summary: QI Residential - FY23-24 - 5 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Wimauma Academy
Wayne Halfway House
(Contract Provider)
4337 Saffold Road
Wimauma, Florida 33598
Review Date(s): April 16-19, 2024
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Marvin D. Bliss, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Belinda Alexander, Office of Education, (Standard 2)
Crystal Blair-Gallon, Office of Accountability and Program Support, Regional Monitor,
(Standard 3)
Jeremy Curvan, Office of Accountability and Program Support, Regional Monitor, (Standard 4)
Aliyah Farley, Department of Juvenile Justice Detention Services, Detention Office 2,
(Standard 5)
Rosa Flores, Office of Accountability and Program Support, Regional Monitor, (Standard 2)
Tamara MahlAdkins, Office of Accountability and Program Support, Regional Monitor, (Standard
3, 4, and interviews)
Kayshala Patterson, Office of Accountability and Program Support, Regional Monitor,
(Standard 2)
Justin Terziu, Office of Accountability and Program Support, Regional Monitor, (Standard 1)
Program Name: Wimauma Academy MQI Program Code:
Provider Name: Wayne Halfway House Contract Number: 10795
Location: Hillsborough County / Circuit 13 Number of Beds: 32
Review Date(s): April 16-19, 2024 Lead Reviewer Code: 173
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
1.15 Advisory Board 3.02 Licensed Mental Health and Substance Abuse Clinical Staff *
2.20 Educational Access*
3.13 Suicide Prevention Training *
4.12 Sick Call Process
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 65 (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 Advisory Board Limited
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 65 (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* Limited
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 65 (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 * Failed
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 * Limited
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 65 (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 Limited
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 65 (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 Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.21 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.22 Visitation and Communication Satisfactory
5.23 Recreation and Leisure Satisfactory
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
5.25 Controlled Observation Non-Applicable
5.26 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 65 (Revised September 2022)
Program Overview
The Wimauma Academy is a 32 bed program, for fourteen to eighteen year old males, located
in Wimauma, Florida. The program is operated by Wayne Halfway House, through a contract
with the Department. The program provides services including Mental Health Overlay Services
(MHOS) and Substance Abuse Treatment Overlay Services (SAOS). In addition, the program
fosters each youth by providing Cannabis Youth Treatment, Living in Balance, Aggression
Replacement Training, Dialectical Behavior Therapy Skills Manual for Adolescents, and Impact
of Crime. Additional treatment services provided include family and individual therapy, therapy
groups, and recreational therapy. Program administration is comprised of a facility administrator,
assistant facility administrator, human resources, registered nurse (RN) manager, and a
licensed clinical director. Case management services are provided by two case managers and a
transitional case manager. Mental health staff at the program include one licensed clinical
director, one licensed therapist, one recreational therapist, and two unlicensed therapists. Also
providing mental health services is a licensed psychiatrist. Medical services are offered 9:00
a.m. through 4:00 p.m. daily and are provided by a registered nurse (RN) manager, one part-
time RN, two full-time RNs, and one contracted medical doctor. Educational services are
provided by a director of education and three instructors employed by the program. The layout
of the program includes an administration building, a vocational building, two dormitories, a
kitchen and dining hall, an education building, and a building with medical, the large group
room, and an additional classroom. The program has fifty-six operating security cameras
providing coverage. At the time of the annual compliance review, the program had three vacant
positions including one assistant facility administrator, one licensed therapist, and one youth
care worker.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 65 (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 outlining the process of conducting initial background
screening for new hires. Since the completion of the start-up review the program hired
seventeen new staff. Each applicable staff was found to have an eligible background screening
in the Agency for Healthcare Administration (AHCA) Clearinghouse system which was
completed prior to each staff having contact with youth or confidential youth records. Three staff
were in training and not in contact with youth during this time. A review of each staff’s personnel
record found the program reviewed each staff’s criminal history report, Staff Verification System
(SVS) report, Florida Department of Law Enforcement (FDLE) Automated Training Management
System (ATMS), and the Department’s Central Communications Center (CCC) Person
Involvement History report prior to hire. All seventeen staff had documentation in their personnel
record indicating they completed and passed a pre-employment assessment tool. None of the
newly hired staff required an exemption prior to working with youth and did not have a break in
service indicated in the SVS. A review of the program’s volunteer roster and sign-in logs verified
the program did not have any volunteers or mentors who required a background screening
during the annual compliance review period. The program did not employ interns during the
annual compliance review period. An Affidavit of Compliance with Level 2 Screening Standards
was submitted to the Department on January 31, 2024. The program has local school board
teachers and background screenings were completed on January 31, 2024.
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 outlining the process of conducting five-year
rescreenings on staff meeting the criteria. A review of the staff, volunteer, mentor, and intern
roster found the program had one staff applicable for a background rescreening during the
annual compliance review period. The staff was found to have a completed and eligible
background screening in the Agency for Healthcare Administration (AHCA) Clearinghouse
system prior to their five-year anniversary date.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 65 (Revised September 2022)
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
 The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
 All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
 Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
 The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
 A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures outlining the provision of an abuse-free environment
for both staff and youth. The policy addresses theft, workplace violence, improper conduct,
dress code, attendance, insubordination, and unethical or abuse behavior. Five youth and five
staff were interviewed on the process of allowing staff and youth to call the Florida Abuse
Hotline or the Department’s Central Communications Center (CCC) to report abuse. Each of the
five staff were able to explain the process of reporting abuse, which included who to notify and
time frames to complete the process for allegations by both staff and youth. Each staff reported
never observing a co-worker telling a youth they could not call the Florida Abuse Hotline or use
profanity towards youth. None of the five interviewed youth felt unsafe in the program. Each
youth reported staff have not stopped them from reporting abuse to the Florida Abuse Hotline or
CCC. Each youth indicated the staff are respectful when they speak to them. Two of the youth
reported they have not heard staff use curse words and two youth reported staff used curse
words occasionally; however, each youth clarified the curse words were not used towards
youth. None of youth reported having exchanged emails, telephone numbers, or social media
contact information with staff. The program had one instance of allegations of abuse against two
staff. Neither allegation indicated potential human trafficking, child sexual exploitation, or labor
trafficking. The incident was still under investigation at the time of the annual compliance review.
A review of five staff personnel records documented each signed a code of conduct upon hire.
During the facility tour, it was observed information for the Florida Abuse Hotline and CCC were
posted throughout the facility. The program is scheduled to complete their first Trauma
Responsive and Caring Environment (TRACE) self-assessment in July 2025. The facility
administrator (FA) interview stated the policy and procedures for the code of conduct, trauma-
responsive practices, contacting the Florida Abuse Hotline/CCC, completing the TRACE self-
assessment, and incident reporting.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 65 (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 outlining the process of how management responds
to allegations of physical, psychological, and emotional abuse. A review of internal incidents
found the program had one incident with two allegations of abuse against staff since the
completion of the start-up review. The incident was still under investigation at the time of the
annual compliance review. Both staff were removed from working with the youth and their
employment was subsequently terminated. A review of the internal documentation confirmed
investigations were conducted for each incident. Investigations included interviews, a review of
written documentation, and a review of video. An interview was conducted with the facility
administrator (FA) who stated the program’s policy and procedures for disciplinary actions due
to allegations of abuse and how they are to respond.
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 outlining the process of reporting incidents to the
Department’s Central Communications Center (CCC). Five staff were interviewed and each staff
was aware of the Florida Abuse Hotline number and where it is posted in the facility. The facility
administrator (FA) was interviewed and recited the programs policy and procedures on incident
reporting and contacting the Florida Abuse Hotline and the CCC. Youth are made aware of how
to report abuse allegations during orientation, in the youth handbook, and postings found on
each living module. During the annual compliance review period, the program had one internal
report verifying a report was made to the CCC. One CCC report was reviewed and was
documented in the logbook. A review of internal incident reports shows the CCC was contacted
within the two hours. There were no other internal incidents to review nor any grievances which
should have been reported.
1.06 Protective Action Response (PAR) and Physical
Satisfactory Compliance
Intervention Rate
The program uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is completed and filed in accordance with the Florida
Administrative Code.
The program had twenty-five incidents of staff utilizing Protective Actions Response (PAR)/Right
Interactions model (RI) during the annual compliance review period. Five PAR/RI Reports were
reviewed. All five reports were completed by the end of the staff member’s shift and included
statements from all staff involved. Mechanical restraints were not utilized in any of the PAR/RI
incidents. None of the reports resulted in an allegation of abuse. All five reports reflected a
review by a PAR/RI certified instructor/supervisory staff and post-PAR/RI interviews were
completed with each youth involved within thirty minutes of the incident. All five reports were
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 65 (Revised September 2022)
reviewed by the administrator or designee within seventy-two hours of the incident. None of five
reports indicated the need for a PAR/RI medical review. The program submitted all PAR/RI
incident data to the Department by the fifteenth of every month during the annual compliance
review period. The program’s PAR/RI plan was updated August 1, 2023 and approved by the
Department on August 8, 2023. The program’s PAR/RI rate during the previous quarter was
3.39 which is above the statewide Residential PAR/RI rate of 1.76. The facility administrator
(FA) cited the program’s policy and procedures for PAR/RI and stated the increase in PAR
incidents was due to being a new contract with new staff. Five pre-service training records
indicated all staff received RI training. There were no applicable in-service training records to
review. Four of five interviewed staff indicated they have had to use PAR/RI.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring.
The program has a policy and procedures outlining training for all new staff before they have
contact with youth. The program has a pre-service training plan which was submitted to the
Department’s Office of Talent, Leadership, and Culture on August 1, 2023, and approved on
August 8, 2023. All instructors of cardiopulmonary resuscitation (CPR), first-aid, automated
external defibrillator (AED), and Protective Active Response/Right Interactions model (PAR/RI)
are qualified to deliver training. Due to Department-wide system outages, it could not be
confirmed if trainings were entered in the Department’s Learning Management System
(SkillPro). A review of the program’s pre-service training plan found all five of the newly hired
staff were still within the first 180 days of employment. One of the five staff completed fifty-
seven hours of the required training with three months remaining in their 180-days, one staff
had ninety-six hours with one month remaining in their 180-days, and one staff had ninety-four
hours of training with three months remaining in their 180-days. One staff had eight-eight hours
of training with four months remaining in their 180-day requirement and the final staff had 160
hours of training with one month remaining in their 180-day requirement. Each applicable staff
completed essential skills training in CPR, first-aid, AED, PAR/RI, suicide prevention and
intervention, emergency procedures, and child abuse reporting prior to contact with youth.
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 indicating 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 in-service training plan was signed by the program on August 1, 2023, and the
Department on August 1, 2023. There were no applicable staff for in-service training due to this
being a new contract signed August 1, 2023, and the program’s start-up review occurring
October 5, 2023.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 65 (Revised September 2022)
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures outlining the grievance process. The program
reported having one grievance submitted since the start-up review in October 2023. The one
grievance was completed as required with the youth agreeing to the outcome. Five youth and
five staff were interviewed for this indicator. The staff indicated grievance forms are placed
throughout the facility, each phase has time frames, and supervisors and the facility
administrator (FA) reviews the grievances. All five youth indicated they knew the grievance
process. Each of the youth reported being able to ask for assistance with filling out the
grievance form. The FA interview stated the grievance procedures.
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 describing what type of delinquency interventions
shall be provided to the youth. A review of intervention group sign-in sheets completed at the
start-up review indicated a total of five staff facilitated various evidence-based groups. Each of
the five staff members had been considered by the program, when making the determination to
deliver delinquency intervention services, based off their education and work experience. All five
staff had training in all groups they facilitated. A review of the contract indicated the program is
required to conduct Impact of Crime (IOC), Cannabis Youth Treatment (CYT) and Aggression
Replacement Training (ART). Each of which was provided by trained therapists or case
managers. A review of the activity schedule indicated the youth are provided with structured,
planned programming or activities for at least sixty percent of their awake hours. The facility
administrator (FA) interview recited the program’s policy for delinquency interventions and listed
who facilitated groups. The designated mental health clinician authority (DMHCA) interview
indicated the program has two separate sections, one for Mental Health Overlay Services
(MHOS) and another for Substance Abuse Treatment Overlay Services (SAOS). The program
provides individual and family therapy services to all youth. Group therapy sessions are
facilitated daily and cover topics such as substance abuse, trauma, healthy relationships, coping
skills, and social skills. Evidence-based curricula provided to youth as needed include
Dialectical Behavior Therapy (DBT), Living in Balance, CYT, and ART curricula.
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 describing the types of delinquency interventions to
be provided to the youth. Education facilitates life skill and social skill groups daily during class.
The transition service manager (TSM) facilitates youth parenting/family, abuse, employment,
money management, health, insurance, licensure, driving activities, and emotions and stress
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 65 (Revised September 2022)
management. All five youth interviews indicated each youth received group sessions. The
facility administrator (FA) interview indicated all youth receive groups according to policy. The
designated mental health clinician authority (DMHCA) interview indicated the program facilitates
Anger Management for Substance Abuse and Mental Health Clients, Matrix Model for Teens
and Young Adults, 100 Activities for Mental Health Substance Abuse Recovery, The Social
Success Workbook for Teens, Group Treatment for Substance Abuse, Interactive
Journaling/Substance Using Behaviors, Life Skills Training, Thinking Feeling Behaving, Don’t
Let Emotions Run Your Life, Living in Balance, Dialectical Behavioral Therapy Skills Manual for
Adolescents, and the Teen Relationship Workbook curricula which are evidence-based, as
identified in the Department’s Sourcebook. The groups address life and social skills needs,
including communication, interpersonal relationships and interactions, non-violent conflict
resolution, anger management, and critical thinking. The program’s group schedule included all
groups which are provided as required by the program’s contract which are Aggression
Replacement Training, DBT, Living in Balance, and Cannabis Youth Treatment. A review of
group sign-in sheets for the curricula during the annual compliance review period indicated
groups were conducted as required. Documentation reviewed during the annual compliance
review week supported life skills services were held as required. The documentation included
the school schedule, recreation calendar, and group sign-in sheets.
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 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 provided opportunities to plan
and participate in reparation activities intended to restore victims and communities, such as
restitution activities and community service projects. Most recently, the youth volunteered at a
local church. 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 on
Tuesday and Friday. An interview with the facility administrator (FA) confirmed the program’s
policy and procedures for youth participation in restorative justice groups and activities. The
designated mental health clinician authority (DMHCA) confirmed youth are provided off-site
community service opportunities along with the IOC group. Five youth were interviewed and
stated they participate in various projects such as outings, cleaning up around the facility, and
helping various church groups. An observation of an IOC group confirmed the service delivery.
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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 outlining the process of entering and maintaining
internal alerts. According to the program’s policy the approved persons to update alerts are
case managers, clinicians, and the nurses. Five staff were interviewed, and each indicated they
are provided with updates of alerts during daily debriefings, the alert binder in master control,
and in the logbook. The facility administrator (FA) recited the program’s policy concerning alerts.
Three of the five reviewed youth were applicable for internal alerts. Each youth had alerts
entered into the internal alert system at the time of admission or when the alert type was
identified while they were in the program. All alerts were entered in the logbook. Due to
Department-wide system outages, a review of the Department’s Juvenile Justice Information
System (JJIS) was unable to be conducted for alerts.
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 has a policy and procedures outlining how confidential youth records, to include
health, mental health, substance abuse, and other related treatment for each youth in the
program, are to be maintained. The program separates youth records into three separate
records including Individual Healthcare Records which are maintained in the medical office,
mental health/substance abuse records which are maintained in each of the assigned
therapists’ office, and case management records which are maintained in the case management
office. All records are maintained behind a locked door in locked file cabinets within each area.
Each of the records contained a tab with the youth’s name, Department identification number,
date of birth, county of residence, and committing offense. Each of the youth records contain
sections including legal information, demographic/chronological information, correspondence,
case management/treatment team activities, and miscellaneous. All the youth records had
“confidential” on the front and were in secured offices.
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Office of Accountability and Program Support Page 16 of 65 (Revised September 2022)
1.15 Advisory Board Limited Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a policy and procedures regarding the community advisory board
expectations. The facility administrator (FA) recited the policy and procedures for advisory
boards. The program solicits members prior to scheduled meetings. The program has solicited
all required community partners except for a LGBTQIA+ community member. Several
community agencies have been contacted for membership and are pending. During the annual
compliance review period, the program had one community advisory board meeting in their first
quarter and has sent out invitations for the third quarterly meeting. The second quarterly
meeting was missed. Attendees for the first quarter meeting either participated in person or
virtually. An informal interview with one of the board members was conducted and they revealed
they were a recent member who attended the first meeting. The board member indicated they
provide mentoring services for the youth in the program. A deficiency was assigned prior to the
annual compliance review due to the program not having an advisory board meeting in the
second quarter or having identified advisory board members. During the annual compliance
review week, the program was able to retrieve the advisory board member list, invitations for the
first quarter advisory board meeting, and meeting minutes from the previous facility
administrator’s email.
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 outlining a system to evaluate staff performance. The
program conducts annual evaluations for each staff; however, the program has only been in
operation since August 1, 2023, so annual evaluations have not occurred. Five ninety-day
evaluations were reviewed and found to have been completed as outlined in policy. Five staff
indicated during interviews the communication amongst staff is either good or very good. One
staff stated evaluations are conducted annually, one stated every six months, and three said
ninety days. The facility administrator (FA) stated the program’s contract began August 1, 2023.
At the time there was an initial change in leadership which resulted in turnover at other positions
in operations, human resources, clinical, and medical. In January there was again a change in
leadership. The program has worked to develop a stronger organizational culture which
promotes professionalism and integrity. The program has hired a new FA. In efforts to minimize
negative turnover and maintain staff morale, administrative staff celebrate and reward
employees of the month. Administration routinely has staff meetings to share information and
build teamwork. Administration enjoys providing program staff coffee, drinks, and snacks as
needed. Administration enjoys feeding staff breakfast, lunch, and dinner. Administration firmly
believes they are building a positive organizational staff culture which translates to a positive
youth culture. Administration believes in training, coaching, and support as key tenants of this
process. The FA indicated during an interview they have morale committee meetings monthly.
Five job descriptions were reviewed, and the descriptions mirrored the ninety-day evaluations.
Each of the five reviewed staff had completed ninety-day evaluations for the 2023 to 2024 fiscal
year. All positions were maintained and performed as outlined in the program’s contract.
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Office of Accountability and Program Support Page 17 of 65 (Revised September 2022)
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.
An interview with the facility administrator (FA) confirmed the program’s policy and procedures
for services provided to the youth. The contract and secretary award letter memo specifies the
program shall agree to offer Aggression Replacement Training (ART), Impact of Crime (IOC),
and Cannabis Youth Treatment (CYT) as their primary services. These groups are in place and
being offered as required. The program agreed to hire a compliance officer for their Florida
contracts and committed to one of their corporate positions being on-site at this program every
two weeks for the first three months of the contract. A regional compliance officer has been
hired. A review of sign-in documentation indicated the compliance representative has been on-
site weekly. The provider agreed to establish a relationship with a local technical college with
the expectation the college will allow youth to obtain industry specific certificates to assist the
youth in obtaining employment once discharged from the program. The program contacted a
local Career Source center and been in conversation with a local technical college, with tours
being set up to gauge interest for three of our youth who are recent graduates and interested in
a trade. Five youth were interviewed, and one youth sated they are not applicable yet, and four
listed the requirements for their technical education services.
1.18 Contract Specific Career and Technical Education
Satisfactory Compliance
Services
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), Special Conditions, or older contracts may not have them clearly identified as a
special condition. Career and technical education service instruction shall be provided so the
interests, aptitudes, and skills of the youth are developed, while building upon their existing
strengths, in a manner supportive of their employability goals which provide an occupational
advantage and workforce readiness in their community. These items may exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code.
The program offers vocational certifications through online career exploration and job analysis,
ServSafe, first-aid/cardiopulmonary resuscitation (CPR), and Occupational Safety and Health
Administration (OSHA) -10 throughout the weekly school schedule. Services are provided by
certified educational staff. Reviewed documentation confirmed youth participation in career and
technical education services. Twenty-six youth received their ServSafe food handler’s
certification, thirty-two youth are enrolled in Florida Ready to Work, twenty-nine youth received
OSHA-10 certification, and twelve youth received their first-aid/CPR certification. The facility
administrator (FA) recited the program’s policy for contract specific requirements. The facility
administrator interview stated Wimauma Academy will offer career and technical education
services based on the youth’s interest inventory and any aptitudes displayed while in the
program. Wimauma Academy shall contact the Regional Workforce Board to ascertain its
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Office of Accountability and Program Support Page 18 of 65 (Revised September 2022)
services and funding opportunities for enhancing the career and technical education certification
of youth in the program or as part of their transition home. The program provides job training
activities and placement resources for youth to ensure an orderly transition into the workplace
and acceptance of work ethic. The program established a relationship with a technical college
which is part of the Hillsborough County Public School System, and will allow eligible youth to
take classes toward a number of certificates either on campus or online. Five youth were
interviewed and four of the five youth were able to list they participated or are participating in
OSHA-10, ServSafe, and first-aid/CPR. One youth stated they were not applicable.
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.
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,
which is included in the program’s practice. This information is shared during corporate staff
meetings, weekly regional staff meetings, and weekly administrator meetings. The program
administration then discusses the findings during the weekly administration meeting with
program department heads. The information includes incident reports, vacancies, physical
interventions, vocational certifications, youth and family surveys, and budget which are shared
during the weekly meeting and monthly all staff meetings. The data is then integrated into the
core practices. All Department program areas and outside contract providers which include the
designated health authority and psychiatrist who are included to discussions data specific to
their area during management meetings. The management team uses data to inform and
educate staff, providers, and stakeholders on a minimum of a quarterly basis.
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Office of Accountability and Program Support Page 19 of 65 (Revised September 2022)
Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures regarding initial contact to the parent/guardian and
court notification after each youth’s admission. Five youth case management records were
reviewed, and all contained documentation indicating the parent/guardian was contacted by
telephone and informed of each youth’s arrival and program information within twenty-four hours
of admission. Each of the five youth case management records contained written notification to
the youth’s parent/guardian within forty-eight hours of the youth’s admission to the program.
Each of the reviewed case management record contained documentation verifying the program
notified the youth’s committing court and juvenile probation officer (JPO) on the day of the
youth’s admission or within five working days of the youth’s admission to the program.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures regarding youth orientation. Five youth case
management records were reviewed. All five youth case management records indicated the
program provided each youth with an orientation within twenty-four hours of admission. The
orientation included all required elements such as services available, the daily schedule,
expectations, and responsibilities. The written behavior management system was conspicuously
posted and provided in the youth handbook, access to medical and mental health services,
access to the Florida Abuse Hotline, zero-tolerance policy regarding sexual misconduct, special
accommodations, right to be free from sexual misconduct, and items considered to be
contraband were also covered in the orientation. The orientation also included the performance
planning process involving the development of goals for each youth to achieve, dress code and
hygiene practices, procedures on visitation, mail, use of the telephone, expectations for release
from the program, community access, grievance procedures, emergency procedures, a program
tour, living unit assignment and treatment team, and medical topics as outlined in Florida
Administrative Code. The program had one youth admission scheduled during the annual
compliance review week; observations validated the program’s admission and orientation
process. Five youth were interviewed, and all youth confirmed receiving an orientation within
twenty-four hours of admission. Each youth indicated the orientation to the program included
program rules, procedures, and schedules, and each youth was able to explain the orientation
process.
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Office of Accountability and Program Support Page 20 of 65 (Revised September 2022)
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 consent for youth who are eighteen years
of age or older. The policy requires the program to obtain written consent of any eighteen-year-
old youth prior to providing or discussing any information related to the youth’s physical or
mental health screenings, assessments, or treatments with the youth’s parent/guardian. Three
of the five youth case management records reviewed were applicable for the youth being
eighteen years of age or older. Each of the three applicable case management records
contained the signed written consent of the eighteen-year-old youth on the day the youth turned
eighteen.
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 to address the classification process and
reassessment for activities. The program’s classification includes a review of physical
characteristics, age, maturity level, identified special needs including medical and mental health,
developmental, intellectual, and physical disabilities; history of violence, applicable gang
affiliation, criminal behavior, sexual aggression or vulnerability to victimization, and identified or
suspected medical, suicide, escape, or security risk. Safety and security risks are identified to
assist the staff in guiding the decision-making process determining youth’s living unit
assignments, room assignment, and the staff assigned to the youth. Five youth case
management records were reviewed. Each of the youth case management records contained
the program’s classification form and a Vulnerability to Victimization and Sexually Aggressive
Behavior (VSAB) Risk Assessment which were entered into the Department’s Juvenile Justice
Information System (JJIS) prior to each youth’s room assignment. Three of the five youth case
management records identified suspected risk factors; one youth had a medical risk, one youth
had a security risk, and three youth indicated other factors. All suspected risk factors, and/or
special needs identified during, or subsequent to the classification process are immediately
entered into the program’s internal alert system and JJIS. Reviewed documentation confirmed
reassessments for classification were completed during monthly treatment team meetings. In an
interview completed by the program’s compliance manager, they confirmed the program has a
policy and procedures regarding classification, and indicated the youth participate in an
admission classification, which includes the history, special needs, risk factors, sets of alerts,
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Office of Accountability and Program Support Page 21 of 65 (Revised September 2022)
and identified safety and security risks which will directly impact living room assignments and
group placement are reviewed.
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 policy and procedures regarding gang identification and notification of law
enforcement. Five youth case management records were reviewed, and one was applicable for
gang identification. An additional two case management records were reviewed. Each of the
three case management records were applicable for gang identification and notification to law
enforcement. Each of the three applicable youth case management records documented the
program notified local law enforcement and law enforcement in the youth’s home county. Each
of the three case management records documented law enforcement in the youth’s home
county and local law enforcement were notified. A gang alert was entered into the program’s
internal alert system and the Department’s Juvenile Justice Information System (JJIS) for each
youth. The documentation reviewed for each applicable record indicated the program notified
the local law enforcement, education provider, and the youth’s juvenile probation officer (JPO)
regarding the youth’s gang involvement.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures regarding gang prevention and intervention
strategies. The program’s policy and procedures address providing program youth an
opportunity to develop plans to disaffiliate with criminal street gangs. Five youth case
management records were reviewed, and one record was applicable for gang
affiliation/identification. Two additional case management records were requested and
reviewed. Each of the applicable case management records validated the youth were
participating in gang prevention and intervention strategies. Each of the youth’s performance
plans included relevant goals and objectives relating to gang intervention strategies. The
program utilizes the Arise: Gangs, 50+ stories of Fractured Lives intervention services
curriculum. A review of the sign-in sheets for the annual compliance review period indicated
each of the applicable youth were participating in monthly gang groups as designated.
Additionally, the program provides Impact of Crime (IOC) curriculum, to bring gang prevention
and awareness to each youth in the program. In an interview completed by the program’s
compliance manager, they confirmed the program has a policy and procedures which address
gang prevention and interventions. Additionally, the compliance manager indicated the program
provides gang prevention and intervention strategies when youth are identified as being a
criminal street gang member, are affiliated with any criminal street gang, or are at high risk of
gang involvement. Identification of youth to participate in gang prevention or intervention
activities shall be based on information obtained through the program’s screening, assessment,
and classification processes, as well as gang-associated behaviors exhibited, or the youth’s
expressed interest, or intent while in the program.
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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 to address the completion of the Residential
Assessment for Youth (RAY) and reassessments. The policy requires the completion of an
initial RAY within thirty days of admission to the program, the completion of a reassessment at
least ninety days after completion of the initial RAY, and reassessments being conducted at
least every ninety days after each subsequent reassessment. Five youth case management
records were reviewed, and each of the five case management records were applicable for
RAYs and four case management records were applicable for reassessments; one youth was
not applicable, as the youth had not reached the ninety-day time frame. Each of the five
applicable case management records documented the initial RAY was completed within thirty
days of admission. Each of the four applicable case management records had a RAY
Reassessment completed. All of the applicable youth’s reassessments were completed meeting
the required time frame. All RAYs and RAY Reassessments were completed in the
Department’s Juvenile Justice Information System (JJIS) and documented in each youth’s case
management record.
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in JJIS on the YNAS.
The program has a policy and procedures to address the completion of a Youth Needs
Assessment Summary (YNAS) which require the completion of the YNAS within thirty days of
admission. Five youth case management records were reviewed, and all youth case
management records were applicable. Each of the five case management records contained a
YNAS which was completed within thirty days of the youth’s admission to the program. Each
YNAS was documented in the Department’s Juvenile Justice Information System (JJIS).
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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 to address the development of the performance plan,
goals, and transmittal. The treatment teams are required to develop an Individualized
Performance Plan within thirty days of the youth’s admission to the program. Five youth case
management records were reviewed, and all five case management records were applicable.
Each of the case management records contained a performance plan for each youth and were
all completed by the program within thirty days of the youth’s admission. All the performance
plans were developed after the initial Residential Assessment for Youth (RAY). Each
performance plan was developed by the treatment team and all relevant members participated
during the development, including parents/guardians, each youth, administrative representative,
living unit representative, treatment staff, educational staff, and/or the Department of Children
and Families (DCF) counselor. The goals were individualized and based on prioritized needs
reflecting the risk and protective factors identified during the initial assessment. All performance
plans contained target dates for completion of goals, youth responsibility to accomplish goals,
and the program’s responsibilities to assist the youth to achieve the goals. Each of the five
youth’s initial performance plans referenced the court-ordered sanctions reasonably able to be
completed in the program. Each of the youth’s initial performance plans referenced the specific
delinquency interventions based on the RAY results. Each of the performance plans included
transition goals for the youth to complete prior to release from the program, the top three
criminogenic needs to be addressed, and were signed by the youth, treatment team leader, and
all parties who had significant responsibilities in goal completion. All of the youth case
management records documented a transmittal letter and copy of the performance plan were
sent to the committing court, juvenile probation officer (JPO), and parent/guardian within ten
working days of the plan being completed. Each of the performance plans were mailed to each
parent/guardian with request to sign and return; however, there were no signed parent/guardian
signature pages returned. Documentation reviewed for the one applicable youth in the care of
the DCF indicated the performance plan was sent to the DCF caseworker. Five youth were
interviewed, and each youth reported they were aware of their current performance plan goals
and each youth indicated they had a copy of their performance plan. Each of the youth reported
they participated in the development of their performance plan.
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 Individualized Performance
Plans, when determined necessary by the intervention and treatment team. The policy requires
revisions when new criminogenic needs are identified during the Residential Assessment for
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Youth (RAY) Reassessments, when the youth demonstrate progress or lack of progress toward
completing a goal, or when new information is acquired or revealed. Five youth case
management records were reviewed. Each of the five case management records reviewed were
applicable and contained a performance plan with revisions due to newly acquired information,
the youth’s progress towards completing goals, and/or lack of progress toward goal completion.
One youth record was not applicable for a RAY Reassessment because the youth was not in
the program for ninety days. One youth record contained performance plan with revisions to
facilitate transition activities during the last sixty days of 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 the requirements for completion of
Performance Summaries every ninety days. Performance summaries are due within ninety days
of the signing of the youth’s performance plan, or earlier, if requested by the committing court.
The policy further requires the treatment team to prepare a Performance Summary prior to the
youth’s release, discharge, or transfer from the program. The Performance Summary provides
information to the youth, parent/guardian, juvenile probation officer (JPO), and other parties
related to the status of each performance goal and describes the youth’s overall adjustment to
and performance in the program. Five youth case management records were reviewed and
each was applicable for the completion of at least one Performance Summary and transmittal.
Each of the reviewed summaries were completed within ninety days of the performance plan.
Each of the five reviewed summaries contained all the elements required including the youth’s
status on each goal, treatment progress, academic status, behavior, level of
motivation/readiness to change, interaction with peers, interaction with staff, adjustment to the
program, and positive/negative events. Each youth was given the opportunity to read and add
comments to their Performance Summaries. Each of the youth’s case management records
contained a signed form by the youth which stated the youth was provided a copy of their
Performance Summary. Each of the reviewed summaries were signed by the applicable
treatment team members, including the youth. Each of the applicable reviewed summaries were
filed in the youth’s case management record and were sent to the committing court, JPO, and
parent/guardian within ten working days of completion. Three applicable youth case
management records were reviewed for release summaries. Each of the reviewed case
management records contained a copy of the original summary sent at least forty-five days prior
to the youth’s anticipated release date, along with the Pre-Release Notification (PRN) to the
JPO. Each summary contained the justification for release. Each of the closed youth case
management records documented the program provided written notification to the
parent/guardian of the approval for release. All of the closed case management records retained
a signed copy of the Performance Summary. The program provided the Performance Summary
and transition plan to the JPO. The program’s policy is to complete an Exit Residential
Assessment for Youth (RAY) for the exit assessment which is then placed in each record;
however, due to Department-wide system outages, the Department’s Juvenile Justice
Information System (JJIS) was not available during the annual compliance review week. None
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of the youth were applicable for the Sexually Violent Predator Program (SVPP). Two of the
three closed youth records contained a waived victim notification and one record did not apply.
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 to address the inclusion of parents/guardians in the
case management process. Five youth case management records were reviewed. Each record
documented the case manager sent an admission letter to the parent/guardian, which included
the dates/times for treatment team meetings. Each case management record contained
documentation to show the parent/guardian was involved in the assessment process and
participated in the development of the performance plan. A copy of the performance plan was
mailed to each parent/guardian with a request to sign and return the signature page. There was
documentation to show the parent/guardian was called for each treatment team meeting. A
treatment team meeting was observed during the annual compliance review week. All
participants were observed to be present and actively participating; additionally, case
management contacted the parent/guardian of the youth as well as the youth’s JPO, and all
were able to participate in the treatment team meeting along with all other required staff. The
youth’s status, goals, and progress were discussed in the meeting. Five interviewed youth
reported their parent/guardian was involved with the youth’s case management activities. An
interview completed with the program's compliance manager confirmed the program has a
policy and procedures regarding parent/guardian involvement. The program encourages and
facilitates involvement with the youth's parent/guardian during the case management process.
Additionally, case management shall make every effort to include the parent/guardian to
participate in the youth's assessments, performance plan development, progress reviews, and
transition planning.
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 ensure academic plans, treatment plans,
and Department of Children and Families (DCF) plans, if applicable, are included in the
performance plan. Five youth case management records were reviewed. Each record contained
a performance plan. Each youth’s academic plans, mental health and substance abuse
treatment plans, and wellness plan were referenced in the performance plans. Each of the case
management records were reviewed, and none were applicable for incorporation of other plans.
An informal interview with the program’s compliance manager indicated the program does not
currently have any youth requiring the incorporation of other plans.
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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 to address the provision of intervention and
treatment teams to ensure representatives from the program’s administration and residential
living unit, education, and others responsible for overseeing the provision of intervention and
treatment services are included in the treatment team meetings. The treatment teams are
required to meet every thirty days to formally review each youth’s performance, to include
Residential Assessment for Youth (RAY) Reassessment results, progress on Individualized
Performance Plan goals, and positive and negative behavior, including behavior which resulted
in physical interventions. The policy requires the case manager to conduct informal reviews of
each youth’s performance bi-weekly each month. The case manager meets with the youth
during informal reviews and incorporates input from treatment team members, as needed.
The program’s treatment team members consist of the case manager/treatment team leader,
youth, and representatives from program administration, education, the youth’s living unit,
mental health treatment, education, and medical. The youth’s parent/guardian or the
Department of Children and Families (DCF) case worker, the transition case manager, and the
juvenile probation officer (JPO) are included as part of the treatment team, when applicable.
Five youth case management records were reviewed. Each of the case management records
documented formal treatment team reviews were held at least every thirty days. Treatment team
documentation included the youth’s name, date of review, comments from treatment team
members, progress in the program, progress of goals, behaviors, skills, treatment progress, and
RAY Reassessment results. All five case management records had documentation showing
informal reviews were conducted bi-weekly, with exception of one youth, which was missing an
informal treatment team for the month of January 2024. Documentation of informal reviews
included the youth’s name, date of review, comments from treatment team members, progress
in the program, progress of goals, behaviors, skills, RAY Reassessment results, and treatment
progress. Each of the reviewed case management records documented the notification to the
required participants of the treatment team meetings and who attended. If the parent/guardian
and/or JPO did not participate in the treatment team meeting, there was documentation to show
attempts to contact the parent/guardian and JPO. All forms contained signatures from required
team members. All formal and informal treatment team documentation was contained in each
youth’s case management record. During the annual compliance review week, a treatment team
meeting was observed, and observations confirmed all required participants were present at the
meeting. Five interviewed youth reported staff review youth’s performance on the performance
plan, goals, behavior, and treatment progress. Each youth indicated they felt they can
demonstrate the skills learned in the program and were able to articulate their involvement
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 addressing transition planning, conferences, and
Community Re-Entry Team (CRT) meetings. Three closed youth case management records
were reviewed and a transition conference for each youth was held at least sixty days prior to
the targeted release date. All required and applicable treatment team members including the
youth, treatment team leader, and the facility administrator (FA), or designee attended the
transition conference in each of the reviewed youth case management records. Each reviewed
record documented the youth’s juvenile probation officer (JPO), parent/guardian, education
staff, and any other pertinent parties were invited to attend the transition conference and all
required parties participated either in person or by telephone. None of the youth reviewed were
applicable for human trafficking services. Each transition conference included a review of
transition activities on the youth’s performance plan, targeted completion dates, persons
responsible for completion, and other pertinent transition activities. Reviewed documentation
validated the treatment team leader obtained attendees’ dated signatures representing their
acknowledgement of the transition goals and accountability for completion. A copy of each plan
was mailed with a request for return with signature to the parent/guardian and JPO. Reviewed
documentation confirmed a copy of the plan was transmitted electronically to the JPO and a
return email acknowledgement receipt was printed and filed with the plan. Each record
confirmed the CRT meeting was conducted prior to the youth’s release and both the youth and
case manager participated in the CRT meeting.
2.16 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures addressing the assembly of an exit portfolio to assist
each youth once they are released back into the community. Three closed youth case
management records were reviewed and the Exit Portfolio for each youth was initiated and
discussed during the transition conference. Reviewed documentation revealed the applicable
exit portfolios included a copy of the transition plan, calendar with all dates, times, and locations
of upcoming community appointments, educational, or vocational certificates, educational
record, school transcripts, résumé, and sample employment applications. Two youth’s closed
case management record did not contain a state identification card, birth certificate, or Social
Security card due to their age. One youth’s closed case management record did not have a
Social Security card, state issued identification, or birth certificate due to the parents/guardian
failing to provide the required documents to obtain them. Reviewed documentation for each
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record validated the youth’s exit portfolio was verified during the exit conference and the exit
portfolio was given to the youth upon release. Each record indicated the exit portfolio was
provided to the youth’s juvenile probation officer (JPO). Each of the youth case management
records reviewed were not applicable for secure maximum risk youth.
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 policy and procedures regarding an exit conference for each youth to review
the status of goals developed at the transition conference and to finalize the release plan. Three
closed youth case management records were reviewed and the exit conference for each youth
was conducted after the program notified the juvenile probation officer (JPO) of the release and
at least fourteen days prior to the youth’s release. Each exit conference included a summary of
pending transition goals, date of the conference, and signatures of all applicable participants.
Due to Department-wide system outages, the Department’s Juvenile Justice Information System
(JJIS) could not be accessed to confirm the date of admission and date of termination
documented in the case management record for each youth. Reviewed documentation for each
record validated the status of transition activities established at the transition conference were
reviewed and updated during the exit conference. For each reviewed record, all required and
applicable members participated in the exit conference. Reviewed documentation confirmed
each exit conference was held separately from the transition and Community Re-Entry Team
(CRT) 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 procedure in place to promote constructive input by youth. The
program has the grievance process, request to talk “411” forms, youth surveys, youth advisory
council, and Trauma Responsive and Caring Environment (TRACE) assessments. The forms
are maintained in the youth dormitories and cafeteria along with the forms drop box. Youth can
submit the form when seeking a discussion with a staff or when requesting any needed item.
Observations during the annual compliance week confirmed the forms were located in the youth
dormitories and in the program’s cafeteria. The program’s youth advisory board meetings are
held weekly and are facilitated by the recreational therapist and facility administrator (FA) and/or
designee. The meetings Include a discussion of program issues and youth are given an
opportunity to speak of any issues. Reviewed documentation validated the program’s practice.
The program’s TRACE surveys capture information they may have concerning staffing,
programmatic issues, and food at the program. An informal interview with the program’s vice
president confirmed surveys are completed annually; however, at the time of the annual
compliance review, the TRACE survey was not available as they are completed in July. Results
are passed to program administration for review. Documentation for youth surveys and the
grievance process were reviewed during the annual compliance review week which validated
the programs practice. Five youth were interviewed, each youth confirmed they can provide
youth input at the program and each youth was able to explain how they provide their input. The
FA, indicated the program has a formal process to promote youth input and staff proactively
engage youth in order to solicit feedback and input.
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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. Educational services
are provided through Wayne Halfway House. The program provides vocational competency
development programs to all youth. The facility administrator (FA) interview indicated Wimauma
Academy must define career education programming which is appropriate based upon the age,
assessed educational abilities and goals of the youth to be served, the typical length of stay,
and custody characteristics at the program to which each youth is assigned. According to the
interview with the lead teacher, youth are enrolled in an online career exploration and job
analysis site. Youth receive ServSafe, and Occupational Safety and Health Administration
(OSHA) -10 certifications upon completion of the course, and the program provides
employability skills training to youth. The youth also work on résumés, sample applications, and
connecting youth to an outside service provider. Three closed youth case management records
were reviewed, and one of the three included sample completed employment applications, a
résumé, and a State of Florida identification (ID) card. Two of the three youth had a résumé,
sample applications, and the transition service manager (TSM) requested vital information to
obtain the youth’s ID but it was not received before discharge. The local Career Source
information was present in all three of the case management records reviewed.
2.20 Educational Access (Critical) Limited Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a policy and procedures to provide for educational access. The program
integrates education into the daily schedule in such a way as to ensure the integrity of the
required minimum instruction time distributed over a twelve-month period. The district approved
calendar and daily school schedule were reviewed, which incorporated the required 250 days of
instruction, with ten days used for teacher planning, and a minimum of twenty-five hours of
instruction weekly. Youth are enrolled in academic courses through Wayne Halfway House and
receive credit, as appropriate, when courses are completed. In a review of the youth interviews,
one said there are interruptions throughout the school day and four said there are not. Youth
comments include only for treatment team, and therapy, and treatment team meetings. A
sample of three videos and six logbook reviews showed youth are being released on average of
ten minutes early each day, which falls short of the required twenty-five hours of instruction a
week.
2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The program has a policy and procedures to provide for an educational transition plan. Three
closed youth case management records were reviewed, and all three had an education
transition plan developed upon entry based on each youth’s post-release goals. All key
personnel related to transition activities were included, and the plans were developed with the
youth, parents/guardians, program, education, and aftercare staff involved. The transition plans
placed specific monitoring responsibilities on individuals responsible for the reintegration and
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coordination of the provision of support services upon the youth’s release, and the youth’s case
manager and parent/guardian were aware of the plan. All five interviewed youth indicated they
were involved in the development of their education transition plans. When asked how well the
youth thought the program was preparing them for a high school equivalency diploma (GED),
high school, vocational school, employment, and/or college, three youth responded they were
being very well; two stated they were well prepared.
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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 maintains a policy and procedures ensuring a State of Florida licensed clinician
will serve as the designated mental health clinician authority (DMHCA), and will be responsible
for providing the coordination, and implementation of mental health, and substance abuse
service delivery. The program has a licensed mental health counselor (LMHC), who serves as
the DMHCA. The DMHCA has a clear and active license which expires on March 31, 2025.
Documentation showed the current DMHCA was on-site for forty hours a week and on call
twenty-four hours a day or as needed as contractually required. The program provided the
license and agreement for review. The program has a back-up DMHCA. The back-up DMHCA
has a clear and active license with an expiration date of May 31, 2025. The DMHCA was
interviewed and reported the role of the DMHCA is oversight of the mental health and substance
abuse services.
3.02 Licensed Mental Health and Substance Abuse Clinical
Failed 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 is contractually required to have two full-time licensed therapists; one acting as the
designated mental health clinician authority (DMHCA). The program had the DMHCA position
filled but has not had a second licensed therapist since November 2023.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The designated mental health clinician authority (DMHCA) provides direct supervision for non-
licensed staff. The DMHCA assures the non-licensed clinical staff working under their
supervision are performing services they are qualified to provide based on education, training,
and experience. At the time of the annual compliance review, the program was fully staffed with
two non-licensed, master’s-level mental health staff working under a full-time DMHCA.
Documentation supported both non-licensed therapists received a minimum of one hour a week
of on-site, face-to-face direct supervision by the DMHCA for the purpose of overseeing and
directing the mental health services provided in the program during the annual compliance
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review period. All supervision meeting minutes were recorded on the Department’s Licensed
Mental Health Professionals and Licensed Substance Abuse Professionals Direct Supervision
Log form. Both non-licensed therapists provide substance abuse services in the program. The
service provider is licensed under Chapter 397 and the therapists are working under direct
supervision of a qualified professional. The Chapter 397 license expires October 16, 2024. One
of two therapist completed twenty hours of training for Assessments of Suicide Risk (ASRs).
The therapists were also trained in assessing suicide risk, mental health crisis intervention, and
emergency mental health services. The training included the administration of five ASRs or
Crisis Assessments completed on-site in the physical presence of a licensed mental health
professional and documented on the Non-Licensed Mental Health Clinical Staff Person’s
Training in Assessment of Suicide Risk form. The program has a recreational therapist who has
a bachelor’s degree with at least one year of experience working with youth.
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 for the implementation of a standardized
admission/intake mental health and substance abuse screening process. The policy and
procedures were reviewed and included a standardized screening process which includes a
review of commitment packet information, reports, and records, administration of the
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) in the Department’s
Juvenile Justice Information System (JJIS), clinical mental health screening by a licensed
mental health professional, Clinical Substance Abuse Screening by a qualified professional, and
referral of juvenile offenders identified by screenings as in need of further evaluation or
immediate attention. The policy and procedures included staff training in mental health and
substance issues, administration of the MAYSI-2, and a standardized process for referral of
youth identified in need of further mental health or substance abuse evaluation to an appropriate
service provider/professional, or when immediate attention is needed to a hospital, Baker Act, or
Marchman Act receiving facility. Five youth mental health and substance abuse records were
reviewed for a mental health and substance abuse screening. All five youth had a MAYSI-2
completed upon admission. All available information was reviewed, which included the
commitment packet, reports, and records for existing documentation of mental health,
substance abuse problems, or history of human trafficking. The five MAYSI-2 screenings were
completed on the date of each youth’s admission to the program in a confidential manner. Due
to Department-wide system outages, the annual compliance review team was unable to access
the Department’s Learning Management System (SkillPro) to verify appropriate MAYSI-2
training was completed. The program indicated they did not have printed copies of the
completed trainings. The designated mental health clinician authority (DMHCA) reviewed all
MAYSI-2 screenings and indicated if the youth needed further assessments or a referral. Four
of five screenings indicated further assessment was required. Staff determined each of the four
youth were assessed to have either a mental health need, substance abuse problem, or was a
suicide risk. MAYSI-2 dates for two youth listed the incorrect year in error. The mental health
service referral dates were used to confirm the correct dates. In four of five mental health and
substance abuse records reviewed, a referral for further evaluation was generated. All five youth
received an Assessment of Suicide Risk (ASR) and were subsequently referred for assessment.
All five ASRs were conducted within twenty-four hours of the referral. The facility administrator
(FA) and DMHCA signed off on all five youth ASRs. All five youth mental health and substance
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abuse records reviewed had an ASR, comprehensive evaluation, and the reason for referral
was documented. The staff who made the referral documented a consultation with the DMHCA
on the mental health substance abuse referral summary. The facility administrator (FA) was
interviewed and reported the youth are screened using the MAYSI-2 and ASR.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program maintains a policy and procedures to address the provision of mental health and
substance abuse assessments/evaluations. Five youth mental health and substance abuse
records were reviewed for mental health and substance abuse assessments and evaluations.
All five youth mental health records included documentation the program completed a new
combined mental health and substance abuse evaluation. All evaluations were completed within
thirty calendar days of admission. If a non-licensed mental health clinical staff or non-licensed
substance abuse clinical staff completed the evaluation, it was reviewed and signed by a
licensed mental health professional within ten calendar days after the evaluation was
conducted. The comprehensive evaluation included the required information in all five mental
health and substance abuse records. All five youth mental health and substance abuse records
included a consent form obtained for substance abuse services. All five substance abuse
evaluations were completed within thirty calendar days of admission. All five mental health and
substance abuse records included documentation which included the reason for assessment,
relevant background information, behavioral observations, methods of assessment, patterns,
impact of alcohol and drug abuse, risk factors of continued alcohol and other drug abuse,
clinical impression, original referral reason, and recommendations. None of the youth required
an updated comprehensive evaluation.
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 in place outlining the program’s mental health and
substance abuse services. Five youth mental health and substance abuse records were
reviewed for mental health and substance abuse treatment. All five youth mental health and
substance abuse records included documentation an initial treatment plan was developed within
seven days of initiation of treatment. All five initial mental health treatment plans were
documented on a form which included all elements of the Department’s Mental
Health/Substance Abuse Treatment Plan form. The initial treatment plan was signed by the
mental health clinical or substance abuse clinical staff. All five mental health and substance
abuse records included documentation the initial treatment plan was completed by a licensed
mental health clinical staff. All five treatment plans were signed by all treatment team members
who participated in the development of the plan, each youth, and parent/guardian. All five
treatment plans were mailed to the parents/guardians the day the plans were signed by the
treatment team. An initial treatment plan was developed within seven days of initiation of
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treatment for all five youth. All five individualized treatment plans were developed for each youth
within thirty days of admission. All treatment plans were developed on forms which contained all
elements of the Department’s Individualized Mental Health/Substance Abuse Treatment Plan
form. Four of five mental health and substance abuse records included documentation of the
treatment team reviews being conducted every thirty days; one youth had one completed three
days late. All five treatment plans included documentation of the prescribed services, to include
individual, group, family, and psychiatric services. All services were individualized for each
youth. A review of three days of video and group sign-in sheets for fourteen groups during the
annual compliance review period indicated all groups were conducted for a minimum of fifty
minutes each, during the time as designated on the group schedule, with no more than ten
youth present, and by a qualified facilitator.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
The program has a policy and procedures addressing treatment and discharge planning.
Five reviewed youth were assigned to a multidisciplinary treatment team within thirty days of
each youth’s admission to the program. Five youth mental health and substance abuse records
were reviewed for treatment and discharge planning. All five youth mental health and substance
abuse records included documentation each youth was assigned to a treatment team upon
arrival to the program. Documentation revealed the treatment team was comprised of the youth,
program administration, residential living unit, education, medical staff, mental health staff,
substance abuse staff, and parents/guardians. All five youth mental health and substance abuse
records included documentation each youth received individual, group, and/or family counseling
provided by a licensed qualified professional, or a non-licensed professional under the direct
supervision of a licensed professional for substance abuse treatment. All five youth mental
health and substance abuse records included documentation an Authority for Evaluation and
Treatment (AET) form was properly executed. All five youth mental health and substance abuse
records included documentation of a signed Youth Consent for Substance Abuse Treatment
Records form. All mental health treatment notes or substance abuse treatment notes were
documented on a form which contains the Department’s Counseling/Therapy Progress Notes
information. All five youth mental health and substance abuse records included documentation
each youth received individual psychotherapy or counseling and psychosocial skills training. All
five treatment plans included the frequency of prescribed services for each youth to include
individual, group, and family sessions. A review of progress notes revealed each youth received
services as stipulated on the treatment plan. The five chosen mental health and substance
abuse records for review were not applicable for discharge planning. The program provided
three closed mental health and substance abuse records for review. All three mental health and
substance abuse records included documentation the discharge plan was completed on the
Department’s Mental Health/Substance Abuse Treatment Discharge Summary form. All three
discharge summaries included the services needed for daily maintenance of the positive
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improvement in behavioral, emotional, and social skills made by each youth during treatment.
The reviewed documentation reflected the discharge plan was discussed with each youth,
parent/guardian, and juvenile probation officer (JPO) during the exit conference. A copy of the
discharge summary was also provided to each youth, JPO, and parent/guardian.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program maintains a policy and procedures to establish a delivery protocol for Substance
Abuse Treatment Overlay Services (SAOS) programming and Mental Health Overlay Services
(MHOS). Substance abuse and mental health treatment are provided on-site through the
provision of SAOS/MHOS. The focus of substance abuse and mental health treatment is to
target and reduce/alleviate the youth’s symptoms of substance related disorder, and/or mental
disorder to improve youth functioning within the program, and ultimately the community. The
program provides SAOS and MHOS services through group therapy, individual therapy, family
therapy, and psychiatric services. Ancillary services shall be provided directly or through referral
in instances where the youth require certain services which may not be provided by the
program. The policy indicated therapy models utilized include Cannabis Youth Treatment,
Aggression Replacement Training, Living in Balance, and Dialectical Behavioral Therapy Skills
Manual for Adolescents. The program does not provide urinalysis drug testing. Non-clinical
groups provided are Impact of Crime and Teen Relationship Workbook. Five interviewed youth
reported participating in individual, group, and family therapy services at the program. Five
interviewed staff reported only mental health clinicians facilitate mental health and substance
abuse groups. The designated mental health clinician authority confirmed services included
SAOS, MHOS, crisis intervention, suicide assessment, and intervention services. The program
provides group services five times each week based on the services prescribed to youth
through their treatment plans. Program youth with co-occurring disorders are provided both
mental health and substance abuse treatment. Caseload sizes were reviewed and reflected the
average caseload for each program therapist was between eight and ten youth, which is below
the contractual maximum of sixteen youth. The reviewed sign-in sheets verified mental health
groups consisted of ten or fewer participants and substance abuse groups consisted of fifteen or
fewer participants. The program has a Chapter 397 license through the Department of Children
and Families to provide substance abuse treatment services to adolescents. All mental health
clinicians working at the program were qualified to provide substance abuse treatment and
education services. A review of psychiatric logs confirmed the psychiatrist was available and
provided services from October to December 11, 2023. According to the vice president of
programming, the psychiatrist departed, and the back-up psychiatrist assisted, until the new
psychiatrist began and services were provided from December 11, 2023, to April 11, 2024. Sign
in psychiatric logs confirmed services were provided as according to the contract requirement.
The program has an agreement with a psychiatrist which requires psychiatric services to be
provided in the facility at least once every two weeks, with no more than fourteen days between
visits, to provide psychiatric evaluations medication management services, and participate in
treatment team meetings and family sessions (when possible). Psychiatric services providers
must be available twenty-four hours a day, seven days a week for emergency consultation
services.
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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 to address the psychiatric services provided to the youth. The
program provides psychiatric services to the youth who require this service. The psychiatrist has
a clear and active license. The psychiatrist is available for emergency consultation twenty-four
hours a day, seven days a week. The psychiatrist briefed a representative of the treatment team
regarding the status of each youth receiving psychiatric services. A review of the sign-in/out logs
confirmed the visit by the psychiatrist dated November 2, 2023 was three days late after the
required fourteen days. A review of the sign-in/out logs also confirmed the back-up psychiatrist
provided services on December 27, 2023, which was two days late after the contractual
requirement of fourteen days. The psychiatrist did participate in, manage, and supervise
psychotropic medication services in the program. Three youth mental health and substance
abuse records were reviewed for psychiatric services. All three youth received an Initial
Diagnostic Psychiatric Interview. All three youth were applicable for psychiatric services. Two of
three youth were admitted on psychotropic medications. One youth started taking psychotropic
medications after admission. Two of three youth received a diagnostic interview within fourteen
days of admission. The initial diagnostic interview included the medical, mental health, and
substance abuse history, Mental Status Examination, and the Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition (DSM-V) diagnosis. All three youth diagnoses were consistent
with each youth’s treatment plan and treatment recommendations. The three youth were taking
prescribed medications, and their initial interview included the need for the medications, target
symptoms, initial treatment goals, potential side effects, risks and benefits of taking the
medication, and frequency of medication monitoring and management. The initial diagnostic
psychiatric interview was documented on a form which contains all required information based
upon the Department’s Clinical Psychotropic Progress Note (CPPN). The psychiatrist and/or the
psychiatric APRN’s evaluation and recommendations for each youth were incorporated into the
mental health clinical staff’s evaluations and the treatment plans. The CPPN was completed on
the Department’s CPPN form. All three youth receiving psychotropic medications did receive
medication reviews as required. The psychiatrist reported they provide the initial psychiatric
evaluations, prescribe medications, and monitor youth taking psychotropic medications every
thirty days. The psychiatrist also reported being available by phone twenty-four hours a day,
seven days a week for emergencies. The designated mental health clinician authority was
interviewed and reported they meet with the psychiatrist bi-weekly for a psychiatric treatment
team meeting.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a written suicide prevention plan which includes identification and assessment
of youth at risk of suicide, staff training, suicide precautions, levels of supervision, referral,
communication, notification, documentation, immediate staff response, and a review process.
The review process includes circumstances surrounding the event, facility procedures relevant
to the incident, all relevant training received by involved staff, pertinent medical and mental
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health services involving the victim, possible precipitating factors, and recommendations. The
plan was reviewed by the facility administrator (FA) on August 1, 2023.
3.11 Suicide Prevention Services (Critical) Satisfactory Compliance
Suicide precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors.
Any youth exhibiting suicide risk behaviors shall be placed on suicide precautions
(precautionary observation or secure observation), and a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations shall be placed on suicide precautions and receive an
Assessment of Suicide Risk.
A review of five youth mental health and substance abuse records indicated each youth was
determined at admission to be at risk of suicide. The program’s process is to complete an
Assessment of Suicide Risk (ASR) for each youth during the admission process. During the
annual compliance review period, the program did not have any youth who received an ASR,
other than during the admission process and no Follow-Up ASRs were completed; therefore, no
observations of precautionary observation could be conducted. Each of the five youth were
referred for an ASR on the day of admission and each ASR was completed on the same day. All
five ASRs were conducted on the Department form and each youth was placed on standard
supervision. Each record had documentation of a conference held by the facility administrator
(FA) and licensed mental health professional to reduce the level of supervision. Two ASRs were
completed by a licensed therapist and three by a clinical staff under the supervision of a
licensed therapist. The three ASRs were reviewed and signed by a licensed therapist within
twenty-four hours, and the non-licensed clinical staff conferred with both the licensed therapist
and the FA/designee, which was documented on each ASR, including the date and time. Due to
Department-wide system outages, the Department’s Juvenile Justice Information System (JJIS)
was down; therefore, JJIS suicide alerts could not be verified. A review of the program’s internal
alerts found no youth to be on suicide precautions. The program does not utilize secure
observation. All five staff interviews indicated if a youth expresses suicidal thoughts, direct care
staff are responsible for notifying mental health. One staff stated to search the youth and room
for sharp objects, separate the youth from others, and talk to them. Two said put the youth on
constant sight and sound and notify the supervisor. Three stated document supervision.
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.
Five youth mental health and substance abuse records were reviewed and two were applicable
for suicide services subsequent to admission. One additional youth record was provided by the
program and reviewed for suicide prevention services. A review of the program's Suicide
Precaution Observation Logs found each youth was placed on precautionary observation (PO)
due to an elevated risk in suicide and the logs were appropriately utilized for the duration each
youth was on suicide precautions. A review of the three applicable youth mental health and
substance abuse records who were placed on PO found the program utilized the Department's
Suicide Precautions Observation Log form. All three youth mental health and substance abuse
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records reflected each youth received the appropriate level of supervision with documentation of
their behaviors. Two of three Suicide Precautions Observation Logs were reviewed and signed
by each shift supervisor and mental health clinician, one was missing the shift supervisor’s
signature. Each reviewed log did not exceed the thirty-minute intervals and were documented in
real time. Safe housing areas of the program were clearly identified on each youth's log.
Documentation showed each youth was appropriately placed on standard supervision after an
ASR was completed.
3.13 Suicide Prevention Training (Critical) Limited 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.
Due to Department-wide system outages, the Department’s Learning Management System
could not be reviewed; therefore, staff training could not be verified. All five program staff did
receive the internal mental health and substance abuse training as documented on the staff
individual training plans. The program had two suicide response kits, one in master control and
one in the clinic, co-located with first-aid kits. The program completed one of three drills during
the annual compliance review period. The program operated on two shifts and two quarters
were reviewed. The mock mental health drills conducted were in response to a simulated
suicide attempt and/or incident of serious self-injury and none of the youth were utilized during
the simulation. The program did provide semi-annual training on emergency response
procedures and provided staff who were not present during a quarterly drill the opportunity to
review each drill scenario and procedures. The facility administrator (FA) interview reiterated the
program’s policy and indicated the program provides training or mock suicide drills for staff,
including emergency response to suicide attempts or self-inflicted injury. All five staff interviews
indicated the program has two suicide response kits, one each in master control and in the
clinic. Three staff stated medical emergency and suicide drills are conducted on each shift
monthly, one said medical drills are done monthly and suicide drills quarterly, and one staff also
stated drills are done two times a month.
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a written crisis intervention plan which includes a notification and alert system,
means of referral including youth self-referral, communication, supervision, documentation, and
review.
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3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a policy and procedures addressing Crisis Assessment and utilizes the
Department’s form. During the annual compliance review period the program did not have any
Crisis Assessments completed.
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 abuse plan which includes
immediate staff response, notifications, communication, supervision, documentation, training,
review, authorization to transport for emergency mental health or substance abuse services, as
well as transport for emergency mental health evaluation and treatment and substance abuse
assessment and treatment.
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 maintains a policy and procedures to address the safety planning process for
each youth. A review of five youth mental health and substance abuse records was conducted
in reference to a safety planning process for each youth. Reviewed documentation found the
program has developed a safety plan form which identifies stimuli to include positive and
negative effects on the youth. The program’s safety plan form included an initial and a review
planning process. The initial planning process is initiated by each youth’s therapist within
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fourteen days of the youth’s admission to the program. The safety plans are jointly prepared by
the youth, parent/guardian or family member, case manager, and clinical staff. The plans are
reviewed and signed by all staff involved in the development of the plan and each youth.
Thereafter, each youth’s safety plan is reviewed and updated every thirty-days to include dated
signatures of the youth and staff. The program’s safety plan form included the youth’s warning
signs, baseline behaviors gathered from collateral contacts, crisis recognition, jointly developed
coping strategies, intervention strategies, and debriefing preferences. All five youth safety plans
incorporated recommendations of previous and current clinical assessments, as required. All
five youth safety plans were updated every thirty days and documented any significant
behavioral or mental health event identified by each youth’s intervention and treatment team.
The youth safety plans were maintained in each youth’s mental health and substance abuse
records and within a centralized binder inside master control, easily accessible by all staff. All
five interviewed youth said they contributed in the development of their safety plan. An interview
with five staff indicated they were aware of the process for reviewing each youth safety plan and
they were reviewed as needed.
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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 has a policy and procedures stating the designated health authority (DHA) shall be
clinically responsible for the medical care of all youth at the program. The designated health
authority (DHA) is a licensed physician, who holds an unrestricted license and meets all
requirements for independent and unsupervised practice in Florida. The DHA’s license expires
on January 31, 2025. The DHA’s specialty training is in pediatrics. The DHA does have one
disciplinary case or public complaint on record. The resolution was obligations imposed. The
program does not employ a physician’s assistant (PA) or advanced practice registered nurse
(APRN). Sign-in and sign-out logs spanning the annual compliance review period were
reviewed. The DHA was on-site at least once a week for the contract required four hours each
week. There were no noted days the DHA had any scheduled absences during the annual
compliance review period. The program does not utilize an APRN, PA, or another’s doctor as a
designee. The program does not have any provisional language contained within the contract to
include either telemedicine or telehealth type services. The DHA confirmed their role which
includes reviewing protocols for different health conditions, medical evaluations for new youth,
and providing ongoing healthcare for each youth in the program. The DHA confirmed they are
on-site once a week, and communicates with program staff regarding youth medical needs
directly when on-site and by telephone or text. The DHA also confirmed they are on call twenty-
four hours a day by telephone call or text and provides on-site clinical services. The DHA
explained the notification documentation is placed in the medical charts, and the results are
faxed or emailed after they are reviewed. The documentation is signed and sent back to be
placed in each youth's medical chart. Verbal orders are signed by medical staff on-site. Medical
issues are discussed weekly when the DHA is on-site.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has a policy and procedures indicating the designated health authority is clinically
responsible for all healthcare services provided to youth at the program. The program has two
full-time registered nurses (RNs) and one part-time RN which meets the contractual
requirements. The program does not have a licensed practical nurse (LPN). A review of all three
nursing licensure credentials found them to be clear and active. In addition, the nursing staff
who provided services at the program had a current certification in cardiopulmonary
resuscitation (CPR). The on-site contract requirement for nursing coverage is ten hours a day,
seven days a week. The RN manager provides clinical supervision, along with medical support
services, Monday through Friday from 7:00 a.m. to 5:00 p.m. totaling fifty hours.
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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 procedures and
protocols utilized at the program. The designated health authority (DHA) reviewed and signed
the program’s treatment procedures on August 4, 2023. The psychiatrist reviewed and signed
treatment procedures on January 11, 2024. The facility administrator (FA) reviewed and signed
treatment procedures on August 1, 2023. Nursing staff reviewed the treatment procedures,
dated, and signed the cover page, as required. There were no new policy changes made and
the start date for this new program was on October 25, 2023. Newly employed healthcare staff
receive a comprehensive clinical orientation to the program’s medical services. Training
covering medical services at the program is provided by on-site registered nurses (RNs).
Documentation was provided to support the DHA approved treatment protocols and standing
procedures and did not delegate them 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 a policy and procedures ensuring the completion of the Authority for
Evaluation and Treatment (AET) authorizing specific treatment for youth in the custody of the
Department. A review of five youth Individual Healthcare Records (IHCRs) found each had a
valid and legible copy of an AET form filed. Four of the five youth had an AET which was signed
by each youth’s parent/guardian. One of the five youth required a court order to be obtained
from the judge for medical treatment. The court order was signed off by a judge and placed into
the IHCR medical record for the youth. Each of the AETs were signed by a Department
representative. Two youth were eighteen or older and there was a documented release of
information in their IHCR. The registered nurse (RN) manager was interviewed and explained
the policy for obtaining a new or current AET involves notifying the juvenile probation officer
(JPO) to get a new AET if the current AET is invalid or not present. The RN manager also
indicated the youth sign a new AET when they turn eighteen.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures to ensure the parent/guardian is informed of
significant changes in the youth’s condition and to obtain consent when new medications and
treatments are prescribed. A review of five youth Individual Healthcare Records (IHCRs) found
the program informs each youth’s parent/guardian of changes in the youth’s condition and
obtains consent when new medications or treatments are prescribed. Three youth had
appropriate notifications for the parent/guardian for over-the-counter (OTC) medications. One
youth had appropriate notifications to the judge for OTC medications. One youth did not have a
parental/guardian notification because they were over the age of eighteen. If new medication
was ordered, there was documentation of any attempted contact with the parent/guardian in the
progress notes for four youth. One youth had documentation of the judge being notified. One
youth was not applicable because of their age. Written notifications were sent utilizing the
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Department’s Parental Notification of Health-Related Care: General or Parental Notification of
Health-Related Care: Medication Forms for four of the five youth. Three of the five youth were
applicable for prescribed psychotropic medication. Staff witnessed telephone call attempts and
conversations for two of the three youth on psychotropic medications. One youth was not
applicable because they were over the age of eighteen. Two of the three IHCRs contained
documentation on page three of the Department’s Clinical Psychotropic Progress Note (CPPN)
form for prescribed, discontinued, and/or changes to psychotropic medication. One youth was
not appliable because they were over the age of eighteen. One of the five youth was applicable
for notification communicated between the program and the Department of Children and
Families (DCF). In this case, the court order authorized all treatment and procedures. In each of
the youth IHCRs reviewed, vaccinations were verified within thirty days of each youth’s
admission to the program. None of the youth were applicable for consent being obtained prior to
administering vaccinations. All five youth had up-to-date immunizations. None of the youth were
applicable for religious exemption from immunization. The program accesses immunization
records online. The medical department is notified of a youth admission prior to arrival. Attempts
are made prior to each youth arriving to verify immunization records, or within thirty days of
arrival. The registered nurse (RN) manager was interviewed and explained the notification
process. The RN manager indicated a parental/guardian notification is made each time a new
prescription or treatment is prescribed. A call is made to give a verbal notification, followed by a
parental/guardian notification by mail. This ensures timely parental/guardian notifications are
made. A call is made to the designated health authority (DHA), facility administrator (FA),
designated person, parents/guardians, and the Department’s Central Communications Center
(CCC) if a youth’s illness or injury requires medical treatment. The nursing staff will first call the
parent/guardian with the psychiatrist to obtain verbal consent. The nursing staff sends page
three of the CPPN and the psychotropic notification by mail to obtain written consent if changes
are made to psychotropic medications. The RN manager also indicated youth are taken to the
Department of Health for vaccinations.
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 maintains a policy and procedures which ensure youth are screened upon
admission for healthcare concerns which may require a referral for further assessment by
healthcare staff. A review of five youth Individual Healthcare Records (IHCRs) revealed each
youth had a completed Facility Entry Physical Health Screening (FEPHS) form. Each of the
FEPHS forms were completed by a registered nurse (RN) on the date of each youth’s
admission to the program. The facility administrator (FA) confirmed none of the youth reviewed
were out of the physical custody of the Department. The RN manager was interviewed and
stated a nurse sees a newly admitted youth within twenty-four hours. The nursing staff are
notified by the clinical director who receives information from the commitment manager when
new youth are admitted. The admission screening is completed by medical staff. The RN
manager indicated if the admission screening is completed by direct care staff, the nurse
documents a review of the form on the last form in the youth’s medical history in the area which
states medical staff. The youth is seen in medical to complete a new FEPHS if there is a change
in custody.
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4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program maintains a policy and procedures to ensure all youth are oriented to the general
process of healthcare delivery services at the program. All five youth Individual Healthcare
Records (IHCRs) contained documentation to support each of the youth were oriented to the
general process of healthcare delivery services at the program. Each youth’s admission
orientation to healthcare services contained all necessary required topics. The registered nurse
(RN) signatures were documented on each of the Orientation to Healthcare Services forms.
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 maintains a policy and procedures to ensure the designated health authority
(DHA) is notified when an admitted youth requires emergency care or routine notification in
accordance with the Department’s requirements. A review of five youth Individual Healthcare
Records (IHCRs) was completed to determine if the DHA was notified when a youth being
admitted to the program required emergency care or routine notification in accordance with
Department requirements. An additional youth records was reviewed for evidence of a referral
to the physician for a chronic condition. Five youth records were reviewed, and two were
applicable for chronic conditions; therefore, one additional record was provided for review.
Three of the six youth records reviewed had a known or suspected chronic condition upon
admission. Two of the youth were taking psychotropic medications prior to arrival to the
program. None of the youth required emergency care upon admission. All six youth had
notifications to the DHA and/or psychiatrist documented within each youth’s IHCR. The
appropriate notifications were made within twelve hours for each youth’s admission to the
program. The registered nurse (RN) manager was interviewed and stated youth admitted with
serious or chronic conditions require immediate notification to the DHA. The RN manager
indicated it is the responsibility of the medical staff or youth care worker to notify the DHA. The
notifications are documented in the chronological records.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a policy and procedures to ensure the Department’s standard Health-Related
History (HRH) form is used for all youth admitted into their physical custody. A review of five
youth Individual Healthcare Records (IHCRs) was completed to determine if the Department’s
HRH form was utilized for all youth admitted into the physical custody of the program. Each
IHCR reviewed had a completed and/or updated HRH form, completed within seven days of
admission. Each HRH was completed prior to the Comprehensive Physical Assessment (CPA).
Each HRH was reviewed by the designated health authority (DHA). The registered nurse (RN)
manager was interviewed and confirmed the RN is responsible for completing the HRH within
twenty-four hours.
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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 maintains a policy and procedures ensuring the standardized Comprehensive
Physical Assessment (CPA) form is used for all youth admitted into the program. A review of
five youth Individual Healthcare Records (IHCRs) was conducted to determine if the CPA form
was utilized for all youth admitted into the physical custody of the program. Each IHCR reviewed
had a completed CPA prior to the youth’s arrival which was reviewed by a registered nurse (RN)
at the time of admission. The CPA was signed and dated on the day it was reviewed.
Furthermore, it was completed on the Department’s Comprehensive Physical Assessment form.
The CPA was completed by the designated health authority (DHA) for all youth reviewed. Each
youth’s Medical Grade was documented on their CPA. All sections of each CPA were marked,
as required. Each of the five youth Problem Lists were updated, as required. There was at least
one verified tuberculosis skin test (TST) documented in each youth’s IHCR. Results of the TST
were also found to match on the CPA and Infectious and Communicable Disease form for each
reviewed youth. All five youth refused a portion of the exam, for which the DHA wrote declined
by youth on the CPA. All five youth also signed a refusal form which reflected the refused
portion on the CPA and matched the date of the exam. The RN manager was interviewed and
explained the DHA completes a new CPA for Medical Grade one every two years. For Medical
Grades two through five this is completed yearly. The RN manager indicated TST screenings
are completed within seventy-two hours of admission, and there are no female youth in the
program so gynecological exams are not applicable.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures ensuring all youth are evaluated and treated, if
necessary, for sexually transmitted infections (STIs). A review of five youth Individual
Healthcare Records (IHCRs) was conducted. All five youth were clinically screened and
evaluated for STIs. One youth was missing a referral on the STI form. The designated health
authority (DHA) did not check the box, but an order was processed in the progress notes for the
labs. One of the five youth’s results from the STI test were not updated on the ICD form but
were placed in the lab section of his IHCR. The other four youth results were completed as
required. None of the five youth were out of the program’s physical custody. All five youth
reviewed were offered counseling and testing for human immunodeficiency virus (HIV). Four of
the five youth refused HIV testing and one youth completed it. All five youth provided written
consent for HIV testing, however, only one youth completed the testing when offered. The five
youth who consented for HIV testing had an applicable consent maintained in their respective
IHCR. One applicable youth who consented to HIV testing had the HIV results filed in their
IHCR, which were maintained in a sealed envelope, and marked Confidential. The one
envelope contained the practitioner signature, on one side of the sealed envelope. In addition,
one youth had documentation of pre-test counseling contained within the IHCR even though the
youth did not receive a test. There were no alerts found of any youth’s HIV status.
The program has a policy and procedures, reflecting HIV test results; whereas, results are only
disclosed to the youth, and entities outlined in Chapter 381, Florida Statute. A local wellness
center provides both pre-test/post-test counseling and testing for HIV. The registered nurse
(RN) manager was interviewed and confirmed youth are screened for STIs and forms are
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completed as required. If there is an indication for further evaluation, urine is collected and sent
to an outside lab in a timely manner. The RN manager indicated STI screenings, evaluations,
referrals, and tests are documented in the IHCR and youth progress notes. Youth are
rescreened if they have been out of the Department's physical custody for more than thirty days
using the STI screening tool. The RN manager also indicated if symptoms are present the DHA
is notified and STI testing is completed following the DHA’s orders. HIV test results are kept in
the lab section of the chart in a sealed envelope with the DHA’s signature. The RN manager
stated youth attend classes facilitated by a local provider, which include HIV counseling, pre-
counseling, and testing if the youth requested it. Test results are maintained in the youth’s
IHCR. All five youth interviewed stated they can ask for an HIV/AIDS test
4.12 Sick Call Process Limited Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a policy and procedures to ensure all youth can submit sick call requests and
have their complaints treated appropriately through the program’s sick call system. A review of
five Individual Healthcare Records (IHCRs) indicated none of the youth presented with similar
sick call complaints three or more times within a two-week period. Two of the five IHCRs
contained Sick Call Request forms completed by each youth and a registered nurse. A review of
the Sick Call Referral Log indicated one of the three remaining IHCRs had one Sick Call
Request form missing, and in the other two IHCRs two Sick Call Request forms were missing
from each. The completed Sick Call Request forms were filed in each youth’s IHCR in reverse
chronological order, were documented in accordance with the Florida Administrative Code, and
none of the youth were in restricted housing. One of the five IHCRs documented all sick calls on
the Sick Call Index. Three of the remaining four IHCRs had two sick calls missing from the Sick
Call Index each, and one IHCR had one sick call missing from the Sick Call Index. All sick calls
were documented on the Sick Call Referral Log. A review of the daily schedule, posted
schedule, and nurse interview indicated the program conducts daily sick call as contractually
required. The program provides sick call twice a day at 9:00 a.m. and 4:00 p.m. which was
noted on the clinic door. Only licensed nurses conduct sick call. When no licensed medical staff
are on-site a supervisor reviews the Sick Call Request forms no more than four hours after
submission. The program has the Sick Call Request forms available to all youth in the dining
hall, dormitories, and group room. During the annual compliance review week, the program did
not have any sick call events; therefore, no sick call observation was conducted. All five
interviewed staff indicated the nurses review and conduct sick call. One also indicated the
trained supervisory staff can review and conduct sick call when licensed medical staff are not
on-site. Two of five youth interviews indicated youth can see the nurse immediately after putting
in a Sick Call Request. The remaining three stated within one day. The registered nurse (RN)
manager indicated youth can request to see a nurse for health complaints by completing a Sick
Call Request form and placing it in the sick call box outside of the clinic; the request will be
addressed within twenty-four hours by a RN. The RN manager also indicated the designated
health authority (DHA) will conduct sick call if on-site and all sick call is conducted in the clinic. If
a youth presents with similar sick call complaints three or more times in a two-week time frame
the nurse will refer the youth to the DHA. The DHA has approved treatment protocols. The RN
manager stated the program does not have restricted housing.
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4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a policy and procedures addressing episodic and emergency care, including
first-aid maintenance and storage, as well as the use, access to, and inventory of Narcan. A
review of five Individual Healthcare Records (IHCR) indicated none of the youth had an episodic
care event. Three more examples were requested. In the three applicable IHCRs, each youth
required on-site first-aid or episodic care conducted by a nurse and each event was
documented in problem-oriented charting. The program has six first-aid kits; one in master
control, one in the kitchen, and four in the clinic for youth transportation. All first-aid kits
maintained the designated health authority (DHA) approved contents. A review of the first-aid kit
checks for the annual compliance review period indicated all were checked monthly, by a nurse,
as the program’s policy specifies, and included expiration dates of the contents. The program
has one automated external defibrillator (AED) which is located on the wall outside of the
administration building and includes the procedures. A review of AED checks for the annual
compliance review period indicated they were completed monthly by the nurses and
documented the AED pads were changed June 28, 2023, and the batteries October 28, 2020.
Observations during the annual compliance review week indicated the AED was in working
order, the batteries expire in May 2026, and the pads November 17, 2025. A review of
emergency medical drills for the annual compliance review period, maintained by the program,
indicated they were conducted at least quarterly on each shift, and simulated an episodic care
event which called for immediate first-aid and/or administration of cardiopulmonary resuscitation
(CPR) techniques, and the initiation of the emergency procedures to follow when a life-
threatening emergency does occur. Due to the program start date being in October 2023, the
requirement for all staff to participate in a drill which included CPR and a “man down” drill
annually could not be completed. A review of training documentation indicated the authorized
direct care staff are appropriately trained on the administration of the epinephrine auto-injector
by a registered nurse. Due to Department-wide system outages, the Department’s Learning
Management System could not be reviewed to confirm the staff training for episodic, first-aid,
and emergency care. Observations during the annual compliance review week indicated the
program posts a list of emergency numbers accessible to all staff and inaccessible to the youth.
The program did not have a first-aid care event during the annual compliance review week;
therefore, episodic care could not be observed. The program stores one box containing two
doses of Narcan in the medical cart and twelve more boxes with the remainder of the
medication inventory. Narcan is inventoried perpetually and weekly, and only supervisory staff
have access. At the time of the annual compliance review week, non-healthcare staff had not
been trained on the use of Narcan. Four of the five staff interviews indicated they can call 9-1-1
in a medical emergency. The four also mentioned they will call a code and notify a supervisor,
as well as a nurse and the doctor. The remaining one staff stated they will let a supervisor know
and the supervisor will make the 9-1-1 call. All five youth interviews indicated they can see a
dentist and/or a doctor if needed. The registered nurse (RN) manager interview verified the
location of the first-aid kits, as well as the AED, and AED procedures. The nurse stated episodic
care is documented on the Episodic Care form and the Episodic Care Log, and when non-
healthcare staff provide the care to a youth it has to be documented on the Department form.
Any youth being sent off campus for emergency care is noted on the Off-Site Care Log. The
interview indicated emergency medical drills are conducted monthly and emergency numbers
are posted in the clinic, the alert book, and the non-healthcare protocol book for access to all
staff and inaccessible to youth.
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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 maintains a policy and procedures ensuring the program provides for timely
referrals and coordination of medical services to off-site healthcare providers. Four of five
Individual Healthcare Records (IHCRs) indicated each youth required off-site care. All four
applicable IHCRs had the Department’s Summary of Off-Site Care Consultation Report form
utilized and filed for each event. Each off-site event was documented on the Off-Site Care Log
and where applicable, parental/guardian notification efforts were documented. All four IHCRs
contained the discharge plans, off-site care findings, instructions, and other applicable
documents, which were reviewed by the designated health authority (DHA)/designee and
initialed/signed. Two of the four youth required follow-up testing/referrals/appointments, which
were tracked, and youth received appropriate, timely follow-up care, as needed. The registered
nurse (RN) manager interview indicated they utilize the Off-Site Care Log to track youth who are
sent off-site for first-aid/emergency care needs. The DHA is called and notified of the discharge
orders. The DHA decides which orders to provide to the nurses to follow, as well as a telephone
order is written in the IHCR, and on each Medication Administration Record. The nurses flag all
off-site care orders for the DHA to follow up with during the next on-site visit. The interview
indicated the nurses utilize the communication book, outlook calendar, and Sick Call Log to
track follow-up testing, referrals, and appointments.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a policy and procedures to ensure youth who have chronic conditions receive
regularly scheduled evaluations and necessary follow-up. Five youth Individual Healthcare
Records (IHCRs) were reviewed. Two of five IHCRs identified each youth as having a chronic
condition. One more example was requested. All three applicable IHCRs identified each youth
on the Facility Entry Physical Health Screening (FEPHS) form as having a current chronic
health condition. None of the youth had a communicable disease, were pregnant, taking anti-
tuberculosis medication or received an off-site periodic evaluation. Two of the three youth were
taking prescribed medication on an on-going basis, and one was undergoing treatment for a
physical health condition. All three youth had a Medical Grade between two and four and were
placed on the chronic illness list. Two of the three received periodic evaluations at least every
ninety days. The remaining youth received one of four periodic evaluations twenty-two days
late. All three IHCRs were reviewed for documentation of each completed periodic evaluation
and each youth’s Problem List was updated as required. Two youth received periodic
evaluations prior to renewing a prescription medication. The facility administrator (FA) interview
reiterated the program’s policy regarding the formalized procedures for healthcare staff to
review the important youth medical issues with the FA and program staff, which is conducted at
least weekly. The designated health authority (DHA) interview indicated youth with chronic
conditions receive periodic evaluations every ninety days and the evaluations are tracked on the
medical tracker. The registered nurse (RN) manager interview indicated youth with chronic
conditions are placed on the medical tracker and are scheduled for follow-up with the DHA
every three months and pro re nata.
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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 a policy and procedures indicating they shall receive, store, inventory, and
provide medication in a safe and effective manner which shall be demonstrated by observation,
as well as review of documentation of procedures and processes. Five youth Individual
Healthcare Records (IHCRs) were reviewed. Three of the five youth were identified on the
Department’s Facility Entry Physical Health Screening (FEPHS) form and in the chronological
progress notes as admitted to the program with medication. Documentation found each youth’s
medications were verified prior to being admitted into the program. The designated health
authority (DHA) and/or psychiatrist were contacted to obtain an order to resume the medication
prescribed prior to admission for all three youth. All medications for all three youth were
observed to have a current, valid order, and were given pursuant to a current prescription. Each
time a medication was continued, discontinued, changed, or a new one was ordered, the DHA
placed an order on a Practitioner Order form. None of the youth were in restricted housing. Two
of the five youth were applicable for over-the-counter (OTC) medications not listed on the
Authority for Evaluation and Treatment form. All OTC medications were administered in
accordance with approved protocols or practitioner’s order. The program utilizes a preprinted
pharmacy Medication Administration Record (MAR), which includes all required elements. A
review of MARs found staff initialed each administered medication and side-effect monitoring
was documented at least weekly for each youth. There were no undocumented explanations for
lapses or errors in medication administration. Non-healthcare staff did not assist in the
administration of medication for any of the reviewed youth. None of the reviewed youth refused
any medication. One reviewed youth required parenteral medication and their medication was
self-administered and observed by licensed staff. Two youth were prescribed psychotropic
medication upon admission, and the DHA and psychiatrist were notified the day of admission for
each. The psychiatrist conducted an Initial Diagnostic Psychiatric Interview with each youth
within fourteen days of admission. All three youth received a medication monitoring/review
every thirty days thereafter, as required. One youth was prescribed psychotropic medications
after admission. There were no standing orders, emergency treatment orders, or pro re nata
orders for psychotropic medications. Medication pass was observed for three youth during the
annual compliance review week. Medication delivery was the sole responsibility of the nurse
during the time of administration. Each youth was escorted to medication pass by direct care
staff and each youth approached the nurse administering medication individually. The nurse
reviewed each youth’s MAR to verify the Six Rights of Medication Delivery/Administration. The
same staff prepared and administered each medication and none of the medications were pre-
poured from their original packaging nor placed in another container for subsequent
administration. One youth took their medication and then did a mouth sweep and coughed. The
remaining two youth had parenteral medications. Both youth took their medication and the nurse
ensured the sharps were disposed of properly. The staff initialed the MAR for each
administration. Five youth were interviewed. All youth stated a nurse dispenses their
medication. All youth explained the process for receiving medication. Five interviewed staff
stated nursing staff dispense medication. One of the five staff stated a supervisor can also
dispense medication. The registered nurse (RN) manager was interviewed and stated, MARs,
orders, and prior facility paperwork are checked for appropriate medication when youth arrive at
facility. This is documented on the Health-Related History (HRH), Facility Entry Physical Health
Screening (FEPHS), DHA notification, and the nurses admission note. Non-healthcare staff do
not verify medication. Only licensed healthcare staff may verify medications at admission. The
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interview indicated the program uses pre-printed pharmacy MARs which include all components
of the Department’s MAR. The health service administrator trains the non-licensed healthcare
staff to properly provide medication, and a list is kept in the medical department and in the OTC
book. Med pass is held from 7:00 a.m. to 7:45 a.m. and 5:00 p.m. to 6:30 p.m. Monday to Friday
and 8:00 a.m. to 8:30 a.m. and 4:00 p.m. to 5:30 p.m. Medication is procured from a local
pharmacy unless medication is brought to the program with the youth during admission, or in
the event of an emergency and the pharmacy is unable to provide medication. The psychiatrist
is on-site every fourteen days and provides psychiatric evaluations and medication
management.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a policy and procedures stating 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. An observation of the program’s medical area revealed medical equipment
classified as sharps, as well as stock medications, are secured and inventoried utilizing a
routine perpetual inventory descending count as each sharp is utilized and disposed of, or when
the medication is administered. Medications were secured in a locked cabinet designated for
storage of medications. The program’s medication cart was observed to be clean and organized
with stock items separate from youth-specific medications. All controlled substances had a
perpetual inventory and were stored separately from other medications. All sharps and
medications were observed to be stored in a separate, secured area, which was locked and
inaccessible to youth. Narcotics and other controlled medications are stored behind two locks
and are not accessible to youth. The program did not have any medications which required
refrigeration. The program’s process for the destruction and disposal of expired or discontinued
medications consists of pouring the medication in a container of Rx Destroyer. A review of the
program’s internal medical logbook documents this process. A review of inventories of sharps
and over-the-counter (OTC) medications demonstrated the program conducts perpetual and
weekly inventories. The registered nurse (RN) manager confirmed the sharps are counted
weekly and there are two daily shift to shift inventory counts for all controlled substances. The
daily shift counts were documented and kept in the medical logbook. The registered nurse (RN)
manager stated the Six Rights of Medication Delivery are taught to all staff and are listed in the
program’s policy and procedures. A list was provided of the supervisory level, non-healthcare
staff trained in the delivery of medication self-administration. Training is provided by the on-site
registered nurse (RN) as needed and annually. An observation of the RN counting three
controlled substances was completed. The final count observed and the final count listed on the
inventory matched with no exceptions. An observation of the RN counting three sharps was
completed with no exceptions. An observation of the RN counting three OTC medications was
completed with one exception. The inventory list for one OTC medication was listed at sixty
packages, but when the RN removed the box with the ointment, an extra package fell out which
totaled sixty-one packages. The inventory was immediately corrected to show the correct
number of packages as sixty-one. The RN manager was interviewed and described the process
for disposal of medication. Medication which is not controlled can be disposed of by two people
with the Rx Destroyer solution. A controlled medication must be destroyed by the pharmacist,
nurse, and another person using the Rx Destroy solution. Controlled substances are placed in a
secured area behind three locks. The program does have a current agreement/contract with a
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consultant pharmacist. The program has a policy in place for destruction of medications;
however, they have not had to destroy any medications since the contract began.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a policy and procedures addressing infection control according to
Occupational Safety and Health Administration (OSHA) federal regulations and the Centers for
Disease Control and Prevention (CDC) guidelines, including prevention, containment, treatment,
and reporting requirements related to infectious diseases. The program’s policy also addresses
a process for needle stick post-exposure evaluation. The designated health authority, facility
administrator (FA), and one nurse reviewed the infection control procedures in August of 2023
and the remainder of the nurses did in January 2024. The program’s infection control
procedures include common, infectious diseases of childhood, self-limiting, episodic contagious
illnesses, viral or 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 pediculosis and/or
scabies, Methicillin-Resistant Staphylococcus Aureus and other emerging antibiotic-resistant
micro-organisms, food-borne illnesses, bio-terrorist agents, chemical exposures in the
workplace, as well as availability for staff to receive Hepatitis B immunizations, and staff access
to protective equipment. The program did not have any infectious diseases during the annual
compliance review period which required contact with the local county health department, CDC,
and/or the Department’s Central Communications Center. The FA can establish a separate file
containing all documents for youth and staff who have experienced a facility/occupational
exposure. The exposure control plan is written in accordance with OSHA standards, is available
to all staff, and was reviewed and signed by the FA/designee on August 1, 2023. The FA
interview reiterated the program’s exposure control and infection control plans. The plan is
maintained in the clinic and a registered nurse provides training on the plans to the staff during
the pre-service period and annually thereafter. The nurse interview indicated a copy of the
exposure control plan is available to nurses. The nurse stated the infection control and exposure
control plan training for staff is conducted by the nurses. Nurses also conduct the youth training
on infection control during admission and pro re nata.
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 has a policy and procedures stating how staff will maintain active supervision of
youth at all times. According to the policy and procedures provided to the annual compliance
review team, staff-to-youth ratios are one to eight during awake hours, one to twelve during
sleep hours, and one to five for off-site activities. Observations of staff made during the annual
compliance review week found staff supervising youth appropriately during all observed
activities. Observed activities included staff supervising youth during school hours, in the multi-
purpose room, recreation, education, and youth movement through the facility. The daily
schedules were posted in the dorms and cafeteria. At no time during the week of the annual
compliance review were youth observed wandering freely about the program. Observations
found counts were conducted at scheduled and unscheduled times and the shift supervisor was
able to give an accurate count when asked. Each of the five interviewed staff confirmed their
understanding of the procedures when there is a discrepancy with the youth count. All the staff
indicated all movement is stopped and the youth count is reconducted until the count is
reconciled. Informal interviews with five staff found they were aware of the number of youth
under their supervision immediately without having to stop and count.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program maintains a policy and procedures addressing the implementation and training of
the program’s behavior management system (BMS). Education staff are part of the program
staff and receive training on the BMS during pre-service training. The education staff were
brought on from the prior provider and were not required to receive pre-service training. The
regional operations director provided an updated training during the start-up. The program
utilizes a phase system, which is a coordinated system of promoting, monitoring, recognizing,
and rewarding a youth’s progress. The phase system is a program of incentives and
consequences which promote individualized skill building, appropriate behavior, and
accountability. Staff use point cards to monitor how well the youth are progressing in the
program. Youth earn points daily for complying with the program rules. At the end of the week,
the points are totaled, and the youth are rewarded based on the number of points earned. Each
youth enters the program on an orientation level prior to starting the BMS and progresses their
way up the four levels. The BMS includes five levels for the youth to advance through prior to
leaving the program. A review of the BMS confirmed it is not used solely to increase a youth’s
length of stay, deny basic rights or services, promote the use of group punishment, allow youth
to punish other youth, or include disciplinary confinement. Youth learn about the BMS during the
orientation process. Each youth is provided a program handbook which describes the BMS. A
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review of the youth handbook indicated the BMS is included and clearly written. In addition, the
parent/guardian handbook includes a description of the BMS. A review of five youth case
management records indicated each youth participated in orientation upon arrival to the
program and received a copy of the youth handbook. Five staff pre-service training records
were reviewed, and all staff were trained in the program’s BMS. Observations found the BMS
was posted throughout the program. Observations of staff and youth interactions verified staff
were adhering to the BMS by utilizing a ratio of four-to-one positive to negative consequences
when redirecting the youth as indicated in the program’s policy. Five youth were interviewed,
and each stated the consequences included write ups, level freezes, level drops, and earning
zero points which affects the daily and weekly incentives. Five youth were interviewed about the
rewards used in the program and all stated youth can earn daily incentives, canteen, off campus
activities, movie passes off-site, and eating at an off-site restaurant. All five interviewed youth
were able to explain the difference between each level, how to move from level to level, and
stated staff are consistent when giving rewards or consequences. Five interviewed staff
explained the BMS consists of a level system where youth earn points, rewards, and
consequences which are based on the youth’s behavior. All five staff stated they received
training on the BMS during orientation. Staff stated the BMS is located in the youth handbook
and the BMS is posted throughout the program. Staff explained it is a level system by earning
points. Five interviewed staff stated youth can earn points to receive daily incentives, canteen,
weekly incentives, outings to the movies or restaurant, extra phone calls, and incentive room or
hygiene items. Each staff stated nothing can be taken away from the youth as a consequence;
however, youth with infractions cannot participate in the incentives. An interview with the facility
administrator indicated youth can participate in outings such as movies, bowling, arcades,
trampoline park, and dinners if earned through the BMS. Youth can also earn video play time,
go to the music studio, weekly incentives, and receive a small snack. Youth can earn extra
incentives based on the level they are on, such as extra phone calls, food items, shirts, and
hygiene items through the token store.
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 and procedures state the program does not use restricted housing, to
include confinement, seclusion, room restriction, or secure observation; therefore, this indicator
is rated non-applicable.
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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.
During the annual compliance review week, the program had fifty-six cameras, all of which were
working with video covering thirty days. A review of one sample of ten-minute check sheets for
thirty-minute increments from the night shift, for each dormitory, from each month during the
annual compliance review period indicated each check was documented in real time, the staff
who completed the checks initialed or signed the check sheet, and all were conducted as
required in no more than ten-minute intervals. Observations of five days of thirty-minute
increments from both dormitories indicated dormitory one had all checks conducted no more
than ten minutes apart. The staff was seen making the rounds by walking by each bed to check
on each youth. The dormitories have no separate rooms but house youth in an open area with
bunk beds. The second dormitory has two cameras which had been installed too close to a light
giving a bluish tint to the entire video footage so it could not be reviewed for fidelity. The
program indicated a work order had been placed to fix the issue. All five staff interviews
indicated room checks/youth checks are conducted every ten minutes. The facility administrator
(FA) interview indicated the facility has fifty-six operational cameras with thirty days of recording.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program maintains a policy and procedures which address population census, counts, and
tracking of youth. The program’s policy indicates headcounts will be conducted at a minimum of
once at the beginning of each shift, during any emergency situation, prior to and after each use
of a vehicle, and before and after each movement. The program utilizes the master control
logbook to document youth counts and movements. Logbooks were reviewed from October
2023 to April 15, 2024. The logbook is utilized to maintain a chronological record of events as
they occur. The youth headcounts are conducted by the shift supervisor at the beginning of
each shift to verify accuracy and document count in the program’s logbook. Counts are
conducted at the beginning of each shift, after outdoor activities, and during emergency
situations. The logbook also tracks youth intakes, releases, transfers, and youth temporally
away from the program. Staff were aware of all youth whereabouts and were able to provide the
proper counts to the annual compliance review team members during the annual compliance
review week. Five staff were interviewed, and each was aware of count procedures, as required
by program policy, including what to do in the case of an unsuccessful count. An observation of
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two youth being escorted to the restroom was conducted. Each youth was searched prior to and
after being escorted by staff. Each youth counted themself prior to and after they were moved.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a policy and procedures addressing logbook entries. The program
maintains a chronological record of events, incidents, and activities in a logbook in accordance
with Florida Administrative Code. Logbook entries are to include emergency situations, Right
Interactions (RI) incidents, special instructions for supervision and monitoring of youth,
population counts at the beginning and end of each shift, and any other population counts
conducted during a shift. Logbook entries also include perimeter security checks and other
security checks conducted by direct care staff, transports away from the program, including the
names of the staff, youth involved, and the destination, requests by law enforcement to access
any youth, removal of any youth from the mainstream population, admission, and releases,
including the name, date, and time of anticipated arrival. Logbooks utilized by the program since
the completion of the start-up monitoring were reviewed. Each reviewed logbook was bound
with numbered pages and entries were made in ink with no white-outs or logbook entries
removed or missing. Logbook entries included movement to and from school and interruptions if
any occurred. At the time of the annual compliance review, the youth were not moving to
classes due to construction being completed in the classrooms. Youth were attending classes in
the group room, education portable, and dining hall. Youth remained in the same location
through the day and the teachers moved to each of the different areas. On-coming staff
members participate in a shift briefing and sign the logbook acknowledging they are aware of all
information from the last two shifts and alert changes. Each reviewed logbook entry was legible
and included the time and date of the entry, printed name, and the signature of the staff member
making the entry. Reported Department’s Central Communications Center (CCC) incidents
which occurred during the annual compliance review period were confirmed to be noted in the
logbook.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program maintains a policy and procedures to ensure key control and security which
includes assignment, inventory, tracking, and storage of keys. Observations made indicated the
program has a system in place for the usage of keys at the program. A review of the center’s
policy and procedures on key control determined it includes the control and use of keys
including key assignment and usage, restrictions on usage, inventory and tracking of keys,
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secure storage of keys not in use, procedures addressing missing or lost keys, and reporting
and replacement of damaged keys. If a key needs to be replaced, maintenance will replace it.
The program’s staff turn in their personal keys and receive a program key. This key is updated
in the logbook to reflect the key with the tag number given to staff. The program staff sign a
permanent key assignment acknowledgment form to receive their keys and acknowledge the
proper procedures for controlled keys. Department heads, the director of support services,
nurses, and clinicians have permanent issued keys. Keys are stored in secured boxes marked
as active key box, restricted key box, and emergency key box in master control. Restricted keys
are only signed out to approved program staff. The key control process was observed during the
annual compliance review week and was conducted appropriately. Visitor keys are exchanged
with a numbered badge. Three random staff were requested to present their keys, which were
compared with the key control log and the inventory to ensure the keys were correct. All three
were correct and the staff had signed their keys out. All three staff were aware of the key
functions. An interview with five staff indicated each staff confirmed there aren’t any youth at the
program with access to the program keys. Due to Department-wide system outages, a review of
the Department’s Central Communications Center (CCC) reports for lost keys could not be
completed. A review of internal incidents found no incidents concerning program 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 system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, program grounds, and youth, which
is clearly explained in the program’s policy and procedures, and youth handbook. The policy
states any staff who is found in possession of contraband in a program will be subject to
disciplinary action up to, and including, dismissal, as well as procedures regarding notification of
law enforcement for items considered illegal as defined in Florida Statutes. The program’s policy
and procedures and the youth handbook define items and materials considered contraband
when found in the possession of youth, provides youth with a list of contraband which meets the
indicator requirements, and informs youth of the consequences if found with contraband. The
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prohibited list includes personal cellular telephones and/or equipment and/or electronic devices
capable of taking pictures and/or audio/video recordings, which are prohibited in the secure
area. The list also includes unauthorized articles of clothing and food, controlled substances,
prescriptions or non-prescription drugs, and any firearm or explosive device. The visitors log
contains a contraband attestation statement and five newly hired staff as of August 1, 2023, had
a completed attestation form in their personnel record. All five interviewed staff were able to
explain the contraband procedures. The contraband notice is posted and states law
enforcement will be contacted for anyone bringing in contraband and a criminal report will be
filed. This practice was confirmed through an interview with the facility administrator (FA) who
recited the program’s policy. The policy stated law enforcement shall be contacted if any found
item would be considered illegal, as defined in state law, or if there is evidence of unlawful
activity. According to the policy and procedures, all searches, as well as the findings and
disposition of contraband/unauthorized items, shall be documented. The FA shall determine the
method of disposition of contraband and unauthorized items which is not illegal. Such
contraband and unauthorized items may be discarded, returned to the original owner, mailed to
the youth’s home, or stored and returned to the youth upon his or her release. Any usable
contraband or unauthorized items, excluding weapons or illegal materials, not able to be
returned, or turned over to law enforcement may be donated to any established charity. All
program staff, visitors, vendors, and contracted providers shall be searched prior to entering the
program. Any program or education staff who refuses to be searched will be denied entry into
the program and may be subject to disciplinary action. Any staff found in possession of
contraband will be subject to disciplinary action up to and including dismissal. All items carried
by program and education program staff are subject to search when entering and leaving the
facility. There were no incident reports for contraband. A review of the weekly search
documentation found searches have been conducted weekly since the start-up review in
October 2023, through April 2024. There has been no contraband found during the searches.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a policy and procedures addressing searches and full body visual
searches. The program conducts searches as a method to prevent the introduction of
contraband and unauthorized items into the facility. Policy indicates searches of youth are
conducted after off-site transports, after visitation, before moving youth from an outside area
into the building, prior to moving youth from the building to an outside area, as well as moving
from one area of the building to another. The program conducted one off-site transport during
the week of the annual compliance review. The annual compliance review team observed a
properly conducted searches before and after the transport. The annual compliance review
team also observed several youth searches during the week of the annual compliance review.
Searches were conducted with each movement of youth from each area of the building such as
the classroom, groups, and dorm. Search procedures and expectations were properly explained
to all youth before searches were conducted. Searches were conducted by staff of the same
gender as the youth, while a second staff member assisted with supervision. Searches were
thorough and done in a manner which did not degrade the youth. All searches were
documented in the program’s logbook. Youth searches were conducted in the classroom prior to
the youth leaving. Both staff members conducting the searches were the same gender as the
youth. Each search was conducted properly according to policy. All five youth and all five staff
interviews revealed all parties were aware of proper search procedures and when the searches
take place, prior to each movement. Five youth stated searches are conducted by staff of the
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same gender and any time they move from one area of the program to another. Five staff
interviews confirmed searches are conducted on the youth as required by policy.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program maintains a policy and procedures addressing vehicles and maintenance. The
program utilizes one vehicle for youth transports. The van passed inspections this annual
compliance review year. The vehicle is also inspected weekly by facility staff. Results of weekly
inspections are documented and stored in the program’s vehicle maintenance log/binder. A
member of the annual compliance review team confirmed the van had a seatbelt cutter, window
punch, and fire extinguisher. The first-aid kits are not stored in the van to preserve the items
inside of the kit. Staff check out a first-aid kit prior to a transport and return the kit to the program
upon return. All seatbelts in the van were in proper working condition. The vehicle was not
required to have a safety screen separating the youth passengers from the driver. An annual
compliance review team member observed the program staff conduct a routine check of all
personal vehicles in the parking lot including the program’s transport vehicle. During a daily
check of staff and program vehicles by an annual compliance review team member, one of the
vehicles was found to be unlocked and unsecured. This was reported to the facility
administrator, who had the vehicle secured. There was one transport observed during the
annual compliance review week and staff followed program procedures. All five staff were able
to identify the youth are secured during transports. All five youth stated they are secured as
required, with seatbelts.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a policy and procedures addressing transportation of youth, outlining
staff to youth ratio during transports as one to five; however, if there are five or less youth, a
minimum of two staff are needed to perform all transports. At no time are youth allowed in
program staff vehicles or to operate staff vehicles. The program has an approved staff driver list
which is updated monthly to ensure staff driver’s licenses are valid. This approved driver’s list is
located in master control. The annual compliance review team was able to observe a transport
during annual compliance review week and staff followed procedures. The facility administrator
(FA) interview stated the program is not a high risk/secure program requiring a safety screen.
Five staff were interviewed, and staff confirmed they are issued a cellular telephone and two
added a program radio is taken on transports as well. Staff do not conduct transports in
personal vehicles, and vehicles are checked before and after transports. All five staff were able
to accurately describe what safety equipment is required for all transports. All five staff were
able to describe the process required in case of an emergency. All five staff knew the ratio of
staff to youth during a transport. None of the five youth stated seeing staff place contraband
inside the vehicle, and all five youth stated they feel safe while being transported.
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5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a policy and procedures to ensure a safe and secure physical plant,
grounds, and perimeter are maintained, and for weekly safety and security audits to be
conducted. The program has developed a policy and procedures outlining the audit/inspection
process. The policy includes the development and implementation of corrective action
warranted because of safety and security deficiencies found during any internal or external
review, audit, or inspection; however, at the time of the annual compliance review the program
did not have any corrective actions warranted. The program has an internal system to verify the
deficiencies are corrected and existing systems are improved, or new systems are instituted as
needed to maintain compliance. Weekly safety and security audits were completed every week
during the annual compliance review period with no concerns or issues. A review of
documentation confirmed all findings were documented on the weekly safety inspection report
and reviewed. Weekly safety and security audits are conducted by the facility administrator (FA)
or designee and documented on the Safety and Security Audit Inspection form. Any deficiencies
are addressed on the form and a work order is submitted to the appropriate staff for corrections.
The program’s Preventive Maintenance Checklist was reviewed to ensure maintenance
schedules and repairs were conducted in accordance with contract language, with no
exceptions. The FA recited the program’s policy for identifying safety and security deficiencies.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a policy and procedures to address tool inventory and management.
The policy addresses the issuance, inventory, and control of equipment and tools. Currently the
program has kitchen tools but has no tools for maintenance. The program has identified their
plant manager as the program’s tool control manager, but the position has been vacant for
twenty-five days as of the time of the annual compliance review. A plant manager from another
facility is completing all maintenance requirements on a weekly basis. The policy classifies tools
into two categories as Class A tools and Class B tools. Class A tools are hazardous with sharp
edges or points and with a high potential to be used as a weapon to inflict serious bodily harm
such as knives, hammers, screw drivers, and electric drills. Class B tools do not have sharp
edges or points such as brooms, mops, and scrub brushes. Youth only have access to Class B
tools which are inventoried monthly. The kitchen maintains Class A tools and they are
inventoried when signed in and out as well as at the beginning and end of each shift. The youth
help in the kitchen but do not have access to Class A tools. All prep work is completed prior to
the youth being in the kitchen. Kitchen tools are secured in the dietary office behind a locked
door and within a locked cabinet. A review of seven kitchen tools found them to be secured on a
shadow board within the locked cabinet, etched for identification, and inventoried. A review of
the inventory found it to be accurate. All Class A maintenance tools are secured with the outside
plant manager and are brought in when on-site. The plant manager stated there were no tools
which were damaged or out of use. The procedure for missing or lost tools states the incident
will be logged in the logbook, all youth movement must halt until a search is complete and the
tool is found. Documentation on a missing tool report shall be completed and will be circulated
to all department heads for review, results of the search will be discussed in shift briefings for
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the purpose of alerting incoming staff to the security concern and to continue searching until the
tool is found or replaced.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a policy and procedures addressing youth tool handling and
supervision. The policy outlines proper procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries to youth and staff. The program completes Risk
Assessments which determine youth’s risk to self and others. Risk Assessments are completed
during formal treatment teams. Five youth case management records were reviewed, and all
records indicated youth have been trained on the proper usage of tools during their orientation
process. Youth signed an acknowledgement of tool training during the orientation process. The
signed acknowledgement form is filed in each youth’s case management record. Youth
interviews confirmed youth are only allowed to use a scrub brush, mop, broom, and dustpan.
Staff interviews revealed youth are allowed to use Class B tools after the orientation training.
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 maintains a policy and procedures which address outside contractors. The
program has established guidelines for outside contractors which include information regarding
tool control and restrictions. The program has a form to be signed by outside contractors which
addresses how tools will be checked upon arrival to and departure from the program,
restrictions of youth to work area access, immediate reporting of missing tools, restriction of
personal cellular telephones, and/or equipment capable of taking pictures and/or recording
audio/video in secure areas. The form also requires contractors to list each tool brought into the
facility. This list is reviewed by the plant manager or designee before the contractor has access
to a secure area. This list is again reviewed before the contractor exits the program. The
contractor’s failure to sign this form prohibits access to work within the program. Outside
contractors are escorted and supervised by the plant manager or designee any time they are
within the facility. The annual compliance review team was not able to observe this process
during the week of the annual compliance review. Program invoices were compared with
outside contractor agreements. All contractor agreements were signed on the date of service
and matched the information on the invoices. No discrepancies were found. The invoices
reviewed were a local plumbing company, local barber, and a local pest control.
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 maintains a policy and procedures to address fire, safety, and evacuation drills.
The program conducts fire, safety, riot, disturbance, and evacuation drills to ensure youth and
staff are prepared for immediate implementation or mobilization in the event of an emergency or
disaster. Drills are consistent with the program’s Continuity of Operations Plan (COOP). All drills
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were documented in the program’s logbook and documented on the program’s designated drill
form. Each drill form contained the type of drill, a description of the drill, the date the drill was
conducted, the time of the drill, and participants’ signatures. A review of drills revealed various
drills were conducted since the completion of the start-up review in October 2024. At least one
fire drill was conducted for each shift each month since October 2024, and two COOP drills
were conducted for each quarter since October 2024. Fire evacuation routes and egress plans
were posted throughout the program. All fire extinguishers were inspected on an annual basis.
An interview with the facility administrator (FA) recited the program’s policy for drills. Staff
interviews revealed staff have participated in fire, weather, bomb threat, mental health/suicide,
and medical drills. All five youth stated they have participated in monthly fire drills.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program has policy and procedures addressing the Continuity of Operations Plan (COOP).
The policy states the COOP is located in master control, facility administrator’s (FA’s) office,
assistant facility administrator’s (AFA’s) office, and staff conference room. The plan addresses
alternative housing plans approved by the applicable Department regional director/designee.
The COOP was last approved on October 3, 2023. The COOP addresses fire prevention and
evacuation, severe weather, disturbances or riots, bomb threats, hostage situations, chemical
spills, flooding, terrorist threats or acts, staff roles and responsibilities, any equipment and
supplies needed, information about youth which may be needed, alternative housing
arrangements, provisions for continuity of care and custody of youth, and provisions for public
protection. The program has food and necessary supplies readily available in case of
emergency evacuation being maintained at Wimauma Academy. The program’s practice for
taking youth records with them in an emergency is to pack all youth records and transport them
with the youth. The program maintains an administrative hard copy on youth in case of
emergency with all required information. The FA recited the program’s policy for the
disaster/COOP plan.
5.18 Storage and Inventory of Flammable, Poisonous, and
Satisfactory Compliance
Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items.
The program maintains a policy and procedures addressing storage and inventory of flammable,
poisonous, and toxic items and materials. The program’s flammable, poisonous, and toxic
materials are stored off-site at another facility and brought in to be used when needed. Only
cleaning chemicals are maintained on-site at Wimauma Academy in the kitchen. The program
maintains proper inventory of these items. The program’s plant manager, assistant facility
administrator, shift supervisor, cook, and the facility administrator are authorized to handle
flammable, poisonous, and toxic materials. Purchased chemicals are removed from the facility
after use. A binder is stored in the cleaning supplies closet containing the Safety Data Sheets
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(SDSs) for the cleaning items located in the cabinet. The cleaning supplies closet is locked at all
times and can only be accessed by staff who sign these items in and out with each use. There
were no discrepancies with the inventories reviewed.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a policy and procedures addressing youth handling and supervision of
flammable, poisonous, and toxic materials. The policy prohibits youth using those items. Youth
do not have access to these items and are supervised by staff during daily cleaning. Youth were
observed participating in facility clean-up during the week of the annual compliance review and
staff sprayed the chemical and the youth clean up after. Five youth were interviewed, and one
youth stated they used paint, one youth stated they used rubbing alcohol, one youth stated
laundry soap, which are laundry pods, one youth stated window or toilet cleaner, and the
remaining youth stated they do not use any chemical or cleaning products. Youth indicated staff
spray the chemicals and the youth then wipe the area clean.
5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program maintains a policy and procedures addressing disposal of all flammable, toxic,
caustic, and poisonous items. The policy prohibits chemicals from being poured on the ground
or being disposed of by any method other than what is outlined by the biohazard guidelines. The
program’s plant manager, assistant facility administrator, shift supervisor, cook, and facility
administrator (FA) are the only individuals authorized to handle flammable, poisonous, and toxic
items. At the time of the annual compliance review, the plant manager was assisting from
another facility. The program’s plant manager was interviewed on the proper procedures of
disposing chemicals and stated all items for disposal are collected by the local county waste
disposal. The plant manager further stated the program has not needed to dispose of any
chemicals. An interview with the FA validated this practice. Kitchen liquid waste which cannot be
disposed of by pouring it down the sink and grease are picked up by a contracted provider and
stored outside the building in a separate container.
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5.21 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity.
Programs allowing youth to participate in water related activities shall have a water safety
plan addressing, at a minimum, safety issues, emergency procedures, and the rules to be
followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures to allow visitation and communication for youth while
in the program. The visitation procedures are posted in the facility. The visitation and
communication procedures are addressed in the youth handbook, parents/guardian handbook
and addressed on the orientation checklist. The program utilizes staff translators or an online
translation site with live translators to be utilized if necessary. All five interviewed youth
indicated they can make weekly calls to the parents/guardian. Five youth were interviewed
about what types of translation services are in place and three of the five stated they use a
translator service, one youth did not know the of the service, but knew a service was available,
and one youth stated they would use their study buddy. Five interviewed staff stated they have
a language line available and two stated they have a translator device available and staff to
translate. The visitation schedule was posted throughout the program. Visitation documentation
indicated visitation is being offered on the weekends as required by policy. The visitation,
telephone, and correspondence logs were reviewed. The logs showed youth have contact with
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only approved persons. Incoming and outgoing mail is searched and recorded in the
correspondence logs, then given to the youth’s case manager who delivers the mail to each
youth and has them open the mail in front of them. There were no youth applicable for a history
of human trafficking; therefore, the program is not required to request clarification from youth’s
juvenile probation officer (JPO) about any parent/guardian past or current human trafficking
investigation involvement. The facility administrator (FA) recited the program’s policy for
visitation and communication.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a policy and procedures stating recreation activities shall be provided for a
minimum of one hour a day. The policy states a schedule shall be made with a selection of
activities for the youth to choose from. The youth have variety of recreation and leisure
activities. The program’s schedule has structured indoor and outdoor recreation and leisure
activities which include a large muscle activity for a minimum of one hour each day. A review of
the logbook since October 2023 indicated recreation was conducted as scheduled. The
program’s contract required a recreation therapist. The recreational therapist is on-site five days
a week and has a bachelor’s-level degree in a related field. A review of five youth records
confirmed each youth record contained a wellness plan. Five interviewed youth stated the
program allows the opportunity to exercise, play outside, read a book, play a board game,
sports, or physical fitness activities. Five youth also stated physical activities are provided for at
least one hour. Five interviewed staff confirmed recreation was occurring and included activities
such as football, basketball, arts and crafts, board games, and playing video games.
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’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.
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report_type: QI Residential

rule: Indicator 1.15

excerpt: Advisory Board

rating: Limited Compliance

rule: Indicator 2.20

excerpt: Educational Access (Critical)

rule: Indicator 3.02

rating: Failed Compliance

rule: Indicator 3.13

excerpt: Suicide Prevention Training (Critical)

rule: Indicator 4.12

excerpt: Sick Call Process