
mandatory contracted requirements. All youth are also included in Boys and Girls Club activities
for gender specific programming. For vocational activities the youth housed in Twin Oaks
Vocational Academy (TOVA) II have aquaponics, gardening, and Department of Transportation
(DOT). The youth housed in the Juvenile Unit for Specialized Treatment (JUST) are able to
participate in carpentry, welding, and DOT. All youth are able to participate in on-site and off-site
campus activities. The designated mental health clinician authority (DMHCA) was interviewed
regarding life and social skills services provided at the program and reported the program
provides Skillstreaming the Adolescent, Impact of Crime, TARGET, Coping with Depression,
and Living in Balance. The DMHCA also reported the youth are able to demonstrate skills
during and between groups and during on and off campus activities.
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.
Impact of Crime (IOC) is the program’s restorative justice group and designated as a
Standardized Program Evaluation Protocol (SPEP) primary service at the Juvenile Unit for
Specialized Treatment (JUST) and Twin Oaks Vocational Academy (TOVA) II programs. For
details related specifically to IOC service delivery, please refer to the annual SPEP report. The
program completes community service activities weekly for all of the youth outside of IOC
groups. Community service is provided on-site and off-site. Youth are also able to participate in
community service through the Department of Transportation (DOT). Also, as a part of the IOC
groups, the youth are required to complete a community service project and all youth participate
in this group. The assigned juvenile probation officers (JPO) are sent emails with all
documentation of community service. All youth also reported during their interviews they have
participated in community service or DOT. Many of the youth are also involved in the carpentry
and welding programs which also complete community service projects on a regular basis. Staff
were observed actively supervising the youth going to and from vocational classes. The youth
were currently working on corn hole boards, shoe racks, a table, a bookshelf, and painting
previously complete projects for the community and for use within the program. The program
director was interviewed regarding restorative justice groups and activities provided in the
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program. The program director reported the youth participate in IOC, community service
projects, and the DOT. Once the youth complete IOC, they participate in on-site and off-site
campus community service projects including clean-up crew, serving chow, debris removal,
pinecone and straw clean-up, and small facility repairs to the boardwalks. The youth also
participate in the Boys and Girls Club which includes enrichment activities. The youth are
afforded the opportunity to complete many community service projects and other sanctions such
as apology letters, go to work on DOT, and pay off restitution. Youth also participate in mental
health and substance abuse treatment including individual, family, and group sessions and may
have visitation on-site or zoom and may have the opportunity to participate in family days. Five
youth were interviewed regarding restorative justice groups and activities they have participated
in at the program. The youth reported they have participated in or are currently participating in
IOC groups, IOC community service, community service outside the program, carpentry
community service, and DOT. The youth also shared they are able to practice new skills learned
in groups while in the program. One youth reported having some anger issues when they first
arrived at the program, but now is able to listen better. Another youth stated they are able to
step away from an altercation, breathe, and ask for a break when needed. A third youth
reported they have learned about the Ripple Effect and how their actions affected others. A
fourth youth reported using SOS, which stands for self-check, orientate, and slow down which is
used when the youth is triggered by something. The fifth youth reported still learning them and
trying to use them.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program maintains a policy and procedures outlining the internal alert system. The policy
and procedures include how the alert system is communicated, which is through daily
debriefings between shifts, daily shift report, and the internal alert system binder. Any staff
member is able to place a youth on alert status in the event of a significant incident where the
youth is exhibiting behavior which presents a significant health, safety, or security issue. The
procedures also include how to remove the youth from the internal alert system. For mental
health alerts and/or suicide risks, a qualified mental health professional is the only person who
can remove this alert. Medical staff are the only ones able to remove a youth from a medical
alert. The program director or designee is responsible for removing a youth from the alert
system for safety and security risks. A review of youth alerts confirmed the program placed
youth on the alert system as outlined in their policy and procedures. Five youth were reviewed
for alerts. All five youth had appropriate alerts entered into the Department’s Juvenile Justice
Information System (JJIS) timely. None of the alerts were applicable to be entered into the
program logbook. All alerts entered into JJIS matched the program’s internal alerts. The
program director was interviewed regarding medical issues being reviewed and the internal alert
system processes. The program director reported medical sees a youth daily for medication
management, otherwise they check in with the youth either weekly or monthly. The psychiatrist
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or psychiatric advanced practice registered nurse (APRN) may see the youth for evaluations
and follow-up medication management and monitoring for signs and symptoms. Medical also
sees the youth for urgent issues and sick call. Alerts are generated by medical. The nursing
staff was interviewed regarding the program's internal alert system. The director of nursing
(DON) is responsible for updating the medical alert system within JJIS. The nursing is also
responsible for updating the internal alerts within the facility. Five staff were interviewed
regarding notification of youth alerts for mental health, medical, and security purposes. Staff
reported they review the logbook, talk with staff, obtain information during the shift briefings,
through emails, the supervisors, and/or designated mental health clinician authority (DMHCA)
also notify the staff.
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 Case Management Record
The program maintains separate youth records for the individual healthcare records, mental
health records, and case management records. All records included the youth’s name, the
Department’s Juvenile Justice Identification (DJJID) number, date of birth, county of residence,
and committing offense. The records also included legal information, demographics,
chronological information, correspondence, case management and treatment team activities,
and a miscellaneous section. All youth records were labeled with “Confidential” and were
maintained in a locked filing cabinet within locked rooms. The filing cabinets for youth records
had a “Confidential” sticker located on the outside.
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’s community advisory board has met quarterly during the annual compliance
review period. Sign-in sheets and agendas for the meetings were provided and reviewed. The
program actively recruits advisory board members from the judiciary community, community
partners, business community, school board, faith community, victim advocate services, and
parents/guardians of youth who were previously in the juvenile justice system. The program
director was interviewed regarding the community advisory board and was able to share the
program’s policy and procedures regarding the community advisory board. An interview with a
board member was attempted; however, the board member was unavailable to be contacted
during the annual compliance review week. An email was sent to attempt contact with the
individual; however, no response was provided. The program director reported the advisory
board member requested an email be sent instead of a phone call due to issues with an illness.
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1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program maintains a policy and procedures for staff performance. The policy and
procedures include staff performance evaluations are done on an annual basis. Three job
descriptions were reviewed to ensure the staff’s performance standards were clearly identified
on the description. Five staff performance evaluations were reviewed and all performance
standards matched the job descriptions for these staff. All position descriptions reviewed also
included the implementation of the program’s behavior modification system (BMS). The program
also ensured the contractually required positions were maintained and performed as outlined in
the contract. The program’s contract also requires a recreational therapist. The credentials,
schedule, and services provided to the youth were reviewed and confirmed the recreational
therapist is meeting contractual requirements. The program director was interviewed regarding
staff turnover and staff morale. The program director included the program’s policy and
procedures for staff communication, annual evaluations, and recruitment and retention. The
program director was also asked about the performance evaluation process for staff. The
program director confirmed the program’s policy and procedures. Five staff were interviewed
regarding formal evaluations on performance. Three staff reported receiving an evaluation
yearly, one reported every six months, and one reported monthly. One of the staff reported they
just started working at the program and are not sure how often they are supposed to get
evaluations.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program has seven special contract conditions which are implemented for the youth. These
conditions include disaster clean-up, baseball/softball grounds cleaning and operating, Florida
Department of Transportation (DOT), farm share, Boys and Girls Club, Money Matters
curriculum, and assisting the House of Hope. During the annual compliance review period,
thirty-three youth participated in these activities. Twin Oaks Juvenile Development, Inc.,
maintains monthly documentation of how many youth participate in the contractual services at
the program. The program director was interviewed regarding special contract conditions;
however, the response was the program does not have contract negotiated items. A review of
documentation revealed the program is providing the special contract conditions on a regular
basis.
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.
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The program’s practice for data trend includes the program director collecting data throughout
each month on the following areas of the program: bed utilization, physical interventions, youth
behavior, abuse/CCC reports, injuries, Risk Management/Commission on Accreditation of
Rehabilitation Facilities (CARF), incentive trips, transportation, Department of Transportation
(DOT) for Leon County, training, and community service hours. This documentation is provided
to Twin Oaks Juvenile Development, Inc. management staff, who compiles all the data into a
spreadsheet for the program. This information is shared with staff and posted on the wall within
the administration building at the program. The data trends are also discussed during staff
meetings as evidenced by meeting notes. Meetings take place on the second Tuesday of every
month, which was confirmed by a review of the documentation. The data trend information is
maintained at the corporate office for Twin Oaks and shared with the management team during
the monthly meetings. As the data trends change, the program staff and corporate staff discuss
ways to improve in those specific areas.
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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.
Five youth case management records were reviewed for initial contact to parent/guardians. All
five records contained evidence the program notified the parent/guardian by telephone within
twenty-four hours of the youth admission to the program. Four of five records had evidence the
program notified the parent/guardian within forty-eight hours by mail. One youth was eighteen
years old and did not require this notification. All five records included evidence the committing
court and juvenile probation officer (JPO) was also notified within five working days from
admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
Five youth case management records were reviewed for orientation practices upon admission.
All five records contained documentation the program provided each youth orientation to begin
on the day of admission. The program’s orientation process included all required topics and
information for presentation to the newly admitted youth, to include areas such as the program
rules and expectations, behavior management system (BMS), availability and access to medical
and mental health services, emergency procedures, a facility tour, assignment to a living area,
procedures for visitation, mail, and use of the telephone, and access to the Florida Abuse
Hotline and the Department’s Central Communications Center (CCC). An observation of a new
admission was unable to be observed during the annual compliance review week. All five
interviewed youth confirmed orientation to the program included a review of program rules,
procedures, and schedules. All five youth also confirmed the process began within the first
twenty-four hours of arrival.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
One of five case management records was applicable and reviewed for written consent
requirements for youth eighteen years of age or older. The program reported having no other
youth eighteen years of age or older. The one applicable record contained documentation for
written consent prior to providing or discussing information with the parent/guardian related to
the youth’s physical, mental health, or treatment assessments and screening.
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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 classification form which includes all required elements when assessing new
youth and classifying youth based on promotion of safety and security as well as effective
delivery of treatment services. The program’s initial classification system is used to assist the
program in assigning each newly admitted youth to a living unit, sleeping area, and therapeutic
group. Five youth records were reviewed and each included evidence classification forms were
used to assess youth risks such as medical, suicide, escape, and security. A review of the
Department’s Juvenile Justice Information System (JJIS) alert information was also used in
classifying new youth. Medical, mental health, substance abuse, security, and special needs
factors are identified and entered into the program’s internal alert system and JJIS. Four of five
youth records reviewed were applicable for reclassification and included this documentation in
the case management records. All four records included evidence the reclassification assessed
an increase in the youth’s privileges and freedom of movement and participation in work
projects. One of the youth reviewed was applicable for participation in off-campus activities
based on the reclassifications done. The program has a policy and procedures regarding
reassessment. The program director was interviewed regarding the program’s classification
system. The program director stated prior to a youth being able to earn off campus privileges, a
risk assessment must be completed. Also, a vocational risk assessment must be done prior to a
youth going into a vocational class for participation. A Security Risk Assessment is done for
each youth when they first arrive. Security Risk assessments are kept for all youth in a binder.
Samples of these assessments were reviewed which confirmed the program’s practice. The
program director interview included a summary of the program’s facility operating procedures as
it relates to classification factors, procedures, and reassessments for youth.
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.
One of five youth case management records selected for review was applicable for gang
identification and notification. The program reported having only one additional applicable
record for review of gang information during the annual compliance review period, which made
a total sample size of two youth records. Based on documentation provided, both of the
applicable records included evidence local law enforcement was notified of suspected gang
activity. In addition, applicable gang alerts were entered for the youth in the Department’s
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Juvenile Justice Information System (JJIS). Neither of the youth were applicable for having to
notify a post-residential counselor. Information about both youth was shared with the
educational provider and local school district, as well as the youth’s juvenile probation officer.
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.
One of five youth case management records selected for review was applicable for gang
identification and gang prevention and intervention activities. The program reported having only
one additional record for review of gang information during the annual compliance review
period, which made a total sample size of two youth records. Both youth were identified as a
gang member or affiliated gang member. Records indicated both youth participated in gang
prevention and intervention strategies as provided by the program. Both youth performance
plans also included relevant goals and objectives related to gang intervention strategies. The
assistant program director reported they meet with the youth once a month for an informal
review to address gang involvement. In addition, the youth also participate in the Impact of
Crime (IOC) curriculum as part of their gang prevention strategies. Samples of group and
individual session sign-in sheets were reviewed which confirmed the groups are being held. The
program has a policy and procedures entitled Criminal Street Gangs, which addresses gang
prevention strategies. The program director was also interviewed and was able to reiterate the
program’s gang policy and procedures.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
Five youth case management records were reviewed for Residential Assessment for Youth
(RAY) assessments and reassessments. All five records contained a completed RAY
assessment done within thirty days of the youth admission to the program. The initial
assessments were maintained in the record as well as within the Department’s Juvenile Justice
Information System (JJIS). Reassessments were also observed in four of the five youth records
reviewed. One youth had not had a reassessment due to not being in the program long enough
to require one. Reassessments were all completed at least every ninety days after completion of
the initial RAY assessment. All reassessment documentation was maintained in the youth case
management records as required.
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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 the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
Five youth case management records were reviewed for completion requirements of the Youth
Needs Assessment Summary (YNAS). All five youth records contained documentation of the
completed YNAS, done within thirty days from the dates of admission. All were documented
within the Department’s Juvenile Justice Information System (JJIS) and each of the five listed
the youths’ top three criminogenic needs.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission. For each goal, the performance plan shall specify the target date for completion,
the youth’s responsibilities to accomplish the goal, and the program’s responsibilities to
enable the youth to complete the goal. Within ten working days of completion of the
performance plan, the program shall send a transmittal letter and a copy of the plan to the
youth’s committing court, the assigned juvenile probation officer (JPO), the parent/guardian,
and the Department of Children and Families (DCF) case manager, if applicable.
Five youth case management records were reviewed for performance plan development, goals,
and transmittal requirements. All five records contained evidence the Individualized
Performance Plan was created within thirty days of the youth admission and after the initial
Residential Assessment of Youth (RAY) and Youth Needs Assessment (YNAS) were
completed. All required intervention and treatment team members were present for each of the
five records reviewed based on signatures observed on each of the five Individualized
Performance Plans. None of the five youth were applicable for having a Department of Children
and Families case worker or Agency for Persons with Disabilities waiver support coordinator.
Parent/guardian signature sheets were documented as mailed to the parents/guardians, but
none were found returned. Treatment team signature sheets were observed filed in each youth
record. All five reviewed performance plans included all required elements, such as
individualized goals based off the top three criminogenic needs, targeted court ordered
sanctions, youth and program staff responsibilities, and target dates for completion. Two of five
Individualized Performance Plans did not list delinquency interventions within the plans. One of
five Individualized Performance Plans did not notate transition activities as required. The
assistant program director was made aware of the missing items in the Individualized
Performance Plans. All five records included documentation the program provided a copy of the
plans to the committing court, juvenile probation officer, and parents/guardians. Five youth
were interviewed and reported they participated in the development of their Individualized
Performance Plans.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
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Five youth case management records were reviewed for performance plan revisions and
incorporation of other plans into the Individualized Performance Plan. Two of five youth had
revisions based on newly acquired/revealed information. The remaining three were not
applicable. Two of five were applicable for, and revised, based on a demonstrated progress
toward completion of a goal. One of five was revised based on a demonstrated lack of progress
toward goal completion. Another was revised based on needed facilitation of transition activities
during the last sixty days of the youth’s stay in the program. All five youth Individualized
Performance Plans reviewed had references to their academic or mental health treatment plans.
None of the five youth reviewed were applicable for having a current behavior support or case
plan through the Department of Children and Families or Agency for Persons with Disabilities.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court. Additionally, the
intervention and treatment team shall prepare a performance summary prior to the youth’s
release, discharge, or transfer from the program. The program shall distribute the
Performance Summary, as required, within ten working days of signing.
Five youth case management records were reviewed for performance summaries and
transmittal requirements. Two of the five youth were not applicable for having completed a
performance summary due to the youth not being at the program long enough. Two of the three
applicable records had evidence the summaries were done every ninety calendar days as
required. One record had one summary completed three days late. Release summaries were
completed as required for all applicable youth and prepared prior to release from the program.
Performance summaries included all required elements such as youth goal status, overall
treatment progress, academic status, interaction with peers and staff, and significant positive
and negative behaviors. Two of the three summaries reviewed did not include the youths’ level
of motivation/readiness to change. All three youth records reviewed documented the youth were
allowed to read and add comments prior to signing, and youth were provided copies of the
performance summaries. The assistant program director was notified of the missing information
and conducted a re-training with the case manager. Original summaries were observed filed in
the youth case management records. All reviewed performance summaries included signatures
from all required parties. Transmittal documentation for each youth summary was observed sent
within ten working days to the committing court, parents/guardians, and juvenile probation
officers (JPO). None of the youth were applicable for requiring notification to the Department of
Children and Families (DCF). Three closed youth records were provided for review. A review of
these three records revealed each contained a release summary, along with justification for the
youth release sent with the Pre-Release Notification (PRN) to the JPOs. The PRN and release
summaries were sent at least forty-five days prior to the youth release. None of the three
reviewed youth records were applicable for sexual offender notification requirements. Signed
copies of the release summaries were retained in each of the case management records. Once
approved for release, the program provided written notification to each youths’ parent/guardian
regarding the planned release. After approval, each youth had a completed Residential
Assessment of Youth (RAY) Exit Assessment as required. Victim notification was also required
for one of three closed records reviewed. For this record, there was evidence the program
submitted the victim notification at least ten days prior to the youth release.
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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 in place to encourage parent/guardian involvement in
case management services. The program reported having family day twice annually, as well as
sending out treatment team letters of notifications, which included treatment team staffing dates.
Families are contacted for each formal and informal treatment team meeting and encouraged to
participate in the performance plan development and revisions when necessary. Observations
were made of treatment team formal reviews during the annual compliance review week which
confirmed parents/guardians were called by the program and participated in the process. Parent
satisfaction surveys were reviewed and are provided to the parents/guardians prior to each
youth release. The assistant program director was interviewed and reported each youth
receives an eight-minute phone call twice a week. In the event a parent/guardian cannot visit
the youth due to distance of travel, the youth will receive Zoom calls as needed. The program
director was interviewed and was able to reiterate the program’s policy and procedures
regarding parent/guardian involvement for youth. All five interviewed youth reported their
parents/guardians participate in case management services.
2.13 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.
Five youth case management records were reviewed for treatment team requirements. A
combination of twenty-five total formal treatment team meetings were required for all five youth
records combined. One formal treatment team meeting was documented to be held ten days
late and one was four days late. The remaining formal treatment team meetings were
documented as completed every thirty-days as required. All treatment team documentation
included the youth name, date of review, comments from team members, progress on
performance plan goals, positive and negative behaviors of youth, and synopsis of youth
progress in the program. Residential Assessment of Youth (RAY) Reassessments were
completed as required for applicable records reviewed. All formal treatment team
documentation was contained in the youth records. Required attendees were documented as
present in all but one record, which did not have a counselor signature for one youth on one
formal treatment team meeting. One formal treatment team meeting was documented as held
for November for a youth, but the signatures were dated for October. According to the assistant
program director, this was done in error. The remaining formal treatment team reviews reviewed
included documentation as required. None of the behaviors discussed resulted in physical
interventions, as the program reported having had no physical interventions during the annual
compliance review period. Informal treatment team meeting requirements were reviewed for the
initial five selected youth. A total of twenty-six informal treatment team meetings were
documented. All meetings were held bi-weekly each month alternating the formal treatment
team meetings. Informal treatment team documentation included youth name, dates of the
reviews, required meeting attendees, comments for team members, brief synopsis of youth
progress, performance plan revisions when applicable, progress with performance plan goals
and treatment progress, and reassessment results when applicable. All informal treatment team
meeting documentation was contained in each record as required. Youth parent/guardian
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participation in informal treatment team meetings were documented for each record. An
observation of a formal treatment team meeting was conducted during the annual compliance
review week. The youth was seen present, along with the case manager, treatment team
leader, and representatives from all required program areas. The parents/guardians and
assigned juvenile probation officers (JPO) participated by telephone. Representatives from each
program area discussed the status of each youth, progress and/or lack of progress in the
program, and performance plan goals. The youth was given the opportunity to speak about
behavior and provide input. All five interviewed youth reported their parents/guardians
participate in treatment team meetings. Each of the five youth also stated they are able to
discuss their skills learned during the meetings. All five youth reported staff discuss their
progress with goals during team meetings.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
Three closed youth records were selected and reviewed for transition planning and Community
Re-Entry Team Meeting (CRT) requirements. All three records contained documentation the
transition conference was held at least sixty-days prior to the youth’s targeted release date.
Documentation also indicated all required treatment team members attended the transition
conference. None of the youth reviewed were applicable for requiring notification due to human
trafficking. A review of all three youth’s transition conference activities found each noted a
review of transition activities on the youth performance plans and identified additional transition
activities as needed. Target dates for completion were noted as required, along with treatment
team leader and attendees signatures representing their acknowledgement of the transition
goals and accountability for completion. Transition plans were transmitted electronically to the
assigned juvenile probation officer (JPO) for all three closed records reviewed. One of the three
records did not include the read receipt email of acknowledgement of receipt by the JPO but
included documentation was sent by the program as required. Each of the closed records
included evidence the CRT meeting was conducted prior to the youth release. Evidence
included an invitation to participate in the CRT meeting was sent through an email invitation.
The case manager and youth participation were documented as required.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
Three youth closed records were reviewed for exit portfolio requirements. All three records
contained evidence the exit portfolio was discussed and initiated for the youth during the
transition conference. Items in each of the three exit portfolios included a state issued
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identification card, copy of the youth’s transition plan, calendar with dates, times and locations
of upcoming community events and appointments, and a completed sample employment
application. Two of the three youth exit portfolios also included a copy of the social security card
and birth certificate. One of three youth was not applicable for requiring this documentation but
did include the state issued identification as required. Vocational and educational information
was not included as this information is provided by Florida Virtual School separate from the
program requirements. All three exit portfolios reviewed were verified during the exit conference
and documentation indicated they were given to the youth upon their release from the
commitment program. Case management records indicated program staff forwarded the exit
portfolio information to the youth’s assigned juvenile probation officer (JPO) for all three youth. A
review of the program’s contractual agreement did not reveal additional requirements for the exit
portfolio.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
Three closed youth records were selected and reviewed for exit conference requirements. All
three records contained documentation the exit conference was conducted after the program
notified the assigned juvenile probation officer (JPO) of the youth release. Each exit conference
was conducted at least fourteen days prior to the release of the youth. Documentation for each
exit conference indicated the date of the conference, signatures of required parties, and a
summary of pending transition goals. A review of the Department’s Juvenile Justice Information
System (JJIS) found evidence each youth release date correlated with the date of release
indicated in JJIS. The status of each youths’ transition activities were established at the
transition conference and plans were reviewed for the youths’ release. The exit conferences
also noted provisions for continuation of education and/or employment for all three youth and
contained evidence the youth’s case manager and parent/guardian were aware of the plan,
documents, and post-release discharge plans. Exit conference participants included signatures
of representation for all required parties such as the education representative, parent/guardian,
intervention and treatment team leader, JPO, and youth. Each exit conference was held
separately from the transition and Community Re-Entry Team meetings.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has formal processes to promote constructive input by youth. The program
director was interviewed and was able to reiterate the program’s policy and procedures
regarding youth input within the program. Four of five interviewed youth reported they are able
to provide input about what happens at the program in such ways as notifying the program
director or supervisor and discussion with staff. One youth reported they were unsure how to
provide this input. The program has an agreement with the Boys and Girls Club, who holds
quarterly Student Advisory Board Meetings to discuss campus issues and activities. Samples of
meeting agendas were provided along with sign-in sheets which confirmed the practice. The
program also facilitates Juvenile Quality of Living (JQOL) surveys, which are administered by
case managers once each youth intake and then again at the youth’s exit, in the form of a Client
Satisfaction Survey, and then once again ninety-days after the youth leaves the program, they
are done over the phone with the youth by the case manager. Copies of the completed JQOL
surveys were observed in the youth records. Parent Satisfaction Surveys are also done during
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the youth transition period prior to their release. Samples of the Parent Satisfaction were
provided, confirming the practice. The assistant program director reported the program
completes Youth Surveys every six months. Survey questions consist of things such as asking
about youth treatment plans and progress with goals, any medical issues, do you feel safe in
the program, staff interaction, and therapeutic issues. Pow Wows are dorm meetings which are
held with all youth in their assigned dorm to discuss any issues youth may have. Samples of
meetings were documented in logbooks. In addition to these activities, youth participate in
formal and informal treatment team meetings regularly with team member representation from
program areas and are able to express any issues they may have during this time. Grievances
are also available for youth in the event they have issues or concerns to express formally.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program’s designated mental health clinician authority (DMHCA) is the director of
treatment, who is a licensed mental health counselor (LMHC), with a clear and active license in
the State of Florida expiring on March 31, 2027. The clinical director is an employee of the
program working forty hours on-site during the week, as well as on weekends when necessary,
providing the coordination and implementation of mental health and substance abuse services.
The program had one back-up DMHCA who is a psychologist with a clear and active license
expiring on May 31, 2026. During the annual compliance review period the backup DHMCA
provided coverage one week. The DMHCA’s position description was reviewed. The DMHCA
provides coverage twenty-four hours a day, seven days a week and additionally is on-site in the
event of any mental health emergency. The clinical director was interviewed and indicated
having the responsibility for overseeing the clinical staff to ensure they are providing the proper
care for each youth at the program. The clinical director also ensures effective mental health
services are provided and provides back-up support services and substance abuse
counseling/group therapy. The DMHCA reported communication with staff occurs daily and
supervision occurs at least once a week.
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 does not employ any other licensed staff other than the designated mental health
clinician authority (DMHCA) and the back-up DMHCA who is a licensed psychologist. The
clinical supervisor, who is the DMHCA, ensures the clinical staff working under their supervision
are performing services they are qualified to do based on job description. The licensed mental
health and substance abuse clinical staffing is in accordance with the current contract and
Florida Administrative Code. All licenses were available for review and were clear and active.
The program’s Chapter 397 license is clear and active and posted within public view at the
program.
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.
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The designated mental health clinician authority (DMHCA) reported four current, non-licensed
clinical staff working under their supervision. All non-licensed clinical staff who worked at the
program during the annual compliance review were found qualified to provide services, based
upon education, training, and experience. The program has a Chapter 397 license which
expires on July 25, 2025, and reviewed documentation verified the substance abuse services
were conducted by the DMHCA and in accordance with the current contract and Florida
Administrative Code. The programs contract requires a recreational therapist, which a review of
the program roster, credentials, and schedule confirmed all requirements were met. Reviewed
documentation confirmed the non-licensed clinical staffing coverage is in accordance with the
current contract for forty hours. The clinical director provided face-to-face direct supervision to
non-licensed clinicians for no less than one hour a week. Supervision includes reviewing
specific treatment needs or concerns, sample treatment documents, and recommendations for
continued service provision. The direct supervision documentation was recorded on a form
which included all elements of the Department’s Licensed Mental Health Professionals and
Licensed/Certified Substance Abuse Professionals Direct Supervision Log form. All four non-
licensed clinical staff held a master’s-level degree from an accredited university or college in an
appropriate human services field. Each of the reviewed non-licensed clinical staff completed
training and supervision assessing suicide risk, mental health crisis intervention, and emergency
mental health services. Each staff had their training for assessing suicide risks documented on
the non-licensed health clinical staff person’s training on the Assessment of Suicide Risk form.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
Five youth mental health and substance abuse records were reviewed or a mental health and
substance abuse screening. Each reviewed record contained a completed Massachusetts
Youth Screening Instrument –Second Version (MAYSI-2). Information reviewed for each youth
included the commitment packet, reports, and records of documentation concerning mental
health and/or substance abuse issues. Each of the MAYSI-2 assessments were completed on
the date of the youth’s admission to the program in a confidential manner. The screenings were
completed within the Department’s Juvenile Justice Information System (JJIS). Each of the
screenings were conducted by trained staff. All five of the reviewed MAYSI-2 assessments
indicated further assessment was required. In each record, a referral for further evaluation was
observed. The program does not utilize a separate clinical mental health and substance abuse
screening. In each record, the program director ensured an Assessment of Suicide Risk (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. In each record, the youth was referred for an immediate assessment. Two
of the five youth reviewed were placed on Precautionary Observation. All five records included
documentation each youth was referred for an Assessment of Suicide Risk (ASR),
comprehensive evaluation, and each included the reason for the referrals. The program director
is responsible for developing a policy and procedures for the implementation of a standardized
admission/intake mental health and substance abuse screening process. The reviewed policy
confirmed the process includes a review of commitment packet information, reports and
records, administration of the MAYSI-2 in JJIS by a qualified professional, and a referral of
youth identified by screenings as in need of further evaluation or immediate attention. The policy
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outlines staff training in mental health and substance abuse issues and administration of the
MAYSI-2, and a standardized process for youth requiring immediate attention and transfer to a
Baker Act or Marchman Act receiving unit. The interviewed program director appropriately
articulated the 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.
The designated mental health clinician authority (DMHCA) was interviewed regarding the
mental health and substance abuse evaluations. The DMHCA indicated referrals are made at
intake by case management and when screenings indicate a need. Additionally, youth are
assigned a primary coordinator who completes the substance abuse and biopsychosocial
assessments. A review of five youth records found the program completed a combined
comprehensive mental health and substance abuse evaluation for each youth. The program’s
practice is to complete a new combined comprehensive mental health and substance abuse
evaluation within thirty calendar days of each youth’s admission. All five youth evaluations were
completed within thirty calendar days of admission to the program. Consent was obtained for
substance abuse services for all five youth. Three of the five evaluations were completed by
non-licensed clinical staff which were reviewed and signed by the DMHCA within ten calendar
days of the evaluation being conducted. The remaining two evaluations were completed and
signed by the DMHCA. The new mental health evaluation included youth demographics, reason
for evaluation, relevant background information, behavioral observations, mental status
examinations, interview or procedures administered, discussion of findings, diagnostic
impressions including the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5) diagnosis, patterns of alcohol and other drug abuse, impact of alcohol and other drug
abuse on major life areas, risk factors of continued alcohol and other drug abuse, and
recommendations.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program maintains a policy and procedures outlining the program’s mental health and
substance abuse treatment services. A review of five youth records reflected an Initial
Treatment Plan was developed within seven days of each youth admission. Each reviewed plan
was documented on the program’s form and included all elements of the Department’s Initial
Mental Health/Substance Abuse Treatment Plan form. The youth’s psychiatric needs, including
medication and frequency of monitoring by the psychiatrist, was documented in all five youth
records. All five youth Initial Treatment Plans were completed by non-licensed clinical staff and
signed by the designated mental health clinician authority (DMHCA) within ten days of
completion. Each Initial Treatment Plan was signed by all treatment team members who
participated in the development of the plan. Each plan was signed by the youth, treatment team
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leader, and program management. Four of the five records documented parent/guardian
participation by telephone. The remaining record did not document parent/guardian participation
as the youth is eighteen years of age. Four of the five records reviewed were applicable for
Individualized Treatment Plan reviews. The remaining record was not due for treatment plan
review at the time of the annual compliance review. Three of the five records included
documentation of psychiatric services including psychotropic medication and frequency of
monitoring by the psychiatrist. Each treatment plan review was documented on a form which
contained all the required elements of the Department’s form. All four records included
documentation of the treatment team reviews being conducted every thirty days. Each
treatment plan review was completed by mental health and substance abuse clinical staff and
signed by the youth, treatment team leader, program management, living unit, education,
medical, program gang liaison, and transition coordinator. Three of the four records documented
parents/guardians participated by telephone. The remaining record did not document
parent/guardian participation as the youth is eighteen years of age. All four records documented
the juvenile probation officer (JPO) participated by telephone. Services and frequency were
outlined within each youth’s Individualized Treatment Plan, including individual counseling,
family counseling, group counseling, and psychiatric services. All services were individualized
for each youth. A video review of mental health and substance abuse groups for three random
days was unable to be completed due to cameras at the program being inoperative during the
annual compliance review.
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.
A review of five youth records reflected each youth was assigned a treatment team upon arrival
to the program. Reviewed treatment plan documentation and the treatment team assignment
form for each reviewed record confirmed the treatment teams were comprised of the youth,
program administration, residential living unit, education, medical staff, mental health staff, and
substance abuse staff. Three of the five records revealed the treatment team was comprised of
vocational training. The other two were not participating in vocational training. Four of the five
records indicated the treatment team was comprised of parents/guardians. The remaining
record was not applicable for parent/guardian participation due to the youth being eighteen
years of age. A review of five records reflected each was determined to need 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. A review of five youth records
found four contained an executed Authority for Evaluation and Treatment (AET) form. The
remaining record was not applicable because the youth was eighteen years of age. Additionally,
each youth record contained a signed Youth Consent for Substance Abuse Treatment and
Youth Consent for Substance Abuse Treatment Records form. All reviewed mental health or
substance abuse treatment notes were documented on the program’s form which included all
requirements of the Department’s Counseling/Therapy Progress Notes form. Reviewed
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progress notes confirmed treatment services included individual psychotherapy or counseling
and psychosocial skills training. Five reviewed treatment plans in comparison with progress
notes confirmed the youth received services as stipulated on their treatment plan. Three closed
records were reviewed for discharge plans. All three discharge plans were completed on the
Department’s Mental Health/Substance Abuse Treatment Discharge Summary form. None of
the reviewed three closed records were applicable for the youth being released on suicide
alert/precautions. Each of the three reviewed summaries documented the future services
needed. A review of documentation reflected each of the three discharge plans was discussed
with the youth, parents/guardians, and juvenile probation officers (JPO) during the exit
conference. Also, a copy of the Mental Health/Substance Abuse Treatment Discharge Summary
was provided to the youth, JPO, and parent/guardian.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
A review of the program’s contract and clinical program description found the program provides
Mental Health Treatment Overlay Services (MHOS), both intensive overlay and continuous care
overlay, to all youth. The counselor to youth ratio for mental health overlay youth are one staff to
sixteen youth. The counselor to youth ratio for intensive mental health youth are one staff to ten
youth. The program provides clinical group therapy of all required groups according to the
contract. The services include individual, group, and family therapy as part of each youth’s
treatment plan at a rate of at least five times a week, as well as receiving daily therapeutic
activities by qualified staff. Reviewed documentation confirmed group therapy sessions were
limited to no more than ten participants. The program is licensed under Chapter 397; therefore,
a qualified professional, who is the designated mental health clinician authority (DMHCA), is on
site five days each week. The program has a licensed psychiatrist who provides psychiatric
evaluations and medication management for the youth and participates in treatment planning.
Clinical staff are on-site seven days a week and counselor caseloads are limited to no more
than twelve youth for each clinician. All five interviewed youth stated they participate in
individual and family counseling. Five staff were interviewed and all five stated they do not
facilitate any mental health or substance abuse groups. An interview with the DMHCA confirmed
the program provides specialized treatment services through clinical groups according to the
contract. An interview with the program director indicated the program provides Mental Health
Treatment Overlay Services (MHOS), both intensive overlay and continuous care overlay
services only.
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 Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
The program provides psychiatric services to the youth who require this service. The contracted
psychiatrist is responsible for psychiatric evaluations, consultation, medication management,
and medical supportive counseling. The reviewed license showed it was free and clear in the
State of Florida with an expiration date of January 31, 2026. Reviewed documentation
confirmed the completion of psychiatric evaluations, medication reviews, and treatment team
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participation. The program utilizes a psychiatric advanced practice registered nurse (APRN).
The psychiatric APRN has a clear and active license in the state of Florida which expires on
April 30, 2025. The psychiatric APRN has a Collaborative Protocol which is maintained on-site.
The psychiatrist is scheduled to be on-site weekly and provides medication evaluations and on-
going monitoring of psychiatric medications. A review of sign-in/out logs confirmed visits during
the annual compliance review period were conducted as required by the agreement. The
psychiatrist is available for emergency consultation twenty-four hours a day, seven days a
week. Five youth records were reviewed and two were applicable for psychiatric services.
Documentation in both youth records indicated the psychiatrist was actively managing and
supervising each youth’s psychotropic medication services. The program has a back-up
psychiatrist with a clear and active license expiring on April 30, 2025. An interview with the
psychiatrist indicated they are responsible for completion of entrance evaluations and provision
of continuing care as needed. Additionally, the psychiatrist indicated they are on-site every
week, providing in-depth evaluations of all youth referred and providing treatment of mental
health, if appropriate, with regular follow-up appointments. Also, face-to-face or telephonic
communication with treatment team members is also facilitated. Five youth records were
reviewed, one was applicable for youth entering the program on psychotropic medication. Two
youth had prior history of psychotropic medications and were prescribed medications after
admission, and the remaining two have never been on psychotropic medications and were not
applicable for psychiatric services. The three youth applicable for psychotropic medications had
a diagnostic interview was completed on each of the three youth within fourteen days of referral.
Each youth’s initial diagnostic psychiatric interview included history of the youth, a mental health
status examination, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5) diagnosis, treatment recommendations, prescribed medications, and explanation of the
need for psychotropic medication. A review of three applicable youth records indicated each
youth was prescribed psychotropic medication related to the youth’s diagnosis. Each diagnostic
interview included target symptoms, initial treatment goals, potential side effects, risks, and
benefits of taking the medication, and frequency of medication monitoring/management. A
review of each applicable youth’s treatment plan verified the plan was consistent with the DSM-
5 diagnosis and included treatment recommendations. The initial diagnostic interview was
documented on the Department’s Clinical Psychotropic Progress Note (CPPN) form. One of the
three initial interviews had “Initial” written on the form at the time of the review. The designated
mental health clinician authority (DMHCA) was made aware of the issue and marked “Initial” on
the forms in front of the reviewer. Five youth records were reviewed, and two youth started
taking psychotropic medications after admission to the program. Each of the three applicable
youth records documented youth were seen for medication reviews by the psychiatrist at least
once every thirty days. The psychiatric evaluations were documented on the Department’s
CPPN form for each youth. The Department’s CPPN included the youth’s identifying data,
diagnosis, target symptoms of each medication, evaluation, description of effect of prescribed
medication on target symptoms, prescribed psychotropic medication including name, dosage,
and name of the medication, side effects of the medication, and the youth’s adherence to the
medication regime. The youth’s height, weight, blood pressure, most recent serum drug levels,
and/or laboratory findings were included with the Individual Healthcare Records. Also, each of
the three CPPN’s indicated there was telephone contact with the parents/guardians to discuss
medication when necessary. The psychiatrist signed and dated each of the three reviewed
CPPN’s. The monthly monitoring of Tardive Dyskinesia was documented for the reviewed
youth. The program does not utilize tele-psychiatry services.
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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 the implementation of a Suicide Prevention
Plan. The program maintains a Suicide Prevention Plan which was last reviewed and signed by
the designated mental health clinician authority (DHMCA), program director, and the psychiatrist
on October 31, 2024. A review of the plan reflected the identification and assessment, staff
training, suicide precautions, levels of supervision, referral, communication, notification,
documentation, immediate staff response, and a review process were included. The review
process for suicide attempts and mortality review included circumstances surrounding the event,
facility procedures relevant to the incident, relevant training received by involved staff, pertinent
medical and mental health services involving the victim, possible precipitating factors, and
recommendations.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
A review of five youth records indicated none were applicable for suicide risk. The program
provided two additional records for review. There were no additional applicable youth during the
annual compliance review period. Each of the two applicable youth were identified as a suicide
risk by staff observation. Both youth were placed on precautionary observation status and
assessed the same day. The Assessments of Suicide Risk (ASR) were completed on the
Department’s ASR form. Both youth were maintained on constant supervision upon immediate
completion of their Assessment of Suicide Risk (ASR). Documentation verified the
parents/guardians and assigned juvenile probation officer (JPO) were notified of the youth’s
potential suicide risk. Documentation in each youth record indicated mental health staff provided
supportive services. One ASR was completed by non-licensed staff and the second ASR was
completed by the designated mental health clinician authority (DMCHA). One youth’s ASR was
completed by an appropriately trained non-licensed staff and reviewed by a licensed staff within
twenty-four hours. As a result of the suicide risk assessment both youth were placed on
precautionary observation. Both ASRs were completed within twenty-four hours of
screening/concerns. Both reviewed ASRs included documentation the parents/guardians were
notified of the youth’s potential suicide risk. The parent/guardian and juvenile probation officer
(JPO) notifications were documented on the ASRs. Neither of the youth were removed from
precautionary observation as a result of the initial ASRs. One youth had an ASR completed
immediately due to the youth being in crisis at the time. Both youth received a follow-up ASR
prior to being removed from precautionary observation which was documented on the
Department’s Follow-Up ASR form. Both youth were maintained on suicide precautions until a
Follow-Up ASR was completed and indicated the youth could be stepped down to a lower level
of supervision. Both youth were maintained on close supervision until it was determined as no
longer necessary by the DMHCA. All steps to lower each youth’s supervision followed the
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program’s suicide prevention plan steps. A review of the Department’s Juvenile Justice
Information System (JJIS) indicated the suicide risk alert was closed accurately following the
recommendations of the Follow-Up ASR. A review of the facility logbook included
documentation the administration provided instructions related to suicide risk for each of the
youth. Both youth were allowed to participate in select activities with other youth in designated
safe housing areas as indicated on the precautionary observation logs. At the time of the annual
compliance review, the program’s camera system was inoperative, therefore, a review of video
to verify precautionary observation procedures were followed was unable to be completed.
3.12 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated non-
applicable.
3.13 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program maintains a Suicide Prevention Plan which outlines levels of supervision and the
process for recording observations of youth on suicide precautions. A review of five records
indicated none were applicable for suicide risk. The program provided two additional records for
review. Each youth record contained documentation where a Suicide Precaution Observation
(PO) Log was maintained for the duration the youth was on precautions. Youth behaviors were
documented in real time and not exceeding thirty-minute intervals for each youth. One youth
was applicable for warning sign observations and documentation indicated notification was
provided to the program director and designated mental health clinician authority (DHMCA).
Additionally, each of the reviewed PO logs indicated review and signature by the shift supervisor
and mental health clinical staff. Both youth PO logs documented safe housing requirements.
3.14 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program maintains a Suicide Prevention Plan which outlines suicide prevention training
requirements. A review of five pre-service and five in-service training records documented staff
completed the required suicide prevention training. The program has a fully equipped suicide
response kit in each of the four dormitories, one in medical, and one in each of the three
transport vehicles, all co-located with first-aid kits. The program is required to complete one
mock suicide drill for each shift at least quarterly. A review of suicide drills since the last annual
compliance review reflected the program conducted a quarterly drill for each shift as required.
All reviewed drills were conducted during the morning shift change and included both day and
night shift staff. Reviewed drills consistently included the use of lifesaving measures to include
the use of cardiopulmonary resuscitation (CPR), suicide kits, first-aid kits, and an automated
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external defibrillator (AED). Documentation verified staff who were not present during a
quarterly drill had the opportunity to review each drill scenario and procedure to understand the
process and receive the necessary training to respond to an incident of a suicide attempt or self-
inflicted injury within the program. At the time of the annual compliance review, the program’s
camera system was inoperative; therefore, it was unable to be determined if all drills were
simulated and whether the program youth were utilized in the simulated drills. The interviewed
program director reported the program conducts monthly training on emergency drills. Five staff
were interviewed and able to explain the process for responsibilities when youth express
suicidal thoughts and where the suicide kits were kept. Additionally, four out of the five
interviewed staff stated emergency and suicide drills are conducted monthly on their shift. The
remaining staff acknowledged participation in emergency and suicide drills but was unable to
articulate the frequency of the drills.
3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has an integrated mental health crisis intervention and emergency mental health
and substance abuse services plan. A review of the plan verified it included notification and alert
system, means of referral including youth self-referral, communication, supervision,
documentation, and review.
3.16 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 an integrated mental health crisis intervention and emergency mental health
and substance abuse services plan. A review of five records indicated none were applicable for
the review of crisis assessments. The program had one applicable youth during the annual
compliance review period and provided this record for review. The youth was determined to be
in crisis and received a Crisis Assessment immediately. The Crisis Assessment included the
reason for assessment, mental health status examination and interview, a determination of
danger to self and/or others, initial clinical impressions, supervision and treatment
recommendations, and recommendations for follow-up. The Crisis Assessment was conducted
by the designated mental health clinician authority (DMHCA). The youth was assessed
immediately after the referral and was found not to be in crisis; therefore, notification to
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parent/guardian of follow-up treatment was non-applicable. No follow-up crisis assessment or
Prison Rape Elimination Act (PREA) event was determined or required.
3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has an integrated mental health crisis intervention and emergency mental health
and substance abuse services plan. A review of the plan included 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 Chapter 394 Florida Statutes (Baker Act), transport for emergency substance
abuse assessment and treatment under Chapter 397 Florida Statutes (Marchman Act),
documentation, training, and review were documented. The program utilizes a local behavioral
health center for Baker Act crisis stabilization and substance abuse Marchman Act.
3.18 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker Act or Marchman Act procedures during the annual
compliance review period; therefore, this indicator is rated non-applicable.
3.19 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.
A review of five youth mental health records was conducted in reference to safety planning.
Reviewed documentation found all five plans were completed within fourteen days of admission
and jointly prepared by the youth, parents/guardians, and the program’s clinical staff. Each
safety plan incorporated recommendations from previous or current clinical assessments and/or
screening instruments and incorporated trauma responsive practices. Two of five safety plans
were updated every thirty-days or following any significant behavioral event identified by the
youth’s intervention and treatment team. Three safety plans were not updated every thirty-days
or following any significant behavioral event identified by the youth’s intervention and treatment
team. One youth’s plan was reviewed ten days late; one youth’s plan was reviewed four days
late; and one youth’s plan was reviewed five days late. Each reviewed safety plan contained
warning signs indicating a youth was escalating in their behaviors. Each safety plan included the
youth’s baseline behavior gathered from collateral contacts, parents/guardians, youth history,
and evaluations. All records included documentation of the youth’s and program staff’s
perception of verbal and non-verbal stimuli which positively and negatively affect the youth. All
safety plans included jointly developed coping strategies, to include people and healthy
environments as defined by the youth, intervention strategies preferred by the youth, and a
debriefing process. The safety plans were maintained in the youth’s case management file and
within a centralized binder in master control, easily accessible to all staff. Five interviewed youth
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reported they contributed to the development of their safety plan. The interviewed program
director reported safety plans are 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 has a licensed medical doctor (MD) with specialty training in internal medicine who
serves as the designated health authority (DHA). The DHA holds an unrestricted license and
meets all requirements for independent and unsupervised practice in Florida. The DHA has a
clear and active license, expiring January 31, 2026. The DHA did not have any disciplinary
cases or public complaints on record for annual compliance review period. The program does
not have a physician’s assistant (PA) or advanced practice registered nurse. The DHA is
contracted to be on-site one time each week and if the DHA is not available the youth can be
seen by another doctor at their practice if the youth are transported to the office. The contract
with the DHA specifies the DHA does not need to come on-site if there are no youth to be seen;
however, the Department’s Office of Health Services (OHS) reported the DHA should be on-site
every week unless they were unavailable. A review of sign-in and sign-out logs for the duration
of the annual compliance review period showed the DHA was not on site for a total of fourteen
weeks during the annual compliance review. The program utilizes a back-up DHA who has an
active license, expiring on January 31, 2026. This doctor is not the official DHA back-up as there
is no contract with the Department; however, the doctor has seen youth on one occasion during
the annual compliance review period, in the absence of the DHA. It was unable to be
determined if the fourteen weeks the DHA was not on-site was due to their unavailability;
therefore, after consultation with OHS, technical assistance will be provided. An interview with
the DHA revealed they review policy and procedures annually and as needed, perform
comprehensive physical assessments (CPA), and conduct periodic evaluations. Chronic clinic
initial paperwork is completed upon admission. All labs and x-rays are reviewed and signed off
when on-site. The DHA is on-site weekly when needed and when not on site, the youth can be
brought to the DHA’s office for evaluation and treatment. The DHA meets with the staff during
on-site visits and is available by phone twenty-four hours a day.
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 licensed nurses to include on-site nursing coverage provided by
registered nurses (RN). The program has not utilized any licensed practical nurses (LPN) during
the annual compliance review period. The three RNs provided medical services during the
annual compliance review period. Each of the three RNs had clear and active licenses in
accordance with the Florida Department of Health. Each of the three nurses had current
cardiopulmonary resuscitation (CPR) certifications. The program’s required on-site hours for the
nursing staff were in accordance with contract; seven days a week for twelve hours a day. The
program’s nursing staff were found in compliance with contract requirements which include the
provision of three nurses. All three RNs have clear and active licenses in the State of Florida.
One expires April 30, 2025, and two expire April 30, 2026.
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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 facility operating procedures (FOP) for all health-related procedures and
nursing protocols, all of which were developed and approved by the designated health authority
(DHA). The DHA, program director, and nursing staff all completed an annual review of the
policies and protocols. The DHA and two nurses signed on August 27, 2024, the program
director signed on November 12, 2024, and the last nurse reviewed the policies on September
23, 2024. The psychiatrist did not sign the FOPs even though psychiatric services are provided
on-site. The program had one newly employed health care personnel during the review period
who received a comprehensive clinical orientation to the Department’s health care policies and
procedures. Training was given by a registered nurse or designated licensed health care
professional. The approval of treatment protocols or standing procedures are written and
authorized by the DHA.
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.
A review of five youth Individual Healthcare Records (IHCR) was conducted for completion of
the Authorization for Evaluation and Treatment (AET). Each of the five youth had an AET filed
within their IHCR. Four of the AETs were signed by the parents/guardians. One record reviewed
was applicable for a youth who is eighteen or older. The AET on file was signed by the youth
and a release of information was not applicable as the youth has not released any information
while at the program. There were no AETs found where a parent/guardian refused to sign. Each
of the five AETs were valid and did not need a court order. None of the reviewed youth records
were applicable for being under the care of the Department of Children and Families. Each of
the five AETs reviewed had a signature by a Department representative. An interview with the
nursing staff revealed when a new AET is required, the nursing staff will contact the parent to
see if the AET can be received by email or fax. The program will mail out the AET to the
parent/guardian to fill out and send back to the program. If there is an issue in obtaining the new
AET by mail, email, or fax, then the juvenile probation officer (JPO) will be contacted to retrieve
the documentation for the program. When a youth turns eighteen in the program or comes into
the program at eighteen or older, an AET is signed by the youth, giving consent for treatment.
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.
A review of five youth Individual Healthcare Records (IHCR) was conducted for completion of
parental notification/consent. Four of the five IHCRs reviewed were applicable for parental
notification for over-the-counter (OTC) medications beyond those covered by the Authority for
Evaluation and Treatment (AET). Each of the four records reviewed had documentation a
consent was provided by the parent/guardian and was stored in the IHCR. Four of the five
records reviewed were applicable for having new medication ordered, with each record having
documentation of attempted contact made to the parent/guardian in progress notes, along with
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the Parental Notification form being completed. One youth record indicated the youth was taking
psychotropic medication at the time of admission. For the youth on psychotropic medication,
there was documentation staff witnessed all telephone call attempts and conversations to the
parent/guardian. For any significant changes to the youth’s medications, parent/guardian verbal
consent was received and documented under the Parental Notifications form and the nurse
progress notes. There were no youth under the care of the Department of Children and
Families. Each of the five youth IHCRs reviewed had documentation where the program
received and verified vaccinations within thirty days of the youth’s admission to the program.
None of the youth were applicable for obtaining new vaccinations or requests for religious
exemption. The Director of Nursing (DON) reported all youth come in with their immunization
records. If the records are not with the youth at admission, the program uses Florida Shots to
obtain new records or to verify the records on hand. An interview with the nursing staff revealed
all parental notifications are made through phone calls when medication is changed and when a
health issue arises, then a letter is sent out regarding the situation. All parental notifications are
made at the time of the event or shortly after the event has happened. If contact cannot be
made with the parent within twenty-four hours, then the juvenile probation officer (JPO) is
contacted for assistance in obtaining consent. For an emergency situation, the health of the
youth is priority, and emergency medical services will be accessed for transportation for
evaluation and treatment of the youth. The designated health authority (DHA), director of
nursing (DON), program director, and parents/guardians will be notified of the situation
immediately. In the event a youth starts new psychotropic medications, increases, decreases, or
discontinuations are made, consent is obtained by phone during the visit with the doctor, nurse,
and youth present. After consent is obtained, a parental notification form is mailed out to the
parent. Vaccinations are not provided on-site and the immunizations records are available when
the youth comes into the program. A review of the record is completed the same day when a
youth is admitted to the program. For exemption from immunization, the parent/guardian must
complete the Religious Exemption form which is provided by the Health Department. After
completion at the Health Department, the form is then submitted to medical. The information is
also located on the internal medical alerts system.
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.
A review of five youth Individual Healthcare Records (IHCR) was conducted for completion of a
Facility Entry Physical Health Screening (FEHPS). Each of the youth had a FEHPS completed
by a registered nurse (RN) on the day of admission. Two of the reviewed IHCRs showed the
youth had a change in physical custody greater than twenty-four hours. For both youth, the
program completed a new FEPHS upon the youth’s return to the program. An interview with the
nursing staff revealed all youth are seen by medical upon arriving to the program. Emails are
sent stating when a youth will be admitted into the program. The designated health authority
(DHA) and psychiatrist are notified by phone of the admission. The admission screening is
completed by medical staff. When physical custody has been broken, a new FEHPS is
completed along with a urine drug and nicotine screening.
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4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
A review of five youth Individual Healthcare Records (IHCR) was conducted for completion of a
youth orientation to healthcare services. Each of the youth records had documentation of
receiving a general care admission orientation. Each orientation included all required topics.
The program requires each youth to sign an orientation completion sheet which is located in the
IHCRs. Health Education is documented on the required Department form and covers all topics
at admission, and as needed thereafter.
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.
A review of five youth Individual Healthcare Records (IHCR) was conducted for completion of
notification to the designated health authority (DHA) and/or designee. Three of the five reviewed
youth were applicable for known suspected chronic conditions. Each youth record had evidence
of a referral to DHA. There were no youth in need of emergency care upon admission. All five
records included documentation the DHA was notified of the youth’s admission to the program
within twelve hours. One of the five records indicated a youth was taking psychotropic
medication at the time of admission and the psychiatrist was notified. An interview with the
nursing staff revealed the DHA is notified by nursing staff when the youth arrive at the program.
The notifications to the DHA are documented in the youth’s IHCR on the admission note.
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.
A review of five youth Individual Healthcare Records (IHCR) was conducted for completion of a
Health Related History (HRH) form. Four of the five reviewed IHCRs showed a completed HRH
within seven calendar days of admission. One IHCR did not have an initial date on the HRH.
The youth was admitted to the program on July 16, 2024, and the HRH was reviewed by the
designated health authority (DHA) on July 18, 2024. Each of the five HRHs were completed
prior to the Comprehensive Physical Assessment (CPA) and were reviewed by the DHA. An
interview with the nursing staff revealed the DHA is responsible for completing the HRH form
within seven days of admission.
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.
A review of five Individual Healthcare Records (IHCR) was conducted for completion of a
Comprehensive Physical Assessment (CPA). Each of the youth had a new CPA completed
within seven days of admission. One record had a CPA completed at the time of admission,
although a new CPA had already been completed. It is the practice of the program to complete
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a new CPA each time a youth is admitted, even if one is already on file. Each CPA was
completed by the designated healthcare authority (DHA). There was no indication of any
missing or incomplete elements on the reviewed CPAs. All sections of the CPA were completed
in full utilizing an “O” and/or applicable “X” markings. Each of the youth refused the genital
examination and subsequently documented the refusal. Each of the IHCRs had the
Department’s problem list updated as required. Additionally, results of each youth’s
Tuberculosis Skin Test (TST) were documented on the CPA and Department’s Infectious and
Communicable Disease (ICD) form. An interview with nursing staff revealed the DHA completes
a new CPA upon admission and when additional reviews are needed. Tuberculosis screenings
are completed upon admission and annually. The program is an all-male program; therefore, is
not applicable for gynecological services.
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.
A review of five Individual Healthcare Records (IHCR) was conducted for completion of sexually
transmitted infections (STI) screening. Each of the five IHCRs reviewed had a youth who was
sexually active and was referred to the designated health authority (DHA). Each of the five
youth were screened and evaluated. None of the reviewed youth required further evaluation.
There is evidence each youth was offered counseling, testing, and if indicated,
treatment/referral for human immunodeficiency virus (HIV). One of the four reviewed IHCRs
included documentation one youth received HIV testing. There was documented consent for the
HIV testing and the results were filed in a sealed envelope marked “Confidential”. There was
evidence of documentation of pre/post-test counseling documented on the Individual Health
Education Record (IHER) and nurse progress notes. The youth’s confidentiality was protected
by not including the youth’s HIV status and any other STI diagnosis on the program’s internal
alert system. The program maintains policy and procedures which reflect HIV test results are
only disclosed to the youth and other entities as described in Florida Statute, Chapter 381. The
director of nursing (DON) reported the Liberty County Health Department provides HIV pre- and
post-testing and counseling services for the youth at the program. Each of the five interviewed
youth reported they can request a HIV/AIDS test at any time. An interview with nursing staff
revealed upon admission the STI form is completed. During the initial intake process and when
an issue presents, the DHA will send the youth to the local health department to have further
testing and treatment if needed. STI screenings are completed on the STI form; referrals are
written on the DHA order and testing is documented in the Health Education section of the
IHCR. If a youth consents to testing which is achieved by completing the STI form, that youth
will be evaluated by the DHA and sent to the local health department, HIV test results are kept
in the youth's IHCR in a sealed envelope with confidential stamped on them. All testing and
counseling services are completed at the local health department after the youth has consented
to testing by completing the HIV form located in the youth's IHCR.
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.
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A review of five Individual Healthcare Records (IHCR) was conducted for a review of the sick
call process. Three of the five records were non-applicable. An additional record was requested
and provided for a sample size of three. An additional record was provided for review to make
the minimum requirement of three. None of the youth had similar sick call complaints three or
more times within a two-week period. Each of the three youth and the nurse completed a sick
call request form. Each of the three youth’s sick call request forms were filed in the IHCRs. No
youth were placed on restricted housing. Each of the three IHCRs had documentation of sick
call forms or progress notes documented as required. Each of the three youth’s sick calls were
documented on the Sick Call Index and Sick Call Referral Log. The dates listed on each Sick
Call Index corresponded to the completed Sick Call forms located in each IHCR. A review of the
daily schedule, posted schedule, and nurse interview confirmed sick call was conducted daily.
Sick call hours and forms are posted outside medical and on youth dorms. The sick call times
for Juvenile Unit for Specialized Treatment program are Monday through Friday 9:30 a.m. and
3:10 p.m., Saturday, 9:45 a.m. and 2:15 p.m., and Sunday, 9:45 a.m. and 4:45 p.m. For Twin
Oaks Vocational Academy (TOVA) II program, the sick call times are Monday through Friday
10:00 a.m. and 5:00 p.m., Saturday 9:45 a.m. and 2:15 p.m. and Sunday 9:45 a.m. and 4:45
p.m. According to the director of nursing (DON), only licensed nurses conduct sick call. The
program has written policy and procedures identifying review of sick call requests for non-
medical staff if there are no licensed medical staff on-site. An examination table was observed
in the medical clinic. During the annual compliance review week, a sick call was able to be
observed. The youth was escorted to sick call by the case manager. Once in medical, the
medical provider identified themselves and stated why the youth was there. The youth was seen
in a private room in the medical clinic with no other youth present to hear the examination. The
youth was examined by the DON while the staff stood at the door away from the youth in order
to maintain privacy and supervision. Five youth were interviewed. One youth answered they are
able to see the nurse immediately, two answered they can be seen within one day, one
answered within three days, while one youth stated never having to request a sick call. An
interview with nursing staff revealed any youth requesting to see the nurse will be seen at
designated times during sick call or at the time of request. The designated health authority
(DHA) will see youth during weekly on-site visits. Sick calls are conducted on-site, seven days a
week at the designated times by the registered nurse (RN). The DHA will conduct sick calls on-
site if they are scheduled. Sick call is located in the medical clinic in the medical exam room.
When a youth presents with the same sick call complaint two times within a two-week period,
the youth is seen by the DHA. The program has approved DHA treatment protocols.
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.
A review of five youth Individual Healthcare Records (IHCR) was conducted for a review of the
episodic/first aid/emergency care process. Three of the five records were non-applicable. An
additional record was requested and provided for a sample size of three. All three records
indicated the youth required on-site first-aid or episodic care. Each of the three applicable
IHCRs had documentation the on-site care was provided by licensed healthcare staff and was
documented either in problem-oriented or standard narrative charting. There were no instances
of youth receiving episodic, first-aid and/or emergency care by non-healthcare staff. The
program maintains episodic and emergency care procedures. There are a total of eighteen first-
aid kits located throughout the program. The first-aid kits are located in four dorms,
administration office, education classroom, medical run pack, kitchen, vocational building,
carpentry, mobile one, mobile two, mobile three, mobile four, Department of Transportation
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(DOT), and the supervisor office. Six of the eighteen kits are utilized for transportation. The
registered nurse (RN) conducts monthly checks on each first-aid kit and documents it in the
first-aid kit logbook. A review of the logbook was conducted and found no issues. Each first-aid
kit contains a sheet at the front with contents and expiration dates. The RN will replace expired
contents and re-seal the kits as needed. If a first-aid kit is used, the staff will bring the used first-
aid kit to medical for inventory and to be re-sealed. A random review of three first-aid kits was
conducted in mobile one, mobile four, and administration. Each of the three first-aid kits had no
discrepancies. The program has one automated external defibrillator (AED) located in the
medical clinic. One of the RNs reported there are no written procedures for the AED, as the
AED gives verbal commands once powered on. The training coordinator for the program is
responsible for ensuring the AED batteries and pads are operable. Nursing staff conducted a
self-test of the AED with no issues observed. A review of documentation confirmed the AED
batteries are set to expire July 31, 2029, while the AED pads are set to expire on February 11,
2026. The AED batteries and pads were both changed on January 25, 2024. While conducting
the facility tour, a list of emergency numbers was observed posted in the medical clinic and
were accessible to non-licensed and licensed staff. The numbers are not accessible to youth. A
review of documentation confirmed direct care staff are appropriately trained on the
administration of the epinephrine auto-injector by the director of nursing (DON). A review of five
training records were reviewed confirming training requirements were met regarding episodic,
first-aid, and emergency care. A review of the program’s episodic, first-aid, and emergency care
drill documentation reflected drills were completed on each shift, quarterly, at a minimum, during
the annual compliance review period. The drills consisted of both announced and unannounced
type drills. All the drills conducted included the administration of cardiopulmonary resuscitation
(CPR) techniques. This afforded each direct care staff the ability to participate in at least one
drill which included the use of CPR, annually. There was one staff who did not have a drill
consisting of the use of CPR during the annual review period. The program reported this staff is
considered direct care; however, does not have interactions with youth and works part-time. The
main job of this staff is to run errands, such as picking up medications. In addition, each of the
reviewed drills included the initiation of emergency procedures and addressed the application of
first-aid practices. Each drill is documented and stored in the program’s drill logbook. Video was
unable to be reviewed during the review week due to it being inoperable. The program has a
policy and procedures which outline the use, access, and inventory of Naloxone. All staff will be
trained to recognize general signs and symptoms of opioid overdose and to administer
Naloxone nasal spray. Naloxone will be available by trained staff twenty-four hours a day. All
Naloxone use, by staff, will be documented and reported to program director, who will then
notify the appropriate chain of command. Nitrile gloves will be stored with Naloxone. The policy
does not cover inventory. Five staff were interviewed. Each of the staff stated they are allowed
to call 9-1-1 if a youth has a medical emergency. Five youth were interviewed and each of the
youth stated they are able to see a doctor and a dentist if needed. An interview with the nursing
staff revealed first-aid kits are located in each dorm, education, administration, supervisor office,
chow hall, DOT, and medical. The program has a total of eighteen first-aid kits. An episodic form
is completed and documented in the youth’s IHCR and in the episodic logbook for medical staff.
If non-healthcare staff provides episodic care, then all documentation will be recorded on the
Department’s Office of Health Services form. When youth are sent off-site for emergency care,
the youth is placed on the calendar and communication is made daily on the nurses'
communication note on each shift. The program has an AED located in the medical clinic. The
AED verbally guides staff on how to proceed with treatment when turned on for usage. Medical
staff checks to ensure the AED batteries and pads are operable. Emergency drills are
conducted each quarter and CPR is conducted during most of these drills. Emergency numbers
are located in the medical exam room, the medical office, and supervisor office. These numbers
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are not accessible to the youth. Emergency medical drills are conducted quarterly. Drills are
called for staff participation.
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.
A review of five youth Individual Healthcare Records (IHCR) was conducted for completion of
off-site care referrals. One of the five records were applicable. Two additional records were
requested and provided for review for a total of three records. For the three applicable IHCRs,
each indicated the youth required off-site care. Each of the three IHCRs indicated the Summary
of Off-Site Care Consultation Report was utilized and filed. Two of the three incidents were not
logged on the Episodic Care Log. The director of nursing (DON) stated incidents are logged on
the nursing calendar. Both incidents took place on a Saturday when the DON was not on-site.
Each of the three IHCRs contained parental notifications, discharge documents, and
documented review of discharge documents by the designated health authority (DHA). Two of
the three applicable records indicated a need for follow-up testing, referrals, or appointments,
and had documented evidence of completed follow-up visits. An interview with the nursing staff
revealed a youth is placed on the calendar and on the daily nurse communication note for off-
site care. When hospital orders are placed, all orders are transcribed onto the youth’s
Department Medication Administration Record (MAR) after continuation of the order by the
DHA. When on-site, the DHA reviews all documentation. This information is kept on the nursing
calendar for the DHA to review. The nursing staff puts all information in the IHCR and on the
nursing 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.
A review of five youth Individual Healthcare Records (IHCR) was conducted for completion of
chronic condition/periodic evaluations. Three of the five IHCRs were applicable for having a
chronic condition. None of the youth were identified as having a communicable disease. Two of
the five youth were actively taking prescribed medication on an on-going basis. One of the five
youth was undergoing treatment for a physical health condition. One of the five youth was
classified with medical grade two to four. Two of the three youth were applicable for periodic
evaluations. The third applicable youth was taken off the chronic list due to a change in dietary
conditions. Two of the three youth were placed on the chronic illness list and also received
periodic evaluations at least every ninety days. None of the youth received evaluations off-site.
There were no indications of lapses in care or missed periodic evaluations. Each of the three
IHCRs confirmed the Department’s Problem List was updated in accordance with the Health
Services Rule. The program director was interviewed regarding the program’s formalized
procedures regarding communication with healthcare staff for important youth medical issues.
The program director revealed a treatment team is formally held each month for each youth and
an informal meeting is also held bi-weekly to review important medical issues with healthcare
staff. An interview with the designated health authority (DHA) revealed periodic evaluations are
conducted every three months, if not sooner. All chronic paperwork is pulled on admission and
completed with a youth’s comprehensive physical assessment (CPA). An interview with the
nursing staff revealed all chronic condition youth are put on the internal medical alert for review.
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All youth with chronic conditions are put on the nursing calendar every ninety days or sooner for
evaluation by the DHA after the initial diagnosis is made by the DHA.
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.
A review of five youth Individual Healthcare Records (IHCR) was conducted for completion of
medication management practices. One of the five IHCRs was applicable for being admitted on
psychotropic medications. For the applicable record, the Facility Entry Physical Health
Screening (FEPHS) form and progress notes were completed, indicating the youth was
admitted with medications. Documentation confirmed the medication was verified and
documented in the Chronological Progress note in the IHCR. Documentation confirmed the
designated health authority (DHA) and the psychiatrist were contacted to obtain the prescription
to resume the specified medications prior to admission. Each of the medications for the
applicable record had a current and valid prescription. No youth were placed in restricted
housing. Each of the five IHCRs indicated youth were given over-the-counter (OTC)
medications which were not listed on the authority for evaluation and treatment (AET) form.
Each of the five IHCRs indicated that the OTCs were administered according to approved
protocols. Each of the five IHCRs had start and stop dates for medication on the individual
medication administration record (MAR). Three of the five IHCRs indicated non-healthcare staff
assisted in the delivery of medication, documenting initials for each administered medication
entry. There were no lapses or errors in medication administration for the annual compliance
review period. Weekly side-effect monitoring was documented on the MARs. One of five youth
refused medications by signing the refusal of treatment form and on the MAR. A total of fifteen
MARs were reviewed for the five youth selected. One youth had incorrect allergies listed and
the wrong Department of Juvenile Justice Identification (DJJID) number listed on three out of
seven MARs. For this same youth, four out of the seven MARs did not have proper medical
alerts listed and were missing a photo of the youth. One youth was missing the medical grade
on one MAR. And two youth had a missing photo on one MAR for each youth. Three of the five
IHCRs included documentation the youth initialed each medication entry as required. None of
the reviewed youth required parenteral medication. One of the five youth was applicable for
being prescribed psychotropic medication at the time of admission. Documentation in the IHCR
confirmed that the DHA and psychiatrist were notified upon admission. The youth received an
initial diagnostic psychiatric interview within fourteen days of admission and received a review
every thirty days. There were no standing orders, emergency treatment orders, or pro re nata
(PRN) orders for psychotropic medication. Medication delivery shall be the sole responsibility of
the nurse/staff during the time of administration. A medication pass was observed during the
annual compliance review week. The youth approached the nurse individually and was escorted
by the mental health clinician. The nurse identified themselves, verified the Six Rights of
Medication Administration, prepared, and administered the medication, and checked to ensure
the youth swallowed the medication. The youth received OTC medication, which was
documented on the MAR. There were no medications observed to be pre-poured. Five youth
were interviewed and four stated they are provided medication by the nurse. One of the five
youth stated they do not take medication. Each of the five youth stated they are provided the
medication in a cup, get water, take the medication, and then are checked by completing a
mouth swab. An interview with the nursing staff revealed when a youth is admitted with
medications, all medications are verified with the parent/guardian, prior program, pharmacy, or
the doctor, by the on-duty nurse. All information is documented in the youth's IHCR on the
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admission nurse note. Non-healthcare staff do not verify medications at the program. The
program uses the standard Department MAR form. Non-healthcare staff are trained in
medication administration by the registered nurse (RN). This documentation is kept at medical
in the MAR book. Medication passes are conducted daily at 7:00 a.m. and 6:00 p.m., or as
needed. The program has a modified Class II pharmacy permit. The program uses a provider
for all medications. All orders are faxed to the pharmacy and picked up when they are ready.
The psychiatrist is on-site weekly. Upon weekly on-site visits, the psychiatrist evaluates the
youth, weekly side effects, medication management, and the youth behavior.
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.
An observation of medical equipment classified as sharps confirmed the items are secured and
inventoried utilizing a routine perpetual inventory descending count as each sharp was used
and then disposed. Additional observation confirmed all medications are identified and secured
in the locked area designated for storage of medications. The medication cart was observed as
clean and organized. All controlled substances had a perpetual inventory and were stored
separately from other medications and locked behind two locks. All medications were locked
and inaccessible to youth. The program had no medications which required refrigeration at the
time of the review. This refrigerator was observed in the medical clinic. The program has a
pharmacist that comes on-site monthly and destroys any expired or discontinued medications
which was verified on the disposal log. Observation also confirmed that perpetual and weekly
inventories of all sharps and over-the-counter (OTC) medications was completed along with
shift-to-shift inventory count of all controlled substances and two signatures were observed. Six
training records were reviewed for non-healthcare staff who were trained by the registered
nurse (RN) annually in the administration of medication. A review of three controlled
substances, three OTC medications, along with two sharps were observed, with no issues in the
inventories. The director of nursing (DON) reported if there is a discrepancy it will be verified
with another person present (supervisor or medical staff). If the discrepancy is confirmed, it is
reported to the program director, the prescribing doctor, and the Department’s Central
Communications Center (CCC). Corrective action and follow-up training is then conducted. An
interview with the nursing staff revealed the pharmacist comes on-site once a month to destroy
medications, conduct medication administration record (MAR) reviews, and medication storage.
All medications are inventoried daily by two staff who verify counts and ensure the medication is
locked behind three locks (the door, the medication cart, and the controlled substance door).
When available, back-stocked controlled substances and sharps are stored in the medical office
behind two locks. The medical staff only have access to these items. The program maintains a
copy of the Consultant Pharmacy License (CPH) on site.
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.
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The program has infection control procedures in place which include prevention, containment,
treatment, and reporting requirements related to infectious diseases, as according to
Occupational Safety and Health Administration (OSHA) federal regulations and the Centers for
Disease Control (CDC) and Prevention guidelines. The policy was reviewed by the designated
health authority (DHA) and the program director on August 24, 2024. The infection control
procedures include all required elements. Staff have access to protective equipment and
hepatitis B immunizations. There were no instances in which the local county health
department, CDC, and/or the Department’s Central Communications Center (CCC) should have
been notified of an infectious disease. The Exposure Control Plan was written in accordance
with OSHA standards and is available to all staff. The plan was reviewed and signed annually
by the program director on August 24, 2024. The plan includes a process for needle stick post-
exposure evaluation. The program director has established a separate record in the event of
any instances of exposure. The program did not have any instances of infectious diseases
which needed to be reported to the local county health department and/or CDC. A review of the
program director’s interview revealed the exposure control and infection control plan is stored in
medical and the supervisor’s office. An interview with nursing staff revealed the infection control
and exposure control training is conducted by the program’s training coordinator. The training is
provided to the youth during intake by the nurse and periodically during the duration of the stay.
County health department services are used for immunizations, human immunodeficiency virus
(HIV) testing, sexually transmitted diseases (STD) testing/treatment, and cultures will be
collected during a visit when needed. Medications are stored in a locked area. This area is
inaccessible to youth or untrained/unlicensed staff. Backstock medications and sharps are
stored in the medical office and a perpetual weekly inventory count is conducted weekly and as
needed. Narcotics or controlled medications are stored behind two locks with a daily count
conducted by two individuals.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains a policy and procedures addressing active supervision of youth. The
program’s policy and procedures consider active supervision as staff actively supervising youth
by interacting in a positive manner, supporting the core values, and consistently applying the
program's behavior management system. The program maintains a staff to youth ratio of one
staff to eight youth during day time activities and one staff to eight youth during night time hours
for the Juvenile Unit for Specialized Treatment (JUST) and a one staff to six youth during day
time activities and one staff to six youth during night time hours for the Twin Oaks Vocational
Academy (TOVA) II. Visual observations were conducted each day of the annual compliance
review to determine the program’s level of active supervision. Observations confirmed there
were no instances when youth were not supervised and the staff to youth ratio was in
compliance with the program’s contract. Positive interaction between staff and youth were
observed as youth engaged in a full schedule of activities. Three random staff were interviewed
to determine if they were aware of the number of youth actively being supervised. Each staff
member was able to accurately articulate the number of youth being supervised. The program’s
daily activity schedule is posted throughout each living area as well as the program’s
administration building. Documentation review also confirmed staff observed youth while they
were in their sleeping rooms.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program maintains a policy and procedures addressing the comprehensive and consistent
implementation of the behavior management system (BMS) and staff training. Documentation
review confirmed all appropriate parties were involved in the development, implementation, and
on-going maintenance of the program’s BMS. According to the program’s policy and
procedures, protocols are in place where staff are provided feedback regarding the
implementation of the BMS. The program currently has an agreement with the school related to
the BMS. Educational staff training on the program’s BMS is conducted by the director of
operations. Five youth case management records were reviewed for inclusion of orientation on
the program’s BMS. Documentation confirmed each youth received appropriate orientation and
review of the program’s BMS. The program’s BMS is also documented within the youth
handbooks. Five staff pre-service training records were reviewed for inclusion of training on the
program’s BMS. Documentation confirmed each staff completed the required BMS training. The
program has postings of the BMS throughout the program in various locations including the
dorm living areas, administration, and education areas. The program’s BMS has not had any
modification during the annual compliance review period. Review of the program’s written BMS
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validated the inclusion of required elements such as promoting safety, respect, and fairness,
protecting youth rights, positive and negative consequences, constructive disciplinary actions
which are non-punitive, opportunities for positive reinforcement, recognition of accomplishments
and positive behaviors at a ratio of four to one, 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 their behaviors, opportunities for staff and youth to discuss the
impact of behaviors on others, reasonable reparations for harm caused to others, discussion of
alternate behaviors, promoting positive dialogue and peaceful conflict resolution, and separation
of youth from population is minimized. The program’s BMS does not include practices of
increased length of stay, denial of a youth’s basic rights or services, promotion of group
discipline, punishment of youth by another youth, or disciplinary confinement wherein a youth is
isolated as a discipline for behavior. Visual observation of staff and youth interactions did
confirm such practices were not implemented. The program has a variety of incentives including
outings and canteen items. Five staff were interviewed and each staff was able to verbally
explain the program’s BMS. Each staff was able to verbalize the types of rewards the program
provides as part of the BMS. Staff provided examples such as Liberty bucks, special meals,
point store items, and incentive trips. Each staff reported the basic rights of youth cannot be
taken away consequently. Each staff was able to verbalize how youth are informed of
consequences and how they can explain their behaviors. Five youth were interviewed and each
youth was able to verbalize consequences the program has for negative behaviors. Youth
provided examples of behavior reports, yard work, added time, and level loss. Each youth was
able to verbalize the types of rewards which can be earned at the program. Youth provided
examples such as point store, Liberty bucks, free time, snacks, incentive trips, and gold level.
All five youth reported staff are consistent with rewards and consequences based upon
behaviors. Each youth was able to explain the difference between each level and how to move
from level to level. Each of the five youth reported youth are not allowed to punish other youth.
The program director was interviewed and was able to explain the policy and procedures on
how the program monitors staff implementation of the BMS to ensure consistency.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated as 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 maintains a policy and procedures addressing the assurance the staff will observe
youth at least every ten minutes while youth are in their sleeping quarters. The program
currently has a total of forty-six cameras of which all were properly functioning at the time of
arrival to the program. The program’s video surveillance system is currently capable of storing
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video recordings for a minimum of thirty days. During the annual compliance review, the
program director reported the surveillance system had experienced a malfunction. The
operating system was unable to properly view recorded video. This malfunction was reported to
the Department’s Central Communications Center (CCC) and was still inoperable at the time the
annual compliance review ended. The ability for live observations and surveillance was
functional; however, since recorded video was unable to be reviewed, ten-minute checks were
unable to be verified by video. Observation of ten-minute check documentation confirmed
checks were documented in real time and staff completing the checks either initialed or signed
the check sheets. A review of logs for the annual compliance review period confirmed checks
were conducted as required. A total of twelve logs of thirty-minute increments were reviewed
and documentation confirmed no discrepancies. Five staff were interviewed. Four of five staff
reported room checks are conducted every ten minutes. The remaining staff reported they were
not sure as this task is not a part of their job functions.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program maintains a policy and procedures addressing census, counts, and tracking of
youth. Youth movement shall be communicated over the radio. Direct care staff shall always
know the exact number of youth and the location of the youth under their supervision. The
supervisor shall conduct a formal count at a minimum of six times daily. Informal counts are
conducted each day by the team leader or supervisor at various intervals to include during
breaks and prior to departure and upon arriving back from off campus activities. In emergency
situations direct care staff shall conduct a sight and sound after securing youth in a safe area.
Counts shall be documented in the daily operations log. All admissions, releases, transfers,
leave of absences, and appointments will be reflected and documented in the daily operations
log. The supervisor shall document the daily census at the beginning of each shift and at the
end of each shift in the program's shift report. An observation of counts was conducted. The
shift supervisor queued staff for an impromptu head count. All movement stopped and each
area containing youth announced the number of youth under their supervision over the radio.
Once all areas announced their total number of youth, a headcount was cleared by the
supervisor initiating headcount. All movement then resumed. A sample of logbooks for the
annual compliance review period was reviewed. Sampling included a full day of each month.
Documentation within logbooks confirmed counts are conducted at the beginning of each shift,
after outdoor activity, as well as during emergency situations. Logbooks contained a total daily
census, headcounts, youth movement, new admissions, releases, direct discharges, transfers,
and youth temporarily away from the program. Five staff were interviewed and each staff was
able to verbalize how and when are youth counts conducted. Staff provided examples such as
each day, all day, three times a shift, various times, every hour to two hours, every forty-five
minutes, and at various times so the youth are not aware when it is going to happen. Each staff
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was able to verbalize the procedures the program follows when a youth count cannot be
reconciled. Staff provided examples such as stop movement, lockdown youth and search for
youth, conduct a master headcount, stop movement until count is reconciled, and secure youth
until a count is complete and cleared. One of five staff reported they were unsure as the
situation has not happened. Staff was able to verbalize when emergency counts are conducted.
Staff provided examples such as when a youth escapes, when a youth is missing, or the count
is off.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a policy and procedures addressing logbook entries and shift report
reviews. A sample of logbooks were reviewed for the annual compliance review period.
Sampling included at least one full day of each month for a total of twelve. Logbooks were
bound with numbered pages, all entries were made in ink with no erasures, and no logbook
entries were destroyed or removed. No logbook contained any errors which required correcting.
All entries included the dates and times of events with the names of staff and youth involved, a
brief description of the events, and the names and signatures of the staff making the entries.
When applicable, internal incidents reported to the Florida Abuse Hotline or the Department’s
Central Communications Center (CCC) were documented. The program does not have
logbooks stored in living areas. Documentation review confirmed the activity schedule and
logbooks documented minimal interference of educational instruction in eleven of twelve entries.
The remaining entry confirmed youth arrived at class one hour and forty minutes late on one
day. Each logbook indicated recreation was conducted as scheduled. A review of shift reports
summarized events, incidents, and activities documented in the program’s logbooks and the
incoming staff signed and dated the shift reports for the previous shift to confirm their review of
the content. A copy of shift reports are maintained on the living units for forty-eight hours. The
program’s logbooks contained documentation of emergency situations, incidents, including the
use of mechanical restraints, special instruction for supervision and monitoring of youth,
population counts at the beginning and end of shifts, perimeter security checks and other
security checks conducted by staff, transports away from the facility including name of staff,
youth involved, and destination. Based on logbook entries reviewed, there were no requests for
law enforcement access, no youth was removed from mainstream population, there were no
admissions and releases, and no information relating to escapes or attempted escapes.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program maintains a policy and procedures addressing key control. The policy includes key
assignment and usage including restrictions on usage, inventory and tracking of keys, secure
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storge of keys not in use, procedures addressing missing or lost keys, and reporting and
replacement of damaged keys. The program’s key inventory was reviewed to ensure the
inventory matches the actual key rings in use. The program key storage area is in the
supervisor’s office in a lockbox secured on the wall. There is also a key lockbox located in the
lobby area of the program which stores visitor keys. The key box is secured on the wall and is
locked when not in use. The key box is not easily accessible to youth. Key distribution was
unable to be observed during the annual compliance review. For permanently assigned keys,
staff receiving keys will sign an agreement indicating they are being assigned permanent keys.
The signed agreement indicates who receives keys, the receiver’s title, key ring number, and
the number of keys on the key ring. Staff print their name and signs the agreement. The
program’s process for reporting and replacement of damaged keys states staff will complete an
incident report to indicate what key has been identified for replacement. An incident report is
turned into the key control operator. The identified key is taken out of inventory until replaced.
The program currently has a key cutter on the grounds. Once replaced, the key is returned back
into circulation. A review of the Department’s Central Communications Center (CCC) and
Program Monitoring and Management (PMM) was conducted and there were no incidents
reported regarding key control issues. An informal interview with the program’s director of
operations was conducted and it was reported staff receiving keys will sign an agreement
indicating they are being assigned permanent keys. The agreement indicates who receives
keys, receiver’s title, key ring number, and the number of keys assigned to the key ring. Staff
print their name and sign the agreement. An informal interview with the program’s director of
operations was conducted and the program’s method for daily tracking and reconciliation of
keys was reported at the beginning of each shift. The on-coming supervisor will meet with the
supervisor on duty. Both supervisors must make a count of all keys in the key box. The on-
coming supervisor will ensure all keys in the lockbox are correct. At shift debriefing, all keys will
be handed out to the shift leaders by the supervisors. Shift leaders will sign the daily key log
sheet for a set of keys. At the end of shift, all keys must be turned back into the supervisor. The
team leader will again sign for the returning key. Five staff were interviewed. Each staff was
able to verbalize the program’s process for personal keys and program keys from when they
walk in to begin a shift until the shift ends.
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
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prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a policy and procedures addressing the introduction of illegal
contraband and prohibited items. The program’s current system includes all the required
elements such as defining items considered contraband, informing youth of consequences if
found with contraband, searching the physical plant, searching the facility grounds, searching
youth, and searching incoming and outgoing mail. Visual observation confirmed the program’s
visitor log contains a contraband attestation statement. The program hired a total of fifteen new
staff since their last annual compliance review. All staff are required to sign the employee
manual indicating the program’s policy regarding introduction of contraband and illegal items
into the facility. All fifteen new employees’ records contained signature of the agreement. The
program’s policy and procedures address any staff who is found in possession of contraband in
the program will be subject to disciplinary actions as outlined in Florida Administrative Code.
The program’s policy further states law enforcement is contacted if any items of contraband is
found which is considered illegal or if there is evidence of any unlawful activity. The program’s
policy and procedures delineates items which are considered contraband. A review of the
Department’s Central Communication Center (CCC) revealed one incident of illegal contraband
had been reported. The program appropriately documented the confiscation of contraband and
the documentation was also noted within the youth’s case management record. Documentation
review confirmed the program appropriately disposed of non-illegal contraband within the
program. A follow-up informal interview with the program’s director of operations confirmed a
youth received non-illegal contraband items within a package received from family. The items
were documented and returned to the youth’s home. The program’s logbooks, incident reports,
and search reports during the annual compliance review period were reviewed for frequency,
quality of searches, and the results of searches. Five staff were interviewed and each staff was
able to explain the program’s process for youth room searches. Staff reported examples such
as every day at random times, anytime when needed, supervisors conduct room searches, and
room searches are conducted every week or two weeks. The program director was interviewed
and was able to explain and provide the policy and procedures regarding how contraband and
illegal contraband in handled and disposed.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a policy and procedures addressing searches and full body visual
searches. Youth were observed being searched after recreation activities, prior to entering and
upon leaving classroom, after restroom breaks, and upon return from off-campus activities with
the Department of Transportation (DOT). Observation of searches confirmed youth were treated
with dignity and respect. Each search observed was conducted by the appropriate number of
staff and gender. All searches were observed for thoroughness, staff demeanor, and
explanation of purpose of searches. All youth searches were conducted as required by the Right
Interaction training manual. During the annual compliance review, observations of youth
searches before and after visitation, before and after transport, and before off-campus activities
were not able to be observed. Video observation of staff and visitor searches were unable to be
conducted due to a malfunction of the program’s video surveillance equipment; however, visual
observation of visitor searches was able to be conducted. Searches consisted of visitors being
visually searched then searched by electronic device. A visitor’s personal belongings were also
searched prior to gaining access to the program. Five staff were interviewed. Four of five staff
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reported youth searches are conducted upon every movement. The remaining staff reported
staff conduct room searches. Five youth were interviewed and each of the five youth reported
searches occur after every movement.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a policy and procedures to ensure vehicles utilized to transport youth
are properly maintained and documentation regarding the use and maintenance of vehicles is
maintained. The program has a total of three vehicles utilized for transportation of youth. All
transport vehicles and five staff vehicles for a total of eight vehicles were checked to ensure
each vehicle was locked when not in use. Visual and physical inspection confirmed each vehicle
was secured and locked. Each transportation vehicle had an updated safety inspection
documented with identified and corrected deficiencies. Each vehicle had documented
maintenance records. Each vehicle was always secured and contained a fire extinguisher,
approved first-aid kit, seatbelt cutter, window punch, and the appropriate number of seatbelts.
Doors to the youth passenger area cannot be opened from the inside.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a policy and procedures addressing staff to youth ratio while youth are
transported off facility grounds. Based on five staff interviews and review of policy and
procedures, it was determined the program issues a cellular telephone and radio each time a
youth is transported away from the program. The program’s policy and procedures dictate a one
staff to five youth ratio excluding the driver. The program’s policy and procedures followed
requirements outlined by the Department related to transportation of youth and driver eligibility.
Based on an informal interview with the program director, driver eligibility is confirmed through
the program’s insurance company. Youth are not permitted to drive program or staff vehicles.
During the annual compliance review, an observation of a transport was not able to be observed
to determine if staff to youth ratios were maintained, if one staff of the same gender was on
each transport, or if staff and youth were wearing seat belts during transport; however, the
program’s policy and procedures address each of these areas. Five staff were interviewed and
each staff was able to verbalize how youth are secured within vehicles. All five staff reported
cellular telephones are provided during transports. Three of five staff were able to adequately
verbalize types of emergency equipment in transport vehicles. Staff reported a fire extinguisher,
window breakers, seatbelt cutter, cellular telephone, knife for life, and Department approved
first-aid kits are maintained in vehicles. One of five staff reported they do not typically transport
youth. The remaining staff reported they were unsure. All five staff reported staff are not allowed
to use personal vehicles to transport youth. Each of the five staff reported transport vehicles are
searched for contraband prior to and after each use. Each staff was able to explain the
emergency response process during vehicle transport. Each staff was also able to verbalize
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staff to youth ratios during transport which coincided with the program’s policy. Five youth were
interviewed. Four of five youth reported they have never been handcuffed to any part of a
vehicle while on transport. The remaining youth reported they have never been on a transport.
All five youth reported they have never seen anyone place contraband in a 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 maintains a policy and procedures addressing weekly safety and security audits to
ensure maintenance of a safe and secure physical plant, grounds, and perimeter. All locks,
windows, doors, fences, gates, electronic systems, metal detectors, and other security devices
are checked daily by shift supervisors. All buildings will have a maintenance/safety check at
least once a week. Any deficiencies are noted and a work order for repair is completed and
submitted to the maintenance department. Maintenance will conduct weekly testing on the
facility’s emergency generator and fire detection suppression equipment. A comprehensive
health and safety inspection is performed annually by the Health Department and Fire
Department. Identified deficiencies are corrected by the Health, Safety, and Risk Management
Officer. This written inspection is reviewed by the Health Safety and Risk Management
Committee. Based on reviewed documentation, the program’s policy and procedures outline the
audit process to include who is responsible for conducting weekly security audits and safety
inspections, the development and implementation of corrective actions warranted as a result of
safety and security deficiencies identified, and internal systems to verify deficiencies are
corrected. Documentation review for the annual compliance review period for safety and
security audits and preventive maintenance schedules confirmed the program completed
weekly safety and security audits and completed repairs as outlined. The residential safety and
security specialist also confirmed the program’s compliance with no issues. A review of the
Department’s Program Monitoring and Management system (PMM) revealed there were no
deficiencies entered since the program’s last annual compliance review. An interview with the
program director was conducted and they were able to provide the policy and procedures as
well as explain the program’s process for identifying and tracking safety and security
deficiencies and how deficiencies are addressed by the program.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a policy and procedures addressing tool inventory, issuance, control,
and management. All tools are inventoried prior to being issued and inventoried following work
activities. Staff utilizes an inventory sheet documenting tools issued out and returned. Tools are
inventoried daily and tools not having sharp edges or points are inventoried monthly. The
program prohibits the use of machetes, bowie knives, or other long blade knives. The program’s
procedures for missing or lost tools dictate the tool control manager will be immediately notified
and a tool report will be written and submitted by a supervisor to the tool control manager. All
students who have access to tools will be held from work until a thorough search has been
made. All youth are frisk searched and electronically searched. Youth who are searched will be
separated. If it is determined the missing tool is linked to reportable incident, the Department’s
Central Communications Center (CCC) will be notified within the required timeframe. In the
event a tool becomes dysfunctional or broken, a tool report must be submitted to the tool control
manager. If the broken tool is not repairable, the tool control manager shall submit a purchase
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request to the site administrator. Tools identified as being dysfunctional which are in an unsafe
condition or disrepair must be discarded away from the program. Tool disposals are only
completed by the tool control manager. The tool control manager will maintain a tool disposal
log which will document each time a tool is removed. A total of ten tools were reviewed to
compare with the inventory. Each tool was secured, had markings for easy identification, and
the inventory for each tool was accurate.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a policy and procedures for youth tool handling and supervision. The
program’s policy contained the required elements such as supervision requirement when youth
use tools, issuance of tools to youth and staff, including an assessment to determine a youth’s
risk to self and others, established ratios, tool distribution and collection, and search criteria
during work projects. The program currently has a one staff to five youth ratio during any
activities involving tool use. Visual observation of tool usage during vocational programming
was conducted. A one staff to two youth ratio was confirmed during welding vocational
programming and a one staff to five youth ratio was confirmed during carpentry vocational
programming. Visual observation of collection of tools and search was unable to be observed
during the annual compliance review. Five youth records were reviewed for inclusion of training
on the intended and safe usage of tools. Each record contained documentation youth were
trained on safe usage of tools. Five youth records were reviewed for inclusion of a completed
risk assessment and each record included the assessment. Five staff were interviewed. Each of
the five staff reported youth are allowed to use mops and brooms. Other responses consisted of
youth are only allowed to use tools is enrolled in carpentry programming. Five youth were
interviewed. Each of the five youth reported youth are allowed to use mops and brooms. Other
responses provided by youth included youth are allowed to use tools when in carpentry and
aquaponics vocational programming.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program maintains a policy and procedures addressing guidelines required for outside
contractors which includes information regarding tool control and restrictions. All outside
contractors and vendors will be required to read the program's tool control policies and sign an
agreement. Each contractor will provide a photo identification card. Each vendor should
maintain a personal inventory of all tools before working on campus. The outside contractor
should always keep tools with them or in clear sight and should not allow youth to handle any
tools. Before leaving the grounds, the vendor will complete a tool verification form indicating all
tools are secured and accounted for when work is completed. Three outside contractors sign-in
and instruction sheets were reviewed. Each instruction sheet contained the vendor’s signature,
date, and purpose of visit. All tools to be utilized were inventoried upon entrance and prior to
exit. Invoices were also compared to sign-in sheets to indicate date of completed service. The
guidelines for outside contractor tools included tools to be checked upon arrival and departure,
tool restrictions while in the program, youth restriction from the work area, and missing tool
follow-up. Three project invoices from outside vendors were reviewed. Each invoice contained
the project to be completed and the total amount to be charged for completed service. Dates of
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sign-in sheets also corresponded with date of completed service. Documentation review
confirmed the program inventoried tools or other equipment when vendors arrived and left.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program maintains a policy and procedures for fire, safety, and evacuation drills. Review of
documentation confirmed the program conducts emergency and Continuity of Operations Plan
(COOP) drills monthly on each shift on a rotating basis. Documentation review affirmed drills
contained all the required elements such as type of drill, date and time of drill, drill participants,
brief scenario, findings, and recommendations. Visual observation confirmed fire evacuation
routes and egress plans were posted throughout the facility. Documentation review and
observations confirmed the facility has a total of twenty-two fire extinguishers and each was
confirmed to be annually inspected. Five staff were interviewed. Four of five staff reported they
have participated in drills within the last twelve months. Staff reported they participated in
suicide, medical, fire, escape, flooding, terrorist, cardiopulmonary resuscitation (CPR), and
hostage drills. The remaining staff reported they have not participated in any drills during the
last twelve months. Five youth were interviewed. Each of the five youth reported they have been
instructed on what to do in the case of a fire. Three of five youth reported drills are conducted
once a month. One of five youth reported having participated in drills three times and the
remaining youth reported having participated in drills one time. The program director was
interviewed and reported fire drills are conducted on a monthly basis and all others are
conducted annually.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature. The program shall
establish and maintain critical identifying information, as well as a current photograph of each
youth, which are easily accessible to verify a youth’s identity, as needed, during his or her
stay in the program.
The program maintains a Disaster and Continuity of Operations Plan (COOP) which is
maintained in the program’s director of operations’ office as well as in the supervisor’s office.
The COOP was submitted to the Department on April 10, 2024 and was approved by the
Department’s regional director on May 15, 2024. The program’s COOP addresses alternative
relocation sites approved by the Department. The program Emergency Disaster Preparedness
Plan and COOP is a combined plan. The program’s equipment and supplies required are stored
in various locations such as the superintendent’s office, storage closets within the administration
building, and dormitory storage closets. Stored supplies consist of water, meals ready to eat
(MRE), toiletries, clothing, and electronic communication devices. Information received during
an informal interview with the program director indicated there is also an emergency evacuation
trailer located at headquarters. The program utilizes both electronic and hard copies of youth
records and information. When the program prepares for evacuation, the program director will
collect stored hard copy information as well as electronic information. The information and
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records will be placed within the vehicle the program director is traveling in until the alternate
relocation destination has been reached. The program maintains youth records and critical
information in case of emergencies. Five youth records were reviewed for critical information.
Each record contained the required information such as youth’s full name, the Department of
Juvenile Justice Identification number, date of birth, gender, race, admission date,
parent/guardian contact information, who to notify in case of an emergency, the assigned
juvenile probation officer’s contact information, name of committing judge, state attorney, public
defender, committing offense, judicial circuit, if the judge retains jurisdiction, victim notification
contact information, physical description of the youth, overall health status, personal physician,
and a photograph of the youth. The program director was interviewed and reported the
supervisor’s office.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and 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 maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program maintains a policy and procedures addressing the storage and inventory of
flammable, poisonous, toxic items, and chemicals. The program’s policy and procedures state
flammable, toxic, poisonous, and caustic materials shall only be drawn by an authorized
employee and be stored in secure areas which are inaccessible to youth and meets the
standard specified by the State Fire Marshall. Flammable, toxic, poisonous, and caustic
materials will be limited on campus. Visual observation confirmed the program’s flammable,
poisonous, and toxic items were stored in the supervisor’s office, were always secured, and
were inaccessible to youth. An informal interview with the program director and the director of
operations reported only utilizing one chemical agent during the annual compliance review
period. A sampling of inventory of one item was conducted. The one item contained a Safety
Data Sheet (SDS) and the inventory of each item matched the actual items observed. Direct
care staff and administrative staff are authorized to handle flammable, poisonous, and toxic
materials. The program’s policy and procedures on the disposal of flammable, toxic, caustic,
and poisonous items states when there is a need to dispose of hazardous chemicals, the safety
officer or maintenance supervisor will notify Liberty County landfill personnel of the type of
chemical to be disposed of in order to get directions regarding steps to be taken regarding
transporting the hazardous material to the landfill. The maintenance supervisor will designate
the appropriate staff for coordinating and safely transporting the hazardous chemicals to the
county landfill. According to documentation review, the program’s disposal procedures are in
accordance with Occupational Safety and Health Administration (OSHA) standards. An informal
interview with the director of operations reported the program utilizes the Liberty County landfill.
No prior notification is required or needed prior to disposal. The program transports items
directly to the landfill. According to policy and procedures, hazardous liquid waste is disposed of
in accordance with SDS and hazardous liquid waste is stored in a hazardous material storage
area. An informal interview with the director of operations also confirmed the program does not
store liquid waste. Once replenishment occurs all excess is immediately targeted for disposal.
Liquid waste such as dirty mop water and unused beverages are not disposed of in plumbing
drains but rather in designated areas. The program does not currently have an onsite kitchen.
Meals for youth are provided by a co-located Department of Children and Families program
operated by the same provider. An informal interview with the director of operations was
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conducted and it was confirmed there have been no reports of chemical spills during the annual
compliance review period. Based on the program’s policy and procedures, the program’s
process for handling chemical spill clean-up entails staff immediately notifying master control on
the location, the shift supervisor or master control directs the shut-down of all air handlers and
ventilation systems, closes all doors and windows at the direction of the on-scene supervisor or
program director, and contacts outside assistance as necessary and consistent with emergency
procedures. An interview with the program director was conducted and the director was able to
explain and provide policy and procedures for the disposal practice of flammable, toxic, caustic,
and poisonous items.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a policy and procedures for youth handling and supervision for
flammable, poisonous, toxic items, and materials. According to the program’s policy and
procedures, youth use such chemicals only under direct staff supervision and with proper
protective equipment. These items are secured when not in use. Youth shall never possess
these items unless under supervision of qualified staff. Staff and/or youth shall use the
appropriate personal protection to include such things as gloves or safety glasses when
required. The program maintains strict control of flammable, poisonous, toxic items, and
materials. Youth are not allowed to use, handle, or clean up dangerous or hazardous chemicals.
Youth do not clean, handle, or dispose of any person’s bio-hazardous materials, body fluids, or
human waste. Youth access to areas where items are used or stored is restricted. An
observation of youth during daily cleaning activities was conducted during the annual
compliance review. Two youth were observed wiping tables then proceeded with sweeping
floors. No issues were observed. No youth was observed handling any chemicals and youth
were adequately supervised. Five youth were interviewed. Four of five youth reported having
used paint. Three of five youth reported not having used any chemicals or cleaning products.
Other responses given by youth consisted of paint being used during Boys and Girls Club, paint
was used during carpentry programming, and paint was used during mental health group.
5.20 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:
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• 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.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a policy and procedures addressing visitation and communication. The
program’s visitation schedule is currently posted in the lobby area of the administration
building’s bulletin board as well as youth living dorms. The program’s policy and procedures
related to visitation, youth correspondence, and telephone usage is to provide for a systemic,
safe and secure visitation for youth, staff, and approved visitors which encourages and enables
visitation and communication between youth and their families. The program’s current visitation
schedule is Saturday and Sunday from 12:00 p.m. to 2:00 p.m. A review of the visitation log and
schedule confirmed adherence. The program offers youth telephone calls two times a week. A
review of telephone logs and youth chronological progress notes confirmed adherence. The
program currently allows youth to correspond with family by mail seven days a week. A review
of the program’s mail correspondence log and schedule confirmed adherence. The program
currently provides alternate visitation arrangements when family members are unable to visit
based upon the current schedule. An informal interview with the program’s director of operations
was conducted. According to the director of operations, if a family is unable to adhere to the
posted schedule due to special circumstances, they are granted a special visitation which is
considered a family therapy session. The director of operations also confirmed the program
does not currently have any youth with a history of human trafficking. Outgoing mail is searched
by staff. The program does not have a third-party agreement with a provider for language
services. The program utilizes current staff members who are fluent in foreign languages. Five
youth were interviewed. Each of the five youth reported they are allowed to call
parents/guardians or send a letter.
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5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program maintains a policy and procedures addressing recreational and leisure activities.
The program’s activity schedule documents a range of supervised and structured indoor and
outdoor recreation and leisure activities for youth at least for one hour daily which includes large
muscle activity. A review of logbooks confirmed recreation was conducted as scheduled.
Activities promote social and cognitive skill development, creativity, teamwork, healthy
competition, mental stimulation, and physical fitness. An observation of recreational activities
confirmed the program takes precautionary measures to prevent overexertion, heat stress,
dehydration, frostbite, hypothermia, and exacerbation of existing illness or physical injury. The
program’s contract requires a recreation therapist. The recreation therapist credentials,
schedule, and services provided to youth were reviewed to ensure requirements were met. Five
youth case management records were reviewed for inclusion of recreational therapy within their
performance plans. Documentation within four of five records confirmed inclusion of a
recreational therapy goal, the remaining plan did not include recreational therapy. Five youth
were interviewed. Each of the five youth reported physical activities are provided for at least one
hour a day. Youth provided example of activities such as Boys and Girls club, basketball,
football, and kickball.
5.23 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.
5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 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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Standard 6: Educational Services
6.01 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
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), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
A review of the program’s contract and an interview with the program director confirmed all
youth who are committed to the Juvenile Unit for Specialized Treatment (JUST) program attend
the welding and carpentry classes, and all youth committed to the Twin Oaks Vocational
Academy II (TOVA) participate in aquaponics and agriculture services. These vocations are
taught by certified instructors who used to be employed by the program, but are now employed
through Florida Virtual School, the educational provider. The program director reported eighteen
youth completed Occupational Safety and Health Administration (OSHA) 10 and sixteen youth
completed cardiopulmonary resuscitation (CPR)/first-aid certifications during the annual
compliance review period. The program director reported they have not been able to conduct
Florida Ready to Work Soft Skills.
The Florida Scholars Academy, through Florida Virtual School, provides welding and building
trades as the required career and technical education services. The Florida Scholars Academy
did not track the number of youth who received the career and technical services during the
annual compliance review period; however, the program director reported all JUST youth go
through these vocational programs at some point during the tenure at the program. Welding and
carpentry services are provided during first and second period Monday through Friday. Between
the hours of 8:30 a.m. and 2:30 p.m., the youth also able to participate in Florida Ready to
Work, OSHA 10, and CPR/first-aid. There are two instructors for the vocational classes who are
certified in the State of Florida. Observations during the annual compliance review week
revealed the career and technical education services were being provided as required by the
contract. Welding was identified as the industry certification from the master credentials list. The
program director was interviewed regarding the contract specific career and technical education
services. The program director reported welding and carpentry are the two services provided by
the Florida Scholars Academy.
6.02 Educational Access (Residential Contract Provider) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 66 of 68 (Revised September 2022)
The center provides education services through a contract with Florida Virtual School (FLVS).
The program has a policy and procedures to provide educational access. A review of four
random dates in the logbook were reviewed and showed the daily class schedule was being
followed. Further review of logbook entries and three days of video footage verified the youth
were attending school as scheduled.
6.03 Educational Access (Education Contract Provider) Non-Applicable
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 contracted educational provider will deliver educational instruction ensuring the required
instructional time. Education services are provided through a contract with Florida Virtual School
(FLVS). The program has a policy and procedures to provide educational access. The center
provides education services through FLVS and the 250-day calendar, distributed over twelve
months, including twenty days used for teacher training and planning. A review of the daily
school schedule revealed the center provides six fifty-minute class periods daily, fulfilling the
weekly requirement of twenty-five hours of instructional time. A review of three days of video
verified education was being provided as required. Youth can receive credit for educational and
training experience. Five youth were interviewed, and all five reported they attend school
Monday through Friday. In addition, all five felt the school was preparing them either very well or
well regarding preparation towards General Education Development platform (GED), high
school, vocational, employment, and/or college. The interview with the instructional leader also
reported there is minimal interference with educational services.
6.04 Career Education (Education Contract Provider) Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The education program provides Type 2 and Type 3 career education services. The career
education program is appropriate for the length of stay, classification, educational abilities, and
goals of the youth in the program. The education program provides content and an orientation to
the broad scope of career choices, based upon personal abilities, aptitudes, and interests. The
education program also encourages the youth to explore and gain knowledge of occupation
options and the level of effort required to achieve these goals. The career education
programming includes communication, interpersonal skills, and decision-making skills. The lead
educator was interviewed regarding career education. The lead educator reported there are
Needs Assessment forms completed upon intake by a paraprofessional. Youth who have
graduated are placed on the survey for Florida Youth College. The assessment coordinator will
implement Xello in the future for youth to complete upon intake.
6.05 Education Transition Plan (Education Contract Provider) Non-Applicable
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The program’s education services are provided by Florida Virtual School (FLVS), which began
their contract on July 1, 2024. None of the closed youth records were applicable for the current
provider as they entered the program prior to July 1, 2024. None of the current program youth
had an Education Transition Plan initiated, as required, by the FLVS staff. It was reported FLVS
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 67 of 68 (Revised September 2022)
has recently created an Education Plan Template and trained their staff to implement the
development of a plan for each youth moving forward.
6.06 Qualified Instructional Personnel (Education Contract
Non-Applicable
Provider)
The program director is responsible for ensuring qualified instructional personnel are provided
to teach and provide exceptional education and related services to students in the facility.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
Three educational instructional personnel were reviewed. All three had a valid Florida
educator’s certificate with appropriate coverage as provided for in the Course Code Directory. A
review of the Florida Department of Education’s website confirmed all three staff had active
credentials. All three teachers on-site were teaching in field according to student schedules,
current teacher certifications, and verification with the course code directory.
6.07 Florida Youth College (Education Contract Provider) Satisfactory Compliance
The education provider shall complete the Florida Youth College referral process for each
youth that earns their high school diploma or GED. Each youth will be assigned a Florida
Youth College Career Navigator.
The program provided four youth records were reviewed for documentation of referrals to
Florida Youth College. One youth was applicable for services and was assigned a Career
Navigator. The three remaining youth who received referrals were direct release from the
commitment program and did not continue with Florida Youth College (FYC) services.
6.08 Florida Youth College (Post-Secondary Contract
Satisfactory Compliance
Provider)
The post-secondary provider, upon receiving the referral for services, shall assign a Florida
Youth College Career Navigator to each youth. Each youth shall attend an orientation session
to develop a career pathway plan. The career pathway plan shall include postsecondary
education options at a state or technical college or pre-apprenticeship/apprenticeship
programming that leads to an industry credential or academic credit. For youth transitioning
from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after
their release.
One youth record was applicable and reviewed for Florida Youth College (FYC) participation.
The youth record included documentation to support the day, date, and time of their FYC
orientation. The record also included a career plan based on a youth’s interests and aptitude.
There was documentation within the record which indicated a thirty-day, sixty-day, ninety-day,
and 180-day follow-up occurred with the youth. The youth was working on being enrolled in a
postsecondary program; however, there have been complications due to the youth’s
background and the referral has been stopped.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 68 of 68 (Revised September 2022)

source: DJJ