state: FL

facility_name: Lake Academy

summary: QI Residential - FY23-24 - 1 finding

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Lake Academy
TrueCore Behavioral Solutions
(Contract Provider)
9504 East Columbus Drive
Tampa, Florida 33619
Review Date(s): January 29 - February 2, 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:
Christine Calvert-Joyner, Office of Accountability and Program Support, Lead Reviewer
(Standard 1)
Rob Aguis, Office of Education, Director, Postsecondary & Workforce Education (Standard 1)
Belinda Alexander, Office of Education, Central Education Coordinator (Standard 2)
Teresa Andersen, Office of Accountability and Program Support, Deputy Supervisor, Central
Region (Standard 2)
Kara Brown, Office of Accountability and Program Support, Deputy Supervisor, Central Region
(Standard 3)
Jennifer Bailey, Office of Accountability and Program Support, Bureau Chief (Standard 2)
Tonya Gittens, Office of Accountability and Program Support, Deputy Supervisor, South Region
(Standard 1 and Interviews)
Melissa Johnson, Office of Accountability and Program Support, Supervisor, Central Region
(Standard 5)
Desiree Taylor, Office of Accountability and Program Support, Deputy Bureau Chief (Standard
5)
Kamille Payne, Office of Accountability and Program Support, Supervisor, North Region
(Standard 3)
LeAnn Gruentzel, Office of Accountability and Program Support, Deputy Supervisor, North
Region (Standard 3)
Cindy Jones, Office of Education, Deputy Director of Education (Standard 2)
Program Name: Lake Academy MQI Program Code: 1069
Provider Name: TrueCore Behavioral Solutions Contract Number: 10714
Location: Hillsbourough County County / Circuit 13 Number of Beds: 45
Review Date(s): January 29 - February 2, 2024 Lead Reviewer Code: 163
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
2.20 Educational Access*
3.08 Specialized Treatment Services*
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 72 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 72 (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 72 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Limited
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Non-Applicable
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 72 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 72 (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
* 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 72 (Revised September 2022)
Program Overview
Lake Academy is a forty-five-bed program, for twelve- to nineteen-year-old females, located in
Tampa, Florida. The program is operated by TrueCore Behavioral Solutions LLC, through a
contract with the Department. The program provides fifteen secure and thirty non-secure beds
for youth who need Intensive Mental Health (IMH), Borderline Intellectual Functioning
(BIF)/Borderline Development Disability (BDD), and Developmental Disability (DD) services.
The program fosters each youth by providing Moral Reconation Therapy (MRT), Skillstreaming
the Adolescent, Process Group, Impact of Crime, Thinking for a Change, ARISE, Problem
Solving Training, Social Perception Training, Living in Balance, and Empathy and Social
Competency Training groups. Additional treatment services provided includes family, individual,
and group therapy, recreational therapy, animal therapy, crisis intervention, emergency
supports, and supportive counseling. Program administration is comprised of one facility
administrator, two program directors/assistant facility administrators, one administrative
assistant, and one human resources generalist. Medical services are provided from 7:00 a.m.
through 7:00 p.m. seven days each week. Medical staff include one full-time registered nurse
(RN) to serve as the health services administrator (HSA), and five nurses. The program
currently staffs one HSA, two full-time RN’s, two full-time licensed practical nurses (LPNs), and
one part-time LPN. Case management services are provided by four case managers, two
transition service managers, and one delinquency intervention coordinator. Mental health staff
at the program includes one designated mental health clinician authority, one psychologist, one
assistant clinical director, four therapists, and two recreation therapists. Educational services
are provided by the Hillsborough County School District. The layout of the program includes one
main building which contains areas for administration offices, case management and mental
health offices, a medical clinic, a cafeteria, a kitchen which prepares cooked food on-site, a
centrally located master control room, three living units, and educational classrooms. The
program has eighty-five operating security cameras providing coverage and all were operational
during the annual compliance review. At the time of the annual compliance review, the program
had twenty vacant positions which included nine youth care worker Is, five youth care worker IIs,
three shift supervisors, one case manager, one recreation therapist, and one administrative
assistant.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 72 (Revised September 2022)
Strengths and Innovative Approaches
• Pregnant youth receive additional pregnancy education from the Nurse Family
Partnership
• Baby showers are held for pregnant youth
• A Pop-up boutique for youth being discharged from the program is hosted in order to
provide youth with clothing
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 72 (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 maintains a written policy and procedures regarding staff recruitment and selection
which outlines the requirements for background screening. The program’s policy requires a
background screening to be completed and an eligible rating for hiring prior to the actual first
day of work, usually the first day of orientation and training. A review of staff, contracted staff,
and volunteer lists indicated thirty-three staff were applicable for an initial background screening
since the last annual compliance review. The program last submitted the Annual Affidavit of
Compliance with Level 2 Screening Standards to the Department’s Background Screening Unit
(BSU) on December 22, 2023, meeting the annual requirement. The program’s teachers are
employed though the Hillsborough County School District. The annual affidavit for teachers was
submitted on December 22, 2023. Reviewed records documented all thirty-three staff had a
background screening completed prior to contact with the youth and confidential youth records.
The program’s practice is to have all newly hired staff attend a three-week orientation training
prior to access to youth and/or confidential youth records. The screenings included a review of
the criminal history report by the hiring authority. None of the reviewed records were applicable
for a break in service as indicated in the Department’s Staff Verification System (SVS). Twenty-
six staff were applicable for a pre-employment assessment tool. The program’s policy required
all direct care staff to pass a pre-employment assessment tool. The program’s assessment tool
and a passing score were observed in each of the reviewed applicable records. Each of the
thirty-three staff were added to the program’s Clearinghouse Employee Roster. An interview
with the regional compliance manager explained the background screenings and assessments
are tracked by the corporate staff. None of the reviewed staff were applicable for obtaining an
exemption prior to working with youth.
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 maintains a written policy and procedures which requires all staff, contracted staff,
and volunteers to be background screened every five-years from their date of hire. A review of
staff, contracted staff, and volunteer lists indicated there was one staff applicable for a five-year
rescreening since the last annual compliance review. The interviewed regional compliance
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 72 (Revised September 2022)
manager explained the background rescreening’s are tracked by the corporate staff. A review of
the applicable rescreening indicated it was submitted to the Department’s Background
Screening Unit (BSU)/Clearinghouse at least ten days prior to the staff’s anniversary date, as
required.
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
▪ The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
▪ All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
▪ Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
▪ The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
▪ A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program maintains a written policy and procedures for employee standards of conduct and
ethics and values. The policy prohibits violations of the program’s drug and alcohol policy,
harassment of youth, personal non-work relationships with youth, and unprofessional
relationships with youth family members. All staff shall protect program youth from physical
abuse and/or the excessive or unnecessary use of force and immediately report any known or
suspected alleged abuse of youth to their supervisor, duty officer, or management staff.
Staff shall not demonstrate sexually abusive conduct towards youth and shall immediately
report any known or suspected alleged abuse. The policy and procedures are to ensure all
allegations of child abuse or suspected child abuse are immediately reported, and youth are
provided a stable, safe, and nurturing environment which preserves personal dignity and
integrity. The program requires all newly hired staff to sign a code of conduct and an attestation
affirming they received the staff handbook. A review of seven staff records confirmed each
contained a signed code of conduct. A tour of the program verified the numbers for the
Department’s Central Communications Center (CCC) and the Florida Abuse Hotline were hung
and accessible to all staff and youth. The program has a direct connect phone on the wall of the
program. All program supervisors have the key to unlock the cover to the phone and the
practice is to bring youth to the phone when they request a call. The program’s policy requires
all program staff to immediately report any knowledge or suspicion regarding an incident of
abuse or harassment to the Florida Abuse Hotline and the CCC. The policy indicates a youth’s
refusal to make the abuse call themselves does not relieve the staff from being mandated to
call, if the staff has reasonable suspicion that abuse has occurred. The staff is to then notify the
on-duty supervisor once the call to the Florida Abuse Hotline and/or CCC has been completed,
as well as the reason for why the call was placed. A supervisory report is not required if the
person has made an anonymous report relating to sexual misconduct and wishes to remain
anonymous. Staff shall then complete an internal incident report form, unless the call was made
anonymously. The program’s assistant facility administrator (AFA) or designee will then
complete the appropriate notifications to the CCC and the regional director, when applicable. All
notifications should be documented on the internal incident report form. The program completed
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 72 (Revised September 2022)
a Trauma Responsive and Caring Environment (TRACE) self-assessment on February 8, 2023.
The TRACE youth and staff surveys were completed on March 10, 2023, and the program’s
action plan was completed on March 28, 2023. The program had four incidents related to abuse
allegations since the last annual compliance review. None of the reviewed incidents were
applicable for potential human trafficking. The program had no substantiated incidents of abuse
since the last annual compliance review. Three incidents were still open, and one was closed
the week of the annual compliance review. Seven interviewed youth reported they have never
been stopped from reporting abuse to the Florida Abuse Hotline or CCC. All seven-youth
reported they knew the number or where to find it. Two youth also reported there was a direct
connect telephone in the hall for abuse calls. Four interviewed youth reported staff are
respectful when talking to youth and three reported sometimes. The three youth who reported
sometimes, added staff may come to work upset, react when a youth displays disrespect, or
when staff become upset, they may use profanity. When asked if staff used profanity when
speaking to youth, one youth reported never, three youth reported once, two youth reported
occasionally, and one youth reported often. Each of the seven interviewed youth reported they
have never exchanged personal information with a staff. Six interviewed staff reported when a
youth wants to make a call to the Florida Abuse Hotline the youth is allowed to make the call,
five reported the supervisor is notified, and one reported the facility administrator (FA) is
notified. Staff reported the supervisor would assist the youth in making the call, the phone is
located in the hall, and after the call is made call information is provided to the AFA. Seven
interviewed staff reported they have never heard a co-worker tell a youth they could not call the
Florida Abuse Hotline. All seven staff reported they never heard a co-worker use profanity
towards a youth and they knew where to find the telephone number for the Florida Abuse
Hotline. The interviewed FA reported the program’s general standards of conduct and
performance apply to all staff and contractors of the company. The standards are categorized
into three levels which include a minor offense, a major offense, and a critical offense. Failure to
follow a standard of conduct may result in disciplinary action from an oral warning to termination
of employment. The severity of the penalty depends on the frequency and nature of a particular
offense. These standards are not all-inclusive but are intended to be illustrative of the minimum
expectations for acceptable work performance and workplace behavior. The system is
progressive, and the company may at its sole discretion deviate from any order of actions and
utilize whatever form of discipline deemed appropriate under the circumstances, up to and
including immediate termination of employment. Additionally, the FA reported CCC reportable
incidents are primarily the responsibility of the FA; however, any staff is able to make a CCC
report. All staff are mandated reporters and can contact the Florida Abuse Hotline at any time.
Youth who request to contact the abuse registry are provided with the opportunity to do so
immediately upon request. Youth are provided with a private space to make their report. The
staff are trained and knowledgeable of the reporting policies and procedures through pre-
service training, in-service training, and through policy review during all-staff meetings.
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 maintains a written policy and procedures regarding incident reporting which
outlines the requirements for management response. Immediately following an incident, the
program must immediately remove the subject staff from contact with all youth when involved in
incidents related to excessive force, allegations of abuse, Prison Rape Elimination Act (PREA)
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 72 (Revised September 2022)
related incidents, and other incidents that involve staff activities that raise concerns about youth
safety and/or staff contact with youth. The program also has a policy and procedures regarding
reporting to ensure that all allegations of child abuse or suspected child abuse are immediately
reported to ensure youth are provided a stable, safe, and nurturing environment that will
preserve personal dignity and integrity. The program had four allegations involving six different
staff since the last annual compliance review. A review of internal incident reports reflected the
program’s facility administrator (FA) took immediate action to address the allegations and
removed the staff from youth contact until an investigation was conducted. The interviewed FA
reported any time management is made aware of any allegations of abuse, an internal
investigation is immediately initiated. Management will place the staff the allegation is made
against on suspension pending investigation with no youth contact to prevent further
incident/allegation. Management will make applicable reports to the Florida Abuse Hotline
and/or the Department’s Central Communications Center. Following the completion of an
investigation, or when warranted during the investigation, disciplinary action will be issued
following the program’s progressive disciplinary system which can lead up to termination of
employment.
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 maintains a written policy and procedures regarding incident reporting to ensure
applicable incidents are reported to the Department’s Central Communications Center (CCC)
within two hours of the incident occurring, or staff becoming aware of the incident. The program
had a total of thirty-eight incidents reported to the CCC since the last annual compliance review.
A review of five incidents indicated each was reported within two hours as required. Each
incident was documented in the program’s logbook in accordance with policy. A review of ten
youth records, incident reports, Protective Action Response (PAR)/Right Interactions (RI)
reports, grievances, and internal incidents did not reveal any additional incidents which should
have been reported to the CCC. The program had an increase of one CCC incident compared
to the last annual compliance review period.
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 maintains a written policy and procedures to ensure the establishment and
maintenance of a safe environment for staff, youth, volunteers, and visitors, and to ensure youth
are not subjected to unnecessary and excessive use of physical force. The program had twelve
Protective Action Response (PAR)/Right Interactions (RI) incidents since the last annual
compliance review, and a review of five incidents was completed. Four reports indicated all
involved staff completed a report by the end of their workday. One incident required three staff
statements and two of the statements were completed the following day. Each PAR/RI Report
included statements from all involved staff. None of the reviewed incidents were applicable for
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 72 (Revised September 2022)
the use of mechanical restraints, a youth injury, or a youth alleging abuse. All five reports were
reviewed by a supervisor and a PAR/RI instructor. Two incidents were applicable for a PAR/RI
medical review based on the post-PAR/RI interview and the PAR/RI medical reviews were
completed as required. Each PAR/RI Report documented the incident was reviewed by an
administrator within seventy-two hours and a copy of each report was maintained in the
program’s centralized binder. A review of the PAR/RI binder indicated the program sent monthly
summaries regarding PAR/RI incidents to the Department’s regional office by the fifteenth of
each month since the last annual compliance review. The program’s PAR/RI policy was last
signed by the facility administrator (FA) on March 1, 2022, and the PAR/RI Plan was last
updated and approved by the Department on January 9, 2023. The program had a total of eight
PAR/RI incidents during the last annual compliance review period, reflecting an increase of five.
The program’s FA reported, and documentation supported, the increase was due to two youth
with multiple incidents requiring PAR/RI interventions. The program’s PAR/RI rate during the
previous quarter was 2.25 which is above the statewide Residential PAR/RI rate of 1.82. The
interviewed FA reported PAR/RI reports are reviewed in the morning management meetings
and reported for tracking in the morning meeting database. The assistant facility administrator
(AFA) conducts a video review of the incident to ensure proper PAR/RI procedures were
followed, there was no use of excessive force, and PAR/RI was a necessary level or response.
The monthly PAR/RI summary report is completed and reviewed for trends and submitted the
Department for tracking. Six of seven interviewed staff reported they have used PAR/RI. Staff
explained they must complete an incident report and determine if a youth needs to see medical
staff.
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 maintains a written policy and procedures for staff training and development to
ensure that all newly hired staff are sufficiently prepared to meet the needs of the program and
youth. The policy outlined required trainings in accordance with contract and Florida
Administrative Code. A review of seven pre-service training records reflected each staff
exceeded the required 120 hours of training. All trainings were completed within the first 180-
days and documented in the Department’s Learning Management System (SkillPro). Each
reviewed record indicated the essential skills trainings in the areas of child abuse recognition,
reporting, and prevention, cardiopulmonary resuscitation (CPR), first-aid, automated external
defibrillator (AED), emergency procedures, Prison Rape Elimination Act (PREA),
professionalism, interpersonal communication, and ethics, including standards of conduct,
Protective Action Response (PAR)/Right Interactions (RI), and suicide awareness and
prevention were completed prior to contact with youth. The remaining required trainings in
active shooter preparedness, adolescent development and behavior, balanced approach to
restorative justice, the Department’s Central Communication Center, civil rights, communication,
confidentiality/Health Insurance Portability and Accountability Act (HIPPA), Department of
Juvenile Justice legacy, Equal Employment Opportunity, gang awareness, human trafficking
intervention, infection control/bloodborne pathogens, information security awareness, Juvenile
Justice Information Systems, mental health and substance abuse, motivational interviewing,
quality report writing, safety, security, and supervision of youth, sexual harassment, effective
and respectful treatment of youth, trauma responsive practices, grievance process, behavior
management system, the intended and safe use of tools, and specialized services were
completed for each staff.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 15 of 72 (Revised September 2022)
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 maintains a written policy and procedures for staff development and annual
training to ensure all staff maintain the necessary training to meet the needs of the program and
youth. The policy outlined required trainings in accordance with contract and Florida
Administrative Code. A review of seven in-service records reflected each staff exceeded the
required twenty-four hours of annual in-service training. Staff completed between ninety-two and
182 hours of training in the areas of active shooter, cardiopulmonary resuscitation (CPR), first-
aid, automated external defibrillator (AED), human trafficking intervention, information security
awareness, mental health and substance abuse, Prison Rape Elimination Act (PREA), ,
Protective Action Response (PAR)/Right Interactions (RI) professionalism, interpersonal
communication, and ethics, sexual harassment, suicide awareness and prevention, and trauma
responsive practices. Each reviewed staff held current CPR/first-aid/AED, and PAR/RI
certifications. Additionally, staff were trained annually in emergency response, infection control,
bloodborne pathogens, and the Exposure Control Plan. Three staff were applicable for at least
eight hours of supervisory training annually. The reviewed records documented each exceeded
the required hours in the areas of coaching, leadership, and/or personal accountability. All
reviewed training was documented in the Department’s Learning Management System
(SkillPro). All reviewed training was provided by qualified trainers in accordance with the training
plan last signed on December 30, 2022. An interview with the facility administrator confirmed
the program has a training center and all trainings are scheduled. Training schedule changes
occur as needed.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program maintains a written policy and procedures for youth to formally file complaints
about conditions, treatment, services, and the actions of program staff and, when applicable,
other youth in violation of their rights. The procedures are developed to ensure complaints are
reviewed in a fair and expeditious manner and resolved in the best interests of the youth, the
program, and the Department. The program’s grievance training is part of the approved pre-
service training plan and includes an informal, formal, and appeal phase. The program’s
informal process is to encourage open communication through the “My Voice Matters” forms
located throughout the program. The program also has formal grievance forms accessible to
youth. The grievance forms are submitted into a locked box, which is checked daily by
administrative staff. A review of documentation and a tour of the program verified the practices
aligned with policy. A review of the program’s grievance documentation indicated the program
had a total of twenty-three formal grievances submitted since the last annual compliance review.
The program’s practice is to keep the grievances for a period of at least twelve months within a
centralized binder. A review of five grievances reflected each was resolved at the formal phase
and an appeal was not necessary. Each form documented the supervisor, and the youth signed
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the form agreeing to a resolution. Seven interviewed youth reported there are forms located
throughout the program and youth complete a form and place it into the grievance box. One
youth reported they have never had to complete a grievance and two additional youth reported
staff would review the grievance and then come and speak to the youth. All seven-youth
reported they could ask for help completing a grievance form if needed. Seven interviewed
youth reported grievance forms are placed throughout the program. Staff also reported the
youth can place the form in the box, administration or case managers will check the grievance
box, and a staff will come and talk to the youth about the grievance. The interviewed facility
administrator (FA) reported all youth shall be treated fairly, respectfully and without
discrimination and enjoy all constitutional rights afforded to them under both state and federal
law. Filing a grievance shall not result in retaliation or barriers to services. There is no time limit
for a youth to file a grievance, and there is no requirement that prohibits a youth from filing a
grievance without first using the informal complaint and resolution steps. Resolution steps
include encouraging youth to resolve questions, disputes, and complaints through informal
communication with program staff. If this does not resolve the issue, a formal, written grievance
may be filed with the grievance officer. Within seventy-two hours, excluding weekends and
holidays, the designee will review the findings to determine whether the finding is unsupported.
If the finding is unsupported, the FA will initial the grievance form and return it to the grievance
officer or designee for processing with the youth.
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 designated staff identified and trained to facilitate group interventions
specified in contract. The program’s therapists facilitate all clinical treatment groups. The
program’s primary service groups include clinical designations and the delinquency intervention
model Impact of Crime (IOC). The program also provides Thinking for a Change (T4C) groups
as indicated/prescribed. A review of facilitator training indicated six staff were trained to facilitate
IOC and three staff were trained to facilitate T4C. Each staff held at least a bachelor’s degree
and had experience working with youth. A review of the group schedule indicated the minimum
number of four to seven groups were scheduled each week and the program was equipped to
facilitate all groups outlined in contract. The reviewed activity schedule confirmed at least sixty
percent of the youth’s waking hours consisted of structured, planned programming. The
interviewed facility administrator (FA) reported only master’s and bachelor’s level staff facilitate
groups. Youth are matched based on their individual needs identified in the pre-classification
meeting prior to admission. Upon completion of the Youth Needs Assessment, any necessary
changes can be made to better suit the needs of the youth. For placement in intervention
groups, the youth’s Residential Assessment for Youth is reviewed to determine which group is
most beneficial based on their individualized needs. A youth's level of understanding and
maturity is also considered to ensure they will benefit from the material presented. An interview
with the designated mental health clinician authority (DMHCA) confirmed the groups offered at
the program.
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1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program maintains a written policy and procedures regarding youth screening and
classification. During the intake process youth are screened and assessed to determine service
goals to include clinical and delinquency interventions. The program has identified the
Skillstreaming the Adolescent curriculum as the life skills group provided to each youth.
Skillstreaming the Adolescent is identified as a practice with demonstrated effectiveness. The
curriculum addresses communication, interpersonal relationships and interactions, non-violent
conflict resolution, anger management, critical thinking, including problem-solving, and decision-
making. The program also promotes and practices gender specific hygiene, incentives,
education, activities, and wellness. Groups and activities for female youth are provided daily. A
review of sign-in sheets indicated life skills groups were provided as scheduled. Seven
interviewed youth reported participating in groups at the program. The interviewed facility
administrator (FA) reported only master’s and bachelor’s level staff facilitate groups. Youth are
matched based on their individual needs. The interviewed designated mental health clinician
authority (DMHCA) verified the Skillstreaming groups were provided three times weekly by the
program’s mental health staff. An interview with the program’s regional compliance manager
indicated the program follows the “Girls Matter,” gender responsive philosophy.
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’s contract requires restorative justice activities to be provided to youth. The
program facilitates Impact of Crime (IOC) groups, Thinking for a Change (T4C) groups, and
integrates restorative justice practices into other programming. IOC and T4C curricula are
designed to assist youth to accept responsibility for harm they have caused by their past
criminal actions, challenging them to recognize and modify their irresponsible thinking, such as
denying, minimizing, rationalizing, and blaming victims, teach youth about the impact of crime
on victims, their families, and their communities, expose youth to victims’ perspectives through
victim speakers, and provide opportunities for youth to plan and participate in reparation
activities intended to restore victims and communities, such as restitution activities and
community service projects. The program’s restorative justice groups are held two times each
week. An interview with the facility administrator (FA) explained the youth participate in
community service projects and the program has had motivational and gun violence prevention
speakers visit the program. A review of visitor logs, sign-in sheets, and youth community service
logs confirmed the program’s practices. Restorative justice programing was not scheduled while
the annual compliance review team was on-site; therefore, observations were not possible. An
interview with the FA explained IOC is a restorative justice group provided to all youth who enter
the program prior to release. Within the group curriculum, community service activities are
designed to assist with applying the discussions. Additionally, youth go on outings depending on
their ability to pass a risk assessment. If the youth have already completed IOC, the program
provides clinical groups which focus on youth delinquency. The youth participate in community
service outings where they give water to the veterans and clean-up local parks in the
community. The program also hosts education drives, clothing drives, and toy drives throughout
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the year. The interviewed designated mental health clinician authority reported youth are
encouraged to practice the skills they have learned in group in all settings such as in groups, on
the living unit, during recreation, during individual therapy, during family therapy, and in class.
Seven interviewed youth reported they participate in IOC, complete community service hours,
watch videos on restorative justice, role play on how behavior affects others, participate in
restorative justice discussions, and participate in toy drives by wrapping gifts. Each of the
seven-youth reported they practice skills learned in groups, through writing, and through
practicing “friendly acts.”
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program maintains a written policy and procedures to ensure all staff are made aware of
medical, mental health, and safety and security issues pertaining to all youth through an alert
system. The program’s medical, mental health, case management, and administrative staff
enter and update alerts as applicable. The program maintains a written internal medical alert
list, a dietary alert list, documents youth alerts in the logbook, maintains a master alert board
accessible to all staff, and utilizes the Department’s Juvenile Justice information System (JJIS)
for alert maintenance as required. A review of seven youth records reflected the youth were
applicable for twenty-nine separate alerts. All alerts were entered by the appropriate case
management, medical, and/or medical staff. Alerts were updated and removed as required. A
review of alerts verified JJIS alerts correlated with the programs internal alerts system. A list of
allergy and dietary alerts was observed in the kitchen during the program tour. The interviewed
facility administrator reported the program utilizes an internal alert system to include an alert
roster and alert board which details all applicable youth alerts. Any change in a youth's alert
status is updated on the board as well as documented in the shift logbook. The outgoing shift
supervisor will brief the incoming shift of any new/changed alerts. In addition, any change/new
alerts are discussed during the morning management meeting. The interviewed nurse explained
all medical alerts are entered, verified, and updated by the program’s medical staff. Seven
interviewed staff reported the program documents alerts in an alert book, alert information is
provided by the supervisor, there is an alert board, the program sends alert emails, staff will
personally inform each other of alerts, and step-down alerts are announced over the radio.
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1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program maintains a written policy and procedures to ensure the management of all
records are consistent across operations and programs, and consistent with legal and
contractual requirements. The program maintains separate medical, mental health and
substance abuse, and case management records. A review of seven youth case management
records verified each documented the youth’s name, Department identification number, date of
birth, county of residence, and committing offense. Each case management record contained
sections which included legal information, demographics, chronological information,
correspondence, case management, treatment activities, and miscellaneous. Each record was
clearly marked “confidential” and secured in a locked cabinet within a locked office, inaccessible
to youth.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program maintains a written policy and procedures regarding the community advisory
board. The program’s facility administrator (FA) also serves as the community relations director
and is responsible for soliciting members and hosting meetings for a community advisory board.
The program coordinates with other programs on the same property for the hosting and
coordination of the meetings quarterly. A review of the community advisory board meeting
invitations, agendas, and meeting minutes verified the program held advisory meetings in
March, May, August, and November 2023. The members included FAs and administrative staff
from programs located in the same community, a law enforcement representative, a member
from the judiciary community, local business and community partners, a representative from the
school district, a faith community member, and a member from the lesbian, gay, bisexual,
transgender (LGBT) community. The board had a total of twenty-four participants.
Documentation also verified the community relations director recruited a victim, victim advocate,
community services representative, and a parent/guardian whose child was previously involved
in the juvenile justice system. In-person and virtual participation was documented on the
reviewed sign-in sheets. A telephone call to a board member confirmed their involvement in the
meetings. The interviewed FA explained meetings are held quarterly and include the review of
an agenda detailing program updates. Following each meeting, meeting minutes are shared
with all board members to inform those who may not have been present. Recruitment letters are
mailed out periodically to solicit new membership and ensure each position on the board is
properly represented.
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1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program maintains a written policy and procedures to ensure staff are provided with an
objective annual performance evaluation. The policy indicates each supervisor shall evaluate
their assigned staff annually and a staff may receive more than one evaluation during a year, as
deemed appropriate by the supervisor. The program completes performance evaluations ninety
days after hire and annually thereafter. The program completes annual evaluations by the end
of the calendar year, not on the anniversary of hire. A review of sixteen job descriptions verified
staff performance standards were clearly identified. A review of seven staff personnel records
confirmed each had evaluations(s) completed in accordance with the program’s policy. Each
staff was evaluated on an established set of performance standards which directly correlated
with the position standards outlined in their job description. The program had twenty vacancies
during the annual compliance review. The interviewed facility administrator (FA) reported the
program has experienced turnover in each department this past year and the trend was due to
staff moving due to promotions. The FA added there has been some turnover in direct care staff
and the focus is always to fill vacancies and maintaining current staff. The program hosts
several celebration weeks, staff outings, and on-campus socials to improve the morale and
boost staff engagement. The Trauma Responsive and Caring Environment (TRACE) champions
team has sponsored staff outings and recently a staff meal. The interviewed FA explained within
ninety days of date of hire, staff are evaluated for performance of job duties. Staff are provided
with feedback and discuss areas needing improvement. The staff and their supervisor develop
goals for the year. Annually, staff are re-evaluated for performance of their job duties. Upon
promotion, a staff may also be evaluated. Five staff were interviewed and four staff stated
performance evaluations are completed after ninety days and one staff reported they haven’t
been at the program for ninety days yet. Additionally, two staff reported evaluations are
completed yearly.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
A review of the program’s contract indicated the program has several special contract conditions
or additional listed services beyond those required in Florida Administrative Code. Additionally
negotiated items include a sensory room, game room, reflection area, “My Voice Matters
Meetings”, the use of volunteers, mentors and community members, specialized training in “Girl
Centered Practice Principles”, a subcontract with a behavioral analyst provider, specialized
trauma informed Cognitive Behavioral Therapy (CBT) training, recreation therapist
collaborations with a youth advisory board, regular faith-based opportunities, a transition
calendar, follow-up services provided by a transition services manager, home passes for eligible
youth, career days, and career and technical education (CTE) and Career and Professional
Education Act (CAPE) programming. Reviewed documentation, on site observations and
interviews with the regional compliance manager and facility administrator (FA) confirmed the
program has a sensory room, game room, and reflection area which are utilized by all youth and
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intertwined with the behavior management system (BMS). The program follows the “My Voice
Matters” model for youth communication and program improvements. The program partners
with animal therapy and faith-based volunteers and community members for activities, career
days, and substance abuse activities. The program utilizes “Girl Centered Practice Principles,”
contracted behavior management services, and trauma informed CBT. The program has
specialized training provided to all therapists and monthly fidelity training sessions with clinical
staff. The program’s recreation therapist works with the youth and staff to develop wellness
goals and incentive calendars. Additionally, the transition services manager (TSM) provides
transition preparation and follow up services to all youth. The interviewed FA reported the
program offers negotiated items such as career day, health fairs, and contract indicated
positions. Five interviewed youth reported the program has a sensory room, game room, and
reflection area. Youth also confirmed the program holds “My Voice Matters” meetings and
regular faith-based activities.
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 shall provide Florida Ready to Work - Soft Skills, cardiopulmonary resuscitation
(CPR)/first-aid, Occupational Safety and Health Administration ten-hour course (OSHA-10) and
an industry certification from the master credentials list. Additionally, employability and career-
themed courses shall be available based upon need and interest and shall include Business
Education, Career Planning through Choices, and ServSafe Certification. The two staff
members who provide the instruction are certified and trained to offer CPR/first-aid, Florida
Ready to Work - Soft Skills and OSHA-10. Additionally, they are trained to be proctors to offer
Entrepreneurship and Small Business in accordance with contract requirements. Career and
technical education (CTE) services are offered on Fridays from 11:30 a.m. to 12:30 p.m. and on
Sundays from 11:00 a.m. to 1:00 p.m. The number of youth currently enrolled in courses or
have completed a certification or received a certificate of completion include thirty-one youth
enrolled in CPR/first-aid, forty-two youth participated in OSHA-10, forty youth enrolled in Florida
Ready to Work, fifty-six youth participated in Safe Staff certification and six attended forklift
training. Thirty youth received the CPR/first-aid certification, eight youth received the OSHA-10
certification, six received forklift operator certifications, four received their Florida Driver’s
permit, and nine received their Safe Staff ServSafe certification. Additional courses offered
which differ from the contract include the Florida driver's permit course, and the forklift
operations online certification. Seven youth were interviewed regarding what CTE they
participated in, and responses included forklift operator, CPR, and ServSafe. Youth reported
participating in CTE services on weekends and weekdays. One interviewed youth reported not
participating in CTE services due to already completing school and assisting other youth. The
interviewed facility administrator (FA) reported employability and career-themed courses shall
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be available based upon need and interest and shall include business education, career
planning through Choices, and ServSafe certification. The FA reported all youth participate in
CTE services.
1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program and provider have several different tools that are utilized for the purpose of data
collection and analysis. Aggregate data is accumulated through program dashboards, electronic
records systems, survey completion, and use of the Department’s Juvenile Justice Information
System (JJIS). The provider utilizes data on a daily, weekly, monthly, quarterly, and yearly basis
to inform their policy development and programming staff. Data flows from the program level to
the senior leadership level and back on an ongoing basis. The movement of data vacillates
freely through multiple management levels. Data is evaluated for both risk and protective trends
as well as for forecasting trends that can impact compliance or programming. Determinations
are made and reviewed with staff during daily management meetings and monthly all staff
meetings. Additionally, trends are reviewed for possible policy changes or if necessary ancillary
trainings. Revised policies and surveys are discussed with the facility administrator during their
monthly one on one meetings with senior leadership and then with all staff during monthly all
staff meetings. If necessary, changes are made programmatically and discussed with both staff
and youth. An example of a programmatic change implemented due to survey collection is the
provider changing food vendors following feedback from youth, staff, and families. Reviewed
documentation supported this practice. The program reported information is also shared through
community advisory board meetings and public website postings.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
Seven youth case management records were reviewed, and each contained a note on the
intake chronological form notating the parent/guardian was notified by telephone, of the youth’s
admission, within twenty-four hours of admission. Each of the seven records contained
documentation confirming the parent/guardian was notified in writing of each youth’s admission
within forty-eight hours of admission. All seven records contained documentation the court and
juvenile probation officer (JPO) were notified of the youth’s admission within five working days
of each youth’s admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
Seven youth case management records were reviewed to confirm each youth was provided with
a program orientation upon admission. Documentation in each youth record confirmed
orientation was completed on the day of admission. The program had one admission during the
annual compliance review week; however, the program did not notify the review team of the
arrival of the admission; therefore, a youth orientation was not observed during the review week.
A review of the program’s orientation process confirmed all the elements of the program’s policy
were included. Seven youth were interviewed regarding the program’s orientation process. Five
youth stated orientation was started within twenty-four hours of admission. Two youth indicated
it was not. One of the two-youth indicated no one talked to them and they had to figure it out on
their own. The program’s process is for each youth to sign a form acknowledging receipt of the
orientation process, in which all seven reviewed youth did acknowledge.
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.
Seven youth case management records were reviewed, and none were eighteen years of age
or older. A request was made to the program for a sample of three youth records for youth over
the age of eighteen. There was only one youth eighteen years of age or older in the program
during the week of the annual compliance review. The one youth case management record was
reviewed and confirmed a written consent was obtained and completed by the youth.
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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 utilizes an admission classification form, which contains all the required elements.
Seven youth case management records were reviewed, and each youth had suspected risk
factors, with exception of one youth. The youth had an open medical alert; however, on the
classification form it was not noted the youth had a medical alert. A review of the Department’s
Juvenile Justice Information System (JJIS) confirmed each youth had a JJIS alert related to
their associated risk. Each youth’s admission classification form confirmed their risk factors
were considered when assigning each youth to a living area, sleeping room, and youth group or
staff advisor. A review of the program’s internal alert system and the Department’s JJIS alerts,
confirmed all alerts were notated as required. According to the program's policy and
procedures, each youth is reassessed, utilizing the youth risk assessment form, monthly during
formal treatment team, which is kept in a centralized binder. In addition, the policy states youth
may be reclassified as the program learns more about each youth. Staff shall reclassify the
youth utilizing the re-classification form for reassignment of living unit, work projects, off-campus
activities, freedom of movement, or privilege changes, and at the request of the facility
administrator (FA) or designee. The program’s process addresses, at a minimum, items outlined
in Florida Administrative Code. A review of the seven youth case management records
confirmed each youth was reassessed monthly, since their admission to the program. None of
the seven-youth participated in any work projects or activities involving the use of tools since
their admission to the program. None of the seven-youth participated in any off-campus
activities requiring a completed reassessment. The interviewed FA stated each youth's living
unit/room placement is based on alerts identified during the admission classification process.
During the admission classification process, input is solicited from the youth and the youth's
parent/guardian to assist in making this determination. The FA meets with the healthcare staff
monthly and as needed.
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.
Seven youth case management records were reviewed and three were applicable for gang
involvement. Local law enforcement and each youth’s home county law enforcement agency
were notified of suspected gang activity/gang affiliation for each of the applicable youth. The
notifications were made prior to the program’s notification of their annual compliance review. A
review of the program’s internal alert system and the Department’s Juvenile Justice Information
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System (JJIS) alerts confirmed all alerts were entered as required. A review of each applicable
youth’s case management record confirmed educational staff and each youth’s juvenile
probation officer were notified of the youth’s gang status.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program’s process is for each youth identified as a gang member to receive Impact of
Crime as their gang prevention and intervention strategy. The provider is working with the
Department's Programming and Technical Assistance staff to provide additional Department
approved gang prevention and intervention strategies. The program also utilized Thinking for a
Change (T4C) as one of the gang prevention and intervention strategies. Seven youth case
management records were reviewed and three were identified as a gang member or affiliated
with a gang. The three applicable records contained documentation confirming each youth
participated in gang prevention and intervention strategies. Each of the applicable youth’s
Individualized Performance Plans (IPPs) included goals and objectives related to gang
intervention strategies which the youth were scheduled to complete prior to their release from
the program. Additionally, the program provides ARISE: Fifty Stories of Fractured Lives
curriculum, as well as addressing delinquency in various groups, such as Moral Recognition
Therapy and Aggression Replacement Therapy. Lastly, therapists target antisocial traits and
delinquency behaviors in treatment plans. A review of the program’s policy and procedures
confirmed the case manager will develop a plan to disaffiliate with a criminal gang, if the youth
so desires. The facility administrator stated, upon admission, a review of each youth’s history
and/or alerts is conducted to confirm if a youth is affiliated with a gang. If a youth is identified as
having gang involvement/membership/affiliation, the youth is issued a gang intervention goal on
their IPP. Youth will be provided with various materials to educate them on the risks of being
involved in a gang through the duration of their commitment. A gang binder is maintained which
contains the youth's goals, a security threat group questionnaire, and copies of notifications
made to law enforcement.
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 ensure the initial Residential Assessment for Youth
(RAY) and RAY reassessments are completed within the required timeframes. Seven youth
case management records were reviewed and confirmed an initial RAY was completed within
thirty days of the youth’s admission and each assessment was maintained in Department’s
Juvenile Justice Information System (JJIS). Six of the seven youth were applicable for ninety-
day reassessments and each record confirmed reassessments were completed as required.
Three of the six youth had documentation in the case management record of the full
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reassessment. The remaining three youth records contained the RAY Comparative Report.
After discussions with the program staff, it was confirmed the non-secure youth records all
contained the full reassessment and the secure youth contained the comparative report.
Program staff indicated the practice would be updated and all youth records will now contain the
full reassessment documentation.
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 ensure a Youth Needs Assessment Summary
(YNAS) is completed on each youth within thirty days of the youth’s admission. A review of
seven youth case management records confirmed each youth had a YNAS completed within
thirty days of their admission. Each YNAS was completed in the Department’s Juvenile
Justice Information System (JJIS) as required.
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 youth’s
Individualized Performance Plan (IPP) within thirty days of the youth’s admission. A review of
seven youth case management records confirmed each youth had a performance plan
developed within thirty days of their admission to the program. Each plan was developed after
the Youth Needs Assessment Summary (YNAS) and Residential Assessment for Youth (RAY)
were completed. Each plan was developed with all members of the treatment team to include
the treatment team leader, youth, administrative representative, living unit representative,
treatment staff, educational staff, parent/guardian, and any additional parties who had significant
responsibilities in goal completion. Five of the seven youth records had documentation of their
parent/guardian participating in the development of the youth’s individualized plan. Two of the
youth had documentation indicating involvement with the Department of Children and Families
(DCF). One of the two youth had documentation to indicate the DCF case worker participated
by phone and the other youth had documentation of the parent/guardian and DCF case worker
participating by phone. There was no documentation in the youth records to indicate the
signature sheet was returned from the parents/guardians. The original signed copy of the plan
was maintained in six of the seven records. The seventh record contained a copy of the
signature sheet. Interviews with program staff indicated this was an oversight and the signed
original document was mailed in lieu of a copy. A review of each plan confirmed goals were
individualized, included the youth’s top three criminogenic needs, and goals were related to
specific delinquency interventions. Additionally, each plan included target court-ordered
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sanctions, transition activities, youth and staff responsibilities in completing the goal, and target
dates for goal completion. A copy of each plan was sent within ten working days to the
committing court, juvenile probation officer, parent/guardian, and DCF case worker if applicable.
Seven youth were interviewed, and each indicated they participated in the development of their
plan. Each youth stated they knew the goals they were currently working on, and six youth
indicated they were provided a copy of their plan upon the plan development.
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 performance plan revisions. A review of
seven youth case management records confirmed each youth had performance plan revisions
completed as needed. Plans were revised based on progress or lack of progress towards goal
completion, newly acquired information, or when the Residential Assessment for Youth (RAY)
reassessment results warranted a revision. Two of the seven youth were applicable for
transition activities and both records contained transition activities to be completed within the
last sixty days of the youth’s stay.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program has a policy and procedures to outline the process for performance summaries
and transmittals. A review of seven youth case management records found five youth were
applicable for ninety-day performance summaries. Each of the five applicable youth had
performance summaries completed every ninety days following the signing of the performance
plan, as required. Additionally, one of the seven youth was applicable for a release/discharge
summary and documentation confirmed the release/discharge summary was completed as
required. All summaries addressed the youth’s status on each performance plan goal,
treatment progress, academic status, behavior, level of motivation/readiness to change,
interactions with peers and staff, overall behavior adjustment to the program, and significant
positive and negative events. Documentation confirmed each youth was allowed to read and
add comments prior to signing the summary and the youth was provided a copy of the
summary. Five of the applicable youth case management records contained the original
summary in the youth’s record, with the exception of one youth record which had one
performance summary which was a copy and not the original. Interviews with program staff
indicated this was an oversight and the original summary was mailed in lieu of a copy. Each of
the summaries were signed and dated by the treatment team leader, staff preparing the
summary, facility administrator, and the youth. Each record contained confirmation a copy of the
summary was sent to the youth’s committing court, juvenile probation officer (JPO), and
parent/guardian or Department of Children and Families (DCF) case worker within ten days of
completion. A review of three closed youth case management records was completed and
documentation confirmed each release summary was sent with a justification for release and
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the Pre-Release Notification (PRN) to the JPO at least forty-five days prior to the youth’s
anticipated release date. Each record included a copy of the release summary. None of the
three records had a court object to the youth’s release and an approved PRN was provided to
the program. Upon approval, the program sent written notification of the planned release to
each parent/guardian. After receiving the approved PRN, an exit Residential Assessment for
Youth (RAY) was completed for each youth. None of the three youth were applicable for the
Sexually Violent Predator Program (SVPP) and none required a letter to be mailed to the victim
informing them of the youth’s anticipated release.
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.
Seven youth case management records were reviewed to confirm parent/guardian involvement
in each youth’s case management services. Documentation in each youth record confirmed
parent/guardian involvement in the assessment process, participation in the development of
each youth’s Individualized Performance Plan (IPP), progress reviews, transition planning, and
each were provided advanced notice of formal treatment team meetings including the dates and
times. In the event the parent/guardian were not able to attend, there was documentation in
each of the seven youth records confirming their participation by telephone. Four treatment
team meetings were observed during the week of the annual compliance review. All four
parents/guardians were contacted by telephone and participated in the youth’s treatment team
meeting. The program provides a parent handbook and parent/guardian input form, by mail, to
the parent/guardian during the admission process. The program holds a “Family Day” quarterly,
with the most recent day being held on December 15, 2023. The program has family visitation
on Saturday and Sunday's from 2:00 p.m. to 4:00 p.m. each week. The facility administrator
indicated parent/guardian engagement is encouraged through the duration of the youth's
commitment. Every attempt is made to ensure the parents/guardians are included in the
admission process, admission classification, youth assessments, and monthly youth treatment
team meetings. They are invited with ample notice to all youths’ treatment team and transition
meetings and encouraged to provide input/feedback regarding youth treatment. Youth are
provided a weekly telephone call with their parent/guardian. Upon intake the program sends
parent/guardian surveys to each parent/guardian to receive feedback on the admission process
and an exit survey which provides feedback on their overall experience with the program during
their youth's commitment. Seven interviewed youth indicated their parents/guardians
participated by telephone during their performance reviews.
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 to ensure the youth’s performance plan shall
reference or incorporate any of the youth’s other treatment or care plans such as mental health,
substance abuse, education, vocational, or Department of Children and Families (DCF) service
plans, as applicable. A review of seven youth case management records found each youth’s
performance plan incorporated or referenced the youth’s mental health/substance abuse
treatment plan and education plans. Two of the seven youth were applicable for involvement
with DCF. One of the two applicable youth had documentation to confirm the youth’s
performance plan incorporated the DCF plan. The other applicable youth’s performance plan did
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not include incorporation of a DCF plan. Interviews with program staff indicated the DCF plan
not being incorporated into the youth’s plan was an oversight.
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 holds both formal and informal treatment team meetings for each youth. A review
of seven youth case management records confirmed each of the seven participated in both
formal and informal treatment team meetings, alternating each meeting every two weeks.
Documentation for all formal and informal treatment team meetings, for each youth, included the
youth’s name, date of the treatment team meeting, all attendees, both required and optional,
comments from treatment team members, a brief synopsis of the youth’s progress in the
program, Individualized Performance Plan (IPP) revisions, progress on IPP goals, positive and
negative behaviors, behaviors resulting in physical interventions, treatment progress and
Residential Assessment for Youth (RAY) reassessment results. Documentation also confirmed,
each youth was provided an opportunity to demonstrate skills acquired in the program. Each of
the seven youth case management records contained all formal treatment documentation. Each
youth’s juvenile probation officer (JPO), parent/guardian, and any additional attendees were
invited in advance and encouraged to participate and if unable, were provided the opportunity to
provide input. All required staff were present for each of the seven youth. An observation of four
treatment team meetings was completed during the annual compliance review week. All
required parties were in attendance for all four meetings. The education staff provided written
input for three of the youth. The parent/guardian was present by telephone for all four youth.
The assigned JPO was present for two of the youth, and an alternate JPO stood in for one of
the youth, since their JPO was not available, and the remaining youth's JPO was not available;
however, a transition provider staff was present for this youth. All JPO and transition staff
participated by telephone. Each youth utilized the program’s treatment team presentation form
to discuss their goal updates, therapy status, education status, and any medical concerns. The
treatment plan was reviewed for each of the four youth, determining each youth’s anticipated
release date. Seven youth were interviewed and confirmed staff review the youth's progress
including negative and positive feedback and progress on goals. Six of seven stated they are
given an opportunity to demonstrate skills they have learned and discuss their input/feedback
regarding the program.
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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 to ensure each youth’s successful transition to the
community upon release from the program. A review of three closed youth case management
records confirmed a transition conference was held for each youth at least sixty-days prior to
their anticipated release date. Documentation confirmed the youth, treatment team leader, and
facility administrator or designee attended the transition conference. Other treatment team
members including the parent/guardian, juvenile probation officer, educational staff, and other
pertinent parties were ablet to provide written input prior to the transition conference if unable to
attend in person. During each conference, participants reviewed and revised transition activities
on the youth’s performance plan, identified target completion dates and persons responsible for
completion of each activity, and attendees signed and dated indicating acknowledgement of the
transition activities and accountability for completion. Two of the three youth records had
documentation to confirm a copy of the plan was sent to attendees who were not present during
the conference. All attendees attended in-person for the conference for the third youth. Each
youth’s parent/guardian participated by telephone and a copy of the plan was sent with a
request for return with a signature. A Community Re-Entry Team (CRT) meeting was conducted
for two of the three youth prior to their release. Both youth and their case manager participated
in the CRT meeting and each record contained documentation of an invitation to participate in
the CRT meeting. The third youth was released early by the assigned judge; therefore, a CRT
meeting was unable to be held prior to their release date.
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 youth’s exit portfolio to assist them
once they are released back into the community. Three closed youth case management records
were reviewed and confirmed the exit portfolio was discussed during each youth’s transition
conference. Each exit portfolio included a copy of the youth’s transition plan, a calendar with
dates, times, and locations of upcoming community appointments, educational and/or vocational
certificates earned in the program, educational records and school transcripts, a résumé, and a
birth certificate. Two of the three records contained a completed sample employment application
and a state-issued identification card. The third youth record did not include these items as the
youth was fourteen years of age upon admission into the program. Two of the portfolios also
included the youth’s Social Security card. The third youth record did not contain the card. Staff
indicated the parent had refused to provide the Social Security card to the program. Two of the
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three portfolios were verified during their exit conference. The third youth did not have an exit
conference due to being released early by the judge prior to their anticipated release date. Two
of the three youth were released and transported through the Departments transportation
system to a detention center; therefore, their exit portfolio was provided to detention staff upon
their release from the residential program. The third youth record had documentation to confirm
the exit portfolio was provided to the youth upon her release from the program. Documentation
in each of the three youth records confirmed all exit portfolio information was sent to the youth’s
juvenile probation officer following the release of the 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 to ensure an exit conference is held prior to the
youth’s anticipated release date. A review of three closed youth case management records
found two of the three documented an exit conference conducted at least fourteen days prior to
the youth’s release date. The remaining youth did not have an exit conference as the youth was
released early by the judge prior to their anticipated release date. The two applicable exit
conferences were held after notification to the juvenile probation officer (JPO) of the youth’s
anticipated release. Each conference was held separate from the transition conference and
Community Re-Entry Team (CRT) meeting. Documentation for each exit conference included
the date of the conference, signatures of those who participated in person, and a summary of
pending transition goals. Additionally, documentation confirmed the treatment team leader,
parent/guardian, education representative, JPO, youth, and other pertinent parties participated
in each conference. A review of the youth’s case management records and the Department’s
Juvenile Justice Information System (JJIS) confirmed the admission and release dates for each
youth were accurately reflected within JJIS.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program maintains a youth advisory board (YAB), where youth can apply for a board
position by completing an application. During the annual compliance review week, the program
provided YAB meeting minutes, which were reviewed, confirming the program has regularly
scheduled meetings. Meetings were held weekly when possible; however, at a minimum a
meeting was held monthly since the last annual compliance review, as required by the
program's policy and procedures. The youth can submit a “My Voice Matters” form to express
concerns which allow the youth to suggest ways to resolve any concerns at the program. The
program holds daily meetings, which are led by youth in the program. In the meeting youth go
over daily praises, apologies, issues, and general announcements. During the week of the
annual compliance review, observations were made of the daily meeting. A review of youth
surveys confirmed the surveys were completed monthly. Seven youth were interviewed and four
stated they are able to submit a “My Voice Matters” form as a method to provide input regarding
the program. One youth stated they would ask a supervisor for assistance if they wanted to
provide input. Two youth stated they were not sure how they would provide input. The facility
administrator (FA) stated youth are able to provide input or feedback by way of a “My Voice
Matters” form, grievance form, and during the daily meeting. At minimum monthly, a community
circle is held for youth to be able to express issues, concerns, and positive
information/feedback. In addition, the YAB is in effect for the youth to provide input. The YAB
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meets bi-weekly, and suggestions and input are provided to the FA for review and approval. In
addition, the FA stated the Trauma Responsive and Caring Environment (TRACE) surveys
provide feedback from the youth and staff, which have been utilized to improve the program.
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 the Hillsborough County School District. The program provides vocational
competency development programs to all youth. The interviewed facility administrator (FA)
indicated the career opportunities provided to the youth include Occupational Safety and Health
Administration certifications (OSHA), first-aid, and ServSafe. The program also partnered with
their local Career Source to offer career education services to the youth. The interviewed lead
teacher indicated all youth are enrolled in career and technical education classes which lead to
certifications upon completion, as well as being given the opportunity to engage in the Florida
Ready to Work platform, which provides employability skills. The courses are all age appropriate
and aligned with the youth’s educational abilities and goals. Three closed youth case
management records were reviewed, and two of the three included sample completed
employment applications, a résumé, and a State of Florida dentification card. The remaining
youth record only contained a résumé; however, the youth was only fourteen and was not
required to have an identification card or a sample application. The local Career Source
information was present in two of the three 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 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. The program’s activity schedule differed in school times when compared to
the schedule provided by the instructional staff. Youth are enrolled in academic courses through
Hillsborough County School District and receive credit, as appropriate, when courses are
completed. Two of the seven youth interviewed indicated there are no interruptions during the
school day, while five stated there are interruptions resulting from the therapists coming and
taking youth out of class, the class being loud, and fights. One youth also stated the teachers do
not provide instruction. A minor deficiency was assigned to this indicator on November 9, 2023,
verified on December 21, 2023, and closed on January 10, 2024. A sample of three logbook
and video reviews, since the closure of the deficiency on January 10, 2024, showed two classes
being up to twenty minutes late on two of the reviewed days, which resulted in youth not
receiving the required educational minutes. Additionally, youth movement was verified by the
video review for the same three days, as there was some missing documentation of youth
movement in the logbook for January 17, 2024.
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2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The program has a written policy and procedures regarding an educational individualized
transition plan (ITP). Three closed youth records were reviewed, and all three had an education
ITP developed upon entry based on each youth’s post-release goals. All key staff related to
transition activities were included and the plans were developed with the youth,
parents/guardians, program staff, education staff, and aftercare staff involved. The transition
plans placed specific monitoring responsibilities on individuals responsible for the reintegration
and 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. Five of seven interviewed youth
indicated they were involved in the development of their education ITP, while one reported they
were not, and one youth reported they have completed school. 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, five youth responded they were being
very well, or well prepared, while two stated not well. The two youth who reported not well
added “there are no teachers to help” and one stated they would “be slow” when they are
released. The youth did not offer any clarifying information and the information was shared with
the program administration during the annual compliance review.
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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 employs a licensed mental health counselor (LMHC) who serves as the
designated mental health clinician authority (DMHCA). The DMHCA has a clear and active
license in the State of Florida which expires March 31, 2025. The DMHCA is a full-time
employee responsible for the coordination and implementation of mental health and substance
abuse services at the program, which was confirmed through a review of the program’s contract
and the DMHCA’s position description. The program’s back-up DMHCA is their full-time
psychologist who has a clear and active license in the State of Florida which expires May 31,
2024. An interview with the DMHCA confirmed their role at the program and their responsibility
for overseeing treatment services, ensuring services comply with all requirements, ensuring all
youth receive appropriate services, overseeing the fidelity of services offered, and ensuring all
services and documentation is completed accurately and timely. The DMHCA reported they
communicate with the clinical team daily to ensure the coordination of services in addition to
weekly supervision and regular fidelity monitoring.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
A review of the program’s contract found the program is required to have one licensed assistant
clinical director, a full-time psychologist, and a psychiatrist to provide services to youth, in
addition to the designated mental health clinician authority (DMHCA). The program’s staff roster
confirmed the program employs two assistant clinical directors and a psychologist, and
contracts with a psychiatrist, meeting the requirements outlined in the contract. The two
assistant clinical directors are both licensed mental health counselors (LMHCs) with clear and
active licenses in the State of Florida, with expiration dates of March 31, 2025. One additional
LMHC provided intermittent services during the annual compliance review period, and they also
had a clear and active licensed with an expiration date of March 31, 2025. The psychologist was
found to have a clear and active license expiring May 31, 2024, and the psychiatrist is a medical
doctor with a clear and active license expiring January 31, 2025. The DMHCA is responsible to
ensure all licensed staff provide services they are qualified to provide, which was confirmed
through an interview with the DMHCA and review of youth records. A program tour found all
licenses for the clinical staff to be available and posted on-site.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The designated mental health clinician authority (DMHCA) is responsible for ensuring all non-
licensed staff are providing services they are qualified to provide. A review of the program’s staff
roster found the program has four non-licensed clinical staff who were the only non-licensed
clinical staff utilized during the annual compliance review period. Each of the four non-licensed
staff are master’s level clinicians approved by the Department’s Office of Health Services to
serve in their role. Each staff also had documentation they completed training and supervision in
the facilitation of Assessments of Suicide Risk (ASR). A review of the contract confirmed the
program is meeting the staffing requirements for non-licensed clinical staff. The program’s
contract also requires two recreation therapists. The staff roster confirmed the program currently
has one recreation therapist, and the other position had been vacant for less than thirty days at
the time of the annual compliance review. Two additional recreation therapists provided services
during the annual compliance review period. A review of education and experience for the three
recreation therapists found each possessed the education and experience requirements
outlined in contract. The DMHCA provided weekly face-to-face supervision for all non-licensed
clinicians without exception for the annual compliance review period. Each non-licensed
clinician received supervision each week they provided services. Supervision was documented
on a form containing all elements of the Department’s Licensed Mental Health Professionals
and Licensed/Certified Substance Abuse Professionals Direct Supervision Log form. The
program has a Chapter 397 license through the Department of Children and Families to provide
substance abuse services to adolescents which expires on September 9, 2024, allowing non-
licensed clinicians to provide substance abuse services under the supervision of the licensed
staff.
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 outlining their standardized mental health and
substance abuse screening and referral process. Seven youth mental health and substance
abuse records were reviewed, and each youth was screened by a trained staff on the day of
admission utilizing the Massachusetts Youth Screening Instrument – Second Version (MAYSI-
2). The program’s record review forms in each youth record found the screener reviewed
applicable information, including the commitment packet, and reports and/or records for existing
documentation of mental health or substance abuse problems or history of human trafficking.
The MAYSI-2 was completed in full and entered in the Department’s Juvenile Justice
Information System (JJIS) on the day of admission for each youth. Six of the seven completed
MAYSI-2s indicated further assessment was required. Staff determined a referral for the
remaining youth was needed based on their history regardless of the MAYSI-2 findings. A
referral for a comprehensive mental health and substance abuse evaluation was made for all
seven youth. The reason for each referral was documented, and the facility administrator (FA)
and designated mental health clinician authority (DMHCA) were notified for each. Two youth’s
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MAYSI-2s indicated a potential suicide risk and both received an Assessment of Suicide Risk
(ASR) within twenty-four hours. The FA was interviewed and stated the program utilizes the
MAYSI-2, ASR, and the screening for Vulnerability to Victimization and Sexually Aggressive
Behavior (VSAB) to screen each youth at admission. The FA indicated a therapist interviews
each youth and parent/guardian, and each youth’s intake packet is reviewed to obtain
information regarding each youth’s mental health and substance abuse history. A
comprehensive mental health and substance abuse evaluation is completed for each youth
within thirty days of admission.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program has a policy and procedures ensuring youth who are identified as in need of
further evaluation are referred for a comprehensive mental health and substance abuse
evaluation. Seven youth mental health and substance abuse records were reviewed, and each
youth was referred for a mental health and substance abuse evaluation on the day of
admission. A new mental health and substance abuse evaluation was completed by a licensed
mental health professional for each youth within thirty calendar days of admission. Each youth’s
evaluation included identifying information, the reason for evaluation, relevant background
information, behavioral observations, a Mental Status Examination, methods of assessment,
patterns of alcohol and other drug abuse, impact of alcohol and other drug abuse on major life
areas, risk factors of continued alcohol and other drug abuse, interview or procedures
administered, a discussion of findings, diagnostic impression/formulation and clinical impression
including Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
diagnosis, and recommendations. Consent was obtained for substance abuse services for all
seven youth.
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 indicating each youth who is receiving mental health
or substance abuse treatment in the program will have an initial or individualized mental health
and substance abuse treatment plan completed when treatment is initiated. Seven youth mental
health and substance abuse records were reviewed and an initial treatment plan, including all
required elements, was developed, and signed by a licensed mental health staff on the day of
admission for each youth. Each plan was also signed by the youth and all treatment team
members who participated in the development of the plan and included the youth’s psychiatric
needs, including medication and frequency of monitoring by the psychiatrist, if applicable. Each
reviewed youth had an individualized treatment plan, including all required elements, developed
within thirty days of admission. Each individualized treatment plan was signed by the clinical
staff completing the plan, all treatment team members who participated in the development of
the plan, and the youth. All seven plans were completed by non-licensed clinical staff, and all
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were reviewed by licensed staff within ten days of completion. Six youth’s individualized
treatment plans included documentation the parent/guardian participated in the development of
the plan. The remaining plan indicated the parent/guardian did not participate. Each reviewed
youth was receiving psychotropic medications, and each of their individualized treatment plans
included the medications they were prescribed and the frequency of monitoring by the
psychiatrist. Six of the youth’s individualized mental health and substance abuse treatment
plans were reviewed every thirty days utilizing a form which included all required information.
The remaining youth had not been in the program long enough to require a review. Each youth’s
individualized treatment plan included an outline of prescribed services. Goals and objectives
were individualized for each youth. Two mental health groups and one substance abuse group
were observed by video. A review of video and logbooks found mental health and substance
abuse groups were facilitated by the appropriate clinical staff, for the required length of time,
and with the appropriate number of youth. A review of group sign-in sheets since the last annual
compliance review found mental health and substance abuse groups were facilitated by the
appropriate clinical staff, with the appropriate number of youth, for the required length of time,
except for one group which ended eight minutes early, one which ended nineteen minutes early,
and one which ended thirty minutes early.
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.
Seven youth mental health and substance abuse records were reviewed, and each youth was
assigned to a treatment team, which included the youth, program administration, a member
from the residential living unit, medical staff, mental health and substance abuse staff, and the
parent/guardian, upon admission. Education staff provided written input for youth treatment
team meetings. Each reviewed youth was determined to be in need of mental health and
substance abuse treatment. Each reviewed youth had a properly executed Authority for
Evaluation and Treatment (AET) form or court order and a signed consent for substance abuse
treatment. The program has a valid Chapter 397 license, allowing non-licensed staff under the
direct supervision of a qualified professional, to provide substance abuse services. A review of
progress notes for each youth found each youth received individual and group counseling
provided by clinical staff as stipulated on their individualized treatment plans. Five reviewed
youth received family counseling by clinical staff as stipulated on their individualized treatment
plans. One remaining youth received ten minutes less than prescribed family counseling one
month, and the other remaining youth was missing an hour of family counseling for one month
during the annual compliance review period. Three closed youth records were reviewed for
discharge plans. Each youth had a discharge plan documented on the Department’s Mental
Health/Substance Abuse Treatment Discharge Summary form which documented the services
needed for daily maintenance of the positive improvement in behavioral, emotional, and social
skills made by the youth during treatment. None of the reviewed youth were on suicide
precautions at the time of release. Documentation in each youth’s record found the discharge
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plan was discussed with the youth and parent/guardian during the exit conference. Each youth,
juvenile probation officer (JPO), and parent/guardian was provided with a copy of the Mental
Health/Substance Abuse Treatment Discharge Summary.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
A review of the program’s contract and an interview with the designated mental health clinician
authority (DMHCA) confirmed the program provides Intensive Mental Health (IMH) and
Borderline Developmental Disabilities (BDD)/Developmental Disabilities (DD) services to youth.
The BDD/DD youth come into the program identified as such and do not need to receive an
additional developmental assessment upon admission, in accordance with the program’s
contract. The IMH youth are provided weekly individual counseling and bi-monthly family
counseling. For both the BDD/DD and IMH youth, each youth’s treatment plan is individualized
to the youth’s identified needs and the youth are offered appropriate treatment as required.
Youth with co-occurring disorders receive substance abuse services from a clinician under the
supervision of a licensed provider. The program has mental health staff on-site seven days a
week and employs a full-time psychologist. Crisis intervention services are available twenty-four
hours a day, seven days a week. The program’s psychiatrist is on-site weekly to provide all
necessary services to youth as required in the program’s contract. A licensed nurse is on-site
during each shift daily to provide the prescribed medications to youth. A review of the therapists’
caseloads found the counselor to youth ratio was one to ten. Youth assigned to each service
type are provided the required groups as outlined in the program’s contract. Seven youth
interviews were conducted, and each youth reported individual therapy is conducted weekly.
Five youth reported family therapy is every other week, one youth reported staff forget to come
get them for family therapy, and one youth did not indicate how often family therapy was held.
Seven staff interviews were conducted, and each staff reported they do not facilitate group
therapy. The facility administrator reported IMH services are offered to program youth. The
designated mental health clinician authority (DMHCA) was interviewed and reported youth
receive either IMH or BDD/DD services and group therapy is provided five days a week,
individual therapy is provided weekly, and family therapy is provided as prescribed.
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 contracts with a licensed psychiatrist to provide psychiatric services to youth at the
program. The psychiatrist is a medical doctor who was found to have a clear and active license
in the State of Florida, expiring January 31, 2025. Reviewed documentation found the
psychiatrist provided services each week of the annual compliance review period and the
program did not utilize a back-up psychiatrist. The psychiatrist signed a log each week verifying
they discussed each youth’s treatment with their treatment team and met with all required youth
during the visit. All visits were on-site with the exception of two weekly visits in which the
psychiatrist provided tele-health services. Approval for tele-health from the Department’s Office
of Health Services (OHS) was found for both dates. The program does not utilize a psychiatric
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advanced practice registered nurse (APRN). The psychiatric logs and seven reviewed youth
records confirmed the psychiatrist actively participates, manages, and supervises psychotropic
medication services at the program. The psychiatrist was interviewed and reported they direct
the provision of consultation, evaluation, follow-up, and medication services at the program. The
psychiatrist reported they are on-site weekly and meet face-to-face with the medical and mental
health staff during this time. The psychiatrist also confirmed they are available by phone if
needed. The designated mental health clinician authority (DMHCA) was interviewed and
confirmed they meet with the psychiatrist weekly at the psychiatric treatment team where all
youth receiving psychiatric services are discussed. The psychiatrist provides evaluations,
psychotropic medications, follow-up as needed, and is on-call twenty-four hours a day, seven
days a week. Seven youth mental health records were reviewed, and each youth was referred
for a psychiatric interview, as the program’s practice is to refer each youth. Six of the reviewed
youth were admitted with psychotropic medication and one was prescribed psychotropic
medication during the interview. All seven youth received a diagnostic interview, documented on
the appropriate form clearly identifying it as an “Initial Diagnostic Psychiatric Interview”, within
fourteen days of admission. Each youth’s psychiatric interview included the youth’s history, a
Mental Status Examination, a Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5) diagnosis, treatment recommendations, initial treatment goals, prescribed
medications, explanation of the need for psychotropic medication related to the youth’s
diagnosis, target symptoms, potential side effects, risks and benefits of taking the medication,
and frequency of medication monitoring/management. Each youth’s diagnosis was consistent
with their treatment plan. A review of thirty-day medication reviews found six youth who received
psychotropic medications at the program were seen for medication reviews by the psychiatrist at
least every thirty days. The remaining youth had not been in the program long enough to require
a review. Each thirty-day medical review included the completion of page three of the
Department’s Clinical Psychotropic Progress Note (CPPN) form, which included documentation
of identifying data, diagnosis, target symptoms of each medication, evaluation and description of
effect of prescribed medications on target symptoms, prescribed psychotropic medication
names, dosage and quantity, normal dosage range, ordered dosage, frequency and route of
administration, reason for changes in medication and/or dosage, side effects, adherence to the
medication regimen, height, weight, blood pressure, most recent serum levels or laboratory
findings, as appropriate, if there was telephone contact with the parent/guardian to discuss
medication, the psychiatrist’s signature, the date, and applicable monitoring for Tardive
Dyskinesia. Five reviewed youth received tele-psychiatry while at the program and the standard
of care was the same as rendered in-person. Documentation indicated the youth agreed to
participate in each tele-psychiatry session and the parent/guardian provided consent, which was
located in each youth’s record.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a Suicide Prevention Plan detailing their suicide prevention procedures. The
program’s Suicide Prevention Plan includes the identification and assessment of youth at-risk of
suicide, staff training, suicide precautions, levels of supervision, referral, communication,
notification, documentation, immediate staff response, and the review process. The program’s
review process for suicide attempts and mortality review includes the circumstances
surrounding the event, the program procedures relevant to the incident, all relevant training
received by involved staff, pertinent medical and mental health services involving the victim,
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possible precipitating factors, and recommendations, if any, for changes in policy, training,
physical plant, medical or mental health services, and/or operational procedures. The program’s
Suicide Prevention Plan was reviewed by the facility administrator on July 7, 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.
The program has a policy and procedures to ensure any youth exhibiting suicide risk behaviors
is placed on suicide precautions and a minimum of constant supervision. Seven youth mental
health and substance abuse records were reviewed, and four youth were applicable for suicide
precautions. Two applicable youth were determined to be at-risk because of staff observations
and two were determined to be at-risk though self-reporting. Each youth was placed on constant
supervision and referred for an Assessment of Suicide Risk (ASR) upon being determined as at-
risk. Each youth’s precautionary observation (PO) status was documented in the program’s
logbook and each youth was allowed to participate in select activities with other youth in
designated safe areas of the program while on PO. A suicide alert was initiated in the
Department’s Juvenile Justice Information System (JJIS) for each youth. Each youth had an
ASR completed by a licensed mental health professional or clinical staff under the supervision
of a licensed mental health professional on the Department’s ASR form within twenty-four hours
of being determined at-risk. Each ASR included documentation of the youth’s parent/guardian
and juvenile probation officer (JPO) being notified of the potential suicide risk. Upon completion
of the ASR, PO was continued for three youth and the remaining youth transitioned to close
supervision. Mental health staff provided supportive services for each reviewed youth. The three
youth who remained on PO had a Follow-Up ASR completed on the Department’s Follow-Up
ASR form indicating they could be stepped down prior to their removal from PO. Each youth
was stepped down to close supervision prior to the transition to standard supervision. Each
youth was maintained on close supervision until it was determined no longer necessary by a
licensed mental health professional. The discontinuation of close supervision was documented
by mental health staff in each youth’s record. A conference was held with the facility
administrator (FA) and licensed mental health staff before reducing the level of supervision for
each youth and the discontinuation of close supervision was documented in accordance with
the program’s Suicide Prevention Plan for each youth. Each youth’s discontinuation from PO
was documented in the program’s logbook and each youth’s suicide alert was accurately closed
in JJIS following the recommendation to return to standard supervision. One reviewed youth
was applicable for secure observation; therefore, two additional records were requested and
reviewed. Each youth’s placement in secure observation was due to at-risk or suicide risk
behavior and was authorized by the FA or designee and the designated mental health clinician
authority (DMHCA). The secure room was inspected immediately prior to each youth’s
placement to ensure it was safe and secure. The Department’s Health Status Checklist was
completed prior to placement in secure observation for each youth. A staff of the same gender
conducted a visual check of each youth to determine if there were any observable injuries which
would make placement in the secure observation room inappropriate. Each youth was
maintained on one-to-one or constant supervision while in the secure observation room and the
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Department’s Suicide Precautions-Observation Log was completed in its entirety for each. An
ASR or Follow-Up ASR was completed for each youth within eight hours of placement and each
youth was removed from secure observation within twenty-four hours. Each youth’s level was
reduced only after a conference with the FA and a licensed mental health professional and there
was documentation reflecting authorization was received from the FA or a designee and a
licensed mental health professional concurred with the removal from secure observation for
each youth. The discontinuation of secure observation and step-down to close supervision was
documented in the logbook for each youth. Three days of video were reviewed for PO status
youth. A total of five youth were observed on PO during the three days reviewed. Video review
confirmed proper supervision was maintained for each. Seven staff interviews were conducted,
and each staff indicated they should notify mental health and search the youth and room for
sharp objects if a youth expresses suicidal thoughts. Six of the staff also indicated they would
document supervision and five of the staff indicated they would place the youth on constant
sight and sound 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.
The program has a policy and procedures ensuring youth placed on suicide precautions are
maintained on one-to-one or constant supervision. Staff shall provide the appropriate level of
supervision and record observations of each youth’s behaviors at a minimum of every thirty
minutes. Seven youth records were reviewed, and four youth were applicable for suicide
precautions. The Department’s Suicide Precautions-Observation (PO) Logs were maintained for
the duration each youth was on suicide precautions and the appropriate level of supervision and
observations of the youth’s behavior was documented in real time, not exceeding thirty-minute
intervals, for three youth. One thirty-minute observation was not documented for the remaining
youth. Notification to the facility administrator and mental health staff was documented on each
youth’s Suicide PO Log when warning signs were observed. Each youth’s Suicide PO Log was
reviewed and signed by mental health clinical staff and a supervisor from each shift. Safe
housing requirements were documented on each log.
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The program has a policy and procedures to ensure each staff who works with youth is trained
in suicide prevention. Seven pre-service and seven in-service staff records were reviewed, and
each staff received the required training in suicide prevention. The program maintains one
suicide response kit in master control which is co-located with a first-aid kit. A review of suicide
drills over the last twelve months found a mock suicide drill, completed in response to a
simulated suicide attempt or serious self-injury, was held no less than quarterly on each shift for
all staff who come in contact with youth. Staff who were not present during the quarterly drills
were able to review each drill scenario. No program youth were used in drill simulations. A
review of drill documentation found semi-annual drills were held including the use of
cardiopulmonary resuscitation (CPR). The facility administrator (FA) was interviewed and stated
a licensed mental health clinician completed mock mental health and suicide prevention drills
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across all shifts, ensuring all staff members participate in a minimum of one drill quarterly. The
FA stated each drill is reviewed monthly in their general staff meeting. Seven staff interviews
were conducted. Two staff indicated mental health drills were held weekly, four staff indicated
they were held monthly, and one staff were unsure how often they were conducted.
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program maintains a Crisis Intervention Plan which includes notification, the alert system,
means of referral, youth self-referral, communication, supervision, documentation, and review.
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 ensuring a Crisis Assessment is completed when a
youth is in psychological distress which is not associated with suicide risk factors or suicide risk
behaviors. A review of seven youth mental health and substance abuse records found one
youth was applicable for a Crisis Assessment; therefore, two additional youth records were
requested. One additional youth record was provided, in which two Crisis Assessments were
completed, for a total of three Crisis Assessments reviewed. Each Crisis Assessment was
completed within twenty-four hours of the youth being determined to be in crisis. Each Crisis
Assessment included all required information, including the reason for assessment, a Mental
Status Examination and interview, determination of danger to self or others, initial clinical
impressions, supervision recommendations, treatment recommendations, and
recommendations for follow-up or further evaluation. Follow-up treatment was recommended in
two of the three assessments, and notification to the parent/guardian was located for both. Each
Crisis Assessment was conducted by a licensed mental health professional or a non-licensed
mental health clinical staff working under the direct supervision of a licensed mental health
professional. Two youth were placed on precautions following the completion of the assessment
and a mental health alert was entered in the Department’s Juvenile Justice Information System
(JJIS) for each. Both youth remained on alert until a follow-up Mental Status Examination was
completed by a licensed mental health staff. Constant supervision was documented on the
Department’s Mental Health Alert - Observation Log for the duration both youth were on alert.
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None of the reviewed assessments were based on being an alleged victim in a Prison Rape
Elimination Act (PREA) event.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program maintains an Emergency Mental Health and Substance Abuse Plan which
includes immediate staff response, notifications, communication, supervision, authorization to
transport for emergency mental health or substance abuse services, transport for Baker Act,
transport for Marchman Act, documentation, training, and review.
3.17 Baker and Marchman Acts (Critical) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program has a policy and procedures ensuring youth who are believed to be an imminent
danger to themselves or others because of mental illness or substance abuse impairment
receive emergency mental health or substance abuse services. Seven mental health and
substance abuse records were reviewed and none of the youth were applicable for Baker or
Marchman Acts. The program had two youth applicable for Baker Acts and no youth applicable
for Marchman Acts during the annual compliance review period. Both youth were referred and
placed on one-to-one supervision when they were determined to be in need of emergency care.
Mental health staff were involved in both instances, and both youth were taken out of the
program and transported by law enforcement to a receiving facility. Transportation was
authorized by mental health staff in both instances. Both youth were placed on constant
supervision when they returned from their Baker Act. Each youth remained on constant
supervision until an Assessment of Suicide Risk (ASR) was completed by a licensed mental
health professional who conferred with the facility administrator or designee, and it was
determined the supervision level could be lowered.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program has a policy and procedure outlining the on-going safety planning process for each
youth. Seven youth mental health and substance abuse records were reviewed, and each youth
had a Safety Plan which included warning signs, baseline behaviors, crisis recognition, jointly
developed coping strategies, intervention strategies preferred by the youth, and the debriefing
process. Each youth’s Safety Plan was completed on the day of admission and six of the plans
were prepared jointly by the youth, parent/guardian, and clinical staff. The remaining plan did
not have documentation the parent/guardian participated in the development of the plan. Each
Safety Plan incorporated recommendations from clinical assessments and screening
instruments and incorporated trauma responsive practices. Five youth’s Safety Plans were
reviewed and updated at least every thirty days and as necessary following any significant
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behavior or mental health events identified by the youth’s treatment team. One of the remaining
youth had one update completed one day late and the remaining youth had one update
completed five days late. Each youth’s Safety Plan was maintained in the staff break area and
in master control and were available for staff to review. Safety Plans are also discussed in
monthly staff meetings. Seven youth were interviewed, and each youth indicated they
contributed to the development of their Safety Plan. Seven staff were interviewed, and six staff
indicated Safety Plans are located in the staff break room, three staff indicated they are also
located in master control, one staff indicated they are also in case management, and the
remaining staff indicated they are located in medical. Four staff indicated they can review Safety
Plans whenever they want, one staff indicated they are reviewed weekly, one staff indicated if
you want to review Safety Plans you contact a supervisor and let medical know, and the
remaining staff indicated they were not sure of the process for reviewing Safety Plans. Three
staff stated they last reviewed Safety Plans last week, one staff stated they reviewed them two
weeks ago, two staff stated they reviewed them two months ago, and the remaining staff stated
they have never reviewed them. The facility administrator was interviewed and indicated Safety
Plans are completed within fourteen days of admission and are updated every thirty days or
following any significant behavioral or mental health events.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program’s designated health authority (DHA) is a licensed physician who holds an
unrestricted license, meeting all requirements for independent and unsupervised practice in the
State of Florida. The DHA license expires on January 31, 2025. The DHA’s specialty training is
in internal medicine with experience in adolescent health. The DHA does not have any
disciplinary cases or public health complaints on record. According to the contract, the DHA is
required to be on-site a minimum of one hour five times a week. A review of the sign-in sheets
for the annual compliance review period indicated the DHA was on-site, as required. If the DHA
has a scheduled absence, the program has an agreement with another licensed physician to
provide medical care to the youth. The DHA does not use an advanced practice registered
nurse and has not needed to utilize the back-up DHA during the annual compliance review
period. The contract includes the use of tele-medicine in the program’s contract; however, only
in emergency situations and only with pre-authorization. The interviewed DHA confirmed
responsibilities included conducting an initial physical exam, periodic evaluations, sick call, and
referring to specialists as needed. The DHA attested to being on site five time a week as well as
available by telephone and answering service on an on-call basis. The DHA explained off-site
findings are flagged in each youth's chart and reviewed when on-site. The DHA is informed of
any new medical developments and meets with staff quarterly. The DHA did not have any
concerns with the program.
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 is contracted for one full-time registered nurse (RN) to serve as the health services
administrator (HSA), and five nurses. The program currently staffs one HSA, two full-time RNs,
two full-time licensed practical nurses (LPNs), and one part-time LPN. Reviewed license
credentials reflected all nursing staff had a clear and active license, four were State of Florida
licenses and one was a multi-state license. In addition, reviewed documentation confirmed each
of the RNs had current cardiopulmonary resuscitation (CPR) certifications. Interviewed nursing
staff and documentation confirmed the program’s nursing staff is on-site twenty-four hours a
day; therefore, in compliance with the contract requirements. The HSA is on-site, Monday
through Friday, for at least forty hours a week, meeting the contract requirement. A review of
youth Individualized Healthcare Records (IHCRs) and observations of sick call treatment forms
supported the HSA provides supervision to each of the LPNs.
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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 policy and procedures for all health-related protocols utilized at the program.
The designated health authority (DHA), facility administrator (FA), and psychiatrist signed and
dated all treatment policies and protocols on July 5, 2023. Documentation supported on-site
nursing staff reviewed, signed, and dated the cover page for medical policies and procedures,
treatment protocols, and other procedures signifying understanding of the health-related
policies. All newly hired medical staff received a comprehensive clinical orientation to the
Department’s and program’s healthcare policies and procedures conducted by the registered
nurse (RN). If new policies or changes in policies were made during the year, nursing staff
reviewed, signed, and dated a signature page with the specific policy listed and date of revision.
The approval of treatment protocols and/or standing procedures were written and authorized
solely by the program’s DHA.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
Seven reviewed youth Individual Healthcare Records (IHCRs) found five were applicable for an
Authority for Evaluation and Treatment (AET) form. Each of the five applicable IHCRs contained
an AET form signed by all required parties with the word “Copy” legibly stamped on it. Each
AET is valid for as long as the youth is in the program or until the youth’s eighteenth birthday.
Two youth were applicable for court orders in lieu of an AET. Both IHCRs contained the signed
court order authorizing all treatment and procedures. One youth was under the care of the
Department of Children and Families and one youth’s guardian was incarcerated. None of the
youth were eighteen years of age or older. An interview with nursing staff confirmed staff
reviews all projected intakes in the Department’s Juvenile Justice Information System (JJIS) and
validates the AET. New admissions are discussed with case management staff prior to the
youth's arrival. If needed, the assigned juvenile probation officer (JPO) will be contacted through
case management to obtain a new AET. The nurse also stated if a youth is eighteen years of
age or older, the youth would sign a release of information form designating whom medical
information can be released to, as well as what type of information can be released, or
indicating the youth is opting to have no information released. Once a youth turns eighteen, they
can consent for all medical treatment.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for parental notification or
consent. Five IHCRs were applicable for parental notifications for over-the-counter (OTC)
medications beyond those covered by the Authority for Evaluation and Treatment (AET). Each
record contained notification to the parent/guardian. The remaining two youth had court orders
encompassing all medications prescribed. Three applicable IHCRs included documentation of
contact to the parent/guardian in the progress notes when a new medication was ordered. All
seven IHCRs contained written notifications documented on the Department’s Parental
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Notification of Health-Related Care: Medication Management form. The program practice for all
youth taking prescribed psychotropic medications is for the registered nurse to contact each
parent/guardian after each thirty-day medication review with the psychiatrist, which is notated in
the progress notes. Four youth were applicable for a new psychotropic medication, change in
dosage, or discontinuation of medication. Two parental consents were documented as required.
One youth is still waiting on consent from parent/guardian who is currently incarcerated, to
which correspondence is sent through the Department of Corrections. The remaining youth was
in the care of the Department of Children and Families (DCF) and the record had a signed court
order authorizing all treatment and procedures. In all seven IHCRs, the youth’s vaccinations
were verified within thirty days of the youth’s admission. None of the youth needed vaccinations
while in the program. The interviewed nursing staff confirmed parental notifications are
completed each time a youth is seen by a medical provider, usually by telephone, as soon as
possible. The parents/guardians are provided written notification within twenty-four hours, which
includes newly prescribed or discontinued medication notifications. When the youth’s illness or
injury requires emergency medical services or is life threatening the DHA is contacted and
orders are obtained, and parents/guardians are notified. Once a youth returns to the program,
the DHA is notified of hospital orders and diagnoses, and parents/guardians are contacted to
obtain consent for orders. The nurse reported vaccination records are obtained either through
the commitment packet or the Florida Department of Health website, which is reviewed prior to
admission. If a youth is exempt from vaccinations, the appropriate Department of Health
documentation would need to be submitted to the program.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for a Facility Entry Physical
Health Screening (FEPHS) form. All seven FEPHS forms were completed by the registered
nurse (RN) or licensed practical nurse (LPN) on the date of the youth’s admission. One youth
was applicable for being out of the physical custody of the Department three times. The RN
completed a new FEPHS re-screening when the youth returned for each time the youth was out
of custody. The interviewed nursing staff confirmed once they receive an email notification of
potential intakes the medical records are reviewed to ensure that the youth's commitment to the
program is medically appropriate. Medical screenings are completed during admission,
immediately after the youth is searched. The nurse usually completes the screening; however, if
direct care staff completes the admission screening, a nursing staff will document a review on
the screening form. A FEPHS re-screening is completed each time the physical custody of the
youth changes and subsequently returns, and two nursing staff will complete a new body chart
diagram and evaluation.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
A review of seven youth Individual Healthcare Records (IHCRs) confirmed all youth were
provided a general care orientation upon admission to the program through signed orientation
sheets. The covered topics included access to medical care, sick call, what constitutes an
emergency, medication processes, the right to refuse care, what to do in the case of a sexual
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assault or attempted sexual assault, the non-disciplinary role of health care providers, and
universal precautions. Each youth’s participation in orientation was evidenced by each youth’s
signature documented on the Health Education form in the IHCR.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has policy and procedures to notify the designated health authority (DHA) or
designee, by telephone or verbally, of each youth’s arrival at the program and provide
immediate notification when any youth admitted to the program requires emergency care. The
program’s practice is to notify the DHA of all youth admissions including youth with chronic
conditions, medical concerns, or any youth admitted on psychotropic medications. Seven youth
Individual Healthcare Records (IHCRs) were reviewed, and all were admitted with a known or
suspected chronic condition or required a referral to the DHA. Each IHCR had documentation
the DHA was notified within twelve hours of admission. None of the youth were identified as in
need of an emergency response upon admission. All records documented the DHA notification
in the youth’s chronological progress notes. Five youth were applicable for taking psychotropic
medication upon admission and the IHCR documented notification to the psychiatrist. An
interview with nursing staff confirmed the DHA is notified by medical staff on the day of
admission and the notification is documented in the youth’s IHCR on chronological notes.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
A review of seven youth Individual Healthcare Records (IHCRs) found all had a Health-Related
History (HRH) form completed on the day of the admission. Each IHCR indicated the HRH form
was completed prior to the Comprehensive Physical Assessment (CPA) as evidenced by the
signatures and date. In each record, the designated health authority (DHA) reviewed the HRH
form as evidenced by a checkbox on the CPA and a focused note within the admission
documentation. An interview with the registered nurse (RN) confirmed the nurse completes the
HRH on the day of admission and the form is updated as needed or required.
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.
Seven reviewed Individual Healthcare Records (IHCRs) confirmed the program utilized the
Department’s Comprehensive Physical Assessment (CPA) form. All CPAs were completed by
the designated health authority (DHA) within seven days of the youth’s admission to the
program. All seven CPAs documented the youth’s Medical Grade. The program completes a
new CPA for all youth; therefore, no prior CPAs were utilized. All sections of the CPAs were
completed in full utilizing required markings, except for genital exams which were all notated by
the DHA as deferred due to no symptoms. This practice was approved by the Department’s
Office of Health Services. The program does not complete gynecological examinations on-site.
The Department’s Problem List was updated for each youth, when applicable. Each CPA
included documentation of the most recent verified Tuberculosis Skin Test (TST), administered
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at the program by the nurse. The results of the TST were documented on each youth’s CPA and
matched the documentation on the Department’s Infectious and Communicable Disease (ICD)
forms. An interview with nursing staff confirmed the CPA is completed by the DHA within seven
days of admission and annually thereafter. The shot records and a prior tuberculosis test is
reviewed prior to admission, The test is administered during admission by the nurse and
documented in the youth's IHCR. A tracker is utilized to monitor due dates.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
A review of seven Individual Healthcare Records (IHCRs) found all youth were clinically
screened and evaluated for sexually transmitted infections (STIs) on the date of admission. Six
youth were applicable for further evaluation and were referred to the designated health authority
(DHA), which was documented on the Department’s Sexually Transmitted Infections form. The
DHA determines, based on the youth’s risk factors, screening tool, and evaluation, whether to
order testing for STIs. All testing, screening, clinical evaluations, and diagnoses were
documented on the Department’s Infectious and Communicable Diseases (ICD) forms,
excluding the human immunodeficiency virus (HIV) results, and filed in the lab section of the
IHCR. All six youth were evaluated by the DHA and were referred for further testing. Four youth
refused further testing. One IHCR contained documentation all requested testing was
performed. One youth is scheduled for testing; however, has not been at the program long
enough to have the tests performed. None of the youth were applicable for a rescreening. Both
IHCRs’ documentation confirmed each youth was offered pre/post-test counseling, if applicable.
The program’s policy ensures a youth’s HIV test results are only disclosed to the youth, the
youth’s legally authorized representative, health care providers during treatment, the
Department of Health for purposes of reporting, health facility staff committees conducting
program monitoring, medical personnel who have been subject to significant exposure, and
health care facility personnel or agents for healthcare provider who have a need to know during
patient care. Pre and post-test counseling services are provided by the DHA. The one
applicable ICHR documented the youth consented for the HIV test and the results, which were
reviewed by the DHA, were filed confidentially in a sealed envelope marked “Confidential”
consistent with Florida Administrative Code. A review of internal alerts found the youth’s
confidentiality was protected. Six interviewed youth stated they can request an HIV test and one
stated they cannot. The interviewed nursing staff reported, according to the DHA, all youth are
screened for STIs during intake and, if further evaluation is needed, the nurse will notify the
DHA. Documentation is filed in each youth’s IHCR in the corresponding sections. Re-screenings
can be completed at any time, or when required, and documented on the appropriate form. It
was reported youth can request HIV counseling and testing services at intake and this is
documented on the consent form and log. The DHA conducts the HIV pre-counseling, testing,
and post-counseling and the local laboratory completes lab work. The process is documented in
the education record and on the Department's Infectious Communicable Disease form. All
results are sealed, marked confidential, filed in IHCR, and given to youth upon discharge.
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4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for the program’s sick call
process. One youth presented with a similar sick call complaint three or more times within a
two-week period. The designated health authority (DHA) was consulted during the first sick call
and provided orders to follow for all other sick calls. The applicable sick calls were not emergent
in nature. All seven IHCRs documented the Department’s Sick Call Request form was
completed by the youth and by the licensed practical nurse (LPN), which was reviewed daily by
the registered nurse (RN). None of the youth were in restricted housing of any kind. Each Sick
Call Request form and progress notes were documented in accordance with Florida
Administrative Code, including vital signs, treatment, education, and follow-up plans. Each of
the sick call events were documented on the Sick Call Index and on the program’s Sick Call
Referral Log. All the dates listed on the Sick Call Index corresponded to the completed Sick Call
Request forms located in the youth’s IHCRs. Sick call occurs three times daily. Sick call hours
are posted throughout the program, and on the medical office door, cafeteria, and in the living
units for the youth to view. Sick call forms are located on the living units, and in the cafeteria, as
well as with the supervising staff who will give to youth upon request. Nursing staff conducts all
sick calls; however, the program does have procedures for a shift supervisor to review sick calls
if a licensed nurse is not on-site. An exam table and equipment are used to perform sick calls.
Seven interviewed staff advised the nurse reviews and conducts sick calls, and one staff
mentioned the supervisor can if needed. Five of seven interviewed youth stated they are usually
seen within a day of making a sick call request. Two youth stated they are seen withing three
days of making a request. The interviewed nursing staff stated sick calls are conducted in the
clinic three times daily. It was relayed if a youth presents with similar complaints the process for
referring to the DHA is based on if the youth has had the same complaint three times within a
fourteen-day period, or if the protocol treatment appears to be ineffective. All treatment
protocols have been approved by the DHA. The nursing staff reported the program does not use
room restriction; however, the procedure requires an assessment to be documented if a youth is
placed in room restriction. If the youth submitted a sick call request form or is prescribed
medication while in restricted housing the health care staff will address sick call requests and/or
administer medication by the end of each scheduled activity. If a youth is placed in medical
isolation, the health care staff will document daily visits regarding the youth’s health status
and/or health complaint, During the annual compliance review week, a sick call was observed
when a youth requested to be seen by medical staff. Observations validated the program’s
practice when conducting a sick call request. Direct care staff was observed escorting the youth
to the medical office. The direct care staff positioned themselves outside the doorway in order to
maintain youth confidentiality. The nursing staff facilitated the sick call, after identifying
themselves, examining the youth in a private area with no other youth present in the room.
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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.
All seven reviewed youth Individual Healthcare Records (IHCRs) required on-site episodic care.
In each applicable IHCR the on-site care was provided by a licensed healthcare staff
documented in problem-oriented charting. The program’s episodic and emergency care
procedures were reviewed. There was a total of eight first-aid kits. One in the kitchen and seven
in master control, with two kits utilized for transportation. The program has a process for ensuring
contents of the first-aid kits are maintained and stored in accordance with guidelines to prevent
expiration or deterioration. An observation of three first-aid kits confirmed the kits were fully
stocked with designated health authority (DHA) approved contents. The nurse monitors the first-
aid kits weekly and checks for expired contents, which is documented on each first-aid kit as
well as maintained on a master inventory located in medical. The program has one automated
external defibrillator (AED) located in master control. The AED procedure is located with the
AED. The AED batteries and pads are checked by the nursing staff once a month, which was
confirmed by reviewed documentation. The nurse conducted a self-test of the AED in front of
the regional monitor with no issues noted. The battery of the AED was last changed in February
2022 and expires in February 2029. The AED pads were changed in February 2022 and expire
in June 2024. The program has a policy and procedures regarding Naloxone Nasal Spray
(NARCAN®), which is a prescription strength medicine for the emergency treatment of a known
or suspected opioid overdose emergency with signs of breathing problems and severe
sleepiness or not being able to respond. NARCAN® is stored in medical, and all staff have
access and are trained on its administration. A review of the emergency drills confirmed the
program conducted an emergency drill to include cardiopulmonary resuscitation (CPR) and/or
use of the AED at least annually. The emergency medical drills simulated an episodic care event
which called for immediate first-aid, and/or administration of CPR techniques, and the initiation
of emergency procedures to follow when a life-threatening emergency does occur. Direct care
staff have the opportunity to participate in at least one emergency drill annually. Unannounced
and announced emergency drills are conducted at least quarterly on each shift. The program
had a list of emergency numbers which were inaccessible to youth. The emergency numbers
were posted in medical and master control. A review of ten training records confirmed all staff
were trained in episodic, first-aid, and emergency care, and the administration of the epinephrine
auto-injector. An episodic care event was not able to be observed during the annual compliance
review. Seven interviewed staff confirmed they are able to call emergency services if needed.
Six of seven interviewed youth reported they can see a dentist at the program and all seven
stated they can see a doctor, if needed. The interviewed nursing staff was able to relay the
locations and inventories of the first-aid kits and AED. The nurse explained the process for
documenting on-site episodic care and reported off-site episodic care episodes are tracked
through the episodic log. Nursing staff follow a drill calendar and plan drills accordingly. Drills
are conducted on each shift, each month, and the calendar has various drills that incorporate
CPR at least quarterly throughout the calendar year.
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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.
A review of seven Individual Healthcare Records (IHCRs) found four were applicable for off-site
first-aid or emergency care. All applicable IHCRs documented a Department’s Summary of Off-
Site Care Consultation Report form was utilized and documented parent/guardian notification
efforts. Each off-site care was documented on the appropriate log. Reviewed IHCRs had each
applicable discharge documentation filed. The designated health authority (DHA) reviewed and
signed all off-site care findings, instructions, and information for all off-site incidents. Two youth
required follow-up testing, referrals, or appointments. There was evidence indicating referrals
were tracked and both youth received appropriate follow-up care as documented in the IHCRs.
The interviewed nursing staff reported off-site emergency care events and any follow-up
appointments are tracked through the episodic log and nursing coordination, notifying all
necessary parties, and through a nursing calendar and tracker. Once a youth returns, the
hospital orders are reviewed by nursing staff who notifies the DHA and flags all documentation
for the DHA to review on the next on-site visit.
4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
A review of seven youth Individual Healthcare Records (IHCRs) found five were identified on the
Department’s Facility Entry Physical Health Screening (FEPHS) form with a current chronic
condition at admission. None of the youth were identified as having a communicable disease.
All five applicable youth were taking prescribed medication on an on-going basis. All applicable
youth were undergoing treatment for a physical health condition and placed on the program’s
chronic illness list. All five applicable youth were classified with a Medical Grade of five.
Reviewed progress note documentation verified each youth received periodic evaluations at
least every ninety days and all applicable youth received a periodic evaluation prior to renewal
of prescriptions which had expired. None of the youth were applicable for taking anti-
tuberculosis medications or pregnancy. Four IHRCs documented an evaluation was conducted
off-site and the evaluation was documented on the Department’s Summary of Off-Site Care
form, which was signed by the designated health authority (DHA). There was no evidence of
any lapses in care or missed periodic evaluations. The Department’s Problem List was updated
for each youth. The interviewed facility administrator confirmed the procedure for nursing staff to
review youth medical issues and meets with medical staff daily to discuss all medical issues
pertaining to youth. An interview with the DHA confirmed periodic evaluations are completed
every two months and maintains updates through a tracking system. The interviewed nursing
staff reported once youth are identified upon intake or by the DHA to have a chronic condition,
they are placed on the medical tracker for monitoring and tracking of the due dates.
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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.
A review of seven youth Facility Entry Physical Health Screening (FEPHS) found all seven were
taking medication at the time of admission. Each of the youth’s medications were verified prior
to the youth being admitted into the program, with the prescription verification being
documented in chronological progress notes. The designated health authority (DHA) and the
psychiatrist were contacted to obtain an order to resume the specified medications prescribed
prior to each admission. Each youth admitted on psychotropic medication received an initial
diagnostic psychiatric interview within fourteen days. All Individual Healthcare Records (IHCRs)
included a current Practitioner Order form indicating the DHA and psychiatrist continued
prescriptions for the youth. None of the youth were in restricted housing of any kind. Three
youth were applicable for over-the-counter (OTC) medications not listed on the Authority for
Evaluation and Treatment (AET), which were administered according to approved protocols.
The Department’s Medication Administration Record (MAR) was used to document all
medications and treatments for all five reviewed IHCRs. The MARs clearly indicated medication
start and stop dates of the youth’s medications. Only nursing staff delivered medications and
initialed each administered medication entry. There were no undocumented explanations for
lapses or errors in medication administration for any of the reviewed IHCRs. Nursing staff
documented side-effect monitoring weekly on the MAR for all reviewed MARs. Three youth
were applicable for refusing medications and each was clearly marked on the MARs with an
accompanying Refusal of Treatment form signed by youth for each refusal. Each MAR
contained all required elements. None of the youth required parental medications. All youth
prescribed psychotropic medications received medication monitoring every thirty days as
required. There were no standing orders for psychotropic medications, emergency treatment
orders for psychotropic medication, or any pro-re-nata (PRN) orders for psychotropic
medications. Four medication passes were observed during the annual compliance review. The
nursing staff administering medications sole responsibility was to conduct medication pass and
not conduct other activities or supervise youth. Each youth was escorted by a direct care staff
and approached the nursing staff individually. Staff identified themselves and confirmed the
reason the youth was present, and then prepared and administered the medication after
verifying the youth’s allergies and alert status. Nursing staff initialed each MAR and then
observed to ensure the medication was swallowed. The Six Rights of Medication Administration
was maintained for each of the youth. Five interviewed youth stated the nurse provides
medication, and two youth stated they do not take medication. All seven interviewed staff stated
the nurse provides medication. The interviewed nursing staff confirmed a youth's medication
regime is verified at the time of though the review of commitment packet as well as interview
with parents/guardians. The program uses the pharmacy alternative MAR and the Department's
MAR for PRN medications. Nursing staff are always on-site and provide all medications;
however, the program has identified approved non-licensed staff who can provide medications,
who are trained by the registered nurse (RN). Medication pass is conducted four times daily.
The program has a modified Class II Institutional Pharmacy permit and prescriptions are
procured through a contracted pharmacy. A psychiatrist is on-site every week and completes
initial psychiatric evaluations, medication management, psychiatric follow-ups, and individual
therapy.
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4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
A review of the medical equipment classified as sharps confirmed the items were securely
stored and inventoried utilizing a routine perpetual inventory descending count as each was
used and disposed. All medications were identified and secured in a locked medication cart
designated for storage of medications. The medication cart was secured, clean, and organized
with stock items separate from youth-specific medications, as well as different types of
medication, injectables, topical, drops, and liquids were secured separately. All medications
were stored in a separate, secured area, inaccessible to the youth. All controlled medications
had a perpetual inventory and stored separately from other medications behind double locks.
Narcotics are also stored behind two locks. Refrigerated medication would be stored in a
secured refrigerator only used for medication; however, none were on-site at the time of the
annual compliance review. The program’s process for the destruction and disposal of expired or
discontinued medications is for the pharmacist to destroy controlled medications with a
registered nurse (RN) and facility administrator (FA) or designee present. Other medications are
returned to the pharmacy for destruction. A review of documentation confirmed the program
conducts a perpetual and weekly inventory of all sharps and stock over-the-counter (OTC)
medications, with no discrepancies found. The nursing staff maintained a shift-to-shift inventory
of all controlled substances on each youth’s Individualized Controlled Medication Inventory
Record form. The number of pills, tablets, or dosages remaining were documented on the
youth’s Individualized Controlled Medication Inventory Record form after each administered
dosage. Observations conducted of inventory counts of three controlled medications, three OTC
medications, and three sharps found no discrepancies. The interviewed nursing staff reported if
there is a discrepancy in the count of inventory, first a recount is conducted, if the discrepancy
remains, the nurse will then check the weekly inventory tracker. The interviewed nurse stated all
required procedures for securing controlled medications is followed. The consultant pharmacist,
whose license is posted in medical, is on-site once a month and reviews the medication and
expiration dates, in accordance with an agreement.
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 combined Exposure Control and Infection Control Plan located in the
medical and maintenance offices, which is reviewed and signed bi-annually and is available to
all staff. The designated health authority (DHA) and facility administrator (FA) signed the plan in
July 2023. The program’s infection control procedures included prevention, containment,
treatment, and reporting requirements related to infectious diseases, as according to
Occupational Safety and Health Administration (OSHA) federal regulations and the Centers for
Disease Control and Prevention (CDC) guidelines. The plan addresses common childhood
infectious, self-limiting, episodic contagious illnesses, viral and bacterial infectious diseases,
tuberculosis, Hepatitis A, B, and C, human immunodeficiency virus (HIV), infectious diseases
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caused by blood-borne pathogens, other outbreaks or epidemics caused by any other infectious
agent, outbreaks of lice or scabies, Methicillin-Resistant Staphylococcus Aureus (MRSA) and
other antibiotic resistant micro-organisms, food-borne illnesses, bio-terrorist agents, and
chemical exposures. Staff have access to personal protective and the program offers Hepatitis
B immunizations to all staff. The program has a comprehensive process for needle stick post-
exposure evaluation. The program had no instances of infectious diseases in which the local
health department or CDC should have been notified, or any instance involving the quarantining
or hospitalization of at least ten percent of the total population of youth or staff during the annual
compliance review period. In addition, the program had no instances of facility exposure during
the annual compliance review period. The interviewed FA verified the Exposure Control and
Infection Control Plan is maintained in the medical and administration offices and reviewed bi-
annually. The interviewed nursing staff verified the Exposure Control Plan, and the Infection
Control Plan are maintained in master control. Nursing staff conducts infection control trainings
for staff and for youth throughout the year, as well as conducting training to staff bi-annually on
the Exposure Control Plan.
4.19 Prenatal Care/Education Satisfactory Compliance
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
The program had one pregnant youth since the last annual compliance review. There was
documentation prenatal care began immediately upon determination the youth was pregnant
and continued until discharge/transfer and through post-partum. There was evidence of the
designated health authority (DHA) providing routine, focused medical evaluations of the youth’s
pregnancy. The youth was placed on the internal alert system for sleeping arrangements and
vital nutrition and health awareness for staff. There was documentation of the youth receiving
prenatal and/or postnatal care at recommended intervals. The youth was provided education
related to alcohol and drug use, smoking, nutrition, sexually transmitted infections (STIs),
contraception, prenatal care, the birthing process, post-partum care, basic baby care,
child/infant development, and parenting skills. All the education was documented in the
Individual Healthcare Record (IHCR) on the Health Education form. A review of seven in-service
training records found a licensed nurse provided education on girl’s healthcare to staff. The
interviewed nursing staff advised pregnant youth are to have periodic evaluations, pre/post-natal
care, human immunodeficiency virus (HIV) testing, ongoing health education, daily monitoring,
special diets, applicable vaccinations, and family planning education. All youth are routinely
tested at admission for pregnancy, as required by policy. Routine monitoring of pregnant youth
includes daily observations of danger signs related to pregnancy and the DHA is contacted as
needed. 9-1-1 is contacted if the youth is in need of emergency medical services. All pregnant
youth receive a special diet. All non-healthcare staff receive annual training on pregnancy
complications and all youth are provided education in all required topics.
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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 procedure addressing youth supervision which indicates active
supervision is the use of effective and efficient supervision. This includes positive contact,
positive reinforcement, structured activities and random/predictable movement which provides
suitable and timely response to the everyday needs of the youth and an immediate response to
emergencies while maintaining the safety and security of the program. The program’s staff-to-
youth contract required ratio is one staff to five youth during awake time activities and one staff
to six youth when the youth are sleeping. Observations of staff supervising youth were
completed each day of the annual compliance review week. Observations included youth
participating in educational services, daily meeting, mealtime, breaks, line movement, and
during leisure activities. Observations throughout the annual compliance review week supported
the staff to youth ratio was consistently met and staff had positive interactions with the youth
and followed the program’s behavior management system. The program has a daily youth
activity schedule which was posted throughout the program. Observations made throughout the
annual compliance review week supported the daily activity schedule was followed and the
youth were engaged in the activities. All seven interviewed staff indicated an emergency
headcount would be conducted if there was a discrepancy the youth count. Three staff also
indicated the staff would stop all movement until the head count is reconciled.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program’s policy and procedures address the comprehensive and consistent
implementation of the behavior management system. The policy includes a protocol on how
staff will be provided feedback regarding their implementation of the behavior management
system (BMS). The policy includes a list of staff titles and the responsibility of staff knowing the
BMS. The policy also indicated the annual performance evaluation will also address feedback
regarding their implementation of the BMS. Six of the program’s job descriptions included the
implementation of the Positive Performance System (PPS) as a job function. The program
maintains a BMS which is known as the PPS. The PPS has not changed since the last annual
compliance review. The original PPS was reviewed and approved by the provider’s corporate
administration. The contract with the local school board includes an agreement between the
program and the school to use a common discipline plan. The facility administrator (FA), the
provider’s corporate education staff, and the regional compliance staff trained the education
staff in the jointly combined BMS/PPS plan, to include use of the BMS/PPS during school, on
January 15, 2023, and February 24, 2023. There was documentation in all seven youth case
management records to support the youth received information about the PPS during the
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orientation to the program. Information about the PPS is also included in the youth handbook.
Documentation supported all youth received a copy of the youth handbook during the
orientation process. The program’s PPS addresses all required information. The PPS does not
deny the youth any basic rights as a form of punishment. The PPS does not promote group
discipline or punishment of youth by other youth. Seven pre-service training records were
reviewed, and all staff were trained in the program’s PPS. Postings of the PPS were observed
throughout the program. Observations of staff and youth interactions verified staff were adhering
to the PPS when interacting and redirecting the youth. Staff are given the opportunity to provide
the youth with the reasons consequences were assigned during the daily meeting with the
youth. During the daily meeting, the youth are provided an opportunity to explain their behavior
and discuss alternate acceptable behaviors. The program also conducts special treatment team
meetings to address the youth’s negative behavior and discuss the consequences assigned.
The seven interviewed youth were able to explain the difference between each level and how to
move from level to level. All seven youth indicated consequences included not being able to
earn incentives, level freezes, and write-ups. The seven youth provided a list of
incentives/rewards they can earn. The list included daily incentives such as game room access,
games, and various food items. The program also has a boutique store which is offered on a
regular basis and monthly incentives include pizza parties and food from local vendors. Seven
interviewed staff explained the PPS consists of a level system where youth earn points. Six of
the seven staff indicated they received training on the BMS used at the program. All seven staff
stated nothing can be taken away from the youth as a consequence; however, youth would not
earn daily points which would affect their participation in incentive activities. The program’s
facility administrator (FA) indicated the program utilizes a BMS compiled of a series of levels.
The youth complete each level by earning daily points to earn a positive day in the program.
Earning positive days allows youth to also participate in nightly incentive. If a youth has a
behavioral infraction, they will not earn points for the task and after so many deducted points
they will not earn enough points to earn their positive day which hinders their progression in the
level. Additionally, youth can earn a special treatment team referral for more serious behavioral
violations. The youth will meet with the treatment team to provide feedback and share their input
on the situation and together will determine an appropriate consequence. All youth have the
equal opportunity to earn daily points towards a positive day. The amount of points issued are
on a zero, one, and two point rating scale for each daily activity. Youth are issued ongoing
prompts to encourage them to make positive choices throughout the day. All youth have the
opportunity to earn incentives which are provided nightly, weekly, and monthly. Youth also have
the opportunity to utilize their earned points in the boutique. The program utilizes a daily tracker
to manage each youth's progress and as means of communication with the staff/youth of where
the youth is at in the program. Point cards are reviewed daily by the shift supervisor and youth
initial acknowledging the points earned. Any time a point is not earned, the reasoning is
explained on the point card, so the youth and other staff are aware in the event the youth have a
question. Youth are referred to a special treatment team to review all major behavioral violations
and discuss the appropriate consequence. Once the consequence is determined, the treatment
team will ensure the youth understands the expectations to get back on a positive track. The
daily tracker also reflects if the youth is on level freeze. Youth are able to monitor their progress
as they earn positive days. Staff are evaluated from commendable to unacceptable in
participation in the maintenance of the therapeutic milieu of the living unit, enforcement of the
level system or other methods of the BMS/PPS. Ongoing informal fidelity is conducted to ensure
any issues with BMS implementation are addressed timely to avoid systemic issues and re-
training is issued as needed.
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5.03 Use of Room Restriction Non-applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, provide constructive discipline and a system of positive and negative consequences
to encourage youth to meet expectations for behavior, provide opportunities for positive
reinforcement and recognition for accomplishments and positive behaviors, promote dialogue
and peaceful conflict resolution, and minimize separation of youth from the general
population.
Supervisors shall monitor staff implementation of the BMS and ensure the use of rewards and
consequences are administered fairly and consistently in application among all staff.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a total of eighty-five video cameras which were all operational during the
annual compliance review. Video recordings are stored for thirty-days. Staff are required to
conduct room checks every ten-minutes while the youth are behind closed doors. The
completed checks are documented on the ten-minute check log. The program was running two
shifts during the annual compliance review period. A review of three separate video footage
samples of ten-minute checks were compared to the completed ten-minute check logs. Staff
were observed looking in the window of each door as they completed their ten-minute checks.
There was one ten-minute check documented on the check log for January 11, 2024, at 7:00
a.m.; however, was not completed as confirmed by video observation. The program reported
this finding to the Department’s Central Communications Center (CCC). A review of check
sheets for the annual compliance review period supported checks were conducted as required.
The program had a major deficiency assigned for ten-minute checks May 12, 2023, and the
deficiency was closed on August 3, 2023. All seven interviewed staff indicated checks are
conducted every ten-minutes when the youth are placed in their rooms for sleeping.
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5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program maintains a policy and procedures addressing youth census, counts, and tracking.
The policy indicates staff will conduct six formal counts within a twenty-four-hour period. The
results of the formal counts are documented in the master control logbook to include the time
count was called, location and number of all youth, and the time count was cleared. The shift
manager is to conduct a second count when an inaccurate formal count is reported. The policy
also indicates informal counts can be conducted at any time. Informal counts must be
completed whenever youth move in groups, following any outside activity, at the beginning of
each shift, and during any emergency situation, escape, incident, or riot. Throughout the week
of the annual compliance review, formal and informal head counts were consistently completed
and documented in the master control logbook. A review of randomly selected dates and times
in the program logbooks for one full day each month for the past twelve months validated head
counts and were conducted at the beginning of each shift, after outdoor activities, and during
emergency situations. The logbooks also included new admissions, releases, transfers, and
youth temporarily away from the program, as well as documentation of total daily census on
each shift. All seven interviewed staff indicated youth counts are conducted every hour when
master control calls the count and when youth go to their rooms for the night. The staff indicated
emergency counts are conducted when there is a discrepancy with the count, whenever an
emergency happens, if a youth is not accounted for or missing, if the power goes out, and after
a drill. All seven staff knew the current program census at the time of the interview.
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 master control logbook. The program maintains logbooks which are
bound with numbered pages. A review of logbooks for one full day each month of the annual
compliance review period found logbook entries were documented in ink with no erasures or
white-out areas. Errors were struck through with a single line, dated, and initialed by the staff
correcting the error. There were no destroyed logbook entries. All entries included the date and
time of the event, the names of the staff and youth involved, as well as a brief description, the
name, and signature of the staff making the entry. The logbook documentation supported
recreation activities were conducted; however, not at the time indicated on the daily activity
schedule. Logbook documentation included entries for emergency situations, incidents, special
instructions for the supervision and monitoring of youth population counts, perimeter checks,
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transports away from the program, requests by law enforcement to access to youth, admissions,
and releases. The program staff consistently documented internal incidents reported to the
Florida Abuse Hotline and/or the Department’s Central Communications Center (CCC) 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 addressing a key control system. The policy
includes key assignment and usage including restricted keys, inventory and tracking of keys,
procedures addressing missing or lost keys, and the reporting and replacement of damaged
keys. Observations made throughout the annual compliance review week found staff and
visitors’ personal keys were collected upon entering the program lobby and stored in a secured
key box located in master control. Visitors are provided with a numbered visitor badge which
indicates where the keys are stored within the locked cabinet. Staff receive their assigned set of
program keys when they go into master control after they secure their personal keys. Upon
receiving the assigned program keys, the master control staff and the program staff receiving
the keys sign the key logbook, enter the date, key ring number, and time the key was signed
out. When exiting the program for break or at the end of their shift, staff return to master control
where they turn in the assigned key ring and sign the key logbook indicating the key was
returned. Master control also signs the key logbook attesting the program keys were turned in. A
review of the key logbook verified this practice. Observation of the key storage cabinet located
in the administration area of the program and the key storage area in master control confirmed
all keys are stored in cabinets which are locked at all times. There is a secure cabinet located in
master control for restricted keys. The program has a list of staff who are assigned permanent
keys. Permanent keys are assigned to individual employees in writing by the facility
administrator (FA). The staff sign a permanent key assignment sheet acknowledging receipt of
the keys and proper procedures for control of keys. Permanent keys are issued, and staff sign
an acknowledgment form indicating a key identification number and the number of keys issued.
An interview with the master control staff confined there are only certain staff allowed to have
restricted key rings. The only people who have access to open the restricted key box is master
control staff. The restricted keys are maintained in a different locked cabinet then the other key
rings. The program’s policy addresses the process for reporting and replacement of damaged
keys. Staff are to immediately notify the FA if a key is damaged or broken to initiate the repair.
The broken/damaged key, including the key ring, shall be returned to the central lock box and a
new set of keys will be issued. Staff are to complete a repair form so the physical plant manager
can repair the key ring. The physical plant manager has the ability to cut new keys. The
program also uses a vendor to provide cut keys for the program. A review of Department’s
Central Communications Center (CCC) reports verified there were no incidents related to key
control since the last annual compliance review. All key rings are tagged to record the ring
number, keys assigned, and number of keys on the ring. A review of three key rings located in
the key cabinet were observed and compared to the inventory and key log. All three key rings
had the correct number of keys on the ring and matched the key inventory. Three staff were
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informally interviewed about the number of keys on their key ring and the function of each key.
The comparison of the key inventory with the assigned key ring found the number of keys on the
ring matched the key inventory. All three staff were able to explain the function of each key.
Interviews with seven staff confirmed each was knowledgeable of the key control process.
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 maintains a policy and procedures addressing contraband procedures and
prohibited items. The policy identifies materials considered to be contraband and consequences
for when contraband is found in the possession of youth in the program. The policy addresses
searching the physical plant, program grounds, youth, and incoming and outgoing mail. The
policy states staff found in possession of contraband are subject to disciplinary action up to and
including dismissal. The policy delineates the required items considered contraband and law
enforcement will be contacted if contraband items are found. The program’s youth handbook
includes a list of contraband items and informs youth of the consequences if found with
contraband. A review of the room search logs and program logbooks supported unannounced
room searches were conducted at least weekly at unpredictable times. Perimeter checks and
searches of common areas were conducted daily. Documentation supported unauthorized items
such as extra food or pencils and pens was found during room searches and disposed of as
required by policy. There was no documentation indicating illegal contraband was found. A
review of the Department’s Central Communications Center (CCC) incidents since the last
annual compliance review also supported no illegal contraband was turned over to law
enforcement. The facility administrator (FA) explained the program’s process for addressing
contraband items. The FA indicated upon entry into the program, staff and visitors are searched
in efforts to prevent contraband from entering the program. All visitors/staff are noticed of
Florida Statue regarding contraband as it is posted at the entrance doors of the program. In
addition, a list of items identified as contraband are noted within the program’s parent/youth
handbook and the staff handbook. Searches of weekly room and common areas are completed,
and findings are documented on the search log. Any unauthorized item/illegal contraband is
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documented on the log and disposed of properly. Any findings of illegal contraband require
notification/reporting to law enforcement and the CCC. Seven staff were interviewed and asked
to explain the program’s process for youth room searches. Two staff indicated room searches
are completed twice a week. One staff indicated room searches are completed twice a week by
the supervisor. Four staff indicated room searches are conducted weekly by a supervisor. Staff
also indicated if contraband is found, it will be removed from the room and will be documented.
Two staff indicated they were not sure of the process to conduct searches or have not seen a
search conducted.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
Youth are searched before all movement, during a new admission, readmission, when returning
from visitation, when returning from off-campus activities and/or appointments, when suspected
of contraband, or when determined to be a security risk. Observations of youth searches were
made throughout the annual compliance review week. The observations supported the youth
are searched before every movement and searches were conducted thoroughly and
appropriately. Searches were conducted by staff of the same gender as the youth and were
conducted in a way to preserve the dignity and respect of the youth. All staff conducted youth
searches in the same manner and the searches appeared to be thorough. Youth searches
before and after transports could not be observed because there were no transports conducted
the week of the annual compliance review. Visitation documentation supported youth searches
were completed prior to and after visitation. Youth do not have access to tools or other
equipment. All seven interviewed youth indicated searches are conducted every time there is a
movement. One youth indicated searches are conducted after visitation. Seven interviewed staff
were asked to explain when and how youth searches are conducted. All seven staff indicated
youth searches are conducted every time youth are moved throughout the program. One staff
indicated youth are searched when they return to the program from being off campus.
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 had two vehicles used to transport youth at the time of the annual compliance
review. Reviewed documentation verified each van received an annual safety inspection and
was regularly maintained by a certified automobile mechanic. Observations of the program
vehicles supported the vans were locked when not in use. Each van was found to have the
appropriate number of seatbelts, a seatbelt cutter, a window punch, an up-to-date fire
extinguisher, and a first-aid kit with approved items by the designated health authority (DHA).
The passenger doors could not be opened from the inside in either van. Throughout the annual
compliance review week, a total of fifteen random vehicles located in the program parking lot
were checked to ensure they were locked. Each was locked as required. Program staff was
observed walking through the parking lot each morning of the annual compliance review week
checking each vehicle in the parking lot to ensure they were locked. Six of the seven
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interviewed youth indicated they were secured within the vehicle during transports by handcuffs.
Five youth also indicated shackles were also used to secure them in the vehicle. One youth
indicated they had not had to be transported. Five of the seven interviewed staff indicated youth
are secured in the transport vehicle with hand and leg cuffs. Two staff indicated the youth are
also secured with seatbelts. Four staff indicated the van doors are locked while youth are in the
transport vehicle. One staff indicated there will always be a male and female staff on transports
and the male staff will drive the vehicle. One staff indicated they do not transport youth.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program has a policy and procedures addressing transportation of youth. The policy
included all requirements outlined by the Department. There were no transports conducted
during the annual compliance review week to observe. The program has a van with a safety
screen to provide secure transportation for high-risk youth. An informal interview with the facility
administrator indicated the program uses a safety screen in the vans. Reviewed documentation
verified all approved drivers had a valid driver’s license. The program assigns a ratio of one staff
to five youth during transport, not including the driver. There is always one staff of the same
gender on all transports. This practice was verified by reviewed transportation checklists. All
seven interviewed youth indicated they have not seen anyone place contraband in a transport
vehicle and they feel staff are driving transport vehicles safely. Five of the seven interviewed
staff indicated cell phones are provided for a communication device used during transports. Two
staff indicated they do not transport youth. Five of the seven staff indicated the safety equipment
in the vehicles during transports included a first-aid kit, wheel lock, and handcuff keys. Two staff
indicated they did not know because they did not transport youth. All seven staff indicated staff
are not allowed to use personal vehicles to transport youth. All seven staff indicated transport
vehicles are searched for contraband before and after each use. Five of the staff indicated they
would call the program and 9-1-1 if needed. Two interviewed staff indicated they would contact
the supervisor so the supervisor can instruct staff on the steps to take in the event of an
emergency. Five staff indicated the ratio is two staff to one youth during transports. One staff
indicated they were not sure because they have never conducted a transport. One staff
indicated the ratio is three staff to one youth and added there are always two staff at a
minimum.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures addressing the weekly safety and security audits.
The weekly safety and security audits are completed by the physical plant manager and
documented on the Department’s Safety and Security Audit Inspection form. The physical plant
manager is responsible for all corrective actions warranted as a result of deficiencies found
during the weekly audit. The physical plant manager reviews the corrective actions with the
facility administrator (FA) on a weekly basis. A review of the safety and security audit forms for
the annual compliance review period supported inspections were completed, as required, to
include documented deficiencies and repair updates. An interview with the FA supported this
practice. The FA indicated the physical plant manager completes the weekly safety and security
inspections. Findings are documented on the weekly safety inspection report and provided to
the FA for review. The report will detail identification of the issue and track the correction of the
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deficiencies. All efforts are made to correct deficiencies in a timely manner, dependent of the
severity of the issue. The annual compliance review team confirmed with the Department’s
residential regional safety and security monitor to ensure all audits were submitted. The
Department’s residential regional safety and security monitor indicated they did not have any
concerns with the submitted weekly safety and security audits. There were no deficiencies
assigned for safety and security audits for the annual compliance review period. A review of the
program’s preventative maintenance checklists completed from July 2023 through January 2024
was conducted. All checklists were completed as required.
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 addressing a tool management system
ensuring youth do not use tools. A review of inventory logs and the tool storage room verified
tools are securely stored when not in use, easily marked for identification, and inventoried prior
to, and following work activities. All sharp edged and pointed tools are inventoried daily when in
use. The physical plant manager completes the inventories on a daily tool log inventory which
documents each tool. All maintenance tools were inaccessible to youth and were observed to
be secured in the tool storage area. Tools were stored using a shadow-board system within the
locked room and were marked for easy identification. Observations of the tool storage area
found it was well organized and secure. Class B tools, including mops, brooms, and buckets,
are maintained in a locked room which is inaccessible to the youth. A monthly inventory of these
tools was completed for each month of the annual compliance review period. An observation of
the kitchen found all sharps are secured in a locked cabinet within the kitchen. All tools were
secured, had marking for easy identification, and were inventoried accurately. Staff are required
to complete a sign-out and sign-in log when items are taken and are returned to the designated
storage area. The procedures for missing tools include completing a corrective action in
instances were tools being checked out by staff and not returned when anticipated and/or when
there is an issue with tools identified. The Department’s Central Communications Center (CCC)
would be contacted to report any incidents of tool misuse or missing tools. The procedure for
disposal and replacement of dysfunctional tools is to place a tag on the shadow board in the
tool's place, signifying the tool is broken. The physical plant manager will notify the facility
administrator of the broken tool. The then tool would be disassembled and discard in the trash
away from facility grounds. The physical plant manager would then purchase a replacement tool
and complete the documentation. If a tool is missing all youth movement is discontinued and the
FA and assistant facility administrator is notified. All youth would be frisk searched as well.
Twenty tools were reviewed to ensure compliance with policy and procedures. All tools were
secured and had a marking for easy identification. The inventory was accurate for all tools
reviewed.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a written policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries. The program’s policy and procedures included
supervision requirements, the process of issuing tools to youth and staff, including an
assessment to determine a youth’s risk to self or others, and established ratios of one staff to
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five youth for any activities involving tool use. Seven youth records were reviewed for Class B
tool risk assessments and training in the intended and safe use of tools, and all contained
documentation of a risk assessment confirming whether the youth was allowed to use tools or
not and training in how to safely use tools. The secure youth records contained risk
assessments documenting whether the youth could use Class B tools and reasoning why if not.
The non-secure youth records contained risk assessments which indicated whether the youth
could use Class B tools, participate in vocational projects, and/or participate in off-site travel. An
observation of youth handling tools could not be completed as the program did not have any
vocational or work projects during the week of the annual compliance review. Seven staff were
interviewed, six indicated youth can use mops and brooms and one stated youth cannot use
any tools. Seven interviewed youth indicated youth can only use mops and brooms.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures establishing guidelines for outside contractors
entering the program with tools to complete work projects. The program’s procedures designate
the physical plant manager or designee to inspect all tools and equipment when an outside
contractor is coming on-site to ensure only necessary tools are being brought into the program.
The physical plant manager or designee must complete a final inspection of the work area along
with the contractor, ensures tools are never left unattended, and maintains constant
communication with the contractor throughout the project being completed. Outside contractors
are required to sign-in and out attesting to the necessity of the tools which they are bringing on-
site. The program ensures youth have no access to tools or the work area, tools are tracked,
appropriate and professional behavior is maintained, and if a tool goes missing, the facility
administrator (FA), assistant facility administrator (AFA), and physical plant manager must be
notified immediately to ensure the safety of the program is maintained. Sign-in sheets were
reviewed with two exceptions; “random tools” with a quantity of one was indicated on one sheet
and “box of parts” with a quantity of one was on another. Three project invoices were reviewed,
and the date the project was completed matched the date of the invoice for two. The third
invoice showed payment prior to the project completion; however, the services provided and
paid for matched. The FA is responsible for providing special approval/permissions for any
unauthorized items needed to complete a work project.
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 written Continuity of Operations Plan (COOP) which outlines a plan for
the completion of fire, safety, and evacuation drills. The COOP requires the program to conduct
unannounced fire drills monthly for each shift. The program has operated on two shifts since the
last annual compliance review, and reviewed documentation validated fire drills were conducted
for both shifts each month. The program additionally conducted other COOP drills each month
including major disturbance, power outage, gang, chemical weaponry, flooding, chemical spill,
lightning, and hostage/active shooter. Drill documentation included the type of drill, date and
time, participants, brief scenario, deficiencies identified during the drill, and applicable corrective
actions. The fire evacuation routes were observed to be posted throughout the program. The
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 66 of 72 (Revised September 2022)
program has twenty-seven fire extinguishers on-site, and all were confirmed to be inspected
annually. Seven staff were interviewed, two indicated they have participated in weather, major
disturbance, bomb threat, hostage, and terrorism drills, four stated they have participated in
chemical spill and escape drills, three stated they have participated in flooding drills, and six
indicated they have participated in fire drills. Seven interviewed youth indicated they have been
instructed on what to do in case of a fire. Three youth stated drills occur monthly, three indicated
they were not sure, and one youth indicated drills occur twice a month. The facility administrator
(FA) was interviewed and stated COOP drills are completed monthly, across each shift and
include disturbances, riots, threats, severe weather, evacuation, and escape. The FA also
indicated fire drills are conducted monthly, across each shift, and each drill is reviewed monthly
in the general staff meetings.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program maintains a Department approved Disaster and Continuity of Operations Plan
(COOP) available for all staff to review. The COOP is combined with the Emergency Disaster
Preparedness Plan and is maintained in the facility administrator’s (FA’s) office and in the staff
duty office, which was confirmed through observations and the FA interview. The COOP was
last reviewed January 23, 2023 and submitted to the Department on February 11, 2023. The
COOP includes alternative relocation sites approved by the applicable Department regional
director/designee. The program maintains emergency supplies in the kitchen including bottled
water in a walk-in cooler, and canned and non-perishable items in dry storage. The COOP
included all required elements such as fire, fire prevention, and evacuation, severe weather,
disturbances or riots, hostage situations, chemical spills, flooding, terrorist threats or acts, staff
roles and responsibilities, equipment and supplies needed, youth information, alternative
housing arrangements, provisions for continuity of care and custody of youth, provisions for
public protection, delegation of authority, new cooperative agreements, vendor contact lists,
emergency and staff contact numbers, and a county cooperation checklist. The program
maintains a binder of youth files containing all critical identifying information for the youth in the
program. This binder is easily accessible and mobile in the event an emergency arises and the
program needs to relocate. One youth had an applicable victim notification indicated in their
record; however, no victim information was included. The program indicated this was marked
yes in error, and corrected the error while the annual compliance review team was on-site.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 67 of 72 (Revised September 2022)
5.18 Storage and Inventory of Flammable, Poisonous, and
Satisfactory Compliance
Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items.
The program maintains a written policy and procedures to ensure youth do not handle
flammable, poisonous, or toxic chemicals and materials. The policy and procedures designate
the physical plant manager and the facility administrator (FA) to inventory these items and they
created a list of staff who are allowed to handle the items including the FA, assistant facility
administrator, dietary manager, and shift managers. The program maintains all chemicals in
locked cabinets in the sally port and stores all flammable items behind a two-lock system.
Inventories were maintained for all flammable, poisonous, and toxic items and materials in the
physical plant managers office. Each cabinet storing chemicals was marked as hazardous and
flammable, as required. Each chemical had a Safety Data Sheet (SDS) which corresponded to it
and each chemical was listed on the inventory list. Five randomly selected chemicals were
reviewed, and upon observation it was confirmed each item matched the ending count on the
inventory, all items were secured, and the SDS was present for the item.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program maintains a policy and procedures prohibiting youth from handling any flammable,
poisonous, and/or toxic items or materials. The policy and procedures indicate staff may spray
cleaner and directly supervise youth wiping down the surface with the cleaner. The program
maintains strict access to chemicals by storing them in locked cabinets in the sally port area
outside of the locked doors of the building. Youth do not clean, handle, or dispose of any
person’s bio-hazardous material, bodily fluids, or waste. An observation of a youth participating
in cleaning activities could not be completed as none of the youth assisted with cleaning while
the annual compliance review team was on-site. Seven interviewed youth all stated they do not
use or handle any chemicals.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 68 of 72 (Revised September 2022)
5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program has a written policy and procedures for disposal of flammable, toxic, caustic, and
poisonous items. The policy and procedures prohibit the dumping of these materials into the
ground or sewer and indicate they shall be disposed of properly in accordance with the items
Safety Data Sheet (SDS). The program maintains a list of staff authorized to assist in the
disposal of these items in accordance with Occupational Safety and Health Administration
(OSHA) standards. The program utilizes a local bio-hazardous waste contractor to dispose of
any flammable, toxic, caustic, and poisonous items, which was confirmed through an interview
with the physical plant manager and the facility administrator (FA). The FA and physical plant
manager indicated the program has not had to dispose of any hazardous liquid waste since the
last annual compliance review. Liquid waste such as mop water, unused beverages, and
kitchen liquids, except grease, were disposed of properly in their respective areas. Kitchen
grease was picked up by a local disposal company on the last day of the annual compliance
review week and was held in a separate container until the company picked it up. The program
has a policy and procedures which confirmed the steps the program must follow in an instance
of a chemical spill. The steps included notifying master control of the location of the spill, master
control or the shift supervisor directing the shut-down of all air handlers and ventilation systems
when indicated by the facility administrator (FA) or designee and obtaining assistance from
outside the program if necessary. The FA was interviewed and indicated they participate in the
local county solid waste management division household hazardous waste program where
disposal of waste can be made the first Saturday of each month.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 69 of 72 (Revised September 2022)
5.21 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity.
Programs allowing youth to participate in water related activities shall have a water safety
plan addressing, at a minimum, safety issues, emergency procedures, and the rules to be
followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
This 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 maintains a written policy and procedures to ensure youth are provided the
opportunity to receive visitation and communication with approved family members. The
program has the visitation schedule posted on the youth living units. The policy and procedures
outline the telephone, correspondence, and visitation procedures. Each youth has a scheduled
day where they are able to make phone calls to people on their approved list they created in
conjunction with the program. Each youth also has an approved mail log and are afforded two
stamps each week so they can send letters. Incoming and outgoing mail is screened in front of
the youth or a youth representative. For visitation days, each youth is allowed to have five
visitors at a time and visitors must go through the approval process with the program. Visitation
is held on the weekends from 10:30 a.m. to 11:30 a.m. and special accommodations can be
made outside of this time frame with advance notice and proper staff coverage. Youth are
afforded letter writing time if they do not have visitors on the weekends. The program requests
clarification from the youth’s juvenile probation officer for any youth with a history of human
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 70 of 72 (Revised September 2022)
trafficking to ensure their family is not under current or previous investigation. The program uses
a third-party translation service for any youth or visitors who do not speak English as a first
language. Six interviewed youth indicated they were not aware of translating services provided
and no youth at the program needed these services, and one youth indicated some staff at the
program are able to speak different languages and can assist with translation. All seven-youth
confirmed they can call their parent/guardian or send them a letter. Seven staff were
interviewed, three indicated they were not aware of interpretation services, and four stated an
interpreter or translation service is used. The facility administrator confirmed the use of the third-
party translation service.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a written policy and procedures which outline the provision of a variety of
recreation and leisure activities. The program’s activity schedule has structured indoor and
outdoor recreation and leisure activity times for a minimum of one hour each day. Activities
include large muscle development, promote social and cognitive skill development, creativity,
teamwork, healthy competition, mental stimulation, and physical fitness. A review of the logbook
indicated recreation was conducted daily. Observations of the youth playing football were
conducted during the annual compliance review week, and master control confirmed they track
the heat index and weather on an hourly basis to ensure youth safety. The program’s contract
requires them to have a recreational therapist, and a review of the staff’s credentials, schedule,
and services provided to youth confirmed all requirements were met. A review of seven youth
records confirmed each incorporated recreational therapy into their individualized performance
and/or treatment plan. Seven youth were interviewed, and each confirmed they participate in
recreation and leisure activities for at least one hour each day including kickball, basketball,
volleyball, running laps, bingo, water day, movies, games, yoga, and football.
5.24 Search and Inspection of Controlled Observation Room Satisfactory Compliance
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program has a written policy and procedures regarding the search and inspection of
controlled observation rooms and youth. All controlled observation rooms were observed and
were confirmed to meet all requirements. Reviewed documentation confirmed staff conducted
searches of the controlled observation room and the youth prior to placing them on controlled
observation, clearly documenting any findings of contraband and unauthorized items. Five
instances of controlled observation were reviewed, four of the five documented the youth and
room were searched prior to placement. One record did not have a search of the youth or room
documented on the controlled observation form.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 71 of 72 (Revised September 2022)
5.25 Controlled Observation Satisfactory Compliance
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program has a written policy and procedures regarding controlled observation of youth.
Five controlled observation reports were reviewed, and each form documented authorization
from a supervisory or higher-level staff. Each report noted the reason the youth was being
placed on controlled observation, staff discussing the reason for placement with the youth, and
a health status checklist was filed with each report. One youth complained of injuries and
healthcare staff were notified immediately. Three youth were placed in controlled observation for
over two hours; however, one report was missing documentation the facility administrator or
designee granted an extension to maintain the youth on controlled observation exceeding two
hours.
5.26 Controlled Observation Safety Checks Release
Satisfactory Compliance
Procedures
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 has a written policy and procedures for safety checks and release procedures
while a youth is in controlled observation. The program’s policy and procedures contained staff
designations for controlled observations. Five controlled observation reports were reviewed, and
all contained the first page of the controlled observation report completed by the staff making
the placement and its submission to the supervisor. Four of the reports documented safety
checks every fifteen minutes or less, one report had one check completed one minute late. Staff
documented all safety checks on the Controlled Observation Safety Checks form. Each form
documented the facility administrator (FA) or designee gave written approval to release the
youth from controlled observation based on behavior and the decision the youth was no longer
a threat to themselves or others. Each form documented the staff determined whether or not an
internal alert was needed. The controlled observation reports, Health Status Checklists, and
safety check forms were all maintained in an administrative file and within the youth’s records.
The FA or designee documented a review and approval of the controlled observation report
within fourteen days for all five youth.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 72 of 72 (Revised September 2022)

source: DJJ

report_type: QI Residential

file_name: Lake Academy-FINAL-FY2324.pdf

program_name_raw: Lake Academy

rule: Indicator 2.20

excerpt: Educational Access (Critical)

rating: Limited Compliance