summary: QI Residential - FY23-24 - 1 finding

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Developing Opportunities through Vocation and Education (DOVE)
Academy
Twin Oaks Juvenile Development, Inc.
(Contract Provider)
5270 Ezell Road
Graceville, Florida 32440
Review Date(s): May 7-10, 2024
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Stephanie Solano, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Patrick Brock, Office of Education, Education Coordinator (Standard 2)
Jillian Cumbo, Regional Workforce Education Coordinator (Standard 1)
Jessica Gibson, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Carlametress Harrell, Regional Workforce Education Coordinator (Standard 1)
Patrick McKinstry, Office of Accountability and Program Support, Regional Monitor (Interviews)
Ken Phillips, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Cedric Prince, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Jake Turley, True Core Behavior Solutions, LLC, Systems Administrator (Standard 2)
Andre Watson, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Developing Oppurtunities through Vocation and Education (DOVE) Academy
MQI Program Code: 1102
Provider Name: Twin Oaks Juvenile Development, Inc. Contract Number: 10774
Location: Jackson County / Circuit 14 Number of Beds: 40
Review Date(s): May 7-10, 2024 Lead Reviewer Code: 209
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
1.15 Advisory Board
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 66 (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 * Non-Applicable
1.04 Management Response to Allegations * Non-Applicable
1.05 Incident Reporting (CCC) * Non-Applicable
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Non-Applicable
1.08 In-Service Training Non-Applicable
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)* Non-Applicable
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Limited
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 66 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
2.19 Career Education Satisfactory
2.20 Educational Access* Satisfactory
2.21 Education Transition Plan Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 66 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Satisfactory
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 66 (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 66 (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 and Inventory of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.21 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.22 Visitation and Communication Satisfactory
5.23 Recreation and Leisure Satisfactory
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
5.25 Controlled Observation Non-Applicable
5.26 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 66 (Revised September 2022)
Program Overview
The Developing Opportunities through Vocation and Education (DOVE) Academy is a forty-bed
program, for fourteen to eighteen year old females, located in Graceville, Florida. The program
is operated by Twin Oaks Juvenile Development, Inc., through a contract with the Department.
The program provides services including Mental Health Overlay Services (MHOS), Substance
Abuse Overlay Services (SAOS), Intensive Mental Health Services (IMH), and vocational
education services. In addition, the program fosters each youth by providing Impact of Crime
(IOC), Moral Reconation Therapy (MRT), Dialectical Behavior Therapy (DBT), and Seven
Challenges. Additional treatment services provided include team building, decision making,
interpersonal relationships, non-violent conflict resolution, communication skills, identifying and
avoidance of high-risk situations, appropriate interactions, anger management, critical thinking,
human sexuality, searching and applying for jobs, problem solving, goal setting, planning,
decision making skills, personal appearance/hygiene, stress management, self-esteem, and
preparing budgets. Program administration is comprised of a program director (PD), assistant
PD, and administrative assistant. Case management services are provided by two case
managers and one transitional specialist. Medical and mental health staff at the program include
four clinical coordinators, two designated health authorities (DHAs), one licensed mental health
counselor (LMHC), one full-time registered nurse, and one part-time registered nurse . Sick calls
are offered daily from 11:30 a.m. to 12:30 p.m. and 3:00 p.m. to 4:00 p.m. Educational services
are provided by the certified lead teacher, one teacher, two vocational instructors, and one
welding instructor. The program has sixty-two operating security cameras providing coverage.
At the time of the annual compliance review, the program had two vacant direct care staff
positions. A waiver for psychiatric services for continuity of medication was granted at the end of
April 2024 to allow for a psychiatric advanced practice registered nurse (APRN) to provide
psychiatric services in the absence of a psychiatrist.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 66 (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.
Based on the staffing roster provided, the program had a total of seventeen staff who required
initial background screening during the annual compliance review period. The seventeen staff
reviewed found each staff was screened and sixteen were found eligible prior to the initial date
of hire. The remaining staff was determined ineligible but obtained a waiver prior to working with
youth, as required. The criminal history report information was reviewed and included for all
seventeen records reviewed. The Department’s Staff Verification System (SVS) could not be
accessed to determine if staff had a break in service due to the system being down. Eleven of
the seventeen staff were eligible for the Diana Screen, the pre-employment assessment the
program utilizes. All eleven obtained a passing score which was documented in each staff’s
record. All but one staff was added to the Clearinghouse employee roster. The program added
the one staff during the annual compliance review week. The program reported having three
volunteers who assisted on an intermittent basis for less than ten hours a month. The program
has a policy and procedures stating volunteers are to be present within the line of sight of a staff
who has been background screened. The program submitted their Annual Affidavit of
Compliance with Level 2 Screening Standards to the Department’s Background Screening Unit
(BSU) on January 4, 2024. The teachers are employed by the program and are included in the
annual screening. The visitor log is located upon entry to the program and contains the
contraband attestation statement as required. A review of seven staff records who were hired
prior to March 1, 2023 revealed all had the contraband attestation forms as required. A review of
seven newly hired staff records revealed all had the contraband attestation from as required.
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.)
A review of six staff indicated four were applicable for the five-year rescreening. All four staff
had their five-year rescreening completed as required. The rescreenings were submitted at least
ten business days prior to the five-year anniversary of each staff. The remaining two staff are
due later this year and are on the Clearinghouse list to complete rescreenings.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 66 (Revised September 2022)
1.03 Provision of an Abuse-Free Environment (Critical) Non-Applicable
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
 The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
 All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
 Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
 The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
 A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
1.04 Management Response to Allegations (Critical) Non-Applicable
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 incidents of physical, psychological, or emotional abuse during the annual
compliance review period; therefore, this indicator is rated non-applicable.
1.05 Incident Reporting (CCC) (Critical) Non-Applicable
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.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
1.06 Protective Action Response (PAR) and Physical
Satisfactory Compliance
Intervention Rate
The program uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is completed and filed in accordance with the Florida
Administrative Code.
The program had twenty-seven Protective Action Response Right Interactions model (PAR/RI)
incidents during the annual compliance review period. A review of five PARs/RIs revealed all
were completed by the end of the staff’s workday. Each report included statements from all staff
involved as required. No mechanical restraints were utilized during any of the PARs/RIs. Due to
statewide technical issues affecting the Department’s Juvenile Justice Information System
(JJIS), the Department’s Central Communications Center reports were unable to be reviewed. .
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 66 (Revised September 2022)
None of the incidents were applicable for reporting to the Florida Abuse Hotline. All five
PARs/RIs were reviewed by a supervisor as required. One of the five required a medical review
according to the post-PAR/RI interview. All PAR/RI incident reports were reviewed by the
administrator or designee within seventy-two hours of the incident. A copy of the PAR/RI Report
was placed in the program’s centralized file within forty-eight hours of approval. During video
review a PAR/RI was observed and there was no PAR/RI Report generated from the incident.
Upon discovery this was reported to the CCC by the annual compliance review team. A written
reprimand was given to the staff who failed to report the PAR/RI incident, by the administration.
The PAR/RI plan was updated on April 29, 2024, and approved by the Department on May 3,
2024. The program had an increase in PARs/RIs during the annual compliance review period in
comparison to the seventeen PARs/RIs during the last annual compliance review period. The
program’s PAR/RI rate during the previous quarter was 0.0 for the intensive mental health youth
and 3.51 for the substance abuse youth, which is above the statewide Residential PAR/RI rate
of 1.76. The assistant program director (PD) stated it was primarily three individuals who were
consistently receiving PARs/RIs. A review of the PARs/RIs confirmed the explanation. Monthly
summaries were maintained by the program of all PARs/RIs and submitted to the Department,
as required. Seven staff were interviewed. Five of the seven staff stated they have used PAR/RI
and were able to explain the program's process and procedures. The remaining two staff have
never used PAR/RI. An interview with the PD revealed a PAR/RI Report shall be reviewed
within seventy-two hours by the assistant director of safety and security or their designee to
determine if the PAR/RI followed policy. The report must also be reviewed by a PAR/RI
instructor or PAR/RI certified supervisory staff. The report shall then be submitted to the
assistant director. The certified PAR/RI instructor and/or the PD or designee shall then review
the report to determine if the PAR/RI followed policy. The PD or designee will review the PAR/RI
report, statements, video footage, comments, and answers along with the committee to
determine if actions of the staff were acceptable, fair, and consistent with requirements. The
findings found from the committee will be shared with the staff involved and could result in
assignment of a PAR/RI refresher course, verbal coaching, or administrative action.
1.07 Pre-Service/Certification Requirements (Critical) Non-Applicable
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
1.08 In-Service Training Non-Applicable
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 66 (Revised September 2022)
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures for the grievance process which include training on
the process. The program’s grievance process includes an informal, formal, and appeal phase.
The informal phase permits the youth to resolve the complaint or condition with the staff
involved. This must be done by the end of the staff’s shift. If in the informal phase the grievance
is not resolved, it will be submitted to the shift leader by the end of the staff’s shift. In the formal
phase the shift leader will investigate the facts of the grievance and submit a decision within
seventy-two hours of receiving the grievance. The shift leader shall consult other members of
the team. Both the youth and shift leader will sign and date the form. The shift leader will return
the grievance to the youth and the youth will place the grievance in the grievance box located in
the cafeteria. The appeal phase starts if the youth is not in agreement with the solution offered
by the shift leader, the grievance officer shall review the grievance with the staff and youth
separately and issue a decision within seventy-two hours. The program had sixteen grievances
during the annual compliance review period. A review of five grievances revealed an informal
phase was documented and all moved into the formal phase. Four of the five were not resolved
during the formal phase, continued to the appeal phase, and were resolved within the required
time frames. The remaining grievance was resolved in the formal phase. Seven youth were
interviewed. All seven youth were able to articulate the grievance process and where forms are
located. Seven staff were interviewed. All seven staff were able to explain the program’s youth
grievance process. An interview with the program director (PD) revealed there are procedures in
place to allow the youth to grieve, in writing, the actions of program staff or their peers, as well
as conditions or circumstances of care and treatment which are a violation of their rights. The
PD verified the program is following their policy and procedures with informal, formal, and
appeal phases.
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
A review of the program’s contract found the program’s primary groups are Moral Reconation
Therapy (MRT), Dialectical Therapy (DBT), Seven Challenges, and Impact of Crime (IOC), each
of which are clinical groups, with the exception of IOC. These groups are facilitated by the
program’s therapist and are reviewed by the Department’s Office of Fidelity, Accountability, and
Support and the Office of Health Services; therefore, are not applicable for this indicator. The
supplemental groups required of the program include gossip girl, coping with anger, anger
management, seeking safety, and life skills. A review of the group schedule and sign-in logs
confirmed groups are being provided as required. These groups are conducted by team leaders
with a high school education. The staff’s education and work experience were considered when
determining the delivery of intervention services. The program director (PD) reported no formal
training is required. Applicable groups were provided as outlined in the contract table. A review
of the program’s activity schedule confirmed the program is providing structured, planned
programming, or activities at least sixty percent of the youth’s awake hours. The program
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 66 (Revised September 2022)
provided documentation staff were trained on EQUIP but never taught the group. The program
is in the process of amending the contract to remove this group as a requirement. An interview
with the designated mental health clinician authority (DMHCA) revealed services are provided to
all youth daily. Individual, family, and group therapy are implemented interventions to address
the need of youth, but are not limited to evidence based, promising practice, or practices with
demonstrated effectiveness. An interview with the PD revealed IOC, MRT, and DBT are
delinquency intervention models or strategies which are evidence based, a promising practice,
or a practice with demonstrated effectiveness and have been implemented to address the
priority needs of youth.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures addressing life and social skills training provided for
youth. The program offers Aggression Replacement Training (ART), Moral Reconation Therapy
(MRT), Impact of Crime (IOC), and Seven Challenges which are all life skills interventions. The
services are provided daily as documented on the program schedule and sign-in sheets. In
addition to the life skills intervention services the program also offers team building, decision
making, interpersonal relationships, non-violent conflict resolution, communication skills,
identifying and avoidance of high-risk situations, appropriate interactions, anger management,
critical thinking, human sexuality, searching and applying for jobs, problem solving, goal setting,
planning, decision making skills, personal appearance/hygiene, stress management, self-
esteem, and preparing budgets. These offerings address the targeted gender group of the youth
in the program. Seven youth were interviewed. All youth reported participating in a life skills
group. Five youth reported participating in IOC, five in MRT, four youth participated in coping
with anger, one youth reported participating in Seven Challenges, and one in gossip girl. An
interview with the program director revealed all youth participate in groups daily. Special focus is
placed on the needs of each youth’s relationships with family members, peers (pro-social,
antisocial, dating), adults outside of the family (positive role models, mentors), and authority
figures in order to build positive relationships and establish safe and appropriate boundaries. An
interview with the designated mental health clinician authority (DMHCA) revealed youth are
provided an opportunity to practice skills they have learned in groups in all areas of the
program.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program’s Impact of Crime (IOC) groups are considered primary services which is a
promising practice. In addition to these restorative justice groups, youth conduct positive youth
justice model with the Boys and Girls Club. The youth participate in knitting blankets for nursing
homes and pregnant mothers, conduct community service by food distribution, catering, and
cleaning up at events. A speaker from a local victim advocacy program comes in monthly to
speak to youth. A review of sign in sheets and pictures revealed youth are active in the Boys
and Girls Club. An observation of a restorative justice group was unable to be made as none
were held during the week of the annual compliance review. Seven youth were interviewed. Six
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 66 (Revised September 2022)
of the youth stated they participate in IOC as a restorative justice group/activity while at the
program. The remaining youth stated they have not started a group. An interview with the
designated mental health clinician authority (DMHCA) revealed group therapy is provided to all
youth as prescribed and indicated in the program’s contract. An interview with the program
director (PD) revealed, the program places an emphasis on mental health issues specific to
girls, such as victimization, neglect, abandonment, depression, domestic violence, motherhood,
and others which might be identified during the comprehensive assessment process. Emphasis
is also placed on addressing substance abuse issues specific to girls, including effects of
substance abuse on families, differing physical and mental effects of substance abuse, and how
to prevent relapse, whether it be through triggers, environment, or physiological or mental
withdrawal. All youth at the program are guided toward taking full responsibility for their criminal
actions, antisocial behavior, and harm to others. Activities and instruction are provided to
increase the awareness of, and empathy for, crime victims and survivors. The PD reported
youth are held responsible for harm caused to the program community. All girls, throughout the
behavior modification system, will be taught restorative justice principles and will be held
accountable for restoring community relationships within the program whenever harm has been
imposed. Additionally, youth will participate in community service projects, such as serving at
local events, cleaning up, participating in food drives, and crocheting blankets for the elderly and
homeless.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Non-Applicable
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.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program maintains separate youth records for mental health, case management, and
medical for each youth. All youth records were labeled confidential. The individual case
management record contained youth’s name, Department identification number (DJJID), date of
birth, county of residence, and committing offense. Each record contained sections labeled as
legal information, demographics and chronological information, correspondence, case
management and treatment team activities, and miscellaneous, as required. All records were
observed to be secured in a locked file cabinet when not being used. The cabinet was labeled
confidential.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 15 of 66 (Revised September 2022)
1.15 Advisory Board Limited 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.
During the annual compliance review period the program was to hold three community advisory
board meetings. A review of documentation indicated the program conducted two and was
unable to provide a reason why one was missed, and not rescheduled. The program director
(PD) solicited active involvement from the business community, victim advocate, and other
community partners. There was no active involvement to recruit law enforcement
representative, judiciary community, school board/district, faith community, LGBTQIA+
community, or a parent/guardian whose child was previously in the juvenile justice system. An
interview with the PD revealed the advisory board should consist of citizens of the local
community interested in actively supporting the growth of the program, including representatives
from law enforcement, the judiciary community, business community, faith community, local
school district, and if possible, the LGBTQIA+ community. In addition, at least one member of
the board should be a victim, a victim advocate, or another representative of the victim services
community, and a parent/guardian whose child was previously involved in the juvenile justice
system. The PD or designee shall ensure the community advisory board meetings will be held
at least every ninety to 120 days. The PD shared who will be invited to the next meeting. An
interview with a board member confirmed their participation in the program’s community
advisory board meetings. They stated they have participated for around seven years. The
program conducts meetings every three months and members are notified of meetings through
email or text. The board member reported they enjoy participating in the meetings, wish to
continue, and believes the PD is doing a fantastic job with the program and the youth.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures which indicates staff are to receive evaluations on
performance annually. Three different job descriptions were reviewed, and evidence was found
each staff position had clearly identified performance standards. Seven staff personnel records
were reviewed and found each had a completed annual evaluation as required. Performance
standards for all seven staff matched the job descriptions for each staff member reviewed. A
review of the provider’s contractual agreement was done in comparison with the program’s
current vacancy list and found the program maintained the required positions. Seven staff were
interviewed. Six staff stated they receive a yearly formal evaluation based on performance
standards. One staff stated they had not been at the program for a year but received a ninety-
day evaluation and six-month evaluation. One staff stated communication at the program is very
good, five indicated it is good, and one indicated it is fair. An interview with the program director
(PD) revealed it has been difficult to fill vacant positions. There has been some turnover due to
new hires not always understanding the gravity of their position. The PD reported the program
has monthly All Staff Meetings where there are nominations for employee of the month, quarter,
and year, and the winners receive monetary gifts, as well as program paraphernalia. The
corporate office provides lunch for staff quarterly and the PD provides shift lunches for staff
quarterly. Once a month usually on a weekend, the program does a cookout or fish fry for
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 16 of 66 (Revised September 2022)
working staff. Staff are provided gifts for major holidays. All staff receive copies of their job
descriptions and are evaluated at ninety days and annually.
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.
A review of special contract conditions revealed the program’s education services shall include
SMART technology, flexible seating, and a driving simulation program. An interview with the
lead teacher revealed the driving simulator was taken from the program three weeks ago due to
being purchased with Title V funds, which is a rural grant and ineligible to transfer into Florida
Scholar's Academy. The contract also outlined the EQUIP curriculum (cognitive behavioral
therapy) named gossip girl would be led by direct care staff and supervisors. A review of
documentation revealed the staff were trained on EQUIP; however, it was never initiated due to
its complicated nature, and staff were having trouble teaching it. At the time of the annual
compliance review gossip girl was taught by direct care staff without the EQUIP portion. This
was agreed upon by the Department’s Office of Fidelity, Accountability, and Support and a
contract revision is pending. The program provides faith-based opportunities by having a local
ministry come in twice a month and a review of vehicle logs indicated youth are able to attend
church off-site at least once a month. The program is partnered with Boys and Girls Club which
is provided seven days a week. A review of sign in sheets, pictures, and crafts created by youth
revealed Boys and Girls Club is an active part of the program as required. The positive youth
justice model includes community service opportunities, opportunities for restoration,
parent/guardian involvement, and mentoring. The welding classes are taking place as required;
however, no youth have received the welding certification. Seven youth were interviewed. All
seven youth stated they participate in SMART technology, flexible seating, driving simulation
program, faith-based opportunities, Boys and Girls Club, community service opportunities,
welding instruction certification, and ServSafe. An interview with the program director revealed
the program implements 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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 17 of 66 (Revised September 2022)
1.18 Contract Specific Career and Technical Education
Satisfactory Compliance
Services
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), Special Conditions, or older contracts may not have them clearly identified as a
special condition. Career and technical education service instruction shall be provided so the
interests, aptitudes, and skills of the youth are developed, while building upon their existing
strengths, in a manner supportive of their employability goals which provide an occupational
advantage and workforce readiness in their community. These items may exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code.
The career and technical education services required to be offered include Florida Ready to
Work Soft Skills, Occupational Safety and Health Administration (OSHA) 10, cardiopulmonary
resuscitation (CPR)/first-aid, and an industry certification from the Master Credential list. The
provider offers culinary and welding. Additionally, youth shall have the opportunity to earn
ServSafe and National Center for Construction Education and Research (NCCER) certifications
and career readiness which they receive through Florida Ready to Work training. A review of
documentation indicated between three to five youth participate in CPR/first-aid training each
month, thirty-nine youth received or are in the process of receiving OSHA 10 training, sixty-eight
youth have completed or are in the process of completing Florida Ready to Work training, and
sixteen youth were enrolled in welding. Twenty-one youth were enrolled in culinary, twenty-three
youth received their CPR/first-aid certificates, three youth received OSHA 10 certifications,
thirty-two youth earned the Florida Ready to Work Soft Skills certificate, and thirty-two youth
completed the ServSafe certification. At the time of the annual compliance review, no youth had
earned the welding certification. Technical education services are provided Monday through
Friday from 9:00 a.m. to 11:30 a.m. and 12:30 p.m. to 3:00 p.m., which are the allotted
classroom days/times. During these days/times, there are separate classrooms for welding,
culinary, and Florida Ready to Work/OSHA. CPR/first-aid is provided on a monthly basis. All
career and technical education services were provided as required. A review of career and
technical education services instructors revealed all had the proper qualifications, as required.
Seven youth were interviewed and reported they participated in OSHA, employability, digital
skills, welding, culinary, education-ingenuity, Florida Ready to Work, computer skills, ServSafe,
high school equivalency diploma (GED) and vocational services. All seven reported they receive
services every day except for weekends. The program director indicated the program provides
culinary arts and welding.
1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program reported they track restraint data and review the data and discuss on what could
have been done differently. In addition, the program director incentivizes the youth to avoid
restraints through the behavior management system (BMS). The collected information is shared
with administration at the weekly management meetings held on Mondays to address all
program related concerns and to disseminate pertinent information to staff. The All Staff
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 18 of 66 (Revised September 2022)
meetings are held monthly. A review of sign in sheets and meeting agendas maintained during
the annual compliance review period supported this practice. The program shares this
information with the Department by the tenth of every month.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 19 of 66 (Revised September 2022)
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.
Seven reviewed case management records had documentation indicating each youth’s
parent/guardian was contacted by telephone within twenty-four hours of each youth’s arrival. All
seven reviewed case management records included written notification of each youth’s arrival to
the program to the parent/guardian within forty-eight hours of admission. All seven reviewed
case management records reflected program staff notified the committing court and assigned
juvenile probation officer (JPO) of each youth’s arrival on the day of admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures to address the youth orientation process. Program
orientation was conducted for all seven reviewed youth case management records within
twenty-four hours of admission. Orientation included expectations and responsibilities of each
youth, written behavioral management system, access to medical and mental health and
substance abuse services, access to the Department’s Central Communications Center (CCC)
and Florida Abuse Hotline, zero tolerance regarding sexual misconduct, what is considered
contraband and illegal items and consequences for having these items, performance plan
process, hygiene and dress code, procedures for visitation, mail, and telephone usage, each
youth’s anticipated length of stay, goal completion, expectations for release, access to
community, grievance process, fire drills and emergency procedures, facility tour, health
education topics, services available, daily schedule, living unit, and treatment team assignment.
Each of the seven youth interviews indicated the orientation process started within twenty-four
hours of arrival. Each youth confirmed the process of orientation. The youth admission
orientation process was observed and included all elements of the program’s policy and
procedures.
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 seven reviewed case management records was applicable for the youth being eighteen
years of age or older; two additional records were reviewed. Documentation was signed by all
three applicable youth for consent to provide physical and mental health information to their
parents/guardians.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 20 of 66 (Revised September 2022)
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
The program has a policy and procedures outlining the classification process for youth upon
admission to the program and completion of reassessments as necessary. Classification factors
were documented in all seven reviewed case management records. Classification
documentation addressed each youth’s gender, height, weight, physical stature, age and
maturity level, special needs, history of violence, gang status, criminal behavior, sexual
aggression or vulnerability to victimization, perception of vulnerability, potential or verified
human trafficking history, and risk factors for medical, suicide, escape, and security. All seven
records demonstrated each youth was assigned to a living unit and room based on the
program’s classification system. Each of the seven reviewed records included the Vulnerability
to Victimization and Sexually Aggressive Behavior (VSAB) documents. The program utilizes an
alert system which staff have access to and provide updated information on each youth,
including medical, mental health, suicide, sexual predator, aggression, escape or security risks.
Each record documented a review of the Department’s Juvenile Justice Information System
Alert List for any issues affecting classification. Any special needs or risk factors identified
during or subsequent to the classification process were immediately entered into the program’s
internal alert system. Six of seven reviewed records included reclassification forms, the
remaining youth was not applicable for a reclassification. All six documented reclassification
prior to the addition of privileges including an increase in freedom of movement, participation in
work projects or other activities, and participation in off-campus activities. The program director
(PD) interview indicated a pre-admission staffing will be held by members of the treatment team
for each youth prior to their admission, when possible, which will be used to guide the staffing,
and documentation will be completed and placed in the youth's case management record. The
PD reported the therapist and case manager will be assigned during the staffing and a dorm will
be tentatively assigned. At the time of admission, the case manager reviews the youth’s record,
intake packet, history, collateral contacts, and initial interactions during orientation. The case
manager will make the final dorm assignment based on the recommendation of the treatment
team during the pre-admission staffing and their interaction with the youth upon admission. All
newly admitted youth shall be screened using the VSAB prior to room assignments. The PD
also reported the VSAB screening tool will be utilized to determine the youth’s potential risks,
which will be entered into JJIS.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 21 of 66 (Revised September 2022)
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.
None of the seven reviewed case management records were applicable for gang identification
and notification. There were no youth applicable during the annual compliance review period.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures to address a youth’s participation in gang prevention
and intervention activities. There were no youth applicable for gang identification and
intervention during the annual compliance review period. The program director interview
indicated all new intakes will be interviewed for any gang affiliation during the admission and
orientation process, this information is passed on to the leadership team, as well as
documented on the classification form and revised if new information is obtained while the youth
is in the program. If a youth expresses the desire to disaffiliate with a criminal street gang, by
either the initial gang assessment or verbally at any time, the program will help develop a plan
to do so. If needed, the program utilizes Impact of Crime as the identified gang intervention
curriculum.
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.
Seven youth case management records were reviewed, and all contained the Residential
Assessment for Youth (RAY) completed within thirty days of admission. Six of the seven initial
assessments were maintained in the Department’s Juvenile Justice Information System (JJIS).
The remaining could not be verified due to ongoing system issues. Two of the seven were
applicable for ninety-day reassessments. One extra record was requested. All three records had
reassessments completed every ninety days as required and were applicable for additional
reassessments deemed necessary by the intervention and treatment team. All three youth case
management records maintained all reassessment documentation as required.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 22 of 66 (Revised September 2022)
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in JJIS on the YNAS.
Each of the seven reviewed youth case management records included a Youth Needs
Assessment Summary (YNAS) completed in the Department’s Juvenile Justice Information
System (JJIS) within thirty days of each youth’s admission.
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.
Each of the seven reviewed youth case management records included performance plans which
were completed within thirty days of admission in the Department’s Juvenile Justice Information
System (JJIS) and done after completion of the Youth Needs Assessment Summary (YNAS).
Documentation in each of the seven youth case management records indicated team members
provided input to the performance plans. Each of the seven youth interviews reflected each
youth participated in the development of their performance plan. All performance plan goals
were measurable and included target completion dates. The individualized goals included in
each performance plan were based upon the prioritized needs reflecting the risk and protective
factors identified ensuring the initial assessment process. Each identified specific delinquency
interventions based on the Residential Assessment for Youth (RAY) results. Performance plan
goals also identified responsibilities of staff and youth. The performance plans included the top
three criminogenic needs identified in the YNAS and transition goals, and targeted court-
ordered sanctions which could be reasonably initiated or completed while the youth was at the
program. Each of the seven interviewed youth reported they know what performance plan goals
they are working on. All seven youth case management records included performance plan
transmittal letters which were sent out to all applicable parties within the required time frame.
Performance plans were signed by the treatment team leader, youth, and other parties who
have responsibilities in goal completion. Original performance plans were maintained in all
seven youth case management records. Each of the seven youth confirmed they had received a
copy of their performance plan.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 23 of 66 (Revised September 2022)
2.10 Performance Plan Revisions Satisfactory Compliance
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team.
Three of seven reviewed case management records were applicable for performance plan
revisions. The youth treatment team was involved in determining the need for performance plan
revisions. Revisions were made based on goal progress, new information, and Residential
Assessment for Youth (RAY) Reassessment results. Two youth were applicable for
reassessments to facilitate transition activities and received reassessments as required.
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.
Four of seven reviewed case management records were applicable for Performance
Summaries, the remaining youth had not been in the program long enough to receive a
Performance Summary. Each applicable Performance Summary included each youth’s goal
progress, behavior, education status, significant events, interactions with peers and staff,
readiness for change, overall treatment progress, and all other required elements. All four
performance summaries were done within ninety days of the performance plan signatures and
prior to the youth’s release, discharge, or transfer from the program. Two of the seven records
included the justification for release, discharge, or transfer. Reviewed documentation in the four
applicable records indicated the youth was allowed to read and add comments prior to signing
the summary, the youth received a copy of the summary, and the original summary was filed in
the youth’s record. Each Performance Summary was signed and dated by all required parties
then a copy was sent within ten business days to the committing court, juvenile probation
officer, parent/guardian, and Department of Children and Families caseworker, as applicable.
Two of the seven records contained a release summary and one additional closed case
management record was reviewed for release summary requirements. In addition to each
youth’s goal progress, behavior, education status, significant events, interactions with peers and
staff, readiness for change, and overall treatment progress, these three release summaries
included the justification for release and Pre-Release Notification (PRN). The release summary
and PRN were sent within the required amount of time. A signed copy was maintained in each
youth’s record. None of the youth were applicable for the court objecting to their release. Once
approved, the program provided written notification to each youth’s parent guardian and the
closed case management record contained an Exit Residential Assessment for Youth. None of
the youth were applicable for the Sexually Violent Predator Program and none required victim
notification to be sent. Original Performance Summaries and copies of release summaries were
in each youth case management records. An informal interview with the case manager indicated
youth receive copies of their Performance Summary.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 24 of 66 (Revised September 2022)
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.
Each of the seven reviewed case management records included documentation demonstrating
program staff attempted to involve parent/guardian in the assessment process, performance
plan development, and progress review. Three additional closed case management records
were reviewed for transition planning invite letters. Parents/guardians were provided with
opportunities to attend or participate in these events. If unable to attend, the parent/guardian is
provided the opportunity to participate by telephone or video conferencing, or to provide verbal
or written input prior to the meeting. A treatment team meeting was observed and the
parent/guardian participated by telephone. The program director (PD) interview indicated to the
extent possible and reasonable, program staff encourage and facilitate involvement of the
youth’s parent/guardian in the case management process, including assessments, performance
plan development, progress reviews, treatment team meetings and transition planning.
Parent/guardian participation is strongly encouraged. Parents/Guardians will be notified for all
treatment team meetings. Each of the seven interviewed youth reported their parents/guardians
are involved in the case management process.
2.13 Incorporation of Other Plans into Performance Plans Satisfactory Compliance
The youth’s performance plan shall reference or incorporate the youth’s treatment or care
plan.
Each of the seven reviewed case management records reflected all applicable plans were
incorporated into each youth’s performance plan, including the youth’s mental health and
education plans. In addition, the program advised none of the youth were served by the
Department of Children and Families and/or the Agency for Persons with Disabilities.
2.14 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
A program shall ensure the intervention and treatment team meets bi-weekly (formally and
informally) to review each youth’s performance, to include RAY Reassessment results,
progress on Individualized Performance Plan goals, positive and negative behaviors,
including behaviors resulting in physical interventions. If the youth has a treatment plan,
review their treatment plan progress.
Seven youth case management records were reviewed for formal and informal treatment teams.
In each of the seven records, the case manager and therapist were identified as treatment team
leaders. The treatment team for each youth included the youth, administration representative,
case manager, living unit representative, education, clinical staff, medical staff, gang coordinator
when applicable, juvenile probation officer (JPO), parent/guardian, and transition service
manager (TSM) when applicable. Participants were present or provided written input. Team
members actively participate or provided input for meetings. The youth’s JPO and
parent/guardian participated by telephone. All seven reviewed case management records
included formal treatment team reviews completed at least once every thirty days as required.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 25 of 66 (Revised September 2022)
One of seven was applicable for an informal bi-weekly treatment team meeting and included all
required elements. Treatment team reviews included youth name, review date, attendees, input
from team members, how youth are progressing, youth behavior, any physical interventions,
and Residential Assessment for Youth (RAY) Reassessment results when applicable. All other
elements were included in the treatment team documentation as applicable, and the
documentation was maintained in each youth’s record. The youth’s treatment team members,
JPO, and parent/guardian were invited and encouraged to participate in youth formal treatment
team reviews. A treatment team meeting was observed which included applicable members and
a review of the youth’s treatment plan to determine their anticipated release date. Each of the
seven interviewed youth reported they have an opportunity to demonstrate learned skills and
youth progress is discussed during formal treatment team meetings. Seven interviewed youth
indicated they are allowed to demonstrate their learned skills and discuss their progress in
treatment team meetings.
2.15 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
Three closed case management records were reviewed for transition planning and the
Community Re-Entry Team (CRT) meeting. Transition conferences were conducted at least
sixty days prior to each youth’s scheduled release date. The youth, treatment team leader,
program director or designee, juvenile probation officer (JPO), parent/guardian, medical, and
education staff were invited and participated in each youth’s transition conference. During the
transition conference the team conducted a review of the transition activities on each youth’s
performance plan, revised the performance plan as necessary, identified additional transition
activities as necessary, identified target completion dates, and identified persons responsible for
completion. A copy of each plan was sent with a request for return with signature to each
applicable party not in attendance at the transition conference. The treatment team leader
obtained participant signatures or electronic acknowledgement of responsibilities. All three
closed case management records included supporting documentation indicating the program
and youth participated in the CRT meeting prior to release and an invitation sent through email
was maintained within the youth records.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 26 of 66 (Revised September 2022)
2.16 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
Three closed case management records were reviewed for Exit Portfolios. Documentation
indicated the Exit Portfolio was present for all three youth. The three closed case management
records included all required documents except for a state-issued identification card, Social
Security card, or birth certificate. The Exit Portfolio was provided to each youth and juvenile
probation officer (JPO). The youth were not applicable for requirements specific to youth in a
secure maximum risk program. The program did not have any additional requirements related to
the Exit Portfolio included in their contract. Each Exit Portfolio was discussed and initiated for
the youth at the transition conference, and then verified during the exit conference.
2.17 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
Three closed case management records were reviewed for Exit Conference requirements. Exit
Conferences were conducted for each youth after notification to the juvenile probation officer
(JPO) and at least fourteen days prior to anticipated release date. Documentation in each
youth’s case management record reflected the JPO, parent/guardian, education staff, and other
pertinent parties were invited to participate in each youth’s Exit Conference. All three Exit
Conferences were documented in each youth’s case management record and held separately
from the transition conference and Community Re-Entry Team meetings. The status of
transition activities established at the transition conference and plans finalized for the youth’s
release were reviewed. Due to statewide system outages the dates of admission and
termination documented within each youth’s record could not be compared to the Department’s
Juvenile Justice Information System. The Exit Conference documents included a review of
transition conference goals, a summary of pending transition goals, and signatures for all
applicable parties. The youth’s JPO and parent/guardian participated by telephone.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures to encourage formal constructive input by youth. A
review of program youth advisory council documents reflected youth can provide input and
feedback concerning services, community, improvements, and staff and youth quality of life.
Documentation supported these meetings were held quarterly. Each of the seven youth
interviews indicated input can be provided through Boys and Girls Club, request to speak forms,
youth advisory, and community meetings. The program director (PD) interview stated the
program strives to provide the youth opportunities to develop self-advocacy, leadership,
teamwork, and empowerment skills. Youth will be provided the opportunity to provide feedback
regarding the services they receive, daily programming, as well as any treatment relative to their
stay at the program. Youth will participate in the development of the behavior modification
system/handbook to provide them the opportunity to have ownership and take responsibility for
their community. Youth are chosen by the youth advisory council in conjunction with the PD.
Meetings are held quarterly or as needed with the PD and/or designee. Youth advisory
representatives will serve for the duration of their stay or until they become ineligible.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 27 of 66 (Revised September 2022)
2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program has a policy and procedures to provide for career education based on age and is
appropriate for the educational abilities, length of stay, and classification of the youth in the
program. The program is a Type 2 vocational program; however, the program offers Type 3
vocational programming to include welding, and culinary arts. The interview with the lead
educator indicated the youth participate in an employability class which addresses career
interests and preparation. The youth work in the Florida Ready to Work online program as well
as the Occupational Safety and Health Administration (OSHA) 10 online certification course. As
youth earn certificates and credentials, they are printed out and kept in the youth’s educational
record. Three closed youth case management records were reviewed. All reviewed records
included a résumé, sample job applications, provisions for continuation of employment,
appropriate documents essential to obtaining employment, and information on the location of
the local Career Source Center. Each record contained documentation the youth’s
parent/guardian and juvenile probation officer were aware of the vocational plan and
documentation indicating the case manager and parent/guardian were aware of the documents
and post-release discharge plans. The three youth records did not have the required State of
Florida identification card (ID). The program director’s interview reiterated the requirements for
the program to provide Type 2 career education to the youth.
2.20 Educational Access (Critical) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a policy and procedures to provide for educational access. The district
approved calendar and daily bell schedule were reviewed and determined the program
incorporated the required 250 days of instruction, with up to ten days used for teacher planning,
fulfilling the weekly requirement of twenty-five hours of instructional time. Minimal school
interruptions were verified through logbook reviews and the lead educator’s interview. Youth are
able to earn credits for educational and training experience. Seven youth were interviewed, and
three reported there is little to no interruption to the school day. The four youth who said yes,
reported most disruptions are caused by other youth and the situations are handled quickly by
staff. A review of four randomly selected logbook reviews for the annual compliance review
period showed the youth were attending school according to the daily bell schedule. Further
review of logbook entries and video footage for three days verified the youth were attending
school as scheduled.
2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The program has a policy and procedures requiring an education transition plan to be
developed upon each youth’s admission. Three closed youth case management records were
reviewed, and all three youth records included the specified Education Transition Plan
developed with the youth based on their post-release goals upon admission. All required
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 28 of 66 (Revised September 2022)
personnel participated in the development of the plan. Each of the three records contained an
exit plan indicating the case manager, parent/guardian, and youth were all aware of the plan.
Included in each record was an Electronic Educational Exit Plan (EEEP), which identified the
next educational placement information and input from the post-release school district
representative, services and interventions based on the youth’s educational needs and post-
release plans, and specific monitoring responsibilities for those responsible for the reintegration
and coordination of the provision of support services. Each of the seven interviewed youth
reported they participated in the development of their education transition plan. Each of the
seven youth reported the program was preparing them very well or well when it came to high
school, high school equivalency diploma (GED), vocational school, employment, and/or college.
The lead educator’s interview reiterated the process of creating the Education Transition Plan.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 29 of 66 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The designated mental health clinician authority (DMHCA) is a licensed mental health
counselor. The DMHCA’s license was provided for review and is valid until March 31, 2025. The
program has not had any other DMHCAs during the annual compliance review period. The
DMHCA is on-site weekly to ensure appropriate coordination and implementation of mental
health and substance abuse services were taking place, as required. The DMHCA is the single
licensed mental health professional responsible for the coordination and implementation of
mental health and substance abuse services. The DMHCA’s position description was provided
for review and there were no issues. The program utilizes a back-up DMHCA, who is also the
program director. The back-up DMHCA had a valid license which expires March 31, 2025. The
DMHCA reported being responsible for assigning youth to groups during the pre-admission staff
meeting. The DMHCA reported individual therapy, family therapy, and group therapy are
provided to the youth. There is daily and weekly communication between the DMHCA and
clinical staff.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program does not have additional licensed mental health and substance abuse clinical staff
outside of the designated mental health clinician authority. A review of the staff roster confirmed
clinical staffing is in accordance with the program’s contract.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The designated mental health clinician authority (DMCHA) assures the non-licensed clinical
staff working under their supervision are performing services they are qualified to provide
based upon their education, training, and experience. Each non-licensed mental health clinical
staff working under the direct supervision of the licensed mental health professional received a
minimum of one hour a week of on-site, face-to-face direct supervision. The direct supervisions
were recorded on a form which included all required elements of the Department’s Licensed
Mental Health Professionals and Licensed/Certified Substance Abuse Professionals Direct
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 30 of 66 (Revised September 2022)
Supervision Log form. The program has a Chapter 397 license located in the front lobby of the
administration building. The Chapter 397 license expires July 5, 2024. The program requires a
recreational therapist; therefore, the program’s staff roster and the recreational therapist’s
credentials were reviewed and there were no issues noted. The non-licensed mental health and
substance abuse clinical staffing is in accordance with the current contact including the number
of hours. There were no vacancies for clinical staff during the annual compliance review week.
The program has employed seven non-licensed mental health and substance abuse staff during
the annual compliance review period. All seven staff held a master’s-level degree from an
accredited university or college in the field of counseling, social work, psychology, or related
human services field. Five of the seven staff provided substance abuse services. The program
maintains a Chapter 397 license and the staff are working under the direct supervision of a
qualified professional. Due to the Department’s Learning Management System (SkillPro) being
inaccessible, staff training for completion of Assessments of Suicide Risk (ASRs) could not be
reviewed.
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.
Seven youth mental health records were reviewed for the mental health and substance abuse
admission screening. All seven youth were given a Massachusetts Youth Screening Instrument,
Second Version (MAYSI-2) and documentation was maintained in each youth’s mental health
record. All seven youth mental health records included documentation the screener reviewed
available information to include the commitment packet, reports and/or records, or existing
documentation of mental health and substance abuse problems or history of human trafficking.
MAYSI-2 trainings were unable to be checked due to the Department’s Learning Management
System (SkillPro) being inaccessible. All MAYSI-2s were completed in the Department’s
Juvenile Justice Information System (JJIS). All screenings were printed from JJIS and
maintained in each youth’s mental health record. All seven completed MAYSI-2s indicated
further assessment was required. A referral for further evaluation was made for all youth. It is
the policy of the program all youth will receive a referral for further evaluation upon intake to the
program. All seven youth mental health records included documentation the staff completed a
referral for further evaluation regardless of the MAYSI-2 findings. None of the completed
MAYSI-2 assessments indicated the youth were in need of a Crisis Assessment, crisis
intervention, or emergency services. Four of the seven youth mental health records included
documentation the program director (PD) 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. All seven youth mental health records included documentation
the referral types were included for ASR, comprehensive evaluation, and the reason for referral.
The program maintains a policy and procedures for the implementation of a standardized
admission/intake mental health and substance abuse screening process. The policy was
provided for review and contained the standardized screening process which includes a review
of the commitment packet information, reports, and records, as well as administration of the
MAYSI-2 in JJIS or clinical mental health screening by a licensed mental health professional,
and clinical substance abuse screening by a qualified professional, and referral of juvenile
offenders identified by screenings as in need of further evaluation or immediate assessment.
The policy also included staff training in mental health and substance abuse issues,
administration of the MAYSI-2, and a standardized process for referral of youth identified as in
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 31 of 66 (Revised September 2022)
need of further mental health and/or substance abuse evaluation to an appropriate service
provider/professional or, when immediate attention is needed, to a hospital or Baker Act or
Marchman Act receiving facility. The PD reported every youth who is admitted to the program is
screened for mental health and substance abuse problems by using the MAYSI-2 or the Clinical
Mental Health/Substance Abuse Screening on the day of admission in a confidential matter. A
suicide risk screening is done through the MAYSI-2. This is completed electronically in JJIS.
While JJIS has been down, the MAYSI-2 has been hand administered and scored. The MAYSI-
2 is only administered by staff who have completed specific training for its administration. All
clinical and mental health screenings are completed, reviewed, and signed by a licensed mental
health professional and/or a qualified professional. A screening process will include a review of
all psychological/psychiatric reports, pre-dispositional reports, and other information regarding
the mental health or substance abuse information for youth.
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.
Seven youth mental health records were reviewed for mental health and substance abuse
evaluations. All seven youth records included documentation the program completed a
combined mental health and substance abuse evaluation for each youth. All seven new
evaluations were completed within thirty calendar days of admission. A non-licensed mental
health clinical staff completed the evaluations, and the evaluations were reviewed and signed by
a licensed mental health professional within ten calendar days after the evaluation was
conducted. All seven evaluations included identifying information, reason for evaluation,
relevant background information, behavioral observations, mental status examinations,
interview or procedures administered, discussion of findings, diagnostic impression/formulation
including the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V)
diagnosis, and recommendations. All seven youth mental health records included
documentation a consent was obtained for substance abuse services. All seven youth received
a new substance abuse evaluation completed within thirty calendar days of admission. The
substance abuse evaluation included the reason for assessment, relevant background
information, behavioral observations, methods of assessment, patterns of alcohol and other
drug abuse, impact of alcohol and other drug abuse on major life areas, risk factors of continued
alcohol and other drug abuse, clinical impression including the DSM-V diagnosis, 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.
Seven youth mental health records were reviewed for mental health and substance abuse
treatment. All seven youth mental health records included documentation the initial treatment
plans were developed within seven days of the initiation of treatment. All seven initial mental
health treatment plans included required elements from the Department’s Initial Mental
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 32 of 66 (Revised September 2022)
Health/Substance Abuse Treatment Plan form. All seven youth mental health records included
documentation the initial treatment plans were developed within seven days of the onset of
treatment or within seven days of the initial psychiatric diagnostic interview. All seven youth
mental health records included documentation the initial treatment plans were signed by the
clinical staff completing the form. Five of the seven initial treatment plans were completed by
non-licensed clinical staff and were reviewed and signed by the licensed clinical supervisor
within ten days of completion. The two remaining initial treatment plans were completed by the
designated mental health clinician authority (DMHCA). All seven initial treatment plans were
signed by all treatment team members who participated in the development of the plan,
parents/guardians, and youth. All seven initial treatment plans included the psychiatric needs of
each youth. All seven youth mental health records included documentation the individualized
treatment plans were developed within thirty days of admission. All seven individualized
treatment plans were developed on a form which contained all required elements from the
Department’s Individualized Mental Health/Substance Abuse Treatment plan form. All seven
individualized treatment plans were signed by the clinical staff who completed the plan and the
licensed supervisor within ten days of completion. All seven individualized treatment plans were
signed by all treatment team members, including the youth. Three of the seven individualized
treatment plans included signatures of the parent/guardian or documentation of participation.
Three of the seven treatment plans did not include signatures of the parent/guardian but did
include documentation the parent/guardian participated. The remaining one treatment plan
included documentation the youth’s assigned Department of Children and Families case
manager and parent/guardian participated in the development of the treatment plan. All seven
individualized treatment plans included a section for psychiatric services. All seven youth mental
health records included documentation the individualized treatment plan reviews were
completed on a form which included all elements from the Department’s Individualized Mental
Health/Substance Abuse Treatment Plan Review form. All treatment plan reviews were
completed every thirty days as required. All seven individualized treatment plans included any
applicable prescribed services to include individual, group, family, and psychiatric. All goals and
objectives were individualized for each youth. A review of three groups on video and sign-in
sheets for groups were conducted. Groups were being completed for the required group
time/length.
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.
Seven youth mental health records were reviewed for treatment and discharge planning. All
seven youth mental health records included documentation the youth were assigned to a
treatment team upon arrival to the program. Reviewed documentation in all seven youth records
included documentation the team members in attendance for treatment teams included the
youth, program administration, residential living unit, education, vocational training, medical
staff, mental health staff, and parents/guardians. All seven youth records included
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 33 of 66 (Revised September 2022)
documentation each youth who was determined to be in need of substance abuse treatment
received individual, group, and/or family counseling provided by a licensed, qualified
professional or a non-licensed clinical staff. Six of the seven youth records included
documentation the youth had a properly executed Authority for Evaluation and Treatment (AET)
form. One youth was involved with the Department of Children and Families and had a signed
court order. All seven youth records included documentation each youth receiving substance
abuse services provided consent through a signed Youth Consent for Substance Abuse
Treatment form. All mental health and substance abuse treatment notes were documented on
the Department’s Counseling/Therapy Progress Notes form. All seven youth records included
documentation the group therapy included individual psychotherapy or counseling and
psychosocial skills training. All reviewed progress notes verified each youth was receiving
services as stipulated in the treatment plan. Three closed youth mental health records were
reviewed for treatment and discharge planning. Two of the three youth records included
documentation the discharge plans were documented on the Department’s Mental
Health/Substance Abuse Treatment Discharge Summary form. One of the records did not
include a discharge plan. None of the youth were released while on suicide precautions. Both
youth’s Mental Health/Substance Abuse Treatment Discharge Summary documented the
services needed for daily maintenance of the positive improvement in behavioral, emotional,
and social skills made by each youth during treatment. Both discharge plans included
documentation the plans were reviewed with each youth, parents/guardians, and the juvenile
probation officer (JPO). The two closed mental health records included documentation the
discharge plans were provided to each youth, JPOs, and the parents/guardians.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program is required to provide clinical groups according to a review of the contract including
Moral Reconation Therapy, Dialectical Behavior Therapy, and Seven Challenges for all
components of the program. Seven youth were interviewed and reported they are all
participating in family and/or individual counseling. Seven staff were interviewed and reported
they do not facilitate any mental health or substance abuse groups. The designated mental
health clinician authority (DMHCA) was interviewed and reported the mental health and
substance abuse services for the program included individual therapy, group therapy, family
counseling, treatment plan reviews, and psychiatric services. The program director was
interviewed and reported treatment services are provided in accordance with Florida Statute,
Florida Administrative Code, and the program’s contract. The program is contracted to provide
thirty-two beds for youth requiring Mental Health Overlay Services (MHOS) or Substance Abuse
Treatment Overlay Services (SAOS) and eight beds for youth requiring Intensive Mental Health,
for a total of forty beds. The program provides individual, group, or family therapy at least five
days a week. The program provides each of these services as part of the individualized
treatment plans. Daily therapeutic activities are provided by mental health clinical staff. Youth
with co-occurring substance abuse disorders receive substance abuse services. Counselor
caseloads are limited to no more than twelve youth. All therapy groups are limited to ten or
fewer for mental health treatment groups. Clinical staff are trained and facilitate substance
abuse education. The program provides substance abuse services to include urinalysis drug
testing, individual, group, and family therapy. All youth receive individual, group, or family
therapy at least five times a week. All substance abuse groups are limited to no more than
fifteen participants. All youth receive daily therapeutic activities. Any youth who have co-
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 34 of 66 (Revised September 2022)
occurring mental health disorders receive mental health treatment. The program operates with a
Chapter 397 license and has a qualified professional on-site, at least five days a week and
provides substance abuse services in accordance with Florida Administrative Code. A licensed
psychiatrist provides psychiatric evaluations, medication management, and participates in
treatment planning. Substance abuse clinical staff are on-site seven days a week. Counselor
caseloads are limited to no more than ten youth for substance abuse treatment services or
fifteen youth for SAOS. The program provides services for dual diagnosed/intensive mental
health youth. The program offers mental health and substance abuse evaluations, mental health
and substance abuse treatment planning, bi-weekly individual therapy, family therapy, daily
support services, substance abuse therapeutic activities, and mental health crisis interventions.
The program maintains staffing to include mental health clinical staff on-site seven days a week
and a registered nurse is on-site daily to ensure appropriate administration of medication, and to
provide nursing observations and assessments, as needed.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.***
The program had a full-time psychiatrist who has resigned. The psychiatric APRN has a valid
license which expires January 31, 2026. The psychiatric APRN is available for emergency
consultation twenty-four hours a day, seven days a week. The psychiatric APRN provides
information to a treatment team representative regarding the psychiatric status of each youth
receiving psychiatric services who is scheduled for a treatment team review. The psychiatric
APRN provides evaluations and recommendations for each youth incorporated into the mental
health clinical staff’s evaluations of the youth and youth’s individualized mental health or
substance abuse treatment plans. The psychiatric APRN’s education, experience, and
certification/licensure in psychiatry was documented on the Department of Health website. The
psychiatric APRN is licensed for autonomous practice and does not require collaborative
practice protocols. A review of the sign-in and out logs confirmed visits during the annual
compliance review period were conducted as required. The psychiatric APRN actively
participated in, managed, and supervised psychotropic medications services in the program
after the psychiatrist left employment. The psychiatric APRN was interviewed and reported they
perform comprehensive mental health evaluations, diagnose mental health conditions, and
assess the physical health status of youth. They reported they develop and implement
individualized treatment plans, which may include psychotherapy and medication management
strategies, prescribe psychiatric medications, monitor their effectiveness, manage side effects,
and make necessary adjustments to the treatment plan. The psychiatric APRN liaises with other
healthcare professionals, such as psychiatrists, psychologists, social workers, staff, and other
nurses, to ensure cohesive and comprehensive youth care. They are responsible for
maintaining detailed and accurate records of patient diagnoses, treatments, and progress. The
psychiatric APRN reported being available telephonically twenty-four hours a day/seven days a
week. The psychiatric APRN reported not having any issues or concerns with the program. The
designated mental health clinician authority (DMHCA) reported meeting weekly or as needed
with the psychiatrist. Seven youth mental health records were reviewed for psychiatric services.
All seven youth records included documentation each youth was referred for a psychiatric
interview upon admission to the program. Four of the seven youth entered the program on
psychotropic medications and received a diagnostic interview within fourteen days of admission.
The initial diagnostic psychiatric interview included the youth’s history, Mental Status
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 35 of 66 (Revised September 2022)
Examination, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V)
diagnoses, and treatment recommendations. The diagnoses were consistent with the reviewed
treatment plans. Four of the seven youth were prescribed or continued on psychotropic
medications. The four youth mental health records included documentation the psychiatric
interviews included the prescribed medications, explanation of the need for psychotropic
medications related to the youth’s diagnosis, target symptoms, initial treatment goals, potential
side effects, risks and benefits of taking the medications, and frequency of medication
monitoring/management. The initial psychiatric interviews were documented on the
Department’s Clinical Psychotropic Progress Note (CPPN). All seven diagnostic interviews were
clearly marked “Initial Diagnostic Psychiatric Interview” as evidenced by an “Initial” stamp on
each front page of the CPPN. Two of the seven initial psychiatric diagnostic interviews resulted
in the prescription of psychotropic medications or changes to the youth’s existing psychotropic
medication regimen, which was documented on page three of the CPPN. Two of the four
youth’s medications did not change. Six of the seven youth mental health records included
documentation each youth was receiving psychotropic medications while at the program; two of
the six youth were placed on psychotropic medication after the initial psychiatric interview. All
six youth mental health records included documentation of medication reviews being completed
every thirty days for each youth on psychotropic medications. All psychiatric evaluations were
documented on the Department’s CPPN form. All six youth mental health records included
documentation when psychotropic medication was prescribed/dispensed/administered by the
psychiatrist or psychiatric APRN including identifying data, diagnosis, target symptoms of each
medication, evaluation and description of effect of prescribed medications on target symptoms,
prescribed psychotropic medications to include name, dosage and quantity of medication,
normal dosage range, ordered dosage, frequency and route of administration, reason for
changes in medication and/or dosage, side effects, youth’s adherence to the medication regime,
height, weight, blood pressure, telephone contact with the parents/guardians, signature of the
psychiatric APRN, and date of signature. The psychiatrist/psychiatric APRN, and the nursing
staff have documented monitoring for Tardive Dyskinesia monthly as indicated on the CPPN.
The program does not use tele-psychiatry.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a written suicide prevention plan detailing suicide prevention procedures. The
suicide prevention plan includes the identification and assessment of youth at risk of suicide,
staff training, suicide precautions, levels of supervision, referrals, communication, notification,
documentation, immediate staff response, and the review process of suicide attempts and
mortality review process. The review process for suicide attempts and mortality review includes
the circumstances surrounding the event, facility procedures relevant to the incident, all relevant
training received by involved staff, pertinent medical and mental health services involving the
victim, possible precipitating factors, and recommendations, if any, for changes in policy,
training, physical plant, medical, or mental health services, and/or operational procedures. The
suicide plan was reviewed annually. The last date of review was August 24, 2023 by the
program director (PD) and assistant PD.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 36 of 66 (Revised September 2022)
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.
Seven youth mental health records were reviewed for documentation of precautionary
observations and suicide prevention services. None of the seven records were applicable.
Three additional youth mental health records were provided for review. All three youth mental
health records included documentation of how and when the youth was determined to be at risk.
The Assessments of Suicide Risk (ASRs) were completed on the Department’s ASR form for all
three youth. All three youth were placed on constant precautionary observation. All three youth
mental health records included documentation the parents/guardians were notified of each
youth’s potential suicide risk, as indicated on the reviewed ASRs, and mental health staff
provided supportive services for all three youth. Two of the three youth had a Follow-Up ASR
completed on the Department’s Follow-Up ASR form prior to the removal of each youth from
precautionary observation. One youth was subsequently sent to a Baker Act facility and had not
returned to the program at the time of the annual compliance review. Two youth were
maintained on suicide precautions and constant supervision until the Follow-Up ASR indicated
suicide precautions could be discontinued. Both youth were stepped down to close supervision
prior to transition to normal routine and standard supervision once each youth’s ASRs indicated
suicide precautions could be discontinued. Both youth were maintained on close supervision
until it was determined no longer necessary by the designated mental health clinician authority
(DMHCA) or licensed mental health professional and the discontinuation of close supervision
was documented in both of the youth mental health records by a clinical staff. Both youth mental
health records included documentation a conference was held by the program director (PD) and
licensed mental health professional to reduce the level of supervision, which was documented in
accordance with the program’s suicide prevention plan. Both youth mental health records
indicated the assessments were completed by the licensed mental health professional or clinical
staff under the supervision of a licensed mental health professional. The Department’s Juvenile
Justice Information System (JJIS) could not be reviewed for alerts during the annual compliance
review week due to the system being down. The facility logbooks were reviewed for all three
youth placed on precautionary observation. The logbooks and the ASRs included evidence
administration or supervisory staff provided instructions related to the suicide risk assessment
findings and suicide precaution decisions. While all three youth were on precautionary
observation, the youth were allowed to participate in select activities with other youth in
designated safe housing/observation areas of the program. All three youth mental health
records included documentation the ASRs were completed within twenty-four hours of
screenings/concerns. All three ASRs were completed by a licensed staff or by an appropriately
trained non-licensed staff. Two of the ASRs were completed by a non-licensed staff, and were
reviewed by a licensed staff within twenty-four hours of its completion. Discontinuation was
documented by a non-licensed staff and reviewed and signed by a licensed staff. One of the
youth had been sent out to a Baker Act facility and had not yet returned to the program at the
time of the annual compliance review. In the two records the discontinuation of close
supervision was documented in the program logbook. Both youth were not stepped down to a
lower level of supervision until the non-licensed mental health clinical staff conferred with both a
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 37 of 66 (Revised September 2022)
licensed mental health professional and the PD, as evidenced on the ASRs. The reviewed
ASRs also included the date and time of the conference. Two of the three youth had ASRs
completed immediately due to each youth being in crisis. The remaining youth was not
applicable. Camera footage was reviewed for one youth who was placed on precautionary
observation to ensure proper supervision was maintained. A review of the video confirmed the
youth was properly observed throughout the duration of their precautionary observation.
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
Seven youth mental health records were reviewed for Suicide Precaution Observation Logs.
None of the seven records were applicable. Three additional youth mental health records were
provided for review. All three youth mental health records included documentation Suicide
Precaution Observation Logs were maintained for the duration each youth was on suicide
precautions. The appropriate level of supervision and observations of youth behavior were
documented in real time and did not exceed thirty-minute intervals. When warning signs were
observed, notification of the program director and mental health clinical staff was documented
on the logs. The logs were reviewed and signed by mental health clinical staff and the shift
supervisor. All reviewed logs documented safe housing requirements.
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
Pre-service and in-service training records could not be reviewed to verify staff training in
suicide prevention due to the Department’s Learning Management System (SkillPro) being
down at the time of the annual compliance review. The program keeps five suicide response kits
co-located with first-aid kits. The program provided documentation of mock suicide drills. The
drills were conducted no less than quarterly on each shift for all staff who come in contact with
youth, to include kitchen and maintenance staff. All reviewed mock mental health drills were in
response to suicide attempts and/or incidents of serious self-injury. No program youth were
used during drill simulations related to mental health or substance abuse care. The program
provided semi-annual training on emergency response procedures which included “mock”
training in emergency response to a suicide attempt or incident of serious self-inflicted injury as
evidenced by reviewed drill documentation and sign-in sheets. Any staff who were not present
during a quarterly drill had the opportunity to review each drill scenario and procedures in an
effort to understand the process and receive the necessary training to respond to an incident of
a suicide attempt or incident of serious self-inflicted injury in the program. The program director
(PD) reported 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. All
staff who work with youth are to receive a minimum of six hours of annual training on suicide
prevention and the implementation of suicide precautions. The procedures include mock suicide
drills be held no less than quarterly on each shift. All mental health drills will be simulated.
Program youth shall not be used in drill simulations related to mental health or substance abuse
care and drills in response to a suicide attempt or incident of serious self-inflicted injury are
conducted for each shift, at a minimum, on a quarterly basis. Seven staff were interviewed
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 38 of 66 (Revised September 2022)
about the process for youth who express suicidal thoughts. Six staff reported they are to notify
mental health staff, four staff reported maintaining the youth on constant sight and sound, and
three staff reported they are to document supervision. Staff additionally reported they talk with
the youth, call for assistance, and remove the youth from other youth. Seven staff reported the
knife-for-life kits are kept on each dorm. Two staff additionally reported the kits are located in
the supervisor’s office. Staff reported emergency and suicide drills are conducted several times
a month, once a month, and twice a month.
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a written crisis intervention plan which included the notification and alert
system, means of referral, including youth self-referral, communication, supervision,
documentation, and review.
3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
Seven youth records were reviewed for mental health crisis intervention services. One was
applicable for review. Two additional youth mental health records were provided for review. All
three youth records included documentation a Crisis Assessment was conducted within twenty-
four hours based on the needs of each youth. The Crisis Assessments included the reason for
assessment, Mental Status Examination and interview, determination of danger to self and/or
others, initial clinical impressions, supervision recommendations, treatment recommendations,
recommendations for follow-up or further evaluation, and notification to parents/guardians of
follow-up treatment. All three youth records included documentation the Crisis Assessments
were conducted by a licensed mental health professional or by a licensed mental health clinical
staff working under the direct supervision of a licensed mental health professional. All three
youth remained on alert until a follow-up Crisis Assessment was completed. The Department’s
Juvenile Justice Information System (JJIS) could not be reviewed due to being down at the time
of the annual compliance review. One-to-one supervision was documented on the Department’s
Mental Health Alert Observation Log for all three youth. One of the three youth had a Crisis
Assessment completed upon return to the program from an off-site Crisis Assessment provider.
The remaining two youth were not applicable. One of the youth was still at a Baker Act facility at
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 39 of 66 (Revised September 2022)
the time of the annual compliance review and the other youth was not sent off-site. One youth
had a follow-up Crisis Assessment completed by a non-licensed mental health clinical staff and
it was reviewed and signed by a licensed mental health professional. The other two youth did
not require a follow-up assessments at the time of the annual compliance review. None of the
youth were alleged victims of a Prison Rape Elimination Act event.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program maintains a written emergency mental health and substance abuse plan which
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, transport for emergency substance
abuse assessment and treatment under Chapter 397, documentation, training, and review.
3.17 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program had only two applicable youth mental health records to review for Baker and
Marchman Act completion requirements for the annual compliance review period. Each of the
two applicable records contained documentation of times and dates as to when each youth was
determined to be in need of emergency care. Staff response, and time of staff notification were
also documented. Both youth were placed on one-to-one supervision at the time of discovery.
Mental health staff were involved in the process of the youth being place of one-to-one
supervision. Both youth had evidence and documentation of their removal from the program and
were transported by local law enforcement. One of the two applicable youth had the Baker Act
process implemented during the week of the annual compliance review, and had not yet
returned from being hospitalized off-site. The other youth reviewed had documentation the
youth had returned to the program from a Baker Act and was placed on constant supervision
upon readmission. In addition, the youth had a mental health referral completed indicating a
Mental Status Examination (MSE) was required. An Assessment of Suicide Risk was completed
by the licensed mental health staff and the youth was maintained on a minimum of constant
supervision until properly transitioned to a lower level of supervision, after assessment by the
licensed mental health staff and a meeting between the staff, program director, and licensed
mental health professional.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
Seven youth records were reviewed for safety planning requirements. All seven youth records
had evidence of a completed safety plan. Each plan was completed within fourteen days of
each youth’s admission to the program. The plans were jointly prepared by each youth,
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 40 of 66 (Revised September 2022)
parent/guardian, and clinical staff. Each included warning signs, youth history, and baseline
behaviors, as identified by collateral contacts. Each of the seven had evidence of crisis
recognition and intervention strategies as preferred by each youth. All seven incorporated a
debriefing process. All seven plans incorporated trauma responsive practices and
recommendations from previous assessments and screening instruments as required. Six of
seven plans were reviewed and updated as necessary at least every thirty days. The remaining
one record had one plan which was updated three days late. Three of the seven safety plan
reviews were applicable for and included evidence of the plans being updated and reviewed
following a significant behavioral or mental health event, as identified by the youth’s intervention
and treatment team. The program maintains all safety plans in the mental health records. In
addition, the program director (PD) reported the program maintains a binder of youth safety
plans in the administration building which is accessible to staff. Seven interviewed youth all
confirmed they contributed to the development of their safety plan. Seven interviewed staff
reported the safety plans are located in the supervisor’s office, on the point cards, and in front of
the administration building. Staff reported they can review safety plans at any time. One staff
reported they reviewed the safety plans a few months ago, three staff reported they reviewed
safety plans last week, two staff reported reviewing the safety plans daily, and one staff reported
thirty minutes ago. The PD reported the safety plans must be updated every thirty days or
following any significant behavioral or mental health event identified by the youth's intervention
and treatment team.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 41 of 66 (Revised September 2022)
Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a policy and procedures addressing the provision of a designated health
authority (DHA) to be clinically responsible for all medical care of all youth at the program. The
program has a licensed physician who serves as the DHA. The DHA holds an unrestricted
license and meets all requirements for independent and unsupervised practice in the State of
Florida. The DHA’s license expires January 31, 2025, and their specialty is in internal medicine
with experience in adolescent health. The DHA did not have any disciplinary cases or public
complaints on record. The program has an advanced practice registered nurse (APRN) with a
specialty in family health or pediatrics whose license expires April 30, 2025. The APRN has a
Collaborative Practice Protocol (CPP) in place which is maintained on-site. A review of sign-
in/out logs during the annual compliance review period confirmed the DHA was on-site at least
two hours a week as required by contract. The DHA was out for one week. The program’s back-
up physician provided coverage and had an equal licensure which expires March 31, 2024. The
DHA performed all administrative duties when the APRN provided clinical services. The DHA
stated as the medical director, they are onsite weekly for two hours to conduct Comprehensive
Physical Assessments (CPA), follow-up on any referred sick calls, review labs, make medication
changes and provide evaluations for any complaints by the youth, educate and order birth
control for any youth leaving from the program, and conduct periodic evaluations. The DHA
collaborates with the nursing staff and program director (PD) on all health-related procedures,
protocols, and operating procedures, which are reviewed annually and as needed. The DHA is
available twenty-four hours a day seven days a week by telephone for the nursing staff and PD
as needed. The DHA reported any off-site care findings, instructions, and information are placed
in their box in the clinic and are reviewed once on-site. If an emergency arises, they are notified
immediately. The DHA has no concerns with healthcare at the program. A review of the
program’s contract confirmed there was no inclusion or use of tele-health throughout the annual
compliance review period.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has a policy and procedures to indicate the designated health authority (DHA) is
clinically responsible for all healthcare services provided to youth at the program. The program
has licensed nurses to provide on-site nursing coverage with one full time registered nurse
(RN), one part time RN, and one licensed practical nurse (LPN). All of the nurse credentials
were reviewed, and each possessed a license which was found to be clear and active. The
license for the full time RN and LPN both expire December 31, 2025. The part time RN license
expires on April 30, 2025. Each of the nurses had a current cardiopulmonary resuscitation
(CPR) certification. Nursing staff is on-site eighty hours a week, seven days a week. Contract
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 42 of 66 (Revised September 2022)
requirements were reviewed, and the nurses were in compliance with specific duties outlined in
the contract.
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has a policy and procedures for all health-related protocols utilized at the program.
The designated health authority (DHA) signed the policies on February 29, 2024. The program
director signed on February 29, 2024. The psychiatrist signed the policies on March 1, 2024. A
review of policies found each nurse signed and dated the cover page on which all policies,
treatment protocols, and other procedures were listed. Any new or changes in policies were also
signed by all respective disciplines on February 29, 2024. The program did not have any newly
employed healthcare personnel during the annual compliance review period. The approval of
treatment protocols or standing procedures were 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.
The program has a policy and procedures ensuring the completion of the Authority for
Evaluation and Treatment (AET) authorizing treatment of youth in the program’s custody. A
review of seven Individual Healthcare Records (IHCR) found six contained an (AET. The one
other youth was in the care of the Department of Children and Families (DCF), the court
authorized all treatment and procedures, and the court order was maintained in the IHCR. Each
of the six forms were found to be stamped “COPY” and were valid. Each AET was signed by the
youth’s parent/guardian and a representative of the Department. The registered nurse revealed,
if a current AET is not in the Department’s Juvenile Justice Information System (JJIS) or sent
with youth upon admission, the program will first make contact with the parent/guardian to try
and obtain a new AET, if contact cannot be made, the juvenile probation officer (JPO) will be
contacted to obtain a new AET. One reviewed youth was over the age of eighteen; once a youth
reaches eighteen years of age, the youth is responsible for authorizing their own healthcare.
The IHCR contained documentation the eighteen-year-old consented to healthcare from the
program.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures to ensure the parent/guardian is notified of any
changes in the youth’s condition and to document informed consent for youth healthcare. A
review of the seven youth Individual Healthcare Records (IHCRs) revealed each youth had
parental/guardian notifications/consents. All youth had parental/guardian notification for over-
the-counter (OTC) medications beyond those covered by the Authority for Evaluation and
Treatment form (AET). Consent was provided by each parent/guardian. All seven youth required
parental notifications for new medications and there was documentation of attempted contact
with each parent/guardian in the progress notes. Written notifications were sent utilizing the
Department’s Parental Notification of Health Related Care: General or Parental Notification of
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 43 of 66 (Revised September 2022)
Health Related Care: Medications forms or the Acknowledgement of Receipt of the Clinical
Psychotropic Progress Note (CPPN) for psychotropic medications. Six of the seven youth were
taking psychotropic medication and there was documentation of a staff witnessing all telephone
call attempts and conversations for psychotropic medication. The registered nurse (RN)
revealed initial notifications are made to parent/guardian upon youth admission and for any
changes in medical conditions including but not limited to medication changes, health status
changes, emergent care, any treatments, and diagnostic tests. Anything not covered by the AET
requires a parental/guardian consent which includes OTC medications not covered in the AET,
vaccinations/immunizations, discontinuation, start, or change in medication, off-site emergency
care, off-site referrals to specialists, surgical procedures, and invasive dental procedures. The
RN revealed contact is made upon admission to the parent/guardian for consent and verification
of address, telephone number, and email address. The program contacts the youth’s
parent/guardian with changes in medical status and treatment is not started until consent is
received by telephone, email, or postal mail. If the program does not receive consent back in a
timely manner, another notification will be made and then if consent is still not obtained, the
youth’s juvenile probation officer (JPO) will be contacted to obtain consent from the
parent/guardian. A review of seven youth records revealed each of the seven youth’s
vaccinations were verified within thirty days of each youth’s admission. The RN revealed the
nurse or designated health authority (DHA) will review each youth's medical record at admission
for immunization records. If a record is not present the nurses utilize the Florida Shots portal to
obtain the current immunization record. If additional immunizations are required, the DHA will
order them as needed. The RN revealed if the parent/guardian claims immunization exemption,
they shall complete the Religious Exemption for Immunization form which is provided by the
County Health Department, have it signed and authorized there, and then submit it to the
program. If the parent/guardian does not consent for medical reasons, a letter shall be provided
to the program by the youth's physician or Department of Health (DOH) indicating the reason for
exemption. Parents/guardians will be notified as soon as possible if there is any change or new
treatment needs in a youth's treatment plan. When starting a youth on medication, a verbal
consent is obtained from the parent/guardian on telephone with a witness present. This is
documented in the chronological note with the nurse and witness signatures. Any changes in
medication, discontinuances, or new prescriptions are sent through mail to the parent/guardian.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a policy and procedures regarding youth healthcare admission screening and
rescreening each time the physical custody of the youth changes. A review of seven youth
Individual Healthcare Records (IHCRs) revealed each youth had a Facility Entry Physical Health
Screening (FEPHS) completed on the date of admission as required. All of the seven FEPHS
were completed by a registered nurse (RN). None of the youth had a change in physical
custody greater than twenty-four hours. The RN revealed medical is the first department to
examine and assess the new youth upon admission to the program. Once the program receives
notification of a new admission, email and verbal notification are made to all departments. The
case manager conducts a pre-planning meeting with all parties involved. The nurse on-duty
completes an admission screening. Youth are seen within two hours of their admission. Youth
come directly to medical once they have arrived at the program. A RN or licensed practical
nurse (LPN) completes all admission screenings.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 44 of 66 (Revised September 2022)
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy and procedures ensuring all youth admitted to the program are
provided an orientation to healthcare services. A review of seven youth Individual Healthcare
Records (IHCRs) found each youth received a general care orientation upon admission to the
program. The healthcare topics included access to medical, sick call procedures, what
constitutes an emergency and who to notify, medication process and side effect monitoring, the
right to refuse care and how it is documented, what to do in the case of a sexual assault or
attempted sexual assault, the non-disciplinary role of the healthcare providers, and standard
universal precautions. The Health Education form was reviewed for documentation of topics
covered, and no issues were noted.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a policy and procedures to notify the designated health authority (DHA) or
designee, by telephone or verbally, of each youth’s arrival at the program and provide
immediate notification when any youth admitted to the program requires emergency care. A
review of seven youth Individual Healthcare Records (IHCRs) found three of the youth were
applicable for a known or suspected chronic condition. The notification to the DHA, occurring
within twelve hours of admission, was documented in each youth’s chronological progress notes
in all seven IHCRs. None of the youth were identified as in-need of an emergency response
upon admission. The registered nurse (RN) revealed the admitting nurse notifies the DHA by
telephone and it is documented on the chronological notes for each youth. The chronological
progress notes in the youth IHCR and the Chronic Condition Log were reviewed for each of the
three youth with chronic conditions and the notification was documented for each. four of the
seven youth was applicable for taking psychotropic medication upon admission and the
psychiatrist was notified as required.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a policy and procedures ensuring the Department’s Health-Related History
(HRH) form is completed prior to the Comprehensive Physical Assessment (CPA) and
healthcare needs are identified. A review of seven youth Individual Healthcare Records (IHCRs)
found each youth had a new HRH completed on the day of admission and prior to the CPA
being completed. Each of the HRHs were reviewed by the designated health authority (DHA) as
noted on the CPA for each youth. The registered nurse (RN) revealed nurses are responsible
for completing the HRH during admission or within twenty-four hours of admission.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 45 of 66 (Revised September 2022)
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a policy and procedures ensuring the acute and chronic healthcare needs of
the youth are addressed by completing a Comprehensive Physical Assessment (CPA) for youth
admitted into the physical custody of the program. A review of seven youth Individual Healthcare
Records (IHCRs) found each record contained a completed CPA, documented on the
Department’s CPA form. Each of the CPAs were completed within seven days of admission by
the designated health authority (DHA). Each youth’s Medical Grade was documented on the
CPA. All sections of the CPA were marked with an “O” or an “X” with no sections missing. Each
of the youth refused a portion of the examination and signed a refusal form which reflected the
refused portion on the CPA exam and matched the date of the exam. The RN revealed
tuberculosis skin test (TST) screenings are completed within the first seventy-two hours of
admission unless one was completed the previous year. Each of the seven reviewed IHCRs
contained TST results which were completed in the last year. The results on the CPA matched
with those documented on the Infectious and Communicable Disease forms. A review of seven
youth records found the Department’s Problem List was updated for each youth when
applicable.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures to ensure all youth admitted to the program are
screened, evaluated, and treated, if applicable, for sexually transmitted infections (STIs) and
human immunodeficiency virus (HIV). A review of seven Individual Healthcare Records (IHCRs)
found all youth had a clinical screening and were subsequently evaluated for STIs. Screening,
testing, and evaluation occurred upon admission to the program. All seven youth were
applicable for further evaluation and were referred to the designated health authority (DHA). The
referrals were all documented on the STI form. Testing was ordered and performed for all seven
youth. Each youth had appropriate documentation filed within their respective IHCR. All seven
youth were offered counseling, testing, and a referral for treatment for HIV, if necessary. One of
the seven youth received HIV testing and documented consent was obtained and maintained in
their IHCR. The youth had their HIV test results filed in the IHCR, maintained in a sealed
envelope, which was marked “confidential.” The envelope contained the designated health
authority (DHA) signature, attesting to a review of the sealed contents. The youth had
documentation of pre-test and post-test counseling within the IHCR. The youth’s confidentiality
was protected as the program did not include the test results in their internal alert system. The
program has a policy and procedures which reflect HIV test results are only disclosed to the
youth, and those entities as outlined within Florida Statutes. The HIV pre-test and post-test
counseling is conducted by the local county health department. Seven youth were interviewed,
and all reported they can ask for a HIV test. An interview with the nurse revealed youth are
screened for STIs utilizing the Department form. If further evaluation is required the youth is
referred to the DHA. STI screenings, evaluations, referrals, and testing are documented in the
chronological notes and laboratory results sections of the IHCR. A rescreening is conducted
using the Department form. Once the DHA provides results they are placed in an envelope
marked confidential and kept in the youth’s IHCR. On admission, the youth is offered testing. If
youth declines, the youth is offered again once the health department is on-site. Youth are also
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 46 of 66 (Revised September 2022)
instructed at any time they can request HIV testing. The process is documented on the required
Department forms.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a policy and procedures addressing the program’s sick call process. None of
the youth presented with a similar sick call complaint three or more times within a two-week
period. A review of seven Individual Healthcare Records (IHCRs) revealed all seven youth
completed a sick call request at the program. The program’s policy requires sick call forms to be
available which was observed in each dorm, the shift leader’s office, cafeteria, and education.
Once a youth completes a sick call, the request is placed in a locked box in the cafeteria. Five
out of the seven youth IHCRs reviewed found the licensed practical nurse (LPN) completed the
sick call request forms and they were reviewed daily by the registered nurse (RN). The
remaining two sick calls were conducted by the RN. All seven sick call request forms were filed
with the progress notes in the IHCR in reverse chronological order. When a licensed nurse is
not on-site, the shift leaders are instructed to call the RN at night if the youth has a complaint
not covered under common sick call complaints or if the staff have any concerns regarding the
complaint. None of the youth were placed in restricted housing of any kind during the annual
compliance review period. Sick call forms and progress notes were documented in accordance
with Florida Administrative Code. All sick calls were documented on the sick call index and sick
call referral log. A tour of the medical clinic found the program has an exam room with an exam
table and equipment used to perform sick calls. Sick call is provided from 11:20 a.m. to 12:30
p.m. and 3:00 p.m. to 4:00 p.m. daily. The sick call hours are posted outside the medical office.
Only licensed nurses conduct sick call. When there is not a licensed nurse on-site, the program
has procedures whereby the shift supervisor reviews all sick call requests as soon as possible
and within four hours after the request is submitted. A sick call observation was unable to be
completed during the annual compliance review week as no youth requested one. Seven youth
were interviewed and six youth stated they can see a nurse immediately once the sick call
request is made, the remaining youth stated they can see a nurse within one day. Seven staff
were interviewed and three staff indicated the nurse reviews sick calls. The remaining four
stated medical staff review sick calls. An interview with the nurse revealed all youth are allowed
to submit a sick call form at any time. Sick calls are checked every four hours and responded to
in a timely manner, no more than twenty-four hours after the sick call form is completed. Sick
call is conducted by the LPN or RN. If a LPN conducts sick call, the RN reviews the sick call
immediately after it is completed. Sick call is conducted in the medical department. If three sick
calls are completed for the same complaint within a two-week period, the youth is then referred
to the DHA.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 47 of 66 (Revised September 2022)
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a policy and procedures to ensure the youth have access to episodic and first-
aid care. A review of seven youth Individual Healthcare Records (IHCRs) found three of the
youth required on-site first-aid or episodic care. On-site episodic care is documented on the
episodic care log and on chronological notes in the IHCR in subjective, objective, assessment,
and plan (SOAP) form charting. None of the youth received episodic/first-aid care by a non-
healthcare staff. There was evidence of the program maintaining an Episodic Care Log to
document the provision of episodic care and first-aid treatment. The Episodic Care Log was
reviewed for the annual compliance review period and compared with all on/off-site events.
There were no episodic care events observed during the annual compliance review week, due
to none occurring while the annual compliance review team was on-site. The registered nurse
(RN) revealed all on-site episodic care is documented on an episodic form in SOAP form and on
the Episodic Care Log. The episodic form is placed in the IHCR. If non-healthcare staff provide
first-aid/emergent care to a youth, it is documented on the required form and placed in the
medical box located in the supervisor office. The program has a total of sixteen first-aid kits
located throughout the program; in the case manager offices, every dorm, education office,
kitchen, laundry, administration, break room, culinary, and medical, three of which are
designated as burn kits. Transportation first-aid kits are kept in the supervisor’s office and
signed out upon a transport. There was documentation of the first-aid kits being monitored
monthly by the RN and stickers on the kits are updated with content expiration dates as items
are replenished. Three first-aid kits were reviewed, and each was fully stocked with designated
health authority (DHA) approved contents. The program has one automated external defibrillator
(AED) located in the copy room in the administration building along with the AED procedures.
There was documentation of the AED being checked monthly by a RN. The AED batteries
expire January 2027 and were last changed in April 2022. The AED pads expire on May 16,
2025, and were last changed in January 2022. The nursing staff conducted a self-test of the
AED in front of the annual compliance review team and there were no issues. A review of
medical drills for the annual compliance review period confirmed the program conducts mock
emergency medical drills monthly on each shift. The mock emergency drills included
cardiopulmonary resuscitation (CPR)/AED demonstration once annually. Direct care staff
participated in at least one drill which included the use of CPR annually. Documented drills
showed they simulated events which called for immediate first-aid care or CPR. All staff with
direct youth contact on a day-to-day basis had the opportunity to participate in one man-down
drill annually. A review of seven staff records confirmed staff training requirements were met
regarding first-aid, emergency, and episodic care. The RN revealed a drill calendar is created
yearly and followed by staff. Emergency medical drills are conducted at least every quarter on
each shift. Seven staff reported they were personally allowed to call 9-1-1. Seven interviewed
youth stated they could see a doctor or dentist if needed. The program has a list of emergency
numbers posted in the medical and administration offices which are inaccessible to youth. All
healthcare and supervisory staff were found to be appropriately trained on the administration of
the epinephrine auto-injector.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 48 of 66 (Revised September 2022)
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a policy and procedures to ensure timely referrals and coordination of medical
services to an off-site healthcare provider are available. A review of seven youth Individual
Healthcare Records (IHCRs) found three were applicable for off-site care. The Summary of Off-
Site Care Consultation Report form was utilized and filed in each IHCR, and each instance of
off-site care was documented on the episodic care log. There was documentation of the
parent/guardian being notified in each of the three records. Discharge and other applicable
documents were filed in each youth’s records. There was documentation of the designated
health authority (DHA) reviewing and signing all off-site care findings, instructions, and
information. None of the youth required follow-up appointments. An interview with nursing staff
revealed episodic logs are used to track youth who are sent off-site for first-aid or emergency
care needs. Hospital orders are reviewed once a youth has arrived back from the off-site visit,
the DHA is notified, and the youth is added to the DHA log for the week. Information is flagged
in the youth’s chart and the youth is placed on the DHA log to ensure the DHA is reviewing and
initialing all off-site care findings, instructions, and information. Nursing staff use a calendar to
track follow-up testing, referrals, and appointments.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a policy and procedures to ensure any youth admitted to the program who
have chronic conditions receive regularly scheduled evaluations and any as-needed follow-up
care. A review of seven youth Individual Healthcare Records (IHCRs) was conducted and three
were applicable for a chronic condition. The three applicable youth were identified on the
Department’s Facility Entry Physical Health Screening (FEPHS) form with a chronic condition
upon admission. None of the youth were identified as having a communicable disease or were
undergoing treatment for a physical health condition. All three youth were taking prescribed
medication on an on-going basis. All three youth had an identified chronic condition. All three
youth were classified with a Medical Grade two or higher. None of the youth were identified as
pregnant. All three youth were placed on the chronic illness list. All three reviewed youth were in
receipt of periodic evaluations at least every ninety days as required. An observation of each
youth’s periodic evaluations revealed no issues. A review of progress notes confirmed they
documented each youth’s periodic evaluation. None of the youth were applicable for taking anti-
tuberculosis medications. Each of the youth had an evaluation completed prior to a prescription
renewal, change, or expiration. One of the youth reviewed was applicable for an off-site
evaluation which was documented on the Summary of Off-Site Care form and filed in the
youth’s IHCR. The Department’s Problem List was updated in accordance with Florida
Administrative Code for the applicable youth. The program director revealed the designated
health authority (DHA) has a health-related schedule on which periodic evaluations are noted. A
chronic physical health conditions monthly roster is used to track and follow all youth who have
chronic conditions to ensure their care is not overlooked. Weekly meetings are held to include
medical staff. The nurse and DHA communicate every day on any medical issues as needed.
The DHA reported youth with chronic conditions are seen every three months or more often, as
needed, and the evaluations are documented in the progress notes. The nursing staff confirmed
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 49 of 66 (Revised September 2022)
the frequency of seeing youth with chronic conditions and indicated there is a chronic logbook
for them to track periodic evaluations.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program has a policy and procedures to ensure the accurate and safe administration of
youth medications. A review of seven youth Individual Healthcare Records (IHCRs) was
conducted, and four youth were applicable for being admitted with medication. The Facility Entry
Physical Health Screening form and progress notes confirmed the youth were admitted on
medication. The medications for youth were verified prior to the youth being admitted into the
program. Prescription medication verification was documented for each youth within
chronological progress notes and on the Department’s Prescription Medication Verification
Checklist form. The designated health authority (DHA) and, when applicable, the psychiatrist
were contacted to obtain an order to resume the specified medication prescribed prior to
admission for each youth. There is no restricted housing at the program. Each of the youth were
applicable for over-the-counter medications and they were administered according to approved
protocols. The program utilizes the Department’s standard Medication Administration Record
(MAR) to document all medications. Any changes to, continuances, discontinuances, or new
medications ordered were documented on the Practitioner Order form. Each of the reviewed
MARs met all requirements outlined within Florida Administrative Code. There is a policy and
procedures for trained non-healthcare staff to assist in the delivery of medications, only when
licensed medical staff are not on-site. Staff initial each administered medication entry as
required. There were no undocumented explanations for lapses or errors in medication
administration. The nursing staff documented side-effect monitoring weekly, at a minimum, on
each MAR. None of the youth refused medication. The MARs contained all the required
elements. None of the youth were applicable for parenteral type medications. Four youth were
applicable for receiving prescribed psychotropic medication upon admission. The DHA and
psychiatrist were notified upon each youth’s admission. The psychiatrist conducted an initial
diagnostic psychiatrist interview within fourteen days of admission as required. Two youth
received psychotropic medication after admission and each received medication monitoring
every thirty days, as required. There were no emergency treatment orders, pro-re-nata (PRN)
orders, or standing orders for psychotropic medications. Medication pass was observed during
the annual compliance review week with no noted issues. Youth were escorted to the
medication pass, which was located in the gymnasium in front of the locked closet where the
medication cart is kept. Direct care staff escorted each youth individually. The nurse was able to
identify themselves, provide a brief description as to why the youth was at medication pass, and
any applicable allergies the youth may have. Medications were accessed from the medication
cart once the youth and nurse identified themselves and the medication to be taken. The nurse
ensured the medication was swallowed each time. The nurse and youth initialed the MAR once
the medication was taken by the youth. The Six Rights of Medication Delivery/Administration
were observed during the observation of medication pass. Seven youth were interviewed. Five
youth stated the nurse gives medication, one youth stated the nurse and staff give medication,
the remaining youth stated they do not take medication. Seven staff were interviewed. Five staff
stated the nurse dispenses medication and the remaining two staff stated a supervisor
dispenses medication. An interview with the nurse revealed youth's parent/guardian is
contacted upon admission to confirm the medication regimen. Non-healthcare staff do not verify
medication upon admission. This is all documented in the admission chronological note. The
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 50 of 66 (Revised September 2022)
program utilizes the standard Department MAR. Non-healthcare staff are trained by a registered
nurse to provide medications to youth. The registered nurse and program director maintain a list
of trained staff. Medications and prescriptions are procured through the local pharmacy. All
psychiatrist visits are on-site and medication management is provided.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a policy and procedures ensuring medications and sharps are secured and
inventoried by using a routine perpetual inventory. A tour of the medical clinic found medications
were stored in a locked medication cart, cabinets, and in the locked refrigerator used for
medication only, inaccessible to youth. The medication cart was clean/organized with stock
items separate from youth-specific medications. All controlled medications were stored behind
two locks as required, only one controlled medication was on-site. A shift-to-shift inventory count
of all controlled substances was documented on the youth’s Individualized Controlled
Medication Inventory Record. All sharps were found secured and inventoried by using a routine
perpetual inventory with descending count as each sharp is utilized and disposed. There was
documentation of a perpetual and a weekly inventory of all sharps and stock over-the-counter
(OTC) medications being conducted. The nurse was observed counting one controlled
medication, three different sharps, and three OTC medications and the counts matched the
inventory. A review of the medication inventories for the annual compliance review period
revealed all counts and inventories matched medications available. Seven staff training records
were reviewed, and each indicated non-healthcare, supervisory-level staff were trained in the
delivery and oversight of medication self-administration. The registered nurse (RN) provided the
training and revealed when a medication is discontinued, any remaining medication will be
securely stored in the medication cart. The consultant pharmacist, on their monthly site visit will
dispose of all medications including controlled medication. Controlled medications which have
been discontinued will be kept under lock and key until the monthly site visit from the licensed
pharmacist. Controlled medications will be destroyed by the pharmacist, consistent with Florida
Statute. The pharmacist will verify/count all meds for disposal which is documented by the
pharmacist and nurse. The pharmacist will take any/all medication with them for disposal.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a policy and procedures related to infection control and an Exposure Control
Plan. A review of the program’s Exposure Control Plan was conducted and confirmed the plan
included all the required elements and was written in accordance with the Occupational Safety
and Health Administration guidelines. The plan was reviewed and signed by the designated
health authority (DHA) on February 23, 2024, and the program director (PD) on February 23,
2024. The PD revealed the exposure/infection control plan is located in the emergency
procedures manual in the PD’s office, assistant PD’s office, supervisor's office, and medical.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 51 of 66 (Revised September 2022)
This plan is reviewed annually with staff. The registered nurse (RN) revealed the assistant PD
or RN conducts infection control training for staff. Youth infection control training is conducted
on admission and periodically through monthly health education sessions. Hepatitis B
immunizations and protective equipment are available for all staff. The PD established a
separate file for youth and staff who have experienced a facility/occupational exposure and is
maintained for a ten-year period. There were no exposures reported during the annual
compliance review period. The program has a process for needle stick post-exposure evaluation
which includes transporting anyone who has been stuck to the local hospital for evaluation and
treatment.
4.19 Prenatal Care/Education Satisfactory Compliance
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
The program has a policy and procedures regarding prenatal care and education for pregnant
youth. The program had one pregnant youth since the last annual compliance review; however,
the youth had been released in February of 2024 and due to Department-wide system outages
at the time of the annual compliance review, the youth’s record could not be reviewed in the
Department’s Juvenile Justice Information System. None of the seven interviewed youth stated
they received prenatal, obstetrical, or gynecological services while at the program. The
registered nurse (RN) revealed they provide non-licensed healthcare staff education on girls’
healthcare. The RN revealed they provide the education to pregnant youth including sexually
transmitted infection screenings during pregnancy, monthly development of fetus and changes
in the mother's body, smoking and drug use during pregnancy, complications during pregnancy,
emergent signs in pregnancy, miscarriage signs and symptoms, birth control after birth, birthing
processes, breast feeding, epidural options, pain management during pregnancy, infant care,
how to care for a newborn, diaper changing, bottle feeding, postpartum care, postpartum
depression symptoms, and exercise during pregnancy and after delivery.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 52 of 66 (Revised September 2022)
Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures regarding staffing and youth supervision. The
program’s policy indicates supervision of youth must be active and not passive. Staff should be
aware of their surroundings and utilize the Youth-Environment-Self system to help maintain staff
awareness. Daily activities and supervision of youth were observed each day of the annual
compliance review week. Youth were seen being supervised in dorms, at mealtimes, and in
classrooms. Youth were observed being supervised at, or within, the required supervision ratio.
Youth were engaged in a full schedule of activities. The daily activity schedule was observed to
be posted in living units and program areas. Three random staff were informally interviewed
concerning supervision numbers for youth, and each was able to accurately give the number of
youth under their direct supervision. Positive interactions were observed between staff and
youth. Seven interviewed staff were able to summarize steps to take in the event a youth
headcount is not cleared.
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’s behavior management system (BMS) has not changed since the last annual
compliance review. All appropriate parties were involved in the development, implementation,
and on-going maintenance of the BMS. The program has a policy and procedures which include
provisions for staff to be provided feedback regarding their implementation of the BMS. All
education staff at the program are employed by the provider and receive BMS training at the
time of their pre-service training. Training in the BMS was unable to be reviewed due to
Department-wide system outages at the time of the annual compliance review. The program
director (PD) and assistant PD facilitate BMS training for staff. Seven reviewed youth case
management records included evidence each youth received BMS training as part of their
orientation to the program. The youth handbook is provided for each newly admitted youth. The
handbook outlines the BMS in detail and discusses the program’s level system, rewards, and
consequences. A sample of position descriptions, which included the team leader, shift
supervisor, and clinical coordinator, were reviewed and found each included implementation of
the BMS. Postings of the program’s BMS were observed in dorms and youth handbooks. The
program’s BMS includes promotion of safety, respect, and fairness, and protection of youth
rights. Recognition of accomplishments and positive behaviors are done at a four to one ratio,
according to the provider’s contractual agreement. Youth are given opportunities to explain their
behavior, staff have a process of explaining to youth reasons for sanctions being imposed, as
well as opportunities for staff and youth to discuss the impact the behavior has on others. The
BMS contains reasonable reparations for harm caused to others, discussions of alternate
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 53 of 66 (Revised September 2022)
behaviors, promoting positive dialogue and peaceful conflict resolution, and separation of youth
from the general population is minimized The program’s BMS does not include punishment of
youth by other youth, disciplinary confinement, promotion of group discipline, denial of youth
rights, or increased length of stay. Examples of various rewards include token store, incentive
trips, special meals and cookouts, extra telephone call time, and field trips. Staff and youth
interactions observed during the week of the annual compliance review confirmed adherence to
the BMS and any negative consequences were in direct relation to the behavior observed. The
PD was interviewed concerning the BMS and stated the program’s BMS consists of positive
reinforcement (pro-social points) for appropriate behavior and natural consequences for
negative behavior. Consequences are used to encourage youth to meet expectations of the
program as well as have an immediate response to negative or harmful behaviors. Youth carry
a point card which represents both positive and negative behaviors. The points which are
received can be used at the point store to purchase things such as food items, hygiene items,
additional telephone calls. The youth go to the point store twice a week to spend their earned
points. Consequences are monitored by point cards and treatment team meetings. There is a
weekly review of point cards by the PD. All program staff and other service providers shall be
properly trained in the program’s BMS. This training will occur in the orientation phase for all
new employees and continually throughout the annual training calendar. All staff and youth will
receive a fully detailed BMS program booklet. Seven interviewed staff confirmed they received
BMS training. All seven were able to summarize the BMS process, and give examples of
various rewards given, such as the point store, ice cream parties, and outings. All seven staff
stated nothing is taken away from youth as a result of a consequence. All interviewed staff
confirmed youth are informed of consequences and have the ability to explain their behaviors.
All interviewed staff confirm supervisors provide feedback of their implementation of the BMS.
Seven interviewed youth were able to summarize the program’s BMS and explain the level
system. All seven were able to describe examples of various rewards offered through the BMS.
All interviewed youth denied youth are able to punish other youth. All seven stated staff use
rewards the same in the program. Four of seven youth rated the BMS as good. Three rated it as
very good. None of the seven youth reported ever being sent to their room for punishment.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, provide constructive discipline and a system of positive and negative consequences
to encourage youth to meet expectations for behavior, provide opportunities for positive
reinforcement and recognition for accomplishments and positive behaviors, promote dialogue
and peaceful conflict resolution, and minimize separation of youth from the general
population.
Supervisors shall monitor staff implementation of the BMS and ensure the use of rewards and
consequences are administered fairly and consistently in application among all staff.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 54 of 66 (Revised September 2022)
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a total of sixty-two cameras, all of which were operating as required according
to the program’s administration. Video recordings are stored for up to thirty days. Each of the
seven interviewed staff all reported checks for youth during sleep times are done so at or within
ten-minute increments. The program operates on a night and day shift. A sample of security
tapes were reviewed for each shift. A total of nine time period increments, covering both day
and night shifts were reviewed and found each check was conducted by staff at or within ten-
minute increments. All video observations made also included examples from each of the six
living units. Staff were observed walking by youth rooms and looking into rooms to observe
youth. No discrepancies were observed. A sample of logs were reviewed for the times selected
during video review and found all logs corresponded with video observed. In addition, a sample
of logs of thirty-minute increments from each shift for each month of the annual compliance
review period was also done and found no discrepancies.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program has a policy and procedures which include a process for conducting formal,
informal, and emergency head counts of youth. Observations were made of formal headcounts
being conducted during the annual compliance review week. Master control operators were
observed calling for headcounts to staff within the program supervising youth and clearing the
counts as they were completed. A review of previous and current program logbooks was made
of one full day for each month of the annual compliance review period to confirm counts were
being conducted as required. There were no discrepancies noted. Head counts and youth
movements were documented as required. Emergency headcounts and youth temporarily away
from the program were also noted during the logbook review. Seven staff were interviewed. One
staff reported headcounts are done if needed for any reason, and one staff reported they were
done during drills. Five stated they were unsure when the emergency counts were done. Each
staff confirmed headcounts are conducted every hour or every movement. The interviewed staff
reported the census of the program as between thirty youth and thirty-seven youth.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 55 of 66 (Revised September 2022)
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 one main logbook which is kept in the master control station. Logbooks
for the annual compliance review period were reviewed. All logbooks were observed as bound
with numbered pages. All entries were made in ink with no erasures or white-out areas. No
pages were observed to be destroyed. Errors were observed struck through with a single line
and initialed by the staff correcting the error. All entries included the dates and times of the
events, names of the staff and youth involved, brief descriptions of the events, and the names
and signatures of the staff making the entries. A review of three full days each month of the
annual compliance review period was made and confirmed education classes, recreation times,
and activities were being conducted as scheduled on the daily activity calendar. The logbook
entries contained all required information. Any internal incidents reported to the Florida Abuse
Hotline or Department’s Central Communications Center were documented, as required. The
program completes shift reports for each shift which include a summarization of the shift events,
alerts for youth, total census, maintenance issues, significant events, and perimeter and
program area searches. All incoming staff sign and date the shift reports for the previous shift to
document a review. Samples of these completed shift reports were observed for the annual
compliance review period, which confirmed the program’s practice. Shift reports are maintained
in the front area of the administration building for incoming staff to observe upon entry to the
facility. Observations of shift exchange meetings were unable to be made during the annual
compliance review week as shift change occurred while the annual compliance review team
was not on-site. Shift reports were not being maintained in the living units at the time of the
annual compliance review; however, this process was corrected during the annual compliance
review week.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures which address key assignment and restrictions on
program key usage, inventory and tracking of program keys, secure storage of keys, and
procedures for missing or damaged keys. Visitor keys were observed being collected and
exchanged for a numbered chit during the annual compliance review week. Visitor keys were
stored securely in the lock box located in the master control station at the front of the
administration building. All program keys which are distributed to staff are maintained in this
secured key box. The key box was observed to be secured when not being accessed.
According to the program’s policy, all keys which are permanently issued must be signed for by
the staff receiving the keys and the key control officer issuing the keys. Upon return of the keys,
the staff and the key control officer must initial indicating they were returned. The program’s
safety and security officer shall document the contents of each ring of keys issued to each staff
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 56 of 66 (Revised September 2022)
member. Direct care staff turn in their personal keys which are exchanged for their program
assigned keys for the shift they are working. This exchange and issuance is documented on the
Daily Key Tracking Log. These tracking logs were observed, which confirmed the program’s
practice. According to program administration, damaged keys are reported to the safety and
security specialist and maintenance staff who are responsible for replacing the keys. The
program reported having had no incidents of damaged or lost keys for the annual compliance
review period. According to the assistant program director, permanent issued keys are restricted
keys. These include keys for medical, administration, maintenance, and education staff. Direct
care staff do not have access to these keys. A sampling of five sets of keys in the key storage
box were reviewed and found each set was noted on the key inventory log and included the
correct number of keys on each ring. In addition, three staff were randomly selected and asked
to present their assigned staff keys. All staff keys matched the keys assigned and signed out for
on the Daily Key Tracking Log for the shift. All keys had the correct number of keys as indicated
on the key log. Two of three staff stated they were aware of the function of each key. One staff
was aware of only one of the three keys on the ring assigned. Each of the seven interviewed
staff were able to summarize the program’s key control process.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items.
A program shall delineate items and materials considered contraband when found in the
possession of youth, the list must include: sharps, escape paraphernalia, tobacco products,
lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food or
clothing, any intoxicating beverage or any beverage which causes or may cause an
intoxicating effect, any controlled substance, any prescription or non-prescription drug which
has a hypnotic, stimulating, or depressing effect, any firearm or weapon of any kind or any
explosive substance, non-facility issued electronic equipment or devices to include
smartwatches, metals, personal non-facility issued cellular devices, unauthorized currency or
coin(s), and non-facility issued keys. The program shall provide youth with the list of
contraband items and materials and inform the youth of the consequences if found with
contraband. The program shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, and both staff and youth.
The program shall document the confiscation of any illegal contraband and the manner of
disposition. The program shall keep a copy of the documentation in the youth’s case record. If
a confiscated item is not illegal or prohibited, the program director or designee has the
discretion to discard of the item, return it to its original owner, mail it to the youth's home, or
return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a policy and procedures which outline contraband, define items considered
contraband, consequences, and search procedures within the program. The program clearly
delineates those items considered to be contraband, which includes all required elements. The
program provides a list of items considered contraband to each youth. Youth are given this
information in their handbook upon admission. The policy also outlines searches of the facility
grounds, searches of youth, staff and visitors, and incoming and outgoing mail. The program’s
policy addresses any staff who is found in possession of contraband in the program will be
subject to disciplinary action up to and including dismissal. Law enforcement is contacted in the
event any item found would be considered illegal as defined in Florida Statutes. The program
documents the confiscation of contraband and maintains the documentation on search forms
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 57 of 66 (Revised September 2022)
and within the youth case management records in the event contraband is found. Random
searches are done twice daily, which covers both day and night shifts, and documented on
Search Report forms. Searches for contraband were also documented within logbooks and shift
reports, indicating program area and perimeter searches were completed. According to an
interview with the program and assistant program director (PD), there have been no incidents
with confiscation of illegal contraband for the annual compliance review period. There were no
instances of non-illegal contraband during the annual compliance review period, however, the
policy indicates it would be disposed of through the PD. Search Report forms were observed for
the annual compliance review period which confirmed the program’s practice. A review of seven
staff records found each staff signed contraband attestation forms as required. Visitors, upon
arrival, sign a contraband attestation statement, as observed during the annual compliance
review week. The PD was interviewed and stated at no time shall illegal contraband, as defined
in Florida Statute, be allowed in the secure perimeter of the program. Contraband incidents
must be reported to the Department’s Central Communications Center (CCC) in accordance
with the CCC Florida Administrative Code. If a contraband related incident involves contacting
law enforcement, the program must contact the residential regional director, in addition to the
CCC. Items which may be used as evidence shall be secured by the discovering staff and hand-
delivered to the PD or designee. The program staff shall document the chain of custody for the
items and provide the information to the responding law enforcement officer. Seven interviewed
staff all reported searches for contraband are conducted daily.
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 ensuring searches and full body visual
searches are performed routinely according to Florida Administrative Code. During the annual
compliance review week, observations of youth searched before and after youth transport were
conducted to determine the thoroughness of the search. Youth were searched upon return from
an off-campus activity involving the Department of Transportation (DOT) work crew and
following access to tools or equipment. Youth searches were conducted by the appropriate
number and gender of staff. During searches, youth were treated with dignity and respect
minimizing stress and embarrassment. Youth searches were conducted according to the
requirements of the Protective Action Response Right Interactions model (PAR/RI) training
manual. Each of the seven interviewed staff confirmed searches are conducted upon youth
movement. Each of the seven interviewed youth reported searches are conducted after any
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 ensuring any vehicles used to transport youth
are properly maintained and have documentation regarding the maintenance of each vehicle. A
total of five staff personal vehicles were checked which found the vehicles were locked when
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 58 of 66 (Revised September 2022)
not in use. The program utilizes four vehicles for youth transport. Each was secured when not in
use. All vehicles observed had documented safety inspections and maintenance records.
During the last inspection, it was documented one of the four vehicle’s rear turn signal needed
repair; however, for this vehicle, all rear lights signals were discovered to be functioning properly
when observed. All four vehicles had up to date fire extinguishers, approved first-aid kits,
seatbelt cutter, window punch, and appropriate number of seatbelts. First-aid kits for vehicles
are maintained in master control when not in use. The kits are checked out when transports
occur. Youth passenger areas for each of the four transport vehicles were unable to be opened
from the inside rear passenger area. Each of the seven interviewed staff confirmed youth are
secured within vehicles using seatbelts. Each of the seven interviewed youth reported being
secured in transport vehicles by way of seatbelts.
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 procedure ensuring minimum staff-to-youth ratio is
maintained while youth are transported off facility grounds. The one to five staff-to-youth ratio is
used during all transports. Based on interview and observations, the program provides a cellular
telephone to staff when transporting youth. An observation of a transport was conducted during
the annual compliance review week. It was determined the staff-to-youth ratio was within the
requirement and there was a staff of the same gender of the youth being transported. There
were two staff and one youth observed for the transport. Staff and youth were all of the same
gender. Both staff and youth were observed properly secured with seatbelts. According to the
program’s policy, youth are not permitted to operate staff or program vehicles. All staff operating
program vehicles are required to have a valid driver’s license. The program’s human resource
department maintains an approved list of drivers and completes annual screenings for approved
drivers. A sample of seven staff records, all of which were on the approved drivers list, were
reviewed and all seven were found to have valid driver’s licenses. Each of the seven
interviewed staff reported a telephone is the type of communication device provided during
transports. Six of seven staff reported items such as first-aid kits and seatbelt cutters are safety
equipment provided. One staff reported they have not done a transport and were unaware. All
seven staff denied staff are allowed to use personal vehicles when transporting youth. All seven
stated vehicles are searched for contraband prior to use. All seven were able to summarize the
emergency response process during vehicle transports. All staff were able to explain the staff to
youth ratio during transports. Each of the seven youth interviews reported they have not
witnessed anyone placing contraband within a transport vehicle and staff are driving safely.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures outlining the facility’s weekly safety and security audit
inspection process. The program’s maintenance staff maintains the Preventive Maintenance
Checklist forms which detail inspections of all program areas for proper functioning. The
assistant program director (PD) and maintenance staff are primarily responsible for completing
the weekly security audits and safety inspections. A review of this documentation was made for
the annual compliance review period which confirmed the program’s practice. The development
and implementation of any corrective actions warranted for areas of concern were observed to
be documented on the corresponding forms. All requirements were made according to Florida
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 59 of 66 (Revised September 2022)
Administrative Rule. An internal process is maintained by the program to ensure any
deficiencies are corrected. Contact was made by telephone with the Department’s safety and
security specialist assigned to monitor the program’s process with submitting the required
documentation. The safety and security specialist confirmed the program provides all required
documentation weekly and responds to any actions needed. The program also had no
outstanding deficiencies at the time of the annual compliance review. There were no exceptions
identified, as confirmed with the Department’s safety and security specialist. The PD was
interviewed and stated daily walk-throughs are made by supervisors. Safety and security
officers are also conducting walk-throughs twice weekly. Any deficiencies are noted and
addressed as soon as possible.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a policy and procedures which include supervision requirements when using
tools. Supervision of youth when using tools is required to be a minimum of one staff to five
youth. The program’s policy also addresses the issuance, control, and inventory of tools at the
program. The program’s policy prohibits machetes, bowie knives, or other long blade knives.
The assistant program director was interviewed and stated there has been no incidents of
missing or damaged tools for the annual compliance review period. The program’s policy
indicates in the event a tool is missing, the tool control manager will be immediately notified. In
addition, a tool report will be written and submitted to the tool control manager by the
supervising staff. Youth who had access to the tool will be held at the work site location until a
thorough search has been made of the work area and all youth are frisk searched and
electronically searched. Youth who are searched will be separated from youth who have not
been searched. If needed, additional staff should be called to assist in the search process. If it is
determined the missing tool is linked to another reportable incident, the Department’s Central
Communications Center (CCC) will be notified within the required time frame. Class B tools
such as mops and brooms were observed in each of the six youth living units. Each included the
number of items matching the inventory. Each unit had two brooms, one mop, and one mop
bucket. The inventory was observed to have been maintained daily by direct care staff.
Inventory forms were completed as required with no discrepancies for each of the six living
units. Kitchen knives are maintained in a locked cabinet in the kitchen using a shadow board
system. Kitchen knives were inventoried daily by dietary staff. Five knives were reviewed and
compared with the inventory form. All knives were accounted for and included an engraved
marking for easy identification. In addition, the culinary closet was observed in the education
class. The closet was secured when not in use. The culinary knives were kept in a locked
cabinet within the secured closet. A review of five knives was done which found each had an
identifying engraved marking. All were accurate on the inventory form. These knives were
documented as inventoried daily by the culinary class instructor.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a policy and procedures which include supervision requirements when using
tools. Supervision of youth when using tools is required to be a minimum of one staff to five
youth. The program’s policy also addresses the issuance, inventory, and training on tool usage,
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 60 of 66 (Revised September 2022)
as well as an assessment for youth to determine risk to self and others prior to tool usage.
During the annual compliance review week, youth were observed in the welding simulation
class, as well as upon returning from the Department of Transportation (DOT) work crew. Youth
were observed being searched after finishing both services. The youth were seen being
supervised at a ratio of one to five as required. A total of seven youth records were reviewed for
youth who have been approved to utilize Class A tools. All seven had a completed risk
assessment indicating their risk level to be low, and thus they were approved for tool usage.
The program administration reported youth are not formally trained on using Class B tools such
as mops and brooms, but an overview for all newly admitted youth is done to discuss proper
tool usage to include Class B tools and chemical restrictions. Seven interviewed staff reported
youth are able to use mops and brooms. In addition, four of seven also stated they may use
tools with the DOT crew, tools when crocheting, dusters, and rags or paper towels. Seven
interviewed youth stated they utilize mops and brooms in the program. Two of seven also stated
they may use tools when working with the DOT work crew.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures indicating all outside contractors and vendors will be
required to be aware of the program’s tool control policies. The program provided sign-in sheets
and instruction sheets for outside contractors for the annual compliance review period.
Guidelines for repair and external workers included tools checked in upon arrival and departure,
restrictions while in the facility, youth restrictions from the work areas, and missing tool follow-up
procedures. Sign-in sheets were reviewed which confirmed the program’s practice.
Maintenance staff are responsible for approving any items which may be considered as
contraband. A review of three project invoices was completed which included the date the
project was worked on and matched the outside contractor sign-in sheets. Tools are checked in
and out and signed off by the program’s maintenance staff person. In addition, the program’s
maintenance staff signs their own maintenance tools in and out on the Maintenance Personnel
Tool Verification form. Documentation of this was observed for the annual compliance review
period, which confirmed the program’s practice. These forms are also to document the shift
supervisor witnessing the maintenance staff signing in and out contractor tools.
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 practices emergency drills, such as fire drills and Continuity of Operations Plan
(COOP) drills once a month on each shift. A review of drill documentation confirmed it included
all requirements, such as a list of participants, brief scenario, recommendations, and corrective
actions, if needed. All drills were maintained in a marked drill binder. A review of this
documentation for the annual compliance review period was done and found fire drills and
COOP drills were done monthly for all shifts with no exceptions noted. Fire evacuation and
egress routes were clearly posted within program areas of the facility. The program has a total
of nineteen fire extinguishers. A sampling of five extinguishers found each was inspected
monthly by maintenance personnel as required. Documentation was received showing the
annual fire extinguisher inspection was last completed August 28, 2023, by the local county fire
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 61 of 66 (Revised September 2022)
marshal office. Seven interviewed staff all confirmed they participate in various drills at the
program. The program director was interviewed and stated the program conducts a wide variety
of emergency drills at various times and on each shift. Drills are meant to be as realistic as
possible but without significantly disrupting the program. Drills are monitored for effectiveness
and are subsequently documented on the designated drill report form. Drill reports are
submitted to the safety and security officer. The results of each drill shall be discussed in the all
staff meetings and risk management meetings held each month. Seven interviewed youth all
confirmed they have been instructed as to what to do in the event of a fire. All confirmed they
have participated in fire drills at the program.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program has a Continuity of Operations Plan (COOP) which is accessible to staff. The plan
is in the administration offices, training, and medical buildings. The COOP was last reviewed
and approved February 21, 2023, by the Department’s Office of Residential Services. The
COOP is an older plan which includes all required elements. The plan was last submitted to the
Department for approval on April 29, 2024. The plan documents alternative relocation sites
approved by the Department. The program’s Emergency Disaster Preparedness Plan and
COOP are combined into one plan. Equipment and supplies required for continuous operation
and services during an emergency were identified in the kitchen area of the program. In
addition, the program reports the provider maintains a trailer at a separate location which
contains various emergency supplies. In the event of an evacuation, the trailer is used in the
relocation and transport of staff and youth. According to an interview with the program director,
should an evacuation occur, the program will take all youth hard copy records with them, which
include the individual case management record, mental health, and healthcare records. All
required critical information for youth was maintained within these records which will accompany
the program during a possible evacuation.
5.18 Storage and Inventory of Flammable, Poisonous, and
Satisfactory Compliance
Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items.
The program has a policy and procedures which address the storage and inventory of
flammable, poisonous, and toxic items and materials. The program’s policy prohibits youth
access and handling of these items. All materials were observed to be secured and within
locations inaccessible to youth. The program maintains a list of facility positions and titles
authorized to handle any cleaning items and chemicals. The program maintains a small supply
of two cleaning products in each of the six youth living units. All six locations were observed.
Each was secured behind two locked doors. There was a corresponding Safety Data Sheet
(SDS) for both items in each living unit, along with an accurate inventory of the items, which is
maintained and documented daily by staff. No discrepancies were identified. A review of
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 62 of 66 (Revised September 2022)
cleaning items stored in the kitchen closet was also completed. A total of five items were
selected. All five were noted on the inventory form and included a SDS. One item, degreaser,
had indicated two jugs on the inventory form, but the actual count was two full jugs and an
additional one with a very small amount of the product left. The master control area was found
to have six bottles of nail polish remover, which all matched the actual count on the inventory
form, and included a SDS for the item. According to the program administration, only
administrators have access to the chemical supply closet. Five items were selected for review in
this area. Two items were not found on the inventory form, nor was a SDS present. The
program administration reported these items were added after a recent outbreak had occurred
with COVID-19, and they were not yet added to the inventory. In addition, there was a
discrepancy with the toilet cleaner containers, as the inventory indicated two items, but six were
present. The toilet cleaner, however, did have a corresponding SDS. These exceptions were
corrected by administration during the annual compliance review week.
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 and toxic items and materials. The program’s policy and procedures indicate under
no circumstances are youth allowed to use or handle cleaning products, clean dangerous or
hazardous chemicals, or respond to chemical spills. The program maintains strict control of
flammable, poisonous, and toxic items and materials. Youth are not allowed to handle, or
dispose of any persons’ bio-hazardous materials, body fluid, or human waste. Youth access is
restricted to areas where items are used or stored. Youth are not allowed to handle, or clean-up
dangerous or hazardous chemicals. All chemicals observed during the annual compliance
review week were found to be secured and inaccessible to youth. Observations of youth during
daily cleaning activities was unable to be made during the annual compliance review week due
to none taking place. Each of the seven interviewed youth reported not handling any chemicals
or cleaning supplies. Youth indicated staff handle the chemicals and cleaning products.
5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program has a policy and procedures which address the disposal of all flammables, toxic,
caustic, and poisonous items. The program maintains a list of positions authorized to dispose of
items. The assistant program director (PD) was interviewed and reported all staff receive tool
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 63 of 66 (Revised September 2022)
and sensitive items control training as part of their training plan. Disposal practices are done in
accordance with Occupational Safety and Health Administration (OSHA) standards. According
to the assistant PD, maintenance has not required any chemicals or poisonous items to be
disposed of for the annual compliance review period. Standard mop water is disposed of in
plumbing drains. Local waste management services come twice weekly to dispose of standard
trash. Any old grease from the kitchen is disposed of in the original containers the items arrived
in and taken off-site for disposal at a local site. According to an interview with the nursing
director, the program maintains a contract with an outside provider who disposes of bio-
hazardous waste monthly. A disposal log was observed with invoices, maintained by the
medical staff. The program has an approved Continuity of Operations Plan (COOP) which
addresses procedures for clean-up of chemical spills and includes all required elements.
According to the PD, any hazardous materials will be disposed of in accordance with local and
state regulations.
5.21 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity.
Programs allowing youth to participate in water related activities shall have a water safety
plan addressing, at a minimum, safety issues, emergency procedures, and the rules to be
followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in water-related activities; therefore, this indicator is rated
non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 64 of 66 (Revised September 2022)
5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a visitation schedule posted within various program areas, such as the
administration building, youth living units, and maintained within the youth handbook. Visitation
is scheduled for Saturdays from 1:00 p.m. until 4:00 p.m. The visitation log and sign-in list were
observed which confirmed visitation is being conducted as scheduled. Special visitation may be
made at the discretion of the program director. The program’s case managers maintain an
approved telephone and mailing/correspondence list for each youth assigned on their case load.
Observations of these lists were made during the annual compliance review week. According to
an interview with the lead case manager, incoming and outgoing mail is searched as required.
Telephone calls for youth are given once each week, and youth may have longer call times
based on their level according to the behavior management system (BMS). The telephone
schedule is made for each youth by the case manager based on a certain weekday youth are
assigned. In addition, youth have the opportunity to mail up to two letters each week. According
to the lead case manager, the program utilizes an outside provider translation service for a third-
party language service when needed. For youth who have a history of human trafficking, there
was evidence the case manager requested clarification from the youth’s juvenile probation
officer (JPO) to verify the parent/guardian and other contacts for the youth. A review of four
youth who had an alert for endangered persons was made and compared with each youth’s
case management record. All four youth had evidence in their chronological notes and
correspondence of the notification being made to the assigned JPO as required. Seven
interviewed staff were unaware of the services the program had in place for youth whose
primary language was not English. Seven interviewed youth also were unaware of these
services. All seven interviewed youth were able to confirm they are able to call and/or send
letters to their parent/guardian. The PD confirmed the third party service available to youth who
do not primarily speak English.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program provides a range of supervised and structured indoor and outdoor recreation and
leisure activities to include large muscle activity. According to documentation for the annual
compliance review period in the master control logbook, recreation was conducted as
scheduled. Activities provided by the program promote social and cognitive skill development,
creativity, teamwork, healthy competition, mental stimulation, and physical fitness. The program
utilizes precautionary measures to prevent overexertion, heat stress, dehydration, and
exacerbation of existing illness or physical injury. According to the provider’s contract, a
recreational therapist is required. The program has a recreational therapist, whose credentials
meet all requirements. Seven youth case management records were reviewed. Each of the
seven records indicated recreational therapy was included in each youth’s individual treatment
plan. Seven youth were interviewed. Each youth reported the program allows the opportunity to
participate in creative arts, sports, or physical fitness activities. Youth participate in activities
such as jump rope, basketball, volleyball, walking, snatch and grab, football, and kickball. Seven
interviewed staff all confirm the program provides recreational activities for youth such as Boys
and Girls Club activities, basketball, football, walking laps, kickball, and exercise equipment. All
seven youth confirmed these activities are provided for at least one hour daily.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 65 of 66 (Revised September 2022)
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.26 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 66 of 66 (Revised September 2022)

report_type: QI Residential

program_name_raw: DOVE Academy

rule: Indicator 1.15

excerpt: Advisory Board

rating: Limited Compliance