facility_name: Center for Success and Independence - Ocala

summary: QI Residential - FY23-24

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Center for Success and Independence
Youth Opportunity Investments,LLC]
(Contract Provider)
4055 NW 105th Street
Ocala, Florida 34482
Review Date(s): August 29 - September 1,2023
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:
Onazina Washington, III, Office of Accountability and Program Support, Lead Reviewer
(Standard 1)
Jeff Campbell, Office of Education, Northeast Education Coordinator, (Standard 2)
Renette Crosby, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Tara Gilligan, Office of Accountability and Program Support, Regional Monitor (Interviews)
Kristine Harshaw, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Peacena Samuels, Office of Accountability and Program Support, Regional Monitor (Standard
2)
Meghan Thrasher, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Center for Success and Independence MQI Program Code: 1449
Provider Name: Youth Opportunity Investments LLC Contract Number: 10575
Location: Marion County / Circuit 5 Number of Beds: 72
Review Date(s): August 29 - September 1, 2023 Lead Reviewer Code: 205
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 63 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training 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 Youth Input Satisfactory
1.16 Advisory Board Satisfactory
1.17 Staff Performance Satisfactory
1.18 Recreation and Leisure Activities Satisfactory
1.19 Special Contract Conditions Satisfactory
1.20 Contract Specific Career and Technical Education Services Satisfactory
1.21 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 63 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Indicator Ratings
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 63 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
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 63 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 63 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
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 Satisfactory
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 63 (Revised September 2022)
Program Overview
The Center for Success and Independence is a seventy-two-bed program, for fifteen to
eighteen-year-old males, located in Ocala, Florida. The program is operated by Youth
Opportunity Investments, LLC, through a contract with the Department. The program provides
services including substance abuse overlay services (SAOS) and mental health overlay
services (MHOS). In addition, the program fosters each youth by providing Trauma Focused
Cognitive Behavioral Therapy, Seven Challenges, Skillstreaming the Adolescent, Young Men’s
Work, Moral Reconation Therapy, and Impact of Crime. Additional treatment services provided
include family and individual therapy. Program administration is comprised of a facility
administrator, assistant facility administrator, human resources business manager, and physical
plant manager. Case management services are provided by one case manager supervisor, two
transition services managers, and four case managers. Mental health staff at the program
include a clinical director, clinical coordinator, contracted psychiatrist, five master’s-level
therapists, a recreation therapist, and a contracted behavioral analyst. Medical services are
offered seven days a week for 120 hours by three registered nurses (RNs), one of whom serves
as the health services administrator (HSA), and two licensed practical nurses (LPNs). The
program also has a contract with a physician who serves as the designated mental health
clinician authority (DMHCA). Educational services are provided by the Marion County School
Board. The layout of the program includes two dormitories, an administration building, a dining
hall and kitchen, four portables which serve as classrooms, and a building which houses
medical as well as two conference rooms. The program has 125 cameras, located in master
control, all of which were operational during the annual compliance review week. At the time of
the annual compliance review, the program had four vacant positions which included a
recreation therapist, shift supervisor, physical plant worker, and case manager.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 63 (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 which indicate background screenings shall be
conducted on all employees and contracted providers. During this annual compliance review
period, the program had thirty-eight newly hired staff, each of whom were reviewed. Each staff
had a clear and eligible background screening completed in the Agency for Healthcare
Administration’s Clearinghouse system prior to working with youth and accessing confidential
records. None of the staff required an exemption. Each applicable staff completed and passed a
pre-employment assessment tool which was maintained in each staff’s record. Each staff’s
criminal history, the Department’s Staff Verification System (SVS), the Department’s Central
Communications Center (CCC) Person Involvement History Report, and Florida Department of
Law Enforcement (FDLE) Automated Training Management System (ATMS) were reviewed.
Each staff was placed on the program’s Clearinghouse roster. None of the staff were applicable
for a break in service as indicated in the SVS. One staff was hired from another provider and a
new background screening was conducted as required. The program did not have
contracted/provider and grant recipient volunteers, mentors, and interns who required a
background screening during the annual compliance review period The Annual Affidavit of
Compliance with Level 2 Screening Standards was completed and sent to the Department’s
Background Screening Unit (BSU) on January 25, 2023. The teachers received an annual
screening on January 25, 2023.
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 indicate all staff will receive a background
rescreening every five years from their initial date of employment. The five-year resubmission
will be completed on or before the five-year anniversary date. A review of the program’s staff,
volunteer, and intern roster found one staff to be applicable for a five-year background
screening during the annual compliance review period. The rescreening was submitted to the
Department’s Background Screening Unit (BSU) as required; however, at the time of the annual
compliance review, the BSU was still processing it.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 63 (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 maintains a policy and procedures to ensure they provide an environment in which
youth, staff, and others feel safe, secure, and not threatened by any form of abuse or
harassment. Staff adhere to a code of conduct which is indicated by each staff’s signature on
the employee handbook. During a program tour, the Florida Abuse Hotline telephone number
and the Department’s Central Communications Center (CCC) telephone number for youth
eighteen years of age and older, were observed to be posted throughout the program. The
program’s abuse reporting policy documents the steps to report allegations of abuse. All staff,
volunteers, interns, and contracted staff are to immediately report any allegations or suspicion of
any incidents of abuse or harassment which have occurred in the program to the Florida Abuse
Hotline and the CCC, for youth eighteen years of age or older. Staff shall notify the facility
administrator (FA) and on-duty supervisor as soon as the call to the Florida Abuse Hotline (or
CCC if applicable) has been placed, as well as the reason for the call. An internal incident report
shall be completed and forwarded to the respective supervisor once the call has been made to
either. The FA shall ensure all designated reportable incident types are reported to the CCC
within two hours of the incident, or within two hours of becoming aware of the incident. The FA
shall ensure the program maintains a separate file of all incident reports and has a system in
place for tracking of incidents. The program had fifteen incidents regarding abuse during the
annual compliance review period. Five incidents were reviewed, and each was substantiated.
Seven youth were interviewed and stated they have not been stopped from calling the Florida
Abuse Hotline or the CCC and stated they know where the abuse number is located. Seven
staff were interviewed and stated if an abuse incident occurs, they will notify the program
director, and will either allow youth to make the call or the supervisor will make the call. An
interview with the FA confirmed the policy and process regarding an abuse-free environment as
outlined in the code of conduct. Staff will immediately be placed on administrative leave with no
youth contact, pending the outcome of the investigation. Law enforcement and the Florida
Abuse Hotline will be contacted if there is an allegation of abuse. Any type of physical abuse or
verbal abuse will not be tolerated and will result in either suspension or termination. The
program completed a Trauma Responsive and Caring Environment (TRACE) self-assessment
on June 14, 2023. To incorporate trauma-responsive practices, the program completes a
TRACE Assessment with the help of youth and staff, and the suggestions are reviewed and put
into place to promote a more trauma responsive environment. This is conducted at new hire
training and reviewed each month.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 63 (Revised September 2022)
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program has a policy and procedures in place to address incidents of physical,
psychological, and emotional abuse. A review of four substantiated incidents indicated there
was evidence management took immediate action to address incidents. Documentation was
reviewed to identify the corrective action taken by the program. All four of the incidents were
substantiated and management staff were provided corrective action for all four staff. An
interview with the program director revealed two of the staff received disciplinary actions due to
allegations of abuse and both staff resigned or were terminated.
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 has a policy and procedures for reporting incidents to the Department’s Central
Communications Center (CCC). During the annual compliance review period, the program had
thirty-three incidents reported to the CCC, of which, five were reviewed. All five of the reviewed
incidents were reported to the CCC within two hours of the incident or within two hours of the
individual becoming aware of the incident, as required. During the annual compliance review
week, there were no additional internal incidents/grievances found, which should have been
reported to the CCC and were not. The program did not experience an increase in the number
of reportable incidents.
1.06 Protective Action Response (PAR) and Physical
Satisfactory Compliance
Intervention Rate
The program uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is completed and filed in accordance with the Florida
Administrative Code.
During the annual compliance review period, the program had a total of twenty-eight Protective
Action Response Right Interactions model (PAR/RI) incidents, of which, five were reviewed. In
all five reviewed PAR/RI Reports, documentation confirmed the reports were completed by the
end of the staff’s workdays and the reports included statements from all staff involved. None of
the incidents involved mechanical restraints. None of the incidents resulted in injury to youth or
injury to staff. The Florida Abuse Hotline was not contacted due to youth alleged abuse. There
was not a PAR/RI medical review or post-PAR/RI interview needed. In all five reviewed
incidents, there was a review by a PAR/RI certified instructor or supervisory staff. The
Department’s Central Communications Center (CCC) was not contacted for any of the incidents
due to there being no injuries to youth or staff. None of the youth alleged abuse. In all five
reviewed incidents, there was a review by the administrator or designee within seventy-two
hours of the incident. A copy of the PAR/RI Reports was placed in the program’s centralized file
within forty-eight hours of approval/signature by the administrator or designee in all five records.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 63 (Revised September 2022)
There was not an increase in PAR/RI incidents since the last annual compliance review. The
program’s PAR/RI rate during the annual compliance review period was 1.51, which is above
the statewide Residential PAR/RI rate of 1.35. The facility administrator was interviewed and
stated, all PAR/RI incidents are reviewed by administrative staff for compliance with PAR/RI
Florida Administrative Code and proper procedures. Seven staff were interviewed and stated,
before PAR/RI is initiated, they first try to de-escalate the situation verbally, and try to use the
least amount of force possible. Once a PAR/RI maneuver has been done, an incident report and
PAR/RI Report have to be written.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring.
The program has a policy and procedures for pre-service training requirements for new staff
during the initial 180 days of employment. All program instructors are qualified to deliver the
trainings provided. Staff who are direct care staff and are counted in the staff-to-youth ratio are
safety and security specialists (levels one through three), and supervisors/administrators may
be included in ratio, providing they are not conducting their regular duties. Seven staff records
were reviewed. Five staff completed a minimum of 120 hours of pre-service training within 180
days of hire, the remaining two are still within the first 180 days of employment. All reviewed
staff records documented completion of the essential skills trainings of cardiopulmonary
resuscitation (CPR), first-aid, automated external defibrillator (AED), forty hours of Protective
Action Response Right Interactions model (PAR/RI), professionalism and ethics including
standards of conduct, suicide prevention, emergency procedures, child abuse reporting, and
Prison Rape Elimination Act (PREA) within ninety days of hire and prior to contact with youth.
All seven staff completed the remaining required courses with one exception. One staff did not
complete the online Equal Employment Opportunity training. All completed trainings were
documented in the Department’s Learning Management System (SkillPro).
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program has a policy and procedures for annual in-service training. Seven staff training
records were reviewed for in-service training. Each of the staff completed the essential in-
service training including cardiopulmonary resuscitation (CPR), first-aid, automated external
defibrillator (AED), human trafficking, active shooter, stress management, Information Security
Awareness, Mental Health and Substance Abuse, Protective Action Response Right
Interactions model (PAR/RI) update, professionalism, interpersonal communication, and ethics,
sexual harassment, Prison Rape Elimination Act (PREA), and suicide prevention which included
two hours of web-based training in the Department’s Learning Management System (SkillPro)
and four hours of instructor-led training. All seven staff also completed other required trainings
specific to their positions or program. All the staff’s trainings were documented in SkillPro. Each
of the seven staff had more than the required twenty-four hours of training. Three supervisor
records were observed. All three supervisors received more than the required eight hours of
training, which included training on coaching, leadership, and personal accountability. All
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 63 (Revised September 2022)
instructors were qualified to deliver the trainings provided. The list of in-service trainings,
including course names, descriptions, objectives, and training hours for any instructor-led
training based on the above topics was approved by the Department’s regional director on
November 20, 2022. The program has an annual in-service training calendar, which is updated
as changes occur.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures regarding the grievance process. The process
includes three phases; informal, formal, and appeal. The informal phase includes the use of
communication request forms which encourage the youth to make all efforts to reach resolution
of issues and complaints immediately and directly with the program staff involved. The formal
phase includes grievance forms available on the module. Youth fill out the form and place it in a
secure grievance form box. All grievances received are reviewed in daily management meetings
and are assigned to an appropriate staff for investigation. Any grievance which alleges a youth
is substantially at risk for imminent sexual abuse or danger are immediately reported to the
facility administrator (FA) for immediate response. During the annual compliance review week,
seven youth were interviewed. All seven youth confirmed where the forms are located within the
program, and all seven were able to explain the process. Each youth confirmed they can ask for
assistance in completing the grievance form. Seven staff were interviewed. All seven staff
confirmed grievance forms are placed throughout the program. All seven staff indicated youth
can request assistance in completing the form, supervisors review the grievances, explained the
three phases of the grievance process, and indicated each phase has associated time frames.
Each staff confirmed the program director reviews the grievances. The program maintains a
binder for grievances for the past twelve months. The program had eight grievances during the
annual compliance review period, five of which were reviewed. All five were resolved in the
formal phase within the required time frame.
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program has a policy and procedures to ensure they utilize interventions which include
evidence-based practices, promising practices, or practices with demonstrated effectiveness.
The program staff’s education and work experience were considered by the program when
determining the delivery of services. The designated staff all received training in the groups they
facilitated. A review of the program’s activity schedule reflected the program held structured,
planned programming or activities at least sixty percent of the youth’s awake hours, as outlined
on the daily schedule and contract table. A review of the contract and program schedule
indicated groups were conducted in accordance with the program’s contract. An interview with
the facility administrator (FA) confirmed youth participate in daily group sessions using
evidence-based curriculum, to include Skillstreaming the adolescent, Seven Challenges, Moral
Reconation Therapy, Trauma-Focused Cognitive Behavioral Therapy, and Impact of Crime. The
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 63 (Revised September 2022)
program’s designated mental health clinician authority (DMHCA) was interviewed and confirmed
services are provided seven days a week. Youth receive group therapeutic services daily, one
individual therapy session with a therapist weekly, and one family therapy session monthly.
Supportive counseling sessions are provided on an as needed basis. The DMHCA also
confirmed all youth participate in daily group sessions facilitated by a trained mental health
professional using evidenced-based curricula, to include Skillstreaming the Adolescent, Seven
Challenges, Moral Reconation Therapy, Trauma-Focused Cognitive Behavioral Therapy, Young
Men’s Work, and Talks my Father Never Had with Me. Youth also complete a cycle of Impact of
Crime facilitated by trained case managers.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures in which the program shall provide a delinquency
intervention model or strategy which is an evidence-based practice, promising practice, or a
practice with demonstrated effectiveness, as well as life and social skills training for each youth.
Life skills training shall provide interventions or instruction focusing on developing life and social
skill competencies in youth. The program provides Impact of Crime, restorative justice projects,
carpentry, painting, financial literacy, college and technical school tours, and community service
opportunities to develop youth’s life and social skills such as communication skills, interpersonal
relationships and interactions, non-violent conflict resolution, anger management, and critical
thinking, which also addressed the needs of the program’s targeted gender group. A review of
the program’s activity schedule reflected groups were provided daily, which was confirmed by a
review of sign-in sheets and group notes. In addition to the life skills intervention services, the
program also conducts restorative justice projects, carpentry, painting, financial literacy, college
and technical school tours, helping in the community, and back to school drive. Seven youth
were interviewed regarding the life skills groups/activities they have participated in while at the
program. All seven youth stated they participate in Skillstreaming the Adolescent, coping skills,
high school equivalency diploma (GED) prep, positive skills development, and learning how to
cope without drugs. All seven youth stated groups are conducted every day in which therapy
and cardiopulmonary resuscitation (CPR) training is offered. An interview with the facility
administrator confirmed groups are conducted daily and all youth participate in group sessions
facilitated by a trained staff and trained mental health professional using evidence-based
curriculum which addresses the needs of targeted gender groups such as, Impact of Crime,
Moral Reconation Therapy, Skillstreaming the Adolescent, Seven Challenges, and Trauma-
Focused Cognitive Behavioral Therapy. An interview with the designated mental health clinician
authority (DMHCA) confirmed the program provides interventions in which youth are provided
an opportunity to practice learned skills daily in group, in their dorm, education, cafeteria,
recreational activities, and off-campus activities.
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1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program has a policy and procedures which address restorative justice awareness for youth
through the implementation of Impact of Crime (IOC) and community service projects.
Restorative justice activities and instruction are designed to assist youth in accepting
responsibility for the harm they have caused by past criminal acts. It challenges the youth to
recognize and modify irresponsible thinking by teaching the youth about the impact of crime on
the victims, their families, and their communities. Youth are exposed to victims’ perspectives
through victim speakers and engaging in follow-up activities to process their reactions to each
victim’s account of how crime affected their life. The youth are providing opportunities to plan
and participate in reparation activities intended to restore victims and communities, such as
restitution activities and community service projects. The program’s activity schedule, group
sign-in sheets, group notes, and observations confirmed restorative justice groups were
provided and conducted as scheduled. A review of the program’s activity schedule showed
restorative justice groups are offered daily. An interview with the facility administrator (FA)
confirmed at the end of every IOC group, youth participate in a restorative justice program. Most
recently, the youth raised money for the homeless with a walk-a-thon and created blessing
bags. The designated mental health clinician authority (DMHCA) confirmed youth are provided
off-site community service opportunities along with the IOC group. Seven youth were
interviewed and stated they participate in various projects such as giving back to the
community, planting flowers, cleaning up the pond area, and feeding the homeless. An
observation of an IOC group confirmed the service delivery.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures to determine how alerts are identified, documented,
updated, and communicated to staff. Program alerts were consistent with the alerts in the
Department’s Juvenile Justice Information System (JJIS). A review of alerts in seven youth
records found five youth had applicable alerts and each of the applicable youth’s alerts were
verified, entered, removed, or downgraded by the appropriate staff as needed. All five youth
were placed on the program’s internal alert system as required by the program’s written
procedures. An interview with the facility administrator confirmed the administrative staff meet
daily during morning management meetings with healthcare staff to review important medical
issues pertaining to the youth at the program. The substance abuse/mental health alerts are
monitored by the clinical director and facility administrator (FA). Medical and food allergy alerts
are monitored by the health services administrator (HSA) who informs the FA and kitchen staff.
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Safety and security alerts are monitored by the assistant facility administrator and case
management. An interview with the nurse confirmed the nursing staff are responsible for
updating the medical alert system. Seven program staff were interviewed and stated they are
notified of alerts through daily shift briefings, alert board, alert book, mental health and medical
staff, and case management when a new intake arrives at the program. Youth on escape alert
have special-colored shirts.
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 separates the youth record into an Individual Healthcare Record and individual
management record. All reviewed individual management records documented the youth’s
name, Department identification number, date of birth, county of residence, and committing
offense. The individual management records contained sections including legal information,
demographic and chronological information, correspondence, case management and treatment
team activities, and miscellaneous. Youth records were labeled “Confidential.” All official youth
records are secured in a locked file cabinet in a locked room. The program clearly identifies any
file cabinet used to store official youth case records as “Confidential.”
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a community advisory board which meets at least every ninety to 120 days. A
review of sign-in sheets confirmed the community advisory board met as required.
Documentation confirmed the facility administrator (FA) solicited active involvement from law
enforcement, the judiciary community, community partners, business community, school district,
faith community, LGBTQIA+ community, victims, victim advocates, or other victim services
community representatives, and a parent/guardian whose child was previously in the juvenile
justice system. A review of sign-in sheets confirmed participation from all members. During the
annual compliance review week, a board member was not available to be interviewed.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures which address the program’s system for evaluating
staff, performance standards, and frequency of evaluations. The program conducts an initial
ninety-day review and annual reviews thereafter for all staff. A review of ten position
descriptions reflected each staff’s performance standards were clearly identified and matched
the job descriptions for each staff. The program’s contract was reviewed to ensure all specific
contractually required positions were maintained and performed as outlined in the contract.
During the annual compliance review week, there were four vacant positions required by
contract, which included a recreational therapist, shift supervisor, physical plant manager, and a
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case manager. Ten performance evaluations were reviewed and showed they were completed
as outlined in policy and reflected staff were evaluated annually on performance standards. The
performance standards matched the program staff job descriptions. The facility administrator
(FA) was interviewed and stated staff receive ninety-day performance evaluations. All annual
performance evaluations are completed in October of each year. Staff also receive coaching
notes as needed. Seven staff were interviewed regarding the program’s system for staff
performance. All seven staff stated performance evaluations are conducted every ninety-days.
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.
In the program’s contract with the Department, there are program-specific requirements. The
program provided documentation of all contract-specific requirements. These requirements
include providing each youth specific-brand clothing, three snacks provided a day, the
opportunity for youth to participate in Alcoholics Anonymous (AA) and Narcotic’s Anonymous
(NA) if requested, a scholarship fund for program graduates, a partnership with Eckerd Connect
Workforce Services, creation of a honor dorm, at least twelve family days during the calendar
year, regular faith based opportunities, three maintenance personnel on staff, and maintenance
of three vans for youth transportation. A review of documentation and observations confirmed
compliance with these conditions. An interview with the facility administrator confirmed the
contract-specific services. Seven youth were interviewed regarding contract-specific items;
however, youth were only questioned regarding vocational services and the scholarship fund.
Three of the seven youth reported they were aware of the scholarship fund.
1.18 Contract Specific Career and Technical Education
Satisfactory Compliance
Services
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), Special Conditions, or older contracts may not have them clearly identified as a
special condition. Career and technical education service instruction shall be provided so the
interests, aptitudes, and skills of the youth are developed, while building upon their existing
strengths, in a manner supportive of their employability goals which provide an occupational
advantage and workforce readiness in their community. These items may exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code.
The program has a policy and procedures which ensure career and technical education services
are implemented with the program. The services provided are cardiopulmonary resuscitation
(CPR), ServSafe, equine program, Microsoft Office, customer service and sales, and forklift
training. During the annual compliance review period eighty youth participated in and received
certifications in CPR, sixty-five youth participated and were certified in ServSafe, thirty-two
youth participated in and received certifications in Microsoft Office, thirty youth participated in
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and received certifications in entrepreneurship, and thirty-three youth participated in the equine
program. A review of records found there was a total of ten youth who participated in forklift and
eight were certified. Fifteen youth participated in customer service and twelve were certified.
The program compliance manager stated the times and dates the services are offered may vary
from the program’s schedule. All career and technical services are delivered by staff trained in
each curriculum. The services are provided according to the program’s schedule. The career
and technical education services provided by the program are appropriate for the abilities and
goals of the youth in the program. Seven youth were interviewed and all seven youth stated
they received training in forklift, CPR, food handling certification classes, career classes, or
résumé writing during transition. The facility administrator was interviewed and stated the
contract-specific, pre-vocational and vocational services provided at the program are forklift,
CPR, and ServSafe.
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’s practice regarding data trend analysis states the program shall maintain a quality
assurance program designed to monitor and evaluate program outcomes, system fidelity,
compliance, the appropriateness and quality of care ensuring program services are consistent
with prevailing professional standards, and to identify and resolve problems objectively and
systematically. The quality assurance program shall ensure the use of a continuous quality
improvement process by tracking performance measures and established standards, evaluate
output measures such as capacities, technology, and infrastructure making up system of care,
evaluate process measures of administrative, clinical, and all components of treatment, evaluate
outcome measures pertaining to the outcome of services, provide a system of analyzing
information and factors, provide a system of reporting the results of quality assurance reviews,
incorporate best practice models for improving performance in the areas which are deficient,
and incorporate peer review processes into protocol. The program uses reporting systems to
track key performance data and ensures timely review and communication of system data with
program and corporate leadership as well as the department which includes daily management
meeting reports, weekly program director reports, weekly leadership data review and reporting,
data entry in the Department’s Juvenile Justice Information System (JJIS), and monthly reports.
The program’s policy was reviewed and supported this practice. Monthly review processes shall
include review of data, review of youth records, review of documentation, peer review
processes, observations, youth, staff, and parent/guardian surveys, fidelity monitoring, and
verification activities. Data collection, review, and analysis are critical to ensuring proactive
assessment, measurement and management of risk, assurance of quality, and continuous
quality improvement. The program uses reporting systems to track key performance data and
ensures timely review and communication of system data with program and corporate
leadership teams as well as the Department.
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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 policy and procedures in place to address notifying the youth’s
parents/guardians, juvenile probation officer (JPO), and committing court of the youth’s
admission to the program. A review of seven youth records indicated telephone notifications
were made to each youth’s parents/guardians within twenty-four hours of the youth’s admission.
All seven records indicated each youth’s parents/guardians were notified in writing within forty-
eight hours of the youth’s admission. Each youth record also indicated the JPO and committing
court were notified of the youth’s admission to the program within five working days.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures in place to address youth orientation. A review of
seven youth case management records revealed each youth was provided orientation the day
of admission. Observations and further review of the orientation process revealed the program’s
orientation process includes all required elements including services available, daily schedule,
expectations and responsibilities of youth, behavior management system, access to medical,
mental health, and substance abuse services, access to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC), zero-tolerance policy, special
accommodations, right to be free from sexual misconduct, contraband, performance planning
process, dress code and hygiene practices, procedures on visitation, mail, and use of the
telephone, expectations for release from the program, community access, grievance
procedures, emergency procedures, facility tour, living room assignment, and treatment team.
Seven youth were interviewed, and all interviewed youth were able to explain the orientation
process and confirmed their orientation began within twenty-four hours of their arrival to the
program.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a policy and procedures to address written consent of youth eighteen years of
age or older. Seven youth case management records were reviewed, and two youth were ages
of eighteen years or older. The program provided one additional case management record for
review. All three applicable records contained a signed consent form allowing the program to
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release information regarding the youth’s physical or mental health screenings, assessments, or
treatment to the youth’s parent/guardian.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
The program has a policy and procedures in place to address classification factors, procedures,
and reassessment for activities. Seven youth case management records were reviewed, and all
seven youth records indicated an initial classification form was completed on the youth’s date of
admission to the program. The classification form included the youth’s physical characteristics,
age and maturity, any special needs, history of violence, gang affiliation, criminal behavior, a
new screening for Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB),
perception of vulnerability, history of potential or verified human trafficking, and each youth’s
identified risk (suicide, medical, escape, and/or security). All seven records indicated the youth
were classified for purposes of assignment to a living area, sleeping room, group, and staff
advisor. A review of the Department’s Juvenile Justice Information System (JJIS) indicated an
alert was entered for all youth identified with risk factors. The program has a written policy and
procedures in place requiring the completion of risk assessments prior to considering an
increase in privileges or freedom of movement, participation in work projects or other activities
involving tools or instruments potentially used as weapons or means of escape, and
participation in off-campus activities. A review of seven youth case management records
revealed a risk assessment was completed for all seven youth as required. According to the
program’s policy, youth are reassessed and reclassified if warranted. The youth are reviewed
for reassessment during their formal treatment team meetings. Seven youth records were
reviewed, and six youth were applicable for reassessments for increase in privileges or freedom
of movement, participation in work projects or other activities involving tools or instruments
potentially used as weapons or means of escape, and participation in off-campus activities. One
youth was not applicable, as the youth did not require a reassessment during the annual
compliance review period. A formal interview with the facility administrator revealed a treatment
team meeting is conducted and all required factors are discussed prior to youth’s room
assignments.
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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 in place to address gang identification and law
enforcement notification. Seven youth records were reviewed for gang identification and
notification to law enforcement. Three youth records were applicable. A review of the three
applicable records indicated local law enforcement was notified by the program of the youth’s
gang or suspected gang involvement. Gang alerts were entered in the program’s internal alert
system and the Department’s Juvenile Justice Information System (JJIS) for all three applicable
youth. The information on the youth’s gang status was also shared with education staff and the
juvenile probation officer for each of the three applicable youth. Two of the three youth were
applicable for having a post-residential counselor, and their gang status was shared with the
counselor.
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 in place to address gang prevention and
intervention strategies. The policy indicates youth are given the opportunity, if they desire, to
develop a plan to disaffiliate with a criminal street gang. Seven youth case management records
were reviewed. Three youth were identified as gang members or affiliates and were applicable
for participation in gang prevention and intervention activities. Goals and objectives related to
gang intervention strategies were included each of the three youth’s performance plans. All
suspected and confirmed gang members participate in monthly Gang Resistance and Drug
Education (GRADE) groups. A review of the sign-in sheets revealed the groups were completed
monthly since the last annual compliance review period. When asked about the program’s gang
intervention and prevention strategies, the facility administrator (FA) indicated during youth’s
intake and progression through the program, if gang affiliation is found, the youth receive gang
goals and gang groups with case management.
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 policy and procedures in place to address the completion of an initial
Residential Assessment for Youth (RAY) within the first thirty days of the youth’s admission and
RAY Reassessment every ninety days thereafter. Seven youth case management records were
reviewed, and an initial RAY was completed for each youth within thirty-days of their admission
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into the program. The initial RAY was maintained in the Department’s Juvenile Justice
Information System (JJIS).
Six of the seven reviewed youth were applicable for a RAY Reassessment, as one youth had
been in the program less than ninety days. One of the six applicable youth was also applicable
for receiving a RAY Reassessment prior to ninety days, as deemed necessary by the
intervention and treatment team. The case management records and JJIS contained all
reassessments as required for all six applicable youth
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 policy and procedures in place to address completion of a Youth Needs
Assessment Summary (YNAS) within thirty days of admission into the program. Seven youth
case management records were reviewed, and a YNAS was completed for all seven youth
within thirty days of admission. Each YNAS was documented in the Department’s Juvenile
Justice Information System (JJIS).
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
The program has a policy and procedures in place to address performance plan development,
goals, and transmittal. Seven youth case management records were reviewed. All seven youth
records indicated the performance plan was developed within thirty days of each youth’s
admission into the program. The performance plan was developed after each youth’s initial
Residential Assessment for Youth (RAY) and Youth Needs Assessment Summary (YNAS). All
parties who have significant responsibility in the youth’s goal completion were present during
the development of each youth’s Individualized Performance Plan. Members present included
intervention and treatment leader, an administrative representative, living unit representative,
treatment staff, and educational staff. None of the reviewed youth were involved with the
Department of Children and Families (DCF) or Agency for Persons with Disabilities (APD);
therefore, DCF or APD members were not present. None of the seven records contained an
attached signature sheet from the parent/guardian in the performance plan or in the official case
records; however, all seven records documented mailed attempts to have parent/guardian sign
the plan and return it to the program.
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A review of seven youth case management records indicated all seven youth had a
performance plan to include individualized goals based upon prioritized needs reflecting the risk
and protective factors identified during the initial assessment process, the youth’s three
criminogenic needs, specific delinquency interventions with measurable outcomes, targeted
court ordered sanctions, transition activities targeted for the last sixty days of youth’s anticipated
stay, program staff responsibilities to enable youth to complete goals, and targeted dates for
goal completion.
Further review of seven youth case management records indicated the program sent each
youth’s performance plan to the committing court, the juvenile probation officer (JPO), and
parent/guardian within ten working days of the plan being completed. Seven youth were
interviewed, and all indicated they participated in the development of their performance plans.
Six of the seven interviewed youth were able to acknowledge their goals and the one remaining
youth indicated they did not remember; however, they were provided a copy of the performance
plan (to include goals), which is located and stays in their room.
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 policy and procedures to address revisions to performance plans. Seven
youth case management records were reviewed. Six of the seven youth’s performance plans
were applicable for revisions, as one youth did not have any revisions to their performance plan.
Revisions were completed for each of the six applicable youth were based on Residential
Assessment for Youth (RAY) results, newly acquired/revealed information, and/or youth
demonstrated progress or lack of progress toward completing a goal. One youth’s performance
plan was revised because there was a need to facilitate transition activities during the last sixty
days of the youth’s stay.
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 policy and procedures to address Performance Summaries and transmittals.
Seven youth case management records were reviewed and six were applicable for completion
of the ninety-day Performance Summary following the signing of the performance plan. Three of
the six applicable youth were also applicable for Performance Summaries being prepared prior
to the youth’s release, discharge, or transfer from the program. All six applicable Performance
Summaries included the youth’s status on each performance plan goal, youth’s overall
treatment progress, academic status, youth’s behavior, level of motivation/readiness to change,
interactions with staff and peers, overall behavior adjustment to the program, and significant
positive and negative events.
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A review of the six applicable youth case management records revealed three of the six youth
were also applicable for having justification for release, discharge, or transfer included in their
Performance Summaries. A review of the six applicable youth’s Performance Summaries
revealed each youth was allowed to read and add comments prior to signing, the original
summary was filed in the youth’s case management record, and the youth received a copy. All
six Performance Summaries included signatures and dates by the treatment team leader, staff
who prepared the summary, facility administrator or designee, and youth. Further review of the
six youth’s Performance Summaries revealed all six Performance Summaries were sent to the
youth’s committing court, juvenile probation officer (JPO), and parent/guardian within ten days
of the completion.
None of the six reviewed youth were applicable for transition services; therefore, the program
provided three closed youth records. All three applicable records included documentation
indicating the original summary was sent with Pre-Release Notification (PRN) to the JPO, and
the release summary and PRN were sent at least forty-five days prior to planned release. All
three youth records included a signed copy of the PRN for release approval and written
notification to the parent/guardian regarding the youth’s anticipated release. Once approved, the
program completed a Residential Assessment for Youth (RAY) exit assessment for all three
reviewed records. The regional compliance manager indicated there were no youth released
from the program during the annual compliance review period who required victim notification or
were applicable for the sexually violent predator program.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures in place to address parent/guardian involvement in
case management services provided to the youth. A review of seven youth’s case management
records revealed the program took necessary measures for each youth to involve the
parent/guardian in the case management process to include the assessment process,
participation in the development of the performance plan, progress reviews, provision of
treatment team meetings dates and time, and transition planning. An observation of a treatment
team meeting during the annual compliance review week revealed the program gives the
parent/guardian the opportunity to participate by telephone/video conferencing or provide
verbal/written input prior to the meeting if the parents/guardians are unable to attend.
Parents/guardians are also encouraged to provide feedback and ask any questions they may
have during the treatment team meeting.
A formal interview with the facility administrator (FA) revealed the program encourages parental
involvement in the case management process through parent/guardian letters, admission
classification contact, and formal and informal treatment team meetings.
Seven youth were interviewed, and all indicated their parents/guardians are involved in their
case management. Six of the seven interviewed youth indicated their parents/guardians are
involved in their case management through treatment team meetings. One of the six youth
further indicated their parents/guardians are also involved in monthly counseling sessions. The
one remaining youth replied to the question by saying “yes”.
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2.13 Incorporation of Other Plans into Performance Plans Satisfactory Compliance
The youth’s performance plan shall reference or incorporate the youth’s treatment or care
plan.
The program has a policy and procedures in place to address the incorporation of the youth’s
treatment or care plan into the youth’s performance plan. A review of seven youth case
management records revealed, if the youth had additional treatment plans, such as academic,
medical, mental health, substance abuse, developmental disability, and Department of Children
and Families when applicable, the plans were incorporated in each youth’s performance plan.
None of the seven reviewed youth were applicable for a support plan through the Agency for
Persons with Disabilities (APD).
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 policy and procedures in place which requires the intervention and treatment
team to meet bi-weekly (formally and informally) to review each youth’s performance. A review
of seven youth case management records revealed formal and informal reviews were
conducted bi-weekly as required. The formal and informal treatment team documentation
included the youth’s name, date of review, required attendees, any comments from treatment
team members or others, brief synopsis of youth’s progress in the program, performance plan
revisions, progress on performance plan goals, positive and negative behaviors, behaviors
resulting in physical interventions, documentation indicating the youth was provided the
opportunity to demonstrate skills acquired in the program, treatment progress, and Residential
Assessment for Youth (RAY) Reassessment results. Further review of seven youth case
management records revealed formal and informal treatment team documentation was
contained in each youth’s record. All seven youth case management records included
documentation to indicate the juvenile probation officer (JPO), parent/guardian, and all pertinent
parties were invited and encouraged through advanced notification to participate in person or
through verbal or written communication.
An observation of treatment team meetings was conducted during the annual compliance
review week. All required staff were present, to include education. The youth’s treatment plan
was reviewed in an effort to determine the youth’s anticipated release date.
Seven youth were interviewed, and all indicated staff reviewed their performance plans which
included all required elements. Each of the seven youth indicated they are given the opportunity
to demonstrate skills learned in the program during treatment team meetings
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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 policy and procedures in place to address transition planning, conference,
and Community Re-Entry Team (CRT) meetings. A review of three closed records revealed
each youth’s transition conference was conducted at least sixty days prior to the youth’s
targeted release date. There was documentation in each youth’s record to indicate the youth,
treatment team leader, program director or designee, and other team members attended the
transition conference or provided information to the team leader prior to the conference. The
treatment team leader invited and encouraged participation of all required parties to include the
youth’s juvenile probation officer (JPO), parent/guardian, education staff, and other pertinent or
applicable parties. Further review of the three closed youth records revealed participants
reviewed transition activities on the youth’s performance plan, revised the performance plan if
necessary, identified additional transition activities, identified target completion dates, and
identified persons responsible for completion. There was documentation in each youth’s record
to indicate the treatment team leader obtained attendees dated signatures, representing their
acknowledgement of the transition goals and accountability for completion. Each youth’s record
indicated 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. If the plan was
transmitted electronically to any required parties, the return email acknowledgment receipt was
printed and filed with the plan. Information contained in the three closed youth case
management records indicated a CRT meeting was conducted prior to the youth’s release
which included the case manager. There was also an email/Outlook invite in each youth’s
record.
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 policy and procedures in place to address an exit portfolio for each youth. A
review of three closed records revealed an exit portfolio was discussed and initiated during the
transition conference. All three closed records contained a state-issued identification card, copy
of youth’s transition plan, calendar with all dates, times, and locations of upcoming community
appointments, Social Security card, birth certificate, educational and/or vocational certificates
earned while in the program, educational records, school transcripts, résumés, and a completed
sample of an employment application. Further review of each youth’s record revealed the exit
portfolio was verified during the exit conference, completed, and given to the youth upon
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release. Each youth’s exit portfolio information was forwarded to their juvenile probation officer
(JPO). A review of the program’s contract found no additional 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 in place to address an exit conference for
each youth. A review of three closed records revealed an exit conference was conducted for
each youth at least fourteen days prior to their release. Each record contained the date of
conference, signatures/names if participated by telephone, and a summary pending transition
goals. A review of the Department’s Juvenile Justice System (JJIS) indicated youth date of
admission and date of termination correlated with information documented in each youth’s
record. The status of transition activities was established at the transition conference and plans
finalized for the youth’s release were reviewed as also indicated in each youth’s record. Further
review of the three closed records indicated the intervention and treatment team leader,
parent/guardian, education representative, juvenile probation officer (JPO), youth, and other
pertinent parties participated in each youth’s exit conference, which 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 policy and procedures in place to address youth input. A review of the
program’s facility operating procedures and advisory board meeting sign in sheets indicated
advisory board meetings are conducted bi-weekly to promote constructive input by the youth.
Seven youth were interviewed and five youth indicated they provide through student council.
One youth indicated through grievances, talking to the counselor, and discussions in house
meeting. The one remaining youth replied by saying “yes”. An interview with the facility
administrator confirmed advisory board meetings are conducted bi-weekly to solicit input from
youth and administrative staff. The facility administrator further indicated the program conducts
weekly town hall meetings to ensure all youth and staff can add input for any program changes.
2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program has a policy and procedures to provide for career education based on age and is
appropriate for the educational abilities of the youth in the program. The program provides Type
2 career education development. An interview with the facility administrator indicated the
program provides appropriate career education programming based on the youth’s age,
assessed educational abilities, and goals. They also provide certifications in first-aid,
cardiopulmonary resuscitation (CPR), and ServSafe. The interview with the lead teacher
indicated the youth participate in career education by learning job skills and writing résumés and
are also allowed to research future career paths. Five closed case management youth records
were reviewed. Four of the five records included a completed employment application. All five
reviewed records included a résumé, an appointment with the CareerSource Center, and
appropriate documents essential to obtaining employment. Documentation indicating the youth's
parent/guardian and juvenile probation officer (JPO) were aware of the vocational plan for the
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youth was contained in each record. Four out of the five records reviewed had a Department of
Highway Safety and Motor Vehicles state-issued State Identification (ID) card. The one youth
missing the ID card had documentation where the parent refused to send a copy of the youth’s
State ID. All five records had a copy of certifications in ServSafe and four of the five had first-
aid/cardiopulmonary resuscitation (CPR).
2.20 Educational Access (Critical) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a policy and procedures to provide educational access. The center provides
education services through Marion County School District and the 250-day calendar, which is
distributed over twelve months, includes ten days used for teacher training and planning. A
review of the daily school schedule revealed the program provides six fifty-two minute class
periods each day with a sixty-minute lunch break, meeting the required twenty-five hours of
weekly instruction. The interview with the lead teacher indicated all the youth receive credit for a
completed course. They also reported the school schedule is adhered to. Seven youth were
interviewed and reported there is little to no interruption to the school day. Two of the youth
reported youth get loud from time to time. The program received a critical deficiency for
educational access during the annual compliance review period, which was closed on June 21,
2023. A review of five randomly selected days in the logbook since the deficiency was corrected
indicated education classes started and ended on time. Observations of the program video on
August 10, 2023, August 14, 2023, and August 21, 2023, indicated school started and ended on
time
2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The program maintains a policy and procedures requiring an Education Transition Plan to be
developed upon each youth’s admission. Five closed youth case management records were
reviewed All five youth records included an individual Education Transition Plan developed upon
entry, including the youth’s post-release goals, meeting the required elements. Each of the five
records contained an exit plan indicating the case manager, parent/guardian, and youth were all
aware of the plan. Seven youth were interviewed, with each youth reporting the program was
preparing them very well when it came to High School, high school equivalency diploma (GED),
vocational school, employment, and/or college. All seven interviewed youth reported they
participated in the development of their transition plan.
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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 has a policy and procedures ensuring the program employs a full-time
psychologist who serves as the designated mental health clinician authority (DMHCA) who is
responsible for providing the coordination and implementation of mental health and substance
abuse services. The program’s contract requires the program’s DMHCA to be a licensed
psychologist. A review of documentation supported the DMHCA is a licensed psychologist who
has a clear and active license in the State of Florida with an expiration date of May 31, 2024.
Documentation supported the DMHCA was on-site forty hours a week from the date of the last
annual compliance review, and they are available by telephone twenty-four hours a day, seven
days a week. The program provides specialized treatment services of which the licensed clinical
staff are responsible for the coordination and implementation of mental health and substance
abuse services. The back-up DMHCA is the regional clinical director who is a licensed mental
health counselor (LMHC) with a clear and active license in the State of Florida expiring March
31, 2025. An interview with the DMHCA stated they meet with clinical staff briefly on a daily
basis and for an extended period of time for supervision once weekly. The DMHCA reported
they have an open-door policy and are available to staff as needed.
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 has a written policy and procedures to establish requirements for qualified
professionals in the delivery of mental health and substance abuse services. The program’s
contract requires one full-time licensed staff. The program has one full time licensed mental
health counselor (LMHC) in the role of clinical director who maintains a clear and active license
in the State of Florida with an expiration date of March 31, 2025. The LMHC ensures the clinical
staff working under their supervision are performing services they are qualified to provide based
on education, training, and experience based on review of the job description and an informal
interview with the designated mental health clinician authority (DMHCA). The licensed mental
health and substance abuse clinical staffing is in accordance with the current contract and
Florida Administrative Code (F.A.C.). Copies of all clinical staff licenses were available on-site
and verified through Florida Department of Health.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a written policy and procedures to ensure requirements for qualified
professionals in the delivery of mental health and substance abuse services. The program’s
psychologist serves as the designated mental health clinician authority (DMHCA) and the
licensed mental health counselor (LMHC) serves as the clinical director at the program. They
are both responsible for supervising all on-site clinical staff. Clinical supervisors ensure clinical
staff working under their supervision are performing services the staff are qualified to provide
based on education, training, and experience. At the time of the annual compliance review, the
program had five non-licensed therapists with master’s-level degrees, with each earned at an
accredited university. All five staff were fully trained at the time of the annual compliance review.
Reviewed documentation supported weekly supervision was documented on a form which
included all information as outlined on the Department’s Direct Supervision Log form. All five
staff had documentation of weekly one-hour on-site face-to-face direct supervision by a licensed
mental health professional. The program is licensed under Chapter 397 and all non-licensed
substance abuse clinical staff are working under the direct supervision of a qualified
professional as required. Reviewed training documentation supported four of the five master’s-
level non-licensed therapists completed the required twenty hours of training and supervised
experience in assessing suicide risk, mental health crisis intervention, and emergency mental
health services. The remaining master’s level non-licensed therapist did not complete any
Assessment of Suicide Risks (ASRs) during the annual compliance review period. Staffing of
non-licensed therapists was in compliance with contractual staffing requirements, including the
number of hours worked. The program is continuing outreach and is in the process of vetting a
potential new hire for the position.
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 policy and procedures to ensure each youth’s mental health and substance
abuse treatment needs are identified through a comprehensive screening process which
ensures referrals are made when youth have been identified with substance and/or mental
health needs or are identified as a possible suicide risk. The program screens each youth upon
admission utilizing the Massachusetts Youth Screening Inventory, Second Version (MAYSI-2).
A review of seven youth mental health and substance abuse records indicated the program
administered a MAYSI-2 screening on the day of admission for each youth. Seven MAYSI-2
assessments documented administration by trained staff. All seven records reflected the
MAYSI-2 indicated a need for further evaluation based on the screening results. The youth were
referred as required. None of the seven youth indicated a need for an Assessment of Suicide
Risk (ASR) needing to be completed; however, the program’s practice is to refer all youth for an
ASR regardless of screening results. Each applicable record indicated the program completed a
documented review of the commitment packet documentation. An interview with the facility
administrator (FA) confirmed the initial mental health and substance abuse screening is
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conducted based on prior history and in-person interviews during the intake process. The ASR
and the Suicide Predictability Scale are conducted upon initial intake and as needed when a
mental health and substance abuse referral is completed.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program has a policy and procedures outlining a process of assessment and evaluation to
guide the development of a youth’s individualized treatment plan. A review of seven youth
mental health and substance abuse records confirmed each youth record contained a new
Comprehensive Mental Health and Substance Abuse Evaluation, which was completed within
thirty days of the youth’s admission. Four of the seven evaluations were completed by a
licensed staff, three were completed by non-licensed staff and they were reviewed and signed
by licensed staff within ten calendar days of the evaluation. All seven reviewed Comprehensive
Mental Health and Substance Abuse Evaluations included identifying information, reason for
evaluation, relevant background information, behavioral observations, a Mental Status
Examination, interview or procedures administered, a discussion of findings, diagnostic
impressions, and recommendations. The evaluations also included patterns of alcohol and other
drug use, the impact of alcohol and drug abuse in major life areas, and risk factors. All seven
youth received an evaluation for substance abuse upon admission to the program. In all seven
records there was a signed Department Youth Consent for Substance Abuse Treatment form
and the Department’s Youth Consent for Release of Substance Abuse Treatment Records form
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has a policy and procedures to ensure mental health and substance abuse
treatment services are available to youth at the program who are determined to meet the clinical
criteria to receive services. A review of seven youth mental health and substance abuse records
showed each youth record contained the required Initial Treatment Plan completed on the day
of the youth’s admission. Initial Treatment Plans were documented on a program form
containing all the required elements of the Department’s Initial Mental Health/Substance Abuse
Treatment Plan form and were signed by all treatment team members. Two youth Initial
Treatment Plans were applicable for psychotropic medications and documented the medication
and frequency of monitoring by the psychiatrist. All youth receive a psychiatric evaluation within
fourteen days of admission and the Initial Treatment Plans also documented this for youth not
prescribed psychotropic meds. All seven records were applicable for and contained an
Individualized Treatment Plan documented on the program’s form containing all elements of the
Department’s Individualized Mental Health/Substance Abuse Treatment Plan form. All seven
plans were developed within thirty days of admission. All seven plans were signed by the mental
health staff completing the plan and treatment team members. Four of the plans were created
by a licensed mental health staff, the remaining three were completed by a non-licensed staff
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and reviewed by a licensed mental health staff within ten days of completion. A review of seven
youth individualized plans outlined services prescribed, such as individual counseling weekly for
thirty minutes to an hour, group therapy services for forty-five minutes to one hour daily, family
counseling monthly for forty-five minutes to an hour, and medication management one time a
month for those youth prescribed medication
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
The program has a policy and procedures addressing mental health and substance abuse
treatment and discharge planning. A review of seven youth mental health and substance abuse
records showed each youth was assigned to a multidisciplinary treatment team upon their
arrival to the program. Seven youth records were reviewed and documented all youth received
substance abuse treatment services in accordance with the youth’s initial and individualized
treatment plan. Each record contained a Treatment Team Assignment form signed by the facility
administrator (FA). Treatment team members included the youth, FA, residential living unit,
education, vocational training (if needed), medical staff, mental health staff, substance abuse
staff (if required), and parent/guardian. All seven youth records documented each youth had a
signed Authority for Evaluation and Treatment (AET) form, a signed Youth Consent for
Substance Abuse Treatment form, and a signed Youth Consent for Release of Substance
Abuse Treatment Records form. Mental health and substance abuse treatment notes were
documented on a form which contains all the information in the Counseling/Therapy Progress
Note form in all seven youth records. A review of progress notes, sign-in sheets, and video
reflected mental health groups were limited to ten or fewer youth and substance abuse groups
were limited to fifteen or fewer youth. Progress notes supported the program was providing
individual, supportive, family, and group therapies as prescribed. A review of three closed and
seven open youth mental health and substance abuse records showed four youth were
applicable for having a discharge plan. Each reviewed discharge summary contained treatment
recommendations for continuing mental health and substance abuse services and were signed
by all required parties. There was documentation in each youth record the youth,
parent/guardian, and juvenile probation officer were provided a copy of the discharge summary.
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3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program has a policy and procedures ensuring specialized treatment services are provided.
A review of the program’s contract and clinical program description indicated the program
provides Mental Health Overlay Services (MHOS) and Substance Abuse Treatment Overlay
Services (SAOS). The program’s contract outlines Moral Reconation Therapy (MRT) for the
MHOS youth and Seven Challenges for the SAOS youth, additional services offered to all the
youth are Trauma-Focused Cognitive Behavioral Therapy, Skillstreaming the Adolescent,
Impact of Crime (IOC), and Young Men’s Work. The Seven Challenges, MRT, and IOC were
identified as the programs primary services. Each youth receives mental health treatment
services and substance abuse treatment services which include individual, group, and family
counseling seven days a week as part of their Individualized Treatment Plan. Therapeutic
activities are provided by mental health clinical staff daily. In addition, the program provides
urinalysis drug testing when needed. An interview with the designated mental health clinician
authority (DMHCA) verified services are provided to all youth. A review of therapist caseloads
verified there was an average of twelve youth on their caseload which is compliant with the
program’s contract. Four therapists were assigned thirteen youth and one was assigned eleven.
Group therapy for mental health groups was limited to ten youth and substance abuse groups
were limited to fifteen youth. The program is licensed under Chapter 397 with an expiration date
of April 1, 2024. A licensed psychiatrist provides psychiatric evaluations and medication
management and participates in treatment planning. The psychiatrist’s license is clear and
active in the State of Florida with an expiration date of January 31, 2024. A review of sign-in
sheets and video observations for a total of three random groups was completed. There were
no discrepancies observed with video playback. Seven youth were interviewed and confirmed
individual therapy occurs weekly and family therapy is conducted on a monthly basis. Seven
staff were interviewed and six stated they do not conduct groups. One staff said they did
conduct groups. This information was presented to the facility administrator who verified no
direct care staff conduct groups; however, they are present to account for supervision
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.***
The program has a policy and procedures to address the psychiatric services provided to the
youth in the program. The program maintains an independent contractor agreement with a
board-certified licensed psychiatrist who has a clear and active license in the State of Florida,
which expires on January 31, 2024. The psychiatrist is scheduled to be on-site two hours each
week and available for emergency consultation twenty-four hours a day and seven days a week.
A review of sign-in documentation indicated the psychiatrist was on-site delivering services
weekly as required by contract. An interview with the psychiatrist confirmed they are on-site
each week on Wednesday and on call twenty-four hours a day and seven days a week. The
psychiatrist conducts facility operating procedure (FOP) reviews, psychiatric evaluations,
medication management, and emergency consultations. The psychiatrist meets regularly with
the designated mental health clinician authority (DMHCA) and program director to discuss
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services. The program utilizes an advanced practice registered nurse (APRN) designated for
clinical responsibilities as needed. The APRN’s license is clear and active with an expiration of
July 31, 2024 and their education and experience is in psychiatric nursing. There is a
Collaborative Practice Protocol in place effective March 1, 2023 which remains in effect until the
APRN acquires independent licensure practice status. A copy of the protocol is maintained on-
site and specifies to be with the psychiatrist on-site. The psychiatric APRN is on-site as needed,
and a review of signed documentation indicated the psychiatrist provided on-site supervision of
the APRN’s services. An interview with the DMHCA confirmed meetings with the psychiatrist
occur weekly and they can be contacted by telephone twenty-four hours a day seven days a
week. Seven youth mental health and substance abuse records were reviewed; although it is
standard practice in accordance with the program’s policy and procedures to conduct a
psychiatric evaluation with all youth within fourteen days of admission, only three youth were
applicable for having psychiatric medication prescribed. All seven youth received psychiatric
evaluations which included documentation of youth history, Mental Status Examination, and a
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis. In the
applicable three records, the evaluation included prescribed medications, and frequency of
medication monitoring. Each reviewed record documented the Initial Diagnostic Psychiatric
Interview on the Department’s Clinical Psychotropic Progress Note (CPPN) form; and each
contained page three of the CPPN. Each of the three mental health and substance abuse
records verified each youth was receiving psychotropic medications. Each youth record
documented the youth was evaluated by the psychiatrist every thirty days. Each assessment
was documented on the Department’s form, including page three of the CPPN, and was
completed in full. There were no documented lapses in psychiatric services for the records
reviewed. Reviewed documentation supported there were no standing, pro re nata, and or
emergency treatment orders for psychotropic medications. A review of three applicable
psychiatric progress notes verified the psychiatrist included the youth’s identifying data,
diagnosis, target symptoms of each medication, and description of the effect of prescribed
medication on target symptoms. In addition, the psychiatrist included the name of the prescribed
psychotropic medication, quantity of medication, normal dosage range, ordered dosage,
frequency and route administration, reasons for any changes in medication, and/or dosage and
side effects. The CPPN included the youth’s adherence to the medication regime, vital signs,
notification to the parent/guardian, signature and date of the psychiatrist, and applicable
monitoring for Tardive Dyskinesia monthly. The program’s contract does not include the use of
telepsychiatry.
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 maintains a written Suicide Prevention Plan which outlines essential guidelines for
the identification, management, and assessment of potentially suicidal or at-risk youth. The plan
included identification and assessment of youth at risk of suicide, staff training, suicide
precautions, levels of supervision, referrals, communication, notification, documentation,
immediate staff response, and a review process. The review process includes circumstances
surrounding the event, facility procedures relevant to the incident, all relevant training received
by the involved staff, pertinent medical and mental health services involving the victim, possible
precipitating factors, and recommendations, if any, for changes in policy, training, physical plant,
medical or mental health services, and/or operational procedures. The Suicide Prevention Plan
is reviewed annually and was last reviewed on July 3, 2023 by the facility administrator (FA) and
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corporate staff and on August 8, 2023 by 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.
The program has a written Suicide Prevention Plan which outlines essential guidelines for the
identification, management, and assessment of potentially suicidal or at-risk youth. All newly
admitted youth are screened for suicide risk factors as part of the initial intake and admission
classification meeting process. Seven youth records were reviewed and none of the sampled
youth mental health and substance abuse records were applicable for suicide prevention
services. The program reported they have had no instances of youth being placed on suicide
precautions since the last annual compliance review. The program’s written policy and
procedures outline all youth admitted to the program as part of their initial intake have an
Assessment of Suicide Risk (ASR) completed. All seven mental health and substance abuse
records had an ASR completed upon admission screening. All seven reviewed youth were
deemed appropriate for standard supervision. All of the ASRs were completed by a licensed
mental health professional or clinical staff under the supervision of a licensed mental health
professional with appropriate training. Two of the seven ASRs were complete by a non-licensed
staff and were reviewed by a licensed staff within the required twenty-four hours. The program
does not utilize secure observation. The program has an established protocol and review
process for every serious suicide attempt or completion which includes all required topics
according to Florida Administrative Code. Due to the program not having any youth placed on
suicide precautions since the previous annual compliance review, video review was unable to
be conducted of suicide precaution procedures. An interview with the designated mental health
clinician authority (DMHCA) verified admission screening procedures for all youth. Seven staff
were interviewed regarding suicide precautions indicating mental health should be notified as
well as the supervisor, the youth should be placed on constant sight and sound supervision, and
all supervision should be documented.
3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
The program has a written Suicide Prevention Plan which outlines essential guidelines for the
identification, management, and assessment of potentially suicidal or at-risk youth. All newly
admitted youth are screened for suicide risk factors as part of the initial intake and admission
classification meeting process. Seven youth records were reviewed and none of the sampled
youth mental health and substance abuse records were applicable for suicide prevention
services. The program reported they have had no instances of youth being placed on suicide
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precautions since the last annual compliance review. The program has an established protocol
and review process for every serious suicide attempt of completion which includes all required
topics.
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 written Suicide Prevention Plan which outlines suicide prevention training
requirements. Seven pre-service and seven in-service staff training records were reviewed and
confirmed all staff had completed the required number of suicide prevention training hours. The
program had three suicide response kits co-located with first-aid kits in the Nike dorm, Under
Armor dorm, and in master control. The suicide response kits contain a knife-for-life, wire
cutters, and needle nose pliers. Suicide training includes mock mental health drills held no less
than quarterly on each shift with the utilization of cardiopulmonary resuscitation (CPR), which all
staff who come in contact with youth participate in, to include kitchen and maintenance staff. A
review of mental health drill documentation determined all mock drills were simulated and no
youth were used in the implementation of the drills. A review of mental health drill
documentation indicated drills are held at least monthly with some months having two to include
all shifts. An interview with the program director confirmed the frequency of the drills and further
indicated the drills are reviewed at every all-staff meeting. Seven interviewed staff confirmed
drills are conducted regularly.
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 a written Crisis Intervention Plan to include notifications and an alert system,
means of referrals, including youth self-referral, communication, supervision (one-to-one,
constant, close, and standard supervision), documentation, and a review process. The Crisis
Intervention Plan was signed by the facility administrator (FA) on July 3, 2023 and the
designated mental health clinician authority (DMHCA) on August 8, 2023
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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 written Crisis Intervention Plan, which includes provisions for crisis
intervention, suicide prevention, and emergency services. A review of seven youth mental
health and substance abuse records found there was one youth applicable for requiring a Crisis
Assessment. The program provided one additional Crisis Assessment for review but had no
others during the annual compliance review period. A review of the Crisis Assessment
documentation showed both youth were assessed on the day of the event placing them in crisis.
Both assessments documented the reason for the assessment, Mental Status Examination,
determination of danger, initial clinical impressions, supervision recommendations, treatment
recommendations, follow-up instructions, and parent/guardian notification. Both assessments
were completed on-site by the licensed clinical director. Both assessment results indicated the
youth were deemed appropriate for standard supervision and did not require an alert or elevated
supervision. One of the assessments was the result of a Prison Rape Elimination Act (PREA)
event. Since the youth was an alleged victim in a PREA event, a Mental Health and Substance
Abuse Referral Summary was immediately submitted for a Crisis Assessment and 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 has a written Emergency Mental Health and Substance Use Services Plan, which
was last revised and approved by the facility administrator (FA) on July 3, 2023 and the
designated mental health clinician authority (DMHCA) on August 8, 2023. A review of the plan
indicated the plan included immediate staff response, notifications, communication, supervision,
authorization to transport for emergency mental health or substance abuse services, transport
for emergency mental health evaluation and treatment under Chapter 394 (Baker Act), transport
for emergency substance abuse and treatment under Chapter 397 (Marchman Act),
documentation, training, and a review process. In the event a youth needs to be transported for
Baker or Marchman Act procedures, the program utilizes a local mental health facility.
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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 Baker Act or Marchman Act procedures during the annual
compliance review period; therefore, this indicator is rated non-applicable.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program has a policy and procedures outlining the guidelines for the creation and review of
safety plans for all youth. A review of seven youth mental health and substance abuse records
confirmed each record contained an initial plan which included youth warning signs, baseline
behaviors, crisis recognition, jointly developed coping strategies, intervention strategies
preferred by the youth, and debriefing preferences. All seven plans were initially completed
within the required fourteen days and contained the required elements as well as
recommendations from previous or current clinical assessments. Safety plans were reviewed
and updated as necessary but at least every thirty-days. The program stores safety plans in the
program’s multipurpose building so they are accessible to staff. An interview with the facility
administrator (FA) indicated plans are reviewed at least every thirty-days by staff. Seven staff
were interviewed and indicated they knew where to locate the safety plans should they need to
review them. Only one staff was unsure of when the plans should be reviewed and the staff was
unsure when the last time they reviewed a safety plan was. One staff indicated they last
reviewed the safety plan binder two months ago; however, the remaining five staff had reviewed
the safety plans at least within the last month. Of seven interviewed youth, six indicated they
were involved in the creation of their safety plan. The remaining youth stated they did not really
remember whether they were or not.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program’s designated health authority (DHA) is a licensed physician who holds an
unrestricted license and meets all requirements for independent and unsupervised practice in
Florida. The DHA license expires on January 31, 2024. The DHA’s specialty training is in family
practice with experience in adolescent health. The DHA does not have any disciplinary cases or
public health complaints on record. According to the contract, the DHA is required to be on-site
weekly, for a minimum of two hours a week. A review of the sign-in sheets for the annual
compliance review period indicated the DHA was on-site, as required. If the DHA has a
scheduled absence, the program has an agreement with another licensed physician to provide
medical care to the youth. The back-up licensed physician holds a clear and active unrestricted
license, which expires on January 31, 2024, and meets all requirements for independent and
unsupervised practice in the State of Florida. The back-up physician did not provide services to
the youth during the annual compliance review period. The DHA reviewed facility procedures as
documented by their dated signature. There was no inclusion of telemedicine in the program’s
contract. The DHA was interviewed, and confirmed their responsibilities include completing
Comprehensive Physical Assessments, periodic evaluations, protocol review, and providing
medical care weekly. The DHA performs any on-site services needed by the program weekly for
two hours and is available by phone. The registered nurse (RN) keeps a log of any youth
needing to be seen.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has three registered nurses (RNs) and two licensed practical nurses (LPNs). One
of the RNs serves as the health services administrator (HSA). A review of each RN’s license
credentials reflected each of the nurses have a clear and active license, in the State of Florida,
according to the Florida Department of Health Medical Quality Assurance website. Three of the
licenses are valid through April 2025, and two valid through July 2025. In addition, each of the
RNs and the LPNs have current cardiopulmonary resuscitation (CPR) certifications. The
required on-site hours according to the contract are seven days a week for a total of 120 hours.
The nursing staff are in compliance with the contractual requirements.
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4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has facility operating procedures (FOPs) for all health-related protocols utilized at
the program. The designated health authority (DHA) and facility administrator (FA) signed and
dated all treatment protocols. The DHA and FA reviewed and signed protocols and FOPs on
July 3, and July 18, 2023. FOPs and protocols related to psychiatric services and psychotropic
medication management are developed and reviewed by the program’s psychiatrist. The
psychiatrist reviewed and signed the psychiatric protocols on July 19, 2023. The nursing
protocols were signed by the nursing staff on July 7, 2023. There were no new policies or
changes in policy made during the annual compliance review period. An annual review of all
FOPs and protocols were signed by the respective individuals from each discipline on July 18,
2023 signifying their understanding of the FOPs and any new health-related Department
policies. All newly hired medical staff receive a comprehensive clinical orientation to the
Department’s healthcare policies and procedures conducted by the registered nurse (RN). The
DHA had written and authorized approval of treatment protocols and standing procedures which
were not delegated to any other person.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has facility operating procedures (FOPs) ensuring the completion of the Authority
for Evaluation and Treatment (AET) authorizing treatment of youth in the program’s custody. A
review of seven youth Individual Healthcare Records (IHCRs) found six were applicable for the
AET forms. Six of the youth had a signed AET form filed in the record with the word “Copy”
legibly stamped on it. The AET is valid for as long as the youth is in the program or until the
youth’s eighteenth birthday. One youth was eighteen and none of the youth were in the care of
the Department of Children and Families. The one applicable eighteen-year-old youth had a
documented release of information. An interview with the registered nurse (RN) confirmed the
youth’s AET is documented in the Department’s Juvenile Justice Information System (JJIS),
within the Electronic Commitment Packet. If the youth does not have a properly signed AET and
requires treatment, the medical staff notify the facility administrator (FA) who contacts the
youth’s juvenile probation officer (JPO). For youth who turn eighteen and remain in the custody
of the Department, the AET signed by the parent is immediately invalidated and the youth is
now responsible for authorizing their own physical and mental health care. The program
completes a release of information form and it is signed by the youth
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 facility operating procedures (FOPs) to ensure the parent/guardian is notified
of any changes in the youth’s condition and to document informed consent for youth healthcare.
A review of seven youth Individual Healthcare Records (IHCRs) found four were applicable for
parental notifications for over-the-counter (OTC) medications beyond those covered by the
Authority for Evaluation and Treatment (AET). The remaining three youth were not applicable as
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no OTCs beyond the AET were required. Two of four applicable IHCRs included documentation
of attempted contact to the parent/guardian in the progress notes when a new medication was
ordered, the remaining two were not applicable for new medications. Five applicable IHCRs
contained written notifications documented on the Department’s Parental Notification of Health-
Related Care: General or Parental Notification of Health-Related Care: Medications forms.
Three of the youth were taking prescribed psychotropic medications. Two of the youth were
applicable for a new psychotropic medication, change in dosage, or discontinuation of
medication which was documented on page three of the Department’s Clinical Psychotropic
Progress Note (CPPN) form. None of the youth were in the care of the Department of Children
and Families (DCF). In all seven IHCRs, the youth vaccinations were verified within thirty days
of the youth’s admission. None of the youth were applicable for a religious exemption from
immunization. An interview with the registered nurse (RN) confirmed parental notifications are
made verbally and in writing for all medications and treatments. Verbal consent is obtained on
the same day as the order and written notification is mailed within twenty-four hours. The
psychiatrist obtains verbal consent from the parent, the nurse signs page three of the CPPN as
the witness, and it is mailed to the parent within twenty-four hours. Immunization records are
obtained from Florida Shots within thirty days of admission.
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 facility operating procedures (FOPs) regarding youth healthcare admission
screening and rescreening each time the physical custody of the youth changes. Seven youth
Individual Healthcare Records (IHCRs) were reviewed for a Facility Entry Physical Health
Screening (FEPHS) form. All seven FEPHS forms were completed by the registered nurse (RN)
on the date of the youth’s admission. None of the youth were out of the physical custody of the
Department. The interview with the RN confirmed the RNs complete the FEHPS forms on the
day of admission on all youth. If a youth is out of custody a new FEPHS is completed upon
return to the facility.
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 facility operating procedures (FOPs) ensuring all youth admitted to the
program are provided an orientation to healthcare services within twenty-four hours of
admission. A review of seven youth Individual Healthcare Records (IHCRs) confirmed all youth
were provided a general care orientation upon admission to the program. The Health Education
form in all seven IHCRs included access to medical care, sick call, what constitutes an
“emergency,” medication process, right to refuse care, what to do in the case of a sexual assault
or attempted sexual assault, the role of non-disciplinary healthcare providers, and Standard
Universal Precautions were discussed with the youth as evidenced by their signature
documented on the Health Education form in the youth’s IHCR.
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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 facility operating procedures (FOPs) 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. The
program’s practice is to notify the DHA of all youth admissions including youth with chronic
conditions, medical concerns, or any youth admitted on psychotropic medications. Seven youth
Individual Healthcare Records (IHCRs) were reviewed, three of the youth were admitted with a
known or suspected chronic condition or required a referral to the DHA. None of the youth were
identified as in need of an emergency response upon admission. All records documented the
DHA notification in the youth’s Chronological Progress Notes and the Chronic Conditions Log
was updated after the notification. Two youth were applicable for taking psychotropic medication
upon admission, and documented notification to the psychiatrist. According to an interview with
the registered nurse (RN), the DHA is notified of all new admissions and any chronic conditions
on the day of admission, as documented on the admission progress note.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has facility operating procedures (FOPs) ensuring the Department’s Health-
Related History (HRH) form is completed prior to the Comprehensive Physical Assessment
(CPA) and healthcare needs are identified. A review of seven youth Individual Healthcare
Records (IHCRs) found each HRH was completed on the day of the admission. All seven
IHCRs indicated the HRH form was completed prior to the CPA to include the date and
signatures. In all IHCRs, the designated health authority (DHA) reviewed the HRH form as
evidenced by a checkbox on the CPA and a focused note in the admission documentation. An
interview with the registered nurse (RN) confirmed a new HRH is completed on the day of
admission for all new youth by the nursing staff.
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 facility operating procedures (FOPs) ensuring the acute and chronic
healthcare needs of the youth are addressed by completing a Comprehensive Physical
Assessment (CPA) within seven days of youth admission. A review of seven Individual
Healthcare Records (IHCRs) confirmed the program utilized the Department’s CPA form. All
CPAs were completed by the designated health authority (DHA) within seven days of the
youth’s admission to the program. All seven had the youth’s Medical Grade documented on the
CPA. The program completes a new CPA for all youth, no prior CPAs were utilized. All sections
of the CPA were completed in full utilizing “O” or “X” markings. All seven youth refused the
genital exam which was documented as “youth refused” on each CPA in the IHCRs, seven
youth signed a refusal form which reflected the refused portion on the CPA. The CPA in all
seven records included documentation of the most recent Tuberculosis Skin Test (TST) which
was administered within the last year to determine exposure to tuberculosis (TB). The results of
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the TST were documented on each youth’s CPA and matched the documentation on the
Department’s Infectious and Communicable Disease (ICD) forms. The Department’s Problem
List was updated for each youth, when applicable. An interview with the registered nurse (RN)
confirmed the DHA completes a new CPA on all admissions and youth receive a yearly TB test.
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 facility operating procedures (FOPs) 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). The designated health authority (DHA)
determines, based on the youth’s risk factors, screening tool, and evaluation, whether to order
testing for STIs. A review of seven Individual Healthcare Records (IHCRs) found all youth were
clinically screened and evaluated for STIs on the date of admission. All seven of the IHCRs
were applicable for further evaluation or referred to the DHA and were all documented on the
Department’s Sexually Transmitted Infections form. All testing, screening, clinical evaluations,
and diagnoses were documented on the Department’s Infectious and Communicable Diseases
(ICD) forms, excluding the HIV results, and were filed in the lab section of the IHCR. None of
the youth were out of the Department’s physical custody; therefore, a rescreening was not
applicable. All seven youth were offered pre/post-test counseling, testing, and referral for
treatment for HIV. Six of youth consented to receive an HIV test, two of the six are awaiting
testing. The program’s policy ensures the youth’s HIV test results are only disclosed to the
youth’s legally authorized representative, healthcare providers during treatment, the Department
of Health for purposes of reporting, health facility staff committees conducting program
monitoring, medical personnel who have been subject to significant exposure, and health care
facility personnel or agents for healthcare provider who have a need to know during patient
care. Pre and post-test counseling services are provided by the local health department. Seven
youth were interviewed, and all advised they can request testing. An interview with the
registered nurse (RN) confirmed all youth are screened at admission and results provided to the
DHA. Testing is ordered as needed and is completed within seven days of admission. Results
are documented on the ICD form and if completed lab results are filed in the lab sections of the
IHCR. An HIV consent is reviewed with youth at admission and youth can be tested by the local
health department.
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 facility operating procedures (FOPs) addressing the program’s sick call
process. None of the youth presented with a similar sick call complaint three or more times
within a two-week period. Three youth had a sick call request, addressed by the registered
nurse (RN). Each of the Sick Call Request forms were filed in the youth’s Individual Healthcare
Record (IHCR) in reverse chronological order. None of the youth were in restricted housing of
any kind. The sick call request forms and progress notes were documented in accordance with
Florida Administrative Code, including vital signs, treatment, education, and follow-up plans.
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Each of the sick call events were documented on the Sick Call Index and on the program’s Sick
Call Referral Log. All the dates listed on the Sick Call Index corresponded to the completed Sick
Call Request forms located in the youth IHCRs. Sick call occurs twice a day, seven days a week
at 8:00 a.m. and 3:00 p.m. Sick call hours are posted on the medical office door and sick call
forms are located on the living units. An exam table and equipment are used to perform sick
call. Seven interviewed staff advised the nurse or health services administrator (HSA) reviews
and conducts sick call. Seven youth were interviewed and five advised they are seen within one
day and two advised immediately. An interview with the nurse advised sick call is conducted in
the am and pm. If a youth presents with the same complaint, the youth is placed on list to see
the designated health authority (DHA) The program did not have any youth who requested a
sick call during the annual compliance review week; therefore, an observation of a sick call
could not be conducted.
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 facility operating procedures (FOPs) to ensure the youth have access to
episodic and first-aid care. A review of seven youth Individual Healthcare Records (IHCRs)
found three youth required on-site episodic care. In the three applicable IHCRs, the on-site care
was provided by a licensed healthcare staff documented including the problem-oriented
subjective, objective, assessment, and plan (SOAP) elements. The program has a total of seven
first-aid kits located in designated areas throughout the program. The kits are in each living unit,
three for transportation, one in the barn, and one in master control. The program has a process
for ensuring contents of the first-aid kits are maintained and stored in accordance with
guidelines to prevent expiration or deterioration. An observation of three first-aid kits confirmed
the kits were fully stocked with designated health authority (DHA) approved contents. The nurse
monitors the first-aid kits weekly and checks for expired contents, which is documented on the
first-aid kits logs. The program has three automated external defibrillators (AEDs) located in
master control, living unit, and medical. The AED procedures are located with the AEDs. The
AED batteries and pads are checked by the registered nurse (RN) once a month.
Documentation confirmed the RN monitored the AEDs as required. The RN checked the
expiration dates and completed a self-test of the AEDs in the presence of the Monitoring and
Quality Improvement regional monitor, with no issues noted. The batteries of the AEDs were
last changed in January 2023 and expire in March 2031. The AED pads were changed August
2023 and expire in November 2028. A review of the emergency drills confirmed the program
conducted an emergency drill to include cardiopulmonary resuscitation (CPR)/AED annually.
The emergency medical drills simulated an episodic care event which called for immediate first-
aid, and/or administration of CPR techniques, and the initiation of emergency procedures to
follow when a life-threatening emergency does occur. The program had a list of emergency
numbers which were inaccessible to youth. The emergency numbers are posted in medical,
kitchen, and in master control. A review of fourteen training records confirmed all staff were
trained in episodic, first-aid, and emergency care, and the administration of the epinephrine
auto-injector. An episodic care event was conducted during the annual compliance review week;
however, the annual compliance review staff was not present during the exam. The program
has facility operating procedures (FOPs) regarding Narcan. The policy states all newly
employed provider staff and newly admitted youth shall receive education on recognizing and
treating symptoms of opioid overdose. Training shall include risk factors for overdose, strategies
to prevent overdose deaths, overdose recognition and response, and Naloxone administration,
the medication which reverses opioid overdose. The training and prevention plan shall also
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include emergency response procedures including when to contact 9-1-1 and initiation of
cardiopulmonary resuscitation (CPR), if indicated. Narcan is stored in medical and inventoried
along with other medication. All staff are trained on the use of Narcan. Seven interviewed staff
confirmed they could call 9-1-1 in the event of an emergency, two staff advised a nurse or
supervisor would make the actual call. Seven youth were interviewed, and all confirmed they
can see a doctor or dentist if needed. The RN advised if a youth presents with a sick call
complaint three or more times during a two-week period, the nurse will automatically refer the
youth to the DHA. Episodic care is documented on a progress note, if a youth requires off-site
care it is documented in a transport log.
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 facility operating procedures (FOPs) to ensure timely referrals and
coordination of medical services to an off-site health care provider. A review of seven youth
Individual Healthcare Records (IHCRs) found three applicable for off-site care. In each of the
three applicable IHCRs, there was an indication the youth required off-site first-aid or
emergency care. The Department’s Summary of Off-Site Care Consultation Report form was
utilized and filed in the youth’s IHCR. All three IHCRs had documentation of the parent/guardian
notification efforts. Three youth were applicable for discharge documentation, and each had the
applicable documents filed in the IHCR. The DHA reviewed and signed all off-site care findings,
instructions, and information in each of the three IHCRs. Two of the youth required follow-up
testing, referrals, or appointments. There was evidence indicating the referrals were tracked and
youth received appropriate follow-up care as documented in the IHCR. The registered nurse
(RN) confirmed the youth are tracked in the transport log and episodic logbook.
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 facility operating procedures (FOPs) to ensure any youth admitted to the
program who have chronic conditions receive regularly scheduled evaluations and any as-
needed follow-up care. A review of seven youth Individual Healthcare Records (IHCRs) found
three were identified on the Department’s Facility Entry Physical Health Screening (FEPHS)
form with a chronic condition at admission. None of the youth were identified as having a
communicable disease. One youth was taking prescribed medication on an on-going basis.
Three youth were classified with a Medical Grade of two to four or were placed on the program’s
Chronic Illness List and received periodic evaluations at least every ninety days. None of the
youth were applicable for taking anti-tuberculosis medications. One of the youth had an
evaluation conducted off-site and the evaluation was documented on the summary of off-site
care form and filed in the IHCR. There was no evidence of any lapses in care or missed periodic
evaluations. The Department’s Problem List was updated for each youth. An interview with the
facility administrator (FA) indicated the program meets daily with medical staff to discuss
important medical issues. The designated health authority (DHA) interview confirmed the youth
with chronic conditions are tracked with the daily medication alert. The nurse confirmed in the
interview the youth are seen by the DHA every ninety day and are tracked with a daily medical
alert.
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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 facility operating procedures (FOPs) to ensure the accurate and safe
administration of youth medications. A review of seven youth Facility Entry Physical Health
Screening (FEPHS) found three youth were taking medication at the time of admission. Each of
the youth medications were verified prior to the youth being admitted into the program, and the
prescription notification was documented and in the youth’s Chronological Progress Notes. The
designated health authority (DHA), and when applicable the psychiatrist, was contacted to
obtain an order to resume the specified medications prescribed prior to admission for each
youth. A review of the seven youth IHCRs found four youth were applicable for current
medications to be continued, discontinued, changed, or for new medications to be ordered.
Each of the four applicable youth IHCRs included a Practitioner Order form indicating the DHA,
or psychiatrist, ordered the prescription for the youth. None of the youth were in restricted
housing of any kind. Four of the youth were applicable for over the counter (OTC) medications,
which were administered according to approved protocols. The Department Medication
Administration Record (MAR) was used to document all medications and treatments for all
reviewed IHCRs. The MAR clearly indicated medication start and stop dates. In all applicable
IHCRs, the staff initialed each administered medication entry. There were no undocumented
explanations for lapses or errors in medication administration for any of the reviewed IHCRs.
The registered nurse (RN) documented side-effects monitoring weekly on the MAR for all three
reviewed IHCRs. The MAR contains all required elements. The youth initialed each provided
medication entry. There were no indications of lapses or errors in medication administration, or
youth refusals. Two youth were applicable for psychotropic medication subsequent to
admission. Both youth received medication monitoring every thirty days as required. There were
no standing orders for psychotropic medications, emergency treatment orders for psychotropic
medication, or any pro-re-nata (PRN) orders for psychotropic medications. A medication pass
was observed. The youth were escorted by the youth care worker and approached the nurse
individually. The medical provider identified themselves and confirmed the reason youth was
present. The medical provider prepared the medication and verified the youth’s allergies and
alert status. The medical provider and youth initialed the MAR, and the medical provider
observed to ensure the medication was swallowed. The Six Rights of Medication
Delivery/Administration was maintained in each of the youth records. Seven youth were
interviewed, and six advised the nurse provides medication and one advised the doctor. Seven
staff were interviewed all advised a nurse provides the medication. An interview with the nurse
indicated the nurse provides mediation three times a day. There is an approved list of non-
healthcare staff who are available to administer medication. The staff are trained yearly by the
RN.
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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 facility operating procedures (FOPs) to ensure medical equipment classified
as sharps/medications are secure and inventoried utilizing a routine perpetual inventory. A
review of the medical equipment classified as sharps confirmed the items were securely stored
and inventoried utilizing a routine perpetual inventory descending count. All medications were
identified and secured in a locked medication cart designated for storage of medications. The
medication cart was secured, clean, and organized with stock items separate from youth-
specific medications. The program had no controlled medication during the annual compliance
review week. All medications were stored in a separate, secured area, inaccessible to the youth.
Narcotics and other controlled medications were stored behind two locks, and refrigerated
medication was stored in a secured refrigerator only used for medication. The program’s
process for the destruction and disposal or return of expired or discontinued medications
includes medications in a bubble pack are sent back to the pharmacy. Controlled Narcotics are
disposed of in a pharmacy approved liquid when the consultant pharmacist is on-site. The
consultant pharmacist is on-site monthly. The program conducts a perpetual and weekly
inventory of all sharps and stock over-the-counter (OTC) medications which did not indicate any
discrepancies. The nursing staff maintain a shift-to-shift inventory of all controlled substances, in
the event a youth is prescribed a controlled substance and documented this on the youth’s
Individualized Controlled Medication Inventory Record. The number of pills, tablets, or dosages
remaining were documented on the youth’s Individualized Controlled Medication Inventory
Record after each administered dosage. Seven supervisory-level staff were trained in the
delivery and oversight of medication self-administration. The training was provided by the
registered nurse (RN). Observations were conducted of inventory counts of three OTC
medications and three sharps. All inventories were correct with no discrepancies. The registered
nurse (RN) reported if there is a discrepancy in the count, the health services administrator
(HSA), designated health authority (DHA), and facility administrator (FA) shall be notified. The
program shall report and investigate unexplained losses of controlled substances and report as
required by rule. The interview with the nurse confirmed all medications are secured in the
medication cart. Prescribed medication is counted on the Medication Administration Record
(MAR). The consultant pharmacist is on-site monthly to inspect all medications and storage
practices.
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 facility operating procedures (FOPs) related to Infection Control and an
Exposure Control Plan. The Infection Control and Exposure Control Plan is signed annually and
was reviewed and signed by the designated health authority and facility administrator (FA) on
July 29, 2023. The program’s infection control procedures include prevention, containment,
treatment, and reporting requirements related to infectious diseases, as according to
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Occupational Safety and Health Administration (OSHA) federal regulations and the Centers for
Disease Control and Prevention (CDC) guidelines. The plan addresses common infectious
diseases of childhood, self-limiting, episodic contagious illnesses, viral and bacterial infectious
diseases, tuberculosis, Hepatitis A, B, and C, Human Immunodeficiency Virus (HIV), infectious
diseases caused by blood-borne pathogens, other outbreaks or epidemics caused by any other
infectious agent, outbreaks of lice or scabies, Methicillin-Resistant Staphylococcus Aureus
(MRSA) and other antibiotic resistant micro-organisms, food-borne illnesses, bio-terrorist
agents, and chemical exposures. The program’s Exposure Control and Infection Control Plan is
written in accordance with the OSHA standards. The program offers Hepatitis B immunizations
to staff. Staff have access to personal protective equipment. The program has a comprehensive
process for needle stick post-exposure evaluation. The program has a separate file containing
all documents of youth and staff who have experienced a facility or occupational exposure. The
program’s Exposure Control Plan was written in accordance with OSHA standards and is in
breakroom, master control, and the medical department. An interview with the FA confirmed the
Exposure Control and Infection Control Plan are in the multipurpose room. The plan is reviewed
annually or whenever a situation arises which warrants a review. An interview with the nurse
confirmed exposure control training is provided by the registered nurse (RN).
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains a policy and procedures requiring all program staff to promote safety
and security by maintaining active supervision of youth to include interacting positively with
youth, engaging youth in a full schedule of constructive activities, closely observing behavior of
youth, and consistently applying the program’s behavior management system (BMS). The
program has a daily youth activity schedule which was posted throughout the program. The
program staff are required to account for the whereabouts of youth under their supervision and
ensure staff-to-youth ratios are compliant with contract requirements. The program’s contract
requires staff-to-youth ratios to be one-to-eight during awake hours and one-to-twelve during
sleep hours. The ratio for off-site activities, transportation, and visitation is one staff to five
youth. Observations of staff supervision for four days during the annual compliance review week
included classroom activities, youth searches, line movement, school breaks, youth headcounts,
youth participating in group and individual counseling, meal and snack time, and outdoor/indoor
recreation activities. The observations verified staff-to-youth ratios were maintained, as
required. During outdoor activities and/or movement, observations showed staff were
strategically positioned to ensure proper supervision of youth and to ensure there were no
physical obstructions in their view of the youth. Observations of interactions between program
staff and youth reflected the interactions were positive and consistent with the program’s BMS.
Informal interviews with three staff verified the staff knew how many youth they were
supervising and the program census. A review of video footage for three different days verified
staff observed youth while in their sleeping rooms. Seven interviewed staff were able to explain
the process for rectifying youth counts.
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 has a policy and procedures describing the collaborative behavior management
system (BMS) which promotes safety, respect, and fairness, promotes and protects youth
rights, includes positive and negative consequences, includes constructive disciplinary actions
as well as opportunities for reinforcement, recognition of accomplishments in a four to one ratio,
promotes socially acceptable means for youth to meet their needs, a process for explaining to
youth the reasons for any sanctioning, gives the youth the opportunity to explain their behavior,
opportunities for staff and youth to discuss the impact of behavior on others, reasonable
reparations of harm caused to others, discussions of alternative behaviors, promotes positive
dialogue and peaceful conflict resolution, and minimizes separation of youth from population.
There is a standing agreement between the program and the school related to the BMS in which
the regional training coordinator provided training to all education staff in the jointly combined
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BMS plan. The program’s policy and procedures include a protocol where staff are provided
feedback regarding the implementation of the BMS, which was supported by seven staff
interviews. Seven youth case management records were reviewed, all seven confirmed youth
orientation included a review of the program’s BMS, and each contained an acknowledgement
form signed by the youth. Seven position descriptions were reviewed and confirmed each job
functions includes implementation of the program’s BMS. Seven reviewed staff records
indicated they were trained in the program’s BMS during pre-service training. The BMS is
posted throughout the program in each living unit and provided in the youth handbook. The
BMS does not include increased length of stay, a denial of a youth’s of basic rights or services,
promotion of group discipline, punishment of youth by other youth, or disciplinary confinement.
Staff and youth interactions were observed for adherence to the BMS, to include negative
consequences and positive rewards, and consequences were in direct relation to the
seriousness of the inappropriate behavior. The program offers a variety of incentives to include
canteen, Mega Monday, Fat Friday, off-campus trips, and movie nights. The provider’s contract
requires an Honor’s dorm as a part of the program’s BMS. The program utilizes two sections in
two dorms as the Honor’s dorm, with requirements detailed in the youth handbook. The facility
administrator reported the BMS is a coordinated system of promoting, monitoring, recognizing,
and rewarding a youth’s progress. It is a program of incentives and consequences which
promote individualized skill building, appropriate behavior, and accountability. This is
accomplished through the use of point cards, which staff utilize to monitor how youth are doing
in the program. You are able to earn points for prosocial behavior as youth exhibit the
appropriate character expectations. Seven youth were interviewed; three youth stated the BMS
is good and four rated it very poor. A follow up interview with these four youth resulted in no
explanation for any of the youth other than they do not like the system. The seven interviewed
youth listed some of the consequences for negative behavior as being early bedtime, privilege
restrictions, level freezes, points taken away, and special treatment teams. Rewards were
reported to include canteen, Fat Friday, Mega Monday, off-site trips, and movie nights. Each of
the seven youth were able to explain the difference between each level and how youth move
from level to level. All seven youth reported youth are not allowed to punish other youth and
staff use rewards the same. Seven staff were interviewed, and all staff indicated they received
training in the BMS. Six of seven staff indicated the BMS operates on points, four were aware of
levels, two staff indicated rewards and consequences were handed out in a four to one ratio,
one staff acknowledged it was posted throughout the program, and one reported the BMS is in
the youth handbook and taught to youth at orientation. All seven staff reported they do not take
anything away from the youth as a punishment for their behavior. The staff collectively reported
youth are rewarded with canteen, Fat Fridays, Mega Mondays, and off-campus outings. Staff
also reported youth are informed of the consequences and are they able to explain their
behavior immediately with staff, during the problem behavior reporting process, where a youth
may document their response to a major infraction and during treatment teams. Seven staff
reported they do take away privileges as part of the BMS to include not receiving the nightly
incentives, having to go to bed earlier, or not being able to participate in off-campus activities.
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5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, provide constructive discipline and a system of positive and negative consequences
to encourage youth to meet expectations for behavior, provide opportunities for positive
reinforcement and recognition for accomplishments and positive behaviors, promote dialogue
and peaceful conflict resolution, and minimize separation of youth from the general
population.
Supervisors shall monitor staff implementation of the BMS and ensure the use of rewards and
consequences are administered fairly and consistently in application among all staff.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
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.
An observation of ten-minute checks was conducted during the week of the annual compliance
review. The observation was completed utilizing video footage compared to written
documentation of ten-minute checks. The program has 125 cameras, of which all are
operational. The program’s camera system stores video recordings for thirty days. A sample of
three days was reviewed for the night shift while youth were sleeping, at thirty-minute intervals.
The review verified staff conducted checks every ten-minutes and documented the times
accurately on the ten-minute check log, as well as initialed each check and signed the form.
Ten-minute checks documentation matched the actual footage reviewed. Staff were observed
looking into each room to ensure the safety of the youth. Seven staff were interviewed, and all
indicated checks are done every eight minutes and two reported master control calls for each
check when it is due.
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5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program’s policy and procedures regarding the youth census, counts, and tracking provides
an outline for the safety of the youth and staff at all times, including in the event of a disaster or
emergency. Staff are to ensure appropriate supervision of the youth is maintained at all times
and are to provide effective positioning for optimal sight and sound supervision of youth. An
observation of a count was conducted; master control called for the head count over the radio
system and asked all movement to stop. After a brief pause, master control called each area of
the facility and asked for the number of youth in the area. If the count is reconciled, all
movement is allowed to resume. According to the program’s logbooks, master control maintains
an ongoing count of all youth and youth movement. Counts were documented hourly, at the
beginning of each shift, after each outdoor activity, and during emergency situations.
Documentation in logbooks included total daily census, head counts, any youth movement, new
admissions or releases, transfers, and youth away from the facility with one exception. In March,
a count was not documented following a fire drill. Seven interviewed staff indicated formal
counts are conducted every hour. Emergency counts are conducted at any time there is a need
for a count, following an incident, following a drill, when a code is called, during a power outage,
and sometimes randomly. When asked about the daily census, staff responses were not
consistent, however, each staff knew how many youth were on their particular dorm when asked
during the annual compliance review week.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a chronological record of events in the master control logbook. The
logbooks are bound with numbered pages and contain fields for events to be documented. The
logbooks were in good shape and not missing any pages. Logbooks were legible and all entries
were made in ink with no erasures or white-out areas. Errors were struck through with a single
line and initialed by the staff correcting the error. All entries included the dates and times of the
events, with the names of the staff and youth involved, brief descriptions of the events, and the
names and signatures of the staff making the entries. Incoming staff signed and dated the
logbook to document it had been reviewed and/or to confirm they were verbally briefed about its
contents. A shift briefing was unable to be observed; however, an informal interview with the
facility administrator (FA) indicated the contents of the previous two shifts are discussed by
supervisors and staff at this time. The activity schedule and logbook document minimal
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interference of educational instruction, classes and recreation are held as required, and the
logbooks reflect youth arrive to and depart school on time. Each logbook documented
emergency situations, incidents, special instructions for supervision of youth, population counts,
perimeter and security checks, transports, law enforcement visits, admissions, releases, and
any information relating to escapes or attempted escapes. A review of the program logbooks
reflected internal incidents were reported to the Department’s Central Communications Center
(CCC) 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.
A review of the program’s written policy and procedures on key control confirmed it includes the
control and use of keys to include key assignment and usage, inventory and tracking of keys,
secure storage of keys, procedures addressing missing or lost keys, and reporting and
replacement of damaged keys. Observations of the key control system indicated the master
control operator maintains the distribution, collection, and documentation of keys. The key
inventory was reviewed and confirmed the inventory matches the actual key rings in use. Keys
are stored in a locked box in the back of the master control room and all keys remained secure
when not in use. The locked storage box is not easily accessible while locked. Permanent
issued keys are kept to a minimum and must be authorized in writing by the facility administrator
(FA). Positions eligible for a permanent key include the FA, assistant facility administrator
(AFA), chief of security, clinical director, director of case management, equine director,
administrative assistant, food service manager, health service administrator, human resource
manager, physical plant manager, registered nurse, and the two unit managers. At the time of
the annual compliance review, on-file permissions for permanent keys include the FA, AFA,
physical plant manager, administrative assistant, human resource manager, equine director,
food service manager, and the director of case management. Provisions for restricted keys were
observed and are accessible to case managers, cooks, nurses, the administrative assistant,
AFA, and FA. There were no damaged keys observed; however, policy indicates they are to be
reported to the shift supervisor and returned to the physical plant manager who is responsible
for discarding them, updating the inventories, and issuing the replacement key. There were no
Department’s Central Communication Center (CCC) incidents or Program Monitoring and
Management (PMM) deficiencies related to key control concerns. An informal interview with the
master control designee indicated keys are tracked and reconciled using a central key log which
indicates the date, time, who the keys were issued to, what type and number of keys, assigned
radio, and what time the keys and radio are returned. Five sets of keys from the key box were
compared to the key inventory with no deficiencies noted. Observations of three staff’s keys
determined their assigned keys were consistent with the key log. Each staff was aware of the
number of keys on their assigned keys as well as what each key was for. Seven staff were
interviewed and indicated master control issues staff keys, which are securely stored. Five of
the seven staff reported there is a daily tracking of keys on a key log, and keys are assigned to
staff upon entry. Three staff said visitors are given a chit in exchange for their keys. One staff
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was aware of the program’s key inventory. All seven staff, when asked, were able to articulate
procedures for any missing and/or damaged keys.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items.
A program shall delineate items and materials considered contraband when found in the
possession of youth, the list must include: sharps, escape paraphernalia, tobacco products,
lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food or
clothing, any intoxicating beverage or any beverage which causes or may cause an
intoxicating effect, any controlled substance, any prescription or non-prescription drug which
has a hypnotic, stimulating, or depressing effect, any firearm or weapon of any kind or any
explosive substance, non-facility issued electronic equipment or devices to include
smartwatches, metals, personal non-facility issued cellular devices, unauthorized currency or
coin(s), and non-facility issued keys. The program shall provide youth with the list of
contraband items and materials and inform the youth of the consequences if found with
contraband. The program shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, and both staff and youth.
The program shall document the confiscation of any illegal contraband and the manner of
disposition. The program shall keep a copy of the documentation in the youth’s case record. If
a confiscated item is not illegal or prohibited, the program director or designee has the
discretion to discard of the item, return it to its original owner, mail it to the youth's home, or
return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a policy and procedures which address illegal contraband and outline all
prohibited items. The program clearly delineates items considered contraband and youth are
provided with a list of items considered to be contraband as part of their admission to the
program and they are notified of the consequences associated with any found contraband. Staff
and youth sign an acknowledgement form reflecting their understanding of the policy. Seven
youth records and seven staff records all contained signed forms. The program staff are
required to search the facility's grounds and the physical plant for contraband. Youth are
searched every time they are moved from one area of the program to another. Any incoming
and outgoing mail is also searched in the presence of youth. The program maintains a log of
youth room searches detailing items found and their disposition, to include documentation in
youth records when necessary. The written policy and procedures address any staff who are
found in possession of contraband will be subject to disciplinary action up to and including
dismissal. If any contraband found is illegal, law enforcement is notified according to policy. No
incidents of contraband have been reported since the last annual compliance review. The facility
logbook, incident reports, and room search reports were reviewed and verified searches for
frequency, quality, and results. An interview with the facility administrator (FA) confirmed the
program’s written policy is adhered to concerning any contraband.
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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.
Searches are conducted on each youth prior to normal movement from one area to another.
Searches are conducted during orientation, intake, and when youth leave from and return to the
program. An observation of searches was conducted every day in relation to youth movement
including between classrooms, living units, recreation, and the dining hall. Youth were treated
with dignity and respect to minimize stress and embarrassment. Searches were conducted by
the appropriate number of staff and gender. Observations determined searches were thorough
and conducted as required by the Protective Action Response Right Interactions model
(PAR/RI) training manual. Seven interviewed staff confirmed youth are searched after every
movement. Seven interviewed youth also indicated they are searched each time they move
from one place to another.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has three vehicles for transportation. Documentation of the annual safety
inspection was reviewed for each vehicle, and no issues were noted. All vehicles had separate
maintenance records. All three vans were secured prior to inspection and included a fire
extinguisher, seatbelt cutter, and window punch. The program has first-aid kits for each van, but
they are kept in master control until transport. Each van had the appropriate number of
seatbelts. The door to the youth passenger area cannot be opened from the inside. Seven staff
and seven youth were interviewed and indicated youth are attached to the vehicle with a
seatbelt. Five of the seven staff reported youth wear handcuffs and leg shackles when being
transported off-campus. Two interviewed youth report if youth have off-campus privileges, youth
do not have to wear handcuffs or shackles. A random check of ten personal vehicles
determined vehicles were locked when not in use.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a policy and procedures to ensure the safety and security of youth and
the community when youth are transported outside of the program. A review of the program’s
policy and procedures, as well as interviews and observations, reflected staff transporting youth
are given a radio and program cell phone. A return from an off-campus transport was observed.
The two youth were wearing seatbelts, and two staff of the same gender were on the transport
with one in the back of the vehicle with the youth. Staff searched youth and the vehicle after
exiting. Each staff tasked with transporting youth has a current, valid driver’s license. Youth are
not permitted to drive program or staff vehicles. Seven staff were interviewed, and all were
aware a first-aid kit is required when transporting youth. Other items mentioned during the
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interviews were a fire extinguisher, seatbelt cutter, window punch device, tire repair kit, and a
steering wheel lock. All seven staff acknowledged youth cannot be transported in personal
vehicles. Six of seven stated vehicles are searched prior to transports, and five of seven knew
what to do in case of an emergency during a transport. Four staff knew the ratio is one staff to
five youth during transports, while the other three explained two staff are required for transports.
Seven youth were interviewed, and all seven reported staff are driving transport vehicles safely
and they have not seen anyone place contraband in a transport vehicle.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures outlining the audit/inspection process. The assistant
facility administrator (AFA) in conjunction with the physical plant manager are responsible for
conducting weekly security audits and safety inspections. Findings are documented on the
Weekly Safety Inspection Report and provided to the facility administrator (FA) for review. The
report details identification of the issues and tracks the correction of the deficiencies. All efforts
are made to correct deficiencies in a timely manner, depending on the severity of the issue.
The policy and procedures meet all requirements according to Florida Administrative Code.
Weekly safety and security audit documentation was reviewed and indicated audits were
completed weekly, as required. The facility administrator reported the program tracks safety and
security deficiencies through weekly safety and security reports and walk-throughs.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a policy and procedures for a tool management system which
ensures youth do not use tools or equipment as weapons or for security breaches. These
address the issuance, inventory, and control of tools and equipment. All tools are stored in the
maintenance shed outside the facility grounds when not in use. The tools are all marked for
easy identification and a shadow board is used for storage. Tools are inventoried prior to being
issued for work and following any work activities. Tools with sharp edges and points are
inventoried daily to include kitchen knives, which are stored in a locked cabinet inside the
kitchen and maintenance tools located inside a locked cage inside the maintenance shed. A
monthly inventory of all other tools is maintained. Machetes, bowie knives, and other long blade
knives are prohibited. There were no cases of any missing tools since the last annual
compliance review; however, an informal interview with the physical plant manager indicated the
understanding of what procedures to follow in the event a tool does go missing. There were two
maintenance tools broken during the annual compliance review period. Both tools were
removed and not replaced. Logs for brooms and mops used by youth were observed and were
in compliance. Three items from the maintenance shed and seven items from the youth living
units were sampled. The logs for each were correct and up to date for all items.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 57 of 63 (Revised September 2022)
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a policy and procedures regarding youth tool handling and supervision. The
written policy includes supervision requirements when youth use tools, issuing tools to youth
and staff including an assessment to determine a youth’s risk to self and others, established
ratios, tool distribution and collection, and search criteria during work projects. An observation of
morning and afternoon cleaning duty indicated the proper staff-to-youth ratio was maintained.
Youth were searched after each work period. A review of seven case management files
indicated the program trains youth on the intended and safe use of tools. Risk assessments
were conducted for any youth permitted to handle tools. Seven youth were interviewed, and
three indicated they are permitted to use mops and brooms. One reported a scrub brush is also
permitted to be used. Two youth reported youth are not allowed to use tools, and two youth
mentioned garden tools if the youth is approved to do so for vocational training. Five of seven
interviewed staff reported youth may handle mops and brooms, one also indicated a scrub
brush, and two report youth are not allowed to use tools.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures establishing guidelines for outside contractors who
come on-site to complete repairs including information regarding tool control and restrictions.
The policy requires private contractors to receive written instruction detailing responsibilities
regarding tool management and contraband and require them to confine their work to the
authorized area using safety and security precautions. Outside contractors must be
accompanied by the maintenance staff or designee. Contractors shall limit tools to only those
necessary. Staff check tools upon the workers arrival to and exit from the program. Youth
access is restricted from the work area. The facility administrator is responsible for providing
approval/permissions for any items required. Personal cellular phones and/or
equipment/electronic devices capable of taking pictures and/or audio/video recordings including
smart watches are prohibited in the secure areas of the facility. A review of sign-in sheet
documentation determined procedures were followed as required. Sign-in sheets included
guidelines for external workers to document any tools checked in upon arrival and departure,
any tool restrictions in the facility, youth restrictions from the work area, and any missing tool
follow-up (if applicable). A review of three project invoices submitted to the program from the
vendor indicated the date the project was worked matches the sign-in sheets of the external
workers. An inventory of tools was conducted upon arrival and departure for each of the outside
contractors reviewed.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 58 of 63 (Revised September 2022)
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 documents Continuity of Operations Plan (COOP) drills on a rotating basis in
accordance with their COOP to include fire, safety, and evacuation. All drill forms document the
type of drill, date and time, participants, a brief scenario, and findings and recommendations.
Fire evacuation routes and egress plans were posted throughout the facility. The program has a
total of thirty-three fire extinguishers. A review of inspection tags indicated they are inspected
annually, and checks are documented monthly by the physical plant manager. According to the
facility administrator, monthly drills include fire, COOP, escape, medical, and mental
health/suicide drills. A review of drill documentation shows at least one monthly drill for the
annual compliance review period on each shift covering monthly COOP drills on a rotating
basis. Five of seven interviewed youth indicated they know what to do in case of a fire and had
participated in a fire drill. Two youth reported fire drills are conducted monthly, one youth
indicated the drills are performed bi-monthly, one youth stated every other month, one youth did
not remember when they were conducted, one reported they have participated in one since
arriving, and one said they have not been told about fire drills nor have they participated in one.
Five of seven interviewed staff indicated they had participated in fire drills, three have
participated in escape drills, two reported weather drills, and one reported a major disturbance
drill.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program maintains a Department approved Disaster and Continuity of Operations Plan
(COOP) available for all staff to review, located in the program’s multi-purpose room and in the
facility administrator’s office. The COOP was submitted and signed by the Department’s
regional director on February 24, 2023. The combined Emergency Disaster Preparedness Plan
and COOP address alternative relocation sites approved by the Department’s residential
regional director. Designated equipment and supplies required for continuous operation and
services during emergency, including water, canned foods, bags with emergency equipment,
first-aid supplies, towels, blankets, and extra clothing which are stored on-site in the kitchen
pantry and other facility storage areas. The COOP addresses phases of a disaster plan as well
as emergency management including preparedness, response, and recovery. The COOP
addresses emergencies including fire, fire prevention, evacuations, severe weather, program
disturbances, bomb threats, hostage situations, chemical spills, flooding, and terrorist attacks. It
also includes staff roles and responsibilities, any equipment and supplies needed, information
about youth needed, alternative housing arrangements, provisions for continuity of care and
custody of youth, and provisions for public protection. The program keeps a binder in master
control with all youth information contained within, each youth has their own divider with
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 59 of 63 (Revised September 2022)
information including their full name, Department identification number, admission date, date of
birth, gender, race, parent/guardian information, contact information of who the youth will be
residing with, who to notify in case of emergency, juvenile probation officer information, names
of the committing judge, state attorney and public defender, committing offense and where it
occurred, notation of jurisdiction retention, victim notification if applicable, a physical description
of the youth, their overall health status, personal physician (if known), and a photograph of the
youth.
5.18 Storage and Inventory of Flammable, Poisonous, and
Satisfactory Compliance
Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items.
The program has a policy and procedures regarding the storage and inventory of flammable,
poisonous, and toxic items and materials. All hazardous items or materials are stored in the
maintenance shed outside the facility grounds and inside a locked storage closet inside the
kitchen, both inaccessible to youth. The physical plant manager maintains strict control of all
flammable, poisonous, and toxic items by utilizing a perpetual inventory. A review of Safety Data
Sheets (SDSs) compared to the inventory determined the facility has SDSs maintained on-site
for all materials with no discrepancies. Inventories were compared to a sample of five items at
the program and no items were missing and no additional items were on the inventory. The
facility administrator, assistant facility administrator, supervisors, and maintenance staff
positions are listed as authorized to handle flammable, poisonous, and toxic materials.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures regarding youth handling and supervision for
flammable, poisonous, and toxic items and materials. According to the program’s policy youth
are prohibited from handling or accessing flammable, toxic, or caustic materials at the program.
Youth are also prohibited from cleaning, handling, or disposing of any person’s bio-hazardous
material, bodily fluids, or human waste. All flammable, poisonous, and toxic materials are stored
securely outside the facility’s grounds inside the maintenance building and within a locked
storage closet inside the kitchen where youth do not have access. Seven youth were
interviewed, and all seven youth reported they do not handle chemicals. An observation of
cleaning duty confirmed this practice.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 60 of 63 (Revised September 2022)
5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program has a policy and procedures for disposal of all flammable, toxic, caustic, and
poisonous items. According to the facility administrator (FA), hazardous items and toxic
substances or chemicals are disposed of in accordance with Occupational Safety and Health
Administration (OSHA) standards. The program disposes of hazardous waste at the local waste
collection center. No hazardous waste has been disposed of during the annual review period.
According to the physical plant manager, hazardous liquid waste is disposed of in accordance
with the manufacturer’s Safety Data Sheet and is stored in a hazardous materials storage area.
Any liquid waste such as dirty mop water or unused beverages are disposed of in plumbing
drains and kitchen liquid waste is disposed of in the kitchen, with the exception of grease.
According to the kitchen staff and physical plant manager, old grease is returned to the
containers the grease came from and then taken to the local recycling facility for disposal by the
physical plant manager. According to the program’s policy and procedures, in the event of a
chemical spill, staff must notify master control of the spill location, the shift supervisor and/or
master control shall direct the shutdown of all air handlers and ventilation systems as well as
close all windows and doors at the direction of the supervisor on-site or facility administrator,
and, if necessary, assistance from outside the facility shall be contacted consistent with any
emergency procedures.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 61 of 63 (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.
An observation of the visitation schedule and reviewed documentation determined visitation is
held on Sundays for one hour. Documentation reflected all incoming and outgoing mail is
searched and monitored by program staff. A review of documentation demonstrates youth are
given opportunities to communicate with their family by telephone, mail, and through virtual and
video conferencing means. The program’s policy and phone logs indicated telephone calls are
offered Monday through Thursday and, for youth whose calls did not go through during the
allotted days, Friday is used as a make-up day. The facility administrator stated the program
utilizes staff with different linguistic backgrounds to assist with translation for youth whose
primary language is not English. Three of seven staff were aware of this practice, when asked.
Two of seven interviewed youth were aware of staff translators.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 62 of 63 (Revised September 2022)
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program’s activity schedule reflects a variety of supervised and structured indoor and
outdoor recreation (or large muscle activity) and leisure activities for the youth for at least one
hour daily. A review of the logbook indicated recreation was conducted for at least one hour
each day, as scheduled. The program’s documented recreation and leisure activities promote
social and cognitive skill development, creativity, teamwork, healthy competition, mental
stimulation, and physical fitness. Recreational activities are observed to ensure the program
takes precautionary measures to prevent overexertion, heat stress, dehydration, frostbite,
hypothermia, and exacerbation of existing illness or physical injury, which is documented in the
facility logbook. Seven youth reported they are given the opportunity to exercise, play outside,
or given down time to read a book or play a board game. All seven youth also stated physical
activities are provided for at least one hour to include basketball, football, running track,
volleyball, and other exercises. Seven interviewed staff report youth participate in various
recreational activities including basketball, volleyball, football, kickball, and handball. The
program has had a vacancy for the recreational therapist for which the program had completed
an Outcome Based Corrective Action Plan (OBCAP) for and the deficiency has been closed.
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 63 of 63 (Revised September 2022)

report_type: QI Residential

program_name_raw: Center for Success and Independence Ocala