summary: QI Residential - FY23-24

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
JoAnn Bridges Academy
Rite of Passage Inc
(Contract Provider)
950 S.W. Greenville Hills Road
Greeneville, Florida 32331
Review Date(s): February 27 - March 1, 2024
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Cedric Prince, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Cionna Allen, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Patrick Brock, Northeast Central Education Coordinator, (Standard 2)
Orlando Mendonca, Office of Research and Data Integrity, (Standard 2)
James Philips, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Stephanie Solano, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Juan Youman, Office of Detention Services, Operations Coordinator (Standard 3)
Program Name: JoAnn Bridges Academy MQI Program Code: 1444
Provider Name: Rite of Passage Inc Contract Number: 10361
Location: Madison County / Circuit 3 Number of Beds: 28
Review Date(s): February 27-March 1, 2024 Lead Reviewer Code: 211
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
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 60 (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 Non-Applicable
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 60 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
2.19 Career Education Satisfactory
2.20 Educational Access* Satisfactory
2.21 Education Transition Plan Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 60 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Non-Applicable
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 60 (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 Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 60 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.21 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.22 Visitation and Communication Satisfactory
5.23 Recreation and Leisure Satisfactory
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
5.25 Controlled Observation Non-Applicable
5.26 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 60 (Revised September 2022)
Program Overview
The JoAnn Bridges Academy is a twenty-eight-bed program, for twelve to eighteen-year-old
females, located in Greenville, Florida. The program is operated by Rite of Passage, Inc,
through a contract with the Department. The program provides services including Mental Health
Overlay Services (MHOS) and substance abuse education. In addition, the program fosters
each youth by providing Aggression Replacement Training (ART), Seeking Safety, Thinking for
a Change (T4C), Impact of Crime (IOC), Voices, and Living in Balance. Additional treatment
services provided include family, individual, and recreational therapy. Program administration is
comprised of a program director (PD), one administrative assistant, one clinical director, one
recreation therapist, one transition coordinator, and a building manager. Case management
services are provided by two therapeutic managers. Mental health staff at the program include
one clinical director, one psychiatrist, one advanced practice registered nurse (APRN), and two
therapeutic managers. Medical services are offered every day as needed and are provided by
one registered nurse (RN), one licensed practical nurse (LPN), and a medical doctor.
Educational services are provided by the program. The layout of the program includes one large
building with two youth dorms, a gymnasium, cafeteria, and two classrooms. There are also two
portables on-site, and an outdoor field for recreation. A tour was conducted on the first day of
the annual compliance review week with no major issues found with program cleanliness. The
program has twenty-eight operating security cameras providing coverage. At the time of the
annual compliance review, the program had seven youth care counselors and one supervisor
positions vacant.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 60 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures to ensure a background screening is conducted for all
staff, volunteers, mentors, and interns with access to youth or confidential youth records. The
program had one newly hired staff since the last annual compliance review. The applicable staff
had an eligible background screening completed prior to their hire date. The newly hired staff
was added to the program’s Clearinghouse roster. The program completed and submitted the
Annual Affidavit of Compliance with Level 2 Screening Standards to the Department’s
Background Screening Unit (BSU) on January 19, 2024, meeting the annual requirement.
Educational services are provided by the program, therefore, an annual affidavit for education
staff was not required.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a policy and procedures which address the five-year background rescreening
process. A background rescreening is required every five years from the initial date of
employment. A review of the program’s staff roster indicated there were no staff eligible for five-
year rescreenings.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 60 (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 staff adheres to a code of conduct, as evidenced by five reviewed staff personnel
records. Each staff signed a receipt indicating they received the program’s code of conduct.
Within the staff’s training records, each indicated a training on Florida Reporting of Child Abuse
requirements. Observations were made throughout the program, showing the Florida Abuse
Hotline and the Department’s Central Communications Center (CCC) numbers were posted and
made available to staff and youth. The program has a written policy and procedures on the
abuse reporting process. The procedures indicate the staff shall provide unhindered access to
report alleged abuse. Staff, supervisors, and youth are allowed to call the Florida Abuse Hotline.
If the abuse call is accepted, then staff must call the CCC. If the call is not accepted, the staff
must go through a problem-solving session. Staff will assist the youth in placing the abuse call,
dialing the number, recording the date and time of the call, and obtaining the operator’s name
and number to document on the internal incident report. The program director was interviewed
concerning the Trauma Responsive and Caring Environment (TRACE) self-assessment. The
program completed the Self- Assessment tool on March 22, 2023. Five staff were interviewed.
All five interviewed staff summarized the abuse reporting process. All five staff reported they
had never observed a coworker telling a youth they could not call the Florida Abuse Hotline. All
five staff reported they had never observed a coworker using profanity when speaking to youth,
using threats, intimidation, or humiliation when interacting with youth. All five staff reported
knowing the number to the Florida Abuse Hotline and knowing where the number is located
throughout the program. Five youth were interviewed. All five youth reported they feel safe at
the program. None of the youth reported they have been stopped from calling the Florida Abuse
Hotline since being at the program. All five youth reported they are aware of where to find the
Florida Abuse Hotline number in the program. Each of the five youth reported the staff are
respectful when talking with youth. None of the five have ever observed a staff using profanity
when speaking with youth. None of the youth reported exchanging emails, telephone numbers,
or social media contact information with staff. There was one allegation of abuse reported
during the annual compliance review period. The one incident was reviewed. The allegation was
not substantiated. The allegation did not include human trafficking incidents.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 60 (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.
A review of incidents reported by the program to the Department’s Central Communications
Center (CCC) revealed one incident related to physical, emotional, and psychological abuse
since the last annual compliance review. The incident concluded with an unsubstantiated
finding. Despite this, the program director assured the allegation was addressed swiftly by the
program. An interview with the program director revealed the staff is no longer with the program.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program had a total of six reports made to the Department’s Central Communications
Center (CCC) during the annual compliance review period. A review of internal incidents and
grievances was conducted, and as a result, no additional calls to the CCC were warranted. A
sample of five CCC reports was reviewed for completion requirements. Four documented calls
were made to the CCC within the two-hour required timeframe, and one CCC incident was
reported; however, the time the program became aware of it was unknown. A review of the
program’s master control logbook showed all four applicable incidents reviewed were
documented. The program has not experienced an increase in reportable incidents to the CCC
since the last annual compliance review period.
1.06 Protective Action Response (PAR) and Physical
Non-Applicable
Intervention Rate
The program uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is completed and filed in accordance with the Florida
Administrative Code.
The program had no Protective Action Response Right Interactions model (PAR/RI) incidents
during the annual compliance review period; therefore, this indicator is rated non-applicable.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring.
One applicable staff training record was reviewed for pre-service training requirements. The
staff completed their 120 hours of pre-service training within 180 days of employment. The
applicable record included essential skills completed prior to contact with youth. The training
record included documentation of active shooter preparedness, adolescent development and
behavior, balanced approach to restorative justice, the Department’s Central Communications
Center (CCC) incident reporting, civil rights, communication, confidentiality/Health Insurance
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 60 (Revised September 2022)
Portability and Accountability Act (HIPAA), diversity, Department legacy, equal employment
opportunity, gang awareness, human trafficking intervention, infection control/bloodborne
pathogens, information security awareness, the Department’s Juvenile Justice Information
System, quality report writing, safety, security, and supervision of youth, sexual harassment,
and trauma responsive practices. The applicable staff received training on the grievance
process, infection control, exposure control plan, behavior management system, and the
intended and safe use of tools. All instructors were qualified to provide the delivered trainings
and the trainings were documented in the Department’s Learning Management System
(SkillPro). The program considers coach counselors, recreation therapists, night coach
counselors, and the transition specialists as the direct care staff counted for in the staff to youth
ratio.
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
Five staff training records were reviewed to include two supervisory staff. The program had only
one supervisory staff applicable for the annual compliance review period. All five staff had
completed all the mandatory training topics as required. All five staff had more than the required
twenty-four hours of annual training. All the required trainings were documented in the
Department’s Learning Management System (SkillPro). Two applicable supervisory records
were reviewed. The trainings completed were more than the required eight hours of training in
coaching, leadership, and personal accountability. All instructors were qualified to deliver the
training provided. The program has an in-service training plan, which was submitted to the
Department’s regional director on January 19, 2024. The program has a 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 written policy and procedures which include the training requirements for the
grievance process. According to the program’s policy, all staff shall be trained on the grievance
process and procedures. The program’s grievance process includes three phases, the first
phase being the informal phase. When concerns arise, youth are encouraged to make all efforts
to reach a resolution immediately through informal communication with the program staff
involved. The youth achieve this by completing a One-on-One form. If the youth is not satisfied
with the outcome, the next step is the formal phase. The youth may speak with a supervisor with
concerns. If the youth is not satisfied at this phase, the last phase is the appeal phase. During
this phase, the youth may bring the issue to the attention of the program administration. All
grievances are reviewed during the daily management meeting. No formal grievances were
submitted during the annual compliance review period. Five staff were interviewed and all five
were able to explain the grievance process. Five youth were interviewed and were able to
summarize the grievance process. The program director was interviewed and indicated the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 60 (Revised September 2022)
director of student services (DSS) is the grievance officer who monitors this process. The
program director described each of the grievance phases.
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
Four total staff training records were reviewed for interventions and facilitator training
requirements. All staff had the required education and experience necessary for working with
juvenile offenders. The staff’s education and work experience were considered by the program
when determining staff delivery of intervention services. Each staff received appropriate training
for the groups being facilitated. A review of the program’s schedule was completed, and all
groups are included in the daily program schedule. All groups were conducted as included in the
program’s contract table to include Impact of Crime (IOC), Seeking Safety, Aggression
Replacement Training (ART), Voices, Girls Trauma and Recovery and Empowerment Model (G-
TREM), Living in Balance, and Character Traits. ART, Seeking Safety, and IOC are the
program’s primary services; therefore, they are not applicable for review. The sign-in sheets for
the non-primary groups were reviewed and verified groups were provided as required and in
accordance with the daily schedule. The program director was interviewed and reported the
curricula utilized in the program include ART, Seeking Safety, G-TREM, Living in Balance,
Character Traits, IOC, and Trauma and Substance Abuse Education. The designated mental
health clinician authority (DMHCA) was interviewed and reported the program ensures qualified
staff are trained and provide interventions to the youth in the program.
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 written policy and procedures addressing life and social skills training for
youth. The policy indicates life skills help youth function more responsibly and successfully in
everyday life situations, including social skills which specifically address interpersonal
relationships. Non-clinical staff may implement only non-clinical life and social skills
interventions or instruction. When skill training or instructional materials are specifically
designed for use by clinical staff or the skill training is delivered in response to a youth’s
treatment plan, the skill training must be provided by clinicians. Life and social skills intervention
services are provided which address identification and avoidance of high-risk situations which
could endanger self or others, communication, interpersonal relationships and interactions, non-
violent conflict resolution, anger management, and critical thinking including problem-solving
and decision-making. Additionally, a weekly reward and recognition event occurs on Fridays
and acknowledges youth gains and achievements over the past week. Participants include the
youth, managers, and direct care staff. The life skills interventions include Character Traits,
Living in Balance, Girls Trauma and Recovery and Empowerment Model (GTREM), Positive
Skills Development, Positive Organization Culture groups, and Body Image/Gender in the
Media. These groups are either evidence-based, promising practice, or a practice with
demonstrated effectiveness. The life and social skill groups provided address the
communication, interpersonal relationships and interactions, non-violent conflict resolution,
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 60 (Revised September 2022)
anger management, critical thinking including problem-solving, and decision-making. A review
of the program activity schedule reflected life skills education and training groups were included.
A review of sign-in sheets and fidelity monitoring forms indicated the groups are being held as
required. The program provides additional life skills training for the youth, which includes health
and wellness and educational groups. The educational groups are provided by nursing staff.
Five youth were interviewed and all five reported the available life and social skills groups they
attend. All five youth also reported the gender-specific groups include Body Image, GTREM,
and Character Traits. The program director was interviewed and reported the youth participate
in groups daily.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
According to a review of the program’s contract, Impact of Crime (IOC) and Aggression
Replacement Training (ART) are the required interventions used to address and provide
activities and instruction intended to increase youth awareness of, and empathy for, crime
victims and survivors. IOC is a primary service; therefore, is not applicable for review. The
program also allows youth the opportunity to participate in community service projects.
Restorative justice activities are reflected on the program’s activity schedule. The program
director was interviewed and reported the program utilizes IOC groups and community service
projects, which are the restorative justice groups and activities for the youth. The youth are
permitted to complete restorative justice projects on campus and in the community. The
designated mental health clinician authority was interviewed and reported the youth attend IOC
groups two days a week. All five youth were interviewed and reported various restorative
activities which included picking up trash in the community, IOC groups, apology letters, retail
theft packets, cleaning around the program, and taking food to food banks. An observation of
youth participating in restorative justice awareness groups and activities was not able to be
conducted during the annual compliance review week.
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 written policy and procedures which outline how alerts are identified,
documented, updated, and communicated to staff. Any case manager, direct care staff,
clinician, or nurse may put a youth on alert status if specific criteria are met. An alert board
communication system is set up for the staff to be aware of current alerts for youth in the
program. Mental health staff may only assign mental health alerts. Shift supervisors notify
oncoming shifts of alert status and youth placed on suicide risk or precautionary observation.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 15 of 60 (Revised September 2022)
Five youth records were reviewed for entering of alert information. A total of ten alerts in the
Department’s Juvenile Justice Information System (JJIS) alerts were applicable for review. All
ten alerts reviewed were found to have been inputted by the appropriate staff member. All ten
alerts were documented in the master control logbook. All of the alerts were entered into the
internal alert system and in JJIS on the same date. All alerts were verified prior to being entered
into JJIS. The program director was interviewed and reported the healthcare staff meet weekly
or as needed with the program director. The program director reported the program’s internal
alert process is the mental health staff input for mental health and substance abuse alerts. The
medical staff input medical and food allergy alerts. Five staff were interviewed, and all five staff
reported they are notified of alerts through shift briefings and the alert book maintained in
master control, email, telephone, and radio. The staff sign off in the logbook once it has been
reviewed. All day rooms have a list of alerts posted. Allergy alerts are posted in the kitchen
area.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program maintains an Individual Healthcare Record (IHCR) and an individual case
management record for each youth. Five youth IHCRs and five individual case management
records were reviewed, and each contained the youth’s name, Department identification number
(DJJID), date of birth, county of residence, and committing offense. Each record included
sections for legal information, demographic and chronological information, correspondence,
case management and treatment team activities, and miscellaneous. All youth records are
labeled, “Confidential” and are maintained in locked cabinets, which are also labeled
“Confidential” in the medical and case management offices.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a community advisory board, which is scheduled to meet on a quarterly basis.
A review of the list of attendees, the board roster, and letters from the program found the
program director (PD) solicited involvement from a law enforcement representative, judiciary
community, other community partners, a business community representative, a school board or
district representative, a faith community representative, and a LGBTQIA+ community
representative. Reviewed letters in the community advisory board binder confirmed the PD
recruited a victim, a victim advocate, and a parent/guardian whose child was previously involved
in the juvenile justice system. Sign-in sheets, agendas, and minutes were reviewed from
quarterly advisory board meetings. An interview with the program director (PD) advised the
program has an active community advisory board which meets once a quarter. This meeting
includes individuals from education, the judiciary, law enforcement, faith based representatives,
a victim advocate, business owners, and the Department. The individuals assist in program
planning of activities and speakers along with providing mentor services to the youth. The
community advisory board members relay recommendations during the quarterly meeting or by
contacting the program director or recreation therapist directly. The board will assist in finding
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resources for youth in the program to include mentoring and vocation. An active board member
was interviewed and provided information on the level of involvement in program activities. The
member is a community business owner who participates in quarterly meetings and can provide
suggestions and input verbally during meetings, telephone calls and emails.
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 written policy and procedures to ensure staff are evaluated, at least
annually, based on established performance standards. A review of seven position descriptions
confirmed each staff’s performance standards were clearly identified. A review of five staff
personnel records confirmed each staff received either a ninety-day or an annual performance
evaluation on established performance standards. Performance standards matched the position
description for each staff. A review of the contract confirmed contractually required positions
were maintained and performed as outlined. An interview with the program director (PD)
advised all staff within the program who have been employed for a year will receive an annual
evaluation in the month of their initial date of hire. This evaluation is the staff formal evaluation
which depicts how the staff has performed throughout the course of the year. Identified in these
evaluations are the staff's strengths, weaknesses, and identified goals. Upon completion of the
evaluation, the process is the staff meets with their supervisor to discuss the areas for
improvement and develop a plan for success. Five staff were interviewed and advised receiving
yearly formal evaluations of performance.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program implements special contract conditions as outlined in the program’s contract. The
program’s contract had a Memorandum of Negotiation (MON) during the procurement process.
The special ongoing contract conditions include providing youth with substance abuse issues
the opportunity to participate in Alcoholics Anonymous or Narcotics Anonymous, ensuring youth
have access to appropriate reading materials external to the educational program and
maintaining a variety of reading materials and diverse media centers, have on-site enrichment
activities, provide a van loop for parents, and provide transition and non-traditional pre-
vocational and vocational services. A review of program documentation confirmed every youth
is screened utilizing the clinical intake form and are provided services based upon the results.
The program did not have any youth applicable for participation in Alcoholics Anonymous or
Narcotics Anonymous during the annual compliance review period. The program has a rolling
media cart, which is available every day on both wings and inside of education. The program
provided at least monthly Zumba and yoga classes. The program provides gas cards or bus
passes if needed to parent to be able to come to the program. The program’s education staff
conduct a STAR assessment upon entry into the program to review youth aptitudes. The
transition plan includes information regarding the aptitudes. During the transition staffing, youth
receive their plan for success, information on the career resource center, and a calendar for
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appointments. An interview with the program director (PD) confirmed the program is complying
with all contractual requirements. An interview with five youth confirmed the program is
providing all required services.
1.18 Contract Specific Career and Technical Education
Satisfactory Compliance
Services
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), Special Conditions, or older contracts may not have them clearly identified as a
special condition. Career and technical education service instruction shall be provided so the
interests, aptitudes, and skills of the youth are developed, while building upon their existing
strengths, in a manner supportive of their employability goals which provide an occupational
advantage and workforce readiness in their community. These items may exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code.
There was evidence of the program implementing career and technical education services. The
program offers a certified nursing assistant (CNA) program, a culinary program, and
cosmetology (hair braiding) classes. During the annual compliance review period, no youth were
certified in CNA, seventeen youth were certified in culinary, and thirteen youth were certified in
cosmetology. Times and days vary for technical education services. The program has three staff
who provide career and technical education services. Each staff is qualified to provide the
services offered to youth based on their education. The career and technical education
programs are appropriate for the age of the youth, the abilities, goals, length of stay, and
classification of the youth in the program. All five interviewed youth confirmed they had
completed and/or were currently participating in career and technical education services. An
interview with the program director confirmed the program provides CNA Classes; however, due
to age requirements, no youth met the criteria to obtain the certification.
1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a written policy and procedures for reviewing and analyzing data trends to
utilize in decision-making practices. The program’s practice regarding data trend analysis is the
Rite of Passage Data Systems. The data captured include key performance indicators, incident
reporting, internal data information, human resource data, site operations summary, goals, and
specific measures. The information is shared with staff and administration monthly through staff
meetings, publications, and emails.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a written policy and procedures outlining the process to ensure initial contact
is made with the youth’s parent/guardian, committing court, and juvenile probation officer (JPO).
A review of five youth records found written documentation of the program notifying the youth`s
parent/guardian by telephone within twenty-four hours of the youth`s admission into the program
as well as sending a notification letter within forty-eight hours. Also, each record had written
documentation of the program notifying the youth’s committing court and assigned JPO within
five working days of youth admission into the program.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures which details the youth’s orientation into the program.
A review of five youth records indicated each record contained documentation of youth
orientation on the day of admission through an orientation signature form. All orientations
addressed the services available in the program, daily schedule, program rules, program goals,
expectations, and responsibilities of youth, written behavioral management system, availability
and access to medical, mental health and substance abuse services, access to the Florida
Abuse Hotline or Department’s Central Communications Center, expectations for release from
the program, and the contraband policy. Moreover, the orientation records included
documentation on the program’s zero-tolerance policy regarding sexual misconduct, including
how to report incidents or suspicions of sexual misconduct, grievance procedures, and
emergency procedures, including strategies for fire drills and building evacuations. Each
orientation highlighted the performance planning process, dress code and hygiene practices,
and procedures on visitation, mail, and telephone use. Each youth completed a facility tour and
was assigned to a living unit/room and a treatment team. No youth orientation was observed as
no youth admissions were scheduled during the annual compliance review week. All five
interviewed youth stated they received an orientation within twenty-four hours of their admission
to the program and were able to explain the orientation process.
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2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
Five youth records were reviewed, and one was applicable for written consent of youth eighteen
years of age or older. No other youth were applicable during the annual compliance review
period for this indicator. The applicable reviewed record contained documentation of signed
written consent by the youth. The record also indicated the written consent was obtained when
the youth turned eighteen while in the program.
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 written policy and procedures which outline the classification factors,
procedures, and reassessments for activities. A review of five youth records indicated the
program utilized a classification system according to the Florida Administrative Code, which
promotes safety, security, and effective delivery of treatment services. Each reviewed record
documented an initial classification form which included physical characteristics of the youth,
age and maturity level, identified special needs, history of violence, gang affiliation, if applicable,
criminal behavior, sexual aggression, and vulnerability to victimization. Also, the form included
the youth’s perception of vulnerability, the youth’s history of potential or verified human
trafficking, and risks such as suicide, medical, escape, and security. Each initial classification
form assigned all newly admitted youth to a living unit and indicated the commitment packet and
alerts were reviewed. All five records indicated youth reassessments and reclassifications were
completed before considering an increase in the youth privileges or freedom of movement. One
applicable youth was reclassified prior to participation in off-campus activities and participation
in work projects or other activities involving tools or instruments. The interviewed program
director explained upon admission, youth factors such as mental health status, physical health
status, cognitive performance, age, and prior victimization are considered in the classification
meeting when assigning youth to a living unit/sleeping room. In addition, this information is used
to determine the best placement for the youth to ensure their safety and well-being. Also, the
data is used throughout the youth’s stay as they may move rooms according to the Positive
Performance System as they level up and earn more incentives.
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2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a written policy and procedures which outline gang identification and
notification of law enforcement. The program did not have any youth identified as being involved
with gang activities during the annual compliance review period; however, the program has
processes in place for notification to law enforcement when a youth is identified as being
involved with a gang. The process includes entering gang alerts into the Department’s Juvenile
Justice Information System (JJIS) upon identification and sharing the information with the
education provider or local school district providing services at the residential program and the
youth`s juvenile probation officer (JPO).
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a written policy and procedures which outline prevention and intervention
activities for youth identified for gang affiliation. The program did not have any youth identified
as being involved with gang activities during the annual compliance review period; however, the
program has gang prevention and intervention strategies in place in case youth are identified as
criminal street gang members or affiliated with any criminal street gang. The program utilizes
Impact of Crime groups and prevention workpapers. The interviewed program director indicated
the program gang intervention and prevention strategies provide the youth with resources as
well as the opportunity to develop a plan to disaffiliate from the criminal street gang if the youth
want to do so.
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.
The program has a written policy and procedures to ensure an initial Residential Assessment for
Youth (RAY) is conducted within thirty days of admission. All five reviewed youth records
indicated each RAY was conducted within thirty days of each youth’s admission into the
program, and the documentation was maintained in the Department’s Juvenile Justice
Information System (JJIS) and in the youth’s official case record. Four of the five reviewed
records were applicable and documented a reassessment was completed every ninety days.
None of the four applicable reviewed records indicated any other updates or reassessments
were deemed necessary.
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2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in JJIS on the YNAS.
The program has a written policy and procedures to ensure a Youth Needs Assessment
Summary (YNAS) of each youth is conducted within thirty days of admission. Each of five
reviewed youth records indicated the program conducted a YNAS within thirty days of
admission. Documentation verified the YNAS was maintained in the Department’s Juvenile
Justice Information System.
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.
The program has a written policy and procedures in which the intervention and treatment team,
including the youth, shall meet and develop the Individual Performance Plan (IPP) based on the
findings of the youth’s initial assessment, within thirty days of admission. Five youth records
were reviewed. Each record indicated the intervention and treatment team, including the youth,
met and developed an IPP within thirty days of being admitted into the program and after the
initial Residential Assessment for Youth and the Youth Needs Assessment Summary were
completed. All five youth plans included each youth’s individualized goals based on their
prioritized needs, reflecting their risk and protective factors identified during the initial
assessment process, and addressed each youth’s top three criminogenic needs and
delinquency interventions. Target court-ordered sanctions were identified and included in all five
youth IPPs reviewed. Each plan also contained transition activities targeted for the last sixty
days of the youth’s anticipated stay, youth responsibilities and target dates to accomplish their
goals, and the program’s responsibilities to enable the youth to complete each goal. Each of the
five youth records contained documentation of participation and the signature of each youth,
administrative representative, treatment leader and/or living unit representative, treatment staff,
and education. All records indicated a copy of the IPP was sent to each of the youth’s
parent/guardian or Department of Children and Families (DCF) case manager along with a
signature page to return in the addressed envelope. Only one signature sheet was returned to
the program, which was attached to the original IPP. Each reviewed record indicated the
program sent a transmittal letter and a copy of the IPP to the youth`s committing court, the
parent/guardian or DCF case manager, and the assigned juvenile probation officer (JPO) within
ten days of completion. All five interviewed youth reported they participated in developing their
performance plan and knew their goals. Each interviewed youth confirmed having received a
copy of the performance plan.
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2.10 Performance Plan Revisions Satisfactory Compliance
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team.
The program has a written policy and procedures in which performance reviews will result in
revisions to the youth’s Individualized Performance Plan (IPP) when determined necessary by
the intervention and treatment team. A review of five youth records indicated each IPP revision
was based on Residential Assessment for Youth (RAY) Reassessments and demonstrated
progress or lack of progress towards goals. None of the reviewed records indicated the youth
being in the transition phase; therefore, there was no need for revisions to the IPP due to the
youth being in the last sixty days of their stay in the program.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program has a written policy and procedures outlining Performance Summaries and
transmittals. A review of five youth records indicated four were applicable for Performance
Summaries. One youth had not been in the program long enough to require a Performance
Summary. All four applicable records contained documentation the treatment team prepared a
Performance Summary at ninety-day intervals, beginning ninety days from signing the youth’s
performance plan, which included all required elements. None of the records reviewed were
applicable for a summary prior to release, discharge, or transfer. All four records indicated the
youth were allowed to read and add comments before signing the Performance Summary. Each
youth was provided a copy of the summary, and the original copy was filed in the youth’s case
management record. Moreover, all the records contained the date and the signature of the
treatment leader, youth, and program director or designee. Each reviewed record documented
the program sent a copy of the youth’s Performance Summary within ten working days to the
youth’s committing court, the parent/guardian or Department of Children and Families case
manager, and the assigned juvenile probation officer (JPO). Three closed youth records were
reviewed for release summary requirements. In each closed record there was evidence the
original summary, along with justification for release, were sent with the Pre-Release
Notification (PRN) to the assigned juvenile probation officer (JPO) at least forty-five days prior to
each youth’s planned release. A signed copy of the PRN was retained in all three closed
records. No court objections to release were documented. Once each approved PRN was
received, the program provided written notification to the youth’s parent/guardian regarding the
planned release. The program completed an Exit Residential Assessment for Youth (RAY) in all
three closed records. None of the reviewed records were applicable for victim notification.
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2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a written policy and procedures outlining parent/guardian involvement in case
management services. A review of three closed records indicated the program encourages and
facilitates the participation of each youth’s parent/guardian in the case management process. All
the reviewed records demonstrated the program involved the parent/guardian in the
assessment process, developing the youth’s performance plan, progress reviews, and transition
planning. Additionally, each record indicated the program facilitated parent/guardian
participation by providing advanced notice of formal treatment team meeting dates and times,
and if the parent/guardian was unable to attend, the program allowed their participation by
telephone or verbal/written input before the meetings. A treatment team was unable to be
observed as none were scheduled during the annual compliance review week. All five
interviewed youth confirmed their parents/guardians were involved in their case management
through participation in treatment team meetings. The program director (PD) interview was
reviewed, and the PD explained during intake and during the youth’s stay, the case
management department sends notifications requesting the parents/guardians involvement in all
treatment teams and meetings related to the youth. Monthly calls are also made to update
parents/guardians on the youth’s progress or lack thereof and any upcoming events or
meetings. Lastly, the director indicated the case management team offers van loops so
parents/guardians can participate in visitation and family day.
2.13 Incorporation of Other Plans into Performance Plans Satisfactory Compliance
The youth’s performance plan shall reference or incorporate the youth’s treatment or care
plan.
Five youth case management records were reviewed for incorporation of other plans on the
Individualized Performance Plan (IPP). All five youth records indicated having additional plans
which included academic and treatment plans incorporated into their IPP. One of the five youth
was in the care of the Department of Children and Families (DCF) and had a current behavior
support plan. All additional plans were incorporated on each IPP.
2.14 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
A program shall ensure the intervention and treatment team meets bi-weekly (formally and
informally) to review each youth’s performance, to include RAY Reassessment results,
progress on Individualized Performance Plan goals, positive and negative behaviors,
including behaviors resulting in physical interventions. If the youth has a treatment plan,
review their treatment plan progress.
The program has a written policy and procedures to ensure all required treatment team
members meets bi-weekly, formally and informally, to review each youth’s performance. Five
youth records were reviewed. Each record indicated formal and informal treatment team
meetings were held every two weeks, alternating every other bi-weekly. Reviewed
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documentation confirmed formal and informal treatment team meetings included all required
elements and were attended by all required participants, with the exception of one youth’s
juvenile probation officer (JPO) not being available for three treatment teams. All records
indicated the youth’s parent/guardian, JPO, and any other pertinent party, through advanced
notification, were invited and encouraged to participate and provide input for each treatment
team. A treatment team was not observable due to none being scheduled during the week of
the annual compliance review. Five interviewed youth stated they are given an opportunity to
demonstrate the skills they have learned in the program and staff review performance, including
progress on goals, positive and negative behavior, and treatment progress, during treatment
teams.
2.15 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
The program has a written policy and procedures which outline transition planning, conferences,
and Community Re-Entry Team (CRT) meetings. Three closed youth records were reviewed
and indicated the transition conference was held at least sixty days prior to the youth’s targeted
release date. The intervention and treatment team members who attended the transition
conference were the youth, treatment team leader, program director, and other team members.
The intervention and treatment team leader invited and encouraged the participation of the
youth’s juvenile probation officer (JPO), parent/guardian, education staff, and any other
pertinent parties. Documentation within the closed records reflected transition activities were in
the youth’s performance plan, identified additional transition activities as needed, target
completion dates, and persons responsible for completion. The treatment team leader obtained
all attendees’ dated signatures representing their acknowledgment of the transition goals and
accountability for completion. A copy of the plan was sent with a request for return with
signature to anyone not in attendance who had a responsibility for completion of transition
goals. In all three closed records reviewed, the CRT meeting was conducted prior to the youth’s
release from the program in which both the youth and case manager participated. There was
evidence an email invitation was sent to the required parties to participate in the CRT meeting.
2.16 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a written policy and procedures which the residential commitment program will
assemble an exit portfolio for each youth to assist the youth when released back into the
community. A review of three closed youth case management records found each youth’s exit
portfolio was discussed and initiated during the transition conference. One of the three youth
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records contained copies of Social Security cards and birth certificates to obtain a state
identification card; however, there was no confirmation the card was obtained. In one record,
documentation verified the program requested the necessary documents several times;
however, they were never received. The last record verified the youth had already obtained a
state identification card through the Department of Children and Families. Each youth record
indicated the exit portfolio was verified during the exit conference and provided to the youth
upon release. Two of the three records documented the program staff forwarded the exit
portfolio to the youth’s juvenile probation officer (JPO). One record did not have the
documentation verifying the portfolio was sent. All three closed case management records
included a copy of the youth’s transition plan, calendar with all dates, times, and all locations of
upcoming community appointments, educational and/or vocational certificates earned in the
program, all educational records, school transcripts, résumés, and completed sample
applications. None of the youth were applicable for secure risk requirements and the program
did not have contract specific requirements for the exit portfolio.
2.17 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a written policy and procedures which indicate an exit conference shall be
conducted, in addition to formal or informal meetings, to review the status of goals developed at
the transition conference and finalize release plans. Three closed youth case management
records were reviewed, and each youth record contained an exit conference which was
conducted after the program notified the youth’s juvenile probation officer (JPO) of the youth’s
release date. Two of the three records indicated the exit conference was held at least fourteen
days prior to the youth’s release date. One record documented the exit staffing was completed
within fourteen days of being released; however, the judge authorized the youth to be released
early due to an immediate family member’s failing health. A review of the documentation
indicated the date of the conference, signatures, and a summary of pending transition goals
were included. Each youth record contained the youth’s date of admission and date of
termination documented in the case record, which correlated with the Department’s Juvenile
Justice Information System (JJIS). The status of transition activities established at the transition
conference and plans finalized for the youth’s release were reviewed. During the review of the
closed records, it was documented the intervention and treatment team leader, parent/guardian,
education representative, JPO, youth, and other pertinent parties all participated in the exit
conference. The exit conference was held separately from the transition and Community Re-
Entry Team meetings.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a written policy and procedures to promote constructive input by youth. The
youth are able to provide constructive input through the bi-monthly youth council meetings and
weekly Questions, Concerns, and Recognition meetings. Reviewed documentation indicated the
bi-monthly youth council meetings recently resumed, as the meetings were previously
postponed, and are now being held as required. Staff recognized the youth during these
meetings and youth can present concerns and questions relating to the program. The youth can
also fill out grievances and Request to Speak forms and submit them through a drop box which
is checked daily by the director of student services. Five interviewed youth confirmed youth
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input is given in the program through youth council, weekly Questions, Concerns, and
Recognition meetings, and Request to Speak forms. The interviewed program director
explained during treatment team meetings the youth’s input is obtained and surveys are
completed. Also, youth can submit Request to Speak forms to provide feedback and participate
in weekly questions and concerns meetings.
2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program has a written policy and procedures to provide career education based on age and
appropriateness for the educational abilities of the youth in the program. The program is a Type
Two vocational program. An interview with the lead educator and program director (PD)
indicated the program offers career services in Florida Ready to Work, Occupational Safety and
Health Administration (OSHA), cardiopulmonary resuscitation (CPR)/first-aid, Certified Nursing
Assistant, and ServSafe. These certifications are kept in the education records and given to
each youth for their IACHIEVE binders. Three closed youth case management records were
reviewed. All reviewed records included a résumé, sample job applications, and information on
the location of the local Career Source Center. There was documentation in each record
indicating the youth's parent/guardian and juvenile probation officer (JPO) were aware of the
vocational plan for the youth. None of the three youth records had the required State of Florida
identification card (ID); however, documentation confirmed the program requested the
necessary Social Security cards and birth certificates to obtain the identification card. The
parents/guardians did not provide the required documentation to the program.
2.20 Educational Access (Critical) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a written policy and procedures to provide educational access. The district
approved calendar and daily bell schedule were reviewed and determined the program
incorporated the required 250 days of instruction, with up to ten days used for teacher planning,
fulfilling the weekly requirement of twenty-five hours of instructional time. The school schedule
runs from 7:45 a.m. to 3:05 p.m. Minimal school interruptions were verified through logbook
reviews and the lead educator’s interview. Five youth were interviewed, and all five reported
little to no interruption to the school day. A review of four randomly selected logbook days
showed the youth were attending school according to the daily bell schedule. Further review of
logbook entries and video footage verified the youth were attending school as scheduled.
2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The program has a written policy and procedures requiring an education transition plan to be
developed upon each youth’s admission. Three closed youth case management records were
reviewed, and all three youth records included the specified education transition plan. Each
record contained an exit plan indicating the case manager, parent/guardian, and youth were all
aware of the plan. Included in each record was an Electronic Educational Exit Plan (EEEP),
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which identified the next educational placement information and input from the post-release
school district representative. Five interviewed youth reported they participated in the
development of their education transition plan. Four out of five youth reported the program was
preparing them very well or well when it came to high school or high school equivalency diploma
(GED). One youth stated the program was not preparing them very well for they are not very
good at learning through virtual classes, only through paper.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program’s designated mental health clinician authority (DMHCA) is a licensed marriage and
family therapist (LMFT). A review of the DMHCA’s license revealed it was valid in the state of
Florida and expires on March 31, 2025. There was evidence of the DMHCA being on-site
weekly for a sufficient amount of time to ensure the appropriate coordination and
implementation of mental health and substance abuse services were taking place. The back-up
DMHCA is a licensed mental health counselor (LMHC) in the state of Florida with a valid license
which expires on March 31, 2025. A review of the DMHCA's position description revealed they
are a full-time staff of the program, present on-site at least forty hours a week, and available
twenty-four hours a day. The DMHCA described their role as actively participating in the
coordination and implementation of mental health and substance abuse services at the facility
by planning and facilitating services as needed as well as providing training and supervision to
the therapists and direct care staff as needed. The DMHCA stated the program provides group,
individual, and family therapy. The DMHCA communicates with the clinical staff frequently
throughout the day. They also maintain an open-door policy, and staff are encouraged to share
their thoughts, concerns, and issues.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program’s policy, procedures, and contract do not require any licensed clinical staff other
than the individual serving as the designated mental health clinician authority (DMHCA). This
was confirmed through a review of the staff roster.
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.
During the annual compliance review period, the program employed two non-licensed
therapists. The designated mental health clinician authority (DMHCA) provides weekly clinical
supervision, which is documented on a form containing all required elements. A review of
weekly supervision documentation revealed each non-licensed clinician who provided services
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during the week was supervised, as required. One of the non-licensed therapists held a
bachelor's-level degree from an accredited university or college in the field of counseling, social
work, psychology, or related human services field with the required fifty-two hours of pre-service
training prior to working with youth. The other non-licensed clinician held a master’s-level
degree from an accredited university or college in the field of counseling, social work,
psychology, or related human services field. The program has a Chapter 397 license for non-
licensed clinicians to provide substance abuse services which expires on March 31, 2025;
however, they did not provide substance abuse treatment. The two non-licensed therapists
administered Assessments of Suicide Risk (ASRs) during the annual compliance review period.
Prior to administering an ASR, both therapists completed twenty hours of training and five
supervised ASRs.
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.
The program has a written policy and procedures in place which identify the mental health and
substance abuse needs of youth 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. A review of five youth mental health and substance abuse
records revealed each contained a completed Massachusetts Youth Screening Instrument,
Second Version (MAYSI-2). There was evidence the screener reviewed all available information
about the youth before completing the evaluation. The screening was completed on the day of
admission in a confidential manner. A review of training records revealed the screenings were
completed by trained staff. All five youth were referred for a Comprehensive Mental Health and
Substance Abuse Evaluation. The reason for the referral was documented in the youth records.
For two applicable records reviewed, the program director ensured an Assessment of Suicide
Risk (ASR) was conducted within twenty-four hours when the MAYSI-2 category “suicide
ideation” indicated further assessment was needed or other information obtained at
intake/admission suggested potential suicide risk. The program director developed written
facility operating procedures for the implementation of a standardized admission/intake mental
health and substance abuse screening process. The policy addressed a standardized screening
process which includes a review of commitment packet information, reports, and records,
administration of the MAYSI-2 in the Department’s Juvenile Justice Information System (JJIS),
referral of youth identified by screenings as in need of further evaluation or immediate attention,
staff training in mental health and substance abuse issues and administration of the MAYSI-2,
and standardized process for referral of youth identified as in need of further mental health
and/or substance abuse evaluation to an appropriate service provider/professional or, when
immediate attention is needed, to a hospital, Baker Act, or Marchman Act receiving facility. The
program director revealed comprehensive evaluations, MAYSI-2s, and ASRs are used to
identify youth at risk for mental health and substance abuse problems and suicide.
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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.
All youth at the program are referred for a Comprehensive Mental Health and Substance Abuse
Evaluation. A review of five youth mental health records revealed the program completed a new
combined mental health and substance abuse evaluation for each youth. The evaluation was
completed within thirty calendar days of each youth’s admission date. In four of the five youth
records a non-licensed mental health clinical staff completed the evaluation, and each was
reviewed and signed by a licensed mental health professional within ten calendar days after the
evaluation was conducted. Each evaluation contained all required components.
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.
A review of five youth mental health and substance abuse records revealed an initial treatment
plan was developed within seven days of initiation of treatment. The initial mental health
treatment plan was documented on the initial treatment plan form which included all elements of
the Department’s Initial Mental Health/Substance Abuse Treatment Plan form. Each of the five
initial treatment plans were signed by the mental health clinical or substance abuse clinical staff
completing the form. Four of the five initial treatment plans were completed by a non-licensed
mental health clinical staff, and the plans were signed by the licensed clinical supervisor, within
ten days of completion. Each plan was signed by all treatment team members who participated
in the development of the plan. All five of the youth mental health records contained an
individualized treatment plan completed within thirty days of admission. Each of the five
individualized treatment plans were developed on a form which contained all of the elements of
the Department’s Individualized Mental Health/Substance Abuse Treatment Plan form. Each of
the plans were completed by a non-licensed staff, and reviewed and signed by the licensed
supervisor, within ten days of completion. Each of the five individualized treatment plans were
signed by all treatment team members who participated in development of the plan. Each of the
five youth had their individualized treatment plan reviewed every thirty days, as required, and
any necessary updates were made on a form which included all required Department form
elements. Each plan outlined the required services and were modified for each youth. Three
random dates were selected to review for video observation of groups. Each group was
facilitated according to the program’s contract and group schedule as documented on the group
sign-in sheet.
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3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
A review of five youth mental health and substance abuse records revealed upon admission,
each youth was assigned to a treatment team consisting of the youth, program administration,
residential living unit, education, medical staff, mental health staff, and parent/guardian. Each of
the youth receiving mental health treatment had a properly executed Authority for Evaluation
and Treatment (AET) and Youth Consent for Substance Abuse Treatment. The mental health
treatment notes were documented on a form which contains all of the information on the
Department’s Counseling/Therapy Progress Notes form. The progress notes in the youth's
mental health and substance abuse records revealed each youth received all services outlined
in their treatment plan from qualified mental health professionals. Individual and family therapy
were administered by licensed or non-licensed clinical mental health professionals. Group
therapy was administered by staff qualified to administer each curriculum. Three closed youth
mental health and substance abuse records were reviewed for discharged plans. Each plan was
documented on the Department’s Mental Health/Substance Abuse Treatment Discharge
Summary form. None of the youth were determined to be at risk for suicide; therefore, a
notification regarding the youth’s suicide risk was not needed to be made to the youth’s
parent/guardian and juvenile probation officer (JPO). The Mental Health and Substance Abuse
Treatment Discharge Summary form documented the services needed for daily maintenance of
the positive improvement in behavioral, emotional, and social skills made by the youth during
treatment. A review of documentation and interview with the designated mental health clinician
authority (DMHCA) reflected the discharge plan was discussed with the youth, parent/guardian,
and JPO during the exit conference. The youth, JPO, and parent/guardian were provided a copy
of the discharge summary.
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.”
Interviews with the program director and designated mental health clinician authority (DMHCA)
revealed the program's contract with the Department mandates the program to provide Mental
Health Overlay Services (MHOS). The contract does not require the use of a psychologist. A
review of the program’s contract, sign-in sheets, and a review of three days of video observation
indicated the program provided all required groups during the annual compliance review period.
A review of five youth mental health and substance abuse records revealed the program offers
therapeutic interventions seven days a week, including individual, group, and family therapy.
The youth also received substance abuse education. Upon admission, each youth is assigned a
primary therapist, and each therapist has a caseload of no more than six youth. Five interviewed
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youth revealed they participated in family and/or individual counseling. The five interviewed staff
revealed mental health therapists facilitate mental health groups.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.***
Psychiatric services are provided by a psychiatrist with a clear and active license which expires
January 31, 2026. The psychiatrist is a licensed medical doctor in the State of Florida. The
program’s contract requires the psychiatrist to be on-site for at least two hours every fourteen
days. A review of sign-in logs for the annual compliance review period revealed the psychiatrist
was on-site for two hours every two weeks. The psychiatrist is also available for emergency
consultation twenty-four hours a day, seven days a week. The program also utilized a
psychiatric advanced practice registered nurse (APRN) whose license expires on July 31, 2024,
as a back-up psychiatrist. The APRN has Collaborative Practice Protocols in place, as required.
The APRN is an autonomous practice APRN. The psychiatrist was interviewed and reported
they evaluate and treat the youth and manage medications as needed. The psychiatrist also
stated they are on-site every two weeks for two hours. The designated mental health clinician
authority (DMHCA) interview revealed the psychiatrist is on-site every two weeks. All referrals
are generated through mental health by written referral. A review of five youth mental health and
substance abuse records revealed each youth was referred for a psychiatric interview. The
Initial Diagnostic Psychiatric Interview was documented on the Department’s Clinical
Psychotropic Progress Note (CPPN) form. The CPPN was clearly identified as an “Initial
Diagnostic Psychiatric Interview”. Page three of the CPPN detailed the medications and all
required information for the youth. One youth was admitted with psychotropic medication and
three youth were prescribed psychotropic medications after their interview. Four of the five
youth were receiving psychotropic medication. There was documentation of the psychiatrist
conducting medication reviews for each youth. The reviewed documentation supported the
youth were seen for a medication review by the psychiatrist or psychiatric APRN, at a minimum,
every thirty days. Any time a medication was prescribed or altered, there was documentation in
which the psychiatrist obtained parental/guardian consent and a witness was present during the
conversation. The psychiatrist and the nursing staff have documentation of monitoring for
Tardive Dyskinesia on a monthly basis as indicated on the CPPN. The program did not utilize
tele-psychiatry during the annual compliance review period.
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 Suicide Prevention Plan which is a written plan detailing suicide prevention
procedures. The plan included identification and assessment of youth at risk of suicide, staff
training, suicide precautions, levels of supervision, referral, communication, notification,
documentation, immediate staff response, and a review process. The review process for suicide
attempts and mortality review included circumstances surrounding the event, facility procedures
relevant to the incident, all relevant training received by involved staff, pertinent medical and
mental health services involving the victim, possible precipitating factors, and recommendations,
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if any, for changes in policy, training, physical plant, medical or mental health services, and/or
operational procedures. The Suicide Prevention plan was reviewed on January 31, 2024, by the
program director and the designated mental health clinician authority (DMHCA).
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors.
Any youth exhibiting suicide risk behaviors shall be placed on suicide precautions
(precautionary observation or secure observation), and a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations shall be placed on suicide precautions and receive an
Assessment of Suicide Risk.
A review of five youth mental health records revealed two were applicable for suicide prevention
services. One additional record was requested and reviewed. Two of the three applicable youth
were determined to be at risk during the admission screening. The other youth were determined
to be at risk due to staff observation. An Assessment of Suicide Risk (ASR) was completed for
each youth on the Department’s ASR form. The three youth were placed on precautionary
observation (PO). The ASR documented the youth’s parents/guardians were notified of the
youth’s potential suicide risk. The Follow-up ASR was documented on the Department’s Follow-
Up ASR form. When the 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 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
record by a mental health clinical staff. There was documentation of a conference held by the
program director and DMHCA to reduce the level of supervision for each youth. The suicide risk
alert for each youth in the Department’s Juvenile Justice Information System (JJIS) was
accurately closed following the recommendations of the ASR. There was also evidence in the
facility logbook the ASR was completed within twenty-four hours of the screening or concern by
a non-licensed clinical staff and reviewed by a licensed staff within twenty-four hours. The
program does not utilize secure observation. No youth were placed on PO within the last thirty
days; therefore, video footage was not applicable to be reviewed. Five interviewed staff were
able to relay the process if a youth expressed suicidal tendencies.
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
A review of five youth mental health records revealed two were applicable for Suicide
Precaution Observation Logs. One additional record was requested and reviewed. The
supervision of each youth was documented on the Suicide Precaution Observation Logs and
maintained for the duration the youth were on suicide precautions. The appropriate level of
supervision and observations of the youth’s behavior was documented in real time and not
exceeding thirty-minute intervals. While on precautionary observation (PO), none of the youth
exhibited any warning signs. The mental health clinician and shift supervisor reviewed and
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signed each Suicide Precaution Observation Log, which documented safe housing
requirements.
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program has a Suicide Prevention Plan which documents staff training requirements. The
review of one staff pre-service training record and five staff in-service training records revealed
each staff completed instructor-led suicide prevention training. Each of the program's seven
suicide response kits were verified and contained all required items. They are stored in the
vans, the two supply closets, the office of the director of student services, the medical closet,
and the human resources office. A review of the program's drill documentation revealed each
shift participated in at least one simulated suicide drill each quarter. In the first six months of the
annual compliance review period, each of the applicable eighteen staff participated in bi-annual
drills as required. In the last six months, each of the fourteen applicable staff participated in bi-
annual drills as required, one of which included the practice of cardiopulmonary resuscitation
(CPR) and the use of an automated external defibrillator (AED). Each drill was documented and
reviewed by clinical staff. The program director and five staff were interviewed and confirmed
monthly mock suicide drills are conducted.
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has developed an integrated mental health crisis intervention and emergency
mental health and substance abuse services plan. The plan included a notification and alert
system, means of referral, including youth self-referral, communication, supervision (one-to-one,
constant, close, and standard), documentation, and review.
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3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a policy and procedures in place addressing Crisis Assessments to ensure
any youth who is deemed to be in a crisis will receive the assistance they require. None of the
five reviewed mental health and substance abuse records were applicable for a Crisis
Assessment. Additional records were requested and two were applicable. The Crisis
Assessment was conducted immediately, within two hours for emergencies, or within twenty-
four hours based on the needs of the youth. The Crisis Assessment included a reason for
assessment, Mental Status Examination and interview, determination of danger to self and/or
others including imminence of behavior, intent of behavior, clarity of danger, and lethality of
behavior, initial clinical impressions, supervision recommendations, treatment
recommendations, recommendations for follow-up or further evaluation, and notification to the
parent/guardian of follow-up treatment. Each Crisis Assessment was conducted by a licensed
mental health professional. One youth was an alleged victim in a Prison Rape Elimination Act
(PREA) event, and there was a Mental Health and Substance Abuse Referral Summary
submitted immediately for a Crisis Assessment. The youth was offered ongoing mental health
treatment services.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program may develop an integrated emergency mental health and substance abuse
services and crisis intervention plan. The plan included immediate staff response, notifications,
communication, supervision, authorization to transport for emergency mental health or
substance abuse services, transport for emergency mental health evaluation and treatment for
Baker Act, transport for emergency substance abuse assessment and treatment under
Marchman Act, documentation, training, and review.
3.17 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 a Baker Act or Marchman Act procedures during the annual
compliance review period; therefore, this indicator is rated non-applicable.
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3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
A review of five youth mental health and substance abuse records found each youth had a
safety plan developed for them within fourteen days of admission. The safety plans were
developed collaboratively and included all required information. Each safety plan incorporated
recommendations from previous or current clinical assessments or screening instruments and
incorporated trauma responsive practices. Each of the youth’s safety plans were reviewed and
updated as necessary at least every thirty days. Each of the five interviewed youth revealed
they contributed to their safety plan. Three of five interviewed staff revealed they did not know
the process for reviewing safety plans. The program director showed the annual compliance
review team a binder which has the safety plans, Trauma Informed Care, and Regulation and
Soothing Plan. The staff knew it by a different name, such as Trauma Informed Care or
Soothing Safety Plan. Additionally, the program director provided the annual compliance review
team with staff training documentation signed by the staff who were interviewed going over the
safety plan and monthly reviews.
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Office of Accountability and Program Support Page 37 of 60 (Revised September 2022)
Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a written policy and procedures addressing the provision of a designated
health authority (DHA) to be clinically responsible for all medical care of all youth at the
program. The program has a licensed medical doctor who serves as the DHA. The DHA holds
an unrestricted license and meets all requirements for independent and unsupervised practice
in Florida. The DHA license expires on January 31, 2026. The DHA’s specialty training is in
family practice. The DHA did not have any disciplinary cases or public complaints on record.
The DHA has not designated a physician assistant (PA) or advanced practice registered nurse
(APRN) for clinical duties; therefore, a Collaborative Practice Protocol (CPP) is not required. A
review of sign-in and out logs noted the DHA was on-site at least once a week for a minimum of
two hours a week. The DHA was out for two separate periods, one week each time. The
program’s back-up physician provided coverage and has equal licensure, which expires on
March 31, 2024. Although the back-up physician provided on-site services, the DHA performed
all necessary administrative duties. The contract for the program does not contain any
information pertaining to telemedicine or telehealth services.
An interview with the DHA revealed visits are conducted weekly to perform Comprehensive
Physical Assessments (CPAs) and see any youth with complaints. Additionally, policy and
procedure discussions occur with nurses and staff. The DHA is on-site once a week.
Communication between the DHA and the program occurs by telephone or text. The DHA is
available by cellular telephone twenty-four hours a day, seven days a week. The DHA provides
all on-site clinical services. A weekly meeting with the DHA and staff ensures off-site care
findings, instructions, and information are reviewed, and documentation is kept on-site.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has a written policy and procedures to indicate the designated health authority
(DHA) as clinically responsible for all healthcare services provided to youth at the program. The
program has licensed nurses to include on-site nursing coverage provided by one registered
nurse (RN) and one licensed practical nurse (LPN). The RN provides direction to the LPN; this
is accomplished through a review of all medical cases daily and being available for on-call
consultation. A review of the licensure credentials for the RN and LPN were clear and active for
each nurse according to the Florida Department of Health Medical Quality Assurance website.
Additionally, each nurse had a current certification in cardiopulmonary resuscitation (CPR). In
accordance with the contract and subsequent amendments, the required on-site hours for the
nursing staff are fifty-six hours a week. The program’s nursing staff are in compliance with the
contracted on-site working hours.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 38 of 60 (Revised September 2022)
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has a written policy and procedures for all health-related protocols utilized at the
program. The designated health authority (DHA) revised and signed the program’s respective
treatment policy and procedures on January 1, 2024. The psychiatrist revised and signed the
program’s respective treatment policy and procedures on January 25, 2024. The facility
administrator revised and signed the program’s respective treatment policy and procedures on
January 16, 2024. Documentation supports on-site nursing staff reviewed, signed, and dated
the cover page on which medical policy and procedures, treatment protocols, and other
procedures were listed. When new policies or changes in policies were made during the year,
nursing staff reviewed, signed, and dated a signature page with the specific policy listed and the
date of revision. The annual review of medical policy, procedures, and protocols was conducted
on January 1, 2024. There were no newly employed healthcare personnel during the annual
compliance review who would need a comprehensive clinical orientation to the Department’s
healthcare policies and procedures, which would be given by the program’s registered nurse
(RN). The approval of treatment protocols and/or standing procedures were written and
authorized solely by the program’s DHA.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a written policy and procedures ensuring the completion of the Authority for
Evaluation and Treatment (AET) authorizing the treatment of youth in the program’s custody.
Five youth Individual Healthcare Records (IHCRs) were reviewed for completion of the AET.
Each IHCR contained a legible copy of an AET, and the word “COPY” was found stamped on
each form. Four of the AETs were signed by the youth’s parents/guardians and Department
representative. One of the four youth turned eighteen years of age while in the program and had
a documented release of information contained within the IHCR. The remaining youth had a
Limited AET signed by the court due to the youth being under the care of the Department of
Children and Families. The court order was also filed within the youth’s IHCR. All five AETs
were found to be valid at the time of each youth’s admission to the program. An interview with
nursing staff revealed the policy for obtaining a new or current AET is to contact the juvenile
probation officer (JPO) immediately if the therapeutic manager determines one is needed. For
all youth who turn eighteen while in the program, the AET for the eighteen-year-olds will be
signed and witnessed by staff.
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 written policy and procedures to ensure the parent/guardian is notified of
any changes in the youth’s condition and to document informed consent for youth healthcare.
Five youth Individual Healthcare Records (IHCRs) were reviewed for parental/guardian
notification and consent, when new medications and treatments are prescribed. Four of the five
youth reviewed were applicable and had documentation of parental/guardian notification for
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 39 of 60 (Revised September 2022)
over-the-counter (OTC) medications prescribed beyond those covered by the Authority for
Evaluation and Treatment (AET). Each of the youth had documentation of consent provided by
the parent/guardian. All five youth records indicated new medication was ordered at some point
during their stay and there was documentation of attempted contact with the parent/guardian
found in the progress notes. In addition, written notifications utilizing the Department’s required
form were sent out to each of the parents/guardians. Four of the five youth reviewed were taking
psychotropic medication during the annual compliance review period. Program nursing staff
witnessed all telephone call attempts and conversations for prescribed psychotropic
medications. Documentation to the parent/guardian was found on page three of the
Department’s Clinical Psychotropic Progress Note (CPPN) form for any new psychotropic
medication being prescribed, discontinued, or the drug dosage significantly changed. The youth
under the care of the Department of Children and Families (DCF) had a court order authorizing
all treatment and procedures and is documented in the youth’s IHCR. All five reviewed youth
IHCRs contained vaccinations which were verified within thirty days of the youth’s admission to
the program. None of the youth were applicable for religious exemption from immunization.
An interview with nursing staff revealed parental/guardian notifications are required for any
applicable appointments and any new medications or changes in status. Parental/guardian
notifications are made the same day of any appointments or change in medications or status.
When a youth illness or injury requires medical services or is life threatening, the
parent/guardian is notified as soon as possible. They will be contacted for updates as needed.
When psychotropic medications, discontinuances, or psychotropic medication need adjustments
the parent/guardian is called by the psychiatrist or nurse for consent. The parental/guardian
notification for psychotropic medications will be sent out with the CPPN form. Witnessed
consent is obtained and signed for. Vaccinations are not provided on-site. The youth are taken
to the health department. The nurse will obtain immunization records through Florida Shots
upon admission if not already in the youth’s record. All records are reviewed the same day the
youth arrive to the program. If the parent/guardian does not consent to immunizations, the nurse
will attempt to obtain the Religious Exemption from Immunization form from the health
department or direct the youth’s parent/guardian to contact the health department for signature
and send a copy to medical for the youth's IHCR.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a written policy and procedures regarding youth healthcare admission
screening and rescreening each time the physical custody of the youth changes. A review of
five youth Individual Healthcare Records (IHCRs) found each youth had a completed Facility
Entry Physical Health Screening (FEPHS) form on the date of admission. Each of the FEPHS
forms were completed by a registered nurse (RN) or licensed practical nurse (LPN). None of the
FEPHS were completed by a direct care staff. None of the youth reviewed were out of the
physical custody of the Department for more than twenty-four hours. An interview with the
nursing staff revealed the youth is seen by the nurse on the first day of admission. The nurse is
notified of any new intakes by email with the juvenile probation officer (JPO). When the youth
arrive at the facility, the staff notifies the nurse, and the admission is completed by the RN or
LPN. For any youth out of the program with a change in physical custody, the youth is brought
to the medical office to be re-screened with the FEPHS.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 40 of 60 (Revised September 2022)
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a written policy and procedures ensuring all youth admitted to the program are
provided an orientation to healthcare services. A review of five youth Individual Healthcare
Records (IHCRs) documented orientation was completed for each youth. The orientation
included all required healthcare and health education topics at the program. All five youth
orientation sheets had documentation of the youth’s signature.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a written policy and procedures to notify the designated health authority (DHA)
or designee, by telephone or verbally, of each youth’s arrival at the program and provide
immediate notification when any youth admitted to the program requires emergency care. A
review of five youth Individual Healthcare Records (IHCRs) found three were applicable for a
known or suspected chronic condition at admission. The three youth had a referral to the DHA
and/or psychiatrist upon admission to the program. None of the youth reviewed were identified
as in need of emergency care response upon admission. A review of five records indicated the
program notifies the DHA or designee within twelve hours of admission for all youth admissions,
regardless of whether the youth had a chronic or suspected chronic condition. The notification is
documented in the youth’s Chronological Progress Notes. One of the five youth was taking
psychotropic medication upon admission and the psychiatrist was notified as required. An
interview with the nursing staff revealed for youth admitted with serious or chronic conditions,
the DHA is notified the same day and no longer than twelve hours after their admission. The
registered nurse (RN) or licensed practical nurse (LPN) makes the notification and documents it
on the DHA notification form.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a written policy and procedures ensuring the Department’s Health-Related
History (HRH) form is completed prior to the Comprehensive Physical Assessment (CPA) and
healthcare needs are identified. A review of five youth Individual Healthcare Records (IHCRs)
indicated each had a completed and/or updated HRH form, within seven days of admission. The
reviewed IHCRs indicated the HRH form was completed prior to the CPA as evidenced by the
signature and date. The HRH was reviewed by the designated health authority (DHA) and was
documented by a checkbox on the CPA, indicating the HRH was reviewed. An interview with the
nursing staff revealed the registered nurse (RN) or licensed practical nurse (LPN) reviews the
youth’s current HRH; however, a new one is completed by the RN when the DHA completes the
CPA.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 41 of 60 (Revised September 2022)
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a written policy and procedures ensuring the acute and chronic healthcare
needs of the youth are addressed by completing a Comprehensive Physical Assessment (CPA)
within seven days of admission. A review of five Individual Healthcare Records (IHCRs)
indicated a CPA was completed for each youth upon admission. Each of the reviewed CPAs
were documented on the Department’s CPA form. A current CPA was on file for each youth at
the time of admission to the program; however, a new CPA was completed by the designated
health authority (DHA) within seven days of each youth’s admission. Each of the reviewed
CPAs documented the youth’s Medical Grade. There were no missing or incomplete elements
on any of the reviewed CPAs. All five youth refused a portion of the examination and signed the
refusal form which matched the CPA. The CPA was signed by each of the youth reviewed, for
portion of the refused examination. All sections of the CPA were completed utilizing an “O” or
“X” marking. All five youth were applicable for having the Department’s Problem List updated.
Each of the youth had their Department’s Problem List updated within each of the IHCRs. All
five youth had documentation of the most recent verified Tuberculosis Skin Test (TST)
administered within the last year. The results for the TST were documented on the CPA and the
Department’s Infectious and Communicable Disease (ICD) form. An interview with the nursing
staff revealed the DHA completes a new CPA for all new youth and annually for any youth at the
program for greater than one year with Medical Grade two through five. TSTs are completed
annually. For female youth, gynecological exams are not completed routinely.
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 written policy and procedures to ensure all youth admitted to the program
are screened, evaluated, and treated, if applicable, for sexually transmitted infections (STIs) and
human immunodeficiency virus (HIV). A review of five Individual Healthcare Records (IHCRs)
found all youth had a clinical screening and were subsequently evaluated for STIs. Screening,
testing, and evaluation occurred upon admission to the program. Three of the youth were
applicable for further evaluation and were referred to the designated health authority (DHA). The
referrals were all documented on the STI form. Testing was ordered and performed for all three
youth. Each youth had appropriate documentation filed within their respective IHCR. None of
the youth reviewed were ever out of the Department’s physical custody. All five youth were
offered counseling, testing, and a referral for treatment for HIV, if necessary. Two of the five
youth received HIV testing, and documented consent was obtained from each youth and
maintained in their IHCR. Both youth had their HIV results filed in their IHCR, maintained in a
sealed envelope, which was marked “Confidential.” Both envelopes contained the DHA
signature, attesting to a review of the sealed contents. Each of the youth had documentation of
pre-test and post-test counseling within their IHCR. There were no alerts indicating HIV status
within the program’s internal alert system. Two of the remaining youth were not applicable for
testing and one youth refused testing. The program has a written policy and procedures which
reflect HIV test results are only disclosed to the youth, and those entities as outlined within
Florida Statutes. The HIV pre-test and post-test counseling is conducted by the local health
department and documented in the IHCR. Five youth were interviewed and reported they could
ask for an HIV test. An interview with the nurse revealed youth are screened for STIs on the STI
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 42 of 60 (Revised September 2022)
Screening form upon admission. For youth who request to be tested, an appointment will be set
up with the local health department. A re-screening is completed if the youth is outside the
program's physical custody for more than thirty days and/or symptoms are present. HIV testing
results are kept in a sealed envelope marked confidential in the youth medical records.
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 written policy and procedures addressing the program’s sick call process.
A review of five Individual Healthcare Records (IHCRs) revealed three youth had completed a
total of five sick call requests at the program. A Sick Call Request form was completed by the
youth for each of the five sick calls reviewed. Three of the five Sick Call Request forms were
completed by a registered nurse (RN). The remaining two sick calls were conducted by a
licensed practical nurse (LPN). Both of the two sick calls completed by the LPN were reviewed
daily either telephonically or in person with an RN and documented on the sick call forms. Each
of the five sick calls were filed within the youth’s IHCR in reverse chronological order. None of
the youth presented with a similar sick call complaint three or more times within a two-week
period. None of the reviewed youth were in restricted housing. Each of the five sick calls were
documented in progress notes in accordance with Florida Administrative Code. Each of the sick
calls reviewed were found to be recorded appropriately on the Sick Call Index. Each of the sick
calls were documented on the program’s Sick Call Referral Log. The dates listed on the Sick
Call Index corresponded to the completed Sick Call Request forms located in each of the youth
IHCRs. The program provides sick call daily, while the nursing staff are on-site at 7:15 a.m. and
as needed. The sick call hours are posted on the medical office door, each wing, and are
reviewed with each youth during orientation at admission. The nursing staff confirmed the exam
table and equipment are used to perform sick calls. Five staff were interviewed, and all reported
the nurse reviews and conducts sick calls. Five youth were interviewed, and three youth
reported seeing the nurse within one day of making a sick call request. One youth reported
seeing the nurse immediately and the remaining youth reported never requesting a sick call. An
interview with the nursing staff revealed sick call is available seven days a week at 7:30 a.m.
Any youth who requests to see the nurse after, they can come to the medication cart. For
anything else, the youth need to tell the staff and the staff will notify the nurse. The RN or the
LPN conduct sick call. If conducted by the LPN, the LPN calls the RN on the day of the sick call
and notifies them of what occurred. The RN will review and sign the sick call the next day they
are on-site. The designated health authority (DHA) will conduct sick call if on-site. Sick call is
conducted in the medical office. For any youth who has placed a same sick call three times in a
two week period, they are placed on the list to see the DHA. The program has DHA approved
treatment protocols. The program does not have restricted housing or confinements. A sick call
observation was unable to be conducted as none occurred during the annual compliance review
week.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 43 of 60 (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 written policy and procedures to ensure the youth have access to episodic
and first-aid care. A review of five youth Individual Healthcare Records (IHCRs) revealed one
youth required a total of two encounters for either on-site first-aid, episodic, or emergency care.
All care provided was conducted by a licensed healthcare staff while on-site. Each incident was
documented with problem-oriented elements, to include subjective, objective, assessment, and
plan (SOAP). None of the episodic or first-aid care was provided for by non-healthcare staff.
The program has a total of nine first-aid kits, one in wing A, one in wing B, one in the kitchen,
one in the medication cart, two in the large trailer, one in the small trailer, and the remaining two
in each vehicle. The nurse checks first-aid kits on a weekly basis and has a list of contents with
expiration dates written inside and outside each first-aid kit to ensure contents are maintained
and stored in accordance with guidelines to prevent expiration or deterioration and are
replenished as needed. A review of three first-aid kits revealed the kits were fully stocked with
designated health authority (DHA) approved contents. A review of the first-aid kit log indicated
the nurse checks each first-aid kit on a weekly basis. The program has one automated external
defibrillator (AED), which is in the medication cart closet located in the gym. The AED
procedures are located next to the AED. The nursing staff check the AED weekly to ensure the
batteries and pads are operable. The nursing staff conducted a self-test of the AED in the
presence of an annual compliance review team member during the annual compliance review
week. There were no noted issues observed during the AED testing. The batteries for the AED
will expire in April 2026. The batteries were last changed in January 2023. The AED pads expire
in March 2025. The pads were last changed in January 2023. Emergency medical drills were
reviewed for each of the program’s four shifts. Each shift conducted emergency medical drills at
a minimum of monthly; with no exceptions noted. The reviewed emergency medical drills
included the demonstration of cardiopulmonary resuscitation (CPR), AED, and “man-down”
procedures and indicated direct care staff participated in at least one drill annually. The program
maintains a binder with documentation of each drill for each shift. The drills consisted of
announced and unannounced type drills and were conducted at least monthly on each shift. The
program has emergency telephone numbers for all staff within the medication cart closet. The
emergency contact numbers along with the poison information control center number are in an
area which is not accessible to youth. Training for the epinephrine auto-injector is conducted for
all healthcare and direct care staff during orientation to the program and then annually
thereafter. Training for the epinephrine auto-injector is conducted by the on-site registered nurse
(RN). A review of one pre-service and five in-service training records identified staff received
training in episodic, first-aid, and emergency care. No episodic care events occurred during the
annual compliance review week; therefore, an episodic care event could not be observed. Five
staff were interviewed, and all reported they are personally allowed to call 9-1-1 if a youth has a
medical emergency. Five youth were interviewed, and all reported seeing a dentist or doctor if
needed. An interview with nursing staff confirmed the locations of the first-aid kits. Episodic care
is documented on the episodic care log and the episodic care form and placed in the medical
records after review by the DHA. All off-site emergency care information is placed in the DHA's
box for review and for any follow-ups needed. The RN or LPN ensure the AED batteries and
pads are operable. A schedule for emergency drills is completed. One drill for each shift is
completed monthly for a total of four drills a month.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 44 of 60 (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 written policy and procedures to ensure for timely referrals and coordination
of medical services to an off-site healthcare provider. There was no off-site care or referrals
during the annual compliance review period. An interview with the nursing staff revealed all
records from the hospital are reviewed by the nurse, checking for any orders or follow-ups, then
placed in the DHA box for their review. The appointment book, referral log, and summary of off-
site care are used by nursing staff to track follow-up testing, referrals, and appointments.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a written policy and procedures to ensure any youth admitted to the program
who have chronic conditions receive regularly scheduled evaluations and any as-needed follow-
up care. A review of five youth Individual Healthcare Records (IHCRs) was conducted and only
three were applicable for a chronic condition. The three youth reviewed were identified on the
Department’s Facility Entry Physical Health Screening (FEPHS) form with a chronic condition
upon admission. None of the youth were identified as having a communicable disease. All three
youth were taking prescribed medication on an ongoing basis. One youth was undergoing
treatment for physical health conditions. All three youth were classified with Medical Grade two
or higher. None of the youth were identified as pregnant. All three youth were placed on the
chronic illness list. All three reviewed youth were in receipt of periodic evaluations at least every
ninety days as required. An observation of each youth’s periodic evaluations revealed no
issues. A review of progress notes confirmed they documented each youth’s periodic
evaluations. None of the youth were applicable for taking anti-tuberculosis medications. Each of
the youth reviewed had an evaluation completed prior to a prescription renewal, change, or
expiration. None of the youth reviewed were applicable for an off-site evaluation. The
Department’s Problem List was updated in accordance with Florida Administrative Code for
each of the reviewed youth. An interview with the program director revealed medical
assessments, sick calls, and weekly health checks are formalized procedures in place with the
healthcare staff to ensure important medical issues are addressed. The program director meets
with healthcare staff, weekly, daily, and as needed. An interview with the DHA revealed periodic
evaluations for youth with chronic conditions are completed and tracked every ninety days or
sooner. The nurse tracks the information to ensure all youth receive periodic evaluations. An
interview with the nursing staff revealed the program monitors youth with chronic conditions by
placing them on the chronic roster.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 45 of 60 (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.
The program has a written policy and procedures to ensure the accurate and safe
administration of youth medications. A review of five youth Individual Healthcare Records
(IHCRs) was conducted, and two youth were applicable for being admitted with medication. The
medications for both youth were verified prior to the youth being admitted into the program.
Prescription medication verification was documented for each youth within the chronological
progress notes and on the Department’s Prescription Medication Verification Checklist form.
The designated health authority (DHA) and when applicable, the psychiatrist was contacted to
obtain an order to resume the specified medication prescribed prior to admission for both youth.
All five youth were on medications at the time of the annual compliance review and had a
current, valid order for their medications which were administered pursuant to a current
prescription. All five youth had a current Practitioner’s Order form in their IHCR. There is no
restricted housing at the program. Four of the five youth were applicable for over-the-counter
medications which were administered according to approved protocols. The program utilizes the
Department’s standard Medication Administration Record (MAR) to document all medications.
Each of the reviewed MARs met all requirements outlined within Florida Administrative Code.
Trained non-healthcare staff assisted in the delivery of medications, only when licensed medical
staff were not on-site, with no noted issues. Staff initial each administered medication entry as
required. There were no undocumented explanations for a lapse or errors in medication
administration. The nursing staff documented side-effect monitoring weekly, at a minimum, on
each MAR. One youth refused medication one time and a refusal of treatment form was signed.
The MARs contained all the required elements. One youth was applicable for parenteral type
medications. The medication is administered by a licensed healthcare staff. One youth was
applicable for receiving prescribed psychotropic medication upon admission. The DHA and
psychiatrist were notified upon youth’s admission. The psychiatrist conducted an initial
diagnostic psychiatrist interview within fourteen days of admission as required. There was no
indication of any type of standing orders for psychotropic medications. There were no
emergency treatment orders for psychotropic medications. There were no pro-re-nata (PRN)
orders for psychotropic medications. A medication pass was observed during the annual
compliance review week with no observed issues. Youth were escorted to the medication pass,
which was located in the gym in front of the locked closet where the medication cart was kept.
Direct care staff escorted each youth individually. The nurse was able to identify themself,
provide a brief description as to why the youth was at medication pass, and any appliable
allergies the youth may have. Medications were accessed from the medication cart once the
youth and nurse identified themselves and the medication to be taken. The nurse ensured the
medication was swallowed each time. A saltine cracker was also given to each youth after
medication was administered. The nurse and youth initialed the MAR once the medication was
taken by the youth. The Six Rights of Medication Delivery/Administration were observed during
the medication pass.
Five youth were interviewed, and all reported receiving medication from the nurse. One youth
also said staff would give them medication. Five staff were interviewed, and all reported the
nurse dispenses medication to the youth. An interview with the nursing staff revealed only the
nursing staff verify medications. This is documented on the Facility Entry Physical Health
Screening tool and the Medication Verification form. The program utilizes the Department MAR.
The non-healthcare staff who provide medications are trained by the RN and the list of trained
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 46 of 60 (Revised September 2022)
staff is on the medication cart. Medication pass times are breakfast, lunch, and dinner.
Medications are procured through a local pharmacy. The psychiatrist services are provided on-
site. Initial psychiatric evaluations are done on all new youth within fourteen days of intake. All
youth on psychotropic meds are seen at least every four weeks and as needed for medication
management.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a written policy and procedures to ensure medical equipment classified as
sharps/medications are secure and inventoried utilizing a routine perpetual inventory. The
medical equipment classified as sharps were observed to be secured and inventoried utilizing a
routine perpetual inventory descending in count as each sharp was utilized and disposed of. In
addition, all medications were secured in locked areas designated for storage of medications.
The medication cart was observed to be clean and organized, with stock items separate from
youth specific medications. There were no controlled medications on-site during the annual
compliance review. All medications were observed to be stored in a separate, secure area,
which was inaccessible to youth. Medications which require refrigeration were stored in a
refrigerator, which was observed to be locked. This refrigerator was utilized for medication
purposes only; however, there were no medications requiring refrigeration during the annual
compliance review period. The program’s process for destruction and disposal or return of
expired or discontinued medications is taken care of by the pharmacist when they come on-site.
Perpetual and weekly inventories of sharps and stock over-the-counter (OTC) medications were
observed to be completed, as required, with no noted issues. A review of six non-healthcare
staff training records was conducted for completion of delivery and oversight of medication
administration. The training was conducted by the on-site registered nurse (RN). Observations
were made of the RN counting three OTC medications and three sharps with no observed
issues. The program has a written policy and procedures which address practices for reporting
any inventory discrepancies. An interview with nursing staff revealed all prescription
medications which have been discontinued are disposed of with the pharmacist consultant,
nurse, and program director/designee. All disposed medications are placed in the drug disposal
container. All controlled medications are kept in the medication cart behind two locks. The
current agreement with the pharmacist requires monthly visits where they regularly inspect the
program’s Medication Administration Records (MARs), medication cart, disposal of medications,
and quarterly and annual meetings.
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 written policy and procedures related to Infection Control and an Exposure
Control Plan. A review of the program’s written infection control and exposure control plans was
conducted. The written plan included prevention, containment, treatment, and reporting
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requirements. The plans are written in accordance with Occupational Safety and Health
Administration (OSHA) federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The infection control plan and exposure control plans are available to all staff.
The designated health authority (DHA) reviewed the program’s plans on January 1, 2024. The
program director reviewed the plans on January 16, 2024. The nurse manager reviewed the
plans on January 16, 2024. The registered nurse (RN) reviewed the plans on January 22, 2024.
The infection control procedures included all required elements. The program makes available
Hepatitis B immunizations for all staff if they choose to get them. Staff have access to protective
equipment. The program has a written facility operating procedure which addresses the process
for needle stick post-exposure practices. The program director maintains a separate binder for
any youth or staff who may have experienced a facility or occupational exposure. There were no
documented instances in which the program had to notify the local county health department,
CDC, and/or the Department’s Central Communications Center (CCC) of any infectious disease
outbreaks. An interview with the program director revealed exposure plans are located in every
office and are reviewed as needed. An interview with the nursing staff revealed the Exposure
Control Plan is located in the medical office. The infection control training for staff is conducted
by the RN and trainer. Infection control training is provided to youth upon admission and
throughout their stay.
4.19 Prenatal Care/Education Satisfactory Compliance
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
The program has a written policy and procedures regarding prenatal care and education for
pregnant youth. There were no youth applicable for prenatal care and education during the
annual compliance review period. An interview with the nursing staff revealed services included
prenatal nutrition and exercise, prenatal care with appointments, and education classes.
Females are routinely tested for pregnancy upon admission. Daily and weekly monitoring is
done, as well as appointments with an obstetrician and the designated health authority (DHA).
Pregnant youth are provided with a special diet. The RN provides non-licensed healthcare staff
education on girl's healthcare. All prenatal and post education topics are provided to pregnant
youth. All pregnant youth are seen by the local county health department for all their prenatal
needs.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures which address youth supervision, movement, and
checks. The program’s policy indicates program staff shall maintain active supervision of youth,
including interacting positively with youth, engaging in a full schedule of activities, closely
observing the behavior of youth, and changes in behavior, while consistently applying the
behavior management system. The program’s ratio requirement of staff to youth is one to eight
for daytime activities, and one to twelve during sleeping times. Observations were made each
day of the annual compliance review week, which found youth and staff adhering to the daily
activity schedule. Youth were observed in classes, at mealtimes, in line movements, in
recreation, and during searches. Positive interactions were observed between youth and staff.
Random informal interviews with three separate staff were conducted, and each staff was able
to give an accurate count of youth under their direct supervision at the time. Five formal staff
interviews were conducted. All five staff were able to summarize the program’s process and
procedure in the event a youth count is not reconciled. Each staff reported a recount would
occur, and the facility would need to be secured in order to proceed with the recount process.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program’s behavior management system (BMS) was observed and documented within the
program’s policy and procedures, youth handbook, and seen posted on walls in living areas.
The BMS was reviewed within the provider’s contractual agreement, and it was revealed all
appropriate parties were involved in the development, implementation, and on-going
maintenance of the BMS. The program’s policies include a protocol where staff are provided
feedback regarding the implementation of the BMS. The program has a trainer who trains all
staff and education staff on the program’s BMS. The one applicable pre-service record reviewed
found the staff received BMS training as part of their pre-service training requirement. Five
youth case management records included evidence each youth was oriented on the program’s
BMS after admission. Three position descriptions were reviewed, which included the coach
counselor, shift supervisor, and therapeutic manager. Each of these position descriptions
detailed job functions which included implementation of the program’s BMS. The program’s
BMS was posted in areas accessible to youth which included rules governing conduct and
positive and negative consequences. The program’s BMS has not changed from the previous
year. The BMS includes all required information, such as promoting safety, respect, and
fairness. The BMS also includes recognition of accomplishments and positive behaviors at a
five to one ratio, a process for youth to explain behaviors, and opportunities for staff to discuss
with youth the impact their actions have on others as well as alternate acceptable behaviors.
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The BMS does not include promotion of group discipline, increased length of stay, denial of a
youth’s basic rights, punishment by other youth, or disciplinary confinement. The program
provides a variety of rewards such as Purple Room, snack times, outings, and education
incentives. The program director was interviewed and stated the BMS used is the Measurable
Achievement Plan (MAP) system. It is an incentive-based system which allows youth to know
their status in the program daily along with being provided incentives for all achievements made
daily. The system consists of five levels in which the youth have to petition their peers and the
treatment team for advancement from level to level. Rewards are monitored by the director of
student services. The program ensures the practice takes place daily in the daily meeting with
the youth at which time they have the opportunity to discuss with all staff any issues or concerns
they may have. The program director reported consequences are tracked daily to ensure
consistency. The program uses an internal fidelity check tool to monitor the process. It is also
monitored by the program director and treatment team. Five interviewed staff reported they
received BMS training. All five were able to summarize the BMS process. All five staff gave
examples of rewards a youth may receive such as extra telephone time, Fun-Friday, movie
nights, Purple Room, outings, and school incentives. The interviewed staff reported nothing can
be taken away from a youth as a result of a consequence. Three of five interviewed staff
reported supervisors provide them feedback on their implementation of the BMS through face-
to-face meetings, counseling, and evaluations. Two staff reported they were not sure when
feedback was given. Five interviewed youth were able to summarize the program’s system of
consequences they may receive for punishments due to behaviors. Consequences included
things such as assignments, extra essays, restrictions, red days, and points deducted. All five
youth gave examples of rewards which included Fun Fridays, school incentives, daily rewards
and snacks, outings, Purple Room, and parties. All five youth were able to summarize the
program’s BMS. None of the five youth stated youth were allowed to punish other youth. All five
youth reported staff use rewards the same. When asked to rate the program’s BMS, three
stated it was very good, one stated it was fair, and one stated it was good.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, provide constructive discipline and a system of positive and negative consequences
to encourage youth to meet expectations for behavior, provide opportunities for positive
reinforcement and recognition for accomplishments and positive behaviors, promote dialogue
and peaceful conflict resolution, and minimize separation of youth from the general
population.
Supervisors shall monitor staff implementation of the BMS and ensure the use of rewards and
consequences are administered fairly and consistently in application among all staff.
The program does not utilize room restriction; therefore, this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a total of forty-three cameras, all of which were operating as required,
according to the program administration. Video recordings are stored for up to thirty days. The
program operates on a night and day shift. Security tapes were reviewed for each shift. A total
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of eight time period increments, covering both day and night shifts, were reviewed, and each
check was conducted by staff at or within ten-minute increments. Staff were observed
documenting on logs and using flashlights when walking down youth living area wings. The
program has a total of two separate wings to which youth are assigned. No discrepancies were
observed. A sample of logs from each month was reviewed for the annual compliance review
period for both living areas. Nineteen total logs were reviewed with thirty-minute time frames
each. All were documented at or within ten-minute increments as required. Staff initialed by
each entry. Documentation was completed in real-time as required. There were no
discrepancies identified. Five interviewed staff all reported checks for youth during sleep times
are done so at or within ten-minute increments.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program has a written policy and procedures outlining the requirements for youth census,
counts, and tracking. Formal and informal youth counts are done throughout each day.
Observations of formal headcounts were made during the annual compliance review week. One
day each month of the annual compliance review period was reviewed within the master
logbook. The reviewed logbooks indicated counts were completed on each shift daily and
multiple times throughout the workday. Formal counts are done at the beginning of the shifts,
after youth movement from classes, outdoor activities, and when youth were temporarily away
from the program. Five staff were interviewed. All five stated headcounts are done at every
youth movement. Emergency counts may be done at times such as fires, natural disasters, or
when a youth is missing and not accounted for. All five interviewed staff were able to give the
program’s current youth census 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 has one master logbook, which is maintained by the shift supervisor or direct care
staff. The logbooks used were observed to be bound with numbered pages. Entries were made
in ink with no white-out or erasure signs. No pages were observed to be destroyed or removed.
Logbooks were provided for the annual compliance review period. Errors observed were
marked through with a single line as required. A minimum of three days for each month of the
annual compliance review were reviewed and found no discrepancies. Logbook documentation
reflected youth counts, youth arrivals, adherence to the daily schedule for recreation, mealtimes,
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and education activities. All entries included the dates and times of events, with the names of
the staff and youth involved, a brief description of events, and the names of staff making the
entries. Logbook reviews were also documented in a different ink color by the staff or supervisor
reviewing the logbook. Significant events were highlighted for easier identification. Logbook
information included all required events such as emergency situations, population counts,
security checks, transports, admissions and releases, and perimeter and security checks. In
addition to the logbook, the program completes a shift report for each shift which documents the
total population count, youth alert information, and significant events. Staff oncoming to the shift
sign a review of the shift report. Shift reports were maintained in the two separate wings of the
youth assigned areas for at least forty-eight hours. Completed shift reports were maintained in
the director of student services office. A review of completed shift reports was done for the
annual compliance review period, which confirmed the program’s practice of completing these
reports as required.
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 key control which includes key assignment,
usage, and restrictions on usage. The policy also notates inventory and tracking of keys, secure
storage, procedures for missing or lost keys, and reporting and replacement of damaged keys.
Personal keys and visitor keys were observed taken up by supervisors and stored in a secure
storage box located in the lobby of the program. The personal keys were replaced with a
numbered chit. Upon arrival to the program, direct care staff are required to turn in their
personal keys and replace them with their assigned facility keys. This assignment is noted on
the daily tracking Key Inventory Log which is signed by the staff and supervisor and indicates
the date and time in and out of the keys, as well as the key ring issued. According to an informal
interview with the director of student services and human resources staff, permanent keys are
assigned in writing by the program director. Permanent keys, which are also called twenty-four
hour keys, are assigned to designated staff, and monthly checks are done for these keys.
Documentation of these monthly checks were done for the annual compliance review period,
which confirmed the program’s practice. Restricted keys, such as case management, medical,
mental health, and administrative keys are documented in the key log and permanently
assigned to those staff authorized by the program director to maintain those keys. Direct care
staff do not have access to those keys. A review of the Department’s Central Communications
Center (CCC) reports for the annual compliance review period found no incidents of lost or
missing keys. A sampling of key rings was observed and compared with the inventory and key
log, which confirmed all keys were in their required location and matched the key number and
total number of keys listed. Three random staff were questioned regarding their work issued
keys. Each staff had the correct keys as notated on their signed key log. Two of three staff
stated they knew the function of each key on the ring assigned. One staff, who was a temporary
staff assigned from another program affiliated with the same provider, was able to name the
function of all but one small key, which was discovered to be the key for the towel dispenser. All
five formally interviewed staff were able to summarize the program’s key control process.
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5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the program director or designee
has the discretion to discard of the item, return it to its original owner, mail it to the youth's
home, or return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a written policy and procedures which outline contraband, define items
considered contraband, and list consequences and search procedures within the program. The
program provides a list of items considered contraband to each youth. Youth are given this in
the youth handbook upon admission to the program. The policy also outlines searches of the
facility grounds, searches of youth, staff, and visitors, and incoming and outgoing mail. The
program’s policy indicates any staff who is found in possession of contraband in the program
will be subject to disciplinary action up to and including dismissal. Law enforcement is contacted
in the event any item found would be considered illegal as defined in Florida Statutes. The
program documents the confiscation of contraband and maintains the documentation on search
forms and within the youth management records in the event contraband is found. Random
searches are done daily and documented in the logbook and on program area search forms.
The forms were observed for the annual compliance review period which confirmed the
program’s practice. An interview with the program administration and a review of the
Department’s Central Communications Center (CCC) reports for the annual compliance review
period was done and found no report of illegal or non-illegal contraband. The program director
was interviewed and stated contraband items will be confiscated and delivered to the shift
supervisor for proper locking and storage and/or disposal. Visitors in possession of contraband
will be asked to lock the items in their vehicle and leave the facility. Illegal contraband will be
quarantined until law enforcement is called and arrives on-site to investigate. Five interviewed
staff summarized the search process for youth rooms. Four reported searches are done daily.
One reported they did not know the frequency of the searches, however, youth are present
when conducting the search.
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5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a written policy and procedures outlining searches of the youth, staff,
and facility grounds for contraband items. Youth searches were observed during the annual
compliance review week, when youth were seen moving from one location to another. Staff of
the same gender were observed performing the searches. Youth were treated with dignity and
respect. The program performs searches prior to youth being moved from one place to another,
for youth transports, and after visitation. Youth searches were observed to be in compliance
with the program’s policy requirements. Five interviewed youth all confirmed staff perform
searches at every youth movement. Five interviewed staff also confirmed searches are done at
every movement. Visitor searches were observed each day of the annual compliance review
week. The staff of the same gender performed the searches. Visitors were asked to remove
items from pockets, remove their shoes, and their jackets. A hand-held metal detecting wand
was used in this process. In addition, visitor bags and cases were also checked by staff prior to
entering the program areas.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a policy and procedures regarding the transportation of youth and the
maintenance of vehicles used in these transports. Five random vehicles were inspected which
ensured they were secured in the program’s parking lot as required. The program has two vans
used to transport youth; these two vehicles were also found secured when not in use. Each
vehicle door could not be accessed by the youth inside being transported. Each vehicle had an
updated annual safety inspection which documented items checked as well as correction of any
deficiencies identified during the inspection. Maintenance records are maintained by the
program’s maintenance staff. Both vehicles have an approved first-aid kit. These kits are
maintained in the program when not being used during transports. In addition, both vehicles had
an approved fire extinguisher, seatbelt cutter, window punch, appropriate number of seatbelts,
flashlight, and roadside emergency equipment. Weekly safety inspections are done by the
maintenance staff. Van keys are kept in a secure locked box. Five staff interviews all confirmed
youth are secured when being transported. Five youth interviews all confirmed youth wear
seatbelts during transports.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a written policy and procedures regarding the transportation of youth
and vehicle maintenance requirements. The program issues a cellular telephone on transports
of youth. The cellular telephone is in the human resources office at the front of the main
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building. The ratio for transportation is one staff to five youth. A transportation was unable to be
observed during the annual compliance review week due to no transports being completed. Five
youth interviews confirmed seatbelts are used when they are being transported. All five
interviewed youth reported they feel safe when being transported by staff. None of the five youth
have witnessed someone place contraband in a transport vehicle. Five interviewed staff all
confirmed they are provided a cellular telephone on transports. All five gave examples of safety
equipment provided as well, which included items such as medical or first-aid kit, road flares,
snacks, and club bar locks. All five staff said they are not allowed to use personal vehicles to
transport youth. All five confirmed vehicles are searched prior to and after each use. All five
were able to explain the emergency response process during vehicle transports.
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 written policy and procedures outlining the weekly safety and security
audit inspection process. The program’s maintenance staff maintains the facility weekly
inspection forms which detail inspections of all program areas for proper functioning. The
director of student services and maintenance staff person are primarily responsible for
completing the weekly security audits and safety inspections. The documentation is captured
using the Department’s Facility Security Audit and Safety Inspection form. The forms are done
weekly. A review of this documentation was done for the annual compliance review period
which confirmed the program’s practice. The development and implementation of any corrective
actions warranted for areas of concern were observed and documented on the corresponding
forms. Contact was made by telephone to the Department’s safety and security specialist
assigned to monitor the program’s process of submitting the required documentation. The safety
and security specialist confirmed the program provides all required documentation weekly and
responds to any actions needed. The program also had no outstanding deficiencies at the time
of the annual compliance review week. There were no exceptions identified, as confirmed with
the Department’s safety and security specialist with Residential Services. The program director
was interviewed and stated identifying and tracking safety and security deficiencies are done
through weekly safety and security audits and perimeter checks.
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 written policy and procedures addressing tool inventory and
management of tools. Class B tools such as brooms and mops are maintained in two secured
closets clearly marked outside each door prohibiting youth from entering. The Class B tool
inventory was maintained in both these locations daily by direct care staff. One wing closet had
one extra mop, not on the inventory form. The item was removed by administrative staff during
the annual compliance review week. All Class A and remaining Class B maintenance tools are
maintained and secured in an outside storage building, which also serves as the maintenance
staff person’s office. The tools are inventoried daily for Class A and weekly for Class B tools. In
addition, when tools leave the building, the maintenance staff signs them in and out on a
perpetual inventory form. All inventory forms were reviewed which confirmed the program’s
practice. A total of thirteen tools were reviewed in comparison with the inventor logs. Each was
found secured and on the inventory form. One of the items, a hacksaw, was classified as a
Class B tool, however, was changed to Class A. All tools had an identifying marking on them
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which matched the inventory form. In addition to the maintenance tools, kitchen knives were
also observed as secured in the kitchen area. The dietary staff provided documentation showing
these items are inventoried daily. All knives were accounted for. Each had a corresponding
identifying number as well for easy identification. The program’s policy and procedures prohibit
machetes, bowie knives, or other long bladed knives. In the event a tool goes missing it is
reported to the shift supervisor, master control, and administration, the program goes on
lockdown until the tool is found, and if not found, a Department’s Central Communications
Center (CCC) report is made and a full program search is conducted.
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 written policy and procedures regarding the handling, inventory, and
storage of tools. Vocational tools used by youth are done so at a one staff to five youth
supervision ratio. The policy outlines all requirements to include ratio, tool distribution, and
supervision of youth when using tools. Observations of youth tool usage were unable to be
made during the annual compliance review week. Youth who have been given permission to
utilize tools have successfully passed a training for the tool usage and have an approved risk
assessment completed by the treatment team. A sample of five youth were reviewed and each
had a verified tool usage form for Class B tools and an updated risk assessment. Five
interviewed youth all reported they only have utilized brooms and mops in the program. Five
interviewed staff all reported youth use only Class B tools such as 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’s procedure for outside contractors includes requirements for outside contractors
to receive written instructions detailing tool management and contraband, as well as confining
work to authorized areas only. Guidelines include tool check-in and out, tool restrictions, missing
tool follow-up, and restricting youth from work areas. The program’s maintenance staff person is
responsible for escorting all outside vendors within the program areas. A review of outside
contractor sign-in forms found evidence tools were signed in and out and checked by program
staff as required. A review of three invoices for projects completed was done which confirmed
they matched dates for the outside contractor sign-in forms reviewed.
5.16 Fire, Safety, and Evacuation Drills Satisfactory Compliance
The program shall conduct fire, safety, and evacuation drills to ensure youth and staff are
prepared for immediate implementation or mobilization in the event of an emergency or
disaster.
The program practices emergency drills such as fire drills and Continuity of Operations Plan
(COOP) drills once a month on each shift. Reviewed drill documentation included all
requirements including a list of participants, brief scenario, and recommendations or corrective
actions needed. All drills were maintained in a marked drill binder. A review of this
documentation for the annual compliance review period was done and found fire drills and
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COOP drills were done monthly for all shifts with no exceptions noted. Fire evacuation and
egress routes were clearly posted within all program areas of the facility. The program has a
total of twenty fire extinguishers. A sampling of five extinguishers found each was inspected
monthly by the program’s maintenance staff. Documentation was received showing the annual
fire extinguisher inspection was last completed on October 5, 2023. Five interviewed staff
confirmed they have participated in various drills over the past year. Five interviewed youth all
reported they had participated in drills and been instructed by the program as to what to do in
the event of a fire. The program director was interviewed and reported monthly medical, fire,
mental health, and COOP drills are completed at the program.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program has a Continuity of Operations Plan (COOP) available in all offices at the program.
The COOP was last approved by the Department’s Office of Residential Services on February
17, 2023. The Department’s Office of Residential Services provided an email notification to the
program on January 30, 2024, advising the program to postpone submitting a new COOP at this
time due to changes being made with the template. The program’s COOP addresses alternative
relocation sites approved by the Department. The program administration reported they have
utilized COOP procedures during the annual compliance review period, as they underwent an
evacuation earlier in the year due to inclement weather conditions in the area. There were no
issues reported for the evacuation process. Emergency supplies and equipment are in the
director of student services office closet area. The program maintains a hard copy binder which
includes all required demographic, legal, and medical information for each youth. The program
administration reported this binder is used, along with all youth medical, mental health, and case
management records in the event an evacuation occurs. The program director was interviewed
and reported the COOP is provided in all offices, and it’s available for all staff.
5.18 Storage and Inventory of Flammable, Poisonous, and
Satisfactory Compliance
Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items.
The program maintains a written policy and procedures for the storage, inventory, and disposal
of flammable, poisonous, and toxic items and materials. According to the maintenance staff, no
gasoline is maintained at the program. All toxic chemicals and cleaning agents are maintained
in secure locations which are inaccessible to youth. Areas used to store these items are the
kitchen, storage closets on youth living area halls, and outside maintenance shed. Each area
was observed as secured. A review of thirteen items was done and found each contained a
daily perpetual inventory which matched the corresponding item, as well as a Safety Data Sheet
(SDS). There were no discrepancies observed. A SDS binder was located within each area
used to maintain these toxic items. Within the inventory binder, there was a list of position titles
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 57 of 60 (Revised September 2022)
who were authorized to handle or dispose of any chemicals. These positions included the
maintenance staff, floor manager, program director, and director of student services.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a policy and procedures for the storage, inventory, and disposal of
flammable, poisonous, and toxic items and materials. According to the program’s policy, youth
shall not be permitted to use, handle or clean dangerous or hazardous chemicals, respond to
chemical spills or clean, handle, or dispose of any person’s biohazardous material, bodily fluids,
or human waste. The program maintains strict control of all hazardous chemicals. All areas
observed to store these items were secured and inaccessible to youth. Five interviewed youth
reported they do not handle any chemicals or cleaning agents. No youth were observed using
any cleaning agents during the annual compliance review week.
5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program maintains a written policy and procedures for the storage, inventory, and disposal
of flammable, poisonous, and toxic items and materials. The program’s policy and procedures
outline all requirements in the event of a chemical spill. The program maintains a Safety Data
Sheet (SDS) for all chemicals. The SDS binder was located within each area used to maintain
these items. Within the binder, there was a list of position titles who were authorized to handle
or dispose of any chemicals. These positions included the maintenance staff, floor manager,
program director, and director of student services. According to the maintenance staff, disposal
procedures are done so according to policy and procedures as well as the SDS. All dirty mop
water is poured down standard plumbing drains. Kitchen grease is disposed of in a grease vat
located outside the program building. The maintenance staff stated no toxic items or flammable
items have been disposed of for the annual compliance review period. The medical staff
maintain a contract with a local bio-medical waste facility, who comes monthly to the program to
collect all bio-hazardous waste, which was observed clearly marked and secured within the
medical office. The medical department maintains these records within a disposal log binder.
The program director was interviewed and stated all chemicals needing disposal are reported to
the maintenance staff at which time they would store the chemicals in a safe place and dispose
of them.
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Office of Accountability and Program Support Page 58 of 60 (Revised September 2022)
5.21 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity.
Programs allowing youth to participate in water related activities shall have a water safety
plan addressing, at a minimum, safety issues, emergency procedures, and the rules to be
followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a visitation schedule posted within youth handbooks and in the lobby area of
the facility. Visitation is scheduled for Sunday from 2:00 p.m. until 5:00 p.m. The visitation log
was reviewed which confirmed visitation is held as scheduled. Case managers maintain each
youths’ telephone, mail, and visitation approved contact list. According to the case manager,
youth are given up to three stamps weekly, and mail is sent out twice a week. The program
director may approve alternate visitation for a youth and family in the event the need arises.
Five interviewed youth all confirmed they could call and send their parent/guardian a letter. Two
of five stated the program uses translators to assist youth who do not speak English as their
primary language. Three of five were unsure when asked. Five interviewed staff stated the
program uses an interpreter by telephone to assist in translation. According to an interview with
the case manager and program director, the program uses Language Line Solutions for their
third-party language service. For youth who have a history of human trafficking, the case
manager stated each youth’s juvenile probation officer (JPO) is contacted and is sent a Juvenile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 59 of 60 (Revised September 2022)
Probation Officer Comments for Needs Assessment form. This form is used to verify the youth’s
parent/guardian and family members to confirm whether on current or past investigation for
human trafficking related issues. According to the case manager, no current youth have had any
alerts for human trafficking. The case manager provided an example of one youth who has
since been released to show this process was completed.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has an activity schedule posted and visible in all program areas. The program
provides outdoor and indoor activities for youth, which was confirmed in a review of the daily
activity schedule and logbook documentation. Activities provided and observed promote social
and cognitive skill development, creativity, teamwork, healthy competition, mental stimulation,
and physical fitness. The program takes precautionary measures to prevent overexertion, heat,
stress, dehydration, and frostbite. The program has an indoor climate-controlled gymnasium
which youth may utilize in the event of inclement weather conditions. The provider’s contractual
agreement requires the employment of a recreational therapist. The recreational therapist holds
all the required credentials for the position. Each of the five reviewed youth case management
records found evidence each youth’s performance plan contained goals for recreation and
leisure activities. Five youth all confirmed the program allows them at least one hour daily for
physical activities, the opportunity to exercise, play outside, or down time to read books, or play
board games. Five interviewed staff confirmed youth are given at least one hour of recreational
activity time. These activities may include things such as volleyball, basketball, football, and
Zoomba classes.
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.26 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 60 of 60 (Revised September 2022)

report_type: QI Residential