summary: QI Residential - FY23-24 - 1 finding

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Juvenile Unit for Specialized Treatment (JUST)
Twin Oaks Vocational Academy II (TOVA II)
Twin Oaks Juvenile Development, Inc.
(Contract Provider)
29841 Liberty Wilderness Road
Sumatra, Florida 32335
Review Date(s): January 16-19, 2024
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Ken Phillips, Office of Accountability and Program Support, Lead Reviewer ([Standard 1])
Diwon Barron, Crestview Youth Academy, Facility Administrator (Standard 5)
Patrick Brock, Office of Education, Education Coordinator (Standard 2 – Education Indicators)
Greg Brown, Circuit 1 Probation, Juvenile Probation Officer (Standard 2)
Jessica Gibson, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Leann Gruentzel, Office of Accountability and Program Support, Deputy Regional Supervisor
(Standard 3)
Lea Herring, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Patrick McKinstry, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Stephanie Solano, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Program Name: JUST/TOVA II MQI Program Code: 1086
Provider Name: Twin Oaks Juvenle Development, Inc. Contract Number: 10696
Location: Liberty County / Circuit 2 Number of Beds: 44
Review Date(s): January 16-19, 2024 Lead Reviewer Code: 145
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
1.13 Internal Alerts System and Alerts (JJIS)*
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 79 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Non-Applicable
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Limited
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board Satisfactory
1.16 Staff Performance Satisfactory
1.17 Special Contract Conditions Satisfactory
1.18 Contract Specific Career and Technical Education Services Satisfactory
1.19 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 4 of 79 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Satisfactory
2.08 Youth Needs Assessment Summary (YNAS) Satisfactory
2.09 Performance Plan Development, Goals and Transmittal * Satisfactory
2.10 Performance Plan Revisions Satisfactory
2.11 Performance Summaries and Transmittals Satisfactory
2.12 Parent/Guardian Involvement in Case Management Services Satisfactory
2.13 Incorporation of Other Plans Into Performance Plan Satisfactory
2.14 Treatment Team Members and Meetings (Formal and Informal Reviews) Satisfactory
2.15 Transitions Planning, Conference, and Community Re-entry Team Meeting (CRT) Satisfactory
2.16 Exit Portfolio Satisfactory
2.17 Exit Conference Satisfactory
2.18 Youth Input Satisfactory
2.19 Career Education Satisfactory
2.20 Educational Access* Satisfactory
2.21 Education Transition Plan Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 5 of 79 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Satisfactory
3.04 Mental Health and Substance Abuse Admission Screening Satisfactory
3.05 Mental Health and Substance Abuse Assessment/Evaluation Satisfactory
3.06 Mental Health and Substance Abuse Treatment* Satisfactory
3.07 Treatment and Discharge Planning * Satisfactory
3.08 Specialized Treatment Services* Satisfactory
3.09 Psychiatric Services * Satisfactory
3.10 Suicide Prevention Plan * Satisfactory
3.11 Suicide Prevention Services * Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Non-Applicable
3.18 Safety Planning Process for Youth Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 6 of 79 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 7 of 79 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction Satisfactory
5.04 Ten Minute Checks * Satisfactory
5.05 Census, Counts, and Tracking Satisfactory
5.06 Logbook Entries and Shift Report Review Satisfactory
5.07 Key Control* Satisfactory
5.08 Contraband Procedure Satisfactory
5.09 Searches and Full Body Visual Searches Satisfactory
5.10 Vehicles and Maintenance Satisfactory
5.11 Transportation of Youth Satisfactory
5.12 Weekly Safety and Security Audit Satisfactory
5.13 Tool Inventory and Management Satisfactory
5.14 Youth Tool Handling and Supervision Satisfactory
5.15 Outside Contractors Satisfactory
5.16 Fire, Safety, and Evacuation Drills Satisfactory
5.17 Disaster and Continuity of Operations Planning (COOP) Satisfactory
5.18 Storage and Inventory of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.19 Youth Handling and Supervision of Flammable, Poisonous, and Toxic Items and Materials Satisfactory
5.20 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.21 Elements of the Water Safety Plan, Staff Training, and Swim Test * Non-Applicable
5.22 Visitation and Communication Satisfactory
5.23 Recreation and Leisure Satisfactory
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
5.25 Controlled Observation Non-Applicable
5.26 Controlled Observation Safety Checks and Release Procedures Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a
program operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these
indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention,
residential, probation).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 8 of 79 (Revised September 2022)
Program Overview
The Juvenile Unit for Specialized Treatment (JUST) program is a thirty-two bed program, for
thirteen to seventeen year-old males, and Twin Oaks Vocational Academy (TOVA) II is a
twelve-bed program, for ten to thirteen-year-old males, located in Sumatra, Florida. Both
programs are operated by Twin Oaks Juvenile Development, Inc., through a contract with the
Department. Both programs provide intensive mental health services to youth in the program
and offer the Impact of Crime (IOC) curriculum, Skillstreaming the Adolescent, The Council for
Boys and Young Men, Trauma Affect Regulation: Guide for Education and Therapy (TARGET),
and Life Skills. The youth at the programs also have an opportunity to participate in Boys and
Girls Club and community projects. Additional treatment services provided include Mental
Health Overlay Services (MHOS), individual, family, group, and recreational therapy. Program
administration is comprised of a program director, assistant program director, training
coordinator, administrative assistant, and shift supervisors. Direct care services were operating
on two twelve-hour shifts at the time of the annual compliance review. Case management
services are provided by a transition therapist and three case managers. Mental health staff at
the program include a licensed mental health counselor who serves as the program’s
designated mental health clinician authority (DMHCA) and six non-licensed therapists. Medical
services are offered from 10:00 a.m. until 6:00 p.m. Monday through Friday, 9:45 a.m. until 3:30
p.m. Saturdays, 9:45 a.m. until 6:30 p.m. on Sundays, and as needed. Medical services are
provided by a medical doctor who serves as the program’s designated health authority (DHA),
two registered nurses, one of which serves as the health service administrator (HSA), and one
licensed practical nurse. Educational services are provided by the program with one teacher
and two vocational instructors. The program is located in the Apalachicola National Forest which
spans 560,000 acres. The program’s administration building is centrally located in the program
and consists of administrative offices, case managers offices, and mental health staff offices.
Another building has the medical clinic and dining tables for youth. Another portable on-site has
two classrooms and a teacher’s office. The program has an area in the back where vocational
classes are located, and another structure on the property where agriculture classes, including
animal care and aquaponics are conducted. The program has forty-six cameras, each of which
were operational. At the time of the annual compliance review, the program director reported
having one mental health therapist vacancy.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 79 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program completed the Annual Affidavit of Compliance with Level 2 Screening Standards
which was sent to the Department’s Background Screening Unit (BSU) on January 2, 2024. The
program reported having had no contracted and grant recipient volunteers, mentors, or interns
for the scope of the annual compliance period who interacted with youth on an intermittent
basis for less than ten hours a month and required background screening. Based on the
provided staff roster/hire date information, the program had a total of twenty employed staff who
were hired during the annual compliance review period and required a background screening.
All twenty personnel records were reviewed, and confirmed each staff had a completed
background screening prior to their date of hire. Criminal history report information was
reviewed for each staff and none were rated as ineligible for hire. The program provides the
Diana Screening instrument for each new hire, regardless of the position they are being hired
for. Based on the records reviewed, all twenty had a completed screening, which included their
passing score, which was noted in the records. The program added the staff to their
Clearinghouse employment roster.
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 in place where all staff are required to receive a
background re-screening every five years from their initial date of hire. A review of the staff
roster found two staff were applicable for a five-year re-screening. Both personnel records had a
completed five-year re-screening as required. Each was submitted to the Department’s
Background Screening Unit (BSU) at least ten business days prior to the five-year anniversary
date.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 79 (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 which encourages an environment in which
youth, staff, and others will feel safe, secure, and not threatened by any form of abuse or
harassment. The policy indicates all allegations of child abuse or suspected child abuse shall be
reported immediately to the Florida Abuse Hotline. A review of ten staff personnel records found
evidence all ten staff signed a receipt for the program’s policies and employee handbook which
outline their code of conduct. Observations made throughout the annual compliance review
week found postings of the Florida Abuse Hotline, Prison Rape Elimination Act (PREA)
emergency number, and the Department’s Central Communication Center (CCC) hotline
number throughout program areas. The program provided documentation of their completed
Trauma Responsive and Caring Environment (TRACE) self-assessment, completed June 30,
2023. According to the program director, the program had one incident related to physical,
psychological, and emotional abuse for the scope of the annual compliance review period.
According to the program director, the incident is still under investigation with the Department’s
Inspector General; however, according to Employee Maintenance Form records obtained, the
staff in question has been terminated effective December 6, 2023. The incident was reported to
the CCC.
The program’s policy and procedures outline the steps for abuse reporting which include
unhindered access for youth and staff to make the report of allegations without obtaining
permission. The first person to witness or have knowledge of the incident shall report abuse as
soon as possible and request the name and identification number of the operator receiving the
abuse call. The reporting person shall complete an internal incident report and record the call in
the Abuse Call Log located in the supervisor office. The supervisor will notify the program
director of the incident and call.
Six youth were interviewed and all reported feeling safe in the program. None of the interviewed
youth reported ever being denied a call to the Florida Abuse Hotline or CCC. Youth stated the
emergency hotline telephone numbers are posted in the program, or they can go to staff to ask
them the numbers. Five of the six youth stated staff are respectful when talking with them and
other youth. One youth stated they are sometimes respectful, as they may be rude at times.
When asked if they have heard staff cursing or threatening them or other youth, four of six youth
reported never, one stated once, and one youth stated occasionally. Those youth who reported
once and occasionally stated this is when they were overheard talking with other staff or during
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 79 (Revised September 2022)
a serious situation. None of the six interviewed youth reported exchanging telephone numbers
or social information with a staff member. Six interviewed staff summarized the abuse reporting
procedures, stating they allow the youth to make the call, and notification is made to the
supervisor and program director. All six staff denied ever hearing a staff deny a youth the
opportunity to make an abuse report. Five of six interviewed staff reported never hearing
another staff threaten or curse at the youth. One staff reported this has happened in the past,
which was in March 2023, but the staff member in question is no longer employed at the
program. None of the interviewed staff could give the exact number for the Florida Abuse
Hotline; however, all were able to explain where the number is located in the program. The
program director was interviewed and outlined the program’s procedure for reporting and
responding to allegations of abuse and neglect.
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 reported having had one incident related to physical, psychological, and emotional
abuse for the scope of the annual compliance review period. According to the program director,
the incident is still under investigation with the Department’s Inspector General. There is
evidence management took immediate action to address the allegations made against the staff
member, and according to Employee Maintenance Form records obtained, the staff in question
had been terminated, with an effective date of December 6, 2023. The incident had been
reported to the Department’s Central Communications Center (CCC) by the program, and
currently remains under investigation with the Department.
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 eight reports made to the Department’s Central Communication
Center (CCC) for the of the annual compliance review week. This is a decrease in reports from
last year’s annual compliance review. A sample of five of CCCs were reviewed and found each
was reported within the two-hour timeframe as required. All five were notated in the program’s
master logbook. A review of internal incidents and grievances was completed and found none
contained evidence a call to the CCC was not reported as required; however, during an
interview with a youth based on follow-up discussion for a previous Crisis Assessment
completed, the youth made allegations of being touched inappropriately by another youth back
in August. The youth was afforded the opportunity to make a report to the Florida Abuse Hotline,
and thus a new CCC report was generated (CCC#202400327).
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Office of Accountability and Program Support Page 12 of 79 (Revised September 2022)
1.06 Protective Action Response (PAR) and Physical
Non-Applicable
Intervention Rate
The program uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is completed and filed in accordance with the Florida
Administrative Code.
There have been no Protective Action Response (PAR) incidents during the annual compliance
review period; therefore, this indicator is rated non-applicable.
1.07 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Residential contracted provider staff satisfies pre-service/certification requirements specified
by Florida Administrative Code within 180 days of hiring.
The program submitted their annual pre-service training plan to the Department’s Office of
Talent, Leadership, and Culture (TLC) on August 23, 2023. The training plan was signed by the
Department on August 23, 2023. A total of ten staff training records were reviewed for pre-
service training requirements. Each of the ten staff had over the required 120 hours of pre-
service training. Seven of ten were still within their 180 days from the date of hire. All ten staff
had the required essential stills completed, such as cardio-Pulmonary resuscitation (CPR), first
aid, automated external defibrillator (AED), child abuse reporting, emergency procedures,
facility operating procedures, Prison Rape Elimination Act (PREA), professionalism and ethics
training, Right Interactions, and suicide awareness and Prevention. Additional contractual
trainings and Department required trainings were all completed with the following exceptions:
One of ten staff did not have Balanced and Restorative Justice Training within their 180 days of
hire. The program’s training director was made aware of this, and the staff member completed
this training during the week of the annual compliance review. All training was documented
within the Department’s Learning Management System (SkillPro). Seven of the ten staff did not
have the Motivational Interviewing (MI) training. All seven of these staff were listed as within
their 180 days from hire. The program’s training coordinator provided email confirmation of the
MI training scheduled with the program by the Department staff for February 1, 2024, to ensure
all staff will participate in MI who have not yet received it.
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
The program submitted their annual in-service training plan to the Department’s Office of Talent,
Leadership, and Culture (TLC) on August 23, 2023. The training plan was signed by the
Department on August 23, 2023. A total of ten staff training records were reviewed for in-service
training requirements. Each of the ten staff reviewed had over the twenty-four required hours for
in-service training. Four of the ten staff reviewed were supervisory staff, and each had evidence
of the additional required eight annual hours of supervisory specific training in coaching,
leadership, and personal accountability. All mandatory topics were completed as required by
each of the ten staff reviewed. Additional trainings such as Exposure Control Plan, Blood-Borne
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Office of Accountability and Program Support Page 13 of 79 (Revised September 2022)
Pathogens training, Infection Control, and Emergency Response and Quarterly Emergency
Drills training was done for all ten staff reviewed, with one exception: five of ten staff did not
have documentation they participated in at least one quarterly suicide response drill for the
scope of the annual compliance review period; however, all ten staff did have evidence of
Suicide Prevention and Emergency Procedures Training notated within the Department’s
Learning Management System (SkillPro) as required. The program has an annual in-service
training calendar which is updated as changes occur. All instructors were qualified to deliver the
trainings provided, such as Right Interactions, first aid and cardio-pulmonary resuscitation
(CPR), automated external defibrillator (AED). Documentation of training certifications were
reviewed and confirmed. The program submitted their list of in-service trainings approved by the
Department’s regional director as required on December 20, 2023.
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 addressing grievances for youth. The program’s
policy does not reflect training requirements for all staff; however, based on a review of ten pre-
service training records, each of the ten staff had grievance training completed and documented
in the Department’s Learning Management System (SkillPro) as part of their pre-service training
requirements. The program’s grievance process has three Phases (informal phase, formal
phase, and appeal phase). In the informal phase (or phase I), the first step in the grievance
procedure must be personal contact. It is the youth’s responsibility to contact the person
involved and talk about the matter in a calm and polite way. If this conference does not resolve
the problem, the youth may request further assistance by moving on to the formal phase (or
phase II). The program reported and provided only one grievance for the scope of the annual
compliance review. The grievance was reviewed and found to have been signed by the youth
and resolved within one day at phase II of the process. Six interviewed youth all stated they can
ask for assistance in completing a grievance if necessary. Six youth were interviewed and
asked about the grievance process. One youth stated they were not certain of the process. The
remaining five youth were able to summarize the grievance process in stating grievances are
completed, they go to staff and if not resolved, they move forward to the program director.
Forms are placed throughout the program. Six interviewed staff also summarized the program’s
grievance process. The program director was interviewed and was able to explain the program’s
grievance process and each phase.
1.10 Interventions and Facilitator Training Satisfactory Compliance
The program shall implement interventions for each youth. Interventions shall include, but are
not limited to, evidence-based practices, promising practices, or practices with demonstrated
effectiveness. Staff whose regularly assigned job duties include the implementation of a
specific intervention and/or curriculum must receive training in its effective implementation.
The program provides interventions for each youth. The program has five masters-level
therapists who have received training in their assigned delinquency intervention model
facilitated. Interventions included Skillstreaming, Coping with Depression, Target group, and
Living in Balance. Each staff’s education and work experience were considered by the program
when determining staff delivery of the delinquency intervention services. All staff reviewed had
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Office of Accountability and Program Support Page 14 of 79 (Revised September 2022)
evidence of training in all groups they are facilitating. A review of the program’s group schedule
reflected the minimum number of groups were provided weekly as required. The program’s Twin
Oaks Vocational Academy (TOVA II) program provides Skillstreaming, Target group, and Coping
with Depression for their population. For the Juvenile Unit for Specialized Treatment (JUST)
program, the program facilitates Target group and Living in Balance curriculum. A review of sign-
in sheets and agendas was done and confirmed groups are being conducted. Group sizes did
not exceed the maximum number of participants, and groups were held for the correct duration.
All groups are provided as outlined in the contract table. The program’s activity schedule was
reviewed and determined the program is providing structured, planned programming activities
for at least sixty percent of the youth’s awake hours. The designated mental health clinician
authority (DMHCA) was interviewed and stated youth services are scheduled and prescribed
according to treatment plans. The program director was interviewed and was able to list each
staff member who has facilitated groups at the program within the last year, as well as provide
their group certification/training and level of education.
1.11 Life and Social Skills Training Provided to Youth Satisfactory Compliance
The program shall provide instruction focusing on developing life and social skill
competencies in youth.
The program has a policy and procedures in place to provide interventions and instruction to
determine how services are provided. The program’s life skill intervention is evidenced based.
The program’s Twin Oaks Vocational Academy (TOVA II) BSU program provides Skillstreaming,
Target group, and Coping with Depression for their population. The Juvenile Unit for Specialized
Treatment (JUST) program facilitates Target group and Living in Balance curriculum. The
program provides life and social skills intervention services which address communication,
interpersonal relationships and interactions, non-violent conflict resolution, anger management,
and critical thinking – to include problem-solving and decision-making. The program also
addresses the needs of the male gendered group through health, hygiene, the physical
environment, life and social skills training, and leisure and recreational activities. Skillstreaming
and Impact of Crime are also used in providing these services. Sign-in sheets were reviewed
which confirmed these groups are being conducted as required. In addition to life skills
intervention services, nursing provides health and hygiene training for youth. The program
director was interviewed and stated all youth are participating in groups. In addition, Boys
Council group was discontinued in January of 2024 in accordance with the Department’s
directive. The program director stated they utilize welding, carpentry, aquaponics, and Boys and
Girls Club and Department of Transportation (DOT) work crew which are all male gender
appropriate. Six interviewed youth all stated they are participating in life skills groups such as
Impact of Crime, Skillstreaming, mental health groups, regular counseling, Target group, anger
management, Boys Council, and Life Skills Training. The designated mental health clinician
authority (DMHCA) was interviewed and stated youth are provided opportunities to practice
skills they have learned in groups during and between groups, on and off campus, during group
in role playing and process discussions, as well as during family phone sessions, and
counseling sessions.
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1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program provides Restorative Justice Awareness for youth by providing Impact of Crime
groups, allowing youth to complete community service hours either on-campus or off-campus
doing various work projects, and with participation in the Florida Department of Transportation
(DOT) work crew. Restorative Justice activities are planned and designed to assist youth in
accepting responsibility for the harm they have caused, teaching youth about the impact crime
has on others, exposing youth to victims’ perspectives through victim speakers, in person or
recordings, and providing youth opportunities in reparation activities intended to restore victims
and communities, which are restitution activities and community service projects. According to
the daily schedule, mental health groups are held twice every weekday. Impact of Crime is
indicated as a primary service at the program. According to the designated mental health clinical
authority (DMHCA), the Impact of Crime group is a closed group which runs for sixteen weeks
and is facilitated twice a week. The program director stated restorative justice activities provided
for youth include community service activities on and off campus, DOT work crew, and
completion of sanctions. If youth have already completed the IOC curriculum. They can still
have opportunities for participating in community service projects and Pow Wow processing on
the dorms, as well as participation in mental health and substance use treatment groups as
prescribed/scheduled. Six youth were interviewed concerning which restorative justice groups
and activities they’ve participated in. The youth responses included games, drawing, coloring,
writing about how they feel, talking, reading about topics, and getting quizzed on them. Youth
stated also they have participated in community service projects, cleaning up around the
program and aquaponics, DOT, and Impact of Crime. When asked if they had practiced any
skills learned, two of six stated not yet. The other four youth gave examples such as
conversation starting, staying to themselves and not letting others get to them while learning
violence is not the answer to problems. One youth also stated they are learning coping, anger
management, and practicing triggers including how to stop and think to get through a situation.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Limited Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The program has a policy and procedures detailing their internal alert system to ensure the
communication of all medical, mental health, and security alerts and concerns of the youth are
disseminated throughout the program. A total of ten youth were reviewed for inputting of alert
information through the Department’s Juvenile Justice Information System (JJIS) and the
program’s internal alert system. Based on the sample size of ten youth, five from each program,
there were a total of twelve alerts combined, which were reviewed. Eight of these twelve were
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for youth assigned to the Twin Oaks Vocational Academy (TOVA II) program. The remaining four
alerts were for the Juvenile Unit for Specialized Treatment (JUST) program youth. All alerts
were documented in the logbook when applicable. All applicable alerts also matched the
program’s internal alert system. There were five exceptions identified. One exception was
identified for a youth assigned to the JUST program. This youth had an alert for Critical-
Impairment Vision. The alert begin date was listed as December 4, 2023, but was created
nineteen days later on December 23, 2023. The remaining four exceptions were identified with
the TOVA II program youth. One youth was identified as a medical grade five due to starting
psychotropic medication at the program. The youth was noted correctly on the internal alert
system, but did not have an alert for psychotropic medication in JJIS. The remaining three
exceptions had beginning dates which did not match the date created in JJIS. One was entered
five days late; one was eighty-four days late, and one was four days late. The program director
was interviewed and was able to define the program’s alert system which detailed identification,
inputting, and review of alerts. Six staff were interviewed and discussed ways they are informed
of youth alerts in the program. Staff gave examples of this notification such as shift briefings,
logbooks, email notification, shift change meetings, and meetings with the supervisors. The
program’s registered nurse was interviewed and stated the nurse is responsible for updating the
medical alert system as needed.
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 youth records in three binders: a mental health record an individual
healthcare record, and a case management record. Offices used to store youth records were
observed to be secured with locks on doors and doors marked ‘confidential’. Each individual
management record included all required information such as the youth name, Department’s
identification number, date of birth, county of residence, and committing offense. Each record
was marked ‘confidential’ and contained the following sections: Legal Information,
Demographics and chronological information, correspondence, case management and
treatment team activities, and miscellaneous information.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program conducts a community advisory board meeting at least quarterly as required.
Evidence of agendas and listing of participants was observed and found meetings for the scope
of the annual compliance review were conducted on June 6, 2023, September 2, 2023, and
December 5, 2023. The program director reported these meetings are held using Skype.
Solicitation for active involvement was observed for all required community advisory
participants. The program director also had documentation of recruitment for a victim advocate
and parent/guardian whose child was previously involved in the juvenile justice system. The
program director reported they contact members by telephone to announce the meeting dates.
The program director reported the next scheduled meeting will be held March 7, 2024.
According to the program director and documentation of letters sent, they have attempted to
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gain the participation of a local judiciary representative but have been unsuccessful at this time.
A face-to-face interview with a board member was done during the annual compliance review
week. The member confirmed they are notified of the meetings through email and at times in
person. They stated they participate regularly and enjoys participation. She stated having no
issues with the meetings and confirmed they meet around every other month, or quarterly.
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 in place ensuring a system which provides for
effective staff communications, annual evaluation of job performance, and staff retention. The
program’s policy indicates employees are evaluated on an annual basis. A review of ten
personnel records found nine of ten had an evaluation completed annually and for the scope of
the annual compliance review period. The evaluations were signed by the supervisor and
employee. One of the ten did not have the evaluation completed the previous year as required.
The staff was a part-time team leader and transport officer. The program director completed the
annual evaluation for this staff during the annual compliance review week. Performance
standards matched job descriptions for all ten personnel records reviewed. Staff performance
standards were clearly identified. According to the provider’s contractual agreement, and an
interview with program administration, all specific contractually required positions were
maintained and outlined as performed in the contract. Four of six interviewed staff reported
communication at the program was good. Two of six reported communication was very good.
When asked how often staff receive performance evaluations at the program, one staff stated
monthly, three stated annually, one stated every couple of months, and one staff responded they
did not remember. The program director was interviewed and stated performance evaluations
are completed annually by supervisors.
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 provides the following pre-vocational and vocational programs: Carpentry;
Welding, Introduction to Agriculture, Food and Natural Resources, and Career Planning
(supported by partnerships with the Boys and Girls Club and the Aquaponics program); and Day
trips in the National Forest. Youth participate in hands-on trade specific projects and job
shadowing events. Community service projects align with the vocational training curriculum,
including County Commission Clean-up Day, Coastal Clean-up, building wheelchair ramps,
building tables for the elementary school, and working with the Veterans Memorial Railroad.
Aquaponics is provided to the Twin Oaks Vocational Academy (TOVA II) youth. The youth must
reach a certain level within the program to participate in Aquaponics and gardening. The youth
reported during interviews of participation in these activities, as well as observations of this
within their performance plans reviewed. Welding and Carpentry programs are offered to the
Juvenile Unit for Specialized Treatment (JUST) program youth. Youth interviews and
observations of performance plans supported their participation in these programs. Other
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contract requirements include provision of weekend visitation as well as the provision of Skype
sessions in lieu of visitation if needed. Based on review of logbooks for the scope of the annual
compliance review, visitation is taking place regularly as scheduled. The program director
reported Skype was not needed for visitation during the scope of the annual compliance review
period; however, Skype was used during treatment team meetings with parent/guardian
involvement. Youth may participate in church services weekly on-site and have the opportunity
to attend off-site services. According to the program director, services and literature are
provided by the Christian Motorcycle Association who has provided religious services, bible, and
other Christian oriented material. Religious and spiritual preferences are documented on each
Youth Needs Assessment located in their individual management record. Five of six interviewed
youth all confirmed they have participated in activities and programs such as Boys and Girls
Club, Carpentry, Sports, Aquaponics, Florida Ready to Work, Gardening, and animal care. One
youth stated they have not been able to participate yet.
1.18 Contract Specific Career and Technical Education
Satisfactory Compliance
Services
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), Special Conditions, or older contracts may not have them clearly identified as a
special condition. Career and technical education service instruction shall be provided so the
interests, aptitudes, and skills of the youth are developed, while building upon their existing
strengths, in a manner supportive of their employability goals which provide an occupational
advantage and workforce readiness in their community. These items may exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code.
The provider’s contract lists career and technical education services to be provided, such as
pre-vocational and vocational services which include carpentry, welding, agriculture, and day
trips to the national forest area. The program director stated all youth in the program participate
in a vocational program. Twin Oaks Vocational Academy (TOVA II) youth are able to participate
in the Department of Transportation (DOT) work crew program and aquaponics through the
Boys and Girls Club. The Juvenile Unit for Specialized Treatment (JUST) program youth
participate in carpentry and welding. Due to the low census numbers for the annual compliance
review week, the program director reported only one youth has received their certification, which
was in carpentry. Career and technical education services are provided according to the
program’s posted daily activity schedule. All instructors are certified by the local school district.
The welding and agriculture instructors have certifications through June of 2027. The carpentry
instructor’s certification expires in June of 2025. All career and technical education services
provided by the program are appropriate for the abilities and goals of the youth in the program
and are appropriate for their length of stay and classification. Observations made during the
annual compliance review week found staff were performing searches of youth after
participation in career and technical education activities. Youth were observed being pat-
searched and searched using a handheld metal detecting device. Six interviewed youth
reported they participate in various career and technical education services such as Florida
Ready to Work, Boys and Girls Club, and carpentry. Youth stated they participate daily in these
activities.
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1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a policy and procedures referring to the Trendstat process, which monitors the
operations and risk management of programs through a monthly quality improvement process.
Through the Trendstat process, data is collected, analyzed, and is submitted monthly to the
corporate leadership team. Data elements include, but are not limited to, number of restraints,
incidents, abuse calls, medication errors, status of corrective actions, staff training and
development, overtime, staff injuries, and other risk management issues The program director
provided documentation showing the correspondence was submitted to corporate leadership
through email notification. The program director also facilitates a monthly call with the chief
operations officer to discuss all the areas covered. In addition, a yearly analysis graph is
developed to compare the program with other state averages of other facilitates. In addition,
program issues are discussed at community advisory board meetings, which are conducted
quarterly. Attendance rosters and agendas were reviewed which confirmed this practice.
Monthly Trendstat report data was observed posted in the administration building next to the
employee time clock, which ensured all employees were able to review the information as
needed each day.
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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.
Juvenile Unit for Specialized Treatment
The program has a policy and procedures outlining the process to ensure the youth’s
parent/guardian is notified by telephone within twenty-four hours of admission. The policy and
procedure included the requirement of the parent/guardian notified in writing within forty-eight
hours of admission. Five youth case management records were reviewed for initial contacts to
parent/guardian and court notification. All five case management records included
documentation the program notified the parents/guardians by telephone within twenty-four hours
of admission. There was evidence in all five records the program notified the parents/guardians
of the youth admission in writing within forty-eight hours of admission. The court, juvenile
probation officer, and post-residential services counselor were notified within five working days
of the youth admission.
Twin Oaks Vocational Academy II
The program has a policy and procedures outlining the process to ensure the youth’s
parent/guardian is notified by telephone within twenty-four hours of admission. The policy and
procedure included the requirement of the parent/guardian is notified in writing within forty-eight
hours of admission. Five youth case management records were reviewed for initial contact with
parent/guardian and court notification. All five case management records included
documentation the program notified the parents/guardians by telephone within twenty-four hours
of admission. There was evidence in all five records the program notified the parents/guardians
of the youth admission in writing within forty-eight hours of admission. The court, juvenile
probation officer, and post-residential services counselor were notified at or within the required
timeframe.
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.
Juvenile Unit for Specialized Treatment
The program has a policy and procedures outlining the process which details the youth’s
orientation into the program. Five youth case management records were reviewed for youth
orientation documentation, which includes: services available, daily schedule, expectations and
responsibilities of the youth, written behavior management system, availability of and access to
medical and mental health and substance abuse services, access to the Florida Abuse Hotline
or the Department’s Central Communications Center(CCC), the program’s zero-tolerance policy
regarding sexual misconduct and how to report incidents, special accommodations which are
available to ensure all written information about sexual misconduct policies, right to be free from
sexual misconduct, retaliation from for reporting misconduct, items considered contraband,
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performance planning process, dress code and hygiene practices, procedures on visitation,
mail, and use of telephone, expectations for release from the program, community access,
grievance procedures, emergency procedures, facility tour, and assignment to a living unit and
room. All five records included documentation the program conducted orientation on the day of
admission. An observation of a youth orientation was not observed due to the program not
having an admission during the annual compliance review week. A review of the program’s
orientation checklist was completed, and all required elements were included on the form.
Twin Oaks Vocational Academy II
The program has a policy and procedures outlining the process which details the youth’s
orientation into the program. Five youth case management records were reviewed for youth
orientation documentation, which includes all required elements. All five records included
documentation the program conducted orientation the day of admission. An observation of a
youth orientation was not observed due to the program not having an admission during the
annual compliance review week. A review of the program’s orientation checklist was completed,
and all required elements were included on the form.
Six youth were interviewed and all reported they received an orientation which explained
program rules, procedures, and schedules.
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.
Juvenile Unit for Specialized Treatment
The program has a policy and procedures for obtaining written consent from any youth
eighteen years of age or older. Five youth case management records were reviewed, and none
of the youth were applicable for being eighteen years of age or older. The program provided
three closed youth records to review for the written consent of eighteen years or older. All three
records included documentation the written consent of eighteen years or older was completed.
Twin Oaks Vocational Academy II
The program has not had any youth eighteen years of age or older during the annual
compliance review period; therefore, this indicator is rated non-applicable for Twin Oaks
Vocational Academy II.
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2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
Juvenile Unit for Specialized Treatment
The program has a policy and procedures which outlined the process for the classification
system to promote safety and security, delivery of treatment services, and addresses the items
outlined in Administrative Rule. The program’s policy states reassessments are done based on
the Residential Assessment of Youth (RAY) results and as the treatment team determines. A
review of the program’s classification documentation included all of the required elements. Five
youth case management records were reviewed for classification factors, procedures, and
reassessments. All five youth case management records included documentation of the initial
classifications for room assignment. Two of the five youth had suspected factors of suicide risk,
medical risk, and escape risk. Three of the youth had suspected risk factors for security risk
along with other factors. All five youth records included documentation the youth were classified
for purposes of assigning to a living area and sleeping room. A review of the Department’s
Juvenile Justice Information System (JJIS) alerts was completed. The alerts reviewed for the
youth included the appropriate information for two of three of the applicable youth. One youth
did not have a required alert entered timely. Two of the five youth were applicable for
classification re-assessments. Both youth records included documentation of the completed re-
assessments for an increase in youth’s privileges or freedom of movement, participation in work
projects and activities involving tools, and participation in off-campus activities.
Twin Oaks Vocational Academy II
The program has a policy and procedures which outlined the process for the classification
system to promote safety and security, delivery of treatment services, and addresses the items
outlined in Administrative Rule. The program’s policy states reassessments are done based on
the Residential Assessment of Youth (RAY) results and as the treatment team determines. A
review of the program’s classification documentation included all of the required elements. Five
youth case management records were reviewed for classification factors, procedures, and
reassessments. All five youth case management records included documentation of the initial
classifications for room assignment. A review of the Department’s Juvenile Justice Information
System (JJIS) alerts was completed. Applicable risk factors were reviewed for each youth.
Medical, mental health, substance abuse, and special needs factors were reviewed for each of
the five youth. Reassessments were completed for all five youth, which contained a review of
the increase in privileges or freedom of movement, participation in work projects, and off-
campus activities. There were no noted exceptions for classification and reassessments for
youth.
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The program director was interviewed and confirmed the classification form and process
included all requirements.
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.
Juvenile Unit for Specialized Treatment
The program maintains a policy and procedures regarding information on gang affiliated or gang
associated youth and sharing the information with law enforcement. Five youth case
management records were reviewed for gang identification and notification of law enforcement.
One of the five youth were applicable. The program gang liaison maintains a binder with all
documentation. Local law enforcement was notified. The notice was completed prior to the
seven-day notice for the annual compliance review. The youth’s home county law enforcement
and the local law enforcement were notified about the youth’s gang association. The gang alert
was not entered into the Juvenile Justice Information System (JJIS) upon identification. The
gang alert was added during the annual compliance review. The educational provider and
juvenile probation officer (JPO) were notified.
Twin Oaks Vocational Academy II
The program maintains a policy and procedures regarding information on gang affiliated or gang
associated youth and sharing the information with law enforcement. Five youth case
management records were reviewed for gang identification and notification of law enforcement.
None of the five reviewed were applicable. The program did not have any applicable youth for
gang notification during the annual compliance review period.
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.
Juvenile Unit for Specialized Treatment
The program maintains a policy and procedures on how to implement gang prevention and
intervention strategies. Five youth case management records were reviewed and one youth was
applicable. The program did not have any other youth identified as a gang member or
associates during the annual compliance review period. The one applicable youth was identified
as an affiliate of gang members. A review of the youth’s performance plan found relevant goals
and objectives related to gang intervention strategies and the youth is participating in gang
prevention and intervention strategies. The program’s gang intervention strategies implemented
are the gang liaison meeting monthly with the youth and the youth participates in Impact of
Crime groups. Impact of Crime groups are primary groups at the program and are reviewed by
the Programming and Technical Assistance Team. The program’s policy and procedures
address providing the youth with an opportunity, if they desire, to develop a plan to disaffiliate
with a criminal street gang.
Twin Oaks Vocational Academy II
The program maintains a policy and procedures regarding information on gang affiliated or gang
associated youth and sharing the information with law enforcement. Five youth case
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management records were reviewed for gang identification and notification of law enforcement.
None of the five reviewed were applicable. The program did not have any youth applicable for
gang intervention during the annual compliance review period.
The program director was interviewed and indicated the program’s policy and procedures
include gang prevention and intervention activities.
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.
Juvenile Unit for Specialized Treatment
The program has a policy and procedures for ensuring the initial Residential Assessment for
Youth (RAY) assessment and re-assessments are completed timely and maintained in the
Department’s Juvenile Justice Information System (JJIS). Five youth case management records
were reviewed for RAY assessments and re-assessments. All five case management records
included documentation the RAY assessments were completed within thirty days of admission
and were maintained in JJIS. One of the five youth was applicable for RAY re-assessments.
The other four youth had not been at the program long enough to receive a RAY re-
assessment. The RAY re-assessment was completed at least ninety-days after completion of
the initial RAY assessment. No other updates were deemed necessary. All RAY re-assessment
documentation was maintained in the youth’s official case record.
Twin Oaks Vocational Academy II
The program has a policy and procedures for ensuring the initial Residential Assessment for
Youth (RAY) assessment and re-assessments are completed timely and maintained in the
Department’s Juvenile Justice Information System (JJIS). Five youth case management records
were reviewed for RAY assessments and re-assessments. All five case management records
included documentation the RAY assessments were completed within thirty days of admission
and were maintained in JJIS. All five reviewed youth were applicable for RAY re-assessments.
The RAY re-assessments were completed at least ninety-days after the initial RAY assessment
was completed for each youth. All applicable updates were completed as required. All RAY re-
assessment documentation was maintained in the youth’s official case record.
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2.08 Youth Needs Assessment Summary (YNAS) Satisfactory Compliance
The program shall ensure a Youth Needs Assessment Summary (YNAS) of each youth is
conducted within thirty days of admission. The program shall maintain all documentation of
the initial assessment process in JJIS on the YNAS.
Juvenile Unit for Specialized Treatment
The program maintains a policy and procedures to ensure the Youth Needs Assessment
Summary (YNAS) reports are completed timely. Five youth case management records were
reviewed and all five confirmed the YNAS was completed within thirty days from admission. All
YNAS documentation was maintained in the Department’s Juvenile Justice Information System.
Twin Oaks Vocational Academy II
The program maintains a policy and procedures to ensure the Youth Needs Assessment
Summary (YNAS) reports are completed timely. Five youth case management records were
reviewed and all five confirmed the YNAS was completed within thirty days from admission. All
YNAS documentation was maintained in the Department’s Juvenile Justice Information System.
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.
Juvenile Unit for Specialized Treatment
The program maintains a policy and procedures for performance plan development, goals, and
transmittals are developed timely and includes all required elements. Five youth case
management records were reviewed for the initial performance plan documentation. All five
case management records included documentation the Individualized Performance Plans (IPP)
were developed within thirty days of the youth admission. All five IPPs were developed after the
completion of the initial Residential Assessment for Youth (RAY) and the Youth Needs
Assessment Summary (YNAS). The following participated in the development of the IPPs for all
five youth: intervention and treatment team leader, youth, administrative representative, a living
unit representative, treatment staff, educational staff, and all parties who have a significant
responsibility in goal completion. None of the reviewed youth were involved in the Department
of Children and Families (DCF) or Agency for Persons with Disabilities (APD). One of the five
case management records included documentation the parent/guardian signature sheet was
returned to the program. The other four were sent to the parents/guardians, but not returned. All
signature sheets were attached to the original performance plan. The signature sheets were
maintained in the official case management record. All five performance plans included the
following elements: individualized goals and prioritized needs reflecting the risk and protective
factors identified during the initial assessment process. Three of the five case management
records included documentation the top three criminogenic needs were included in the initial
IPP. Two of the IPPs did not include the top three criminogenic needs. Each of these records
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had an explanation as to why they were not addressed added to the record after the case
management supervisor was notified of the issue. None of the IPPs included specific
delinquency interventions based on RAY results. This issue was brought to the attention of the
case management supervisor. All five youth case management records included documentation
the targeted court-ordered sanctions which could be completed while in the program were
included in the IPP. All five IPPs included transition activities, the youth’s responsibilities to
accomplish goals, the program staff’s responsibilities to accomplish goals, and the target dates
for goal completion. All five youth case management records included documentation a
transmittal letter and a copy of the IPPs were mailed within ten working days of completing of
the plan to the following: committing court, juvenile probation officer, and parents/guardians.
None of the reviewed youth were involved with DCF.
Twin Oaks Vocational Academy II
The program maintains written policy and procedures for performance plan development, goals,
and transmittals are developed timely and includes all required elements. Five youth case
management records were reviewed for the initial performance plan documentation. All five
case management records included documentation the Individualized Performance Plans (IPP)
were developed within thirty days of the youth admission. All five IPPs were developed after the
completion of the initial Residential Assessment for Youth (RAY) and the Youth Needs
Assessment Summary (YNAS). The following participated in the development of the IPPs for all
five youth: intervention and treatment team leader, youth, administrative representative, a living
unit representative, treatment staff, educational staff, and all parties who have a significant
responsibility in goal completion. None of the reviewed youth were involved in the Department
of Children and Families (DCF) or Agency for Persons with Disabilities (APD). Five of the five
case management records included documentation the parent/guardian signature sheet was
returned to the program. Signature sheets were attached to the original performance plan. The
signature sheets were maintained in the official case management record. All five performance
plans included the following elements: individualized goals and prioritized needs reflecting the
risk and protective factors identified during the initial assessment process. Each case
management record included documentation the top three criminogenic needs were included in
the initial IPP. All of the IPPs included specific delinquency interventions based on RAY results.
All five youth case management records included documentation of the targeted court-ordered
sanctions which could be completed while in the program were included. All five IPPs included
transition activities, the youth’s responsibilities to accomplish goals, program staff
responsibilities to accomplish goals, and the target dates for goal completion. All five youth case
management records included documentation a transmittal letter and a copy of the IPPs were
mailed within ten working days of completing of the plan to the following: committing court,
juvenile probation officer, and parents/guardians. None of the reviewed youth were involved with
DCF.
Six youth were interviewed about their participation in the development of performance plans.
Five youth reported they participated in their performance plan development. One youth
reported they did not participate. The youth explained their performance plan was still in
development at the time of the annual compliance review. Four of the six youth reported their
performance plan goals. Two youth were not sure of their performance plan goals. Three youth
reported they had a copy of their performance plan and three reported they did not.
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2.10 Performance Plan Revisions Satisfactory Compliance
Performance reviews shall result in revisions to the youth’s performance plan when
determined necessary by the intervention and treatment team.
Juvenile Unit for Specialized Treatment
The program maintains a policy and procedures for performance plan revisions based on the
youth’s performance and the intervention and treatment team. Five youth case management
records were reviewed for performance plan revisions. None of the five youth were applicable
for performance plan revisions. Three closed case management records were provided and
reviewed. All three closed case management records included documentation the Individualized
Performance Plans (IPP) were revised based upon the Residential Assessment for Youth (RAY)
and when youth demonstrated progress or lack of progress toward completing goals. None of
the youth required an updated performance plan based on newly acquired information. All three
youth case management records included documentation revisions to the performance plans
were made when transition activities were added.
Twin Oaks Vocational Academy II
The program maintains a policy and procedures for performance plan revisions based on the
youth’s performance and the intervention and treatment team. In all five, a Residential
Assessment for Youth (RAY) was completed as required. Revisions were completed for all five
youth when demonstrating progress toward goal completion. Two of the five youth were
applicable for, and included performance plan revisions needed during the last sixty days of the
youths’ stay in the program.
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.
Juvenile Unit for Specialized Treatment
The program maintains a policy and procedures for performance summaries being prepared
and transmitted timely. Five youth case management records were reviewed, and none were
applicable for performance summaries. Three closed youth case management records were
provided for review. All three closed youth records included documentation the initial
performance summaries were completed at ninety days following the signing of the initial
Individual Performance Plans (IPPs). All performance summaries reviewed were completed
prior to the youth release from the program. The reviewed performance summaries included the
following elements: youth’s status on each performance plan goal, overall treatment progress,
academic status, behavior, level of motivation/readiness to change, interaction with peers and
staff, overall significant adjustment to the program, significant positive and negative events, and
justification for release. All youth case management records included documentation the
transmittals included youth comments, the youth was provided a copy of the summary, and the
original summary was filed in each youth case management file. All youth case management
records included documentation the performance summaries were signed and dated by
required participants. The documentation also included a copy of the summary was sent within
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ten working days to the following: committing court, juvenile probation officer (JPO), and
parent/guardian.
Twin Oaks Vocational Academy II
The program maintains a policy and procedures for performance summaries being prepared
and transmitted timely Five youth case management records were reviewed for performance
summaries. All were completed at ninety-day intervals as required. Performance summaries
included all required documentation concerning the youth’s progress and status in the program.
Justification for release or discharge was included in two of the five youth records reviewed, as
the remaining three records were not applicable for release. Youth were provided copies of
performance summaries for all five reviewed. Each youth performance summary was filed in the
youth’s case management record. Performance summaries in all five records were signed by all
required participants, to include the youth. Copies were sent to all required parties, which
include the following: committing court, the youth’s juvenile probation officer, and the
parent/guardian. None of the five youth were applicable with the Department of Children and
Families (DCF). Three closed youth case management records were provided for review of
release summaries. All three included all required elements for documentation, such as the
justification for release, pre-release notification, and discharge summary. Each release
summary was sent within the required timeframe. Signed copies were maintained in the youth’s
case management record. Written notification was made to each youth’s parent/guardian
regarding the planned release. The program completed a Residential Assessment of Youth
(RAY) exit assessment for all three closed records. Victim notification was waived for each of
the three youth closed records.
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 maintains a policy and procedures to ensure the encouragement and involvement
of the youth’s parents/guardians in the case management process. The program, to the extent
possible and reasonable, encouraged and facilitated the involvement of youth’s parent/guardian
in the case management process, which included the assessment process, participation in the
development of the youth’s performance plan, progress reviews, advanced notification of formal
treatment team dates and times, and transition planning. If parents/guardians were unable to
attend, they attended by telephone based upon the documentation reviewed. A treatment team
meeting was observed and the parents/guardians attended by telephone. The program
facilitates parent/guardian involvement through letters, treatment team meetings and invites,
family counseling sessions, visitation days, and family days. The program director interview
confirmed the program maintains a process for parent/guardian involvement in case
management services. Six youth were interviewed and each youth reported their
parents/guardians are involved in their case management process through phone calls,
treatment teams, visitation, and their case managers.
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2.13 Incorporation of Other Plans into Performance Plans Satisfactory Compliance
The youth’s performance plan shall reference or incorporate the youth’s treatment or care
plan.
Juvenile Unit for Specialized Treatment
The program maintains a policy and procedures to ensure the performance plans incorporate
other plans such as a treatment or care plan. Five youth case management records were
reviewed for the incorporation of other plans into the performance plans. All five youth case
management records included documentation to confirm performance plans included or
referenced the additional plans, to include treatment and academic. No other plans were
required for the five youth.
Twin Oaks Vocational Academy II
The program maintains a policy and procedures to ensure the performance plans incorporate
other plans such as a treatment or care plan. Five youth case management records were
reviewed for the incorporation of other plans into the performance plans. All five youth case
management records included documentation to confirm performance plans included or
referenced the additional plans, to include treatment and academic. No other plans were
required for the five youth.
2.14 Treatment Team Members and Meetings (Formal and
Satisfactory Compliance
Informal Reviews)
The treatment team members include, at a minimum, the youth, representatives from the
program’s administration and residential living unit, education, and others responsible for
providing or overseeing the provision of intervention and treatment services.
A program shall ensure the intervention and treatment team meets bi-weekly (formally and
informally) to review each youth’s performance, to include RAY Reassessment results,
progress on Individualized Performance Plan goals, positive and negative behaviors,
including behaviors resulting in physical interventions. If the youth has a treatment plan,
review their treatment plan progress.
Juvenile Unit for Specialized Treatment
The program maintains a policy and procedures for treatment team members and meetings.
Five youth case management records were reviewed for formal treatment team meetings. All
five records included documentation formal treatment team meetings were held, at least every
thirty days. All reviewed treatment team documentation included the following elements: youth’s
name, date of review, all required attendees, comments from treatment team members, youth’s
progress or lack of progress in the program, progress on performance plan goals, positive and
negative behaviors, and treatment progress. The other three youth did not require updates on
their performance plans. One of the youth were applicable for a review of the Residential
Assessment for Youth (RAY) re-assessment results. The other four youth did not require RAY
re-assessments. All five youth case management records included documentation of the formal
treatment team meetings. Five records included documentation of formal and informal
treatment teams. Formal treatment teams were held for all five youth reviewed as required. Four
of the five youth records included documentation informal treatment teams were held as
required. One youth had not been in the program long enough to have an informal treatment
team completed at the time of the annual compliance review. All four youth records included the
following elements for informal treatment team meetings: youth’s name, date of review, meeting
attendees, comments from treatment team members, a brief synopsis of the youth’s progress,
positive and negative behaviors, provided opportunities to demonstrate skills acquired in the
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program, and treatment progress. None of the youth were applicable for performance plan
revisions or behaviors resulting in physical interventions. All four records included
documentation the following were invited and encouraged to participate in the treatment team
meetings: juvenile probation officer (JPO), parents/guardians, and all other pertinent parties.
A formal treatment team meeting was observed during the annual compliance review. All
required staff were present, and a review of treatment plans were completed to determine the
youth’s anticipated release date.
Twin Oaks Vocational Academy II
The program maintains a policy and procedures for treatment team members and meetings.
Five youth case management records were reviewed for formal treatment team meetings. All
five records included documentation formal treatment team meetings were held, at least every
thirty days. All reviewed treatment team documentation included the following elements: youth’s
name, date of review, all required attendees, comments from treatment team members, youth’s
progress or lack of progress in the program, progress on performance plan goals, positive and
negative behaviors, and treatment progress. Five of the five records included documentation of
performance plan revisions. Each had Residential Assessment for Youth (RAY) re-assessment
results. All five records included documentation of the formal treatment team meetings.
Five youth case management records included documentation of informal treatment teams. In
all five records, informal treatment teams were completed bi-weekly and alternating formal
treatment team meetings. All five records included the following elements for informal treatment
team meetings: youth’s name, date of review, meeting attendees, comments from treatment
team members, a brief synopsis of the youth’s progress, positive and negative behaviors,
provided opportunities to demonstrate skills acquired in the program, and treatment progress.
All five contained performance plan revisions as applicable. All five records included
documentation the following were invited and encouraged to participate in the treatment team
meetings: juvenile probation officer (JPO), parents/guardians, and all other pertinent parties. A
formal treatment team meeting was observed during the annual compliance review week. All
required staff were present and a review of treatment plans were completed to determine the
youth’s anticipated release date.
Six youth were interviewed and all reported staff reviewed youth performance to include
progress on performance plan goals, positive and negative behaviors, and treatment progress.
Five of the six youth reported being given an opportunity during treatment team meetings to
demonstrate any skills learned in the program. One youth reported not being willing to talk
during treatment team meetings. Another youth reported their performance plan was not yet
completed at the time of the interview.
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2.15 Transition Planning, Conference, and Community Re-
Satisfactory Compliance
Entry Team Meeting (CRT)
A program shall ensure the intervention and treatment team is planning for the youth’s
successful transition to the community upon release from the program, when developing each
youth’s performance plan and throughout its implementation during the youth’s stay. During
the Transition Conference, participants shall review transition activities on the youth’s
performance plan, revise the activities if necessary, and identify additional activities/services,
as needed. Target completion dates and persons responsible for their completion shall be
identified during the conference. The intervention and treatment team leader shall obtain
conference participant’s dated signatures, representing their acknowledgement of the
transition activities and accountability for their completion pursuant to the youth’s
performance plan.
Each youth must attend their scheduled Community Re-Entry Team (CRT) meeting prior to
discharge.
Juvenile Unit for Specialized Treatment
The program maintains a policy and procedures for transition planning, transition conferences,
and the community re-entry team meetings. Three closed youth case management records
were provided for review. All three records included documentation the transition conferences
were held at least sixty days prior to the youth’s targeted release date. All three records
included documentation the following intervention and treatment team members attended the
transition conference: youth, treatment team leader, program director, and other team members.
The following were encouraged and invited to attend the transition conference: juvenile
probation officer (JPO), parents/guardians, education staff, and other pertinent parties. A review
of the conference documentation included the following were completed during the transition
conference: a review of transition activities on the youth’s performance plan, revision of the
performance plan, identifying additional transition activities and target completion dates, and
identifying persons responsible for completion. All reviewed transition conference forms
included signatures and dates of the treatment team leader and attendees. All three closed
records included documentation a copy of the transition plan was sent with a request for return
with signatures to anyone not in attendance. All three records also included documentation the
plan was transmitted electronically to the JPOs and the Department Children and Families
(DCF) assigned case managers. All three records included documentation a Community Re-
entry Team (CRT) meeting was completed prior to the youth’s release. There was
documentation all three youth and their case managers participated in the CRT meeting. All
three records included evidence of an invitation to participate in the CRT.
Twin Oaks Vocational Academy II
The program maintains a policy and procedures for transition planning, transition conferences,
and the community re-entry team meetings. Three closed youth case management records
were provided for review. All three records included documentation the transition conferences
were held at least sixty days prior to the youth’s targeted release date. All three records
included documentation the following intervention and treatment team members attended the
transition conference: youth, treatment team leader, program director, and other team members.
The following were encouraged and invited to attend the transition conference: juvenile
probation officer (JPO), parents/guardians, education staff, and other pertinent parties. None
were applicable for a human trafficking specific service provider. A review of the conference
documentation included the following were completed during the transition conference: a review
of transition activities on the youth’s performance plan, revisions to the performance plan,
identifying additional transition activities and target completion dates, and identifying persons
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responsible for completion. All reviewed transition conference forms included signatures and
dates of the treatment team leader and attendees. All three closed records included
documentation a copy of the transition plan was sent with a request for return with signatures to
anyone not in attendance. All three records included documentation a Community Re-Entry
Team (CRT) meeting was completed prior to the youth’s release. There was documentation all
three youth and their case managers participated in the CRT meeting. All three closed case
management records included evidence of an invitation to participate in the CRT. No exceptions
were identified for transition planning and community re-entry team meetings.
2.16 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
Juvenile Unit for Specialized Treatment
The program maintains a policy and procedures for what is included in an Exit Portfolio to be
provided to the youth upon discharge from the program. Three closed youth case management
records were reviewed. All three records included documentation the Exit Portfolio was
discussed and initiated for the youth during the Transition Conference. The following elements
were included in each portfolio: state-issued identification card, a copy of the youth’s transition
plan, a calendar with all dates, times, and locations of upcoming community appointments,
social security card, birth certificate, educational and vocational certificates earned in the
program, educational records and documents, school transcripts, resume, and completed
sample employment applications. All reviewed Exit Portfolios were verified during the Exit
Conference. All three closed youth records included documentation the Exit Portfolio was
completed and given to the youth upon release. Each record confirmed the Exit Portfolios were
forwarded to the youth’s juvenile probation officers (JPOs).
Twin Oaks Vocational Academy II
The program maintains a policy and procedures for what is included in an Exit Portfolio to be
provided to the youth upon discharge from the program. Three closed youth case management
records were reviewed for Exit Portfolios. All three records included documentation the Exit
Portfolio was discussed and initiated for the youth during the Transition Conference. Two of
three Exit Portfolio’s had state-issued identification cards and three contained a copy of the
youth’s transition plan and a calendar with all dates, times, and locations of upcoming
community appointments. Two of three had a social security card and birth certificate. The
program youth are fifteen years of age and under; therefore, they were not applicable for
additional documents. All three records contained evidence of educational and vocational
certificates earned in the program, educational records and documents, school transcripts,
resume, and completed sample employment applications. All reviewed Exit Portfolios were
verified during the Exit Conference. All three closed records included documentation the Exit
Portfolio was completed and given to the youth upon release. Each record confirmed the Exit
Portfolios were forwarded to the youth’s juvenile probation officers (JPOs).
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2.17 Exit Conference Satisfactory Compliance
An Exit Conference shall be conducted, in addition to a formal or informal meeting, to review
the status of goals developed at the transition conference and finalize release plans.
Juvenile Unit for Specialized Treatment
The program maintains a policy and procedures for Exit Conference requirements. Three closed
case management records were reviewed for Exit Conference documentation. All records had
documentation the Exit Conference was conducted after the program notified the juvenile
probation officer (JPO) of the youth’s release date. The conferences were conducted at least
fourteen days prior to the youth’s release. The Exit Conference documentation included the date
of the conference, signatures of all participants, and a summary of any pending transition goals.
A review of the Department’s Juvenile Justice Information System (JJIS) revealed the admission
dates and discharge dates for the three youth matched the closed case management records.
All transition activities established at the Transition Conference were finalized for the youth’s
release in all three closed case management records. The following people participated in the
Exit Conference: intervention and treatment team leader, parent/guardian, education
representative, JPO, youth, and any other pertinent parties. All three closed youth case
management records included documentation the Exit Conference was held separately from the
transition and community re-entry team meetings.
Twin Oaks Vocational Academy II
The program maintains a policy and procedures for Exit Conference requirements. Three closed
youth case management records were reviewed for Exit Conference documentation. All three
records had documentation the Exit Conference was conducted after the program notified the
juvenile probation officer (JPO) of the youth’s release date. The conferences were conducted at
least fourteen days prior to release. The Exit Conference documentation included the date of
the conference, signatures of all participants, and a summary of any pending transition goals. A
review of the Department’s Juvenile Justice Information System (JJIS) revealed the admission
dates and discharge dates for the three youth matched the closed case management records.
All transition activities established at the Transition Conference were finalized for the youth’s
release in all three closed case management records. The following people participated in the
Exit Conference: intervention and treatment team leader, parent/guardian, education
representative, JPO, youth, and any other pertinent parties. All three closed youth case
management records included documentation the Exit Conference was held separately from the
transition and community re-entry team meetings.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program maintains a policy and procedures outlining the formal process to promote
constructive input by the youth. The program’s formal process to promote constructive input by
youth through treatment team meetings and youth advisory board. Youth surveys were provided
for review. The youth utilize “Quality of Life” surveys and provided feedback on various areas of
the program they enjoy and suggestions for areas of needed improvement. The youth are able
to provide input through youth surveys, the TRACE Assessment process, and Quality of Life
surveys. Six youth were interviewed about being able to provide input on the program. Five of
the six youth reported they could request to speak with staff in order to provide feedback about
the program. One youth reported being able to talk with a supervisor but did not feel like the
supervisor was listening and they were not being heard. The program director was interviewed
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regarding youth input. The program director reported the program’s formal process to solicit
youth input about the program is completed through youth surveys, request to see staff,
advisory board meetings, treatment team meetings, and quality of life surveys.
2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
Juvenile Unit for Specialized Treatment
The program has a policy and procedures to provide career education based on age and is
appropriate for the educational abilities of the youth in the program. The program is a type two
vocational program; however, the program offers type three vocational programming to include
welding, carpentry, and an opportunity to complete portions of the National Center for
Construction Education and Research (NCCER) Curriculum. The interview with the lead
educator indicated the primary assessment tools used are the Department’s Common
Assessment, Diagnostic Assessment, and state testing. Three closed youth case management
records were reviewed. All reviewed records included a résumé, sample job applications, and
information on the location of the local Career Source Center. The three youth records also had
the required State of Florida identification card (ID).
Twin Oaks Vocational Academy II
The program has a policy and procedures to provide career education based on age and is
appropriate for the educational abilities of the youth in the program. The program is a type two
vocational program; however, while the program does offer type three vocational programming,
the younger youth of this program only take the Occupational Safety and Health Administration
(OSHA) career education due to age restrictions to participate in welding or carpentry. The
interview with the lead educator indicated the primary assessment tools used are the
Department’s Common Assessment, Diagnostic Assessment, and state testing. Three closed
youth case management records were reviewed. All reviewed records included a résumé,
sample job applications, and information on the location of the local Career Source Center. Two
of the three youth had the required State of Florida identification card (ID), while one youth did
not have the required identification card.
2.20 Educational Access (Critical) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a policy and procedures to provide for educational access. The program
integrates education into the daily schedule with support from the local school district. The
district approved calendar and daily bell schedule were reviewed and determined the program
incorporated the required 250 days of instruction, with up to ten days used for teacher planning,
fulfilling the weekly requirement of twenty-five hours of instructional time. Minimal school
interruptions were verified through logbook reviews and the lead educator’s interview. Three
youth were interviewed, and each reported there is little to no interruption to the school day. A
review of four randomly selected logbook reviews confirmed the youth were attending school
according to the daily bell schedule. Further review of logbook entries and video footage for
three days verified the youth were attending school as scheduled.
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2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
Juvenile Unit for Specialized Treatment
The program maintains a policy and procedures requiring an education transition plan to be
developed upon each youth’s admission. Three closed youth case management records were
reviewed, and all three youth records included the specified education transition plan. Each of
the three records contained an exit plan indicating the case manager, parent/guardian, and
youth were all aware of the plan. Included in each record was an Electronic Educational Exit
Plan (EEEP), which identified the next educational placement information and input from the
post-release school district representative.
Twin Oaks Vocational Academy II
The program maintains a policy and procedures requiring an education transition plan to be
developed upon each youth’s admission. Three closed youth case management records were
reviewed, and all three youth records included the specified education transition plan. The lead
educator stated she has a similar process developed which addresses the continuation of the
youth’s education and employment, but she does not complete the actual transition plan. Each
of the three records contained an exit plan indicating the case manager, parent/guardian, and
youth were all aware of the plan. Included in each record was an Electronic Educational Exit
Plan (EEEP), which identified the next educational placement information and input from the
post-release school district representative.
Three youth were interviewed, and each reported they participated in the development of their
education transition plan. Two out of three youth reported the program was preparing them very
well or well when it came to high school, high school equivalency diploma provided through the
General Education Development platform (GED), vocational school, employment, and/or
college. One youth reported he does not feel the program is preparing them well in this area,
stating school is online and they are supposed to be going back to public school.
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Office of Accountability and Program Support Page 36 of 79 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical
Satisfactory Compliance
Coordinator
Each program director is responsible for the administrative oversight and management of
mental health and substance abuse services in the program.
Programs providing specialized treatment services must have a single licensed mental health
professional designated as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services in the program.
The program has a licensed mental health counselor (LMHC), who serves as the designated
mental health clinician authority (DMHCA). The DMHCA has a clear and active license under
Chapter 491, Florida Statutes, which expires on March 31, 2025. The DMHCA is on-site full-time
weekly to oversee the coordination and implementation of mental health and substance abuse
services at the program. The program provided the license and agreement for review. The
program provides Intensive Mental Health Treatment Services and Mental Health Overlay
Services (MHOS), and the DMHCA is responsible for the coordination and implementation of
those services. The program has a licensed psychologist who serves as the back-up DMHCA.
The back-up DMHCA has a clear and active license under Chapter 490, Florida Statutes, which
expires on May 31, 2024. The DMHCA was interviewed and reported the role of the DMHCA is
to provide oversight and mental health services for the youth and their families. The DMHCA
reported she provides supervision of the mental health staff and ensures services are provided.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff (Critical)
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The program has a licensed psychologist with a clear and active license expiring on May 31,
2024, in addition to the designated mental health clinician authority (DMHCA). The licensed
psychologist is required to be on-site every week and as needed. The psychologist does not
sign-in or sign-out when on-site. The clinical supervisor, who is the DMHCA, ensures the
licensed clinical staff working under their supervision are performing services they are qualified
to do based on their education, training, and experience based on position descriptions. The
licensed mental health and substance abuse clinical staffing is in accordance with the current
contract and Florida Administrative Code. All licenses were available for review and were clear
and active. The program’s Chapter 397 license is clear and active and posted within public view
at the program.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 37 of 79 (Revised September 2022)
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff
The program director is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors shall ensure
clinical staff working under their supervision are performing services the staff are qualified to
provide based on education, training, and experience.
The designated mental health clinician authority (DMHCA), a licensed mental health counselor
(LMHC), provides direct supervision for non-licensed staff. The program has employed six non-
licensed staff throughout the annual compliance review period. The DMHCA ensures the non-
licensed clinical staff working under their supervision are performing services they are qualified
to provide based on education, training, and experience. Six therapists were supervised during
the annual compliance review period. All six therapist supervisions included a minimum of one
hour a week of on-site, face-to-face direct supervision by the DMHCA for the purpose of
overseeing and directing the mental health services provided in the program during the annual
compliance review period. All supervisions were recorded on the Department’s Licensed Mental
Health Professionals and Licensed Substance Abuse Professionals Direct Supervision Log
form. All six therapists hold a master’s-level degree from an accredited university or college in
the field of counseling, social work, psychology, or related human services field. The six
therapists provided substance abuse services under the program’s Chapter 397 and direct
supervision of a qualified professional as defined in Florida Statutes. Five of the six therapists
completed twenty hours of training and five supervised Assessments of Suicide Risk (ASRs).
One therapist had not worked at the program long enough to complete the twenty-hour training
and did not complete any ASRs.
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.
Juvenile Unit for Specialized Treatment
Five youth mental health and substance abuse records were reviewed for a mental health and
substance abuse screening. All five youth had a Massachusetts Youth Screening Instrument-
Second Version (MAYSI-2) completed upon admission. All available information was reviewed
which included the commitment packet, reports, and records for existing documentation of
mental health or substance abuse problems, or history of human trafficking. The five MAYSI-2
screenings were completed in a confidential manner on the date of the youth’s admission to the
program. Case management staff conducted all five MAYSI-2s and completed the appropriate
MAYSI-2 training within the Department’s Learning Management System (SkillPro). All five
screenings indicated further assessment was required. In each record, a referral for further
evaluation was generated. None of the five reviewed records indicated an Assessment of
Suicide Risk (ASR) was needed due to the MAYSI-2 category of suicide ideation indicating
further assessment or other information obtained at intake/admission suggested potential
suicide risk. All five reviewed youth records had an ASR, comprehensive evaluation, and the
reason for referral was documented. The program director was interviewed and explained the
process to identify youth at risk for mental health and substance abuse problems and suicide is
to screen all youth at admission using the MAYSI-2 and meet with the clinical therapist to
complete the suicide risk assessment tool. Intake staff review all documentation in the youth’s
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 38 of 79 (Revised September 2022)
commitment packet to identify any mental health and substance abuse issues of the youth and
respond accordingly by making the necessary referrals and including it in treatment.
Twin Oaks Vocational Academy II
The program maintains a policy and procedures for mental health and substance abuse
services, which addresses a standardized intake and mental health and substance abuse
screening process. This process includes a review of commitment packet information, reports
and records, and administering the Massachusetts Youth Screening Instrument- Second
Version (MAYSI-2) in the Department’s Juvenile Justice Information System (JJIS). The policy
also includes staff training in mental health and substance abuse issues and a standardized
process for referral of youth identified as in need of further mental health and/or substance
abuse evaluation to a proper professional or, when immediate attention is needed, to a hospital
or Baker Act or Marchman Act receiving facility. A review of five youth mental health and
substance abuse records found the program completed a MAYSI-2 for each youth upon
admission. Each reviewed MAYSI-2 resulted in the youth requiring a referral for further
evaluation. Program practice is to conduct further evaluation and complete an Assessment of
Suicide Risk (ASR) on each youth admitted regardless of the MAYSI-2 results. Each youth
received a new Mental Health and Substance Abuse Comprehensive, Evaluation In-Depth
Assessment, and an ASR regardless of MAYSI-2 screening results. The ASR was completed
within twenty-four hours for each reviewed youth. Each record reflected the screening was
completed in JJIS on the day of the youth admission by a trained clinical staff. All records
documented staff conducting mental health and substance abuse admission screenings
reviewed each youth’s commitment packet information and records for existing documentation
of mental health and substance abuse problems.
The program director interview confirmed the intake screening process for youth at risk for
mental health and substance abuse problems and suicide.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identify via 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.
Juvenile Unit for Specialized Treatment
Five youth records were reviewed for mental health and substance abuse assessment and
evaluation. All five youth records included documentation the program completed a new mental
health and substance abuse evaluation. All evaluations were completed within thirty calendar
days of admission. If a non-licensed mental health clinical staff completed the evaluation, it was
reviewed and signed by a licensed mental health professional within ten calendar days after the
evaluation was conducted. Both the mental health and substance abuse comprehensive
evaluations included the required information in all five records and addressed the original
referral reason. All five youth records included a consent obtained for substance abuse services.
None of the youth required an updated comprehensive evaluation.
Twin Oaks Vocational Academy II
A review of five youth mental health and substance abuse records found each youth received a
new separate mental health and substance abuse evaluation within thirty-days of each youth
admission. All evaluations for each youth were reviewed and signed by the designated mental
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 39 of 79 (Revised September 2022)
health clinician authority (DMHCA) within ten calendar days after the evaluation was completed
by the non-licensed clinical staff. For each youth, the mental health evaluation and substance
abuse evaluation contained identifying information, reason for evaluation, relevant background
information, behavioral observations, mental status examination, interview or procedures
administered, discussion of findings, methods of assessment, patterns and impact of alcohol
and other drug abuse, risk factors of continue use, diagnostic and clinical impressions, and
recommendations. In all youth records, signed consents were observed for substance abuse
treatment.
An interview with the DMHCA verified youth are referred by either case managers based upon
MAYSI-2 and needs assessment for services or youth can self-refer themselves for services.
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.
Juvenile Unit for Specialized Treatment
Five youth records were reviewed for mental health and substance abuse treatment. All five
youth records included documentation an initial treatment plan was developed within seven
days of initiation of treatment. All five initial mental health treatment plans were documented on
a form which included all elements of the Department’s Mental Health/Substance Abuse initial
treatment plan form. The initial treatment plan was signed by the mental health clinical staff
completing the form. All five records included documentation the initial treatment plan was
completed by a non-licensed mental health clinical staff, and all were signed by the licensed
clinical supervisor within ten days of completion. All five treatment plans were signed by all
treatment team members who participated in the development of the plan, the youth, and
parent/guardian. All five treatment plans were mailed to the parents/guardians. All five youth
records had documentation the initial treatment plans included the youth’s psychiatric needs, to
include medication and frequency of monitoring by the psychiatrist. All five plan were developed
for the youth within thirty days of admission and on forms which contained all elements of the
Department’s Individualized Mental Health/Substance Abuse Treatment Plan form. Each plan
was signed by the mental health or substance abuse clinical staff completing the plan and
signed by the licensed supervisor within ten days of completion. Plans included signatures of all
treatment team members who participated in the development of the plan. All five records
included documentation the treatment plans included psychiatric services, including
psychotropic medication and frequency of monitoring by the psychiatrist. Five youth records
were reviewed for treatment plan review documentation. All five records included documentation
of the treatment team reviews being conducted every thirty days. Two of the five records had
one treatment plan review which was four days late, out of a total of ten treatment plan reviews
between the five records. All five treatment plans included documentation of the prescribed
services to include individual, group, family, and psychiatric services. All services were
individualized for each youth. A review of video for three random days revealed groups were
being held, as required.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 40 of 79 (Revised September 2022)
Twin Oaks Vocational Academy II
A review of five youth mental health and substance abuse records indicated an initial treatment
plan was developed within seven days of initiation of treatment and documented on a form
containing all elements of the Department’s Initial Mental Health/Substance Abuse Treatment
Plan form. Each of the initial treatment plans were developed within seven days of the onset of
treatment, signed by the non-licensed clinical staff who completed the form, and signed by a
licensed clinical supervisor within ten days of completion. Signatures from all treatment team
members who participated in the development of the plan and the youth were documented on
the plan. The plan was mailed out for signature to each youth’s parent/guardian, who signed as
allowed. The four applicable plans contained the youth’s psychiatric needs, which included the
medication and frequency of monitoring. The Individualized Treatment Plan was developed for
all five youth within thirty days of admission and documented on a form containing all the
elements of the Department’s Individualized Mental Health/Substance Abuse Treatment Plan
form. All plans were signed by the non-licensed clinical staff completing the plan and signed
within ten days of completion by the licensed supervisor. In each reviewed record, the plan was
signed by all treatment team members who participated in the development of the plan and the
youth. The parent/guardian was mailed out a copy of the plan for signature, who signed as
allowed. All five of the original Individualized Treatment Plans were applicable and included
psychiatric services to be monitored once a month. Reviews of the plans were completed every
thirty days, as required, in all five records. Services and frequency were outlined within each
youth’s Individualized Treatment Plan, including individual counseling, family counseling, and
group therapy. The frequency of services was amended in each plan when revised by the
Department. Services were individualized for each youth. A review of video and sign-in sheets
indicated groups were conducted for the required length of time by the qualified facilitator.
An interview with the designated mental health clinician authority (DMHCA) confirmed formal
and informal treatment plans are completed every two weeks and monthly, and are reviewed
and signed by the treatment team, including parent/guardians and juvenile probation officers.
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.
Juvenile Unit for Specialized Treatment
Five youth records were reviewed for treatment and discharge planning. All five youth records
included documentation the youth were assigned a treatment team upon arrival to the program.
Documentation revealed the treatment team was comprised of the youth, program
administration, residential living unit, education, vocational training, medical staff, mental health
staff, substance abuse staff, and parents/guardians. Three of the five youth records were youth
determined in need of substance abuse and received individual, group, and/or family counseling
provided by a licensed qualified professional or a non-licensed professional under the care of a
licensed professional for substance abuse treatment. The other two records were not applicable
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 41 of 79 (Revised September 2022)
for substance abuse treatment. All five youth records included documentation an Authority for
Evaluation and Treatment (AET) form was properly executed. All five youth records included
documentation of a signed Youth Consent for Substance Abuse Treatment Records form. All
mental health treatment notes or substance abuse treatment notes were documented on a form
which contains the Department’s Counseling/Therapy Progress Notes information. Not all
treatment was accurately documented with the youth’s mental health or substance abuse
treatment notes. Treatment notes could be produced by the designated mental health clinician
authority (DMHCA) when asked about missing treatment. The DMHCA reported the program is
in the process of updating the notes to accurately reflect treatment provided. All five youth
records included documentation the youth received individual psychotherapy or counseling and
psychosocial skills training. Three closed records were reviewed for discharged planning. All
three records included documentation the discharge plan was completed on the Department’s
Mental Health/Substance Abuse Treatment Discharge Summary form. All three discharge
summaries included the services needed for daily maintenance of the positive improvement in
behavioral, emotional, and social skills made by the youth during treatment. The reviewed
documentation reflected the discharge plans were discussed with the youth, parent/guardian,
and juvenile probation officer (JPO) during the Exit Conference. A copy of the discharge
summaries were also provided to the youth, JPO, and parent/guardian.
Twin Oaks Vocational Academy II
A review of five youth mental health and substance abuse records verified each youth was
assigned to a treatment team upon arrival to the program comprised of the youth,
administration, the residential living unit, and all other staff responsible for delinquency
intervention and treatment services. Documentation reflected the youth, program administration,
school staff, residential living unit, medical staff, mental health/substance abuse staff, vocational
staff, and parent/guardian participated in the treatment team meetings. In all records, youth
were determined in need of substance abuse treatment and received individual, group, and
family counseling according to their individualized plans, provided by a licensed qualified
professional or a non-licensed substance abuse clinical staff under Chapter 397. Reviewed
documentation confirmed each youth had a properly executed Authority for Evaluation and
Treatment (AET) form or court order and a signed Youth Consent for Substance Abuse
Treatment form. Each youth’s mental health treatment and substance abuse treatment notes
were documented on the program’s form containing all the elements of the Department’s
Counseling/Therapy Progress Note form. In all records reviewed, individual psychotherapy or
counseling occurred in a one-on-one capacity between a youth diagnosed with a mental health
disorder and a mental health clinical staff professional. Therapeutic activities designed to
address specific skill deficits or maladaptive behaviors and promote skill development and
improved functioning of youth with mental disorders were present in all records reviewed. In all
records reviewed, progress notes showed youth received services as stipulated in their
treatment plan, except missing three individual sessions, five group sessions, and twenty family
sessions for all youth throughout the annual compliance review period. An interview with the
designated mental health clinician authority (DMHCA) revealed some family services were not
included in weekly progress reports though documentation was provided evidencing the
sessions were completed. The DMHCA also explained the process used for individualized
mental health and substance abuse treatment planning, which youth work with a coordinator
and parents to develop the goals identified by screenings, assessments, and sessions.
Three closed youth mental health and substance abuse records were reviewed for discharge
plans. In each record, the program utilized the Department’s Mental Health/Substance Abuse
Treatment Discharge Summary form. None of the records were applicable for being released
while still on suicide risk. The youth discharge summaries in all records documented the
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 42 of 79 (Revised September 2022)
services needed for daily maintenance of the positive improvement in behavioral, emotional,
and social skills made by each youth while in treatment. The reviewed documentation revealed
the discharge plans were discussed with each youth, their parent/guardian, and their juvenile
probation officer (JPO) during the exit conference, and a copy was provided to all required
parties.
3.08 Specialized Treatment Services (Critical) Satisfactory Compliance
Specialized treatment services shall be provided in programs designated as “Specialized
Treatment Services Programs” or are designated to provide “Specialized Treatment Overlay
Services.”
A review of the program’s contract and clinical program description found the program provides
Mental Health Treatment Overlay Services (MHOS), both intensive overlay and continuous care
overlay, to all youth. Provided clinical group therapy included all required groups according to
the contract. The services include individual, group, and family therapy as part of each youth’s
treatment plan at a rate of at least five times a week, as well as receiving daily therapeutic
activities by qualified staff. Reviewed documentation confirmed group therapy sessions were
limited to no more than ten participants. The program is licensed under Chapter 397; therefore,
a qualified professional, who is the designated mental health clinician authority (DMHCA), is on
site at least five days a week. The program has a licensed psychiatrist who provided psychiatric
evaluations and medication management for the youth as well as participated in treatment
planning. Clinical staff are on-site seven days a week and counselor caseloads are limited to no
more than twelve youth for each clinician. All six interviewed youth stated they participate in
individual and or family counseling. Three youth stated counseling is completed once a week,
two youth stated they cannot participate in the family counseling at the moment but counseling
is available, one stated monthly, and two youth stated they participate; however, did not give
time frames. Four of six interviewed staff reported they do not facilitate mental health or
substance abuse groups. Two staff stated they only provide Impact of Crime (IOC) groups. An
interview with the DMHCA confirmed the program provides specialized treatment services
through clinical groups according to the contract.
3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.***
The program provides psychiatric services to the youth who require this service. The program
provided documentation of the advanced practice registered nurse (APRN) and supervising
psychiatrist. The APRN and psychiatrist have clear and active licenses as outlined in the Florida
Administrative Code, with licenses expiring on April 30, 2025, and January 31, 2026. The
psychiatric APRN’s education, experience, and certification in psychiatry and mental health
were reviewed and the psychiatric APRN has a Collaborative Practice Protocol in place which
was reviewed. The Collaborative Practice Protocol for the APRN was maintained on-site. The
psychiatric APRN is available for emergency consultation twenty-four hours a day, seven days a
week. The psychiatrist and/or psychiatric APRN briefs a representative of the treatment team
regarding the status of each youth receiving psychiatric services for the treatment team reviews.
A review of the sign-in and sign-out logs confirmed visits by the psychiatric APRN were
conducted as required by the contract or agreement. The psychiatric APRN was approved by
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Office of Accountability and Program Support Page 43 of 79 (Revised September 2022)
the Department’s Office of Health Services to provide services at the program. The psychiatric
APRN was interviewed and reported the services they provide at the program to be
assessments, medication management, and on-call coverage for emergency situations. The
psychiatric APRN stated they coordinate, prescribe screenings for diagnostic purposes and
sleep logs, monitor labs and side effects, review youth records and collaborate with staff weekly.
The psychiatric APRN and designated mental health clinician authority (DMHCA) stated the
psychiatric APRN is on-site weekly for at least two hours.
Juvenile Unit for Specialized Treatment
Five youth records were reviewed for psychiatric services. All five youth received an Initial
Psychiatric Interview, and four of the five youth were applicable for psychiatric services. Three
youth were admitted on psychotropic medications and one youth was placed on psychotropic
medications based on the Initial Diagnostic Psychiatric Interview. All five youth received a
diagnostic interview within fourteen days of admission. The Initial Diagnostic Psychiatric
Interview included the medical, mental health, and substance abuse history, Mental Status
Examination, and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-
5) diagnosis. All five youth diagnoses were consistent with the youth’s treatment plan and
treatment recommendations. Four of the youth were taking prescribed medications which
included the need for the medications, target symptoms, initial treatment goals, potential side
effects, risks and benefits of taking the medication, and frequency of medication monitoring and
management. The Initial Diagnostic Psychiatric Interview was documented on a form which
contains all required information based upon the Department’s Clinical Psychotropic Progress
Note (CPPN). The psychiatrist and/or the psychiatric APRN’s evaluation and recommendations
for each youth were incorporated into the mental health clinical staff’s evaluations and
treatment plans. Page three of the CPPN was completed on the Department’s CPPN form. The
four youth receiving psychotropic medications received medication reviews, as required with
one review completed four days late out of a total of seven reviews. All four youth records
included documentation the psychiatrist, psychiatric APRN, and the nursing staff have
documented monitoring for Tardive Dyskinesia on a monthly basis as indicated on the CPPN.
Twin Oaks Vocational Academy II
Five youth mental health and substance abuse records were reviewed. The program’s practice
is to provide a psychiatric evaluation to all youth admitted and all five reviewed youth were
referred for a psychiatric interview. Two of the youth entered the program on psychotropic
medication. Documentation indicated each youth entering the program received a diagnostic
interview within fourteen days of admission. Each of the five youth’s initial diagnostic psychiatric
interview included the history of the youth, a Mental Status Examination, diagnosis, and
treatment recommendations. Two of the youth were prescribed to continue psychotropic
medication, one youth was prescribed new medication at the initial interview, and two youth
were prescribed psychotropic medications at a later date. The psychiatrist explained the need
for psychotropic medication, targeted symptoms, initial treatment goals, potential side effects,
risks and benefits of taking the medication, and frequency of medication monitoring. All
psychiatric evaluations were completed on the Department’s Clinical Psychotropic Progress
Note (CPPN) form and were clearly identified as an initial psychiatric interview. All applicable
reviewed youth records indicated each youth received the prescribed psychotropic medications
and each documented monthly face-to-face medication monitoring reviews. The corresponding
CPPNs were completed, signed, and dated by the psychiatrist. Documented on the CPPN was
the youth’s adherence to the medication regimen, any laboratory findings, if applicable, whether
or not telephone contact was made to the parent/guardian, and monitoring of Tardive
Dyskinesia, as required.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 44 of 79 (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 suicide prevention plan addressing suicide prevention planning and detailing
suicide prevention procedures. The plan is reviewed annually by the program director, the
designated mental health clinician authority (DMHCA), regional clinical director, and mental
health staff. The suicide prevention plan was signed on January 16, 2024. The plan included
suicide prevention procedures for identification and assessment of youth at-risk of suicide,
requirements for staff training, implementation of suicide precautions, levels of supervision,
referral process, communication, notification, documentation, immediate staff response, and
review process. The review process for suicide attempts and mortality review included
circumstances surrounding the event, procedures relevant to the incident, relevant training
received by involved staff, pertinent medical and mental health services involving the victim,
possible precipitating factors, and recommendations, if any, for changes in policy, training,
physical plant, medical or mental health services, and/or operational procedures.
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.
Juvenile Unit for Specialized Treatment
Five youth records were reviewed for suicide prevention services. All five reviewed youth
records included documentation an Assessment of Suicide Risk (ASR) was completed on the
Department’s Assessment of Suicide Risk form as part of the admission process. The ASR
referral dates for all five-youth corresponded with the date of admission and all ASRs were
completed within twenty-four hours of the youth’s admission. Three of the youth remained on
standard and one youth remained on precautionary observation (PO) upon completion of the
initial ASR. The remaining youth’s ASR was incorrectly documented as the youth stepping down
from PO to standard when the youth was not on PO. The designated mental health clinician
authority (DMHCA) was interviewed and explained they thought the youth was still on PO from
detention because the youth had fresh self-harm markings on their wrist. The ASRs included
documentation the youth’s parent/guardian and juvenile probation officer (JPO) were notified of
the youth’s potential suicide risk, when necessary. The mental health staff provided supportive
services for all five youth. Three of the five ASRs were completed by the DMHCA and two were
completed by a clinical therapist with the DMHCA’s signature within ten days of completion. All
five youth showed alerts were correctly opened and closed in the Department’s Juvenile Justice
Information System (JJIS) in all five records reviewed. One youth placed on precautionary
observation was maintained on suicide precautions and constant supervision until the Follow-Up
ASR indicated suicide precautions could be discontinued as determined by a licensed mental
health professional, and was stepped down to close supervision prior to the transition to
standard supervision after a conference was held by the program director and a licensed mental
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Office of Accountability and Program Support Page 45 of 79 (Revised September 2022)
health professional. The youth was allowed to participate in select activities with other youth in
designated safe housing/observation areas of the program. Discontinuation of close supervision
was documented in accordance with the program’s Suicide Prevention Plan. None of the
reviewed youth were in need of an ASR due to the youth being in crisis and the program did not
have any youth placed in secure observation.
Twin Oaks Vocational Academy II
Five reviewed mental health and substance abuse records found the program places all youth
on suicide precautions upon admission and all are assessed using the Department's
Assessment of Suicide Risk (ASR) form. All ASRs were completed during admission by a
qualified and contained all required elements. All youth were placed on standard supervision
after assessment. Only two youth were placed on suicide precautions through staff observations
during the annual compliance review period. Both records were reviewed, and the ASRs were
completed within twenty-four hours of concern either by licensed staff or qualified non-licensed
staff, as well as signed by a licensed staff, if necessary, within twenty-four hours of assessment.
Both youth were placed on close supervision (CO) and precautionary observation (PO). The
parents/guardians of each youth were notified and documented on the ASR. Staff provided
supportive services to each youth. The two applicable youth had a Follow-Up ASR, documented
on the Department’s form, completed prior to stepping the youth down to close supervision.
Each of the youth had documentation on the ASR, where the licensed mental health
professional conferred with the program director (PD) or designee, prior to finalizing the
supervision level. The one youth applicable was maintained on close supervision until it was
determined no longer necessary by the DMHCA, documented in the youth’s record by clinical
staff. The discontinuation of close supervision was documented in accordance with the
program’s suicide prevention plan. One youth was Baker Acted by law enforcement and
transported to the crisis stabilization center. A suicide alert was entered into the Department’s
Juvenile Justice Information System (JJIS) for both youth placed on PO and closed following
recommendations. Reviewed logbooks found both youth who were placed on PO indicated
appropriate instructions were provided regarding ASR findings and suicide precaution decisions.
While on PO, both youth were allowed to participate in select activities with other youth in
designated safe housing and safe observation areas of the program. The licensed staff signed
the one applicable documentation of discontinuation of PO completed by the non-licensed staff
and documentation of discontinuation of PO by the PD or designee was notated in the logbook
and on the ASR. The other youth was transferred to another program prior to being stepped
down after returning from being Baker Acted. Two youth was placed on PO with the timeframe
to review video footage with corresponding documentation. The video review verified proper
supervision was maintained.
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3.12 Suicide Precaution Observation Logs (Critical) Satisfactory Compliance
Youth placed on suicide precautions shall be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth shall provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of thirty minutes, at a
minimum.
Juvenile Unit for Specialized Treatment
A review of five youth records found one youth was applicable for review of Suicide Precaution
Observation Logs with two incidents, and one additional record was provided for review. The
remaining youth received Assessments for Suicide Risk (ASR) as part of the standard
admission process and did not require precautionary observation. The logs were maintained for
the duration the youth were on suicide precaution, documented safe housing requirements, and
the appropriate level of supervision and observation of the youth’s behavior in real time not
exceeding thirty-minute intervals. The youth did not have any warning signs. The Suicide
Precaution Observation Logs were reviewed and signed by each shift supervisor and the mental
health professional.
Twin Oaks Vocational Academy II
A review of five youth mental health and substance abuse records found one was applicable for
suicide prevention log documentation. One additional youth record was applicable during the
annual compliance review period and was reviewed. The remaining youth received
Assessments for Suicide Risk (ASR) as part of the standard admission process and did not
require precautionary observation. Both applicable records utilized the Department’s Suicide
Prevention Observation Log forms documenting the appropriate level of supervision,
observations of the youth’s behavior in real time, not exceeding thirty-minute intervals, and safe
housing requirements. None of the logs were applicable for documented warning signs while on
precautionary observation. Both logs were reviewed and signed by each shift supervisor and
mental health clinical staff.
3.13 Suicide Prevention Training (Critical) Satisfactory Compliance
All staff who work with youth shall be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
A review of five pre-service and five in-service training records confirmed each staff completed
the required suicide prevention training. The program has a fully equipped suicide response kit
in each of the four dormitories, one in medical, and one in the administration building, all co-
located with first-aid kits. A review of the program’s mock suicide drills confirmed the program
completed the required quarterly drills, several being completed at a time when both shifts could
participate. Each drill included the use of life saving measures including the use of
cardiopulmonary resuscitation (CPR), suicide response kits, or an automated external
defibrillator (AED). Reviewed documentation supported one mock drill including the use and
demonstration of CPR annually. Documentation verified staff who were not present during a
quarterly drill had the opportunity to review each drill scenario and procedure in an effort to
understand the process and receive the necessary training to respond to an incident of a suicide
attempt or serious self-inflicted injury within the program. An interview with the program director
validated the program conducts monthly training on emergency drills. Six interviewed staff were
able to explain the process for responsibilities when youth express suicidal thoughts. Each staff
knew where the suicide kits were kept and stated suicide drills are completed monthly.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 47 of 79 (Revised September 2022)
3.14 Mental Health Crisis Intervention Services (Critical) Satisfactory Compliance
Every program shall respond to youth in crisis in the least restrictive means possible to
protect the safety of the youth and others, while maintaining control and safety of the facility.
The program shall be able to differentiate a youth who has an acute emotional problem or
serious psychological distress from one who requires emergency services. A youth in crisis
does not pose an imminent threat of harm to himself/herself or others which would require
suicide precautions or emergency treatment.
The program has a written integrated mental health crisis intervention and emergency mental
health and substance abuse services plan. The plan includes a notification and alert system,
means of referral, communication, supervision, documentation, and review process.
3.15 Crisis Assessments (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
Juvenile Unit for Specialized Treatment
Five youth records were provided for review of Crisis Assessments. None of the five selected
were applicable for the review of crisis assessments. The program had and provided only one
youth who was applicable for review. This record was reviewed, and the youth was determined
to be in crisis and received a Crisis Assessment within two hours. The Crisis Assessment
included the reason for assessment, mental health status examination and interview, a
determination of danger to self and/or others, initial clinical impressions, supervision and
treatment recommendations, recommendations for follow-up, and parent/guardian notification.
The Crisis Assessment was conducted by the designated mental health clinician authority
(DMHCA). The youth was assessed immediately after the referral and was not found to be in
crisis and the youth was removed from constant supervision. No follow-up crisis assessment or
Prison Rape Elimination Act (PREA) event was determined or required.
Twin Oaks Vocational Academy II
The program had only one youth requiring a Crisis Assessment during the annual compliance
review week. The date the youth was in crisis was documented on assessment and completed
within the required twenty-four-hour timeframe. The Crisis Assessment documented the reason
for the assessment and included a mental health status examination and interview,
determination of danger to the youth or others, initial clinical impressions, supervision
recommendations, treatment recommendations, and recommendations for further follow-up or
evaluation. The Crisis Assessment was conducted by a licensed mental health professional.
The youth supervision was lowered straight to standard when the assessment was completed;
therefore, did not require a mental health alert to be entered into the Department’s Juvenile
Justice Information System (JJIS), was not deemed to pose a safety or security risk, did not
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 48 of 79 (Revised September 2022)
require off-site care, guardian contact, or needed follow-up assessments. The youth was
determined not to be an alleged victim of a Prison Rape Elimination Act incident. The youth
received an immediate Mental Health and Substance Abuse Referral Summary and offered
ongoing mental health treatment services.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has an integrated mental health crisis intervention and emergency mental health
and substance abuse services plan. The plan included procedures for immediate staff response,
notifications, communication, supervision, authorization to transport for emergency mental
health or substance abuse services, transport for emergency mental health evaluation and
treatment under Chapter 394 Florida Statutes (Baker Act), transport for emergency substance
abuse assessment and treatment under Chapter 397 Florida Statutes (Marchman Act),
documentation, training, and review. The program utilizes a local behavioral health center for
Baker Act crisis stabilization and substance abuse Marchman Act.
3.17 Baker and Marchman Acts (Critical) Non-Applicable
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
Juvenile Unit for Specialized Treatment
The program did not utilize Baker Act or Marchman Act procedures during the annual
compliance review period; therefore, this indicator is rated non-applicable.
Twin Oaks Vocational Academy II
The program had one applicable youth with a Baker Act incident during the annual compliance
review period . Upon determining the youth was in need of emergency care, the staff notified the
designated mental health clinical authority (DMHCA), and the youth was placed on
precautionary observations (PO) with one on one supervision until an Assessment of Suicide
Risk (ASR) was completed. The program’s DMHCA completed a Mental Status Examination as
part of the Crisis Assessment. Upon completion of the assessment, the youth was sent out for
Baker Act services to a stabilization facility, and was transported by local law enforcement.
Upon returning to the program, the youth remained on constant supervision until being
transferred to another program. Documentation of the youth’s observations while on close
supervision was maintained with no exceptions.
3.18 Safety Planning Process for Youth Satisfactory Compliance
A program shall conduct an on-going safety planning process for each youth. The safety plan
shall be designed to identify stimuli which have both positive and negative effects on the
youth.
Juvenile Unit for Specialized Treatment
Five youth records were reviewed for the safety planning process for youth. Each reviewed
safety plans contained warning signs indicating a youth was escalating in their behaviors. Each
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Office of Accountability and Program Support Page 49 of 79 (Revised September 2022)
safety plan included the youth’s baseline behavior gathered from collateral contacts,
parent/guardian, youth’s history, and evaluations. All records included documentation of the
youth and program staff’s perception of verbal and non-verbal stimuli which positively and
negatively affect the youth. All five records included documentation each safety plan was
completed within fourteen days of admission. All safety plans were jointly prepared by the youth,
parent/guardian, and clinical staff. All five safety plans incorporated recommendations from the
current clinical assessments or screenings, along with trauma responsive practices. All five
safety plans were reviewed every thirty days or following any significant behavioral or mental
health event identified by the youth’s intervention and treatment team. All safety plans were
reviewed by staff who have contact with the youth and all plans were maintained in the youth
mental health records and the supervisor’s office. The program director was interviewed and
confirmed staff review safety plans every month or as needed.
Twin Oaks Vocational Academy II
Five youth mental health records were reviewed in reference to a safety planning process for
each youth. Each safety plan included warning signs, youth baseline behavior, crisis
recognition, jointly developed coping strategies to include people and healthy environments as
defined by the youth, intervention strategies preferred by the youth, and a debriefing process.
All five plans were developed and completed, jointly prepared by the youth, parent/guardian or
family member, case manager, and clinical staff, within fourteen days of the youth’s admission
to the program. Each safety plan incorporated any recommendations from previous or current
clinical assessments and/or screening instruments, as well as included trauma responsive
practices. The youth safety plans were updated every thirty-days and were maintained in each
record, as well as maintained in master control in a centralized binder to be easily accessible to
all staff.
Five of six interviewed youth stated they contributed to their safety plans and one youth stated
they are able to go over their safety plans with their therapist. Three interviewed staff reported
safety plans are kept in the supervisor office, one stated the mental health office, one stated the
toolbox on the dormitory, and one staff was not sure where the plans were kept. Two staff
stated they review the safety plans daily, one stated weekly, two were unsure , and one stated
whenever needed. One interview staff stated they last reviewed a safety plan last week, two
stated either today or last night, one stated a couple of months ago, one stated only when first
started, and one stated they are not applicable to review safety plans. The program director
stated the safety plans are updated monthly and as needed.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 50 of 79 (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 has a licensed medical doctor (MD) who serves as the designated health authority
(DHA). The DHA holds an unrestricted license and meets all requirements for independent and
unsupervised practice in the State of Florida. The DHA has a clear and active license, expiring
on January 31, 2026, with specialty training in internal medicine. The DHA did not have any
disciplinary cases and/or public complaints on record. The program does not have a physician’s
assistant (PA) or advanced practice registered nurse (APRN). The DHA is contracted to be on-
site and/or youth can be transported to the office, for a minimum of two hours each week. A
review of sign-in/out logs for the duration of the annual compliance review period confirmed the
DHA provided medical services as agreed upon between the provider and the program. The
DHA had no vacation or scheduled absences during the annual compliance review period. The
program has a back-up DHA who is a licensed MD with a clear and active license in the State of
Florida expiring on January 31, 2026; however, the back-up DHA was not utilized during the
annual compliance review period. The provider did not utilize any tele-medicine services during
the scope of the annual compliance review period .
An interview with the DHA revealed they review policy and procedures annually or as needed,
perform comprehensive physical assessments (CPA), conduct periodic evaluations, complete
chronic clinic initial paperwork upon youth admission, review all labs and x-rays, and sign off
when onsite. The DHA is onsite weekly and on-call twenty-four hours a day, seven days a week
and available to nurses or staff onsite as needed. The nurses prepare all the documentation in
the individual healthcare record (IHCR) and the DHA reviews all the documentation and signs
off on forms when onsite weekly to ensure all off-site care findings, instructions, and information
is reviewed.
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 licensed nurses to include on-site nursing coverage provided by registered
nurses (RN). The program has not utilized any licensed practical nurses (LPN) during the
annual compliance review period. The program had three RNs, providing medical services
during the scope of the annual compliance review period. Each of the three RNs had clear and
active licenses in accordance with Florida Department of Health. Each of the three reviewed
nurses had current cardiopulmonary resuscitation (CPR) certifications. The program’s required
on-site hours for nursing were in accordance with the contract; seven days a week for twelve
hours a day. The program’s nursing staff were found to be in compliance with contract
requirements, which included the provision of three nurses, one of which is identified as the RN
health services administrator (HSA).
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 51 of 79 (Revised September 2022)
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 for all health-related procedures and nursing
protocols, all were developed and approved by the designated health authority (DHA). The
DHA, program director, psychiatrist, and nursing staff all completed an annual review of the
policies and protocols on December 21, 2023, and acknowledged their review by signing a
cover page which indicated there were no updates to the policies and protocols during the
annual compliance review period. There was one newly employed health care staff during the
review period and this staff was still in the process of receiving a comprehensive clinical
orientation to the Department’s healthcare policies and procedures by the registered nurse
(RN).
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.
Juvenile Unit for Specialized Treatment
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
the Authorization for Evaluation and Treatment (AET). Each of the five youth had an AET filed
within their IHCR. The AET form were found to be signed by the youth’s parent/guardian. There
were no AET found where a parent/guardian refused to sign an AET. Each of the AET forms
were signed by a department representative. The AET forms were all found to be valid. There
were no instances of youth eighteen years of age or older. There were no cases of youth in the
care of the Department of Children and Families.
Twin Oaks Vocational Academy II
Five youth Individual Healthcare Records (IHCRs) were reviewed for a valid Authority for
Evaluation and Treatment (AET). Each IHCR included a legible copy of a valid AET, stamped if
required and signed by the youth’s parent/guardian and a department representative. None of
the files reviewed contained a parent refusal or required a court order for the AET. None of the
youth are over the age of eighteen or in the care of the Department of Children and Families
(DCF).
An interview with the nursing staff revealed during admission, an authority for evaluation and
treatment (AET) will be sent via mail if needed, and if an AET is not present during admission,
the JPO will be contacted to assist with the procedure. All youth who are eighteen years old or
older will sign an AET for eighteen and over while at the program.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 52 of 79 (Revised September 2022)
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.
Juvenile Unit for Specialized Treatment
Five youth Individual Healthcare Records (IHCRs) were reviewed for completion of parental
notification/consent. Four of the five records were applicable for parental notification for over the
counter (OTC) medications beyond those covered by the Authority for Evaluation and Treatment
(AET). In each of these cases, consent was provided for by the parent/guardian. Four of the five
youth records were applicable for having had new medication ordered. In each of these cases,
documentation of attempted contact was made to the parent/guardian in the youth’s IHCR
under progress notes. All five youth had written notifications sent utilizing the appropriate
Department forms; four of the youth were prescribed psychotropic medication and the fifth youth
was in receipt of OTC type medication. For each of the youth taking psychotropic medication, a
staff witnessed all telephone call attempts and conversations. There were no significant
changes made to any of the four applicable youth’s prescribed psychotropic medication. There
were no youth who were under the care of the Department of Children and Families. All five
youth had documentation where the program received and verified youth’s vaccination records
on the date of admission. None of the youth were applicable for requiring new vaccinations or
requesting religious exemption. The program utilizes the Florida Shots website for verification of
vaccinations, this occurs during the youth admission to the program.
Twin Oaks Vocational Academy II
Five youth Individual Healthcare Records (IHCRs) were reviewed for parent/guardian
notifications for changes in the youth’s health or consent for medications. All five youth were
applicable for parental notifications. All five records documented parental notification for over-
the-counter medications beyond those covered in the Authority for Evaluation and Treatment
(AET). In each instance consent was obtained from the parent/guardian. New medication was
ordered for three of the five youth and there was documentation of parent/guardian notification
in the progress notes as required. Written notification utilizing the Parental Notification of Health
Related Care form was used in every instance. Three youth were taking psychotropic
medications and in each of the three times a staff witnessed all telephone call attempts and
conversations for psychotropic medications. When a new psychotropic medication was
prescribed or discontinued, or the drug dosage was significantly changed, parental/guardian
verbal consent for psychotropic medication was documented on the Clinical Psychotropic
Progress Note (CPPN) as required. None of the youth were in the care of the Department of
Children and Families (DCF). Each of the original five records was reviewed for vaccinations
and each youth’s vaccinations were verified on the day of admission. None of the youth were
applicable for refused consent for an immunization.
An interview with the nursing staff revealed all parental notifications are conducted when there
are appointments for off-site visits, medication starts and changes, and when something
happens with the youth during their stay at the facility. All parental notifications are made
verbally first then a letter is sent out in the mail regarding what has happened or is happening.
To ensure parental notifications are made timely a telephone call is made and letter sent out at
the time of occurrence. When the youth require emergency services an ambulance will be called
to come onsite for transport of the youth. When a change in medication or a new medication is
started the parent will be contacted by phone for consent to start the medication during the
psych visit. If the parent is unavailable during the psych visit by telephone, another attempt will
be made by the nurse with a witness available for verification. Vaccinations are not provided on-
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Office of Accountability and Program Support Page 53 of 79 (Revised September 2022)
site. Immunizations are checked when the youth comes into the facility by checking the
immunization record is present in the youth’s chart. An alert will be made on the youth’s binder
cover of his individual healthcare record (IHCR) and the medical alert list. If there is an
exemption for immunizations.
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.
Juvenile Unit for Specialized Treatment
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of a
Facility Entry Physical Health Screening (FEPHS). Each youth had a FEPHS completed on
date of admission. Each of the screenings were completed by a registered nurse (RN). There
was no indication any of the reviewed youth had a change in physical custody greater than
twenty-four hours.
Twin Oaks Vocational Academy II
Five youth Individual Healthcare Records (IHCRs) were reviewed, and each included a Facility
Entry Physical Health Screening (FEPHS). The screening was completed on the day of
admission by a registered nurse (RN). One of the five youth records was applicable for change
in physical custody over twenty-four hours. A new FEPHS was completed upon re-admission as
required.
An interview with the nursing staff revealed the youth is seen as soon as they arrive on-site by
medical. The medical staff are notified via email when youth are admitted to the program. The
admission screening is completed by the nurse. Additionally, upon the youth leaving facility
custody and upon returning to the facility, the youth will have another Facility Entry Physical
Health Screening Form (FEPHS) completed along with a urine drug screen (UDS) and flu/covid
screening.
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.
Juvenile Unit for Specialized Treatment
A review of five youth Individual Healthcare Records (IHCRs) was conducted for the completion
of a youth orientation to healthcare services. Each of the youth had documentation of receiving
a general care admission orientation. Each youth’s orientation included all required topics. The
program has each youth sign completion of orientation individually on an orientation form.
Twin Oaks Vocational Academy II
Five youth Individual Healthcare Records (IHCRs) were reviewed, and each included a
general care admission orientation. Each Health Education form documented all
required healthcare orientation topics covered upon each youth’s admission.
Additionally, each youth signed an orientation form listing each covered topic on the day
of their admission, acknowledging the orientation was received.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 54 of 79 (Revised September 2022)
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.
Juvenile Unit for Specialized Treatment
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion for
notification of the designated health authority (DHA) and/or designee. Three of the five youth
were applicable for known or suspected chronic conditions and there was evidence of a referral
having been made to the DHA. There were no youth in need of emergency care upon
admission. The program notifies the DHA of all youth admissions regardless of any suspected
or known medical conditions. There was evidence in each of the five youth IHCR of the DHA
being notified of the youth’s admission to the program. Four of the five youth were applicable for
taking psychotropic medication and subsequent documentation found where the psychiatrist
was notified at admission.
Twin Oaks Vocational Academy II
Five youth Individual Healthcare Records (IHCRs) were reviewed for notification to the
designated health authority (DHA) upon admission. Two youth were identified with a chronic
condition upon admission and a referral was sent to the physician for each case. None of the
youth were identified as in need of emergency care upon admission. The program did not have
any additional youth applicable for chronic conditions or emergency care upon admission during
the annual compliance review period. The DHA was notified of each youth’s admission on the
day of admission by telephone and within twelve hours of youth’s admission. Two youth were
taking psychotropic medication upon admission and the psychiatrist was notified as required.
An interview with the nursing staff revealed the Designated Health Authority (DHA) is notified by
medical upon gaining knowledge of the youth’s serious chronic conditions. The notifications are
documented in the youth’s Individual Health Care Record (IHCR) and admission nurse note.
4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
Juvenile Unit for Specialized Treatment
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
the Health-Related History (HRH) form. Each of the five youth had the HRH form completed
within seven days of admission. The HRH form was completed prior to the completion of the
CPA. Each of the HRH were reviewed by the designated health authority (DHA).
Twin Oaks Vocational Academy II
Five youth Individual Healthcare Records (IHCRs) were reviewed for Health-Related History
(HRH). All five youth had an HRH completed within seven days of admission prior to the
completion of the Comprehensive Physical Assessment (CPA), as evidenced by the signature
and date. The HRH was reviewed by the designated health authority (DHA) prior to completion
of the CPA as evidenced by a checkbox on the CPA.
An interview with nursing staff revealed the Health-Related History (HRH) is completed by the
nurse when the youth arrives on-site.
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Office of Accountability and Program Support Page 55 of 79 (Revised September 2022)
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.
Juvenile Unit for Specialized Treatment
A review of five Individual Healthcare Records (IHCRs) was conducted for completion of a
Comprehensive Physical Assessment (CPA). Each of the youth had a new CPA completed
within seven days of admission. All the CPAs were completed by the designated health
authority (DHA). There was no indication of any missing or incomplete elements on the
reviewed CPAs. All sections of the CPA were completed in full utilizing an “O” and/or applicable
“X” markings. Each of the youth refused the genital examination, and subsequently documented
the refusal, which included the youth’s signature. Each of the IHCRs had the Department’s
problem list updated as required. Additionally, results of each youth’s Tuberculosis Skin Test
(TST) were documented on the CPA and Department’s Infectious and Communicable Disease
(ICD) form.
Twin Oaks Vocational Academy II
Five youth Individual Healthcare Records (IHCRs) were reviewed for completion of a
Comprehensive Physical Assessment (CPA). All five youth had a physical assessment
completed on the Department’s Comprehensive Physical Assessment located in IHCR. There
was no current CPA on file at the time of admission; therefore, all CPAs were completed within
seven days of admission. All five CPAs were completed by the designated health authority
(DHA). The medical grade for three was five, the remaining two were one and two, respectively.
All five youth had a new CPA completed upon admission, a CPA completed prior to the youth’s
current admission was not used or altered. All five CPAs were completed in full as required and
included the youth’s initials on the form for any part of the exam refused. The Department’s
Problem list was updated as required. Each CPA documented one verified Tuberculosis Skin
Test (TST) within the last year which matched the TST results documented on each youth’s
Infectious and Communicable Disease (ICD) form.
An interview with the nursing staff revealed the Comprehensive Physical Assessment (CPA) is
completed by the Designated Health Authority (DHA) upon admission and yearly thereafter.
Upon admission, Tuberculosis Skin Test (TST) screenings are completed and throughout their
stay. This information is included in the medical alert internal system.
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.
Juvenile Unit for Specialized Treatment
A review of five Individual Healthcare Records (IHCRs) was conducted for the completion of
sexually transmitted infections (STI) screening. One of the five IHCR reviewed were applicable
for this part of the indicator, and an additional two records were requested for review. Each of
the three IHCR reviewed, had a youth who was sexually active and subsequently referred to the
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Office of Accountability and Program Support Page 56 of 79 (Revised September 2022)
designated health authority (DHA). Testing was ordered by the DHA for each of the youth;
however, testing has not yet been completed. One youth had an order in October 2023, and the
two remaining youth had orders in December 2023. Seven IHCRs were reviewed for human
immunodeficiency virus (HIV) testing (the original five records, where only one was applicable
for STI screening, plus the two additional records pulled to meet the total of three records for
STI screening). All seven youth were offered HIV counseling, whereas four of the seven
declined further testing or evaluation. The three remaining youth accepted HIV counseling and
testing. Each of the three youth were referred for HIV testing; however, the testing was not
performed. Each of the youth had documented consent maintained in the IHCR. None of the
youth were applicable for having HIV results filed in the IHCR. Pursuant to Florida
Administrative Code 63M-1, testing time limits for STI or HIV are not identified. The
Department’s Office of Health Services indicated an actual doctor’s order for STI testing should
have been followed through with immediately and HIV testing should have been completed in a
timely manner, or within thirty days. The program maintains a policy and procedures which
reflect HIV test results are only disclosed to the youth and other entities as described in Florida
Statute Chapter 381. The on-site nursing staff reports, HIV pre and post-test, and counseling
services are provided through the local health department.
Twin Oaks Vocational Academy II
Five youth Individual Healthcare Records (IHCRs) were reviewed, and one was applicable for
being clinically screened and evaluated for sexually transmitted infections (STIs). The remaining
youths were not required to be screened for STIs. The program had no additional youth
applicable for STI testing during the annual compliance review period. Following the initial
screening, the one applicable youth required further evaluation. The applicable youth was
referred to the designated health authority (DHA), who ordered STI testing for the youth. The
screening and referral were documented on the required Department form. The youth received
testing off-site with the Liberty County Health Department (LCHD); however, LCHD did not
provide written results of the testing to document in the youth’s record. Testing, screening
results, clinical evaluations, and diagnoses were documented on the Infectious and
Communicable Disease (ICD) form excluding HIV. None of the youth were applicable for STI
rescreening. Each of the five youth had documentation in their record they were offered
education and testing for HIV regardless of whether they were applicable to be screened and
evaluated for STIs. One of the five youth consented to HIV testing and there was documentation
the youth was provided testing and pre/post-test counseling off-site by the LCHD as evidenced
by a Summary of Off-Site Care Consultation Report form. The LCHD does not provide written
HIV results; therefore, results are not documented in the youth’s IHCR. Pre/post-test counseling
was not documented on the Health Education form and the youth’s HIV status was not shared
on the program’s alert system. The program has a policy and procedures which specifies HIV
status is only disclosed to parties outlined in Florida Administrative Code.
Six youth were interviewed, and each reported they could request an HIV test at any time. An
interview with nursing staff revealed youth are screened for STIs upon admission. After
screening, if the youth desires to be tested, an appointment is made at the local health
department within thirty days. STI screenings, evaluations, referrals, and testing are
documented in the admission orders, under the infectious disease section, and under the lab
section in the youths IHCR. Youth are rescreened at the youth’s discretion and consent; the
youth will be sent out for testing at the local health department. HIV test results are kept in the
youths IHCR under the lab section in a sealed envelope with confidential written or stamped on
the outside. HIV counseling and testing services are conducted at the local health department.
The process is documented in the health education record in the youth’s IHCR.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 57 of 79 (Revised September 2022)
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.
Juvenile Unit for Specialized Treatment
The program reports there have been no sick call requests during the scope of the annual
compliance review period. Sick call signage was observed outside the medical clinic for the
program, and offered Monday through Friday, 9:30 a.m. and 3:10 p.m., Saturday, 9:45 a.m. and
2:15 p.m., and Sunday, 9:45 a.m. and 4:45 p.m. daily. According to on-site medical staff, only
licensed nurses would conduct sick call. The program does have written policies and
procedures identifying the review of sick call request, when necessary if there are no licensed
medical staff on-site. Sick call request forms were observed to be available to youth outside the
medical clinic. An examination table was observed in the medical clinic. During the annual
compliance review week, there were no sick call requests made by any youth; therefore, an
observation of a sick call was unable to be conducted.
Twin Oaks Vocational Academy II
Five youth Individual Healthcare Records (IHCRs) were reviewed, and none were applicable for
sick call encounters. The program did not have any additional youth applicable for sick call
encounters during the annual compliance review period. Sick call is provided Monday - Friday
10:00 a.m. - 10:10 a.m. and 5:00 p.m. - 6:00 p.m.; Saturday 9:45 a.m. - 10:00 a.m. and 2:15
p.m. - 3:30 p.m.; Sunday 9:45 a.m. - 10:00 a.m. and 4:45 p.m. - 6:30 p.m. Only licensed nurses
conduct sick call. When there is not a licensed nurse on-site, the program has procedures
whereby the shift supervisor reviews all sick call requests as soon as possible and within four
hours after the request is submitted. Sick call forms are available outside the medical office, the
dorms, and upon request. The exam table and equipment are used to perform sick calls.
Six youth were interviewed, and one reported they were seen immediately after submitting a
sick call, one reported they were seen within a day, and four youth had never submitted a sick
call. Seven staff were interviewed, and four staff reported the nursing staff reviews sick call
forms, while one reported the doctor reviews the forms, the remaining two staff indicated the
nurse and doctor review the sick call forms. All seven staff reported the nurses conduct the sick
calls. In addition, three staff reported the doctor and one staff reported the supervisor. An
interview with nursing staff revealed the youth may submit a sick call which is obtained by
asking staff and they are seen at the designated times. The Registered Nurse (RN) conducts
sick calls. If the Designated Health Authority (DHA) is on-site during sick call, then the DHA will
conduct sick call. Sick calls are conducted in the medical clinic. Sick call is conducted daily,
seven days a week at the designated times located at medical and as needed. If the youth has
the same complaint within two weeks, the youth is referred to the DHA for evaluation. The
program has DHA approved treatment protocols.
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4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
Juvenile Unit for Specialized Treatment
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
an episodic, first aid, and or emergency care situation. Four of the five IHCR reviewed were
applicable for completion of an episodic, first aid, and or emergency care situation. Each of the
four situations were taken care of by a licensed healthcare staff. The licensed healthcare staff
documented the findings in subjective, objective, assessment, and plan (SOAP) format. There
were no instances of an episodic, first aid, and or emergency care situation being provided for
by non-healthcare staff.
Twin Oaks Vocational Academy II
The program has a policy and procedures for the provision of episodic and emergency care.
Five youth Individual Healthcare Records (IHCRs) were reviewed, and four youth were
applicable for episodic care. Reviewed documentation for all four applicable records validated
each youth was provided with on-site care by a licensed healthcare staff and documented in the
youth IHCR, as required. None of the youth received first-aid care from a non-healthcare staff.
The program’s fifteen first-aid kits are located throughout the program. The first aid kits are in
each youth dormitory, education, supervisor office, kitchen (dining area), medical, and
administration. Four of the fifteen first kits are specifically utilized for transportation purposes.
The medical staff check first aid kits monthly to ensure contents are maintained and stored in
accordance with guidelines. A review of three random first aid kits was conducted. One of the
three first aid kits had one bottle of eye wash solution, which had expired in November 2023; all
other contents in each of the kits were observed to be in good condition. Review of the on-site
first aid log confirmed kits are monitored monthly. The program has one automated external
defibrillator (AED) located in the medical clinic. The AED procedures are located with the AED.
On-site nursing checks the AED at a minimum monthly to ensure batteries and pads are
operable. Nursing staff conducted a self-test of the AED and no issues were observed. On-site
documentation confirmed the AED batteries and pads will expire in May 2024.
A review of the program’s episodic, first aid, and or emergency care drill documentation,
reflected drills were completed on each shift. The drills were completed at a minimum quarterly
during the annual compliance review period, with the exception of the night shift, which was
missing a drill for one of the quarters. The drills consisted of both announced and unannounced
type drills. All the drills conducted included the administration of cardiopulmonary resuscitation
(CPR) techniques. This afforded each direct care staff the ability to participate in at least one
drill which included the annual use of CPR.. In addition, each of the reviewed drills included the
initiation of emergency procedures and addressed the application of first aid practices. A list of
emergency numbers was found in the medical office and accessible to all staff and inaccessible
to youth. There was no training roster provided for by the program concerning the administration
of an epinephrine auto-injector. A total of ten staff training records documented the completion
of episodic, first aid, and emergency care training.
The program has a policy and procedures which outline the use, access, and inventory of
Narcan. The policy addresses the program’s commitment to ensuring the safety and well-being
of the youth in our care and custody. Therefore, all staff must be diligent in conducting proper
youth and room searches, be knowledgeable and observant to recognize signs of distress
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consistent with drug overdose and be prepared to take life-saving action when necessary. The
program stores Narcan in the medical office. Only medical staff, shift supervisors, and
administration staff have access to the Narcan. The program has not provided specific training
to all staff pertaining to Narcan; however, the program did conduct an emergency drill in
December 2023, which included policy and procedures on Narcan use. The program inventories
Narcan along with other medication counts at a minimum weekly.
Six youth were interviewed, and five reported they could see a dentist, if requested. The
remaining youth stated no. The youth requested to see a dentist upon admission and has not
seen one yet. All six-youth reported being able to see a doctor, if requested. Seven staff were
interviewed, and all stated they are personally allowed to call 9-1-1 if a youth has a medical
emergency. An interview with the nursing staff revealed there are sixteen first aid kits and are
located on the facility grounds. They are in the dorms, in education, supervisors’ office, kitchen,
medical office and administration office. When the youth have an episodic encounter, the youth
is assessed by the nurse and the documentation is provided on the episodic form, documented
in the episodic log and in the youths, nurse note in the Individual Health Care Record (IHCR).
The youth is placed on the medical calendar when an off-site visit is conducted and documented
in the youths IHCR under the off-site section in the youths IHCR. An email is sent out to staff as
well. The program has an Automated External Defibrillator (AED) located outside the medical
exam/office room. The procedures are located with the AED. The medical and training
coordinator checks the AED batteries and pads to ensure they are operable. The AED batteries
expire in May 2024 and the AED pads expire in February 2024. In addition, the medical drills
are conducted quarterly. The emergency numbers are located outside medical on the bulletin
board.
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.
Juvenile Unit for Specialized Treatment
A review of five youth Individual Healthcare Records (IHCRs) was conducted for completion of
off-site care referrals. Three of the five IHCRs reviewed were applicable for this indicator. Each
of the three IHCRs had an indication the youth required off-site care. The three IHCRs
contained a Summary of Off-Site Care Consultation Report form. There was no indication any of
the off-site events were for emergency care. Two of the three off-site events contained parental
notification documentation. The third youth had refused treatment (off-site), prior to departure;
therefore, no notification was required. The two applicable youth had discharge and other
applicable documents filed accordingly in the IHCR. Each of the IHCR had documentation
where the designated health authority (DHA) reviewed and signed off on filed documentation.
None of the reviewed youth required any follow-up testing, referrals, or appointments.
Twin Oaks Vocational Academy II
Five youth Individual Healthcare Records (IHCRs) were reviewed for off-site care, and one was
applicable. The program had no additional youth who required off-site care during the annual
compliance review period. The youth’s IHCR included the Summary of Off-Site Care
Consultation Report forms for the off-site care event. It was also documented on the off-site
emergency episodic care log. Parental notification efforts were documented as required. The
discharge and other applicable documents were filed in the IHCR. The DHA reviewed and
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signed all of the off-site care findings, instructions, and information. The youth did not require
follow up testing or appointments.
An interview with the nursing staff revealed youth who go off-site during emergencies are
tracked by the medical calendar, their off-site form within their IHCR and the nurse
communication notes. When the youth return back on-site, the orders are called into the DHA
and continued or changed and put on their Medication administration record. The medical staff
ensure the DHA is reviewing off-site care by reviewing the youths IHCR. All the follow up
testing, referrals, and appointments are tracked using the medical calendar.
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.
Juvenile Unit for Specialized Treatment
A review of five youth Individual Healthcare Records (IHCRs) was conducted for the completion
of chronic condition periodic evaluations. Three of the five were applicable for having a chronic
condition. None of the youth were identified as having a communicable disease. One youth was
taking non-psychotropic type medication on an on-going basis. None of the youth were
undergoing treatment for a physical health condition. Three of the youth were classified with a
medical grade between two and four, not for psychotropic type medication. None of the youth
were identified as being pregnant. The three applicable youth were placed on a chronic illness
list. One of the three youth was applicable for receiving a periodic evaluation every ninety-days.
The remaining two youth had not been at the program long enough to have received a periodic
evaluation. The one applicable youth had the required documentation filed in the IHCR. None of
the periodic evaluations were conducted off-site. There was no indication of any lapses in care
or missed periodic evaluations. The Department’s Problem List for each youth was updated in
accordance with Florida Administrative Code.
Twin Oaks Vocational Academy II
Five youth Individual Healthcare Records (IHCRs) were reviewed and two were applicable for
chronic conditions. The program had no additional youth who were applicable for chronic
conditions. One youth was identified as taking psychotropic medications. The other youth was
identified as having a chronic health condition and classified as a medical grade between two
and four. Each youth were placed on the chronic illness list as required. One youth did receive
periodic evaluations every ninety days as required. The other youth had his second periodic
ninety day completed six days late. The progress notes were reviewed for documentation of
each completed periodic evaluation as required. The periodic evaluations were conducted prior
to the renewal of prescription medications. The youth did not require off-site care and there was
no indication of any lapses in care. The problem list was updated for each youth as required.
The program director and healthcare staff meet on a daily basis.
An interview with the program director revealed a treatment team is held twice a month or as
needed to review important medical issues with healthcare staff. An interview with the
designated health authority (DHA) revealed periodic evaluations for youth with chronic
conditions are completed and tracked at a minimum every three months, if not sooner. It is
tracked by the nurses on the medical calendar. An interview with the nursing staff revealed
youth with chronic conditions are placed on the internal medical alert list and on the medical
calendar to be seen every three months or sooner by the DHA.
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4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
Juvenile Unit for Specialized Treatment
A review of five youth Individual Healthcare Records (IHCRs) was conducted for the completion
of medication management practices. Each of the youth were admitted to the program on
medication, one for over the counter (OTC) medications, and the remaining four on psychotropic
medications. All five youth Facility Entry Physical Health Screening (FEPHS) forms documented
the inclusion of medications accordingly. Medication was verified by the program upon the
youth’s admission to the program and included in the IHCR. The designated health authority
(DHA), along with the psychiatrist was notified as required to resume medications prescribed
prior to admission. Each youth’s medication had a current, valid order, and were administered
pursuant to the current prescription. Each of the youth’s medications had a practitioner order
form completed by the DHA. None of the reviewed youth were in restricted housing during the
annual compliance review period. Four of the five youth were applicable for prescribed OTC
type medications. Each of the youth taking OTC medications had appropriate practitioner’s
orders. All five youth were applicable for taking either an OTC and or psychotropic medications,
whereas the program utilized the standard Department Medication Administration Record
(MAR) to document all medication and treatment. Four of the five youth were applicable for
having had trained non-healthcare staff assist in the delivery of medications. During the annual
compliance review period, there were three separate occasions where staff did not initial the
MAR when administering medications. In four out of the five youth MAR reviewed, there were
four separate occasions when youth did not initial for receipt of medications. All five youth had
at a minimum weekly side-effect monitoring documented by nursing staff on the MAR. There
was only one occasion where a youth had refused taking medication. Subsequently a refusal
form was completed, and the MAR clearly documented the refusal. Each of the MARs reviewed,
contained all required elements. None of the youth required parenteral medication. Four of the
five youth were applicable being prescribed psychotropic medication. All four youth had
documentation within the IHCR where the psychiatrist was notified upon admission to the
program. Each of the youth were in receipt of an initial diagnostic psychiatric interview within
fourteen days of admission. Three of the four youth received a medication review every thirty
days as required. The fourth youth received a review which was five days late.
Twin Oaks Vocational Academy II
Five youth Individual Healthcare Records (IHCRs) were reviewed for medication management
and two were applicable for taking medications during the annual compliance review period.
The program did not have any additional youth who were applicable for medication
management. Each youth were admitted with medications. A review of the Facility Entry
Physical Health Screening (FEPHS) forms and progress notes indicated each youth were
admitted with medication. Each youth were admitted with medications and the medication was
verified prior to admission utilizing the required Department forms and filed in the youth’s IHCR.
The psychiatrist and designated health authority (DHA) were contacted upon the youth’s
admission to receive an order to continue the medications. Three of the youth were applicable
for having a current, valid order for all prescription medication which was documented as
required. All three youth with prescription medication had their medications changed while in the
program and the psychiatrist provided a valid order for the new prescription, as required.
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All five youth were applicable for receiving over-the-counter (OTC) medications beyond those
covered on the Authority for Evaluation and Treatment (AET). The OTC medication was
administered pursuant to an order from the DHA. The program utilized the standard Department
Medication Administration Record (MAR) to document youth medications, which included all
required elements. Staff initialed all medication administration entries, and on three occasions,
non-healthcare staff provided medications for one youth, both the youth and staff initialed the
MAR except for three instances, where there were no youth initials. Side effect monitoring was
documented daily regardless of who administered the medication. There were no indications of
lapses or errors in medication administration. None of the youth were applicable for refusal of
medications. The MAR contained all the required elements. None of the youth required
parenteral medication. One youth was applicable for psychotropic medications and the youth
received the Initial Diagnostic Psychiatric Evaluation within fourteen days of admission. When
applicable all youth received a medication monitoring summary every thirty days when as
required.
There were no standing orders, emergency treatment orders, or pro re nata (PRN) orders for
psychotropic medication. Medication delivery shall be the sole responsibility of the nurse/staff
person during the time of administration. A medication pass was observed during the annual
compliance review and the youth approached the nurse individually and was escorted by direct-
care staff. The nurses identified themselves, verified the Six Rights of Medication
Administration, prepared and administered the medication, and checked to ensure the youth
swallowed the medication. No OTC medications were administered, and the nurse did not pre-
pour any medication.
Six youth were interviewed, and all six reported they take medication and were each able to
explain the medication administration process. Seven staff were interviewed, and each reported
the nurse administers medication. Additionally, one staff reported a doctor administers
medication when on-site. An interview with the nursing staff revealed medication is verified by
the medication disposition record which comes in with the youth and with the youth’s
parent/guardian. The program utilizes the Department of Juvenile Justice (DJJ) Medication
Administration Records (MAR). Non-healthcare staff are trained in medication administration by
the Registered Nurse (RN), and this information is kept in medical. Medication pass is at 7:00
a.m. and 6:00 p.m. daily. The program utilizes the community pharmacy. The program utilizes a
psychiatrist.
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.
Medical equipment classified as sharps, were observed to be secured and inventoried utilizing a
routine perpetual inventory. In addition, all medications are identified and secured in the locked
area designated for storage of medications, medical cart, and locked cabinets The medication
cart was observed and was found to be clean and organized. All controlled substances were
observed having a perpetual inventory, locked behind two locks, and stored separately from
other medications. All medications were locked away in an area inaccessible to youth.
Medications requiring refrigeration where observed stored in a secured refrigerator used for
medication storage only. The program has an agreement with a pharmacist who comes out
monthly and takes all expired or no longer needed medications. A log was observed on-site of
this process. Six training records were reviewed for non-healthcare staff for training in the
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administration of medications. Training on the delivery of medications is conducted by the on-
site registered nurse (RN) annually.
A review of three controlled, three over the counter (OTC) medications, along with three sharps
were observed, with no issues in inventories. The on-site RN says, if there are any
discrepancies in either sharps or medications, this would be immediately reported to
administration, a thorough search conducted, and reported to the Department’s Central
Communication’s Center.
An interview with the nursing staff revealed the pharmacist comes on-site once monthly and
destroys the medication. All controlled medications are inventoried daily by two staff counting
and verifying the counts and are locked behind three locks. The program currently has an
agreement with a pharmacist. The pharmacist comes on-site once monthly to monitor the
medicine, MAR's, and destroy medications. The program maintains a copy of the Consultant
Pharmacy License (CPH) on-site.
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 an infection control policy which includes an Exposure Control Plan which
includes prevention, containment, and treatment and were written in accordance with
Occupational Safety and Health Administration (OHSA) and Centers for Disease Control and
Prevention (CDC) guidelines. The policy and plan were last reviewed by the designated health
authority (DHA), program director, and nursing staff on December 12, 2023. The infection
control procedures include all required elements. There were no instances in which the local
county health department, CDC, and/or the Department’s Central Communications Center
(CCC) should have been notified of an infectious disease. The Exposure Control Plan was
written in accordance with OSHA standards and includes all required elements to include a
process for post-needle stick exposure. Both the infection control policy and Exposure Control
Plan are available to all staff. The program’s process for needle stick exposure is the program
director will be notified immediately and make available a confidential medical evaluation.
Documentation on the eval will only identify the source individual if consent is given. Post
exposure treatment will be provided. The program director has established a separate file in the
event of any instances of exposure. The program did not have any instances of infectious
diseases which needed to be reported or quarantining of youth during the annual compliance
review period.
An interview with the program director revealed the Exposure Control and Infection Control
plans are located in medical office and supervisor’s office. An interview with the nursing staff
revealed the Exposure Control Plan is available to staff. The training coordinator conducts the
infection control training for all staff. The training is conducted upon admission. The program
currently uses the local health department for the following services: Immunizations, human
immunodeficiency virus (HIV) testing/treatment and sexually transmitted infection (STI)
testing/treatment. All medications are always secured behind two locks. Weekly counts are
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completed on all over the counter medications.
4.19 Prenatal Care/Education Non-Applicable
The program shall provide access to prenatal care for all pregnant youth. Health education
shall be provided to both youth and staff.
This is an all-male program; therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Youth Supervision (CRITICAL) Satisfactory Compliance
Program staff shall maintain active supervision of youth, including interacting positively with
youth, engaging in a full schedule of constructive activities, closely observing behavior of
youth and changes in behavior. Program staff can account for the whereabouts of youth
under their supervision at all times.
The program maintains a policy and procedures requiring all program staff to promote safety
and security by maintaining active supervision of youth to include interacting positively with
youth, engaging youth in a full schedule of constructive activities, closely observing the behavior
of youth, and consistently applying the program’s behavior management system (BMS). The
program utilizes a schedule to include education, therapeutic groups, recreation, etc. The
schedules were posted in the administration building, youth living units, and cafeteria. A review
of the logbook revealed the program substantially followed the posted schedule. The program’s
written policy indicates active supervision ensures ratios are maintained based on the number of
staff to youth in each area. A total of six direct care staff and a vocational instructor were
interviewed in reference to youth supervision and staff to youth ratio. All staff were able provide
an accurate count of each youth without having to physically count. Staff were able to explain
the program’s procedures if the count is not accurate. Each staff explained they would
immediately stop all movement, lock down the program, conduct a recount, and ensure all youth
are accounted for before returning to normal operations. Staff were observed throughout the
annual compliance review week, posted in appropriate positioning, alert, and engaging with
youth when necessary. The required staff to youth ratios were maintained throughout
observations. A review of the video indicated staff to youth ratio was appropriate. No other
issues were noted during the video review conducted. During the annual compliance review,
youth were seen engaged in a full schedule of activities. Positive interactions were observed
with the youth. Six formal staff interviews were conducted. All six staff were able to summarize
the process the program takes in the event a youth count cannot be reconciled. Staff gave
examples of actions to include halting youth movement, lining up youth, and conducting a
recount.
5.02 Comprehensive and Consistent Implementation of the
Satisfactory Compliance
Behavior Management System and Staff Training
The program shall have a detailed written description of the collaborative behavior
management system (BMS). The written description is conspicuously posted and provided in
a resident handbook to allow easy access for youth, including rules governing conduct and
positive and negative consequences for behavior including while in the classroom.
All staff shall be trained in the BMS utilized at the program.
The program has a policy and procedures addressing the implementation and training of the
program’s behavior management system (BMS). The written policy indicates the BMS is
designed to promote safety, respect, fairness, protection of youth rights, positive and negative
consequences, constructive discipline, opportunities for positive reinforcement, and recognition
of accomplishments and positive behaviors at a ratio of four positives to one negative. The
written policy promotes socially acceptable means for youth to meet their needs, includes a
process for explaining to youth the reasons they are being sanctioned with youth being able to
explain their behavior, an opportunity for staff and youth to discuss the impact of their behaviors,
and reasonable reparations for harm caused to others. The BMS addresses the need to discuss
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alternate behaviors which could have been acted on, promotes positive dialogue and peaceful
conflict resolution, minimizes the separation of youth from the population, and does not allow for
an increased length of stay, denial of basic youth rights or services, group discipline,
punishment of youth by other youth, or disciplinary confinement. All youth sanctions were a
result of inappropriate behavior. Special provisions for the BMS are listed in the provider’s
contract to include incentive events for the youth who have met their level. The BMS includes
different incentives to include going on outings in the community, movie nights, ice cream
parties, and cookouts. Six interviewed youth all were able to provide examples of consequences
for behaviors such as receiving a behavior referral, taking of points, and level drops. Five of the
six interviewed youth gave examples of rewards they may earn to include things such as Liberty
Bucks, point store, extra snacks, linger telephone calls, extra hygiene items and longer
showers. One youth stated they are not sure about rewards; however, confirmed they received
a youth handbook. Five of six were able to summarize the program’s BMS. One stated you must
be on gold status or silver to leave the program, but they are unsure how to reach the different
levels. All six denied the program youth are ever authorized to punish other youth. All six stated
staff use rewards the same. Five of six rated the program’s BMS as fair. One stated it was very
good. Five of the six interviewed staff all reported they received training in the BMS. One staff
reported they weren’t trained but are familiar with the process. All were able to summarize the
program’s BMS. All were able to give examples of rewards youth may receive such as Liberty
Bucks, cookouts, point store, off-campus trips, and special meals. All six stated nothing is taken
away as a result of receiving a consequence. All six staff confirmed youth are informed of the
consequences they receive and are able to explain their behavior. All stated supervisors provide
them feedback regarding their implementation of the program’s BMS. All ten pre-service training
records reviewed confirmed staff received training in the BMS. There is an agreement between
the program and the school related to Behavior Management as the teachers are not employed
by the school board; however, the program training coordinator provided the BMS training to the
education staff in the joint plan in order to include the use of the BMS during school.
Observations of staff throughout the review were conducted indicating the staff were alert,
interacting appropriately, addressing youth needs, and met staff to youth ratio. Observations
confirmed peer to peer interactions were positive and encouraging as one youth provided
another youth with positive feedback. The program director was interviewed and was able to
define and describe the program’s BMS.
5.03 Use of Room Restriction Non-Applicable
The program’s behavior management system (BMS) is designed to maintain order and
security, provide constructive discipline and a system of positive and negative consequences
to encourage youth to meet expectations for behavior, provide opportunities for positive
reinforcement and recognition for accomplishments and positive behaviors, promote dialogue
and peaceful conflict resolution, and minimize separation of youth from the general
population.
Supervisors shall monitor staff implementation of the BMS and ensure the use of rewards and
consequences are administered fairly and consistently in application among all staff.
The program does not utilize Room Restriction; therefore, this indicator is rated non-applicable.
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5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
The program has a policy and procedures to conduct and document ten-minute checks during
sleep hours or at other times, such as during an illness. The program has a total of forty-six
video cameras capable of recording thirty days of video footage. All forty-six cameras were
operating as required, according to the assistant program director. Ten-minute checks are
documented on a head count sheet. Documentation included the actual time of each check,
staff initials, and name. Reviewed video of ten-minute checks on nine various days, times, and
shifts confirmed staff were using flashlights and pausing at each youth room door within the ten
minute required timeframes. Observations confirmed staff were alert and positioned
appropriately throughout the night. Six interviewed staff reported room checks are done every
ten minutes.
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 addressing youth census, counts, and tracking. A
review of the program’s logbook reflected head counts are conducted at the beginning of the
shift, after outside activities, and after escapes. The program logbook documents population
counts at the beginning and end of each shift, during emergency situations, as well as tracking
the daily census, all head counts, and youth movement. Observations of youth counts found
staff conducting formal counts and ensuring all youth were accounted for. Logbook review was
conducted for one day each month of the annual compliance review period and found no
discrepancies or exceptions. Documentation included any applicable admissions, releases,
youth movement, emergency situations, and formal headcounts. Six interviewed staff all
confirmed counts are conducted at the program. Four of the six staff interviewed were able to
give the total accurate count of all youth currently in the program. The remaining two staff did
not give the total count of youth assigned, but only the number of youth assigned to them for
the shift. All six interviewed staff gave examples of when emergency counts may be conducted,
such as when an incorrect count occurs, when a youth is missing, after an outside activity, or
during drills.
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5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a policy and procedures to maintain a chronological record of events,
incidents, and activities in a central logbook. Program logbooks are bound with numbered
pages. Entries are legible, include date and time of event, names of staff and youth involved, a
brief description of the event, the name and signature of the person making the entry, and the
date and time of the entry. All entries were made in ink with no erasures or white out areas.
Mistakes are lined out and initialed by the person correcting the error. The activity schedule and
logbook documented minimal interference with educational instruction. Further review of the
logbook indicated education classes were conducted as scheduled. The logbook reflected the
youth arrived and departed school on time, as well as indicated recreation was conducted as
scheduled. The program does not maintain a logbook on each living unit; therefore, a shift
report is reviewed with each oncoming shift and summarizes the events, incidents, and activities
documented within the logbook. Documented events in the logbook include emergency
situations, special instructions for youth supervision, population counts at the beginning and end
of each shift as well as any other random counts, perimeter security checks and any other
security checks needed, transports, admissions, and any information relating to escapes and/or
attempted escapes. Incoming staff sign and date the shift report and according to an informal
interview with staff, a copy of the shift report is maintained at each living unit for one week. The
logbook was reviewed for incidents reported to the Department’s Central Communications
Center (CCC), and all were found documented in the master logbook.
5.07 Key Control (CRITCAL) Satisfactory Compliance
The program has a system in place to govern the control and use of keys including the
following:
• Key assignment and usage including restrictions on usage;
• Inventory and tracking of keys;
• Secure storage of keys not in use;
• Procedures addressing missing or lost keys; and
• Reporting and replacement of damaged keys.
The program has a policy and procedures which addresses key control. Keys are counted at
each shift and either secured or permanently assigned. The program’s policy addresses 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. On-site observations of the distribution and collection of keys
indicated the shift supervisor accounted for all keys on paper and secured staff personal keys.
The assistant program director secured visitor personnel when entering the administration
building area. Master keys are kept in a locked metal box in a locked office, and keys being
issued are kept in a locked metal box inside the shift supervisor’s office. A review of the key
inventory documentation verified the inventory matches the actual key rings in use. Any
permanent keys assigned are documented on the inventory list along with the names of those to
whom the keys are issued , the number of keys, the key ring number, and the staff signature
indicating receipt of the set of keys. Any restricted keys are those permanently issued and not
available to any staff who are not allowed access to them. A formal interview with the assistant
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program director confirmed the information provided. The program has an internal reporting
system when keys are damaged and need replacement as they cut the new keys at the
program. The key box used for storage was not easily accessible when locked and keys are
inventoried twice during shift change for daily tracking and reconciliation of keys. A review of
three staff key inventory matched the actual key rings in use. A review of five permanently
assigned key documents were confirmed with the assistant program director. Personal keys
were all locked and secured not when there were random checks of staff. Six interviewed staff
were able to summarize the program’s key process. An interview with the assistant program
director was conducted who reported the program’s policy includes restricted key usage for
keys such as medical, and youth and staff records, as well as youth personal property. These
keys are secured in a control room.
5.08 Contraband Procedures Satisfactory Compliance
The program’s policy must address illegal contraband and prohibited items.
A program shall delineate items and materials considered contraband when found in the
possession of youth, the list must include: sharps, escape paraphernalia, tobacco products,
lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food or
clothing, any intoxicating beverage or any beverage which causes or may cause an
intoxicating effect, any controlled substance, any prescription or non-prescription drug which
has a hypnotic, stimulating, or depressing effect, any firearm or weapon of any kind or any
explosive substance, non-facility issued electronic equipment or devices to include
smartwatches, metals, personal non-facility issued cellular devices, unauthorized currency or
coin(s), and non-facility issued keys. The program shall provide youth with the list of
contraband items and materials and inform the youth of the consequences if found with
contraband. The program shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, and both staff and youth.
The program shall document the confiscation of any illegal contraband and the manner of
disposition. The program shall keep a copy of the documentation in the youth’s case record. If
a confiscated item is not illegal or prohibited, the program director or designee has the
discretion to discard of the item, return it to its original owner, mail it to the youth's home, or
return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program maintains a policy and procedures to identify materials considered contraband, to
prevent contraband from entering the program, and consequences for when contraband is
found in the possession of youth in the program. The program’s policy includes and delineates
all items considered contraband, as outlined in the Florida Administrative Code. The program
provides youth with a list of items considered contraband. The program’s policy outlines a
search of the physical plant, program’s grounds, the youth, and any incoming and outgoing mail
for any contraband. The program’s policy specifies how any unauthorized or contraband item is
to be confiscated and/or disposed of. A review of the program’s logbooks, daily incident reports,
and perimeter checks verified searches and program checks were conducted. The program’s
policy and procedures and orientation training provided to staff stipulate staff found in
possession of contraband will be subject to disciplinary action up to and including dismissal. All
instances involving confiscation of illegal contraband require the program to turn the item over to
local law enforcement authorities and file a criminal report. A review of reports to the
Department’s Central Communication Center (CCC) for the scope of the annual compliance
review found there have been no reported incidents of illegal contraband which had to be turned
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over to law enforcement. An interview was conducted with the assistant program director, who
confirmed any suspicions of contraband and/or evidence shall notify the shift leader on duty
immediately. If the evidence is relevant to a crime scene, the appropriate law enforcement
department must be notified, and the evidence must not be touched or removed until law
enforcement arrives. Upon removal, evidence must be handled using rubber or disposable
gloves. Evidence and contraband must be placed in plastic bags and properly identified and
labeled. Illegal substances and evidence shall be stored in a locked drawer or cabinet in the
program director’s office until turned over to the appropriate law enforcement department. Six
interviewed staff confirmed searches of youth areas for contraband are conducted at the
program. Searches of the youth are done at every movement, according to five of six
interviewed staff. One staff reported they were unsure of the frequency of the youth searches.
The program director was interviewed, and was able to explain the program’s search and
contraband policy and procedures.
5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program maintains a policy and procedures to ensure searches and full body visual
searches are conducted according to the Florida Administrative Code at the time of admission,
after off-campus activities, and visitation. Throughout the annual review, observation of youth
searches during movement and tool use revealed staff were thorough, same gender, and within
the Right Interactions curriculum. Searches were not conducted in a manner to degrade youth.
Electronic hand-held metal detectors are used to search visitors and supplement youth
searches. Full body visual searches were not observed during the annual compliance review
week due to the program not having any admissions. Six staff were interviewed, as well as the
vocational instructor, assistant program director, and program director who all stated youth are
searched during every movement. Six youth were interviewed and discussed they are searched
before leaving each class, recreation, each restroom break, and/or anytime a youth leaves and
enters the building.
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 to ensure vehicles used to transport youth are
properly maintained and in working order. The program uses six vehicles used for youth
transport, including a seatbelt cutter, window punch, fire extinguisher, and a first-aid kit. All
vehicles had the proper number of seatbelts with the exception of one vehicle which has a
broken seatbelt. The program director reported the vehicle is currently not being used. Shop
records indicated vehicles are inspected regularly and deficiencies were corrected. Six youth
were interviewed and indicated during transport they were secured in a vehicle with a seatbelt
and could not open the door from the inside. Six staff and the assistant program director were
interviewed and indicated youth use seatbelts during transport and handcuffs and leg shackles
are used depending on the youth’s security risk. The assistant program director reported the
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Department of Transportation (DOT) work crew vehicles remain offsite and only come onsite to
transport youth. They were both equipped with window puncher, fire extinguisher, and first aid
which was confirmed with pictures of the required equipment. All six formal youth interviews
confirmed youth use seatbelts when being transported.
5.11 Transportation of Youth Satisfactory Compliance
Appropriate minimum staff-to-youth ratio shall be maintained while youth are transported off
facility grounds to ensure the safety and security of youth, staff, and the public.
The program maintains a policy and procedures to ensure the safety and security of youth and
the community when youth are transported outside of the program. All approved drivers had a
valid driver’s license which was reviewed and confirmed with the assistant program director. A
Interview with the assistant program director indicated a transportation telephone and/or radio
is issued to the driver of the vehicle. The program maintains a one staff to five youth ratio during
all transports and staff are the same gender of the youth. An informal interview with the shift
supervisor confirmed staff and youth each wore their seatbelts and staff were actively
supervising youth while in the vehicle. Youth are not permitted to operate the program or staff
vehicles and a random check of the parking lot revealed vehicles were locked when not in use.
A youth transport was unable to be observed during the annual compliance review week. Six
staff were interviewed and they were able to articulate personal vehicles are not to be used to
transport youth and transport vehicles are searched for contraband prior to and after transport
and were aware of what safety equipment is in the transport vehicle. All six staff and the
assistant program director were able to explain the program process for emergencies while on
transport. All six staff reported youth do not operate the vehicles, wear seat belts, and
supervised throughout the transport.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program maintains a policy and procedures requiring a safe and secure physical plant,
grounds, and perimeter to be maintained and for weekly safety and security audits to be
conducted. The provider owns and maintains the facility in which the program operates. The
assistant program director is responsible for conducting weekly safety and security audits and
submitting the audits to the Department’s safety security specialist. An interview with the
assistant program director confirmed all locks, windows, doors, fences, gates, electronic
systems, metal detectors, and other security devices are checked daily. Any security device
needing repair takes priority over other facility repairs. Buildings have a maintenance safety
check at least once a week. Deficiencies are noted, and a work order for repair is completed
and submitted to the maintenance department. Maintenance conducts weekly testing on the
facility’s emergency generator, and fire detection, and suppression equipment. A comprehensive
health and safety inspection is performed annually by an authority from the health department
for kitchen areas and the fire department. Daily perimeter checks are conducted for contraband
which may have been placed or hidden on the outdoor grounds. The program director was
interviewed and was able to provide and explain the program’s safety and inspection policy and
procedures.
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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 maintains a policy and procedures which addresses tool management, and which
ensures youth do not use tools or equipment as weapons or for security breaches. The policy
addresses the issuance, inventory, and control of equipment and tools. The program staff use
inventory sheets to identify and keep track of tools which include identification markings to
assist with identification. Tools are inventoried prior to each day’s work and after being returned.
Tools are kept in locked spaces when not in use. A review of the tool inventory confirmed tools
are inventoried when used daily if sharp or pointed and monthly for all other tools. Youth who
had access to the tool remain at the work location until searches are completed. Youth who are
searched are separated from youth who have not been searched. The program disposes of
dysfunctional tools and replaces them as needed. In the event a tool becomes dysfunctional or
otherwise broken, a Tool Report form must be submitted to the tool control manager by the end
of the workday. A “D” is placed in the corresponding Tool Control Inventory, and the
dysfunctional tool is immediately removed and turned into the tool control manager along with
the Tool Report form. The tool control manager inspects the tool to determine if it is repairable. If
repairable, a maintenance request is submitted or the tool is repaired by the tool control
manager. If not repairable, a purchase request is submitted to the site administrator. Once
repaired or replaced, the next inventory conducted indicates an “R” in the corresponding
section. The assistant program director reported tools are signed out and returned after each
use. The program’s policy also addresses procedures for missing/lost tools, whereas in the
event this would occur, the tool control manager completes a Tool Report form, and youth who
had access to the tool would then remain at the work location until searches for the item were
completed. Youth who are searched are separated from those who have not been searched.
Observations were made of areas used to store tools. A total of six items were reviewed and
found all were secured, had a marking for easy identification, and were accurate as listed on the
tool control inventory form.
5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program maintains a policy and procedures to ensure youth use tools safely and are
supervised appropriately to prevent injuries. The ratio involving youth using tools is one staff to
five youth and the staff to youth ratio for vocational training is one staff to four youth.
Observations of staff to youth ratios during vocational welding was one staff to four youth. The
program has a policy and procedures for issuing tools, youth risk assessment, and youth
searches. Youth were searched after each work period. Youth risk assessment documentation
reflected if they are cleared for using tools. A review of five youth records confirmed
documentation indicating youth were trained in tool usage. Tool usage risk assessments are
completed by vocational instructor and safety officer prior to youth using tools. Six youth were
interviewed and they reported not being able to use any tools and if you are able to do you have
to pass risk assessment before being able to use any tools. One of six interviewed staff reported
youth do not use tools. Five reported youth use mops and brooms. The interviewed staff also
reported vocational tools are used for youth who participate in those areas. Tools are used
under staff supervision. One of six formally interviewed youth reported he has not used tools.
Five of the six stated they have used mops and brooms.
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5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures which addressed outside contractor’s tools, conduct,
confidentiality, youth interaction, restriction of personal cellular telephones, and procedures
concerning missing tools. Program policy requires all outside vendors and/or contractors to
review the tool control policy, sign, and agree. Each vendor or contractor is required to have a
photo identification card which matches the agreement documentation. Also, the policy requires
all vendors and/or contractors to maintain an inventory of all tools while onsite. The outside
contractor should always keep their tools with them or in clear view. Youth are not allowed to
handle any tools. Before leaving the grounds, the vendor completes a tool verification form
indicating all tools are secured and accounted for. A review of the contractor visit documentation
revealed tools were inventoried and contractors were informed of the procedures. Tools were
checked upon arrival and departure, the contactors had tool restrictions while inside the facility,
no youth were permitted in the work area, and if any tools were missing, there was follow-up.
One work invoice was reviewed and confirmed with the program director which was received
via email. The program director reported all invoices are maintained at the provider’s corporate
office.
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 conducts 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. A review
of documentation indicated the program conducted monthly Continuity of Operations Plan
(COOP) drills on a rotating basis, covering each shift. The program is currently operating on two
shifts. Drill documentation contained the type of drill, date, time, staff participants, brief
description, findings, and/or recommendations. The assistant program director was interviewed
and indicated the COOP includes fire, natural disasters, riots, violence, terrorism threats, bomb
threats, hostage situations, chemical spills, flooding, power outages, suspicious packages,
escapes, and medical drills. The fire evacuation routes are posted throughout the program. Six
interviewed staff reported they participated in fire and COOP drills. Four of six interviewed
youth stated they had been instructed on what to do in case of a fire. Two of six reported they
had not been instructed. The assistant program director reported all staff and youth are required
to participate in monthly drills and receive feedback upon completion. The program director was
interviewed and stated fire drills are done monthly, and other COOP drills are done annually.
The program director reported the COOP itself is located in the supervisor’s office.
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5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program maintains a written Continuity of Operations Plan (COOP) which was reviewed
and approved by Regional Director on February 21, 2023. The COOP is located in the
supervisor’s office and administration and is readily available to all staff. The plan addresses
alternative relocation sites which are approved by the Department along with the alternative
relocation sites representative. The COOP addresses phases of a disaster plan as well as
emergency management including preparedness, response, and recovery. The COOP is
maintained in the supervisor office and addresses emergencies including fire prevention, bomb
threats, disturbances or riots, hostage situations, evacuations, chemical spills, severe weather,
and terrorist attacks. The COOP includes staff roles and responsibilities, equipment and
supplies needed, and provisions for continuity of care and custody of youth as well as provisions
for public protection. A review of the plan indicated alternative housing has been identified
should the program require evacuation due to an emergency or disaster. Supplies and/or
equipment needed during an emergency or disaster are stored on the program’s campus and
include pallets of water, hygiene products, paper supplies, and three days’ worth of ready to eat
meals. An interview with the program director confirmed in the event of an evacuation, all hard
copy youth records are transported in a secure trailer. A review of ten youth case management
records verified each record included the youth’s name, a photograph, Department identification
number, admission date, date of birth, gender and race, overall health status, address, and
parent/guardian contact information, including the name, address, telephone number of the
person with whom the youth resides and their relationship to the youth, and person(s) to notify
in case of an emergency. In addition, the records contained the youth’s assigned juvenile
probation officer (JPO), committing judge, state attorney, public defender, and victim notification
contact information.
5.18 Storage and Inventory of Flammable, Poisonous, and
Satisfactory Compliance
Toxic Items and Materials
The program director or designee shall maintain strict control of flammable, poisonous, and
toxic items and materials and a complete inventory of all such items.
The program has a policy and procedures which addresses the storage and inventory of
flammable, poisonous, and toxic items. These items are stored in the shift supervisor’s office
and dorm storage rooms, which are to remain secure at all times. Observations made during the
annual compliance review found chemicals and cleaning agents were secured and inaccessible
to youth. Inventories were maintained for all flammable, poisonous, and toxic items. Per and
interview with the assistant program director, all staff are trained to handle these items. Safety
Data Sheets (SDS) were observed for all items reviewed. A sample of three items was
observed, and found each to have a corresponding SDS present and no discrepancies were
noted with the inventory present.
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5.19 Youth Handling and Supervision for Flammable,
Satisfactory Compliance
Poisonous, and Toxic Items and Materials
The program shall maintain strict control of flammable, poisonous, and toxic items and
materials.
Youth shall not be permitted to use, handle, or access dangerous or hazardous chemicals or
respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s biohazardous material, bodily fluids, or human waste.
The program shall establish and implement cleaning schedules, a pest control system, a
garbage removal system, and a facility maintenance system which shall include maintenance
schedules and timely repairs based on visual and manual inspections of the facility structure,
grounds, and equipment, which shall be conducted bi-weekly, monthly, quarterly, semi-
annually, yearly, and every three years, as prescribed in the Preventive Maintenance
Checklist (RS 123, February 2019).
The program has a policy and procedures which address control of and who can handle
flammable, poisonous, and toxic items. The program maintains strict control of flammable,
poisonous, and toxic items and staff control access to cleaning supplies and do not let youth
handle flammable, poisonous, and toxic items. Youth are not permitted to use, handle, or clean-
up dangerous or hazardous chemicals, or dispose of any person’s bio-hazardous material,
bodily fluids, or human waste. The program maintains restricted youth access to areas where
items are used or stored. Observations were made during the annual compliance review week
of three youth cleaning after lunch. One youth was mopping, one was wiping a table, and one
was sweeping. No issues were observed or reported. A staff was present, providing supervision.
Six youth were interviewed concerning their access to chemicals at the program. Three youth
stated they do not use any chemicals or cleaning products. One youth stated they have used
toilet or window cleaner, one stated they used paint in carpentry class and two responded they
have used bleach. The youth who stated they had used chemicals all reported the staff put the
chemical in a bucket or on a rag, and they sprayed or wiped with it.
5.20 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance personnel, or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous and/or solid waste, shall be responsible for disposing of
hazardous items and toxic materials.
The program has a policy and procedures for the disposal of flammable, toxic, caustic, and
poisonous items. The program director was interviewed and reported the program uses the
most common disposal method for both municipal non-hazardous and hazardous waste, which
is land filling. All hazardous chemicals are transported to the county landfill for proper disposal.
When there is a need to dispose of hazardous chemicals, the safety officer or maintenance
supervisor notifies the county landfill personnel of the type of chemical to be disposed of in
order to get directions regarding steps to be taken regarding transporting the hazardous
material to the landfill. The program’s list of positions, authorized to dispose of items includes
the program’s safety officer and maintenance staff. Disposal procedures are in accordance with
Occupational Safety and Health Administration (OSHA) standards. The program’s disposal log
determined when, how often, and how materials are disposed of. Hazardous liquid is disposed
of in accordance with the Safety Data Sheets (SDS). All hazardous materials are stored in a
hazardous materials storage area. Liquid waste, to include dirty mop water, is disposed of in
plumbing drains. The program does not have a kitchen or grease disposal. Based on the
program’s policy and procedures, chemical spills are to be notified to master control by staff,
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and the shift supervisor will direct the shutdown of all air handlers and ventilation systems and
close all windows and doors in the direction of the on-scene supervisor or program director.
Assistance from outside the program shall be contacted, as necessary, and consistent with
emergency procedures.
5.21 Elements of the Water Safety Plan, Staff Training, and
Non-Applicable
Swim Test (Critical)
Programs choosing to participate in water-related activities shall develop and implement a
water safety plan to ensure proper supervision and safety of the youth during water related
activities. The plan shall also ensure staff are appropriately trained for each specific type of
water activity.
Programs allowing youth to participate in water related activities shall have a water safety
plan addressing, at a minimum, safety issues, emergency procedures, and the rules to be
followed during water related activities, as follows:
• Determination of the risk level for each participating youth, including whether or not
the youth can swim, an assessment of swimming ability, and other factors to include
age and maturity, special needs such as physical and mental health issues, and
physical stature and conditioning;
• Type of water, such as pool or open water;
• Water conditions, such as clarity, turbulence, and bottom conditions;
• Type of activity, such as swimming, boating, canoeing, rafting, snorkeling, scuba
diving, and shoreline and offshore activities to include fishing from a bank or pier,
fishing while wading, or picnicking close to a body of water.
• Lifeguard-to-youth ratio and positioning of lifeguards;
• Other staff supervision; and
• Safety equipment needed for the activity, such as personal flotation devices when
youth are in a boat, canoe, or raft, and availability of a lifeline during shoreline and
offshore activities.
Programs choosing to participate in water-related activities shall ensure staff are
appropriately trained for each specific type of water activity. Programs choosing to participate
in water-related activities shall assess each youth's aquatic ability prior to participation in
water-related programming.
The program does not participate in any water-related activities; therefore, this indicator is rated
non-applicable.
5.22 Visitation and Communication Satisfactory Compliance
The program allows visitation and communication for youth while in the program.
The program has a posted visitation schedule visible in the lobby area of the administration
building and youth dorms. The program has a policy and procedures which addressed visitation
for youth and youth usage of the telephone and correspondence. Visitation days are conducted
on the weekends. A review of the telephone log and schedule confirmed youth are able to make
telephone calls at a weekly basis. In the event alternate visitation days are needed, the program
will make these options available. For youth with a history of human trafficking, the program will
request clarification from the assigned juvenile probation officer to verify the youth’s contact
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person and other family members to ensure they are not under current or past investigation for
human-trafficking related charges. Outgoing mail is searched by staff. Four of six interviewed
youth reported they were not aware of services the program uses for youth whose English is not
their primary language. One youth stated the program does have a service but is not sure what
it is. One youth stated the program will get someone who speaks the language to translate. All
six youth stated they are able to call their parent/guardian and mail letters. Six staff were
interviewed. Five of six staff reported they have bilingual staff who will assist a youth in
translating in the event English was not their primary language. One staff reported they are not
certain what services the program has to assist youth in language translation if needed. The
program director was interviewed and also stated the program employs multiple bilingual staff to
assist youth in translation when needed.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program has a posted daily activity schedule which documents a range of supervised and
structured indoor and outdoor recreation and leisure activities for the youth at least one hour
daily. The schedule allows for indoor and outdoor large muscle activity. A review of the
program’s logbook also indicated recreation is conducted as scheduled. Activities offered
promote social and cognitive skill development, creativity, teamwork, healthy competition mental
stimulation, and physical fitness. Recreational activities were observed ensuring the program
takes precautionary measures to prevent overexertion, illness, or physical injury due to weather
related issues. The program employs a recreational therapist who meets all contract
requirements for the position. A review of five youth records revealed recreational therapy was
included in each youth’s individualized performance and treatment plan. Six interviewed staff
reported youth have the opportunity to participate in outdoor activities at least one hour daily.
Staff gave examples of these activities, such as basketball, football, aquaponics, kickball, ping
pong, and foosball. Six interviewed youth confirmed the program allows them the opportunity to
exercise, play outside, or spend downtime to reading a book or playing board games for at least
one hour daily.
5.24 Search and Inspection of Controlled Observation Room Non-Applicable
The program shall conduct youth searches and room inspections prior to placing a youth on
Controlled Observation.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
5.25 Controlled Observation Non-Applicable
Programs shall only place youth in Controlled Observation when non-physical interventions
would not be effective.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 78 of 79 (Revised September 2022)
5.26 Controlled Observation Safety Checks Release Procedures Non-Applicable
The program shall conduct safety checks for youth on Controlled Observation.
The program director or designee shall approve a release when it is determined, based on
the youth’s behavior, the youth is no longer an imminent threat to self or others.
The program’s policy, procedures, and practice confirm the program does not use controlled
observation; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 79 of 79 (Revised September 2022)

report_type: QI Residential

program_name_raw: Juvenile Unit for Specialized Treatment (JUST) & Twin Oaks Vocational Academy II

rule: Indicator 1.13

rating: Limited Compliance