state: FL

facility_name: Cypress Creek

summary: QI Residential - FY23-24

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Cypress Creek Treatment Center
TrueCore Behavioral Solutions LLC
(Contract Provider)
2856 West Woodland Ridge Drive
Lecanto, Florida 33461
Review Date(s): April 2 - 5, 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:
Jennifer Tummino, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Rob Aguis, Office of Education, Director of Postsecondary and Workforce Education (Standard
1)
Crystal Blair-Gallon, Office of Accountability and Program Support, Regional Monitor (Standard
3)
Marvin Bliss, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Jeff Campbell, Office of Education, Education Coordinator (Standard 2)
Jillian Cumbo, Project Anchor, Regional Workforce Education Coordinator (Standard 1 Shadow)
Jeremy Curvan, Office of Accountability and Program Support, Regional Monitor (Standard 1
Shadow)
Heather Molinario, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Luis Rodriguez, Brevard Regional Juvenile Detention Center, Superintendent, (Standard 5)
Justin Terziu, Office of Accountability and Program Support, Regional Monitor (Standard 1 and
Standard 5)
Bonita Williams, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Cypress Creek Treatment Center MQI Program Code: 1055
Provider Name: TrueCore Behavioral Solutions LLC Contract Number: 10207
Location: Citris County / Circuit 5 Number of Beds: 64
Review Date(s): April 2 - 5, 2024 Lead Reviewer Code: 201
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures) and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 70 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Non-Applicable
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 70 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
2.19 Career Education Satisfactory
2.20 Educational Access* Satisfactory
2.21 Education Transition Plan Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 70 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Non-Applicable
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 70 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 70 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.21 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.22 Visitation and Communication Satisfactory
5.23 Recreation and Leisure Satisfactory
5.24 Search and Inspection of Controlled Observation Room Satisfactory
5.25 Controlled Observation Satisfactory
5.26 Controlled Observation Safety Checks and Release Procedures 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 8 of 70 (Revised September 2022)
Program Overview
Cypress Creek Juvenile Offender Correctional Center is a maximum-risk program with a bed
capacity of sixty-four beds. The Cypress Creek Juvenile Offender Correctional Center serves
males fifteen to twenty-one years of age, located in Lecanto, Florida. The program is operated
by TrueCore Behavioral Solutions LLC, through a contract with the Department. The program
provides mental health and substance abuse services. In addition, the program fosters each
youth by providing Aggression Replacement Training, SkillStreaming the Adolescent, the
Passport Program, the Bullying Workbook for Teens, Social Perception Training, the Stress
Reduction Workbook for Teens, Problem Solving Training, Empathy and Social Competence
Training, Living in Balance, Resilience Builder Program for Children and Adolescents, and
Impact of Crime. Additional treatment services provided include family and individual
counseling. Program administration is comprised of a facility administrator (FA), assistant facility
administrator of operations, assistant facility administrator of support services, and a chief of
security. Case management services are provided by one director of case management, six
case managers, one intake specialist, and two transition services managers. Mental health staff
at the program includes one contracted psychiatrist, one clinical director, who serves as the
designated mental health clinician authority (DMHCA), one assistant clinical director, seven
therapists, two recreational therapists, and one record technician. Medical services are offered
6:30 a.m. to 7:00 p.m. daily and are provided by one designated health authority (DHA), one
health services administrator, and four registered nurses. Educational services are provided by
the program’s educational staff. The layout of the program includes one large building which
houses all dormitories, kitchen, classrooms, administration, clinic, offices, controlled observation
rooms, maintenance, mental health, case management, and master control. The program has
121 operating security cameras providing coverage, with one camera not working in the Echo
dayroom. At the time of the annual compliance review, the program had thirty-four vacant
positions including twenty-five youth care workers, four teachers, two para-professionals, one
registered nurse, one case manager, and one part-time physical plant worker. The program
identified a major maintenance issue with their tilt skillet.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 70 (Revised September 2022)
Strengths and Innovative Approaches
Innovative Practices for Youth
• Positive Youth is a celebration of all youth who do not have any incident reports or
behavior reports for the month. Youth who achieve this goal receive a special meal.
• Birthday Club is for the youth who have a birthday each month. Youth celebrate their
birthday with cake and ice cream. Youth additionally receive a birthday card signed by all
the management team.
• Youth who achieve their daily goals from Thursday through Monday are awarded with a
hamburger. Additionally, youth who achieve their daily goals from Monday through
Thursday are awarded with a sausage dog as an additional snack.
• Honors/Honors Gold Club is for youth who earn a specific level, which allows them to get
together and have a meal.
• Independent Night is for youth on a specific level, which allows them to have a meeting
to discuss how to earn the next level and receive a special snack.
• When a dormitory earns “dormitory of the month”, the youth assigned to the dormitory
receive a meal and control over what to watch on television for the month.
Innovative Practices for Staff
• Employee of the Month is an award staff receive for positive performance and
attendance.
• The program has weekly themed activities associated with, but not limited to Football,
States, Heart Awareness, Breast Cancer Awareness, and holidays.
• Monthly Morale meetings are scheduled to discuss more staff activities, where staff are
invited to join or send their ideas.
• Staff are awarded for things such as performance, going above and beyond, mentoring
youth, and rising stars.
• The program recognizes staff monthly for their anniversary.
• The program holds All Staff Meals, and yearly Thanksgiving and Christmas meals.
• Birthday Cards with gift cards are mailed to staff on their birthday each month; all cards
are signed by the management team.
• The program provides a daily snack bar for staff with items such as snacks, cocoa, tea,
coffee, and cereal.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 70 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures addressing pre-employment background screenings.
An informal interview with the facility administrator (FA) confirmed the program had one new
volunteer who assisted or interacted with youth on an intermittent basis for less than ten hours a
month and did not need to be background screened. The program’s policy requires a staff who
is background screened to always be present within the line of sight of the volunteer who is not
background screened. An Annual Affidavit of Compliance with Level 2 Screening Standards was
completed and submitted to the Department’s Background Screening Unit (BSU) on December
6, 2023, meeting the annual requirement. A review of the program’s staff, volunteer, and
contractor rosters found nine staff were applicable for an initial background screening during the
annual compliance review period. No volunteers were applicable for an initial background
screening during the annual compliance review period. Each of the nine applicable staff had a
completed and eligible background screening, as required, prior to contact with youth and
confidential youth records. Reviewed documentation validated a criminal history report was
reviewed for each staff. A pre-employment assessment tool was administered for each direct
care staff and a pre-employment assessment passing score was documented in each reviewed
direct care staff’s record. All nine staff were added to the program’s roster in the Agency for
Healthcare Administration’s Clearinghouse system, as required. None of the nine staff had a
break in service indicated in the Department’s Staff Verification System (SVS).
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a policy and procedures addressing five-year background rescreening for
staff. There were no staff or volunteers applicable for a five-year background rescreening during
the annual compliance review period.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 70 (Revised September 2022)
1.03 Provision of an Abuse-Free Environment (Critical) Satisfactory Compliance
The program provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment.
 The program shall post the Florida Abuse Hotline telephone number for youth under
the age of eighteen and the Central Communications Center (CCC) telephone number
for youth eighteen years of age and older.
 All allegations of child abuse or suspected child abuse shall be immediately reported to
the Florida Abuse Hotline.
 Youth and staff have “unhindered access” to report alleged abuse to the Florida Abuse
Hotline pursuant to Section 39.201 (1)(a), F.S.
 The environment is free of physical, psychological, and emotional abuse (incorporating
trauma-responsive principles).
 A code of conduct for staff which clearly communicates expectations for ethical and
professional behavior, including the expectation for staff to interact with youth in a
manner promoting their emotional and physical safety, while also incorporating trauma-
responsive practices.
The program has a policy and procedures to ensure program-related incidents, which place at-
risk or have the potential to place at-risk, the health, safety, or welfare of the public or of youth,
staff, visitors, the security of the facility, or the reputation of the provider are reported and
handled appropriately and in a timely fashion. The program has a zero-tolerance policy in
regard to any abuse. All staff shall immediately report any knowledge or suspicion regarding an
incident of abuse which occurred in the program by calling the Florida Child Abuse Hotline
calling the Department’s Central Communications Center (CCC), and the regional director. The
program had one incident report during the annual compliance review period which was a claim
against staff for physical, psychological, or emotional abuse, which was unsubstantiated. The
program conducted the Trauma Response and Caring Environment (TRACE) self-assessment
on February 13, 2024. Staff adhere to a code of conduct, as acknowledged by the review and
signing of a code of conduct form during their orientation, which is contained in the staff records.
Fifteen staff code of conduct forms were reviewed. Five reviewed pre-service training records
and five in-service training records reflected staff received training on child abuse reporting.
During the facility tour, the Florida Abuse Hotline and CCC telephone numbers were observed
to be posted throughout the facility. All five interviewed youth reported they feel safe in the
program. All five youth reported they have never been prevented from making a call to the
Florida Abuse Hotline. None of the five youth reported knowing the telephone number for the
Florida Abuse Hotline; however, all five youth knew where it was posted. Four of five youth
reported staff are respectful when talking with youth and the remaining youth indicated staff are
sometimes respectful. Three of the five youth reported never hearing staff curse around youth,
while one youth indicated they have heard staff use curse words once in a while and in
conversations, one youth indicated they have heard staff cursing at other youth; however,
neither youth provided any context about the situations. The program indicated they take their
culture very seriously and work hard to ensure staff are free from profanity and uphold their
TRACE initiatives. Additionally, the program added the topic is discussed in all their staff
meetings and trainings and all staff will continue to be coached. None of the five youth have
ever exchanged emails, telephone numbers, or social media contact information with staff. Each
of the five interviewed staff were familiar with the program’s abuse reporting procedures. All five
interviewed staff reported they have never observed a coworker denying a youth the right to an
abuse call. All five staff also reported they have not witnessed their coworker’s using profanity,
using threats, intimidation, or humiliation when interacting with youth. All five staff knew where
to locate the telephone number for the Florida Abuse Hotline. The facility administrator (FA)
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 70 (Revised September 2022)
reported the program’s code of ethics directs staff to provide youth with quality care, promotes
excellent customer service, and states the abuse of youth (verbal or physical) will not be
tolerated. Staff are provided new hire training and discussions take place in all staff meetings to
ensure staff are knowledgeable in contacting the Florida Abuse Hotline and CCC. The youth
handbooks and youth information boards contain contact information as well. All calls at the
program are tracked in the master control logbook and are discussed in the daily management
meetings. The program incorporates trauma-responsive practices by utilizing the champion
team to develop a plan based on surveys and Can We Discuss forms. Additionally, the program
addresses trauma-responsive practices in community meetings and provides educational
handouts monthly to staff and youth.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program has a policy and procedures to ensure immediate action is taken to address
incidents of physical, psychological, and emotional abuse. The program administration manages
youth and staff needs and provides direction to each on how to access the Florida Abuse
Hotline. The program had one allegation of physical, psychological, or emotional abuse during
the annual compliance review period. The incident was found to be unsubstantiated. A review of
the incident report indicated the facility administrator (FA) took immediate action to address the
concerns by removing the staff from youth contact. Documentation was reviewed to identify
applicable corrective action taken by management for follow-up to allegations. An interview with
the FA indicated the program’s management response to allegations of abuse is for any
allegation to be discussed and investigated. Any negligence or abuse allegation is called into
the Florida Abuse Hotline or the Department’s Central Communications Center (CCC). The FA
indicated there were no staff who had disciplinary actions due to allegations of abuse towards a
youth since the last annual compliance review.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program has a policy and procedures addressing the process for contacting the
Department’s Central Communications Center (CCC). The program reported twenty-nine
incidents to the CCC during the annual compliance review period. A review of five reportable
CCC incidents during the annual compliance review period revealed all five incidents were
reported to the CCC within the required time frame and each incident was documented in the
center’s logbook. There were no additional internal incidents or grievances during the annual
compliance review period which should have been reported to the CCC and were not. The
program experienced an increase of four reportable incidents to the CCC. An interview with the
facility administrator indicated when a youth requests an abuse call, the youth is taken to the
telephone to make the call. Any reportable incident must be reported to the CCC within two
hours.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 13 of 70 (Revised September 2022)
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 has a policy and procedures requiring a Protective Action Response (PAR)/Right
Interactions (RI) Incident Report be completed and filed in accordance with Florida
Administrative Code any time staff use a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints other than
for regular transports. The program had a total of twenty-eight PAR/RI incidents during the
annual compliance review period. A sample of five PAR/RI Reports were reviewed. All five
reports were completed by the end of the staff’s workday and included statements from all staff
involved. One of the five PAR/RI incidents required the use of mechanical restraints and a
review of the Mechanical Restraint Supervision Log confirmed the incident was recorded. One
of the five PAR/RI incidents resulted in injury to a youth or staff and there were no allegations of
abuse; staff contacted the Department’s Central Communications Center (CCC), within two
hours. All the PAR/RI Reports were reviewed by a supervisor, a PAR instructor, and the facility
administrator (FA) within seventy-two hours of the incident. None of the PAR/RI incidents
required a medical review or a call to the Florida Abuse Hotline. Copies of the PAR/RI Reports
were placed in the program’s centralized file within forty-eight hours of approval/signature by the
FA. Monthly summaries of all PAR/RI incidents were submitted to the Department’s regional
office by the fifteenth of each month and are maintained by the program. The program last
updated and submitted the PAR/RI plan on January 6, 2023, and the program is awaiting a
response from the Department. The program had a total of thirty-one PAR/RI incidents during
the previous annual compliance review period. The program experienced a decrease in PAR/RI
incidents from the time of the previous annual compliance review. The program’s PAR/RI rate
during the previous quarter was 1.99, which is above the statewide Residential PAR/RI rate of
1.76. The FA was interviewed and advised PAR/RI incidents are reviewed daily during the
management meetings. Five staff were interviewed and three reported they had used PAR/RI,
while two said they had not. Two of the three staff who have used PAR/RI were able to describe
the procedures and the program’s process in which they could use PAR/RI. The remaining staff
indicated not remembering procedures due to not utilizing PAR/RI techniques in two years.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring.
The program has a policy and procedures outlining the training and certification requirements
for all new staff. Five staff training records were reviewed for pre-service/certification
requirements. All five staff completed all required pre-service trainings and essential skills prior
to contact with any youth. Two staff had not completed Motivational Interviewing (MI) at the time
of the annual compliance review; however, both staff were still within their initial 180 days of
hire. The program indicated one staff is signed up to attend MI on April 17through18, 2024 and
the remaining staff will be signed up to attend MI in August 2024. All five staff completed
trainings as required by other Rules or manuals. All trainings were documented in the
Department’s Learning Management System (SkillPro), as required.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 14 of 70 (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 has a policy and procedures outlining the in-service training requirements for staff.
Five staff training records were reviewed for in-service trainings including three direct care staff
and two supervisory staff. All three direct care staff completed all required in-service trainings.
Both of the supervisory staff training records included all required in-service trainings and
exceeded the required eight hours of supervisor trainings in the areas of coaching, leadership,
and personal accountability. All five staff completed trainings as required by other Rules or
manuals. All trainings were entered into the Department’s Learning Management System
(SkillPro). The program maintains an annual in-service training calendar which is updated as
changes occur. The program submitted a list of in-service training to the Department’s Office of
Talent, Leadership, and Culture and the training plan was signed on December 30, 2022.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program has a policy and procedures which include training requirements for the grievance
process, as well as the informal, formal, and appeal phase. Youth are encouraged to resolve
questions, disputes, and complaints through informal communication with program staff. Staff
are directed to use active listening skills, respectful conversation, and give youth the opportunity
for full expression of feelings regarding the conflict with the ultimate goal of encouraging and
promoting open communication, and to assist the youth in the development of improved
problem resolution skills. Informal complaints should be handled within twenty-four hours. The
program maintained grievance logs for each month of the annual compliance review period;
however, there were no formal grievances filed during the annual compliance review period. All
five youth interviews indicated they knew where to find a grievance form and each youth knew
what to do with the form upon completion. All five youth stated they could ask for assistance in
completing a grievance form. Five staff were interviewed and each were able to describe the
grievance review process. Four of five interviewed staff indicated the grievance forms are
placed throughout the program; three staff stated youth can request assistance in completing
the forms; two staff stated the supervisor reviews the grievances; one staff indicated the facility
administrator (FA) reviews them as well; and one staff said the grievance process has three
phases and each phase has associated time frames. The FA interview indicated the program's
informal grievance process is resolved by using the Can We Discuss forms. Youth place the
completed grievance in the box, it is collected, and then reviewed in the management meeting.
The forms are logged and resolved with the youth and, if not resolved, the FA will review the
complaint and make a final decision.
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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.
A review of ten facilitators since the last annual compliance review indicated eight had training
in the groups they facilitated and were determined to be the right fit regarding education and
work experience to deliver the delinquency intervention services. There are two staff who
require training, one staff is on medical restriction and has not facilitated a group since February
2023 and the remaining staff has not yet completed the training or facilitated any groups. Both
staff possessed over ten years of work experience. A review of the schedule indicated the
minimum number of groups were provided each week as indicated on the schedule. The
program’s activity schedule was reviewed and confirmed the program is providing structured,
planned programming, or activities for at least sixty percent of the hours youth are awake. The
facility administrator (FA) interview indicated Skillstreaming the Adolescent, Aggression
Replacement Therapy (ART), and Impact of Crime are utilized as evidence-based promising
practices to address the needs of youth. The designated mental health clinician authority
(DMHCA) interview indicated the licensed and non-licensed mental health professionals provide
group, individual, family, and supportive sessions. Recreation therapists provide therapeutic
activities. Based upon the findings of the comprehensive evaluation, youth shall have an
individualized treatment plan developed, which includes service provision for all identified
treatment needs. Treatment interventions and frequency are specified on the plan. A review of
current services, as well as service needs, is based upon the findings of the comprehensive
evaluation and is reviewed during monthly multidisciplinary treatment team meetings for each
youth. The program also provides specialized clinical and delinquency groups. The clinical
specialized groups include Skill Streaming the Adolescent and ART conducted by a trained
master’s-level clinical staff. Impact of Crime (IOC) is provided as the delinquency intervention
group. Individual, group, and weekly progress notes are reviewed weekly through an online
tracking system to ensure services have been provided, and are complying, with frequency and
duration. Additionally, the director of clinical services reviews the weekly progress notes to
confirm effective interventions are utilized which are consistent with the treatment planning
documentation.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures addressing how life and social skills training are
provided to youth. Impact of Crime (IOC) is provided twice a week by a trained case manager
or youth care worker. Living in Balance (LIB) consists of twelve core sessions addressing
emotional components and substance abuse situations, in addition to twenty-one supplemental
sessions and is offered once a week. Skillstreaming the Adolescent utilizes homework
assignments for each youth to practice their newly learned skills in between sessions. The
group is offered once a week by a trained therapist. A review of groups sign-in sheets indicated
all groups were provided as required. In addition to the life skills intervention services, the
program works with the youth in career counseling, which includes resume building, finances,
budgeting, and determining career choices. The program has begun adding goals which include
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career counseling, and the Holland assessment, which measure strengths and weaknesses,
with regards to career paths. Two of the five interviewed youth stated they were all enrolled in
groups which included anger management and Skillstreaming the Adolescent. The remaining
three youth indicated they participate in football and music. The facility administrator (FA)
interview indicated youth are currently enrolled in IOC and Aggression Replacement Training
(ART). The designated mental health clinician authority (DMHCA) interview indicated the groups
being offered at the program included Living in Balance, Pathways to Self-Discovery and
Change, Group Treatment for Substance Abuse, Teen Relationships, The Bullying Workbook
For Teens, The Stress Reduction Workbook For Teens, Skill Streaming the Adolescent,
Resilience Builder Program, The Passport Program, 100 Interactive Activities for Mental Health
and Substance Abuse Clients, Anger Management for Mental Health and Substance Abuse
Clients, Process Groups, and ART. The DMHCA advised youth are able to practice skills
through their daily use of the positive performance system and how they navigate advancement
through the level system. Youth participate in daily meetings where they are provided an
opportunity to appropriately discuss their grievances and issues, can demonstrate their
leadership skills, and present for their levels where they are encouraged to recognize and
address their strengths and weaknesses or areas in need of improvement. Many of the youth
utilize conflict resolutions as a means to formally problem solve with peers, to safely express
their feelings, and work together to solve problems. Youth are provided opportunities to co-
facilitate mental health and substance abuse groups and they take turns in leading recreational
activities; however, this has been addressed with the Department’s Office of Fidelity,
Accountability, and Support and the Office of Residential Services as youth are not allowed to
co-facilitate groups. The youth advisory board is an opportunity for youth to demonstrate their
ability to advocate for self and others.
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 provides the Impact of Crime (IOC) curriculum which addresses restorative justice
awareness for youth and helps them develop empathy for crime victims and survivors, while
increasing personal accountability for criminal actions and harm to others. The IOC curriculum is
facilitated by the case managers of the program. The program’s activity schedule addresses
group times. The IOC restorative justice groups are considered primary services as of January
10, 2024 and ART is a primary service as well. In addition to the IOC and ART curriculum, the
program affords youth multiple opportunities to complete community service hours on-site; for
instance youth made Lucky Charm and Football Frenzy bags for fellow youth for the Superbowl
and St. Patrick’s Day, sending letters to members of the armed forces and appreciation letters
to mothers, recognizing the International Day of Peace, participation in “Plant a Tree Day”,
donating blankets to a local pregnancy center, a Hate Crime Awareness Project in March, and
participation in the Blue Campaign to End Human Trafficking. Additionally, there were mentoring
opportunities such as the “Three A’s of Mentorship” offered through Big Brothers/Big Sisters.
Five youth were interviewed, and one youth indicated they participated in restorative justice
groups; however, did not specify which group and didn’t think they had practiced any new skills
they learned in group. One youth stated they talk about life, what to do when they get out, and
talk about how they can do better with their lives; the youth reported they have practiced new
skills they learned in group; however, did not specify any. The remaining three youth indicated
they do not participate in or do not know what restorative justice groups are and have not
practiced any new skills learned in group. The facility administrator advised each youth who
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enters the program is required to participate in an IOC group and they complete projects
associated with restorative justice throughout the year, which are presented to the community
by the staff. The designated mental health clinician authority (DMHCA) was interviewed and
confirmed the youth participate in various restorative justice projects throughout the year. The
DMHCA advised youth utilize skills learned in life and social skills training when participating in
these projects and daily meetings where they are provided an opportunity to appropriately
discuss their grievances and issues, can demonstrate their leadership skills, and present for
their levels, where they are encouraged to recognize and address their strengths and
weaknesses or areas in need of improvement.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures which address and determine how youth alerts are
identified, documented, updated, and communicated to program staff. The program maintains a
continually updated internal alert system which is easily accessible to program staff and keeps
them alerted about youth who are security or safety risks, including escape risks, suicide or
other mental health risks, medical risks, sexual predator risks, and other assaultive or violent
behavior risks. A review of alerts for five youth was completed to address the program entering
alerts in the Department’s Juvenile Justice Information System (JJIS). Four applicable youth
records reflected alerts were entered into JJIS, as required, and the remaining youth was found
non-applicable for alerts. All alerts were verified prior to being entered into JJIS. Each of the
eight reviewed youth alerts were applicable for being documented within the program’s logbook.
A review of the program’s logbook determined the applicable alerts were documented. A review
of the program’s internal alerts found they were consistent with alerts entered within JJIS. All
alerts requiring removal or downgrading were found to have been done so by the appropriate
staff. The facility administrator indicated the program utilizes an internal alert system to include
an alert form and an alert board which details youth alerts. Case management, medical, and
mental health staff are responsible for entering and closing out alerts in JJIS. Alerts are
reviewed during daily management meetings. Important medical issues pertaining to the youth
are relayed to the facility administrator from the health service administrator (HSA). Additionally,
the HSA attends the daily management meetings to discuss medical concerns, issues, or
appointments. Nursing staff are present along with program staff, security, case management,
and mental health staff in the morning meeting held daily, where alerts are discussed. The
nurse interview confirmed licensed healthcare staff are responsible for updating the medical
alert system. Five interviewed staff reported they are briefed on youth alerts through briefings
with shift supervisors, an alert binder in the break room, and the case managers will inform staff
of alerts.
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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 separates each youth record into two separate files including an individual case
management record, and an Individual Healthcare Record. All youth records are marked
‘Confidential.’ All records are maintained in either locked cabinets or locked rooms within the
responsible program area’s office. No records were observed to be accessible to youth. Office
area doors are marked ‘Confidential.’ A review of five individual case management records
found each record had a label which included the youth’s name, Department’s identification
number, date of birth, county of residence, and committing offense. Each individual case
management record included legal information, demographic and chronological information,
correspondence, case management and treatment team activities, and miscellaneous.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a joint community advisory board which is scheduled to meet on a quarterly
basis. A review of the community advisory board binder found meetings were held on June 15,
2023, September 14, 2023, December 13, 2023, and March 13, 2024, during the annual
compliance review period. Board meetings are held in person at the program. A review of the
list of attendees, the board roster, and letters from the program found the facility administrator
(FA) has solicited involvement from a law enforcement representative, a judiciary community
representative, other community partners, a business community representative, a school board
or district representative, a faith community representative, and a LGBTQIA+ community
representative. Reviewed documentation reflected a representative from each category was a
member of the community advisory board or had been invited to join the advisory board. An
interview was conducted with the FA who confirmed meetings are held quarterly. The FA
maintains the community advisory board requirements. Community advisory board meetings are
held quarterly and include review of an agenda detailing program updates and community
advisory board member updates. Recruitment letters are mailed out annually to solicit new
membership and ensure each position on the board is properly represented. The interviewed
board member stated she serves on the board, confirmed she attended the March 2024 and
June 2023 meetings, and will continue attending the quarterly meetings, as frequently as she
can.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures for evaluating staff, performance standards, and the
frequency of evaluations. The program’s policy indicates evaluations are to be completed after a
ninety-day introductory period and annually and are completed by supervision and management
staff. A review of seven position descriptions was conducted and determined each staff’s
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performance standards were clearly identified. A review of seven performance evaluations
confirmed annual evaluations have taken place consistent with the program’s policy. Staff are
evaluated at the ninety-day mark for first year staff and annually for all additional staff on their
established performance standards. The performance standards matched job descriptions for
each staff position reviewed. The program’s contract requires the one facility administrator (FA),
one assistant facility administrator, five registered nurses, one designated health authority, one
designated mental health clinician authority, one licensed therapist, two transitional case
managers, and two recreational therapists. Key vacancies at the time of the annual compliance
review included one registered nurse. An interview was conducted with the FA who stated staff
turnover has been a consistent issue; staff have cited their reasons for leaving as they were not
suited for the job, the hours of the job, and the pay for direct care staff. The program has a staff
morale committee which meets monthly and plans activities for staff to participate and has a
staff suggestion box. The program conducts hiring events to hire new staff. The FA additionally
indicated staff evaluations are completed after the first ninety days and then yearly thereafter.
Five staff were interviewed and three staff reported they felt communication was very good
amongst staff at the program, two indicated very good. Additionally, four staff reported they
receive a formal evaluation of their performance based on performance standard annually, and
one newer staff indicated monthly.
1.17 Special Contract Conditions Satisfactory Compliance
The program shall implement all items or services either negotiated or outlined in the contract
which are considered Special Contract Conditions or listed within the Scope of Services
Attachment. These may be referenced as the Memorandum of Negotiation (MON), Summary
of Negotiated Points, Special Conditions, or older contract may not have them clearly
identified as a special condition. These items typically exceed the minimum requirements
outlined in Florida Statutes and Florida Administrative Code.
The program’s contract with the Department includes a Memorandum of Negotiation (MON),
Summary of Negotiated Points, or Secretary letter. There are four special contract conditions
not covered by the Monitoring and Quality Improvement indicators.
The first special contract condition requires either the president or the chief operating officer to
make a visit to the program at least once a quarter. A review of the facility visitor sign-in log
confirmed the first quarter visit took place in January of 2024. Additionally, the Cypress Creek
High annual compliance review documented numerous visits which were made during the
annual compliance review period including four in June 2023, one in July 2023, one in August
2023, one in October 2023, two in November 2023, and two in December 2023, far exceeding
the quarterly visit requirement.
The second special contract condition requires eighty percent of eligible youth to be working
part-time or full-time within thirty days of exiting the program. The transition specialist shall track
employment of youth for the thirty days following their exit. There were five youth who left the
program in March 2024, and one youth was not applicable because they were arrested. A
review of closed records for the four youth released in March confirmed the transition specialists
made three contacts with youth after release. One youth was released less than a week before
the annual compliance review week, on March 29, 2024. No contacts have been made for the
recently released youth, yet.
The third special contract condition requires 100 percent of youth to complete, on average,
eighty percent of their community service hours prior to their release. During the annual
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compliance review period there were no applicable youth released with court ordered
community service hours.
The final special contract condition requires an additional forty-five vocational slots to be made
available beyond those mentioned in the contract, covering computer programming in the future,
twenty driving certifications in commercial driver license (CDL) of forklifts, five food service
manager certifications, and twenty Microsoft Office certifications. The program offers agriculture
services, where the youth receive high school credits. Food handling and food management are
both offered, affording the youth certificates after completion. The program has a Home Builders
Institute (HBI) program on-site for youth to participate in, after vetted, and accepted, where
youth can receive a myriad of certificates. The vocational program offers basic computer literacy
programs such as Microsoft Word, PowerPoint, and Excel, where youth are able to receive a
certificate after completion. The program offers CDL courses, including opportunities in semi-
truck and forklift training, carpentry, electrical, brick masonry, landscape, and painting. Since the
Cypress Creek High annual compliance review in January 2024, fifty-one youth were certified in
cardiopulmonary resuscitation (CPR)/first-aid, one youth completed the CDL course, twenty-two
youth received certificates from Florida Ready to Work, and seven youth have completed the
ServSafe Food Services Manager. Additionally, the program has Microsoft slots available;
however, there were no youth enrolled at the time of the annual compliance review based on
interest. Youth are informally asked at the beginning of each semester to gauge interest.
The facility administrator interview indicated the contract negotiated items are provided to the
youth. Five youth confirmed they have either heard of or participated in the driving certifications
(CDL or forklift), food service manager certifications, and Microsoft Office certifications.
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’s contract requires them to provide career and technical education (CTE) services.
The program’s services include a Driving Certification, which shall aid in preparation for the
commercial driver license (CDL) or forklift certification. The program shall provide certifications
in ServSafe Food Service Manager, cardiopulmonary resuscitation (CPR)/first-aid, Florida
Ready to Work - Soft Skills, Occupational Safety and Health Administration (OSHA)-10, and
Microsoft Office. As a result of the CTE services offered at the program, fifty-seven youth have
received CPR/first-aid services, three OSHA-10, twenty-nine Florida Ready to Work Soft
Skills/Digital Skills, seven ServSafe Food Protection Manager, and one CDL. The number of
youth who have completed a certification or received a certificate of completion for CTE
services are fifty-one in CPR/first-aid, two in OSHA-10, twenty-two in Florida Ready to Work
Soft Skills/Digital Skills, seven in ServSafe Food Protection Manager, and one in CDL. There
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were nineteen youth enrolled in ServSafe at the time of the annual compliance review; however,
the program currently does not have an instructor to deliver this course. Additionally, the
program offers the Home Builders Institute (HBI), which yields industry certifications and is
provided under a separate contract with the Department. According to the program’s schedule,
CTE services are offered every Thursday between 2:20 p.m. and 3:20 p.m., and 3:20 p.m. to
4:20 p.m. CPR/first-aid is offered all day on the first Friday of each month. HBI is offered
Monday to Friday in two four-hour blocks. A review of the schedule and observations during the
annual compliance review week confirmed CTE services are available. CTE instruction is
provided by two transition service managers, who possess bachelor’s-level degrees and have
certifications in CPR/first-aid, OSHA-10, and Florida Ready to Work. Five youth were
interviewed, and all were aware of the CTE services provided by the program. The interview
with the facility administrator confirmed CTE services CPR/first-aid, OSHA-10, and Florida
Ready to Work are being provided to youth.
1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a policy and procedures for reviewing and analyzing data trends to utilize in
decision-making practices. The provider uses several systems for the purposes of tracking data
and outcome measures. The provider has implemented an internal database and dashboard
system which allows for daily data entry by every program. This daily process and outcome
information is aggregated into weekly and monthly totals, displayed in interactive dashboards
specific to each program, and provided back to corporate as well as program management for
the purposes of tracking trends and informing risk management. The dashboards are updated
every Monday with the previous week's data. Additionally, the program compiles information
obtained from youth surveys and parent/guardian surveys completed upon exit from the
program. Information is shared with staff and administration during staff meetings, morning
meetings, shift briefings and during community advisory board meetings. A review of four youth
exit surveys, seven parent/guardian surveys and the management meeting sign-in sheet from
one day each month in 2024, which took place on January 29, 2024, February 22, 2024, March
6, 2024, and April 3, 2024, confirmed the information sharing with staff and administration. A
review of the quarterly community advisory board agendas, meeting minutes and sign-in sheets
for March 2024, June, September, and December 2023, confirmed the information sharing with
providers and stakeholders. The program additionally takes information received during
supplemental and annual compliance reviews and shares the outcome with staff.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures to ensure the parent/guardian of each youth is
notified by telephone within twenty-four hours of the youth’s admission and in writing, within
forty-eight hours. The program is also required to notify the committing court, assigned juvenile
probation officer (JPO), and post-residential provider in writing within five working days of
admission. Five youth case management records were reviewed. All five records contained
documentation of parent/guardian notifications by telephone within twenty-four hours and in
writing within forty-eight hours, as required. All five records contained documentation of the
required notification for the committing court, assigned JPO, and post-residential provider.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures to ensure each admitted youth receives an
orientation with all required elements within one day of admission. The program’s orientation
documentation was reviewed and was a standardized orientation form with a checklist including
all required topics. The orientation form is initialed by the youth next to each covered topic and
signed by both the youth and staff conducting the orientation. Five youth case management
records were reviewed. All five records contained documentation of a completed orientation
within the required time frame which addressed all required elements. An orientation was not
observed during the annual compliance review week because the program did not have any
admissions. Five youth were interviewed, and all five confirmed an orientation was conducted
within one day of their admission. Each youth was able to explain and confirm the orientation
process included program rules, procedures, schedules, and other required elements.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
The program has a policy and procedures to ensure program staff obtain written consent from
all youth eighteen years of age or older before providing or discussing any of the youth’s
information with the parents/guardians. Two of five youth case management records reviewed
were applicable and the remaining three records were for youth under the age of eighteen. An
additional youth record was requested. All three applicable records contained documentation
the program obtained written consent from the youth prior to communicating any information
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related to the youth’s physical or mental health screenings, assessments, or treatments to their
parents/guardians.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
The program has a policy and procedures to ensure each youth is assessed for the proper
placement within the program’s classification system. The assessment is required at admission
and a youth can be reassessed and reclassified when needed to change the level of privileges,
to include freedom of movement, work project participation, utilization of tools, and off-campus
activities. The classification system at the program utilizes a standardized form addressing all
the required elements needed to be reviewed. Five youth case management records were
reviewed, and each youth’s classification form was found to have all the required elements
documented accurately based on known and reported information. Each classification was
conducted on the day of admission and all risk/alert information corresponded to the
Department’s Juvenile Justice Information System (JJIS) alert list. The classifications were
utilized for living area and room assignment. Two of five youth case management records
contained documentation of reassessment and reclassification; the remaining three records
were not applicable. One of the youth’s reclassifications was conducted to increase freedom of
movement, work project participation involving utilization of tools, and off-campus activities. The
remaining applicable youth had a reclassification completed for an increase in freedom of
movement and off-campus activities. The facility administrator (FA) was interviewed and was
able to explain how factors such as mental health status, physical health status, cognitive
performance, age, and prior victimization are considered during the admission classification
process and are used to assign a living unit for each youth.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program has a policy and procedures to gather and report gang information regarding the
youth. Two of five youth case management records contained gang documentation. The
remaining three records were not applicable. An additional record was selected to achieve a
minimum review of three records. All three applicable youth case management records
contained documentation the program notified local law enforcement, prior to the program’s
seven-day notice for the annual compliance review, of the youth’s gang affiliation. All three
youth records contained documentation of notification to the youth’s home county law
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enforcement agency and each record included the required the Department’s Juvenile Justice
Information System (JJIS) alerts. All three youth appeared in the internal alert binder and on the
program’s alert board. The gang status of each youth was shared with the program’s education
department and the youth’s juvenile probation officer (JPO), and notifications to post-residential
providers were not required.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures ensuring the implementation of gang prevention and
intervention strategies for all youth in the program. The policy and procedures also address
providing youth an opportunity, if the desire, to develop a plan to disaffiliate with a criminal street
gang. The program utilizes a specific gang prevention and intervention curriculum titled Achieve
Realistic Impact to Sustainable Enhancement (ARISE). A lesson is taught at the monthly
community meeting for the youth in the program. Documentation of the gang intervention and
prevention lessons were evidenced by meeting agendas, meeting minutes, and youth sign-in
sheets. Youth identified with gang alerts or significant risk factors have additional gang
intervention/prevention goals included on their Individual Performance Plan (IPP). Two of five
youth case management records contained evidence of gang affiliation and the remaining three
records were not applicable. An additional record was selected to achieve a minimum review of
three records. All three applicable youth case management records contained documentation of
the youth’s identification or affiliation with a criminal gang. Each youth was located on the sign-
in sheets for the gang intervention/prevention lessons and each IPP contained gang related
intervention goals. The interview with the facility administrator (FA) revealed youth who are
identified as a suspected gang member receive interventions on their performance plans and
during the community meeting.
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 each youth receives an initial Residential
Assessment for Youth (RAY), within thirty days of admission, and a RAY Reassessment every
ninety days thereafter. The policy includes procedures for RAY Reassessments when deemed
necessary by the treatment and invention team. All RAY assessments are required to be
maintained in the Department’s Juvenile Justice Information System (JJIS) and in the youth’s
case management record. All five reviewed youth case management records contained
documentation an initial RAY assessment was completed within thirty days of admission and
each initial RAY assessment was maintained in JJIS as required. Two of five reviewed youth
case management records were applicable for at least one ninety-day RAY Reassessment and
the remaining three youth had been in the program less than ninety days. Both applicable
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records contained documentation of each RAY Reassessment being completed and maintained
in JJIS and the youth’s record. One youth record had all three required reassessments and the
remaining record had the two required reassessments. None of the five reviewed records
contained documentation of other updates or reassessments completed before a ninety-day
RAY Reassessment was required.
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) for each youth is completed within thirty days of admission and the documentation shall
be maintained in the Department’s Juvenile Justice Information System (JJIS). All five reviewed
youth case management records included documentation the YNAS was completed within thirty
days of admission and each YNAS was documented in JJIS.
2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
The program has a policy and procedures for ensuring an Individual Performance Plan (IPP)
consisting of goals based on the youth’s initial assessment, with all required elements, is
developed by the assigned intervention and treatment team for each youth. The intervention
and treatment team are required to consist of the treatment team leader, youth, administrative
staff, living unit staff, educational staff, and staff providing treatment. Each IPP goal must
contain a target date of completion and action steps/responsibilities for the youth and staff to
meet the goal. A copy of the IPP with a transmittal letter must be submitted to the committing
court, assigned juvenile probation officer (JPO), and the parent/guardian within ten working
days of completion. Five youth case management records were reviewed for documentation of
performance plan development, goals, and transmittals. All five youth case management
records reviewed had documentation each initial IPP was completed within thirty days of
admission and after the completion of the Residential Assessment for Youth (RAY) and Youth
Needs Assessment Summary (YNAS). All five records contained documentation the required
members of each intervention and treatment team were present during the development of the
IPP which was evidenced by the signature of each required member of the team on the original
sign-in sheet attached to the IPP. Each goal had specified responsibilities for the youth,
applicable staff, and if necessary, the parent/guardian. Two of the five reviewed records
contained the returned signature sheets from the parent/guardian; the remaining three records
contained documentation the parent/guardian signature was requested by mail after the
treatment team meetings were held. Each IPP contained the required elements to include
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individualized goals based upon the prioritized needs reflecting the risk and protective factors
identified during the initial assessment, goals related to the identified top three criminogenic
needs, specific delinquency interventions based on the RAY results, court-ordered sanctions,
transition activities for the last sixty days, youth and staff responsibilities, and target dates for
the completion of each goal. All five applicable reviewed records contained documentation a
transmittal letter and copy of the IPP was submitted to the committing court, JPO, and
parent/guardian. Five youth were interviewed and four of five youth confirmed they participated
in the development of their IPP, have a copy of their IPP, and were able to state specific goals
contained in their IPP. The remaining youth indicated they did not participate in the development
of their IPP nor did they have a copy of the IPP; however, they were able to articulate specific
goals from the IPP. An informal interview was held with the program’s facility administrator (FA)
regarding the negative responses received and the FA confirmed the program’s policy and
procedures including each youth signs their IPP at the completion of the treatment team
meeting formulating the IPP and each youth record contains a signed acknowledgement of
receipt for the copy of the IPP provided.
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 for performance plan revisions based on performance
reviews. Five youth case management records were reviewed for performance plan revisions.
All five reviewed youth case management records contained documentation warranting a
revision to the performance plan. All five records included documentation the performance
plans were reviewed due to the youth demonstrating progress toward completing a goal. Two of
the youth’s performance plans were revised as a result of the Residential Assessment for Youth
(RAY) Reassessment results. Two youth records indicated the performance plans were revised
due to the youth’s demonstrated lack of progress toward completing a goal.
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 ensure Performance Summaries are completed at
ninety-day intervals once the performance plan is developed, and at the request of the
committing court, if necessary. A final Performance Summary is required prior to the youth’s
release, discharge, or transfer from the program. Two of the five reviewed youth case
management records contained documentation of the required Performance Summaries within
the required time frames or specified event; the three remaining youth had not been in the
program for ninety-days at the time of the annual compliance review. An additional youth case
management record was reviewed to meet the minimum requirement of three reviewed records.
All three reviewed records contained all required ninety day Performance Summaries. All
completed Performance Summaries in each of the three applicable records contained
documentation of all the required elements including the youth’s status on each goal, overall
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treatment progress, academic standing, behavior, level of motivation/readiness to change,
interactions with peers and staff, overall behavioral adjustment to the program, significant
events, and, if applicable, justification for release, discharge, or transfer. All reviewed
performance transmittals contained documentation of the youth’s comments and signature,
each youth was provided a copy, and the originals were all contained in each of the reviewed
records. Each reviewed Performance Summary was properly dated and signed by all required
parties, including treatment team leader, staff preparing the summary, facility administrator or
designee, and the youth. All three applicable reviewed records had documentation each
summary was sent within ten working days to the committing court, juvenile probation officer
(JPO), and the parents/guardians.
Three closed youth case management records were reviewed for Release Summaries. All three
reviewed records contained documentation the original summaries with release justification
were sent to the JPO with the Pre-Release Notification (PRN) within the required forty-five days
prior to the anticipated release date. A signed copy of the PRN was located in each closed
record. None of the three closed records contained a PRN with court objection. Each closed
record contained documentation of notification to the parents/guardians and the completion of a
Residential Assessment for Youth (RAY) exit assessment after the approved PRN was
received. One of three closed records required victim notification which was completed at least
ten days prior to release; the remaining two closed records were not applicable.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures to ensure parent/guardian involvement in case
management services. All five reviewed youth case management records contained
documentation of parent/guardian involvement, or attempts to solicit participation, in the
assessment process, development of the performance plan, progress reviews, advanced
notification of formal treatment team meetings with specified dates and times, and transition
planning. The program documentation confirmed when a parent/guardian is unable to attend in
person, telephone participation is offered and arranged or written input is accepted prior to the
meeting. No treatment team meetings were scheduled or held during the annual compliance
review week; therefore, no treatment teams were observed. The program facilitates and
encourages parent/guardian involvement by hosting family days, visitation hours, calls for
families who cannot travel to the program, inclusion/invitation in all case management activities,
and parental/guardian surveys. The facility administrator (FA) interview confirmed the program’s
procedures and practices to solicit parent/guardian involvement throughout the length of stay
and through multiple ways. Five youth were interviewed and confirmed their parents/guardians
participation and involvement in case management activities.
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 each youth’s Individual Performance Plan
(IPP) includes, and makes reference to, all other treatment or care plans developed for the
program. All five youth case management records contained documentation on each IPP of
other treatment or care plans to include academic and mental health plans. None of the
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reviewed records required Department of Children and Families (DCF) or Agency for Persons
with Disabilities (APD) plans to be included.
2.14 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
A program shall ensure the intervention and treatment team meets bi-weekly (formally and
informally) to review each youth’s performance, to include RAY Reassessment results,
progress on Individualized Performance Plan goals, positive and negative behaviors,
including behaviors resulting in physical interventions. If the youth has a treatment plan,
review their treatment plan progress.
The program has a policy and procedures to ensure each youth is assigned an intervention and
treatment team with all required members at admission. The policy and procedures ensure
formal and informal treatment team meetings are conducted with all required participation. All
five youth case management records contained documentation all required formal and informal
treatment team meetings were held at the required monthly frequency. Each conducted
treatment team had documentation of attendance and written input of each required member.
The treatment team meeting signature documentation was completed for all required members
in all twenty-three reviewed formal treatment team meetings. The treatment team
documentation contained all required elements, including any member comments, brief
synopsis of the youth’s progress, Performance Plan revisions and reassessments, if applicable,
positive and negative observed behavior, including if physical intervention was needed, youth’s
ability to demonstrate acquired skills, and treatment progress. All formal treatment team
documentation was maintained in the reviewed records. This is a maximum risk program which
does not require informal treatment teams to be held on the alternating bi-weekly schedule;
however, the program does complete informal treatment team meetings with the youth and case
manager. All reviewed informal treatment team meetings contained all required member
signatures or input, and required elements were observed in the documentation of each meeting
held. All informal treatment team meeting documentation was maintained in each youth case
management record. None of the reviewed records contained any documentation for a special
treatment team meeting. No treatment team meetings were scheduled or held during the annual
compliance review week; therefore, no treatment teams were observed. Five youth interviews
confirmed each youth had staff review goals and progress with them, and each youth was
provided an opportunity during treatment team meeting to demonstrate acquired skills.
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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 the intervention and treatment team plans
for the youth’s successful transition to the community upon release from the program. The
transition activities and goals with target completion dates are reviewed at the transition
meeting, and revisions are made if needed. The program ensures the youth’s attendance at the
Community Re-Entry Team (CRT) meeting prior to discharge. Three closed youth case
management records were reviewed. All three records contained documentation of a transition
conference held at least sixty days prior to the youth’s targeted release date. A review of
documentation confirmed all required treatment team members attended each transition
meeting in person. Included in the meetings were the youth, team leader, administrative, living
unit, and treatment staff as evidenced by a review of signatures. The parents/guardians and
juvenile probation officers (JPOs) were in attendance by telephone; and educational staff
submitted written input. The documentation of each transition conferences confirmed the
members reviewed the transition goals, revised performance plans to include additional
transition goals as needed, identified target completion dates, and included signatures of
members in attendance. Revised performance plans were not able to be verified in the
Department’s Juvenile Justice Information System (JJIS) due to the system being down. A copy
of the plan was sent to members with responsibilities in transition goals, who were not in
attendance, for signature and requested return. None of the three closed case management
records were applicable for mandatory attendance of a human trafficking service provider. Each
transition plan was electronically submitted to each assigned JPO, as evidenced by the printed
email acknowledgement receipt which was filed with the plan and maintained in each closed
record. All three closed records included documentation of the CRT meetings which were held
prior to the youth’s release with the youth and assigned case manager participation noted. An
invitation to the treatment team for the CRT meeting was documented in each record.
2.16 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
The program has a policy and procedures to ensure a completed exit portfolio is created for
each released youth. Three closed youth case management records were reviewed and each
record documented the exit portfolio was discussed and initiated at the transition conference.
Two of three closed records contained all required items including a state-issued identification
card, a copy of the youth’s transition plan, calendars with all dates, times, and locations of
upcoming community appointments, Social Security card, birth certificate, education and
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vocational certifications earned, educational records/documents, school transcripts, a résumé,
and completed sample employment applications. The remaining closed record did not have the
Social Security card or birth certificate as the parent/guardian did not respond to multiple
requests to send the documents to the program Each closed record documented the exit
portfolio was verified at the exit conference and original exit portfolio was provided to the youth,
as evidenced by the youth’s signature at release. Each exit portfolio was forwarded to the
assigned juvenile probation officer (JPO). All three exit portfolios contained the required
completed forms with clear instructions and specific individuals responsible for working with the
youth to complete the tasks. The program does not have any additional contractual
requirements for the exit portfolio.
2.17 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
The program has a policy and procedures to ensure an exit conference is conducted for each
youth release. Three closed youth case management records were reviewed and each record
contained documentation of the exit conference being held after the program’s notification of
anticipated release to the assigned juvenile probation officer (JPO) and at least fourteen days
prior to release. All exit conference documentation contained the required elements including
the date, signatures, and summary of transition goals. Due to Department-wide system outages,
the Department’s Juvenile Justice Information System (JJIS) was not available to verify
admission and release dates matched the reviewed youth records. All transition activities
established at the transition conference were finalized in the documentation at the exit
conference which was attended by the treatment team leader, youth, treatment staff,
parent/guardian, and JPO by telephone. Written input from educational staff was included in all
three closed records reviewed. All three closed records had documentation to confirm the exit
conference was held separately from the transition conference and Community Re-Entry Team
meetings.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures to cultivate youth input. The program’s formal
process to promote constructive youth input includes holding monthly Resident Council
Meetings. The meetings were confirmed through the review of minutes and attendance logs for
each meeting from January 2024 through March 2024. From May 2023 to January 2024
meetings were reviewed during the annual compliance review of the other program housed
within this facility; with the exception of June 2023. Meetings included both Cypress Creek High
and Max Risk participants. Each attendance log documented three to six youth attendees and
the staff who supervised the meeting. Each set of meeting minutes documented the agenda
items covered which included messages from management, daily, weekly, and monthly
scheduled activities, and canteen. Community meetings are held monthly with each dormitory
as evidenced by sign-in sheets, meeting minutes, and copies of activities/information. The
program solicits input from youth, parents/guardians, and other stakeholders utilizing surveys.
The parents/guardians are sent a survey request at admission, throughout the youth’s length of
stay, at exit through email, and in-person during visitation. The surveys address general topics
of clinical services, case management, and medical services. Youth complete surveys
throughout the length of stay, at a minimum of quarterly regarding general topics of
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admission/access, input, rights, treatment plan, quality of care, quality of life, cultural
competency, accessibility, best staff, most improved youth, and other topics which may need to
be evaluated. The program conducted Trauma-Responsive and Caring Environment (TRACE)
assessments at least annually. The youth always have an informal process available to request
to speak with staff. Four of five youth interviews confirmed youth know how or where to provide
input about what happens at the program. The remaining youth stated not being sure on how to
provide input. The facility administrator (FA) was informally interviewed about the negative
response and stated all youth are given a handbook at admission and sign an acknowledgment
of receipt, which provides information and details about the different ways the youth can provide
input. The FA interview confirmed the program’s process for youth input through formal and
informal methods, to include the Can We Discuss form, grievances, treatment team, community
meetings, resident council meetings, and occasionally a youth will attend a weekly management
meeting.
2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program has a policy and procedures to provide for career education based on age which is
appropriate for the educational abilities, goals, and the length of stay of the youth in the
program. The program provides Type 3 career education development and provides pre-
apprentice certification and industry certification such as ServSafe certification, Home Builders
Institute, first-aid, cardiopulmonary resuscitation (CPR), and agricultural science. Three youth
education records were reviewed and all three contained certifications. The course
programming includes instruction in interpersonal skills, communication skills, and decision-
making skills. An interview with the lead educator indicated the program administers a career
assessment using O*Net to identify and research potential career options which is maintained in
the youth education record. An interview with the facility administrator indicated the program
provides career counseling, as well as career and technical education. Three closed youth case
management records and education records were reviewed. All three records contained
provisions for continuation of education and/or employment, a completed employment
application, a résumé, contact information for the local Career Source Center, and
documentation essential to obtaining employment. Two of the three reviewed records had a
Department of Highway Safety and Motor Vehicles state-issued identification card (ID); the
remaining record included documentation the parent/guardian refused to provide the necessary
documents to obtain a state ID. Each record included documentation indicating the
parent/guardian and juvenile probation officer were aware of the vocational plan for the youth,
along with evidence each had a post-release discharge plan.
2.20 Educational Access (Critical) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a policy and procedures to provide educational access. The program provides
education services through the provider. The program has a 253-day calendar which is
distributed over twelve months and includes ten days used for teacher training and planning. A
review of the daily school schedule revealed the center provides six, fifty-five minute classes
from 7:45 a.m. through 2:10 p.m. with a thirty-five minute lunch break from 11:40 a.m. through
12:15 p.m., fulfilling the weekly requirement of twenty-five hours of instructional time. The lead
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teacher was interviewed and confirmed the educational instructional schedule and reported the
school schedule is adhered to. Four of five interviewed youth indicated there were no
interruptions during school, while the remaining youth reported yes, for good cause. A review of
five randomly selected days in the logbook indicated education classes started and ended on
time or within a few minutes of the scheduled time. Observations of the program video on March
4, 2024, March 20, 2024, and April 1, 2024, confirmed classes started and ended on time, as
scheduled.
2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The program has a policy and procedures requiring an Education Transition Plan to be
developed upon each youth’s admission. Three closed youth case management records were
reviewed. All three youth records included an individual Education Transition Plan developed
upon entry which included the youth’s post-release goals, meeting the required elements. Each
of the three records contained an exit plan indicating the case manager, parent/guardian, and
youth were all aware of the plan. Included in each record was an Electronic Educational Exit
Plan (EEEP) which identified the next educational placement information and input from the
post-release school district representative. Five youth were interviewed and three of the five
youth reported they participated in the development of their transition plan, while two youth were
not applicable because they had already graduated high school. All five youth indicated the
program was preparing them well or very well when it came to high school, high school
equivalency diploma (GED), vocational school, employment, and/or college. The interview with
the lead teacher indicated information is shared with the multi-disciplinary treatment team
members bi-weekly at treatment team meetings. The transition plan includes educational,
vocational, and special education services, when needed. Education staff assist the youth in
developing the transition plan which is inclusive of youth needs from intake, through release,
and beyond.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program has a policy and procedures ensuring a State of Florida licensed clinician will
serve as the designated mental health clinician authority (DMHCA) and will be responsible for
providing the coordination and implementation of mental health and substance abuse service
delivery. The program has a licensed mental health counselor (LMHC) who serves as the
designated mental health clinician authority (DMHCA). The DMHCA has a clear and active
license under Chapter 491, Florida Statutes, which expires on March 31, 2025. Documentation
showed the DMHCA was on-site for forty hours a week and on call twenty-four hours a day, as
needed, as contractually required. The program provided the license and agreement for review.
The program has a back-up DMHCA. The back-up DMHCA has a clear and active license under
Chapter 491, Florida Statutes with an expiration date of March 31, 2025. The DMHCA was
interviewed and reported the role of the DMHCA is oversight of the mental health and substance
abuse services.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a licensed psychologist in addition to the designated mental health clinician
authority (DMHCA). The licensed psychologist is required to come on-site every two weeks and
is available by telephone twenty-four hours a day, seven days a week. The three licensed
mental health and substance abuse clinical staff are in accordance with the current contract and
Florida Administrative Code. All licenses were available for review. All licenses and Chapter 397
licenses are posted within public view at the program. The program has an assistant director of
clinical services, a part time licensed mental health professional, and a regional director acting
as a DMHCA.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The designated mental health clinician authority (DMHCA) provides direct supervision for non-
licensed staff. The DMHCA assures the non-licensed clinical staff working under their
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supervision are performing services they are qualified to provide based on education, training,
and experience. At the time of the annual compliance review the program was fully staffed with
five non-licensed, master’s-level mental health staff working under a full-time DMHCA. All five
therapists received a minimum of one hour a week of on-site, face-to-face direct supervision by
the DMHCA for the purpose of overseeing and directing the mental health services provided in
the program during the annual compliance review period. All supervisions were recorded on the
Department’s Licensed Mental Health Professionals and Licensed Substance Abuse
Professionals Direct Supervision Log form. Each of the five therapists hold a master’s-level
degree from an accredited university or college in the field of counseling, social work,
psychology, or related human services field. The service provider is licensed under Chapter 397
and the therapists are working under direct supervision of a qualified professional as defined in
Florida Statute. Two of the five therapists completed twenty hours of training and completed
Assessments of Suicide Risk (ASRs). The therapists were trained in assessing suicide risk,
mental health crisis intervention, and emergency mental health services. The training included
the administration of five ASRs or Crisis Assessments completed on-site in the physical
presence of a licensed mental health professional and documented on the Non-Licensed Mental
Health Clinical Staff Person’s Training in Assessment of Suicide Risk form. The remaining three
are newly hired therapists and did not complete suicide assessments as of the current annual
compliance review.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program has a policy and procedures for the implementation of a standardized
admission/intake mental health and substance abuse screening process. The policy and
procedures were reviewed and included a standardized screening process which includes a
review of commitment packet information, reports and records, administration of the
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) in the Department’s
Juvenile Justice Information System (JJIS), a Clinical Mental Health Screening by a licensed
mental health professional, a Clinical Substance Abuse Screening by a qualified professional,
and referrals for juvenile offenders identified by screenings as in need of further evaluation or
immediate attention. The policy and procedures included staff training in mental health and
substance issues, administration of the MAYSI-2, and included a standardized process for
referral of youth identified in need of further mental health and/or substance abuse evaluation to
an appropriate service provider/professional or, when immediate attention is needed to a
hospital, Baker Act, or Marchman Act receiving facility. Five youth records were reviewed for a
mental health and substance abuse screening. All five youth had a MAYSI-2 completed upon
admission. All available information was reviewed which included the commitment packet,
reports, and records for existing documentation of mental health or substance abuse problems,
or history of human trafficking. The five MAYSI-2 screenings were completed on the date of
each youth’s admission to the program in a confidential manner. Case management staff
conducted all five MAYSI-2 assessments and had completed the appropriate MAYSI-2 training
within the Department’s Learning Management System (SkillPro). The designated mental health
clinician authority (DMHCA) reviewed all MAYSI-2 screenings and indicated if the youth needed
further assessments or a referral. Four of five screenings indicated a further assessment was
required. Staff determined each of the youth assessed either had a mental health need,
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substance abuse problem, and/or was a suicide risk. In four of five records reviewed a referral
for further evaluation was generated. All five youth received an Assessment of Suicide Risk
(ASR) and were subsequently referred for assessment. All five ASRs were conducted within
twenty-four hours of the referral. The facility administrator and DMHCA signed off on all ASRs
being done within twenty-four hours when the MAYSI-2 category suicide ideation indicated
further assessment was needed or other information obtained at intake/admission suggested
potential suicide risk. All five youth records reviewed had an ASR, comprehensive evaluation,
and the reason for referral was documented. The staff who made the referral documented a
consultation with the DMHCA on the Mental Health Substance Abuse Referral Summary. The
facility administrator was interviewed and reported the youth are screened using the MAYSI-2
and ASR.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
The program has a policy and procedures to address the provision of mental health and
substance abuse assessments and evaluations. Five youth records were reviewed for mental
health and substance abuse assessment and evaluation. All five youth records included
documentation the program completed a new combined mental health and substance abuse
evaluation. All evaluations were completed within thirty calendar days of admission. If a non-
licensed mental health clinical staff or non-licensed substance abuse clinical staff completed the
evaluation, it was reviewed and signed by a licensed mental health professional within ten
calendar days after the evaluation was conducted. The comprehensive evaluation included the
required information in all five records. All five youth records included a consent obtained for
substance abuse services. All five substance abuse evaluations were completed within thirty
calendar days of admission. All five records included documentation which included the reason
for assessment, relevant background information, behavioral observations, methods of
assessment, patterns and impacts of alcohol and drug abuse on major life areas, risk factors of
continued alcohol and other drug abuse, clinical impression including diagnoses, original referral
reason, and recommendations. None of the youth required an updated comprehensive
evaluation.
3.06 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
(Critical)
Youth determined to have a serious mental disorder or substance abuse impairment and are
receiving mental health or substance abuse treatment in a program, shall have an Initial or
Individualized Mental Health or Substance Abuse Treatment Plan. When mental health or
substance abuse treatment is initiated, an Initial or Individualized Mental Health or Substance
Abuse Treatment Plan is completed.
The program has a policy and procedures in place outlining the program’s mental health and
substance abuse services. Five youth records were reviewed for mental health and substance
abuse treatment. All five youth records included documentation an Initial Treatment Plan (ITP)
was developed within seven days of initiation of treatment. All five initial mental health treatment
plans were documented on a form which included all elements of the Department’s Mental
Health/Substance Abuse Treatment Plan form. All five Initial Treatment Plans were signed by
the mental health or substance abuse clinical staff completing the form. All five records included
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documentation the Initial Treatment Plan was completed by a non-licensed mental health clinical
staff and all were signed by the licensed clinical supervisor within ten days of completion. All five
treatment plans were signed by all treatment team members who participated in the
development of the plan, the youth, and parent/guardian. All five treatment plans were mailed to
the parent/guardian the day the plans were signed by the treatment team. Three of the five
youth records had documentation the Initial Treatment Plans included each youth’s psychiatric
needs, to include medication and frequency of monitoring by the psychiatrist. Two of five youth
were not applicable for the receipt of psychiatric services, including psychotropic medication.
All five individualized treatment plans were developed for the youth within thirty days of
admission. All treatment plans were developed on forms which contained all elements of the
Department’s Individualized Mental Health/Substance Abuse Treatment Plan form. All five initial
mental health treatment plans were developed within seven days of the onset of treatment. All
five records included documentation of the treatment team reviews being conducted every thirty
days. All five treatment plans included documentation of the prescribed services, to include
individual, group, family, and psychiatric services. All prescribed services were individualized for
each youth. Video review was conducted for three randomly selected days and revealed groups
were being held as required.
3.07 Treatment and Discharge Planning (Critical) Satisfactory Compliance
Mental health and substance abuse treatment planning in programs focus on providing
mental health and/or substance abuse interventions and treatment to reduce or alleviate the
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
The treatment team is responsible for assisting in developing, reviewing, and updating the
youth's Individualized and Initial Mental Health/Substance Abuse Treatment Plans.
All youth who receive mental health and/or substance abuse treatment while in a program
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the program.
The program has a policy and procedures addressing treatment and discharge planning and to
ensure the multidisciplinary treatment team development of an Initial Treatment Plan (ITP)
within thirty days of the youth’s admission to the program. Five youth records were reviewed for
treatment and discharge planning. All five youth records included documentation the youth were
assigned a treatment team upon arrival to the program. Documentation revealed the treatment
team was comprised of the youth, program administration staff, residential living unit staff,
education staff, medical staff, mental health staff, substance abuse staff, and parent/guardian.
All five youth records included documentation the youth received individual, group, and/or family
counseling provided by a qualified professional or a non-licensed professional under the care of
a licensed professional for substance abuse treatment. All five youth records included
documentation an Authority for Evaluation and Treatment (AET) form was properly executed. All
five youth records included documentation of a signed Youth Consent for Substance Abuse
Treatment Records form. All mental health treatment notes or substance abuse treatment notes
were documented on a form which contains the Department’s Counseling/Therapy Progress
Notes information. All five youth records included documentation each youth received individual
psychotherapy or counseling and psychosocial skills training. All five treatment plans included
the frequency of prescribed services for each youth to include individual, group, and family
sessions. A review of progress notes revealed each youth received services as stipulated on the
treatment plan.
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The five youth records selected for review were not applicable for discharge planning. The
program provided three closed records for review. All three records included documentation the
discharge plan was completed on the Department’s Mental Health/Substance Abuse Treatment
Discharge Summary form. All three discharge summaries included the services needed for daily
maintenance of the positive improvement in behavioral, emotional, and social skills made by
each youth during treatment. The reviewed documentation for all three youth reflected the
discharge plan was discussed with the youth, parent/guardian, and juvenile probation officer
(JPO) during the exit conference. A copy of the discharge summary for all three youth was
provided to the youth, JPO, and parent/guardian.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
The program has a policy and procedures regarding specialized treatment services. A review of
the contract indicated the program’s required clinical groups are The Passport Program,
Skillstreaming the Adolescent, and Living in Balance. Five youth were interviewed and stated
they participate in family and individual counseling. Five staff were interviewed and stated they
do not facilitate any mental health or substance abuse groups. The designated mental health
clinician authority (DMHCA) was interviewed and stated youth participate in group therapy
services four days each week. The facility administrator (FA) was interviewed and indicated the
program provides Substance Abuse Treatment Overlay Services (SAOS) and Mental Health
Overlay Services (MHOS) to youth at the program. The program provides individual, group, or
family therapy and these are included on the youth treatment plans. The program provides daily
therapeutic activities which include psychosocial skills training, psychoeducation, and supportive
counseling. These services are provided by mental health clinical staff an average seven days
a week. Youth with substance abuse disorders receive substance abuse services under
Chapter 397. The average caseload for therapists in the program is five youth. All group sign-in
sheets reviewed were limited to ten or fewer youth. The program has Chapter 397, which allows
unlicensed therapist to provide services under the supervision of a licensed therapist.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.***
The program has a policy and procedures to address the psychiatric services provided to the
youth. The program provides psychiatric services to the youth who require this service. The
psychiatrist has a clear and active license as outlined in Florida Administrative Code which
expires January 31, 2026. The psychiatrist is available for emergency consultation twenty-four
hours a day, seven days a week. The psychiatrist briefed a representative of the treatment team
regarding the status of each youth receiving psychiatric services. A review of the sign-in/out logs
confirmed visits by the psychiatrist were conducted as required by the contract or agreement.
The psychiatrist did participate in, manage, and supervise psychotropic medication services in
the program. Two of five youth records contained evidence the youth entered the program on
psychotropic medication and the remaining three records were not applicable. An additional
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applicable record was selected to achieve a minimum review of three records for psychiatric
services. All three reviewed youth were admitted on psychotropic medications and each youth
received a diagnostic interview within fourteen days of admission in accordance with Florida
Administrative Code. The initial diagnostic psychiatric interview included the medical, mental
health, and substance abuse history, Mental Status Examination, and the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) diagnosis. All three youth
diagnoses were consistent with the youth’s treatment plan, treatment recommendations,
prescribed medications, and included the need for the medications, target symptoms, initial
treatment goals, potential side effects, risks and benefits of taking the medication, and
frequency of medication monitoring and management. Each initial diagnostic psychiatric
interview was documented on a form which contained all required information based upon the
Department’s Clinical Psychotropic Progress Note (CPPN) and was clearly identified as “Initial
Psychiatric Interview”. The psychiatrist’s evaluation and recommendations for each youth were
incorporated into the mental health clinical staff’s evaluations and the treatment plans. A review
of each youth’s CPPN confirmed all three youth receiving psychotropic medications received
medication reviews as required. The psychiatrist was interviewed and reported providing the
initial psychiatric evaluations, prescribing medications, and monitoring youth taking psychotropic
medications every thirty days. The psychiatrist reported being available by telephone twenty-
four hours a day, seven days a week for emergencies. The designated mental health clinician
authority (DMHCA) was interviewed and reportedly meets with the psychiatrist bi-weekly for a
psychiatric treatment team meeting.
3.10 Suicide Prevention Plan (Critical) Satisfactory Compliance
The program follows a Suicide Prevention Plan to safely assess and protect youth with
elevated risk of suicide in the least restrictive means possible, in accordance with the Rule
63N-1, Florida Administrative Code.
The program has a policy and procedures to address the provision of suicide prevention
planning and detailing suicide prevention procedures. The procedures included the identification
and assessment of youth at risk of suicide, staff training to include six hours annually, suicide
precautions, levels of supervision, referral, communication, notification, documentation,
immediate staff response, and the review process. A review of documentation confirmed the
review process for suicide attempts and mortality review included the circumstances
surrounding the event, facility procedures relevant to the incident, all relevant training received
by involved staff, pertinent medical and mental health services involving the victim, possible
precipitating factors, and recommendations for change, if any. The Suicide Prevention Plan was
reviewed by the licensed mental health counselor on February 26, 2024.
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.
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The program has a policy and procedures to address suicide prevention services. The program
did not have any applicable youth since the last annual compliance review.
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 maintains a policy and procedures to address suicide precautions maintaining
youth on one-to-one or constant supervision. The program did not have any applicable youth
since the last annual compliance review.
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 staff who work with youth are trained to
recognize verbal and behavioral cues indicating suicide risk, suicide prevention, and the
implementation of suicide precautions. Five in-service and five pre-service staff training records
were reviewed and indicated the staff had completed suicide prevention training. The program
has five suicide response kits, one in master control, sub control, the controlled observation
area, the computer/digital lab, and one to be used in the transport vehicle. All suicide response
kits contain a knife-for-life, needle nose pliers, and wire cutters, along with a one-way
cardiopulmonary resuscitation (CPR) mask, micro shield or face shield, non-latex gloves, and
first-aid supplies. A review of the suicide prevention drills indicated the program conducted drills
at least quarterly on each shift, for all staff who come in contact with youth, including kitchen
and maintenance staff. Each reviewed drill documented a description of the incident, a synopsis
of the response, involved staff, and any applicable deficiencies and/or corrective action,
incorporating the use of life saving measures including the use of a first-aid kit, CPR, or an
automated external defibrillator (AED). Staff who were not present during the quarterly drills had
the opportunity to review each scenario and procedures during monthly staff meetings. An
interview with the facility administrator (FA) indicated the designated mental health clinician
authority (DMHCA) completes mental health and suicide prevention drills across all shifts,
ensuring each staff participates in at minimum of one drill on a quarterly basis. Each drill is
reviewed monthly during the general staff meeting with all staff. An interview of five staff
indicated when a youth expresses suicidal thoughts, direct care staff are responsible for
notifying mental health, keeping the youth under consistent sight and sound observation, and
documenting the supervision. Additionally, four staff stated the youth and room are searched for
sharp objects and one staff said they would notify management. Four of five interviewed staff
identified the suicide response kits as being kept in master control and the supervisor’s office,
one said in medical, and all five indicated sub control. All five staff indicated medical emergency
and suicide drills are conducted monthly on each shift.
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3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a policy and procedures to address mental health crisis intervention services
for youth. The written crisis intervention plan includes a notification and alert system, a means of
referral which includes youth self-referral, communication, supervision of youth, 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 addressing Crisis Assessments. The program only
had one Crisis Assessment completed since the last annual compliance review. The program
did not have any other youth applicable for Crisis Assessments during the annual compliance
review period. One youth was determined to be in crisis and a Crisis Assessment was
completed within two hours. The Crisis Assessment included the reason for assessment, Mental
Status Examination and interview, a determination of danger to self and/or others, initial clinical
impressions, supervision and treatment recommendations, recommendations for follow-up, and
parent/guardian notification. The Crisis Assessment was conducted by the designated mental
health clinician authority (DMHCA). The youth was assessed immediately after the referral and
was found to be in crisis. The youth was then Baker Acted. No follow-up assessment was
conducted because the youth was Baker Acted. When the youth returned from the off-site Crisis
Assessment, the youth was placed on constant supervision until a mental health clinical staff
reviewed the off-site assessment documents. The program had no alleged Prison Rape
Elimination Act (PREA) events since the last annual compliance review.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a policy and procedures regarding the emergency mental health and
substance abuse services which include a written mental health and substance abuse plan. The
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emergency mental health and substance abuse plan includes immediate staff response,
notifications, communication, supervision, transportation services, 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 to address Baker and Marchman Acts. The program
reported having one Baker Act since the last annual compliance review involving one youth. A
review of one youth record documented the direct care staff immediately notified mental health
staff and the shift supervisors. The youth was placed on one-on-one supervision. The
designated mental health clinician authority (DMHCA) began the Baker Act process and
authorized the transport for the youth. The Baker Act event documented the youth was
transported by local law enforcement. Upon return to the program from the Baker Act crisis
stabilization unit, the youth was placed on precautionary observation (PO) and a Mental Status
Examination was conducted. An Assessment of Suicide Risk (ASR) was completed by the
licensed staff for the youth. The event documented the youth remained on PO until properly
transitioned to close supervision, and subsequently, standard supervision. The program did not
have any Marchman Acts since the last annual compliance review.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
The program has a policy and procedures to address the safety planning process for each
youth. A review of five youth mental health records was conducted in reference to the safety
planning process for each youth. The program’s safety plan form included an initial and a review
planning process. The initial planning process is initiated by each youth’s therapist within
fourteen days of the youth admission to the program. The safety plans are jointly prepared by
the youth, parent/guardian or family member, case manager, and clinical staff. The plans are
reviewed and signed by all staff involved and the youth. Thereafter, the youth’s safety plan is
reviewed and updated every thirty-days to include signatures and date of the youth and staff.
The program’s safety plan form included the youth warning signs, baseline behaviors gathered
from collateral contacts, crisis recognition, jointly developed coping strategies, intervention
strategies, and debriefing preferences. All five youth safety plans incorporated
recommendations of previous and current clinical assessments, as required. Four of five youth
safety plans were updated every thirty days and documented any significant behavioral or
mental health event identified by the youth’s intervention and treatment team. One youth safety
plan was one day late. The youth safety plans were maintained in each youth’s mental health
and substance abuse record and within a centralized binder inside the breakroom easily
accessible to all staff. Four of five interviewed youth reported they each contributed in the
development of their safety plan, while the remaining youth reported not knowing about safety
plans. All five interviewed staff were able to provide the location of youth safety plans. Four of
five interviewed staff indicated they were aware of the process for reviewing safety plans, while
the remaining staff was unable to remember the process during the interview. When asked for
the last time the staff reviewed safety plans, one staff stated today at the beginning of their shift,
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one said yesterday, two staff had not reviewed any safety plans, and one staff indicated they did
it last year because mostly the supervisors do it. An interview with the facility administrator (FA)
confirmed safety plans are updated monthly or when a serious issue arises with a youth.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program has a policy and procedures stating the designated health authority (DHA) shall be
clinically responsible for the medical care of all youth at the program. The program’s DHA is a
licensed physician who holds a clear and active license with an expiration date of January 31,
2025. The physician’s specialty training is in internal medicine. The DHA does not have any
disciplinary cases or public complaints on record. The program does not utilize a physician’s
assistant or advanced practice registered nurse (APRN). Reviewed sign-in/out logs since the
last annual compliance review confirmed the DHA was on-site for two hours each week, as
required by contract. The program has a back-up physician in the event of the DHA’s absence
who holds a clear and active license with an expiration date of January 31, 2025; however, the
DHA has not been absent since the current provider took over the contract. A review of the
program’s contract and DHA’s contract found the program does not utilize tele-medicine or tele-
health for medical services. The DHA was interviewed and indicated they see youth for initial
intake physical exams, periodic evaluations, sick calls, and referrals to specialists as needed.
The DHA stated all items needing review are placed in a folder. The DHA indicated medical staff
inform them of any new medical developments involving youth. The DHA and medical staff meet
weekly. The DHA reports being available by telephone when not on-site.
4.02 Licensed Medical Staff (Critical) Satisfactory Compliance
The designated health authority (DHA) is clinically responsible for all healthcare services
provided to youth at the program. Daily clinical care shall be performed by licensed medical
staff (RN, LPN) according to developed and authorized protocols. This includes the intake
evaluations, assessments, health education, medication management, and other assigned
duties according to the Department’s Rule, as well as the program’s facility operating
procedures and nursing protocols approved by the DHA.
The program has a policy and procedures indicating the designated health authority (DHA) is
clinically responsible for all healthcare services provided to youth at the program. Daily clinical
care shall be performed by licensed medical staff according to developed and authorized
protocols. The program’s contract indicates the program will have a full-time health services
administrator (HSA), four full-time registered nurses (RNs), and one licensed practical nurse
(LPN). Nursing staff are on-site for forty hours, seven days a week along with the HSA as
required. The LPN can only work while there is an RN on shift. A review of nursing licensure
credentials on the Florida Department of Health Medical Quality Assurance website confirmed
each of the RN’s licenses were clear and active. The HSA’s license expires on April 30, 2024,
one RN’s license expires April 30, 2024, and three RN’s licenses expire July 31, 2024. The
LPN’s license expires July 31, 2025. Each nurse has a current cardiopulmonary resuscitation
certification card.
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4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has facility operating procedures (FOPs) for all health-related procedures and
protocols utilized at the program. The medical FOPs were signed by the designated health
authority (DHA) and the facility administrator (FA) on July 5, 2023. The psychiatrist signed the
FOPs on July 5, 2023. A cover page indicating all FOPs and nursing protocols were reviewed
was signed by the program’s health services administrator and pro re nata (PRN) registered
nurse (RN) on August 31, 2023. They were also signed by three full-time RNs on August 31,
2023. Medical FOPs were revised on August 31, 2023. Each revised FOP was signed by the
DHA and FA, and a signature page, with the specific policies and date of revision, was signed
by nursing staff following the revisions. The program had three newly hired nursing staff since
the last annual compliance review and each had reviewed and signed the FOP review form.
Approval of treatment protocols and standing procedures were written and authorized by the
DHA and were not delegated to any other person.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a policy and procedures ensuring the completion of the Authority for
Evaluation and Treatment (AET) authorizing specific treatment for youth in the custody of the
Department. Five youth Individual Healthcare Records (IHCRs) were reviewed. All five IHCRs
contained a valid AET form. Each AET was a copy and was stamped with the word “copy.” Each
AET was signed by a parent/guardian and a Department representative. Two youth were
eighteen years of age or older and both had a documented release of information in their
IHCRs. There were no youth in the care of the Department of Children and Families (DCF)
where there had been a termination of parental/guardian rights. An interview with the health
services administrator (HSA) indicated nursing staff review all intakes in the Department’s
Juvenile Justice Information System (JJIS) admission packet to validate the AET. If needed,
case management staff would contact the youth’s assigned juvenile probation officer (JPO) to
obtain a new AET. Youth who are eighteen years of age or older sign a release of information,
which is placed in their IHCR.
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures to ensure the parent/guardian is informed of
significant changes in the youth’s condition and to obtain consent when new medications and
treatments are prescribed. Five youth Individual Healthcare Records (IHCRs) were reviewed
and four were applicable for parent/guardian notification and the remaining youth was eighteen
years of age at the time of admission. Two youth IHCRs were applicable for parental/guardian
notifications for over-the-counter (OTC) medications beyond those covered by the Authority for
Evaluation and Treatment (AET). Both IHCRs contained documentation of parent/guardian
notification and consent for each OTC medication. New medication was ordered for two of the
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five youth. Documentation of notification to the parents/guardians for each new medication was
in each youth’s IHCR. All written notifications were sent utilizing the correct forms. Two youth
were taking psychotropic medications. Both youth had a new psychotropic medication
prescribed, discontinued, or had the dosage significantly changed. Documentation in the two
IHCRs found parent/guardian verbal consent was documented on page three of the Clinical
Psychotropic Progress Note (CPPN). Two applicable CPPNs included a progress note signed
by a witness, indicating staff witnessed telephone call attempts or conversations regarding the
psychotropic medication. There were no youth in the care of the Department of Children and
Families (DCF) where there had been a termination of parental/guardian rights. All five reviewed
youth had their vaccinations verified within thirty days of admission. None of the reviewed youth
received a vaccination at the program. None of the reviewed youth required an exemption for a
vaccination. An interview with the health services administrator (HSA) found parental/guardian
notifications are made when new medications are ordered or OTC medications are provided by
the facility nursing protocols and are not covered by the AET. Attempts to contact the
parents/guardians are made while the psychiatrist is in the facility. If they cannot contact
parents/guardians, calls are made until verbal consent is obtained before starting medication.
The third page of the CPPN and agent of record (AOR) are sent certified to the parent/guardian
and by regular mail. Discontinued medication and adjustments are sent on the AOR. The
program obtains immunization records from Florida Shots and if an immunization is needed, the
county health department is notified. The records are reviewed as soon as possible.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a policy and procedures which ensure youth are screened upon admission for
healthcare concerns which may require a referral for further assessment by healthcare staff.
Five youth Individual Healthcare Records (IHCRs) were reviewed for completion of the
Department’s Facility Entry Physical Health Screening (FEPHS) form. Each youth’s IHCR
contained a FEPHS form completed by a registered nurse (RN) on the day of their admission.
The program did not have any youth with a change in physical custody for greater than twenty-
four hours. An interview with the health services administrator (HSA) indicated a pre-notification
email is sent by the intake specialist before the youth's arrival. On the day the youth arrive to the
facility, they are brought to the medical clinic where the intake process begins. If the youth arrive
during off hours, a FEPHS will be filled out by a non-licensed healthcare designee and then
reviewed by a licensed healthcare staff during the following normal hours of operation. Licensed
healthcare staff have twenty-four hours to review the FEPHS on a youth who arrived during off
hours. If a youth is admitted with a serious chronic condition, the DHA is notified immediately by
nursing staff and a chronological progress note is documented in the IHCR.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy and procedures to ensure all youth are oriented to the general
process of healthcare delivery services at the program. Five youth Individual Healthcare
Records (IHCRs) were reviewed for healthcare orientation. Each youth received a general care
orientation on the day of admission. The program’s healthcare orientation included all required
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topics including access to medical care, sick call, what constitutes an “emergency” and when to
notify staff, medication process to include side-effect monitoring, the right to refuse care and
how it is documented, what to do in the event of sexual assault or attempted sexual assault, the
non-disciplinary role of healthcare providers, and Standard Universal Precautions. Each youth’s
IHCR included a signed Health Care Services Orientation form and a signed acknowledgment
form stating they reviewed and understood the Health Education Packet; therefore, the program
did not need an education orientation binder to ensure all required orientation topics are
reviewed with the youth.
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a policy and procedures to ensure the designated health authority (DHA) is
notified when an admitted youth requires emergency care or routine notification in accordance
with the Department’s requirements. The program’s practice is to notify the DHA of each
admission. Five youth Individual Healthcare Records (IHCRs) were reviewed. Three reviewed
youth had a known or suspected chronic condition upon admission. None of the reviewed youth
were identified as in-need of an emergency response upon admission. Each youth’s IHCR
contained documentation of notification being made to the DHA within twelve hours of
admission. Two of the three applicable youth was taking psychotropic medication when admitted
to the program and the psychiatrist was notified as required. During an interview, the health
services administrator (HSA) stated if the admitted youth require emergency care, the DHA is
notified immediately by a medical healthcare staff and the notification is documented in the
chronological progress 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.
The program has a policy and procedures to ensure the standard Department’s Health-Related
History (HRH) form is used for all youth admitted into their physical custody. Five youth
Individual Healthcare Records (IHCRs) were reviewed for completion of a HRH form. A new
HRH form was completed within seven calendar days of admission for each youth. Each
reviewed HRH form was completed prior to the Comprehensive Physical Assessment (CPA)
and reviewed by the designated health authority (DHA). The health services administrator
stated a new HRH is completed on the day of admission for all new youth by the registered
nurse; otherwise, one shall be updated and completed within seven days of youth admission.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a policy and procedures ensuring the standardized Comprehensive Physical
Assessment (CPA) form is used for all youth admitted into the program. A review of five youth
Individual Healthcare Records (IHCRs) found a new CPA form was completed by the
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designated health authority (DHA) on the Department’s CPA form within seven days of
admission for each youth. Each youth’s Medical Grade was documented on their CPA. Three
youth were identified as Medical Grade five, one youth was identified as Medical Grade four,
and one youth was identified as Medical Grade one. All sections of each CPA were marked with
an “O” or an “X.” Those sections marked with an “X” had comments by the DHA in the
comments section of the form for each youth. Each youth signed a refusal form which reflected
the refused portion on the CPA exam and matched the date of the exam. The Department’s
Problem List was updated, as required, for each youth. All five youth had at least one verified
Tuberculosis Skin Test (TST) completed and documented within a year of admission. Each
youth’s results were documented on their CPA and Infectious Communicable Disease form, and
each youth’s test results matched on both forms. An interview with the health services
administrator (HSA) found the DHA does a new CPA on all admissions, within seven days of the
date of admission and yearly for all youth. There are no females in this facility.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures ensuring all youth are evaluated and treated, if
necessary, for sexually transmitted infections (STIs). Five youth Individual Healthcare Records
(IHCRs) were reviewed. Each youth’s IHCR contained documentation showing they were
screened and evaluated for STIs on the day of admission. Further evaluation was not required
for any youth. None of the reviewed youth required a rescreen. Consent forms in all five
reviewed IHCRs reflected each youth was offered counseling, testing, and if indicated,
treatment/referral for human immunodeficiency virus (HIV). All five of the reviewed youth
refused HIV testing and a refusal was documented. The program’s policy and procedures
indicate youth HIV test results are only disclosed to entities as outlined in Florida Administrative
Code. Five interviewed youth stated they can ask for a HIV test. The health services
administrator (HSA) was interviewed and was able to accurately summarize the procedures for
STI screening and testing.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a policy and procedures to ensure all youth can submit sick call requests and
have their complaints treated appropriately through the program’s sick call system. Five
Individual Healthcare Records (IHCRs) were reviewed and three were applicable for sick calls.
None of the three applicable youth presented with a similar sick call complaint three or more
times within a two-week period. Each reviewed Sick Call Request form was completed by the
youth requesting a sick call and the registered nurse (RN) conducting the sick call. Each youth’s
Sick Call Request forms were filed in their IHCR in reverse chronological order and documented
in accordance with Florida Administrative Code. Each youth’s sick call was documented on their
Sick Call Index in their IHCR and documented on the program’s Sick Call Referral Log. All dates
listed on the Sick Call Indexes corresponded to the completed Sick Call Request forms located
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in the IHCRs. None of the youth were in restricted housing. A review of the daily schedule,
posted schedule, and nurse interview found sick call is held daily from 2:20 p.m. to 5:30 p.m.,
Monday through Friday and 11:30 a.m. to 12:30 p.m., and Saturday and Sunday. Sick call hours
are posted outside of the medical clinic and on the living unit. An exam table is located in the
medical clinic to utilize during sick calls. Sick Call Request forms are available to youth on the
living units. Completed forms are submitted by youth into a box in the living units. If there are no
nursing staff on-site, the program’s policy indicates Sick Call Request forms should be turned in
to the shift supervisor promptly; however, no longer than two hours after being submitted. Five
interviewed staff stated nursing staff review sick calls and one staff added supervisors collect
sick calls. All five staff confirmed nursing staff conduct sick call. Five youth were interviewed. All
five youth stated they see a nurse within one day when a sick call is requested. During the
annual compliance review week there was one sick call request made by a youth, requesting to
be seen by the medical staff; therefore, an observation of a sick call was able to be conducted.
Observations validated the program’s practice when conducting a sick call request.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a policy and procedures to ensure a comprehensive process for the provision
of episodic care and first-aid care. Five youth Individual Healthcare Records (IHCRs) were
reviewed and four were applicable for episodic care. On-site care was provided by licensed
healthcare staff for each event. Each event was documented in the required subjective,
objective, assessment, and plan (SOAP) format. All four events were documented on the
Episodic Care Log. An episodic care event was not observed, as one did not take place during
the annual compliance review week. All five interviewed staff stated they can call 9-1-1 if a youth
has a medical emergency. All five interviewed youth indicated they can see a dentist or doctor if
needed. The program maintains seven first-aid kits. The kits are kept in the Home Builders
Institute (HBI) work area, vocational area, room 127, kitchen, north sub control, south sub
control, and master control. Three of the first-aid kits maintained in master control are utilized for
transportation, one assigned to each vehicle used at the program. Daily checks of first-aid kits
are conducted by staff to ensure the kits are still sealed and documentation is noted on the
Safety and Security Check List form. If a kit is found unsealed or used, the staff take the
unsealed kit to medical for check and/or restock; this is documented as well. Medical returns the
kit back to the assigned location. Medical is responsible for restocking and resealing all used
kits and to inventory the first-aid kits on a regular basis. A weekly First-Aid Kit Inspection Log
form is maintained for the medical staff checks and the documentation is maintained to track
expiration dates of items within the kits on this form. Three first-aid kits were checked during the
week of the annual compliance review to ensure they were secure and contained the listed
items. The three kits were found to be secure with all items listed. An interview with the health
service administrator (HSA) confirmed the number and location of the first-aid kits. The program
has one automated external defibrillator (AED) which is located in master control. Instructions
are located in a binder in master control. Reviewed documentation confirmed on-site healthcare
staff check to ensure the AED batteries and pads are operable. The green light was observed to
be flashing on the AED during the annual compliance review week and no issues were noted. It
was unknown when the batteries were last changed, however, the current battery is set to
expire in June 2024 and a back-up battery is set to expire August 2025. The pads were last
changed November 29, 2021, and are set to expire November 2025. An interview with the HSA
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confirmed the location of and expiration dates for the AED. A review of emergency drill
documentation found the program has conducted drills monthly and on each shift which
simulated an episodic care event. These drills included first-aid and/or administration of
cardiopulmonary resuscitation (CPR) techniques and the initiation of the emergency procedures
to follow when a life-threatening emergency occurs. A review of drill documentation found direct
care staff participated in a drill or participated in a review of a drill including the use of CPR and
all staff had the opportunity to participate in at least one emergency drill annually. The program
has a list of emergency numbers inaccessible to youth located in offices, administration, and the
medical clinic. A review of training sign-in sheets found all seventeen staff who are trained to
assist in the administration of medication, were trained by a registered nurse (RN) on the
administration of the epinephrine auto-injector. A review of five pre-service staff training records
and five in-service staff training records found all staff were trained in episodic, first-aid, and
emergency care. The program has a policy on the use, access, and inventory of NARCAN®.
The policy indicated NARCAN® is kept in the medication cart in the medical clinic, the
examination room, and in master control, which was observed and confirmed the program is
following the policy. The program is to carry at least one dose of NARCAN® for emergency
purposes, a perpetual/daily inventory must be maintained, and the NARCAN® must be stored at
room temperature away from light. Only nursing staff and staff trained to assist in the
administration of medication have access to the NARCAN®. Training on when and how to use
NARCAN® is included in the medication administration training. The program inventories
NARCAN® on their medication inventory documentation. An interview with the HSA confirmed
emergency numbers are posted throughout the facility. The HSA stated medical drills are done
monthly on each shift. Often a review is completed at their all staff meeting with staff simulating
the drill. An interview with the HSA additionally confirmed on-site episodic care is documented
on a nursing note and on an episodic care log. If the non-healthcare staff provide first-
aid/emergency care to the youth it is documented on the Non-Licensed Healthcare form by the
staff providing care.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a policy and procedures ensuring the program provides for timely referrals
and coordination of medical services to off-site healthcare providers. There have been no off-
site care or referrals conducted during the annual compliance review period. The doctor, dentist,
and mobile x-ray come on-site due to the youth being committed to a maximum risk program.
The nurse interview indicated youth who are sent off-site for first-aid or emergency care needs
are tracked through the off-site log and an off-site schedule book. The designated health
authority (DHA)/designee is called once the youth returns from the off-site event to confirm all
off-site orders. The off-site paperwork is placed in the front of the Individual Healthcare Record
(IHCR) for the DHA to review and sign when on-site.
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4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a policy and procedures to ensure youth who have chronic conditions receive
regularly scheduled evaluations and necessary follow-up. Five youth Individual Healthcare
Records (IHCRs) were reviewed. Three of the youth were applicable for chronic conditions. All
three reviewed youth were identified on the Department’s Facility Entry Physical Health
Screening (FEPHS) form as having a chronic condition. None of the reviewed youth had a
communicable disease. Two youth were taking prescribed medication on an ongoing basis. All
three youth who had an identified chronic health condition were undergoing treatment for a
physical health condition and were classified with an appropriate Medical Grade. Each youth
was placed on the program’s Chronic Illness List. A review of progress notes found each youth
received periodic evaluations at least every ninety-days. There were no youth at the program
who were taking anti-tuberculosis medication. All periodic evaluations were conducted on-site
prior to renewing any prescription medications which expired. There were no instances of
lapses in care or missed periodic evaluations for any youth. The Department’s Problem List was
updated, as required, for all three youth. The program’s facility administrator (FA) was
interviewed and stated the health service administrator (HSA) informs the FA of any medical
issues and this information is disseminated to all staff on a need-to-know basis. The HSA
attends all daily management meetings to discuss medical concerns. An interview with the DHA
stated periodic evaluations are done every sixty days, the nurses have a chronic clinic log, and
youth are scheduled every sixty days or less. The interview with the HSA stated youth with
chronic conditions are monitored every sixty days by the DHA and youth are listed on the
chronic clinic log.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program has a policy and procedures indicating they shall receive, store, inventory, and
provide medication in a safe and effective manner which shall be demonstrated by observation,
as well as review of documentation of procedures and processes. Five youth Individual
Healthcare Records (IHCRs) were reviewed. Four of the five youth were identified on the
Department’s Facility Entry Physical Health Screening (FEPHS) form and in the chronological
progress notes as admitted to the program with medication. Documentation found each youth’s
medications were verified prior to being admitted into the program. The designated health
authority (DHA) and/or psychiatrist were contacted to obtain an order to resume the medication
prescribed prior to admission for all four youth. All medications for all four youth were observed
to have a current, valid order, and were given pursuant to a current prescription. Each time a
medication was continued, discontinued, changed, or a new one was ordered, the DHA placed
an order on a Practitioner Order form. None of the youth were in restricted housing. Two of the
five youth were applicable for over-the-counter (OTC) medications not listed on the Authority for
Evaluation and Treatment (AET) form. All OTC medications were administered in accordance
with approved protocols or practitioner’s order. The program utilizes a pre-printed pharmacy
Medication Administration Record (MAR), which included all required elements. A review of
MARs found staff initialed each administered medication and side-effect monitoring was
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documented at least weekly for each youth. There were no undocumented explanations for
lapses or errors in medication administration. Non-healthcare staff did not assist in the
administration of medication for any of the reviewed youth. None of the reviewed youth refused
any medication. One youth required parenteral medication and their medication was self-
administered and observed by licensed staff. Three youth were prescribed psychotropic
medication upon admission and the DHA and psychiatrist were notified on the day of admission
for each. The psychiatrist conducted an Initial Diagnostic Psychiatric Interview with each youth
within fourteen days of admission. All three youth received a medication monitoring review
every thirty days as required. None of the reviewed youth were prescribed psychotropic
medications after admission. There were no standing orders, emergency treatment orders, or
pro re nata (PRN) orders for psychotropic medications. Medication pass was observed for three
youth during the annual compliance review week. Medication delivery was the sole
responsibility of the nurse during the time of administration. Each youth was escorted to
medication pass by direct care staff and each youth approached the nurse administering
medication individually. The nurse reviewed each youth’s MAR to verify the Six Rights of
Medication Delivery/Administration. The same staff prepared and administered each medication
and none of the medications were pre-poured from their original packaging nor placed in
another container for subsequent administration. The youth took their medication, did a mouth
sweep, and coughed. The remaining two youth had parenteral medications. Both youth took
their medication and the nurse ensured the sharps were disposed of properly. The staff initialed
the MARs for each administration. Five youth were interviewed and all five youth stated a nurse
dispenses their medication. All five of the youth explained the process for receiving medication.
One youth stated they go to the medical room with a small window and the nurse asks their
name and date of birth, then the nurse gives the medication to the supervisor who makes sure
the medication is swallowed. Another youth reported having a condition where they take
medication through a parenteral route. The youth explained they go to the medical room and the
nurse watches them take their medication as prescribed. Two youth stated when they go to the
little room the nurse will ask their name, birthday, and then they give the medication and makes
sure it is swallowed. The remaining youth stated if they need a medication, they will ask the
direct care staff and nurse. Five interviewed staff stated nursing staff dispense medication and
one of the five staff additionally stated a supervisor can dispense medication. The health
services administrator (HSA) was interviewed and stated MARs, orders, and prior facility
paperwork are checked for appropriate medication when youth arrive at the facility. This is
documented on the Health-Related History (HRH), Facility Entry Physical Health Screening
(FEPHS), DHA notification, and the nurse’s admission note. Non-healthcare staff do not verify
any medication when a youth arrives at a facility, only licensed healthcare staff may verify
medications at admission. The program uses pre-printed pharmacy MARS which include all
components of the Department’s MAR. The HSA trains the non-licensed healthcare staff to
properly provide medication, and a list of trained staff is kept in the medical department and in
the OTC medications book. Medication pass is held 7:00 a.m. to 7:45 a.m. and 5:30 p.m. to 6:30
p.m., Monday to Friday and 8:00 a.m. to 8:30 a.m. and 4:30 p.m. to 5:30 p.m. on weekends and
holidays. Medication is procured from the local pharmacy unless medication is brought with
youth during admission to the facility, or in the event of an emergency and the pharmacy is
unable to provide medication. The psychiatrist is on-site every fourteen days and provides
psychiatric evaluations and medication management.
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4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a policy and procedures stating any medical equipment classified as sharps,
as well as stock medications, shall be secured and inventoried utilizing a routine perpetual
inventory descending count as each sharp is utilized and disposed of or when the medication is
administered. The program’s sharps are secured in a locked cabinet in the medical clinic. A
review of sharps inventories found weekly inventories were conducted by healthcare staff. All
medications were identified and secured in a locked area designated for storage of medications
in the medical clinic. Medications are kept in the locked medication cart with all overflow
medications stored in a locked cabinet in the medical clinic. The medication cart was found to
be organized with stock items separate from youth-specific medications and all injectable,
topical, drops, and liquids are separated. There is a locked drawer within the locked medication
cart for controlled substances. Nursing staff document a shift-to-shift inventory count for each
controlled medication, as well as a count each time a dose is administered. The program has a
dedicated refrigerator for medication requiring refrigeration. A review of over-the-counter (OTC)
inventories found a perpetual inventory is done whenever an OTC medication is utilized and
weekly inventories are conducted by healthcare staff. All discontinued medications are disposed
of in a pharmacy approved liquid when the consultant pharmacist is on-site. All controlled
medications which have been discontinued are destroyed on-site with the pharmacist and a
nurse. Seventeen staff training records were reviewed for non-healthcare staff who may assist
in delivery and oversight of medication self-administration. Each staff received training delivered
by a registered nurse (RN), on medication administration. The health services administrator
(HSA) was observed counting the only controlled medications on-site, three OTC medications,
and three sharps. All counts matched the ending inventory numbers. The HSA was interviewed
and confirmed the program’s inventory process, as well as medication destruction process. The
HSA additionally stated controlled narcotics are kept in the medication cart behind two locks.
The program has an agreement with a consultant pharmacist with a local pharmacy. The
consultant pharmacist is on-site on a monthly basis and the clear and active license is
maintained in the pharmacy operations book.
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 implemented infection control procedures which include prevention,
containment, treatment, and reporting requirements related to infectious diseases, as according
to Occupational Safety and Health Administration (OSHA) federal regulations and the Center for
Disease Control and Prevention (CDC) guidelines. The program’s Infection Control Plan and
Exposure Control Plan were reviewed and signed by the designated health authority (DHA),
facility administrator (FA), and chief compliance officer on July 9, 2023. The program’s Infection
Control Plan includes all required topics. Hepatitis B immunizations are available for all staff and
staff have access to protective equipment as needed. There were no instances in which the
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local county health department, CDC, and/or the Department’s Central Communications Center
(CCC) should have been notified of an infectious disease. There have been no facility or
occupational exposures since the last annual compliance review. The program’s Exposure
Control Plan was found to be written in accordance with OSHA standards and is available to all
staff. The program has a comprehensive process for needle stick post-exposure evaluation
which explains exposure must be reported to the FA immediately and evaluation must be made
available immediately. The evaluation process is outlined in the program’s Exposure Control
Plan. The FA was interviewed and stated the Exposure Control Plan is reviewed on a yearly
basis and is located in the breakroom, master control, medical clinic, and in the policy book. An
interview with the health services administrator (HSA) confirmed the Infection Control/Exposure
Control Plan is reviewed on a bi-annual basis by the HSA. The trainer reviews the plans during
annual training and pre-service training. Infection control training is provided to the youth upon
admission and yearly thereafter. A review of infection control may be done on an individual
basis.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program has a policy and procedures ensuring proper youth supervision. The policy
outlines the use of effective and efficient supervision, which includes positive contact, positive
reinforcement, structured activities, and random/predictable movement, which provides suitable
and timely response to the everyday needs of each youth. The supervision includes an
immediate response to emergencies while maintaining the safety and security of the program.
Program staff can account for the whereabouts of youth under their supervision at all times. The
program adheres to a staff-to-youth ratio of one to eight during daytime activities and one to
twelve during hours of sleep. A daily activity schedule was found posted in each dormitory. Staff
and youth were observed on all four days of the annual compliance review during daily activities
such as school, recreation, meals, breaks, and line movements. On each of the four days, staff
were actively supervising youth and ensured compliance with ratio, and were observed to be
positively interacting with youth while they were engaged in a full schedule of activities.
Additionally, observations confirmed staff are consistent with the application of the behavior
management system (BMS), close monitoring of youth behavior, and supervision of youth while
they were in their sleeping rooms. During the annual compliance review week, three staff were
able to immediately answer and respond with accuracy, the number of youth under their
supervision. All five interviewed staff stated if the youth count could not be reconciled, they
would immediately stop all movement and conduct an emergency recount of youth. If the
recount was not able to be reconciled, all youth would be returned to their room and the
program would immediately go to lockdown status and search the facility until counts are
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 has a policy and procedures which ensure the implementation of a comprehensive
behavior management system (BMS)/Positive Performance System (PPS). The program’s BMS
is clearly posted in the living areas of each dormitory and incorporated in the youth handbook.
Rules governing conduct and positive and negative consequences for behaviors are posted in
the living areas and in the youth handbook. The program’s written BMS states the program shall
provide a system of behavior management and a positive behavior reinforcement for youth in
the program. This system shall be based upon sound behavioral theory with a goal of
developing self-monitoring and self-regulation in the youth. It features a relatively small number
of reasonable program expectations with clearly communicated rationale based upon physical
and emotional safety and respect for the person and property of others within the setting.
Rewards and consequences for both positive and negative behavior must be clearly
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understood. The ratio of rewards to punishments shall exceed four-to-one. The behavior
management and positive behavior reinforcement system focuses on improving the youth’s
emotional and behavioral functioning, addressing, and eliminating behaviors which have
contributed to the youth’s delinquency, and promoting behavior and competencies which
encourage pro-social change, self-growth, and law-abiding behavior. The program incorporates
principles and practices related to trauma-informed care into the BMS. The program’s BMS has
not changed since the previous annual compliance review and is not in the process of being
revised. All five interviewed staff confirmed they received training in the BMS. Each of the five
interviewed staff were able to explain the program’s BMS, elaborating on the BMS points, level
system, and type of rewards and consequences youth earn for demonstrated behaviors. All five
staff stated the youth receive incentives and two of the five provided examples such as burger
night, pizza, games, and canteen for positive rewards. All five staff confirmed the program does
not withhold food as a form of punishment to youth for negative behaviors. Instead, the program
may remove extra snacks, access to special meals, or privileges. Each of the five interviewed
youth were able to describe BMS rewards such as movie night, burger night, canteen, games,
special meals, and consequences, such as a behavior report, canteen restriction, and
placement in controlled observation because of their behavior. Two of five youth were able to
explain the process for moving through levels, one youth indicated knowing the difference
between each level but couldn't remember them and the remaining two youth were unable to
remember during the interview. All five youth agreed youth cannot punish other youth and staff
use rewards the same. Three youth relayed the BMS was fair and two stated it is good.
According to the facility administrator (FA), the program uses the positive based incentive
management system for the youth BMS in the program. The FA stated the treatment team and
daily monitoring of behavior cards confirm how rewards are monitored and ensures rewards
outnumber consequences, at least four to one. Staff implementation of the BMS is reviewed
through the daily scorecard meeting and behavior reports. Incident reports are reviewed during
management meetings and conflict resolution is conducted if there appears to be an issue.
Retraining is conducted on the process, if necessary, and annually.
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 utilize restricted
housing to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
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5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a policy and procedures which require staff to observe youth at least every ten
minutes while the youth are in their sleeping quarters. Staff are required to conduct the
observations in a manner to ensure the safety and security of each youth. These checks shall
be documented in real time. The program had 120 operating security cameras during the annual
compliance review week. One camera was not working and a work order had been initiated for
the repair. The program maintains thirty days of video recording. The program’s practice is to
conduct checks of youth in their rooms every eight to ten minutes. A sample of security tapes
and corresponding logs were reviewed to verify ten-minute checks. The sample included three
samples of thirty-minute increments from each shift from stored video from each housing
module. The review confirmed no more than ten minutes passed between checks. All checks
were documented in real time. A review of the ten-minute check sheets confirmed staff who
completed the checks initialed the check sheets. Video review further confirmed checks were
conducted as required and staff did not just walk by the rooms without pausing for a moment to
observe the youth thoroughly enough to guarantee their safety. A review was conducted of
check sheets for the annual compliance review period which reflected checks were conducted
as required. Five staff were interviewed, and all advised checks are conducted every eight
minutes. The facility administrator (FA) interview confirmed the program has 121 cameras with
one work order submitted for a single non-functioning camera and video coverage is stored for
thirty days.
5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program has a policy and procedures which address population census, counts, and
tracking of youth. The policy indicates headcounts will occur and shall be documented at a
minimum of six times within a twenty-four-hour period. The program utilizes the master control
logbook to document youth counts and movements, as well as to maintain a chronological
record of events as they occur. A review of a full day of logbook entries for each month, since
the last annual compliance review indicated the program documents counts at the beginning of
each shift, after each outdoor activity, during emergency situations, total daily census counts,
head counts, after youth movements, documents new admissions, releases, transfers, and
youth temporarily away from the program. Observations of staff conducting counts during the
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annual compliance review week included recreation, education, group which confirmed the
program’s practice. All staff were aware of all youth whereabouts and were able to provide the
proper counts to the annual compliance review team during the annual compliance review
week. Five staff interviews indicated all staff were aware of count procedures, as required by
program policy, including what to do in the case of a count discrepancy.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program has a policy and procedures addressing logbook entries and shift report reviews.
The program maintains a chronological record of events, incidents, and activities in a
logbook in accordance with Florida Administrative Code. A review of program logbooks used
since the last annual compliance review was completed. Each reviewed logbook was bound
with numbered pages and entries, made in ink, with no evidence of white-outs or logbook
entries being destroyed or removed, and all errors were completed correctly using a single line
stuck through with staff initials. The program does not utilize living unit logbooks. A review of the
logbooks during the annual compliance review period documented minimal interference of the
educational instruction period. The master control logbooks only documented class start times,
as the youth classrooms are located on their dormitories. The program utilizes shift reports,
which have the census of all living units, incidents, youth out of the facility, youth alerts, gang
members, security alerts, staffing assignments, sick calls, and perimeter checks and their
findings. Shift reports are reviewed by the supervisor from the previous shift and the on-coming
shift during staff briefings at shift change. Shift reports reviewed during the annual compliance
review period included signatures of staff and supervisors confirming their review of the shift
report. During the week of annual compliance review week a shift briefing was attended, in
which the program supervisor verbally briefed staff with the shift report, along with the
supervisor from the previous shift, staff were given their assignments, and a review of the shift
report was documented. Logbook entries included emergency situations, incidents, special
instructions for supervision and monitoring of youth, population counts at the beginning and end
of each shift, other population counts conducted during a shift, perimeter security checks and
other security checks conducted by direct care staff, and transports away from the facility,
including the names of the staff, youth, and the destination. The logbooks additionally
documented requests by law enforcement to access any youth and removal of any youth from
the mainstream population, such as when a youth is placed on controlled observation,
admissions and releases including the name, date, and time of anticipated arrival or departure,
mode of transportation, and information relating to escapes or attempted escape incidents.
Each reviewed logbook entry was legible and included the time, date of the entry, and printed
name and signature of the staff making the entry. On-coming staff along with previous staff
participate in a shift briefing and sign shift reports acknowledging they are aware of all
information from the last two shifts and alert changes. A review of the Department’s Central
Communications Center (CCC) incidents which occurred during the annual compliance review
period indicated all were noted in the logbooks.
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5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures to address key control, including key assignment and
usage, 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.
Master control issues keys based on position. The key boxes located in master control are not
easily accessible while locked. Each set of keys has an assigned number and corresponding
key ring. A review of the key inventory matched the key rings in use. The keys are kept in a
secure lock box within a secure closet in master control, which is not accessible to youth. Each
set of keys has an assigned key hook. The facility administrator (FA) assigns the permanent
and restricted keys based on the position. An acknowledgment form for permanent keys is
completed for each permanent key assigned with signature, key number, and return date.
Restricted keys are stored in a separate locked box from non-restricted keys and only assigned
to staff who can access the restricted key box. The program has a broken key report which is
given to the plant manager who is the only one authorized to replace keys. Both key boxes were
not easily accessible. During the annual compliance review period there were no incidents of
lost keys, which was verified by the review of internal incident and the Department’s Central
Communications Center (CCC) reports. There were no reports of broken or damaged keys. A
random check of three staff key rings confirmed the keys matched the inventory. Five informal
interviews with staff confirmed staff’s knowledge of their key rings and assigned keys. All
observations during the annual compliance review week found personal keys were secured and
staff were aware of program keys in their possession. Key control logs documented the issuing
and return of keys on a consistent basis. Explanations indicated staff will turn in facility keys to
master control at the end of the shift and then receive personal keys prior to exiting the facility.
All five interviewed staff confirmed their knowledge of the key control policy and procedures, as
well as the operation. Furthermore, all five staff reported if keys were damaged, they would
notify their supervisor and submit a maintenance request. An informal interview with the chief of
security specified assigned keys are only assigned by the FA, restricted keys are kept apart
from non-restricted keys, and only assigned staff can access restricted keys. The shift
supervisor tracks keys as they are signed out and in by staff prior to receiving their personal
keys.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items.
A program shall delineate items and materials considered contraband when found in the
possession of youth, the list must include: sharps, escape paraphernalia, tobacco products,
lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food or
clothing, any intoxicating beverage or any beverage which causes or may cause an
intoxicating effect, any controlled substance, any prescription or non-prescription drug which
has a hypnotic, stimulating, or depressing effect, any firearm or weapon of any kind or any
explosive substance, non-facility issued electronic equipment or devices to include
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smartwatches, metals, personal non-facility issued cellular devices, unauthorized currency or
coin(s), and non-facility issued keys. The program shall provide youth with the list of
contraband items and materials and inform the youth of the consequences if found with
contraband. The program shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, and both staff and youth.
The program shall document the confiscation of any illegal contraband and the manner of
disposition. The program shall keep a copy of the documentation in the youth’s case record. If
a confiscated item is not illegal or prohibited, the program director or designee has the
discretion to discard of the item, return it to its original owner, mail it to the youth's home, or
return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and youth, which
are clearly explained in the program’s policy and procedures and youth handbook. The policy
states any staff who are found in possession of contraband in the program will be subject to
disciplinary action up to, and including, dismissal, as well as procedures regarding notification of
law enforcement for items considered illegal as defined in Florida Statutes. The program has a
policy and procedures identifying items which are contraband and exemptions. Each youth
receives a handbook which defines contraband items and consequences when found in
possession of those items. The forbidden list includes all required items, as well as personal
cellular telephones, cellular telephone equipment, and/or electronic devices capable of taking
pictures and/or audio/video recordings, which are prohibited in the secure area and
unauthorized articles of clothing and food, controlled substances, prescription or non-
prescription drugs, and any firearm or explosive device. According to the policy and procedures,
all searches, as well as the findings and disposition of contraband/unauthorized items, shall be
documented. The facility administrator (FA) shall govern the method of disposition of
contraband and unauthorized items which are not illegal. The contraband notice is posted on
the front gate and states law enforcement will be contacted for anyone bringing in contraband
and a criminal report will be filed. This practice was confirmed through an interview with the FA.
The FA stated law enforcement shall be contacted if any item found is considered illegal, as
defined in state law, or if there is evidence of unlawful activity. Such contraband and
unauthorized items may be discarded, returned to the original owner, mailed to the youth’s
home, or stored and returned to the youth upon their release. Any contraband or unauthorized
items, excluding weapons or illegal materials, not able to be returned or turned over to law
enforcement may be donated to any established charity. Under no circumstances may a staff be
allowed to retain possession of any contraband found in the facility. All facility staff, visitors,
vendors, and contracted providers shall be searched prior to entering the facility. Any program
or education program staff who refuses to be searched will be denied entry into the facility and
may be subject to disciplinary action. Any staff found in possession of contraband will be subject
to disciplinary action up to and including dismissal. A review of documentation specified the
program documents confiscation of contraband items, as well as method of disposal, which is
maintained in each youth record. Staff and supervisory staff were able to explain the contraband
procedures. The program did not have an incident related to contraband or any contraband
reports during the annual compliance review period. A review of the Department’s Central
Communication Center (CCC) reports showed there were no reports of contraband being
confiscated. A review of the facility logbooks and youth room search reports for the annual
compliance review period showed the program conducted searches as required. Contraband
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items or illegal contraband is documented on the search log and disposed of as required. The
interview with the FA states; all contraband is given to the shift supervisor the chief of security. If
necessary, the CCC is contacted; if the item is illegal, the police will remove it from the facility
grounds. If the incident is CCC reportable, the contraband is kept until the end of the
investigation then removed and disposed of by administration. Five interviewed staff reported
contraband checks are conducted three times a day on every shift and are documented in the
master control logbook.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a policy and procedures addressing searches and full body visual searches.
The program conducts searches as a method to prevent the introduction of contraband and
unauthorized items into the facility. The policy indicates searches of youth are conducted after
off-site transports, after visitation, before moving youth from an outside area into the building,
and prior to moving youth from the building to an outside area. Observations of an off-site
transport during the annual compliance review week confirmed the staff conducted proper
searches and full visual searches before and after the transport. The annual compliance review
team observed several youth searches during youth movements, including classroom, groups,
vocational, and in the dormitories. Search procedures and expectations were properly explained
to all youth before searches were conducted. Searches were conducted by staff of the same
gender as each youth, while a second and third staff assisted with supervision. Searches were
in-depth and done in means which did not degrade the youth. All searches were documented in
the program’s master control logbook. The program did not have any admissions or releases
during the annual compliance review week. Visitation did not take place during week of annual
compliance review. Searches for vocational services were conducted and observed in the
classroom and following access or ability to obtain tools or other equipment. Both staff
conducting the searches were the same gender as each youth. Each search was conducted
properly and according to policy. Five youth and five staff interviews were conducted; all youth
and staff were aware of proper search procedures and indicated searches take place prior to
each movement.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has a policy and procedures addressing vehicles and maintenance. The program
utilizes four vehicles for youth transports. Three of the four vans passed the annual inspection
with no issues noted and the remaining vehicle was out of service at the time of the annual
compliance review, awaiting surplus. The vehicles are inspected weekly by the plant manager.
Results of weekly inspections were documented and stored in the program’s vehicle
maintenance log/binder. Observations of all program vehicles indicated all required equipment
was maintained and vehicles were locked when not in use. Equipment included a seatbelt
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cutter, window punch, and fire extinguisher. The first-aid kits are stored inside the facility to
preserve the items inside of each kit. Staff check out a first-aid kit prior to a transport and check-
in the kit upon return. All seatbelts in the van were in proper working condition. The vehicles had
a safety screen separating the youth passengers from the driver and the youth passenger area
cannot be opened from inside. During the annual compliance review week random checks of
personal vehicles found all were locked. One transport was observed and staff followed the
program procedures. All five interviewed staff were able to identify the required way youth are
secured during transports. Four of five interviewed youth indicated they are searched, shackled,
placed in an orange jumpsuit, and put in seatbelts when transported. The remaining youth
stated not being sure of the process as they have not been transported anywhere.
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 driver eligibility and transportation of
youth, outlining staff to youth ratio during transports as one to five; however, if there are five or
less youth, a minimum of two staff are needed to perform all transports. The program has an
approved transport list which is updated monthly to ensure staff driver’s licenses are valid. This
approved driver’s list is in the administrative area. The review of the program’s policy indicated a
program cellular telephone is issued for all transports. The master control logbook entries
identify and provide evidence staff are given communication devices before leaving for
transport. During the week of the annual compliance review a transport was observed, staff
followed the required procedures; including an observation of two staff, one of whom was the
same gender as the youth. The program provides secure transportation for the youth placed in
this program. The transport vehicles were equipped with a safety screen separating the driver
from the youth passenger compartment. Youth are not permitted to drive program or staff
vehicles. Observations during the annual compliance review week included the assistant facility
administrator and facility transporter conducting routine checks of all personal vehicles in the
parking lot, including the program’s transport vehicles. All vehicles were found locked and
secured. Five staff interviews confirmed staff are issued a cellular telephone before transport,
staff do not conduct transports in personal vehicles, and vehicles are checked before and after
transports. All five staff were able to accurately describe what safety equipment is required for
all transports and the process required in case of an emergency. All five staff knew the ratio of
staff to youth during a transport. Five youth interviews confirmed none have seen staff place
contraband inside the vehicle. The facility administrator (FA) stated all youth transport vehicles
have safety screens installed. All five youth indicated they feel safe when staff are driving
transport vehicles.
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 designating the physical plant manager as the person
responsible for conducting the weekly safety and security audits. The policy includes the
development and implementation of corrective actions warranted because of safety and security
deficiencies found during any internal or external review, an internal system to verify the
deficiencies are corrected and existing systems are improved, or new systems are instituted as
needed to maintain compliance. A review of weekly safety and security audits since the last
annual compliance review indicated audits were conducted weekly as required and were
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reviewed during the weekly safety committee meetings. These meetings consisted of the facility
administrator (FA), assistant FA, chief of security, the physical plant manager, and another
member of the management team, with the exception of three weeks in July of 2023, in which
the chief of security was not present. During the meetings findings are discussed and a
corrective action plan is implemented to fix any deficiency noted. A review of the program’s
preventative maintenance checklist confirmed documentation of safety, maintenance repairs
needed, and the date and time the repairs were completed, or due to be completed. The form
covers various items such as radios, cameras, keys, telephones, mechanical restraints, the
generator, flashlights, fire safety equipment, alarms, youth rooms, recreation area, grounds,
corrective action needed, and corrective action completed. All were reviewed and signed by the
FA. The interview with the FA revealed the FA utilizes weekly safety inspection sheets, work
orders, daily perimeter checks, and discusses items in daily management meetings to identify
and track safety and security deficiencies.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program has a policy and procedures to address inventory, issuance, and control of
equipment and tools. The policy includes the process for missing, lost, or dysfunctional tools,
replacement of tools, and classifies tools into two categories as Class A tools and Class B tools.
Class A tools are hazardous with sharp edges, points, and with a high potential to be used as a
weapon to inflict serious bodily harm such as knives, hammers, screw drivers, and electric drills.
Machetes, long-blade knifes, and bowie knifes are prohibited. Class B tools do not have sharp
edges or points and are such items as brooms, mops, and scrub brushes. The program has
identified their plant manager as the program’s tool control manager. Observations indicated
tools are neatly secured behind a locked door and are placed within a shadow board with a
photo of the tool to identify proper placement. All tools were in good repair and accounted for in
the plant manager’s building. Upon observation, the plant manager’s building was neat, clean,
and organized. All program Class A tools are inventoried daily by the plant manager except on
weekends and holidays when the maintenance office is not accessed. Class B tools are
inventoried daily by program staff. All program tools are signed out by staff before use and
signed back in once they are returned to their proper location. There were no tools missing
during the annual compliance review period. The procedures for missing/lost tools include
stopping all youth movement and notifying the facility administrator (FA), assistant facility
administrator (AFA), and the plant manager. The staff will search all youth and search the area
thoroughly when the tool goes missing. The program’s tool inventory records showed tools
being issued and were inventoried following return. Eleven tools were randomly selected for
review, all were secured, were easily identified, and accurately matched the inventory list.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a policy and procedures addressing supervision requirements when youth use
tools including the one staff to five youth ratio, issuing tools to youth and staff, tool distribution
and collection, and search criteria during work projects. The program does not utilize
disciplinary work projects. Five youth case management records were reviewed and all
indicated youth have been trained on the proper usage of tools during their orientation process
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and each youth signed an acknowledgement of tool training. The program completes risk
assessments to determine youth’s risk to self and others, which are completed and approved
before youth are allowed access to tools as part of the vocational training at the Home Builders
Institute (HBI) program and the kitchen for ServSafe certification. The risk assessments are
completed monthly. The staff to youth ratio during activities involving tools is one to five. The
HBI program and the kitchen staff maintain their tool inventories and a tool sign-in and sign-out
log throughout the day. Youth are searched prior to leaving the HBI and kitchen work areas and
when returning to the dormitory. Observations during the annual compliance review week
indicated youth were participating in HBI with a one to five staff to youth ratio being maintained
with youth being searched prior to leaving the HBI work area. Five staff and five youth were
interviewed and all confirmed youth are only allowed to use a mop, broom, and scrub brush.
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 which address outside contractors. The established
guidelines include information regarding tool control and restrictions. The program has a form to
be signed by outside contractors which addresses how tools will be checked in at arrival to and
departure from the program, youth restrictions and access to the work area, instantaneous
reporting of missing tools, and the restriction of personal cellular telephones and/or equipment
capable of taking pictures and/or recording audio/video in secure areas. The form necessitates
contractors to list each tool brought into the facility which is reviewed by the plant
manager/designee before the contractor has access to a secure area and prior to the contractor
exiting the program. The contractor’s failure to sign this form forbids access to work within the
program. Outside contractors are escorted and supervised by the plant manager/designee any
time they are within the facility. A review of five instances on the sign-in sheets all confirmed the
tools for outside contractors were inventoried before and after work and each contractor signed
the contraband and contractor policies/rules form. The last three program invoices were cross
checked with sign-in sheets to ensure outside contractor agreements were signed on the date of
service. All invoices and contractor agreements matched.
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 has a policy and procedures to address fire, safety, and evacuation drills.
The program conducts fire, safety, riot, disturbance, Continuity of Operations Plan (COOP), and
evacuation drills to ensure youth and staff are prepared for immediate implementation or
mobilization in the event of an emergency or disaster. A review of drills revealed seventy-six
various drills were conducted over the annual compliance review period and at least one fire
and one COOP drill were conducted for each shift each month. All drills were appropriately
documented in the program’s logbook and on the facility’s selected drill form. Each drill form
contained the type of drill, a description of the drill, the date and time the drill was conducted,
participant signatures, findings, and recommendations. Observations confirmed fire evacuation
routes and egress plans were posted throughout the facility. Documentation indicated all eight
fire extinguishers were inspected on an annual basis. An interview with the facility administrator
verified fire drills, COOP drills, medical drills, and mental health drills are conducted monthly on
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all shifts and emergency drills are completed quarterly. All five staff interviews revealed they
have participated in various drills including fire, escape, weather, major disturbance, bomb
threat, hostage situation, chemical spills, and terrorism. All five interviewed youth reported they
have been instructed on what to do in case of a fire and confirmed fire drills occur monthly.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program has a policy and procedures addressing the Continuity of Operations Plan
(COOP). The policy and the facility administrator (FA) interview indicated copies of the
program’s COOP are in the FA’s office, assistant facility administrator’s (AFA’s) office, and the
staff break room. The program’s COOP includes delegation of authority, vendor contact list,
emergency and staff contact numbers, and county cooperation checklist. The plan addresses
alternative housing plans approved by the applicable Department regional director/designee, as
well as fire prevention and evacuation, severe weather, disturbances or riots, bomb threats,
hostage situations, chemical spills, flooding, terrorist threats or acts, and staff roles and
responsibilities. The COOP incorporates any equipment and supplies needed, information about
youth which may be needed, alternative housing arrangements, provisions for continuity of care
and custody of youth, and provisions for public protection. The COOP was last approved on
March 3, 2022, with the new COOP having been submitted to the Department on February 2,
2023, and is still awaiting approval as of the annual compliance review week. The program
rations include canned, pre-packaged food in the kitchen, extra water and necessary supplies in
the plant manager area, and youth related items on the living modules readily available in case
of emergency evacuation. The program utilizes the Department’s Juvenile Justice Information
System (JJIS) as well as hard copies of youth records. In case of an emergency relocation the
program will hand transport medical records, program records, logbooks, education records, as
well youth demographics. A review of five youth records indicated the program maintains an
administrative hard copy for each youth in case of emergency with all required information,
which are in the office of the director of case management.
5.18 Storage and Inventory of Flammable, Poisonous, and
Satisfactory Compliance
Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items.
The program has a policy and procedures addressing storage and inventory of flammable,
poisonous, and toxic items and materials. The program’s flammable, poisonous, and toxic
materials are stored in a flame-resistant cabinet accompanied by a binder with the coordinating
Safety Data Sheets (SDSs). The program additionally stores cleaning supplies in a locked
storage room, only accessible by the plant manager, supervisors, and canteen operator. The
items in the storage rooms are inventoried and have an accompanying SDS located in a binder.
None of the flammable, poisonous, and toxic items and materials are accessible to youth and
items are always secured. The program maintains a list of positions authorized to handle
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flammable, poisonous, and toxic materials which includes the facility administrator (FA),
assistant facility administrators (AFAs), chief of security, maintenance staff, and shift
supervisors. A review of five items within the chemical storage cage in the maintenance garage
and four items within the outside secured area for flammables, indicated all inventory counts
were completed as required and no items were missing at the time of the annual compliance
review. Staff sign items in and out with each use.
5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures addressing youth handling and supervision of
flammable, poisonous, and toxic materials. The policy prohibits youth using those items and
materials. Youth in the Home Builders Institute (HBI) program have access to paint, paint
thinner, and wood stain under the direct supervision of staff and only after being trained on how
to handle these items. Flammable, poisonous, and toxic materials are stored in a storage locker
located in the maintenance area. Youth do not have access to these items and are supervised
by staff during daily cleaning. Observations during the annual compliance review week included
youth cleaning their rooms with no chemicals present. All five youth interviews indicated they
are prohibited from using chemicals/cleaning products; however, when using cleaning supplies
staff will spray the chemical and youth wipe down the area. None of the interviewed youth
participated in the HBI program.
5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program has a policy and procedures addressing disposal of all flammables, toxic,
caustic, and poisonous items. The policy prohibits chemicals from being poured on the ground
or being disposed of by any method other than what is outlined by the Occupational Safety and
Health Administration (OSHA) standards and bio-hazard guidelines. The program disposes of
liquid waste, like mop water, in the plumbing drains and kitchen liquid waste in the kitchen. The
program’s plant manager is the only individual authorized to handle flammable, poisonous, and
toxic items. The program’s plant manager indicated the proper procedures for disposing of
chemicals are for the items to be provided to the local bio-hazardous waste contractor. The
plant manager further stated the program has not needed to dispose of any chemicals since the
last annual compliance review. The facility administrator (FA) stated during the interview the
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program utilizes the landfill and obtains a receipt for disposal of any flammable, toxic, caustic, or
poisonous items.
5.21 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity.
Programs allowing youth to participate in water related activities shall have a water safety
plan addressing, at a minimum, safety issues, emergency procedures, and the rules to be
followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures addressing visitation and communication for youth
while in the program. It is the program’s policy to make every effort to assist youth in
maintaining and strengthening positive family and community ties in an environment which
unobtrusively monitors and controls the movement of visitors within the program. Each youth is
provided an opportunity on a regular basis to correspond with identified individuals specified on
their Approved Correspondence List and legal representatives. The program provides postage
for two letters a week for each youth within the program and does not limit the number of letters
which a youth is able to mail each week. Youth may use their own postage to mail more than
the two letters paid by the program a week. Youth have access to a telephone to initiate a
minimum of one telephone call to their home each week. The program’s visitation schedule is
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Office of Accountability and Program Support Page 67 of 70 (Revised September 2022)
posted at the door, on the fence, and on the wall in the lobby. The visitation and communication
procedures are covered in the youth handbook, parent/guardian handbook, and are addressed
on the orientation checklist. The program’s visitation hours are Saturdays and Sundays from
1:00 p.m. to 4:00 p.m. A review of the visitation logs validated visitations were taking place on
weekends, according to the schedule. Telephone calls and opening of mail are conducted by
the youth with their case managers and documented in each youth’s case record. Incoming and
outgoing mail is searched and recorded in the correspondence logs, then given to the youth’s
case manager who delivers the mail to the youth and has the youth open the mail in front of
them. A review of five youth case management records confirmed each youth was given
opportunities to communicate with their family by telephone and mail. The program can arrange
video teleconferencing or hold an alternative visitation time, as alternative measures for youth
communication with their parents/guardians. There were no applicable youth with a history of
human trafficking; however, the program does have a policy and procedures for requesting
clarification from the youth’s juvenile probation officer to ensure the youth’s parent/guardian or
other family are not under current or past investigation for human trafficking related charges.
The program utilizes third party language services for language barriers with families and youth;
in addition, the program has several bilingual staff who are utilized for language barriers as well.
All five interviewed youth confirmed they can call or send a letter to their parent/guardian;
however, none of the five interviewed youth were aware of any services the program has in
place for youth who do not speak English as their primary language. It was noted all five youth
speak English, fluently. Four of five staff confirmed the program does have access to a
language interpretation line and the remaining staff was not able to confirm the access. The
facility administrator (FA) stated education staff provide English as a Second Language
Services and the program additionally has a language interpretation service to assist in
communication with youth and families.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program provides a variety of recreation and leisure activities for the youth, such as
football, four square, spike ball, basketball, cornhole, badminton, kickball, soccer, and
dodgeball. The program activity schedule contains, at least, one hour of supervised and
structured indoor and outdoor recreation and leisure activities, to include large muscle activity,
for youth each day. A review of the logbook confirmed recreation and leisure activities were
conducted as scheduled. The activity opportunities promote social and cognitive development,
creativity, teamwork, healthy competition, mental stimulation, and physical fitness. The program
takes precautionary measures to prevent overexertion, heat stress, dehydration, frostbite,
hypothermia, and exacerbation of existing illness or physical injury. The program has a
recreational therapist on staff according to their contractual agreement. The recreational
therapist completes a schedule of activities and services provided to meet all youth
requirements. Five youth mental health and substance abuse records were reviewed and each
contained an individual treatment plan. Each youth’s individualized treatment plan contained
recreational therapy goals. Five youth were interviewed and each confirmed the program allows
the opportunity to exercise, play outside, or downtime to read a book or play a board game for
at least one hour and each youth was able to state which activities they choose to participate in.
Five staff were interviewed and confirmed youth are given at least one hour of recreation or
free-time activity each day and were able to provide activity opportunities the program offers
each youth.
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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 policy and procedures to ensure searches of the youth and the controlled
observation (CO) room are completed prior to a youth being placed on CO. The program has
four CO rooms, and each meets all requirements including at least thirty-five unencumbered
square feet, have a metal door with shatter-resistant window, room vents are not easily
accessible and have the required covering, recessed light fixtures, no electrical outlets or
switches within the room, and use of a fire-resistant mattress. The program had a total of eighty-
five COs within the annual compliance review period, and a sample of eight COs were
reviewed. All eight reviewed CO reports indicated one same gender staff searched the youth
and another staff conducted a room search prior to placing the youth on CO.
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 policy and procedures to ensure youth are only placed in controlled
observation (CO) when non-physical intervention would not be effective. The program had a
total of eighty-five COs within the annual compliance review period, and a sample of eight COs
were reviewed. All eight reviewed CO reports documented supervisory or higher authorization
and none of the eight contained documentation of a youth exhibiting mental health crisis or
suicidal behaviors. All eight CO reports contained documentation each youth met at least one of
the three required criteria for a CO placement. Seven of eight youth were exhibiting actively
aggressive behaviors to others and were physically out of control and unable to be managed by
less restrictive methods. The remaining youth’s CO report documented violent behavior which, if
continued, was likely to cause immediate injury or harm to self or others. All eight reviewed CO
reports contained documentation identifying the need for staff to regain control swiftly to
maintain the safety and security of the program, advisement provided to the youth about the
reason for the CO, and a completed health status check form completed by a same gender
staff, confirming no injury or complaints. Two of eight reviewed CO reports contained
documentation the facility administrator (FA) or designee granted an extension of the CO
placement beyond two hours and the remaining six reviewed CO reports were not applicable as
they were terminated prior to the two-hour mark.
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 policy and procedures to ensure safety checks are conducted at a minimum
of every fifteen minutes while a youth is in controlled observation (CO). Staff designations for
CO are included in the policy. The program had a total of eighty-five COs within the annual
compliance review period, and a sample of or eight COs were reviewed. All eight reviewed CO
reports contained documentation confirming the staff making the CO placement had a
completed first page of the report, which was submitted to a supervisor, and received the
required written approval for the CO. Safety checks were completed every ten minutes
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throughout the duration of the CO period and logged on the CO Safety Checks form. Staff also
determined if an internal alert was required. Each reviewed CO report was maintained in an
administrative binder along with the health status checklist and CO safety checks. Copies of
each document were located in the youth case management records. Written approval by the
facility administrator prior to the termination of CO for each youth, CO report approval within the
required fourteen days, and staff determination of applicable internal alerts were observed
within each reviewed CO report. All five CO reports confirmed all requirements were met.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 70 of 70 (Revised September 2022)

source: DJJ

report_type: QI Residential

program_name_raw: Cypress Creek Max Risk