summary: QI Residential - FY24-25 - 1 finding

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Alachua Academy
Wayne Halfway House
(Contract Provider)
3430 NE 39th Ave
Gainesville], Florida 32609
Review Date(s): October 22-25, 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:
Tara Gilligan, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Cio’nna Allen, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Lori Bright, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Renette Crosby, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Kristine Harshaw, Office of Accountability and Program Support, Co-Lead Reviewer (Standard 1
and Interviews)
Michele Maynard, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Ines Parker, Circuit 4 Probation, Juvenile Probation Officer Supervisor (Standard 2)
Meghan Thrasher, Office of Accountability and Program Support, Lead Reviewer (Standard 3)
Devon Whitten, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Alachua Academy MQI Program Code: 1165
Provider Name: Wayne Halfway House Contract Number: 10189
Location: Alachua County / Circuit 8 Number of Beds: 28
Review Date(s): October 22-25, 2024 Lead Reviewer Code: 188
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
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 64 (Revised September 2022)
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Standard 1: Management Accountability
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 64 (Revised September 2022)
In d ic a t o r R a t in g s
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * 1 .0 1
F iv e -Y e a r R e s c re e n in g /R e n e w a l 1 .0 2
P ro v is io n o f a n A b u s e -F re e E n v iro n m e n t * 1 .0 3
M a n a g e m e n t R e s p o n s e to A lle g a tio n s * 1 .0 4
In c id e n t R e p o rtin g (C C C ) * 1 .0 5
P ro te c tiv e A c tio n R e s p o n s e (P A R ) a n d P h y s ic a l In te rv e n tio n R a te 1 .0 6
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * 1 .0 7
In -S e rv ic e T ra in in g 1 .0 8
G rie v a n c e P ro c e s s 1 .0 9
In te rv e n tio n s a n d F a c ilita to r T ra in in g 1 .1 0
L ife S k ills T ra in in g P ro v id e d to Y o u th 1 .1 1
R e s to ra tiv e J u s tic e A w a re n e s s fo r Y o u th 1 .1 2
In te rn a l A le rts S y s te m a n d A le rts (J J IS )* 1 .1 3
Y o u th R e c o rd s (H e a lth c a re a n d M a n a g e m e n t) 1 .1 4
A d v is o ry B o a rd 1 .1 5
S ta ff P e rfo rm a n c e 1 .1 6
S p e c ia l C o n tra c t C o n d itio n s 1 .1 7
C o n tra c t S p e c ific C a re e r a n d T e c h n ic a l E d u c a tio n S e rv ic e s 1 .1 8
D a ta T re n d A n a ly s is 1 .1 9
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Standard 2: Assessment and Performance Plan
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 64 (Revised September 2022)
In d ic a t o r R a t in g s
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
In itia l C o n ta c ts to P a re n t/G u a rd ia n a n d C o u rt N o tific a tio n 2 .0 1
Y o u th O rie n ta tio n 2 .0 2
W ritte n C o n s e n t o f Y o u th E ig h te e n o r O ld e r 2 .0 3
C la s s ific a tio n F a c to rs , P ro c e d u re s , a n d R e a s s e s s m e n t fo r A c tiv itie s 2 .0 4
G a n g Id e n tific a tio n : N o tific a tio n o f L a w E n fo rc e m e n t 2 .0 5
G a n g Id e n tific a tio n : P re v e n tio n a n d In te rv e n tio n A c tiv itie s 2 .0 6
R e s id e n tia l A s s e s s m e n t fo r Y o u th (R A Y ) 2 .0 7
Y o u th N e e d s A s s e s s m e n t S u m m a ry (Y N A S ) 2 .0 8
P e rfo rm a n c e P la n D e v e lo p m e n t, G o a ls a n d T ra n s m itta l * 2 .0 9
P e rfo rm a n c e P la n R e v is io n s 2 .1 0
P e rfo rm a n c e S u m m a rie s a n d T ra n s m itta ls 2 .1 1
P a re n t/G u a rd ia n In v o lv e m e n t in C a s e M a n a g e m e n t S e rv ic e s 2 .1 2
In c o rp o ra tio n o f O th e r P la n s In to P e rfo rm a n c e P la n 2 .1 3
T re a tm e n t T e a m M e m b e rs a n d M e e tin g s (F o rm a l a n d In fo rm a l R e v ie w s ) 2 .1 4
T ra n s itio n s P la n n in g , C o n fe re n c e , a n d C o m m u n ity R e -e n try T e a m M e e tin g (C R T ) 2 .1 5
E x it P o rtfo lio 2 .1 6
E x it C o n fe re n c e 2 .1 7
Y o u th In p u t 2 .1 8
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Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 64 (Revised September 2022)
In d ic a t o r R a t in g s
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity o r C lin ic a l C o o rd in a to r 3 .0 1
L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff * 3 .0 2
N o n -L ic e n s e d M e n ta l H e a lth a n d S u b s ta n c e A b u s e C lin ic a l S ta ff 3 .0 3
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A d m is s io n S c re e n in g 3 .0 4
M e n ta l H e a lth a n d S u b s ta n c e A b u s e A s s e s s m e n t/E v a lu a tio n 3 .0 5
M e n ta l H e a lth a n d S u b s ta n c e A b u s e T re a tm e n t* 3 .0 6
T re a tm e n t a n d D is c h a rg e P la n n in g * 3 .0 7
S p e c ia liz e d T re a tm e n t S e rv ic e s * 3 .0 8
P s y c h ia tric S e rv ic e s * 3 .0 9
S u ic id e P re v e n tio n P la n * 3 .1 0
S u ic id e P re v e n tio n S e rv ic e s * 3 .1 1
S u ic id e P re c a u tio n O b s e rv a tio n L o g s * 3 .1 2
S u ic id e P re v e n tio n T ra in in g * 3 .1 3
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s * 3 .1 4
C ris is A s s e s s m e n ts * 3 .1 5
E m e rg e n c y M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e rv ic e s * 3 .1 6
B a k e r a n d M a rc h m a n A c ts * 3 .1 7
S a fe ty P la n n in g P ro c e s s fo r Y o u th 3 .1 8
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p ro g ra m o p e ra te s b e lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra
in d ic a to rs . F a ilu re to d o s o w ill re s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m
re s id e n tia l, p ro b a tio n ).
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Standard 4: Health Services
Residential Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 64 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Non-Applicable
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage, Inventory, and Disposal 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 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.21 Visitation and Communication Satisfactory
5.22 Recreation and Leisure Satisfactory
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
5.24 Controlled Observation Non-Applicable
5.25 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 64 (Revised September 2022)
Program Overview
Alachua Academy is a twenty-eight bed program, for twelve to eighteen year old females,
located in Gainesville, Florida. The program is operated by Wayne Halfway House, through a
contract with the Department. The program provides Substance Abuse Treatment Overlay
Services (SAOS). In addition, the program fosters each youth by providing Impact of Crime
(IOC), Living in Balance, and Seeking Safety. Additional treatment services provided include
family, individual, group, and recreational therapy. Program administration is comprised of a
facility administrator, assistant facility administrator, four shift supervisors, director of nursing,
human resources, and facility maintenance manager. Case management services are provided
by two case managers and a recreation therapist. Mental health staff at the program includes a
clinical director who is a licensed mental health counselor, two master’s level, non-licensed
therapists, and a contracted psychiatrist. Medical services are offered 8:00 a.m. to 6:00 p.m.
and are provided by a contracted medical doctor (MD) who also serves as the designated health
authority (DHA), a director of nursing, two full time nurses, and two pro re nata (PRN) nurses.
Educational services are provided by Florida Virtual School. The layout of the program includes
the main building comprised of the main gathering area, dormitory, therapist offices, kitchen and
dining area, a multi-purpose room, and the case managers office. Three separate buildings are
used for education and training classes. There is also a utilities and storage building. The
program has fifty-eight operating security cameras providing coverage. At the time of the annual
compliance review, the program had no vacant positions.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 64 (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.
Twenty-two staff were hired during the annual compliance review period. The program had no
new volunteers during the annual compliance review period. The program has a policy and
procedures for volunteers, mentors, and interns who work with youth less than ten hours a
month requiring sight and sound supervision. A background screening was completed for each
of the twenty-two staff prior to contact with youth and access to confidential youth records. A
criminal history report was reviewed for each staff. Each staff received an eligible rating on the
background screening and did not require an exemption. A pre-employment assessment tool
was administered to all twenty-two of the direct care staff and twelve received a passing score.
Ten staff received a score of “caution.” The program stated the assessment is used as a tool to
identify strengths and areas of improvement. Those areas of improvement are intended to be
enhanced through training or monitoring, however, the assessment does not necessarily
provide a “pass/fail” score. The program added each staff to their Clearinghouse employment
roster. An Annual Affidavit of Compliance with Level 2 Screening Standards was completed and
sent to the Department’s Background Screening Unit (BSU) on January 30, 2024. The teachers
are employed by Florida Virtual School.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and renewal is conducted for all Department staff and volunteers
and all contracted provider and grant recipient employees, volunteers, mentors, and interns
with access to youth and confidential youth records. Staff and volunteers are rescreened
every five years. (Note: The term contracted providers, for the remaining portions of this
document, also include grant recipients.)
The program has a policy and procedures which outline the requirements for staff five-year
rescreenings. The program did not have any staff applicable for a five-year rescreening during
the annual compliance review period.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 64 (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 in place to promote an environment of physical,
psychological, and emotional safety. All staff, volunteers, interns, and contracted staff who have
knowledge, or reasonable cause to suspect a youth is being abused or neglected, are to report
the information to the Florida Abuse Hotline or the Department’s Central Communications
Center (CCC), if the youth is eighteen years or older. All allegations are reviewed by the facility
administrator (FA). A review of five staff personnel records revealed staff sign and adhere to a
code of conduct. Since the last annual compliance review, the program had a total of four
alleged incidents related to physical, psychological, or emotional abuse reported to the CCC.
One of the incidents was unsubstantiated, two resulted in the termination of the staff involved,
and one is still under investigation. A tour of the program found the Florida Abuse Hotline and
CCC numbers posted throughout the facility. When a youth requests to make an abuse report,
staff will facilitate the abuse call and notify administration. The program completed a Trauma
Responsive and Caring Environment (TRACE) self-assessment on June 6, 2024.
Five youth were interviewed. All five youth confirmed they felt safe at the program and denied
ever being stopped from reporting abuse. All five youth were able to articulate the location of the
CCC and Florida Abuse Hotline telephone numbers. Three of five youth stated staff are not
always respectful when speaking with them; two of the youth stated staff use curse words often
and one said they use curse words occasionally. The FA stated they will address the use of
profanity during an all-staff meeting and provide additional training and coaching for staff. The
remaining two youth stated the staff are respectful when speaking to them. All five youth denied
exchanging social media information with staff. Five staff were interviewed, and all were able to
explain the process for allowing staff and youth to call the Florida Abuse Hotline or CCC to
report suspected abuse. Five staff stated youth are allowed to call. Two staff additionally stated
they notify the supervisor, and the supervisor can make the call. All five staff denied seeing
another staff prevent a youth from calling the Florida Abuse Hotline. When asked if the staff had
ever heard another staff use profanity with youth, two staff stated “never,” one stated “often,”
one stated “occasionally,” and one stated “once.” An interview with the FA confirmed the
program has a policy and procedures to include time frames, documentation, and follow-up for
abuse allegations.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 64 (Revised September 2022)
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program had four allegations of physical, psychological, or emotional abuse during the
annual compliance review period. Documentation was reviewed to identify corrective action
taken by management for follow-up to allegations and/or substantiated incidents. Two incidents
were substantiated, and the program responded by terminating the staff. One incident was
found to be unsubstantiated upon internal investigation. One incident is still under investigation.
An interview with the facility administrator confirmed staff who are involved in incidents with
substantiated findings for allegations of abuse or neglect receive progressive disciplinary action
in line with the nature of the offense. Incidents which involve allegations of abuse or neglect
result in immediate removal of the alleged staff from youth contact, and in egregious cases,
immediate termination may occur. Opportunities for additional coaching and training are utilized
to address staff concerns or deficiencies prior to being returned to youth contact.
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program had a total of fifty-two reports to the Department’s Central Communications Center
(CCC) during the annual compliance review period. Five reports were selected for review. All of
the incidents were reported within the required two-hour time frame. Each of the incidents were
documented in the logbook, with no exception. A review of the program’s internal incidents and
grievances found there were no additional incidents which should have been reported to the
CCC and were not. The program has experienced an increase in the number of reportable CCC
incidents. The facility administrator (FA) reported the increase was significantly related to
medical calls, twenty of which were Baker Acts for ten different youth; however, four youth made
up a large portion of these incidents. Those four youth were later transferred to secure
programs which were a more appropriate placement for the youth. The program has shifted its
focus from using reactive practices, to proactive processes of assessments and screening to
mitigate risk and maintain youth safety in the program. The improvements in therapeutic
services reflect a commitment to better serving the needs of current and future youth.
Additionally, there was an increase in youth altercations, youth physical management incidents,
staff injury related to physical management incidents, and a staff altercation. Changes were
made in program’s leadership which included evaluating staff and making needed changes to
personnel.
1.06 Right Interactions (RI) and Physical Intervention Rate Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. 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
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than for regular transports), a RI Incident Report is completed and filed in accordance with
the Florida Administrative Code.
The program had seventy-one Right Interactions model (RI) incidents during the annual
compliance review period, eight of which were reviewed. Each report was completed by the end
of the staff’s workday, six of the eight records included statements from all staff involved. Two
were missing one or more witness statements from involved staff. Six of eight reports reflected
the report was reviewed by a supervisor and a RI instructor or RI-certified supervisor. All RI
incident reports were reviewed by the administrator or designee within seventy-two hours of the
incident, with one missing the date it was signed. None of the reports involved mechanical
restraint, injuries, or allegations of abuse.
Monthly summaries were maintained by the program of all RI incidents and were submitted to
the Department’s regional office by the fifteenth of each month. The program’s RI plan was
updated by the provider on September 24, 2024, and approved by the Department’s regional
director on October 23, 2024. The number of RI incidents from the previous annual compliance
review was eleven, which reflects the program experienced a significant increase in the number
of RIs since the last annual compliance review. Turnover in the clinical department negatively
impacted therapeutic relationships. Additionally, in some instances, therapists were not
providing the appropriate services at the scheduled times. This led to “down time” which would
otherwise not have been present and did not allow for the youth to make progress toward their
mental health or substance abuse treatment. The clinical department is now fully staffed and are
ensuring appropriate services are being offered. The program has also recently hired a
statewide clinical director who will provide enhanced oversight over the clinical department and
provide ongoing coaching and training.
The program’s RI rate during the previous quarter was 7.46, which is above the statewide
Residential RI rate of 1.81. Four of five interviewed staff report they use RI and each of the four
staff were familiar with the policies and process. One staff has not participated in any physical
managements, as they hold the position as a case manager. The facility administrator was
interviewed and confirmed the program’s policies for RI.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring. Supervisory direct care staff shall
have sixteen hours of supervisor training in addition to the required pre-service trainings.
All program staff are considered to be direct care staff and are counted in the
staff-to-youth ratio, provided they are not conducting their other duties while being included in
ratio. All program instructors are qualified to deliver the trainings provided. The program
submitted a pre-service training plan/calendar prior to implementation. The program’s training
calendar was signed by the highest ranking official at the program and the assistant secretary of
Residential Services, however, it was not signed by the director of the Department’s Talent,
Leadership, and Culture (TLC). Five staff records were reviewed and all five had between 134
and 173 hours of training completed within 180 days of hire. All reviewed records documented
completion of the essential skills trainings of cardiopulmonary resuscitation (CPR), first-aid,
automated external defibrillator (AED), Right Interactions model (RI), professionalism and ethics
including standards of conduct, facility or program operating procedures, emergency
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procedures, child abuse reporting, suicide awareness and prevention, and Prison Rape
Elimination Act (PREA) prior to contact with youth. All other required pre-service trainings were
completed as required including job specific training outlined in the contract, required by other
rules or manuals, or for the administration of specialized services. Due to Department-wide
system outages, all required trainings were not entered into the Department’s Learning
Management System (SkillPro). The program is continuing to add trainings to SkillPro and was
able to show evidence of the completion of the required trainings.
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
Five in-service training records were reviewed. All five staff completed between fifty-two and
seventy hours of in-service training. All five staff completed training in the mandatory training
topics, including trainings required by other rules and by contract. Two of the staff are
supervisors and completed an additional eight hours of training in coaching and leadership. Due
to Department-wide system outages, all required trainings were not entered into the
Department’s Learning Management System (SkillPro). The program is continuing to add
trainings to SkillPro and was able to show evidence of the completion of the required trainings.
All instructors were qualified to deliver the trainings provided. The program has an annual in-
service training calendar which is updated as changes occur. The training calendar was signed
by the highest ranking official at the program and the assistant secretary of Residential
Services, however, it was not signed by the director of the Department’s Talent, Leadership,
and Culture.
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 outline the grievance process and required
staff training. The program’s grievance process includes informal, formal, and appeal phases
and associated timelines. The program’s informal phase of the process is documented as a
discussion with the supervisor and the youth, and the program’s practice correlates with their
process. A review of the program’s grievance documentation confirmed the program maintains
grievances for the past twelve months, which included eleven grievances across all program
youth for the annual compliance review period. Four of the grievances were reviewed and all of
the grievances were responded to within the required time frame. Each grievance was resolved
during the formal phase.
All five interviewed youth were familiar with how to submit a grievance, from locating it on the
wall of the dorm to submitting it to the grievance box or the assistant facility administrator. All
five youth stated they could get help completing the grievance, if needed. Five interviewed staff
were asked about the grievance process. All five were aware grievance forms are placed
throughout the program, four of five reported the supervisor reviews grievances, three said the
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program manager reviews the grievances, and one staff knew youth can request assistance in
completing form. Four of the five staff stated the grievances are completed and dropped in a
grievance box for the administration to retrieve. The facility administrator was able to recite the
program’s policy on grievances.
1.10 Interventions and Facilitator Training Non-Applicable
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program does not offer any non-clinical, non-primary groups; therefore, this indicator is
rated non-applicable.
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’s policy and procedures outline social and life skills which are addressed in
problem solving groups and educational groups facilitated by team leaders, the program
manager, and youth counselors. The groups are utilized in the development and tracking of the
Performance Summaries and performance plans through documentation of the topic discussed,
the facilitator, youth participation, and resolution. The social services program is administered
and supervised by a person qualified and trained in the social or behavior sciences. The
program provides life and social skills activities which address communication, interpersonal
relationships and interactions, non-violent conflict resolution, anger management, and critical
thinking, including problem-solving and decision-making. The program addresses the needs of
the program’s targeted gender group through health and hygiene, the physical environment, and
leisure and recreational activities. Sign-in sheets, observations, and the schedule were reviewed
to confirm life and social skills groups and activities were offered and incorporated in the youths’
daily routine. The program provides psychoeducational activities such as pro-social outings.
This includes college tours, yoga, gardening, volunteering in the community, cardiopulmonary
resuscitation (CPR) and first-aid training, ServSafe certificate program, community cleanup, and
animal care.
Five youth were interviewed and stated they participate in daily therapy, groups which talk about
gender specific medical and hygiene related topics, substance abuse and anger management,
they are taught to crochet and paint, and attend trips. An interview with the facility administrator
confirmed the program provides gender specific programming including life and social skill
training, as well as experiential opportunities for youth to learn and practice life and social skills
which will prepare them to be responsible and productive members of their home communities.
It is the responsibility of the assistant facility administrator, clinical director, and director of
nursing or designee to provide psychoeducational classes to teach social and life skills, and the
responsibility of all staff to model and reinforce those skills being taught at the facility. An
interview with the designated mental health clinician authority (DMHCA) confirmed the program
provides Living in Balance (LIB) groups twice a week. Groups are facilitated by trained
therapists and the DMHCA. The Seeking Safety group is provided twice a week. Groups are
facilitated by trained therapists and the DMHCA, and the Impact of Crime (IOC) group is
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provided twice a week by staffs who possess an IOC certification. The DMHCA stated youth are
given an opportunity to practice the skills they learn while in the community on outings.
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 offers activities which reflect the restorative justice philosophy including providing
a restorative environment which holds youth accountable for their behavior, including the harm
their crimes caused to the victim and community, offers the youth opportunities for competency
development in skill areas valued by the community in preparation for reintegration into
productive community life, and partners with community stakeholders. The program fosters a
restorative community within the program creating a culture which encourages staff and youth to
be actively involved and give input, participate in decisions, practice leadership roles, use
restorative conflict resolution strategies, and contribute to the community. The program utilizes
Impact of Crime (IOC) which is designed to teach youth about the impact of crime on victims,
their families, and their communities. IOC is designated as a Standardized Program Evaluation
Protocol (SPEP) primary service at the program; therefore, is not applicable for this annual
compliance review. The program also offers other volunteer opportunities and outings to
practice restorative justice awareness. The program engages in restorative justice projects with
the faith-based community, volunteering with the community domestic violence provider, and a
local assisted living facility by crocheting, reading, and playing games with the residents. A
review of the program’s schedule, sign-in sheets, and calendar of events revealed the youth are
participating in IOC and other restorative justice activities as required.
An interview with the facility administrator determined the program’s treatment program places
an emphasis on making youth aware of the harm caused to victims and victimized communities
through groups conducted daily, individual counseling, community projects, and guest speakers.
The program assists youth in accepting responsibility for harm they have caused by their past
criminal actions and challenging them to recognize and modify their irresponsible thinking, such
as denying, minimizing, rationalizing, and blaming victims. The program also exposes youth to
victims’ perspectives through victim speakers, in-person, on videotape, audiotape, or through
victim impact statements, and engage youth in follow-up activities to process their reactions to
each victim’s accounting of how crime affected her life. Five youth were interviewed and two
youth stated they have not started their IOC groups; the remaining three youth stated they have
participated in IOC, skits and role playing, completed packets, and learned definitions related to
restorative justice. Four of the youth stated they have been able to practice the skills they have
learned while volunteering in the community or during roleplay activities. One youth stated they
did not need to practice their skills.
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.
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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 established a continually updated internal alert system which is easily
accessible to program staff which keeps them alerted to youth who pose a risk to security or
safety, including escape, suicide, other mental health, medical, sexual offender, and other
assaultive or violent behavior risks. All alerts are documented on an internal alert form with
accompanying supportive documentation, including the youth’s alert in the Department’s
Juvenile Justice Information System (JJIS), if applicable, internal incident documentation,
Assessment of Suicide Risk or Crisis Assessment, and/or youth’s classification or re-
classification form. Open internal alerts are also posted on the alert board in a prominent
location available to staff, identifying which youth are on specific alerts. The internal alert form
will document any instructions for a youth regarding the alert. All alerts are documented in the
Alerts Binder which is accessible to all staff and may be reviewed by staff at any time. The
Alerts Binder is located in master control. A current listing of youth on suicide risk alert or mental
health alert in JJIS is maintained and provided to direct care and clinical staff on a daily basis.
This is done at shift briefings conducted by the shift supervisor before each shift. Any youth
actively on suicide precautions and/or any other increased level of supervision needs according
to the youth’s Assessment of Suicide Risk and/or Crisis Assessment will be handled by the
supervisor and documentation will be kept with the logbook. Alerts in JJIS will be reviewed
monthly by appropriate corporate staff with oversight for program and any discrepancies are
addressed and documented.
Twelve alerts across five youth records were reviewed. Eleven of the alerts were entered or
updated as required. One youth was missing a gang alert which should have been entered by
the program. All required parties were informed of the gang alert, as required, however, the alert
was not entered into the JJIS system. The alert was entered into JJIS once the program was
informed of the missing alert.
An interview with the facility administrator confirmed the program has a policy and procedures
outlining the expectations for JJIS and internal alerts and explained it is responsibility of the
facility administrator and/or designee, clinical director, director of nursing, and shift supervisors
to ensure compliance. An interview with the program’s nurse confirmed the nurses are
responsible for updating medical alerts. Five staff were interviewed and stated they are informed
of youth’s alerts at shift briefing, through email, or by the alert board.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program maintains individual management records which consist of three separate records
including a case management record, a mental health record, and an Individual Healthcare
Record. Each of the youth records contained the youth’s name, Department identification
number (DJJID), date of birth, county of residence, and committing offense. The case
management records also contain sections labeled as legal information, demographics and
chronological information, correspondence, case management and treatment team activities,
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and miscellaneous. All youth records were labeled “Confidential” and/or securely maintained
electronically. All official youth records are secured in locked cabinets labeled “Confidential,”
located inside a locked room.
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 facility administrator solicits active involvement of interested community
partners.
The program has a policy and procedures in place to ensure the program has a community
support group or advisory board meeting at least every ninety to 120 days. There was
documentation of the facility administrator (FA) soliciting active involvement from a law
enforcement representative, judiciary community, community partners, business community,
school board or district, faith community, and the LGBTQIA+ community, when possible. There
was also evidence of the FA recruiting a victim or victim advocate, and a parent/guardian whose
child was previously involved in the juvenile justice system. A review of the meeting agendas
and minutes revealed meetings were held virtually, and as required, with no meetings being
rescheduled during the annual compliance review period.
An interview with the FA confirmed the program’s policy and procedures to maintain a
community advisory board (CAB) which serves as a link between the program and the
community. The purpose and duties of the CAB are to help keep the program in touch with the
local community and allow the local community to better understand the goals, objectives, and
purpose of the program and be involved with special projects. Two board members were
interviewed. One member stated they provide religious services at the program monthly and
provide a lunch or game night with the youth. The board member stated they have been actively
participating at the program for six years. The other board member stated they provide an eight-
week violence prevention program at the program, which consists of hour-long weekly
workshops which include assertive communication, boundaries, consent, teen dating violence,
healthy relationships, healthy breakups, gender stereotypes, relationship self-sabotage and
other enrichment opportunities. The board member stated they have been involved with the
program for two years.
1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures which outline the program’s system for staff
evaluation, performance standards, and frequency of evaluations, which include an initial ninety-
day and 180-day evaluation for all staff, and annual evaluations to assess competency in their
position. Five position descriptions were reviewed for staff whose job functions included
implementation of the program’s behavior management system, and the staff’s performance
standards were clearly identified. Performance evaluations for five staff were reviewed and were
completed as outlined in policy, at least annually. Performance standards matched the job
descriptions for all five staff. All specific contractually required positions were maintained and
performed, as outlined in the contract, which included a recreational therapist, whose
credentials, schedule, and services provided to the youth met all requirements.
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During an interview, the facility administrator explained the program experienced turnover in
direct care and clinical during the annual compliance review period. Those positions have been
filled. The program recognizes staff with monthly employee of the month awards and bonuses
and provides other small incentives such as snacks, meals, company merchandise, and gift
cards. Five staff were interviewed regarding how often they receive a formal evaluation of their
performance based on their performance standards. Four staff stated they receive one yearly,
and the remaining staff stated they had not been at the program long enough to receive one yet.
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 special contract conditions include providing guest speakers for education topics,
faith-based opportunities, transportation services for parents/guardians, in-home assessments
for youth after release, and providing youth with substance abuse issues the opportunity to
participate in Alcoholics Anonymous (AA) and/or Narcotics Anonymous (NA). The program has
guest speakers from Peaceful Paths provide an eight-week curriculum on dating violence which
takes place once each week. The program’s faith-based provider also brings guest speakers in
monthly. The program provides in-house religious services monthly to the community, and youth
participate in a faith-based choir which travels to churches in the community to perform. The
program has had no parents/guardians wanting transportation assistance, however, confirmed
they will provide transportation assistance if needed.
An interview with the facility administrator confirmed the program has unsuccessfully attempted
to engage in services through AA/NA over the past several years; however, the youth do
receive additional substance abuse support through outside guests, speakers, and testimonials.
The program hosts outside guests and speakers to provide additional education on relevant
topics such as teen dating violence. The youth receive regular faith-based opportunities through
the a local temple, which provides both on-site services as well as opportunities for youth to
attend in person. Additionally, the program has a youth choir which performs at a variety of
churches in the community. The program provides youth the opportunity to earn community
service hours through program chores as well as in the community with clean-ups and a weekly
scheduled visit to a local assisted living facility in which the youth read, play games, and interact
with the elderly residents. The program has offered to provide transportation assistance for
discharged youth, either by providing financial resources or to transport the youth directly to
their home county. There have been no requests to provide in-home assessments since the
youth receive this service from other providers.
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.
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The program has a policy and procedures which include the review and analysis of data in
decision-making practices. The program reviews data such as Right Interaction (RI) Reports
and incidents reported to the Department’s Central Communications Center (CCC) on a regular
basis. This information is shared during a Performance and Quality Improvement (PQI) process
with corporate leadership, during weekly program management meetings and monthly all staff
meetings. Reviewed documentation supported this practice. Information is shared with
stakeholders and providers through Trauma Responsive and Caring Environment (TRACE)
assessments, quarterly Department meetings, the Department’s Office of Health Services
reports, monthly Department reports, Standardized Program Evaluation Protocol (SPEP)
monitoring, and company surveys. Reviewed documentation supported this practice. During an
interview, the facility administrator explained the RI Report information is used to provide extra
training to staff who use RI procedures too often or incorrectly, and to train staff to de-escalate
youth so staff are not required to use RI for altercations. CCC data is used to improve staff
training, coaching, or disciplinary action, by helping program administration understand the
interactions between youth and staff and create corrective action plans to mitigate RI
responses.
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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.
Five youth case management records were reviewed for initial contacts to the parent/guardian
and court notification. Four of the case management records indicated parent/guardians were
notified by telephone within twenty-four hours during the youth’s admission. One case
management record was not applicable as the youth was eighteen years of age and written
consent of the youth was signed after admission. Of the four applicable case management
records reviewed, the parents/guardians were notified by writing within forty-eight hours of
admission, as required. All five case management records indicated the committing court,
assigned juvenile probation officer (JPO), and post-residential case manager, if applicable, were
notified by writing within five working days of admission.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program utilizes an orientation checklist to explain and discuss program rules, expectations,
goals of the program, and services applicable to the youth. Each of the five records had
documentation the youth received an orientation, and the orientation checklist was signed by
each youth on the day of admissions. Orientation included all required elements such as
program rules, services available, the daily schedule, expectations and responsibilities, the
written behavior management system (BMS) conspicuously posted and provided in the youth
handbook, access to medical and mental health services, access to the Florida Abuse Hotline,
zero-tolerance policy regarding sexual misconduct, special accommodations, right to be free
from sexual misconduct, and items considered contraband. Also included in the orientation is
the performance planning process involving the development of goals for each youth to achieve,
dress code and hygiene practices, procedures on visitation, mail, use of the telephone,
expectations for release from the program, community access, grievance procedures,
emergency procedures, a facility tour, living unit assignment, and treatment team and medical
topics as outlined in Administrative Rule. A youth orientation was observed, and the orientation
included all elements outlined in the program’s policy. Five youth were interviewed, and all five
reported receiving an orientation to the program which included all the required elements. Two
of the five youth interviewed provided an explanation of the process in detail. Four of the five
youth reported the orientation to the program began within twenty-four hours, and one youth
reported the orientation began closer to forty-eight hours.
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2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
Five youth case management records were reviewed for written consent of youth eighteen
years of age or older. Three of the five case management records reviewed were applicable for
youth who were eighteen years of age or older. Each of the three records had documentation
signed by the youth giving consent to release information regarding physical or mental health
screenings, assessments, or treatments to their parent/guardian.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
The program has a policy and procedures for a classification system promoting safety and
security when assigning youth to a living unit, sleeping room, and youth group or staff advisor
on the day of admission, as well as reassessments for activities. The program reviews
classification factors to include physical characteristics of the youth, the youth’s age and
maturity level, identified special needs, history of violence, gang affiliation, criminal behavior,
sexual aggression or vulnerability to victimization, the youth’s perception of vulnerability, and
any history of potential or verified human trafficking, level of risk to include suicide, medical,
escape, and security, and any other suspected risk factors. These factors are documented on a
classification form and a copy is placed in the youth’s case management record. Youth are
reviewed for reassessment during their formal treatment team meetings. The program has a
continually updated internal alert system which is easily accessible to program staff. The system
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.
Five youth case management records were reviewed. Each of the five reviewed youth records
contained documentation indicating the youth were initially classified on the date of admission
based on the classification criteria and factors identified on the classification forms. A new
Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) was completed and
entered into the Department’s Juvenile Justice Information System (JJIS) prior to each youth’s
room assignment. Each of the five records contained documentation indicating each youth was
classified for the purposes of assignment to a living area, sleeping room, youth group, staff
advisor, and medical, mental health, substance abuse, security risk factors, and/or special
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needs. Each youth’s record was identified with risk factors, entered into JJIS, and contained
monthly reassessments for each of the youth to increase the youth’s privileges or freedom of
movement, participation in work projects or other activities involving tools or instruments, or
participation in off-campus activities. Each of the five youth participated in work projects or other
activities involving tools or other instruments, and one of the five youth participated in off-
campus activities. An interview with the facility administrator (FA) confirmed classification of
youth is based on the premise youth are assigned rooms and groups to prevent threat or harm
of violence to themselves or others and to maximum therapeutic gain. At intake, the clinical
director or designee completes the Admission Classification Worksheet, using information from
the commitment packet, discussions with the assigned juvenile probation officer, observations of
the youth through the intake process, and collateral information from the facility administrator,
nursing, and shift supervisor to determine group placement. Each youth will have a completed
VSAB entered into JJIS prior to being assigned a room. The FA explained how classification
factors such as mental health, physical health, cognitive performance, age, and prior
victimization are considered when assigning youth to a sleeping area. The program’s policy and
procedures clearly outline the classification process and include a classification system which
promotes safety and security, as well as effective delivery of treatment services, based on the
determination of each youth’s individual needs and risk factors, which addresses, at a minimum,
items outlined in Florida Administrative Code. Throughout the youth's commitment, the
treatment team will reassess and reclassify youth, 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.
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.
Five youth case management records were reviewed for gang identification. Three of the five
were applicable. In each of the three records, local law enforcement was notified of suspected
gang activity. In each of the three records, documentation indicated local law enforcement and
law enforcement in the youth’s home county were notified by the program of the youth’s gang
involvement prior to the annual compliance review team’s seven-day notice. Two of the three
reviewed records showed gang alerts were entered into the internal alert system and the
Department’s Juvenile Justice Information System (JJIS) upon identification. In the remaining
record the gang alert was not entered. In each of the three records reviewed, information on the
youth’s gang status was shared with the educational provider or local school district providing
services at the residential program. In two of the three records reviewed, information on the
youth’s gang status was shared with youth’s assigned juvenile probation officer or post-
residential counselor, if applicable. One of the record’s reviewed was not shared with youth’s
juvenile probation officer or post-residential counselor, as required.
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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.
Five youth case management records were reviewed for gang identification, prevention and
intervention strategies. Identification of youth to participate in gang prevention or intervention
activities is based on information obtained through the program’s screening, assessment, and
classification processes, as well as gang-associated behaviors exhibited or the youth’s
expressed interest or intent while in the program. Three of the five records reviewed were
applicable for gang identification. Each of the three records reviewed had documentation the
youth participated in gang prevention and intervention strategies. All three records indicated the
youth’s performance plan included relevant goals and objectives related to gang intervention
strategies for the youth to complete prior to release from the program.
Gang intervention strategies are implemented when youth are identified as being a criminal
street gang member, are affiliated with any criminal street gang, or are at high risk of gang
involvement. Identification of youth to participate in gang intervention activities is based on
information obtained through the program’s screening, assessment, and classification
processes, as well as gang-associated behaviors exhibited or the youth’s expressed interest or
intent while in the program. Services are determined by each youth's individualized treatment
team and input from the gang coordinator. Gang prevention/awareness efforts provided to youth
at the program include the Impact of Crime (IOC) curriculum, a gang packet outlining the
program's policy and procedures, and education is utilized as a component of the program's
gang awareness/prevention strategy. The program’s policy and procedures also address
providing youth an opportunity, if they desire, to develop a plan to disaffiliate with a criminal
street gang.
An interview with facility administrator confirmed the program has a policy and procedures in
place for gathering information on gangs to identify and to share information with law
enforcement, both local and in-home county, education provider, assigned juvenile probation
officer, and aftercare counselor, if applicable. The IOC curriculum is utilized as a component of
the program’s gang awareness/prevention strategy, in addition to gang awareness assignments
from the ARISE curriculum.
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 assess each youth using the Residential
Assessment for Youth (RAY) within thirty days of admission and reassessment within ninety
days. Five youth case management records were reviewed. All five records had documentation
which showed the youth was assessed within thirty days of arrival to the program. In three of the
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five records, documentation of the process was maintained in the Department’s Juvenile Justice
Information System (JJIS). In two of the five records the initial assessment was not documented
in JJIS due to Department-wide system outages. Two of the five youth case management
records indicated a RAY Reassessment was completed at least every ninety-days after
completion of the initial RAY. In one record, the RAY Reassessment completed within the
second ninety-day period was thirty-seven days late. Two of the five records reviewed were not
applicable for reassessment. Three of the five youth were applicable for updates or
reassessments, when deemed necessary by the intervention and treatment team, to effectively
manage the youth’s case, and reassessments were completed, as necessary.
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 the Department’s Juvenile Justice Information System (JJIS)
on the YNAS.
The program has a policy and procedures to complete a Youth Needs Assessment Summary
(YNAS) of each youth within thirty days of admission. Five youth case management records
were reviewed. Four case management records indicated each youth was assessed within thirty
days of admission to the program. Two of the records had documentation of the process
maintained in the Department’s Juvenile Justice Information System (JJIS.) Three of the case
management records were not documented in JJIS due to Department-wide system outages.
One case management record indicated the assessment was completed seven days late. All
five records showed the youth’s top three criminogenic needs were identified and
documentation was maintained in each youth’s case management record.
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.
Five youth case management records were reviewed for performance plan development, goals,
and transmittal. Three of five case management records indicated the Individualized
Performance Plans (IPPs) were developed within thirty days of the youth admission. The
remaining two records showed the IPPs were developed seven days late. All five case
management records showed the IPPs were developed after the initial Residential Assessment
for Youth (RAY) and Youth Needs Assessment Summary (YNAS). All performance plans were
developed with the intervention and treatment leader, youth, administration representative, living
unit representative, treatment staff, and education staff. One of the five records reviewed had
Department of Children and Families (DCF) involvement. In four of the five records
documentation indicated the parent/guardian participated by telephone. In all five records
reviewed, documentation indicated the signature sheets were mailed to the parent/guardian. In
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three of the five records, signature sheets were not returned. In one record, documentation
indicated the signature sheet was returned and the other record was not applicable. Each of the
five records showed performance plans included goals individualized for each youth based upon
the prioritized needs reflecting the risk and protective factors identified during the initial
assessment process, the youth’s top three criminogenic needs, delinquency interventions,
targeted court-ordered sanctions which could be reasonably initiated/completed while in the
program, transition activities targeted for the last sixty days of the youth’s anticipated stay, youth
responsibilities to accomplish goals, program staff responsibilities to enable youth to complete
the goals, and target dates for goal completion. In two of the five records, documentation
indicated the program sent a transmittal letter and copy of the plan to the youth’s committing
judge within ten working days of completion. In all five records documentation indicated the
program sent a transmittal letter and copy of the plan to the youth’s juvenile probation officer,
parent/guardian, and/or Department of Children and Families (DCF) caseworker, as applicable,
within ten working days of completion. In four of five records, documentation indicated the
committing court was sent a transmittal letter or a copy of the plan. The remaining record did not
have evidence the plan was sent to the committing court. Five youth were interviewed, and all
five reported participating in the development of their performance plan.
2.10 Performance Plan Revisions and Incorporation of Other
Satisfactory Compliance
Plans
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team. The youth’s performance plan
shall reference or incorporate the youth’s treatment or care plan.
Five youth case management records were reviewed for performance plan revision and
incorporation of other plans. All five records reviewed had documentation the Residential
Assessment for Youth (RAY) Reassessment results warranted revision, and three of five were
also due to newly acquired/revealed information, the youth demonstrating progress toward
completing a goal, or the youth demonstrating lack of progress toward completing a goal. In
three applicable records, revisions to the Individualized Performance Plan made when the
program needed to facilitate transition activities during the last sixty days of a youth’s stay. All
five youth had additional plans, including academic or treatment plans, incorporated into their
performance plan. One youth was applicable for having a current behavior support plan or case
plan through the Department of Children and Families (DCF), and the youth’s performance plan
coordinate with DCF for related issues.
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.
Five youth records were reviewed for the completion of Performance Summaries and
transmittals. Four of the five youth case management records had the initial Performance
Summaries completed within ninety days following the signing of the performance plan. The
remaining record was not applicable as ninety days had not passed at the time of the annual
compliance review. Four of five records showed the youth’s status, overall treatment progress,
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academic status, and credits earned in the program, including performance and behavior in
school, level of motivation/readiness to change, interaction with peers and staff, overall behavior
adjustment to the program, and significant positive and negative events. The remaining record
was not applicable as ninety days had not passed at the time of the annual compliance review.
In four applicable records reviewed, youth were allowed to read and add comments prior to
signing, were provided a copy of the summary, and the original summary was filed in the youth’s
case management record. Four applicable records showed the Performance Summaries were
signed and dated by the treatment team leader, facility administrator or designee, and the youth.
Of the four applicable records, two records showed the summary was sent within ten days to the
judge. The remaining two were not sent. Four applicable records were sent to the youth’s
juvenile probation officer (JPO), parent/guardian, and Department of Children and Families
(DCF), as applicable.
Three closed youth records were reviewed for release summaries. Each of the closed records
contained documentation indicating the original summary was sent with the Pre-Release
Notification (PRN) to the youth’s assigned JPO. Release summaries and PRNs were sent at
least forty-five days prior to each youth’s planned release, as required. Signed copies were
retained in each youth’s case management record. Once approved, all three of the closed
youth’s records documented the program provided written notification to the youth’s
parent/guardian advising them of the youth’s anticipated release. Each of the three closed
records had a completed Residential Assessment for Youth (RAY) Exit Assessment. One
closed record was applicable and showed documentation the program mailed the Victim
Notification of Release letter to the victim or designee at least ten days prior to the youth’s
release. The remaining two closed records were not applicable for victim notification.
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 encourage and facilitate involvement of the youth’s
parent/guardian in the case management process. The program invites the youth’s
parent/guardian to participate in the assessment process, development of the youth’s
performance plan, progress reviews, advanced notice of formal treatment team meeting dates
and times, and transition planning. If unable to attend, the program gives the parent/guardian
the opportunity to participate by telephone/video conference or provide written input prior to the
meeting. There were no treatment team meetings held during the week of the annual
compliance review; therefore, observations could not be completed. An interview conducted
with the facility administrator (FA) indicated the youth’s parents/guardians are involved in the
case management process. The case manager and/or designee will make every effort to
include parents/legal guardians to participate in the youth’s assessments, performance plan
development, progress reviews, and transition planning. Treatment team documentation
provided information of attendance or the attempts to contact the parent/ guardian to participate
as documented by the case manager and/or designee. The information is filed in the youth’s
case management record to determine the parent/guardian involvement in case management
services. Five youth were interviewed, and all five youth reported their parents/guardians are
involved in their treatment by participating in treatment teams and family therapy.
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2.13 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.
The program has a policy and procedures identifying treatment team members which include, at
a minimum, the youth, representatives from the program’s administration, residential living unit,
education, and others responsible for providing or overseeing the provision of intervention and
treatment services. The program ensures the intervention and treatment team meet formally, on
a bi-weekly basis, to review each youth’s performance, to include Residential Assessment for
Youth (RAY) Reassessment results, progress on Individualized Performance Plan (IPP) goals,
and positive and negative behaviors including behaviors resulting in physical interventions. The
gang prevention specialist, transition services manager, Department of Children and Families
(DCF), and trafficking-specific service provider are included when applicable. Five youth case
management records were reviewed. In each of the five records, treatment teams were
composed of a treatment team leader, youth, administrative representative, living unit
representative, treatment staff, educational staff, juvenile probation officer (JPO),
parent/guardian, medical staff, and recreational therapist. In one of the five records,
documentation indicated the bi-weekly informal review was eight days late. In the remaining four
records, documentation indicated the intervention and treatment team meet informally on a bi-
weekly basis, to review each youth’s performance, to include RAY Reassessment results,
progress on IPP goals, and positive and negative behaviors including behaviors resulting in
physical interventions. In each of the five interviewed youth case management records,
documentation indicated the parents/guardians were involved in the youth’s treatment by
participating in treatment team meetings, family therapy, discussions on progress on
performance plan goals, positive and negative behaviors, treatment progress, and how to
practice the skills learned at the program in the community. All five records indicated informal
treatment team meetings documented the youth’s name, date of review, meeting attendees,
comments from treatment team members or others, synopsis of the youth’s progress in the
program, and performance plan revisions. There were no treatment team meetings during the
week of annual review; therefore, observations could not be completed. Five youth were
interviewed. All five interviewed youth reported their parents/guardians are involved in their
treatment by participating in treatment teams and family therapy. All five youth reported staff talk
to them about their performance to include progress on performance plan goals, positive and
negative behaviors, and treatment progress. Each of the five youth stated they are able to
discuss and explain how they practice the skills they are learning at the program in the
community.
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2.14 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.
Three closed youth case management records were reviewed for transition planning and
conferences, and Community Re-Entry Team (CRT) meetings. Each of the three case
management records had documentation which reflected the transition conferences were held
at least sixty days prior to the youth’s targeted release date with the youth, youth’s juvenile
probation officer (JPO), parent/guardian, education staff, and any other pertinent parties through
advance notification. All three transition plans included appropriate goals and end dates for the
youth’s release back into the community. In all three records, documentation indicated all
parties were offered an opportunity to provide verbal and written input prior to the meeting. All
three records showed transition activities on the youth’s performance plan, which were revised
when necessary to identify additional transition activities, target completion dates, and identified
the persons responsible for completion of transition activities. In all three records, the treatment
team leader obtained attendees’ dated signatures, representing their acknowledgement of the
transition goals and accountability for completion, and a copy of the plan was sent with a
request for return with signature to anyone not in attendance who had a responsibility for
completion of transition goals. The plan was transmitted electronically to the JPO and
Department of Children and Families (DCF) counselor, if applicable, and a return email
acknowledged receipt was documented in the youth’s case management records. In all three
records, a CRT meeting was conducted and documentation indicated invitations were sent to all
participants involved.
2.15 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
Three closed case management cases were reviewed for exit portfolios. Each of the three
records had documentation which indicated the exit portfolio was discussed and initiated for the
youth during the transition conference. One of the three youth records included a state-issued
identification (ID) card. The remaining two did not include ID cards; however, documentation
indicated the program made efforts to obtain them. All three records included the youth’s
transition plan, calendar with all dates, times, and locations of upcoming community
appointments, educational/vocational certificates, educational records, school transcripts,
résumé, and completed samples of employment applications. One record included the youth’s
Social Security card. One record did not include a social security card; however, documentation
reflects the program’s attempts to obtain it. One record was not applicable due to the youth’s
age. None of the three records included the youth’s birth certificate, however documentation
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indicated the program made efforts to obtain them. In each of the three records reviewed,
documentation indicated the youth’s exit portfolio was verified during the exit conference,
completed, and provided to the youth upon release.
2.16 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.
Three closed youth case management records were reviewed. All three records had
documentation which indicated an exit conference and formal and informal meetings were
conducted to review the status of goals developed at the transition conference and finalize
release plans. Each of the three records indicated the exit conference was held separately from
the transition and Community Re-Entry Team (CRT) meetings, and included the youth, youth’s
juvenile probation officer (JPO), parent/guardian, treatment team leader, education, and other
pertinent staff essential for the youth’s transition back into the community.
2.17 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a formal process to promote or solicit constructive input from the youth
through multiple avenues of communication which will allow youth to give input and feedback on
a daily, weekly, and monthly basis. These processes include the Request for Service form,
grievance and request to talk system, and monthly town hall meetings. This will give the youth
experience in identifying systemic issues impacting their residential community and making
recommendations for resolution to improve conditions and enhance the quality of life for staff
and youth in the program. Reviewed documentation indicated monthly town halls are conducted
with all the youth, youth care workers, supervisors, and the facility administrator and/or
designee. Input is also gathered through an annual Trauma Responsive and Caring
Environment (TRACE) survey, youth exit surveys, and the daily clap-up activity. Five youth were
interviewed. Three of the five youth reported they can provide input about what happens at the
program by speaking directly to administration, and two youth stated they either do not provide
input or they talk to other youth. An interview with the facility administrator confirmed the
program has a formal process to solicit input from youth through multiple avenues of
communication which will allow youth to give input and feedback on a daily, weekly, and
monthly basis. Staff ensure grievance, Request to Talk, and Request for Service forms are
always available. The facility administrator and/or designee check the appropriate boxes
routinely to address immediate issues.
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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 facility administrator 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 designated mental health clinician authority (DMHCA) is a licensed mental health
counselor. The DMHCA’s license was provided for review and is valid until March 31, 2025. The
program did not utilize any other DMHCA during the annual compliance review period. The
DMHCA is on-site weekly to ensure appropriate coordination and implementation of mental
health and substance abuse services were taking place. A copy of the DMHCA’s position
description was reviewed with no issues noted. The DMHCA is the single licensed mental health
professional responsible for the coordination and implementation of mental health and
substance abuse services. Back-up DMHCA coverage is provided by the clinical director of the
closest sister program or at the regional level. Both individuals have valid licenses in the State
of Florida which expire on March 31, 2025.
The DMHCA was interviewed and reported the provision of weekly supervision for therapists
and case managers and other clinical services such as individual, group, and family counseling,
psychological assessments, Crisis Assessments, and Baker Acts. The DMHCA stated they
provide daily communication to staff either directly or through an on-call basis telephonically.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The facility administrator is responsible for ensuring mental health and substance abuse
services are provided by individuals with appropriate qualifications. Clinical supervisors shall
ensure clinical staff working under their supervision are performing services the staff are
qualified to provide based on education, training, and experience.
The program’s policy, procedures, or contract do not require any other licensed clinical staff
other than the individual serving as the designated mental health clinician authority (DMHCA).
The DMHCA is the licensed mental health professional and staffing is in accordance with the
current contract. A copy of the DMHCA’s license was available on-site and expires March 31,
2025. A copy of the Chapter 397 license was posted in the lobby and expires on May 9, 2025.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The facility administrator 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) assures the non-licensed clinical
staff working under their supervision are performing services they are qualified to provide based
on education, training, and experience. The reviewed documentation serving as the direct
supervision logbook demonstrated the two non-licensed mental health professionals received a
minimum of one hour weekly of on-site, face-to-face direct supervision by a licensed mental
health professional with the exception of seven weeks. Of the seven weeks, one week the
DMHCA was out, three weeks the therapists did not report to work, two weeks the therapists
had approved time off, and one week the new therapist was onboarding. For the one week the
DMHCA was out, the non-licensed therapists still provided services without direct supervision.
All direct supervision completed was recorded on the Department’s Licensed Mental Health
Professionals and Licensed/Certified Substance Abuse Professionals Direct Supervision Log
form. The program has a Chapter 397 license which is posted in the lobby and expires on May
9, 2025. All non-licensed mental health and substance abuse clinical staffing is compliant with
current contractual levels. No vacancies were reported at the time of the annual compliance
review.
The program had two non-licensed mental health clinical staff applicable for the annual
compliance review period, and both hold a master’s-level degree from an accredited university
or college in the appropriate field of study. The program is licensed under Chapter 397 and two
non-licensed substance abuse clinical staff are working under the direct supervision of a
qualified professional and have a minimum of a bachelor’s degree from an accredited university
or college in the appropriate field of study. The two non-licensed mental health clinical staff
conducting Assessments of Suicide Risk have completed twenty hours of training and
supervised experience in assessing suicide risk, mental health crisis intervention, and
emergency mental health services as evidenced in training records and direct supervision
documentation 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.
Five youth mental health and substance abuse treatment records were reviewed. All five youth
had a Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) completed upon
admission to the program. The screener reviewed available information to include the
commitment packet, reports, and/or records for existing documentation of mental health or
substance abuse problems or history of human trafficking. Four of the five records contained the
dates of completion with one record missing the date of the completed screening. Three of the
five screenings were completed by trained staff and the remaining two records were missing the
name of the staff completing the screening. One of the five screenings was completed in
Department’s Juvenile Justice Information System (JJIS) on the day of admission, two were
completed when there were Department-wide system outages, one was conducted fifty-six days
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late, and the other was conducted seventy-one days late. All five screenings were completed in
full and all five indicated further assessment was required and referrals were made for further
evaluation. Reasons for the referral included the need for an updated comprehensive
evaluation, traumatic experiences, anger, and substance use. When the MAYSI-2 or other
admission information indicated the need for an assessment, crisis intervention, or emergency
services, the facility administrator or designee was notified and a referral was made to alert the
designated mental health clinician authority (DMHCA) in all five records reviewed. The facility
administrator ensured an Assessment of Suicide Risk (ASR) was conducted within twenty-four
hours when the MAYSI-2 category “suicide ideation” indicated further assessment was needed
or other information obtained at intake/admission suggested potential suicide risk. All five
records showed the youth were placed on precautionary observation, referred for an ASR and a
Comprehensive Evaluation as part of the intake process, and the referral documented the
reason for the referral.
The facility administrator is responsible for developing the written policy and procedures for the
implementation of a standardized admission/intake mental health and substance abuse
screening process. The program’s policy outlines a standardized screening process which
includes a review of commitment packet information, reports, and records, administration of the
MAYSI-2 on JJIS or clinical mental health screening by a licensed mental health professional
and clinical substance abuse screening by a qualified professional. The procedures also include
referral of juvenile offenders identified by screenings as in need of further evaluation or
immediate attention and staff training in mental health and substance abuse issues and
administration of the MAYSI-2. The policy also includes a standardized process for referral of
youth identified as in need of further mental health and/or substance abuse evaluation to an
appropriate service provider/professional or, when immediate attention is needed, to a hospital,
Baker Act, or Marchman Act receiving facility. The facility administrator was interviewed and
reported adherence to written policies and procedures as it relates to admission screenings and
identifying youth at risk and in need of mental health and substance use services.
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.
Five youth records were reviewed for mental health and substance abuse
assessments/evaluations. The program completed a new combined mental health and
substance abuse evaluation within thirty calendar days of admission for three of the five
applicable youth, with two youth having the evaluation completed thirty-one and thirty-three
days after admission respectively. All five youth records contained the signed consent for
substance abuse services. All five assessments were completed by a licensed mental health
professional and included identifying information, reason for the evaluation, relevant background
including home environment and family functioning, history of physical abuse, sexual abuse,
neglect, witnessing violence and other forms of trauma, behavioral functioning, physical health,
mental health and substance abuse history, and education functioning. The evaluations also
included behavioral observations, Mental Status Examinations, interview or procedures
administered, discussion of findings, diagnostic impressions/formulation including a Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) diagnosis, patterns of alcohol
and other drug abuse, impact of substance use on major life areas, risk factors of continued
alcohol and other drug abuse, and recommendations.
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The designated mental health clinician authority (DMHCA) was interviewed and confirmed,
during the admission intake, the case managers conduct assessments and refer youth to mental
health for additional screenings to identify needs. The process for obtaining information for the
comprehensive mental health and substance abuse assessment based on behavior is gathered
through ongoing individual and family therapy sessions.
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.
Five youth records were reviewed for mental health and substance abuse treatment plans. In all
five records, the initial treatment plan was developed within seven days of the initiation of
treatment and completed on the Department’s Initial Mental Health/Substance Abuse Treatment
Plan form or an initial treatment plan which included all elements of the form. All five plans
included the youth’s psychiatric needs, when applicable, including medication and frequency of
monitoring by the psychiatrist. All five initial treatment plans were signed by the mental health or
substance abuse clinical staff completing the form. One of the five treatment plans was
completed by a non-licensed mental health clinical staff and signed by the licensed clinical
supervisor within ten days of completion. All five treatment plans were signed by the youth and
four out of five plans were mailed out to the parents/guardians with a request to sign and return
to the program; only one plan was returned with parent/guardian signature. Four out of five
initial treatment plans were signed by the treatment team leader and program management.
Five records were reviewed for individualized treatment plans. One of the five youth had not
been in the program long enough for a review to be completed. Of the four applicable records,
three individualized treatment plans included psychiatric services including psychotropic
medication and the frequency of monitoring by the psychiatrist for those prescribed psychotropic
medication. All four applicable individualized treatment plan reviews were completed on the
Department’s Individualized Mental Health/Substance Abuse Treatment Plan Review form or a
form containing all the elements of the form. Eighteen treatment plan reviews were conducted
for the four applicable youth. All were conducted every thirty days except two were one day late.
All five records showed the individualized treatment plan was signed by the mental health or
substance abuse clinical staff completing the plan. Two of five plans were completed by a non-
licensed staff, and were reviewed and signed by the licensed supervisor within ten days of
completion. All five individualized treatment plans were signed by the youth, treatment team and
program management when applicable. Three of the five treatment plans were signed by or
mailed out to the parent/guardian. A review of all five individualized treatment plans
demonstrated the inclusion of prescribed services such as individual, group, and family therapy
and individualized goals and objectives. A video review was conducted to observe group times,
length, and staff ratios. Three different groups from various dates were observed and found to
be compliant with all elements.
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Office of Accountability and Program Support Page 34 of 64 (Revised September 2022)
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.
Five open youth records were reviewed for treatment and discharge planning. All five open
youth records showed each youth was assigned to a treatment team upon arrival to the
program. A review of treatment team documentation showed the youth, facility administrator,
medical staff, mental health and substance abuse staff, and parents/guardians were in
attendance for treatment team reviews. Education and vocational staff provided written input for
the treatment team regarding each youth’s progress. All five youth were determined to be in
need of substance abuse treatment. Four of the five youth received individual, group, and/or
family counseling provided by a qualified professional, or a non-licensed substance abuse
clinical staff in accordance with the youth’s initial or individualized substance abuse treatment
plan. One youth record applicable for three months was missing documentation of individual
counseling for two of three months, group counseling for one of three months, and family
counseling for all three months. Three applicable youth who received mental health treatment
had a properly executed Authority for Evaluation and Treatment (AET) form. The other two
youth were eighteen years old. All five youth receiving substance abuse treatment provided
consent through a signed Youth Consent for Substance Abuse Treatment. All five youth signed
a Youth Consent for Release of Substance Abuse Treatment Records form. In all five records
reviewed, mental health treatment notes or substance abuse treatment notes were documented
on a form which contained all of the information in the required form. In four of the five records
reviewed, individual psychotherapy or one-to-one counseling between a youth with a diagnosed
mental health disorder and a mental health clinical staff professional occurred. One reviewed
record was missing documentation of individual counseling for two of three months. All five
youth records indicated the youth received psychosocial skill training. A review of progress
notes determined youth received services as stipulated on the treatment plan in four of the five
records. One record showed no evidence of youth receiving services as stipulated in the
treatment plan.
Three closed youth records were reviewed for discharge planning. In all three records, the
discharge plan was documented on the Department’s Mental Health/Substance Abuse
Treatment Discharge Summary form. None of the reviewed youth were released while on
suicide alert. The Mental Health/Substance Abuse Treatment Discharge Summary form
documented the future services needed in all three records reviewed. A review of
documentation reflected the discharge plan was discussed with the youth, parent/guardian
when allowed, and juvenile probation officer (JPO) during the exit conference, in all three
records reviewed. A copy of the Mental Health/Substance Abuse Treatment Discharge
Summary form was provided to the youth, JPO, and to the parent/guardian, as allowed, in all
three records.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 35 of 64 (Revised September 2022)
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’s required clinical groups are Living in Balance and Seeking Safety. The program
provides substance abuse treatment services. Therapeutic activities, including psychosocial
skills training, psychoeducation, and supportive counseling are provided by the licensed mental
health counselor and two master’s-level therapists who are under the direct supervision of the
licensed mental health counselor. They are on-site at least five days a week and on call twenty-
four hours a day, seven days a week. The counselor to youth ratio is one to twelve.
The program provides individual, group, and family therapy. Four of five reviewed youth records
indicated youth were receiving individual therapy biweekly. In one record, individual therapy was
only provided one month out of three applicable months. Four of five reviewed youth records
indicated monthly family therapy was received. One record indicated out of three applicable
months, family therapy was not provided at all. The psychiatrist provided services at least once
every two weeks. Group therapy was provided as required in four of five youth records. No
youth missed services due to being on medical quarantine. Five interviewed youth indicated
they each received services monthly. Five interviewed staff indicated they do not facilitate
groups. The designated mental health clinician authority stated individual, group, and family
sessions are provided to youth. An interview with the facility administrator confirmed the
program’s policy and procedures.
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 Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental disorder and each youth
receiving psychotropic medication in the program as set forth in Rule 63N-1, F.A.C.
Psychiatric services are provided by a psychiatrist licensed under Chapter 458 with a clear and
active license in the State of Florida, expiring on January 31, 2026, and meeting the
requirements in Florida Administrative Code. The psychiatrist is available for emergency
consultation twenty-four hours a day, seven days a week. The psychiatrist or psychiatric
advanced practice registered nurse (APRN) providing psychiatric services briefs a
representative of the treatment team regarding the psychiatric status of each youth receiving
psychiatric services who are scheduled for treatment team review through face-to-face
interaction or telephonic communication with the representative or treatment team. If a
psychiatric APRN is utilized, the position is a designee for clinical responsibilities only. The
program’s psychiatric APRN holds a clear and active license in the State of Florida, with the
license expiring July 31, 2026. The APRN’s education, experience, and certification/licensure is
in psychiatry/mental health, as stated on the Department of Health website. If the psychiatric
APRN provides psychiatric services, the psychiatric APRN has a Collaborative Practice Protocol
in place with the psychiatrist. There was a review of the Collaborative Practice Protocol with the
APRN to verify a copy is maintained on-site and specifies to be with the psychiatrist on-site. A
review of sign-in/out logs confirmed visits during the annual compliance review period were
conducted as required by the contract or agreement. A review of documentation confirmed the
psychiatrist actively participates in, manages, and supervises psychotropic medication services
in the program. A review of documentation showed when duties were delegated to the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 36 of 64 (Revised September 2022)
psychiatric APRN, the psychiatrist provided bi-weekly on-site supervision of the APRN’s
medication management services and was available to evaluate and monitor youth as needed.
The psychiatrist was available to the APRN by telephone or by another communication device
when not physically available on the premises. The program’s contract does not include
tele-psychiatry.
An interview with the psychiatrist confirmed the psychiatrist completed evaluations on every
youth entering the program and medication management is provided monthly to youth on
psychotropic medications. The psychiatrist confirmed they are on-site every other week to
provide psychiatric services and psychotropic medication management. The psychiatrist meets
with the designated mental health clinician authority (DMHCA) every time they are on-site, and
is on-call twenty-four hours a day, seven days a week if needed by the medical staff to discuss
the youth needs, psychiatric services, and any important medical issues/concerns, and provides
face-to-face communication with the treatment team. The psychiatrist had no concerns
regarding mental health or substance abuse services at the program. An interview with the
DMHCA confirmed they meet with the psychiatrist when needed to discuss youth receiving
psychiatric services.
Five youth records were reviewed for psychiatric services. Two of five youth were admitted to
the program on psychotropic medications. All five youth were referred for a psychiatric interview
as part of the intake process. All five youth received a psychiatric interview within fourteen days
of admission as required. Each of the Initial Diagnostic Psychiatric Interviews included the
youth’s medical, mental health, and substance abuse history, Mental Status Examination,
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis which was
consistent with the treatment plan, and treatment recommendations. Three of the five Initial
Diagnostic Psychiatric Interviews indicated the youth needed to be prescribed medications. One
of those three youth refused to take the medicine at first. The youth started taking medicine two
months after their arrival to the program. The other two youth records included an explanation of
the need for psychotropic medications related to the youth’s diagnosis, target symptoms, initial
treatment goals, potential side effects, risks and health benefits of taking the medication, and
frequency of medication monitoring/management. The Initial Diagnostic Psychiatric Interview
was documented on a form developed by the program which contains all the information
included on the Department’s Clinical Psychotropic Progress Note (CPPN) and the CPPN
clearly identified the form as the Initial Psychiatric Assessment, in all five records. When the
psychiatric evaluation resulted in the prescription of psychotropic medication or changes to the
youth’s existing psychotropic medication, page three of the CPPN was completed, regardless of
the form used to document the evaluation. Reviewed documentation showed youth was not
seen for medication review by the psychiatrist or psychiatric APRN at a minimum of every thirty
days. When psychotropic medications were prescribed/dispensed/administered by the
psychiatrist or psychiatric APRN, identifying data, diagnosis, target symptoms of each
medication, evaluation, and description of effect of prescribed medication on target symptoms
were documented in three applicable records. Prescribed psychotropic medication, including the
name, dosage and quantity of the medication, normal dosage range, ordered dosage, frequency
and route of administration, reasons for changes in medication and/or dosage were also
documented in all three records reviewed. Side effects, adherence to the medication regimen,
signature of the psychiatrist or psychiatric APRN, date of signature, and Tardive Dyskinesia
monitoring were also recorded in all three records.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 37 of 64 (Revised September 2022)
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 regarding suicide prevention services to include a
written plan detailing suicide prevention procedures. The plan includes identification and
assessment of youth at-risk of suicide, six hours of staff training annually, suicide precautions,
levels of supervision including one-to-one supervision, constant supervision, and close
supervision, drills for all staff on each shift, referrals, communication, notification,
documentation, immediate staff response, and a review process. The review process for suicide
attempts and mortality includes the circumstances surrounding the event, facility procedures
relevant to the incident, relevant training received by staff, pertinent medical and mental health
services involving the victim, possible precipitating factors, and recommendations, if any, for
changes in policy, training, physical plant, medical or mental health services, and/or operational
procedures. The Suicide Prevention Plan is reviewed annually and was last reviewed October
20, 2024, by the designated mental health clinician authority (DMHCA) and facility administrator.
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.
Five youth records were reviewed for suicide prevention services. It is program policy to have all
youth placed on precautionary observation (PO) during their admission screenings, until they
are seen by mental health staff. All five records had an Assessment of Suicide Risk (ASR)
completed on the Department’s ASR form within twenty-four hours of admission. Four of five
records showed documentation of the youth being placed on standard supervision after the ASR
screening. One record showed the youth being placed on constant supervision after the ASR
screening. The program does not require the parent/guardian or juvenile probation officer (JPO)
to be notified if the youth is placed on PO during their admission screening and then cleared by
the ASR. In a review of two applicable records, one record showed mental health staff provided
supportive services, the other did not. In all five records, the ASR was completed by a licensed
mental health professional or clinical staff under the direct supervision of a licensed mental
health professional. In three applicable records, when discontinuation of PO was documented
by a non-licensed staff, it was reviewed and signed by a licensed staff. In one record, the ASR
was completed by licensed staff. In four applicable records, discontinuation of close supervision
was documented in the youth’s mental health/substance abuse record by a mental health
clinical staff and there was documentation of a conference held by the facility administrator (FA)
and designated mental health clinician authority (DMHCA) to reduce the level of supervision.
Documentation confirmed the actual date/time the DMHCA conferred with the FA on the ASR in
the date/time sections. None of the instances found the youth to be in crisis. One applicable
youth needed a Follow-Up ASR completed prior to the removal of the youth from PO and the
form was not completed.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 38 of 64 (Revised September 2022)
An alert in the Department’s Juvenile Justice Information System (JJIS) was entered for three
applicable records. Two records were unable to be entered due to Department-wide system
outages. Two of the three applicable alerts were accurately closed following the
recommendations of the ASR. The remaining record was unable to be closed at the time the
alert was no longer valid due to the Department-wide system outages. It is the program’s policy
when a youth is placed on PO during screening, they are always in the presence of mental
health staff, immediately seen, and cleared, if applicable; therefore, documentation is not placed
into the logbook. A review of one of the five records indicated the youth was placed on PO again
at a different time after already admitted into the program. There was documentation this event
was in the logbook as required. While on PO, the at-risk youth were allowed to participate in
select activities with other youth in designated safe housing/observation areas of the facility.
There were no youth who had been placed on PO in the last thirty days, as such, no video was
able to be viewed for PO.
3.12 Secure Observation (Critical) Satisfactory Compliance
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The program does not utilize secure observation; therefore, this indicator is rated “Non-
Applicable.”
3.13 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
Five youth records were reviewed for Suicide Precaution Observation Logs. The Suicide
Precaution Observation Logs were maintained in four of the five records. In the remaining
record, the youth’s Assessment of Suicide Risk (ASR) indicated they were to be continued on
constant supervision, however, there were no logs past the time of the ASR. This youth also did
not have a Follow-Up ASR completed. The program stated the only reason the youth was kept
on precautions was due to having just arrived to the program with no other sign or indications of
suicidal ideation, threat, or intent. The program reported the wrong box was checked and the
youth should have been taken off PO. In the four applicable records reviewed, the appropriate
level of supervision and observations of the youth’s behavior were documented in real time and
not exceeding thirty-minute intervals. In the four applicable records reviewed, the logs were
signed by each shift supervisor, reviewed and signed by mental health clinical staff, and
documented safe housing requirements.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 39 of 64 (Revised September 2022)
3.14 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.
Five pre-service and five in-service staff training records were reviewed for suicide prevention
training. All ten staff completed two hours of training in the Department’s Learning Management
System (SkillPro) and four hours of instructor-led suicide prevention training. Training included
mock suicide drills held no less than quarterly on each shift, for all staff who come in contact
with youth including kitchen and maintenance staff. The program has three suicide response
kits which include a knife-for-life, wire cutters, and needle nose pliers. Suicide response kits are
co-located with first-aid kits in master control, on the medical cart, and in the laundry room. All
mock mental health drills in response to a suicide attempt and/or incident of serious self-injury
were simulated, and no youth were used in the simulations, this was verified by video and
documentation review. The program provided semi-annual training on emergency response
procedures which included mock training in emergency response to a suicide attempt or
incident of serious self-inflicted injury, as confirmed by a review of drills and an interview with
the facility administrator. Staff who were not present during a quarterly drill had the opportunity
to review each drill scenario and procedures to understand the process and receive the
necessary training to respond to an incident of a suicide attempt or incident of serious self-
inflicted injury in the facility. Five staff were interviewed, and all indicated they are required to
notify mental health, three staff indicated they are to provide constant sight and sound of a
youth who expresses suicidal thoughts, and two staff indicated they would also document the
youth supervision. When asked where suicide response kits are located in the facility, three staff
stated they are in maser control, one staff indicated there is a kit in the laundry room, and two
staff were unsure where the kits were located due to being newly hired. Five staff indicated
medical emergency drills and suicide drills are conducted monthly on their shift.
3.15 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 regarding mental health crisis intervention services
which includes written crisis intervention procedures. The crisis intervention plan includes a
notification and alert system, a means of referral including youth self-referral, communication,
supervision, documentation, and review.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 40 of 64 (Revised September 2022)
3.16 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program has a written crisis intervention plan which includes a process for implementation
of a Crisis Assessment form. The form includes the reason for the assessment, Mental Status
Examination and interview, determination of danger to self and/or others, initial clinical
impressions, supervision, treatment, follow-up recommendations, and notification to the
parent/guardian of follow-up treatment. Five youth mental health and substance abuse records
were reviewed, one was applicable for having a Crisis Assessment completed, as such, the
program provided two additional records. In all three records the Crisis Assessment was
conducted within the required time frame and included the reason for the assessment, Mental
Status Examination and interview, determination of danger to self and/or others, initial clinical
impressions, treatment recommendations, and recommendations for follow-up or further
evaluation. One of the three records did not include supervision recommendations. The required
box was not checked on the form. Two youth required parental/guardian notification and of
those, one was completed. All three Crisis Assessments were 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. None of the three youth were placed on precautionary
observation following the assessment, nor were any of the youth deemed a safety and security
risk. Two of the three records were as a result of a Prison Rape Elimination Act (PREA) event
and a referral was submitted for a Crisis Assessment as well as each youth being offered
ongoing mental health treatment services.
3.17 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a written emergency mental health and substance abuse plan which includes
immediate staff response, notifications, communication, supervision, authorization to transport
for emergency mental health or substance abuse services, transport for emergency mental
health evaluation and treatment under Baker Act, transport for emergency substance abuse
assessment and treatment under Marchman Act, documentation, training, and review.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 41 of 64 (Revised September 2022)
3.18 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.
Five youth mental health and substance abuse records were reviewed for Baker and Marchman
Acts. Only one record was applicable, as such, the program provided two additional records for
review. When a youth was determined to be in need of emergency care, in all three records the
youth was with mental health staff and Baker Act procedures were immediately initiated. The
notification was made by the program’s licensed mental health professional (LMHP). Mental
health staff were involved in all three records, and the youth were taken out of the program in all
three records and transported by law enforcement, which was authorized by the facility
administrator (FA). Upon return to the program from a Baker Act, each youth was placed on
constant supervision. A mental health referral was completed indicating a Mental Status
Examination (MSE) needed to be conducted for all three records. An Assessment of Suicide
Risk was completed by a LMHP. All three youth were maintained on a minimum of constant
supervision until properly transitioned to a lower level of supervision. The youth’s supervision
level was not lowered until the LMHP conferred with the FA or designee in all three records.
3.19 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.
Five youth mental health and substance abuse records were reviewed, and documentation
showed all youth had a safety plan which included warning signs, the youth’s baseline behavior,
intervention strategies, crisis recognition, and a debriefing process. All five plans included jointly
developed coping strategies. All five plans were completed within fourteen days of each youth’s
admission to the program. Four of the five plans were jointly prepared by the youth,
parents/guardians, or a family member. One had no indication of family involvement. Four of the
five plans incorporated recommendations from previous or current clinical assessments or
screening instruments and incorporated trauma responsive practices. One did not have the
required box checked indicating this step was completed. Four of five records did not contain
updated plans as required. All five records had reviews completed every calendar month;
however, not within thirty days of the plan or the previous update. Two youth records had one
late update, one youth record had two late updates, and one youth record was missing an
update entirely. The program had a deficiency in mental health and substance abuse closed as
of September 3, 2024, pertaining to staff separation. New staff have since been hired and a
four-hour re-training took place with all mental health and substance abuse staff to rectify the
issues noted within this indicator. Safety plans are maintained in a safety plan binder located in
master control, as well as copies maintained in each individual record, and are reviewed by staff
who have contact with the youth. An interview with five youth indicated all participated in the
development of their safety plan. According to the facility administrator, safety plans are
developed and maintained according to program policy and procedures.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 42 of 64 (Revised September 2022)
Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program’s designated health authority (DHA) is a licensed physician who has an
unrestricted license and meets requirements for independent and unsupervised practice in the
State of Florida. The license expires on January 31, 2026. The DHA’s training is in family
practice with experience in adolescent health. The DHA has no disciplinary cases or public
complaints on record. The contract outlines the DHA must be at the program for two hours
weekly and a review of the sign-in sheets for the annual compliance review period indicated the
requirement was met. If the DHA is unavailable, the program has a written agreement with a
licensed physician for back-up. The back-up physician holds a clear and active unrestricted
license which expires on July 22, 2025, and was used for two weeks during the annual
compliance review period. The DHA was interviewed and confirmed they must see youth with
chronic conditions at least once every three months. The DHA is schduled to see youth for sick
call, and reviews and develop policies and procedures. The DHA communicates with the rest of
the staff through the nurses. The periodic exams are completed every three months at a
minimum. The DHA is available by telephone and a record with documents to review and sign
upon arrival at the program is kept in master control.
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 two full-time registered nurses (RNs), one of whom serves as the health
services administrator (HSA), and two pro re nata (PRN) RNs. In addition, the state nursing
director, who is a RN and provided services during the annual compliance review period, is
housed out of the program. Each of the RNs had a clear and active license in the State of
Florida and a current cardiopulmonary resuscitation (CPR) certification. The program’s nursing
staff and hours on-site are in accordance with contractual requirements.
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 procedures and protocols,
which are part of the policy procedures used daily by the program. The designated health
authority (DHA) and the facility administrator (FA) signed and dated the health protocols on
January 8, 2024, and January 4, 2024, respectively. The nursing staff reviewed and dated the
health protocols in August and September of 2024. All newly employed healthcare personnel
received a comprehensive clinical orientation of the Department’s healthcare policies and
procedures by the health services administrator.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 43 of 64 (Revised September 2022)
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.
Five youth records were reviewed for the Authority for Evaluation and Treatment (AET) form.
Three of the five youth had valid AETs which were filled out completely and signed by the
parent/guardian and juvenile probation officer (JPO). The remaining two youth were eighteen
years of age and did not require a parent/guardian signature. According to the nursing staff
youth arrive at the program with an AET signed by the parent/guardian or if the youth is with the
Department of Children and Families (DCF), signed by a judge/court.
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 in place for parental/guardian notification when a
youth’s condition changes while in the program. A review of five records showed three were
applicable for the Authority for Evaluation and Treatment (AET) forms and consent was
provided by the parent/guardian. Notification was sent on the Department’s Parental Notification
of Health-Related Care form. Three youth were taking psychotropic medications upon
admission and when a new medication was prescribed or discontinued, or if the dosage was
significantly changed, parental/guardian verbal consent was obtained and placed in the
chronological notes. Calls for parent/guardian consent were made for the three youth on
psychotropic medications with a witness present. Verifications for vaccinations were reviewed
within thirty days of admission for each of the five reviewed youth by the nursing staff. There
were no youth applicable for exemption from immunizations. Immunizations are obtained upon
the youth’s arrival at the program. If a parent/guardian claims exemption, and does not give
consent for vaccinations, they shall complete the Religious Exemption From Immunization form,
sign, and submit it to the program.
4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a policy and procedures on youth screened upon admission for healthcare
concerns who may require a referral for further assessment by healthcare staff. Five youth
records were reviewed each of which included a Facility Entry Physical Health Screening
(FEPHS) form completed by the registered nurse (RN) on the day of admission. Two youth had
a change in physical custody greater than twenty-four hours. Both youth had a new FEPHS
completed upon returning to the facility.
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4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy and procedures on youth being oriented to the general process of
healthcare delivery services at the program. In all five youth records reviewed, the youth were
provided a general healthcare orientation by the nursing staff upon admission and documented
in the youth’s record. All required topics were discussed including access to medical care, the
sick call process, when to notify staff in an emergency and what constitutes an emergency, the
medication process, the side effects of medication, refusal of care, what to do in case of a
sexual assault, the non-disciplinary role of healthcare providers, and standard universal
precautions. Health education was completed monthly as required.
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 in which the designated health authority (DHA) is
notified when youth are admitted or require emergency care. Five youth records were reviewed.
Three of the youth had a chronic condition and a referral was placed to the physician and
placed in the chronological notes. None of the youth needed emergency care upon admission.
The DHA was notified upon admission for each youth regardless of chronic condition. Three of
the youth were admitted with psychotropic medication and the psychiatrist was notified. The
nurse interview indicated an understanding of the registered nurse (RN) contacting the DHA
upon each youth admission, and reported all notifications are documented as an intake note, on
the DHA appointment list, and on the medical tracker.
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 in which the standard Department Health-Related
History (HRH) form shall be used for all youth admitted into the physical custody of the program.
A review of five youth records confirmed a HRH was completed within seven days of admission.
All five HRHs were completed prior to the Comprehensive Physical Assessment (CPA) as
evidenced by signature and date. In all five records, the designated health authority (DHA)
reviewed the HRH forms as evidenced by a checked box on the CPA and a corresponding note
in the admissions documentation. The nursing staff interview indicated a new HRH is completed
for all new youth entering the program.
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4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a policy and procedures ensuring the chronic health needs of the youth are
met by completing a Comprehensive Physical Assessment (CPA) within seven days of the
youth’s admission. A review of five youth records confirmed the program used the Department’s
CPA form and a new CPA was completed for each youth. All five records included the youth’s
Medical Grade documented on the CPA and all sections of the CPA were completed in full
utilizing “O” and “X” markings. The Medical Grade for each youth was listed on the front of each
record and on the CPA. All five youth refused a portion of the exam which was documented as
“youth refused” on each CPA. All five records confirmed the most recent verified Tuberculosis
Skin Test (TST) which was administered in the last year to determine exposure to tuberculosis
(TB). The results with dates of the TSTs were documented on each of the Department’s
Infectious and Communicable Disease (ICD) forms. The Department’s Problem List was
updated for each youth as applicable. The nurse interview indicated the CPA form is used for all
youth admitted to the program and the TST is completed annually.
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 to ensure all youth are evaluated and treated for
sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). Three of the
five reviewed records had youth who were referred for further evaluation to the designated
health authority (DHA) after being screened. Three youth were tested, screened, and their
diagnosis was documented on the Infectious and Communicable Diseases (ICD) form and
recorded in the lab section of the Individual Healthcare Record (IHCR). None of the five youth
were out of the Department’s physical custody; therefore, re-screenings were not needed. All
five youth were offered counseling and testing for HIV and three youth received testing after
giving written consent. The policy ensures the youth’s HIV result are only disclosed to the
youth’s legally authorized representative, healthcare providers during treatment, the Department
of Health of purposes of recording, and health facility staff committees conducting program
monitoring. Pre and post-test counseling are provided by the DHA and five interviewed youth
indicated they can request testing. An interview with the registered nurse (RN) confirmed all
youth were screened at intake and results were given to the DHA. The STI results are recorded
in the lab section of each youth’s record. Testing documentation is entered on the ICD forms
and the results of HIV are placed in a sealed envelope marked “Confidential” and placed in the
lab section of the youth’s record.
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4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a policy and procedures in which youth in the program shall be able to submit
sick call requests and have complaints treated through the sick call system. The program shall
respond timely and appropriately. All sick call encounters must be documented as required by
the Department. Five youth records were reviewed and none of the youth presented with similar
sick call complaints three or more times within a two-week period; however, all five youth
completed a Sick Call Request form and in all cases the registered nurse completed the Sick
Call Request form. The Sick Call Request forms were recorded in reverse chronological order in
the youth’s Individual Healthcare Record (IHCR). The sick call forms were documented in
accordance with Florida Administrative Code, and the youth’s sick calls were documented on
the Sick Call Index and the program’s Sick Call Referral Log. All dates corresponded to the
completed Sick Call Request forms located in the youth’s IHCRs. Sick call is seven days a
week, twice a day. Sick call hours can be found at the nurse’s station and in the common area
within the dorms. Only licensed nurses conduct sick call and if there is not a nurse at the
program, the shift supervisor reviews all requests within four hours of the request being
submitted. An exam table is used for sick call. Five youth were interviewed, and they all advised
they are seen within one day. The nurse interview indicated the youth must enter a sick call
request form, then place it inside a locked sick call box. The boxes are checked twice daily by
medical personnel. The sick calls are performed in the nursing station twice daily. Five staff
interviews were conducted, and all knew the sick call process. Each staff indicated the youth
must fill out a Sick Call Request form, place it in the box, and will be seen within twenty-four
hours of submitting it. There was not a sick call to observe during the annual compliance review
week.
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 for a comprehensive process for the provision of
episodic care and first-aid care. Five youth records were reviewed and three had an indication
they required on-site first-aid or episodic care. In all three cases, the on-site care was provided
by a licensed healthcare staff and documented in the youth’s record as required. The program
has nine first-aid kits located in the laundry room, kitchen, master control, school office, multi-
purpose portable, the two classrooms, and the two vans. The program checks the first-aid
boxes monthly to ensure expiration dates have not passed. Each kit has a form on the front
which shows the expiration date for the medical perishables. Three first aid kits were checked,
and they all had expirations dates in the future. The first-aid kits were fully stocked with
designated health authority (DHA) approved contents. The program has a log which is filled out
monthly for each first-aid kit. If the kits have any expired items, they are refilled with non-expired
items. The program has one automated external defibrillator (AED) located in master control.
The procedures for the AED are located within the machine. The AED pads and batteries are
monitored by the registered nurse (RN) monthly and neither had expired at the time of the
annual compliance review. There were no issues with the test and the light was green. The
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expiration date for the AED batteries were September 2027 and the batteries were last changed
on April 27, 2024. The expiration date for the AED pads were January 17, 2026, and the pads
were last changed on April 27, 2024. There was a list of emergency numbers in the control
room for staff. The list is inaccessible to youth. Ten training records, five pre-service and five in-
service, were reviewed and found the requirements for episodic, first-aid, and emergency care
and the epinephrine auto-injector were completed. There was documentation showing an
emergency drill for cardiopulmonary resuscitation (CPR) was given annually as a training. The
program has a policy on Narcan. The policy states Narcan nasal spray is to be given right away
and does not take the place of emergency care. The nurses check monthly to ensure the
Narcan has not expired. Four out of five interviewed staff stated they had the ability to call 9-1-1
if there was an emergency. One stated the supervisor would have to call because they did not
have access to a telephone. A poster was in the program stating staff could call 9-1-1 if the
need arises. Five interviewed youth indicated they could see a dentist or doctor if they needed
to. The nursing staff interview revealed the emergency drills are completed monthly switching
each month between the first and second shifts. Emergency medical drills included an episodic
event which called for immediate first-aid, administration of CPR techniques, and what to do
when a life-threatening emergency does occur. Observations of an episodic care event were
unable to be conducted as none occurred during the annual compliance review week.
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 in which they provide timely referrals and
coordination of medical services to an off-site healthcare provider, both emergent and non-
emergent, and document such services, as required by the Department. A review of five youth
records indicated three youth required off-site care. The Summary of Off-Site Care Consultation
Report form was utilized in all three cases and two of the youth had parental/guardian
notification efforts documented. The third youth was eighteen years of age, and the program
was not required to attempt to reach out to a parent/guardian. The discharge documents and
other applicable documentation were in the youth’s record and the designated health authority
(DHA) signed off on the findings, instructions, and information. One youth required a follow-up
appointment with the dentist, and it was tracked in the youth’s record. The nurse interview
indicated all off-site findings, instructions, and information are passed to the DHA from the
registered nurse (RN). Off-site summaries with attachments are flagged in the youth’s chart for
the DHA to review, sign, and date. The nurse tracks testing referrals and appointments on a
medical tracker, calendar, and episodic log.
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. Three of the five reviewed youth
records indicated a current chronic condition. The youth did not have a communicable disease,
however, two of them were taking prescribed medication on an ongoing basis. One youth was
undergoing treatment for abnormal Body Mass Index (BMI). None of the youth were identified
as pregnant. All three youth were placed on a chronic illness list, and they all received periodic
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evaluations at least once every ninety-days. None of the youth were applicable for taking anti-
tuberculosis medications, nor were any periodic evaluations done off-site. Periodic evaluations
were completed before renewal of any youth prescriptions, and no lapse of care was noted. The
Department’s problem list was updated in accordance with Florida Administrative Code. The
facility administrator (FA) was interviewed and confirmed the psychiatrist completes medication
management with the youth and registered nurses (RNs) give the medication to the youth. All
medications are under lock and key and controlled by the medical staff. The designated health
authority (DHA) was interviewed and indicated the role of the DHA as seeing youth with chronic
conditions at least once every three months. The DHA sees youth referred from sick call and
works on policy and procedures. The DHA confirmed they are on-site weekly for two hours and
communicates with the staff through the RNs. The DHA is available to staff by telephone if
needed, and findings and instructions can be found in the doctor binder for documents to review
and sign weekly upon arrival at the program. The nursing interview was reviewed, and the RN
indicated youth on the chronic list are seen every three months. The chronic information is
monitored by the RN on the medical tracker and in the chronic clinic binder. All youth’s
medications are verified upon admission using the prescription medication form. All medications
must have a pharmacy label intact with the youth’s name on it.
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 on medication management. The medication shall be
received, stored, inventoried, and provided in a safe and effective manner. Three of the five
reviewed youth records indicated the youth were admitted with medication on the Facility Entry
Physical Health Screening (FEPHS) form. The medication was verified in all three applicable
records. Prescription verification was included in the chronological progress note in the
Electronic Medical Record (EMR) located in the youth’s record. The designated health authority
(DHA) and the psychiatrist were contacted to obtain the order to resume the medication prior to
youth’s admission. All medications had a current, valid order. The medication was changed, and
the medical staff placed an order on the Practitioner Order form. There were no standing orders
for psychotropic medications, emergency treatment orders for psychotropic medication, or pro
re nata (PRN) orders for psychotropic medication. Over-the-counter (OTC) medications were
administered according to approved protocols. None of the medication was administered by
non-healthcare staff. The Department Medication Administration Record (MAR) in each record
clearly indicated medication start and stop dates. The program utilizes the pre-printed pharmacy
MAR. Medical staff initialed each administered medication entry. In all three applicable records,
the nursing staff indicated weekly side-effect monitoring on the MAR. The youth did not refuse
any medications. The MAR contained the youth name, Department identification, date of birth,
youth allergies, precautions, Medical Grade, medical alerts, and picture of the youth. The
medical staff gave the medication, and the youth did not require parenteral medication. All three
youth were seen by the psychiatrist within fourteen days of admission, and they received a
medication management review every thirty days. A medication pass was observed. The youth
was escorted by a youth care worker and approached the nurse individually. The medical staff
identified themselves and confirmed the reason youth was present. The nurse prepared the
medication and verified they youth’s allergies and alert status. The youth and the nurse initialed
each MAR, and the nurse observed the youth taking the medication to ensure it was swallowed.
The six rights of medication administration were met to include right youth, right medication,
right dosage, right time, right route, and right documentation. All five interviewed youth knew the
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nurses hand out the medication. All five staff knew the nurses handle medication for the youth.
The nurse was interviewed and indicated non-healthcare staff are trained to give medication.
The nurse interview confirmed there is a non-licensed healthcare staff protocol book located
next to the medication box. The nurses are trained by the director of nursing (DON) and the
training is kept in the education binder. Medication pass is 8:30 a.m., 12:30 p.m., and 5:00 p.m.
Medications are procured primarily by a vendor, with any remaining medication filled by a
community pharmacy, when needed.
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 for medical equipment classified as sharps, as well
as stock medications. The sharps shall be secured and inventoried utilizing a routine perpetual
inventory descending count as each sharp is utilized and disposed of or when the medication is
administered. A review of the medical equipment classified as sharps confirmed the items were
securely stored and inventoried utilizing a routine perpetual inventory with a descending count.
All medications were identified and secured in a locked medication cart. The medication cart
was well-organized and well-stocked with items separated from the youth’s medication.
Narcotics and other controlled medications are stored behind two locks and medications
needing to be refrigerated were locked by themselves in a small refrigerator. The program has a
policy for destruction and disposal of medications. Weekly inventories of all sharps and stock
over-the-counter (OTC) medications were completed as required. There is a shift-to-shift
inventory count of all controlled substances documented on the individualized youth controlled
medication inventory record. Supervisory-level and non-healthcare staff are trained in the
delivery and oversight of medication by the registered nurse (RN). None of the five youth
records reviewed had any non-healthcare staff providing medication. Two controlled
medications were observed. There were no discrepancies in the count. Three OTC medications
were observed and there were no discrepancies. Three sharps were checked and there were no
discrepancies in the count. The nurse reported the criteria regarding inventory discrepancies is
to report them to the pharmacy consultant and call the Department’s Central Communications
Center (CCC) if a controlled substance count was incorrect. The nurse confirmed all
medications and sharps are securely stored. The registered nurse (RN) was interviewed and
relayed two nurses must dispose of medication. All controlled medication requires two nurses
and a pharmacy consultant. The pharmacy consultant monitors the medication cart, the
Medication Administration Record (MARS), medication disposal, and storage of medication.
4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a policy and procedures for infection control procedures including prevention,
containment, treatment, and recording requirements related to infectious diseases, according to
Occupational Safety and Health Administration (OSHA) federal regulations and the Centers for
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Disease Control and Prevention (CDC) guidelines. The comprehensive education plan includes
pre-service and in-service training for all staff. Education for the youth is also provided at the
time of intake and when the need is identified. The control procedures include common
diseases, contagious illnesses, viral or bacterial diseases, tuberculosis, Hepatitis A, B, and C,
and human immunodeficiency virus (HIV), other outbreaks, lice and/or scabies, Methicillin-
Resistant Staphylococcus Aureus (MRSA), food-borne illnesses, bio-terrorist agents, and
exposures in the workplace. Hepatitis B shots are available to staff and the staff do have
protective equipment. There were no exposures during the annual compliance review period.
The exposure plan is written in accordance with OSHA standards and the plan is available to all
staff at the program. The exposure plan was reviewed and signed on January 8, 2024. Any
needle stick exposure must immediately be reported to the facility administrator by the chain of
command. It was indicated the director of nursing (DON) conducts training for the nurses for
infection control annually. There were no instances in which the Department’s Central
Communications Center (CCC) or county health department were contacted for infectious
diseases. An interview with the nurse confirmed exposure control training is provided by the
registered nurse.
4.19 Prenatal Care/Education Satisfactory Compliance
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
The program has a policy and procedures which provide access to prenatal care for all pregnant
youth. Health education is provided to both youth and staff. The program had one pregnant
youth during the annual compliance review period. There was documentation prenatal physical
and psychological care began immediately upon determination the youth was pregnant. There
was evidence of the designated health authority (DHA) providing routine, focused medical
evaluations of the youth’s pregnancy every thirty days, or sooner if ordered. The youth was
placed on the internal alert system for vital nutrition and health awareness for staff and an alert
was entered into the program’s internal alert system regarding the youth’s sleeping
arrangements. The youth had a human immunodeficiency virus (HIV) test and there is a
documented plan for post-birth psychological and physical care. The youth is receiving prenatal
care at recommended intervals and the youth receives nutritious food in quantities. The DHA
monitors the youth’s nutritional weight status regularly. The education topics provided to the
youth included alcohol and drug use, smoking, nutrition, sexually transmitted infections,
contraception, prenatal care, birthing process, postpartum care, basic baby care, child/infant
development, and parenting skills. The education was documented in the Health Education
Record in the youth’s record. All non-healthcare staff involved with the youth received in-service
education and a licensed nurse provided the training. In-service training included observation
and monitoring of emergency care needs and symptoms of possible miscarriage. The program
has nursing protocols and provides treatment plans for pregnant youth. A review of the nursing
interview confirmed youth are tested for pregnancy upon their admission to the program.
Pregnant youth are seen by the registered nurse (RN) weekly for blood pressure and weight
checks. Youth are seen at least once a month by the DHA as needed and goes off-site to an
obstetrician as well. Pregnant youth get double fruits and vegetables and an extra evening
snack.
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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 written policy and procedures to maintain active supervision of youth while
engaging in constructive activities, interacting positively with youth, closely observing behavior
and behavior changes in youth, and consistently applying the program’s behavior management
system (BMS). The policy states all program staff shall provide appropriate levels of physical
sight and sound supervision. An informal interview with three staff members advised two out of
three staff members knew the correct count of youth in their supervision. One staff member
counted less than what was displayed. The program’s staff-to-youth contract required ratio is
one-to-eight during daytime activities and one-to-twelve during nighttime. The program’s ratio
was observed throughout the annual compliance review week and found to be in compliance
with the contract’s requirements. The program has a daily schedule to be followed which is
posted and available to youth in each living unit/dormitory. Observations throughout the annual
compliance review week confirmed all youth were engaged in a full schedule of activities. Staff
were observed during school, recreation, line movements, and group therapy actively
supervising youth. On one day, youth were observed waiting to begin school. Some youth were
horseplaying, while others were submitting requests and conversing amongst each other. Staff
maintained the appropriate ratio while supervising youth. A video review of three nights
confirmed the staff observe youth in their rooms during sleep hours every ten minutes as
required.
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 detailed written description of the collaborative behavior management
system (BMS). The BMS is posted throughout the facility and is easily accessible to youth inside
of the youth handbook. The written description includes rules governing conduct and positive
and negative consequences for behavior including while in the classroom. The appropriate
parties were involved, including education, in the development, implementation, and on-going
maintenance of the BMS. The BMS did not change within the annual compliance review period.
A facility observation tour was conducted and found the BMS to be posted in the youth dorms
and the main hallway near the common area. Five youth case management records were
reviewed to confirm each youth’s orientation included a review of the program’s BMS. A review
of the BMS verified it included promoting safety, respect, fairness, promoting and protecting
youth rights, positive and negative consequences, constructive disciplinary/non-punitive actions,
opportunities for positive reinforcement, recognition of accomplishments and positive behaviors
at a four to one ratio, promoting socially acceptable means for youth to meet their needs, a
process for explaining to youth the reasons for any sanctions imposed, youth having the
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opportunity to explain to explain their behavior, opportunities for staff and youth to discuss the
impact of behaviors on others, reasonable reparations for harm caused to others, discussion of
alternate behaviors, promoting positive dialogue and peaceful conflict solutions, and separation
of youth from population is minimized. The BMS does not include increased length of stay,
denial of rights, promotion of group punishment, punishment of youth by other youth, or
disciplinary confinement. The program has a special provision in place to transport
parents/guardians to the program to visit youth. The program reported they have not had any
parents/guardians during the annual compliance review period who needed transportation
assistance. Five staff position descriptions were, reviewed and each included the BMS in the job
functions. Five pre-service staff training records were reviewed and each included
documentation staff were trained in the program’s BMS.
Five staff were interviewed, and all five were very familiar with the behavior management
system used at the program. Each understood the level expectations, time frames, and point
system. The five staff reported youth rewards include incentives for meeting goals, “pretties” or
tokens for doing the right thing, and a point store which contains upgraded hygiene items,
snacks, and group outings. All five staff confirmed basic rights cannot be taken away from youth
as a consequence. The interviewed staff explained youth are informed of the consequences and
are able to explain their behavior in emergency treatment team, conducted by the youth's
regular treatment team. The facility administrator was interviewed and confirmed staff use of the
BMS is monitored by consistency by supervisors and administration.
Four of five youth reported the consequences they can get are additional days added to their
treatment, restriction of privileges, writing sentences, and a program “re-start”. One youth added
youth are given boundary restrictions. All five youth said rewards for positive behaviors and
meeting goals include the point store, which has snacks, drinks, and upgraded hygiene
supplies, and off-campus outings. Three of the five youth reported staff are consistent in what
behaviors they give rewards and consequences to. Two of the five youth report some staff have
youth they favor over others. All five interviewed youth were very familiar with the level/point
system used at the program. Each youth was able to explain, in detail, each level’s expectations
and how to progress in the BMS. All five stated youth are never allowed to punish other youth.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, and provide constructive discipline. The program may use room restriction for major
infractions, temporarily restricting participation in routine activities by requiring the youth to
remain in his or her sleeping quarters.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
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The program has a written policy and procedures in place to conduct ten-minute checks while
the youth are in their sleeping rooms. The program’s policy states staff shall observe youth at
least every ten minutes while the youth are in their sleeping quarters. Staff shall conduct the
observation in a manner to ensure the safety and security of each youth and each observation
shall be documented in real time. The program has a total of fifty-eight operating cameras which
store recordings for thirty-days. Staff are required to conduct room checks every ten minutes
and document the time of the check on the ten-minute check log when youth are sleeping. A
review of nine samples of video footage in the program’s single dormitory confirmed staff
conducted checks as required and to fidelity.
A review of the ten-minute check logbook revealed checks are conducted every eight minutes.
One day of each month since the last annual compliance review were observed and confirmed
checks were conducted in real time, and staff observed youth for safety. All reviews were on B-
Shift due to this being the only shift which conducts ten-minute checks. Five interviewed staff
reported checks are completed every eight minutes when youth are in their rooms for sleeping
or non-punishment reasons.
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 for ensuring youth are always accounted for through
a system of physically counting youth at various times throughout the day and documenting
each count as well as a chronological order of events. The policy states youth counts should be
conducted during emergency situations such as escapes, riots, or in an event which disrupts the
safety and security of the program. The policy maintains a track record of the daily census
information which includes total daily census count, new admissions, releases or direct
discharges, transfers, and youth temporarily away from program. If staff are unable to account
for the whereabouts of youth, the program’s policy ensures the program will reconcile it
immediately. A review of one day each month since the last annual compliance review in the
facility logbook confirmed youth head counts were performed at the beginning of each shift,
after each outdoor activity, and during emergency situations. The logbook also documented
total daily census counts, head counts, youth movements, new admissions, releases or direct
discharges, transfers, and youth temporarily away from the program. During the annual
compliance review week, counts were observed during movements from the common area, to
and from the classroom, and to outdoor activities.
Five interviewed staff stated census counts are conducted hourly by master control, with some
informal counts conducted throughout the day. If the count cannot be reconciled, all five staff
reported youth are lined up in the hallway, the supervisor does a physical count of each youth,
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and a search will begin with available staff. All five staff responded emergency checks are
conducted after emergencies and drills.
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 to ensure the program maintains a chronological
record of events, incidents, and activities in a logbook located in master control. The program
ensures the logbooks are bound with numbered pages. Some pages in the logbooks reviewed
during the annual compliance review week displayed pages stapled together and some ripped
slightly. Pages were numbered consistently with no missing pages.. A couple mistakes were
scratched out and uninitialed, the remaining were crossed out with a single line and initialed by
the staff making the entry. There were no erasures or white out areas. All entries included the
dates and times of the events, with the names of the staff and youth involved, brief description
of the events, and the names and signatures of staff making the entries. The logbook indicated
activities are held as scheduled. A review of the logbooks found the program documented
incidents which included the use of medical restraints, special instructions for monitoring youth,
population counts at the beginning, during, and end of shift, perimeter security checks,
transports away from facility including the names of staff, youth, and destination, and admission
and releases, including the name, date, time of anticipated arrival or departure, and mode of
transportation. Information from the logbook is reviewed during the beginning of each shift and
staff document their review. All incidents reported to the Department’s Central Communication
Center (CCC) were documented in the logbook as required.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures in place to maintain key control and security which
consists of key assignment, inventory, tracking, and storage of keys. The policy includes the
protocol for addressing missing or lost keys, and reporting and replacing damaged keys.
Observations conducted during the annual compliance review week verified staff and visitors
submitted their personal keys to master control upon entering the program. The keys are then
stored in a locked wooden cabinet in master control along with program keys. Upon entry into
the program, staff exchange their personal keys for program keys based on their job function.
Staff sign the key logbook, enter the date, key ring number, and time the keys were taken. Upon
exiting the program, staff will enter the time and sign the key logbook indicating the keys were
returned. A review of the key logbook for the annual compliance review period verified this
procedure was followed. The program maintains a list of staff who are assigned permanent keys
authorized by the facility administrator. Permanent keys are issued following the staff approval
process and signed acknowledgement form indicating a key identification number and the
number of keys on the key ring. Damaged or lost keys are to be reported to the shift supervisor
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and a maintenance request is completed. The damaged keys are given to the maintenance
manager and staff are given new keys. There were not any incidents reported to the
Department’s Central Communications Center (CCC) or Program Monitoring and Management
(PMM) deficiencies related to key control concerns. An informal interview with the master
control operator was conducted and determined the process for restricting usage of keys such
as medical, youth and staff records, and youth property locker keys consists of each department
issues separate keys in order to gain access to certain storage areas. Five sets of keys were
observed and compared to the inventory and key log, with each matching. All three staff
informally interviewed knew the number of keys on their key ring and the function of each key.
Their responses were compared to keys observed in the key inventory with no discrepancies.
Five staff were interviewed. Each of the five staff reported their personal keys are securely
stored and they are given assigned program keys. Three of five staff mentioned there is a daily
tracking log and an inventory for keys, and two of the three staff said staff keys are given to
master control upon entry.
5.08 Contraband Procedures Limited Compliance
The program’s policy must address illegal contraband and prohibited items. A program shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect, any
controlled substance, any prescription or non-prescription drug which has a hypnotic,
stimulating, or depressing effect, any firearm or weapon of any kind or any explosive
substance, non-facility issued electronic equipment or devices to include smartwatches,
metals, personal non-facility issued cellular devices, unauthorized currency or coin(s), and
non-facility issued keys. The program shall provide youth with the list of contraband items and
materials and inform the youth of the consequences if found with contraband. The program
shall establish a system to prevent the introduction of contraband and identify contraband
items and materials through searches of the physical plant, facility grounds, and both staff
and youth. The program shall document the confiscation of any illegal contraband and the
manner of disposition. The program shall keep a copy of the documentation in the youth’s
case record. If a confiscated item is not illegal or prohibited, the facility administrator or
designee has the discretion to discard of the item, return it to its original owner, mail it to the
youth's home, or return it to the youth upon release. In all instances involving confiscation of
illegal or prohibited contraband, the program shall turn the item over to local law enforcement
and a criminal report must be filed.
The program has a policy and procedures to establish a system to prevent the introduction of
contraband which include all required items and outline the consequences for possessing
contraband as required by Florida Administrative Code. Youth are provided a list of items
considered to be contraband and the consequences of possessing contraband upon admission
in the youth handbook. Upon arrival to the program all visitors are required to sign a sign-in log
which includes a contraband attestation statement. Staff are required to sign attestation forms
acknowledging the contraband policy and the consequences up to and including dismissal,
upon hire. Twenty-two staff were hired during the annual compliance review period and each
staff signed a form as required. Logbooks and search reports were reviewed for the annual
compliance review period and found searches were conducted as required by policy; however,
no contraband items were found during the annual compliance review period. There were no
reported incidents to the Department’s Central Communications Center (CCC); however, during
the annual compliance review week, a visitor was reported to be in possession of a cellular
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telephone which was reported to the CCC and an investigation initiated, which included findings
of a staff not conducting a proper search on the visitor. The facility administrator was
interviewed and reported there are contraband notices posted throughout the facility, staff
conduct searches of youth and youth rooms, and staff are notified of the contraband policy upon
hire. If contraband is found, disposal is conducted in accordance with the program policy and all
illegal contraband turned over to law enforcement. Five interviewed staff each reported
supervisors search youth rooms daily and document the outcome on the search log.
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 written policy and procedures to perform searches to prevent contraband
from entering the program. Searches are conducted according to Florida Administrative Code at
the time of admission, before and after off-campus activities, visitation, and randomly. All
parents/guardians are notified of searches during visitation by way of the parent/guardian intake
letter, which is sent at the time of each youth’s admission. All youth are searched before all
movements, during a new admission, returning from visitation, returning from off campus
activities or appointments, when there is suspicion of contraband, or when a youth is identified
as a security risk. During the annual compliance review week, youth searches were performed
by staff of the same gender in a respectful manner, thoroughly, and in accordance with the
Right Interactions (RI) manual. There were no transports, visitation, or off-campus activities
during the annual compliance review week to observe. During observation of video, five staff
and visitors were observed being searched completely by same gendered staff, upon entering
program. Five interviewed staff reported youth searches are conducted prior to all movements.
All five interviewed youth advised searches are conducted each time movement occurs.
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 in place to ensure any vehicles used by the program
to transport youth are properly maintained and inspected for safety. The program has two vans
to transport youth. Both vans received an annual safety inspection which was documented in
the vehicle logbook. Maintenance records for both vehicles were documented. Both vans were
observed during the annual compliance review week and found each vehicle to be secured and
include a fire extinguisher, approved first-aid kit, seatbelt cutter, window punch, and appropriate
number of seatbelts. Both van doors accessible to the youth passenger area were unable to be
opened from the inside. Neither contained a safety screen; however, this is a non-secure
program. Nine vehicles including both vans were checked and confirmed vehicles are secured
when not in use.
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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 to ensure the staff-to-youth ratio is maintained while
youth are outside of the program to provide safety and security of youth, staff, and the public. A
ratio of one-to-five, not including the driver, is used during all transports. During the annual
compliance review week, no transports were conducted. An informal interview with the human
resources staff advised all staff are to possess a valid driver's license. Four of five interviewed
staff stated there is a transportation telephone given to staff prior to transporting youth. One
staff reported the transportation telephone is broken, so they have had to use their personal
cellular telephone when on a transport. The facility administrator confirmed they gave
authorization for staff on a transport to utilize their personal telephones until the program
telephones were fixed. Each of the five staff explained transporters bring a first-aid kit and a
“transport bag” containing other safety items and any required youth documents. All five staff
said transport vehicles are searched before and after each use and youth are not allowed to be
transported in personal vehicles. Four of the five staff relayed in case of an emergency on a
transport, they would notify the facility and contact law enforcement and/or emergency services,
if needed. One staff was not sure of the emergency response process, as they do not transport
youth. Four of the five staff were aware of the youth to staff ratio requirements for transports,
and one staff, who responded they do not do transports, stated they did not know. None of the
five interviewed youth stated they have been handcuffed to a transport vehicle, and none have
witnessed anyone placing contraband in a transport vehicle.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures which outline the audit/inspection process to include
who is responsible for conducting the weekly security audits and safety inspections, the
development and implementation of corrective actions warranted as a result of safety and
security deficiencies found during any internal or external review, audit, or inspection, and an
internal system to verify the deficiencies are corrected and existing systems are improved or
new systems are initiated. The facility administrator (FA), assistant facility administrator (AFA),
or designated staff are responsible for conducting the weekly security audits and safety
inspections. A review of the program’s preventative maintenance checklist confirmed
maintenance schedules and repairs were conducted as outlined in the Florida Administrative
Code. During an interview with the FA, the process of identifying and tracking safety and
security deficiencies was explained to include a weekly meeting with staff to discuss
surveillance video, radios/communication, keys/locks/doors, metal detectors, mechanical
restraints, sally port, transportation, youth rooms/living areas/bathrooms, classroom/education,
kitchen/dining room, grounds, exterior structure, perimeter fencing, chemicals and storage
areas, tool and sensitive item control, and their deficiencies. Any deficiencies will be reviewed
with the FA who will create a corrective action plan. Once corrected, the FA will approve the
deficiency to be removed from Safety and Security Audit document.
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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 regarding tool management to ensure youth do not
use tools or equipment as weapons or security breaches. The program’s policy and procedures
address the issuance, inventory, and control of equipment and tools. A tour of the facility
revealed all tools are secured when not in use and marked for identification. The tools in the
maintenance office were reviewed. Ten reviewed tools were secured properly, individually
marked for easy identification, and had an accurate inventory. The tool inventory logbook
located in the maintenance office displayed tools being checked in and out accurately. A review
of the tool inventory logbook located in the laundry room revealed tools are inventoried daily.
The program maintains a locked box in the kitchen which contains knives, pitch forks, and pizza
cutter. Machetes, bowie knives, or other long blade knives are prohibited. In the event a tool is
broken or non-operational, the maintenance manager is immediately notified and is responsible
for replacing the broken tool. There were no dysfunctional tools on-site at the time of the annual
compliance review. If a tool is missing, administration is immediately notified by staff, the
program will stop all youth movement, and the program will be searched until the tool is found. A
review of the tool inventory list found the tools were inventoried as required.
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 to ensure youth supervision requirements while
handling tools are maintained and address all required elements. The facility administrator
advised youth do not use tools while admitted at the program; therefore, youth are not assessed
for tool usage or trained in the use of tools. Each of the five interviewed youth reported they are
allowed to use scrub brushes, mops, and brooms. One youth disclosed they may be allowed to
use a rake to help with yard clean-up. Five interviewed staff reported youth are only allowed to
use scrub brushes, mops, and brooms.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures to maintain guidelines required for outside
contractors regarding tool control and restrictions. The program’s policy states it is the
maintenance manager and facility administrator’s (FA) responsibility to monitor the use of tools
and equipment in the facility. The plant manager contacts contractors when a repair is needed.
The program has procedures in place when a repair person or other external worker with tools
arrive on-site. The program advises them of the guidelines for worker tools which include tools
are to be checked upon arrival and departure, tools restrictions are initiated while in the facility,
youth are restricted from the work area, and if a tool is missing, there will be a follow-up. Upon
arrival, contractors are also instructed to sign in and out of the facility on a separate contractor
visitor log and sign an agreement form confirming the awareness of items which are
unauthorized. The FA or designee must approve of any unauthorized items needed by the
contractor. During the annual compliance review week, three invoices were reviewed and
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compared to the contractor visitor log. The contractors’ names, signatures, and tool count were
all documented appropriately.
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 in place to prepare youth and staff for immediate
implementation or mobilization in the event of an emergency or disaster. The program conducts
medical, fire, safety, and evacuation drills on a monthly rotating basis. During the annual
compliance review week, a review of the drill logbook confirmed Continuity of Operations Plan
(COOP) drills are performed at least once a month on each shift as required. Each recorded drill
contained the type of drill, date and time, participants, brief scenario, and findings and
recommendations. While on a program tour, fire evacuation routes and egress plans were
posted throughout the facility. Five fire extinguishers were present at the facility. The facility
administrator (FA) advised drills are conducted at least once a month on each shift. The
program conducts drills which include riots and other major disturbances, hurricane or other
severe weather/evacuation, fire, hostage situations, escape drills, bomb threats, chemical spills,
flooding, and terrorist threats/acts. Each of the five interviewed staff recounted having
participated in fire drills in the last twelve months. Four of the five reported being in suicide drills,
one staff said they had completed an evacuation drill, one staff said medical drills, and one staff
could recall an escape drill. All five interviewed youth stated they have been instructed on what
to do in case of a fire, and each reported they have participated in monthly or more frequent fire
drills.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program has a Disaster and Continuity of Operations Plan (COOP) approved by the
Department to ensure youth receive basic care and custody in the event an emergency or
disaster occurs. The plan was reviewed and update on April 17, 2024, and approved by the
department on April 29, 2024. The plan addresses alternative relocation sites approved by the
applicable Department regional director or designee. The plan is posted and readily available in
the facility administrator’s office, master control, and training officer’s office. Emergency
equipment and supplies include lock box of records, medications, first-aid kits, food, water,
toiletries, clothing, mattresses, and blankets. The program reported in the event of an
emergency, records are kept in a lock box and brought to the evacuation site. Five youth
emergency records were reviewed and each included all required and applicable information.
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5.18 Storage, Inventory, and Disposal of Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The facility administrator or designee shall maintain strict control of flammable, poisonous,
and toxic items and materials and a complete inventory of all such 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 to ensure strict control of flammable, poisonous and
toxic items and materials. All chemicals entering the facility must be approved and be
maintained in a safe and secure manner. It is the responsibility of the maintenance manager,
under the supervision of the assistant facility administrator (AFA) and facility administrator (FA),
to maintain a monitoring system to ensure overall compliance with the flammable, poisonous,
and toxic control program. During a tour of the facility, flammable, poisonous, and toxic items
and materials were found to be securely stored. Supervisors, the FA, and the maintenance
manager are authorized to handle these items.
An informal interview with the maintenance staff confirmed the program has a procedure to
inventory all items and to maintain a Safety Data Sheet (SDS) for each item. A SDS is located
inside the laundry room and kitchen for each material corresponding to the SDS. The laundry
room inventories were compared with the actual items at the program and there were no
missing or additional items on the inventory. The chemical inventory logbook located in the
kitchen was compared to actual items at the program and there were no missing or additional
items inventoried. During the annual compliance review week, seven stored chemicals were
reviewed, and all were inventoried, had an accompanying SDS, and secured. The program’s
policy includes a provision for chemical spills which includes all required elements.
The FA advised during an interview the responsibility of the maintenance manager consists of
maintaining inventories for all hazardous items in the facility. Items identified as such are to only
be drawn by an authorized person to include the facility manager, facility administrator, assistant
facility administrator, shift leader, and the cook. Youth are not allowed to handle these items and
they do not have access where these items are being used and/or stored. Cleaning products
are securely stored in areas throughout the program. A Safety Data Sheet (SDS) binder is
located inside the closet with a picture and description of each material corresponding to the
SDS. The program did not have any chemicals they needed to dispose of during the annual
compliance review period and all wastewater is disposed through the plumbing drains.
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).
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The program has a policy and procedures to ensure youth shall not be permitted to handle
flammable, poisonous, toxic items and materials and prohibited where these items are being
used and stored. Youth are not permitted to clean, handle, or dispose of any person’s bio-
hazardous material, bodily fluids, or human waste. Youth were not observed during daily
cleaning activities. Five interviewed youth report they do not handle chemicals, however, wipe
down surfaces after staff have sprayed the cleaner.
5.20 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.
5.21 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a policy and procedures in place to allow visitation and communication for
youth while in the program and provide youth, staff, and visitors with a safe environment. The
policy ensures youth may receive approved visitors except where there is documented evidence
the visitor poses a threat to the safety and security of the program. Youth are offered telephone
calls on a weekly basis and may earn extra time. Youth can receive unlimited mail from
parents/guardians and other authorized individuals. The visitation schedule is posted throughout
the facility on the daily schedule. Visitation is conducted on Saturday’s between 12:00 p.m.
through 2:00 p.m. Youth are given the opportunity to communicate with family members by mail
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and telephone. For youth with a history of human trafficking, the Human Trafficking Service
Coordinator Assignment forms are sent to the youth’s juvenile probation officer (JPO)
concerning the situation. The form is sent back to let the program know if everyone is clear.
Incoming and outgoing mail is searched in the presence of the youth. A translator is provided
upon request in the event a language translation service is needed.
All five interviewed youth stated they can call their parent/guardian or send a letter. The facility
administrator advised all incoming and outgoing letters and packages are inspected for
contraband and monitored in the presence of youth to detect information which could present a
threat to the security or safety of the program. The process includes all envelopes used for
outgoing mail to be reviewed by staff to ensure obscene writing, illegal activity, gang related
slogans or signs, and inappropriate content or material which may contribute to a breach in
security are not present. If correspondence is read, the youth must be present when the letter is
opened. If any suspicious substance is seen coming out of an opened envelope, the program
must remove all youth and staff from the area and dial 911. Incoming and outgoing letters may
be held by the program for no longer than twenty-four hours, and packages for no more than
forty-eight hours, excluding weekends and holidays. Mail is withheld or rejected if the mail is
knowingly inappropriate, has any obscene writing, illegal activity, or gang related slogans and
signs present, or at the request of the courts or the referring agent. Mail withheld by staff for any
reason is placed in the youth's personal effects until the youth is released, or returned to the
sender. When correspondence is withheld or returned, the youth is notified. If any contraband is
found, the letter and its contents should be directed to the facility administrator or program
manager for disposition. Youth send sealed letters to a specified class of persons and
organizations. Privileged mail is searched for contraband only, not for written content. Privileged
correspondence is opened in the presence of the case manager to communicate any court
dates or necessary information.
5.22 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has written policy and procedures which provides a variety of recreation and
leisure activities to the youth. The daily activity schedule documents a range of supervised and
structured indoor and leisure activities for youth at least one hour daily. Indoor and outdoor
activities do not involve large muscle activity. A review of the logbook confirmed recreation was
conducted as scheduled. The program promotes social and cognitive skill development,
creativity, teamwork, healthy competition, mental stimulation, and physical fitness. During the
annual compliance review week, youth were observed doing yoga, jogging, and playing cards.
Five interviewed youth reported the youth get at least one hour of recreation time where they
play volleyball, kickball, and capture the flag. The youth also get to paint, crochet, and
participate in Zumba classes. Five interviewed staff stated youth are given an hour or more of
recreation time every day. The staff communicated youth participate in kickball, volleyball,
crafts, crochet, and painting during this time.
5.23 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedure, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
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5.24 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedure, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The facility administrator or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedure, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 64 of 64 (Revised September 2022)

report_type: QI Residential

file_name: Alachua Academy-FINAL-FY2425.pdf

rule: Indicator 5.08

excerpt: Contraband Procedures

rating: Limited Compliance