summary: QI Residential - FY24-25

raw_content:
ST AT E OF FLORIDA
DEPART MENT OF JUVENILE JUST ICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Deep Creek Youth Academy - Mental Health Overlay Services (MHOS)
and Substance Abuse Overlay Services (SAOS)
Youth Opportunity Investments
(Contract Provider )
765 E Saint Johns Avenue
Hastings, Florida 32145
Review Date(s): February 11-14, 2025
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Kristine Harshaw, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Lori Bright, Office of Accountability and Program Support, Regional Monitor (Standard 1,
Interviews)
Jeff Campbell, Office of Education, Northeast Education Coordinator (Standard 6)
Jessica Gibson, Office of Accountability and Program Support, Regional Monitor (Standard 2)
LeAnn Gruentzel, Office of Accountability and Program Support, Deputy Regional Supervisor
(Standard 4)
Carlametress Harrell, Florida Youth College, Workforce Education Coordinator (Standard 6)
Jennifer Harris, Regional Compliance Director, Rite of Passage (Standard 5)
Rebecca Smith, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Brad Taylor, Office of Accountability and Program Support, Regional Monitor (Standard 1,
Interviews)
Meghan Thrasher, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Deep Creek Youth Academy MQI Program Code: 1486
Provider Name: Youth Opportunity Investments, LLC Contract Number: 10677
Location: St. Johns County / Circuit 7 Number of Beds: 40
Review Date(s): February 11-14, 2025 Lead Reviewer Code: 187
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, (5) Safety and Security, and (6) Educational
Services, which are included in the Residential Standards.
Overall Rating Summary
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 66 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Non-Applicable
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Non-Applicable
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 66 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions and Incorporation of Other Plans Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.14 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.15 Exit Portfolio Satisfactory
2.16 Exit Conference Satisfactory
2.17 Youth Input Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 66 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Secure Observation* Non-Applicable
3.13 Suicide Precaution Observation Logs * Satisfactory
3.14 Suicide Prevention Training * Satisfactory
3.15 Mental Health Crisis Intervention Services * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.18 Baker and Marchman Acts * Non-Applicable
3.19 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 66 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 66 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
5.24 Controlled Observation Non-Applicable
5.25 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 66 (Revised September 2022)
Standard 6: Educational Services
Residential Rating Profile
Standard 6 - Educational Services
6.01 Contract Specific CTE Services (Residential Contract) Satisfactory
6.02 Educational Access (Residential Contract) * Satisfactory
6.03 Educational Access (Education Contract) * Non-Applicable
6.04 Career Education (Education Contract) Satisfactory
6.05 Education Transition Plan (Education Contract) Non-Applicable
6.06 Qualified Intructional Personnel (Education Contract) Non-Applicable
6.07 Florida Youth College (Education Contract) Satisfactory
6.08 Florida Youth College (Post-Secondary Contract) Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators.
Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 66 (Revised September 2022)
Program Overview
The Deep Creek Youth Academy is a forty bed program, for males twelve to nineteen year old,
located in Hastings, Florida. The program is operated by Youth Opportunity Investments, LLC,
through a contract with the Department and is co-located with the Deep Creek Youth Academy
Intensive Mental Health (IMH), Comprehensive Mental Health, Intensive Medical, and
Borderline Developmentally Disabled (BDD)/Developmentally Disabled (DD) program. The
program provides the following services: Mental Health Overlay Services (MHOS) and
Substance Abuse Treatment Overlay Services (SAOS). In addition, the program fosters each
youth by providing Skillstreaming the Adolescent, Moral Reconation Therapy, Living in Balance,
and Impact of Crime. Additional treatment services provided include individual and family
therapy, animal assisted therapy, and recreational therapy. Program administration is comprised
of a facility administrator and five assistant facility administrators. Case management services
are provided by a director of case management, three transition services managers, and six
case managers. Mental health staff at the program includes a designated mental health clinician
authority (DMHCA) who is a licensed psychologist, three assistant clinical directors, one
licensed therapist, nine non-licensed therapists, and two recreational therapists. Medical
services are offered twenty-four hours a day and are provided by a designated health authority
(DHA), psychiatrist, health services administrator (HSA), six registered nurses, and one medical
records clerk. Educational services are provided by the Florida Scholars Academy. The layout
of the program includes: one main building which houses administration, master control,
education, medical, kitchen and dining areas, multi-purpose space, and two buildings housing a
total of four youth modules. The program has 177 security cameras and all were operating and
providing coverage. At the time of the annual compliance review, the program had four vacant
therapist positions.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 66 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
A review of the staff roster found forty-one staff were hired during the annual compliance review
period. Each staff received a clear and eligible background screening in the Clearinghouse
system and their criminal history reports were reviewed prior to contact with youth or
confidential youth records. One of the staff required an exemption, which was received prior to
the staff’s hiring. One staff was applicable for a break in service, and a new background screen
was completed. None were applicable for being hired from another provider. Each applicable
staff was administered a pre-employment assessment tool and a passing score was obtained
and documented in their personnel records. Forty of the forty-one staff were added to the
program’s roster in Clearinghouse and the remaining staff was added during the annual
compliance review week.
The program did not have any volunteers, mentors, contract staff, or interns who required a
background screening. The Annual Affidavit of Compliance with Level 2 Screening Standards
was submitted for the program on January 7, 2025, and for the teachers who are provided by
Florida Scholars Academy through a contract with the Florida Virtual School on January 28,
2025.
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 to ensure all staff are administered background
rescreenings every five years of employment. A review of the staff roster found no staff were
eligible for a five-year background rescreening; however, two staff required new fingerprints,
which were completed within the required time frame.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 66 (Revised September 2022)
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures to ensure an abuse-free environment which outlines
the staff code of conduct, which staff are required to sign upon hire, in addition to the program’s
abuse reporting procedures. The abuse reporting procedures indicate youth shall have
unhindered access to the Florida Abuse Hotline and the staff are to notify the supervisor, who
will notify the assistant facility administrator, and immediately allow the youth to make the call.
Ten personnel records were reviewed and confirmed the staff signed their code of conduct upon
hire. A program tour, during the week of the annual compliance review, confirmed the program
has postings for the Florida Abuse Hotline and the Department’s Central Communications
Center (CCC) throughout the program in areas
accessible to youth. The program last completed a Trauma Responsive and Caring
Environment (TRACE) self-assessment in June 2024. The program had nine incidents of
alleged abuse during the annual compliance review period, all of which were reviewed and two
of which were substantiated. Each of the nine reviewed incidents wasere reported to the CCC
and one originated from the Florida Abuse Hotline. None of the reviewed incidents involved
allegations of human trafficking or exploitation. An interview with the facility administrator
confirmed the program follows the abuse reporting procedures and ensure youth have
unhindered access to the Florida Abuse Hotline. Ten youth were interviewed and confirmed
they have never been stopped from reporting abuse and know where the Florida Abuse Hotline
number is posted. Each of the ten interviewed youth reported feeling safe in the program. Eight
of ten youth reported staff never use profanity, and two youth reported they use profanity
occasionally but not directed at youth. None of the interviewed youth had ever exchanged
contact or social media information with staff. Ten staff were interviewed, and each reported in
the event a youth wants to report an allegation of abuse, the staff notify the supervisor, and the
supervisor takes the youth to call the Florida Abuse Hotline or the CCC. Nine of the ten staff
also stated staff can let youth make the call, and four staff said they would report it to the facility
administrator. Five staff additionally noted youth are always allowed to call if they request it.
None of the ten staff reported hearing other staff deny youth an abuse call or use profanity while
speaking with youth.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 66 (Revised September 2022)
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 nine allegations of abuse against staff reported the Florida Abuse Hotline
and/or the Department’s Central Communications Center (CCC) during the annual compliance
review period, all of which were reviewed. Incident reports were provided which confirmed the
program took immediate action and placed staff on no youth contact pending the investigation
into each incident. In three of the four reported incidents, the staff was unknown and the report
was a result of an outside entity or person making contact with the CCC. Each of these
incidents were investigated or are currently under investigation. Corrective action was taken
based upon the results of the investigations, with one incident determined substantiated,
resulting in the termination of the staff. The facility administrator confirmed the program takes
immediate action and places staff accused of abuse on no youth contact pending an
investigation.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program had nineteen incidents reported to the Department’s Central Communications
Center (CCC) during the annual compliance review period, five of which were reviewed. Each
reviewed incident was called into the CCC within two hours of the incident occurring or
discovery of the incident and was found in the program’s master control logbook. There were no
additional incidents found which should have been reported to the CCC and were not. The
program had a small increase in reports from the previous annual compliance review period,
which the facility administrator noted was due to the increase in outside reports to the CCC.
1.06 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The program uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program had no Right Interactions (RI) incidents during the annual compliance review
period, five of which were reviewed. The program’s RI Plan was last updated on December 12,
2023. The program’s RI plan was approved by the Department on December 13, 2024. The
program has not experienced an increase in RI incidents of five or more since the last annual
compliance review period. The facility administrator was interviewed and reported the RI
escalation matrix should be used and physical intervention should be used when all alternatives
have been exhausted. Each of the ten interviewed staff reported they utilize RI. All five
interviewed staff stated they will use verbal de-escalation and re-direction prior to utilizing
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 66 (Revised September 2022)
physical RI techniques. The program’s RI rate during the previous quarter was 0.00, which is
below the statewide Residential RI rate of 1.17.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
Five staff records were reviewed for pre-service training requirements. Each of the ten staff
completed in excess of 120 hours of training in the first 180 days of hire. Each staff completed
all essential skills training prior to contact with youth and all additional required training to be
certified within 180 days of hire. All training was documented in the Department’s Learning
Management System (SkillPro). None of the staff were applicable for re-certification training of
staff who were separated from employment. All staff who could be responsible for the
supervision of youth received the required training. All instructors were qualified to deliver
trainings provided.
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
Ten staff records were reviewed for in-service training requirements. Each staff completed in
excess of the required twenty-four hours of annual in-service training, which included training in
all required topics, with the exception of one staff missing one training. Each staff maintained
required certifications. Three staff were applicable for supervisory training. All three received
thirty-two or more hours of supervisor training in coaching, leadership, and personal
accountability. All training was documented in the Department’s Learning Management System
(SkillPro). All instructors were qualified to deliver trainings provided. The program has an in-
service training plan and an in-service training calendar which is updated as changes occur.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures in place which includes the training requirements of
the grievance process. The process includes the informal phase, formal phase, and appeal
phase. Documentation showed the program’s practice correlates with their process and copies
of the grievances are maintained for the past twelve months. Five grievances were reviewed
which showed each of the five grievances were reviewed within the required time frame. Each
of the five grievances were resolved in the formal phase. Ten youth were interviewed. Two
youth stated they have not needed to submit a grievance but are able to if they need to. All
interviewed youth stated there are grievance forms on the module they have access to. Once a
form is filled out, the youth are able to drop them into the drop box. Each of the ten interviewed
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 66 (Revised September 2022)
youth stated they are able to ask for assistance in completing a grievance form. Ten staff were
interviewed, of which each said grievance forms are placed throughout the program and a youth
can request assistance in completing the form. Five staff reported the process has three phases
and each phase has associated time frames. Four staff noted the supervisor reviews
grievances, while six staff stated the facility administrator reviews grievances. The facility
administrator explained in an interview each youth has the right to grieve actions of program
staff and conditions or circumstances in the program related to a violation or denial of basic
rights. Informal resolution of complaints is encouraged. All staff are trained in the grievance
process and procedures and youth receive instruction on procedures to file a grievance within
the orientation process. Youth have access to grievance forms and the facility administrator
ensures actions are taken to resolve complaints which are communicated. Grievances are
maintained for one year from the date the grievance was submitted.
1.10 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures which outline life skills training shall be provided to all
youth and youth are assigned to life skills groups based on the specialized services they
receive. All formal life skills groups are primary services; however, youth participate in a
program called SNAP (Stop Now And Plan), which teaches emotional regulation, self-control,
and problem-solving. This program is a compliment to the provider’s behavior management
system. Youth are able to practice these skills in their community and off-campus during trips
and outside appointments. The facility administrator stated in an interview the majority of the
youth’s time is spent in structured, therapeutic activities, with a minimum of one hour of each
youth’s day devoted to the delivery of treatment services targeted to address the youth’s
identified risk, criminogenic needs and treatment needs. The designated mental heath clinical
administrator reports youth are able to practice learned skills on daily basis and process during
the following group sessions. Five youth were interviewed and each report they attend therapy
groups daily, including substance abuse treatment.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 15 of 66 (Revised September 2022)
1.12 Restorative Justice Awareness for Youth Non-Applicable
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
Impact of Crime (IOC) is designated as a Standardized Program Evaluation Protocol (SPEP)
primary service at Deep Creek Youth Academy program. For details related specific to IOC
service delivery, please refer to the annual SPEP report.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures regarding the alert process which outline alerts shall
be consistent in the internal alert system and the Department’s Juvenile Justice Information
System (JJIS) and only authorized staff shall update or close applicable alerts. The program
utilizes an alert board in the staff break room to track all internal alerts. Five youth records and
corresponding JJIS records were reviewed. All alerts were placed in JJIS, and none were
entered late. Only authorized staff entered, downgraded, and closed alerts. The nurse was
interviewed and reported nurses update medical alerts as changes are made and they are
reviewed weekly. The facility administrator was interviewed and reported alerts are reviewed at
the morning briefings. The facility administrator verified the program utilizes an alert board and
all alerts should be reflected on the alert board, in JJIS, and in the logbook. Ten staff were
interviewed, and each reported they knew where to find alerts or who to ask. Eight of ten staff
referred to the breakroom alert board as the location alerts are updated, as well as master
control logbook. Six of ten staff reported they are informed of alerts by word of mouth, one staff
stated the alerts are in the mantraps in each of the dorms, and one said alerts are discussed
during briefings. Alerts for food allergies are posted in the kitchen, inaccessible to youth.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Case Management Record
The program maintains separate individual management records, mental health records, and
Individual Healthcare Records. Five youth records were reviewed, and each record is labeled
confidential and maintained in locked cabinets and offices marked as confidential. Each
individual management record includes all required information and is separated into required
sections.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 16 of 66 (Revised September 2022)
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program operates a Community Advisory Board which included representatives from all
required community partners. A review of sign-in sheets and meeting minutes confirmed
meetings were held hybrid, in-person, and by video conferencing at least quarterly during the
annual compliance review period. The facility administrator was interviewed and verified
meetings are held quarterly with all required parties and invitations are sent to solicit active
involvement from board members. A board member was interviewed and reported they work
with youth inside the program to improve their perspectives of law enforcement.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures which outline performance evaluations will be
conducted ninety days after hire and annually thereafter. Position descriptions for five different
position types were reviewed and compared with the ten staff records reviewed and confirmed
staff were evaluated based on established performance standards. A review of the program’s
staff roster and contract confirmed all required positions were maintained with the exception of
four non-licensed therapists. The facility administrator was interviewed and reported turnover
has decreased and the program’s staff morale committee has continued retention initiatives
which improved morale and recognizes staff performance. Ten staff were interviewed, and each
reported they receive performance evaluations annually and monthly. Three staff reported they
receive evaluations quarterly.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program’s contract was reviewed for contract-specific requirements. Documentation
confirmed the program is providing each of the fifteen contract-required activities. The program
has agreements, sign-in sheets, and picture documentation of activities with Friends in Blue
through the St. Johns Sheriff’s Office, mentoring through Compassion St. Augustine, animal
assisted programming through the Hands and Feet Foundation, and First Coast Technical. The
program maintains space for youth to utilize as part of their behavior management system
including an enhanced basketball court, arcade, barbershop, diverse media center and music
studio. The nurses taught three classes during the annual compliance review period with an
infant simulator to instruct youth in caring for an infant. Youth are provided the required
clothing, salads with lunch and dinner, opportunities to receive the iHope patch for fitness
achievement, and input through the youth advisory board. The program provided documentation
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 17 of 66 (Revised September 2022)
they have leases for four passenger vans, exceeding the contract requirement of three. A
review of the program’s staff roster confirmed they have a medical clerk and a physical plant
worker with certifications in heating, ventilation, and air conditioning (HVAC). The program
utilizes recruitment and retention efforts confirmed through their staff handbook. The facility
administrator confirmed the contract-specific opportunities offered to youth. Ten youth were
interviewed and eight of the youth reported participating in Occupational Health and Safety
Administration (OSHA) 10 and cardiopulmonary resuscitation (CPR)/first-aid trainings, two
mentioned ServSafe certification, and one youth said they have participated in Florida Ready to
Work. Sign-in sheets, pictures, and agreements confirmed the program is providing the activities
as required.
1.18 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a practice regarding data trend analysis, which is as follows. Satisfaction
surveys are incorporated into the monitoring and verification activities as a part of the program’s
quality assurance program. Satisfaction surveys are provided routinely and are completed on at
least a quarterly basis. Surveys include youth surveys, family surveys, and staff surveys at a
minimum. Surveys target admission activities, topic-specific assessments, and discharge
satisfaction. Survey data is reviewed and evaluated monthly in program-level and corporate
leadership meetings. Survey outcomes are collected and communicated as a part of ongoing
program communication and quality improvement activities. Monthly incident trackers are
distributed to the program which describe trends. Quarterly monitoring and verifications are
conducted according to the program’s compliance team, which formulates a report and provides
support, technical assistance, and coaching to promote improvement, professional
development, and implementation and assurances of corrective strategies, as appropriate.
Program and corporate leadership meetings include monthly quality assurance review
processes which incorporate review of facility data, surveys, and findings of formal monitoring
and verification activities. Within each meeting, progress to date, program strengths,
improvement needs, and corrective action is discussed. Recommendations are made by the
team with ongoing review and follow-up and technical assistance provided, as applicable.
Data gathered by the program and the Department is used for long-term planning, provisions for
staffing, and a system of communication to keep staff. Stakeholders are informed and provided
opportunities for feedback, performance improvement, and budgeting. The program provided
documentation to support this practice.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 18 of 66 (Revised September 2022)
Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
Five youth case management records were reviewed for initial contacts to parents/guardians
and court notifications. All five records included documentation the program notified the
parents/guardians by telephone within twenty-four hours of admission and in writing within forty-
eight hours. The court and juvenile probation officers (JPO) were notified in writing within five
working days of each youth’s admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
Five youth case management records were reviewed for youth orientation documentation. All
five youth records included documentation an orientation was completed the day of each
youth’s admission. There were no intakes during the annual compliance review week; therefore,
no youth orientation could be observed. The program utilizes an orientation checklist which
included services available, daily schedule, expectations and responsibilities of youth, written
behavioral management in the youth handbook, access to medical, mental health, and
substance abuse services, access to the Florida Abuse Hotline and the Department’s Central
Communications Center, the program’s zero-tolerance policy regarding sexual misconduct,
special accommodations which are available to ensure all written information about sexual
misconduct and right to be free from sexual misconduct, items considered contraband,
performance planning process, dress code, hygiene practices, procedures on visitation, mail,
and telephone, expectations for release from the program, community access, grievance
procedures, emergency procedures, facility tour, and assignment to a living unit and room. Five
youth were interviewed regarding their orientation to the program and each reported their
orientation began within twenty-four hours of their admission. All five youth reported they
received a handbook to review and signed an acknowledgment form.
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.
Five youth case management records were reviewed for written consent of eight years or older
youth. None of the youth selected were applicable. The program provided three additional
records to make the minimum of three. All three youth records included written consents for all
three youth.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 19 of 66 (Revised September 2022)
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor. Youth are reassessed and
reclassified, if warranted, prior to considering an increase in privileges or freedom of
movement, participation in work projects, or other activities involving tools or instruments
which may be used as potential weapons or means of escape, or participation in any off-
campus activity. All youth admitted to residential commitment programs shall be screened for
vulnerability to victimization and sexually aggressive behavior prior to room assignment.
Room assignments by staff shall ensure a youth’s potential for victimization or predatory risk
has been reviewed. The screening shall be completed in JJIS.
The program has a classification form which includes all required elements. Five youth case
management records were reviewed for classification documentation and each included
documentation the initial classifications were completed on the date of admission. One youth
had a medical risk, one youth had an escape risk, and two youth had security risks. One youth
did not have any notated risk factors. All five youth were classified for purposes of being
assigned to a living area and sleeping room. All required alerts were entered into the
Department’s Juvenile Justice Information System (JJIS) as required. Of the three reviewed
youth, three were granted an increase in the privileges, two were granted permission to
participate in work projects and tools, and one was granted permission for off-site activities. The
program's written policy and procedures outline the process for classification reassessments.
The reassessments are completed at intervals throughout the youth's stay. The youth are
reassessed when there are changes in supervision status, new and/or updated alerts,
behavioral concerns, and changes with safety and security. The program’s policy and
procedures outline the classifications process to include a classification system which promotes
safety and security, as well as effective delivery of treatment services, based on determination
of each youth’s individual needs and risk factors. The policy also includes procedures for
reassessments. The reassessments are completed at intervals throughout the youth's stay. The
youth are reassessed when there are changes in supervision status, new and/or updated alerts,
behavioral concerns, and changes with safety and security. The increase in privileges and
freedoms are documented on the risk assessment forms. The facility administrator summarized
the program's policy and procedures regarding classifications and reassessments for the youth
in the program.
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 notification of law enforcement for
gang identification. None of the five youth were applicable for review. The program provided an
additional record for review. The program did not have any other youth identified as a gang
member or affiliate during the annual compliance review period. The program maintains all gang
documentation in a binder for the facility. The notification for local law enforcement and the
youth’s home county law enforcement was reviewed with no issues noted. The notifications
were completed prior to the Monitoring and Quality Improvement (MQI) seven-day notice. The
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 20 of 66 (Revised September 2022)
gang alert was previously entered into the Department’s Juvenile Justice Information System
(JJIS) and was observed on the program’s internal alert board. The gang binder also included
documentation the educational provider and juvenile probation officer were notified of the
youth’s gang status.
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 notification of law enforcement for
gang identification. None of the five youth were applicable for review. The program provided an
additional record for review. The program did not have any other youth identified as a gang
member or affiliate during the annual compliance review period. The program provides the
Gang Resistance and Drug Education (G.R.A.D.E.) curriculum for the youth. The program
provides groups once a month with the youth. A review of the sign-in sheets confirmed the
groups were being held and the applicable youth is attending the gang intervention. The
program also conducts Impact of Crime (IOC) groups and all youth are required to complete this
curriculum. A review of the Individualized Performance Plan (IPP) confirmed the youth had a
goal and objectives related to gang intervention strategies. The program has a policy and
procedures which address providing the youth an opportunity, if they desire, to develop a plan to
disaffiliate with a criminal street gang. The facility administrator was interviewed and
summarized the program’s policy and procedures for gang interventions and strategies.
2.07 Residential Assessment for Youth (RAY) Assessments
Satisfactory Compliance
and Re-Assessments
The program shall ensure an initial assessment of each youth is conducted within thirty days
of admission. Documentation of the initial assessment process is to be maintained in JJIS.
The program shall ensure reassessments are completed for each youth at least every ninety
days from the initial assessment. The program shall ensure any other updates or
reassessments are completed, when deemed necessary, by the intervention and treatment
team to effectively manage the youth’s case. The program shall maintain all reassessment
documentation in the youth’s official youth case record.
Five youth case management records were reviewed for Residential Assessment for Youth
(RAY) and RAY reassessments. All five youth records included documentation the initial RAY
assessments were completed within thirty days of admission. All initial assessments were
maintained in the Department of Juvenile Justice Information System (JJIS). Four out of the five
youth had been at the program long enough to have had a RAY reassessment and all were
completed within ninety days. All RAY reassessments were maintained in each case
management record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 21 of 66 (Revised September 2022)
Five youth case management records were reviewed for Youth Needs Assessment Summaries
(YNAS) reports. All five YNAS reports were completed within the first thirty days of admission.
All YNAS reports were documented within the Department’s Juvenile Justice Information
System (JJIS).
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 records included Individualized Performance Plans (IPP) which
were developed within thirty days of admission for each youth. All IPPs were developed after
the initial Residential Assessments for Youth (RAY) and the Youth Needs Assessment
Summary (YNAS) reports. The following intervention and treatment team members were
present during the development of the IPPs: intervention and treatment leader, youth,
administrative representative, living unit representative, treatment staff, educational staff, and all
other parties who have significant responsibility in goal completion. One of the five youth had
their Department of Children and Families (DCF) caseworker on the telephone for the
development of their IPP. All five IPPs were sent to the parties who were not present for
signature but none were sent back to the program. All signature pages were filed in each
youth’s record. All five reviewed records included all required elements. All five youth records
included documentation the transmittal letters were sent to the committing court and assigned
juvenile probation officers (JPO). Four out of the five records included documentation the
parents/guardians transmittal letters. One youth was involved with the Department of Children
and Families (DCF) and a transmittal letter was sent to the assigned case worker. Five youth
were interviewed and each reported they participated in the development of their IPP.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
Five youth case management records were reviewed for performance plan revisions and
incorporation of other plans into the performance plan. One out of five youth had a revised
performance plan due to the Residential Assessment for Youth (RAY) reassessment results
warranting the update. Four out of five Individualized Performance Plans (IPP) were updated
due to newly acquired information. All five youth had updated IPPs due to the youth
demonstrating progress and/or lack of progress toward completing a goal. All initial IPPs
included transition goals. All five youth records were reviewed for incorporation of other plans
into the IPPs, which included education and treatment plans. One youth’s IPP included a
Department of Children and Families (DCF) case plan.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 22 of 66 (Revised September 2022)
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. A review of the youth records revealed three of the five had performance
summaries completed every ninety calendar days following the signing of the initial performance
plan. One youth record had one performance summary completed three days late. Another
youth had not been at the program long enough to have a performance summary due. All
reviewed performance summaries included the following elements, youth status on each
performance plan goal, overall treatment progress, academic status, behaviors, level of
motivation and readiness to change, interaction with peers, interaction with staff, overall
behavior adjustment to the program, and significant positive and negative events. All reviewed
performance summaries reflected the youth was allowed to read and add comments prior to
signing and the original performance summaries were maintained in each youth’s case
management record. All performance summaries were signed and dated by the treatment team
leader, staff preparing the summaries, the facility administrator or designee, and the youth. A
copy of the summaries were sent within ten working days to the committing court, the assigned
juvenile probation officers (JPO), and the parents/guardians for the four applicable youth.
Three closed case management records were reviewed for release summary documentation. All
three records included documentation the original release summaries included justification for
each youth’s release. All release summaries were sent with the Pre-Release Notification (PRN).
All three youth were at the program longer than forty-five days and the release summaries along
with the PRNs were sent, at least, forty-five days prior to release of each youth. One youth had
a denied PRN. A second PRN was sent and subsequently approved on the day the youth was
released from the program. A signed copy of the performance summaries were retained in each
closed youth record. A review of documentation revealed the program provided written notice of
release to the parents/guardians once the PRNs were approved. An exit Residential
Assessment for Youth (RAY) was completed for all three youth. None of the youth reviewed
were required to complete a victim notification.
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 encourages parent/guardian involvement during the assessment process,
development of performance plans, progress reviews, and transition planning. A review of youth
case management records revealed the program sends letters with an invitation to all treatment
team meetings, which included dates and times of the meetings. Parents/guardians are
provided the opportunity to attend by telephone if unable to attend the meetings in person. A
treatment team meeting was not observed due to one not being held during the annual
compliance review week. The program sends out invitations to the parents/guardians for family
days, transition meetings, and exit conferences. The facility administrator was interviewed
regarding parent/guardian involvement at the program and included the program's policy and
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 23 of 66 (Revised September 2022)
procedures for parent/guardian involvement in the case management processes. Five youth
were interviewed and each reported their parent/guardian participates through visitation,
telephone calls, family sessions, and treatment teams.
2.13 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
Five youth case management records were reviewed for treatment team members and
meetings. All five records included documentation formal treatment teams were held, at least
every thirty days. The formal treatment team meetings included the following elements for each
youth: youth’s name, date of review, juvenile probation officer (JPO), parents/guardians,
treatment team leader, program management, living unit representative, education, mental
health, and medical staff as evidenced by a review of signature pages and documented input by
each area of the program. The reviewed treatment team documentation for each youth included
comments from treatment team members, a brief synopsis of the youth’s progress in the
program, performance plan revisions, progress on performance plan goals, positive and
negative behaviors, treatment progress, and Residential Assessment for Youth (RAY)
reassessment results. Four of the of five treatment team meetings forms included
documentation of the youth behaviors resulting in physical interventions. One youth did not have
any physical interventions since being at the program. All formal treatment team documentation
was contained in each youth’s record. A review of five youth case management records
indicated all youth were provided informal treatment team meetings bi-weekly since being
admitted to the program. The informal treatment team documentation included all required
elements, and all documentation was maintained in each youth’s record. The following parties
were invited and encouraged to attend treatment team meetings for each youth, JPO,
parents/guardians, and all other required parties. No treatment teams were held during the
annual compliance review week; therefore, no meetings were observed. Five youth were
interviewed and each reported they are able to discuss struggles they have had in the program
and how they have overcome them, they are able to discuss the status of their goals, and to talk
about progress made. One youth reported they receive scenarios to see how the youth thinks
about things and whether their thought process has changed.
2.14 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan. Each youth must attend their scheduled Community Re-Entry Team (CRT)
meeting prior to discharge.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 24 of 66 (Revised September 2022)
Three closed youth records were reviewed for transition planning and meetings and Community
Re-Entry Team (CRT) meetings. All three records included documentation a transition
conference was held at least sixty days prior to the youth’s release. The following treatment
team members attended the transition conference, youth, treatment team leader, facility
administrator or designee, and other treatment team members, as needed. Each youth’s
juvenile probation officer (JPO), parents/guardians, education staff, and other pertinent parties
were invited to attend in writing prior to the meetings. A review of transition conference
documentation revealed the participants reviewed transition activities on the performance plans,
identified target completion dates, and identified persons responsible for completion for each
youth. The treatment team leader obtained all attendees signatures and dates on the signature
page for each youth. A copy of each youth’s plan was sent with a request to return with
signature for anyone not in attendance who had responsibility for completing a transition goal.
Each closed record included documentation the transition plan was sent electronically to the
JPO and the read-receipts were located in each youth’s closed record.
All three youth records included documentation a CRT was conducted prior to the youth’s
release. The assigned case manager and each youth participated in the CRT meetings. Two of
the three records included documentation the case manager and youth were invited to attend
the CRT meetings. One youth record did not include an invitation; however, there was
documentation in the closed record which indicated the case manager and youth attended the
CRT meeting.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
Three closed youth records were reviewed for exit portfolio documentation and each included
documentation the Exit Portfolio was discussed and initiated at the transition conference for
each youth. All three records included a copy of the youth’s transition plan, a calendar or list of
dates, times, and locations of upcoming community appointments, educational and vocational
certificates earned in the program, all educational records, school transcripts, resumes, and
sample employment applications. Two youth records included documentation the youth had
obtained a Florida Identification card prior to coming to the program. The third record included
documentation of the program’s attempts to obtain the needed documentation; however,the
parent/guardian would not provide it. All three Exit Portfolios were verified during the Exit
Conference. The program had a signature page the youth and parenst/guardians signed upon
the youth’s release from the program verifying the youth had
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 25 of 66 (Revised September 2022)
received their Exit Portfolio. All three records included documentation the Exit Portfolio
information was forwarded to the juvenile probation officer (JPO). The program’s contract
includes an additional requirement indicating the Exit Portfolios be provided in a leatherbound
portfolio with the required documents to the youth upon release. A review of documentation
indicated the program is meeting the additional requirement.
2.16 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
Three youth records were reviewed for exit conference documentation. All three exit
conferences were held after the program notified the juvenile probation officer (JPO) of the
release. Each conference was held at least fourteen days prior to each youth’s release date.
The reviewed exit conference documentation for each youth included the date of the
conference, signatures, an indication of participants who appeared by phone, and a summary of
pending transition goals. The dates of admission and release documented in each youth’s case
record correlated with the Department’s Juvenile Justice Information System (JJIS). During the
exit conferences for each youth, it was documented the status of transition activities were
finalized, provisions for continuation of education and/or employment, documentation the
youth’s parents/guardians and JPOs were aware of vocational plans for each youth, and
evidence each youth’s case manager and parents/guardians were aware of the plan,
documents, and post-release discharge plans. The following participated in each youth’s Exit
Conference, intervention and treatment team leader, education representative, JPO, youth, and
all other pertinent parties in two of the three records. One youth’s parent/guardian did not
participate in the Exit Conference. There was documentation in the record which indicated the
program attempted contact with the parent/guardian and sent an invitation prior to the meeting.
All Exit Conferences were held separate from the Transition Meeting and Community Re-Entry
Team meeting.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a written policy and procedures for youth input which include Youth Student
Council meetings. The Youth Student Council is the avenue for the youth to have a voice within
the program, an opportunity to be part of program decision making, be part of planning and
preparation for reparation activities, recreational activities and incentives, and have an
established forum to communicate directly with representatives of the program management
team. The Youth Student Council meetings are to be facilitated bi-weekly by the assistant facility
administrator, appointed youth, and designated management staff. The council members are to
keep meeting minutes and signatures of participants. During the week of the annual compliance
review, the program provided binders which included sign-in sheets for the youth and staff along
with meeting minutes and topics discussed during the Youth Student Council meetings. The
meetings have been taking place weekly on each dorm. The program is complying with the
policy and procedures for the Youth Student Council. Five youth were interviewed regarding
youth input in the program andtwo youth reported being able to complete "Let's Talk" forms, two
youth reported being able to go to administration or dorm managers, and one youth reported
they have not needed to provide input. The facility administrator was interviewed regarding the
program's formal process to solicit input from youth on systemic issues which impact the
program. The facility administrator may assign staff to conduct observations of staff interactions
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 26 of 66 (Revised September 2022)
and interventions with youth and will ensure managerial presence and open
communication/involvement with youth through participation in community meetings,
performance reviews, treatment team forums and advisory board meetings.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 27 of 66 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program. Programs providing specialized
treatment services must have a single licensed mental health professional designated as the
designated mental health clinician authority (DMHCA) who is responsible for the coordination
and implementation of mental health and substance abuse services in the program.
The program has a designated mental health clinician authority (DMHCA) who is a psychologist
with a clear and active license with an expiration date of May 31, 2026, as required by the
program’s contract. A review of the position description confirmed the DMHCA is a full-time staff
who works at least forty-hours a week and is responsible for the coordination and
implementation of clinical services at the program. The program utilizes a back-up DMHCA who
is a licensed psychologist with a clear and active license in the State of Florida expiring May 31,
2026.
The DMHCA indicated they provide clinical supervision for non-licensed mental health
professionals, provide weekly group schedules, and monthly fidelity and feedback. The DMHCA
submits a monthly service calendar of scheduled individual and family sessions to the clinical
director or designee. During the intake process, the licensed mental health professional (LMHP)
gathers current information from the youth and within the first five days of admission. The LMHP
also confirms youth reports by referring to collateral information obtained in the Department’s
Juvenile Justice Information System and completes the Brief Behavioral Health Status Exam.
The LMHP completes and/or reviews all Assessments of Suicide Risk (ASRs). The LMHP also
provides any group therapy, individual/family therapy, and any needed clinical service in the
absence of a therapist.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a policy and procedures ensuring mental health and substance abuse
services are provided by individuals with appropriate qualifications. The clinical supervisor
ensures the licensed clinical staff working under their supervision are performing services they
are qualified to provide based on education, training, and experience, which was determined by
a review of job descriptions and an informal interview with the designated mental health clinician
authority (DMHCA). The licensed mental health and substance abuse clinical staffing is in
accordance with the current contract and Florida Administrative Code. Copies of the licenses
were available on-site. Licenses of all licensed mental health professionals and licensed
qualified professionals employed at the program during the annual compliance review period
were reviewed and found to be clear and active. The program’s contract requires two assistant
clinical directors and one additional licensed therapist. A review of the staff roster and licenses
found the program was in compliance with this requirement.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 28 of 66 (Revised September 2022)
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program maintains a policy and procedures ensuring mental health and substance abuse
services are provided by individuals with appropriate qualifications. The clinical supervisor
assures the non-licensed clinical staff working under their supervision are performing services
they are qualified to provide based on education, training, and experience based on a review of
job descriptions and an informal interview with the designated mental health clinician authority
(DMHCA). The program had seven non-licensed master’s-level clinical staff at the time of the
annual compliance review. The program had four vacancies for therapist positions; one has
been open for four months and the remaining three for three months. During the annual
compliance review period, the program had five additional non-licensed master’s-level clinicians
and one bachelor’s-level clinician who provided services but were no longer with the program. A
review of the clinician’s credentials found each was qualified to provide services based on their
education, training, experience, and the contractual requirements. The reviewed documentation
reflected each non-licensed mental health clinical staff working under the direct supervision of a
licensed mental health professional received a minimum of one hour a week of on-site, face-to-
face direct supervision by a licensed mental health professional for the purpose of overseeing
and directing the mental health services provided in the program during the annual compliance
review period, as required. Direct supervision 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. The program has a Chapter 397
license which expires April 1, 2025. The non-licensed mental health and substance abuse
clinical staffing is in accordance with current contract to include the number of hours. All seven
non-licensed mental health clinical staff hold a master’s-level degree from an accredited
university or college in the field of counseling, social work, psychology, or related human
services field. The non-licensed substance abuse clinical staff provide substance abuse
services in the program which is licensed under Chapter 397, Florida Statute. Six applicable
employed non-licensed mental health clinical staff who conducted Assessments of Suicide Risk
completed twenty hours of training and supervised experience in assessing suicide risk, mental
health crisis intervention, and emergency mental health services, as required. A review of the
six non-licensed staff no longer employed at the program confirmed five applicable staff also
completed twenty hours of training and supervised experience in assessing suicide risk, mental
health crisis intervention, and emergency mental health services, as required.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
Five youth mental health and substance abuse records were reviewed and each had a
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) completed during
admission. The screener reviewed available information to include the commitment packet, and
reports and/or records for existing documentation of mental health or substance abuse
problems or history of human trafficking in all five records. All five records included the date of
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 29 of 66 (Revised September 2022)
completion. In all records, screenings were completed in full. All of the records were verified to
be completed by trained staff. Four of the five MAYSI-2s indicated further assessment was
required and a referral was made for further evaluation which included the referral reason. In the
remaining record, a referral was still submitted in accordance with facility operating procedures.
When the MAYSI-2 or other admission information indicated the need for an assessment, crisis
intervention, or emergency services, the facility administrator (FA) or designee was notified, and
a referral was made to alert the designated mental health clinician authority (DMHCA) in four of
the five records. One of the reviewed youth had a hit on the MAYSI-2 for suicide ideation and
the FA ensured an Assessment of Suicide Risk (ASR) was completed within twenty-four hours.
None of the reviewed youth were in crisis, nor were any placed on precautionary observation
(PO). The FA is responsible for developing written facility operating procedures for the
implementation of a standardized admission/intake mental health and substance abuse
screening process. The program’s policy addresses the standardized screening process which
includes review of commitment packet information, reports, and records; administration of the
MAYSI-2 in the Department’s Juvenile Justice Information System (JJIS) or Clinical Mental
Health Screening by a licensed mental health professional and Clinical Substance Abuse
Screening by a qualified professional, and referral of juvenile offenders identified by screenings
as in need of further evaluation or immediate attention. The policy also includes staff training in
mental health and substance abuse issues and administration of the MAYSI-2, and a
standardized process for referral of youth identified as in-need of further mental health and/or
substance abuse evaluation to an appropriate service provider/professional or, when immediate
attention is needed, to a hospital or Baker Act or Marchman Act receiving facility. An interview
with the FA confirmed the evaluation and assessment process.
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.
Five youth mental health and substance abuse records were reviewed for mental health and
substance abuse assessments/evaluations. The program completed a new, combined mental
health and substance abuse evaluation for all five youth. The new evaluations were completed
within thirty days of admission for all five records. Licensed mental health clinical staff or
licensed substance abuse clinical staff completed the evaluations in one record. The remaining
four records were completed by non-licensed clinical staff and then reviewed by licensed clinical
staff within ten calendar days of the evaluation being conducted. All five new combined mental
health and substance abuse evaluations included identifying information, reasons for the
evaluation, methods of assessment, patterns of alcohol and drug use, impact of alcohol and
drug use on major life areas, risk factors, relevant background information, behavioral
observations, Mental Status Examination, interview or procedures administered, discussion of
findings, diagnostic impression/formulation including diagnosis, and recommendations. Consent
was obtained for all five youth for substance abuse services. According to the designated
mental health clinician authority (DMHCA), when a youth completes the intake process to
include classification, problem areas are discussed with youth and the parent/guardian. During
the intake process, the licensed mental health practitioner (LMHP) gathers current information
from youth and within five days confirms the youth's reports by referring to collateral information
obtained in youth records to complete the Brief Behavioral Health Status Exam. Each youth
receives a comprehensive assessment within thirty days of the intake based on their current
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 30 of 66 (Revised September 2022)
and past behavior by a licensed or non-licensed mental health professional and it is then
reviewed by the clinical director or designee.
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.
Five youth mental health and substance abuse records were reviewed for mental health and
substance abuse treatment. All five initial mental health treatment plans were developed within
seven days of admission. All five initial mental health treatment plans were completed on a form
which included all elements of the Department of Juvenile Justice Initial Metal Health/Substance
Abuse Treatment Plan form. The initial mental health treatment plan or initial substance abuse
treatment plan for each youth was developed within seven days of the onset of treatment, or if
prescribed psychotropic medication, within seven days of the Initial Psychiatric Diagnostic
Interview. Each initial treatment plan was signed by the mental health clinical staff or substance
abuse clinical staff completing the form. Two of the five initial treatment plans were completed
by a licensed mental health clinical staff. The remaining three were signed by non-licensed
mental health clinical staff and signed by the licensed clinical supervisor within ten days of
completion. Each plan was also signed by all treatment team members who participated in the
development of the plan and the youth. Individual treatment plans and reviews contained within
each youth record included the youth’s psychiatric needs (when applicable), including
medication and frequency of monitoring by the psychiatrist. All five plans were developed within
thirty days of admission on a form containing all the elements of the Department’s Individualized
Mental Health/Substance Abuse Treatment Plan form. Reviews of the treatment plans were
conducted every thirty days in each of the five youth records. All five records showed the
Individualized Treatment Plan was signed by the mental health or substance abuse clinical staff
completing the plan. Four of the five individualized treatment plans were completed by non-
licensed mental health clinical staff and signed by the licensed clinical supervisor within ten
days of completion. All five Individualized Treatment Plans were signed by all treatment team
members who participated in development of the plan, the youth, and parent/guardian (as
allowed). All five youth plans included prescribed services which included individual, group, and
family therapy. Four of five plans included psychiatric service requirements. Goals and
objectives were individualized for each youth. Video observations were not conducted as all
groups are primary clinical services and are currently being monitored by the Department’s
Technical Assistance staff.
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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 31 of 66 (Revised September 2022)
The program has a written policy and procedures for youth treatment and discharge planning.
Five youth mental health and substance abuse records were reviewed for treatment and
discharge planning. Each of the five youth records showed each youth was assigned a
treatment team upon arrival to the program. A review of treatment team documentation showed
all required team members were in attendance. Three of the five youth were determined to be in
need of substance abuse treatment and received individual, group, and/or family counseling
provided by a licensed qualified professional or a non-licensed substance abuse clinical staff in
accordance with the youth’s initial or individualized substance abuse treatment plan. Each of the
five reviewed youth had a properly executed Authority for Evaluation and Treatment (AET) form
and provided consent through a signed Youth Consent for Substance Abuse Treatment form. All
the youth signed a Youth Consent for Release of Substance Abuse Treatment Records form. In
all five youth records, mental health treatment notes or substance abuse treatment notes were
documented on a form which contained all the required information of the Department’s
Counseling/Therapy Progress Notes form. Mental health and substance abuse group therapy
included individual psychotherapy or one-to-one counseling between a youth with a diagnosed
mental health disorder and a mental health clinical staff in all five records reviewed. The mental
health and substance abuse groups included psychosocial skills training. All five reviewed youth
records included documentation of the youth attending psychosocial skills training groups. A
review of progress notes determined youth received services as stipulated on the treatment plan
in all five records reviewed.
Three closed youth records were reviewed for discharge planning. The three discharge plans
were documented on the Department’s Mental Health/Substance Abuse Treatment Discharge
Plan form. No notification for suicide risk was necessary for the three records reviewed. Each of
the Mental Health and Substance Abuse Treatment Discharge Summaries documented
services needed for daily maintenance of positive improvement in behavioral, emotional, and
social skills made by youth during treatment. The discharge plans reflected all were discussed
with each youth, parent/guardian, and juvenile probation officer (JPO) during the exit
conference. A copy of the Mental Health and Substance Abuse Treatment Discharge Summary
form was provided to each youth, JPO, and parents/guardians.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program is contracted to provide specialized treatment for Substance Abuse Treatment
Overlay Services (SAOS) and Mental hHealth Overlay Services (MHOS). The scope of SAOS
and MHOS delivery is outlined within the contract between the provider and the Department.
The program is licensed under Chapter 397 and has a qualified professional on-site at least
forty hours a week. Substance abuse clinical staff are on-site seven days a week and mental
health staff are on -site at least five days a week. Counselor caseloads for SAOS do not exceed
sixteen youth and MHOS caseloads do not exceed twelve youth. Any non-licensed staff at the
program holds a master’s-level degree or were currently enrolled in a master’s degree level
program. The program at a minimum provided individual therapy once every two weeks, family
therapy monthly, and had a psychiatrist providing services at least once every two weeks. A
licensed psychologist and/or licensed mental health counselor provided on-site services as
needed and group therapy included four total substance abuse and/or mental health groups
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 32 of 66 (Revised September 2022)
each week for all youth. The program had no youth miss services due to quarantine during the
annual review period.
The program’s contract requires clinical groups including Living in Balance, Moral Recognition
Therapy (MRT), and Skillstreaming the Adolescent. All groups are primary clinical services and
are monitored by the Department’s Technical Assistance staff. Five youth were interviewed and
all five indicated they are receiving family and individual counseling. All five youth indicated
individual sessions occur weekly and family sessions occur monthly. Five staff were
interviewed, and all indicated they do not facilitate any group sessions. An interview with the
facility administrator indicated the program provides Intensive Mental Health, Borderline
Developmental Disability, Developmental Disability, Comprehensive Mental Health, or Medically
Complex Overlay services. All program youth shall be prescreened and placed by the
Department of Juvenile Justice based upon identified treatment needs. The focus of treatment
services shall include targeting and reducing/alleviating risk factors and addressing the youth’s
symptoms and co-occurring mental health and substance related disorders, as applicable
enabling the youth to improve functioning and ultimately functioning within the community.
Ancillary services shall be provided directly or through referral in instances where the program
cannot or does not provide certain services needed by the individual youth.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
Psychiatric services are provided by two psychiatrists who both possess a clear and active
license in the State of Florida, both expiring January 31, 2026. The psychiatrists are available
for emergency consultation twenty-four hours a day, seven days a week. The psychiatrists
providing psychiatric services brief a representative of the treatment team regarding the
psychiatric status of each youth receiving psychiatric services who is scheduled for treatment
team review. The psychiatrists’ evaluations and recommendations for the youth are
incorporated into the mental health clinical staff’s evaluations of the youth and the youth’s
individualized mental health or substance abuse treatment plan. A review of sign-in/out logs
confirmed visits during the annual compliance review period were conducted as required by the
contract for both psychiatrists. The psychiatrists actively participate in, manage, and supervise
psychotropic medication services in the program. The program did not use a back-up
psychiatrist during the annual compliance review period. An interview with one of the
psychiatrists confirmed their role at the program is to complete initial psychiatric exams for all
the patients assigned to their caseload. These are completed within two weeks of admission if a
youth arrived on medications, within thirty days if not on medications. The psychiatrist stated
they also review comprehensive evaluations of the youth prior to completing the initial
examination and obtain parental consent for any significant change or new medication. Follow-
up appointments are scheduled from one week to one month depending on the needs of the
patient. Youth on medication are reviewed in follow-up at least monthly. Patient's not on
medication are followed intermittently as needed by self-referral or referral through the youth's
therapist. The psychiatrist also confirmed they perform diagnostic evaluation services and in-
service training when designated. The psychiatrist meets with the designated mental health
clinician authority (DMHCA) weekly and an interview with the DMHCA indicated they meet with
both psychiatrists a total of two times a week.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 33 of 66 (Revised September 2022)
Five youth mental health and substance abuse records were reviewed for psychiatric services.
Four youth were admitted on psychotropic medications; however, all five received a diagnostic
interview within fourteen days of admission. Four youth were prescribed medications after the
initial interview. All five initial diagnostic interviews included the youths’ history, Mental Status
Examination, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V)
diagnosis consistent with the youth’s treatment plan, treatment recommendations, prescribed
medications, explanation of the need for psychotropic medication related to the youth’s
diagnosis, target symptoms, initial treatment goals, potential side effects, risks and benefits of
taking the medication, and frequency of medication monitoring/management. The initial
diagnostic psychiatric interview was documented on the Department’s Clinical Psychotropic
Progress Note (CPPN) form in all five records reviewed. The CPPN forms were clearly identified
as an “Initial Diagnostic Psychiatric Interview” in all five records. When the initial psychiatric
diagnostic interview resulted in the prescription of psychotropic medications or changes to the
youth’s existing psychotropic medication regimen, page three of the CPPN was completed,
regardless of the format used to document the psychiatric interview, in all five records.
Medication reviews were conducted monthly as required for the four applicable youth prescribed
medication. The psychiatric evaluation was documented on the Department’s CPPN form and
included all three pages in all applicable youth records. When the psychiatric evaluation resulted
in the prescription of psychotropic medication or changes to the youth’s existing psychotropic
medication, page three of the CPPN was completed in all applicable records reviewed. None of
the youth had an updated psychiatric evaluation completed; all youth had a new evaluation.
When psychotropic medication was prescribed/dispensed/administered by the psychiatrist,
identifying data, diagnosis, target symptoms of each medication, evaluation and description of
the effect of prescribed medication on target symptoms, prescribed psychotropic medication
information including the name, dosage and quantity of the medication, normal dosage range,
ordered dosage, frequency and route of administration, and reasons for changes in medication
and/or dosage were documented in all applicable records. The youth’s adherence to the
medication regimen, height, weight, blood pressure, most recent serum drug levels or laboratory
findings, when appropriate, telephone contact with the parent/guardian to discuss medication,
signature of the psychiatrist and date of signature were also documented in all applicable youth
records. The psychiatrist and nursing staff have documented monitoring for Tardive Dyskinesia
on a monthly basis as indicated on the CPPN in all applicable records reviewed. The program
did not use tele-psychiatry with the reviewed youth.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a written plan detailing suicide prevention procedures. The plan includes
identification and assessment of youth at-risk of suicide, staff training of six hours annually,
suicide precautions, levels of supervision including one-to-one supervision, constant
supervision, and close supervision, referrals, communication, notification, documentation,
immediate staff response, and a review process. The review process for suicide attempts and
mortality review includes circumstances surrounding the event, facility procedures relevant to
the incident, all relevant training received by involved staff, pertinent medical and mental health
services involving the victim, possible precipitating factors, and recommendations, if any, for
changes in policy, training, physical plant, medical or mental health services, and/or operational
procedures. The Suicide Prevention Plan is reviewed annually and was last reviewed March 25,
2024, by the designated mental health clinician authority (DMHCA) and the facility administrator.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 34 of 66 (Revised September 2022)
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors. Any youth exhibiting suicide risk behaviors shall be placed on
suicide precautions (precautionary observation or secure observation), and a minimum of
constant supervision. All youth identified as having suicide risk factors by screening,
information obtained regarding the youth, or staff observations shall be placed on suicide
precautions and receive an Assessment of Suicide Risk.
The program has a written policy and procedures for suicide prevention services. Five youth
mental health and substance abuse records were reviewed for suicide prevention services.
Each of the reviewed youth were screened during the admission process. An Assessment of
Suicide Risk (ASR) was completed during admission to the program and all five youth were
placed on standard supervision; however, one youth in the sample was subsequently placed on
precautionary observation (PO) and the program provided two additional records for review. In
all three records provided the ASRs were completed on the Department’s ASR form and each
youth was continued on PO. The youth’s parent/guardian and juvenile probation officer (JPO)
were notified of the youth’s placement on PO in all three records. Mental health staff continued
to provide supportive services while on PO. One ASR was completed by a licensed mental
health professional and two ASRs were completed by clinical staff under the supervision of a
licensed mental health professional and reviewed by a licensed staff within twenty-four hours
either in person or telephonically, or the next time the licensed staff was on-site. In all three
records the ASR was completed within the required time frame and each youth was continued
on PO. All three youth were maintained on PO until the Follow-Up ASR indicated suicide
precautions could be discontinued using the Department’s Follow-Up Assessment of Suicide
Risk form. When the youth’s Follow-Up ASR indicated suicide precautions could be
discontinued, each youth was stepped down to close supervision prior to transition to normal
routine and standard supervision. Close supervision was maintained for each youth until it was
determined no longer necessary by the designated mental health clinician authority (DMHCA) or
licensed mental health professional. Discontinuation of close supervision was documented in
each youth’s mental health/substance abuse record by a mental health clinical staff and there
was documentation of a conference held by the facility administrator and licensed mental health
professional to reduce level of supervision for each youth in accordance with the program’s
suicide prevention plan. An alert was initiated in the Department’s Juvenile Justice Information
System (JJIS) when each youth was placed on PO and each alert was ended following the
recommendations of the ASR. For all three youth there was evidence in the facility logbook
indicating administration or supervisory staff provided instructions related to the suicide risk
findings and suicide precaution decisions. While on precautionary observation, each youth was
allowed to participate in select activities with other youth in designated safe housing/observation
areas of the facility.
3.12 Secure Observation (Critical) Non-Applicable
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated non-
applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 35 of 66 (Revised September 2022)
3.13 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program has a written policy and procedures for the use of Suicide Precaution Observation
Logs. Five youth mental health and substance abuse records were reviewed for Suicide
Precaution Observation Logs. One of the five youth records reviewed was applicable for
precautionary observation (PO) logs; therefore, the program provided two additional records.
The PO logs were maintained for the duration each youth was on suicide precautions. In the PO
logs available for review, the appropriate level of supervision and observations of each youth’s
behavior was documented in real time and did not exceed thirty-minute intervals. Warning signs
were noted when observed in one applicable reviewed log. Notification of the facility
administrator or designee and mental health staff was documented on all three reviewed PO
logs. All the reviewed PO logs were signed by each shift supervisor, reviewed, and signed by
mental health staff, and documented the safe housing requirements. Five staff were interviewed
and stated when a youth expresses suicidal thoughts, direct care staff should notify mental
health, search the youth and their room for sharp objects, place the youth on constant sight and
sound, and document all supervision.
3.14 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program maintains a policy and procedures for suicide prevention training for staff. Ten
staff training records, five pre-service and five in-service, were reviewed for suicide prevention
training. All ten staff received suicide prevention training. The program maintains four suicide
response kits in the program. All suicide response kits are located on the youth living modules.
All dorms have suicide response kits co-located with first-aid kits. Reviewed documentation
confirmed the program is conducting mock suicide drills, at least once a quarter on each shift for
all staff who come in contact with the youth. The program conducted mock suicide drills each
month for each shift during the annual compliance review period. All mock mental health drills
included a suicide attempt or serious self-injury. No youth were used during the mental health
drills. After each drill, the program provided training on the emergency response procedures.
The program documented on each drill form “areas of improvement”. This information was then
reviewed with the staff who participated in the drill and during all staff meetings as documented
on the reviewed drill forms. If there were staff who were not present during a quarterly drill, they
did have an opportunity to review the drill scenario and procedures in an effort to understand the
process and receive the necessary training to respond to an incident of a suicide attempt or
incident of serious self-inflicted injury in the program. The facility administrator reported in
addition to drills, the facility has an emergency response plan to serve as the program’s
emergency response procedures and all staff receive training in this as well. Five staff were
interviewed and two stated drills are completed twice a month while the remaining three stated
they are done monthly. All five staff confirmed the suicide response kits are located on the
dorms.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 36 of 66 (Revised September 2022)
3.15 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a written crisis Intervention plan which includes notification and alert system,
means of referral, including youth self-referral, communication, supervision, documentation, and
review.
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a written mental health crisis intervention and emergency mental health and
substance abuse services plan which was reviewed and approved by the facility administrator
and designated corporate staff on March 25, 2024. None of the five reviewed youth mental
health and substance abuse records were applicable for requiring a Crisis Assessment. The
program reported there were no applicable Crisis Assessments conducted since the last annual
compliance review.
3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a written emergency mental health and substance abuse services plan which
includes immediate staff response, notifications, communication, supervision, authorization to
transport for emergency mental health and substance abuse services, transport for emergency
mental health evaluation and treatment under Chapter 394, Florida’s Baker Act, transport for
emergency substance abuse assessment and treatment under Chapter 397, Marchman Act,
documentation, training, and review.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 37 of 66 (Revised September 2022)
3.18 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
3.19 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program maintains a policy and procedures addressing the safety planning process. A
review of five youth safety plans showed all five plans included warning signs, youth’s baseline
behaviors as gathered from collateral contacts, parent/guardian input, youth’s history, and
evaluations, if applicable. All five plans also included crisis recognition, intervention strategies,
debriefing preferences, and crisis recognition. All five safety plans were developed on the day of
admission; therefore, meeting the fourteen-day time frame. All five plans were jointly prepared
by the youth, program’s clinical staff and other applicable staff involved with the treatment of the
youth. None of the youth’s parents/guardians provided input on the youth’s safety plans;
however, the program provided a means for the parents/guardian to provide input. All five safety
plans incorporated recommendations from previous or current clinical assessments or screening
instruments and incorporated trauma responsive practices. All five plans were reviewed and
updated as necessary at least every thirty days. All five plans were reviewed and updated as
necessary following any significant behavioral or mental health event identified by the youth’s
intervention and treatment team. The safety plans are reviewed by staff who have contact with
the youth and are maintained in the youth’s case management record, mental health record,
and in a binder in master control. Five youth were interviewed and all confirmed they contributed
to their safety plans. An interview with the facility administrator confirmed the safety plan
development and review process as well as what is included in each plan and the process for
updating them.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 38 of 66 (Revised September 2022)
Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program’s designated health authority (DHA) is a licensed physician who holds an
unrestricted license and meets all requirements for independent and unsupervised practice in
Florida. The DHA license expires on March 31, 2026. The DHA’s specialty training is in family
practice with experience in adolescent health. The DHA does not have any disciplinary cases or
public health complaints on record. According to the contract, the DHA is required to be on-site
one hour each day five days a week. A review of the sign-in sheets for the annual compliance
review period indicated the DHA was on-site, as required. A back-up DHA was not utilized
during the annual compliance review period. The DHA reviewed facility procedures as
documented by signature and date. There was no inclusion of telemedicine in the facility’s
contract. The DHA was interviewed, and confirmed their responsibilities include performing
Comprehensive Physical Assessments upon intake, reviewing health-related history, chart
review, lab review, provide medical care, and review policy and procedures.
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 four licensed practical nurses (LPNs) and eight registered nurses (RNs), one
of the RNs serves as the health services administrator (HSA), and four licensed practical nurses
(LPN). A review of each license credentials reflected each of the nurses have a clear and active
license, in the State of Florida, according to the Florida Department of Health Medical Quality
Assurance website. In addition, each of the LPNs and RNs had current cardiopulmonary
resuscitation (CPR) certifications. The required on-site hours according to the contract are
seven days a week for a total of 220 hours. The nursing staff were in compliance with the
contractual requirements and nursing coverage is provided twenty-four hours a day as required
by the program’s contract.
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has a policy and procedures for all health-related protocols utilized at the program.
The designated health authority (DHA) and facility administrator (FA) signed and dated all
treatment protocols. The DHA and FA reviewed and signed protocols and facility operating
procedures (FOPs) on February 5, 2025, and February 4, 2025, respectively. FOPs and
protocols related to psychiatric services and psychotropic medication management are
developed and reviewed by the program’s psychiatrist. The psychiatrist reviewed and signed the
psychiatric protocols on March 25, 2024. The nursing protocols were signed by the nursing staff
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 39 of 66 (Revised September 2022)
on January 13, 2025. There were no new policies or changes in policy made during the annual
compliance review period. An annual review of all FOPs and protocols was conducted by the
respective individuals from each discipline on February 6, 2025, with a signature signifying their
understanding of the FOPs and any new health-related Department policies. All newly hired
medical staff receive a comprehensive clinical orientation to the Department’s healthcare
policies and procedures conducted by the registered nurse (RN). The DHA had written and
authorized approval of treatment protocols and standing procedures which were not delegated
to any other person.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
Five Individual Healthcare Records (IHCRs) were reviewed for the completion of the Authority
for Evaluation and Treatment (AET) forms and four were applicable. The four applicable, valid
AETs, signed by the parent/guardian and Department representative, were stamped as a copy
and filed each IHCR. One youth was in the care of the Department of Children and Families and
had court orders filed in the IHCR relating to the parent’s termination of rights as well as court
authorizing all treatment and procedures. The interviewed nurse stated AETs are obtained from
the juvneile probation officer, and confirmed once a youth turns eighteen a consent is signed.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures to ensure the parent/guardian is notified of significant
changes in the youth’s condition and obtain consent. A review of five youth Individual
Healthcare Records (IHCRs) found two were applicable for parental/guardian notifications for
over-the-counter (OTC) medications beyond those covered by the Authority for Evaluation and
Treatment (AET) and each IHCRs had documentation consent was provided by the
parent/guardian. Four reviewed IHCRs were applicable for new medication being ordered and
three records documented in the progress notes the parent/guardian was notified, as well as
written notifications documented on the Department’s Parental Notification of Health-Related
Care: General or Parental Notification of Health-Related Care: Medications forms. One youth
was in the care of the Department of Children and Families (DCF), and a court order was
included in the IHCR authorizing all treatment and procedures. Four of the five reviewed youth
were taking prescribed psychotropic medications at admissions and staff witnessed all
telephone attempts and conversation. Three of the youth were applicable for a new
psychotropic medication, change in dosage, or discontinuation of medication which was
documented on page three of the Department’s Clinical Psychotropic Progress Note (CPPN)
form. In each reviewed IHCR, the youth vaccinations were verified within thirty days of the
youth’s admission. None of the youth were applicable for obtaining consent prior to
administering a vaccination, which was confirmed by a signed Department’s Parental
Notification of Health Related Care: Vaccinations/Immunizations form filed in the youth’s IHCR.
The interviewed nursing staff confirmed it is required to send parental notification when
medication changes occur, which are sent out the same day as the change. If the medication is
psychotropic, the psychiatrist obtains verbal consent from the parent/guardian, which is
witnessed by the nurse, as well as sending a written consent with a copy of page three of the
CPPN. If an emergency medical situation occurs, emergency services are contacted and the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 40 of 66 (Revised September 2022)
DHA and parent/guardian are notified. The nursing staff explained immunizations records are
obtained through the Florida Shots website, school records, and/or county health department,
and, if needed, immunizations are given on-site.
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.
Five youth Individual Healthcare Records (IHCRs) were reviewed for completion of a Facility
Entry Physical Health Screening (FEPHS) form. All five FEPHS forms were completed by the
registered nurse (RN) or licensed practical nurse (LPN) on the date of the youth’s admission.
None of the youth were out of the physical custody of the Department. The interviewed nursing
staff explained they are notified of a new admission through management meetings and emails
and the youth is seen by medical staff within thirty minutes of arrival to complete screening,
which is filed in the youth’s IHCR. If a change in custody occurs a new FEPHS is completed.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy and procedures ensuring healthcare service orientation is provided to
all youth when admitted to the program. Five reviewed youth Individual Healthcare Records
(IHCRs) confirmed all youth received a general care orientation upon admission. A review of
The Health Education forms, signed by all five youth and filed in each IHCR, confirmed
orientation discussion included access to medical care, sick call procedures, what constitutes an
emergency and when to notify staff, medication process, right to refuse care and
documentation, what to do in the case of a sexual assault or attempted sexual assault, the role
of non-disciplinary healthcare providers, and Standard Universal Precautions.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a policy and procedures to notify the designated health authority (DHA) or
designee, by telephone or verbally, of all youth’s arrival at the program and provide immediate
notification when any youth admitted to the program requires emergency care. Five youth
Individual Healthcare Records (IHCRs) were reviewed and though four were applicable
requiring a referral to the DHA due to the youth being admitted with a known or suspected
chronic condition, all five IHCRs documented the DHA notification, completed on the day of and
within twelve hours of admission, in each youth’s Chronological Progress Note. None of the
youth were identified as in need of an emergency response upon admission. Four youth were
applicable for taking psychotropic medication upon admission, and notification to the psychiatrist
was documented. The interviewed nursing staff confirmed the DHA is notified if a youth is
admitted with a serious or chronic condition and documented in the progress notes.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 41 of 66 (Revised September 2022)
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) found a Department’s Health-
Related History (HRH) was completed on the day of the admission, prior to the Comprehensive
Physical Assessment (CPA), as evidenced by date and signatures for each youth. On each
HRH, the designated health authority (DHA) noted a review on the form as evidenced by a
checkbox on the CPA and a focused note in the admission documentation. The interviewed
nursing staff stated medical staff are responsible for completion of the HRH at admission.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
A review of five Individual Healthcare Records (IHCRs) confirmed the program utilized the
Department’s Comprehensive Physical Assessment (CPA) form and each CPA was completed
by the designated health authority (DHA) within seven days of the youth’s admission to the
program. Each IHCR had the youth’s Medical Grade documented on the CPA. The program
completes a new CPA for all youth, no prior CPAs were utilized. All sections of the CPA were
completed in full utilizing required markings. Four of the five reviewed records indicated a
refusal of the genital exam which was documented as “youth refused” on the applicable CPAs in
the IHCRs, and the four applicable youth signed a refusal form which reflected the refused
portion on the CPA. All five reviewed CPAs included documentation of the most recent verified
Tuberculosis Skin Test (TST), which was administered within the last year to determine
exposure to tuberculosis (TB). The results of the TST were documented on each youth’s CPA
and matched the documentation on the Department’s Infectious and Communicable Disease
(ICD) forms. The Department’s Problem List was updated for each youth, when applicable. The
interviewed nusrsing staff confirmed a CPA is completed by the DHA upon admission and
annually thereafter. Nursing staff stated TB screening are completed within seventy-two hours
of admission by either TST or chest x-ray.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures to ensure all youth admitted are evaluated and
treated, if applicable, for sexually transmitted infections (STIs) and human immunodeficiency
virus (HIV). A review of five Individual Healthcare Records (IHCRs) found one youth was
applicable for being clinically screened and evaluated for STIs on the date of admission. Two
additional applicable IHCRs were requested and provided. Each youth was applicable for further
evaluation or referred to the DHA, which was documented on the Department’s Sexually
Transmitted Infections form. All three youth had orders for testing which was performed. All
testing, screening, clinical evaluations, and diagnoses were documented on the Department’s
Infectious and Communicable Diseases (ICD) forms, excluding the HIV results, and were filed in
the lab section of the IHCR. None of the youth were out of the Department’s physical custody;
therefore, a rescreening was not applicable. Each youth were offered pre/post-test counseling,
testing, and referral for treatment for HIV. One youth did not consent for the HIV test. Two IHCR
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 42 of 66 (Revised September 2022)
documented the consent by each youth to receive a HIV test. One youth’s HIV results were filed
confidentially in a sealed envelope marked “Confidential” and signed by the DHA indicating their
review. The remaining youth received the HIV test after a change in Florida Administrative Code
which only requires the test being filed in the IHCR in a confidential marked envelop. Pre/post-
test counseling was documented on both youth’s Individual Health Education Record. Each
youth’s confidentiality was protected by not including the youth’s HIV status on the program’s
internal alert system. The program’s policy ensures the youth’s HIV test results are only
disclosed to the youth’s legally authorized representative, healthcare providers during treatment,
the Department of Health for purposes of reporting, health facility staff committees conducting
facility monitoring, medical personnel who have been subject to significant exposure, and
healthcare facility personnel or agents for healthcare provider who have a need to know during
patient care. Pre and post-test counseling services are provided by the Health Department staff
certified in HIV counseling and/or medical staff. All five interviewed staff stated they can ask for
a HIV test if needed. The interviewed nursing staff confirmed the policy and procedures for STI
screening.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a policy and procedures addressing the sick call process. Five reviewed
Individual Healthcare Records (IHCR) found two were applicable for in need of a sick call. One
additional IHCR was requested and provided for review. None of the reviewed youth presented
with a similar sick call complaint three or more times within a two-week period. Each youth
completed a Sick Call Request form which was also completed by nursing staff and filed in each
youth’s IHCR in reverse chronological order. Two sick calls were conducted by a licensed
practitioner nurse (LPN) which was reviewed and documented by the registered nurse (RN).
None of the youth were in restricted housing of any kind. Each Sick Call Request form and
progress note was documented in accordance with Florida Administrative Code, including vital
signs, treatment, education, and follow-up plans. Each of the sick call events were documented
on the Sick Call Index and on the program’s Sick Call Referral Log. All the dates listed on the
Sick Call Index corresponded to the completed Sick Call Request forms located in each
reviewed IHCR. Sick call hours, conducted twice daily by only licensed staff, are posted on the
medical office door, in the education area, and each dormitory. Sick call forms are located on
each dormitory. An exam table and equipment are used to perform sick call. Five interviewed
youth stated they are seen within one day of submitting a sick call request. The interviewed
nursing staff advised once a youth completes and submits a sick call form in the sick call box
they are seen within two hours by the nurse or the designated health authority (DHA), if on-site,
with sick call being conducted twice daily. If a youth presents with a similar sick call three times
in a two week period, the youth are referred to the DHA and added to the log. The nurse stated
the DHA approves treatment protocols and if youth are in restricted housing they are still offered
sick call by nursing staff. The program provides medical care twenty-four-hours a day. A sick
call was not able to be observed for one did not occur while the review team was on-site during
the annual compliance review.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 43 of 66 (Revised September 2022)
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a policy and procedures for a comprehensive process for the provision of
episodic and first-aid care. Five reviewed youth Individual Healthcare Records (IHCRs) found
three were applicable to require on-site episodic care. Each IHCR documented the on-site care
was provided by a licensed healthcare staff and included the problem-oriented, subjective,
objective, assessment, and plan (SOAP) elements. The program has a total of ten first-aid kits
located in designated areas throughout the program. The kits are in the kitchen, maintenance,
medical, multipurpose room, one in each of the dormitories, and four for transport. The program
monitors each first-aid kit monthly to ensure the contents are maintained and stored in
accordance with guidelines to prevent expiration or deterioration, which reviewed
documentation on the first-aid logs confirmed is being completed as required. An observation of
three first-aid kits confirmed the kits were fully stocked with designated health authority (DHA)
approved contents. The program has two automated external defibrillators (AEDs) located in
medical and Charlie dormitory. The AED procedures are located with each AED and each AED
batteries and pads are checked by nursing staff once a month, confirmed through
documentation review. The nurse conducted a self-test of the AEDs during the week of the
annual compliance review, with no issues noted. The batteries of the AED were last changed
March 2024 and July 2023 and expire September 2029 and March 2027 respectively. The AED
pads were last changed October 2023 and January 2025 and expire November 2028 and April
2027, respectively. The program had a list of emergency numbers, accessible for all staff,
posted in medical and master control, which are inaccessible to youth. A review of ten staff
training records confirmed all staff were trained in episodic, first-aid, and emergency care, and
the administration of the epinephrine auto-injector.
A review of the emergency drills during the annual compliance review period confirmed the
program conducted announced and unannounced emergency drills monthly on each shift, to
include cardiopulmonary resuscitation (CPR)/AED at least annually. The program ensures all
staff have the opportunity to participate in at least one emergency CPR drill annually. A review
of video footage and drill documentation confirmed the emergency medical drills simulated an
episodic care event which called for immediate first-aid and/or administration of CPR
techniques, and the initiation of emergency procedures to follow when a life-threatening
emergency does occur. An episodic care event was not able to be observed for one did not
occur while the review team was on-site during the annual compliance review. The program has
a written policy and procedures regarding access and use of Narcan. The policy states all newly
employed staff and admitted youth shall receive education on recognizing and treating
symptoms of opioid overdose. Training includes risk factors for overdose, strategies to prevent
overdose deaths, overdose recognition and response, and administration of Narcan. The
training and prevention plan also includes emergency response procedures. Narcan is stored in
medical in the medication cart and inventoried along with other medication. Medical staff and
supervisors have access and are trained on the use of Narcan. One of five interviewed staff
confirmed they are allowed to call 9-1-1 in the event of an emergency. Three staff stated they
would notify supervisor who would call, and one staff stated they would notify master control to
call. Five interviewed youth confirmed they can see a doctor if needed. The interviewed nursing
staff provided information relating to AED and location of emergency numbers. Nursing staff
also verified emergency drills are completed monthly on each shift.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 44 of 66 (Revised September 2022)
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a policy and procedures to ensure timely referrals, coordination, and
documentation of medical services to an off-site healthcare provider. Five reviewed Individual
Healthcare Records (IHCRs) found two were applicable for off-site care. One additional
applicable IHCR was requested and provided for review. All three applicable IHCRs indicated
an off-site first-aid or emergency care was required and confirmed by the documentation on the
Department’s Summary of Off-Site Care Consultation Report form filed in each IHCR. All three
IHCRs had documentation of the parent/guardian notification efforts. All reviewed IHCR
documentation confirmed discharge findings, instructions, and information documentation was
present, which was reviewed and signed by the DHA. All three youth required follow-up testing,
referrals, and/or appointments which documentation confirmed are tracked; and each youth
received appropriate and timely follow-up care. The interviewed nursing staff confirmed all off-
site emergency care or first-aid are tracked on the transport log, episodic log, and documented
in progress notes. Upon return, all forms are reviewed with the DHA to ensure all orders are
followed, which is documented on the order sheet. The DHA follow-ups on the next on-site visit
and reviews all flagged off-site care forms which are flagged for DHA review, and youth are
tracked utilizing an appointment binder and white board.
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) found three were identified on the
Department’s Facility Entry Physical Health Screening (FEPHS) form with a current chronic
condition at admission. None of the youth were identified as having a communicable disease or
undergoing treatment for a physical health condition. Two of the youth were taking prescribed
medication on an on-going basis. All three youth were classified with a Medical Grade of two to
four and were placed on the program’s Chronic Illness List, as well as the Department’s
Problem list being updated as required. Two of the three were applicable for receiving periodic
evaluations which were completed at least every ninety days, as required. One youth was not
applicable and was still within ninety days of being admitted into the program. None of the youth
were applicable for taking anti-tuberculosis medications. One youth was applicable for needing
a periodic evaluation prior to renewing an expiring medication, which was completed as
required. None of the youth had an evaluation conducted off-site. There was no evidence of any
lapses in care or missed periodic evaluations. The interviewed facility administrator (FA) verified
youth’s medication is ascertained upon admission and to ensure no lapses occur, all
prescriptions are processed immediately if necessary or are obtained expediently from a
licensed pharmacy or local pharmacy in the event of an emergency, with parental notifications
being sent. The interviewed designated health authority (DHA) confirmed periodic evaluations
are completed every three months for youth with chronic conditions, with a tracker and calendar
being utilized to endure youth receive evaluations. The interviewed nursing staff confirmed an
appointment binder and white board are utilized to track all youth with chronic conditions as well
all follow-up testing, referrals, and appointments.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 45 of 66 (Revised September 2022)
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.
Five Individual Healthcare Records (IHCRs) were reviewed for medication management. All
reviewed records indicated on the Department’s Facility Entry Physical Health Screening
(FEPHS) and progress notes each youth was taking medication at the time of admission. Each
of the youth medications were verified prior to the youth being admitted into the program which
was noted on the youth’s Chronological Progress Notes. The designated health authority (DHA)
and the psychiatrist were notified for each youth at admission and was contacted to obtain an
order to resume the specified medications prescribed prior to admission for each youth. Each
IHRC documented the youth received medication while in the program and all medications were
continued, discontinued, changed, or new medications ordered utilizing the Practitioner Order
form. Each medication had a current and valid prescription or order. None of the youth were in
restricted housing of any kind. Two of the five reviewed youth were applicable for over-the-
counter (OTC) medications, which were administered according to approved protocols. The
Department’s Medication Administration Record (MAR) was used to document all medications
and treatments for all reviewed IHCRs and each MAR clearly indicated medication start and
stop dates of each youth’s medications. In all applicable IHCRs, the nursing staff initialed each
administered medication entry. Non-healthcare staff do not assist in delivery of medications.
There were no undocumented explanations for lapses or errors in medication administration for
any of the reviewed IHCRs. The registered nurse (RN) documented side-effects monitoring
weekly on the MAR for all five reviewed IHCRs. Two youth had refusals, which were clearly
documented on the MAR. The MAR contains all required elements. Each youth’s picture is
located in the current MAR binder along side of the MAR. None of the youth required parenteral
medication. Four of the five youth were admitted to the program on psychotropic medications
and the psychiatrist was notified. Each applicable youth received a psychiatric evaluation within
fourteen days and received periodic evaluations every thirty days as required. There were no
standing orders for psychotropic medications, emergency treatment orders for psychotropic
medication, or any pro-re-nata (PRN) orders for psychotropic medications.
Three medication passes were observed, and the nurse’s sole responsibility was the delivery of
medication and was not supervising youth. The youth were escorted by the assistant facility
administrator and each approached the nurse individually. The medical provider identified
themself and confirmed the reason each youth was present. The medical provider prepared the
medication and verified each youth’s allergies and alert status. The medical provider initialed the
MAR as well as ensured the medication was swallowed. The Six Rights of Medication
Delivery/Administration were maintained for each youth. One additional youth was brought up
by accident and due to the nurse following medication delivery, the misunderstanding was
caught showing the nurse’s diligence. One of five interviewed youth reported the nurses give the
medication and was able to explain the process. The remaining four youth do not take
medication. The interviewed nursing staff stated when a youth is admitted a medication
verification is verified with the previous doctor, if applicable.
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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 46 of 66 (Revised September 2022)
The program has a policy and procedures to ensure medical equipment classified as sharps
and medications are secure and inventoried utilizing a routine perpetual inventory. Reviewed
medical equipment classified as sharps confirmed the items were securely stored and
inventoried utilizing a routine perpetual inventory descending count. Reviewed medications
were identified and secured in a locked, clean, and organized medication cart designated for
storage of medication, located in a secured area inaccessible to youth, with narcotics and other
controlled medications being stored behind two locks, and refrigerated medication being stored
in a secured refrigerator only used for medication. Stock items are kept separate from youth
specific medications. The program’s process for the destruction and disposal of non-controlled
medications is for two nurses to destroy all medication using the chemical drug buster.
Controlled medication is destroyed when the pharmacist consultant is on-site with one
registered nurse (RN). Discontinued medications are sent back to the pharmacy. A review of the
programs perpetual and weekly inventory of all sharps and stock over-the-counter (OTC)
medications verified completion as required with no discrepancies. Reviewed documentation
verified the nursing staff maintain a shift-to-shift inventory of all controlled substances which is
documented on each youth’s Individualized Controlled Medication Inventory Record. Nursing
staff are on-site twenty four hours a day to provide oversight and the delivery of medication.
Observations were conducted of inventory counts of three controlled medications, three OTC
medications, and three sharps with no discrepancies found. The interviewed nursing staff
confirmed controlled medication is located behind double locks in the medical office and are
destroyed as witnessed by the pharmacist consultant and one nursing staff. The health services
administrator (HSA) reported if there is a discrepancy in the count, the nursing staff will inform
the HSA and facility administrator (FA) immediately and conduct a recount and inventory to
check and/or find where the discrepancy originated. Once confirmed, a call to the Department’s
Central Communications Center (CCC) will be placed.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a policy and procedures related to an Infection Control and Exposure Control
Plan. The Infection Control and Exposure Control Plan, which is written in accourdance with the
Occupational Safety and Health Adminstration and available to all staff, is signed annually and
was reviewed and signed by the designated health authority (DHA) on February 5, 2025, facility
administrator (FA) on February 4, 2025, and provider’s corporate office on February 4, 2025.
The program’s infection control procedures include common infectious diseases of childhood,
self-limiting, episodic contagious illnesses, viral and bacterial infectious diseases, tuberculosis,
Hepatitis A, B, and C, human immunodeficiency virus (HIV), infectious diseases caused by
bloodborne pathogens, other outbreaks or epidemics caused by any other infectious agent,
outbreaks of lice or scabies, Methicillin-Resistant Staphylococcus Aureus (MRSA) and other
antibiotic resistant micro-organisms, foodborne illnesses, bio-terrorist agents, and chemical
exposures. The program offers Hepatitis B immunizations to staff as well have access to
personal protective equipment. The program has a comprehensive process for needle stick
post-exposure evaluation. If necessary, the program would have a separate file containing all
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 47 of 66 (Revised September 2022)
documents of youth and staff who have experienced a program or occupational exposure;
however, there has not been a need as neither youth nor staff have had an exposure or any
reportable infectious disease. The interviewed FA confirmed the plan is located medical and
master control, with the staff completing a bi-annual review of the plan. The interviewed nursing
staff confirmed infectious and exposure control plan training is provided by the health services
administrator (HSA) and nursing staff provide training to youth at admission and on an as
needed basis. Nursing staff routinely utilize the county health department to obtain youth
immunizations.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 48 of 66 (Revised September 2022)
Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures stating how the program shall maintain active
supervision of youth at all times. Active supervision is described as 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 behavior management system.
Additionally, program staff shall be able to account for the whereabouts of youth under their
supervision at all times.
Observations of staff during the annual compliance review week found staff supervising youth
appropriately during all observed activities, three staff were able to accurately provide the
number of youth under their current supervision when asked. According to the policy and
procedures provided to the annual compliance review team, staff-to-youth ratios are one staff
to eight youth during awake hours, one staff to ten youth during sleep hours, and one staff to
five youth for off-site activities. Observed activities made during the four-day annual
compliance review were supervision of youth during school hours, in the dining area,
recreation, supervised cleaning activity, and youth movement through the program. The daily
schedules were posted in the dormitories, common areas, and cafeteria. Youth were observed
to be supervised at all times during the annual compliance review week. Positive interactions
were observed between youth and staff. Youth were observed while they were in their sleeping
rooms.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom. All staff
shall be trained in the BMS utilized at the program.
The program maintains a policy and procedures addressing the implementation and training of
the program’s behavioral management system (BMS), which has not changed since the last
annual compliance review and contains all the required elements. The program utilizes the
iChoose System which is a coordinated system of promoting, monitoring, recognizing, and
rewarding a youth’s progress. It is a program of incentives and consequences which promote
individualized skill building, appropriate behavior, and accountability. Staff use point cards to
monitor how well the youth are progressing in the program. Youth earn points daily for
complying with the program rules. At the end of each day, the points are totaled, and the youth
are rewarded based on the number of points earned.
Each youth enters the program on an orientation level prior to starting the BMS and progresses
their way up the four levels. A review of the BMS confirmed it is not used solely to increase a
youth’s length of stay, deny basic rights or services, promote the use of group punishment,
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 49 of 66 (Revised September 2022)
allow youth to punish other youth, or include disciplinary confinement. Youth learn about the
BMS during the orientation process, each youth is provided a program handbook which
describes the BMS. A review of the youth handbook indicated the BMS is included and clearly
written. A review of ten staff training records indicated staff were trained on the BMS. Education
staff are Florida Virtual School (FLVS) and each educator received BMS training by the
program’s staff development manager. The education staff is not responsible for the
implementation of BMS, the program staff remains responsible for the implementation of BMS
throughout the school day. A review of ten youth case management records indicated each
youth participated in orientation upon arrival to the program and received a copy of the youth
handbook. Observations found the BMS was posted throughout the program and accessible to
youth. Observations of staff and youth interactions verified staff were adhering to the BMS by
utilizing a ratio of four-to-one positive to negative consequences when redirecting the youth as
indicated in the program’s policy. A review of the program’s BMS indicated a variety of
rewards/incentives: staff vs youth kickball games, candy, snacks, youth night outings, and pizza.
Special provisions were outlined in the program’s contract, assuring ongoing supportive
services for the youth who may experience relapse, incorporate principles and practices related
to trauma informed care, and will ensure positive reinforcement is implemented.
Ten staff were interviewed, and all ten reported they were trained in the BMS. Ten staff stated
the BMS consists of a point system to include different levels with rewards and consequences.
The interviewed staff stated the BMS rewards youth with daily and weekly incentives including
reward parties, extra snacks, hygiene, ice cream, off-site activities, and canteen. Each of the ten
interviewed staff stated nothing can be taken away from a youth as a consequence and youth
are informed of the consequences of their behavior at the time of the incident and are able to
explain. The ten interviewed staff reported the supervisors inform staff on how the BMS should
be utilized and provide feedback during shift briefings, at meetings, and one-on-one if
corrections are needed. Ten youth were interviewed, and each youth stated the consequences
included emergency treatment team, level freezes, privilege restriction, and early bedtime. Ten
youth reported they receive daily and/or weekly incentives such as special meals, snacks, and
canteen. Each youth was familiar with the program’s BMS level system stating upon entering
into the program they start as a Freshman then move up in rank upon completion of a packet
with each level. All ten youth reported staff use rewards the same. All ten interviewed youth
reported youth are not allowed to punish other youth. An interview with the facility administrator
(FA) confirmed the program utilizes the iChoose System BMS and reiterated the program’s
BMS policy.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, and practice confirm the program does not use room
restriction; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 50 of 66 (Revised September 2022)
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a policy and procedures in place to conduct and document ten-minute checks
during sleeping hours or at other times when youth are behind a locked door, such as during an
illness. The program has a total of 177 video cameras capable of recording thirty-days of video
footage. During the annual compliance review week, all 177 of the cameras were operational.
Prior to conducting checks, staff are positioned where they are able to see any movement within
the living unit. Staff are required to conduct room checks every ten minutes and document the
time of the check on the Ten-Minute Check Log when youth are sleeping. The program’s
practice is to complete checks at eight minute intervals, master control initiates the checks using
radio communication, so all dormitories are completed at the same time. A video review of ten-
minute checks, including samples from each of the living units, verified staff were conducting
checks every eight minutes and documented the times accurately on the Ten-Minute Check
Log. In addition, the Ten-Minute Check Logs since the last annual compliance review were
reviewed. A sample of various days, times, and shifts indicated the ten-minute checks were
completed within the required frequencies. Ten interviewed staff verified room checks are
conducted every eight minutes when youth are placed in their rooms for sleeping or non-
punishment reasons. In a formal interview, the facility administrator stated the program has 177
working cameras with video recording capabilities for thirty days.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day. The program shall conduct and document
youth counts, minimally, at the beginning of each shift, after each outdoor activity, and during
emergency situations such as escapes or riots. The program shall maintain a chronological
record of events as they occur, or, if an event disrupts the safety and security of the program,
as soon as is feasible after order has been restored. The program tracks daily census
information, including, at a minimum, the total daily census count, new admissions, releases
or direct discharges, transfers, and youth temporarily away from the program. If at any time
staff cannot account for the whereabouts of any youth, or discrepancies are found between
youth counts and census information, the program reconciles immediately and takes follow-
up action, as needed.
The program maintains a policy and procedures to ensure youth are always accounted for
through a system of physically counting youth at various times throughout each day. The
program conducts formal head counts each hour and after outdoor activities. The program’s
policy indicates counts are conducted during power outages, escapes, program disturbances, or
any other disruptions which may occur. A review of the policy and procedures and well as the
Continuity of Operations Plan (COOP) verified program staff must always account for the
whereabouts of the youth in the care and custody of the program. This includes the need for
continual head counts to be conducted minimally at the beginning of each shift, during any
emergency situations, and at regular intervals. A review of twelve randomly selected dates and
times in the program’s logbook since the last annual compliance review validated head counts
were conducted at the beginning of each shift, hourly, after outdoor activities, during emergency
situations such as program disturbances, and during actual and/or simulated drills. In addition,
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 51 of 66 (Revised September 2022)
the program logbooks included documentation of new admissions, releases, transfers, and
youth temporarily away from the program. Observations made during the annual compliance
review week indicated it is the program’s practice to conduct hourly youth counts and to
announce youth counts before all movement. Ten interviewed staff explained formal counts are
conducted every hour. Ten interviewed staff explained formal counts are conducted every hour
and informal counts are conducted with every youth movement. Each staff stated emergency
counts are conducted when youth are missing, after emergency drills, and if there is a
discrepancy in the count.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a policy and procedures to ensure the maintenance of a chronological
record of events, incidents, and activities in a central logbook. The program maintains a bound
logbook with numbered pages for each month. A review of logbook entries
confirmed they were documented in ink with no erasures or white-out areas. Errors were
struck through with a single line, dated, and initialed by the staff correcting the error.
Reviewed documentation of randomly selected days within the logbooks reflected each entry
included the date and time of the event, the name of the staff and youth involved, as well as a
brief description, the name, and signature of the staff making the entry. Logbooks included
entries for emergency situations, population counts, law enforcement access to youth, perimeter
checks, and youth movement. In addition, admissions and releases were documented as well
as transports away from the program. There were no precautionary observations during the
annual compliance review period to review. A review of the activity schedule and logbook
documentation verified there was minimal interference of education instruction. Logbook entries
for education included youth movement to and from the classrooms and school start and end
times. Logbook entries and observations verified recreation was conducted as scheduled. A
review of internal incidents reported to the Florida Abuse Hotline and/or the Department’s
Central Communications Center (CCC) verified each were documented in the logbook. The
program ensures direct care staff, including each supervisor, are briefed when coming on duty.
Each staff signs the shift briefing section of the logbook to acknowledge receiving the
information. Observation of the youth living areas confirmed a copy of shift reports were
maintained in each living area for forty-eight hours.
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 for assignment, inventory, tracking, and storage of
program keys. Keys are bound on a tamper resistant ring which includes a brass-colored tag
with the number of keys and a tracking number. The facility administrator (FA) is responsible for
inventory and tracking of all program keys including issuance, verification activities, and tracking
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 52 of 66 (Revised September 2022)
of keys including retrieval of keys from permanent staff. Shift supervisors with the assistance of
the master control operator are responsible for the inventory, issuance, and return of keys from
shift to shift. Observations verified program keys and staff personal keys are maintained in
master control in a secured cabinet with a lock. The program has a Daily Key Log to track keys.
The log indicates the name of staff and what type of key they are to be assigned according to
their position. The program maintains a master inventory list of program keys. A random check
of five different sets of program keys compared to the inventory list indicated the keys were
accounted for. The program identifies keys as active and restricted which are kept in a locked
drawer below the key cabinet in master control. Active keys are assigned to direct care staff
while restricted keys are designated for medical staff, kitchen staff, case managers, and
therapists. The program’s practice is when staff arrive at the program, personal keys are
collected by master control and placed in the key cabinet. Active program keys are given to staff
by master control who also documents in the key logbook. A review of the key logs since the
last annual compliance review verified this practice. In addition, the program has a list of staff
who are assigned permanent keys. Permanent keys are issued, and staff sign an
acknowledgment form indicating the key identification number and the number of keys issued. A
review of the signed acknowledgment forms indicated each staff signed for the use of
permanent keys. A random check of three staff indicated they had program keys, knew the
number of keys on the key ring, and knew the function of each key. If a key becomes damaged,
a Broken Key Report is filled out which includes the date, reporting staff, key hook number, key
number, description, and attach the broken key with tape. The shift supervisor and key control
manager sign the form and the key is replaced. A review of the Department’s Center
Communications Center (CCC) reports since the last annual compliance review indicated there
was one report made to the CCC for missing keys. The disposition of the CCC indicated the
staff had found the missing keys, the case was closed. An informal interview was conducted
with the safety and security supervisor who reported staff keys are given to master control upon
entry into the facility, those personal keys are securely stored, and program keys are assigned
to the staff. Visitor keys are given to master control upon entry into the facility and are given a
“numbered tab” to return upon their departure. Observations indicated there is a daily tracking
key log, and inventory of keys. The safety and security supervisor stated staff are to notify
master control of missing or lost keys and when keys are damaged. Master control notifies the
assistant facility administrator (AFA) then the program’s physical plant manager has the
damaged/broken key replaced. The CCC is notified of any keys missing. Ten interviewed staff
were able to explain the process in which personal keys and program keys are administered
and tracked. Ten interviewed staff stated they provide master control with their personal keys up
entering the facility, the keys are kept in a secure cabinet, and they are documented into a
logbook when facility keys are provided to them.
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
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 53 of 66 (Revised September 2022)
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 maintains a policy and procedures to identify materials considered to be
contraband, to prevent contraband from entering the program, and consequences when found
in the possession of youth in the program. The program has a system in place to prevent
contraband entering the facility which includes defining items/material considered contraband,
as well as exemptions, providing youth with a list of contraband, informing youth of
consequences if found with contraband, and searches the physical plant, program grounds,
youth, and incoming and outgoing mail. The facility visitor log and all ten sampled staff
personnel records contained a signed contraband attestation statement. All forty-one new hire
staff records contained the contraband attestation statement. The attestation statement
addresses any staff who is found in possession of contraband in a program will be subject to
disciplinary action up to and including dismissal as outlined in Florida Administrative Code. The
policy also states law enforcement will be contacted if any found item is considered illegal as
defined in Florida Statutes, or if there is evidence of any type of unlawful activity. The program
clearly delineates those items considered contraband and keeps a contraband log documenting
the focus of the search, items found, and the disposition of any items found. A review of the
Department’s Central Communications Center (CCC) reports since the last annual compliance
review indicated one report of contraband being found and turned over to local law enforcement.
The program logbooks, search and contraband logs, and incident reports were reviewed to
determine frequency and quality of searches and the results of each search, and each were
found to be in compliance with policy. An interview with the facility administrator (FA) confirmed
the program’s policies and procedures on how contraband is handled and disposed of is at the
discretion of the FA. Contraband not considered illegal shall be discarded, returned to their
original owner, mailed to the youth’s home, or stored and returned upon release. The FA
confirmed in all cases involving the confiscation of illegal contraband, the confiscated items shall
be turned over to law enforcement authorities and a criminal report filed. Ten staff interviews
were conducted and six staff stated youth room searches are conducted daily. Four of the ten
staff stated the assistant facility administrator conducts youth room searches on a weekly basis.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a policy and procedures to ensure searches, including full body visual
searches, are conducted according to Florida Administrative Code at the time of admission,
after off-site activities, and visitation. Parents/guardians are notified of searches during
visitation by way of the parent/guardian intake letter, which is mailed at the time of each youth’s
admission. Youth are searched after school, group, outdoor recreation, and meals. Youth who
are a new admission, readmission, returning from visitation, returning from off-site activities
and/or appointments, suspected of contraband, or are a security risk are full body searched.
Observations made throughout the annual compliance review week validated youth are
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 54 of 66 (Revised September 2022)
provided instructions regarding the search, youth searches were conducted by staff of the same
gender as the youth, were conducted in a manner so as not to degrade the youth, and were
based on the Protective Action Response (PAR)/Right Interactions (RI) training manuals.
Searches observed during the annual compliance review week verified youth were searched
after every movement. Youth searches were observed upon returning from a transport and upon
intake. All observed searches were completed thoroughly and respectfully. Youth appeared to
be comfortable and accustomed to the process. Ten staff were interviewed and nine of the staff
stated youth are searched at every movement and returning from any transport. One staff stated
youth are searched four to five times a week. Ten interviewed youth confirmed they are
searched upon every movement. Two youth stated the youth are also searched if any item is
missing from the facility or returning from any work detail. Video observations were conducted
for staff and visitor searches. Five reviewed videos confirmed all employees and visitors are
wanded with an electronic devise, pat searched, and all bags searched for contraband.
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 center maintains a policy and procedures for transportation, operation, and maintenance of
each vehicle used to transport youth. The center has a total of four vehicles of which all four are
used to transport youth. Two of the vans are Department issued and two are provider-owned.
Each vehicle had an annual safety inspection conducted by a certified automobile mechanic.
Observations of the four program vehicles were conducted. Each reviewed vehicle was locked
when not in use. The four youth transport vehicles have the appropriate number of seatbelts, a
safety screen, a seatbelt cutter, a window punch, up-to-date fire extinguishers, and an assigned
first-aid kit with approved items by the designated health authority (DHA) which is checked out
by staff prior to departure with youth and returned to medical upon the completion of the
transport. Weekly visual vehicle inspection checks are conducted on all vehicles as required
and documented on the preventative maintenance check sheets. The four observed vehicles
had working seatbelts and the passenger doors could not be opened from the inside. A random
check of five staff personal vehicles during the annual compliance review week found all the
vehicles were locked and secured when not in use.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a policy and procedures to ensure the safety and security of youth and
the community when youth are transported outside of the program. Reviewed documentation
verified all approved drivers had a valid driver’s license; human resources conduct a monthly
driver’s license check on all staff to ensure all staff operating a program vehicle have a current
license. The program assigns a ratio of one staff to five youth during transport, not including the
driver. An observation of a transport was conducted, there were two staff with one youth, one
male and one female. Upon observation, the youth and staff were exiting the vehicle, therefore
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 55 of 66 (Revised September 2022)
no observation of seatbelt compliance was noted. Logbook entries with names of staff
transporting youth reflects at least one staff of the same gender as the youth is on each
transport. Ten staff were interviewed, each staff confirmed they are not allowed to use personal
vehicles to transport youth. Ten interviewed staff confirmed they are provided with a cellular
telephone and two-way radio for communication during transport. Nine of the ten interviewed
staff stated youth are secured with shackles, two of the ten staff stated youth are secured in the
vehicles with seatbelts during transport. This was discussed with the program and they reported
the staff likely heard secured and reported on shackles; however, it is the program’s policy to
ensure all youth and staff have seatbelts secured while in a transport vehicle. Ten interviewed
staff confirmed emergency equipment in the transport vehicle included a first-aid kit. Three staff
stated there was a knife-for-life in the vehicle, two staff stated there are jumper cables, and five
of the staff stated there was a fire extinguisher inside all transport vehicles. Each of the ten
interviewed staff confirmed the vehicle is searched prior to and after each use for contraband.
Each staff stated in the event of an emergency during transport, they are to pull over, contact
the program, call 9-1-1, and assist the youth if there are any injuries or illnesses. Seven of the
ten staff stated the staff-to-youth ratio for transport is one staff to five youth, one staff stated the
ratio is one staff to four youth, and two staff stated the ratio is two staff to one youth. Ten
interviewed youth stated they had never witnessed anyone placing contraband into the vehicles,
and have never been handcuffed to any part of the vehicle.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a policy and procedures to ensure safety and security is maintained.
The policy addressed who is responsible for conducting the audits, procedures to implement
corrective actions for deficiencies, and an internal system to verify deficiencies are corrected.
Weekly safety and security audits are conducted by the assistant facility administrator (AFA)
and physical plant manager or designee and documented on the Safety and Security Audit
Inspection form. Any deficiencies are addressed on the form and a work order is submitted to
the appropriate staff for corrections. In addition, deficiencies are discussed during the morning
management meeting. The weekly audit forms are reviewed by the facility administrator (FA). A
review of the Safety and Security Inspection forms since the last annual compliance review
indicated inspections were completed, as required. The program’s Preventive Maintenance
Checklist was reviewed to ensure maintenance schedules and repairs were conducted as
required. All maintenance issues found during the annual compliance review period had be
addressed and corrective action taken when the issue was identified.In a formal interview, the
AFA stated weekly safety and security inspections and daily perimeter checks are conducted,
and any deficiencies identified are discussed amongst the management team and addressed,
as necessary. There were no deficiencies assigned as a result of physical plant deficiencies
during the annual compliance review period. A formal interview with the FA confirmed all
deficiencies identified are reviewed with staff along with corrective action plans to address the
issue.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a policy and procedures to have a tool management system which
ensures youth do not use tools or equipment as weapons or for security breaches. The policy
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 56 of 66 (Revised September 2022)
addresses the issuance, inventory, and control of equipment and tools. A review of inventory
logs and observations verified tools are securely stored when not in use, easily marked for
identification, inventoried prior to, and following work activities. All sharp edged and pointed
tools are inventoried daily when in use. A review of nine unique tools in the maintenance area
verified the inventory matched the inventory list. The maintenance staff are responsible for
conducting the inventories and securely maintaining all Class A tools and equipment. The
maintenance staff complete a tool inventory list which documents each tool in inventory. All
maintenance tools were inaccessible to youth and were observed to be secured in the
maintenance area. Observations of the tool storage area found it was organized and secure.
Class B tools including mops, brooms, and buckets are maintained in locked closets by each
dormitory and in a locked closet in the kitchen area. The items are used by staff and youth when
performing daily cleanup activities. Staff are required to complete a sign-out and sign-in log
when items are taken and are returned to the designated storage room. Reviewed
documentation verified there were no instances of missing or lost tools since the last annual
compliance review. Prohibited tools at the program include machetes, bowie knives, and other
long bladed knives. According to the program policy, if a tool is broken or inoperable, the
maintenance staff is alerted and makes a notation on the inventory log. The physical plant
manager is responsible for replacing the broken tool. If a tool is missing, staff shall notify
administration, fill out an incident report, document the incident in the logbook, place a tag on
the shadow board, call the Department’s Central Communications Center (CCC), and the
program shall be searched until the tool is found.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries. A review of the program’s procedures verified staff
are required to complete a sign-out and sign-in log when Class B tools are taken and are
returned to the designated storage room. A risk assessment is completed by the case
manager prior to youth using any tools. The program’s staff-to-youth ratio during a work project
is no less than one staff to five youth. Program staff search youth after a work detail has been
completed. Ten youth records were reviewed, all youth had risk assessments completed to use
class B tools. No youth were observed utilizing class B tools during the annual compliance
week, due to youth being in the educational classrooms and cleaning with class B tools is
completed prior to school and after dinner. Ten youth were interviewed and nine youth reported
they use mops, brooms and scrub brushes and one youth stated they are not allowed to use
any tools. Ten interviewed staff all stated the youth are allowed to use brooms, mops, and scrub
brushes.
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 establishing guidelines for outside contractors who
come on-site to complete repairs. The program's policy stipulates the facility administrator (FA)
is responsible for providing approval and permissions if a personal cellular telephone and/or
equipment/electronic devices capable of taking pictures and/or audio or video records, including
smart watches, are required. The program’s procedures specify tools are restricted to only the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 57 of 66 (Revised September 2022)
tools needed for the job, tools are checked upon arrival and departure, and youth are restricted
from the work area. When a contractor arrives on-site, they sign the Outside Contractor On-Site
Work Project Log which includes the vendor’s name, date, and time in, a list of tools needed for
the job, the beginning quantity of tools and ending quantity of tools, staff name checking the
tools, and date and time out. The form states the vendor must report any lost tools to
administration immediately. A review of vendor sign-in sheets since the last annual compliance
review confirmed tools and other equipment were inventoried when the vendor arrived and
inventoried when they left. Three reviewed project invoices showed the date of the project
matched the vendor sign-in sheets.The programs policy and procedure isoutside vendors are
accompanied by staff to the work area
and youth access is restricted from the work area. Staff must supervise vendors in the work
area where youth are located. No observations of outside contractors were conducted, due to
no outside contractors present at the facility during the annual compliance week.
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’s Continuity of Operations Plan (COOP) addresses fire, safety, and evacuation
emergency processes, and the frequency of conducting drills at random times and under varied
conditions. Reviewed documentation validated emergency drills were conducted for all shifts
each month, as required. In addition, the program conducted emergency drills on each shift
ensuring fire, riot, severe weather, flooding, terrorist threats, chemical spills, medical situations,
and bomb threats were covered on a rotating basis. Drill documentation included the type of
drill, date and time, participants, a brief scenario description, deficiencies identified during the
drill, and applicable corrective actions. Observations of the program during the annual
compliance review week indicated there were twenty-nine annually inspected fire extinguishers
and egress plans are posted throughout the program. Ten staff were interviewed and each
stated they had participated in a fire drill in the last twelve months. Eight of the ten interviewed
staff stated they have participated in COOP drills, seven of the ten staff stated participation of
suicide drills and escape drills, and six of ten stated participation in medical drills. Ten
interviewed youth stated fire and emergency drills are conducted on a monthly basis and
sometimes two or three times a month. An interview with the facility administrator indicated the
program maintains a drill calendar which includes drills for fire prevention, Right Interactions,
medical, suicide, escapes, bomb threats, contraband, COOP, hostage, weather related
incidents, terrorist threats, and disturbances. Drills are conducted randomly on each shift,
monthly in accordance to the program’s contract.
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.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 58 of 66 (Revised September 2022)
The program maintains a Department approved Continuity of Operations Plan (COOP) available
for all staff to review. The COOP plan was submitted on April 11th, 2024, and approved by the
Department on April 29th, 2024. The COOP provides for basic care and custody of youth in the
event of an emergency or disaster. The COOP also addresses phases of a disaster plan as well
as emergency management including preparedness, response, and recovery. The COOP
addresses emergencies including fire prevention, bomb threats, evacuations, chemical spills,
severe weather, and terrorist attacks. A review of the plan indicated alternative housing has
been identified should the program require an evacuation due to an emergency or disaster. The
program also has provisions of equipment and supplies maintained in the kitchen, the
maintenance building, and the assistant facility administrator’s (AFA) office to ensure a
continuous operation of services during emergency or disaster situations. These items include
but are not limited to; clothing, shoes, flashlights, radios, batteries, bedding, raincoats, hygiene
products and nonperishable food items. In addition, the program has a generator to provide
continuous power for ten to fourteen days. The program maintains identifying information on
each youth in the program, and in the event the program has to evacuate the youth record
accompanies the youth to the temporary location, secured in a locked storage box. A review of
the program’s COOP binder indicated each youth’s name, Department identification number,
admission date, gender, race, contact information, emergency contact, assigned juvenile
probation officer (JPO), committing judge, victim information, physical description, health status,
and a photograph was contained within. The interviewed facility administrator (FA) reported the
copy of the COOP is maintained in master control and the FA’s office.
5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items. The maintenance
personnel, or other trained staff who have the safety equipment for diluting, handling, and
disposing of hazardous and/or solid waste, shall be responsible for disposing of hazardous
items and toxic materials.
The program has a policy and procedures for the storage and inventory of flammable,
poisonous, and toxic materials. Toxic items are stored outside of the program in a locked shed.,
inaccessible to youth.
Cleaning supplies are located in the locked closets by each dormitory and in a locked closet in
the kitchen area. A list of staff which includes the facility administrator (FA), assistant facility
administrators (AFAs), supervisors, and maintenance staff designates they are authorized to
handle flammable, poisonous, and toxic materials. All flammable, poisonous, and toxic materials
are stored according to type and use. A Safety Data Sheet (SDS) binder is located inside the
storage area with a picture of each material and a number corresponding to the SDS for each
chemical. A perpetual chemical inventory list is maintained, and the chemicals are checked
daily. A review of the inventory list verified this practice. The perpetual inventory form identifies
the chemical number, description, amount used, amount remaining, date chemical is used, and
initial of staff. Observations of the storage area indicated it is clearly marked hazardous
chemicals and securely locked. A review of eight unique chemical inventories were compared to
the actual items in the storage areas and verified the inventory was correctly documented.
The program maintains a policy and procedures to ensure all flammable, toxic, caustic, and
poisonous items are disposed of appropriately. All unused hazardous materials are kept in the
locked storage shed located outside the program and are disposed of according to the Safety
Data Sheet (SDS). An interview with the FA indicated disposal of hazardous chemicals is
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 59 of 66 (Revised September 2022)
accomplished within parameters of state, local and federal laws. The maintenance staff is
responsible for the safe and lawful disposal of these items and only maintenance or other
trained staff who have the safety equipment for diluting, handling, and disposing of hazardous
and solid waste are responsible for disposing of hazardous items and toxic materials. The FA
stated there were no chemicals disposed of during the annual compliance review period. Used
kitchen grease and waste is stored in a large container outside the kitchen area and is disposed
of by a local vendor. All liquid waste from work details is disposed down plumbing drains. The
program’s policy states all chemical spills are reported to master control immediately and the
shift supervisor. An evacuation of the affected area is conducted and a determination by the FA
whether to contact outside assistance to contain the spill. Staff and youth are not allowed to
return to the affected area until it has been deemed safe by a qualified professional. The FA
indicated disposal of hazardous items and toxic substances or chemicals is completed by taking
them to the local transfer station. Bio-hazardous waste is disposed of at the local fire
department.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials. Youth shall not be permitted to use, handle, or access dangerous or hazardous
chemicals or respond to chemical spills. Youth shall not be permitted to clean, handle, or
dispose of any other person’s biohazardous material, bodily fluids, or human waste. The
program shall establish and implement cleaning schedules, a pest control system, a garbage
removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a policy and procedures prohibiting youth from handling any flammable,
poisonous, and/or toxic items or materials. Youth are not to clean, handle, or dispose of any
toxic chemicals, biohazardous bodily fluids, or human waste. Youth are strictly prohibited from
the maintenance area where toxic items and chemicals are stored. Ten youth were interviewed
and eight of the youth stated they do not use any chemicals or cleaning products. Two of the
youth stated staff will spray window cleaner or toilet cleaners and the youth will wipe the
cleaning product up; however, they do not physically spray the substances.
5.20 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity. Programs allowing youth to participate in water related activities shall have a
water safety plan addressing, at a minimum, safety issues, emergency procedures, and the
rules to be followed during water related activities, as follows:
• 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;
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 60 of 66 (Revised September 2022)
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program maintains a policy and procedures for youth to have visitation and communication
with family members in order to reestablish family and community relationships. Youth are
informed of visitation upon admission during the orientation process. The program encourages
visitation from the parents/guardians by forwarding a welcome letter upon the youth’s admission
notifying the days and time of visitation, who is allowed to visit, and the corresponding rules of
visitation. A list of authorized visitors and correspondence is maintained in the youth’s case
management records and updated, as needed. A review of five youth case management
records verified each record contained an approved correspondence, visitation, and telephone
log. Visitation is held Sundays from 1:00 p.m. through 3:00 p.m. Special visitations are also
provided for parents/guardians who are unable to participate in the regularly scheduled visitation
days. A review of the program logbooks and visitation sign-in logs since the last annual
compliance review verified visitation and special visitation are conducted. Youth are also
provided one fifteen-minute telephone call each week, writing material, and a self-addressed
and stamped envelope to talk with and send letters to approved family members. A review of
the mail logs since the last annual compliance review showed the youth were receiving and
sending mail to approved family members. Youth can have unimpeded access with the courts,
attorneys, their juvenile probation officer (JPO), and/ or the Department of Children and Families
case worker. Ten youth were interviewed, each youth indicated they are given the opportunity to
communicate with family members by mail, telephone, and/ or visitation. In a formal interview
with the facility administrator, it was confirmed the program has an agreement with an
interpreter company, for youth whose primary language is not English.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a daily activity schedule which reflects the youth receive at least one hour of
recreation each day and additional time allotted for leisure activities. The program’s contract
requires two recreation therapists. Both Recreation therapists have the required credentials
outlined in the program’s contract. The contract does not require special provisions for the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 61 of 66 (Revised September 2022)
incorporation of recreation into the youth’s performance or treatment plans. The recreation
therapist created monthly activity calendars which reflect the recreation and leisure
opportunities available to youth each day. A review of the activities confirmed they promote
social and cognitive skill development, creativity, teamwork, healthy competition, mental
stimulation, and physical fitness utilizing large muscle activities. Logbooks were reviewed for the
annual compliance review period and recreation was documented each day for at least one
hour, as required. Recreation was observed during the annual compliance review week at its
scheduled time and staff were found to be taking precautionary measures to ensure the health
and safety of the youth. Ten youth were interviewed, all youth confirmed the program allows
them the opportunity to exercise, play outside, or participate in activities indoors for at least an
hour each day. Ten youth stated various activities included basketball, football, and volleyball.
Ten staff were interviewed and reported youth are provided recreation time for a minimum of
one hour each day. Staff provided examples of indoor and outdoor activities available for the
youth to include but not limited to football, basketball, kickball, card games, and stretching
exercises.
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 62 of 66 (Revised September 2022)
Standard 6: Safety and Security
6.01 Contract Specific Career and Technical Education
Satisfactory Compliance
Services (Residential Contract Provider)
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), or Special Conditions. Older contracts may not have them clearly identified as
a special condition. Career and technical education service instruction shall be provided so
the interests, aptitudes, and skills of the youth are developed, while building upon their
existing strengths, in a manner supportive of their employability goals which provide an
occupational advantage and workforce readiness in their community. These items may
exceed the minimum requirements outlined in Florida Statutes and Florida Administrative
Code.
According to the program’s contract, the career and technical education (CTE) services required
to be provided are ServSafe, Occupational Safety and Health Administration (OSHA) -10, first-
aid/cardiopulmonary resuscitation (CPR), and Florida Ready to Work Soft Skills. CTE services
were provided to the following number of youth: twenty-two youth earned the ServSafe
certification, fifty-four youth earned the first-aid/CPR certification, sixty-nine youth earned the
OSHA-10 certification, and sixty-four youth completed Florida Ready to Work Soft Skills. Three
staff provide instruction for the ServSafe certification; each has the ServSafe Manager
certification. One staff provides instruction for the first-aid/CPR certification; the staff is a
registered nurse and has the first-aid /cardiopulmonary resuscitation (CPR) certification. One
staff facilitates OSHA-10 and Florida Ready to Work; certification is not a requirement because
youth earn their certification from each organization upon passing the web-based modules and
assessments. The ServSafe certification can lead to the Food Safety and Science industry
certification identified on the Master Credentials List (MCL). OSHA-10 serves as a base level
certification leading to multiple industry certification opportunities from American Welding
Society (AWS) and National Center for Construction Education & Research (NCCER), each
identified on the MCL. At the time of the annual compliance review, nineteen youth were
enrolled in coursework towards earning an industry certification in ServSafe, forty-eight youth
were enrolled in OSHA-10, and forty-five youth were enrolled in Florida Ready to Work. Five
youth were interviewed and three reported they are being very well prepared for high school,
high school equivalency diploma (GED), vocational school, employment, or college, the
remaining two reported they were being well prepared. The facility administrator (FA) confirmed
career education services are provided to the youth at the program including career and
technical education (CTE)/C-Tech programming which are special contract conditions. The FA
also confirmed which contract specific pre-vocational and vocational services are provided at
the program.
6.02 Educational Access (Residential Contract Provider) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 63 of 66 (Revised September 2022)
The program has a written policy and procedures to provide educational access. The center
provides education services through Florida Virtual School (FLVS). A review of the facilities'
activity schedule and the daily academic schedule indicated the facilities' activity schedule
incorporates the daily school schedule. No discrepancies were found. Five youth were
interviewed and three reported there were no interruptions during school, and the remaining two
youth reported the few interruptions are due to youth behavior. Observations of classroom
activity from the program video were made. In each of the three reviewed samples, the youth
were in class for the required amount of time.
6.03 Educational Access (Education Contract Provider) Non-Applicable
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
Education services are provided through a contract with Florida Virtual School (FLVS). The 250-
day calendar is distributed over twelve months and includes twenty days for teacher training and
planning. A review of the daily school schedule revealed education provides six fifty-minute
classes from 8:30 a.m. through 2:45 p.m. with a sixty-minute lunch break, fulfilling the weekly
requirement of twenty-five hours of instructional time. The interview with the lead teacher
indicated all the youth receive credit for completing a course and the school schedule is
adhered to. Three samples of video were observed, confirming teachers were present during
scheduled classroom time.
6.04 Career Education (Education Contract Provider) Non-Applicable
Staff shall develop and implement a career education competency development program.
The education contract provider is responsible for developing a career education program
appropriate for the educational abilities and goals of youth in the program and appropriate for
the length of stay and classification of youth in the program. The career education program
includes Type 1 through Life Management Skills and Personal Finance and Money
Management courses. The career education program includes Type 2 programming through
career and technical education (CTE) course offerings which provide exploration and knowledge
of occupations within those specific careers. The career education program also includes Type
3 programming through CTE course offerings which provide content and competencies for
those specific careers. A career strengths and interest questionnaire is completed by youth at
admission. Each CTE course offered by the education provider includes soft skills for those
specific careers. The education contract provider is also responsible for providing Career and
Professional Education (CAPE) courses leading to pre-apprentice certifications and industry
certification. Youth at this program are enrolled in Digital Information Technology and
Foundations of Programming which are courses leading to the CAPE Industry Certification
CompTIA A+. The lead educator interview was completed by the instructional leader. The lead
instructional leader reported students take different CTE courses including Digital Information
Technology, Foundations of Programming, Personal Finance. Students take all state mandated
assessments for FLVS and Florida Youth College.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 64 of 66 (Revised September 2022)
6.05 Education Transition Plan (Education Contract Provider) Non-Applicable
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
In accordance with the contract, the contracted educational provided is required to develop an
Education Transition Plan for each youth. Upon entering a residential commitment program, an
Education Transition Plan must be developed for each youth. Three closed case records were
reviewed; none contained an education transition plan. Most youth in the program were
admitted prior to July 1, 2024, when the new education provider, Florida Virtual School (FLVS),
started,; therefore, they would not have had an Education Transition Plan developed by the new
provider. None of the current youth had an Education Transition Plan developed upon
admission by FLVS, as required; however, FLVS has recently developed an education plan
template and trained its staff to implement an Education Transition Plan for each youth moving
forward. The interview with the instructional leader indicated exception student education (ESE)
services are provided for students with disabilities, English language learners (ELL) services,
and intervention groups for those below grade level in reading and/or math are all offered. The
instructional leader reported an Educational Transition Upon Entry form is completed with each
student which discusses their educational needs and goals after leaving the program.
6.06 Qualified Instructional Personnel (Education Contract
Non-Applicable
Provider)
The program director is responsible for ensuring qualified instructional personnel are provided
to teach and provide exceptional education and related services to students in the facility.
Instructional leaders shall ensure instructional personnel working under their supervision are
teaching and providing services in the areas they are qualified in based on their education,
training, and experience.
The contracted educational provider has policy and procedures in place to provide qualified
instructional personnel. In reviewing the educational instructional staff for the program, including
flex teachers who provide virtual education at the program, it was confirmed all the teachers
have an active certification, according to the Florida Department of Education website. Flex
teacher certifications suggest all are currently certified in their teaching subjects. Eight teachers
were teaching in the field, and seven were also teaching courses out of the field. The provider
sent parent/guardian notification for those teachers who were also teaching out of the field;
however, the letter did not indicate which subjects were taught out of field. Three teachers are
providing exception student education (ESE) services at the program, and the provider has
provided their certification as ESE instructors.
6.07 Florida Youth College (Education Contract Provider) Satisfactory Compliance
The education provider shall complete the Florida Youth College referral process for each
youth that earns their high school diploma or GED. Each youth will be assigned a Florida
Youth College Career Navigator.
The contracted education provider is responsible for referring all youth who receive their high
school diploma or equivalent to Florida Youth College so they can work with a career navigator
on post-secondary courses and/or enrollment in a state or technical college. Three youth
records were reviewed and one of the three youth were referred to Florida Youth College. The
Florida Scholars Academy instructor was informally interviewed regarding post-secondary
pathways and support offered to youth. The instructor identified Florida Youth College and Britt
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 65 of 66 (Revised September 2022)
Technical Youth Academy as post-secondary pathways and stated support is provided through
individual assessment of students’ academic needs, guided notes, and additional time.
6.08 Florida Youth College (Post-Secondary Contract
Satisfactory Compliance
Provider)
The post-secondary provider, upon receiving the referral for services, shall assign a Florida
Youth College Career Navigator to each youth. Each youth shall attend an orientation session
to develop a career pathway plan. The career pathway plan shall include postsecondary
education options at a state or technical college or pre-apprenticeship/apprenticeship
programming that leads to an industry credential or academic credit. For youth transitioning
from the Department, follow-up shall be completed in thirty, sixty, ninety, and 180 days after
their release.
Each referral received by Florida Youth College (FYC) from the contracted education provider is
assigned a career navigator. The career navigator then connects with youth through the
program to schedule an orientation session. During orientation, the youth and career navigator
develop a career pathway plan to include post-secondary courses and/or enrollment in a state
or technical college. The career navigator continues to assist youth on their career pathway plan
and have incremental follow-up sessions scheduled through the residential contract provider.
For the three reviewed records, two of the three youth were not referred to FYC; therefore, a
career navigator was not assigned to these youth. One of the three youth was referred to FYC
and assigned a Career Navigator. There was documentation to support the date of orientation
and the occurrence of a thirty-day follow-up. The youth’s sixty-day, ninety-day and 180-day
follow-ups were not documented. The FYC case notes for this youth stated the Career
Navigator was waiting on follow-up from the transition service manager to schedule the next
session. The youth was released before any further follow-up was required. A career plan based
on the youth’s interests and aptitude was not included in FYC’s records. The FYC case notes
indicate education options were discussed with the youth during the thirty-day follow-up. A copy
of admission to a post-secondary program was not included in FYC’s records.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 66 of 66 (Revised September 2022)

report_type: QI Residential