summary: QI Residential - FY23-24 - 2 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Escambia Boys Base
Associated Marine Institute, Inc.
(Contract Provider)
640 Roberts Avenue Building 3780
Pensacola, Florida 32511
Review Date(s): June 25-28, 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:
Patrick M McKinstry, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Jessica Gibson, Office of Accountability and Program Support, Regional Monitor (Standard 2)
LeAnn Gruentzel, Office of Accountability and Program Support, Deputy Regional Supervisor
(Standard 3)
Carlametress Harrell, Postsecondary and Workforce Education, Regional Coordinator (Standard
1)
Ken Myers, Office of Education, Education Coordinator Circuit 1 (Standard 2)
Kayshala Patterson, Office of Accountability and Program Support, Regional Monitor (Standard
3)
James Phillips, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Rebecca Smith, Office of Accountability and Program Support, Regional Monitor (Interviews and
Standard 5)
Stephanie Solano, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Andre Watson, Office of Accountability and Program Support, Regional Monitor (Interviews and
Standard 1)
Program Name: Escambia Boys Base MQI Program Code: 1271
Provider Name: Associated Marine Institute, Inc. Contract Number: 10761
Location: Escambia County / Circuit 1 Number of Beds: 28
Review Date(s): June 25-28, 2024 Lead Reviewer Code: 144
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
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 70 (Revised September 2022)
T h e fo llo w in g lim
Lim ited R atings
1.08 In-S ervice Training
5.04 Ten M inute C hecks *
ite d a n d /o r fa ile d in d ic a to rs re q u ire im m e d ia te c o rre c tiv e a c tio n
Failed R atings
.
Standard 1: Management Accountability
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 70 (Revised September 2022)
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * 1 .0 1
F iv e -Y e a r R e s c re e n in g /R e n e w a l 1 .0 2
P ro v is io n o f a n A b u s e -F re e E n v iro n m e n t * 1 .0 3
M a n a g e m e n t R e s p o n s e to A lle g a tio n s * 1 .0 4
In c id e n t R e p o rtin g (C C C ) * 1 .0 5
P ro te c tiv e A c tio n R e s p o n s e (P A R ) a n d P h y s ic a l In te rv e n tio n R a te 1 .0 6
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * 1 .0 7
In -S e rv ic e T ra in in g 1 .0 8
G rie v a n c e P ro c e s s 1 .0 9
In te rv e n tio n s a n d F a c ilita to r T ra in in g 1 .1 0
L ife S k ills T ra in in g P ro v id e d to Y o u th 1 .1 1
R e s to ra tiv e J u s tic e A w a re n e s s fo r Y o u th 1 .1 2
In te rn a l A le rts S y s te m a n d A le rts (J J IS )* 1 .1 3
Y o u th R e c o rd s (H e a lth c a re a n d M a n a g e m e n t) 1 .1 4
A d v is o ry B o a rd 1 .1 5
S ta ff P e rfo rm a n c e 1 .1 6
S p e c ia l C o n tra c t C o n d itio n s 1 .1 7
C o n tra c t S p e c ific C a re e r a n d T e c h n ic a l E d u c a tio n S e rv ic e s 1 .1 8
D a ta T re n d A n a ly s is 1 .1 9
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
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tin g in e a c h o f th e s e
a re a (d e te n tio n ,
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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 70 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 70 (Revised September 2022)
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity o r C lin ic a l C o o rd in a to r 3 .0 1
L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff * 3 .0 2
N o n -L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff 3 .0 3
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A d m is s io n S c re e n in g 3 .0 4
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A s s e s s m e n t/E v a lu a tio n 3 .0 5
M e n ta l H e a lth a n d S u b s ta n c e A b u s e T re a tm e n t* 3 .0 6
T re a tm e n t a n d D is c h a rg e P la n n in g * 3 .0 7
S p e c ia liz e d T re a tm e n t S e rv ic e s * 3 .0 8
P s y c h ia tric S e rv ic e s * 3 .0 9
S u ic id e P re v e n tio n P la n * 3 .1 0
S u ic id e P re v e n tio n S e rv ic e s * 3 .1 1
S u ic id e P re c a u tio n O b s e rv a tio n L o g s * 3 .1 2
S u ic id e P re v e n tio n T ra in in g * 3 .1 3
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s * 3 .1 4
C ris is A s s e s s m e n ts * 3 .1 5
E m e rg e n c y M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e rv ic e s * 3 .1 6
B a k e r a n d M a rc h m a n A c ts * 3 .1 7
S a fe ty P la n n in g P ro c e s s fo r Y o u th 3 .1 8
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b
S a tis fa c to ry
e d ia te a tte n tio n if a
tin g in e a c h o f th e s e
a re a (d e te n tio n ,
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Standard 4: Health Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 70 (Revised September 2022)
S ta n d a r d 4 - H e a lth S e r v ic e s
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e * 4 .0 1
L ic e n s e d M e d ic a l S ta ff* 4 .0 2
F a c ility O p e ra tin g P ro c e d u re s 4 .0 3
A u th o rity fo r E v a lu a tio n a n d T re a tm e n t 4 .0 4
P a re n ta l N o tific a tio n /C o n s e n t 4 .0 5
H e a lth c a re A d m is s io n & R e s c re e n in g F o rm 4 .0 6
Y o u th O rie n ta tio n to H e a lth c a re S e rv ic e s /H e a lth E d u c a tio n 4 .0 7
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e A d m is s io n N o tific a tio n 4 .0 8
H e a lth -R e la te d H is to ry 4 .0 9
C o m p re h e n s iv e P h y s ic a l A s s e s s m e n t/T B S c re e n in g 4 .1 0
S e x u a lly T ra n s m itte d In fe c tio n & H IV S c re e n in g 4 .1 1
S ic k C a ll P ro c e s s 4 .1 2
E p is o d ic /F irs t A id C a re /E m e rg e n c y C a re 4 .1 3
O ff-S ite C a re /R e fe rra ls 4 .1 4
C h ro n ic Illn e s s /P e rio d ic E v a lu a tio n s 4 .1 5
M e d ic a tio n M a n a g e m e n t 4 .1 6
M e d ic a tio n /S h a rp s In v e n to ry a n d S to ra g e P ro c e s s 4 .1 7
In fe c tio n C o n tro l/E x p o s u re C o n tro l 4 .1 8
P re n a ta l C a re /E d u c a tio n 4 .1 9
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
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N o n -A p p lic a
e d ia te a tte n tio n if a
tin g in e a c h o f th e s e
a re a (d e te n tio n ,
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Standard 5: Safety and Security
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 70 (Revised September 2022)
S ta n d a rd 5 - S a fe ty a n d S e c u rity
Y o u th S u p e rv is io n * 5 .0 1 S a tis fa c to ry
C o m p re h e n s iv e a n d C o n s is te n t Im p le m e n ta tio n o f th e B e h a v io r M g t S y s te m a n d S ta ff T ra in in g 5 .0 2 S a tis fa c to ry
U s e o f R o o m R e s tric tio n 5 .0 3 S a tis fa c to ry
T e n M in u te C h e c k s * 5 .0 4 L im ite d
C e n s u s , C o u n ts , a n d T ra c k in g 5 .0 5 S a tis fa c to ry
L o g b o o k E n trie s a n d S h ift R e p o rt R e v ie w 5 .0 6 S a tis fa c to ry
K e y C o n tro l* 5 .0 7 S a tis fa c to ry
C o n tra b a n d P ro c e d u re 5 .0 8 S a tis fa c to ry
S e a rc h e s a n d F u ll B o d y V is u a l S e a rc h e s 5 .0 9 S a tis fa c to ry
V e h ic le s a n d M a in te n a n c e 5 .1 0 S a tis fa c to ry
T ra n s p o rta tio n o f Y o u th 5 .1 1 S a tis fa c to ry
W e e k ly S a fe ty a n d S e c u rity A u d it 5 .1 2 S a tis fa c to ry
T o o l In v e n to ry a n d M a n a g e m e n t 5 .1 3 S a tis fa c to ry
Y o u th T o o l H a n d lin g a n d S u p e rv is io n 5 .1 4 S a tis fa c to ry
O u ts id e C o n tra c to rs 5 .1 5 S a tis fa c to ry
F ire , S a fe ty , a n d E v a c u a tio n D rills 5 .1 6 S a tis fa c to ry
D is a s te r a n d C o n tin u ity o f O p e ra tio n s P la n n in g (C O O P ) 5 .1 7 S a tis fa c to ry
S to ra g e a n d In v e n to ry o f F la m m a b le , P o is o n o u s , a n d T o x ic Ite m s a n d M a te ria ls 5 .1 8 S a tis fa c to ry
Y o u th H a n d lin g a n d S u p e rv is io n o f F la m m a b le , P o is o n o u s , a n d T o x ic Ite m s a n d M a te ria ls 5 .1 9 S a tis fa c to ry
D is p o s a l o f a ll F la m m a b le , T o x ic , C a u s tic , a n d P o is o n o u s Ite m s 5 .2 0 S a tis fa c to ry
E le m e n ts o f th e W a te r S a fe ty P la n , S ta ff T ra in in g , a n d S w im T e s t * 5 .2 1 S a tis fa c to ry
V is ita tio n a n d C o m m u n ic a tio n 5 .2 2 S a tis fa c to ry
R e c re a tio n a n d L e is u re 5 .2 3 S a tis fa c to ry
S e a rc h a n d In s p e c tio n o f C o n tro lle d O b s e rv a tio n R o o m 5 .2 4 N o n -A p p lic a b
C o n tro lle d O b s e rv a tio n 5 .2 5 N o n -A p p lic a b
C o n tro lle d O b s e rv a tio n S a fe ty C h e c k s a n d R e le a s e P ro c e d u re s 5 .2 6 N o n -A p p lic a b
* T h e D e p a rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a
p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n ,
re s id e n tia l, p ro b a tio n ).
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Program Overview
The Escambia Boys Base is a twenty-eight-bed program, which provides services for fourteen
to eighteen-year-old males, located in Pensacola, Florida. The program is operated by AMIkids,
Inc. through a contract with the Department. The program provides Mental Health Overlay
Services (MHOS). In addition, the program fosters each youth by providing Aggression
Replacement Therapy (ART), Impact of Crime (IOC), and Moral Reconation Therapy (MRT).
Program administration is comprised of an executive director, business manager, director of
operations, and director of treatment. Case management services are provided by a transition
coordinator and two case managers. Mental health staff at the program include a director of
treatment, two therapists, and one psychiatrist. Medical services are offered seven days a week
and are provided by two full time registered nurses and one medical doctor. Sick call is offered
two times a day, as required. Educational services are provided by the Escambia County School
Board. The layout of the program includes one building, which houses all departments and
youth rooms. The program does not have a dining facility on-site. The program is co-located on
the Pensacola Naval Base and shares the dining facility with the base. The program has forty-
two security cameras providing coverage, all cameras were observed as operable at the time of
the annual compliance review. At the time of the annual compliance review, the program had
two vacant positions; both were direct care staff.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 70 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program reported not having any volunteers, mentors or interns who required background
screening. The program’s Annual Affidavit of Compliance with Level 2 Screening Standards was
completed and sent to the Department’s Background Screening Unit (BSU) on January 19,
2024. The annual screening for the teachers was completed on January 25, 2024. Based on a
review of the staff roster, the program had a total of fifteen staff who required an initial
background screening during the annual compliance review period. All background screenings
were completed as required and prior to contact with youth. A pre-employment assessment tool
was administered to direct care applicants. Each of the direct care staff had passing scores filed
in their personnel record. There was one staff applicable for having a completed background
when a provider staff was hired by another contracted provider company.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a policy and procedures which address five-year rescreening. Staff and
volunteers are rescreened every five years from the date of hire. During the annual compliance
review week, the program had no eligible staff meeting the requirements for completion of a
five-year rescreening.
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 70 (Revised September 2022)
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures to address providing an abuse free environment.
During the annual compliance review, observations verified the Florida Abuse Hotline telephone
number was posted throughout the facility for youth under the age of eighteen and the
Department’s Central Communications Center (CCC) telephone number for youth eighteen
years of age or older. The program’s steps for reporting abuse are immediately defined as
occurring near the time of the incident or when the information is first received. Any person who
knows or has reasonable cause to suspect a child is abused, abandoned, or neglected by a
parent/guardian, legal custodian, caregiver, or other person responsible for the child’s welfare,
should report such knowledge or suspicion to the Department. The program completed the
Trauma Responsive and Caring Environment (TRACE) self-assessment in May of 2024. Based
on a review of CCC reports during the annual compliance review week, the program had a total
nine incidents related to physical, psychological, or emotional abuse. Two were documented
with substantiated findings, six remained open, and one was found with unsubstantiated
findings at the time of the annual compliance review. A total of five incidents out of the nine
were reviewed and each indicated the Florida Abuse Hotline or the CCC was notified. None of
the reviewed incidents indicated there was any potential human trafficking victim, child sexual
exploitation, or labor trafficking. Five staff records were reviewed. Documentation supported
each of the five staff personnel records included a signed receipt of the program’s code of
conduct.
Five youth were interviewed. Each of the five youth reported they feel safe in the program. Five
youth reported they have never been stopped from calling the Florida Abuse Hotline or the
CCC. One of five youth reported knowing the number to the Florida Abuse Hotline. The
remaining four youth reported knowing the Florida Abuse Hotline number was posted
throughout the facility. Five youth reported staff are respectful when speaking to youth. One
youth reported they occasionally heard staff use profanity when speaking to the youth. The
youth indicated during a behavior correction attempt, staff used profanity. The remaining youth
reported never hearing a staff use profanity towards youth. None of the youth had ever
exchanged contact or social media information with staff. Five staff were interviewed, each of
the five staff were able to explain the process for allowing youth and staff to call the Florida
Abuse Hotline. Each of the five staff reported they have never observed a co-worker denying a
youth the opportunity to Florida Abuse Hotline. Four of five staff reported they have never
observed a co-worker using profanity when speaking to a youth. One of five staff reported
observing a co-worker using profanity when speaking to a youth. One of five staff reported
knowing the telephone number to the Florida Abuse Hotline. Four of five staff reported not
knowing the number to the Florida Abuse Hotline but knew where the telephone number was
located throughout the program.
An interview with the executive director (ED) was conducted. The ED was able to outline the
program’s procedures related to the staff code of conduct. The ED indicated trauma responsive
practices are incorporated through staff being trained in trauma response care, TRACE self-
assessment along with staff and youth surveys, mental health and first-aid training, motivational
interview training, and youth safely plans which incorporate recommendations from previous or
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current assessments or screening instruments and trauma responsive practices. The ED was
able to outline the program’s incident reporting process. The ED indicated the program provides
an environment in which youth, staff, and others feels safe, secure, and not threatened by any
form of abuse or harassment. The program posts telephone numbers for the Florida Abuse
Hotline and the CCC. All staff are trained on grievance procedures and contacting the CCC and
Florida Abuse Hotline. All youth receive information about the Florida Abuse Hotline and CCC in
their orientation packets.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program had a total of five allegations of abuse reported to the Florida Abuse Hotline, which
contained evidence management took immediate action to address allegations of physical,
psychological, and emotional abuse. An interview was conducted with the executive director
(ED). According to the ED there was a total of seven staff who had disciplinary action due to
allegations of abuse toward youth.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
During the annual compliance review period, the program had a total of thirty-three incidents
reported to the Department’s Central Communications Center (CCC). A sample of five CCC
reports were reviewed. All were reported within a two-hour period. All CCC reports were
documented in the logbooks. There were no additional internal incidents or grievances which
should have been reported to the CCC. According to a review of documentation, the program
has experienced an increase in the number of CCC reports as compared to the previous annual
compliance review. The program’s response to the increase in CCC reports was attributed to
the employment vacancy rate, influx of new youth, and inexperience of new staff.
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 a total of ten Protective Action Response Right Interactions model (PAR/RI)
incidents reported during the annual compliance review period. Five PAR/RI Reports were
reviewed. All reviewed reports were completed by the end of the staff’s workday. All reviewed
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reports included statements from all staff involved. There were no indications mechanical
restraints were utilized in any PAR/RI incidents requiring completion of the mechanical restraint
log. There were no PAR/RI incident reports which resulted in the injury of youth or staff. There
were no PARs/RIs in which youth alleged abuse. All five PAR/RI incident reports were reviewed
by a supervisor and a PAR/RI instructor. None of the PAR/RI incidents required a medical
review to be conducted. All PAR/RI incident reports were reviewed by the executive director or
designee within seventy-two hours of the incident excluding weekends and holidays. In each
incident, a copy of the PAR/RI Report was placed in the program’s centralized file within forty-
eight hours of approval and signature by the administrator or designee. Monthly summaries of
all PAR/RI incidents maintained by the program were submitted to the Department by the
fifteenth of each month. The program’s PAR/RI plan was updated on December 15, 2023, and
the plan was approved by the Department on December 18, 2023. The program had a total of
three PAR/RI incidents during the previous annual compliance review period. The program has
experienced an increase of five or more PARs/RIs since the last annual compliance review. The
program’s response regarding the reason for the increase was due to vacancy rates, influx of
new youth, and inexperience of new staff. The program’s PAR/RI rate during the previous
quarter was 1.80, which is above the statewide Residential PAR rate of 1.76.
An interview with the executive director (ED) was conducted. The ED reported, anytime the
program uses physical intervention techniques, a PAR/RI incident report is completed and filed
in accordance with the Florida Administrative Code. A copy of all PAR/RI related incidents is
also maintained. Five staff were interviewed. Three of five staff reported they have never used
PAR/RI. Two of five staff reported they have used PAR/RI.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring.
The program utilizes youth care specialists as the primary direct care position. The program
may also utilize the one maintenance staff as direct care on occasions when the program is
short-staffed. Five pre-service records were reviewed for pre-service training requirements.
Each of the five reviewed training records indicated staff received all essential required trainings
prior to contact with youth. Each reviewed training record included training completed in child
abuse recognition, reporting, and prevention, cardiopulmonary resuscitation (CPR), first-aid,
automated electronic defibrillator (AED), emergency procedures, facility or program operating
procedures, Prison Rape Elimination Act (PREA), Protective Action Response Right Interactions
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model (PAR/RI), and suicide awareness and prevention prior to contact with youth. Each staff
was still completing the remaining pre-service training requirements and were still within their
first 180 days of hire to complete the required trainings.
1.08 In-Service Training Limited Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
Five staff records were reviewed for in-service training requirements. Four of five had over the
twenty-four required hours of in-service training for the calendar year reviewed. One of the five
staff had twenty-one and a half total hours. All five reviewed staff had training in active shooter
preparedness, cardiopulmonary resuscitation (CPR), first-aid, human trafficking, Prison Rape
Elimination Act (PREA), and automated external defibrillator (AED). All held current CPR/first-
aid certifications. One staff was missing training in information security awareness, mental
health and substance abuse, trauma responsive practices, and professionalism and ethics. One
of five staff had the required minimum of six hours of training in suicide prevention. Two of the
five were missing six hours of suicide prevention training, one staff was missing one hour of the
training, and one staff was missing two hours of the training. All five had Protective Action
Response Right Interactions model update training as required. A review of the Department’s
Learning Management System (SkillPro) revealed two of the five staff had all trainings
documented in SkillPro as required. Three of the five staff did not have all trainings
documented. Two of the five staff reviewed were in supervisory positions. One of these two
applicable staff had over the additional eight hours required of supervisor specific training. The
remaining staff did not have this additional training. All instructors were qualified to deliver
trainings provided. The program provided their list of in-service trainings, approved by the
Department’s regional director, which included course names, descriptions, objectives, and
training hours for any instructor-led trainings. This in-service training plan was last submitted
November 29, 2024. The program has an annual in-service training calendar which is updated
as changes occur.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program maintains a policy and procedures for the grievance process. The program’s
grievance process includes an informal, formal, and appeal phase. There is an informal phase
which permits the youth to resolve complaints with staff on duty at the time of the occurrence of
the grieved situation. Based on documentation reviewed, the program maintains a copy of
grievances for the past twelve months. The program had a total of four youth grievances during
the annual compliance review period. Each of the grievances were reviewed and addressed
pursuant to the program’s policy.
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Five youth were interviewed. Each of the five youth reported forms are placed throughout the
program. Each of the five youth reported they can ask for assistance in completing a grievance.
An interview was conducted with the executive director (ED) and the ED was able to explain the
grievance procedure.
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 confirmed the program has no non-clinical, non-primary
service groups to review. The program’s activity schedule was reviewed, and documentation
confirmed the program is providing structured programming activities. An interview with the
executive director (ED) was conducted. The ED was able to provide a list of all staff who
participated in facilitating groups as well as the group facilitated and whether they are still
facilitating the group. The designated mental health clinician authority (DMHCA) was
interviewed addressing overall group therapy services provided by the program including clinical
and primary service groups. The DMHCA reported master’s-level counselors, licensed clinical
social workers, and case management staff provide services. Staff conduct group therapy four
to five days a week. Staff conduct Cannabis Youth Treatment, Aggression Replacement
Therapy (ART), Impact of Crime (IOC), Mental Health Overlay Services (MHOS), and Moral
Reconation Therapy (MRT) groups.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program maintains a policy and procedures for providing instruction focusing on
developing life and social skill competencies in youth. All youth receive an assessment of life
skills at intake during their comprehensive evaluation by a therapist. Based on the
assessment, life skills and social skills curriculum will be provided to youth based on their
individualized needs and according to their treatment plan.
An interview with five youth was conducted. Each of the five youth confirmed their participation
in groups. An interview with the executive director (ED) was conducted. The ED confirmed
youth are participating in groups. An interview with designated mental health clinician authority
(DMHCA) was conducted. The DMHCA was knowledgeable of names of groups, frequency of
groups, and facilitators of groups. The DMHCA confirmed youth are allowed to practice skills
daily. The program conducts The Council for Boys and Young Men and life skills groups to
address the needs of gender specific groups.
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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
youth’ criminal actions and harm to others.
A review of the program’s contract found their restorative justice group, Impact of Crime (IOC),
is a primary service; therefore, the group is not applicable for review. Youth are also allowed to
participate in Youth Left Behind, a community service and engagement, mentoring, and victim
impact group which addresses peer group empowerment, diversity, inclusion, and equality. The
program also teaches and provides essential building blocks for becoming exemplary citizens
for the community, fostering values of respect, and resilience. This program is fostered by group
speakers who come into the program every two weeks. An observation of youth participating in
restorative justice groups and activities was not able to be conducted during the annual
compliance review week.
An interview with the executive director (ED) was conducted. The ED reported youth participate
in IOC groups, community service activities, engage with victim speakers, and participate in
conflict resolution groups. Youth participate in peer empowerment and conflict resolution groups
if IOC groups have already been received. Communities and victims are restored by teaching
youth about the impact of crimes on victims, families, and communities, assist youth to accept
responsibility for harm they have caused by past actions, expose youth to victim perspectives,
and provide opportunities for youth to plan and participate in reparation activities. An interview
with the designated mental health clinician authority (DMHCA) was conducted. The DMHCA
was knowledgeable of groups, activities, and services. The DMHCA was knowledgeable of the
names of groups, frequency of the groups and the facilitators of groups. An interview with five
youth was conducted. Each of the youth indicated they are actively participating in IOC group.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program maintains a policy and procedures on how alerts are identified, documented,
updated, and communicated to staff. Any direct care, supervisory, or clinical staff may place a
youth on alert status if they meet the criteria for inclusion in the program’s alert system. A
suicide risk alert shall be entered when a youth is identified during screening or evaluation as a
potential suicide risk. A mental health alert shall be entered when a youth is identified as having
a mental disorder or acute emotional distress which may pose a security or safety risk. Only a
licensed mental health professional or mental health clinician may downgrade or discontinue
suicide risk or other mental health alerts. Only a medical staff person may downgrade or
discontinue medical alerts, upon verification the health condition or situation no longer exists.
Nursing staff shall verify all alerts in the medical alert system are accurate and up to date. The
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executive director (ED), assistant director, or on-site supervisor must ensure security alerts are
up to date. Five youth records were reviewed for entering of alert information. A total of sixteen
alerts in the Department’s Juvenile Justice Information System (JJIS) were applicable for
review. Of the sixteen alerts entered, three had documented issues. One of sixteen was entered
nine days late, one was entered three days late, and one was entered two days late.
An interview with the ED was conducted. The ED reported the program maintains an internal
alert system which is easily accessible to program staff and alerts them to youth who have risk
alerts. When risk factors are identified during or after classification, the program immediately
enters the information into the internal alert system. The ED was also able to explain the alert
system process. An interview was conducted with nursing staff. The nursing interview confirmed
each of the registered nurses are responsible for updating the medical alert system. An
interview with five staff was conducted. One of five staff reported they are informed of youth
alerts during intake, logbook review, and shift meetings. Two of five reported they are informed
of youth alerts through daily debriefing. Two of five staff reported they are informed of youth
alerts through the safety plan book.
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 case management, medical, and mental
health. A review of five individual case management records confirmed all contained the youth’s
name, Department identification number, date of birth, county of residence, and committing
offense. All individual management records contained legal information, demographics and
chronological information, correspondence, case management and treatment team activities,
and a miscellaneous section. All youth records were labeled confidential and were secured in a
locked file cabinet or a locked room. The filing area is clearly identified as confidential.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
According to documentation, the community advisory board met at least every ninety to 120
days. Documentation supports the executive director solicited involvement from law
enforcement, judiciary community, business community, school board, other community
partners, and faith community. The program did not recruit a victim, victim advocate, or other
victim services community representatives. The program did not recruit a parent/guardian
whose child was previously involved in the juvenile justice system. The program informed they
have intentions of adding this as part of an agenda item on monthly advisory board meetings to
recruit from areas not currently attending. Sign-in sheets, agendas, and meeting minutes were
reviewed confirming completion of advisory board meetings.
An interview with the executive director (ED) was conducted. The ED was able to describe the
community board meeting, the meeting times, current members, member involvement, and
recommendations. A member of the advisory board was interviewed to determine their level of
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involvement in program activities. The advisory board member reported the board committee
members meet monthly and they participate each month. The members may meet occasionally
for special meetings if circumstances require.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures in place to address staff performance through annual
evaluations. Five program staff job descriptions were reviewed to ensure performance
standards were clearly identified. Five performance evaluations were also reviewed to ensure
evaluations were completed as outlined in policy. Each of the five reviewed staff records
revealed staff were evaluated annually, and performance standards matched job descriptions.
The program’s contract was reviewed to ensure all specific contractually required positions were
maintained and performed as outlined. The program has two vacant positions; however, all
contract-required positions were filled.
An interview with the executive director (ED) was conducted. According to the ED, the program
posts vacancies and conducts interviews regularly. To increase morale and reduce turnover,
staff are involved in the decision-making process. Staff receive incentives, earn privileges, and
participate in staff appreciation month. The ED was also able to explain the performance
evaluation process for staff. Upon hiring, staff receive a job description which specifies job
duties, qualifications, and performance standards. Each manager is required to review
performance at least annually and offer feedback. The director of operations and ED review
evaluations and provide feedback as well. Five staff were interviewed. Three of five staff
reported communication amongst the staff in the program is good. Two of five staff reported
communication amongst staff in the program is very good. Two of five staff reported they
receive a formal evaluation of their performance every six months. One of five staff reported
they receive a formal evaluation of their performance yearly. One of five staff reported they
receive a formal evaluation of their performance every three to six months. One of five staff
reported they have not had a formal evaluation of their performance.
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 the program’s contract and documentation supported the program provided and/or
has implemented all items or services either negotiated or outlined which are considered special
contract conditions. The program offered regular faith-based opportunities, challenge events,
decorated living areas, family participation in celebrations, guest speakers, and one-on-one
mentoring opportunities, as required.
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An interview with the executive director (ED) was conducted. The ED stated special contract
services provided include Florida Ready to Work, cardiopulmonary resuscitation (CPR), first-aid,
Occupational Safety and Health Administration (OSHA), job training activities and placement
resources for youth, ServSafe food handler certification, work-based learning, career coaching
and employability skills, career track in culinary, community workplace learning labs, and job
placement. Five youth were interviewed. Four of five youth reported they were knowledgeable of
or participated in negotiated contract items. One of five youth denied knowing of or participated
in negotiated contracted items.
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.
According to the provider’s contract, career and technical educational services to be offered
include Florida Ready to Work, Occupational Safety and Health Administration (OSHA),
cardiopulmonary resuscitation (CPR), first-aid, ServSafe food handler certification, work-based
learning, career coaching and employability skills, career track in culinary, community workplace
learning labs, and job placement. A total of twenty-eight youth participated in CPR and first-aid
training during the annual compliance review period. Twenty-one youth received or are in the
process of receiving OSHA training. Twenty-one youth have completed or are in the process of
completing Florida Ready to Work training. Fourteen youth are enrolled in culinary. Twenty-eight
youth received their CPR and first-aid certifications. Fifteen youth received OSHA certifications.
Twenty-one have received the Florida Ready to Work certificate. Fifteen youth have completed
the ServSafe certification. Career and technical education services are provided Monday
through Friday from 4:00 p.m. to 5:30 p.m. according to allotted classroom days and times.
During these times, there is one classroom for culinary and Florida Ready to Work, and OSHA,
CPR, and first-aid are provided monthly in a separate classroom. According to documentation,
career and technical services were provided as required. Career and technical services were
provided by staff certified in culinary, Florida Ready to Work, and OSHA. The other staff is
certified in CPR and first-aid.
Five youth were interviewed. Each of the five youth reported they participate in educational
services. Two of five youth reported they participate in services five days a week. Two of five
youth reported they participate in career and technical education services every day. One of five
youth reported participating in services four days a week. The executive director (ED) was
interviewed and stated contract specific pre-vocational and vocational services provided include
CPR, first-aid, OSHA, job training activities and placement resources for youth, ServSafe food
handler certification, work-based learning, career coaching and employability skills, career track
in culinary, community workplace learning labs, and job placement.
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1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program reviews and analyzes data in every-day decision-making practices. Operation data
is compiled monthly by the home office data and research department. The data is reviewed as
part of weekly leadership meetings and monthly staff meetings. Information is also emailed to
team members directly from the home office data department. Documentation confirmed the
practices are being upheld. A quarterly data quality report is produced and shared across
programs. An impact report is produced annually and is available for reviewing. Reviewed
documentation supports practices are being upheld. The program utilized their data to make
decisions in program operations during the annual compliance review. The program created a
new educational plan which contains scheduling, interventions, and youth rewards. Program
management implemented a process to award staff with incentives such as gift cards and
caricatures. Management established staff appreciation month. The program introduced conflict
resolution. The program introduced a program manager to assist with and provide oversight with
operations and staffing.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
Five youth case management records were reviewed for parent/guardian notification. All five
youth records included documentation the program notified the parents/guardians by telephone
within twenty-four hours of admission. All five records also included the program notified the
parents/guardians in writing within forty-eight hours of admission. All letters were sent the day of
admission. The committing court and assigned juvenile probation officer (JPO) were notified
within five working days of all five youth admissions. The program also provides “Performance
Feedback forms” to the parents/guardians with the notification letters to allow parents/
guardians to provide questions and feedback to the program throughout the youth’s stay.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures in place to address youth orientation. Five youth case
management records were reviewed. All five records included documentation the youth
received orientation on the date of admission to the program. The program’s documentation
included the services available, daily schedule, expectations and responsibilities of youth,
written behavioral management system provided in a resident handbook, availability of and
access to medical, mental health, and substance abuse services, access to the Florida Abuse
Hotline or the Department’s Central Communications Center (CCC), the program’s zero-
tolerance regarding sexual misconduct and how to report incidents, special accommodations
which are available, right to be free from sexual misconduct, right to be free from retaliation for
reporting such misconduct, the program’s sexual misconduct response policy and procedures,
items considered contraband, performance planning process involving the development of goals
for each youth to achieve, dress code and hygiene practices, procedures on visitation, mail, and
use of the telephone, expectations for release from the program, including the youth’s
successful completion of Individual Performance Plan goals, recommendation to the court for
release based on the youth’s performance in the program, the court’s decision to release,
community access, grievance procedures, emergency procedures to include fire drills and
building evacuations, facility tour, and assignment to a living unit, room, and a staff advisor.
Five youth were interviewed regarding youth orientation. All five youth reported their orientations
began within twenty-four hours of admission. All five youth also reported the orientation included
program rules, procedures, schedules, and other required topics. All youth were able to explain
the orientation process.
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2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program provided three youth records for review of documentation for written consent of
eighteen years or older. All three youth records included documentation a written consent was
obtained timely for each youth.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
A review of the program’s classification forms revealed they included the physical
characteristics of the youth, age, maturity level, identified special needs, history of violence,
gang affiliation, criminal behavior, sexual aggression or vulnerability to victimization, youth’s
perception of vulnerability, youth’s history of potential or verified human trafficking, suicide risk,
medical risk, escape risk, and security risk.
Five youth records were reviewed for classification factors, procedures, and reassessment. All
five youth had an initial classification completed on the dates of their admission. One out of five
youth had suspected risk factors of medical risk, escape risk, security risk, and was an identified
gang member. Two additional youth had suspected risk factors of mental health and
aggression. The other two youth records reviewed did not have suspected risk factors. Due to
Department-wide system outages, a review of the Department’s Juvenile Justice Information
System (JJIS) for alerts could not be conducted. One youth did have a JJIS alert in the gang
binder for review. The alert was created timely for the youth. Reviewed evidence showed all five
youth were classified for purposes of assigning youth to a living area, sleeping room, and staff
advisor.
Five youth records were reviewed for reclassification. All five youth had a reclassification
completed. Two of the three reclassifications allowed the youth to participate in work projects,
activities using tools or instruments which may be used as potential weapons, and participation
in off-campus activities. Two of the youth’s reclassification forms did not indicate if the youth
was allowed more freedom or if the youth was still on security risk. The transition case manager
reported the statement on the reclassification forms should have been checked for these two-
youth indicating both youth had been on campus over thirty-days and were still considered
security risks. The fifth youth had a reclassification completed, and it indicated the youth was
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still a security risk due to significant behavioral issues. These three youth were not allowed to
participate in using tools, working on the lawn crew, or participate in off campus activities.
The program’s policy and procedures clearly outlined the classification process and included a
classification system which promotes safety and security, as well as effective delivery of
treatment services, based on the determination of each youth’s individual needs and risk
factors, which addresses items outlined in Florida Administrative Code. A review of the
program’s policy and procedures for reclassification confirmed they included all the required
elements.
The executive director (ED) reported the program’s goal is to protect youth through a
classification system which ensures the most appropriate unit assignment and sleeping room
assignment while providing the type of care best suited to the needs of the individual and the
protection of the individual’s physical, mental, moral integrity, and well-being. The management
designee will review each new youth’s legal file and new youth are assessed based on the
information obtained from their youth classification form, Massachusetts Youth Screening
Instrument, Second Version (MAYSI-2) results, collateral contacts, and information contained in
the commitment packet. The ED was able to summarize the appropriate factors taken into
consideration for youth classification.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
Five youth case management records were reviewed for gang identification and notification of
law enforcement. One youth record was applicable for gang identification. One additional youth
record was provided by the program for review. The program maintains youth gang member
information, notifications, and the gang curriculum in a binder titled “Gang Book”. Both youth
records included documentation the law enforcement agencies of the youth’s home counites
were notified of suspected gang activity when the youth arrived at the program. Documentation
confirmed local law enforcement was notified prior to the Monitoring and Quality Improvement
seven-day notice for both youth. The Department’s Juvenile Justice Information System (JJIS)
alerts were reviewed for both youth as they were maintained in the program’s Gang Book. Both
alerts were completed timely in JJIS. The information on each youth’s gang status was shared
with the local school district and the assigned juvenile probation officers.
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.
Five youth case management records were reviewed for gang identification and notification of
law enforcement. One of the five youth records was applicable for gang prevention and
intervention activities. One additional youth record was provided by the program for review. Both
youth were identified as suspected gang members. Both youth were participating in gang
prevention and intervention strategies at the time of the annual compliance review. This was
evidenced by sign-in sheets for the curricula the program utilizes. Both youth’s performance
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plans included relevant goals and objectives related to gang intervention strategies for the youth
to complete prior to the release from the program.
The program implemented Gang Awareness and Impact of Crime as the curricula utilized for
gang intervention. Gang Awareness is one intervention being provided to youth identified as a
gang member or affiliate. The group is being held weekly with the identified youth. A review of
the program’s policy and procedures for gang prevention and intervention activities confirmed
the program provides youth the opportunity to develop a plan to disaffiliate with a criminal street
gang.
The executive director (ED) reported the program creates a sense of community and
acceptance of all its members, which erodes the strong pre-existing gang ties and prevents
recruitment. The best way to erode hard-core membership is to help the youth to focus on their
own personal goals and future. It is believed somewhere deep down the youth has a dream of
being socially acceptable. The staff help by rigorously policing the program and eliminating gang
symbolism and activity. Those symbols have power, and their presence strengthens gangs. If
the symbols are eliminated and the lines of communication are interrupted, this paves the way
for real and long-lasting change. It is the responsibility of the program staff to make the program
safe and remove the ability of youth to threaten other youth with violence. A local gang liaison
provides a gang class quarterly, if available. A youth-first and family culture are cultivated by the
program and is a sure way to combat gang involvement.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
Five youth case management records were reviewed for Residential Assessments for Youth
(RAYs) and RAY Reassessments. All five records included documentation the RAYs were
completed within thirty days of the youth admissions. Four of the five initial RAYs were
maintained in the Department’s Juvenile Justice Information System (JJIS). Due to Department-
wide system outages, one RAY could not be completed or maintained in JJIS. The program’s
case management staff completed the RAY on paper, and it is maintained in the case
management record. The youth's initial formal treatment team was held the same day as the
completion of the RAY along with the youth's performance plan meeting.
Four of the five youth case management records included documentation RAY Reassessments
were completed at least every ninety-days after the completion of the initial RAY assessment.
One youth had not been at the program long enough to have received a RAY Reassessment.
All RAY Reassessments were maintained in the youth’s official case records.
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2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in JJIS on the YNAS.
Five youth case management records were reviewed for completion of the Youth Needs
Assessment Summaries (YNAS). All five YNAS reports were completed within thirty days of the
youth admissions. Four out of the five YNAS reports were completed in the Department’s
Juvenile Justice Information System (JJIS). Due to Department-wide system outages, one
youth’s YNAS report could not be completed in JJIS at the time the youth entered the program.
The YNAS report was completed on the Department’s paper form and maintained in the youth’s
case management record.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
Five youth case management records were reviewed for performance plan development, goals,
and transmittals. All five youth records included documentation the Individualized Performance
Plan (IPP) were developed within thirty days of the youth’s admissions. All five IPPs were
developed after the initial Residential Assessment for Youth (RAY) and the Youth Needs
Assessment Summary (YNAS). All five IPPs included signatures from the intervention and
treatment team leader, youth, administrative representative, treatment staff, educational staff,
and all other parties who have significant responsibility in goal completion. Four of the five IPPs
had signatures for a living unit representative. One IPP did not have this signature; however,
input was provided from a living unit representative for this youth. All five youth records included
documentation the signature page was mailed to the parents/guardians. None of the signature
pages were returned to the program.
All five IPPs included the individualized goals based upon the prioritized needs reflecting the
risk and protective factors identified during the initial assessment process, the top three
criminogenic needs, specific delinquency interventions based upon the RAY results with
measurable outcomes, transition activities targeted for the last sixty days of the anticipated
release dates, youth responsibilities to accomplish goals, program staff responsibilities to
enable youth to complete goals, and target dates for goal completion. Two of the five IPPs
included targeted court-ordered sanctions which could be reasonably initiated/completed while
in the program. The other three youth did not have targeted court-ordered sanctions.
Five youth case management records were reviewed for transmittal letters. All five youth
records included documentation the committing courts, juvenile probation officers, and
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parents/guardians had the transmittal letters mailed to them within ten workings days of the
IPPs being completed.
Five youth were interviewed regarding performance plans. All five youth were able to describe
the goals on their performance plans. All five youth also reported they all have a copy of their
performance plans.
2.10 Performance Plan Revisions Satisfactory Compliance
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team.
Five youth case management records were reviewed for performance plan revisions. . Four of
the five Individualized Performance Plans (IPPs) were revised for the youth demonstrating
progress towards completing a goal. One youth did not have a revised IPP at the time of the
annual compliance review due to only being in the program three months. Three of the five IPPs
were revised for youth demonstrated lack of progress toward completing a goal. All IPPs had
transition activities included on them at the initial IPP.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
Five youth case management records were reviewed for Performance Summaries and
transmittals. Four of the five youth records included documentation of Performance Summaries
being completed every ninety calendar days following the signing of the performance plans.
One youth has been at the program for three months and a Performance Summary was not due
at the time of the annual compliance review.
Two of the five youth had Performance Summaries prepared prior to the request for release or
transfer. Three of the youth were not at the point in the program to require a request for release.
Four out of four Performance Summaries included the following elements: youth’s status on
each performance plan goal, youth’s overall treatment progress, youth’s academic status,
youth’s behavior, level of motivation/readiness to change, interaction with peers, interaction with
staff, overall behavior adjustment to the program, and significant positive and negative events.
Two of the five youth had justification for release and transfer. The program had made a request
to transfer one youth due to behaviors in December 2023; however, the transfer request was
denied.
All four youth records included documentation the transmittals reflected the youth was allowed
to read and add comments prior to signing and the youth was provided a copy of the summary.
The program has the youth sign they received a copy of the Performance Summary. All four
Performance Summaries were included in the youth case management records. All four
Performance Summaries were signed and dated by the treatment tea leader, executive director
or designee, and the youth.
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All four youth records included documentation a copy of the Performance Summaries were sent
within ten workings days to the committing court, assigned juvenile probation officer, and
parents/guardians.
Three closed youth case management records were provided for the review of Performance
Summaries and transmittals for releases. All three records included documentation the original
Performance Summary was sent with the Pre-Release Notification (PRN) to the juvenile
probation officers. All three release summaries and PRNs were sent at least forty-five days prior
to the youth’s planned release. All three were signed and a copy was retained in the case
management records. All three PRNs were approved, the records included documentation the
program provided written notification to the parents/guardians regarding the planned release.
and all three records included an exit Residential Assessment for Youth (RAY). All three youth
did not have qualifying charges for victim notifications.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program provided documentation they encourage and facilitate involvement of the
parents/guardians in the case management process. The reviewed documentation included
invitations to the assessment processes, participation in the development of the youth’s
performance plan, progress reviews, advanced notice of formal treatment team meetings dates
and times, and transition planning. If the parents/guardians were unable to attend they were
provided the opportunity to participate by video conferencing or telephone conferencing.
A treatment team was observed during the annual compliance review week. The
parent/guardian participated through video conferencing.
The program utilizes treatment teams, weekly calls, family therapy sessions, letters, and family
days to facilitate involvement of the parents/guardians.
The executive director (ED) reported the program invites the parents/guardians to participate in
treatment team meetings for the purpose of developing the youth’s performance plan,
conducting formal performance reviews of the youth’s progress in the program, and planning for
the youth’s transition to the community upon release. If unable to attend, the parent/guardian is
given the opportunity to participate through telephone or video conferencing, or to provide
written input prior to the meeting.
Five youth were interviewed regarding parent/guardian involvement. All five youth reported they
receive telephone calls during the treatment teams. The program provides weekly telephone
calls to parents/guardians.
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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.
Five youth case management records were reviewed for the incorporation of other plans into
performance plans. All five youth records included documentation all youth have additional
plans at the program for education and treatment. Three of the five Individualized Performance
Plans (IPPs) incorporated the education and treatment plans. Two of the IPPs did not
incorporate the education plans. The director of treatment was notified of the missing elements
and discussed the issue with staff.
All five youth records included documentation of having separate treatment plans. None of the
youth were involved with the Department of Children and Families or 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.
Five youth case management records were reviewed for treatment team members. All five
records included documentation formal treatment teams were held at least every thirty days.
The reviewed documentation regarding formal treatment teams included the youth name, date
of review, required attendees, any comments from treatment team members or others, brief
synopsis of the youth’s progress in the program, performance plan revisions, progress on
performance plan goals, positive and negative behaviors, the youth was provided an opportunity
to demonstrate skills acquired in the program, and treatment progress. Four of the five youth
had documentation of their Residential Assessment for Youth (RAY) Reassessments reviewed
during the formal treatment teams. One of the youth had not been at the program long enough
to receive a RAY Reassessment at the time of the annual compliance review. None of the youth
had behaviors which resulted in physical interventions. All formal treatment team documentation
was contained in the youth records.
Five youth case management records were reviewed for informal treatment team reviews. All
five records included documentation the informal treatment team reviews were held bi-weekly
each month alternating with formal treatment team meetings. All informal treatment team
documentation included all the required elements. One of the four youth had not been at the
program long enough to have received a RAY Reassessment. None of the youth had behaviors
which resulted in physical interventions.
The assigned juvenile probation officer (JPO), parents/guardians, and other pertinent parties
were invited and encouraged to participate in treatment team meetings. If someone cannot
participate in person, they are invited to attend through video conferencing, telephone, or
provide input prior to the meeting.
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A treatment team meeting was observed during the annual compliance review week. All
required staff were present, except for education staff. Education staff did provide input and it
was reported by the clinical case manager during the meeting. During the review of the
treatment plan, the anticipated release timeframe was reviewed.
Five youth were interviewed regarding treatment teams. All five youth reported the staff review
all the required information during the treatment team meetings. All five youth reported they
were provided an opportunity during treatment team meetings to demonstrate any skills they
have learned in the program.
2.15 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
Three closed youth case management records were reviewed for transition planning and
conference and the Community Re-Entry Team (CRT). All three records included
documentation the transition conference was held, at least sixty days prior to the targeted
release dates. The intervention and treatment team members who attended the transition
conference included the youth, treatment team leader, executive director or designee, assigned
juvenile probation officer (JPO), parents/guardians, education staff, and other pertinent parties.
All three youth records included documentation the transition activities on the individualized
performance plans, identified additional transition activities, identified target completion dates,
and identified persons responsible for completion were reviewed during the transition
conference. The treatment team leader obtained all required signatures and dates representing
their acknowledgement of the transition goals and accountability for completion. All three
records included documentation a copy of the transition plan was sent with a request for return
with signature to anyone not in attendance who had a responsibility for completion of transition
goals.
All three records included documentation the CRT meeting was conducted prior to the youth’s
release. The youth and case managers participated in the CRT meetings according to a review
of the documentation. All three records included evidence of an invitation to participate in the
CRT meetings.
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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 youth case management records were reviewed for Exit Portfolio documentation.
All three youth records included documentation the Exit Portfolios were discussed and initiated
for the youth during the transition conference. The state-issued identification card, copy of the
transition plans, calendar with all dates, times, and locations of upcoming community
appointments, Social Security cards, birth certificates, educational and/or vocational certificates
earned while in the program, educational records/documents, school transcripts, résumé, and a
completed sample of employment applications were all included, as required. All three records
included documentation the Exit Portfolios were verified during the Exit Conference. All three
records included documentation indicated the Exit Portfolios were completed and given to the
youth upon release. All three records included documentation the program staff provided a copy
of the Exit Portfolio information to the assigned juvenile probation officer (JPO).
2.17 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
Three closed youth case management records were reviewed for Exit Conference
documentation. All three conferences were conducted after the program notified the juvenile
probation officer (JPO) of release dates and were conducted at least fourteen days prior to
release. Reviewed documentation indicated the dates of the conferences, signatures, names of
participants who appeared by telephone, and a summary of pending transition goals. Due to
Department-wide system outages, the dates of admission and release could not be reviewed in
the Department’s Juvenile Justice Information System (JJIS). All three records included
documentation of the status of transition activities which were established at the Transition
Conference and all plans were finalized for the release and were reviewed during the Exit
Conference.
The signatures of participants included the intervention and treatment team leader,
parents/guardians, education representative, JPO, youth, and all other pertinent parties. There
was evidence the Exit Conferences were held separately from the Transition Conference and
Community Re-Entry Team meetings.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program’s formal process for youth input was reviewed. All youth committed to the program
are provided an opportunity to give constructive input into program operations. Soliciting input
from the youth in the program allows the youth to identify systemic issues impacting their
residential community and make recommendations for resolution to improve conditions and
enhance the quality of life for staff and youth in the program. The program provides a vehicle for
youth to provide input into program operations by way of the youth advisory council meetings,
youth interviews, exit surveys, and the idea suggestions box.
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The program’s Trauma Responsive and Caring Environment (TRACE) assessment was
completed and provided for review. The house meeting minutes were also provided for review.
House meetings are held at least monthly where the youth can ask questions, bring up
suggestions, and receive an immediate answer from staff. The executive director (ED) conducts
the house meetings. The program’s policy and procedures stated the youth advisory council
meets quarterly, at a minimum, with a mentor of the management team as a representative.
Youth council meetings are held quarterly as evidenced by agendas provided for review. There
were no sign-in sheets or meeting minutes for the youth council meetings. All youth, upon exit
from the program, are also provided a survey along with their parent/guardian. This
documentation was observed in three closed youth records.
Five youth were interviewed regarding youth input. The youth reported they can put in a 411,
request to speak with staff, or can talk with their therapist. One youth reported there is a
process, however, it takes too long.
The ED reported the program has a formal process to promote constructive input by youth. This
process is developed through the utilization of youth advisory council, youth interviews,
suggestion box, and exit surveys.
2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
Staff shall develop and implement a career education competency development program. The
program’s career educational programming is Type 2. The program has personal accountability
skills and behavior appropriate work habits for employment incorporated into the programming.
Programming includes communication, interpersonal skills, and decision-making skills. Three
closed youth case management records were reviewed and had samples of completed
employment applications and a résumé summarizing education, work experience, and/or career
training. Each youth record included all required documents. The youth had Career Source
Center information. Documentation indicated the youth’s parent/guardian and juvenile probation
officer (JPO) were aware of the youth’s educational plan. The interview with the lead educator
indicated the Educational Transition Plan was shared during the treatment team meeting.
2.20 Educational Access (Critical) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a policy and procedures to provide educational access for the youth.
Educational services are provided by the Escambia County School District, who also approves
the 250-day school calendar. A review of the daily education schedule revealed youth are
provided twenty-three hours and thirty minutes of instruction each week. This schedule was
changed from twenty-five hours in March. The school schedule was provided by the lead
educator. Although the youth are receiving 240-days of instruction, the calendar only allows for
the teachers to utilize two days for training/planning throughout the school year. The school
district stated they cannot change the calendar due to collective bargaining. The daily schedule
is followed with minimal interruptions and school is not canceled for any reason. The lead
teacher did indicate, if there happens to be a weather emergency, then this could possibly result
in a school cancellation. The lead teacher and staff interviews indicated there are minimal
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interruptions during the school day. Five youth were interviewed and all five stated the daily
schedule is followed and they attend school daily. The youth stated they are well prepared for
either a high school equivalency diploma (GED), returning to their home school, or some type of
vocational or secondary education. Three days in the month of June were reviewed in program
logbooks and three days from the past thirty days were also reviewed on video; each showed
no issues pertaining to the daily school schedule. A review of the video showed the youth began
class and ended as expected. The interview with the lead educator indicated the youth were
arriving to school on time and left at the appropriate times.
2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The program maintains a written policy and procedures requiring an Educational Transition Plan
to be developed upon each youth’s admission. Three youth closed case management records
were reviewed. The youth records included an individual Education Transition Plan developed
upon entry and included the youth’s post-release goals. Three closed youth case management
records contained an exit plan indicating the case manager, parent/guardian, and youth were all
aware of the plan. Five youth were interviewed. Two youth reported they were involved in the
development of their transition plan. Three youth indicated they were not applicable for being
involved in the development of their plan; however, they did not expand on their responses. The
five youth also reported they felt the program was preparing them very well or well when it came
to preparing them for the high school equivalency diploma (GED), high school, vocational
school, employment, and/or college.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each executive director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program’s designated mental health clinician authority (DMHCA) is the director of
treatment, who is a licensed clinical social worker (LCSW), with a clear and active license in the
State of Florida expiring on March 1, 2025. The clinical director is a staff of the program,
working forty hours on-site during the week, as well as on weekends when necessary, providing
the coordination and implementation of mental health and substance abuse services. The
program had two back-up DMHCAs since the last annual compliance review. One is a licensed
mental health clinician (LMHC) with a license expiring on March 31, 2025; one is a licensed
clinical social worker (LCSW) with a license expiring March 31, 2025. During the annual
compliance review period, the backup LMHC DHMCA provided coverage in the DMHCAs
absence on July 25 through 28, 2023; the backup LCSW DMHCA provided coverage in the
DMHCAs absence on June 4 through 7, 2024. The clinical director also provided direct
supervision to non-licensed clinicians for no less than one hour a week of face-to-face
supervision. Supervision included reviewing specific treatment needs or concerns, sample
treatment documents, and recommendations for continued service provision. The DMHCA’s
position description was provided and reviewed, which states the DMCHA is the single licensed
mental health professional responsible for the coordination and implementation of mental
health/substance abuse services. The DMHCA is available by telephone to provide coverage
twenty-four hours a day, seven days a week, in the event of any mental health emergency. The
clinical director was interviewed and indicated having the responsibility for overseeing the
clinical staff to ensure they are providing the proper care for each youth at the program ensuring
effective mental health services are provided and providing backup support services and
substance abuse counseling/group therapy. The DMHCA reported communication with staff
occurs daily and supervision occurs at least once a week.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The executive 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.
A review of the program’s policy, procedures, and contract confirmed they do not require any
other licensed clinical staff other than the individual serving as the designated mental health
clinician authority (DMHCA).
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The executive director is responsible for ensuring mental health and substance abuse
services are provided by individuals with appropriate qualifications. Clinical supervisors shall
ensure clinical staff working under their supervision are performing services the staff are
qualified to provide based on education, training, and experience.
The designated mental health clinician authority (DMHCA) reported three non-licensed clinical
staff have been working under their supervision. All non-licensed clinical staff who worked at the
program during the annual compliance review period were found to be qualified to provide
services based upon education, training, and experience. The program does not have a Chapter
397 license and reviewed documentation verified the substance abuse services, including all
Comprehensive Assessments, were conducted by the DMHCA, in accordance with the current
contract and Florida Administrative Code. The program’s contract requires a recreational
therapist, and a review of the program roster, credentials, and schedule confirmed all
requirements were met. Reviewed documentation confirmed the non-licensed clinical staffing
coverage is in accordance with the current contract for forty hours a week. Reviewed
documentation maintained during the annual compliance review period verified each non-
licensed clinical staff received a minimum of one hour a week, on-site face-to-face supervision
by the current DMHCA. The direct supervision documentation was recorded on a form, which
included all elements of the Department’s Licensed Mental Health Professionals and
Licensed/Certified Substance Abuse Professionals Direct Supervision Log form. All non-
licensed clinical staff reviewed held a master’s-level degree from an accredited university or
college. Each non-licensed clinical staff held a masters in the field of social work. Two of the
three reviewed non-licensed clinical staff completed training and supervision in assessing
suicide risk, mental health crisis intervention, and emergency mental health services. Both staff
had their training for assessing suicide risks documented on the Non-Licensed Mental Health
Clinical Staff Person’s Training in the Assessment of Suicide Risk form. One clinical staff was
hired in February and has not received the training to complete the Assessment of Suicide Risk
(ASR). The DMHCA reported the staff did not complete any ASRs, nor were any ASRs
observed with the staff’s name on them.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
Five youth records were reviewed for mental health and substance abuse admission screening.
Each reviewed record contained a completed Massachusetts Youth Screening Instrument,
Second Version (MAYSI-2). Information reviewed for each youth included the commitment
packet, reports, and/or records of documentation concerning mental health and/or substance
abuse issues. Each of the MAYSI-2s were completed on the date of the youth’s admission to
the program, in a confidential manner. The screenings were completed within the Department’s
Juvenile Justice Information System (JJIS). Each of the screenings were conducted by trained
staff. None of the reviewed MAYSI-2s indicated further assessment was required; however, it is
the program’s practice to assess suicide risk for all youth upon admission to the program. All
five records verified each youth was referred for an Assessment of Suicide Risk (ASR) and
comprehensive evaluation, and each included the reason for the referrals. The program does
not utilize a separate clinical mental health and substance abuse screening. The program’s
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executive director (ED) is responsible for the implementation of the standardized
admission/intake mental health and substance abuse screening process. The reviewed policy
confirmed the process includes a review of commitment packet information, reports and
records, administration of the MAYSI-2 in JJIS by a qualified professional, and a referral of
youth identified by screenings as in need of further evaluation or immediate attention. The policy
outlines administration staff training and a standardized process for youth requiring immediate
attention and transfer to a Baker Act or Marchman Act receiving unit. The interviewed ED was
knowledgeable of the screening process for youth at risk and reported, an ASR and a MAYSI-2
are completed with each youth at intake.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program maintains a policy and procedures to address the provision of mental health and
substance abuse assessments/evaluations. A review of five youth records found each youth
received a comprehensive mental health assessment prior to admission into the program. The
program’s practice is to complete a new combined comprehensive mental health and substance
abuse evaluation within thirty calendar days of each youth’s admission. All five youth
evaluations were completed within thirty calendar days of admission to the program. Each
evaluation was completed by non-licensed clinical staff and reviewed and signed by the
designated mental health clinician authority (DMHCA) within ten calendar days of the evaluation
being conducted. The mental health evaluation included youth demographics, reason for
evaluation, relevant background information, behavioral observations, Mental Status
Examinations, procedures administered, discussion of findings, diagnostic impressions including
the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis, and
recommendations. A review of five records verified each youth received a new substance abuse
assessment within thirty days of admission. Each youth record included the reason for the
substance abuse assessment, all relevant background information, behavioral observations,
methods of assessment, patterns of alcohol and substance abuse, impact of alcohol and other
drug abuse on major life areas, risk factors, clinical impression including the DSM-5 diagnosis,
and recommendations. All five reviewed youth records indicated the mental health/substance
abuse assessment addressed the original referral reasons. In all five youth records signed
consents were documented for substance abuse treatment, release of treatment records to the
judicial court and parent/guardian, and consent for urine collection and analysis.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program maintains a policy and procedures outlining the program’s mental health and
substance abuse treatment services. A review of five youth records reflected an Initial
Treatment Plan was developed within seven days of each youth admission. Each reviewed plan
was documented on the program’s form and included all elements of the Department’s Initial
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Mental Health/Substance Abuse Treatment Plan form. All five youth Initial Treatment Plans
were completed by non-licensed clinical staff and signed by the designated mental health
clinician authority (DMHCA) within ten days of completion. Each Initial Treatment Plan was
signed by all treatment team members who participated in the development of the plan. Each
plan was signed by the youth and documented the juvenile probation officer (JPO) and
parent/guardian participated by telephone. None of the reviewed youth records were applicable
for the inclusion of psychiatric needs on the Initial Treatment Plan. Five youth records were
reviewed for completion of an Individualized Treatment Plan and periodic reviews. Each of the
Individualized Treatment Plans reviewed were developed within thirty days of the youth’s
admission to the program and developed on a form which contained all the elements of the
Department’s Individualized Mental Health/Substance Abuse Treatment Plan form. A review of
five records reflected the Individualized Treatment Plans were completed and signed by a non-
licensed clinical staff and subsequently reviewed and signed by the DMHCA within ten days of
completion. All the reviewed Individualized Treatment Plans were signed by treatment team
members who participated in the development of the plans. Two of the five Individualized
Treatment Plans reviewed were applicable for inclusion of psychiatric needs and included
medication and monitoring frequency by the psychiatrist. A third youth was applicable for
psychiatric services and their updated plan included psychiatric needs, medication, and
frequency of monitoring by the psychiatrist. Each of the records reviewed were applicable for
Individualized Treatment Plan reviews. The Individualized Treatment Plan reviews were
completed and documented on a form containing all the elements within the Department’s
Individualized Mental Health/Substance Abuse Treatment Plan Review form. There was a total
of forty Individualized Treatment Plan reviews completed between the five youth records
reviewed and none were late. Each youth was prescribed services customized according to
their respective Individualized Treatment Plans. Prescribed services allowed for youth to be in
receipt of individualized face-to-face counseling twice a month. Each of the groups met
anywhere from once a week to four times each week. Family counseling, for those youth
prescribed, was held once a month. The two youth prescribed psychotropic medications had a
minimum of once a month encounters with the psychiatrist. Due to the program only running
primary service groups during the annual compliance review period, a cross-examination
between the program logbooks, video, and sign-in sheets was not applicable.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
The program has a policy and procedures addressing treatment and discharge planning. A
review of five youth records reflected each youth was assigned a treatment team upon arrival to
the program. Reviewed treatment plan documentation and the treatment team assignment form
for each reviewed record confirmed the treatment teams were comprised of the youth, program
administration, residential living unit, education, medical staff, mental health staff, substance
abuse staff, and parent/guardian. A review of five youth records reflected each was applicable
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for a substance abuse diagnosis and treatment. The program is not licensed through the
Department of Children and Families under Chapter 397 to provide substance abuse services to
adolescents; therefore, all substance abuse services were provided by the designated mental
health clinician authority (DHMCA). A review of five youth records found each contained an
executed Authority for Evaluation and Treatment (AET) form. Additionally, each youth record
contained a signed Youth Consent for Substance Abuse Treatment and Youth Consent for
Substance Abuse Treatment Records form. All reviewed mental health or substance abuse
treatment notes were documented on the program’s form and included all the information on the
Department’s Counseling/Therapy Progress Notes form. Reviewed progress notes confirmed
treatment services included individual psychotherapy and psychosocial skills training. One of
the five reviewed treatment plans in comparison with progress notes confirmed the youth
received services as stipulated on their treatment plan. One youth received all services
stipulated on their treatment plan with the exception of one missing session out of four in one
week. Three of the five treatment plans in comparison with progress notes confirmed the youth
did not receive services as stipulated on their treatment plan. Each of the three youth received
all mental health and substance abuse groups as stipulated on treatment plans; however,
reviewed documentation found youth did not receive all individual or family counseling as
prescribed. One youth received ten of fourteen individual counseling sessions and was missing
one family session; one youth received ten of fourteen individual counseling sessions and was
missing three family sessions; and one youth received none of twelve individual counseling
sessions.
Three closed records were reviewed for discharge summaries. All three discharge summaries
were completed on the Department’s Mental Health/Substance Abuse Treatment Discharge
Summary form. None of the reviewed records were applicable for the youth being released on
suicide alert/precautions. Each of the three reviewed summaries documented the services
needed for daily maintenance of the positive improvement in behavioral, emotional, and social
skills made by the youth during treatment. Each reviewed discharge summary documented the
telephone participation of the assigned juvenile probation officer (JPO) and parent/guardian
during the exit conference. Reviewed documentation verified the program mailed a copy of the
summary to each assigned JPO and the parent/guardian upon release.
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 maintains a policy and procedures to establish a delivery protocol for Mental
Health Overlay Services (MHOS). The program provides daily group therapy, bi-weekly
individual therapy, monthly family therapy, and psychiatric services. The program utilizes
Aggression Replacement Therapy (ART) as the primary service curriculum for MHOS treatment.
In addition, for youth with co-occurring substance abuse disorders, the program utilizes the
Cannabis Youth Treatment (CYT) curriculum. Other clinical groups according to the contract are
Seeking Safety, Adolescent Co-Occurring Disorders Series, and Anger Management for
Substance Abuse and Mental Health Clients. A review of five records, along with group sign-in
sheets, indicated the program provided individual, group, and/or family counseling as part of the
youth’s Individualized Treatment Plan. Therapeutic activities are provided by mental health
clinical staff seven days a week. Those youth with co-occurring substance abuse disorders
receive substance abuse services by the designated mental health clinician authority (DMHCA).
A review of the program’s contract and five youth records confirmed the program provides
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urinalysis drug testing. A review of sign-in documentation verified mental health groups are
limited to ten or fewer youth and substance abuse groups are limited to fifteen or fewer youth. A
licensed psychiatrist provides psychiatric evaluations, medication management, and participates
in treatment planning. The program also arranges for a psychologist to be available when
needed. The required contract caseload for each non-licensed clinical staff is sixteen and
therapists at the program have a twelve-youth caseload. In an interview with the designated
mental health clinician authority (DHMCA) it was indicated youth receive clinical groups four to
five days a week. Also, youth receive individual sessions two times a month and family sessions
one time a month. An interview with the executive director indicated the program provides
specialized treatment services for the youth as identified by the contract.
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 maintains a policy and procedures for the provision of psychiatric services within
the program. The program’s contracted psychiatrist is responsible for psychiatric evaluations,
consultation, medication management, and medical supportive counseling. The program
maintains an agreement with a medical doctor for psychiatric services. The reviewed license
showed it was free and clear in the State of Florida with an expiration date of January 31, 2026.
Reviewed documentation confirmed the completion of psychiatric evaluations, medication
reviews, and treatment team participation. The program does not utilize a psychiatric advanced
practice registered nurse (APRN). The psychiatrist is scheduled to be on-site bi-weekly and
provides medication evaluations and on-going monitoring of psychiatric medications. A review of
sign-in/out logs confirmed visits during the annual compliance review period were conducted as
required by the agreement. Each reviewed attendance log documented the psychiatrist signed-
in and signed-out. The psychiatrist is available for emergency consultation twenty-four hours a
day, seven days a week. Five youth records were reviewed and three were applicable for
psychiatric services. Documentation in all three applicable youth records indicated the
psychiatrist was actively managing and supervising each youth’s psychotropic medication
services. The program has a back-up psychiatrist with a clear and active license expiring on
January 31, 2026. The program utilized a back-up psychiatrist since the last annual compliance
review. An interview with the psychiatrist indicated they are responsible for completion of
entrance evaluations and provision of continuing care as needed. Additionally, the psychiatrist
indicated they are on-site every other Wednesday morning from 8:00 a.m. to 12:00 p.m.,
providing in-depth evaluations of all youth referred to mental health and providing treatment of
mental health issues, if appropriate, with regular follow-up appointments. Face-to-face or
telephonic communication with treatment team members is also facilitated. Five youth records
were reviewed, and none were applicable for youth entering the program on psychotropic
medication. Although none of the youth entered the program on psychotropic medication, a
diagnostic interview was completed on each youth within fourteen days of referral. Each youth’s
initial diagnostic psychiatric interview included history of the youth, a Mental Status Examination
and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis,
treatment recommendations, prescribed medications, and explanation of the need for
psychotropic medication. A review of the three applicable youth records indicated each youth
was prescribed psychotropic medication related to the youth’s diagnosis. Each diagnostic
interview included target symptoms, initial treatment goals, potential side effects, risks, and
benefits of taking the medication, and frequency of medication monitoring/management. A
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review of each applicable youth’s treatment plan verified the plan was consistent with the DSM-
5 diagnosis and included treatment recommendations. The initial diagnostic interview was
documented on the Department’s Clinical Psychotropic Progress Note (CPPN) form which was
clearly identified as the Initial Diagnostic Psychiatric Interview for each applicable youth. Five
youth records were reviewed, and three youth started taking psychotropic medications after
admission to the program. Each of the three applicable youth records documented youth were
seen for medication reviews by the psychiatrist at least once every thirty days. The psychiatric
evaluations were documented on the Department’s CPPN form for each youth. The
Department’s CPPN included the youth’s identifying data, diagnosis, target symptoms of each
medication, evaluation, description of effect of prescribed medication on target symptoms,
prescribed psychotropic medication including name, dosage, side effects of the medication, and
the youth’s adherence to the medication regime. The youth’s height, weight, blood pressure,
most recent serum drug levels or laboratory findings were not applicable as being needed for
each of the three CPPNs. Also, each of the three CPPNs indicated there was telephone contact
with the youth’s parent/guardian to discuss medication when necessary. The psychiatrist signed
and dated each of the three reviewed CPPN’s. The monthly monitoring of Tardive Dyskinesia
was not applicable for the reviewed youth. The program does not utilize tele-psychiatry services.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a policy and procedures regarding the implementation of a Suicide Prevention
Plan. The plan shall provide guidelines for the identification, management, and assessment of
potentially suicidal youth. The program maintains a Suicide Prevention Plan which was last
reviewed and signed by the designated mental health clinician authority (DHMCA) and the
psychiatrist on July 5, 2023. A review of the plan reflected it included identification and
assessment, staff training, suicide precautions, levels of supervision, referral, communication,
notification, documentation, immediate staff response, and a review process. The review
process for suicide attempts and mortality review included circumstances surrounding the event,
facility procedures relevant to the incident, relevant training received by involved staff, pertinent
medical and mental health services involving the victim, possible precipitating factors, and
recommendations.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors.
Any youth exhibiting suicide risk behaviors shall be placed on suicide precautions
(precautionary observation or secure observation), and a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations shall be placed on suicide precautions and receive an
Assessment of Suicide Risk.
The program maintains a Suicide Prevention Plan which outlines the methods used for suicide
precautions which include observing, monitoring, and housing youth identified as a suicide risk.
A review of five records indicated two were applicable for suicide risk. The program provided
one additional record for review. Each of the three applicable youth were identified as a suicide
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risk by self-reporting. All three youth were placed on precautionary observation status and
assessed the same day. Each Assessment of Suicide Risk (ASR) was completed on the
Department’s ASR form. The three youth’s ASRs were completed by the designated mental
health clinician authority (DMHCA). All three applicable youth were maintained on constant
supervision upon immediate completion of their ASR. Documentation verified the
parent/guardian and assigned juvenile probation officer (JPO) were notified of the youth’s
potential suicide risk. Documentation in each youth record indicated mental health staff provided
supportive services. Three applicable youth records indicated a Follow-Up ASR was completed
on the Department’s Follow-Up ASR form. Each Follow-Up ASR indicated suicide precautions
could be discontinued for all three applicable youth, and all three applicable youth were stepped
down to close supervision. Each youth’s reviewed ASR and Follow-up ASR clearly documented
the time, date, and results of a conference held with the executive director (ED) and the
licensed mental health staff prior to stepping the youth down to close supervision. Due to
Department-wide system outages, a review was unable to be completed to determine if alerts
were initiated and closed as required. A review of the program’s logbooks and assessments
indicated the administration staff provided instructions regarding suicide precaution decisions.
Documentation indicated all three youth on suicide precautions were able to participate in select
activities with other program youth in the specified safe housing areas. The program does not
utilize secure observation. The program’s camera footage is stored for thirty days. No youth
were placed on precautionary observation within the last thirty days to be able to review camera
footage and corresponding documentation. Five staff were interviewed, and all staff were able to
verbalize the necessary steps such as notifying mental health staff, searching the youth and
room for sharp objects, maintaining constant sight and sound, and documenting supervision if a
youth expresses suicidal thoughts. Each of the staff were also able to identify both locations of
the program’s suicide response kits.
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program maintains a Suicide Prevention Plan which outlines levels of supervision and the
process for recording observations of youth on suicide precautions. A review of five records
indicated two were applicable for suicide risk. The program provided one additional record for
review. Each youth record contained documentation where a Suicide Precaution Observation
Log was maintained for the duration the youth was on precautions. Youth behaviors were
documented in real time and not exceeding thirty-minute intervals for each youth. One youth
was applicable for warning sign observations and documentation did not indicate notification
was provided to the executive director and designated mental health clinician authority
(DHMCA). Two of the reviewed logs indicated review and signature by the shift supervisor and
mental health staff. One of reviewed logs indicated review and signature by the mental health
staff; however, the shift supervisor signature was not documented. The program acknowledged
the oversight, however, did not provide a reason. All three youth’s logs documented safe
housing requirements.
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3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program maintains a written Suicide Prevention Plan which outlines suicide prevention
training requirements. The program’s Suicide Prevention Plan requires six hours of annual
training which includes two hours of training in the Department’s Learning Management System
(SkillPro) and four hours of instructor-led training. A review of five pre-service training records
documented staff completed the required six hours of suicide training. A review of five in-service
training records documented two staff completed the required training; however, three staff did
not complete the required six hours of suicide training. The program has a total of two suicide
kits which are located inside a cabinet in the soft chair area and the nurse’s station. The suicide
kits are co-located with the program’s first-aid kits. The program is required to complete one
mock suicide drill for each shift at least quarterly. A review of suicide drills since the last annual
compliance review reflected the program conducted a quarterly drill on each shift as required.
Reviewed drills consistently included the use of lifesaving measures to include the use of
cardiopulmonary resuscitation (CPR), suicide kits, first-aid kits, and an automated external
defibrillator (AED). All drills were simulated, and the program youth were not utilized in the
simulated drills. The program has a practice to review drill scenarios and procedures with any
staff who were not present during a quarterly suicide drill during staff meetings.
The interviewed executive director (ED) reported, at a minimum, quarterly mock drills are
conducted for all staff which include emergency response to suicide attempts or self-inflicted
injuries. Drills include review of the location and procedures for using the suicide response kit
and knife-for-life and are documented in training files for staff. Five staff were interviewed, two
staff indicated suicide drills are conducted once each month, one staff indicated quarterly, one
staff said every few months, and one staff indicated suicide drills are conducted once each shift.
All five staff knew the location of the suicide response kits.
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 policy and procedures outlining operation procedures for crisis
intervention. The program’s Crisis Intervention Plan addresses mental health crisis intervention
services and Crisis Assessments. A review of the plan verified it included notification and alert
systems, means of referral including youth self-referral, communication, supervision,
documentation, and review.
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3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
executive director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a written Crisis Intervention Plan which addresses mental health crisis
intervention services and Crisis Assessments. The program had no youth applicable for Crisis
Assessments since the last annual compliance review.
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 policy and procedures outlining the mental health and substance
abuse procedures for youth who are believed to be an imminent danger to themselves or others
because of mental illness or substance abuse impairment. The Integrated Mental Health Crisis
Intervention and Emergency Mental Health and Substance Abuse Services Plan require youth
to receive the highest quality of care, safety, and management. The program’s Integrated
Mental Health Crisis Intervention and Emergency Mental Health and Substance Abuse Services
Plan was last signed by the designated mental health clinician authority (DMHCA) and
psychiatrist on July 5, 2023. A review of the plan validated it included immediate staff response,
notifications, communication, supervision, authorization to transport for emergency mental
health or substance abuse services, transport for emergency Baker Act, transport for
emergency Marchman Act, documentation, training, and review.
3.17 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program had two applicable youth each with a Baker Act incident since the last annual
compliance review. Upon determining the youth’s needed emergency care, the staff notified the
designated mental health clinician authority (DMHCA) and the youth were placed on
precautionary observation until an Assessment of Suicide Risk (ASR) was completed. The
program’s DMHCA completed a Mental Status Examination for each youth as part of the
Assessment of Suicide Risk. Upon completion of the assessment, the youth were sent out for
Baker Act services. For both youth, local law enforcement transported the youth to the Baker
Act stabilizing facility. Once both youth returned to the program, each youth remained on
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constant supervision until the DMHCA was able to conduct a follow-up assessment and then
was transitioned to standard supervision appropriately after conferring with the executive
director (ED). A Mental Status Examination was completed for each youth. Documentation of
the observations of the youth while on supervision was maintained with no exceptions.
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.
The program maintains a policy and procedures to address the safety planning process for each
youth. A review of five youth mental health records was conducted in reference to safety
planning. Reviewed documentation found the program has developed a program specific Safety
Plan form which identifies stimuli which included positive and negative effects on the youth. The
program’s Safety Plan form included an initial and a review planning process. The initial
planning process is initiated by the youth’s therapist within fourteen days of the youth’s
admission to the program. The Safety Plans are jointly prepared by the youth, parent/guardian
or family member, case manager, and clinical staff. The plans are reviewed and signed by all
staff involved and the youth. Thereafter, the youth’s Safety Plan is reviewed and updated every
thirty-days to include dated signatures of the youth and staff. The program’s Safety Plan form
included the youth’s warning signs, baseline behaviors as gathered from collateral contacts,
crisis recognition, jointly developed coping strategies, intervention strategies, and debriefing
preferences. All five youth Safety Plans incorporated recommendations of previous and current
clinical assessments, as required. There was a total of forty-three safety plans between each of
the five youth reviewed. All the safety plans were updated every thirty days except for one,
which was two days late. All the safety plans documented any significant behavioral or mental
health event identified by the youth’s intervention and treatment team. The youth’s Safety Plans
were maintained in the youth’s case management record and within a centralized binder within
the secure area of the program and easily accessible to all staff.
Five interviewed youth reported they contributed to the development of their Safety Plan. An
interview with five staff indicated they were aware of the process for reviewing each youth’s
safety plan and plans were reviewed weekly, monthly, or as needed. The interviewed executive
director (ED) reported youth 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.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The designated health authority (DHA) is a licensed osteopathic physician (DO). The DHA holds
an unrestricted license and meets all requirements for independent and unsupervised practice
in the State of Florida. The DHA has a license which expires March 31, 2026. The DHA has
specialty training in internal medicine. There was no indication the DHA had any disciplinary
cases and/or public complaints on record. The program does not have a physician’s assistant
(PA) or advanced practice registered nurse (APRN) employed. A review of sign-in/out logs
during the annual compliance review period confirmed the DHA was on-site at least once a
week for a minimum of two hours, with no observed issues. The contract requires the DHA to be
on-site for a minimum of two hours a visit. There was no indication the DHA had any vacations
and or scheduled absences during the annual compliance review period. The program had a
back-up medical doctor through December 2023 who held an unrestricted license and met all
requirements for independent and unsupervised practice in the State of Florida. The back-up
medical doctor’s license expired March 31, 2024. The program is in the process of obtaining a
new back-up DHA. There was no indication the program used any type of tele-medicine
services during the annual compliance review period. An interview with the DHA revealed they
are on-site every nine days. Communication with program staff regarding youth medical needs
is conducted verbally and by email. The DHA is available by text or telephone twenty-four hours
a day, seven days a week when not on-site. All off-site care findings, instructions, and
information are reviewed by DHA. On the days the DHA is not at the clinic, the staff will text the
reports to review if it is urgent; otherwise, the DHA will review documents the next time they are
in the clinic. The DHA or medical staff will reach out for coverage which will be needed on given
dates if the DHA has scheduled absences.
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 total of two licensed nurses providing on-site nursing coverage. All nurse
licensure credentials were clear and active, according to the Florida Department of Health
(DOH). All nursing staff have a current cardiopulmonary resuscitation (CPR) certification.
According to contract, the required on-site hours for nursing services include one health service
administrator for forty hours weekly, and one additional registered nurse (RN) for forty hours
weekly.
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Office of Accountability and Program Support Page 44 of 70 (Revised September 2022)
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The designated health authority (DHA) conducted an annual review of all respective treatment
facility operating procedures (FOPs). The DHA last signed and dated on September 5, 2023.
The executive director also conducted an annual review, signed, and dated treatment FOPs on
September 4, 2023. In addition, the psychiatrist completed an annual review, signed, and dated
the respective treatment FOPs on September 13, 2024. A review of nursing staff found one
nurse had not reviewed, signed, and dated a cover page on which medical FOPs were listed.
The nurse started in January 2023, and it was corrected while the annual compliance review
team was on-site. The FOPs were revised on September 1, 2023, during the year reviewed.
The newly employed healthcare staff received a comprehensive clinical orientation to the
Department’s healthcare FOPs, which was given by a registered nurse. A review of approved
treatment protocols and standing procedures confirmed they were authorized by the DHA, as
required.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
an Authorization for Evaluation and Treatment (AET) form. All five youth had a completed AET
filed within the IHCR with the word “copy” stamped, as required. All five youth AET’s had the
youth’s parent/guardian signature and there was no indication a parent/guardian refused to sign
the AET. All five AET’s were signed by a Department representative. All the AET’s were
observed to be valid. There were no cases of youth being eighteen years of age or older or in
the care of the Department of Children and Families (DCF). An interview with the nursing staff
revealed when youth turn eighteen years of age in custody or the guardianship changes for the
youth, a new AET is obtained.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
the parental/guardian notification/consent. Four of the five youth were applicable for
parental/guardian notification of over-the-counter (OTC) medications beyond those covered by
the Authority for Evaluation and Treatment (AET). In each of the four applicable youth records,
there was documentation of consent provided by the parent/guardian. Documentation was
noted within progress notes of an attempt made to contact the parent/guardian when medication
was ordered. Written notifications were sent to parent/guardian utilizing the appropriate
Department forms. Three of the five youth were applicable for taking psychotropic medications.
One youth was admitted to the program on psychotropic medication the remaining two were
prescribed psychotropic type medication after admission to the program. For each of the youth
prescribed psychotropic type medication, staff witnessed all telephone call attempts to
parent/guardian. Each of the youth on psychotropic medication, whether new, discontinued, or
significantly changed had parental/guardian verbal consent documented on page three of the
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Office of Accountability and Program Support Page 45 of 70 (Revised September 2022)
Clinical Psychotropic Progress Note (CPPN). There were no youth reviewed who were under
the care of the Department of Children and Families (DCF). All five youth had documentation
where the program verified the youth’s vaccinations within thirty days of admission. None of the
youth were applicable for requiring new vaccinations or requesting religious exemption. An
informal interview with nursing staff confirmed the program utilizes the Florida Shots website for
verification of youth vaccinations.
An interview with the nursing staff revealed parental/guardian notifications are done verbally and
in writing for treatments or medications which are added or changed by the DHA or psychiatrist,
and anything not covered by the AET form, emergencies, off-site appointments, hospitalizations,
and injuries. To ensure timely notifications, verbal notifications are written in chronological
progress notes at the time when verbal consent was obtained from the parent/guardian and the
parental/guardian written notification is generated at the same time to make sure the process is
completed. Notification attempts are started when the DHA or psychotropic order is written. For
youth illness or medical emergencies parents/guardians are notified as soon as possible by
telephone and updated information is also given as it becomes available. Vaccinations are
provided on-site if ordered or youth are sent to the Health Department. Immunization records
are obtained through Florida Shots online. Records are reviewed by a nurse upon admission
and three chart audits are due monthly. Verbal and written exemption are obtained for
immunization exemption.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
healthcare admission screening and rescreening forms. Each of the IHCRs contained a Facility
Entry Physical Health Screening (FEPHS) form, which was completed on date of admission. All
the FEPHS were completed by a registered nurse (RN). None of the FEPHS were completed by
direct care staff. Two of the five youth were applicable for a change in custody lasting greater
than twenty-four hours, whereas a FEPHS re-screening was completed for each youth upon
their return date after the change in custody. One youth had four additional rescreenings due to
home visits and the remaining youth had two additional rescreenings due to home visits.
An interview with the nursing staff revealed a newly admitted youth is usually seen within three
to four hours by nursing staff. The RN completes the admission screening. If it is completed by
direct care staff, the nurse documents on the form where it sates "reviewed by" within twenty-
four hours. The Facility Entry Physical Health screening form is required each time physical
custody changes.
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4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
youth orientation to healthcare/education services. All youth had documentation for completion
of orientation to healthcare services upon admission to the program. The youth’s orientation
included all necessary topics, and the form was signed by each youth on a separate
healthcare/education form.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
notification to the designated health authority (DHA) and/or designee. Two of the five youth
were found applicable for having a chronic condition. One additional youth record was
requested. All three youth were applicable for a known or suspected chronic condition. None of
the youth were identified as in-need of emergency care upon admission. All three youth had
documentation of a referral being sent to the DHA within twelve hours of the youth’s admission.
One youth was applicable for taking psychotropic medication upon admission. The applicable
youth admitted on psychotropic type medications had documentation of the psychiatrist being
notified. The program’s facility operating procedures indicate the DHA and/or designee will be
notified for all newly admitted youth. An interview with nursing staff revealed the DHA is notified
about a youth's chronic condition after intake is completed. The registered nurse (RN) is
responsible for the notification. The notifications are documented in chronological progress
notes and admission orders.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
the Health-Related History (HRH) form. All five reviewed youth IHCRs contained a HRH
completed within seven calendar days of admission. Each of the HRHs reviewed were
completed prior to completion of the Comprehensive Physical Assessment (CPA); as evidenced
by signature and date. All the HRHs were reviewed by the designated health authority (DHA);
this was indicated by the checkbox on the CPA. An interview with the nursing staff revealed the
DHA is notified after the admittance of a youth with chronic conditions. The RN is responsible
for making the notification and notifications are documented in the chronological progress notes
and the admission orders. The HRH is completed by the nurse upon the youth’s admission.
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Office of Accountability and Program Support Page 47 of 70 (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.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of a
Comprehensive Physical Assessment (CPA) form. All the CPAs reviewed were completed on
the Department’s CPA form, as required. The program’s facility operating procedures indicate a
new CPA will be completed regardless of if one is in the youth’s IHCR at the time of admission.
All the reviewed CPAs were completed within seven calendar days of the youth’s admission to
the program. Each of the new CPAs were completed by the designated health authority (DHA).
All five reviewed CPAs documented the correct Medical Grade. Each section of the CPA was
marked respectively with an “O” or an “X” accordingly. All five youth refused a portion of the
examination. All five of the youth IHCRs did not contain a refusal form completed on date of the
actual examination. A refusal form was signed by all youth while the annual compliance review
team was on site. Medical staff stated they would ensure to continue this practice moving
forward. All five youth had the Department’s Problem List updated, as required. All five youth
had at least one verified tuberculosis skin test (TST) documented in the IHCR. The TST were
found documented on the CPA and Infectious and Communicable Disease (ICD) forms. An
interview with the nursing staff revealed the DHA completes the CPA on a yearly basis. TST
screenings are conducted yearly or upon exposure.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
sexuality transmitted infection (STI) screenings. Three of the five youth were applicable for
further evaluation and were referred to the designated health authority (DHA). The youth had
documentation of the referral on the STI form. In each of the cases, testing was ordered and
performed. All five youth had the results from testing documented on the Infectious and
Communicable Diseases (ICD) form and results were filed in the lab section of the IHCR. None
of the youth were rescreened for STIs.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for human
immunodeficiency virus (HIV) testing. All five youth were offered HIV counseling, testing, and/or
evaluation. Three of the five youth consented for HIV testing and documented forms were found
in their IHCRs. The remaining two youth had documented refusal forms found in the IHCR. All
three applicable youth had HIV results filed confidentially in a sealed envelope marked
“confidential.” The envelope is not signed by DHA; however, a log is maintained where the DHA
acknowledges their review of results. Pursuant to Florida Statute, the program has a policy and
procedures which address HIV testing results which are only disclosed to youth and statutorily
identified entities. All HIV pre and post-test counseling services are provided by a local
foundation, which is contracted by the county health department.
An interview with the nursing staff revealed youth who are sexually active are screened for STIs.
If screening indicates further evaluation, the urine STI screening is sent to the lab. STI
screenings, evaluations, referrals, and testing are documented on the ICD forms, chronological
progress notes, and lab results. HIV results are placed in a confidential marked envelope which
the youth get on discharge. The local foundation comes to the program quarterly for HIV
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Office of Accountability and Program Support Page 48 of 70 (Revised September 2022)
counseling and testing services. The youth are informed when a representative is coming, and a
consent is signed by the youth to consent to the testing or to decline the testing.
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.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
the sick call process. Four out of the five youth records were applicable for sick call reviews.
None of the reviewed youth presented with any similar sick call complaints three or more times
within a two-week period. Twenty sick calls from the four applicable youth records were
reviewed; the individual youth completed a Sick Call Request form for each instance. In each of
the sick calls, the nurse completed the Sick Call Request form. None of the sick calls reviewed
were completed by a licensed practical nurse (LPN). The sick calls were each found filed in the
IHCR in reverse chronological order. None of youth had been in restricted housing during the
annual compliance review period. The reviewed sick call forms were each documented in
accordance with Florida Administrative Code. Each sick call reviewed was found documented
on the program’s Sick Call Index. The sick calls were documented on the program’s Sick Call
Referral Log. The dates listed on the sick call index corresponded to the completed sick call
form located in each IHCR.
A review of the daily schedule, along with posted schedule, and nurses interview, confirmed sick
call was conducted as contractually required. Sick call hours were posted outside the medical
clinic. Sick call is seven days a week at 7:00 a.m. and 3:00 p.m. or as needed. An informal
interview with the nurse revealed the sick call box is checked in the morning, at noon, and
evening. A review of sick call documentation supported only licensed nurses conduct sick call.
The program has a policy and procedures, which allow for a shift supervisor to review any sick
call request, when there are no licensed healthcare staff on-site. The review of sick call occurs
as soon as possible and within four hours after the request is submitted. Observations verified
sick call forms were in the common room area of the program. The medical clinic has an exam
table and equipment to perform sick call if necessary. A sick call request was made by a youth
and subsequently observed during the annual compliance review week. The youth was escorted
to medical by administration staff. The healthcare staff identified themself and upon review of
the sick call, articulated the purpose for the youth’s visit. The youth was seen at the medical
window with no other youth present. The youth was examined by a licensed healthcare staff to
include completion of the youth’s vitals, but they never entered the medical office. The
administration staff was observed next to youth.
Five youth were interviewed. All five youth stated they see the nurse within one day of making a
sick call request. Five staff were interviewed. All five staff stated sick calls are reviewed and
conducted by the nurse. The nursing staff confirmed after hours, the supervisor must address
sick calls within four hours. The registered nurse (RN) routinely conducts sick calls. The
designated health authority (DHA) can conduct sick call if sick call is scheduled when they are
on-site. If a youth presents with a similar sick call complaint three times within three days, the
youth is referred to the DHA. The program has DHA approved treatment protocols and does not
have restricted housing.
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Office of Accountability and Program Support Page 49 of 70 (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.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
an episodic, first-aid, and/or emergency care situation. All five youth reviewed were applicable
for completion of episodic, first-aid, and/or emergency care. Each of the five medical incidents
were conducted by licensed healthcare staff. The healthcare staff documented each case in
subjective, objective, assessment, and plan (SOAP) format. There were no cases of episodic,
first-aid, and/or emergency care having been provided by non-healthcare staff. The program’s
episodic and emergency care procedures were reviewed with no issues. There is a total of
eleven first-aid kits, two of which are utilized for transportation. First-aid kits are in the medical
office, classrooms, laundry room, common area, and director of operations office. On-site
healthcare staff confirmed a monthly review of first aid kits is conducted to ensure contents are
maintained and stored in accordance with guidelines to prevent expiration and replenished as
needed. A review of three first-aid kits documented kits are fully stocked with designated health
authority (DHA)-approved contents. Additionally, a review of monthly tracking sheets
demonstrated on-going monitoring of first-aid kits occurs as required.
The program has two automated external defibrillators (AEDs), one is kept in medical office and
the other in hallway outside the administration offices. The operating procedures for the AED
are located with the AED. On-site nursing checks the AED to ensure batteries and pads are
operable monthly. The medical staff conducted a self-test of both AEDs with no issues. The
AED batteries are due to expire September 2025 and were last changed June 2022. The AED
pads are due to expire January 2026 and were last changed December 2023.
A review of the program’s episodic, first-aid, and or emergency care drill documentation
reflected drills were completed on each of the three shifts. The drills were completed monthly
during the annual compliance review period and were all documented and maintained the
medical drill binder. The drills consisted of unannounced type drills. The May 2024 drill
conducted was the only drill which included the administration of cardiopulmonary resuscitation
(CPR) techniques. In addition, each of the reviewed drills included the initiation of emergency
procedures and addressed the application of first-aid practices. A list of emergency numbers
was found in the medical office, accessible to all staff and inaccessible to youth. Six direct care
staff certificates were provided verifying staff were appropriately trained on the administration of
the epinephrine auto-injector. Training is conducted by the director of nurses as needed. A total
of ten staff training records documented the completion of episodic, first-aid, and emergency
care training.
Five staff were interviewed. Four of the five staff stated they are personally allowed to call 9-1-1
if the youth have a medical emergency. The remaining staff stated they did not know. Five youth
were interviewed. All five youth reported they can see a doctor or dentist if needed. An interview
with the nursing staff revealed first-aid kits are in medical, recreation room, laundry room, and
classrooms. Transportation kits are housed in medical. On-site episodic care is documented on
episodic care sheets and tracked in the episodic care log. The non-healthcare staff document
on the Department’s Report of On-site Health Care by Non-Health Care Staff form. Youth who
are sent off-site for emergency medical care are tracked on the off-site log. Emergency drills
with CPR are held for each shift on a yearly basis. Emergency numbers, to include poison
control, are not accessible by youth. Training on different emergency topics are conducted
monthly with staff.
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Office of Accountability and Program Support Page 50 of 70 (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.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
off-site care referrals. All five IHCRs reviewed were applicable and required some type of off-
site care. For each of the off-site care instances provided, a Summary of Off-Site Care
Consultation Report form was found filed in the youth’s IHCR. The off-site care cases were each
found documented on the Episodic Care Log. Each case had documentation of
parental/guardian notification efforts. Only six of the nineteen off-site cases were applicable for
discharge documents. For each case, the designated health authority (DHA) reviewed and
signed the off-site care findings. Four of the five youth required follow-up appointments. Three
of the four applicable youth received the appropriate follow-up care. The remaining youth
refused the follow-up care and signed the refusal of treatment form which was documented in
youth IHCRs.
An interview with nursing staff revealed nursing staff are notified if a youth is sent off-site for any
reason. The nurse has an off-site tracking sheet and an off-site packet which travels with the
youth. Hospital orders are followed by notifying the DHA and obtaining orders. The orders are
added to treatment or Medication Administration Records (MARs). The DHA reviews the sheets
and are signed in the medical record. Nursing staff track follow-up testing, referrals, and
appointments by calendar. The appointments are added along with referral appointments,
follow-up testing is ordered, and a sheet is printed with the testing time/date and the test to be
done, all of which is put on the calendar.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
chronic condition periodic evaluations. Two of the five youth were found applicable for having a
chronic condition. Two additional youth records were requested. A total of four youth were
reviewed for having a chronic condition. Three of the four youth were applicable and identified
on the Facility Entry Physical Health Screening upon admission. The remaining one youth was
later identified with a chronic condition. None of the youth had been identified as having a
communicable disease. All five youth were taking medication on an on-going basis. Four of the
five youth were taking medication for a chronic condition. The remaining youth was taking
psychotropic medication. Three of the five youth were undergoing treatment for a physical
health condition.
Two of the five youth were classified with a Medical Grade between two and four. The remaining
three youth were classified as a five due to psychotropic medication; however, one was lowered
to a Medical Grade one. All applicable youth were placed on the chronic illness list.
The four youth applicable for a chronic condition required a periodic evaluation every ninety
days. The remaining youth was on psychotropic medication and received a periodic evaluation
by the psychiatrist every thirty days. Three of the four applicable youth received a periodic
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Office of Accountability and Program Support Page 51 of 70 (Revised September 2022)
evaluation at least every ninety-days as required. The remaining youth was due for their first
periodic evaluation on June 25, 2024, and it was not completed; however, an appointment is
scheduled for July 2, 2024. There was no indication of any youth requiring anti-Tuberculosis
medication. All five youth had periodic evaluations conducted prior to renewing a prescription
medication which expired. None of the youth required an evaluation to be conducted off-site.
Four out of five youth had the Department’s Problem List updated in accordance with Florida
Administrative Code. The one remaining youth did not have the Problem List updated as
required.
An interview with the executive director revealed, any youth diagnosed with a chronic illness at
the time of admission will be seen by the designated health authority (DHA) at a minimum of
three-month intervals, and no less than every thirty days when prescribed medications. An
interview with the DHA revealed, youth with chronic conditions are evaluated every ninety days
if well controlled; otherwise, every one to two weeks until the condition is controlled. Nursing
staff perform routine chart reviews to ensure those in the chronic clinic are evaluated every
ninety days. An interview with the nursing staff revealed youth with chronic conditions are seen
in the chronic care clinic with the DHA as the DHA orders.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
medication management. Two of the five youth were found applicable for being admitted to the
program on medication. One additional record was requested. All three youth had a completed
Facility Entry Physical Health Screening (FEPHS) form. In addition, a prescription verification
was included in each of the youth’s progress notes and the prescription medication verification
checklist. The designated health authority (DHA) and psychiatrist were contacted to resume
specified medications prescribed prior to admission. During the annual compliance review
period, four youth from the sample were prescribed medications; however, one was no longer
taking medication to make a total of three youth taking medications. All prescribed medications
for each of the three applicable youth had a current, valid order, and were administered
according to a valid prescription. All medications prescribed had a practitioner order form
completed by the DHA, as documented on the practitioner order form. There were no youth
observed as having been in restricted housing. Four of the youth were applicable for being
prescribed either over-the-counter (OTC) medication and/or psychotropic medications. The OTC
medications not listed on Authority for Evaluation and Treatment (AET) form were administered
according to approved protocols or practitioner’s order unless the parent/guardian prohibited the
administration of OTC medications. The program documents all medication administrations on
pre-printed pharmacy Medication Administration Records (MARs), which included all information
required by Florida Administrative Code. There were no instances of trained non-healthcare
staff administering medications. Two youth had missed staff initials on MAR medication
administration entries. The first youth had three missed registered nurse (RN) initials and the
other youth had one RN initial missed, for a total of four RN initials missed. There were no other
undocumented explanations for lapses or errors in medication administration. Each youth
reviewed had weekly side-effect monitoring documented on the MAR. None of the youth were
applicable for refusal of medication. Each of the four youth MARs reviewed for the annual
compliance review period had all required elements. None of the reviewed youth required
parenteral medication. One youth reviewed was applicable for having prescribed psychotropic
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Office of Accountability and Program Support Page 52 of 70 (Revised September 2022)
medication upon admission to the program. There was documentation in the IHCR where the
psychiatrist was notified of the youth’s admission. The youth was in receipt of an initial
diagnostic psychiatric interview within fourteen days of admission. There were two youth during
the annual compliance review period who were prescribed psychotropic medication after
admission. Each of these youth had an initial diagnostic psychiatric interview conducted. All
three youth prescribed psychotropic medications were in receipt of medication monitoring every
thirty days as required. There were no standing orders for psychotropic medications observed.
There was no indication of any emergency treatment orders for psychotropic medications
observed. There was no indication of any pro re nata (PRN) orders for psychotropic medications
observed.
A medication administration pass was observed during the annual compliance review week. The
youth was escorted to the medical clinic by direct care staff. The medical staff identified
themself and the purpose for the youth’s visit. In addition, the medical staff asked for the youth
to identify themself by asking for their name, date of birth, and allergies. The medical staff also
prepared the medications and reviewed with the youth any allergies and alerts. The Six Rights
of Medication Administration were observed to have been conducted by the medical staff
administering the medication. The medical staff gave the youth water and medication. The youth
took the medication along with the water and swallowed the pill. The medical staff had the youth
open their mouth and did a visual check. The medication pass was documented on the youth’s
MAR. There is a list of program staff who are trained in administering medication to youth
located in a binder.
Five youth were interviewed. Four out of five youth stated they receive medication from the
nurse. The remaining youth stated they do not receive medication but knows the nurse
distributes medication. Three of the youth were able to explain the process for medication
distribution. One youth did not answer, and the remaining youth stated they do not take
medication. Five staff were interviewed. All five staff stated the nurse dispenses medication to
youth. Additionally, two staff stated the trained staff are allowed to dispense medication to
youth. An interview with nursing revealed allergies and medications are confirmed with the
parent/guardian and documented in the chronological progress notes and written confirmation is
also mailed. The facility utilizes the standard Department MAR. The non-healthcare staff provide
medications, and the director of nursing (DON) does the medication training for OTC
medications at the program. Nurses give the prescription medications. Medication pass is 7:00
a.m. and 3:00 p.m. The program has a psychiatrist who visits twice a month and does
medication management.
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 equipment in the medical clinic classified as sharps were observed to be secured and
inventoried utilizing a routine weekly perpetual inventory. Three sharps were observed and
counted. The final count listed on the program's inventory matched the actual count observed.
All observed medications were identified and secured in a locked area designated for storage of
medications. The medication cart was observed to be clean and organized. Three over-the-
counter (OTC) medications were observed and counted. The final count listed on the program’s
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Office of Accountability and Program Support Page 53 of 70 (Revised September 2022)
inventory matched the actual count observed. The program did not have narcotics or controlled
substances on-site at the time of the annual compliance review. An informal interview with the
nurse revealed a shift-to-shift inventory is conducted. An observation of where the controlled
medication would be stored found it would be separate from all other medications and behind
two locks as required. The program did not have medications which required refrigeration;
however, an observation of the refrigerator was made and revealed it was locked, only for
medication storage, and inaccessible to youth. All medications were found stored in a separate,
secured area, inaccessible to youth. Medications are destroyed by the pharmacist and one
nurse, using the RX destroyer solution. The nurse will document in the binder those medications
being destroyed. There is a list of five program staff who are trained in administering medication
to youth in a binder. Training is delivered by the director of nurses. An informal interview with
the registered nurse (RN) was conducted to ascertain practices for reporting medication
inventory discrepancies. The RN will check the count, if there is an issue with the count and/or
inventory exists, the executive director will be immediately notified, a call to the Department’s
Central Communications Center (CCC) will be conducted, and documentation will be provided
concerning the discrepancy.
An interview with nursing staff revealed the program disposes of medication using red sharp
containers and a charcoal pill receptacle with contracted pick up. Controlled substances such as
narcotics are secured in the medication cart with a locked narcotics box on it. The program has
an agreement with a consultant pharmacist for monthly inspections, reports, and
recommendations. The program maintains a copy of the pharmacy consultant license on-site
and confirmed them to be a consultant pharmacist.
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’s infection control procedures include prevention, containment, treatment, and
reporting requirements related to infectious diseases, according to federal regulations and the
Centers for Disease Control and Prevention (CDC) and Occupational Safety and Health
Administration (OSHA) guidelines. The infection control procedures were reviewed last by the
designated health authority (DHA) August 1, 2023, by the executive director (ED) August 1,
2023, by the psychiatrist August 6, 2023, by the director of operations August 1, 2023, and five
registered nurses, of which two were still employed at the time of the annual compliance review.
The infection control practices included all required elements. Hepatitis B immunizations and
protective equipment are available to all staff. There were no instances in which the local county
health department, CDC, and/or the Department’s Central Communications Center (CCC) had
to be notified for an infectious disease during the annual compliance review period. The
program has an exposure control plan. The written exposure control plan included all required
elements, in addition it addresses a process for post-needle stick exposure. The exposure
control plan is available to all staff and located in the medical clinic and ED’s office. The plan
was last reviewed and signed annually by the ED August 1, 2023, and DHA August 1, 2023.
The ED has an established separate file maintained for any youth or staff who may have
experienced a facility and/or occupational exposure.
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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.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
Supervision of youth by staff was observed each day of the annual compliance review week.
The staff to youth supervision ratio requirement is one to eight for daytime activities and one to
twelve during night/sleep times. Youth were observed each day in line movements, classes,
groups, recreation activities, and transports on the base for noon time meals. Staff to youth
supervision was observed within the required ratio. Positive interactions between youth and staff
were observed. A total of three staff were randomly selected and were able to state how many
youth were under their direct supervision at the time of the questioning. The program has a
policy and procedures which indicates 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, and consistently applying the
program’s behavior management system (BMS). Program staff must always account for youth
whereabouts under their supervision. The program has a daily schedule posted in program
areas. Five interviewed staff were able to summarize the process in the event a youth count
cannot be reconciled.
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 uses the Personal Growth Model as their behavior management system (BMS).
The program utilizes the same BMS as the previous year. The program’s BMS was developed
by all appropriate parties, including education. The program’s policy and procedures regarding
their BMS includes protocol where staff are provided feedback regarding their implementation of
the BMS. The program also has a classroom BMS which outlines educator responsibilities,
goals, rules, and expectations, as well as expectations from youth. Correspondence was
received revealing the BMS plan for education was discussed with all instructors along with
provider’s corporate personnel. The program also trains all education staff in the jointly
combined BMS plan. Each of the five reviewed case management records confirmed each
youth received BMS training as part of their orientation to the program. Position descriptions for
direct care personnel and case management staff both revealed BMS implementation as part of
their expectations for their position responsibilities. A printout of training completed for all
program staff with regards to the Personal Growth Model was provided indicating all staff were
trained in the BMS during the annual compliance review period. The program’s BMS is
comprised of a level and rank system. The BMS rank system was observed to be posted visibly
in the large dayroom areas. Rules governing positive and negative consequences were also
posted in the youth handbook, which is provided to each youth upon orientation. The program’s
BMS includes all required information and does not promote group punishment, discipline by
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youth on other youth, increasing a youth’s length of stay, or promoting group discipline. A review
of five case management records found evidence each contained point sheets for each youth
confirming the program’s practice regarding the BMS. Positive and negative consequences are
at a four to one ratio. During the annual compliance review week, staff were observed
maintaining the youth’s BMS binder with them and completing point sheets. Youth earn points to
increase their level and privileges while in the program. The program provides various rewards
and incentives such as the token store, off campus activities, and extra telephone call time. The
executive director was interviewed and described the program’s BMS as the provider having
established a BMS which provides both rewards and privileges for positive behaviors and
consequences for negative behavior. Performance and hard work should precede any rewards.
The program believes in recognizing positive behavior and actions, while isolating and
counseling youth exhibiting negative behavior. The BMS includes a point card system, which
awards points to youth based upon their level of behavior. Negative points are never used;
however, youth modeling appropriate behavior receive higher points than those youth who are
not. There is also a rank system, which is linked directly to the point system, through which each
youth must advance to reach graduation from the program. There are established requirements
to obtain each rank and youth must make application for their advanced rank and appear before
the multidisciplinary treatment team members who determine the youth’s eligibility for rank.
Consequences for inappropriate behavior are explained to the youth during orientation. Youth
rules of conduct are signed by the youth upon entry, posted in the dorms, and found in the youth
handbook. Youth are reminded of the various consequences for their actions daily. Through this
system, youth learn to accept responsibility of their actions and take ownership of their behavior.
Discipline is handled on an individual basis and will not resort to group punishment. All major
disciplinary actions will be reviewed and discussed in the affected youth multidisciplinary
treatment team meeting. Five youth were interviewed regarding the program’s BMS. Youth gave
examples of punishments and consequences used as well as rewards used in the program.
Each youth was able to summarize the point system. All five youth reported youth are not
authorized to punish other youth. All five stated staff use rewards consistently. All five report the
BMS is a good system. None of the five interviewed youth reported ever being sent to their
room for punishment. Five interviewed staff all confirmed they received training in the program’s
BMS. All were able to summarize the BMS process, and name examples of rewards youth can
earn. Three of five staff reported nothing can be taken from a youth because of a consequence.
One staff reported early bedtime can be taken, and one staff reported a youth’s level may be
taken because of a consequence. Staff reported youth are informed of the consequences of
their behaviors and can explain their behavior. Supervisors provide feedback on their
implementation of the BMS through avenues such as shift briefings, in private, and supervision
meetings.
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5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, provide constructive discipline and a system of positive and negative consequences
to encourage youth to meet expectations for behavior, provide opportunities for positive
reinforcement and recognition for accomplishments and positive behaviors, promote dialogue
and peaceful conflict resolution, and minimize separation of youth from the general
population.
Supervisors shall monitor staff implementation of the BMS and ensure the use of rewards and
consequences are administered fairly and consistently in application among all staff.
The program does not utilize room restriction; therefore, this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Limited 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 forty-two cameras used to monitor video of various program areas.
All cameras were reportedly functioning as required during the time of the annual compliance
review. Video recordings have a storage capability for up to thirty-days. Five interviewed staff all
confirmed checks are done at ten-minute increments of youth during sleep hours. The program
structure has one main living area. Dorm rooms have no doors on them. The staff to youth ratio
is established at one to twelve during sleep times. A review of nine separate dates and times, of
approximately thirty-minutes each, was conducted to confirm the practice of staff ten-minute
observation check completion. There were two exceptions noted. One which revealed a
seventeen-minute gap in checks on the morning of June 19, 2024, from the period of 4:18 a.m.
until 4:35 a.m. Also, there was a thirty-three-minute gap with no checks completed on the
morning of June 26, 2024, between the time of 3:21 a.m. and 3:54 a.m. These were both
completed and documented by the same staff member. For both exceptions, the ten-minute
observation check sheets were reviewed and found staff documented the checks were done in
ten-minute increments, thus resulting in falsification of the checks being done. The information
was presented to the program administration who notified the Department’s Central
Communication Center (CCC) and a report was generated. In addition, the program provided
documentation of a written reprimand given to the staff member who falsified the
documentation. Observation sheets for the remaining seven examples were observed and
found no major issues identified. In addition, a sample of ten-minute observation logs for the
annual compliance review period was conducted. The sample size included one thirty-minute
increment from each shift each month of the annual compliance review period. No major issues
were identified during the sample size review. Checks are documented by staff initialing and
indicating the time the check was completed.
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5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program has a policy and procedures as well as Continuity of Operations Plan (COOP)
which address census, counts, and tracking of youth. The program’s policy indicates staff are to
document significant program activities. Observations were made of counts of youth being
conducted during the annual compliance review week. A review of logbooks for one day each
month of the annual compliance review period was done and found counts were documented at
the beginning of each shift, after outdoor activities, during youth movements, when youth were
temporarily away from the program, as well as total daily census counts. In addition, the
program documents room searches and drill information. Five interviewed staff were able to
give examples of when emergency counts were conducted, such as incidents of fighting, when
a key is lost, or when a youth may be missing. All five staff were able to give the accurate count
of the program’s total youth census. All five staff reported youth counts are conducted at every
youth movement.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains one main logbook which captures daily movement and activities. The
shift supervisor or designee are primarily responsible for maintaining the logbook in their
possession throughout the shift. A review of three randomly selected full days for each month of
the annual compliance review period was conducted. The logbook review revealed entries were
made with ink and no erasures or white-out areas were found. Pages were numbered and not
observed as ripped out. Errors were observed as marked through with a single line and initialed
by staff. Some entries were observed written over by the staff entering the information. A review
of activities documented found recreation times were conducted as scheduled. Education
classes were conducted as scheduled with some noted exceptions. On three days classes were
documented as ending several minutes early. On one day it was documented youth were thirty
minutes late arriving to class. Logbooks were documented as reviewed by incoming staff.
Logbooks documented transports, room and area searches, youth movements, emergency
situations and drills, and special instructions for monitoring youth. In addition, the program also
utilizes a shift report to summarize the youth census and special incidents and events. A review
of shift reports revealed the incoming staff sign and date the reports for the previous shift to
document they were briefed about its contents. Copies of the shift reports were maintained in
the common area of the program.
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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 control, key assignment and
usage, storage, procedures for missing/lost/broken keys, and inventory of keys utilized at the
facility. Visitor keys were observed taken up by staff and replaced with a numbered chit. Visitor
keys are kept in a separate lock box located in the foyer area of the program. Upon arrival for
shift, direct care staff turn in their personal keys to the shift supervisor who secures them in a
locked storage box and replaces them with their assigned staff keys. The staff keys issued are
notated, along with the time in/out, on the Key Log. The Key Log was observed which confirmed
the program’s practice. The staff keys are kept secured in a locked box in a secured closet of
the administration hallway. The executive director was interviewed and stated permanent key
assignment is limited to the executive director, business manager, director of operations, and
maintenance staff. Restricted keys include any keys not assigned for the approved staff
member, such as the therapist and case management keys, supervisor, administration, and
medical staff keys. The executive director reported in the event a key is damaged, the program
will contact a locksmith to replace the key. A review of reports to the Department’s Central
Communications Center (CCC) found no documentation of missing or lost keys for the annual
compliance review period. Staff keys were observed to be affixed with an engraved chit on the
tamper resistant key ring. The engraving indicated the number of keys and key assignment
number. Some engravings appeared worn and needed to be redone. A sampling of five key
rings was observed and compared with the inventory. All five were notated on the inventory
form. One key, located hanging in the storage box, was broken and taken up by the
administration. Three staff were randomly selected and asked to present their program assigned
keys to compare with the Key Log inventory. All three staff were aware of the function of each
key they possessed. The key number matched the rings singed out in each of the three selected
for review. Five interviewed staff were each able to summarize the program’s key control
process.
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5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items.
A program shall delineate items and materials considered contraband when found in the
possession of youth, the list must include: sharps, escape paraphernalia, tobacco products,
lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food or
clothing, any intoxicating beverage or any beverage which causes or may cause an
intoxicating effect, any controlled substance, any prescription or non-prescription drug which
has a hypnotic, stimulating, or depressing effect, any firearm or weapon of any kind or any
explosive substance, non-facility issued electronic equipment or devices to include
smartwatches, metals, personal non-facility issued cellular devices, unauthorized currency or
coin(s), and non-facility issued keys. The program shall provide youth with the list of
contraband items and materials and inform the youth of the consequences if found with
contraband. The program shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, and both staff and youth.
The program shall document the confiscation of any illegal contraband and the manner of
disposition. The program shall keep a copy of the documentation in the youth’s case record. If
a confiscated item is not illegal or prohibited, the program director or designee has the
discretion to discard of the item, return it to its original owner, mail it to the youth's home, or
return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a policy and procedures which address contraband and searches for
contraband throughout the program. The program’s policy addresses any staff who is found in
possession of contraband will be subject to disciplinary action up to and including dismissal. The
program clearly delineates items considered contraband to include all required elements. A
review of thirty-two staff records revealed thirty staff have a signed contraband attestation
included. Two staff did not have this documentation, as they have not yet onboarded, according
to program administration. The program’s contraband procedures include search procedures for
program areas, facility grounds, physical searches of youth and staff, and searches of incoming
and outgoing mail in presence of youth. A review of reports to the Department’s Central
Communications Center (CCC) for the annual compliance review period found no
documentation of illegal contraband collected, which required to be turned over to law
enforcement. The program provided documentation of searches completed. The program
maintains a binder which includes all Room and Common Area Search forms. According to the
director of operations, these searches are conducted on each shift. Three random rooms are
selected for search on each shift. Documentation of these forms confirmed the program’s
practice. Non-illegal contraband was documented as being disposed of as required. Five youth
interviews confirmed youth are searched at numerous times throughout the program day, such
as after outdoor activities, when returning from off-campus activities, after meals, and anytime
they are coming out of their rooms. Five staff were interviewed and confirmed room searches for
contraband are done daily. The executive director was interviewed and stated the program
maintains documentation to verify searches are conducted as necessary to control contraband
or to ensure safety. The program maintains documentation when any item or material is
confiscated from a youth, the reasons for the confiscation and the manner of disposition. This
documentation will be in writing, and a copy of the documentation is filed in the contraband log.
At the discretion of the director of operations, contraband or other material which is not illegal is
either discarded, returned to its original owner, mailed to the youth's home, or stored and
returned to the youth upon release. In all instances involving the confiscation of contraband,
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which is illegal, the confiscated items are turned over to authorities and a request will be made
for a copy of the criminal report affidavit. The program documents searches in the facility
logbook.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
Searches of youth, staff, and visitors were observed during the annual compliance review week.
Youth were observed being pat-down searched after transports and prior to all youth movement
from one location to another. Searches were conducted by staff of the same gender as the
youth. Youth were observed being treated with dignity and respect. Prior to entering the facility,
all staff and visitors were searched using a frisk search as well as using a hand-held metal
detecting device. Staff and visitors were asked to remove their shoes as well. Visitor and staff
keys were collected prior to allowing entrance to the program areas. Five youth interviews
confirmed youth are searched at numerous times throughout the program day, such as after
outdoor activities, when returning from off-campus activities, after meals, and anytime coming
out of their rooms. Five interviewed staff all reported searches of youth are done prior to any
youth movement occurring.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has a total of two vehicles used to transport youth off program grounds. Each of
the vehicles were inspected and found to have an annual safety inspection and maintenance
records documented. Both have all safety equipment, such as an approved fire extinguisher,
seatbelt cutter, window punch, and appropriate number of seatbelts. Each has an approved
first-aid kit, which is stored inside the program, and checked out prior to transporting the youth.
Each program vehicle was secured when not in use. A random check of five personal vehicles
was conducted in the program’s parking lot area. Each was found to be secured as required.
Five interviewed staff reported youth are secured using only seatbelts during transports. Five
interviewed youth also all reported they use seatbelts during transports.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a policy and procedures which address the transportation of youth. The ratio
of staff to youth during transportation is required to be at a minimum of one staff to every five
youth. A transport was observed during the annual compliance review week which revealed
staff performing searches of the vehicles and ensuring youth wore seatbelts during the
transportation process. The ratio requirement was observed in compliance along with the staff
including at least one staff of the same gender as the youth. The program’s business manager
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was interviewed and stated all staff operating the transport vehicles have a valid driver license.
The business manager utilizes the Samba Safety system online which monitors all staff driver
records and alerts the program in the event a driving infraction occurs, making the staff ineligible
to use the transport vehicles. The list of valid and invalid drivers was observed. A sample of five
random staff permitted to operate transport vehicles was selected and found each had a valid
driver’s license. Five interviewed youth reported never witnessing anyone place contraband in a
transport vehicle. All five reported they felt staff were operating vehicles safely during transports.
All five interviewed staff reported youth are to use seatbelts during transports. Four of five staff
reported a duty telephone is issued during transports. One staff reported they are issued a
hand-held radio. All five interviewed staff gave examples of safety equipment in transport
vehicles to include items such as first-aid kits, window punch, and a fire extinguisher. None of
the five staff stated staff can use personal vehicles to transport youth. All five stated transport
vehicles are searched prior to use. Four of five gave the accurate staff to youth ratio when
asked. One stated the transport ratio was one to eight. Four of five summarized the emergency
response process during transports. One staff did not respond to the question.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a policy and procedures outlining the weekly safety and security audit
inspection process. The program’s maintenance staff maintains the program’s Preventive
Maintenance Checklist which details inspections of all program areas for proper functioning. The
director of operations and maintenance staff person are primarily responsible for completing the
weekly security audits and safety inspections. The documentation is captured using the
Department’s Facility Security Audit and Safety Inspection form. These forms are done weekly.
A review of this documentation was done 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. Contact was made by telephone to 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 consistently and responds to any actions needed.
The program also had no outstanding deficiencies at the time of the annual compliance review
week. There were no exceptions identified, as confirmed with the Department’s safety and
security specialist with the Office of Residential Services. The executive director was
interviewed and stated the program shall conduct weekly safety and security audits. The
findings of the weekly audits shall be electronically sent to the Department’s regional office
designee. The program shall designate a responsible party such as the director of operations,
compliance specialist, or executive director to conduct the weekly audit, electronically send the
weekly audit, and implement corrective actions if warranted.
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 address tool inventory and management of
tools used at the program. The policy includes supervision requirements of youth using tools to
be at a minimum ratio of one staff to every five youth. All tools are inventoried daily by the
maintenance staff person. Sign in and out forms are used for all tools used for maintenance
work as well as Class B tools used for standard cleaning. The program’s policy prohibits
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machetes, bowie knives, or other long bladed knives. Procedures for missing/lost tools are
addressed in the policy which includes immediate notification to the shift supervisor or
administrative staff, securing of youth, and maintaining continuous visuals of youth while
investigating the missing item. An interview with the maintenance staff revealed there have
been no instances of missing or broken tools during the annual compliance review period.
Maintenance tools were observed to be maintained in the secured garage area, located outside
the main facility. Ten percent of all maintenance tools, twenty-eight total, were reviewed, which
found all were secured, had markings for easy identification, and were accurate and included on
the maintenance tool inventory form provided. Class B tools, to include mops and brooms, were
in the Class B tool shed, also located outside the facility main building. The shed was secured
with a padlock and inaccessible to youth. The inventory form included all items present but had
two additional dust pans and six broom head replacements not addressed on the Class B
inventory form. The program’s maintenance staff corrected the inventory form to include these
items. All tools are inventoried daily by the maintenance staff person. Sign in and out forms are
used for all tools used for maintenance work as well as Class B tools used for standard
cleaning. All items were found to be secured when not in use.
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 address tool inventory and management of
tools used at the program. The policy includes supervision requirements of youth using tools to
be at a minimum ratio of one staff to every five youth. The policy includes supervision
requirements, issuance of tools to youth and staff, to include a determination of youth risk to self
and others, ratio requirements, and requirements for ratio of one to three during any disciplinary
work projects when applicable. No youth were able to be observed using any tools during the
annual compliance review week. Training for Class B tool usage for youth was observed to be
documented and provided within the youth handbook. Each of the five reviewed youth case
management records determined each received a copy of the youth handbook during
orientation to the program. Each of the five records also included evidence of a completed and
updated risk assessment prior to the use of any tools. Training documentation was provided for
youth who have been trained to utilize certain designated lawn equipment. Three of five
interviewed youth reported they have used mops and brooms in the program. One stated they
have used a scrub brush. One youth also commented staff provide supervision when cleaning.
One youth stated youth can use the blower if they pass a test to use certain tools. Four of five
interviewed staff reported youth use mops and brooms. Staff also responded stating lawn
equipment can also be used after youth are certified and trained.
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 addressing guidelines for outside vendors and
contractors which include information regarding tool control and restrictions within the program
grounds. The program uses the Contract Tool Inventory form. The Contractors sign and date
the form, which is witnessed by the program maintenance staff or designee. The form lists tools
brought in and checked off showing they were taken back out of the facility after project
completion. Guidelines of the repair/external workers included tools checked upon arrival and
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departure, restrictions in the facility, restricting youth from the work area, and missing tool
follow-up procedures. The program’s policy and procedures address personal cellular
telephones and electronic devices capable of taking pictures and recording as prohibited in the
program areas. A total of four invoices were provided by the program’s business manager which
revealed each invoice matched the sign-in/out date for the corresponding visitor log, as well as
the corresponding Contract Tool Inventory Verification form.
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 operates on three primary shifts. Drill documentation for all fire drills and
Continuity of Operations Plan (COOP) drills were received and reviewed for the annual
compliance review period. As a result, the program provided documentation of drills completed
on each shift monthly as required. Drill documentation included the type of drill, date and time, a
list of participants, brief scenario, and findings and recommendations. Fire egress routes and
lighted exit signs were observed to be posted throughout areas of the program structure. A total
of five fire extinguishers were sampled and found each had been inspected monthly by the
program’s maintenance staff. Documentation of an annual fire extinguisher inspection was
found last completed by an outside contractor in October of 2023. The program has a total of
eight extinguishers. The executive director reported fire and COOP drills are conducted monthly
on each shift. Five interviewed staff all reported they complete fire drills monthly. In addition,
staff gave examples of other drills they’ve participated in such as medical drills, suicide,
weather-related drills, and major disturbances. Each of the five interviewed youth all reported
they have been instructed on what to do in the event of a fire. All five youth reported fire drills
are done at least monthly.
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) located in the copier room in the
large dayroom area. The plan is accessible to all staff. The plan was last reviewed and
approved by the Department’s Office of Residential Services regional director in March of 2023.
According to an email notification provided by the executive director, the COOP was sent to be
reviewed annually by the program; however, email confirmation revealed the Department’s
Office of Residential Services area is developing a new template which had not been finalized at
the time of the annual compliance review. The program’s COOP addresses the delegation of
authority, any new cooperative agreements, a vendor contract list, emergency and staff contact
numbers, and county cooperation checklist. Evacuation sites are also listed within the COOP.
Supplies for evacuation purposes are maintained in a secured closet within the youth living area
of the building. Supplies were observed and included items such as clothing, linens, and canned
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goods. The program’s Emergency Disaster Preparedness Plan and COOP are combined into
one plan. The executive director was interviewed and confirmed the location of the program’s
COOP, which is in the copier room. In addition, the executive director and director of operations
confirmed in the event of an evacuation, all youth medical records, mental health records, and
case management records are taken with the program which include all relevant and required
youth information. In addition, the director of operations maintains an evacuation binder which
includes each youth’s immunization record, current Comprehensive Physical Assessment
(CPA), the Department’s Juvenile Justice Information System (JJIS) Face Sheet, safety plan,
and copy of the Authority for Evaluation and Treatment (AET).
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 addressing the storage and inventory of all
flammable, poisonous, and toxic items, and materials. The program’s policy addresses strict
access for these items and prohibits youth handling of chemicals directly. The program
maintains a limited supply of cleaning items. An inspection of six items found each item was
secured and inaccessible to youth. Each had a corresponding Safety Data Sheet (SDS). All but
one item was found on the corresponding inventory form. One item, a spray bottle of all-purpose
cleaner, was found secured, with an SDS, but was not included on the inventory form. This was
added by the maintenance staff during the annual compliance review week. In addition, the
maintenance staff maintains a small supply of gasoline in a metal locked cabinet located outside
the facility. The gasoline was identified correctly on the inventory form and had a corresponding
SDS present with the item. All chemicals are inventoried daily by the maintenance staff. The
program also maintains a list of positions authorized to handle any of the items.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures addressing the storage and inventory of all
flammable, poisonous, and toxic items, and materials. The program’s policy addresses strict
access for these items and prohibits youth handling of chemicals directly. Youth are not
authorized to clean, handle, or dispose of any person’s bio-hazardous material, bodily fluids, or
human waste. Observations of youth cleaning were unable to be done during the annual
compliance review week. Five interviewed youth all reported they do not use any chemicals or
cleaning products.
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5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program has a policy and procedures which address the disposal of all flammables, toxic,
caustic, and poisonous items. All chemicals are disposed of in accordance with Occupational
Safety and Health Administration (OSHA) and Safety Data Sheet (SDS) requirements.
According to an interview with the maintenance staff, the program has not required disposal of
any toxic or flammable items for the annual compliance review period. In the event disposal is
required, the maintenance staff stated the military base personnel would be notified.
Maintenance staff did state standard mop water is disposed of through pouring in mop drains
located outside the main building. The program does not have a kitchen; therefore, no grease
traps or grease disposal is applicable. According to an interview with the registered nurse,
biohazardous waste is maintained in a marked box located in a secure closet of the medical
office. The program has an agreement with a biohazardous waste contractor who comes when
contacted to remove the items. A disposal log was observed to be maintained in the medical
office. The program maintains a list of staff positions authorized to dispose of any chemicals.
Based on a review of reports to the Department’s Central Communications Center (CCC) for the
annual compliance review period, there have been no incidents related to chemical spills at the
program. The program’s approved Continuity of Operations Plan (COOP) addresses all
requirements and procedures in the event a chemical spill occurs at the facility. The executive
director was interviewed and stated the program will dispose of all flammable, poisonous, and
toxic fluids used in the facility in a safe and approved manner. The base may be used for
disposal along with local disposal sites when necessary.
5.21 Elements of the Water Safety Plan, Staff Training, and
Satisfactory Compliance
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity.
Programs allowing youth to participate in water related activities shall have a water safety
plan addressing, at a minimum, safety issues, emergency procedures, and the rules to be
followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
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• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program has a written policy and procedures which address elements of the water safety
plan, staff training, and swim testing for youth. The program has three certified swimming
instructors. A review of all three staff records confirmed certifications were maintained as
required, and each staff was trained in emergency procedures. Swim test documentation was
provided which included the type of water activity used. Swim tests were consistent with the
water activity used during the swim testing. The program’s water safety plan addressed safety
issues, emergency procedures, and the rules to be followed during water-related activities. The
risk level for each youth participating in swimming activities included whether the youth can
swim, assessment of swimming ability, factors such as age and maturity, special needs,
physical and mental health issues, physical stature, and conditioning. Activities participated in
have only been in the pool. Activity dates for the annual compliance review period included once
in May and twice in June of 2024. The lifeguard-to-youth ratio and positioning of lifeguards were
included in the water safety plans. A minimum ratio of one staff for every five youth was also
maintained in each event. Five youth were interviewed. Two stated they have participated in
water activities and have taken a swim test. One stated they have not taken a swim test. One
stated they are waiting to take a swim test. One youth stated they do not participate in water-
related activities.
5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program’s visitation schedule was observed to be posted along with the weekly activity
schedule on walls throughout program areas. Visitation is scheduled for Sundays from 1:00 p.m.
until 4:00 p.m. Visitors sign in and out on the regular visitor sign in sheet located in the foyer
area of the program. The visitor log was observed, which confirmed compliance with the
visitation schedule, showing visitors and family members singing in and out as required. The
program’s case manager was interviewed and stated youth are afforded the opportunity to
communicate with approved family members and individuals through visitation, telephone, and
mail. The case managers and direct care staff maintain an approved correspondence list for
each youth, which was observed. The direct care staff facilitate telephone calls for all youth on
scheduled time frames. Each youth has a designated call day. The schedule was observed in a
telephone log binder. The mail log was also observed. Youth can mail unlimited letters weekly to
approved individuals. Mail is searched for contraband by staff and then brought to the business
manager to be sent out. The case manager stated for all youth entering the program, a review
of the Department’s Juvenile Justice Information System (JJIS) Face Sheet is done to verify
youth contact persons and any history of human trafficking. In addition, the youth’s assigned
community juvenile probation officer (JPO) is contacted for this information. During the annual
compliance review week there were no youth with an alert for human trafficking or endangered
person. In addition, five youth records which were selected for the sample size were reviewed
and found none of these youth face sheets included an alert for human trafficking or
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endangered person. According to the executive director, the provider’s home office is able to
assist with language interpreter services. Five interviewed youth confirmed they can call or send
letters to their parent/guardian. One of five interviewed staff reported the program has two staff
who speak other languages to help translate for youth and families. Four of five interviewed staff
reported they were unaware of services the program may have for youth who do not speak
English as their primary language.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a weekly activity schedule which was observed to be posted throughout
program areas. The schedule documents a range of supervised and structured indoor and
outdoor activities for youth at least one hour daily. A review of logbook documentation revealed
recreation activities are provided as scheduled. Activities provided promote social and cognitive
skill development, creativity, teamwork, healthy competition, mental stimulation, and physical
fitness. The program has guidelines for preventing overexertion due to potentially hazardous
weather conditions. The program employs a recreational therapist whose credentials meet all
requirements. A review of five youth case management records found each youth’s
performance plan included goals for recreational therapy. Five interviewed staff described
examples of indoor and outdoor activities provided at the program for at least a minimum of one
hour daily. These activities included games such as basketball and football. Five interviewed
youth all confirmed they are given at least one hour daily to participate in outdoor activities.
These activities include basketball, football, exercise bar, frisbee, and jogging. All five youth
confirmed the program allows them the opportunity to exercise, play outside, or down time to
read a book, or play board games.
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program does not utilize 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 does not utilize 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 does not utilize controlled observation; therefore, this indicator is rated non-
applicable.
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report_type: QI Residential

rule: Indicator 1.08

excerpt: In-Service Training

rating: Limited Compliance

rule: Indicator 5.04

excerpt: Ten-Minute Checks (Critical)