summary: QI Residential - FY23-24 - 6 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Oak Grove Academy
Rite of Passage, Inc.
(Contract Provider)
11180 NE 38th Street
Jasoer, Florida 32052
Review Date(s): October 24-27, 2023
Promoting Continuous Improvement and Accountability
In Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Tara Gilligan, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Patrick Brock, Office of Education, North Central Education Coordinator (Standard 2)
Renette Crosby, Office of Accountability and Program Support, Regional Monitor (Standard 4
and Interviews)
LeAnn Gruentzel, Office of Accountability and Program Support, Deputy Supervisor (Standard 3
and Interviews)
Kristine Harshaw, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Jillian Lewandowski, Probation and Community Intervention, Assistant Chief Probation Officer
(Standard 2)
Program Name: Oak Grove Academy MQI Program Code: 1450
Provider Name: Rite of Passage, Inc. Contract Number: 10590
Location: Hamilton County / Circuit 3 Number of Beds: 40
Review Date(s): October 24-27, 2023 Lead Reviewer Code: 188
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Assessment and Performance Plan, (3) Mental Health and
Substance Abuse Services, (4) Health Services, and (5) Safety and Security, which are included
in the Residential Standards.
Overall Rating Summary
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
2.07 Residential Assessment for Youth (RAY) 5.08 Contraband Procedure
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff
3.06 Mental Health and Substance Abuse Treatment*
3.12 Suicide Precaution Observation Logs *
3.15 Crisis Assessments *
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 3 of 68 (Revised September 2022)
Standard 1: Management Accountability
Residential Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening * Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Provision of an Abuse-Free Environment * Satisfactory
1.04 Management Response to Allegations * Satisfactory
1.05 Incident Reporting (CCC) * Satisfactory
1.06 Protective Action Response (PAR) and Physical Intervention Rate Satisfactory
1.07 Pre-Service/Certification Requirements * Satisfactory
1.08 In-Service Training Satisfactory
1.09 Grievance Process Satisfactory
1.10 Interventions and Facilitator Training Satisfactory
1.11 Life Skills Training Provided to Youth Satisfactory
1.12 Restorative Justice Awareness for Youth Satisfactory
1.13 Internal Alerts System and Alerts (JJIS)* Satisfactory
1.14 Youth Records (Healthcare and Management) Satisfactory
1.15 Advisory Board 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 68 (Revised September 2022)
Standard 2: Assessment and Performance Plan
Residential Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court Notification Satisfactory
2.02 Youth Orientation Satisfactory
2.03 Written Consent of Youth Eighteen or Older Satisfactory
2.04 Classification Factors, Procedures, and Reassessment for Activities Satisfactory
2.05 Gang Identification: Notification of Law Enforcement Satisfactory
2.06 Gang Identification: Prevention and Intervention Activities Satisfactory
2.07 Residential Assessment for Youth (RAY) Limited
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 68 (Revised September 2022)
Standard 3: Mental Health and Substance Abuse Services
Residential Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority or Clinical Coordinator Satisfactory
3.02 Licensed Mental Health and Substance Abuse Clinical Staff * Satisfactory
3.03 Non-Licensed Mental Health and Substance Abuse Clinical Staff Limited
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* Limited
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 * Limited
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Crisis Assessments * Limited
3.16 Emergency Mental Health and Substance Abuse Services * Satisfactory
3.17 Baker and Marchman Acts * Satisfactory
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 68 (Revised September 2022)
Standard 4: Health Services
Residential Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee * Satisfactory
4.02 Licensed Medical Staff* Satisfactory
4.03 Facility Operating Procedures Satisfactory
4.04 Authority for Evaluation and Treatment Satisfactory
4.05 Parental Notification/Consent Satisfactory
4.06 Healthcare Admission & Rescreening Form Satisfactory
4.07 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.08 Designated Health Authority/Designee Admission Notification Satisfactory
4.09 Health-Related History Satisfactory
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory
4.11 Sexually Transmitted Infection & HIV Screening Satisfactory
4.12 Sick Call Process Satisfactory
4.13 Episodic/First Aid Care/Emergency Care Satisfactory
4.14 Off-Site Care/Referrals Satisfactory
4.15 Chronic Illness/Periodic Evaluations Satisfactory
4.16 Medication Management Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control Satisfactory
4.19 Prenatal Care/Education 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 68 (Revised September 2022)
Standard 5: Safety and Security
Residential Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Youth Supervision * Satisfactory
5.02 Comprehensive and Consistent Implementation of the Behavior Mgt System and Staff Training Satisfactory
5.03 Use of Room Restriction 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 Failed
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 68 (Revised September 2022)
Program Overview
Oak Grove Academy is a forty-bed program for fourteen to nineteen-year-old males, located in
Jasper, Florida. The program is operated by Rite of Passage, Inc., through a contract with the
Department. The program provides services including Substance Abuse Treatment Overlay
Services (SAOS) where youth receive individual and group mental health, behavioral health,
and substance abuse treatment services, and family and individual therapy. In addition, the
program fosters each youth by providing primary services of Aggression Replacement Training
(ART), Seeking Safety, and Impact of Crime (IOC), as well as non-primary services of Thinking
for a Change (T4C), Living in Balance (LIB), and The Council for Boys and Young Men: Men of
Honor. The program’s optional supportive groups include Active Parenting and Cognitive
Behavioral Intervention for Substance Abuse. Additional services include equine therapy,
ServSafe food handlers’ certifications, culinary arts, and masonry. Program administration is
comprised of a program director and two shift supervisors. Case management and mental
health services are provided by the designated mental health clinician authority (DMHCA), three
transition service managers, and four therapeutic managers. Medical services are offered
twenty-four hours a day, seven days a week and are provided by a medical doctor, a health
services administrator, one full-time registered nurse, and one psychiatrist. Educational services
are provided by the program using four teachers and two paraprofessionals. The layout of the
program includes an administration building, cafeteria, two youth modules, two basketball
courts, a vocational building, and an education building. The program has fifty-one cameras
providing video coverage, which were all operational. At the time of the annual compliance
review, the program had sixteen vacancies including a director of youth services, three night
coach counselors, one cook, four teachers, two part-time teachers, one equine program
director, one human resources specialist, one licensed practical nurse, one compliance and
training coordinator, and one paraprofessional.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 9 of 68 (Revised September 2022)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted providers and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. (Note: The term contracted providers, in the remaining
portions of this document, also include grant recipients.) A contracted provider may provide
training and orientation to a potential staff before the screening process is completed.
However, these individuals may not have contact with youth or confidential youth records until
the screening is completed, the determination is “eligible,” a copy of the criminal history report
has been reviewed, and the staff demonstrates he or she exhibits no behaviors warranting
the denial of employment. An Annual Affidavit of Compliance with Level 2 Screening
Standards must be completed annually. This affidavit attests all persons working or
volunteering during the past year were screened according to Level 2 standards.
The program has a policy and procedures to ensure background screenings are conducted for
all staff, volunteers, mentors, and interns with access to youth or confidential youth records. The
program completed and submitted the Annual Affidavit of Compliance with Level 2 Screening
Standards to the Department’s Background Screening Unit (BSU) on January 12, 2023, meeting
the annual requirement. The program does not have any teachers employed by the school
board. The program had twenty-three newly hired staff since the last annual compliance review.
Each staff had a background screening completed prior to contact with youth and confidential
records. Criminal history reports were reviewed prior to hire for each staff. One staff was
applicable to a break in service as indicated in the staff verification system (SVS) and the
applicable staff had a new background screening completed, as required. The program
completed a pre-assessment tool for all newly hired staff, all of whom had a passing score in
their staff record. The staff applicable for the break in service had a pre-employment
assessment tool from their original hire date in 2019. A new assessment was not administered;
however, the original assessment was in the staff’s record. All staff were added to the program’s
Clearinghouse 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 which address the five-year background rescreening
process. A background rescreening is required every five years from the initial date of
employment. A review of the program’s staff roster indicated one staff required a five-year
rescreening. A rescreening/renewal was submitted to the Department’s Background Screening
Unit/Clearinghouse at least ten business days prior to the five-year anniversary or retained
prints expiration date, as required.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 10 of 68 (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 provides an environment in which youth, staff, and others feel safe, secure, and
not threatened by any form of abuse or harassment. The program had fourteen incidents related
to physical, psychological, or emotional abuse since the last annual compliance review. Five of
those incidents were reviewed, and all five were reported to the Department’s Central
Communications Center (CCC). Four incidents were substantiated, all of which had corrective
action. None of the incidents included potential human trafficking, child sexual exploitation, or
labor trafficking. A review of five staff records showed staff review and sign a code of conduct
outlining staff expectations. The Florida Abuse Hotline and the CCC numbers were found to be
posted throughout the facility. Staff have unhindered access to report alleged abuse. Staff are
provided telephone access to report allegations of abuse. At no time are youth prevented from
self-reporting or making a call to the Florida Abuse Hotline or the CCC. The program completed
a Trauma Responsive and Caring Environment (TRACE) self-assessment on May 23, 2023.
Five youth were interviewed and each stated they felt safe in the program and denied ever
being stopped from reporting abuse to the Florida Abuse Hotline or CCC (if 18 years or older)
since being at the program. All five youth confirmed they knew where the Florida Abuse Hotline
phone number is posted in the facility. Four of five youth stated staff are respectful when talking
to them. One youth stated certain staff will try to punish youth for “small things.” When the youth
were asked if they have heard staff use curse words when speaking to them or other youth, two
youth stated “never,” one stated “once,” and two stated “occasionally.” The program director
provided the corrective action in place for staff who have been found using profanity with youth.
All five youth denied ever exchanging emails, telephone numbers, or social media contact
information with staff.
Five staff were interviewed. When asked to explain the process for allowing staff and youth to
call the Florida Abuse Hotline or CCC (if the youth is eighteen years or older) to report
suspected abuse, five staff stated they would notify the supervisor, one stated they would notify
the program director, three stated they would allow the youth to make the call, and one stated
the supervisor would make the call. Staff also stated they will log the abuse call in the logbook,
the supervisor would complete the abuse call process, and they would notify master control to
put the call into the logbook. All five staff denied they have ever observed a co-worker telling a
youth they could not call the Florida Abuse Hotline. When asked if they have ever observed a
co-worker using profanity when speaking to youth, using threats, intimidation, or humiliation
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 11 of 68 (Revised September 2022)
when interacting with youth, one stated they had, and four stated they had not. The staff who
stated they had heard a staff curse at a youth further explained, a previous staff cursed at a
youth during a stressful situation. The program director stated he was aware of this, and the
staff was reprimanded. All five staff either knew the number to the Florida Abuse Hotline or
knew where it was located.
An interview with the program director determined the code of conduct includes how staff will
represent the department and will protect individuals from the misconduct of others. Conduct
which interferes with operations or is offensive to staff, youth, and their families is not tolerated.
The program uses a progressive corrective action system, but does not tolerate offenses in
which physical abuse, threats, or profanity towards youth are used. The program incorporates
trauma-responsive practices by ensuring each youth has a safety plan which is created upon
admission, reviewed by all staff, and is in a general location for staff reference as needed. All
staff and volunteers of the program are required to adhere to the Florida Administrative Code.
relating to the reporting of incidents, as well as procedures for reporting incidents which are not
required to be called in to the CCC. The program director and compliance manager are the only
persons authorized to make reports to the CCC. The program director ensures any matter
requiring reporting to the CCC is verbally reported within two hours of the incident or learning of
the incident, and reported verbally and in writing within twenty-four hours to the supervising
director of operations or back-up designee. If there is doubt at any time as to whether an
incident or event is reportable, the presumption is the incident or event is reportable and shall
be reported. The program director also ensures the program maintains a separate file of all
incident reports and has a system in place for tracking all incidents. To ensure staff and youth
are knowledgeable in contacting the Florida Abuse Hotline and CCC, the program has postings
throughout the facility with all pertinent information regarding contacting the Florida Abuse
Hotline and CCC. All incidents are tracked in the program’s incident report tracker and all calls
to the CCC and Florida Abuse Hotline are discussed daily in management meetings and daily
shift briefings for all shifts and professional staff.
1.04 Management Response to Allegations (Critical) Satisfactory Compliance
Management shall be cognizant of youth and staff needs and provide direction to each on
how to access the Florida Abuse Hotline. There is evidence management takes immediate
action to address incidents of physical, psychological, and emotional abuse.
The program has a policy and procedures ensuring management takes immediate action to
address incidents of physical, psychological, and emotional abuse. The program had twelve
incidents since the last annual compliance review. Five incidents were reviewed and each
involved a complaint against staff for physical or emotional abuse. A review of documentation
found management took immediate action to address each incident along with the corrective
action taken by management for follow-up allegations and/or substantiated incidents of abuse or
neglect. The program director explained any time management is made aware of any
allegations of abuse, an internal investigation is immediately initiated. Management will place
the staff with the allegation on suspension pending an investigation, with no youth contact to
prevent further incident/allegation. Management will contact the Florida Abuse Hotline and/or
the Department’s Central Communications Center (CCC) to make the reports as required.
Following the completion of investigation, or when identified during the investigation, disciplinary
action is issued, as outlined in the program’s progressive disciplinary system, which can lead up
to termination of employment.
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 12 of 68 (Revised September 2022)
1.05 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The program shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident occurring, or within two hours of any program staff becoming aware of
the reportable incident.
The program maintains a policy and procedures to ensure the Department’s Central
Communications Center (CCC) is notified within two hours of an incident occurring, or within two
hours of any program staff becoming aware of a reportable incident. A total of thirty-six incidents
were reported to the CCC during the annual compliance review period. Five incidents were
reviewed and each was reported within the required two-hour time frame. Four of five incidents
were documented in the logbook, as required. A review of incidents, grievances, and youth
records found no additional incidents which should have been reported to the CCC. The
program experienced a total of fourteen incidents which were reported to the CCC during the
last annual compliance review period. The program director (PD) was interviewed and explained
the reason for the increase of CCC reportable incidents was based on unusually high staff
turnover and a shift in youth culture.
1.06 Protective Action Response (PAR) and Physical
Satisfactory Compliance
Intervention Rate
The program uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is completed and filed in accordance with the Florida
Administrative Code.
The program has a policy and procedures regarding the use of physical intervention techniques
in accordance with Florida Administrative Code. Anytime staff use a physical intervention
technique, or apply mechanical restraints, a Protective Action Response Right Interactions
model (PAR/RI) incident report is completed and filed in accordance with Florida Administrative
Code. The program had twelve PAR/RI incidents reported during the annual compliance review
period; five of those incidents were reviewed. All five PAR/RI incident reports confirmed each
was completed by the end of the staff’s workday and included a statement from each staff
involved. None of the incidents were applicable for the use of mechanical restraints. Two of the
reviewed PAR/RI Reports resulted in an injury to staff or youth, and the Department’s Central
Communications Center (CCC) was contacted within two hours of the incident, as required, in
both incidents. None of the reviewed incidents alleged abuse. Each incident report included a
review by a supervisor and/or PAR/RI instructor. No PAR/RI medical reviews were conducted,
as the two youth who reported injuries were immediately sent out for treatment at a hospital. All
five PAR/RI Reports were reviewed by the program director (PD) within seventy-two hours of
the incident. A copy of each PAR/RI Report was placed in the program’s centralized file within
forty-eight hours of approval/signature by the PD or designee for all five incidents reviewed.
Monthly summaries were maintained by the program of all PAR/RI incidents submitted to the
Department’s regional office by the fifteenth of each month, during the annual compliance
review period.
The program has a PAR/RI plan which was updated on January 13, 2023, and approved by the
Department on January 20, 2023. The number of PAR/RI incidents from the program during the
previous annual compliance review period was thirteen, as such, the program did not
experience an increase in the number of PAR/RI incidents since the last annual compliance
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Office of Accountability and Program Support Page 13 of 68 (Revised September 2022)
review. The program’s PAR rate during the previous quarter was 1.24, which is below the
statewide Residential PAR/RI rate of 1.35. An interview with the PD determined all use-of-force
incidents are to be communicated with supervisory and administrative staff immediately. If
administrative staff are not on-site, PAR/RI Reports are scanned to administrators prior to
completion of the shift. All PAR/RI incidents and use-of-force incidents are monitored daily in the
morning meetings, and the facility keeps an internal monitoring process to address all trends
regarding PAR/RI and use-of-force. Five staff were interviewed. Three staff stated they have
never used PAR/RI while at the program. One staff stated if a youth shows warning signs, staff
are to use multiple verbal prompts to deescalate the situation before using a physical PAR/RI.
Once a PAR/RI is used, program staff must follow-up with the youth, and complete a PAR/RI
Report. The remaining staff stated they would try and talk to the youth using verbal commands;
if there was no de-escalation, then they would call for support and use techniques taught in
PAR/RI training. Once the PAR/RI was over, staff would speak with the youth for follow-up, and
participate in a post-PAR/RI interview.
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.
Five staff records were reviewed for pre-service training. Three of five records reflected all
required trainings were completed within 180 days of hire. The remaining two records showed
the 120 hours of pre-service training was not completed within 180 days of hire.
Five records reflected all essential skills trainings were completed within 180 days of
hire and prior to any contact with youth. Four records showed the staff failed to complete
additional trainings in adolescent behavior and development, balanced approach to restorative
justice, and the Department’s Central Communications Center (CCC) incident reporting. The
remaining staff failed to complete adolescent development and behavior training and CCC
incident reporting. All five staff completed trainings required by other Rules or manuals, as
required. None of the reviewed records reflected entry requirements were completed in the
Department’s Learning Management System (SkillPro) for all applicable trainings.
1.08 In-Service Training Satisfactory Compliance
Residential contracted provider staff shall complete twenty-four hours of in-service training,
including mandatory topics specified in Florida Administrative Code, each calendar year,
effective the year after pre-service/certification training is completed. Supervisory staff shall
complete eight hours of training in addition to the twenty-four hours of annual in-service
training) in the areas specified in Florida Administrative Code.
Five staff training records were reviewed for in-service training. All staff were missing at least
one training in the Department’s Learning Management System (SkillPro) at the time of the
annual compliance review. Three staff were missing active shooter training and two did not
complete human trafficking intervention training in 2022 or 2023. Two staff were missing
professionalism, interpersonal communication, and ethics trainings, trauma responsive
practices, and suicide awareness and prevention trainings. One additional staff was also
missing suicide awareness and prevention training. Three supervisory staff were reviewed and
two failed to complete the eight additional hours of training required for supervisory staff.
However, the staff are required to complete the trainings by December 31, 2023, which falls
outside of the annual compliance review period. The program was notified of the missing
trainings for the staff reviewed and will be requiring the staff to complete all the trainings prior to
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Office of Accountability and Program Support Page 14 of 68 (Revised September 2022)
the end of the year, in accordance with the program’s annual in-service training calendar. All
completed trainings were documented in SkillPro or in the staff’s individual training plan, as
required. All instructors were qualified to deliver the training provided. The program has an in-
service training plan which was submitted to the Department’s Office of Talent, Leadership, and
Culture on April 26, 2023. The program’s annual in-service training calendar is updated as
changes occur.
1.09 Grievance Process Satisfactory Compliance
Program staff shall be trained on the program’s youth grievance process and procedures.
The program adheres to the grievance process and shall ensure it is explained to youth
during orientation and grievance forms are available throughout the program. Completed
grievance forms shall be maintained by the program for a minimum of twelve months.
The program maintains a policy and procedures which include the training requirements for the
grievance process. The program’s grievance process includes three phases. During the informal
phase, youth are encouraged to resolve complaints immediately and directly though informal
communication with program staff. The formal phase includes communication request forms
which are available for youth to fill out and submit through grievance boxes located throughout
the program. The program maintains copies of all grievances from the past twelve months. A
review of five grievances determined the program’s practice correlates with their process. Five
youth were interviewed and each youth explained the program’s grievance process to include
the number of phases and time frames for each phase. All five youth confirmed they can ask for
help in completing the form. One youth stated the program takes a long time to check the
grievance boxes, and staff will “hold grudges” against youth who complete a grievance. An
informal interview with the program director (PD) regarding the youth’s response determined the
program has a process to check the grievance boxes prior to the daily morning meeting and all
grievances are brought to the morning meeting for review and logging. The PD further stated all
grievances are reviewed in accordance with the program’s facility operating procedures. Five
staff were interviewed. All five staff explained forms are placed throughout the facility and
supervisors review grievances. Staff also confirmed the youth can request assistance in
completing forms, the process has three phases, and the PD and supervisors review
grievances. An interview with the PD confirmed the compliance manager is the program’s
grievance officer and monitors the grievance process. The phases include an informal phase
where the youth will attempt to process the grievance with staff to learn pro-social
communications skills. The second phase of the grievance includes the supervisor attempting to
provide a resolution. The final phase is the meeting with the PD or director of operations to
come to a conclusion on the matter.
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’s contract table requires the program to provide interventions to each youth
including primary services of Aggression Replacement Training (ART), Seeking Safety, and
Impact of Crime (IOC), as well as non-primary services of Thinking for a Change (T4C), Living
in Balance (LIB), and The Council for Boys and Young Men: Men of Honor. The program had
eleven facilitators implementing specific intervention and/or curriculum during the annual
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compliance review period. All eleven staff were reviewed and found to have training in all
groups they were facilitating. All eleven staff had education and work experience considered by
the program when determining staff delivery of delinquency intervention services. The group
schedule indicated the minimum number of groups were provided each week, as required. A
review of sign-in sheets showed the program provided optional supportive groups including
Active Parenting and Cognitive Behavioral Intervention for Substance Abuse, as needed. Group
sizes did not exceed the maximum number of youth allowed and were held for the correct
duration and frequency. Sign-in sheets determined T4C groups were required to be provided
twice a week for twenty-three weeks, however, it was not completed for three weeks and was
only provided once a week for eleven weeks. Cognitive Behavioral Intervention is required to be
completed twice a week for thirty weeks but was completed only once during two of the weeks.
The Council for Boys and Young Men: Men of Honor, is required to be completed once a week
for ten weeks, but was not completed, as required, with one class missed during one week of
one of the three cycles.
The program director (PD) was interviewed regarding the program’s intervention models. The
PD stated ART is a cognitive behavioral intervention used for the reduction of aggressive and
violent behavior. ART is a multimodal program which has three components including social
skills, anger control training, and moral reasoning. Seeking Safety is the first empirically studied
integrative treatment approach developed specifically for co-occurring post-traumatic stress
disorder and substance abuse. Cognitive Behavioral Therapy (CBT) is a psycho-social
intervention which aims to improve mental health. CBT focuses on challenging and changing
unhelpful cognitive distortions and behaviors, improving emotional regulation, and the
development of personal coping strategies which target solving current problems. An interview
with the designated mental health clinician authority (DMHCA) confirmed there are three full-
time therapeutic managers and one part-time therapeutic manager. The DMHCA confirmed the
program provides evidence-based clinical groups, including ART, Seeking Safety, CBT, and
LIB. These group therapy services assist in providing skills needed to manage substance use,
anger, and trauma the youth may be experiencing.
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 policy and procedures which ensure youth are provided life skills which help
youth function more responsibly and successfully in everyday life situations, including social
skills which specifically address interpersonal relationships. The program provides Positive
Skills Development (PSD) and Living in Balance (LIB), both of which are evidence-based
models. Non-clinical staff may implement only non-clinical life and social skills interventions or
instruction. When skill training or instructional materials are specifically designed for use by
clinical staff or the skill training is delivered in response to a youth’s treatment plan, the skill
training is provided by clinicians. Life and social skills intervention services are provided which
address, at a minimum, identification and avoidance of high-risk situations which could
endanger self or others, communication, interpersonal relationships and interactions, non-
violent conflict resolution, anger management, and critical thinking, including problem-solving
and decision-making. Health and hygiene, physical environment, life and social skills training,
and leisure and recreational activities consider the gender of the program’s targeted gender
group and address the group’s needs. Direct care staff model pro-social behaviors for youth
throughout the course of each day, reinforce delinquency interventions, and guide and redirect
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students toward prosocial behaviors and positive choices. Additionally, staff engage youth in
constructive dialogue to peacefully resolve conflict when it occurs or, if imminent safety and
security issues delay intervention to resolve the conflict, as a follow-up process after safety and
security are restored. A review of sign-in sheets confirmed life skills services were held, as
required. In addition to the life skills intervention services, the program incorporates additional
life skills for the youth to include the completion of résumés, mock job interviews, and financial
literacy courses.
Four of the five interviewed youth confirmed they participated in PSD and learned how to think
about and handle difficult situations, deal with failures, anger, and peer pressure. One youth
confirmed he participates in LIB where he learned about positive and negative choices. Four
youth confirmed the program offers The Council for Boys and young Men: Men of Honor for
gender-specific activities, but only one youth had completed the program. One youth denied
participating in gender-specific groups. An interview with the program director (PD) and
confirmed the program offers The Council for Boys and Young Men: Men of Honor as the
gender-specific group. An interview with the program’s designated mental health clinician
authority (DMHCA) confirmed youth should practice skills daily while interacting with their peers,
during education, and in the community when they participate in off-site activities. The youth are
also able to utilize skills when they are having visitation with their families, either in person or
during telephone calls.
1.12 Restorative Justice Awareness for Youth Satisfactory Compliance
The program shall provide activities and instructions intended to increase youth awareness
of, and empathy for, crime victims and survivors, and increase personal accountability for
youths’ criminal actions and harm to others.
The program has a policy and procedures ensuring the program provides activities and
instructions intended to increase youth awareness of, and empathy for, crime victims and
survivors, and increase personal accountability for youths’ criminal actions and harm to others.
The program offers the primary service of Impact of Crime (IOC), a promising practice. Thinking
for a Change (T4C), a promising practice, is also provided as a restorative justice intervention to
all youth, who are provided opportunities to participate in restorative justice services while at the
program. The restorative justice activities or instruction are designed to assist youth to accept
responsibility for harm they have caused by their past criminal actions, challenging them to
recognize and modify their irresponsible thinking, such as denying, minimizing, rationalizing,
and blaming victims, and teach youth about the impact of crime on victims, their families, and
their communities. They also expose youth to victims’ perspectives through victim speakers, in
person or on videotape or audiotape, or through victim impact statements, and engage youth in
follow-up activities to process their reactions to each victim’s accounting of how crime affected
their life. In addition, the youth are provided opportunities to plan and participate in reparation
activities intended to restore victims and communities, such as restitution activities and
community service projects. According to the program schedule, restorative justice awareness
groups and activities are offered between 6:15 p.m. and 7:15 p.m. four times each week.
A review of sign-in sheets and worksheets confirmed restorative justice groups and activities
were conducted as outlined in the program’s activity schedule. An interview with the program
director determined IOC is provided to all youth who enter the program. Within the group
curriculum, community service activities are designed to assist with the practical application of
the group’s discussion topics. Due to COVID-19, youth have been exposed to victim speakers
through YouTube videos to gain perspective on the impact crimes have on victims. In addition,
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community service activities are completed on-site and off-site to engage the youth in giving
back to their communities. Youth have participated in collecting clothing and hygiene products
to donate to the homeless and completing community service projects off campus with a local
mentoring group. COVID-19 has affected off-site outings; however, the youth have written
letters to the elderly in nursing homes and planted flowers/plants around the facility grounds in
honor of victims. An interview with the designated mental health clinician authority (DMHCA)
confirmed IOC and T4C are each offered two times a week. Five youth were interviewed and
each confirmed they participate in IOC. Four of five youth discussed what they learned in IOC,
such as the impact of their crimes on the victims and giving back to their communities. All five
youth confirmed they have had opportunities to practice the skills they have learned outside of
their groups, which included breathing exercises, avoiding negative peers, and self-control.
1.13 Internal Alerts System and Alerts (JJIS) (Critical) Satisfactory Compliance
The program shall maintain and use an internal alert system easily accessible to program
staff and keeps staff alerted about youth who are security or safety risks, and youth with
health-related concerns, including food allergies and special diets. When risk factors or
special needs are identified during or after the classification process, the program
immediately enters this information into the internal alert system. The program ensures only
appropriate staff may recommend downgrading or discontinuing a youth’s alert status.
When risk factors or special needs are identified during, or after, the classification process,
the program immediately enters this information into the Department’s Juvenile Justice
Information System (JJIS). Upon recommendation from appropriate staff, JJIS alerts are
downgraded or discontinued.
The Department’s Juvenile Justice Information System (JJIS) Critical Alert List is used by
mental health clinical staff or other staff to indicate risk type and special instructions. Mental
health clinical staff input, or have appropriate staff input alerts based upon type and updated
information. An alert board communication system has been established to notify staff of youth
on alert status. The alert board includes the name, Department identification number (DJJID),
and photograph of the youth along with a color-coded dot system for all program-related alerts.
The alert codes are designated in categories on the communication board as victimization,
medication/psychotropic, suicide risk/mental health, allergies, gang, escape risk, out of
placement, and activity restriction. Only a mental health clinician may classify a youth as “high-
risk” with regards to a mental health situation, and only a nurse may classify a youth as a “high-
risk” for medical situations. Administration and direct care staff may place a youth on constant or
one-to-one supervision until the youth is evaluated by the mental health clinician or program
nurse to assess the youth. Only a licensed mental health professional or mental health clinical
staff may recommend downgrading or discontinuing a youth’s alert status for suicide risks or
other mental health alerts. Only medical staff may recommend downgrading or discontinuing a
youth’s alert status for medical alerts, upon verification of the health condition or situation no
longer exists. Only the program director (PD), designee, or on-site supervisor may recommend
downgrading or discontinuing a youth’s alert status for security alerts. Shift supervisors are
responsible for briefing each oncoming shift of the events and information of the previous two
shifts to include alert status and youth placed on suicide risk alert or precautionary observation.
Communication includes information passed from the mental health clinician and any special
instructions for the youth. Five youth records, which included a total of nineteen alerts, were
reviewed. All five youth were placed on the alert system as specified in the program’s written
procedures. All nineteen alerts included the name and title of staff removing or updating the
alerts. All applicable alerts were entered into the facility logbook, as required. Alerts were
entered into the internal alert system and the JJIS on the same date, and all alerts matched the
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JJIS and internal alert system. An interview with the PD determined the program has formalized
procedures in place with the healthcare staff to review the important medical issues pertaining
to the youth at the program through daily morning meetings and medication management
meetings. The psychiatrist also attends clinical supervision procedures. The alert process is
managed by each department head. These department heads oversee inputting and closing
alerts. The alerts are monitored daily and are discussed in the morning management meeting.
The department heads also assist with ensuring the internal alert board is updated daily with all
pertinent information from each department. This information is then shared with all staff during
the daily briefing, in which representation from each department is in attendance. An interview
with the nurse determined the health services administrator (HSA) and the registered nurse are
responsible for updating the Medical Alert Roster. Five interviewed staff explained they are
informed of alerts through safety plans, Suicide Precaution Observation Logs, shift briefings, as
well as being verbally and electronically informed by supervisors, medical, and mental health
staff of new alerts.
1.14 Youth Records (Healthcare and Management) Satisfactory Compliance
The program maintains an official case record, labeled “Confidential,” for each youth, which
consists of two separate records:
• An Individual Healthcare Record
• An Individual Management Record
The program separated the youth records into an Individual Healthcare Record (IHCR) and an
individual case management record for each youth. Five youth IHCRs were reviewed and
contained the youth’s name, Department identification number, date of birth, county of
residence, and committing offense. Five individual case management records were reviewed
and included sections for legal information, demographic and chronological information,
correspondence, case management and treatment team activities, and miscellaneous
information. All youth records are labeled “Confidential” and are maintained in locked cabinets,
which are also labeled “Confidential,” in the medical and case management offices.
1.15 Advisory Board Satisfactory Compliance
The program has a community support group or advisory board meeting at least every ninety
to 120 days. The program director solicits active involvement of interested community
partners.
The program has a community advisory board (CAB) which is scheduled to meet on a quarterly
basis. The program director (PD) solicited active involvement from a law enforcement
representative, the judiciary community, business community, school board, faith community,
and LGBTQIA+ community. A review of the CAB binder showed the PD recruited a victim, victim
advocate, or other victim services community representative, and a parent/guardian whose child
was previously involved in the juvenile justice system. Sign-in sheets and agendas from the
quarterly advisory board meetings were reviewed and confirmed the program attempted to hold
virtual meetings. The PD was interviewed and stated the program has an active CAB which
meets once a quarter, generally at 5:30 p.m. on the 2nd Thursday of the designated month. The
members assist in program planning of activities and include speakers along with providing
mentorship services to youth. A board was interviewed by telephone. The board member stated
they participated on a quarterly basis with youth in activities and financial literacy.
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1.16 Staff Performance Satisfactory Compliance
The program ensures a system for evaluating staff, at least annually, based on established
performance standards.
The program has a policy and procedures for evaluating staff, at least annually, based on
established performance standards. Five position descriptions were reviewed, and each staff’s
performance standards were clearly identified. A sample of performance evaluations were
reviewed and showed evaluations were completed as outlined in policy, at least annually. Five
staff records reflected staff were evaluated annually on established performance standards,
which matched the job descriptions for each staff. The program’s contract was reviewed and a
review of staffing throughout the annual compliance review period confirmed all specific
contractually required positions were maintained and performed, as outlined in the contract. An
interview with the program director (PD) determined the program has experienced problems
with staff turnover and staff morale, but has put into affect staff retention planning, including
steps to minimize turnover and improve staff morale. The PD stated the program has recently
implemented a morale committee to address the needs of the staff. The program has been able
to maintain a core of staff, and staff are partaking in pro-social activities off-campus, as well as
staff appreciation weeks and special events. The program has also been successful in
promoting from within the facility, which has improved staff retention. Regarding staff
performance evaluations, the PD confirmed all staff within the program who have been
employed for a year have an annual evaluation in the month of their initial date of hire. This
evaluation is the formal evaluation which depicts how the staff has performed throughout the
course of the year. Identified in these evaluations are the staff strengths and weaknesses, and
upon completion of the evaluation process, each staff meets with the PD and their supervisor to
discuss areas of improvements and to develop a plan for success. Five staff were interviewed,
and two staff stated communication at the program was “good,” and three stated it was “fair.”
Staff went on to explain messages are not always relayed appropriately, communication is
improving but still needs more improvement, and communication between departments has
improved. The PD stated with recent changes in the program’s leadership, communication has
been identified as an issue, and areas for improvement are addressed through daily shift
briefings, monthly all-campus meetings, and one-on-one supervision with staff in an effort to
encourage open dialogue.
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 implements special contract conditions as outlined in the program’s contract. The
program’s contract had a memorandum of negotiation (MON) during the procurement process.
The special contract conditions include the use of video-chat during all communication between
youth and family, vocational services, therapeutic managers to be on-site for family day, and
nursing staff requirements to include licensed practical nurses (LPNs). Transition service
managers are to complete a home visit within ninety days prior to release (within a 125-mile
radius), and to complete six months of post-release monthly contact with youth.
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The program has not been utilizing video-chat for all communication between the youth and
family, however, the program is working to increase the use of video-chat until it is used for all
communication. The program is providing career and technical education services to youth, as
required, which was determined by a review of youth certifications earned and interviews with
youth who are currently in career and technical education services since the last annual
compliance review. A review of family day sign-in sheets confirmed therapeutic managers are
on-site for family day. Current staffing and staff schedules confirmed the program has the
appropriate coverage for nursing staff, as required. A review of phone logs showed the
transition service managers completed phone checks for youth since the last annual compliance
review period, as required. The program had three youth applicable for the home evaluations,
and all three evaluations were reviewed and confirmed the evaluations were occuring.
An interview with the program director determined the program provides individual, family, and
group therapy services to youth, some of which is provided through video-chat. Youth group
services include Seeking Safety, Aggression Replacement Training (ART), Living in Balance
(LIB), and Impact of Crime (IOC). Seeking Safety focuses on coping skills and psychoeducation
for youth with a history of trauma and substance abuse. ART is a cognitive behavioral
intervention program designed to help children improve social skill competence, better manage
anger, and reduce aggressive behavior. LIB is a program which emphasizes relapse prevention.
IOC assists offenders to become more aware of the impact their crime had on families and
victims, and it helps them to take responsibility for their actions. Five youth were interviewed,
and two youth confirmed the services the program provides. Two youth stated they participate in
video-chat communication during treatment. One youth indicated he had not participated in any
of the special contracted services.
1.18 Contract Specific Career and Technical Education
Satisfactory Compliance
Services
The program shall implement all career and technical education services (formerly referred to
as pre-vocational and vocational services) negotiated or outlined in the contract which are
considered Contract Specific Conditions or listed within the Scope of Services Attachment.
These may be referenced as the Memorandum of Negotiation (MON), Summary of
Negotiated Points, Summary of Supplemental Response Request (SSRR), Best and Final
Offer (BAFO), Special Conditions, or older contracts may not have them clearly identified as a
special condition. Career and technical education service instruction shall be provided so the
interests, aptitudes, and skills of the youth are developed, while building upon their existing
strengths, in a manner supportive of their employability goals which provide an occupational
advantage and workforce readiness in their community. These items may exceed the
minimum requirements outlined in Florida Statutes and Florida Administrative Code.
A review of the program’s contract reflected career and technical education services are
required and include ServSafe food handler and food manager certificates, junior achievement
program, Workplace Learning Essentials, masonry, cardiopulmonary resuscitation and first-aid,
Guided Workforce Learning, Occupational Safety and Health Administration 10 (OSHA-10),
horse care training through the Thoroughbred Retirement Foundation, and the 4-H curriculum.
Twenty-two youth received each of the career and technical education services provided for the
annual compliance review period. Sixteen youth received certifications in first-aid and CPR,
fourteen received certifications for OSHA-10, and four in Florida Ready to Work Soft Skills.
Career and technical education services are offered daily from 4:40 p.m. to 5:40 p.m. Career
and technical education services are provided, as required, according to the program’s schedule
and contract. OSHA-10 is provided online. Staff provide CPR and first-aid, masonry, and the
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equine program, all of whom were qualified to provide the programs they teach. The career and
technical education programs offered are appropriate for the age of the youth in the program,
are appropriate for the abilities and goals of the youth in the program, and are appropriate for
the length of stay and classification of the youth in the program. Four of five interviewed youth
confirmed they were either participating in a career and technical education program or had
completed certifications. The remaining youth stated he was focused on getting into college and
currently had a job, to which the program transports him. An interview with the program director
confirmed the program offers OSHA-10, ServSafe, masonry, Florida Ready to Work Soft Skills,
CPR, and first-aid.
1.19 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The program has a policy and procedures for reviewing and analyzing data trends to utilize in
decision-making practices. The program’s data trend analysis is tracked through the Rites of
Passage Data Systems. The information is shared with staff and administration monthly through
staff meetings, publications, and emails. The program provided a PowerPoint, which was
reviewed and found to include data trend information regarding staff turnover and exits, referrals
and training, reported injuries, intakes, length of stay, exits, runaways, assaults and fights, and
use of restraints. The program’s practice is to share the information during the community
advisory board meetings with stakeholders. The program analyzes the collected data and
reviews current systems. If revisions are needed to current systems, they are done so to ensure
the safety and security of youth and staff as well as to ensure the fidelity of the program.
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Standard 2: Assessment and Performance Plan
2.01 Initial Contacts to Parent/Guardian and Court
Satisfactory Compliance
Notification
The program notifies the youth’s parent/guardian by telephone within twenty-four hours of the
youth’s admission, by written notification within forty-eight hours of admission. The program
notifies the youth’s committing court, assigned juvenile probation officer (JPO), and post-
residential services case manager (if applicable) in writing within five working days of any
admission.
The program has a policy and procedures to address youth admissions whereby the youth’s
assigned therapeutic manager is to contact the parent/guardian(s) by telephone during the
intake process or no later than twenty-four hours to notify them of the youth’s admission to the
program. The therapeutic must also notify the parent/guardian in writing within forty-eight hours
of the youth’s arrival, and notify the committing judge and juvenile probation officer (JPO) within
five working days of the youth’s admission. Five case management records contained
documentation the parent/guardian was contacted on the youth’s day of admission or within
twenty-four hours of their admission to the program. In addition, each record documented the
parent/guardian was also notified in writing within forty-eight hours of the youth’s admission.
Each record documented the youth’s assigned JPO and the judge/court were notified in writing
within five working days of the youth’s admission to the program.
2.02 Youth Orientation Satisfactory Compliance
The program shall provide each youth an orientation to the program’s rules, expectations,
goals of the program, and services applicable to youth, to begin the day of, or prior to, the
youth’s admission.
The program has a policy and procedures to address the orientation process. According to the
program’s policy, the assigned case manager is to provide each youth an orientation during the
intake and admission process. Five case management records confirmed each youth was given
an orientation on the youth’s date of admission. There were no new admissions scheduled
during the annual compliance review week; therefore, an orientation was unable to be observed.
Documentation confirmed the orientation process included a review of the services available,
the daily schedule, the expectations and responsibilities of the youth, the written behavioral
management system, and access to medical and mental health services. Each orientation
included information regarding access to the Florida Abuse Hotline or the Department’s Central
Communications Center if the youth was eighteen years of age or older, the program’s zero
tolerance policy regarding sexual misconduct, and whether or not the youth required any special
accommodations for limited reading skills or youth who are visually impaired, deaf, or otherwise
disabled. Each record contained a signed form titled “You Have the Right To Be Safe From
Sexual Violence,” which included the youth being notified of the right to be free from sexual
misconduct, rights to be free from retaliation for reporting such misconduct, and the agency’s
sexual misconduct response policy and procedures. Each record included a signed prohibited
contraband list, a youth’s rights form, a signed grievance procedures form, and signed receipt of
the youth handbook. Each record documented orientation also included the performance
planning process, dress code and hygiene practices, procedures for visitation and
correspondence, expectations for release, community access, emergency procedures, a facility
tour, assignment to a living unit and room, and treatment team. Five youth were interviewed,
and each youth confirmed they were provided an orientation within twenty-hours of admission,
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which included a review of the Prison Rape Elimination Act (PREA), a tour of the facility,
expectations, program rules, consequences, a review of the housing, and the program’s level
system.
2.03 Written Consent of Youth Eighteen Years or Older Satisfactory Compliance
The program obtains written consent of any youth eighteen years of age or older, unless the
youth is incapacitated and has a court-appointed guardian, before providing or discussing
with the parent/guardian any information related to the youth’s physical or mental health
screenings, assessments, or treatment.
Five case management records were reviewed for written consent of youth eighteen years or
older. One reviewed record was applicable, as such, the program provided two more records for
review. Each applicable case management record documented a written consent was obtained
and signed by the youth eighteen years of age or older before providing or discussing with the
parent/guardian information related to the youth’s physical or mental health screenings,
assessments, or treatments.
2.04 Classification Factors, Procedures, and Reassessment
Satisfactory Compliance
for Activities
The program utilizes a classification system, in accordance with Florida Administrative Code,
promoting safety and security, as well as effective delivery of treatment services. Initial
classification should be used for the purposes of assigning each newly admitted youth to a
living unit, sleeping room, and youth group or staff advisor.
Youth are reassessed and reclassified, if warranted, prior to considering an increase in
privileges or freedom of movement, participation in work projects, or other activities involving
tools or instruments which may be used as potential weapons or means of escape, or
participation in any off-campus activity.
All youth admitted to residential commitment programs shall be screened for vulnerability to
victimization and sexually aggressive behavior prior to room assignment. Room assignments
by staff shall ensure a youth’s potential for victimization or predatory risk has been reviewed.
The screening shall be completed in JJIS.
The program has a policy and procedures addressing classification, which outline the program
is to conduct an admission classification meeting with the youth, therapist, case manager, nurse
and living unit representative, and each parent/guardian is to be invited to participate in the
classification meeting, if they are available. According to the policy, the classification factors
shall include a review of the youth’s physical characteristics, including sex, height, weight, and
general physical stature, age and maturity level, any identified special needs, including mental,
developmental or intellectual, and physical disabilities, history of violence, gang affiliations,
criminal behavior, sexual aggression or vulnerability to victimization to include the youth’s
perception of vulnerability, any identified or suspected risk factors such as medical, suicide and
escape or security risks, and a review of the Department’s Juvenile Justice Information System
(JJIS) Alert List for any issues affecting classification. In addition, the program’s policy
addresses the re-classification program in which each youth is to be re-classified at intervals
throughout their length of stay to include when warranted based upon changes in the youth’s
supervision status, new/updated alerts, behavioral concerns, and relevant information to the
treatment team to ensure safety and security of the youth and program. The policy indicated
several examples requiring re-classification, which may include when there is a living unit or
room assignment change, assignment to work projects or activities which involve tools or
instruments which may be used as potential weapons or means of escape, prior to level
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change, increase in privileges and advancement or freedom of movement, prior to anticipated
off-campus activity, or at the request of the program director (PD) or designee. Five reviewed
case management records confirmed a classification meeting occurred for each reviewed youth.
The program utilizes classification forms which address the youth’s physical characteristics, age
and maturity level, any identified special needs, their history of violence, any gang affiliation,
criminal behavior, sexual aggression or their vulnerability to victimization, the youth’s history of
potential or verified human trafficking, any suicide risk, medical risk, escape risk, or security risk.
One youth was identified as having a potential suicide risk and they were referred for an
Assessment for Suicide Risk (ASR). Five youth were identified as having a medical risk and
each had an applicable alert entered into JJIS and the program’s internal alert list. Each youth
was classified for purposes of assigning to a living area, sleeping room, and the youth group or
staff advisor. Each record contained a classification re-assessment for any increase in the
youth’s privileges or freedom of movement, participation in work projects, or participation in off-
campus activities. When asked how factors such as mental health status, physical health status,
cognitive performance, age, and prior victimization are considered when assigning youth to a
living unit/sleeping room, the PD reported this information is shared during the intake process in
the classification meeting. They stated the information is used to determine the best placement
for the youth to ensure the safety and the wellbeing of the other youth. In addition, they reported
this information is also used throughout the course of each youth’s stay, as they may move
rooms according to the Positive Performance System as they level up and for more incentives.
2.05 Gang Identification: Notification of Law Enforcement Satisfactory Compliance
The program shall gather information on gangs, (e.g., gang members, tattoos, other body
markings) and share this information with law enforcement.
The program only had two youth applicable for gang identification and notification to law
enforcement. Each applicable youth was identified as having gang involvement prior to their
admission into the program. Each record documented an email was submitted to local law
enforcement in Hamilton County, the youth’s home county law enforcement agency, and the
assigned juvenile probation officer (JPO) of the reported gang involvement, which occurred prior
to the seven-day Monitoring and Quality Improvement (MQI) notice. Each youth entered the
program with the applicable gang alert entered into the Department’s Juvenile Justice
Information System (JJIS). The youth’s gang status was shared with the educational provider at
the residential program, the JPO, and the youth’s post-residential counselor, if applicable.
2.06 Gang Identification: Prevention and Intervention
Satisfactory Compliance
Activities
A program shall implement gang prevention and intervention strategies. The program shall
provide intervention strategies when youth are identified as a criminal street gang member,
are affiliated with any criminal street gang, or are at high-risk for gang involvement.
The program has a policy and procedures which address providing the youth with the
opportunity to develop a plan to disaffiliate with a criminal street gang, if they desire. The
program only had two youth applicable for gang prevention and intervention activities. Each
applicable youth was identified as having gang involvement prior to their admission into the
program. The performance plan for each youth contained a gang intervention strategy as part of
their goals and objectives. Each youth participated in monthly Gang Resistance and Drug
Education (GRADE) for gang prevention and intervention strategies. GRADE is a seven-lesson
program designed to educate youth on setting goals, respect, making good choices, conflict
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resolution, internet safety, gang intervention, and drug awareness. The program maintained
monthly sign-in sheets to verify the intervention activities, which also listed which intervention
lesson the youth had worked on.
An interview with the program director indicated the program conducts a review of youth’s
history and/or alerts upon admission to identify if a youth is gang affiliated. If a youth is identified
as having gang involvement, membership, or affiliation, the program includes a gang
intervention goal on their Individualized Performance Plan (IPP). According to the program
director, the identified gang-involved youth are provided with various materials to educate them
on the risks of being involved in a gang throughout the duration of the commitment.
2.07 Residential Assessment for Youth (RAY) Assessments and
Limited Compliance
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.
Five case management records were reviewed and all five contained a completed Residential
Assessment for Youth (RAY) within thirty days of admission into the program. The RAYs were
maintained in the Department’s Juvenile Justice Information System (JJIS) and the youth’s
official case record. One youth record contained RAY Reassessments at least once every
ninety days after the completion of the initial RAY; however, the remaining four records
documented the RAY Reassessments were not completed at least once every ninety days after
the initial RAY with one reassessment reflecting it was two days late, one reassessment was
three days late, one reassessment was four days late, and the remaining record documented
the reassessment was six days late.
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.
Five case management records were reviewed for the completion of the Youth Needs
Assessment Summary (YNAS). Each record contained a completed YNAS within thirty days of
the youth’s admission into the program, which was maintained in the Department’s Juvenile
Justice Information System (JJIS) and the youth’s official case record.
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2.09 Performance Plan Development, Goals, and Transmittal
Satisfactory Compliance
(Critical)
The intervention and treatment team, including the youth, shall meet and develop the
performance plan, based on the findings of the youth’s initial assessment, within thirty days of
admission.
For each goal, the performance plan shall specify the target date for completion, the youth’s
responsibilities to accomplish the goal, and the program’s responsibilities to enable the youth
to complete the goal.
Within ten working days of completion of the performance plan, the program shall send a
transmittal letter and a copy of the plan to the youth’s committing court, the assigned juvenile
probation officer (JPO), the parent/guardian, and the Department of Children and Families
(DCF) case manager, if applicable.
Five case management records were reviewed and confirmed the development of the initial
performance plan occurred within thirty days of each youth’s admission. Each plan was
developed after the initial Residential Assessment for Youth (RAY) and Youth Needs
Assessment Summary (YNAS). Each performance plan was developed with the intervention
and treatment team members present to include the treatment team leader, the youth, a
representative form administration, a living unit representative, mental health/substance
treatment staff, and education staff. One youth was applicable for involvement with the
Department of Children and Families (DCF) and the DCF caseworker was involved in the
development of the initial performance plan. All parties involved signed the initial plan and a
copy was mailed to the youth’s parent/guardian for signature; however, none of the signature
sheets were returned to the program by the parent/guardian. Each record contained the
signature sheet attached to the original performance plan, which was filed in the youth’s official
case record. Each performance plan contained the youth’s individualized goals based on the
prioritized needs reflecting the risk and protective factors during the initial assessment process
to include the top three criminogenic needs based on the RAY and/or the YNAS. Each initial
performance plan contained specific delinquency interventions based on the RAY results, with
measurable outcomes aimed at decreasing the youth’s criminogenic risk factors and promoting
strengths, skills, and support to reduce the likelihood of the youth reoffending. Each initial
performance plan contained court-ordered sanctions which could be reasonably completed
while in the program, transition activities targeted for the last sixty days of the youth’s
anticipated stay, target dates for goal completions, and the responsibilities of the youth and
program staff to enable the youth to complete the goals. Each initial performance plan was
mailed to the committing court/judge, the juvenile probation officer, the parent/guardian, and the
DCF caseworker where applicable, within ten days of completion.
Five interviewed youth confirmed they participated in the development of their performance
plan, were provided a copy of their plan, and each youth was able to identify performance goals
listed on their plans to include a goal addressing aggression, substance abuse, family
relationships, school, attitudes and behaviors, and conduct.
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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.
The program has a policy and procedures addressing revisions to the performance plans based
upon reassessment results, and the youth’s progress or lack thereof. The treatment team is to
revise the plan as needed to facilitate transition activities targeted for completion during the last
sixty days of the youth’s program stay. Five youth case management records were reviewed
and each was applicable for a Residential Assessment for Youth (RAY) and each performance
plan was revised for newly acquired information when warranted or if the youth demonstrated a
lack of progress toward completing a goal. One of the five records documented a revision was
made to the Individualized Performance Plan to facilitate transition activities during the last sixty
days of the youth’s stay. One of the five records included a performance plan revision due to
negative behaviors displayed in the program and as a result, an additional goal was added to
the youth’s performance plan to address aggression.
2.11 Performance Summaries and Transmittals Satisfactory Compliance
The intervention and treatment team shall prepare a Performance Summary at ninety day
intervals, beginning ninety-days from the signing of the youth’s performance plan, or at
shorter intervals when requested by the youth’s committing court.
Additionally, the intervention and treatment team shall prepare a performance summary prior
to the youth’s release, discharge, or transfer from the program.
The program shall distribute the Performance Summary, as required, within ten working days
of signing.
The program has a policy and procedure which indicate the program's case manager is to
complete a performance summary for each youth every ninety days after the development of
the Individualized Performance Plan, unless the committing court requests a summary at a
shorter interval of thirty days. Two of five reviewed case management records contained
performance summaries completed at least once every ninety calendar days following the
signing of the performance plan. One case management record documented a performance
plan was completed ninety-six days and ninety-eight days after the previous performance
summary, thus making them six and eight days late, respectively. A second case management
record documented a performance summary was completed 117 days after the previous
performance summary, making it twenty-seven days late. The third record documented a
performance summary was completed 142 days after the previous performance summary,
making it fifty-two days late. Each performance summary included the youth’s status for each
performance plan goal, the youth’s overall treatment progress, academic status, and credits
earned in the program. Each performance summary included a review of the youth’s behavior at
school, their overall behavior in the program, their level of motivation/readiness to change, and
their interactions with peers and staff. Each performance summary included a review of the
youth’s overall behavior, adjustment in the program, and any significant positive and negative
events. One youth record was applicable for a youth in the transition phase, which included the
justification for release in the performance/discharge summary. Documentation in all applicable
records reflected a performance transmittal allowed for the youth to read and add comments
prior to signing and contained a separate signature page confirming the youth was provided a
copy of the performance summary. All documentation was filed in the youth’s case management
record.
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Each performance summary was signed and dated by the treatment team leader, the staff
preparing the summary if not the treatment team leader, the program director or designee, and
the youth. The case management record for each youth contained documentation a copy of the
performance summary was sent to the committing court/judge, the youth’s juvenile probation
officer (JPO), and parent/guardian, to include one Department of Children and Families (DCF)
case worker within ten working days of its completion.
Only one of the five reviewed case management records was applicable for the completion of a
release/discharge summary; therefore, three additional closed records were reviewed. Three of
the four applicable records documented the original summary, along with the justification for
release, were sent with the Pre-Release Notification (PRN) to the JPOofficer at least forty-five
days prior to the youth’s anticipated release date. The remaining reviewed record documented
the PRN was sent to the JPO forty-one days prior to the youth’s anticipated release date. Each
record contained a copy of the signed release/discharge summary. Three records confirmed the
court approved the PRN, and the program then provided a written notification to the youth’s
parent/guardian regarding the planned release. For each youth approved for release, the
program completed an Exit Residential Assessment for Youth (RAY). None of the reviewed
records were applicable for the sexually violent predator program or required victim notification
of release.
2.12 Parent/Guardian Involvement in Case Management
Satisfactory Compliance
Services
The program shall, to the extent possible and reasonable, encourage and facilitate
involvement of the youth’s parent/guardian in the case management process.
The program has a policy and procedures regarding family involvement, which begins upon the
youth’s admission into the program. This includes asking for the family’s input for performance,
treatment and transition planning, participation in treatment team meetings, family therapy
sessions as needed, which is specified within the individualized treatment plan, as well
asparticipation in conferences for family outreach to address family reunification issues. Upon
admission to the program, a Parent/Guardian Input form and a Performance Contract Goal
Proposal for Parents/Guardians form are sent to the family regarding their input for the
assessment process and the development of the youth’s performance plan. If the
parent/guardian is unable to attend any progress reviews or treatment team meetings, they are
given the opportunity to participate by telephone or provide verbal/written input prior to the
meeting. During the annual compliance review week, two treatment team meetings were
observed. Prior to each treatment team meeting, the youth’s assigned juvenile probation officer
and the parent/guardian were contacted to participate. One parent/guardian required the use of
a translator, which the program was able to accommodate this request. To solicit
parent/guardian involvement, the program reaches out to the parent/guardian by telephone,
mails written letters, and hosts family days once a month on select Saturdays, during which staff
are available for family involvement.
An interview with the program director confirmed information is shared with the parent/guardians
during the intake process in a classification meeting to determine the best placement for the
youth to ensure their safety and the well-being of other youth. Two of five interviewed youth
reported their parent/guardian provides input by phone, one youth reported the parent/guardian
provides input by email, another youth reported they see their parents every weekend and they
discuss goals with the therapist, and the remaining youth reported they are nineteen years of
age, but their parents/guardians are involved with his permission.
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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.
Five reviewed case management records each included additional plans such as education,
mental health/substance abuse, or recreation incorporated into their performance plans. One
applicable crossover youth had the incorporation of the Department of Children and Families
(DCF) case/care plan added to their performance plan. Three of the performance plans also
incorporated a recreation or health/wellness goal.
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.
Five reviewed case management records each contained documentation a formal treatment
team meeting was conducted at least once every thirty days. Each formal treatment team
meeting was documented in the youth’s case management record. Four of five reviewed case
management records documented an informal treatment team meeting was held on a bi-weekly
basis each month alternating with formal treatment team meetings. One reviewed case
management record documented bi-weekly informal treatment team meetings from March 2023
through August 2023; however, one informal treatment team meeting was held twenty-two days
apart, which exceeded the bi-weekly basis as required. Each formal and informal treatment
team meeting form documented the youth’s name, the date of the review, and all required
attendees, including the youth, juvenile probation officer (JPO), parent/guardian, treatment team
leader, program management, a living unit representative, an education representative, a
mental health representative, and a medical representative. Each treatment team meeting
documented comments from treatment team members, a brief synopsis of the youth’s progress
in the program, performance plan revisions, and progress for each performance plan goal. Each
treatment team meeting also documented any behaviors resulting in physical interventions,
treatment progress, Residential Assessment for Youth (RAY) Reassessment results, and each
youth was provided an opportunity to demonstrate skills acquired in the program. Two treatment
team meetings were observed during the annual compliance review week, which confirmed the
presence of all required parties, including the youth, case management, the mental health
therapist, director of student services, operations/direct care, medical, and education staff. Each
parent/guardian and JPO were contacted during the treatment meeting and were able to
participate. Each treatment team meeting reviewed the youth’s anticipated release date.
Five youth were interviewed and confirmed staff review their performance, including progress on
performance plan goals, positive and negative behavior, and treatment progress. Each youth
reported they are given an opportunity during treatment team meetings to demonstrate any
skills they have learned in the program. The youth reported they are given time to speak or
explain their achievements, give feedback on their goals, review their grades, and receive
feedback.
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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.
Five youth case management records were reviewed for transition planning. One of five
reviewed case management records was applicable for transition planning; therefore, an
additional two records were provided by the program for review. Each applicable record
documented a transition conference was held at least sixty days prior to the youth’s targeted
release date. Each transition conference plan documented the participation of the intervention
and treatment team members to include the youth, treatment team leader, program director or
designee, the parent/guardian if available, the juvenile probation officer, the case manager,
education personnel (in person or by telephone), medical staff, and the mental health/substance
abuse department. Each transition plan documented a review of the transition activities on the
youth’s performance plan, identified additional transition activities as needed, identified target
completion dates, the persons responsible for completion of goals, recommendations for post
residential services, recommendations from medical, and any long-term academic
recommendations. Each transition plan documented signatures and dates of the treatment team
participants, which represented their acknowledgement of the transition goals and accountability
for completion. A copy of the transition plan was mailed to individuals who participated by
telephone, to be returned with signatures. Each applicable case management record
documented the youth and the case manager participated in the Community Re-Entry Team
(CRT) meeting, which was conducted prior to the youth’s release from the program. Each of the
applicable records contained documentation of the invitation to participate in the CRT meeting
sent by the probation department.
2.16 Exit Portfolio Satisfactory Compliance
The program will assemble an Exit Portfolio for each youth to assist once released back into
the community.
Three closed case management records were reviewed for an exit portfolio. Each record
documented the exit portfolio was discussed and initiated for the youth during the transition
conference. Each exit portfolio contained a copy of the youth’s transition plan, a calendar with
all dates, times, and locations of upcoming community appointments, any educational and
vocational certificates earned while in the program, education records, school transcripts,
résumé, and completed sample employment application(s). Each record documented the
youth’s state-issued identification card, Social Security card, and birth certificate were requested
from the parent/guardian; however, they were not obtained. The program acknowledged these
items were requested throughout the youth’s length of stay but were not provided by the
parent/guardian. Each record confirmed the youth’s exit portfolio was verified during the exit
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conference, and an Acceptance of Custody for Release form, signed by each youth,
documented they were provided a copy of the exit portfolio upon release. Each record contained
an email to the juvenile probation officer documenting they were provided a copy of the youth’s
exit portfolio upon release.
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.
A review of three closed case management records confirmed an exit conference was
conducted after the program notified the juvenile probation officer (JPO) of the release and the
exit conference was held at least fourteen days prior to the youth’s release date from the
program. Each exit conference form documented the date of the exit conference, signatures of
those who participated, and a summary of pending transition goals. A review of the case
management records, and the Department’s Juvenile Justice Information System (JJIS)
confirmed the youth’s date of admission and date of termination/release matched. Two of the
three reviewed records documented the exit conference participants included the intervention
and treatment team leader, the parent/guardian, an education representative, the JPO, the
youth, any other pertinent parties such as a representative from the medical and mental
health/substance abuse department, an admissions and transition manager, as well as any
applicable post-residential service providers. The remaining case management record did not
document the education representative was present at the exit conference; however, the
representative provided input for the meeting. In this record, the parent/guardian did not
participate; however, a message was left for them when the program attempted to contact them
to attend the exit conference.
2.18 Youth Input Satisfactory Compliance
The program has a formal process to promote constructive input by youth.
The program has a policy and procedures addressing the formal process to promote
constructive input by youth. This includes providing opportunities for the youth to share input on
programming, concerns, improvements, systemic issues, and recommendations through the
use of youth surveys, student government, request to speak forms, safety meetings, treatment
team meetings, town hall meetings, maintenance requests, a problem resolution process, and
grievance forms. The policy does not specify a required time frame for this youth input.
Reviewed sign-in sheets confirmed the program conducts a town hall meeting and a student
government meeting at least once per month. The program conducts three random youth
surveys each month and all youth are to complete a youth survey upon discharge for their input.
The youth provide written and verbal input during informal and formal treatment team meetings
as documented in each case management record for treatment team meetings. Five interviewed
youth each reported they participate in town hall meetings and two youth reported they
participate in student council. An interview with the program director indicated the youth have
access to the Request to Speak forms, which are located on the living unit. According to the
program director, upon completion of this form, staff have forty-eight hours to meet with youth to
discuss any issues or concerns the youth may have. The program director also reported they
meet with the youth daily to conduct meetings in which all youth and staff are present to discuss
any issues and concerns.
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2.19 Career Education Satisfactory Compliance
Staff shall develop and implement a career education competency development program.
The program has a policy and procedures to provide career education based on the age and
educational abilities of the youth in the program. The program provides type two career
education development. An interview with the lead educator indicated this includes STAR 360
and Common Assessment, career interest surveys, spreadsheets, and reports. An interview
with the program director indicated the program provides career education through an
Occupational Safety and Health Administration 10 certificate online training for culinary,
manufacturing, CPR/first-aid certification, Florida Ready to Work Soft Skills, and masonry.
Three closed youth records were reviewed and included a completed employment application, a
résumé, and appropriate documents essential to obtaining employment. There were not any
documented appointments with the local Career Source Center in all three youth records.
Documentation indicating the youth's parent/guardian and juvenile probation officer (JPO) were
aware of the vocational plan for the youth was included. All three records reviewed were
missing a State of Florida identification card (ID), however, the program requested the IDs from
the parents/guardians.
2.20 Educational Access (Critical) Satisfactory Compliance
The program shall integrate educational instruction (career and technical education, as well
as academic instruction) into the daily schedule in such a way ensuring the integrity of
required instructional time.
The program has a policy and procedures to provide educational access. The program provides
education services with support from the Hamilton County School Board, and the 250-day
calendar, which is distributed over twelve months and includes ten days for teacher training and
planning, is approved by the district. A review of the daily school schedule revealed the program
provided five sixty-minute class periods from 7:30 a.m. to 12:53 p.m., finishing out with lunch
daily, fulfilling the weekly requirement of twenty-five hours of instructional time. An interview with
the lead educator indicated the program adheres to the school schedule. Five youth were
interviewed and each reported there is little to no interruption to the school day. A review of
seven randomly selected logbook reviews from June 14, July 5, August 10, September 18,
October 5, October 24, and October 25, 2023, showed the youth were attending school
according to the daily bell schedule. Video review of October 5, October 24, and October 25
verified the logbook entries were accurate.
2.21 Education Transition Plan Satisfactory Compliance
Upon admission, staff and youth develop an education transition plan which includes
provisions for continuation of education and/or employment.
The program maintains a written policy and procedures requiring an education transition plan to
be developed upon each youth’s admission. Three closed youth case management records
were reviewed. Each of the three youth records included the specified education transition plan
and an exit plan indicating the case manager, parent/guardian, and the youth were all aware of
the plan. Included in each record was an Electronic Educational Exit Plan (EEEP), which
identified the next educational placement information and input from the post-release school
district representative. Five youth were interviewed and each reported they participated in the
development of their education transition plan and the program was preparing them very well or
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well when it came to high school, high school equivalency diploma (GED), vocational school,
employment, and/or college.
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Office of Accountability and Program Support Page 34 of 68 (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 employed a clinical director who serves as the designated mental health clinician
authority (DMHCA). The DMHCA is responsible for the coordination and implementation of
mental health and substance abuse services and the supervision of non-licensed mental health
staff. The DMHCA is a licensed mental health counselor (LMHC) with a clear and active license
with an expiration date of March 31, 2025. A review of the contract and documentation found
the DMHCA was on-site forty hours a week, as required, and on call twenty-four hours a day to
ensure services were taking place. The DMHCA’s position description was reviewed and it was
found they are the sole LMHC responsible for coordinating and implementing the program’s
specialized services, as well as other required mental health services. The back-up DMHCA is
the regional clinical director with a clear and active license as a LMHC, set to expire on March
30, 2025. An interview with the DMHCA confirmed they are on site from 8:00 a.m. to 5:00 p.m.
Monday through Friday and on-call on the weekends. The DMHCA ensures each youth receives
the prescribed treatment according to their treatment plan, as well as attend and participate in
groups. The program provides daily group therapy, individual therapy once a week, and family
therapy once a month. The program provides specialty substance abuse treatment overlay
services. The clinical staff have an open and fluid communication, relaying information through
staff meetings, weekly group supervision, and emails.
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 two additional licensed mental health professionals of whom the clinical
director/designated mental health clinician authority (DMHCA) ensures they are performing
services they are qualified to provide. Documentation, position descriptions, and an informal
interview with corporate staff verified both clinical staff are qualified to provide the program
required services. The full-time clinical staff, a licensed marriage and family therapist, and the
part-time clinical staff, a licensed mental health counselor, both hold clear and active licenses
with expiration dates of March 31, 2025. The program’s mental health and substance abuse
licensed staffing is in accordance with the current contract and Florida Administrative Code.
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3.03 Non-Licensed Mental Health and Substance Abuse Clinical
Limited Compliance
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 program has three non-licensed, master’s-level mental health staff working under a full-time
designated mental health clinician authority (DMHCA), a licensed mental health counselor
(LMHC). One non-licensed clinical staff has been on extended leave since before the previous
annual compliance review, including the entire current annual compliance review period. In the
interim, the regional clinical director and a non-licensed mental health clinical staff from a
partner program are filling in for coverage requirements. Each of the non-licensed therapists
hold a master’s-level degree from an accredited university. All applicable therapists were
providing substance services in a program under a Chapter 397 licensure and working under
the direct supervision of a qualified professional. The non-licensed master’s-level therapists
carried a caseload under the required sixteen youth limit. The program’s DMHCA is responsible
for providing face-to-face clinical supervision to the non-licensed clinical staff. Reviewed Clinical
Supervision Logs, since the last annual compliance review, found the DMHCA conducted the
required weekly face-to-face supervision with each non-licensed clinical staff. Reviewed
documentation supported the weekly supervision was documented on a form which included all
the required information as outlined on the Department’s Licensed Mental Health Professionals
and Licensed/Certified Substance Abuse Professionals Direct Supervision Log form. The
reviewed documentation found the completed Clinical Supervision Logs included a review of
case history, caseload directions, review of fidelity checks, clinical service instructions,
documented strengths, findings, trends, problem areas, situational concerns, and training. A
review of Assessment of Suicide Rrisk training documentation supported each master’s-level
non-licensed therapist completed the required twenty hours of supervised experience in
assessing suicide risk, mental health crisis intervention, and emergency mental health services.
The clinical staffing was in accordance with the current contract, including coverage of required
hours.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk.
The program maintains a policy and procedures for mental health and substance abuse
services which address 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,
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. The program’s practice is to conduct further evaluation and complete an
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Assessment of Suicide Risk (ASR) on each admitted youth 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 of the reviewed MAYSI-2s
reflected the screening was completed in JJIS on the day of the youth’s 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. An interview with the
program director indicated the program uses the MAYSI-2 and ASR as a screening process to
identify youth at risk for mental health, substance abuse problems, and suicide.
3.05 Mental Health and Substance Abuse
Satisfactory Compliance
Assessment/Evaluation
Youth identified by screenings, staff observations, or behaviors post-admission as in need of
further evaluation must be referred for a Comprehensive Mental Health Evaluation and/or
Comprehensive Substance Abuse Evaluation or Updated Evaluation.
A review of five youth mental health and substance abuse records found each youth received a
new combined mental health and substance abuse evaluation within thirty days of each youth’s
admission. Each evaluation was reviewed and signed by the designated mental health clinician
authority (DMHCA) within ten calendar days after the evaluation was completed by the non-
licensed clinical staff. All five new evaluations 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 continued 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
clinical staff completes screening assessments at admission and evaluations within thirty days,
with requested input on the youth’s behavior from the youth’s parent/guardian.
3.06 Mental Health and Substance Abuse Treatment (Critical) Limited Compliance
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.
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. None of the Initial Treatment Plans were applicable for psychiatric needs to be
included. The Individualized Treatment Plan was developed for each youth within thirty days of
admission in all five records on a form which contained all the elements of the Department’s
Individualized Mental Health/Substance Abuse Treatment Plan form. The Individualized
Treatment Plans were signed by the non-licensed clinical staff completing the plan and signed
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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. None of the original Individualized Treatment Plans were applicable to include
psychiatric services. Three reviewed plans were modified to include psychiatric services with
psychiatric medication and frequency of monitoring by the psychiatrist as they were later
prescribed psychotropic medication. Individualized Treatment Plan reviews were completed
every thirty days, as required, in all five records reviewed. Services outlined within each youth’s
Individualized Treatment Plan included individual counseling once a week, family counseling
once a month, and daily group therapy. Psychiatric monitoring was included at a frequency of
once a month as needed for youth not taking psychotropic medication and once a month for the
three applicable youth taking psychotropic medications. Services were individualized for each
youth. A review of video playback indicated groups were conducted for the required length of
time and consisted of no more than fifteen youth in a group. Sign-in sheets determined groups
were not being provided as prescribed. Thinking for a Change, requiring a duration of twenty-
three weeks with a dosage of twice a week, was not completed for three weeks and only once a
week for eleven weeks. Cognitive Behavioral Intervention, requiring a duration of thirty weeks
with a dosage of twice a week, was completed only once for two weeks. The Council for Boys
and Young Men: Men of Honor, requiring a duration of ten weeks with a dosage of once a week,
was not completed once during one week of one of the three cycles. During an interview with
the designated mental health clinician authority, it was confirmed reviews of the treatment plan
are completed every thirty-days, reviewed and signed by the treatment team. The program’s
activity schedule was reviewed and determined the program is providing structured, planned
programming, or activities at least sixty percent of the youth’s awake hours.
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.
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 provided by a licensed qualified professional or a non-licensed substance
abuse clinical staff under Chapter 397 according to their individualized substance abuse
treatment plan. Reviewed documentation confirmed each youth had a properly executed
Authority for Evaluation and Treatment (AET) form, or release of records for youth eighteen
years of age or older, and a signed Youth Consent for Substance Abuse Treatment form. None
of the youth were applicable for needing a signed Youth Consent for Release of Substance
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Abuse Treatment Records 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 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. Youth
treatment plans included the frequency of prescribed services for each youth including
individual, family, and group therapy sessions. In all records reviewed, progress notes
demonstrated youth received services as stipulated in their treatment plan. 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. No records were applicable for being released while still on suicide risk. The
youth discharge summaries in all records documented the services needed for daily
maintenance of the positive improvement in behavioral, emotional, and social skills made by
each youth while in treatment. 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
Substance Abuse Treatment Overlay Services (SAOS) to all youth. Group therapy includes
Seeking Safety and Cognitive Behavioral Interventions. The SAOS services include urinalysis
drug testing with any positive tests followed up by appropriate clinical intervention and
sanctions, individual, group, and family therapy as part of each youth’s treatment plan at a rate
of at least five times a week. Licenses were reviewed to verify substance abuse education is
being provided by qualified staff. Reviewed documentation confirmed group therapy sessions
were limited to no more than fifteen participants. Each youth received daily therapeutic activities
to include substance abuse education, relapse prevention, substance refusal skills, and coping
skills. Any youth with co-occurring mental health disorders received additional mental health
treatment. Since the program is licensed under Chapter 397, a qualified professional 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. Substance abuse clinical staff are on-site seven days a week and counselor
caseloads are limited to no more than sixteen youth for each clinician. All five interviewed youth
reported they are participating in family counseling once a month and individual counseling once
a week. Five interviewed staff confirmed direct care do not facilitate any mental health or
substance abuse group sessions. An interview with the DMHCA confirmed the program
provides SAOS specialized treatment services through clinical groups.
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3.09 Psychiatric Services (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.***
The program has a policy and procedures to address the psychiatric services provided to youth.
The program maintains an independent contractor agreement with a licensed psychiatrist to
oversee the psychiatric services and supervise the treatment of youth who are prescribed
psychotropic medications. The psychiatrist is scheduled to be on-site every other week for two
hours and provides medication evaluation and on-going monitoring of psychiatric medications.
The psychiatrist has a clear and active license which expires on January 31, 2024. A review of
the attendance logs since the last annual compliance review validated the psychiatrist has been
providing on-site services bi-weekly. Each reviewed attendance log documented the
psychiatrist’s sign-in and sign-out was accompanied with their signature. The psychiatrist is
available for emergency consultation twenty-four hours a day, seven days a week. The
psychiatrist works with a psychiatric advanced practice registered nurse (APRN), who provided
services once during the annual compliance review period. The psychiatric APRN position is
designated for clinical responsibilities only. A review of the Department of Health website
verified the psychiatric APRN has a clear and active license, expiring July 31, 2023, in which
education, experience, and license were in psychiatric/mental health. The psychiatric APRN
Collaborative Practice Protocol was reviewed and is maintained on-site. Duties of the
psychiatrist were never delegated to the psychiatric APRN. Reviewed documentation verified
the psychiatrist actively participated, managed, and supervised psychotropic medication
services in the program. The psychiatrist has a back-up clinician to provide coverage while on
vacation or leave; however, no back-up coverage was needed during the annual compliance
review period. A review of the back-up psychiatrist’s license showed it was a clear and active,
with an expiration date of January 31, 2024.
The program’s policy and practices are to provide a psychiatric evaluation to all youth admitted.
A review of five youth mental health and substance abuse records verified eachyouth was
referred for a psychiatric interview. None 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 youth’s Initial Diagnostic Psychiatric Interview
included history of the youth, a Mental Status Examination, diagnosis, and treatment
recommendations. None of the youth were prescribed psychotropic medication at the initial
interview. Two youth, who were prescribed psychotropic medications at a later date, and an
additional record were reviewed. 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 three psychiatric
evaluations were completed on the Department’s Clinical Psychotropic Progress Note (CPPN)
form and were clearly identified as an initial psychiatric interview. All three applicable reviewed
youth records indicated each youth received the prescribed psychotropic medications and
documented monthly face-to-face medication monitoring reviews. The corresponding CPPNs
were completed, signed, and dated by the psychiatrist. TheCPPN documented the youth’s
adherence to the medication regimen, any laboratory findings (if applicable), and whether or not
telephone contact was made with the parent/guardian. None of the youth required monthly
monitoring for Tardive Dyskinesia, and telepsychiatry is not utilized. An interview with the
designated mental health clinician authority (DMHCA confirmed they meet with the psychiatrist
on a bi-weekly basis or as needed. The interview with the psychiatrist confirmed their role in the
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coordination and implementation of services through evaluations, assessing needs for
medication, prescribing medication whenever needed, assisting in developing treatment plans,
and being available for any psychiatric emergencies. The psychiatrist is on-site every two weeks
and meets with DMHCA and the program director as needed, as well as meets with clinical staff
when assessing youth to go over recent behavior and current problems. Communication is
usually face-to-face, however, can be by telephone if needed. The psychiatrist has no concerns
with the mental health and substance abuse treatment at program.
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 the provision of 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 July 27, 2023. 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 a 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.
A review of five mental health and substance abuse records found one youth was admitted with
suicide precautions and was assessed using the Department's Assessment of Suicide Risk
(ASR) form. Two additional records of youth placed on suicide precautions through self-
reporting were also reviewed. Two ASRs were completed within twenty-four hours of screening
or concerns 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. One ASR was completed
immediately due to the youth being found to be in crisis. One youth’s ASR found the youth was
not at-risk of suicide and was immediately stepped down to standard supervision. The two self-
referred youth were placed on precautionary observation (PO). The parent(s)/guardian(s) of all
three youth were notified, which was 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
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(LMHP) conferred with the program director (PD) or designee, prior to finalizing the supervision
level. For both youth who were stepped down to close supervision, documentation close
supervision was maintained until it was determined no longer necessary by the DMHCA, LMHP,
or where it is documented in the youth’s record by clinical staff could not be located. Each
discontinuation of close supervision was documented in accordance with the program’s suicide
prevention plan. A suicide alert was entered into the Department’s Juvenile Justice Information
System for all three youth placed on PO and closed according recommendations. Reviewed
logbooks found two of the three youth placed on PO indicated appropriate instructions were
provided regarding ASR findings and suicide precaution decisions. A logbook entry for
instructions could not be located for the remaining youth. While on PO, 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 two applicable documentations of
discontinuation of PO which was completed by the non-licensed staff. Documentation of
discontinuation of PO by the PD or designee in the logbook was found for one of the three
youth. Two entries could not be located. All three youth were not transitioned to a lower level of
supervision until conferring with all required parties, which was documented on the ASR. Only
one youth was placed on PO within the time frame to review video footage with corresponding
documentation. The video review verified proper supervision was maintained.
3.12 Suicide Precaution Observation Logs (Critical) Limited 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.
A review of five youth mental health and substance abuse records found one youth was
applicable for suicide prevention log documentation. Two additional youth records were
reviewed. All three records utilized the Department’s Suicide Precaution Observation Log forms
documenting the appropriate level of supervision, observations of the youth’s behavior in real
time, not exceed thirty-minute intervals, and safe housing requirements. Two youth logs were
applicable for documented warning signs while on precautionary observation. Neither log
documented notification was sent to the program director or mental health clinical staff when the
warning signs were observed. All three 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 mod and one in the shift supervisor office co-located with first-aid kits. A review of the
program’s mock suicide drills confirmed the program exceeded the required quarterly drills on
each shift, completing one each month since the last annual compliance review. Reviewed
documentation found staff participated in suicide drills at least quarterly. 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
each staff participated in at least one drill which included the use and demonstration of CPR
annually and staff who were not present during a quarterly drill had the opportunity to review
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each drill scenario and procedures 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. Five interviewed staff were able to describe direct care
staff responsibilities when youth express suicidal thoughts and where each suicide response
kits is kept. Three interviewed staff reported medical emergency and suicide drills are
conducted every month, one staff stated drills occur once a quarter, and one staff stated they
have not completed a drill since being at the program for three months.
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 notification and alert systems,
means of referral, communication, supervision, documentation, and a review process.
3.15 Crisis Assessments (Critical) Limited Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or by a non-licensed mental health clinical staff
working under the direct supervision of a LMHP, to determine the severity of a youth's
symptoms, and level of risk to self or others. When staff observations indicate a youth’s acute
psychological distress is extreme/severe and does not respond to ordinary interventions, the
program director or designee shall be notified of the crisis and need for a Crisis Assessment.
A Crisis Assessment is to be utilized only when the youth’s crisis (psychological distress) is
not associated with suicide risk factors or suicide risk behaviors. If the youth’s behavior or
statements indicate possible suicide risk, the youth must receive an Assessment of Suicide
Risk instead of a Crisis Assessment.
The program had two youth requiring a Crisis Assessment since the last annual compliance
review. The date each youth was in crisis was not documented on either assessment, however,
an examination of the Department’s Central Communication Center incident report associated
with each crisis allowed for the establishment of the date for each. One Crisis Assessment was
determined to have been completed within the required twenty-four-hour time frame. The other
assessment was determined to have been completed eighteen days late, though the clinical
staff completing the assessment signed one day after the completion of the Crisis Assessment.
Neither Crisis Assessment documented the reason for the assessment. Each assessment did
include a Mental 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. One youth’s parent/guardian was
notified, but it could not be determined if the other youth’s parent/guardian was notified. Both
Crisis Assessments were conducted by a licensed mental health professional (LMHP) or by a
non-licensed mental health clinical staff working under the supervision of a LMHP. Both youth’s
supervision levels were lowered to standard supervision when the assessment was completed,
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therefore, the youth did not require a mental health alert to be entered into the Department’s
Juvenile Justice Information System (JJIS), were not deemed to pose a safety or security risk,
did not require off-site care, and did not need follow-up assessments. Both youth were
determined to be assessed for being an alleged victim of a Prison Rape Elimination Act incident.
One youth received an immediate Mental Health and Substance Abuse Referral Summary and
one youth did not receive a referral at the time of the incident. Both youth were offered ongoing
mental health treatment services once the Crisis Assessment was completed.
3.16 Emergency Mental Health and Substance Abuse
Satisfactory Compliance
Services (Critical)
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in the program require emergency care provided in
accordance with Rule 63N-1, F.A.C., and the program’s Emergency Care Plan.
The program has a policy and procedures detailing 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) Satisfactory Compliance
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The program had one applicable youth with two Baker Act incidents since the last annual
compliance review. Upon determining the youth was in need of emergency care, the staff
notified the designated mental health clinician authority (DMHCA) and the youth was placed on
precautionary observation until an Assessment of Suicide Risk (ASR) was completed for both
incidents. Upon completion of both assessments, the youth was sent out for Baker Act services.
The first time, it could not be determined who transported the youth and the local law
enforcement transported the youth to the Baker Act stabilizing facility for the second incident.
Both times the youth returned to the program, the youth remained on constant supervision until
the DMHCA was able to conduct a follow-up assessment. The youth then was transitioned to
standard supervision appropriately after the DMHCA conferred with the program director. A
Mental Status Examination was completed only in one of the incidents; documentation of the
examination could not be located for the other incident. Documentation of the youth’s
observations while on supervision were maintained with no exceptions.
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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.
Five youth mental health records were reviewed in reference to the safety planning process.
Each safety plan included warning signs, 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. The safety plans had
an initial and a review planning 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 trauma responsive practices. The youth safety plans were updated every thirty-days
and were maintained in each youth’s record as well as in a centralized binder in master control,
easily accessible to all staff. Five youth were interviewed, and each stated they contributed to
their safety plans by relaying triggers, feelings of safety, behavior, and how staff can help. Five
interviewed staff stated safety plans are to be reviewed when there is a new admission and as
needed, weekly, and/or daily. When asked when they last reviewed the safety plans, one staff
stated every morning, one stated this week, one stated last month, one stated it was only shown
during training, and the last staff stated at the last admission. During an interview with the
program director, it was confirmed each safety plan is updated every thirty days.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee (Critical) Satisfactory Compliance
The designated health authority (DHA) shall be clinically responsible for the medical care of
all youth at the program.
The program’s designated health authority (DHA) is a licensed physician who holds an
unrestricted license and meets all requirements for independent and unsupervised practice in
Florida. The DHA’s license expires on January 31, 2024. The DHA’s specialty training is in
family practice with experience in adolescent health. The DHA does not have any disciplinary
cases or public health complaints on record. According to the contract, the DHA is required to
be on-site weekly, a minimum of two hours a week. A review of the sign-in sheets for the annual
compliance review period indicated the DHA was on-site, as required. If the DHA has a
scheduled absence, the program has an agreement with another licensed physician to provide
medical care to the youth. The back-up licensed physician holds a clear and active unrestricted
license, which expires on March 31, 2024, and meets all requirements for independent and
unsupervised practice in the State of Florida. The back-up physician provided services to the
youth for two weeks during the annual compliance review period. The DHA reviewed facility
procedures as documented by signature and date. There was no inclusion of telemedicine in the
program’s contract. The DHA was interviewed, and their responsibilities include completing
comprehensive physical assessments, weekly sick call, policy and procedure review, and being
oncall seven days a week for medical questions.
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 three registered nurses (RNs), one whom serves as the health services
administrator (HSA). A review of each RN’s license credentials reflected each of the nurses
have a clear and active license in the State of Florida, according to the Florida Department of
Health Medical Quality Assurance website. Two of the licenses are valid through July 2024, and
one is valid through April 2025. In addition, each of the RNs have current cardiopulmonary
resuscitation (CPR) certifications. The required on-site hours according to the contract are
seven days a week for a total of 108 hours. The nursing staff has been in compliance with the
contractual requirements.
4.03 Facility Operating Procedures Satisfactory Compliance
The program shall have facility operating procedures (FOP) for all health-related procedures
and protocols utilized at the program.
The program has a policy and procedures for all health-related protocols utilized at the program.
The designated health authority (DHA) and program director (PD) signed and dated all
treatment protocols. The DHA and PD reviewed and signed protocols and facility operating
procedures (FOPs) on July 12, and July 11, 2023. FOPs and protocols related to psychiatric
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services and psychotropic medication management are developed and reviewed by the
program’s psychiatrist. The psychiatrist reviewed and signed the psychiatric protocols on July
27, 2023. The nursing protocols were signed by the nursing staff on July 12, 2023. There were
no new policies or changes in policy made during the annual compliance review period. An
annual review of all FOPs and protocols were signed by the respective individuals from each
discipline on July 12, 2023, signifying their understanding of the FOPs and any new health-
related Department policies. All newly hired medical staff receive a comprehensive clinical
orientation to the Department’s healthcare policies and procedures conducted by the registered
nurse (RN). The DHA had written and authorized approval of treatment protocols and standing
procedures which were not delegated to any other person.
4.04 Authority for Evaluation and Treatment Satisfactory Compliance
Each program shall ensure the completion of the Authority for Evaluation and Treatment
(AET) authorizing specific treatment for youth in the custody of the Department.
The program has a policy and procedures ensuring the completion of the Authority for
Evaluation and Treatment (AET) authorizing treatment of youth in the program’s custody. A
review of five youth Individual Healthcare Records (IHCRs) found each was applicable for the
AET forms. Each youth had a signed AET form filed in the record with the word “Copy” legibly
stamped on it. The AET is valid for as long as the youth is in the program or until the youth’s
eighteenth birthday. One youth was eighteen years of age and had a documented release of
information. None of the youth were in the care of the Department of Children and Families
(DCF). An interview with the registered nurse (RN) confirmed a new of current AET has to be
requested from the youth’s juvenile probation officer (JPO).
4.05 Parental Notification/Consent Satisfactory Compliance
The program shall inform the parent/guardian of significant changes in the youth’s condition
and obtain consent when new medications and treatments are prescribed.
The program has a policy and procedures to ensure the parent/guardian is notified of any
changes in the youth’s condition and to document informed consent for youth healthcare. A
review of five youth Individual Healthcare Records (IHCRs) found four were applicable for
parental/guardian notifications for over-the-counter (OTC) medications beyond those covered by
the Authority for Evaluation and Treatment (AET). One youth was eighteen years old. Four of
the applicable IHCRs included documentation of attempted contact to the parent/guardian in the
progress notes when a new medication was ordered. All four applicable IHCRs contained
written notifications documented on the Department’s Parental Notification of Health-Related
Care: General or Parental Notification of Health-Related Care: Medications forms. Two of the
youth were taking prescribed psychotropic medications. None of the youth were applicable for a
new psychotropic medication, change in dosage, or discontinuation of medication which was
documented on page three of the Department’s Clinical Psychotropic Progress Note (CPPN)
form. None of the youth were in the care of the Department of Children and Families (DCF). In
all five IHCRs, the youth vaccinations were verified within thirty days of the youth’s admission.
An interview with the registered nurse (RN) confirmed parents/guardians are notified of any
significant changes in a youth’s condition, provider appointments, and when new medications
are prescribed. Written parental/guardian notification is documented using a standardized form
each time a new medication or treatment is prescribed and mailed to parents/guardians.
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4.06 Healthcare Admission Screening and Rescreening
Satisfactory Compliance
Form (Facility Entry Physical Health Screening Form)
Youth are screened upon admission for healthcare concerns which may require a referral for
further assessment by healthcare staff.
The program has a policy and procedures regarding youth healthcare admission screening and
rescreening each time the physical custody of the youth changes. Five youth Individual
Healthcare Records (IHCR) were reviewed for a Facility Entry Physical Health Screening
(FEPHS) form. All five FEPHS forms were completed by the registered nurse (RN) on the date
of the youth’s admission. None of the youth were out of the physical custody of the Department.
During an interview with the RN, it was confirmed the RNs complete the FEHPS forms upon
arrival to the program.
4.07 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education
All youth shall be oriented to the general process of healthcare delivery services at the
program.
The program has a policy and procedures ensuring all youth admitted to the program are
provided an orientation to healthcare services. A review of five youth Individual Healthcare
Records (IHCRs) confirmed all youth were provided a general care orientation upon admission
to the program. The Health Education form in all five IHCRs included access to medical care,
sick call, what constitutes an “emergency,” medication process, right to refuse care, what to do
in the case of a sexual assault or attempted sexual assault, the role of non-disciplinary
healthcare providers, and Standard Universal Precautions were discussed with the youth as
evidenced by their signature
4.08 Designated Health Authority (DHA)/Designee
Satisfactory Compliance
Admission Notification
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The program has a policy and procedures to notify the designated health authority (DHA) or
designee, by telephone or verbally, of each youth’s arrival at the program and provide
immediate notification when any youth admitted to the program requires emergency care. The
program’s practice is to notify the DHA of all youth admissions including youth with chronic
conditions, medical concerns, or any youth admitted on psychotropic medications. Five youth
Individual Healthcare Records (IHCRs) were reviewed, three of the youth were admitted with a
known or suspected chronic condition or required a referral to the DHA. None of the youth were
identified as in need of an emergency response upon admission. All records documented the
DHA notification in the youth’s Chronological Progress Notes and the Chronic Conditions Log
was updated after the notification. One youth was applicable for taking psychotropic medication
upon admission and documented notification to the psychiatrist. During an interview with the
registered nurse (RN), it was confirmed the DHA is notified of all new admissions and any
chronic conditions on the day of admission are added to the DHA appointment list and medical
tracker.
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4.09 Health-Related History Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be used for all youth
admitted into the physical custody of a Department facility.
The program has a policy and procedures ensuring the Department’s Health-Related History
(HRH) form is completed prior to the Comprehensive Physical Assessment (CPA) and
healthcare needs are identified. A review of five youth Individual Healthcare Records (IHCRs)
found each HRH form was completed on the day of the admission. All five IHCRs indicated the
HRH form was completed prior to the CPA to include the date and signatures. In all IHCRs, the
designated health authority (DHA) reviewed the HRH form as evidenced by a checkbox on the
CPA and a focus note in the admission documentation. An interview with the registered nurse
(RN) confirmed the medical staff are responsible for completing the HRH form upon admission.
4.10 Comprehensive Physical Assessment/TB Screening Satisfactory Compliance
The standardized Comprehensive Physical Assessment (CPA) form shall be used for all
youth admitted into the physical custody of a Department program.
The program has a policy and procedures ensuring the acute and chronic healthcare needs of
the youth are addressed by completing a Comprehensive Physical Assessment (CPA) within
seven days of youth admission. A review of five Individual Healthcare Records (IHCRs)
confirmed the program utilized the Department’s CPA form. All CPAs were completed by the
designated health authority (DHA) within seven days of the youth’s admission to the program.
All five had the youth’s Medical Grade documented on the CPA. The program completes a new
CPA for all youth, no prior CPAs were utilized. All sections of the CPA were completed in full
utilizing “O” or “X” markings. All five youth refused the genital exam, which was documented as
“youth refused” on each CPA in the IHCRs. All five youth signed a refusal form, which reflected
the refused portion on the CPA. The CPAs in all five records included documentation of the
most recent verified Tuberculosis Skin Test (TST) which was administered within the last year to
determine exposure to tuberculosis (TB). The results of the TST were documented on each
youth’s CPA and matched the documentation on the Department’s Infectious and
Communicable Disease (ICD) forms. The Department’s Problem List was updated for each
youth, when applicable. An interview with the registered nurse (RN) confirmed a new CPA is
completed within seven days of arrival and renewed yearly.
4.11 Sexually Transmitted Infection/HIV Screening Satisfactory Compliance
The program shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STI) and human immunodeficiency virus (HIV) risk factors.
The program has a policy and procedures to ensure all youth admitted to the program are
screened, evaluated, and treated, if applicable, for sexually transmitted infections (STIs) and
human immunodeficiency virus (HIV). The designated health authority (DHA) determines, based
on the youth’s risk factors, screening tool, and evaluation, whether to order testing for STIs. A
review of five Individual Healthcare Records (IHCRs) found all youth were clinically screened
and evaluated for STIs on the date of admission. All five of the IHCRs were applicable for
further evaluation or referred to the DHA, which was documented on the Department’s STI form.
All testing, screening, clinical evaluations, and diagnoses were documented on the
Department’s Infectious and Communicable Diseases (ICD) form, excluding the HIV results,
and were filed in the lab section of the IHCR. None of the youth were out of the Department’s
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physical custody; therefore, a rescreening was not applicable. All five youth were offered
pre/post-test counseling, testing, and referral for treatment for HIV. None of youth consented to
receive a HIV test. The program’s policy ensures the youth’s HIV test results are only disclosed
to the youth’s legally authorized representative, healthcare providers during treatment, the
Department of Health for purposes of reporting, health facility staff committees conducting
facility monitoring, medical personnel who have been subject to significant exposure, and
healthcare facility personnel or agents for healthcare providers who have a need to know during
patient care. Pre and post-test counseling services are provided by the DHA. Five youth were
interviewed and all advised they can request testing. An interview with the registered nurse (RN)
confirmed all youth are screened for STIs by completing the health screening form upon
admission.
4.12 Sick Call Process Satisfactory Compliance
All youth in the program shall be able to submit sick call requests and have complaints
treated appropriately through the sick call system. The program shall respond appropriately,
in a timely manner, and document all sick call encounters, as required by the Department. All
youth in room restriction/controlled observation shall have timely access to medical care, as
required by Rule.
The program has a policy and procedures addressing the program’s sick call process. A review
of five youth records found none of the youth presented with a similar sick call complaint three
or more times within a two-week period. Four of five youth had a sick call request addressed by
the registered nurse (RN). Each of the Sick Call Request forms were filed in the youth’s
Individual Healthcare Record (IHCR) in reverse chronological order. None of the youth were in
restricted housing of any kind. The sick call request forms and progress notes were documented
in accordance with Florida Administrative Code, including vital signs, treatment, education, and
follow-up plans. Each of the sick call events were documented on the Sick Call Index and on the
program’s Sick Call Referral Log. All the dates listed on the Sick Call Index corresponded to the
completed Sick Call Request forms located in each youth’s IHCR. Sick call occurs seven days a
week, twice a day. Sick call hours are posted on the medical office door and living units, while
sick call forms are located on the living units and the common area. An exam table and
equipment are used to perform sick call. No sick call events occurred during the annual
compliance review week, therefore, one was not able to be observed. Five interviewed staff
advised the nurse reviews and conducts sick call. Five youth were interviewed and each
advised they can see a doctor or dentist if needed. During an interview with the nurse, it was
confirmed youth must complete a sick call request and it is answered within twenty-four hours.
4.13 Episodic/First-Aid and Emergency Care Satisfactory Compliance
The program shall have a comprehensive process for the provision of episodic care and first-
aid care.
The program has a policy and procedures to ensure the youth have access to episodic and first-
aid care. A review of five youth Individual Healthcare Records (IHCRs) found four youth
required on-site episodic care. In each IHCR, the on-site care was provided by a licensed
healthcare staff, with documentation including the problem-oriented subjective, objective,
assessment, and plan (SOAP) elements. The program has a total of nine first-aid kits located in
designated areas throughout the program. The kits are in education, each of the two living units,
training building, medical, and three for transport. The program has a process for ensuring
contents of the first-aid kits are maintained and stored in accordance with guidelines to prevent
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expiration or deterioration. An observation of three first-aid kits confirmed the kits were fully
stocked with designated health authority (DHA) approved contents. The nurses monitor the first-
aid kits weekly and check for expired contents, which is documented on the first-aid kits logs.
The program has four automated external defibrillators (AEDs) located in each of the two living
units, education, and the kitchen. The AED procedures are located with the AEDs. The AED
batteries and pads are checked by the registered nurse (RN) once a month. Documentation
confirmed the RN monitored the AEDs as required. The RN checked the expiration dates of the
AEDs in the presence of the Monitoring and Quality Improvement regional monitor and
conducted a self-test with no issues noted. The batteries of the AED were last changed in
March 2021 and expire in March 2028. The AED pads were changed March 2022 and expire in
January 2024. A review of the emergency drills confirmed the program conducted an
emergency drill to include cardiopulmonary resuscitation (CPR)/AED annually. The emergency
medical drills simulated an episodic care event which called for immediate first-aid, and/or
administration of CPR techniques, and the initiation of emergency procedures to follow when a
life-threatening emergency does occur. The program had a list of emergency numbers which
were inaccessible to youth. The emergency numbers are posted in master control. A review of
ten training records confirmed all staff were trained in episodic, first-aid, and emergency care,
and the administration of the epinephrine auto-injector. The program has a facility operating
procedure (FOP) regarding Narcan. The policy states the program will maintain at least one
prescribed stock nasal spray kit for emergency purposes of accidental overdose for use on
youth. Naloxone (Narcan) Nasal Spray should not be ordered for each individual youth. The
Naloxone Nasal Spray stock must be maintained in a designated area. Naloxone Nasal Sprays
are located in the locked, wall-mounted safety glass cabinet located in each of two living units,
medical, master control, and education. Safety glass cabinets are locked at all times but include
a breakaway tab making the contents accessible to both nurses and supervisory staff trained to
assist in the delivery of medications when the emergency arises. Supervisors are able to access
the stock Naloxone Nasal Spray when there are no medical staff in the facility. Narcan is stored
in medical and inventoried along with other medication. Supervisors are trained on the use of
Narcan. Five interviewed staff confirmed they could call 9-1-1 in the event of an emergency.
Five youth were interviewed and each confirmed they can see a doctor if needed. The RN
advised episodic care is documented on an episodic form and logged in the episodic logbook.
4.14 Off-Site Care/Referrals Satisfactory Compliance
The program shall provide for timely referrals and coordination of medical services to an off-
site health care provider (emergent and non-emergent), and document such services, as
required by the Department.
The program has a policy and procedures to ensure for timely referrals and coordination of
medical services to an off-site healthcare provider. A review of five Individual Healthcare
Records (IHCRs) found three were applicable for off-site care. In eacg applicable IHCR, there
was an indication the youth required off-site first-aid or emergency care. The Department’s
Summary of Off-Site Care Consultation Report form was utilized and filed in the youth’s IHCR.
All three IHCRs had documentation of the parent/guardian notification efforts. All three youth
were applicable for discharge documentation, and each had the applicable documents filed in
the IHCR. The DHA reviewed and signed all off-site care findings, instructions, and information
in each of the three IHCRs. None of the youth required follow-up testing, referrals, or
appointments. The registered nurse (RN) confirmed all off-site care completed forms are
flagged for DHA review.
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4.15 Chronic Conditions/Periodic Evaluations Satisfactory Compliance
The program shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The program has a policy and procedures to ensure any youth admitted to the program who
have chronic conditions receive regularly scheduled evaluations and any as-needed follow-up
care. A review of five youth Individual Healthcare Records (IHCRs) found three youth were
identified on the Department’s Facility Entry Physical Health Screening (FEPHS) form with a
current chronic condition at admission. None of the youth were identified as having a
communicable disease. Three of the youth were taking prescribed medication on an on-going
basis. One youth was undergoing treatment for physical health condition. All three youth were
classified with a Medical Grade of two to four, were placed on the program’s Chronic Illness List,
and received periodic evaluations at least every ninety days. None of the youth were applicable
for taking anti-tuberculosis medications. None of the youth had an evaluation conducted off-site.
There was no evidence of any lapses in care or missed periodic evaluations. The Department’s
Problem List was updated for each youth. An interview with the program director (PD)confirmed
meetings with healthcare staff are held daily to discuss all medical issues pertaining to youth.
The designated health authority (DHA) interview confirmed youth with chronic conditions are
seen every ninety-days. The nurse confirmed all youth with chronic conditions are monitored
using the chronic roster.
4.16 Medication Management Satisfactory Compliance
Medication shall be received, stored, inventoried, and provided in a safe and effective manner
which shall be demonstrated by observation, as well as review of documentation of
procedures, and processes.
The program has a policy and procedures to ensure the accurate and safe administration of
youth medications. A review of five youth Facility Entry Physical Health Screening (FEPHS)
forms found three youth were taking medication at the time of admission. Each youth’s
medications were verified prior to the youth being admitted into the program, and the
prescription notification was documented in each youth’s Chronological Progress Notes. The
designated health authority (DHA), and when applicable, the psychiatrist, were contacted to
obtain an order to resume the specified medications prescribed prior to admission for each
youth. A review of the five youth Individual Healthcare Records (IHCRs) found three youth were
applicable for current medications to be continued, discontinued, changed, or for new
medications to be ordered. Each of the three applicable youth IHCRs included a Practitioner
Order form indicating the DHA, or psychiatrist, ordered the prescription for the youth. None of
the youth were in restricted housing of any kind. All five of the youth were applicable for over-
the-counter (OTC) mdications which were administered according to approved protocols. The
Department’s Medication Administration Record (MAR) was used to document all medications
and treatments for all reviewed IHCRs. The MAR clearly indicated medication start and stop
dates. In all applicable IHCRs, the staff initialed each administered medication entry. There
were no undocumented explanations for lapses or errors in medication administration for any of
the reviewed IHCRs. The registered nurse (RN) documented side-effect monitoring weekly on
the MAR for all five reviewed IHCRs. The MAR contained all required elements. The youth
initialed each provided medication entry. There were no indications of lapses or errors in
medication administration. One youth had refusals, which were clearly documented on the
MAR. None of the youth were applicable for parenteral medications. Three youth were
prescribed psychotropic medications and the DHA or psychiatrist was notified,as required. An
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Initial Diagnostic Psychiatric Interview was conducted for each of the three youth. There were
no standing orders for psychotropic medications, emergency treatment orders for psychotropic
medication, or any pro-re-nata (PRN) orders for psychotropic medications. A medication pass
was observed. The youth were each escorted by the youth care worker to approach the nurse
individually. The medical provider identified themselves and confirmed the reason youth was
present. The medical provider prepared the medication and verified the youth’s allergies and
alert status. The medical provider and youth initialed the MAR, and the medical provider
observed to ensure the medication was swallowed. The Six Rights of Medication
Delivery/Administration were maintained in each of the youth records. Five youth were
interviewed, and each confirmed the nurse provides medication and could explain the process
for receiving medication. Five staff were interviewed and each confirmed a nurse provides the
medication. An interview with the nurse confirmed medication is verified on admission.
4.17 Medication/Sharps Inventory and Storage Process Satisfactory Compliance
Any medical equipment classified as sharps, as well as stock medications shall be secured
and inventoried utilizing a routine perpetual inventory descending count as each sharp is
utilized and disposed of or when the medication is administered.
The program has a policy and procedures to ensure medical equipment classified as
sharps/medications are secure and inventoried utilizing a routine perpetual inventory. A review
of the medical equipment classified as sharps confirmed the items were securely stored and
inventoried utilizing a routine perpetual inventory descending count. All medications were
identified and secured in a locked medication cart designated for storage of medications. The
medication cart was secured, clean, and organized with stock items separate from youth-
specific medications. The program had no controlled medication during the annual compliance
review week. All medications were stored in a separate, secured area, inaccessible to the youth.
Narcotics and other controlled medications had an area where they would be stored behind two
locks, refrigerated medication was stored in a secured refrigerator only used for medication. The
program has a process for the destruction and disposal of medications. Controlled medications
are disposed in a drug buster bottle in the presence of the pharmacy consultant. Other
medications are disposed in the drug buster with two medical staff present. The program
conducts a perpetual and weekly inventory of all sharps and stock over-the-counter (OTC)
medications, which did not indicate any discrepancies. The nursing staff maintain a shift-to-shift
inventory of all controlled substances. In the event a youth is prescribed a controlled substance,
this is documented on the youth’s Individualized Controlled Medication Inventory Record. The
number of pills, tablets, or dosages remaining are documented on the youth’s Individualized
Controlled Medication Inventory Record after each administered dosage. Two supervisory level
staff were trained in the delivery and oversight of medication self-administration. The training
was provided by the registered nurse (RN). Observations were conducted of inventory counts of
three OTC medications and three sharps. All inventories were correct with no discrepancies.
The RN reported if there is a discrepancy in the count, the health services administrator (HSA),
designated health authority (DHA), and program director (PD) shall be notified immediately for
any discrepancies with daily controlled substance inventory count. The program shall report and
investigate unexplained losses of controlled substances and report as required by Florida
Administrative Code. An interview with the nurse confirmed the process for disposal and
destruction of medications.
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4.18 Infection Control – Surveillance, Screening, and
Satisfactory Compliance
Management
The program shall have implemented Infection Control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as
according OSHA federal regulations and the Centers for Disease Control and Prevention
(CDC) guidelines. The Comprehensive Education Plan is to include pre-service and in-
service training for all staff. Education for youth regarding infection control shall also be
provided at the time of intake and subsequently when the need is identified.
The program has a policy and procedures related to Infection Control and an Exposure Control
Plan. The Infection Control and Exposure Control Plan is signed annually and was reviewed and
signed by the designated health authority (DHA) on July 12, 2023, and by the program director
(PD) on July 1, 2023. The program’s infection control procedures include prevention,
containment, treatment, and reporting requirements related to infectious diseases, in
accordance with Occupational Safety and Health Administration (OSHA) federal regulations and
the Centers for Disease Control and Prevention (CDC) guidelines. The plan addresses common
infectious diseases of childhood, self-limiting, episodic contagious illnesses, viral and bacterial
infectious diseases, tuberculosis, Hepatitis A, B, and C, human immunodeficiency virus (HIV),
infectious diseases caused by blood-borne pathogens, other outbreaks or epidemics caused by
any other infectious agent, outbreaks of lice or scabies, Methicillin-Resistant Staphylococcus
Aureus (MRSA) and other antibiotic resistant micro-organisms, food-borne illnesses, bio-
terrorist agents, and chemical exposures. The program offers Hepatitis B immunizations to staff.
Staff have access to personal protective equipment. The program has a comprehensive process
for needle stick post-exposure evaluations. Any exposure incident will be immediately reported
to the PD by the chain of command. Staff complete the required form, and subsequently, the
exposed individual and their supervisor will evaluate the situation and provide suggested
preventative measures and corrective actions. The program has a separate file containing all
documents of youth and staff who have experienced a program or occupational exposure. The
program’s Exposure Control Plan is available in the breakroom, master control, and the medical
department. An interview with the PD confirmed the plan is also located in the living units,
kitchen, and maintenance. An interview with the nurse confirmed exposure control training is
provided by the registered nurse (RN).
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 behavior of
youth, and consistently applying the program’s behavior management system (BMS). The
provider defines active supervision as interacting positively with youth, engaging in a full
schedule of constructive activities, closely observing behavior of youth and changes in behavior,
and consistently applying the BMS. The program has a daily youth activity schedule which was
posted throughout the program. The program staff are required to account for the whereabouts
of youth under their supervision and ensure staff-to-youth ratios are compliant with contract
requirements. The program’s contract requires staff-to-youth ratios to be one-to-eight during
awake hours and one to-twelve during sleep hours. The ratio for off-site activities,
transportation, and visitation is one staff to five youth. Observations of staff supervision for four
days during the annual compliance review week included classroom activities, youth searches,
line movement, school breaks, youth headcounts, youth participating in group and individual
counseling, meal and snack time, medication distribution, youth transportation, and
outdoor/indoor recreation activities. Daily observations during the annual compliance review
week verified staff-to-youth ratios were maintained at required levels. During all activities and/or
movement, observations showed staff were properly positioned to ensure active supervision of
youth and to ensure there were no physical obstructions in their view of the youth. Observations
of interactions between program staff and youth reflected the interactions were positive and
consistent with the program’s BMS. Informal interviews with three staff verified the each was
aware of the number of youth they were currently supervising and the program census. A review
of video footage for three separate days verified staff observed youth while in their sleeping
rooms. Five staff were interviewed and each was able to explain the process for rectifying youth
counts.
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 describing the collaborative behavior management
system (BMS). The BMS promotes safety, respect, and fairness, promotes and protects youth
rights, includes positive and negative consequences, constructive disciplinary actions as well as
opportunities for reinforcement, recognition of accomplishments in a five-to-one-ratio, and
promotes socially acceptable means for youth to meet their needs. The BMS also includes a
process for explaining to youth the reasons for any sanctioning, gives the youth the opportunity
to explain their behavior, opportunities for staff and youth to discuss the impact of behavior on
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others, reasonable reparations of harm caused to others, discussions of alternative behaviors,
promotes positive dialogue and peaceful conflict resolution, and minimizes separation of youth
from population. A review of the program’s BMS reflected each of the appropriate parties,
including education, were involved in its development, implementation, and on-going
maintenance. The teachers are staff of the provider and are trained on the BMS by the
provider’s training manager. Five staff interviews indicated the program’s policy and procedures
include a protocol where staff are provided feedback regarding the implementation of the BMS.
Five youth case management records were reviewed, and each confirmed youth orientation
included a review of the program’s BMS, and each contained an acknowledgement form signed
by the youth. Five position descriptions were reviewed and each confirmed each job function
included the implementation of the program’s BMS. Five interviewed staff and a review of five
pre-service and five in-service staff training records indicated each staff was trained in the
program’s BMS. The BMS details are posted throughout the program, on the living units, and
are provided in the youth handbook. The BMS does not include increased length of stay, a
denial of a youth’s basic rights or services, promotion of group discipline, punishment of youth
by other youth, or disciplinary confinement. Staff and youth interactions were observed for
adherence to the BMS, to include negative consequences and positive rewards, and
consequences were in direct relation to the seriousness of the inappropriate behavior. The
program offers a variety of incentives to include canteen, off-campus outings, food from outside
restaurants, fun days, and various games.
The program director (PD) reported the program uses the Measurable Achievement Plan (MAP)
as its BMS. MAP is an incentive-based system which allows the youth to know their status in the
program daily, along with being provided incentives for their achievements. The system consists
of five levels in which the youth have to petition their peers and the treatment team to advance
from level to level. The PD also reported the recreational therapist monitors the BMS to ensure
consistency in delivery and fair treatment of youth. Daily meetings are held to give youth the
opportunity to discuss issues or concerns. The program utilizes an internal fidelity check tool to
monitor the BMS, as well. The regional compliance manager, along with the treatment team,
review practices on a monthly and quarterly basis. The provider’s policy requires staff to be
evaluated annually on administering this process fairly and consistently.
Five youth were interviewed, and four stated the BMS is good. One youth reported it was poor.
The five interviewed youth listed some of the consequences for negative behavior as privilege
restrictions, special treatment teams, and a “re-focus” which requires youth to go back a level
for a time period. Youth report incentives including canteen, ice cream and pizza parties, and
off-site trips. Each youth was able to explain the difference between the levels and how youth
move from one to the next. All five youth reported youth are not allowed to punish other youth,
and staff use rewards the same.
Five staff were interviewed, and each indicated they received training in the BMS. All staff
indicated the BMS operates on points, four staff indicated rewards and consequences were
handed out in a four-to-one-ratio, and two reported the BMS is a level system. All staff reported
they do not take anything away from the youth as a punishment for their behavior. The staff
collectively reported youth are rewarded with canteen, ice cream parties, snacks, games, and
off-campus outings. Staff also report youth are informed of the consequences and are they able
to explain their behavior immediately with staff, during the behavior reporting process, and
during special treatment teams. Each staff reported they are given feedback on their
implementation of the BMS from their supervisors immediately, in meetings, and in evaluations.
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5.03 Use of Room Restriction Satisfactory Compliance
The program’s behavior management system (BMS) is designed to maintain order and
security, provide constructive discipline and a system of positive and negative consequences
to encourage youth to meet expectations for behavior, provide opportunities for positive
reinforcement and recognition for accomplishments and positive behaviors, promote dialogue
and peaceful conflict resolution, and minimize separation of youth from the general
population.
Supervisors shall monitor staff implementation of the BMS and ensure the use of rewards and
consequences are administered fairly and consistently in application among all staff.
The program’s policy, procedures, or contract states the program does not use restricted
housing, to include confinement, seclusion, room restriction, or secure observation; therefore,
this indicator is rated non-applicable.
5.04 Ten-Minute Checks (Critical) Satisfactory Compliance
A program shall ensure staff observe youth at least every ten minutes while the youth are in
their sleeping quarters, either during sleep time or at other times, such as during an illness or
room restriction. Staff shall conduct the observations in a manner to ensure the safety and
security of each youth and shall document real time observations manually or electronically.
An observation of ten-minute checks was conducted during the week of the annual compliance
review. The observation was completed utilizing video footage compared to written
documentation of ten-minute checks. The program has a closed-circuit surveillance system with
fifty-one cameras, all of which were operational. The program’s camera system stores video
recordings for thirty days. A sample of three days was reviewed for the night shift while youth
were sleeping, at one-hour intervals. The review verified staff conducted checks at least every
ten minutes, documenting the times accurately on the ten-minute check log, as well as initialing
each check and signing the form. Ten-minute check documentation matched the actual footage
reviewed. Staff were observed looking into each room to ensure the safety of the youth. Five
staff were interviewed, and each indicated checks are required to be completed every ten
minutes with one reporting checks are actually done every eight to nine minutes to vary the
times of the checks.
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5.05 Census, Counts, and Tracking Satisfactory Compliance
The program ensures youth are accounted for at all times through a system of physically
counting youth at various times throughout the day.
The program shall conduct and document youth counts, minimally, at the beginning of each
shift, after each outdoor activity, and during emergency situations such as escapes or riots.
The program shall maintain a chronological record of events as they occur, or, if an event
disrupts the safety and security of the program, as soon as is feasible after order has been
restored.
The program tracks daily census information, including, at a minimum, the total daily census
count, new admissions, releases or direct discharges, transfers, and youth temporarily away
from the program. If at any time staff cannot account for the whereabouts of any youth, or
discrepancies are found between youth counts and census information, the program
reconciles immediately and takes follow-up action, as needed.
The program has a policy and procedures to ensure youth are accounted for at all times through
a system of physically counting youth at various times throughout the day. Master control staff
maintain an ongoing count of all youth and youth movement within the facility. All youth counts
and movement are documented in the logbook. The program’s policy requires counts prior to
movement from location to location, at thirty-minute intervals throughout each day, at the
beginning of each shift, after each outdoor activity, and during emergency situations. The
program maintains a chronological record of events as they occur. The program tracks daily
census information, including the total daily census count, new admissions, releases or direct
discharges, transfers, and youth temporarily away from the program. Staff are required to know
the exact number and location of all youth for whom they are assigned to supervise at all times.
Observations of program counts were conducted. In each instance, master control called for the
head count over the radio system and asked all movement to stop. After a brief pause, master
control called each area of the facility and asked for the number of youth in the area. If the count
was reconciled, all movement was allowed to resume. Five staff were interviewed and each
indicated counts are conducted every thirty minutes. Staff reported emergency counts are
conducted after a drill, following power outages, any time a youth cannot be located, or any
emergency. When asked about the daily census, all five staff knew the census for the program
the day of the interview.
5.06 Logbook Entries and Shift Report Review Satisfactory Compliance
The program maintains a chronological record of events, incidents, and activities in a central
logbook maintained at master control, living unit logbooks, or both. The program ensures
direct-care staff, including each supervisor, are briefed when coming on-duty.
The program maintains a chronological record of events in the master control logbook. Separate
logbooks are also kept on each living unit. The logbooks are bound with numbered pages. The
logbooks were in good shape and were not missing any pages. Logbooks were legible and all
entries made in ink with no erasures or white-out areas. Errors were struck through with a single
line and initialed by the staff correcting the error with two exceptions. In two areas, the corrected
error was written over instead. All entries included the dates and times of the events, with the
names of the staff and youth involved, brief descriptions of the events, and the names and
signatures of the staff making the entries. Incoming staff signed and dated the unit logbook to
document it had been reviewed. A shift briefing was unable to be observed in person; however,
an informal interview with the group living director indicated the contents of the previous two
shifts are discussed by supervisors and staff at this time. The activity schedule and logbook
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documented minimal interference of educational instruction, classes and recreation are held as
required, and the logbooks reflect youth arrive and depart school on time. Each logbook
documented emergency situations, incidents, special instructions for supervision of youth,
population counts, perimeter and security checks, transports, law enforcement visits,
admissions, releases, and any information relating to escapes or attempted escapes. A review
of the program logbooks reflected internal incidents were reported to the Department’s Central
Communications Center (CCC).
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.
A review of the program’s policy and procedures on key control confirmed it includes the control
and use of keys to include key assignment and usage, inventory and tracking of keys, secure
storage of keys, procedures addressing missing or lost keys, and reporting and replacement of
damaged keys. Observations of the key control system indicated the master control operator
and group living director are jointly responsible for the distribution, collection, and
documentation of keys. Staff keys are exchanged in the supervisor’s office and the visitor keys
are kept in a key box in the lobby. A review of the key inventory confirmed the inventory
matches the actual key rings in use. Keys are stored in a locked box in the supervisor’s office
and all keys remained secure when not in use. The locked storage box is not easily accessible
while locked. Permanent issued keys must be authorized in writing by the program director
(PD), and staff receiving these keys must sign a Permanent Key Assignment Sheet,
acknowledging receipt of the keys and proper procedures for control of keys. Positions eligible
for permanent keys include the PD, clinical director, and health service administrator. Each
position had a signed form on file. Provisions for restricted keys were observed and are
accessible to case managers, medical staff, dietary staff, clinical director, and therapists. There
were no damaged keys observed; however, policy indicates they are to be reported to the shift
supervisor and returned to the PD, who is responsible for discarding them, issuing the
replacement key, and updating the appropriate inventories. There were no incidents reported to
the Department’s Central Communication Center or Program Monitoring and Management
(PMM) deficiencies related to key control concerns. An informal interview with the group living
director indicated keys are tracked and reconciled using a central key log which indicates the
date, time, recipient of the keys, type and number of keys, assignment of a radio, securing of
personal keys, and the time the keys and radio were returned. Five sets of keys from the key
box were compared to the key inventory with no deficiencies noted. Observations of three staff’s
keys determined their assigned keys were consistent with the key log. Each staff was aware of
the number of keys on their assigned keys as well as what each key was for. Five staff were
interviewed and each reported personal keys are securely stored, visitor personal keys are
given to master control upon entry, there is a daily tracking of key and a key log, and program
keys are assigned to staff. Four staff stated staff keys are given to master control upon entry,
and three staff said there is an inventory of keys, and a chit or token is provided to visitors in
exchange for their personal keys. One staff reported missing keys are reported to master control
and the facility and youth are searched. One also reported any damaged keys are replaced.
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5.08 Contraband Procedures Failed Compliance
The program’s policy must address illegal contraband and prohibited items.
A program shall delineate items and materials considered contraband when found in the
possession of youth, the list must include: sharps, escape paraphernalia, tobacco products,
lighters or matches, electronic or vaporless cigarettes, any unauthorized article of food or
clothing, any intoxicating beverage or any beverage which causes or may cause an
intoxicating effect, any controlled substance, any prescription or non-prescription drug which
has a hypnotic, stimulating, or depressing effect, any firearm or weapon of any kind or any
explosive substance, non-facility issued electronic equipment or devices to include
smartwatches, metals, personal non-facility issued cellular devices, unauthorized currency or
coin(s), and non-facility issued keys. The program shall provide youth with the list of
contraband items and materials and inform the youth of the consequences if found with
contraband. The program shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, and both staff and youth.
The program shall document the confiscation of any illegal contraband and the manner of
disposition. The program shall keep a copy of the documentation in the youth’s case record. If
a confiscated item is not illegal or prohibited, the program director or designee has the
discretion to discard of the item, return it to its original owner, mail it to the youth's home, or
return it to the youth upon release. In all instances involving confiscation of illegal or
prohibited contraband, the program shall turn the item over to local law enforcement and a
criminal report must be filed.
The program has a policy and procedures which address illegal contraband and outline all
prohibited items. The program clearly delineates items considered contraband and youth are
provided with a youth handbook containing a list of items considered to be contraband and the
consequences associated with any found contraband as part of their admission to the program.
Staff and youth sign an acknowledgement form reflecting their understanding of the policy. Five
youth records and five staff records all contained a signed form. The program staff are required
to search the facility's grounds and the physical plant for contraband. Youth are searched every
time they move from one area of the program to another. All incoming and outgoing mail is
searched. Contraband logs have not been kept since June 2023. The program changed
procedures from utilizing a contraband search form to documenting contraband searches on the
backside of the ten-minute check forms. Since the change occurred, contraband searches,
items found, and their disposition have not been documented regularly on the ten-minute check
forms. Due to the lack of documentation, it is not possible to see if any found contraband was
documented in the youth case records. The written policy and procedures address any staff
found in possession of contraband will be subject to disciplinary action up to and including
dismissal. If any contraband found is illegal, law enforcement is notified according to policy.
One instance of contraband was reported to the Department’s Central Communications Center
(CCC). The contraband discovered was illegal, and law enforcement was contacted. The facility
logbook was reviewed and verified searches are conducted. An interview with the program
director confirmed the program’s written policy.
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5.09 Searches and Full Body Visual Searches Satisfactory Compliance
The program shall perform searches to ensure no contraband is introduced into the facility.
The program has a policy and procedures to control the introduction of contraband and
unauthorized items into the facility. Searches of youth are conducted prior to all movement,
before and after visitation, before and after tool usage, and upon returning to the program after
being off campus. Facility searches are conducted at random, in youth rooms, and any common
area utilized by youth. An observation of searches was conducted every day in relation to youth
movement including between classrooms, the living unit, recreation, the dining area, and after
cleaning detail. Youth were treated with dignity and respect to minimize stress and
embarrassment. Searches were conducted by the appropriate number of staff and gender.
Observations determined searches were thorough and conducted as required by the Protective
Action Response Right Interaactions model (PAR/RI) training manual. Five youth and five staff
were interviewed and each confirmed youth are searched prior to every movement.
5.10 Vehicles and Maintenance Satisfactory Compliance
The program ensures any vehicle used by the program to transport youth is properly
maintained and documentation regarding the use and maintenance of each vehicle is
maintained. Each vehicle used for transporting youth shall pass an annual safety inspection.
Each vehicle used to transport youth is to be equipped with the appropriate number of seat
belts, a seat belt cutter, a window punch, a fire extinguisher, and an approved first-aid kit.
Youth and staff wear seat belts during transports, and youth are not attached to any part of
the vehicle by any means other than the proper use of a seat belt.
The program has two vehicles for transportation. Documentation of the annual safety inspection
was reviewed for each vehicle, and no issues were noted. Each vehicle had current
maintenance records. Both vans were secured prior to inspection and included the appropriate
number of seatbelts. The staff driving the vehicles bring a backpack containing a fire
extinguisher, a first-aid kit, and a binder with vehicle and trip information. The van keys are
attached to a seatbelt cutter and window punch. These backpacks are kept in the supervisor’s
office until transport. The door to the youth passenger area cannot be opened from the inside.
During interviews with five staff and five youth, it was confirmed youth are secured in vehicles
with seat belts. A random check of ten personal vehicles determined vehicles were locked when
not in use.
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. A review of the program’s
policy and procedures, as well as interviews and observations, reflected staff transporting youth
are given a radio and program cellular telephone. Reviewed documentation verified all approved
drivers had a valid driver’s license. The program assigns a ratio of one staff to five youth during
transport, not including the driver. An observation of a youth leaving for work was conducted. All
the required procedures were observed. Five staff were interviewed, and three of five verified
use of a facility cellular telephone and four reported they bring a radio. All five staff knew the
vehicles have first-aid kits and fire extinguishers, and two were aware of seatbelt cutters. One
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staff knew the keys have window punches. All five staff confirmed transport vehicles are
searched for contraband prior to and after each use. Each of the five staff were aware of what to
do in case of an emergency and confirmed youth are not allowed to be transported in personal
vehicles. Youth are not permitted to drive program or staff vehicles. Five youth were
interviewed, and each reported staff are driving transport vehicles safely and they have not seen
anyone place contraband in a transport vehicle.
5.12 Weekly Safety and Security Audits Satisfactory Compliance
A program shall maintain a safe and secure physical plant, grounds, and perimeter.
The program has a policy and procedures outlining the audit/inspection process. The policy
includes who is responsible for conducting the weekly security audits and safety inspections, the
development and implementation of corrective actions warranted as a result of safety and
security deficiencies found, an internal system to verify the deficiencies are corrected, existing
systems are improved or new systems are instituted, and meets the requirements of Florida
Administrative Code. The group living director is responsible for conducting weekly security
audits and safety inspections. Findings are documented on the Weekly Safety Inspection Report
and provided to the program director (PD) for review. The report details identification of the
issues and tracks the correction of the deficiencies. A review of weekly safety and security audit
documentation indicated audits were completed weekly, as required. The PD reported weekly
safety and security audits and perimeter checks are utilized for identifying and tracking safety
and security deficiencies.
5.13 Tool Inventory and Management Satisfactory Compliance
The program shall have a tool management system ensuring youth do not use tools or
equipment as weapons or security breaches.
The program maintains a policy and procedures for a tool management system which
ensures youth do not use tools or equipment as weapons or for security breaches. This system
addresses the issuance, inventory, and control of tools and equipment. All tools, with the
exception of mops, brooms, dust pans, and mop buckets, are stored in the maintenance
building when not in use. The tools in the living units and in the maintenance building are all
marked for easy identification, and a shadow board or photo identification is used for storage.
Tools are inventoried prior to being issued for work and following any work activities. Tools with
sharp edges and points are inventoried daily to include kitchen knives, which are stored in a
locked cabinet inside the kitchen, and maintenance tools, which are located inside a locked
cabinet inside the maintenance building. A monthly inventory of all other tools is maintained.
Machetes, bowie knives, and other long blade knives are prohibited. There were no cases of
any missing tools since the last annual compliance review; however, an informal interview with
the group living director confirmed an understanding of what procedures to follow in the event a
tool does go missing. The program has a new maintenance manager, who also understands the
procedures for replacing missing or broken tools. There were no reports of broken or lost tools
during the annual compliance review period. Logs for brooms and mops used by youth were
observed and were in compliance. Seven items from the kitchen and nine items from the
maintenance building were sampled and the logs for each were correct and up to date.
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5.14 Youth Tool Handling and Supervision Satisfactory Compliance
There shall be procedures to ensure youth use tools safely and are supervised appropriately
in order to prevent injuries to themselves, other youth, and staff.
The program has a policy and procedures to ensure youth use tools safely and are supervised
appropriately in order to prevent injuries to the youth, other youth, and staff. The written policy
includes supervision requirements when youth use tools, issuing tools to youth and staff
including an assessment to determine a youth’s risk to self and others, established ratios, tool
distribution and collection, and search criteria during work projects. An observation of post-
lunchtime and afternoon cleaning duties reflected the proper staff to youth ratio was maintained
and youth were searched. A review of five case management records indicated the program
trains youth on the intended and safe use of class B tools. Risk assessments were conducted
for any youth permitted to handle tools. Five youth were interviewed, and four indicated they are
permitted to use mops and brooms and one stated youth cannot use tools. One youth reported
being able to use a kitchen knife when working in the kitchen, and one youth reported using a
trowel in masonry. Five staff were interviewed and each reported youth may handle mops and
brooms, and two reported youth may use scrub brushes. One staff reported youth who
participate in vocational services may use masonry tools or yard equipment, another reported
cleaning towels, and one more staff said youth use dust pans.
5.15 Outside Contractors Satisfactory Compliance
The program shall establish guidelines required for outside contractors, which includes
information regarding tool control and restrictions.
The program has a policy and procedures establishing guidelines for outside contractors who
come on-site to complete repairs. When a contractor arrives on campus, they sign the visitors
sign-in log and the Written Notification and Guidelines for Outside Contractors form, which lists
unauthorized items and contraband. If any unauthorized items are needed by the contractor
while in the program, approval is obtained by the program director (PD) or designee. Any
tools required to be used within the program are inventoried and recorded on the
Vendor/Outside Contractor Tool Inventory Form before and after the repair is completed. Three
reviewed invoices showed the vendors signed contractor agreements. The reviewed invoices
indicated vendors arrived on-site with tools which were logged on the contract agreement forms
and all
equipment was inventoried before entering and leaving the program. Contractor visits were
verified in the program’s master control logbook.
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 drill documentation reflected the program conducts Continuity of Operations Plan (COOP)
drills monthly on each shift, in accordance with their COOP. All drill forms documented the type
of drill, date and time, participants, a brief scenario, and findings and recommendations. Fire
evacuation routes and egress plans were posted throughout the facility. The program has
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twenty-nine fire extinguishers, and a review of inspection tags indicated they are inspected
annually by a contracted inspection service and monthly by the maintenance manager. During
an interview with the program director, it was confirmed COOP and fire drills are conducted
twice monthly on each shift. Five youth were interviewed and each indicated they know what to
do in case of a fire and all were aware drills are completed monthly. Five staff were interviewed
and each indicated they had participated in fire drills, two have participated in weather drills, and
one reported participation in a major disturbance and bomb threat drill.
5.17 Disaster and Continuity of Operations Planning Satisfactory Compliance
The program shall have a coordinated disaster plan and Continuity of Operations Plan
(COOP) or one comprehensive plan incorporating both. The plan(s) shall provide for the
basic care and custody of youth in the event of an emergency or disaster and continuity of the
aforementioned, while ensuring the safety of staff, youth, and the public. The plan shall be
submitted to the regional director, or designee, for approval and signature.
The program shall establish and maintain critical identifying information, as well as a current
photograph of each youth, which are easily accessible to verify a youth’s identity, as needed,
during his or her stay in the program.
The program maintains a Department approved Disaster and Continuity of Operations Plan
(COOP) available for all staff to review, located in the program’s administration office. The
COOP was submitted and signed by the Department’s regional director on February 21, 2023.
The combined Emergency Disaster Preparedness Plan and COOP address alternative
relocation sites approved by the Department’s residential regional director. Designated
equipment and supplies required for continuous operation and services during emergency,
including water, canned foods, bags with emergency equipment, first-aid supplies, towels,
blankets, and extra clothing are stored on-site in the kitchen pantry, storage rooms, and the
maintenance building. The COOP addresses phases of a disaster plan as well as emergency
management including preparedness, response, and recovery. The COOP addresses
emergencies including fire, fire prevention, evacuations, severe weather, program disturbances,
bomb threats, hostage situations, chemical spills, flooding, and terrorist attacks. It also includes
staff roles and responsibilities, any equipment and supplies needed, information about youth
needed, alternative housing arrangements, provisions for continuity of care and custody of
youth, and provisions for public protection. The program keeps a binder in the administration
office with the COOP containing all required youth information. This information includes their
full name, identification number, admission date, date of birth, gender, race, parent/guardian
information, contact information for the person the youth will reside with, who to notify in case of
emergency, juvenile probation officer information, names of the committing judge, state
attorney, public defender, committing offense and where it occurred, notation of jurisdiction
retention, victim notification if applicable, a physical description of the youth, their overall health
status, personal physician (if known), and a photograph of the youth.
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 regarding the storage and inventory of flammable,
poisonous, and toxic items and materials. All hazardous items or materials are stored in the
maintenance building and inside a locked storage closet inside the kitchen, both inaccessible to
youth. The maintenance manager maintains strict control of all flammable, poisonous, and toxic
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items by utilizing a perpetual inventory. A review of Safety Data Sheets (SDS) compared to
samples from the inventories in the kitchen and the maintenance building determined the facility
has a SDS maintained on-site for all materials with no discrepancies. Inventories were
compared to a sample of the actual items at the program and no items were missing and no
additional items were discovered on the inventory. The program director (PD), maintenance
manager, and kitchen staff are listed as authorized to handle flammable, poisonous, and toxic
materials, with specific designation for the PD and maintenance manager as the only staff
allowed to remove chemicals from storage.
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 regarding youth handling and supervision for
flammable, poisonous, and toxic items and materials. According to the program’s policy, youth
are prohibited from handling or accessing flammable, toxic, or caustic materials at the program.
Youth are also prohibited from cleaning, handling, or disposing of any person’s bio-hazardous
material, bodily fluids, or human waste. All flammable, poisonous, and toxic materials are stored
securely inside the maintenance building and within a locked storage cabinet inside the kitchen,
where youth do not have access. Five youth were interviewed and each reported they do not
handle chemicals. Observations of youth cleaning the living unit and cafeteria confirmed this
practice.
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 disposal of all flammable, toxic, caustic, and
poisonous items. According to the program director (PD), hazardous items and toxic substances
or chemicals are disposed of in accordance with Occupational Safety and Health Administration
(OSHA) standards. The program uses the local county waste facility to dispose of toxic
chemicals. All chemicals needing disposal must be reported to the maintenance manager at
which time the chemicals are stored in a safe place until the waste facility is contacted and
comes to the facility to remove them. No hazardous waste has been disposed of during the
annual compliance review period. According to the PD, hazardous liquid waste is disposed of in
accordance with the manufacturer’s Safety Data Sheet and is stored in a hazardous materials
storage area. Any liquid waste, such as dirty mop water, is disposed of in plumbing drains, and
kitchen liquid waste is disposed of in the kitchen, with the exception of grease. According to the
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kitchen staff, used grease is returned to the containers the grease came from and disposed of.
According to the program’s policy and procedures, in the event of a chemical spill, staff must
notify master control of the spill location, the shift supervisor and/or master control shall direct
the shutdown of all air handlers and ventilation systems as well as close all windows and doors
at the direction of the supervisor on-site or PD, and, if necessary, assistance shall be contacted
in accordance 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.
An observation of the visitation schedule confirmed it is posted in the front of the facility and in
the youth handbook. Reviewed documentation determined visitation is held on Saturdays for
two hours. Documentation reflected all incoming and outgoing mail is searched and monitored
by program staff. A review of documentation demonstrated youth are given opportunities to
communicate with family by telephone, mail, and during visitation. One youth had a history of
human trafficking, and documentation reflected the program requested and received clarification
Florida Department of Juvenile Justice Residential Annual Compliance Report
Office of Accountability and Program Support Page 66 of 68 (Revised September 2022)
from the juvenile probation officer (JPO) to verify the youth’s parent/guardian and other family
members were not under current or past investigation for human trafficking-related charges. The
program’s policy and phone logs indicated telephone calls are offered to youth on assigned
days, and youth are given opportunities to make up a call which was unanswered on their
assigned day. Five youth were interviewed and each stated they can call their parent/guardian
or write them a letter. The program director stated the program utilizes LanguageLine services
to assist with translation for youth whose primary language is not English. Five staff were
interviewed and three of five were aware of this practice. Four of five interviewed youth were
aware of the translation services.
5.23 Recreation and Leisure Activities Satisfactory Compliance
The program shall provide a variety of recreation and leisure activities.
The program’s activity schedule reflects a variety of supervised and structured indoor and
outdoor recreation (or large muscle activity) and leisure activities for youth for at least one hour
daily. The recreational therapist position was vacant at the time of the annual compliance
review; however, the program had a candidate awaiting hire. A review of the previous
recreational therapist’s credentials confirmed all requirements were met. A review of the
logbook indicated recreation was conducted for at least one hour each day, according to the
schedule, as required. The program’s documented recreation and leisure activities promote
social and cognitive skill development, creativity, teamwork, healthy competition, mental
stimulation, and physical fitness. Recreational activities are observed by staff to ensure the
program takes precautionary measures to prevent overexertion, heat stress, dehydration,
frostbite, hypothermia, and exacerbation of existing illness or physical injury, which is
documented in the facility logbook. A review of five youth record confirmed each included a
recreation plan within their performance and/or treatment plan. Five interviewed youth reported
they are given the opportunity to exercise, play outside, or given down time to read a book, or
play a board game. Each youth also stated physical activities are provided for at least one hour
to include basketball, football, kickball, and other sports activities. Five interviewed staff reported
youth participate in various recreational activities for one or more hours including basketball,
football, kickball, volleyball, books, games, and equine activities.
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 67 of 68 (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 68 of 68 (Revised September 2022)

report_type: QI Residential

rule: Indicator 2.07

rating: Limited Compliance

rule: Indicator 3.03

rule: Indicator 3.06

rule: Indicator 3.12

rule: Indicator 3.15

excerpt: Crisis Assessments (Critical)

rule: Indicator 5.08

excerpt: Contraband Procedures

rating: Failed Compliance